Feasibility and Effectiveness of Mini-Clinical Evaluation Exercise (Mini-CEX) in an Undergraduate Medical Program: A Study From Pakistan.

Background In clinical settings, direct observation (DO) with feedback is an effective method to assess and improve learner performance. One tool used for DO is the mini-clinical evaluation exercise (Mini-CEX). We conducted a study to assess the effectiveness and feasibility of Mini-CEX for medical students at Aga Khan University, Karachi. Methods Utilizing a purposive sampling technique, a total of 199 students in six core clerkships of Years 3 and 4 were selected for this study. Participating faculty underwent training workshops for use of Mini-CEX and feedback strategies. Each student was assessed twice by one faculty, using a modified version of the Mini-CEX, which assessed four domains of clinical skills: Data Gathering, Communication, Diagnosis/Differential, and Management Plan and Organization. Feedback was given after each encounter. Faculty and students also provided detailed feedback regarding the process of DO. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA), with categorical variables arranged as frequencies and percentages. The Chi-squared test was used for further statistical analyses, and a P-value of < 0.05 was considered statistically significant. Effectiveness was assessed via a change in student performance between the first and second Mini-CEX, and feasibility was assessed via qualitative feedback. Results We obtained three sets of results: Mini-CEX forms (523), from which we included a total 350 evaluations for analysis, 216 from Year 3 and 134 from Year 4, and feedback on DO: student (70) and faculty (18). Year 3 students performed significantly better in all foci of the Mini-CEX between the first and second assessment (P ≤ 0.001), whereas in Year 4, significant improvement was limited to only two domains of the Mini-CEX [Communication of History/Physical Examination (P = 0.040) and Diagnosis/Differential and Management Plan (P < 0.001)]. Students (65.7%) and faculty (94.4%) felt this exercise improved their interaction. 83.3% faculty recommended its formal implementation compared to 27.1% of students, who reported challenges in implementation of the Mini-CEX such as time constraints, logistics, the subjectivity of assessment, and varying interest by faculty. Conclusion Direct observation using Mini-CEX is effective in improving the clinical and diagnostic skills of medical students and strengthens student-faculty interaction. While challenges exist in its implementation, the strategic placement of Mini-CEX may enhance its utility in measuring student competency.

Association of trinucleotide repeat polymorphisms CAG and GGC in exon 1 of the androgen receptor gene with male infertility: a cross-sectional study.

BACKGROUND: : Infertility is a global problem that brings about serious sexual and social consequences that strain the health sector and society. The expansion of CAG and GGC repeats in androgen receptor (AR) gene (Ensembl number ENSG00000169083) may lead to reduced fertility. Our objective was to determine the association of CAG and GGC repeats with altered sperm parameters in male infertile subjects. METHODS: This was a cross-sectional study conducted at Aga Khan University, Karachi, Pakistan. A total of 376 males were recruited, out of which group A (N = 208) and group B (N = 168) were comprised of subjects with normal and altered sperm parameters, respectively, from 18 to 60 years. The numbers of CAG and GGC repeats were determined by using PCR amplification and sequence analysis using the Molecular Evolutionary Genetic Analysis (MEGA) software version 6.0. Statistical analysis was performed using the SPSS version 20 and the P-value of <0.05 was considered significant. RESULTS: The mean androgen receptor gene CAG repeats were significantly longer in males with altered sperm parameters as compared to male subjects with normal sperm parameters (P < 0.001). There was no significant difference found for GGC repeats for subjects with altered sperm parameters. DISCUSSION: Longer CAG length corresponded to greater severity of spermatogenic defect and may lead to subfertility recommendations.

Estimation of folic acid/micro nutrients levels; Does it reflect sperm parameters.

