University Pre-Professional Program: A Transitional Phase from Didactic to PBL Pedagogy.

Purpose: The College of Science and Health Professions offers the University Pre-Professional Program (UPPP) to newly enrolled students. This study aimed to evaluate the effectiveness of the program in preparing students to become self-directed learners and to seek students' perceptions about student-centered teaching. Methods: A quantitative quasi-experimental study that used a pre and post-test survey in two stages, before and after semester-4. A self-developed questionnaire was distributed online. Results: The t-test showed students (n=701) after semester-4 had a significant increase in the understanding of Problem-Based Learning (PBL) (t (699) = -8.27, p < 0.01), PBL dynamics (t (699) = -5.12, p < 0.01), learning and dynamics of Case-Based Learning (CBL) and Self-Directed Learning (SDL) (t (699) = -6.48, p < 0.01), and facilitators' role in such curriculum (t (699) = -3.41, p < 0.01). The ANOVA showed students attending various courses perceived the program variables differently (Learning in PBL p = 0.08, PBL dynamics p < 0.01, CBL and SDL dynamics p < 0.01, role of facilitator in PBL p < 0.01). Regarding the resources used by students during the basic medical sciences courses, no significant difference was observed between the study groups (p = 0.06). However, the only significant difference observed was in their satisfaction with the question related to assessment and course (p < 0.01). Conclusion: The UPPP improved students' understanding of student-centered teaching and learning approaches, especially the PBL. Thus, UPPP helps students shift their learning habits from didactic to student-centered modern learning approaches. Variation among different students' groups could be attributed to their previous academic background and change in learning medium to English. This study suggests that preparatory teaching programs like UPPP are helpful for students interested in joining the bachelor's programs in countries like Saudi Arabia where English is not a native language.

Learning clinical skills through audiovisual aids embedded in electronic-PBL sessions in undergraduate medical curriculum: perception and performance.

Learning clinical skills in a large group of undergraduate medical students is challenging. Innovative technology-based modalities are being evaluated to complement limited hospital rotations. We determined the effectiveness of clinical skills-related audiovisual (AV) aids embedded in electronic-problem-based learning (PBL) sessions, in terms of students' feedback and formative Objective Structured Clinical Examinations (OSCE) grades. This mixed-method study was conducted during the Cardiovascular System module in year 3 of the Bachelor of Medicine, Bachelor of Surgery program. The AV aids, mainly consisting of abnormal chest auscultation sounds, were linked to the cases for the intervention group. The control group received only a description of clinical signs. Sessions were conducted using an intranet platform. At the end of the module, feedback was obtained from intervention group students and faculty using a self-administered questionnaire. The learning was compared between intervention and control groups through an OSCE. Finally, focus group interviews were conducted to explore factors underlying deviation from the expected results. Out of 110 intervention group students, 86 (78%) responded. The students appreciated the inclusion of AV aids, as suggested by a high average satisfaction score of 4.2 (SD 0.8). They agreed that, apart from being appropriate and relevant, the aids improved the learning environment and engagement in the process. The tutors also gave a similar feedback. However, no difference in the OSCE scores was found between control and intervention groups. The study indicates that inclusion of AV aids improved students' engagement and classroom environment in electronic-PBL sessions, but did not improve diagnostic abilities based on the learned clinical skills.

Use of beta blockers is associated with hearing loss.

OBJECTIVE: This study was conducted to investigate the hypothesis that patients using ß-blockers will develop hearing loss. DESIGN: A cross-sectional study. STUDY SAMPLE: A total of 125 patients completed the study. A total of 63 patients were on ß-blockers and 62 were not on ß-blockers. RESULTS: Carvedilol was significantly associated with hearing loss. Other beta-blockers including metoprolol and atenolol showed no association with hearing loss. Linear multiple regression analysis was run including variables of gender, age, ischaemic heart disease, cardiac failure/dilated cardiomyopathy, frusemide and carvedilol use as predictors for total hearing loss severity at all frequencies. Age and gender, as well as carvedilol, were found to be the only statistically significant predictors for hearing loss severity. CONCLUSION: Chronic use of carvedilol was associated with significant hearing loss. This may need to be taken into account when prescribing the drug. Further randomised controlled studies with baseline audiometric hearing tests before starting treatment, and periodic follow-up tests, would provide a better assessment of the effect of carvedilol on hearing.

Do general practitioners know what they are prescribing?

