Stress Ulcer Prophylaxis during Invasive Mechanical Ventilation.

BACKGROUND: Whether proton-pump inhibitors are beneficial or harmful for stress ulcer prophylaxis in critically ill patients undergoing invasive ventilation is unclear. METHODS: In this international, randomized trial, we assigned critically ill adults who were undergoing invasive ventilation to receive intravenous pantoprazole (at a dose of 40 mg daily) or matching placebo. The primary efficacy outcome was clinically important upper gastrointestinal bleeding in the intensive care unit (ICU) at 90 days, and the primary safety outcome was death from any cause at 90 days. Multiplicity-adjusted key secondary outcomes were ventilator-associated pneumonia, Clostridioides difficile infection, and patient-important bleeding. RESULTS: A total of 4821 patients underwent randomization in 68 ICUs. Clinically important upper gastrointestinal bleeding occurred in 25 of 2385 patients (1.0%) receiving pantoprazole and in 84 of 2377 patients (3.5%) receiving placebo (hazard ratio, 0.30; 95% confidence interval [CI], 0.19 to 0.47; P<0.001). At 90 days, death was reported in 696 of 2390 patients (29.1%) in the pantoprazole group and in 734 of 2379 patients (30.9%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.85 to 1.04; P = 0.25). Patient-important bleeding was reduced with pantoprazole; all other key secondary outcomes were similar in the two groups. CONCLUSIONS: Among patients undergoing invasive ventilation, pantoprazole resulted in a significantly lower risk of clinically important upper gastrointestinal bleeding than placebo, with no significant effect on mortality. (Funded by the Canadian Institutes of Health Research and others; REVISE ClinicalTrials.gov number, NCT03374800.).

REVISE: Re-Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol.

INTRODUCTION: The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS: REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION: All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER: NCT03374800.

Teaching the Teacher: Assessing Barriers to Identity Formation of Clinical Teachers in a Developing Country.

PHENOMENON: Clinical teachers' identity formation is understudied in developing countries like Pakistan. Despite producing thousands of international medical graduates per year, Pakistani medical education is still in its infancy. The application of Western medical education methods and theories is beset by unique socio-cultural challenges. These must be identified and addressed to ease our physicians' transition from clinician to teacher and maximize their teaching output in a resource-limited setting. APPROACH: Eight clinical teachers were interviewed from Combined Military Hospital Kharian, Punjab, Pakistan in July 2020. Semi-structured questionnaires were used, and interviews were audio-taped to generate transcripts. These were analyzed qualitatively and coded, developing themes regarding barriers to identity formation. FINDINGS: Six themes reflected possible barriers to identity formation and fell under two domains: individual and systemic issues. At the individual level these themes were: conflicting priorities, lack of autonomy, and language barriers. Systemic issues were found to be: disconnect between educationists and teachers, the absence of incentives, and lack of institutional support. INSIGHT: Identifying barriers to identity formation can aid clinical teachers' development and encourage discourse around providing increased institutional support to teachers to overcome said barriers. Both the individual and the institute are stakeholders in the process of identity formation and dialogue between the two can lead to improved teaching outcomes.

Obstructive Sleep Apnoea in Pakistan: A Single Tertiary Care Center Experience.

INTRODUCTION: Considerable interest has been shown in the field of sleep medicine in recent decades. Obstructive sleep apnoea (OSA) is a common condition that remains neglected in most parts of the world. Data are scarce, if any, when it comes to developing countries. We sought to describe the patient population in a single private tertiary care center from such a country. MATERIALS AND METHODS: A cross-sectional study that included a total of 203 patients over a five-year period was conducted. Polysomnographic studies were conducted in a dedicated sleep laboratory, under the supervision of sleep physicians. Data were described and analyzed based on clinical and self-reported outcomes, as well as polysomnographic characteristics, and compared them between genders and severity. RESULTS: With the participants having an average age of 50.84 years and a BMI of 34.7 kg/m2, the study found that the increase in age and BMI was significantly correlated with an increase in the severity of obstructive sleep apnea in the Pakistani population. There was a significant difference in sleep latency (20.6 min in women vs. 10.8 min in men; p-value = 0.001) and efficiency (63.7% in women vs. 69.8 in men; p-value = 0.02) between the two genders. Decreases in nadir saturation, total sleep time, and sleep latency were also associated with an increase in the level of severity. CONCLUSION: There is a dire need for Pakistani, and in extension Asian, medical professionals to ramp up their pace to meet the needs of their population with regard to sleep medicine.

