Pakistan Journal of Medical Sciences最新文献

Objective: This study was conducted to explore the underlying factors for requesting elective caesarean section without an obstetric indication in primigravida.

Methodology: A qualitative case study was conducted in Obstetrics & Gynaecology department at Central Park Hospital from September 2023 to February 2024. The study participants were primigravidas who presented after 37 weeks of gestation and requested for caesarean section without any medical indication. Semi-structured interviews were taken from fifteen participants for an in-depth analysis of the causes of elective caesarean section. Thematic analysis was done using NVivo 14.

Results: The analysis of the reasons given by women to seek caesarean section led to the identification of four main themes: psychological fear, negative birth experiences, behavioral control, and maternal firmness. Traumatic birth experiences of near relatives and friends emerged as a main reason that resulted in fear of childbirth. Psychological fear related to labour pains and vaginal examination were yet another reason. Behaviour control expressed as distress after witnessing another woman's labour, ashamed of exposure and lithotomy positioning were described by few of participants. Most respondents reported more than one reason for requesting caesarean section.

Conclusion: We found that CDMR in primigravidas is multifactorial and had personal, behavioural and social contexts. Listening to horrific birth stories from surroundings was most pronounced factor that created a negative impression of vaginal delivery on first-time mothers and generated self-perceived harm which led to multi-faceted fear regarding birth process.

Background & objective: The intensive care unit (ICU) management of neurosurgical patients is critical for early detection of complications, optimizing recovery, and improving outcomes. The study aimed to determine the outcomes of neurosurgical patients admitted to ICU.

Methodology: After taking exemption from ethical review committee, study was conducted from November 2020 to May 2023 at ICU of a The Aga Khan University Hospital, Pakistan. All adult neurosurgical patients requiring ICU admission were included. Data including demographic variables, comorbid conditions, reasons for ICU referral, complications and expected outcomes were gathered and was analyzed using R. Studio.

Results: Total 93 neurosurgical patients (mean age of 40 years, 69% males) were analyzed. Most of them were admitted to ICU after supratentorial craniotomy (40%). ICU course for them was associated with neurological (78%), metabolic (78%), respiratory (56%), cardiovascular (38%), and infectious (34%) complications. 50% of patients required tracheostomy. The mean length of stay (LOS) in ICU was 6.99 days with ICU mortality of 14.6%. Significant number of these patients (77%) were transferred from the ICU to ward care. The average LOS in ward was 8.43 days, with ward mortality of seven percent. The average LOS in hospital stay was 15.3 days. Comparison of adverse outcomes revealed, patients admitted from ward tend to have the longest ICU stay, higher frequency of having neurological deficit, seizures and sepsis. While higher chances of unsuccessful extubation and need of tracheostomy in patients presented with head injury.

Conclusion: Despite medical advances, morbidity and mortality remain high in neurosurgical patients. The high incidence of neurological, metabolic and respiratory complications and related outcome particularly patients coming from ward and after trauma needs special consideration.

Objective: To compare the changes in levels of inflammation markers in the patient with non-valvular atrial fibrillation (NVAF) who were on Warfarin and then switched to Apixaban.

Methodology: The files of 149 consecutive patients, who had NVAF, who were previously using Warfarin, but for various reasons switched to Apixaban were screened retrospectively. Forty-one patients were excluded from the study. Last coagulation parameters were used for analysis. The evaluation of hemogram parameters in patients undergoing treatment with Warfarin, subsequently transitioning to Apixaban, revealed significant insights into various hematological indices. Notably, the Neutrophil/Lymphocyte Ratio, Platelet/Lymphocyte Ratio, the Systemic Immune-Inflammation Index, Systemic Inflammation Response Index (SIRI), the aggregate index of systemic inflammation and Monocyte/Lymphocyte Ratio were meticulously assessed and compared between the groups.

Results: The study involved 108 individuals with NVAF. The average lymphocyte level of the patients on Apixaban therapy was statistically significantly higher than on Warfarin therapy (p<0.001). Also, The Neutrophils (p<0.001), Monocytes (p=0.008), and Platelets (p<0.001) were significantly lower in patients treated with Apixaban compared to those on Warfarin. When the systemic inflammation indices of the patients were compared, the averages of the patients' NLR, PLR, MLR, SII, SIRI, and AISI indices were statistically and significantly lower than time on Warfarin therapy.