A cross-sectional study was conducted to explore general practitioners' (GPs) knowledge regarding the major therapeutic use and adverse effects of drug(s) they prescribe. Three drugs namely tablet Montelukast Sodium, tablet Somatriptan and inhaler Fluticasone Propionate were selected from the list of drugs approved by the Ministry of Health in Pakistan. GPs who had prescribed at least one of the three were inquired about the cost, therapeutic use and one common adverse effect. For each question, one correct option and three distracting options were given. Two hundred and ninety four responses of 131 GPs were included in the final analysis. The correct options for therapeutic use and adverse effect were identified by 61.2% (n = 180) and 40.8% (n = 120) respectively. A statistically significant (p < 0.01) deficit of knowledge regarding adverse effects was observed for those GPs who identified pharmaceutical advertisements as their primary source of information for new drugs and those who were less experienced.

Comparision of obstetric outcome among teenage and non-teenage mothers from three tertiary care hospitals of Sindh, Pakistan.

OBJECTIVE: To compare the obstetric outcome of teenage pregnancies with that of non teenage pregnancies. METHODS: A prospective case-control study was conducted in three tertiary care hospitals of Sindh, Pakistan from September 2008 to November 2008. The data regarding obstetric outcome of all teenagers (13-19 years) delivering in the three hospitals was compared with that of selected non teenage women (20 to 35 years) taken as controls. Chi-square and students' t-test were applied with 0.05 as level of significance. RESULTS: Teenage mothers were more likely to suffer from severe anaemia (8% versus 4.3%; p = 0.03) and chorioamnionitis (2.8% vs 0.8%, p = 0.01) and their infants were more likely to suffer from post maturity (4.6% vs 1.8%, P = 0.02) and meconium aspiration syndrome (6.5% vs 2.4%, p < 0.01) compared to non-teenage mothers. On the other hand they were less likely to be overweight than the non-teenagers. Teenagers had instrumental deliveries more often than non-teenagers (7.1% vs 2.2%, p < 0.01). The risk of preterm delivery, low birth weight infant, respiratory distress syndrome, foetal and perinatal death was not significantly different in the two groups. CONCLUSION: Teenage mothers are at a higher risk of developing severe anaemia and chorioamnionitis. They are more likely to have an instrumental delivery than non-teenagers. Post maturity and meconium aspiration syndrome are the neonatal complications seen in infants born to teenage mothers.

Home deliveries: reasons and adverse outcomes in women presenting to a tertiary care hospital.

OBJECTIVE: To identify the reasons and adverse outcomes of home deliveries in women presenting to a tertiary care hospital. METHODS: A prospective, descriptive study was undertaken in the Department of Obstetrics and Gynaecology, Unit III, Civil Hospital Karachi from 1st April, 2007 to 31st August, 2007. All patients who were admitted with any complication of home delivery during this period were included in the study. Patients and/or their attendants were interviewed to collect data regarding age, parity, sociodemographic characteristics, reasons for home delivery, presenting complaints and complications of home delivery. The data was recorded on structured questionnaires, analyzed by SPSS version 16 and presented as frequencies and percentages. RESULTS: The mean age of patients was 26 +/- 5.3 years and the median parity was 2. The majority of the patients were Urdu-speaking (57.5%) followed by Sindhi (20.3%) and Balochi-speaking (11.9%). Eighty-seven percent of women had received either no or just primary education. The two most frequent reasons quoted for home deliveries were family tradition in 190 (72.8%) and lack of affordability in 179 women (68.6%). Postpartum haemorrhage was the main adverse outcome in 132 women (50.6%) followed by retained placenta/placental pieces in 74 women (28.4%). CONCLUSION: The main reasons for having a home delivery are family tradition and poor socioeconomic condition of the family and the most important adverse outcomes of home delivery are postpartum haemorrhage and retained placental tissue.

Reasons of refusal and drop out in a follow up study involving primigravidae in Pakistan.

OBJECTIVE: To determine the reasons underlying the refusals to participate and drop outs from a follow up study involving primigravidae. DESIGN: A descriptive study. METHODS: Aga Khan University and Aga Khan Hospital for Women, Karachi, jointly initiated a nested case-control study on primigravidae for determining the predictability of preeclampsia using various biochemical markers in blood. The protocol-eligible study subjects were counseled along with their accompanying family members to participate in the study. All women recruited in this study were followed up throughout their pregnancy till delivery. RESULTS: One thousand six hundred and sixty-five primigravidae were identified as the potential study subjects. Out of which, 1,307 (78.5%) consented and 358 (21.5%) refused to participate in the study. The most common reason underlying the refusal was inability to get permission from the family members (n=84; 34.4%) followed by fear of prick (n=51; 20.9%). For 114 refusals, either the reason was not mentioned by the counseled women (n=60) or the data was missing (n=54). Out of 1,307 women recruited in the research, only 611 (46.7%) women completed the study according to the prescribed protocol. Among the rest, 102 (7.8%) subsequently withdrew from the research, 503 (38.5%) were dropped out, and 91 (7.0%) were lost to follow up. CONCLUSIONS: Refusal to participate and drop out from the research program are two significant factors hindering the smooth flow of a study. In Pakistan, the major reason for the refusal by the protocol-eligible pregnant women for participating in a research program is the unwillingness of the family members.

