Mini-cex: an assessment tool for observed evaluation of medical postgraduate residents during their training program: an overview and recommendations for its implementation in cpsp residency program

The mini-CEX is a workplace-based assessment to assess professional performance of medical trainees. Proper reporting of the gap between desired and observed performance forms the basis and the incentive for the trainees to improve their skills. It plays a key role by combining learning with assessment There is an urgent need for including this form of assessment in our clinical training programs especially postgraduate residents training

Cardiac arrest in intensive care unit: case report and future recommendations

Initiation of hemofiltration in a patient in septic shock can cause hemodynamic compromise potentially leading to cardiac arrest. We propose that the standard '4Hs and 4Ts' approach to the differential diagnosis of a cardiac arrest should be supplemented in critically ill patients with anaphylaxis and human and technical errors involving drug administration [the 5th H and T]. To illustrate the point, we report a case where norepinephrine infused through a central venous catheter [CVC] was being removed by the central venovenous hemofiltration [CVH] catheter causing the hemodynamic instability. CVVH has this potential of interfering with the systemic availability of drugs infused via a closely located CVC

Vesico vaginal fistula after interval debulking in epithelial ovarian cancer

Mrs. S.E, 45 years of age was diagnosed as a case of ovarian carcinoma and had interval debulking, following which she developed vesico-vaginal fistula. Continuous bladder drainage was done for 6 weeks and she was given post operative chemotherapy with cisplatin and gemcitabine. On her 6 weeks postoperative examination, the fistula had healed completely. She is receiving her chemotherapy cycles and is in satisfactory condition

Pretherapy gallium-67 scanning in paediatric patients with Hodgkin's disease

To investigate the correlation between gallium-67 [67Ga] uptake and histological subtypes of Hodgkin's disease [HD] in paediatric patients. Subjects and Fifty-eight patients [45 males and 13 females aged 9.2 +/- 4 years, range 1.5-17 years] with histologically diagnosed HD underwent pretherapy 67Ga scanning on days 2, 5, 12 or 14 days after intravenous administration of 25-50 MBq [0.7-1.4 mCi] of 67Ga citrate. The scans were evaluated both visually and quantitatively using the activity of 67Ga in the liver as a reference. Clinical outcome of 11 patients with high diffuse 67Ga skeletal uptake was compared with that of 17 patients showing normal distribution of 67Ga in the skeleton. Of the 58 patients, the 67Ga scans were positive in 47 patients with 117 lesions. Visual analysis did not differentiate between the histological variants of HD. However, quantitative analysis of lesion-to-liver ratios showed significantly higher values of 67Ga uptake in the mixed cellularity type than in the nodular sclerosis type [t = -3.7, p < 0.001]. Patients with high skeletal uptake had a higher relapse rate [6/11] than those with normal skeletal uptake [3/17]. The findings show that quantitative analysis of 67Ga uptake can differentiate between the two main subtypes of HD [mixed cellularity and nodular sclerosis]. Further diffuse skeletal uptake of 67Ga indicates a higher relapse rate

ESWL monotherapy of renal calculi

To study efficacy of extracorporeal shock wave lithotripsy [ESWL] monotherapy for renal calculi. Three hundred patients with renal stones less than 3.5 cm in diameter were selected. All were treated in supine position. Dornier HM4 machine was used for the study. JJ stent was placed in cases with complex and larger than 2.5cm size stones. Pregnant women and patients with pacemaker were excluded from the study. ESWL monotherapy was performed on three hundred patients and three hundred sixteen renal units between Jan. 98 and Dec. 98. Almost 50% of the stones were larger than 2 cm. Post ESWL complications were seen in 49 [16.2%] of the cases. Overall success rate of ESWL was 98.8%. Extracorporeal shock wave lithotripsy is a preferable treatment option for small and medium sized stones. Prophylactic JJ stenting helped in treating patients from far off areas. Complex renal calculi with low stone bulk could be treated with lithotripsy with JJ stent in situ

Methods of ureteric stent placement and removal: experience with 200 patients

Objective To study the advantages of ureteric stents in management of ureteric obstruction, injury or surgery. Methods Ureteric stents were inserted in 200 patients by endoscopic, percutaneous or open operation approach. Local anaesthesia, sedoanalgesia and general anaesthesia was used according to requirement of the patient. Removal of the stens was also endoscopic or in complicated cases by exploration. Results Ureteric stents were placed endoscopically in 190, by open operation in 6 and percutaneous approach in 4 cases. Conclusion Ureteral stent for managing ureteral injury is a safe and simple procedure in modern urology practice. Local anaesthesia was used in 143, analgesia in 31 and general anaesthesia in 26 patients. Endoscopic removal of stents was possible in 177 cases whereas 23 patients had to undergo open surgery due to fractured or upward migrated stents. Local anaesthesia was used in 150 analgesia in 21 and general anaesthesia in 29 cases

Thyroid hormone levels in hepatitis B

Thyroid hormone levels were estimated in fifty patients with hepatitis B. In acute phase, T[3] was raised in 10% and T[4] in 60%. This rise was directly proportional to the transaminases levels. Twenty cases were also studied in the recovery phase where thyroid hormones returned to within normal limits. This rise of T[3] and T[4] in acute phase is attributed to increased thyroxin binding capacity due to release of thyroid binding globulin into circulation from necrosing hepatocytes

