Case based learning and traditional teaching strategies: where lies the future?

To explore the perceptions of final year medical students about efficacy of traditional teaching methods and Case based learning [CBL] and to evaluate the effect of CBL on students' performance and satisfaction level during their clinical rotation in Obstetrics and Gynaecology Department. Sequential mixed method study. Department of Obstetrics and Gynaecology, Holy Family Hospital, Rawalpindi from January 2013 to June 2013. Students expressed their perceptions on a Likert scale in a questionnaire. It was triangulated with data collected from 4 focus group discussions [FGD]. Students for FGD were selected using purposive sampling. Students' performance in OSPE and long case was compared with another group who was taught with traditional methods. Quantitative data was analyzed by SPSS version 17. For qualitative data, themes and patterns were identified using content analysis technique. Of 141 students, 134 returned completed forms giving a response rate of 95%.Gender distribution was similar in both the groups. There was no statistically sigruficant difference in performance assessment. Strong preference for CBL was expressed by 97% as it improved their confidence [83%], clinical and presentation skills [91and 80%], attitude and student teacher relationship [68 and 77%], strengthened link between theory and practice [90%], and integrated basic and clinical knowledge [92%]. Seventy six percent stated that all teaching should be CBL. Qualitative data from SGD strongly supported these views. Although test performance was similar in both the groups, students expressed strong preference for CBL as compared to traditional methods

Seroprevalence of syphilis in patients attending a tertiary care hospital in Southern India

Objective: To report our experience with two tests, anti-cardiolipin antibody test [venereal disease reasearch laboratory (VDRL) test] and specific treponemal test (Treponema pallidum hemagglutination assay), used for screening antenatal, high risk cases and cases from sexually transmitted infection in a tertiary care hospital from January 2006 till December 2008. Methods: A total of 14 639 samples received from various patient groups including antenatal cases, patients attending sexually transmitted disease (STD) clinic, blood donors and HIV positive patients were screened. Results: Among the 14 639 samples collected, 103 were positive by VDRL test. Of these 89 cases were confirmed by quantitative VDRL test and Treponema pallidum hemagglutination assay. The cumulative seroprevalence over two years was found to be 0.61% in this study. The syphilis seroprevalence reduced from 0.88% in 2006 to 0.40% in 2008. Among the various sub-populations studied, patients attending the sexually transmitted infection clinic showed a seroprevalence of 2.62%. The seroprevalence decreased significantly from 4.00% in 2006 to 1.39% in 2008. Conclusions: Our study showed a statistically significant declining rate of syphilis in STD clinics as well as the overall seroprevalence. These findings could be interpreted as indicators of improved programmes for prevention and management of STDs.

Genetic polymorphism of agr Locus and antibiotic resistance of Staphylococcus aureus at two hospitals in Pakistan

The accessory gene regulator [agr] locus in Staphylococcus aureus [S. aureus] is a global regulator of quorum sensing and controls the production of virulence factors. This study was carried out to investigate the agr specific groups both in methicillin resistant and sensitive Staphylococcus aureus [MRSA and MSSA] and their relation with antibiotic resistance. A total of 90 clinical S. aureus isolates were studied from two tertiary care hospitals. The isolates were identified by standard biochemical tests. Methicillin resistance was confirmed by oxacillin and cefoxitin resistance. Multiplex PCR was used to determine the agr groups. MRSA prevalence was found to be 53.3%.The agr groups' distribution in MRSA was as follows: 22 [45.8%] belonged to group I, 14 [29.1%] belonged to group III and 2 [4.1%] belonged to group II. agrIV was not detected in MRSA. For 17 isolates, the agr group was not detected.agr III isolates showed higher antibiotic resistance than agrI isolates except in case of oxacillin and linezolid. Strict infection control policy and antibiotic guidelines should be adopted to control the problem of MRSA. Higher prevalence of agr I and agr III shows that they are dominant agr groups of our area