Critical appraisal of apparently evidence-based written advertising in Pakistan.

OBJECTIVES: The objective of the study was to critically assess references cited in support of claims in drug advertisements. METHODS: Drug advertising brochures were collected from privately practicing General Practitioners from different parts of Karachi. Three blinded reviewers then categorized each reference in the brochure according to the sources viz: journals (both Medline indexed and non-indexed), medical reference books, web addresses, personal communications or testimonials, abstracts presented at symposia/conferences, WHO and National Health Guidelines, 'data on file' and 'others' (which included a diverse set of references). Each reviewer then assessed and analyzed the references further into 2 broad categories: traceable and non-traceable. Traceable references were appraised and, depending upon the claim with which the reference was attached, were classified into justifiable, inaccurate/false, exaggerated and ambiguous. RESULTS: We collected a total of 175 different brochures. Thirty-nine (22.3%) brochures did not cite any references and were not subjected to further analysis. The remaining 136 (77.7%) contained a total of 559 references. 305 (54.6%) of these references were from Medline-indexed journals; 67 (12.0%) were from non-indexed journals; 55 (9.8%) references quoted medical reference books; 27 (4.8%) references cited web addresses; 12 (2.1%) references were personal communications/testimonials; 11 (2.0%) references referred to abstracts presented at symposia/conferences; 12 (2.1%) references were from WHO and National Health Guidelines; 8 (1.4%) references were listed as 'data on file', while the remainder that could not be defined were classified as 'others' (13.1%). Out of a total of 559 references, 249 (44.5%) could not be traced. After critically analyzing the 310 traceable references, 197 (63.5%) were adjudged justifiable, 30 (9.7%) inaccurate/false, 79 (25.5%) exaggerated and 15 (4.8%) ambiguous. CONCLUSION: Results of this study show for the first time that the claims substantiated with references in the pharmaceutical advertisements in Pakistan are highly unreliable.

Critical evaluation of the claims made by pharmaceutical companies in drug promotional material in Pakistan.

BACKGROUND: In Pakistan, there is no mechanism to monitor the drug promotional campaign by pharmaceutical industry despite the fact that there is enough evidence that irrational pharmacotherapy is increasingly encountered even in the developed countries due to unethical practices of pharmaceutical promotion. Objectives. To audit the drug promotional claims made by the pharmaceutical companies in Pakistan. METHODS: Drug promotional pamphlets and brochures containing claims for the drugs, which were circulated by the pharmaceutical representatives were collected from 122 general practitioners (GPs) from Karachi and Larkana cities of the Sindh Province. The claims were critically analyzed and audited with the help of currently available evidence in the medical literature. RESULTS: 345 distinct advertisements covering 182 drugs from different manufacturers were critically analyzed for information content. Sixty two out of 345 (18%) of the reviewed advertisements were adjudged to be misleading / unjustifiable, which were again classified as, exaggerated (32%), ambiguous (21%), false (26%), and controversial (21%). The primary source of information (approximately 78%) about the newly launched drugs for the GPs was found to be the pharmaceutical representatives followed by hospital doctors (5%) and colleagues (5%). Furthermore, 110 (90%) GPs were of the view that the drug promotion has definitely an influence on their prescribing pattern. CONCLUSIONS: Since GPs in Pakistan rate pharmaceutical companies as their primary source of information regarding drugs, it can be anticipated that inappropriate advertisement claims would lead to irrational prescribing if physicians had no any other information to follow.

Low extracellular Cl- environment attenuates changes in intracellular pH and contraction following extracellular acidosis in Wistar Kyoto rat aorta.

