Prevalence of Elevated D-dimer Levels in Confirmed COVID-19 Cases in Intensive Care Unit of a Tertiary Care Centre of Western Nepal.

INTRODUCTION: D-dimer is currently the best available marker for COVID-19 associated hemostatic abnormalities. This study aims to find out the prevelance of elevated D-dimer levels in confirmed COVID-19 cases in intensive care unit of a tertiary care hospital of western Nepal. METHODS: This descriptive cross-sectional study was conducted among 95 patients admitted to COVID Intensive Care Unit of a teriary care centre from August 2020 to January 2021 after taking ethical clearence from Institutional Review Committee in order to determine the D-dimer levels in confirmed COVID-19 cases. D-dimer value was measured at the admission and the highest D-dimer value was recorded during the course of hospital stay with the risk of mortality in confirmed COVID-19 cases. The normal range of D-dimer was taken as <0.35 mg/dl as per our hospital laboratory standards. Convenience sampling method was used. Data entry and descriptive analysis were done in Statistical Package for the Social Sciences version 25.0, point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Out of total 95 cases of COVID-19 included in this study, 25 (89.3%) patients with age ≥ 65 years and 42 (62.69%) patients aged <65 years had elevated D-dimer on admission. Data showed that 29 (67.4%) patients having elevated D-dimer at admission had mortality. CONCLUSIONS: Elevated D-dimer levels was frequently seen in patients admitted in Intensive Care Unit with COVID-19. Our study suggested that measurement of D-dimer may guide in clinical decision making.

Nepal's Response to Contain COVID-19 Infection.

Nepal is a landlocked country bordering two most populous countries, India and China. Nepal shares open border with India from three sides, east, south and west. And, in north with China, where the novel coronavirus infection (CVOVID-19) began in late December 2019. The first confirmed imported case in Nepal was reported in 2nd week of January 2020. The initial response of Nepal to COVID-19 were comparably slow but country geared efforts after it was declared a 'global pandemic' by WHO on 11 March, 2020. Government of Nepal's steps from 18 March, 2020 led to partial lock down and countrywide lockdown imposed on 24 March, 2020. Government devised comprehensive plan on 27 March, 2020 for quarantine for peoples who arrived in Nepal from COVID-19 affected countries. This article covers summary of global status, South Asian Association of Regional Cooperation (SAARC) status, and Nepal's response to contain COVID-19 infection discussed under three headings: Steps taken before and after WHO declared COVID-19 a global pandemic and lab services regarding detection of COVID-19. Nepal has documented five confirmed cases of COVID-19 till the end of March 2020, first in second week of 15 January, 2020 and 2nd case 8-weeks thereafter and 3rd case two days later, 4th on 27 March and 5th on 28 March. Four more cases detected during first week of April. Non-Pharmacological interventions like social distancing and excellent personal habits are widely practiced. Country has to enhance testing and strengthen tracing, isolation and quarantine mechanism and care of COVID-19 patients as Nepal is in risk zone because of comparably weak health system and porous borders with India. The time will tell regarding further outbreak and how it will be tackled. Keywords: COVID-19; lockdown; Nepal; pandemic; response.

Clinical vignette-based interactive discussion sessions: feedback from residents.

INTRODUCTION: A clinical vignette is a useful tool for teaching both clinical and basic sciences courses. The clinical vignette-based interactive discussion sessions were conducted for residents in the internal medicine department of Universal College of Medical Sciences( Bhairahawa, Nepal) with aim to link the residents to clinical practice setting. The objective of this study was to assess the feedback of participant. METHODS: The sessions were done five days a week between January 16 and February 26, 2019. Each session was between 45 and 60 minutes. The clinical vignettes related to internal medicine were downloaded using Google. Each vignette was divided into sections, related questions with responses were developed and the discussion was updated referring to the latest articles on subject. Eleven residents participated in the session. At the end of last session feedback was taken on a validated semi-structured questionnaire. The data was analyzed using SPSS version 21. RESULTS: Residents rated the clinical vignette-based interactive discussion sessions on the scale 1 = poor to 10= excellent; usefulness (9.45±1.04), content (9.27±0.90), relevance of session (9.18±1.08), facilitation (9.27±1.10), and overall (9.36±0.81). Participants rated the structure of vignettes discussed (3.73±0.47), the questions related to vignettes discussed (3.82±0.40), and discussion related to vignettes done (3.64±0.50) on a Likert scale 1-4 (4= extremely important, 3= moderately important, 2= slightly important, 1= not important). The two-way interaction, the approach toward differential diagnosis, diagnosis and management, choosing appropriate investigation, clinical relevancy of vignettes, boosts understanding, enhances thinking power and thinking outside the box, improving clinical approach and academic learning were among the strengths of sessions shared by residents. All residents proposed to continue these sessions and develop vignettes of our patients. The majority of the residents recommended conducting session on alternate days. CONCLUSION: This method of learning allowing the residents to follow and construct clinical outcome in a logical and systematic sequence that may be applicable in real-life clinical practice settings. This method enhances the thinking power of residents and their problem-solving capacity.

