Introduction and Implementation of Early Clinical Exposure in Undergraduate Medical Training to Enhance Learning.

CONTEXT: Conventional medical curricula have created an impenetrable wall between the preclinical and clinical years of training, thus submerging relevance of basic sciences in clinical setup. Recently, the Medical Council of India has introduced a number of changes and updates in the medical education, including "early clinical exposure" (ECE) in newly proposed competency-based medical education. ECE does not replace the basic and clinical sciences but enriches and contextualizes that learning, therefore motivating the students to develop a better insight into medical profession. AIMS: (1) To develop a protocol for the introduction of ECE in undergraduate medical training, (2) to validate and to deliver it to the 1st year MBBS students and assess their perceptions. SETTINGS AND DESIGN: It was a prospective, nonrandomized, interventional study. SUBJECTS AND METHODS: After taking permission from the institutional research committee and institutional ethical committee, a protocol for the introduction of ECE in Biochemistry was developed. The feedback questionnaire for the students and the faculty and retro-preself-efficacy questionnaire for the students were designed and validated. The ECE protocol was delivered to 143 1st-year MBBS students, and perceptions of concerned were collected and analyzed. STATISTICAL ANALYSIS USED: Collected data were analyzed in terms of percentages, medians, and satisfaction index and were represented in graphs. RESULTS: Students reported that the ECE session was an enjoyable, satisfactory, and effective learning tool, with the improvement in knowledge, retention, attention, and motivation. Students also reported that this method of teaching-learning should be implemented in other topics as well as in other subjects of the first professional course. CONCLUSIONS: ECE protocol was perceived as very satisfactory by the students, and it helped in improvement of knowledge and to understand the relevance of preclinical subject in clinical setup.

Pre- and Post-operative Comparative Analysis of Serum Lipid Profile in Patients with Cholelithiasis.

BACKGROUND: Gallstones have become a major health problem because of their silent manifestation and unclear pathogenesis. Although the association between the disturbed lipid metabolism and formation of gallstones has been elucidated in many studies, the effect of cholecystectomy on lipid profile has not been studied in detail. AIM: The aim of the present study was to study the effect of cholecystectomy on lipid levels in patients with gallstones. MATERIALS AND METHODS: The study was conducted on 50 patients with gallstones and 30 healthy volunteers for comparison of lipid levels. Subsequently, cholecystectomy was conducted on patients with gallstones and pre- and post-operative lipid levels were compared. RESULTS: There was a significant decrease in total cholesterol, and triglycerides levels and increase in high-density lipoprotein levels after 1 month of surgery, while low-density lipoprotein levels and very low-density lipoprotein were not statistically changed. CONCLUSION: Cholecystectomy can significantly improve lipid levels in patients with gallstones.

Possible role of elevated serum testosterone in pathogenesis of renal stone formation.

BACKGROUND: Urolithiasis or renal stone formation occurs with three times higher frequency in males and decreases with age in parallel with the serum testosterone levels, suggesting a role played by male sex hormones. Androgens appear a promotion action and estrogens an inhibitory action on kidney stone formation in several animal models suggesting a study to be carried out to deduce the role played by serum testosterone in the formation of renal stones. AIM: The aim of this study is to define the involvement of serum total testosterone, free testosterone, and dihydrotestosterone in the pathogenesis of urolithiasis in males by comparing the results with healthy males with no present or past history of urolithiasis as controls. MATERIALS AND METHODS: A case-control study was undertaken with 108 participants: 78 males diagnosed with urolithiasis and 30 age-matched healthy males. RESULTS: The difference between mean age and body mass index of patients and controls were found to be nonsignificant. The total serum testosterone levels, serum dihydrotestosterone levels, were found to be higher in patients when compared to controls, and the difference was found to be significant. The levels of free testosterone and serum estradiol were also found to be higher in urolithiatic patients. CONCLUSION: The study demonstrates that elevated levels of serum testosterone and serum dihydrotestosterone might be involved in increased incidences of stone formation. The higher levels of estradiol do not seem to be a protective factor in males with urolithiasis with higher serum testosterone levels.

Current Treatment Strategies for Acute Type B Aortic Dissection.

Acute type B aortic dissection (ATBAD) is a medical emergency that is a common occurrence in patients with atherosclerotic disease. The presentation is usually severe, with tearing pain that radiates to the back, and various levels of end-organ ischemia and malperfusion, even rupture, may occur. Everyone agrees that prompt and aggressive blood pressure control with ß-blockers and nitroprusside is imperative, but when to surgically intervene is still not well characterized. However, the advent of minimally invasive stent graft placement has reshaped our thoughts regarding therapeutic intervention for ATBAD. This review is an attempt to define the current surgical indications for treating ATBAD.

Appropriate use of D-dimer testing can minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital.