This study was conducted to investigate the influence of extracellular Cl- ([Cl-]o) on the intracellular pH (pHi) regulation and the contractile state of the isolated aorta from Wistar Kyoto (WKY) rats. Isometric tension recording and fluorometry techniques were utilized to measure contractile response and pHi in isolated aortic strips. Decreasing extracellular pH (pHo) from 7.4 to 6.5 produced a marked contraction, which was 75.8 +/- 5.6% of the 64.8 mmol/l KCl-induced contraction. The acidosis-induced contraction was significantly attenuated in low [Cl-]o solution, the magnitude of which was 56.0 +/- 3.0% of the 64.8 mmol/l KCl-induced contraction. Decreasing pHo of the normal solution to 6.5 rapidly decreased pHi in aortic smooth muscle cells and produced a corresponding contraction. When the pHo was decreased in low [Cl-]o solution, a rapid fall in pHi followed by reversal of pHi changes, in a time-dependent manner was observed, despite low pHo. Omission of HCO3- from the low [Cl-]o solution restored the contractile response to acidosis, which was comparable to that in normal solution. Similarly, following decrease in pHo to 6.5, no recovery of intracellular acidosis was observed. We conclude that low [Cl-]o environment causes activation of extracellular HCO3- -dependent pHi-regulating mechanism, that results in the rapid recovery of pHi following acidosis, and the attenuation of acidosis-induced contraction of WKY aorta.

Acidosis-induced relaxation of human internal mammary artery is due to activation of ATP-sensitive potassium channels.

Metabolic acidosis is associated with various clinical situations including diabetes mellitus and renal diseases. The aim of this study was to investigate the effects of acidosis on the resting as well as precontracted human left internal mammary artery. The vessels were obtained from the patients undergoing coronary artery bypass grafting surgery at The Aga Khan University Hospital, Karachi. Left internal mammary artery was cut into rings and isometric tension recording experiments were performed. Decrease in pH of the bathing solution from 7.4 to 6.8 had no effect on the resting tension of left internal mammary artery, whereas, acidic pH markedly relaxed the contractions to 24.8 mM KCl and 300 nM phenylephrine. Interestingly, when the KCl- or phenylephrine-contracted rings were treated with 3 microM glibenclamide; an inhibitor of ATP-sensitive potassium (K(ATP)) channels, the relaxant effect of acidosis was abolished. Similarly, acidosis failed to cause relaxation of 100 nM endothelin-1-induced contraction in Ca2+-free bathing solution or in the presence of a voltage-dependent Ca2+ channel inhibitor, verapamil (10 microM), whereas, endothelin-1-induced contraction was attenuated by acidosis in Ca2+-containing normal solution. From all these data, it is concluded that under the acidic pH conditions, opening of K(ATP) channels occurs; resulting in the hyperpolarization, decrease in Ca2+ influx via voltage-dependent Ca2+ channels and subsequent relaxation of human left internal mammary artery.

Reliability of rodent animal models in biomedical research.

Despite the discrepancies observed between the data generated from humans and animals, it is a usual practice that the results obtained from animal models are extrapolated on humans. This review stresses that while animal models are essential for the research and development, a critical caution needs to be practiced in interpreting the results. Uncritical reliance on the results of animal experimentation can be dangerously misleading and has resulted in damages to human health in several cases. This review also discusses the role of certain confounding factors in using animal models due to which appropriate precautions need to be taken while deciding to conduct a study using animal models and caution is warranted in extrapolating the data obtained from pre-clinical studies on humans.

Acidosis-induced protein tyrosine phosphorylation depends on Ca2+ influx via voltage-dependent Ca2+ channels in SHR aorta.

The contractile response to acidosis in isolated aorta from spontaneously hypertensive rat (SHR) depends upon tyrosine phosphorylation of phosphatidylinositol 3 kinase (PI3-kinase) and Ca2+ influx via voltage-dependent Ca2+ channels (VDCC). In this study, verapamil, a VDCC inhibitor, was shown to markedly inhibit acidic pH-induced contraction, whereas the residual contraction in the presence of verapamil was unaffected by the PI3-kinase inhibitor, 2-(4-morpholinyl)-8-phenyl-4H-1-benzopyran-4-one hydrochloride (LY-294002). Interestingly, the LY-294002-insensitive component of contraction was further inhibited by verapamil in the presence of LY-294002. Western blotting revealed that acidosis stimulated tyrosine phosphorylation of p85, which was abolished when tissues were pretreated with tyrphostin 23, a tyrosine kinase inhibitor, verapamil or EGTA. In fura-2-loaded aortic strips, acidosis induced a rise in intracellular Ca2+ ([Ca2+]i) that was partially inhibited by LY-294002. The residual increase in [Ca2+]i caused by acidosis in the presence of LY-294002 was abolished by verapamil. These findings suggest that acidosis-induced Ca2+ influx through VDCC is the upstream event leading to the tyrosine phosphorylation of PI3-kinase, which in turn contributes to the enhancement of Ca2+ entry to some extent in SHR aorta.