Conclusion: Current study results suggested that Apixaban has more effective anti-inflammatory potential compared to Warfarin. The study implicates new perspectives on the anti-inflammatory effects of oral anticoagulants used in the treatment of NVAF.

Background and objective: Clopidogrel is essential to prevent cardiovascular events in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Despite adherence to clopidogrel, a significant number of cardiovascular events (CVEs) occur in patients after angioplasty. In this study, we sought to determine the association of CVEs with genetic polymorphisms in CYP2C19*2 (rs4244285) that affect metabolic activation of clopidogrel.

Methodology: A prospective cohort study (n=204) was conducted from August 2022 to March 2023 at Khyber Medical University and Kuwait Teaching Hospital in Peshawar, Pakistan. STEMI patients (age 30-75 years, all genders) undergoing PCI were included and followed for 12 months. Genotyping of CYP2C19*2 (rs4244285) was performed by TaqMan assay. CVEs (mortality, stent thrombosis, recurrent MI, ischemic events and stroke) were compared between wild-type and variant genotypes. Statistical analysis used Fisher's exact test to compare CVEs between wild and mutant group, while binary logistic regression examined the relationship between CVEs and risk factors (SPSS v22).

Results: The CYP2C19*2 (rs4244285) GA and AA genotypes were significantly associated with cardiovascular events (CVEs) (p < 0.003), whereas the wild-type GG genotype showed no significant correlation. During the 12-month follow-up after PCI, CVEs included: mortality (n = 10; GG = 2, GA+AA = 8), stent thrombosis (n = 5; GG = 0, GA+AA = 5), recurrent myocardial infarction (n = 9; GG = 1, GA+AA = 8), ischemia-related hospitalizations (n = 17; GG = 1, GA+AA = 16), and cerebrovascular accidents (n = 3; GG = 0, GA+AA = 3).

Conclusion: Individuals carrying one or two non-functional CYP2C19*2 (rs4244285) alleles - GA and AA genotypes classified as intermediate and poor metabolizers, respectively- - showed a significant association with CVEs. Conversely, subjects with GG genotypes (normal metabolizers) had a significantly lower incidence of CVEs.

Background & objective: Audio podcasts offer flexibility and align with adult learning principles, yet their role in enhancing clinical reasoning and optimal delivery format remains unclear. This study compared descriptive and interview-based podcasts to evaluate their effectiveness in improving clinical reasoning in undergraduate medical students and determine the superior podcast format.

Methodology: The study conducted from March to May 2024 used a pretest-posttest crossover design to evaluate the effectiveness of two podcast formats (descriptive and interview-based) in enhancing clinical reasoning skills among 93 fourth year MBBS students at Islamic International Medical College during their surgery clerkship. Ethical approval was obtained, and participants were randomly divided into two groups (A and B). Four podcasts, approximately 10 minutes each, were created on acute appendicitis and acute cholecystitis. In Round-1, a pretest on acute appendicitis was followed by Group-A listening to a descriptive podcast and Group-B to an interview-based podcast, with a posttest conducted afterward. In Round-2, the groups crossed over for acute cholecystitis, followed by a posttest. Data were analyzed using SPSS, with paired t-tests comparing pretest and posttest scores within groups and independent t-tests comparing performance between formats.

Results: Both groups demonstrated notable increases in knowledge. In Rounds 1 and 2, Group-A's mean pretest/posttest score differences were 4.33 and 6.91, respectively, but Group-B were 8.00 and 6.97 (p<0.001). The advantage of the interview-based approach was demonstrated by independent sample t-tests (p<0.001).

Conclusion: Clinical reasoning abilities can be improved with the use of podcasts. Compared to the descriptive style, the interview-based format was more successful, indicating that it may be used as an additional learning aid in medical education.

Objectives: The present study aimed to assess and compare the solubility of three resin-based luting cements in artificial saliva under varying pH conditions.