Misoprostol toxicity

Misoprostol is a synthetic prostaglandin E1 analogue, commonly used for the medical termination of pregnancy in the first trimester. We present a case of a 29-year-old woman who was admitted due to misoprostol overdose, for a self induced abortion followed by a second overdose for a suicidal attempt. Manifestations of toxicity included agitation, high-grade fever, abdominal pain, diarrhea and minimal pervaginal bleeding. She was managed by a multidisciplinary team involving Medical, Psychiatric and Gynaecological doctors. Treatment was supportive and included gastric lavage, administration of intravenous fluids, anti-pyretics and analgesics. The pregnancy and fetal viability was followed on serial beta hCG levels and ultrasound scan respectively, and required surgical management of miscarriage. Patient was discharged in satisfactory physical condition

Fatal Delftia acidovorans infection in an immunocompetent patient with empyema

Delftia acidovorans (earlier known as Comamonas acidovorans) is an aerobic, non-fermentative, Gram negative rod, classified in the Pseudomonas rRNA homology Group III. Reports of isolation of the organism from serious infections like central venous catheter associated bacteremia, corneal ulcers, otitis media exist. The microbiologists can identify this organism based on an orange indole reaction. This reaction demonstrates the organism's ability to produce anthranilic acid from tryptophan on addition of Kovac's reagent; which gives the media its characteristic "pumpkin orange" colour. Here we report the isolation of this organism from the Endotracheal tube aspirate of a 4 year old child. With the increasing use of invasive devices, it has become important to recognize these non fermentative gram negative bacilli as emerging source of infection even in immunocompetent individuals.

Spontaneous bilateral tubal pregnancy

With the increase in incidence of ectopic pregnancy over the decades, bilateral ectopic pregnancy is also increasing. It is usually associated with assisted reproductive techniques [ART] but in recent years few cases of spontaneous bilateral ectopic pregnancy have been reported. Gynaecologists should be aware of this and that ultrasonography has limitations in diagnosis. In cases of ectopic pregnancy where contralateral adnexa is not clearly identified on ultrasound and fertility needs to be conserved, patient should be managed by experts in well equipped centres. A case of spontaneous bilateral tubal pregnancy that remained undiagnosed till laparotomy, is described

analysis of critically ill obstetric patients admitted to intensive care unit of a tertiary care centre

To review the demographic characteristics, indications for admission and interventions done in the intensive care unit for critically ill cases as well as the outcome of these patients. Prospective, observational and descriptive study. Intensive care unit of Benazir Bhutto Hospital, Rawalpindi. Duration was from January 2009 - December 2009. All the obstetric patients admitted to the intensive care unit from January 2009 - December 2009 were included. Data was collected on a specially designed form after taking informed valid consent from family members of critically ill patients. The relevant data regarding demographic features, indications for admission, intervention done and pregnancy outcome was recorded. Statistical analysis was done using SPSS software. Thirty seven obstetric patients [mean age, 32 years; mean gestational age, 32 weeks] were analysed. The most common cause of obstetric admissions was haemorrhage [n=14, 38%] and postpartum haemorrhage [n=7,19%] being the commonest among this group. After haemorrhage comes pregnancy associated hypertensive disorders [n=6, 16%] and sepsis [n=6,16%]. The commonest non-obstetric reason for admission was cardiac disease [n=5,13.5%]. Ventilatory support was required in 30% [n=11]. In 48.5% of the patients monitoring was done using central venous pressure line. lonotropic support was given to 38% of the patients. 88% patients received more than 2 blood transfusions. Haemorrhage especially the postpartum haemorrhage was the most common cause of admissions to the intensive care unit followed by preeclampsia/eclamsia and sepsis. Most of the maternal deaths are preventable but need appropriate antenatal care, availability and access to comprehensive obstetric care along with overall improvement in socio-economic conditions and literacy rate of the society