Workshop on proposal writing on research for health care professionals: a brief report.

A one-day workshop on proposal writing for research for health care professionals was organized by Hospital Research Board (HRB), Nepal Cancer Hospital and Research Center Pvt. Ltd, Harisiddhi, Lalitpur, Nepal on 2nd March 2019. The main aim of this workshop was to identify, motivate and prepare health care professionals for conducting research in their respective professional institution in collaboration. The workshop was facilitated by international and national resource persons. The deliberations of the workshop were focused on seven topics: "Turning research into impact, Essentials of the research protocol, Why proposals are rejected?, Plagiarism in medical research, Research with medical records, Grant writing workshop, Manuscript writing workshop" based on a presentation by the different resource persons. Ninety-nine persons participated in the workshop including physicians, medical oncologists, pharmacists, nurses and other allied health professionals. The interactive teaching-learning methods were utilized in all sessions of the workshop. The feedback of the participants was taken on semi-structured feedback format. Overall evaluations from the feedback forms showed that majority (90%) of the participants agreed that the workshop achieved its objectives with a major recommendation as to the allocation of short duration for the workshop and timely organize of research activities regarding scientific writing. In conclusion, the workshop on research proposal writing for health care professionals was successfully organized and the participants are looking forward for future ones.

Simulation-based education workshop: perceptions of participants.

BACKGROUND: Simulation-based education (SBE) is increasingly endorsed as an educational strategy. It allows health-care professionals to practice clinical skills within a safe learning environment, and requires devices for simulation or simulated patients, trained teachers, and an appropriate environment. The objective of this study was to evaluate perceptions of participants on SBE and an SBE workshop. METHODS: A 1-day SBE workshop was conducted on September 4, 2018, in collaboration with Laerdal Global Health Nepal and the National Centre for Health Professions Education (NCHPE), Institute of Medicine, Kathmandu, Nepal. Semistructured pretest and posttest questionnaires were used to evaluate the perceptions of participants regarding SBE and the effectiveness of the workshop. Data were analyzed using SPSS 21. RESULTS: The mean difference in participant perceptions of SBE before and after participation in the workshop was significant (P<0.05) on seven statements: enhances communication skills (pretest 4.53±0.72, posttest 4.84±0.75; P=0.03), helps in seeing and managing even rarest of cases (pretest 3.59±1.00, posttest 4.21±0.92; P=0.02), overcomes the problem of uncooperative patients (pretest 3.12±0.93, posttest 3.95±1.22; P=0.004), increases confidence of students in dealing with real patients (pretest 4.29±0.77, posttest 4.79±0.42; P=0.041), enables preparation of rating scales for skills and attitude evaluation (pretest 3.76±0.83, posttest 4.11±0.76; P=0.049), provides immediate feedback during simulation (pretest 4.06±0.9, posttest 4.58±0.51; P=0.016), and keeps materials/equipment ready before simulation (pretest 4.29±0.68, posttest 4.79±0.53; P=0.007). Mean scores for participant feedback on the workshop using a Likert scale of 1-5 (5= strongly agree, 1= strongly disagree) were notable: objective of workshop fulfilled (4.16±0.688), session very interesting (4.37±0.597), session useful for future job (4.47±0.513), scenario relevant to subject (4.21±0.787), what I learnt will be useful in practice (4.05±0.78), resource persons/facilitators were helpful and effective (4.37±0.597), professional (4.42±0.507), and answered all questions (4.32±0.478), and course content was presented clearly (4.26±0.452). Almost all participants found the workshop useful and well presented, and suggested conducting such workshops frequently. CONCLUSION: The SBE workshop produced substantial differences in perceptions of participants. Participants found the workshop effective in improving knowledge and understanding of SBE.

