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Objectives: To assess learning styles and the association of various teaching methodologies of medical students. Methods: A cross-sectional study was carried out amongst 523 medical students of Baqai Medical College, Baqai Medical University, Karachi, from July 2019 to October 2019. All students from first to final year, who attended the undergraduate MBBS program were included. The study instrument was a questionnaire containing students’ demographic details, David Kolb’s Learning Style Inventory 4.0 and traditional and PBL teaching methodologies were asked. The association of various learning styles and preferred teaching methodologies with year of study was also assessed by using Pearson’s chi-square test. Results: Out of 523 students, 518 returned the completed questionnaire. A majority of the students had either imagining or experiencing learning style. No change in learning style was observed between years of study. A significant association between the teaching methodologies and year of study was found in the imagining (p=0.033) and experiencing (p=0.044) learning style groups. Conclusion: Students from different years of study at medical school did not have significantly different learning styles though the student’s preferences to teaching methodologies seem to change over time in the respective learning style groups. Longitudinal studies are necessary to identify the factors influencing such change and explore the association between learning styles over time on teaching methodologies in medical education. doi: https://doi.org/10.12669/pjms.37.1.2275 How to cite this:Hydrie MZI, Naqvi SMZH, Alam SN, Jafry SIA. Kolb’s Learning Style Inventory 4.0 and its association with traditional and problem based learning teaching methodologies in medical students. Pak J Med Sci. 2021;37(1):146-150. doi: https://doi.org/10.12669/pjms.37.1.2275 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Life-threatening hemobilia is a rare cause of gastrointestinal hemorrhage. Giant choledochal cyst is also a rarely reported diagnosis. Similarly, arteriocholedochal fistulas are also rarely reported and usually occur after invasive procedures for diagnosis or treatment of hepatopancreatobiliary-related disorders. In this report, the authors describe a case of a spontaneous arteriocholedochal fistula that occurred in a giant choledochal cyst and led to life-threatening hemobilia. The patient ultimately required a Whipple’s pancreatoduodenectomy for treatment, which is again rarely undertaken as an emergency procedure. We describe the management this patient underwent and discuss the reasons why we resorted to undertake such a formidable procedure for the patient as his treatment option.

Traumatic extrahepatic biliary tract injuries are rare occurrences because they are a relatively small target of injury following trauma. They are almost always associated with injuries to surrounding structures, which take precedence during initial management. The management of extrahepatic biliary tract injuries depends on the extent and level of the injury. This may include primary repair to high-level biliary-enteric anastomoses. We report a case of injury to the biliary confluence that occurred after blunt trauma abdomen. The injury was associated with an extensive liver injury that was the focus of initial treatment. We discuss the possible mechanisms that led to injury of this relatively hidden area and describe the various treatment options that can be applicable in such cases.

Efferent loop syndrome has been rarely reported after pancreatoduodenectomy. In those cases that have been reported, the majority presented late and recurrence or peritoneal metastases were found to be the usual causes. Foreign body giant cell reactions (FBGCR) also rarely develop into masses that are large enough to cause problems or mimic malignancy. This report presents a case of a middle-aged female who underwent completion extended cholecystectomy for carcinoma of the gallbladder. Whipple’s pancreatoduodenectomy was also performed at the same surgery due to presence of a hard mass at the cystic duct stump that was densely adherent to the common bile duct and duodenal cap. This was later found to be FBGCR. The patient underwent re-exploration just three weeks later for efferent loop syndrome, the cause of which was again found to be a mass due to FBGCR that was not previously present. Despite a difficult initial treatment phase, the patient is disease free and doing well after two and half years of completing treatment for the carcinoma gallbladder.

