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Objective: To determine the frequency of subtypes of Down syndrome by karyotyping, and to establish the frequency of congenital cardiac defects in this population., Methods: The cross-sectional study was conducted at the Department of Genetics, Children Hospital, Lahore, Pakistan, from June 2016 to June 2017, and comprised of Down Syndrome patients aged <15 years. They were subjected to karyotypic analysis for determining the subtype of the syndrome, and echocardiography of all cases was done for the assessment of congenital cardiac defects. The two findings was subsequently used to establish a relation between the subtypes and congenital cardiac defects. Data collected, entered and analyzed by the SPSS version 20.0., Results: Among the 160 cases, trisomy 21 was found in 154(96.2%), translocation 5(3.1%) and mosaicism 1(0.6%). Overall, 63(39.4%) children had cardiac defects. Among such patients, patent ductus arteriosus was most common 25(39.7%), followed by ventricular septal defects24(38.1%), atrial septal defects16(25.4%), complete atrioventricular septal defects 8(12.7%), and Tetralogy of Fallot3(4.8%), while 6(9.5%) children had other defects. Atrial septal defects was the most common double defect 9(56.2%) and had the highest coexistence with patent ductus arteriosus in Down syndrome cases with congenital cardiac defects., Conclusions: In Trisomy 21, the most common cardiac defect was patent ductus arteriosus, followed by ventricular septal defects in isolated defects, whereas in mixed defects, atrial septal defects and patent ductus arteriosus were the highest.

Objective: To find out the frequency of mental distress among medical students in Pakistani medical colleges., Methods: The systematic review comprised a search on PubMed and Google Scholar databases for articles published in English language between 2004 and 2019 having the key words 'mental distress', 'medical undergraduate', 'depression' and 'anxiety'. After a four-phase scrutiny process, articles were shortlisted for detailed review. Conventional content analysis was utilised for data analysis., Results: Of the 30 articles, 18(60%) were reviewed in detail. Distress among Pakistani medical students was reported up to 90% which is alarmingly high. Study year, financial issues and academic burden were the noteworthy causal factors. Academics and examinations were substantial stress factors and religion was the commonly adopted coping strategy., Conclusions: Multiple studies showed evidence of an increasing rate of mental distress among medical undergraduates having various causative factors, mainly the academic burden.

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., Methods: 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., Conclusions: 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.

Objective: To explore students' perceptions regarding self-directed learning, their experience of it, and how it may play a role in life-long learning., Methods: The exploratory study was conducted at the Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia, in January and February 2018, and comprised male undergraduate medical students from academic years 2-6. Data was collected through focus group discussions regarding the students' perception of self-directed learning. The sessions were audiotaped, transcribed, and analysed thematically. Validation was done by member-checking and external audit., Results: There were 29 male students with a mean age of 22.4±1.9 years. A total of 4 focus group discussion sessions were conducted; 2(50%) with students of preclinical years 2 and 3, and 2(50%) with students of clinical years 4-6. Five major themes generated were: understanding of self-directed learning; views about self-directed learning as a strategy; process of the strategy; effects of self-directed learning; self-directed learning and life-long learning. Subthemes which led to developing major themes included self-study, personal efforts, and objectives and goals formed theme1; good strategy, boredom with lectures, and need guidance theme2; time management, outline of planning, and internet browsing theme3; deep learning and curiosity theme4; life-long learning and future progress theme 5., Conclusions: The students were found to have mixed perceptions regarding self-directed learning. Most students perceived that SDL could affect their learning and future progress positively. However, they needed support to effectively use this strategy. The faculty role was found to be crucial in this regard.

