Benefits in quality of life following an obstructive sleep apnea screening and treatment program in patients with acute ischemic stroke. / Beneficios en la calidad de vida de un programa de cribado y tratamiento de apnea obstructiva del sueño en pacientes con ictus isquémico agudo.

INTRODUCTION: Obstructive sleep apnea (OSA) has been proposed as a factor that worsens stroke prognosis. Our aim was to determine if an OSA intervention could improve quality of life (QOL, first objective) and modified Rankin score (mRS, second objective). PATIENTS AND METHODS: The intervention group of this quasi-experimental study included patients with acute ischemic stroke <72 hours who underwent polygraphy and Continuous Positive Airway Pressure (CPAP) and hygienic-dietary measures if required. The control group followed routine clinical practice. The Short Form 36 Health Survey (SF-36) and mRS were applied at the sixth month after stroke in both groups. RESULTS: Fifty-five vs. sixty-two patients were included in the intervention and control group respectively. In the intervention group, 64.71% of patients accepted the proposed CPAP (16 cases with a good adherence). An improvement in SF-36 items was detected in the intervention group: physical functioning (p = 0.008), role physical (p = 0.002), bodily pain (p = 0.008), general health (p <0.001), vitality (p = 0.001) and role emotional (p = 0.015). In a per-protocol analysis, all these improvements were verified in the group of patients treated with good CPAP adherence (p < 0.05 in all the same SF-36 items). The percentage of patients with physical component summatory = 50 was higher in the intervention group (p = 0.003). There were no differences in the median of mRS (p = 0.262). CONCLUSIONS: Although more evidence is needed, a significant improvement in QOL was suggested after our OSA intervention, particularly in patients with good CPAP adherence.

TITLE: Beneficios en la calidad de vida de un programa de cribado y tratamiento de apnea obstructiva del sueño en pacientes con ictus isquémico agudo.Introducción. La apnea obstructiva del sueño (AOS) se ha propuesto como un factor de mal pronóstico en el ictus. Pretendemos determinar si una intervención sobre la AOS puede mejorar las escalas de calidad de vida (primer objetivo) y de discapacidad (segundo objetivo). Pacientes y métodos. El grupo de intervención de este estudio cuasi experimental incluye a pacientes con ictus isquémico agudo menor de 72 horas de evolución a quienes se les realizó poligrafía, así como presión positiva continua en las vías aéreas (CPAP) y medidas higienicodietéticas si se requerían. En el grupo de control se siguió la práctica clínica habitual. Se aplicaron las escalas Short Form 36 Health Survey (SF-36) y modified Rankin Score (mRS) en el sexto mes del ictus en ambos grupos. Resultados. Se incluyó a 55 y a 62 pacientes en el grupo de intervención y en el de control, respectivamente. En el grupo de intervención, el 64,71% de los pacientes aceptó la CPAP indicada (16 casos con buena adhesión). Se detectó una mejoría en los ítems de la escala SF-36 en el grupo de intervención: funcionamiento físico (p = 0,008), rol físico (p = 0,002), dolor corporal (p = 0,008), salud general (p menor de 0,001), vitalidad (p = 0,001) y rol emocional (p = 0,015). En un análisis por protocolo, todas estas mejorías se comprobaron en el grupo de pacientes tratados con CPAP con buena adhesión (p menor de 0,05 en todos los ítems de la SF-36). El porcentaje de pacientes con el sumatorio del componente físico = 50 fue más alto en el grupo de intervención (p = 0,003). No había diferencias en la mediana de la mRS (p = 0,262). Conclusiones. Aunque se necesitan más evidencias, nuestro estudio sugiere una mejoría significativa de la calidad de vida tras nuestra intervención en la AOS, especialmente en pacientes con buena adhesión a la CPAP.

Medical students' clerkship experiences and self-perceived competence in clinical skills.