Medical students' perceptions of their learning environment during clinical years at Chitwan Medical College in Nepal.

BACKGROUND: The educational environment of an institution affects learning and has a significant role in determining students' academic achievement. The objective of the study was to determine the undergraduate medical students' perception about educational environment in clinical years of study utilizing Dundee Ready Education Environment Measure (DREEM) questionnaire. METHODS: A descriptive cross-sectional questionnaire-based study was conducted among fourth and fifth-year medical students toward the end of their 2016 academic year in Chitwan Medical College, Bharatpur, Nepal. The 50-item DREEM questionnaire was used to collect the data. The items were scored based on a 5-point Likert scale. The data were analyzed using SPSS version 20. Scores obtained were expressed as mean±SD. RESULTS: The mean total DREEM score was 122/200. The mean score for Students' Perceptions of Learning, Students' Perceptions of Teachers, Students' Academic Self-Perceptions, Students' Perceptions of Atmosphere, and Students' Social Self-Perceptions were 29.8/48, 25.9/44, 20.3/32, 28.6/48, and 17.27/28, respectively. This shows the environment for learning was satisfactory. There were nine problem areas with a mean score of ≤2. There was no significant difference observed in educational environment subscales scores according to enrollment year, gender, or funding source for education. CONCLUSION: The overall student's perception of the educational environment was satisfactory. Nevertheless, the study revealed some problematic areas in the learning environment which require remedial measures to make the environment more conducive for learning to satisfy the students and achieve a far better outcome.

Conflict Management in Healthcare.

The conflict is a disagreement within oneself or differences or dispute among persons that has potential to cause harm. It is inevitable and may occur in any profession including healthcare. It could be among any group of healthcare professionals or healthcare team between different group of healthcare professionals or between patient and any of the member of healthcare team. The conflict has a critical effect on the competence, confidence, and morale of healthcare professionals. Consequently, it affects patient care too. To prevent or limit the conflict, emphasis must be focused on proper and impartial implementation of a professional code of conduct, ground rules and discipline. The sources of conflict could real or imagined differences in values, dissimilar goals among individuals, improper communication and personalization of generic or organizational issue. Generally, there are four types of conflicts, intrapersonal, interpersonal, intragroup and intergroup.The conflict usually goes through four phases, frustration of one or more parties involved in conflict, conceptualization or rationalization of cause, expression of behaviors and behaviors resulting in negative outcome. Thomas and Kilmann postulated a matrix explaining five distinct responses or styles to conflict resolution or management varying along the axis of assertiveness and cooperativeness. These five styles are avoiding, accommodating, compromising, competing and collaborating. The issue in conflict is not its existence, rather its management. When it is managed poorly, the outcome will be uncomplimentary with counterproductive results and if managed properly, it encourages competition, recognize legitimate differences and becomes powerful source of motivation. Keywords: Conflict, healthcare, management of conflict, source of conflict, type of conflict.

Evaluation of teachers training workshop at Kirkpatrick level 1 using retro-pre questionnaire.

BACKGROUND: Teacher training focusing on teaching learning methodologies, assessment tools, and approaches that motivate the teachers and enhance their confidence is one of the fundamental programs of faculty development. The objective of this study was to assess the self-reported perceived confidence of faculty members after participating in a basic teachers training workshop. METHODOLOGY: The retrospective post-then-pre design questionnaire was used for evaluating the faculty members' self-reported perceived confidence at Kirkpatrick level 1 (evaluation of reaction) after completing basic teachers training workshops. The self-reported perceived confidence on 30 statements were analyzed by 3 categories (not confident, confident, and highly confident) on a Likert scale. RESULTS: Out of 60 participants (18 in the 3rd and 21 each in the 4th and 5th teachers training workshops), 58 (96.67%) responded to all statements. The mean age of the participants was 34.14±5.15 years; 70.7% were male and 29.3% female. Overall, the self-reported perceived confidence level of the participants of the 3rd (pre-training median 57, post-training median 70, p<0.001), 4th (pre-training median 51, post-training median 67, p<0.001) and 5th (pre-training median 51, post-training median 68, p<0.001) training workshops was significantly increased after training. There was a noticeable change in the level of confidence of the participants after training. The observed percentage change in self-reported perceived confidence was 29.63% in those who received no training prior to joining college (n=51, 87.9%); this was 2 times more than those who received some sort of training prior to teachers training (n=7, 12.1%). CONCLUSION: Overall, the self-reported perceived confidence level of the participants was significantly increased after teachers training workshop.