Objectives: To investigate the prophylactic effect of the active isolated stretching technique on exercise-induced muscle damage of wrist flexors., Methods: The mixed model randomised controlled interventional study was conducted at the University of Sargodha, Sargodha, Pakistan, from November 2018 to May 2019, and comprised young adults who were untrained, sedentary and healthy who were randomly divided into intervention group A and control group B. Group A participants received self-assisted active isolated stretching before inducing muscle soreness of wrist flexors by eccentric exercises. Group B did not receive any intervention. The outcome measures were pain intensity, muscle soreness, pressure pain threshold, range of motion, and grip strength. Data were collected at baseline, after one hour, and daily from day 1 to 7 after inducing muscle soreness. Data were analysed using SPSS 21., Results: Of the 60 subjects, there were 30(50%) in each of the two groups. There were 14(23.3%) males and 46(76.7%) females. The overall mean age was 21.47±1.9 years. Group A showed early recovery in pain and muscle soreness compared to group B (p<0.05). Also, a limited deficit in the range of motion, grip strength, and pain pressure threshold was found in group A compared to group B (p<0.05)., Conclusions: Active isolated stretching before strenuous, unaccustomed exercise was found to be useful in ameliorating the symptoms of muscle soreness.

Objective: To provide an overview of existing literature regarding ethics in undergraduate medical education around the world, and to identify gaps in literature for recommending areas for future research., Methods: The scoping review was conducted in March 2016. PubMed and Web of Science search engines were used to identify English language literature on ethics in undergraduate medical education published over the preceding 20 years. Google search was used for grey literature. Two reviewers independently screened eligible studies for final study selection and review. Descriptive analysis of data was performed with mutual consensus., Results: Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature. Papers covered almost all regions of the world, including North and South America, Europe, Africa, and different Asian regions like Middle East, central, south-east and far east. The analysis identified several curriculum designs and teaching methods used for ethics education., Conclusions: The review identified gaps in evidence that required further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning strategies, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions.

Eccentric exercises are being used widely as a strategy to manage sarcopenia. However, eccentric exercises are linked to increased risk of myofibre damage and delayed recovery. There is elevated muscle soreness, decrease muscle strength and increased levels of muscle-specific circulatory protein. There is a huge variation in the severity of the symptoms after eccentric exercise. Several factors affect the degree and severity of muscle soreness. It includes exercise intensity, duration, mode, muscle group, age, gender, genetics and nutritional status. Therefore, designing a specific individual exercise plan is required to overcome injuries, myofibre damage and muscle soreness. At present, we still do not have enough knowledge about the exact sources and factors that trigger muscle soreness linked with strenuous exercise. Deep insight and identification of the risk factors which predispose individuals at an increased risk of muscle soreness after unaccustomed exercises may be a key to help them by prescribing personalised exercise therapy to speed up recovery and adaptation. Non-steroidal anti-inflammatory drugs are being used widely to manage muscle soreness, pain and tenderness linked with post exercise complications. But there is more to it than just treating pain. Is there any substantive gain besides pain relief? Can they improve muscle function? Could they prevent muscle soreness or speed up recovery? The current narrative review was planned to discuss the sources and factors that trigger exercise-induced muscle damage. Furthermore, it also provides a comprehensive analysis of the literature concerning the effectiveness of non-steroidal anti-inflammatory drugs in reducing symptom and improving muscle function in exercise induced muscle soreness.

Objective: To ascertain knowledge of first aid among parents of children suffering from burns., Methods: The cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan, from July 2017 to January 2018, and comprised parents of patients in the paediatric burns unit. Questionnaires were filled by the duty doctor after interviewing parents, and data was collected regarding first aid, application of traditional remedies and demographic details. Optimal knowledge was defined as parent's knowledge of application of tap water on burns as first aid. SPSS 20 was used for data analysis ., Results: There were parents of 310 patients who had a mean total body surface area of burns of 25.11}13.80%. All (100%) accidents had occurred at home. All (100%) parents had removed their children from heat and electric source immediately after the accident, while 282(91%) stripped their children of their clothes. Only 41(13.2%) parents irrigated the burn area with tap water and 93(30%) applied traditional remedies. Further, 21(6.8%) parents had covered the burnt area with sterile dressing, while 25(8.1%) had covered the child to avoid hypothermia. One (0.3 2%) parent had attended a first aid course, while 13(4.2%) had knowledge of first aid because of previous history of a child having suffered from burns. Optimal knowledge wasstatistically associated with previous knowledge of first aid (p=0.0001), level of education of the parent (p=0.003) and monthly income (p=0.01)., Conclusions: The knowledge of first aid among parents was found to be inadequate and there was an urgent need to introduce campaigns focussing on prevention and first aid to manage burns, especially among illiterate and poor classes.