Methodology: This in-vitro experimental study was conducted at the College of Dentistry, King Faisal University, Al Ahsa, Saudi Arabia, over a period of two months. A total of 45 disc-shaped specimens (8mm diameter, 4mm thickness) were prepared using cylindrical molds: 15 each of Self-Adhesive Methacrylate-Based Resin Cement (Non-MDP), Self-Adhesive MDP-Based Resin Cement, and Resin-Modified Glass Ionomer Cement. The specimens were light-cured for 40 seconds using an LED curing unit (450 mW/cm²) and finished with Sof-Lex discs. Each group was further subdivided, with five specimens immersed in artificial saliva at pH 3.4, pH 6.7, and distilled water at pH 7.0, respectively, for four weeks. Solubility was determined by calculating the mass loss of each specimen after immersion in the test solutions for four weeks. One-way ANOVA and Tukey's HSD post-hoc test were applied for group comparisons at a significance level of p < 0.05.

Results: The solubility of all three cements was significantly higher in acidic artificial saliva (pH 3.4), with Self-Adhesive MDP-Based Resin Cement demonstrating the lowest solubility (0.022 ± 0.010 mg/mm³), and both Self-Adhesive Methacrylate-Based Resin Cement (Non-MDP) and RMGIC showing similarly high solubility values (0.08 ± 0.021 mg/mm³ and 0.08 ± 0.005 mg/mm³, respectively). No significant difference was observed among the groups at pH 6.7 and pH 7.0.

Conclusion: The solubility of resin-based luting cements is influenced by pH, with significantly greater degradation under acidic conditions. Self-Adhesive MDP-Based Resin Cement exhibited superior resistance, making it more suitable for low pH environments.

Objective: To compare the efficacy of continuous versus intermittent nebulization of salbutamol (SB) in the treatment of acute severe asthma (ASA) in children visiting the emergency department.

Methodology: This randomized controlled trial was performed at the emergency department of pediatric medicine, The Children's Hospital and The Institute of Child Health, Multan, Pakistan, during April 2024 to September 2024. Children aged 2-12 years, diagnosed with severe exacerbation of acute asthma, with clinical asthma score (CAS) > 8. Group-A was administered continuous SB nebulization at 0.3 mg/kg/hour for four hours, with 5-15 mg/hour. In Group-B, SB was administered intermittently at a dose of 0.15 mg/kg per dose. CAS, length of hospital stay, and treatment duration, were compared.

Results: In a total of 120 children, 68 (56.7%) were male. The mean age was 8.06±1.6 years. Between Group-A (Continuous), and Group-B (Intermittent), there were no significant differences at 20 minutes (p=0.673), 40 minutes (p=0.419), one-hour (p=0.365), two-hours (p=0.536), and four-hours (p=0.536) in terms of CAS. The time to treatment initiation (p=0.837), time to treatment stop (p=0.77), duration of treatment (p=0.084), and hospital stay duration (p=0.959) were statistically similar in both treatment groups. Both groups reported relatively higher safety profile (95.0% [n=57] patients without any side effects in Group-A vs. 96.7% [n=58] in Group-B, p=0.648).

Conclusion: Continuous, or intermittent nebulization of SB were both effective methods for treating severe exacerbation of acute asthma in children. CAS, treatment duration, or length of hospital stay between the two methods did not exhibit any significant differences. Trial Registration: NCT06754631 (ClinicalTrials.gov).

Objectives: This study investigated the relationship between learning styles and burnout among undergraduate medical students.

Methodology: This cross-sectional survey was conducted at Alfaisal University, Riyadh, Saudi Arabia, between April and June 2024. Burnout levels were assessed using the Oldenburg Burnout Inventory, and learning style preferences were assessed using the Grasha Reichmann Learning Style Scale. Demographic information, including age, gender, academic year, and living situation, was also collected. Multiple linear regression (MLR) was used to identify independent predictors of burnout components, controlling for gender.

