A randomised controlled trial study on the effectiveness of high-fidelity simulation in enhancing skills among undergraduate medical students.

INTRODUCTION: High-fidelity simulation (HFS) provides a high level of interactivity and realistic experience for the learner by means of using full scale computerised patient simulators. It imitates clinical experience in a controlled and safe environment that closely resembles reality. The purpose of this study was to compare the efficacy of HFS versus video-assisted lecture (VAL) based education in enhancing and consolidating retention of skills among undergraduate medical students. MATERIALS AND METHODS: A randomised controlled trial (RCT) study involving 111 undergraduate medical students was conducted where the competency of skills was assessed by objective structured clinical examination (OSCE) in the first, fourth and seventh/eighth weeks. A cohort of 12-14 students was enrolled for each session. The randomisation of the participants into control (VAL-based teaching) and intervention (HFS-based teaching) groups was achieved by implementing the computer-based random sequence generation method. VAL-based teaching module was a fully interactive face-to-face teaching session where a prerecorded video clip was used. The video clip detailed the diagnosis of tension pneumothorax in an acute medical emergency and its management by performing needle decompression on a high-fidelity patient simulator (METIman). HFS-based teaching module was delivered as a fully interactive hands-on training session conducted on the same METIman to demonstrate the diagnosis of tension pneumothorax in an acute medical emergency and its management by performing needle decompression. OSCE scores were compared as the denominator of learning (enhancement and retention of skills) between two groups who underwent training with either VAL-based or HFS-based teachings. The OSCE assessments were used to evaluate the participants' performance as a group. These scores were used to compare the enhancement and medium-term retention of skills between the groups. The outcome was measured with the mean and standard deviation (SD) for the total OSCE scores for skills assessments. We used General Linear Model two-way mixed ANOVA to ascertain the difference of OSCE marks over assessment time points between the control and the intervention groups. ANCOVA and two-way mixed ANOVA were used to calculate the effect size and the partial Eta squared. p value less than 0.05 was taken to be statistically significant. RESULTS: The two-way mixed ANOVA showed no statistically significant difference in mean OSCE scores between intervention and control groups (p=0.890), although the mean score of the intervention group was better than the control group. CONCLUSION: Our study demonstrated that HFS was not significantly effective over VAL-based education in enhancing skills and consolidating retention among undergraduate medical students. Further research is needed to determine its suitability for inclusion in the course curriculum considering the cost-effectiveness of implementing HFS that may supplement traditional teaching methods.

Evaluation of a simple intervention to reduce exchange transfusion rates among inborn and outborn neonates in Myanmar, comparing pre- and post-intervention rates.

BACKGROUND: In Myanmar, approximately half of all neonatal hospital admissions are for hyperbilirubinaemia, and tertiary facilities report high rates of Exchange Transfusion (ET). The aim of this study was to evaluate the effectiveness of the pilot program in reducing ET, separately of inborn and outborn neonates. METHODS: The study was conducted in the Neonatal Care Units of four national tertiary hospitals: two exclusively treating inborn neonates, and two solely for outborn neonates. Prior to intervention, no high intensity phototherapy was available in these units. Intervention in late November 2011 comprised, for each hospital, provision of two high intensity LED phototherapy machines, a photo radiometer, and training of personnel. Hospital-specific data were assessed as Relative Risk (RR) ratios comparing ET rates pre- and post-intervention, and individual hospital results were pooled when appropriate. RESULTS: In 2011, there were 118 ETs among inborn neonates and 140 ETs among outborn neonates. The ET rate was unchanged at Inborn Hospital A (RR = 1.07; 95 % CI: 0.80-1.43; p = 0.67), and reduced by 69 % at Inborn Hospital B (RR = 0.31; 95 % CI: 0.17-0.57; p < 0.0001). For outborn neonates, the pooled estimate indicated that ET rates reduced by 33 % post-intervention (RRMH = 0.67; 95 % CI: 0.52-0.87; p = 0.002); heterogeneity was not a problem. CONCLUSION: Together with a photoradiometer and education, intensive phototherapy can significantly reduce the ET rate. Inborn Hospital A had four times as many admissions for jaundice as Inborn Hospital B, and did not reduce ET until it received additional high intensity machines. The results highlight the importance of providing enough intensive phototherapy units to treat all neonates requiring high intensity treatment for a full course. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001171505 , 2 November 2015.

Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals.

BACKGROUND: Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13-20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression. RESULTS: Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5). CONCLUSION: The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta.

BACKGROUND: Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy. METHODS: We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre. RESULTS: Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%). CONCLUSION: In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.

[Confirmation of a prenatal diagnosis of trisomy 13 with comparative genomic hybridization (CGH)]. / 13-as trisomia praenatalis diagnózisának megerósítése comparativ genomialis hybridisatio (CGH) módszerrel.

