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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.

Medical and dental education during the COVID-19 pandemic has transitioned from face-to-face classroom learning into an online environment. While this transition has many learning opportunities, it has its fair share of drawbacks. Most universities worldwide have adopted ZoomTM, a video conferencing platform for teaching students in an online environment. The silver lining of online learning is that most of what was taught physically could be taught effectively online. However, a frequent complaint by faculty and teachers using zoom is a lack of interaction with students. Twenty practical tips have been proposed that will make teaching and learning through Zoom a conducive learning environment. Most of the course content in medical and dental education can be effectively delivered through the zoom platform. The key to success is interaction through breakout rooms and the use of pre-test, post-test, and polling that will not only engage students but will result in worthwhile learning.

Objective: To find out the frequency of mental distress among medical students in Pakistani medical colleges. Method: 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. Key Words: Mental stress, Medical undergraduates, Pakistani medical college, Depression and anxiety stress.

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.

Background Complexities of ethics education, combined with socio-cultural issues specific to the medical curricula of the developing country context, have created resource constraints that impact medical ethics education delivery in countries like Pakistan and Saudi Arabia. These constraints include the dearth of contextually relevant texts, shortage of trained teachers and confines in institutional regulations in the regions. Focused strategies are required to address these constraints. Workbook-based ethics learning (WBEL) is one such strategy based on a contextually relevant ethics education model. Purpose This study aimed to evaluate the effectiveness of ethics education, delivered through the WBEL strategy, on students’ learning and satisfaction in medical colleges of Pakistan and Saudi Arabia. Methods A pre-post-test intervention study was conducted in two medical colleges, Jinnah Sindh Medical University, Pakistan and King Abdulaziz University, Saudi Arabia. An ethics course was structured using the WBEL strategy and delivered to early clinical years medical students. The impact on student learning was measured by pre-and-post administration of a set of Key Feature Questions (KFQ) and a Script Concordance Test (SCT). A twenty-eight-item course feedback questionnaire was developed to collect students’ perceptions regarding the WBEL strategy. Results Of the total 125 students who consented, 90 (72%) completed the pre-and post-test measures, and 103 returned the feedback forms at the two sites. The post-test scores in KFQs were significantly higher than pretest scores in both Pakistani and Saudi students (p-value

BackgroundDelivery of medical ethics education is complex due to various reasons, compounded by the context-dependent nature of the content. The scarcity of relevant resources in the contexts of some developing countries adds a further layer of difficulty to ethics education in these contexts. We used a consultative approach with students, teachers and external experts to develop a practical approach to medical ethics education. This study aimed to develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia.MethodsThe study utilised an explorative qualitative methodology to seek views of students and faculty of Rabigh Faculty of Medicine, Saudi Arabia, and international experts in the field of ethics and education to review and enhance a new ethics learning strategy which included a workbook-based tool. Three focus groups with 12 students, in-depth interviews with four faculty members and qualitative feedback from eleven external experts enabled the study participants to objectively critique the WBEL and provide feedback to enhance its quality. Thematic content analysis of the data was done to draw inferences which were used to refine the educational strategy.ResultsThe analysis generated twenty-one sub-themes within four main themes: design features, content, teaching methods and assessment. These findings helped to design the educational strategy to improve its effectiveness in the given context.ConclusionThe study drew on the views of students, faculty and external experts to systematically develop a novel approach to ethics education for countries like Saudi Arabia. It also demonstrated the use of the consultative approach for informing a culturally relevant educational strategy in the Middle East context.

Background Medical education has a longstanding tradition of using logbooks to record activities. The portfolio is an alternative tool to document competence and promote reflective practice. This study assessed the acceptance of portfolio use among Saudi undergraduate medical students. Methods Portfolios were introduced in the 2nd through 5th years at King Abdulaziz University over a two-year period (2013-2015). At the end of each academic year, students completed a mixed questionnaire that included a self-assessment of skills learned through the use of portfolio. Results The results showed a difference in focus between basic and clinical years: in basic years students' focus was on acquiring practical skills, but in clinical years they focused more on acquiring complex skills, including identifying and managing problems. The questionnaire responses nonetheless revealed a positive trend in acceptance (belief in the educational value) of portfolios among students and their mentors, across the years of the program. Conclusions Using portfolios as a developmental learning and formative assessment tool in the early undergraduate years was found to contribute to students' ability to create their own clinical skills guidelines in later years, as well as to engage in and appreciate reflective learning.

