The effect of low versus high tidal volume ventilation on inflammatory markers in animal model undergoing lung ventilation: A prospective study.

BACKGROUND AND AIMS: Mechanical ventilation (MV) with high tidal volume (Vt.) may induce or aggravate lung injury in critically ill patients. It might also cause an overwhelming systemic inflammation leading to acute lung injury (ALI), diffuse alveolar damage (DAD) and multiple organ failure (MOF) with subsequent high mortality. The objective of this study was to compare the effects of different Vt. on the inflammatory markers of the broncho-alveolar lavage (BAL) fluid and lung biopsy in a group of animal model (Beagle dogs). METHODS: A two-phased prospective study involving 30 Beagle dogs (15 dogs/phase), each phase divided into three groups (each 5 dogs/group). In the first phase each group received MV with Vt. of 8 (low), 10 (normal, control group), and 12 (high) ml/kg body weight (b.w.) respectively. BAL fluid was obtained at the time of induction of anesthesia immediately following tracheal intubation and one hour later following MV to count the macrophages, neutrophils and lymphocytes. In the second phase of the experiment, in addition to obtaining (BAL) fluid similar to the phase one, mini thoracotomy and lung biopsy obtained from the upper lobe of the right lung at same timings for histopathological examination study. Mann-Whitney-Wilcoxon test was used for statistical analysis of the data obtained. RESULTS: BAL fluid analysis showed increase in the counts of macrophages and lymphocytes with Vt. of 12 ml/kg b.w. compared to the control group (10 ml/kg b.w.) (P < 0.05). in the second phase, similar findings obtained. The histopathological study of the lung tissue obtained in the second phase of the study from the group that received a high Vt. of 12 ml/kg b.w. showed significant inflammatory changes with presence of neutrophil infiltration and edema in the bronchial wall compared to the control group (10 ml/kg b.w.) (P < 0.05). CONCLUSIONS: The use of high Vt. in ventilated animal lung model may increase the risk of inflammation and subsequent damage in healthy lungs, these findings may help physicians to avoid using high Vt. in short-term mechanically ventilated patients in the operating room setting.

Use of cross-institutional progress test as a predictor of performance in a new medical college.

BACKGROUND: The progress test was initiated by Qassim University in 2000 as a tool to evaluate the educational process among Saudi medical colleges. Princess Nourah Bint Abdul Rahman University (PNU) College of Medicine is a new medical college established in 2012 that implemented the same innovative reformed curriculum of King Saud University College of Medicine. OBJECTIVES: The objective of this study was to use the progress test to evaluate the rate of knowledge acquisition among a new medical school compared to other long-established medical schools in Saudi Arabia. MATERIALS AND METHODS: As part of an ongoing strategy, the progress test was administered before the end of the academic year. Students in PNU were enrolled for 2 years in the progress test. We compared the mean progress test scores for PNU students compared to students at comparable stages in other medical schools in Saudi Arabia. RESULTS: The results showed that the rate of knowledge acquisition was similar in students at PNU to students in other well-established medical schools in Saudi Arabia. CONCLUSION: The present study showed that the interinstitutional progress test demonstrated that the level of acquisition of knowledge and performance of students in a new medical school was similar to other medical colleges in Saudi Arabia.

A stepwise model for simulation-based curriculum development for clinical skills, a modification of the six-step approach.

BACKGROUND: Despite the rapid growth in the use of simulation in health professions education, courses vary considerably in quality. Many do not integrate efficiently into an overall school/program curriculum or conform to academic accreditation requirements. Moreover, some of the guidelines for simulation design are specialty specific. STUDY DESIGN: We designed a model that integrates best practices for effective simulation-based training and a modification of Kern et al.'s 6-step approach for curriculum development. We invited international simulation and health professions education experts to complete a questionnaire evaluating the model. We reviewed comments and suggested modifications from respondents and reached consensus on a revised version of the model. RESULTS: We recruited 17 simulation and education experts. They expressed a consensus on the seven proposed curricular steps: problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, individual assessment/feedback, program evaluation, and implementation. We received several suggestions for descriptors that applied the steps to simulation, leading to some revisions in the model. CONCLUSION: We have developed a model that integrates principles of curriculum development and simulation design that is applicable across specialties. Its use could lead to high-quality simulation courses that integrate efficiently into an overall curriculum.

IL-17 Enhances Chemotaxis of Primary Human B Cells during Asthma.