Attitude and perception of undergraduate medical students toward the problem-based learning in Chitwan Medical College, Nepal.

BACKGROUND: Problem-based learning (PBL) was introduced into Basic Medical Sciences early in the 1980s at Tribhuvan University (TU), Nepal, followed by other universities where didactic lecture method was still followed as the main teaching strategy. Despite gaining its popularity worldwide as integrated teaching learning method, PBL is not given importance in Nepal. This study aimed to assess the attitude and perceptions of undergraduate medical students regarding learning outcomes of PBL and to know their views about role and qualities of effective tutors for its successful implementation. METHODS: This descriptive study was based on a self-administered questionnaire. The first part of the questionnaire measured students' perception and attitude toward benefits of PBL and the second part measured students' perception about role of PBL tutor. Bachelor of Medicine and Bachelor of Surgery (MBBS) first year (2014/2015 academic year) students at Chitwan Medical College, TU, were asked to express their opinions about the importance of learning outcomes by rating each statement on a five-point Likert scale and the responses were combined into three categorical variables: "agree" (strongly agree plus agree), "neutral", and "disagree" (strongly disagree plus disagree). Data were analyzed using SPSS version 21.0. RESULTS: Approximately 85.5% participants agreed that PBL is an interesting method of teaching learning. Most of them (86.7%) accepted that PBL is an interactive and a mutual learning method and improves self-directed learning (83.2%). Although 78% had recommended it better than lecture, many (54.2%) pointed it out as a time-consuming method. The participants were also highly rated (80.5%) to the statement - the tutor's role in enhancing the constructive active learning and maintaining good intra-personal behavior. CONCLUSION: Student's attitude toward PBL was positive. They highly appreciated the roles of a tutor as facilitators and motivators for proper activities in PBL session. PBL sessions were considered effective in improving students professional knowledge and refining problem-solving and self-directed learning skills along with enriching teamwork experience.

Diabetes Mellitus with Poor Glycemic Control as a Consequence of Inappropriate Injection Technique.

Majority of patients with diabetes mellitus (DM), who are on insulin therapy, use insulin pen for convenience, accuracy, and comfort. Some patients may require two different types of insulin preparations for better glycemic control. We have reported a case of poor glycemic control as a consequence of inappropriate insulin injection technique. A 57-year-old man with type 2 DM had been using premix insulin 30 : 70 for his glycemic control for the last 12 years. On follow-up visit, his blood sugar level (BSL) had increased; therefore the treating physician increased the dose of premix insulin and added basal insulin with the aim of controlling his blood sugar level. Despite these changes, his BSL was significantly higher than his previous level. On investigation, the cause of his poor glycemic control was found to be due to inadequate delivery of insulin (primarily premix) as a consequence of lack of priming and incompatibility of single insulin pen for two cartridges. His basal insulin was discontinued and the patient along with his grandson was instructed to administer insulin correctly. After correction of the errors, the patient had a better glycemic control.

Do Face-to-Face Training and Telephonic Reminder Improve Dry Powder Inhaler Technique in Patients with COPD?

Introduction. Current modes of instruction on inhaler technique are inadequate. We aimed to evaluate the value of face-to-face training and telephonic reminder (FFTTR) for improving Rotahaler technique in experienced patients with COPD. Materials and Methods. A single group pre-/postinterventional study was conducted at Chitwan Medical College Teaching Hospital, Nepal. We assessed the Rotahaler technique of thirty consecutive patients using Rotahaler device for more than one year. Patients with incorrect technique (n = 20) were instructed and trained by a pharmacist. Telephonic reminder was used to reinstruct patients on the correct technique on weekly basis for two weeks and technique was reassessed after 4 weeks of their first training. Descriptive statistics including Wilcoxon Signed Rank test were applied. Results. The mean age was 66.06 ± 10.6. Of 30 patients, 10 (33.3%) performed Rotahaler technique correctly at baseline and were excluded from FFTTR intervention. FFTTR corrected the technique in 18 (90%) patients and the median (IQR) score increased from 6 (5-6) to 8 (8-8) (p < 0.001). The most incorrect steps were "breathe out gently but not towards the inhaler mouthpiece" (16, 80%) and "hold breath for about 10 seconds" (18, 90%) at baseline which improved after intervention. Conclusion. FFTTR approach markedly improved Rotahaler technique in patients with COPD.