Serum vitamin D deficiency, a new epidemic

Vitamin D deficiency has profound adverse effects on health. Serum calcium, phosphorus and even alkaline phasphatase cannot predict underlying vitamin D deficiency. 1. To determine the frequency of vitamin D deficiency in outpatient private clinic 2. To determine the relation of vitamin D deficiency with the presenting symptom of bone or body aches. To see the relation of its deficiency to the serum calcium, alkaline phosphate and phosphate levels. Descriptive study. One of the local private clinic. 800 patients who presented to the clinic due to any ailment, having presenting complains with bone or body aches or not, were included in this study. The duration of study was 7 months from June to December 2008. The study showed among total 33% [n=264] were male and 67% [n=536] were female. 33 patients [4.1%] were below age of 20 years, 364 patients [45.2%] were having age between 20-40 years, 252 [31 .5%] were between 41 -60 years, 1 43 [1 7.8%] were between 61 -80 years and only 8 patients [1%] were above 80years. Over all vitamin D present in sufficient amount [>30 ng/ml] in only 4 patients [0.5%], reaming patients [n=796, 99.5%] were deficient in vitamin D were further divided into those who were having deficiency [serum level <20 ng/ml] [n=636, 79%] and insufficiency [serum level between 21-29 ng/ml] [n=160, 20%]. All the deficient patients were having normal serum calcium and phosphate levels and only 33 patients were having modestly raised serum alkaline phosphate. Among the sample only 318 [39.7%] were having bone or body aches as a presenting feature while remaining 482 [60.3%] were having no pains. More ever pain has got insignificant relation to any level of serum vitamin D level [p-value=0.201], however younger deficient patients were having lesser chance of bone or body aches as compared to age more then 60 year [p-value<0.001]. Vitamin D deficiency is more prevalent in our community, as compared to published data, targeting young population. Vitamin D supplementation should be planned to decrease its varied and multidimensional ill effects on health

Effect of vitamin d replacement in patients of fibromyalgia

Fibromyalgia is a common condition characterized by long-term, body-wide pain and tender points in joints, muscles, tendons, and other soft tissues. It is a chronic pain disorder that is difficult to treat. Recently Vitamin D has shown promising impact in the treatment of this disorder. To see the therapeutic role of vitamin D replacement in patients of fibromyalgia. Prospective study. Multicentre, Three private clinics. Out of 223 patients presenting with body aches and pains over the course of six months [January to June 2008], 100 patients [96 females and 4 males] between 20 to 50 years of age fulfilled the American College of Rheumatology [ACR] criteria of fibromyalgia and were included in the study. Using standard proforma, frequency of complaints other than ACR criteria were also documented.All of them were on some form of pain medication by various general practitioners/ consultants for more than three months but their symptoms were persistent. After informed consent, their serum vitamin D3 [25OHD3] level was requested as the cost of investigation was to bear by patients themselves. Patients were then replaced with vitamin D with an expected target of > 50 ng/ml and followed for 6 months duration. Supplementation with calcium in a dose of 1000mg/day was also done. In this study 83% of patients were having vitamin D between 11-20 ng/ml[mean =13 +/- 2], 11% between 5-10 ng/ml [mean=7 +/- 1] and 6% were below 5ng/ml [table-2]. There were four male patients, all [100%] with age distribution of 41-50 year and all were deficient in vitamin D [<20ng/ml]. Among 96 female patients 80[76.8%] were having level between 11-20 ng/ml, 10 [9.6%] between 5- 10ng/ml and 6 [5.7%] were below 5 ng/ml. After replacement with vitamin D achieving expected target serum levels >50ng/ml. Improvement in ACR criteria of fibromyalgia syndrome consisting of widespread musculoskeletal pains and 11 out 18 tender points was improved in more than 76% of the patients. Improvement in the associated conditions was also observed e.g. restless legs in 91.3% chronic fatigue in 97.6%. Similarly 85% reported relief from muscle spasm and 65% from tingling. There was also improvement in neuropsychiatric conditions like depression 71%] and anxiety 46.8%. Moreover, improvement in cognitive function like concentration and forgetfulness was also reported by 69.8% and 67.7% respectively [Table-4]

Diabetes mellitus; prevalence of high blood cholesterol, obesity, smoking and physical activity in urban population of Faisalabad