Trisomy 13 was diagnosed with genetic amniocentesis in a fetus of a 50 years old patient. Fetopathologic examination has shown cyclopy, proboscis and semilobar holoprosencephaly of the fetus, which is consistent with Patau syndrome. DNA was extracted from frozen liver tissue. Result of comparative genomic hybridization (CGH) was consistent with trisomy 13. They processed the DNA according Kallioniemi's method with modifications. CGH was developed for cancer genetics in mid 90s and now it is widely used in prenatal diagnosis too. CGH allows global analysis to detect unbalanced chromosome gains and losses in the whole genome in a single experiment without the need for cell culture. Significant results can be expected in those cases where conventional cytogenetics is not able to provide an answer either because postmortem tissue is not appropriate for cytogenetics or because the chromosomal change is sub-microscopical. CGH is a fluorescent in situ hybridization on a healthy target metaphase, with equal amount of competitive hybridization of green labelled digested test DNA and red labelled digested control DNA. Red to green ratio is assessed with the help of an image analyser. Green dominance represents chromosome gain, while red shift chromosome loss. In the paper they present the fetopathologic report of a trisomy 13 fetus and illustrate the method being the first Hungarian obstetric case diagnosed by CGH.

The role of comparative genomic hybridisation in prenatal diagnosis.

The aims of this study were to assess the feasibility of using comparative genomic hybridisation instead of conventional cytogenetics in prenatal diagnosis and to determine the size of DNA loss that can be detected. Using comparative genomic hybridisation, six cases with standard aneuploidies were diagnosed correctly. This technique clearly identified a partial duplication of the long arm of chromosome 1 but was not capable of detecting the associated inversion. A small interstitial deletion on short arm of chromosome 10 also was detected precisely. Although the current comparative genomic hybridisation resolution is similar to the sensitivity of the highest resolution G banding, the latter is not a routine strategy in prenatal diagnosis. Comparative genomic hybridisation can allow full chromosome assessment equal to the highest resolution cytogenetic studies without the need for cell culture.

An assessment of the use of interphase FISH with chromosome specific probes as an alternative to cytogenetics in prenatal diagnosis.

We have assessed the effects that would have been observed if we had changed from standard prenatal diagnosis to interphase fluorescence in situ hybridization (FISH) on our amniocentesis samples. We aimed to estimate the number of cases with aberrations other than chromosomes 13, 18, 21, X and Y, which would not have been detectable by FISH and to assess the potential clinical implications for these cases. In 1687 prenatal diagnoses, 111 cases had abnormal cytogenetic reports (6.5% aneuploidy rate). Out of those 111 cases, 14 had chromosomal abnormalities not detectable by FISH but four of these had major structural abnormalities diagnosed on ultrasound, which would have lead to counselling of a very poor prognosis anyway. In 10 cases without abnormal ultrasound findings, if FISH had been used rather than cytogenetics, it appears that there may have had no detrimental effects on the clinical outcomes of the cases studied. Out of those 10 cases, two pregnancies were terminated because of abnormal cytogenetic results (one was due to maternal age and the second one was due to abnormal biochemical screening) (mosaic 46,XY, /47,XY,+mar and 46,X,del(8)(p21) respectively) and their post-mortem results also did not show any abnormalities. One pregnancy was continued in spite of a de novo chromosomal rearrangement and resulted in an apparently normal live birth. Five cases (including a set of twins) with inherited balanced translocations resulted in four normal live births and one unexplained intrauterine death at 32 weeks' gestation and post-mortem was declined. One case with a paternally derived abnormal chromosome 21, decided to continue the pregnancy and resulted in a normal live birth. The last case in this group resulted in a rhesus related intrauterine death in the second trimester, and although an abnormal chromosome 13 insertion (paternally derived known aberration) there was no abnormality found at post-mortem. Therefore, we suggest that it is reasonable to use FISH as an alternative prenatal diagnosis for indications such as advanced maternal age and abnormal maternal serum biochemical screening when high quality ultrasound scanning is performed, but FISH should only be used as an additional test to conventional cytogenetics for the other indications, especially when abnormalities are found on ultrasound scan.

The application of comparative genomic hybridization to previously karyotyped cervical cancer cell lines.

This investigation is concerned with the application of comparative genomic hybridization (CGH) to DNA from previously fully karyotyped cervical cancer cell lines using G-banding and fluorescence in situ hybridization (FISH) to compare the chromosome copy numbers observed in karyotypes with the profile shifts seen in CGH analysis. It has demonstrated that diploid DNA can be used as a reference to cohybridize with a test sample of any modal number because of the proportional representation of every chromosome arm and region in equal volumes of both test and reference DNAs. Profile shifts in the near-diploid line gave a clear indication of over and under-representation of either the whole or parts of chromosome arms. In near-tetraploid samples, profile shifts, either gain or loss due to copy number changes from four to five, five to six, or four to three were smaller and were not always seen; however, the points of profile shift would have allowed us to work out most of the breakpoints if karyotype information had not been available. The profiles, however, did not provide accurate information on the ploidy status; this would need to be measured by other means for the CGH data to be interpreted correctly. The 3q and 8q gain in all the squamous cell carcinoma cell lines appeared very clearly. Comparative genomic hybridization revealed a new breakpoint at 7q31 which was not detected originally on the karyotype in DE3. A breakpoint on 9q was reassigned on the basis of the profile shift from 9q13 to 9q22 in JE6. Clarification of the origin of a small fragment from chromosome 20 constantly present in JE6 showed it to be 20q22-qter.

