The Effect of Teaching Professionalism by Using Real Lifetime Scenarios in Undergraduate Medical Students: An Educational Trial.

Introduction: The objective of this research is to evaluate the effect of teaching professionalism by real lifetime scenario to undergraduate MBBS medical students. Methods: This comparative quasi-experimental trial was conducted in OBS/GYN department from May 2019 to Jan 2020. The final year MBBS students of Shalamar Medical and Dental College, Lahore, who attended the clinical rotation of Gynae OBS were enrolled in the study using consecutive sampling. Each batch consists of 15 students. The first two batches were taken as active control, whereas the third batch was taken as an interventional group. The certified faculty in medical education assessed professionalism by using P-MEX at the start and end of the rotation in the gynae ward. P-MEX data are presented as mean and standard deviation. The comparison between the two groups was done using independent sample t-test, and pre- and post-comparison within group was done by paired sample t-test. P-value less than 0.05 was considered as significant. Results: Among the 45 students, 28(62.22%) were male and 17(37.78%) were female. Age and gender were statistically similar in both groups. The average total score, at the start of the rotation of the intervention group was 1.95±0.294, whereas the active control group was 2.23±0.31. At the end of the rotation, the average total score of the intervention group was 3.22±0.48 and active control was 2.56±0.53. Pre- and post P-MEX score was statistically significant with P<0.001. Conclusion: This research showed that the teaching of professionalism using real lifetime scenarios led to statistically significant improvement of professionalism in the form of P-MEX mean score among final MBBS students.

Factors Leading to Diagnostic and Therapeutic Delay of Rheumatoid Arthritis and Their Impact on Disease Outcome.

Objective To identify the factors which lead to delay in diagnosis and initiation of disease-modifying anti-rheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients and their impact on disease outcome and functional ability. Methodology This cross-sectional study was conducted from June 2021 to May 2022 at the Department of Rheumatology and Immunology, Sheikh Zayed Hospital, Lahore. Inclusion criteria were patients aged >18 years who were diagnosed with RA, based on American College of Rheumatology (ACR) criteria 2010. Delay was defined as any sort of delay which leads to delay in diagnosis or initiation of treatment of more than three months. The factors and impact on disease outcome were measured by using Disease Activity Score-28 (DAS-28) for disease activity and Health Assessment Questionnaire-Disability Index (HAQ-DI) for functional disability. The collected data were analyzed with Statistical Package for Social Sciences (SPSS) version 24 (IBM Corp., Armonk, NY, USA). Results One hundred and twenty patients were included in the study. Mean delay in referral to a rheumatologist was 36.75±61.07 weeks. Fifty-eight (48.3%) patients with RA were misdiagnosed before presentation to a rheumatologist. Sixty-six (55%) patients had the perception that RA is a non-treatable disease. Delay in diagnosis of RA from onset of symptoms (lag 3) and delay in start of DMARDs from onset of symptoms (lag 4) were significantly associated with increased DAS-28 and HAQ-DI scores (p-value 0.001). Conclusion The factors which led to diagnostic and therapeutic delay were delayed consultation with a rheumatologist, old age, low education status and low socioeconomic status. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies had no role in diagnostic and therapeutic delay. Many RA patients were misdiagnosed with gouty arthritis and undifferentiated arthritis before consulting a rheumatologist. This diagnostic and therapeutic delay compromises RA management leading to high DAS-28 and HAQ-DI in RA patients.

Correlation of Hypothyroidism With Disease Activity Score-28 in Patients of Rheumatoid Arthritis.

