Effect of Progressive Resistance Exercise Training on Hepatic Fat in Asian Indians with Non-Alcoholic Fatty Liver Disease.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is closely associated with obesity and insulin resistance and lifestyle measures form the cornerstone of therapy. Objective: To study the effect of progressive resistance training (PRT) on hepatic fat content, body composition and insulin sensitivity in patients with NAFLD. Methods: This study included 24 adult patients with NAFLD diagnosed on ultrasonography. Subjects with alcohol intake >140 gm/week and any secondary cause of fatty liver were excluded. Patients underwent thrice weekly sessions (40 minutes each) of resistance exercises including flexion at biceps, triceps, and hip flexion, knee extension and heel rise for 12 weeks. Pre- and post-intervention evaluation included anthropometry, BIA analysis, short insulin tolerance test (SITT), lipid profile and hepatic fat quantification by MRI. Results: Twenty four patients (17 males, 7 females, mean age 39.8±10.5 yrs) completed the study protocol with 78.7% compliance to PRT protocol. There was significant decrease in waist, hip and mid-thigh circumferences and skinfold thicknesses at biceps, triceps, subscapular and suprailiac regions (p<0.05), with no significant change in BMI and WHR. Insulin sensitivity improved significantly at 12 weeks as indicated by increase in k-value (rate of change of glucose) on SITT (0.84 vs 1.3, p=0.002). A decrease in total cholesterol and LDL-c with increase in HDL-c was noted after 12 weeks (p<0.05). Hepatic fat content also decreased at 12 weeks (22.3±3.9 vs 21.4±4.0 %, p=0.01). Conclusion: Moderate intensity PRT is associated with significant improvement in hepatic fat, truncal subcutaneous fat and insulin sensitivity in patients with NAFLD.

Workplace-based assessment: Measuring and shaping clinical learning.

Assessment of clinical competence is a challenge. It should not only help us in measuring performance but also in improving performance. Traditional assessment has many flaws, mainly related to snapshot observations, artificial settings and lack of opportunity to improve performance. Workplace-based assessment (WPBA) refers to direct observation of performance at the workplace. It builds on the ways people learn at the workplace. The key feature of all tools used for WPBA is direct observation of trainee performance at the workplace followed by provision of feedback based on that observation. This makes such an assessment valid. Though most of the tools use subjective observations, the assessment is reliable due to use of multiple encounters being assessed by multiple assessors in multiple settings. In addition, WPBA has high utility in terms of its educational impact. WPBA involves sampling of the clinical work using logbooks or encounter cards and direct observation of performance of clinical competence and procedural skills. These are supplemented by assessment by various people who can provide authentic information about a trainee’s work habits. The encounters and ratings are documented in a portfolio, which allows a longitudinal record of trainees’ progress. Experience suggests that WPBA has the potential to shape clinical learning and steer it towards desirable learning outcomes. Most of the tools used for WPBA can be applied in the Indian context.

Assessment in medical education: Evolving perspectives and contemporary trends.

Assessment is an important part of the educational process. It influences students’ learning. Traditionally, assessment has been used to measure the achievement of students for certification or selection. However, increasing attention is being paid to using formative assessment to improve learning. Miller’s pyramid provides a good conceptual model to assess clinical competence by providing tiered levels of assessment. All levels of the pyramid need to be included in the assessment process. To be useful, assessment should be valid (measuring what it is supposed to measure), reliable (confidence in the results), acceptable (to various stakeholders), feasible and have a positive educational impact. The major attributes (validity and reliability) refer to judgements that we make from the assessment data and are not the inherent property of any test or tool. All validity is construct validity. There is often a trade-off between validity and reliability but an assessment which is low on one can still be useful by virtue of its being high on the other. No one tool is enough for assessing students and a combination of tools is preferred to get a composite picture of students’ attainment. Assessment of knowledge is largely made by written assessment. The tests and questions should be contextual and look for application of knowledge rather than mere recall of facts. Assessment of clinical skills is done by traditional methods such as long and short cases and newer methods such as mini-clinical evaluation exercises, objective-structured clinical examinations, case-based discussions and portfolios. An adequate and representative sample of clinical tasks and direct observation of performance are the key to the validity and reliability of the assessment process. Faculty training is important for improving the quality of assessments.

Structured internship orientation programme for undergraduate students: Easy transition to clinical work.

Background. Internship is a phase of training when a new graduate is expected to acquire skills under supervision, so that he/she may become capable of functioning independently. Often, new graduates go through this period without a clear aim. We conducted an orientation programme before fresh graduates started their 1-year internship to familiarize them with their clinical tasks and their role in the community. Methods. Interns were invited to participate in a one-anda- half day programme conducted by faculty members and administrators that included interactive lectures, structured panel discussions, group discussions and role plays. The participants provided feedback using a structured questionnaire and during informal group discussions. They were also evaluated by a pre-test and post-test questionnaire. Results. Of the 41 interns who attended the programme on day 1 and the 28 who completed it on day 2, 19 completed the post-test questionnaire. The post-test score (median 14.5; range 10–18) represented a significant improvement over the pre-test score (median 13, range 3–16). All participants felt that the workshop was successful in achieving its objectives. Conclusion. A brief and structured orientation programme before internship offers a practical means of making the transition of new graduates from students to practising doctors smoother.

Faculty development and medical education units in India: A survey.

Background. Faculty development in medical education is gaining momentum in India. While planning a National Conference on Medical Education (NCME 2007), we did a survey of principals and faculty of medical colleges to understand the status of faculty development programmes and medical education units in medical colleges in India. Methods. Questionnaires were sent to principals of medical colleges by surface mail and to faculty through a web-based programme to elicit information on various aspects of faculty development programmes and medical education units. The responses of both groups were analysed. Results. The number of medical education units has increased rapidly after regulations have been revised in 1997 by the Medical Council of India. The main activities of medical education units were to conduct workshops targeted at medical teachers. The frequently covered topics were teaching–learning, media and student assessment. Lectures dominated the methodology of imparting information. Evaluation was done mainly by feedback questionnaires and pre-test/post-test questionnaires. Projects and follow up were rarely used. The responses from both groups were strikingly similar. The major strengths of medical education units were perceived as availability of trained and motivated faculty, good infrastructure and supportive leadership. The shortcomings were lack of infrastructure, funding and full-time faculty, besides time constraints and resistance to change. The respondents suggested strengthening of infrastructure, appointment of full-time faculty and staff, incentives and recognition of contributions to faculty development, making participation a mandatory requirement, extending the scope of faculty development programmes to include research and networking at the national level. Conclusion. The study reveals the need for policy decisions that support functioning of medical education units in India besides active participation of the faculty.

Bleomycin-induced scleroderma.

Systemic sclerosis is a connective tissue disease, which can be triggered by environmental factors. We report one such case of bleomycin-induced scleroderma.

Giant cell arteritis--a rare cause of fever of unknown origin in India.

Giant cell arteritis (GCA) is a systemic large vessel vasculitis. Awareness of various manifestations of GCA is essential for early recognition and prompt treatment so as to prevent complications like blindness. GCA is one of the relatively common causes of fever of unknown origin (FUO) in the elderly in USA and Europe. However, no such cases have been reported from India. A case of GCA presenting as FUO is reported and the literature reviewed.