OBJECTIVE: To study the impact of vitamin B12, folic acid (FA) and methylmalonic acid (MMA) on sperm parameters; count, motility and morphology leading to male fertility. METHODS: The cross-sectional study comprised of one hundred and eighty-six subjects with normal sperm parameters (fertile) and 88 subjects with abnormal sperm parameters labelled as "infertile" from a sample population of Karachi, Pakistan. Vitamin B12, FA and MMA levels in serum were analysed by enzyme linked immune sorbent assay. Unadjusted and adjusted prevalence ratio with their 95% CI were reported by using cox regression algorithm to assess the association of Vitamin B12, FA and MMA and other factors with male Infertility. Unadjusted and adjusted beta coefficients with 95% CI were reported by using linear regression analysis for assessing relationship of Vitamin B12, FA and MMA and other factors with semen parameters (count, motility and morphology); P value of <.05 was considered significant. RESULTS: It was declared that with every 1 unit increase in vitamin B12, FA and MMA the prevalence of infertility was decreased by 1%, 17% and 74%, respectively. Multivariate analysis revealed that vitamin B12, FA and MMA had a significant association with total sperm count, motility and morphology. The sperm parameters were also affected by increase in; LH, BMI and body fat %. There was a significant positive correlation of; LH with Vitamin B12 and FA (0.423 < 0.001, 0.338 < 0.001) and testosterone with vitamin B12 and FA (0.326 < 0.001, 0.291 < 0.001), respectively. CONCLUSION: All the studied micronutrients; Vitamin B12, FA and MMA had a positive effect on sperm parameters; count, motility and morphology and the associated reproductive hormones which explains their role on reproductive functions required to acquire fertility.

Association of trinucleotide repeat polymorphisms CAG and GGC in exon 1 of the Androgen Receptor gene with male infertility: a cross-sectional study.

BACKGROUND: Infertility is a global problem that brings with serious sexual and social consequences that strain the health sector and society. The expansion of CAG & GGC repeats in androgen receptor (AR) gene Ensembl number; ENSG00000169083 may leads to reduced fertility. Our objective was to determine association of CAG and GGC repeats with altered sperm parameters in male infertile subjects. MATERIALS AND METHODS: It was a cross sectional study conducted at Aga Khan University, Karachi Pakistan. A total of 376 males were recruited, out of which group A (N=208) and group B (N=168) comprised of subjects with normal and altered sperm parameters respectively from 18 to 60 years. Numbers of CAG and GGC repeats were determined by using PCR amplification and sequence analysis using Molecular Evolutionary Genetic Analysis (MEGA) software version 6.0. Statistical analysis was done using SPSS version 20 and p-value of < 0.05 were considered significant. RESULTS: The mean androgen receptor gene CAG repeats were significantly longer in males with altered sperm parameters as compared to male subjects with normal sperm parameters (p< 0.001). There was no significant difference found for GGC repeats for subjects with altered sperm parameters. CONCLUSIONS: Longer CAG length corresponded to greater severity of spermatogenic defect and may lead to subfertility recommendations.

Oxidative stress and male infertility: a cross sectional study.

OBJECTIVE: To compare stress markers and antioxidants in fertile and infertile males, and to explore their effects on reproductive hormones and fertility. METHODS: The cross-sectional case-control study was conducted from July 2017 to July 2018 at the Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan, and comprised male subjects aged 25-55 years. Infertile subjects were the cases, while healthy fertile males acted as the controls. Stress hormones cortisol and adrenaline and antioxidants glutathione peroxidase and superoxide dismutase were measured using enzyme-linked immunosorbent assay. Data was analysed using SPSS 22. RESULTS: Of the 376 subjects, 241(64%) were cases and 135(36%) were controls. Median cortisol, adrenaline, superoxide dismutase and glutathione levels were significantly higher among the cases compared to te controls (p<0.05). Follicle stimulating hormone and luteinizing hormone levels were higher in cases compared to the controls (p=0.05). Mean testosterone level was higher among the controls than the cases (p<0.001). After adjusting for other covariates, every increase of 7 units in cortisol increased the prevalence of infertility by 3% (p=0.001). There was significant interaction between luteinizing hormone and testosterone in the final model (p<0.05). CONCLUSIONS: Stress together with decrease in antioxidants was found to play a significant role in reducing the fertilising potential of male infertile subjects.