Experience with Ambulatory Management of Pleural Pathologies Utilizing Small-Bore Indwelling Pleural Catheters.

Introduction Pleural effusion is the excess fluid that accumulates in the pleural space. Pneumothorax is the collection of free air in the pleural cavity, while empyema is the collection of pus in the pleural cavity. Such pleural pathologies pose a great challenge to patients and health care professionals alike. While multiple management options exist, the major portion of it is carried out in the inpatient setting. We sought to evaluate the ambulatory use of indwelling pleural catheters for pleural pathologies, including malignant pleural effusion, empyema, and primary spontaneous pneumothorax. Methods We conducted a prospective case series analysis of 15 patients with various pleural pathologies in which an indwelling pleural catheter was placed by interventional radiologists on an outpatient basis and subsequently followed-up in a pulmonary clinic. Results were analyzed on the basis of clinical, as well as radiological progress with parameters being complete, partial, or no resolution. We also obtained prospective data on the quality of life of these patients. Results Six out of seven patients with malignant pleural effusion reported clinical (complete or partial) resolution, while three reported radiological (complete or partial) resolution. Two of the three patients with nonmalignant pleural effusions reported complete clinical as well as radiological resolution. All three patients with empyema reported complete clinical resolution and partial radiological resolution, while both patients with primary spontaneous pneumothorax reported complete clinical and radiological resolution. Patients reported preserved or improved quality of life with the whole process managed on an outpatient basis. Conclusion We report a high rate of clinical and radiological resolution in various pleural pathologies in our study, which is first of its kind from this part of the world. It demonstrates the feasibility of ambulatory management of pleural pathologies with a multidisciplinary approach.

A Simplified MCQs Interpretation Guide for Faculty.

OBJECTIVE: To devise a guide for faculty to interpret Psychometric Analysis of MCQs followed by its assessment. STUDY DESIGN: Across-sectional study. PLACE AND DURATION OF STUDY: Shifa College of Medicine, Islamabad, from January to July 2009. METHODOLOGY: A simplified interpretation guide comprising of a visual format and an interpretive summary was designed for faculty members to help them understand the item analysis of the MCQs in an uncomplicated way. A feedback from the faculty was obtained after administration to see the results. RESULTS: Eighty five percent of course coordinators (n=14) agreed that they could understand the MCQ analysis. Eight percent (n=3) faculty strongly, while 82% (n=13) agreed that analysis is helping them to refine the process of MCQ making. Forty five percent (n=7) faculty agreed that analysis of MCQ was helpful in identifying knowledge gaps in students. All the course coordinators agreed that they found the revised format easy to understand. CONCLUSION: The faculty found the interpretation guide for MCQs user-friendly and helpful.

Delivering endocrinology and reproduction in an integrated modular curriculum.

OBJECTIVE: To ascertain the perceptions of students and faculty of Shifa College of Medicine, Islamabad regarding the delivery of Endocrinology and Reproduction module as a component of the newly introduced Integrated Modular Curriculum. METHODS: A descriptive study, using mixed qualitative and quantitative method, starting from June 6 to August 15 2008. A period of 10 weeks was spent on the study including 8 weeks of planning, 2 weeks of delivery and assessment and a 2 weeks period of post hoc analysis and data collection. A multidisciplinary team of faculty developed themes, clinical cases, objectives and table of specification of the Endocrinology and Reproduction Module for Fourth Year MBBS Class. Continuous assessment was done by theme-based assignments and student presentations. Summative assessment was done by Multiple Choice and Short Answer Questions. Likert scale-based student feedback questionnaire was administered while the students were also encouraged to comment on the module for improvement. Feedback was obtained from the faculty in a similar manner. RESULTS: Out of a class of 86 students, 47 (55%) agreed to a balance between basic and clinical concepts addressed in the module, 21 (24%) agreed that emphasis on clinical concepts was appropriate, 37 (43%) agreed that learning strategies were well integrated, 50 (58%) were of the opinion that the assigned learning material was consistent with the session objectives, while 39 (45%) agreed that case-based instruction was useful, and 40 (47%) students were of the opinion that large group discussion was useful. Faculty feedback was positive towards integrated learning. CONCLUSIONS: Integrated Endocrinology and Reproduction module received mixed response from students. This led us to modify and tailor the curriculum to better cater for the needs of students. Feedback from students and faculty is essential for improvement in the quality of educational interventions.