Results: A total of 161 students completed the questionnaire. Females had significantly higher exhaustion scores than males. Males preferred independent and competitive learning styles. The MLR analysis revealed that the avoidant learning style was the strongest predictor of total burnout (β = 3.14), indicating that disengagement is the primary driver of burnout. Conversely, the collaborative style significantly buffered against emotional detachment (β = -1.32), and the participant style significantly reduced emotional exhaustion (β = -1.89). The MLR confirmed that the relationship between avoidant style and burnout was independent of gender. Dependent, independent, and competitive learning styles had no significant predictive impact on burnout. Also, the study found no link between age, living situation, and learning style preferences.

Conclusions: The avoidant learning style is an independent risk factor for burnout in undergraduate medical students, while collaborative and participant styles are protective. The findings emphasize the importance of early screening for avoidant characteristics and using adaptable teaching techniques that promote engagement and teamwork to mitigate high-risk learning behaviors and reduce burnout rates. Future work could investigate the mechanisms underlying this relationship and the roles of other variables, such as social support and personality traits.

Objective: The characteristics of benign and malignant breast lesions often overlap and intersect, leading to missed diagnosis or inaccurate diagnosis and excessive biopsy, besides surgical procedures. This study aimed to assess the diagnostic value of radiomics based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in evaluating the pathological characteristics of breast cancer.

Methodology: This retrospective case-control study included 110 patients with breast lesions who underwent DCE-MRI and obtained pathological results at Yongkang First People's Hospital and Yongkang Hospital of Traditional Chinese Medicine from September 2019 to December 2024. According to the results, 55 patients with confirmed breast cancer lesions (malignant group) were matched with a cohort of patients with benign lesions (benign group) at a 1:1 ratio. Radiomic parameters from DCE-MRI were analyzed in the two groups.

Results: The radiomic features derived from DCE-MRI showed significant differences not only between benign and malignant breast lesions but also among subgroups stratified by histological grade and axillary lymph node metastasis. Specifically, patients with higher histological grades demonstrated elevated values in long run emphasis and all-angle cluster prominence variance (×10¹³), and decreased values in all-angle correlation, surface-to-volume ratio, and uniformity. Similarly, patients with axillary lymph node metastasis exhibited significantly higher long-run emphasis and cluster prominence variance, and lower uniformity and all-angle correlation (all P < 0.05).

Conclusion: DCE-MRI-based radiomics can effectively differentiate benign and malignant breast lesions and has a predictive value for assessing histological grade and axillary lymph node status. Radiomic features may therefore serve as noninvasive imaging biomarkers to support breast cancer diagnosis, grading, and staging.

Background & objective: Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of the hepatic venous outflow and is characterized by hepatomegaly, ascites, abdominal pain. The successful anaesthetic and transfusion treatment of a patient with BCS who had a hepatic hydatid cyst following LDLT is described in this report. Venous obstruction and parasitic cysts together pose a significant perioperative risk, especially in cases of severe intraoperative bleeding.

Case presentation: A 30 years old woman was admitted with weight loss, abdominal distension, recurrent haematemesis, and progressive jaundice. She had undergone multiple endoscopic variceal band ligations and treatment for pulmonary tuberculosis. Imaging revealed hepatic vein thrombosis, caudate lobe hypertrophy, and a hydatid cyst in segment VII that measured 5.8 × 4 cm. Anaemia (haemoglobin 7.6 g/dL) with preserved renal and coagulation function was found in the laboratory (MELD 14, Child-Turcotte-Pugh A6). LDLT was scheduled for her following multidisciplinary optimization.

Management and outcome: General anesthesia was achieved and then transesophageal echocardiography, arterial, central venous and PiCCO lines, were placed for invasive haemodynamic monitoring. The more than 10 liters of intraoperative blood loss were controlled by an organized massive transfusion protocol that used packed red blood cells, plasma, cryoprecipitate, and 2.9 litres of autologous blood through cell salvage. In order to preserve haemodynamic stability and keep mean arterial pressure above 70 mmHg, norepinephrine and vasopressin infusion were used. The patient showed stable graft function and recovered without any problems.

Conclusion: Even in severe hemorrhagic episodes during LDLT for BCS, successful outcomes can be ensured by multidisciplinary coordination, advanced monitoring, and adherence to transfusion protocols.