Introduction Rheumatoid arthritis (RA) is a chronic autoimmune disorder with variable disease course including periods of flares and remissions. High disease activity in terms of disease activity score-28 (DAS-28) results in significant morbidity. Hypothyroidism is found to be associated with higher DAS-28 scores in RA. This study is planned to determine overt and subclinical hypothyroidism and its correlation with the DAS-28 score in patients with RA. Methodology This study was conducted from June 2021 to March 2022 at the department of rheumatology and immunology at Shaikh Zayed Hospital, Lahore, Pakistan. Inclusion criteria were any male and female patients aged between 18 and 70 years. The blood samples of diagnosed patients with RA were sent for thyroid function tests (thyroxine [FT4], thyroid-stimulating hormone [TSH]), and erythrocyte sedimentation rate (ESR), and the patients were categorized as overt hypothyroidism, subclinical hypothyroidism, and non-hypothyroid. The collected data were analyzed on Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY). Results The mean age of patients was 38.18 ± 9.78 years. The mean duration of symptoms was 14.65 ± 1.04 months. There were 182 (91%) females and 18 (9%) males. The mean number of swollen joints was 2.26 ± 2.8, and the mean number of tender joints was 4.16 ± 5.11. Sixty patients (30%) had high disease activity, i.e., DAS-28 score > 5.1. Fifty-seven patients (28.5%) with RA had subclinical hypothyroidism, and 19 patients (9.5%) had overt hypothyroidism. Pain visual analog scale (VAS) and DAS-28 were significantly higher in hypothyroid patients. Conclusion It was concluded that patients of RA with concomitant hypothyroidism had increased disease activity with increased tender joints. Thyroid function tests should be included in the clinical evaluation of RA patients. The evaluation of thyroid functional status must be done during screening in RA patients. This will detect thyroid disorders earlier, with early treatment initiation and possibly a better prognosis.

Assessment of Medical Professionalism among Students and Faculty Members of Shalamar Medical and Dental College, Lahore.

INTRODUCTION: Medical professionalism is an essential part of training and professional development of medical students. Unprofessional behavior in medical school may lead to professional misconduct in the future careers. The Learner's Attitude of Medical Professionalism Scale (LAMPS) is a self-assessment questionnaire. It has been used in this study to assess and compare self-reported attitudes about different domains of medical professionalism among First and Final Year students and Faculty of Shalamar Medical and Dental College (SMDC). LAMPS has been used to identify the gaps in the attitudes of medical students and professionals, which can be addressed through a training program of professionalism. METHODS: This is a cross-sectional survey conducted in SMDC from June to Dec 2018. First Year and Final Year Students and Faculty were recruited by non-probability convenience sampling. The sample size was calculated by the Cochran's Formula, keeping the level of significance at 5% and margin of error at 3%. The reliability of LAMPS using Cronbach's alpha is 0.7. It has been validated by 32 experts followed by pilot testing. The domains of professionalism were scored according to Likert Scale. The data were analyzed using SPSS 24. T-test was used for comparison of the means. RESULTS: There were a total of 204 study participants; 88 students from First Year, 78 from Final Year and 38 Faculty Members. Honor/Integrity was the most valued trait and Excellence/Autonomy was the lowest scored domain of medical professionalism. There was a significant difference among attitudes of the First and Final Year students in the domains of Excellence/Autonomy and Altruism. Excellence/Autonomy and Honor/Integrity showed a significant difference between the Final Year students and Faculty. CONCLUSIONS: Medical students and faculty have significantly different views of certain attributes of professionalism. Honor/Integrity was the most valued trait and Excellence/Autonomy was the lowest valued trait of medical professionalism.

Frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus.

OBJECTIVE: To determine the frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus in a Pakistani population, presenting at a tertiary care hospital. METHODS: This cross-sectional study was conducted at the Department of Rheumatology, Shiekh Zayed Hospital, Lahore from March to June 2018. A total of 97 patients, who fulfilled the Systemic Lupus Erythematosus (SLE) criteria of American College of Rheumatology (ACR) 1992 were enrolled. Pulmonary Arterial Hypertension (PAH) was measured by calculating pulmonary arterial systolic pressure through echocardiography by a single consultant cardiologist. Disease characteristics and demography was collected in a self-administered proforma. PAH was defined as mean pulmonary arterial pressure of 25mmHg or above by calculating with a formula. SPSS version 20 was used for analysis of data. RESULTS: Out of 97 patients, 89.7% (n=87) were females and 10.3% (n=10) were males, with mean age of 31.29± 8.824 years. The mean disease duration was 24.21 ± 30.46 months. PAH was found in 23.3% (n=23) patients, including 19 females and 4 males. On further analysis of data, Raynaud phenomenon, rheumatoid factor and nephritis were assessed as predictors of PAH and all of these showed statistical significance for presence of PAH as per Chi-square test (p<0.05). CONCLUSION: In this study, 23.3% SLE patients showed evidence of PAH and positive statistical significance was found between predictors like Raynaud phenomenon, rheumatoid factor, nephritis and presence of PAH. So it is imperative to detect PAH early and start prompt treatment to achieve better quality of life.