IL-17 is a pro-inflammatory mediator that is believed to play a critical role in regulating tissue inflammation during asthma, COPD, as well as other inflammatory disorders. The level of expression of IL-17 has been shown to be upregulated in lung bronchial tissue of asthmatic patients. Several reports have provided further evidence that this cytokine could play a key role in enhancing the migration of inflammatory as well as structural cells of the bronchial lung tissue during asthma and COPD. B cell infiltration to sites of inflammation during inflammatory disorders such as bowel disease, asthma and COPD has been reported. Accordingly, in this study we hypothesized that IL-17 may exert a chemotactic effect on primary B cells during asthma. We observed that B cells from asthmatic patients expressed significantly higher levels of IL-17RA and IL-17RC, compared to those of healthy subjects. Using an in-vitro migration assay, B cells were shown to migrate towards both IL-17A and IL-17F. Interestingly, blocking IL-17A and IL-17F signaling using either anti-IL-17R antibodies or MAP kinase inhibitors prevented in vitro migration of B cell towards IL-17. These observations indicate a direct chemotactic effect of IL-17 cytokines on primary peripheral blood B cells with higher effect being on asthmatic B cells. These findings revealed a key role for IL-17 in enhancing the migration of B cells to the lung tissue during asthma or COPD.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy.

AIM: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy. METHODS: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. RESULTS: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). CONCLUSION: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students' interest in learning, in clinically applying anatomic fact, and in surgery as a future career.

Experience and attitude of interns to pelvic and sensitive area examinations during their undergraduate medical course.

OBJECTIVE: To explore the experience of interns in sensitive area examination during their undergraduate medical course and identify factors interfering with such examinations. METHODS: A cross sectional study was carried out from May to June 2010. Interns (n=315) at King Saud University College of Medicine were invited via email to complete a web-based questionnaire developed using surveymonkey.com. RESULTS: Out of 315 interns, 211 completed the questionnaire; 60% males and 40% females. The mean percentage of interns who never performed any of these examinations was 28.9% for digital rectal examination, 17.5% for breast, 43.1% for female pelvic examination, 13.3% for inguinal (hernia), and 34.6% for male external genitalia. Compared to females, male students conducted more rectal examinations (87 versus 63, p<0.005), and male external genitalia examinations (112 versus 26, p<0.001). On the other hand, compared to male students, females conducted more pelvic examination (68 versus 52, p=0.03) and breast examinations (92 versus 82, p=0.27). The most common reasons for not performing sensitive area examinations included patient's refusal (33.1%), and examining patients of opposite gender (27.6%). Confidence in performance of these examinations was correlated to increased frequency of the examination. CONCLUSION: This study highlights that most common factors interfering with the students' conducting sensitive area examinations are patient's refusal and examining patients of the opposite sex. There is a strong correlation between increased frequency of conducting an examination and student's confidence in performance.

Surgical management of retrosternal goiter: Local experience at a university hospital.

BACKGROUND AND OBJECTIVE: Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Surgery plays an important role in the treatment of these patients, but whether all or selected patients with RSG should undergo this operation remains controversial. Our aim is to look into the demographics, presentation, and treatment of patients with RSG and essentially to determine the role of surgery in its treatment. SETTING AND DESIGN: Retrospective study, teaching hospital-based. METHODS: Retrospective analysis of 537 thyroidectomies performed at King Khalid University Hospital between 2003 and 2010. The twenty-six patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. Statistical analysis was performed, where age was expressed as mean and range, and other variables were presented as numbers and percentage. RESULTS: There were 26 patients (4.8%) with RSG out of 537 thyroidectomies, who underwent an operation for removal of RSGs, in a seven-year period. The most common presentation was dyspnea (34.6%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 96% of the cases. The final histological diagnosis revealed malignancy in 26.9% of the thyroid specimens. There was no mortality and minor complications occurred in nine patients. CONCLUSIONS: The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy.

Mediastinal seroma post laparoscopic repair of type IV paraesophageal hernia.

Laparoscopic repair of paraesophageal hernia is safe and feasible and can provide comparable results for patients with type IV paraesophageal hernia. We report a rare case of mediastinal seroma in an 80-year-old gentleman who had a giant type IV paraesophageal hernia and was eventually admitted to our hospital for elective laparoscopic repair and recovered very well after surgery with resolution of the atelectatic lungs and air-fluid collection in his chest.