Necrotizing fasciitis (NF) is a rare entity with its subacute form being even rarer. The condition has also been described to occur in the peristomal area in relation to different clinical scenarios. However, it has not been described in the setting of adjuvant chemotherapy where these medications have already been given. While the diagnosis may be delayed or missed due to the subtle symptomatology of the indolent subacute form of NF, another reason for a delayed or missed diagnosis may be the excessive use of tape and the stoma belt around the stomal appliance to prolong the life of the appliance beyond its recommended days of usage due to economic constraints. This, in turn, covers a larger area around the peristomal skin and developing skin changes associated with necrotizing fasciitis. Despite the less aggressive presentation of the subacute form, it may still represent a unique surgical challenge in this setting, as the chemotherapy-induced neutropenia bound to occur a few days after the chemotherapy may expose the patient to serious complications at that time. As such, the surgical plan at the time of presentation may become the determinant of morbidity and mortality. Here, a case is presented of a young patient who underwent abdominoperineal resection for stage III adenocarcinoma of the rectum. He was referred to us on the day of the fourth cycle of adjuvant chemotherapy by the oncology service where he had received part of his chemotherapy regimen. On presentation, he was found to be having significant skin changes in the peristomal area consistent with necrotizing fasciitis despite being clinically stable. The authors present this unique case as a study from which many lessons can be learned. They also explain the thought process behind a well-planned but simple surgical strategy that was implemented with a successful patient outcome. In addition to describing this surgical strategy, the case report is concluded by highlighting some factors that may raise suspicion of this condition and by emphasizing routine history-taking for peristomal symptomatology and a thorough examination of the peristomal site prior to administration of chemotherapy in patients with stomata, as this condition, if overlooked, may lead to a fatal outcome.

To compare the length of hospital stay and return of bowel movement using the conventional management versus 'enhanced recovery after surgery' protocol.This study was conducted at the Civil Hospital, Karachi, from June 2014 to May 2015, and comprised patients undergoing stoma reversal. Patients were randomly allocated in two equal groups, i.e. A (treated with conventional peri-operative management) and B (with 'enhanced recovery after surgery' protocol). Prolonged ileus, wound infection and length of hospital stay between the two groups were compared. SPSS 20 was used for statistical analysis.There were 60 participants who were divided into two groups of 30(50%) each. Overall, 39(65%) patients were males and 21(35%) were females. The mean age was 27.80±9.99 years in group A and 23.87±4.56 years in group B. Besides, 25(83%) patients in group A had prolonged ileus compared to 3(10.7%) in group B (p=0.00). Moreover, 14(46.7%) patients in group A and 8(26.7%) patients in group B had wound infection (p=0.10). The mean duration of hospital stay was also less in group B compared to group A (p0.05).The application of 'enhanced recovery after surgery' protocol was found to be safe.

Iatrogenic duodenal injuries are rare complications of upper gastrointestinal endoscopic procedures, gallbladder, and right kidney operations. Management includes diverse options depending on a number of factors that include the size of the injury, timing of presentation, degree of peritoneal contamination, and presence of peritonitis and/or sepsis, etc. While most duodenal injuries are small, large complex non-reconstructable injuries may occasionally occur, requiring complex surgical procedures rather than primary repair which if done in the latter cases, may lead to further morbidity and mortality. Whipple’s pancreatoduodenectomy has rarely been performed for complex duodenal injuries especially in the iatrogenic setting. Here a case is reported of an iatrogenic duodenal injury that presented 12 days after a right open nephrectomy, with a dehisced right lumber incision having greater than one liter per day bilious discharge, for which Whipple’s pancreatoduodenectomy was performed. A discussion regarding factors which influenced per-operative decision making and probably led to a successful patient outcome is presented.

