Journal of the Pakistan Medical Association最新文献

The widespread use of proton pump inhibitors (PPIs) has raised safety concerns, especially among patients with chronic kidney disease (CKD), where long-term use has been linked with acute interstitial nephritis (AIN), hypomagnesaemia, and potential progression to endstage kidney disease (ESKD). Recent observational studies and meta-analyses have yielded mixed evidence, calling for a nuanced and individualized approach to acid suppression in CKD. The concept of gut guardianship emphasizes cautious, indication-based prescribing, dose minimization, and structured deprescribing to preserve gut-renal health. This article reviews the current evidence and proposes a clinical toolkit for rational PPI use in CKD, based on risk stratification, guideline-based indications, and ongoing monitoring.

Mammary analogue secretory carcinoma (MASC) of the salivary gland is an extremely rare salivary gland tumour. It shows the same morphological, immunohistochemical and molecular features as that of the secretory carcinoma of the breast, making it a diagnostic enigma. Here, we report a case of ETS variant transcription factor 6 (ETV6)- neurotrophic receptor tyrosine kinase 3 (NTRK3) fusion gene positive MASC. A 59-year-old woman presented to our hospital with a mass on the right cheek. Computed tomography (CT) showed a nodular shadow in the right mandibular region, and the post-operative pathological diagnosis was confirmed as MASC (pT1N0M0). Immunohistochemical staining showed that the tumour cells were positive for pan-TRK, mammaglobin, and S-100. Fluorescence in situ hybridisation (FISH) confirmed the diagnosis. ETV6 gene translocation and ETV6-NTRK3 gene fusion, but MET gene translocation was negative. Immunohistochemistry and genetic analysis are important tools to differentiate MASC from its morphological mimickers. The treatment approach for MASC has not been well defined or standardised, necessitating further studies to develop evidence-based guidelines.

Objectives: To implement and evaluate a needs-based faculty development programme in a female-only medical college.

Methods: The mixed methods study was conducted in 2022-23 at the Women Medical and Dental College, Abbottabad, Pakistan. The faculty needs assessment was conducted in February 2022 using an online questionnaire, followed by identification of institutional needs through consultation in various organisational forums. Faculty development activities were planned and implemented in 2022-23 based on the needs assessment. At the end of each faculty development activity, the participants were asked to fill a feedback questionnaire. At the conclusion of the programme, 10 individual semistructured face-to-face interviews were conducted, and the data was thematically analysed to evaluate the programme.

Results: Areas including development of multiple choice questions, use of teaching aids, medical education research, curriculum development, leadership in medical education, time management, and small group interactive teaching were identified during the needs assessment phase. The total average feedback score for all activities combined was 4.2 out of 5 (SD=0.17), with positive feedback in open-ended questions. Five core themes emerged from the interview data: teaching skills development, applicable content, needs-based programme, networking opportunities, and learner-centred activities.

Conclusions: Faculty development programmes should be needs-based, and should focus on context-specific content, learner-centred activities and networking opportunities. Continuous evaluation of the programme is an important element.

Henoch-Schönlein purpura (HSP) also known as IgA vasculitis is a systemic small vessel vasculitis mainly affecting the skin, kidneys, joints, and gastrointestinal tract. However, the disease can affect any organ system of the body. The classic tetrad of presentation in Henoch- Schönlein purpura includes palpable purpura, joints pain, abdominal pain sometimes associated with bleeding, and renal disease. Pulmonary and pleural involvement in HSP is a rare manifestation and occurs more commonly in adults than in children. We report the case of a 67-year-old woman with diabetes and HSP complicated by pulmonary haemorrhage and pleural effusion. She was managed initially with pulse Methylprednisolone and Cyclophosphamide followed by a course of oral steroids. An excellent outcome was achieved.

Objectives: To establish an effective and practical bowel management protocol to achieve social continence in children operated for anorectal malformations.

Methods: The quasi-experimental study was conducted from January to December 2021 at the Colorectal Clinic of the National Institute of Child Health, Karachi, and comprised patients aged >3 years who had completed surgical management for anorectal malformations. Tailored modifications were made to a one-week bowel management boot camp to adapt to institutional constraints and the practical needs of the patient population. History, examination, abdominal X-ray and incontinence score were recorded before and after the commencement of high-volume saline enemas. Data was analysed using SPSS 22.

Results: Of the 80 patients, 46(57.5%) were boys with mean age 6.74±3.24 years and 34(42.5%) were girls with mean age 5.41±1.84 years. Among the boys, rectobulbar fistula was the most common anomaly 26(56.5%), whereas rectovestibular fistula was the most frequent anomaly in girls 20(58.8%). The mean incontinence score at presentation was 5.375±1.72, which improved significantly to 3.637±1.74 following bowel management (p<0.001). For the soiling component, the mean score difference was 1.275±0.45 (p<0.001).

Conclusion: Modified bowel management programme was effective in keeping the incontinent and constipated patients after anorectal malformation surgical treatment.

Objectives: To identify the competencies regarding entrustable professional activities among postgraduate plastic surgery residents for informed consent taking before any elective surgical procedure and to choose the appropriate assessment strategies.

Methods: The Modified Delphi study was conducted from July 2022 to January 2023 after approval from the ethics review committee of the Islamic International Medical College, Islamabad, Pakistan, and comprised two iterative rounds using the expert consensus approach involving consultant plastic surgeons serving in public, private and military teaching hospitals in Pakistan and abroad. Following literature search, competencies related to informed consent before elective plastic surgery procedures were identified. A 5-point Likert scale was formulated and the document was distributed online. Items reaching consensus level were included in the final document. The competencies that failed to reach the consensus level or needed amendments were sent in the second round along with additional questions regarding assessment strategies and supervision level. Data was analysed using SPSS 21.

Results: Of the 51 plastic surgery consultants, 30(58.8%) responded in the first round. Out of 58 competencies initially identified, 49(84.5%) reached consensus level. No new entrustable professional activities or competencies were identified. Of the 9 competencies in the second round, consensus was achieved on 6(67.7%), with the response rate being 70%. The final set comprised 55 competencies under 8 entrustable professional activities.

Conclusions: The entrustable professional activities identified provide a comprehensive competence-based assessment framework for taking informed consent in plastic surgery practice.

Objectives: To assess the effectiveness of de-escalation training among nurses exposed to workplace violence in hospitals.

Methods: The quasi-experimental study was conducted at the private-sector Ziauddin Hospital and the public-sector Dr Ruth K.M. Pfau Civil Hospital, Karachi, from June to December 2022, and comprised nurses aged 20-50 years with a minimum of six months of professional experience who had faced exposure to workplace violence in the preceding two months. The subjects were randomised into intervention group A and control group B. Those in group A received de-escalation training, while their counterparts in group B engaged in infrequent discussions. De-escalation training was delivered through a oneday workshop. Nurses' self-attributed confidence levels were measured at baseline and two months post-training using the Confidence Coping with Patient Aggression instrument. Data was analysed using SPSS 22.

Results: Of the 131 subjects, 95(72.5%) were females, 36(27.5%) were males and 102(77.9%) were aged 20-30 years. There were 67(51.1%) subjects from the public-sector facility and 64(48.9%) were from the private-sector entity. There were 67(51.1%) subjects n group A and 64(48.9%) in group B. De-escalation training proved significantly effective both in private and public hospital settings compared to baseline scores (p<0.05) and the control group (p<0.05).

Conclusions: Among the nurses exposed to workplace violence, de-escalation training was successful in boosting the confidence level of the nurses.