Case report of a lupus patient with a severe flare and miliary tuberculosis: need for proper guidelines for management.

Systemic lupus erythematosus (SLE) is an autoimmune disease that is frequently treated with high doses of corticosteroids and other immunosuppressive drugs. Thus patients with SLE are at increased risk for infections with several pathogens including Mycobacterium tuberculosis. There are no established guidelines available for treatment of tuberculosis in SLE patients with high disease activity due to lack of relevant studies and management based more on physician expertise. We report a case of a young SLE patient with high disease activity index (SLEDAI19) as evidenced by the presence of a vasculitic rash, non-healing ulcer on forearm and proteinuria of >1 g/d along with miliary tuberculosis. She was treated with intravenous methylprednisolone pulse up to 3 g and antituberculous therapy, but the result was a fatal outcome. This case report emphasizes the need for formal guidelines for co-management of active tuberculosis and SLE with high disease activity.

Undifferentiated vasculitis or an evolving systemic autoimmune rheumatic disease?

Undifferentiated connective tissue diseases usually present with arthralgias, sicca symptoms, Raynaud's phenomenon and leucopenia. This case presents the atypical presentation of an undifferentiated connective tissue disease with extensive cutaneous involvement of fingers and toes leading to gangrene with absence of typical rheumatological symptoms. The autoimmune profile showed positive ANA and anti-Ro/SS-A. Thromboembolism was ruled out on the basis of transthoracic and transesophageal echo. She was treated with I/V corticosteroids and cyclophosphamide that halted the disease progression.

Cardiovascular risk score in Rheumatoid Arthritis.

OBJECTIVE: To determine the 10-year Cardiovascular risk score with QRISK-2 and Framingham risk calculators in Rheumatoid Arthritis and Non Rheumatoid Arthritis subjects and asses the usefulness of QRISK-2 and Framingham calculators in both groups. METHODS: During the study 106 RA and 106 Non RA patients age and sex matched participants were enrolled from outpatient department. Demographic data and questions regarding other study parameters were noted. After 14 hours of fasting 5 ml of venous blood was drawn for Cholesterol and HDL levels, laboratory tests were performed on COBAS c III (ROCHE). QRISK-2 and Framingham risk calculators were used to get individual 10-year CVD risk score. RESULTS: In this study the mean age of RA group was (45.1±9.5) for Non RA group (43.7±8.2), with female gender as common. The mean predicted 10-year score with QRISK-2 calculator in RA group (14.2±17.1%) and Non RA group was (13.2±19.0%) with (p-value 0.122). The 10-year score with Framingham risk score in RA group was (12.9±10.4%) and Non RA group was (8.9±8.7%) with (p-value 0.001). In RA group QRISK-2 (24.5%) and FRS (31.1%) cases with predicted score were in higher risk category. The maximum agreement scores between both calculators was observed in both groups (Kappa = 0.618 RA Group; Kappa = 0.671 Non RA Group). CONCLUSION: QRISK-2 calculator is more appropriate as it takes RA, ethnicity, CKD, and Atrial fibrillation as factors in risk assessment score.

Frequency of metabolic syndrome in Pakistani cohort of patients with rheumatoid arthritis.

OBJECTIVE: To determine the frequency of metabolic syndrome in rheumatoid arthritis patients and its association with different factors i.e., age, gender, disease duration and treatment. METHODS: The cross-sectional study was conducted at Shaikh Zayed Hospital, Lahore, from July 2014 to June 2015, and comprised consecutive rheumatoid arthritis of either gender between the ages of 20 and 60 years. Frequency of metabolic syndrome was assessed by the National Education Cholesterol Programme 2004. SPSS 22 was used to compare the frequency of the syndrome among different treatment, age and gender groups. RESULTS: Of the 384 patients, 287(74.7%) were females, and 97(25.3%) were males with an overall mean age of 43.8±10.6 years (range: 20-60 years). Overall, 173(45.0%) patients were in >45years of age, and metabolic syndrome was found in 120 (31.3%). A negative association with metabolic syndrome was found when compared with treatment group of methotrexate alone and methotrexate in combination (p>0.05). CONCLUSIONS: Metabolic syndrome, an important risk factor for cardiovascular diseases, was more prevalent in rheumatoid arthritis patients.