INTRODUCTION: In a traditional curriculum, medical students are expected to acquire clinical competence through the apprenticeship model using the Halstedian "see one, do one, and teach one, approach". The University of Zambia School of Medicine used a traditional curriculum model from 1966 until 2011 when a competence-based curriculum was implemented. OBJECTIVE: To explore medical students' clerkships experiences and self-perceived competence in clinical skills. METHODS: A cross-sectional survey was conducted on 5th, 6th, and 7th year medical students of the University of Zambia, School of Medicine two months prior to final examinations. Students were asked to rate their clerkship experiences with respect to specific skills on a scale of 1 to 4 and their level of self-perceived competence on a scale of 1 to 3. Skills evaluated were in four main domains: history taking and communication, physical examination, procedural, and professionalism, team work and medical decision making. Using Statistical Package for Social Scientist (SPSS), correlations were performed between experiences and self-perceived competence on specific skills, within domains and overall. RESULTS: Out of 197 clinical students 138 (70%) participated in the survey. The results showed significant increase in the proportion of students performing different skills and reporting feeling very competent with each additional clinical year. Overall correlations between experience and self-perceived competence were moderate (0.55). On individual skills, the highest correlation between experience and self-perceived competence were observed on mainly medical and surgical related procedural skills with the highest at 0.82 for nasal gastric tube insertion and 0.76 for endotracheal intubation. CONCLUSION: Despite the general improvement in skills experiences and self-perceived competence, some deficiencies were noted as significant numbers of final year students had never attempted common important procedures especially those performed in emergency situations. Deficiencies in certain skills may call for incorporation of teaching/learning methods that broaden students' exposure to such skills.

Overview of Diagnostic Reasoning: Hypothetical-Deductive Strategy; Problem Representation; Semantic Qualifiers; Illness Scripts; Pattern Recognition and Prototypes

Context: This current paper is a non-systematic review of diagnostic reasoning exclusive of the Bayesian model which we considered a decision-making stratagem. The paper reviews primarily the literature on hypothetical-deductive reasoning and pattern recognition; the two archetypes of analytical and non-analytical reasoning; respectively. Though a lot of work has been reported in this field internationally our medical training in Zambia does not overtly tackle diagnostic reasoning and expectedly not many clinicians in Zambia are acquainted with the subject matter. Nevertheless; our clinicians pass on to future generations; by apprenticeship; their diagnostic reasoning processes; but to be effective educators clinicians must understand diagnostic reasoning well. Purpose: The purpose of the current paper is threefold: 1) to share the generally accepted concepts in diagnostic reasoning in order to help clinicians become more effective educators in the clinical settings; 2) provoke clinicians and students alike to critically consider the subject of diagnostic reasoning and 3) also to inform readers about prospective research initiatives at the University which intend to investigate diagnostic reasoning practices of Zambian-educated medical graduates. Conclusions: Generally; there are three accepted diagnostic reasoning models; i.e.; hypothetical-deductive reasoning; pattern recognition; and pathognomonic recognition of signs and symptoms. These are categorised as analytical methods (principally the hypothetical-deductive strategy) and non-analytical methods (pattern recognition and pathognomonic approaches). The Diagnostic Reasoning Research - Zambia Project (DRR-Z) will be the first in Zambia to study diagnostic reasoning processes of graduates from University of Zambia School of Medicine. Clinicians who are well informed about the diagnostic reasoning process can teach it more effectively

Characterisation and Quantification of Anatomy Concepts in a Standard Clinical Methods Textbook: a Content Analysis Approach

"Aim: To analyse the nature and quantity of anatomy concepts intrinsic in a standard clinical methods textbook; used for teaching medical students clinical methods; in order to identify anatomy concepts to be taught to medical students in preparation. Methods: Five categories of anatomy indicators developed in consultation with and accepted by an international panel of anatomists were used to content analyse the 19th Edition of Hutchinson's Clinical Methods. The five categories were subdivided into two classes designated ""General Anatomy Terms"" and ""Technical Anatomy Terms"". The inter-rater reliability of coding instructions was 0.76 (P value = 0.0005). Results: A total of 17; 223 recording units were coded of which 10;162 were anatomy indicators and 6;980 were technical anatomy terms. The average total anatomy indicators ratio (TAIR = total anatomy indicators/total recording units) was 0.55 and the technical anatomy terms ratio (TATR = technical anatomy terms/total anatomy terms) was 0.68 respectively. There was variability in requirement for technical anatomical terms between the 17 different chapters in the textbook. Sixty-five anatomy themes emerged from the 17 chapters. Conclusions: These results suggest that a student cannot benefit sufficiently from Hutchinson's Clinical Methods without substantial knowledge of anatomy. The implications for medical educationists are that 1) educators must be wary of teaching methods that consider anatomy learning in a superficial and simplistic manner; and 2) educators must ensure that students attain adequate depth and scope of anatomy knowledge before or concurrently to learning clinical methods."