The study highlights the spectrum of abdominal TB in emergency surgery and its outcome. A proforma based prospective cross sectional study was conducted from March 2008 - March 2014, at the Department of General Surgery, Dow University of Health SciencesCivil Hospital Karachi, Pakistan. Total patients studied were hundred. Ninety percent patients presented through the emergency department. Mean age was 30 ± 7.29 years. Family history of TB was positive in 46 (46%) patients. Pulmonary TB was present in 22 (22%), and 52 (52%) - were already on Antitubercular Therapy-- Emergency exploratory laparotomy was performed in 85 (85%) patients with 61 (61%) having peritonitis. and 24 (24%) having acute intestinal obstruction. A total of 15 (15%) patients were kept on ATT under observation, Of these 7(7%) were diagnosed with Ileocaecal mass, 5 (5%) with enterocutaneous fistula, and 3(3%) had sub-acute intestinal obstruction. Ileum was the most common site for abdominal TB in 36(36%), followed by ileocaecal TB in 13 (13%) and jejunal TB in 12 (12%). Stoma and abdominal washout was the minimum procedure which was performed in 34 (34%) cases. Fourteen (14%) patients diagnosed with ileocaecal TB, received limited right hemi colectomy with two end stoma whereas 7(7%) patients were subjected to limited right hemi colectomy with primary anastomosis. Patients with multiple strictures and perforations were subjected to segmental resection with two end stoma. This was performed, in 12 (12%) cases and primary repair and anastomosis in 9 (9%). Only washouts and laparostomy was performed in 5 (5%) and adhenolysis in 4(4%) cases. Redo surgery was required in 44 (44%). The overall mortality was 18%. This study concludes that abdominal TB patients usually present late with complications in emergency surgery because of diagnostic delay, having a high morbidity and mortality.

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.

To aspirate breast abscess through a wide bore (14-gauge) intravenous (I/V) cannula and determine its efficacy in terms of the number of recurrences and number of aspirations.Case series.Dow University of Health Sciences and Civil Hospital and Bantva Hospital, Karachi, Pakistan, from January 2009 to December 2011.Patients with breast abscesses confirmed on ultrasound without skin ulceration were selected. The soft area of breast abscess with positive fluctuation was marked and fixed with index finger and thumb. A 14-gauge cannula was inserted. Pus was aspirated through a 50 cc syringe, repeated till no aspirate could be obtained. All patients were followed weekly for 4 weeks, clinically for size of lump, local tenderness and temperature, while complete resolution was confirmed on ultrasound, as resolution of the lesion.A total of 55 patients were included in this study. Mean age was 29 ± 5.58 years while ranging from 20 - 40 years. Complete resolution of abscess was seen in 31 (56.4%) cases by single aspiration. Second aspiration was required in 24 (43.6%) patients and third aspiration in single setting was required in one case only. Recurrence after the second aspiration occurred in 08 (14.5%). Incision drainage was required in 7 (12.7%) patients.Percutaneous aspiration of breast abscess through a wide bore (14-gauge) I/V cannula is a simple alternative to incision and drainage.

To assess the improvement in participant's knowledge and skills pertaining to medical writing by interactive hands-on workshops.During the course of three months (January to March 2009), four interactive 5 hours hands-on workshops were organized on Medical Writing. All participants completed a pre-workshop and post-workshop questionnaire. Fourteen questions were included in both questionnaires related to workshop outline. Eight questions were related to knowledge of the participants about different aspects of medical writing (yes/no). Participants were also asked six questions to rate their skills relating to medical writing on a numerical scale of 1-5 (1: no skills and 5: expert). Participant's feedbacks were also analyzed. The pre-workshop and post-workshop responses were compared to see if there was any significant difference by using McNemar test and paired-t test where appropriate.Response to eight questions regarding knowledge (authorship criteria, types of data, application of significance test, search techniques, plagiarism, Vancouver style of reference and copyright statement) showed that there was a significant difference in all responses (p0.005). Same trend was observed in skills rating (literature search, basic data analysis, writing an original article, writing references, paper submission for publication) of participants themselves before and after the workshop (p0.0001). Analysis of feedback showed that participants found the workshop informative, practical and helpful in improvement of their skills for paper writing.Short interactive hands-on medical writing workshops are helpful and beneficial in improving the knowledge and skills of the participants.