The Impact of the Addition of a Virtual Reality Trainer on Skill Retention of Tourniquet Application for Hemorrhage Control Among Emergency Medical Technician Students: A Pilot Study.

INTRODUCTION: Trauma is a leading cause of preventable death in the United States. Emergency Medical Technicians (EMTs) often arrive first at the scene of traumatic injuries to perform life-saving skills such as tourniquet placement. While current EMT courses teach and test tourniquet application, studies have shown efficacy and retention of EMT skills such as tourniquet placement decay over time, with educational interventions needed to improve retention of skills. METHODS: A prospective randomized pilot study was conducted to determine differences in retention of tourniquet placement among 40 EMT students after initial training. Participants were randomly assigned to either a virtual reality (VR) intervention or a control group. The VR group received instruction from a refresher VR program 35 days after initial training as a supplement to their EMT course. Both the VR and control participants' tourniquet skills were assessed 70 days after initial training by blinded instructors.  Results: There was no significant difference in correct tourniquet placement between both groups (Control, 63% vs Intervention, 57%, p = 0.57). It was found that 9/21 participants (43%) in the VR intervention group failed to correctly apply the tourniquet while 7/19 of the control participants (37%) failed in tourniquet application. Additionally, the VR group was more likely to fail the tourniquet application due to improper tightening than the control group during the final assessment (p = 0.04).  Conclusion: In this pilot study, using a VR headset in conjunction with in-person training did not improve the efficacy and retention of tourniquet placement skills. Participants who received the VR intervention were more likely to have errors relating to haptics, rather than procedure-related errors.

The Comparative Effectiveness of Virtual Reality Versus E-Module on the Training of Donning and Doffing Personal Protective Equipment: A Randomized, Simulation-Based Educational Study.

Introduction Preventing errors in donning and doffing of personal protective equipment (PPE) is critical for limiting the spread of infectious diseases. Virtual reality (VR) has demonstrated itself as an effective tool for asynchronous learning, but its use in PPE training has not been tested. The objective of this study was to compare donning and doffing performance between VR and e-module PPE training. Methods A prospective randomized open-blinded controlled trial was conducted to determine differences in donning and doffing performance after VR and e-module PPE training among medical staff and medical students at a single institution. The primary outcome was donning and doffing performance with real PPE, assessed using a 64-point checklist. The secondary outcome was participant preparedness and confidence level after training.  Results Fifty-four participants were randomized, mostly consisting of medical students (n=24 {44%}) or emergency medicine and otolaryngology residents (n=19 {35%}). The VR group (n=27 {50%}) performed better than the control in the overall PPE scores but this was not statistically significant (mean {SD}, VR: 55.4 {4.4} vs e-module: 53.3 {8.1}; p = 0.40). VR participants also reported higher levels of preparedness and confidence after training. Residents as a subgroup achieved the highest increases after VR training compared to their counterparts in the control training group (mean {SD}, VR: 55.6 {4.9} vs e-module 48.4 {5.5}, p = 0.009).  Conclusion In this randomized trial, VR training was found to be non-inferior to e-module for asynchronous PPE training. Our results suggest that in particular residents may benefit most from VR PPE training. Additionally, VR participants felt more confident and prepared to don and doff PPE after training compared to e-module participants. These findings are particularly relevant given the ongoing coronavirus disease 2019 (COVID-19) pandemic. Future studies need to focus on VR integration into residency curriculum and monitoring for long-term skill retention.

Serous cystadenocarcinoma of pancreas.

Serous cystic neoplasms of pancreas are relatively rare tumours. Malignancy in these tumours is even more rare which is confirmed by metastasis to other organs or by perineural, vascular or surrounding soft tissue invasion. A 60 years old lady presented with vague upper abdominal pain. Computed tomography scan showed multiloculated cystic mass in the body of pancreas measuring 9 x 6 x 5 cm and not involving spleen. Pancreatectomy specimen showed a multicystic tumour having sponge-like appearance which showed vascular and soft tissue invasion of surrounding stroma on microscopic examination and was diagnosed as serous cystadenocarcinoma of pancreas.

Correlation of steatosis with fibrosis and necro-inflammation in chronic hepatitis C infection in the absence of confounding factors.

OBJECTIVE: To assess the frequency and degree of hepatic steatosis in patients of chronic hepatitis C infection and determine its correlation with stages of fibrosis and necro-inflammatory grades. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: The study was carried out in the Department of Pathology (Histopathology), Army Medical College, Rawalpindi, from March 2006 to March 2007. METHODOLOGY: Patients who had undergone a liver biopsy for evaluation of hepatitis C virus infection were included in the study. Demographic characteristics and laboratory data were collected at the time of biopsy. First hundred biopsy specimens meeting the inclusion criteria were assessed for steatosis, necro-inflammation and fibrosis. RESULTS: Steatosis was present in 46 patients and graded as mild (41.3%), moderate (54.3%) and severe (4.3%). An overall significant correlation was found between grades of steatosis with stage of fibrosis (p < 0.0001) but no correlation was found with necro-inflammatory grades. Only focal necrosis revealed weak correlation with grades of steatosis (p < 0.003). CONCLUSION: These results suggest a possible role of the hepatitis C virus itself in the pathogenesis of steatosis and indicate its close relationship with fibrosis and focal degeneration in chronic hepatitis C. Necro-inflammation seen in liver biopsy is host immune reaction to hepatitis C virus and is not related to steatosis.

Primary perisplenic hydatid cyst.

