Implementing work place based assessment: The modified direct observation of procedural skills (DOPS) across medical specialties - An experience from a developing country.

OBJECTIVE: To assess the skill level of residents regarding central venous catheterisation insertion, and to assess the reliability of scores in a simulated situation. METHODS: The quasi-experimental study with pre- and post-test design was conducted from February to June 2013 at the Aga Khan University, Karachi, and comprised four workshops attended by residents. The workshops were video-recorded for feedback and self-assessment. At the end of the workshops, knowledge and procedural skills were assessed using a self-generated 38-item, task-specific instrument after ensuring its content validity. Data was analysed using SPSS 19. RESULTS: There were 40 residents in the sample. The self-generated instrument was reliable with Cronbach's alpha value 0.83 and inter-rater coefficient 0.79. There was significant improvement in the skills level post-intervention compared to the baselines mean values (p=0.001). The subjects were satisfied with the workshops, as indicated by a mean score of 8.83±1.367. CONCLUSIONS: The workshops appeared to improve the central venous catheterisation insertion skills of the residents.

Pleural effusion as a manifestation of multiple myeloma.

Multiple myeloma is a clonal B-cell malignancy, characterised by proliferation of plasma cells and secretion of paraproteins. These plasma cells accumulate predominantly in the bone marrow; rarely, they invade other areas, especially the thorax. Myeloma presenting with a pleural effusion is rare and reported in only 6% of patients with myeloma. Such patients generally present late and have a poor prognosis. Here, we describe a patient presenting with a lung mass, renal failure and a massive unilateral pleural effusion due to multiple myeloma who was treated successfully.

Safety and tolerability of inhalational anticholinergics in COPD.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. With the significant toll of the disease, more resources have been invested in developing new treatment modalities. Among these medications, inhalational anticholinergics are widely used for the management of stable COPD. The newer agents, with longer half-lives and better safety profiles, have emerged and helped to improve management of COPD patients. The available data from randomized clinical trials support use of these agents. Multiple randomized clinical trials show safety and efficacy of the newer long-acting inhaled anticholinergics, including tiotropium and aclidinium. A recent meta-analysis of tiotropium delivered with Respimat(®) raised some safety concerns. A large trial, comparing different doses and delivery methods of inhaled tiotropium, is ongoing to determine the effect on mortality. As clinical trials may not comprehensively represent the entire COPD population, caution should be exercised when these agents are used in higher-risk populations, like individuals with cardiac arrhythmias or urinary obstruction. In this publication, we review the safety of inhalational anticholinergics.

Influence of gender on continuous positive airway pressure requirements in patients with obstructive sleep apnea syndrome.

INTRODUCTION: Gender differences have been noted in key aspects of upper airway physiology and pathophysiology of obstructive sleep apnea (OSA). We postulate that these will lead to disparities in pharyngeal collapsibility and, consequently, positive airway pressure requirements of patients with OSA. METHODS: A retrospective review of 95 adult patients (56 women, 39 men) with OSA was done. Patients who underwent continuous positive airway pressure (CPAP) titration were included in the study. RESULTS: The study groups were similar with regard to the severity of OSA (median apnea-hypopnea index of 34 in men and 24 in women, p = 0.13). The men were older and less obese than the women (mean age of 46 and 41 years, p = 0.03, BMI of 42 and 49 kg/m(2), p < 0.001, in men and women, respectively); Epworth score was similar in the two groups (12 vs.11, p = 0.91). CPAP requirement was higher in men than in women (12.7 vs. 10.2, p < 0.0001). The effect of gender on CPAP requirement was found to be significant even when confounding variables were accounted for using linear regression. CONCLUSION: Men with OSA are more likely to require higher levels of CPAP support than women. The effect of gender on CPAP requirement persisted even after correcting for the severity of OSA.

Utility of exhaled nitric oxide in the diagnosis and management of asthma.

PURPOSE OF REVIEW: The fraction of nitric oxide in exhaled air (FeNO) is elevated in the presence of airway inflammation, and it may be a useful biomarker in asthma. The purpose of the present review is to highlight the current literature investigating the use of exhaled nitric oxide in the diagnosis and management of asthma. RECENT FINDINGS: The measurement of exhaled nitric oxide has been studied in normal populations and in asthmatics. FeNO appears to be a useful screening tool for asthma, although nondisease factors may confound the interpretation of an elevated FeNO level. Clinical trials investigating the use of FeNO measurements in predicting asthma exacerbation and tailoring maintenance therapy have had varying success. Further studies incorporating individualized FeNO profiles into treatment algorithms are needed. SUMMARY: FeNO shows promise as a tool in the diagnosis and treatment of asthma. However, further studies are needed to address outstanding questions about its exact role in guiding asthma management.