Teaching and Teacher Education for Health Professionals: Perspectives on Quality and Outlook of Health Professionals Education in Zambia

Purpos: To measure students' perspectives on the teaching quality of the school of medicine at University of Zambia and concurrently measure health professionals educators perspectives on the need for teaching courses for health professionals educators (educational skills training). The results are discussed as indications for educational skills training for educators in health professionals' education. Method: 250 medical students from the MB ChB programme were surveyed; in an evaluation exercise; to rate the teaching contribution of all the full-time and honorary lecturers (n=88). The students were requested to rate each lecturer out of 10 on eight scales: a) attendance; b) punctuality; c) clarity; d) interest in the subject; e) supportiveness to students; f) ability as a lecturer; g) appropriate use of audiovisual aids; and h) amount of workload done in the academic year. Additionally; a multi-site study surveyed 426 health professionals educators; defined as persons who considered themselves as continually participating in teaching students in a training institutions for health professions in the Country on the necessity for and their willingness to enroll into a teaching programme for health educators. Results: Two hundred students of the eligible 250 completed the evaluation giving a response rate of 80. The scores for teaching quality ranged from 8/ 40 to 40/40. The mean score was 32.2. The results showed that about 27.2(n=24) did not meet the merit standard which was set at 30/40 as the quality assurance benchmark by the School. This result suggests that a large proportion of teaching staff could benefit from teacher education. Four hundred and four questionnaires were completed and returned out of the 426 that had been distributed; yielding a response rate of 94.8. The Cronbach's alpha for reliability test was 0.62 - 0.70 on the teaching skills sub-scale and 0.76 - 0.78 on the Educational skills sub-scale. The majority; over 85; acknowledged they lacked expertise in educational skills and that they would enrol in a programme to improve their educational skills. There was overwhelming (90) agreement in topics to be covered. Limitations: Quality of teaching contributions only measured at school of medicine; Large proportion of educators' survey were not full-time teaching staff. Implications: The belief that professional qualifications are sufficient for preparation for teaching health professionals is now being confronted. Formal systems of teacher education in the health professions have emerged worldwide and are now also available in Zambia

A Review of Outcome of Postgraduate Medical Training in Zambia

The University of Zambia School of Medicine was opened in 1966. Since inception; over 1200 undergraduate students have graduated with Bachelor of Medicine and Bachelor of Surgery. The postgraduate Master of Medicine (M.Med)programme was started in 19822 with the intention of providing district specialists in the rural and semi urban communities of Zambia. Additional hope was to stem the brain drain to other countries. This is a study to describe the deployment of graduates of the M.Med training programs at the University of Zambia School Of Medicine in relation to the objectives defined by the University of Zambia senate in 1981. It was found that the School of Medicine has produced 118 Master of Medicine graduates in 5 clinical programs over a period of 22 years. The average graduation rate is 5 students per annum. The largest specialist group has been in General surgery with 34 (29) of all graduates. The ratio of men to women was 3 to 1. The ratio of Zambian to Non Zambian ratio was 10:1. Of all students who have graduated over this period 13 (11) have gone abroad and 7(6) have died.; Eighty-eight (75) of the graduates are working along the line of rail in the 5 most urbanized towns in the country. Twenty-five ( 21) are doing non clinical jobs which involve health programs administration and 12 (10) are working in private practice. We concluded that external migration is not a major problem and; overall; the creation of a local postgraduate training program has reduced brain drain. The key challenge is internal brain drain

Student Evaluation of Teaching: A Case Study from School of Medicine (UNZA)