Splenic parasitic cysts due to flat worm Echinococci resulting in hydatid disease are a rare presentation as primary site even in the endemic regions. Primary splenic parasitic cysts have an incidence of 0.5-4%. A 21-year-old male with pet dogs at home, presented with 3 months history of gradually increasing discomfort in the left hypochondrium and tender splenomegaly. He had marked eosinophilia with normal liver function tests and positive serum IgM Echinococcus antibodies. Ultrasonography showed a cyst in the hilar region of spleen having septations with internal echos. An upper midline laparotomy was performed and a perisplenic cyst was removed along with spleen from the sub-diaphragmatic location. Histopathological examination confirmed acellular fibrous wall of hydatid cyst with germinal layer and scolices in the centre. Postoperatively, patient was continued on oral Albendazole for one month.

Frequency of bcl-2 gene rearrangement in B-cell Non-Hodgkin's lymphoma.

OBJECTIVE: The objective of the study was to determine the frequency of bcl-2 gene rearrangement in B-cell Non-Hodgkin's lymphoma (NHL) and identify different breakpoints of bcl-2 gene. METHODS: Thirty cases of B-cell lymphoma (including 8 cases of follicular lymphoma, 19 cases of diffuse large B-cell lymphoma and 3 cases of T-cell rich B-cell lymphoma) were included in the study. Good quality of DNA was extracted in 4 cases from formalin fixed paraffin embedded tissue and in 26 cases from fine needle aspirate. The polymerase chain reaction was done for major break point region (mbr), minor cluster region (mcr) and intermediate cluster region (icr) of the bcl-2 gene. RESULTS: The bcl-2 gene rearrangement was identified in 23.3% of B-cell lymphoma, 50% of follicular lymphoma, 15% of diffuse large B-cell lymphoma and no bcl-2 rearrangement was identified in any of the T-cell rich B-cell lymphomas. Further analysis showed the icr breakpoint in 16.7% of B-cell lymphoma, 37.5% of follicular lymphoma and 10.5% of diffuse large B-cell lymphoma. Involvement of the mbr breakpoint was found in 6.7% of B-cell lymphoma, 12.5% of follicular lymphoma, and 5.3% of diffuse large B-cell lymphoma. Involvement of the mcr breakpoint was not seen in any of the cases. CONCLUSION: The bcl-2 gene rearrangement is quite frequent in follicular lymphoma, followed by diffuse large B-cell lymphoma. The commonest breakpoint in present series is icr followed by mbr. This indicates that primers for bcl-2 gene must include icr primer, whenever the bcl-2 gene is being evaluated for B-cell NHL in this part of the world and this might reduce the variability of frequency of bcl-2 gene rearrangement within and between different regions.

Histological and immuno-histochemical study of male breast carcinoma in Northern Pakistan.

OBJECTIVE: To study routine histological as well as immunohistochemical prognostic markers including ER, PR, p-53 and Her-2/neu in male breast carcinoma and compare the above parameters with breast carcinoma in female patients of the same population. Association of the immunohistochemical markers with histological prognostic markers was also studied. METHODS: Cross-sectional descriptive study was carried out from January 2004 to May 2007 at AFIP, Rawalpindi on 55 cases of male breast carcinoma. Assessment of tumour size on gross examination followed by microscopic evaluation of tumour grade and lymph node metastasis was done. Immunohistochemistry was performed for ER, PR, Her-2/neu and p-53. RESULTS: The male breast cancer patients had a mean age at diagnosis of 57 years with a mean tumour size of 4.25cm, constituting 4.7% of malignancies in men. Infiltrating ductal carcinoma was the predominant subtype with 47 (87.3%) cases. Majority of the tumours were grade II (64.2%) followed by grade III (32.1%). Out of 28 cases with axillary clearance; lymph node metastasis was present in 20 (71%) cases. ER and PR expression was seen in 81% and 79.3% cases respectively while Her-2/neu expression was seen in 24.5%. p-53 was expressed in 14 (26.4%) patients. No association of immunohistochemical markers was seen with lymph node and tumour grade. CONCLUSION: Male breast cancer has a higher incidence and occurs in a decade younger than the Western population with a larger tumour size and higher number of patients with lymph node metastasis. Men have a higher ER, PR expression as compared to female breast cancer patients without any association with histological prognostic markers. Her-2/neu and p-53 expression in males is comparable to the West but their prognostic role in terms of survival and treatment strategies needs to be ascertained by follow up studies.

Guillain Barre syndrome: the leading cause of acute flaccid paralysis in Hazara division.

BACKGROUND: Acute flaccid paralysis (AFP) can be caused by a number of conditions. A common preventable cause is poliomyelitis which is still being reported in Pakistan, Guillain Barre Syndrome (GBS), also known as Acute Inflammatory Demyelinating Polyneuropathy, is another common cause of acute flaccid paralysis. It is important to recognize GBS in childhood as parents consider all acute flaccid paralysis to be due to poliomyelitis. The present study was designed to know the frequency of different causes of acute flaccid paralysis in Hazara division. METHODS: This is a retrospective analysis of cases of acute flaccid paralysis reported from various districts of Hazara division during the period January 2003 to December 2004. Acute flaccid paralysis was diagnosed clinically through history and clinical examination. The underlying cause of acute flaccid paralysis was investigated by appropriate laboratory tests, such as serum electrolytes, cerebrospinal fluid analysis, electromyogram, nerve conduction study and stool culture for polio virus and other enteroviruses. Diagnosis of Poliomyelitis was confirmed by stool testing for poliovirus. RESULTS: 74 patients presented with AFP during the study period. 36 were male and 38 were female. Guillain Barre syndrome and enteroviral encephalopathy were the two leading causes of acute flaccid paralysis. Majority of the cases were reported from Mansehra district. Children of age groups 12 to 24 months and > 96 months constituted the majority (20% each). CONCLUSION: Guillian Barre syndrome was the leading cause of acute flaccid paralysis reported from various parts of Hazara division.