The aim of the study is to study the pattern of injuries from road traffic accidents presented at the emergency department of a rural teaching institution in Karachi. This descriptive case series was conducted prospectively in the Emergency Department of Fatima Hospital and Baqai Medical University from 1 January 2012 to 21 March 2013. There were 385 patients in the series. All of the patients with recent injuries from road traffic accidents were included. Cases with injuries more than 72 h old were excluded. The majority of patients had lower limb injuries 172 (44.7%), followed by head and neck injuries 107 (27.8%), multiple injuries 62 (16.1%), upper limb injuries 22 (5.7%), abdominoperineal injuries 19 (5%), and chest injuries 3 (0.8%). Majority (229, 59.5%) of patients were given first aid treatment and discharged, while 151 (39.3%) patients were either admitted or referred to better equipped hospitals. Three patients were brought dead, and two patients left against medical advice. The lower limb injuries were the commonest road traffic accidental injuries, followed by head and neck injuries, multiple injuries, upper limb injuries, abdominoperineal injuries, and chest injuries.

Over recent decades, the use of portfolios in medical education has evolved, and is being applied in undergraduate and postgraduate programs worldwide. Portfolios, as a learning process and method of documenting and assessing learning, is supported as a valuable tool by adult learning theories that stress the need for learners to be self-directed and to engage in experiential learning. Thoughtfully implemented, a portfolio provides learning experiences unequaled by any single learning tool. The credibility (validity) and dependability (reliability) of assessment through portfolios have been questioned owing to its subjective nature; however, methods to safeguard these features have been described in the literature. This paper discusses some of this literature, with particular attention to the role of portfolios in relation to self-reflective learning, provides an overview of current use of portfolios in undergraduate medical education in Saudi Arabia, and proposes research-based guidelines for its implementation and other similar contexts. Saudi Med J 2016; Vol. 37 (3): 245-248 doi: 10.15537/smj.2016.3.12937 How to cite this article Fida NM, Shamim MS. Portfolios in Saudi medical colleges. Why and how? Saudi Med J 2016; 37: 245-248.

Context: There is a high prevalence of diabetes mellitus in Saudi Arabia. Also, the diabetic foot complication rate is alarmingly high with many patients ending in amputation. Aims: To assess the knowledge, attitude, and practices regarding diabetic foot care among Saudi and non-Saudi diabetic patients in Alkharj. Settings and Design: It is a cross-sectional study conducted from May 22nd, 2019 to April 1st, 2020 at Diabetic clinic, Military Hospital in Alkharj. Methods and Materials: Non-randomized, non-probability convenience sampling technique was used to collect data from 224 patients by using a validated and confidential questionnaire in either face-to-face interviews or as an electronic survey. All adult patients over 18 years of age of both sexes having type 1 and 2 diabetes mellitus were included. The patients who were unable to provide the requested information were excluded. Statistical Analysis: The data were analyzed using SPSS version 24. Results: The mean age of patients was 49.37 years with 58.5% male and 41.5% female patients. About 58% of patients had diabetes for more than 10 years. More than half of the patients reported some foot problems, while 9.4% have had active or healed ulcerations. The mean scores for knowledge, attitude, and practice were 8.576, 4, and 13, respectively, all statistically significant. Conclusions: Our study population has sufficient knowledge about diabetes and its foot complication, and they also had a positive attitude towards its management. However, they were lagging in the practices required for diabetic foot management.

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.

To analyse students' perception regarding the use of portfolio-workbook in ethics course.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.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.The use of portfolio-workbook in teaching ethics to undergraduates was found to be encouraging as it generated interest and interaction.

To evaluate students' perception about the educational environment at two medical colleges.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.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 (p0.05 each).Students' perception of their educational environment was positive in both campuses, it was more positive in Jeddah compared to Rabigh.

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.

Objective To find out the most appropriate learning theory for the ethics education of medical undergraduates. Methods Two electronic databases were searched PubMed and Web of Science. We searched for published articles written in English without a time limit using the keywords: ethics education, medical undergraduates and learning theory. In the four-phased retrieval process, six full texts out of 133 citations were included in this review. Data were analyzed done by conventional content analysis. Results This systemic review revealed that reflection is the most effective pathway to develop ethical attributes and values of the physician. Social constructivist and experiential theory seem appropriate to form the basis for developing effective ethics curriculum. Conclusions This review heightens the importance of learning theories for ethics education. It gives prompt evidence that reflection is the most suitable model for ethical education. Therefore, the educational theories and teaching activities that endorse reflective learning should be used for ethics education.

To perform an outcome-based evaluation of the diploma programme initiated in 2006 at the Centre of Biomedical Ethics and Culture.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.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.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.