Online role-playing for faculty development.

BACKGROUND: There has been a rapid growth of online teaching in the past few years, yet the implementation of role-play for formal educational activities in an online setting is growing more slowly. The use of online role-playing for the development of health professions educators is virtually un-documented in the literature. INNOVATION: In the project reported here we use role-playing as a method to motivate and increase active participation in an online web-based discussion on community-based medical education (CBME). The Foundation for Advancement of International Medical Education & Research (FAIMER(®) ) Institute hosts virtual group discussions for fellows as part of its fellowship programmes, in order to deepen their knowledge base in health professions education and research. In June 2008, a group of seven FAIMER(®) fellows and faculty members moderated an online discussion on CBME using an online role-play exercise with other fellows and faculty members. RESULTS: Out of a total of 102 fellows, 36 (35.3%) participated actively, which exceeded the typical percentage of list server participation. In addition, a rich discussion resulted in a comprehensive report on the goals, challenges, logistical components, role of Health Ministry policy and the possible ethical mandate of CBME in developing countries. CONCLUSION: Online role-play encouraged distributed participation among a highly diverse international group of participants, supporting the conclusion that role-playing can be used effectively with mid-career health professional faculty members in the online environment.

Competency-based integrated practical examinations: Bringing relevance to basic science laboratory examinations.

BACKGROUND: The practical examinations in subject-based curriculum have been criticized for lack of relevance and clinical application. We developed competency-based integrated practical examinations (IPEs) for first two years incorporating basic science principles with clinical relevance in our integrated curriculum. AIM: To bring relevance to basic science laboratory practical examinations by conducting competency-based IPEs. METHODS: IPEs were developed according to competency-based blueprinting for each integrated module. Clinical scenarios were used as triggers followed by tasks pertaining to laboratory tests, relevant physical diagnosis and ethics/professional aspects utilizing standardized patients. Checklists were developed for standardized marking. A feedback questionnaire and two focus group discussions were administered to a random group of students from both first and second year students. Faculty members' feedback was also recorded on a questionnaire. RESULTS: Almost all the students agreed that IPE was a useful experience. Eighty-nine percent agreed that it was a fair examination and elicited a lesser degree of psychological stress. Eighty-two percent agreed that IPE encouraged critical thinking and application of knowledge. However, students suggested better organization and longer duration of stations. Faculty members also liked the experience. CONCLUSION: In conclusion, IPEs were well-received and valued both by students and faculty members.

Experience with a theme-based integrated renal module for a second-year MBBS class.

Integrated learning is the need of the hour. We at Shifa College of Medicine switched to an integrated modular curriculum last year. In the present article, we describe our experience with the renal module in year 2 of a 5-yr undergraduate medical curriculum. A multidisciplinary renal modular team developed the relevant objectives, themes, and clinical cases. The learning strategies used were large-group interactive sessions, small-group learning, problem-based learning, practicals, and self-directed learning. Assessment was both formative and summative. Student and faculty feedback questionnaires were administered at the end of the module. Forty-four percent of the students agreed that the basic science and clinical concepts were well balanced and integrated. Fifty-seven percent of the students believed that important learning issues could be identified and that participation and critical thinking were encouraged during the small-group sessions. Eighty-five percent of the facilitators agreed that they were able to motivate students for critical thinking and better learning through integrating various disciplines. In conclusion, the integrated method of curricular delivery was well received by students and faculty members, and it can be used successfully in undergraduate medical education in developing countries.

Percutaneous tracheostomy in critically ill patients: 24 months experience at a tertiary care hospital in United Arab Emirates.