To estimate the prevalence of diabetes high total cholesterol obesity smoking and physical activity in urban population of Faisalabad. The project was limited to population based screening for above mentioned variables using WHO criteria. Study was conducted by holding numerous screening camps in different urban areas over the course of two years. People age 20 years or above were included in the study. Total 5349 people, 58% males [3102] and 42% females [2247] were screened for diabetes and high blood cholesterol. Body mass index was calculated by measuring height in meter square and weight in kilograms. People were interviewed for smoking and physical activity and relevant data was entered in the designed proforma. Within the chosen age range, total prevalence of diabetes was 16% and among them 11% were previously diagnosed and 5% were unaware of their diabetes [newly diagnosed]. Cholesterol was high [>/= 200 mg/dl] in 48% males and 34% females. 9.2% of the males were found to be obese [BMI>30] in comparison to 14.3% of females whereas 36.26% of males and 36.84% of females were overweight [BMI >/= 25 to 29.9 kg/m[2]]. The prevalence of smoking was 38.8% in males and 1.2% in females respectively. In daily routines only 6.8% of the males were doing the physical exercise [30 minutes exercise five days a week or equivalent] whereas among females it was 1.9%. Diabetes and metabolic syndrome in adults is now a global health problem, and the population of developing countries like Pakistan are facing this menace especially in the urban areas where it is on the rise with each passing day

Maternal mortality; an analysis of the determinants and causes

The women residing in a developing country have 200 times greater risk of suffering from pregnancy and childbirth related mortality compared with the women of a developed country. To investigate relevant causes and the determinants of maternal mortality through conducting scientific clinical studies. We conducted a prospective study of maternal deaths in the obstetrics and gynaecology unit of RGH for one year. January 2007 to December 2007. We investigated the socio-demographic variables-- including age, parity, socio-economic status and literacy-- along with the social behavior towards the antenatal. We designed standardized data collecting forms to collect data from the confidential hospital notes of the patients. The collected medical data of the patients proved useful in analyzing the underlying causes and the risk factors behind direct and indirect maternal mortalities. In our unit, we have recorded 28 maternal deaths during the study period. 24 [86%] deaths are due to the direct causes and 4 [14%] are due to the indirect causes. The leading direct causes are hemorrhage 9 [37.5%], eclampsia 7 [29%], septicemia 5 [21%] and anaesthesia complications 2 [8%]. Similarly, the distribution of indirect causes is: blood transfusion reactions 2 [50%], hepatic failure 2 [50%], Consequently, crude maternal mortality rate can be extrapolated at 645 per 100,000 maternities and maternal mortality ratio at 659 per 100,000 live births. The socio demographics of the dead mothers are: 16 [57%] patients in the age group of 25-35 years, 13 [52%] are multiparas [G2-G4] and 10 [36%] are grandmulti para i.e. G5 and above. Moreover, 13 [46%] of them expired at term. The majority of them is illiterate and belongs to lower socio-economic group. 14 [42%] mothers have not received antenatal care and just 4 [15%] of them have received antenatal care from RGH or other hospital. 23 [92%] patients have been suffering from anemia and we received 15 [54%] of them in a critical state with the hospital stay of less than 1 2 hours. In our study hemorrhage and hypertensive disorders of pregnancy are the leading causes of maternal deaths. We argue that most of these maternal deaths could have been possibly avoided by periodic interventions during the pregnancy, child birth and the postpartum period

comparison of pelvic examination, pelvic ultrasound and operative findings in ovarian masses

To compare and correlate the pelvic examination in adnexal masses with pelvic ultrasound and peroperative findings. June 2006 to May 2007. Descriptive observational study. A sample set of 22 patients with adnexal masses have been included in the study to do a comparative study of the pelvic examination with pelvic ultrasound and peroperative findings. Our analysis show a wide range of diversity among the age groups of our sample set. The majority of the patients [81.8%] belong to the reproductive age group between 20-40 years and only 13% of patients are menopausal. Another important observation is that 87% of all patients visited out patient department with subacute symptoms and remaining 13% presented with acute symptoms in the Emergency Department. Moreover, 54.54% have right-sided adnexal masses and the remaining 45.45% have left-sided adnexal masses. We have seen only in the 9% of cases that the operative findings are different from that of the ultrasound examination. The final outcome of our research is that the ultrasound examination - an important noninvasive investigation - can only be used as a complementary method to the pelvic examination because the findings can be accurately confirmed only on laparoscopy