Purpose: This paper presents a case study of an academic department's experience with evaluation. The purpose is to review the impact of student evaluation of teaching. The paper also introduces a new evaluation scoring method: the University of Zambia Staff Appraisal System (UNZASAS) method. Method: Anonymous 5-point Likert scale evaluation rating forms were administered to 134 third-year medical students in two consecutive years to measure students' perceptions of teaching quality of four faculty members in an academic department at School of Medicine. The rating forms were scored using the UNZASAS method. Results: The response rate averaged 83. The group average lecturer rating improved from 120 to 141.5. Individual performance of three lecturers improved while that of one declined. The UNZASAS method was effective in summarizing data to identify the areas of weakness and strength in the faculty members. The specificity and sensitivity of this method were fundamental to its success as a diagnostic tool for formative evaluation of teaching quality. Conclusions et Implications: The quality of teaching in the academic department improved after evaluation of teaching was introduced. The UNZASAS method proved to be an effective tool for scoring evaluation data and for providing faculty with useful and specific formative feedback. Health professionals training institutions can consider using the UNZASAS method for their evaluation of teaching contribution by educators

Educational status and dietary fat and anti-oxidant intake in urban subjects.

To assess correlation of dietary atherogenic and anti-atherogenic factors with socio-economic status (SES) we performed nutritional survey among 182 (122 men, 60 women) randomly selected individuals using 24 hour diet recall and a food-frequency questionnaire. SES was assessed by educational level which strongly correlated with occupational class (r = 0.55) and income levels (r = 0.88). There was significant (p < 0.05) positive correlation (r values) of educational level with intake of calories (0.55), proteins (0.19), fat (0.45), fat derived energy (en%) (0.14), saturated fat en% (0.45), linoleic acid (0.17), vitamin A (0.14), vitamin C (0.16), vitamin E (0.44), fruits and vegetables (0.34) and fibre (0.24) and negative correlation with intake of linolenic acid (-0.35), monounsaturated fat (MUFA) en% (-0.15), polyunsaturated fat (PUFA)/saturated fat (SFA) (-0.33) and MUFA/SFA (-0.42). In persons of highest educational level (> 15 years education) vs illiterates, the daily intake of SFA (29.1 +/- 15 vs 7.8 +/- 6), SFA en% (13.2 +/- 5 vs 6.7 +/- 4), linoleic acid en% (5.4 +/- 3 vs 3.9 +/- 2) and n6/n3 (24.0 +/- 58 vs 4.5 +/- 5) was more and intake of linolenic acid en% (0.7 +/- 1 vs 1.6 +/- 1), MUFA en% (8.6 +/- 7 vs 15.6 +/- 9), PUFA/SFA (0.6 +/- 1 vs 1.0 +/- 1) and MUFA/SFA (0.7 +/- 1 vs 4.0 +/- 5) was less. Intake of antioxidant vitamins A, C and E and fruits and vegetables was significantly more in better educated.

Estudio comparativo entre parto vaginal y cesárea en presentacion de nalgas

Se realiza un estudio retrospectivos de 133 partos con feto en presentación de nalgas en el hospital provincial de Cotopaxi (HPC) en un período comprendido entre enero de 1993 hasta diciembre de 1995. Se excluyó del estudio a los embarazos gemelares. Se obtuvo una incidencia de 1.99 por ciento de presentación pelviana con respecto al total de partos. El 57.14 por ciento de pacientes fueron atendidos por cesárea. Se realiza luego un estudio comparativo entre nacidos por vía vaginal y por vía abdominal. En cuanto a variables como edad materna, paridad, edad gestacional y peso al nacimiento no hay diferencia significativa, pero sin en el apgar que fue mejor en nacidos por cesárea y la morbimortalidad fetal que está aumentada en nacidos por vía vaginal.

Congenital absence of the internal carotid artery.

A case of a 27 year old male who was found to have the unusual congenital absence of one internal carotid artery is presented. A second case with similar but slightly different X-ray findings due to occlusion of the internal carotid is presented for comparison. Only forty cases of agenesis of the internal carotid artery have been found by us in the literature and this appears to be the first from Africa.