Kulsoom Ghias

Colorectal cancer carcinogenesis：a review of mechanisms

Colorectal cancer (CRC) is the second most common cancer in women and the third most common in men globally. CRC arises from one or a combination of chromosomal instability, CpG island methylator phenotype, and microsatellite instability. Genetic instability is usually caused by aneuploidy and loss of heterozygosity. Mutations in the tumor suppressor or cell cycle genes may also lead to cellular transformation. Similarly, epigenetic and/or genetic alterations resulting in impaired cellular pathways, such as DNA repair mechanism, may lead to microsatellite instability and mutator phenotype. Non-coding RNAs, more importantly microRNAs and long non-coding RNAs have also been implicated at various CRC stages. Understanding the specific mechanisms of tumorigenesis and the underlying genetic and epigenetic traits is critical in comprehending the disease phenotype. This paper reviews these mechanisms along with the roles of various non-coding RNAs in CRCs.

Self-reported attitudes and behaviours of medical students in Pakistan regarding academic misconduct: a cross-sectional study

BackgroundHonesty and integrity are key attributes of an ethically competent physician. However, academic misconduct, which includes but is not limited to plagiarism, cheating, and falsifying documentation, is common in medical colleges across the world. The purpose of this study is to describe differences in the self-reported attitudes and behaviours of medical students regarding academic misconduct depending on gender, year of study and type of medical institution in Pakistan.MethodsA cross sectional study was conducted with medical students from one private and one public sector medical college. A pre-coded questionnaire about attitudes and behaviours regarding plagiarism, lying, cheating and falsifying documentation was completed anonymously by the students.ResultsA total of 465 medical students filled the questionnaire. 53% of private medical college students reported that they recognize copying an assignment verbatim and listing sources as references as wrong compared to 35% of public medical college students. 26% of private medical college students self-report this behaviour as compared to 42% of public medical college students. 22% of private versus 15% of public medical college students and 21% of students in clinical years compared to 17% in basic science years admit to submitting a fake medical certificate to justify an absence. 87% of students at a private medical college believe that cheating in an examination is wrong as compared to 66% of public medical college students and 24% self-report this behaviour in the former group as compared to 41% in the latter. 63% of clinical year students identify cheating as wrong compared to 89% of their junior colleagues. 71% of male versus 84% of female respondents believe that cheating is wrong and 42% of males compared to 23% of females admit to cheating.ConclusionsThere are significant differences in medical students’ attitudes and behaviours towards plagiarism, lying, cheating and stealing by gender, seniority status and type of institution. The ability to identify acts of academic misconduct does not deter students from engaging in the behaviour themselves, as evidenced by self-reporting.

Guarding the guardians: Bioethics curricula for psychiatrists-in-training in developing countries.

A good physician must be both clinically and ethically competent. High ethical standards are especially important in psychiatry in which several unique challenges present due to a vulnerable patient population, intimate physician–patient relationships, diagnoses made on signs and symptoms rather than irrefutable laboratory investigations, and therapeutic options directed at altering thinking and behaviour. It is critical that psychiatric training equip practitioners with the ability to identify ethical dilemmas in clinical practice and research and respond appropriately. Despite a call to action and the development of guidelines for ethical practice by several regulatory bodies, formal ethics teaching in psychiatry training programmes is still in embryonic stages in the developed world and virtually non-existent in the developing world. Here we highlight the current status of bioethics teaching in psychiatry residency programmes in Pakistan, an example of a developing country where such training is vital, as unethical practices abound in resource-poor settings where clinical and research practices are non-transparent and there are no effective regulatory, legal and accountability bodies. It is critical and urgent that needs-responsive bioethics curricula are developed, institutionalized and implemented in medical schools and post-graduate training programs across the developing world. “Take-home” points • Bioethics teaching should be a key, assessed component of all psychiatric training programmes • Bioethics curricula should be culturally contextual, responsive to stakeholder needs and geared towards preparing psychiatrists for ethical clinical practice and research, bioethics teaching and institutional leadership Future directions • Comprehensive needs assessment studies should be conducted to document current bioethics-related knowledge and attitudes in psychiatry training programmes in developing countries • Development, institutionalization and dissemination of needs-responsive bioethics curricula for psychiatry programmes in developing countries

Video or paper for delivery of problem‐based learning cases?

What problem was addressed? Problem-based learning (PBL) is one of the pedagogical approaches utilised in the Aga Khan University Medical College. In Years 1 and 2, students derive learning objectives related to anatomy, biochemistry, community health sciences, ethics, microbiology, pathology, pharmacology and physiology from clinical scenarios presented as text-based paper PBL cases. As informal feedback by students and formal case evaluations revealed a decline in student interest in the paper-based PBL cases, we piloted a change in delivery strategy by introducing video PBL cases, the premise being that the students, as digital natives, may engage more with video cases, which might also enhance the student-centred learning process. What was tried? All first-year undergraduate medical students and their PBL facilitators consented to participate in this Ethical Review Committeeapproved study during the introductory module. One hundred students were randomly divided into groups of 9–10 students each for PBL sessions and each group was facilitated throughout the study by an experienced faculty member. Four PBL cases were used; two were introduced using the traditional paper format and two were presented as video cases, each of 5–10 minutes’ duration using simulated patients or amateur actors. Students and facilitators were asked to complete a brief structured questionnaire after each PBL case using: (i) a 7point Likert scale to query whether the case was engaging, interesting, appropriate, relevant; (ii) open-ended questions asking respondents to comment on their perceptions regarding the effectiveness or ineffectiveness of the PBL delivery method. Data were entered and analysed using SPSS v19.0 (SPSS, Inc. Chicago, IL, USA). Proportions and means were calculated and Student’s t-test was applied to compare the difference in student and facilitator preference of video versus paper cases. Statistical significance was defined as p ≤ 0.05. What lessons were learned? In total, 392 studentcompleted (98% response rate) and 42 facilitatorcompleted (95% response rate) questionnaires on four cases were evaluated. Students found paper cases more effective compared with video cases (p = 0.001). More than 90% of students found paper cases interesting, engaging and helpful in enhancing the group discussion, dynamics and communication skills compared with video (p = 0.0001). Ninety-three per cent found triggers in paper cases more appropriate to derive learning objectives and helpful in improving their thinking process compared with video cases (p = 0.0001). Facilitators found no significant difference between the effectiveness of the two approaches (p = 0.19). Facilitators found video more interesting (p = 0.031) as compared with students as a delivery method in PBL. However, facilitators found no difference between the two delivery methods in enhancing the group discussion, dynamics and communication skills (p = 0.49). In light of student and facilitator responses and the development cost of video cases, we recommend that videos be utilised selectively for problems that provide observable cues for deriving learning objectives. Utilisation otherwise may prove more detrimental and unnecessarily costly than beneficial. Video cases should be introduced once students have become accustomed to the PBL approach using more traditional case delivery methods, such as paper cases, rather than at the point of entry into medical school.