The recurrence of inguinal or other abdominal hernia due to Prolene polypropylene mesh dissolution has never been reported in the literature. This is a report of two cases of recurrent inguinal hernias after mesh hernioplasty, but, on exploration, no mesh was found.

The American Academy of Family Physicians (AAFP) has recently been criticized for accepting a large corporate donation from Coca-Cola to fund patient education on obesity prevention. Conflicts of interest, whether individual or organizational, occur when one enters into arrangements that reasonably tempt one to put aside one’s primary obligations in favor of secondary interests, such as financial self-interest. Accepting funds from commercial sources that seek to influence physician organizational behavior in a direction that could run counter to the public health represents one of those circumstances and so constitutes a conflict of interest. Most of the defenses offered by AAFP are rationalizations rather than ethical counterarguments. Medical organizations, as the public face of medicine and as formulator of codes of ethics for their physician members, have special obligations to adhere to high ethical standards.

Surgeons are still following the old habit of routine subhepatic drainage following laparoscopic cholecystectomy (LC). This study aims to compare the outcome of subhepatic drainage with no drainage after LC. This prospective study was conducted in two phases. Phase I was open, randomized controlled trial (RCT), conducted in Civil Hospital Karachi, from August 2004 to June 2005. Phase II was descriptive case series, conducted in author’s practice hospitals of Karachi, from July 2005 to December 2009. In phase I, 170 patients with chronic calculous cholecystitis underwent LC. Patients were divided into two groups, subhepatic drainage (group A: 79 patients) or no drainage (group B: 76 patients). The rest 15 patients were excluded either due to conversion or elective subhepatic drainage. In phase II, 218 consecutive patients were enrolled, who underwent LC with no subhepatic drainage. Duration of operation, character, and amount of drain fluid (if placed), postoperative ultrasound for subhepatic collection, postoperative chest X-ray for the measurement of subdiaphragmatic air, postoperative pain, postoperative nausea/vomiting, duration of hospital stay, and preoperative or postoperative complications were noted and analyzed. Duration of operation and hospital stay was slightly longer in group A patients (P values 0.002 and 0.029, respectively); postoperative pain perception, nausea/vomiting, and postoperative complications were nearly same in both groups (P value 0.064, 0.078, and 0.003, respectively). Subhepatic fluid collection was more in group A (P = 0.002), whereas subdiaphragmatic air collection was more in group B (P = 0.003). Phase II results were nearly similar to group B patients in phase I. Routine subhepatic drainage after LC is not necessary in uncomplicated cases.

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.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.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).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 This study aimed to determine the frequency, pattern and management of acute abdomen in patients with dengue fever. Methods This descriptive case series is a prospective analysis of acute abdomen in dengue fever that was performed at three secondary care hospitals in Karachi, Pakistan from June 1, 2005 to December 31, 2008. The inclusion criterion was all patients with confirmed diagnosis of dengue fever. Patients with incomplete laboratory, ultrasound or histopathology data were excluded. Results Among 357 patients with dengue fever, 43 (12.04%) had acute abdomen. There were 15 men and 28 women, with a median age of 29 years. These included 26 cases of acute cholecystitis, 7 cases of acute appendicitis, 7 cases of nonspecific peritonitis, and 3 cases of acute pancreatitis. Dengue hemorrhagic fever/shock syndrome was found in acute pancreatitis, and two of these patients died. Emergency surgery was required in eight patients (5 appendectomy and 3 open cholecystectomy). Substantial transfusion of blood and its components was required in eight patients who underwent emergency surgery. Conclusion Early diagnosis and prompt conservative management of dengue acute abdomen is necessary to avoid mortality and emergency surgery-related morbidity. However, if needed, surgery can be performed with acceptable morbidity.

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.

Pancreatic pseudocyst is a complication following resolution of pancreatitis. The optimum treatment for this condition has been under much debate. Laparoscopic surgery has changed the outlook of surgical management for the condition by reducing the operation related morbidity. The procedure has not been reported in local literature and is relatively new for the medical-surgical community. We report a case of pseudocyst gastrostomy and explain the procedure through laparoscopic approach.

The incidence of Complete Androgen Insensitivity Syndrome (CAIS) is about 1 in 20,000. People with CAIS are normal appearing females, despite the presence of testes and a 46, XY chromosome constitution. We came across a case in which a 17 years old girl presented with the complaint of inguinal hernia and amenorrhea. Subsequent investigations were done revealing absence of female internal genitalia and the presence of abdominal mass, possibly testes. Syndrome has been linked to mutations in AR, the gene for the human Androgen Receptor, located at Xq11-12 leading to the insensitivity of the receptor to testosterone. Gonadectomy was performed and life long Hormone replacement therapy was advised.