Debilitating pain, stiffness, tenderness, fatigue, impaired muscle function, lack of strength subsequent to exercise are not welcomed by those not accustomed to it. It may discourage an individual from participating in regular exercise. Numerou s ph armacological and non - pharmacological strategies have been used to alleviate symptoms of muscle soreness, muscle pain, improving muscle function, the range of motion and recovery time. Non-steroidal anti-inflammatory drugs are suggested to have a beneficial impact on muscle soreness, but fail to rejuvenate muscle weakness and range of motion coupled with muscle soreness. Furthermore, oral antiinflammatory drugs are widely used to mitigate muscle soreness symptoms, but chronic use can lead to different side effects in terms of peptic ulcer and liver toxicity. Non-pharmacological remedies and interventions can be a better choice. This narrative review is intended to provide insight into the non-pharmacological strategies to combat exercise-induced muscle damage.

The world is geographically divided into hemispheres, continents and countries, with varying cultures in different regions. Asia, the largest of continents, has a variety of philosophically distinctive cultures and lifestyles, informing the norms of societies that are much different from cultures in other continents. These complexities in the societal norms in Asian cultures have created unique issues in development of ethics education in the region. This paper looks in to the distinctions in what is generally referred to as the "non-western" Asian culture, the importance of cultural context and how it influences the ethics curriculum in the region.

Anterior Cruciate ligament (ACL) is a typical athletic injury. One of the most frequent complication after ACL reconstruction is reduced range of motion (ROM) due to the impingement on the inter-condylar notch of a fibrous tissue mass, defined as Cyclops Syndrome. We report the case of a 25 years old male, who underwent reconstruction of ACL with Gracilis-semitendinosus (GR-ST) tendons with delayed onset of loss of knee extension seven years after ACL reconstruction. Clinical and magnetic resonance image (MRI) findings were consistent with Cyclops syndrome. The patient underwent arthroscopy in May 2015, which revealed a fixed fibrous nodule impinging on the inter-condylar notch in extension that was treated by mechanical shaving, radiofrequency ablation remodeling inter-condylar notch and releasing of the ACL transplant. After surgery our patient returned to his routine activities after 5 days and started running about 10 days later, without anterior knee pain and without deficit of hyperextension.

Objective: To analyse students' perception regarding the use of portfolio-workbook in ethics course., Methods: This mixed method study was conducted at the King Abdulaziz University, Jeddah, Saudi Arabia, in 2014, and comprised fourth-year medical students. The "portfolio-workbook", developed on principles of cognitive load and guided learning theories, contained essential reading material. Learning sessions were also facilitated by teaching tools like role-plays, movie/video clips, vignettes, etc., followed by reflective writing exercises. Feedback questionnaire with open- and closed-ended questions was used to collect data. Quantitative data was analysed for frequencies and percentages. Content analysis was conducted for the open-ended responses., Results: Of the 20 participants, 10(50%) considered using portfolio-workbook as difficult initially. However, on completion of module 16(80%) found it easy. Moreover, 17(85%) appreciated it as a learning tool. Besides, 19(95%) students found teaching videos and 13(65%) found open discussions as effective learning tools. Portfolio-workbook as an assessment tool was preferred by 19(95%) students., Conclusions: The use of portfolio-workbook in teaching ethics to undergraduates was found to be encouraging as it generated interest and interaction.

Objective: To evaluate students' perception about the educational environment at two medical colleges., Methods: The cross-sectional study was conducted at King Abdulaziz University, Rabigh and Jeddah campuses, in Saudi Arabia, during the first semester of the year 2014 using Dundee Ready Education Environment Measure inventory. Data was collected from undergraduate medical students and analysed using SPSS 16., Results: Of the 279 subjects in the study, 141(50.5%) belonged to the Rabigh campus, and 138(49.5%) to the Jeddah campus. Overall mean Dundee Ready Education Environment Measure inventory score was 124.90±20.66. The score for Jeddah was 131.38±21.37 and for Rabigh it was 118.56±17.85 (p=0.0001). The difference was also statistically significant in all domains of the inventory (p<0.05 each)., Conclusions: Students' perception of their educational environment was positive in both campuses, it was more positive in Jeddah compared to Rabigh.