How we developed a bioethics theme in an undergraduate medical curriculum

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Exposure assessment of lead from food and airborne dusts and biomonitoring in pregnant mothers, their fetus and siblings in Karachi, Pakistan and Shimotsuke, Japan.

Abstract Aim: Exposure assessment of lead (Pb) and Arsenic (As) from food, water, and house dust intake were assessed among pregnant women, their children and fetuses in Pakistan and Japan, as well as their body burden of the metals in their blood. Method: Fifty families which included a pregnant woman, a fetus and the 1–3-year-old siblings were recruited in Karachi and Khairpur in Pakistan, and Shimotsuke and Asahikawa in Japan, respectively. Their dietary exposure to Pb and As was measured in 3-day food duplicates and drinking water by ICP-MP. Pb in house dust and respirable dust was evaluated with an energy dispersive X-ray fluorescence spectrometry. Non-radioactive isotope Pb profiles of blood specimens will be compared with those of the exposure origins, such as food duplicates, respirable house dust, the soils nearby, and gasoline. Results: Judging from the data collected and analyzed so far, contribution from dietary intake is highly correlated to higher body burden of Pb among Pakistani mothers. Additional data analyses will reveal the status of Pb and As body burden in Pakistani mothers, fetuses and their siblings, and causal sources of high body burden is delineated by Pb isotope profile analysis of different sources of Pb exposure.

Stretching the boundaries of medical education: A case of medical college embracing humanities and social sciences in medical education

Objective: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. Methods: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. Results: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. Conclusions: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians.

Research as a Pedagogical Approach in Undergraduate Medical Education: An Experience

The importance of health research training in medical education has been well-documented in the literature and is fully recognized at Aga Khan University Medical College (AKUMC). The goals and attributes of undergraduate medical education (UGME) at AKUMC emphasize the ability to become critical thinkers and conduct basic science research. In the UGME curriculum, research is a longitudinal theme throughout the five year program. AKUMC is one of few medical schools to have a designated research-based community health sciences (CHS) course in Year 4. However, to instill this capacity and interest in undergraduate students and to further systemize research training, a four week dedicated Introduction to Research module was recently introduced in Year 2. The aim of this innovative module was to give students the intellectual tools to investigate new problems and evaluate data critically, rather than solve the problem entirely. In keeping with the spiral nature of the curriculum, this module laid the foundation for research skills that are further expanded and utilized in a Year 4 CHS rotation. The Year 2 Research module is a curricular innovation that encourages analytical and creative thinking and promotes a research culture among students. It is a valuable addition to the undergraduate medical curriculum and along with the Year 4 CHS rotation, it serves to enhance knowledge, skills and attitudes that are now necessary for medical graduates.

Flipping the classroom: training the flippers

are taught through reflection-based exercises during virtual and classroom-based learning. A robust departmental faculty development exercise was conducted for curriculum development, active teaching and learning, VL master training and the use of the flipped classroom. What lessons were learned? A majority of students (78.6%) reported that they found the blended curriculum more engaging both during and between classes. They provided positive feedback on both the curricular elements and the use of VLE. One challenge was that faculty members found it hard to change their T/L roles from the traditional expert-led teaching culture; they were not comfortable using Moodle and had limited engagement with VL. Faculty members’ comfort was increased by a non-clinical VL team who provided supervision and facilitation. Another challenge identified by the core team was aligning outcomebased formative assessment to the institution-based summative assessment system. Overall, the use of VL was helpful in creating an integrated and blended curriculum for a medical student psychiatry clerkship. This comprehensive curriculum can be offered to other Pakistani medical colleges in the future that face challenges of limited faculty members with minimal VL expertise, as long as it is accompanied by faculty development in T/L methods.

Viral etiology of prostate cancer: Genetic alterations and immune response. A literature review

Prostate cancer is one of the most common cancers in men. Recent estimates suggest that over a million men are diagnosed with the disease annually. Prostate cancer pathogenesis involves both heritable and environmental factors. The molecular events involved in the development or progression of prostate cancer are still unclear. Recent body of literature highlights the role of viral infections in initiation or progression of prostate cancer. In this regard, certain viruses have been reported to interact with host proteins and bring about changes in genetic, immunological and inflammatory events that lead to initiation or progression of prostate cancer. We conducted a comprehensive PubMed database search to identify publications relevant to viruses associated with prostate cancer. In this review, we discuss the possible viral etiology of prostate cancer and evidence of viral-mediated genetic changes, and immune dysregulation involved in initiation or progression of prostate cancer.