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal.

BACKGROUND: The majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler®) technique in such patients and the factors associated with the correct use. METHODS: A pre-post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients' demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2 weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann-Whitney U test, Spearman's correlations and Kruskal-Wallis test, were performed for statistical analysis. RESULTS: Before intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10 seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p≤0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient's education level (p=0.013) and source of instruction (p<0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention. CONCLUSION: The current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique.

Opinion of hospital pharmacy practitioners toward the Continuing Pharmacy Education program: a study from a tertiary care hospital in central Nepal.

BACKGROUND: Meeting participants' needs and matching their preferences are important prerequisites for an effective Continuing Pharmacy Education (CPE) program. The objective of this pilot study was to assess the opinion of hospital pharmacy practitioners with respect to the CPE program. METHODS: The pretested questionnaires were distributed to 20 pharmacy practitioners working in a pharmacy at a tertiary care hospital in Nepal which asked for their opinions and suggestions with respect to the CPE program. Descriptive statistics were performed using IBM SPSS version 20. RESULTS: Topics related to skills development (75%) and recent innovations in pharmacy practice (65%) were mostly preferred. Live (in-person) presentations (80%) and small group discussion (60%) were the most suitable methods for delivery. Improving knowledge (75%), improving skills (60%) and keeping up-to-date in the latest information (60%) were major motivating factors to participate, while lack of time (75%) was a major barrier. Approximately 55% of the participants believed that face-to-face interview was a suitable method for evaluating the effectiveness. Allocation of separate time for the program, assessing baseline knowledge and skills of the participants along with delivery of quality materials in an understandable way were the top common suggestions for improving the CPE program. CONCLUSION: Hospital pharmacy practitioners' opinions and suggestions were assessed with respect to the CPE program and this was upgraded accordingly to meet their expectations.

Assessment of Insulin Injection Practice among Diabetes Patients in a Tertiary Healthcare Centre in Nepal: A Preliminary Study.

INTRODUCTION: Proper insulin injection practice is essential for better diabetic control. This study aims to assess the insulin injection practice of patients with diabetes. MATERIALS AND METHODS: A cross-sectional study was conducted at Chitwan Medical College Teaching Hospital, Bharatpur, Nepal, from February 2017 to May 2017. Patients injecting insulin through insulin pens (n = 43) for a minimum of 4 weeks were consecutively recruited. Patients' baseline characteristics, current insulin injection technique, insulin transportation practice, complications of insulin injection, disposal practice of used needle, and acceptability of insulin were recorded. Descriptive statistics were performed using IBM-SPSS 20.0. RESULTS: The insulin injection technique of patients and their relatives was inadequate. The majority of patients and their relatives (25, 58.1%) mentioned that they transport their insulin cartridge without maintaining cold chain. Thirteen patients (30.2%, n = 43) reported complications of insulin injection and the most common complication among those patients was bruising (10, 76.9%, n = 13). Almost all patients disposed the used needle improperly, and the common method was disposing the needle in a dustbin and then transferring to municipal waste disposal vehicle. Insulin was accepted by just 16 (37.2%) patients. CONCLUSION: There was a significant gap between the insulin delivery recommendation through insulin pen and current insulin injection practice.

Overweight and its associated risk factors among urban school adolescents in Nepal: a cross-sectional study.

OBJECTIVES: The prevalence of non-communicable diseases is increasing in Nepal. Overweight and obesity are the major risk factors of many non-communicable diseases. Adolescence is a critical phase for development of overweight and obesity. Risk factors associated with overweight and obesity are not well understood in Nepal. The objective of the study was to identify the factors associated with overweight and obesity among adolescent students. SETTING: A cross-sectional descriptive study was carried out on higher secondary school students in the Lalitpur sub-metropolitan city, Nepal. PARTICIPANTS: A random sample of 360 students aged 16-19 years from eight schools was included in the study. RESULTS: The prevalence of overweight among adolescent students was 12.2% (95% CI 8.9 to 15.5). Factors associated with being overweight included being male (adjusted OR (AOR) 2.64, 95% CI 1.18 to 4.88), studying in private school (AOR 2.10, 95% CI 1.03 to 4.28), high socioeconomic status family (AOR 4.77, 95% CI 1.36 to 16.72), watching television for more than 2 h per day (AOR 8.86, 95% CI 3.90 to 20.11), and consuming fruit four times or less per week (AOR 3.13, 95% CI 1.39 to 7.01). There was no statistically significant association between adolescent overweight and age, ethnicity, mother's education level, mother's occupation, number of siblings or family type. CONCLUSIONS: Socioeconomic status, watching television for a longer time and consuming less fruit are major risk factors for overweight among adolescents in Nepal. Interventions are needed to increase awareness about the risk factors of adolescent overweight and obesity to decrease prevalence of overweight-associated non-communicable diseases.