Selective cleaning of the cell debris in human chromosome preparations studied by scanning force microscopy.

The chromosome structure is one of most challenging biological structures to be discovered. Most evidence about the structure comes from optical microscopy. Scanning force microscopy (SFM) can achieve molecular resolution and allows imaging in liquids. However, little information about the chromosome structure has been revealed by SFM. In this work, a mild enzymatic treatment is applied to the chromosomes to remove selectively the RNA and proteins coming from the cell. The resulting SFM images indicate that a protein film with embedded RNA molecules covers chromosomes in standard cytogenetic preparations. The thickness of the protein layer is 15-35 nm and the RNA adheres preferentially to the chromosome surface. The cell material film results in a quite smooth chromosome surface without evidence of any structural detail. After treatment, the chromosome was cleaned from cell residues and individual chromatin fibers at the surface were resolved. Furthermore, insights about the higher order structure of the chromosome can be inferred.

Antenatal invasive therapy.

The value of fetal therapy relates to the balance of benefit versus risk taking into account alternatives such as post-natal therapy. Since this balance is also determined by the natural history and prognosis of a given condition, the fact that any condition diagnosed pre-natally has a worse prognosis than the same condition diagnosed post-natally will be described. On this basis we classify the interventions into those that are clearly of benefit in the right cases, those that are possible now but are still being assessed and other experimental ideas.

Specificity of radioiodinated MIBG for neural crest tumors in childhood.

UNLABELLED: The high sensitivity of metaiodobenzylguanidine (MIBG) scintigraphy for sympathomedullary tumors such as neuroblastoma and pheochromocytoma is well documented. The specificity of MIBG scintigraphy for these tumors is also high but has been incompletely characterized for other neural crest tumors and non-neural crest tumors of childhood. METHODS: The medical records and MIBG scans of all children who had undergone MIBG scintigraphy for known or suspected neuroblastoma or pheochromocytoma were retrospectively reviewed at five major referral centers. Those patients found to have pathologies other than neuroblastoma or pheochromocytoma form the basis of this study. RESULTS: One hundred children with a total of 110 lesions met the inclusion criteria. All had negative MIBG scans except 1 of 2 children with infantile myofibromatosis, 1 of 2 with neuroendocrine carcinomas, 1 of 2 with pancreaticoblastomas and 1 of 10 with primitive neuroectodermal tumors. CONCLUSION: MIBG scintigraphy is highly specific for neuroblastoma and pheochromocytoma. Only 4% (4/100) of nonsympathomedullary tumors (non-pheochromocytoma and non-neuroblastoma) in childhood showed MIBG uptake, of which only 2% (2/100) were of non-neural crest origin.

Molecular cytogenetic analysis of five newly established cervical cancer cell lines using G banding and fluorescence in situ hybridization.

Cervical tumors nearly all have complex karyotypes and more precise cytogenetic information is required to establish whether specific rearrangements occur, and if they are related to the type of HPV infection found. The karyotypes of five recently established cervical cancer cell lines, three from squamous cell carcinomas (two HPV 16 +ve and one HPV 18 +ve), one from an adenocarcinoma (HPV -ve), and one from an adenosquamous carcinoma (HPV 16 +ve), have been analysed using fluorescence in situ hybridization (FISH), with 23 chromosome specific paints, YACs and cosmids as probes, in addition to conventional G banding, in order to identify markers and clarify the breakpoints. Chromosomes 1 and 3 were rearranged in all cell lines. Breakpoints in the squamous lines were all in 3q. but in different regions. Small metacentrics involving chromosome 5 were a del(5q) in one line, and a t(X;5) in another, rather than i(5p). The region 6q21 was involved in three cases and chromosome 9 was rearranged in four. An i(8q) was found in three squamous carcinoma cell lines. Structural changes of 11q were found only in two cases, but a marker 11 representing amplification in the 11q14-22 region was duplicated in the adenosquamous line.

Knowledge, attitudes and practices of mothers on childhood acute respiratory infections (ARI).

A total of three hundred mothers in both rural and urban areas were interviewed and their knowledge, attitude and practice (KAP) on acute respiratory infections (ARI) were compared. It was observed that KAP on ARI of mothers in both categories was almost the same with the exception of their health care seeking practice. Most had traditional beliefs as to the cause of ARI with only a minority knowing the causes. Only one third of mothers knew signs and symptoms of pneumonia; the majority had not experienced the fatal danger sign, chest indrawing and could not recognize it. As regards health care seeking practices, private general practitioners were identified as favorite health providers in urban areas. Utilization of government health facilities was higher among rural mothers. Self medication was found to be common in both categories of mothers, with western medicine being the top of the list.