BACKGROUND: The sensitivity of d-dimer (DD) in detecting deep venous thrombosis (DVT) is remarkably high; however, many institutions send patients immediately for a venous duplex ultrasound (VDU). This study was designed to examine the appropriate utilization of DD and VDU in a high-volume hospital. METHODS: A retrospective study was conducted on consecutive patients who presented to a high-volume emergency department (ED) with lower extremity limb swelling/pain over a 30-day period, who were sent for VDU during an evaluation for DVT. VDU data were merged with electronic DD laboratory results. The enzyme-linked immunosorbent assay method was used to provide DD values and thresholds. Values above 0.60 mg/fibrinogen equivalent unit (FEU) were considered abnormal. RESULTS: We reviewed the medical records of 517 ED patients in the month of June 2013. After applying the Wells criteria, 157 patients (30.4%) were excluded because of a history of DVT or pulmonary embolism, having been screened for shortness of breath, or sent for surveillance-leaving 360 for analysis. The average age was 59.3 ± 16.5 years with more women (210, 58.3%) and the majority reported limb pain or swelling (73.9%). DD was performed on 51 patients with an average value of 3.6 ± 5.4 mg/FEU, of which 43 (84.3%) were positive. DD identified all positive and negative DVT patients (100% sensitivity and negative predictive value), but also included 40 false positives (16.7% specificity). On the other hand, 309 patients were sent directly to VDU without DD; of those, 43 (13.9%) were positive for DVT. However, 266 (86.1%) patients were negative for DVT by VDU without DD and these were deemed improper by our current study protocol. Potential charge savings were calculated as VDU for all (360 × $1000 = $360,000), DD for all (360 × $145 = $52,200), and VDU for both true and false positives (estimated to be about 25% of the cases; 90 × $1000 = $90,000); this equals a charge savings of $217,800 and would avoid unnecessary VDUs. CONCLUSIONS: Based on the results of our study, we suggest that the DD test be utilized during the initial work-up for patients with limb swelling/pain in the emergency room. Appropriate utilization of DD, as well as other clinical criteria, may limit the over-utilization and added cost of VDU, without a negative impact on patient care. The results of DD tests should be utilized to limit the number of patients sent for VDU to only those patients with a positive DD or other significant underlying concerns.

Splenic artery embolization for the treatment of bleeding gastric varices secondary to splenic vein thrombosis.

Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.

Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature.

Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.

New trick for removal of intravascular retained foreign body: a case report and review of literature.

A 54-year-old male presented to the vascular service for an urgent inpatient consultation. During an infusaport removal, the catheter was accidentally disconnected and lost intravascularly within the left subclavian vein, with the tip still in the right ventricle. We report on a novel technique for removing such intravascular foreign bodies (FBs), which will add a valuable technical option to our existing armamentarium regarding intracorporeal FB removal.

Cystic adventitial disease of the common femoral vein: a case report and review of the literature.

We report on a 52-year-old female patient who presented with a 6-month history of right lower extremity swelling and tenderness. The patient was treated as an outpatient with full anticoagulation, without any improvement. Her medical history was significant for hypertension and high cholesterol, and she had a full coagulopathy profile that was negative for any hypercoagulable syndrome. On examination, the patient was moderately obese, with significant tenderness over the medial aspect of the right groin. A venous duplex examination revealed hypoechoic structure ± acute deep vein thrombosis of right common femoral vein (CFV). A computed tomography of the venous phase revealed an eccentric compression over the medial wall of the right CFV. During surgical exploration, adventitial cystic mucinous disease was enucleated from the medial wall of the right CFV, and the pathological examination confirmed the diagnosis. The postoperative course was uneventful, and all swelling and tenderness were completely resolved. The patient continued to do well, and she had an unremarkable venous duplex evaluation at her 6-month follow-up.

A study of psycho-behavioral patterns in patients emerging from general anesthesia using sevoflurane, propofol and their combination in early, intermediate and late post-operative period: A randomized controlled trial.

BACKGROUND: It has been contended the general anesthetic agents also may affect the psycho-social behavior of the patients, especially during the emergence from GA. This assumes much significance in day cases where, patients have to be roadworthy and mentally stable before discharge. AIMS: We compared the psycho-behavioral effects of propofol, sevoflurane and their combination, while emerging from anesthesia. SETTINGS AND DESIGN: The patients coming for short duration day care anesthesia were studied in a prospective randomized controlled comparison. MATERIALS AND METHODS: The psycho-behavioral changes in early, intermediate and late recovery period were studied in 60 consenting patients undergoing Total Intra Venous Anesthesia (TIVA) using Propofol, Volatile Induction and Maintenance Anesthesia (VIMA) using Sevoflurane and the combination of these two agents. STATISTICAL ANALYSIS: Statistical Analysis of the data and application of various statistical tests was carried out with help of Statistical Package for Social Services (SPSS version 18). Data were compiled, analyzed and presented as frequency, proportions, mean and standard deviation. The tests of significance, like Chi-square test, percentages, independent sample t test, paired t test, and P value were used in the study. RESULTS AND CONCLUSIONS: Both the modalities of GA, viz; TIVA and VIMA, do produce significant psycho-behavioral changes in the patients after GA, though transiently. So it is imperative for the Clinicians to anticipate the entire aspect of Psycho-behavioral patterns before discharging the day cases from the Post anesthesia Care Unit (PACU).

Renal fibromuscular dysplasia.

Renal artery fibromuscular dysplasia is a noninflammatory, nonatherosclerotic vasculopathy that can affect renal arteries at various degrees with different severity. The etiology is still unknown, but there is a strong belief that a genetic disorder is the main cause for the pathogenesis of this disease. The main presentation is a sudden onset of recalcitrant hypertension at a young age, which is usually resistant to medical treatment. Once renal artery fibromuscular dysplasia is suspected, several diagnostic tools are available to make an accurate diagnosis. The advent of minimally invasive interventions has revolutionized the options for treatment. This update should provide the clinician with a base understanding of available evidence for diagnosing and treating renal artery fibromuscular dysplasia.