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.

Objective: To perform an outcome-based evaluation of the diploma programme initiated in 2006 at the Centre of Biomedical Ethics and Culture., Methods: The broad based evaluation was done at the Centre of Biomedical Ethics and Culture, Sindh Institute of Urology and Transplantation, Karachi, from July 2011 to June 2012 and comprised pass out batches from 2006 to 2010. Outcome logic model was applied through a questionnaire-based approach. Emails were sent to the graduates, containing a mix of closed and open-ended questions. Quantitative feedback was analysed for frequencies and percentages. Content analysis was conducted for open-ended responses. SPSS 19 was used for statistical analysis., Results: Four batches had graduated in the five-year study period. A total of 50 students had been enrolled, while 41(82%) graduated. Of them, 31(76%) graduates responded. Overall, 10(24%) graduates completed their Masters in bioethics, and 16(39%) were involved in institutional ethics committee. All (100%) believed the diploma had increased their knowledge of ethics and they were involved in disseminating the acquired knowledge through presentations, seminars/conferences 29(93.5%), teaching and awareness activities 22(71%). Besides, 28(90%) respondents believed their behaviour had changed and 27(87%)were improving the quality of work and environment, while 18(58%) had published related articles after their diploma., Conclusions: The programme was found to have achieved its objective during the first five years of its inception.

Formative assessment, described as "the process of appraising, judging or evaluating students' work or performance and using this to shape and improve students' competence", is generally missing from medical schools of Pakistan. Progressive institutions conduct "formative assessment" as a fleeting part of the curriculum by using various methods that may or may not include feedback to learners. The most important factor in the success of formative assessment is the quality of feedback, shown to have the maximum impact on student accomplishment. Inclusion of formative assessment into the curriculum and its implementation will require the following: Enabling Environment, Faculty and student Training, Role of Department of Medical Education (DME). Many issues can be predicted that may jeopardize the effectiveness of formative assessment including faculty resistance, lack of motivation from students and faculty and paucity of commitment from the top administration. For improvement in medical education in Pakistan, we need to develop a system considered worthy by national and international standards. This paper will give an overview of formative assessment, its implications and recommendations for implementation in medical institutes of Pakistan.

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's 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.

Objective: To compare the results of open with laparoscopic appendectomy in terms of postoperative pain, rate of wound infection and hospital stay., Methods: This quasi-experimental study was conducted in Deprtment of Surgery, Ziauddin University Hospital, Karachi, over a period of six months. Patients undergoing surgery for acute appendicitis were randomly assigned into one of the two groups (A or B) after obtaining written and informed consent. In Group-A patients underwent open appendectomy and in Group B laparoscopic appendectomy was performed. Post operatively pain chart and wound infection was recorded and, at the time of discharge, number of days in hospital was calculated., Result: Sixty patients (38 male, 22 female), with clinical diagnosis of acute appendicitis based on Alvarado score of six and above, were included in the study. They were randomized into 2 groups of A and B with 30 patients in each group. Group-A comprised open appendectomy procedure and Group-B comprised laparoscopic appendectomy. Mean comparison of postoperative pain by visual analogue scale, was significantly low in Group B, compared with Group A, on day 0, 1 and 2. Number of days in Hospital was 4.1 +/- 0.8 days in Group A and 1.5 +/- 0.06 days in Group B. None of the patients in Group B, while 8 (26.67%) patients in-Group A, developed postoperative wound infection at 1 week follow up., Conclusion: Laparoscopic appendectomy is safe and effective. Wound infection and postoperative pain is significantly lower after this mode of surgery

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.

Posterior Leukoencephalopathy is a rare, though reversible complication of eclampsia. We report two cases, in which patients with eclampsia presented with seizures, visual disturbances and focal neurological signs with high intensity areas predominantly in parieto-occipital white matter on cranial MRI, where successful control of blood pressures led to complete resolution of neurological deficits as well as radiological abnormalities. It is an infrequently recognized neurological disorder, not known to many physicians, which has almost complete recovery with early diagnosis and treatment. The purpose of presenting this case series is to highlight the importance of early recognition and treatment of this potentially reversible disorder.