Economy and quality assessment of home made clinical chemistry reagents

Most laboratories in Pakistan use expensive imported clinical chemistry reagent kits resulting in high cost/test to the patients. To reduce these costs, reagents were prepared from basic chemicals, substrates and enzymes imported from Sigma Chemical Company U.K. This reduced the cost/test by upto 500% in some reagents. The quality of these reagents was tested by Wellcome External, Q.C. Locally prepared reagents were comparable to or better than commercial reagents systems in terms of accuracy and precision. This paper describes the preparations according to I.F.C.C., costs and quality control of some of the reagents i.e., glucose, calcium, bilirubin, albumin, total protein, urea, ALT, AST and LDH and their comparisons with equivalent commercial kits

Pattern of leukocyte acid phosphatase reaction in T-cell lymphoblastic leukemia

Acid phosphatase [AP] reaction is a specific cytochemical marker for T-cell lymphoblastic leukaemia [T-ALL]. Twenty six cases of ALL were diagnosed as T-ALL employing cytochemical profiles including AP and sheep red blood cell rosettes. Three distinct patterns of AP reaction were observed. On one end of the spectrum, 100% of the positive blasts showed the classical dot- like reaction while on the other 100% showed a scattered reaction. Between the two a mixed pattern was observed with 30- 80% of the positive blasts showing the dot-like reaction while the rest showed scattered pattern. Dot-like pattern showed L[1] morphology, high counts and low SRBC rosettes while scattered showed L[2] morphology, low counts and high SRBC rosettes. The pattern observed in our series differs from the dot-like reaction observed in T-ALL in the western series. We recommend that this pattern must be borne in mind when employing AP reaction for T- ALL diagnosis

Multiparameter studies in t-cell acute lymphoblastic leukemia [T-all] in Karachi children

T-ALL is known to be associated with bad prognosis within ALL. Morphology of the ten cases studied showed L2 70% while L1 was 30% indicating the more malignant nature of the disease. Haematological blood parameters showed high haemoglobin and platelets and low numbers of blasts in the marrow indicating better preservation of the marrow and suggesting non-marrow origin of the disease. Acid phosphatase reaction was positive in majority of the blasts. P.A.S. stain was negative in majority of the cases while myeloperoxidase and alpha-napthyl esterase was negative. Sheep red blood cells rosettes were negative in a few cases suggesting that surface marker develop at a later stage than cytochemical enzymes since acid phosphatase was positive in all cases. This study shows continental variation of T-ALL since we report low presentation counts and high frequency of L2 in T-ALL. This further explains the more malignant nature of the disease and explain the poor prognosis of ALL in Karachi Children

Quality assessment of the reflotron system: a blood chemistry reagent strip analyser

We tested the accuracy of the Reflotron System by comparing results given by this system for estimations of glucose, SGOT, SGPT, cholesterol and triglycerides on patients samples which were already analysed on either an autoanalyser HITACHI 705 or manually on CLINICON 4010. Reflotron estimations correlated well with both Hitachi and Clinic on estimations and the strips gave reproducible results. We conclude that this or similar systems will be ideal for small laboratories in our expanding rural health services

Efficacy of internal and external quality control in chemical pathology

Quality control in chemical pathology is based on internal and external quality assessment. The internal quality control in clinical chemistry section of AKUH laboratory is based on the analysis of commercially available Beckman normal and abnormal range control sera. These have known concentrations of blood chemistry constituents. After repeated estimations, mean values of all constituents were established for both normal and abnormal sera. Patients samples were analysed only when both controls were within +/- 2SD from the mean or one control reads within +/- 2SD and the other read between +/- 2-3SD [once only] for each constituent. Samples were not analysed if one control was greater than +/- 35D from the mean or both controls were greater than +/- 2SD or one control was between +/- 2-3 SD on two successive runs. External quality control sera with unknown constituent concentrations were analysed twice monthly and results sent to Wellcome England. Our results were compared with the mean of estimations by 1000 laboratories for each constituent. The acceptable standard deviation from this mean for each constituent was +/- 2SD. External quality control evaluated our accuracy in wide ranges of constituent concentrations encountered and helped us identify under or over reporting of different parameters, both substrates and enzymes, at high or low levels or vice versa which internal quality control could not address. Hence external quality control formed the basis of our corrective actions in terms of equipment and reagents. We conclude that internal quality control is limited in the sense that its efficacy has to be tested by external quality assessment

Acid phosphatase positive Tlymphoblastic leukaemia [T-ALL] in Pakistani children

T-Lymphoblastic leukaemia [T-ALL] appears to be associated with factors known to be of bad prognosis in Acute lymphocytic leukaemia [ALL]. Acid phosphatase reaction [AP], a specific non-immunological cytochemical marker for T-ALL was performed on peripheral blood and bone marrow slides of fifty children with ALL to assess the frequency of T-ALL in our population. Myeloperoxidase [P] and Alpha-Napthyl Esterase [NASA] were performed to exclude Acute myelocytic and Monoblastic leukaemia. A strong localised AP reaction in more than fifty percent of the blasts was taken as positive for T-ALL. Of the fifty cases studied 32% showed strong AP positivity in majority of the cells. These were negative for both P and NASA and showed varied Periodic Acid Schiff [P.A.S.] positivity. This high frequency of T-ALL in our series may explain the poor response to therapy and high relapse rates observed in our population