Medical Humanities in Nepal: Present Scenario.

Humanities have an essential role in medical education. The current gap between the humanities and medicine has to be bridged and there should be continuous and vigorous debate about the theory and practice of medical humanities. Medical humanities is a relatively new concept even in developed countries, and is at infancy stage in developing countries. In Nepal, modules on medical humanities have been initiated in certain medical schools by enthusiastic faculties and it requires further debates for inclusion in curriculum.

Assessment of structured physical examination skills training using a retro-pre-questionnaire.

PURPOSE: The effectiveness of physical examination skills (PES) training is very rarely assessed using the "post-then-pre" approach. In this study, a retro-pre-questionnaire was used to study the effect of structured physical examination skills training (SPEST) imparted to second-year undergraduate medical students. METHODS: KIST Medical College (KISTMC) affiliated to Tribhuvan University Nepal admitted its first batch of MBBS students in November 2008. The university curriculum recommends the involvement of Medicine and Surgery Departments in PES training, but the methods for teaching and assessment are not well defined. KISTMC has made training more structured and involved the Medicine, Surgery, Gynaecology and Obstetrics, Orthopaedics, ENT, Ophthalmology, Paediatrics, and Family Medicine Departments. SPEST includes the teaching/learning of basic PES for 210 minutes once a week for 28 weeks. Self-assessment is done by using a retro-pre-questionnaire at the end of the last session of training, and these data are analysed using SPSS. RESULTS: Out of 100 students, 98 participated in the objective structured clinical examination (OSCE); 82 completed the retro-pre-questionnaire. Forty-six skills representing various systems were selected for inclusion in the retro-pre-questionnaire from among the many skills taught in different departments. The average perceived skills score (maximum score, 46×4=184) before training was 15.9 and increased to 116.5 after training. The increase was statistically significant upon the application of a paired t-test. CONCLUSION: The students perceived that their level of skills improved after the training. The retro-pre- instrument seems to be useful for assessing the learners' self-reported changes in PES after training if a large number of skills need to be assessed. However, it should be noted that although a retro-pre-questionnaire may reveal valuable information, it is not a substitute for an objective measure or gold standard.

Medical education and medical educators in South Asia--a set of challenges.

South Asia has vast unmet health needs especially in rural areas. Community-based medical education can partly address these needs and can serve to introduce students to a number of community health problems. Climate change has the potential to produce major challenges for health and food security in South Asia. Medical students should be taught about climate change and methods to tackle its impact on health. The pharmaceutical industry in South Asia aggressively promotes their products. Disease mongering is becoming more common in South Asia. Educational initiatives to sensitize students regarding promotion are common in developed countries. In Nepal, an educational initiative critically looks at the industry's promotional tactics. Similar initiatives are required in other medical schools. The nature of the doctor-patient relationship is changing. An increasing demand for patient autonomy and for their involvement in therapeutic decisions is seen. Access to the internet and internet sources of health information is increasing. Medical schools should address these issues as well. Medical Humanities modules and courses in communication skills are required. Research can play an important role in alleviating the health problems of South Asia. Students should be taught the basics of scientific research and student research should be strongly encouraged.

Smoking habits amongst house physicians working at Jinnah Postgraduate Medical Center, Karachi, Pakistan.

The objective of this study was to estimate the prevalence of smoking among house physicians working at Jinnah Postgraduate Medical Center, Karachi, Pakistan. Sixty-four (32%) of the 200 house physicians were smokers; 50% (36) had started smoking in their twenties and 44% (28) in their teens. Seventy-five per cent (48) of the smokers were influenced by friends, 20% (13) by cigarette commercials and the remainder by their parents. Ninety-five per cent (61) smoked during duty hours. The frequency of smoking among young doctors was higher than the overall prevalence of smoking in Pakistan.