Accessory breast and duct ectasia are common clinical problems in their own right. However, their coexistence is a rare entity. Duct ectasia is a dilation in one or more of the larger lactiferous duct filled with a stagnant brown or green secretion, which may or may not discharge through the nipple. This material acts as an irritant and leads to periductal mastitis. Duct ectasia may present with subareolar mass, nipple discharge, nipple retraction, non-cyclical mastalgia or mammary fistula. Surgical options are microdochectomy or cone excision of major ducts. This case report describes the presence of duct ectasia in both accessory breast situated in the axilla and ipsilateral normal breast simultaneously.

To evaluate the result of surgical procedures adopted for repair of iatrogenic injuries of extrahepatic biliary tract over T-tube.An interventional study conducted at Surgical Unit 1 of Abbasi Shaheed Hospital, Karachi; and private hospitals in Karachi, from 1974 to 2004 (30 years). All the iatrogenic injuries of extrahepatic biliary tract during open cholecystectomies were recorded. The records included age and sex of patients, site and extent of injury, method of repair and post-operative complications, if any. All primary repairs were done over T-tube. For injuries at the confluence, the T-tube was converted into a Y-tube, and its short limbs were introduced into the lumen of right and left hepatic ducts. Follow up was done in the outpatient department weekly for a month after discharge, and then annually for maximum 5 years.A total number of 5,000 open cholecystectomies were performed during the study period. Eleven patients (0.22%) had intraoperative extrahepatic biliary tract injury: 6 out of 11 had injury of common bile duct (CBD), 2 had common hepatic duct (CHD) and 3 had injury at the confluence. One patient was lost to follow up after a year. One patient died of myocardial infarction after two years. Nine patients were clinically and biochemically well at five years follow up after primary repair of the injuries.Primary repair of extrahepatic duct injuries, situated at CBD, CHD or at the confluence, over the T-tubes is safe. In case of injury at the confluence the T-tube may be shaped like a Y-tube for secure anastomosis of all the three cut ends.

A survey was undertaken to assess the knowledge, attitude and practice of medical ethics among surgical residents and interns in three teaching hospitals of Karachi, Pakistan. 101 out of 120 completed responses were included in the study. Fifty-one respondents had heard about the Code of Ethics formulated by the Pakistan Medical and Dental Council. Forty-four had read the code. Seven had no knowledge about it. Forty-seven reported taking consent for procedures. Forty-two respondents gave correct answers on questions of confidentiality and knowledge of law pertaining to trauma victims. Only 11 reported having been taught ethics as students. Four did not feel the need of its teaching at an undergraduate level. Doctors graduating within the last 10 years gave fewer correct answers than those graduating earlier. Knowledge of medical ethics and its application on the surgical floors is extremely poor. The survey results support the view that medical ethics should be part of the undergraduate medical curriculum.

A case of malignant melanoma metastatic to small bowel mesentery in an old female is reported. Her primary malignant melanoma of nasal mucosa was already treated. She presented with intestinal obstruction, underwent surgical excision of the tumour and was tumour-free postoperatively.

Background Perforation peritonitis is the most common surgical emergency encountered by the surgeons all over the world as well in Pakistan. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counter part. This study was conducted at Dow University of health sciences and Civil Hospital Karachi (DUHS & CHK) Pakistan, designed to highlight the spectrum of perforation peritonitis in the East and to improve its outcome. Methods A prospective study includes three hundred consecutive patients of perforation peritonitis studied in terms of clinical presentations, Causes, site of perforation, surgical treatment, post operative complications and mortality, at (DUHS&CHK) Pakistan, from 1st September 2005 – 1st March 2008, over a period of two and half years. All patients were resuscitated underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. Results The most common cause of perforation peritonitis noticed in our series was acid peptic disease 45%, perforated duodenal ulcer (43.6%) and gastric ulcer 1.3%. followed by small bowel tuberculosis (21%) and typhoid (17%). large bowel perforation due to tuberculosis 5%, malignancy 2.6% and volvulus 0.3%. Perforation due to acute appendicitis (5%). Highest number of perforations has seen in the duodenum 43.6%, ileum37.6%, and colon 8%, appendix 5%, jejunum 3.3%, and stomach 2.3%. Overall mortality was (10.6%). Conclusion The spectrum of perforation peritonitis in Pakistan continuously differs from western country. Highest number of perforations noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. Most common cause of perforation peritonitis is perforated duodenal ulcer, followed by small bowel tuberculosis and typhoid perforation. Majority of the large bowel perforations are also tubercular. Malignant perforations are least common in our setup.