OBJECTIVE: We assessed the safety and complications related to percutaneous tracheostomy (PCT) without bronchoscopic guidance in our intensive care unit (ICU). METHODS: The prospective data over a period of 24 months were collected for patients who underwent PCT. Major, minor and long-term complications were recorded. The parameters recorded were: age, gender, Glasgow Coma Scale (GCS) score on the day of tracheostomy, acute physiology and chronic health evaluation II (APACHE) score, and predicted mortality based on score on admission and on the day of procedure, number of days on ventilator before and after the procedure, total number of days in the hospital before the final outcome, number of successful decannulations and mortality. The patients were stratified in two groups of survivors and nonsurvivors. RESULTS: A total of 117 patients underwent PCT. Overall mean GCS and APACHE-II scores before PCT were 7 ± 3 and 16 ± 5, respectively. The only significant difference was APACHE-II score and the predicted mortality based on APACHE-II score on the day of PCT, which was higher amongst the nonsurvivors (P = 0.008 and P = 0.006). All 57 (49%) survivors were successfully decannulated with mean post tracheostomy days of 24 ± 15. The major complication observed was three episodes of major bleeding. Only six patients had an episode of desaturation during the procedure and there were three episode of accidental puncturing of endotracheal (ET) tube pressure cuff. During subsequent follow-up in hospital, six patients developed stomal cellulitis. CONCLUSIONS: PCT without bronchoscopic guidance can be performed safely by carefully selecting patients and having an experienced team High APACHE score on the day of procedure may lead to poor outcome.

Assessment of knowledge about evidence based medicine in medical students and doctors in a Pakistani health care setting.

BACKGROUND: Evidence based practice promotes self assessment and ensures delivery of up to date care to patients. The concept of Evidence Based Medicine (EBM) in developing countries is still in its infancy where strong opinions drive patient care. METHODS: We conducted a cross sectional survey to explore the knowledge, perceptions and attitudes regarding EBM in final year medical students and physicians of our institution. The survey was distributed to all students and residents of the college and the affiliated hospital. RESULTS: The response rate was 57% (74/130). Seventy-one percent (53/74) of respondents were not aware of EBM. Out of these, 38 were medical students and 15 were house officers. Only 16 (9 students and 7 doctors) admitted that they had heard about EBM. Those who heard about EBM recognised its importance in patient care. Teaching at both under- and postgraduate level was strongly suggested. Participants recognised the need for EBM skills and expertise. Financial constraint was considered as the main hindrance in practicing EBM. CONCLUSION: The concept of EBM is still alien to most of the students and residents at our institution. There is need for incorporating formal teaching of EBM at all levels of medical education.

Making evidence-based medicine (EBM) doable in developing countries: a locally-tailored workshop for EBM in a Pakistani institution.

OBJECTIVE: To demonstrate that evidence-based medicine (EBM) training can be imparted in developing countries using minimal resources. DESIGN: Development of a minimal cost workshop with validation of gain in EBM skills using the Berlin questionnaire. SETTING: Teaching hospital in Pakistan. PARTICIPANTS: Multidisciplinary faculty from The Shifa College of Medicine and Nursing, Pakistan. INTERVENTION: A 14-hour locally-tailored McMaster-style workshop, using a problem-based, learner-focused small group format, with pre- and post-workshop evaluation of EBM skills. RESULTS: Analysis of the pre- and post-Berlin questionnaires of the participants revealed that the pre-workshop Berlin questionnaire score for the group was 4.7+/-2.3, with a post-workshop Berlin score of 7.6+/-1.0 (p<0.001). CONCLUSION: EBM workshops can be locally-tailored in developing countries, where access to such workshops is generally not available. Workshops can serve to promote EBM skills in faculty, who can then help to disseminate and model concepts. The process increases awareness and interest in EBM, which in this case resulted in formation of a national platform for EBM.

Revising an objective structured clinical examination in a resource-limited Pakistani Medical School.

INTRODUCTION: The objective structured clinical examination (OSCE) has not been used extensively in undergraduate medical education in resource-constrained locations, including Pakistan. The Shifa College of Medicine (SCM) in Islamabad modified an end-of-clerkship OSCE assessment in internal medicine for final year medical students from a previous static, pattern-recognition format to an interactive, clinical reasoning and skill-based format. METHODS: We modified the OSCE to be more dynamic and effective by creating a customized clinical skills laboratory, using standardized patients, developing competency checklists for OSCE stations, and stimulating more active participation from faculty members. Students were surveyed at the end of their medicine clerkship about the OSCE's organization, content, perceived utility and validity and its stressfulness. Faculty involved in the modified format also reported their perceptions in an open-ended survey. RESULTS: The modified format was generally received positively by students and faculty. Twenty-eight percent of students found the OSCE to be stressful, which is a lower proportion than reported in the literature in other settings. Students suggested that OSCEs should be given more frequently and come with clearer instructions, and they indicated a need for better training in counseling skills. Responses from faculty were generally positive even though the modified format was regarded as more labor-intensive and time-consuming. CONCLUSION: The OSCE, in its true sense, can be created and successfully implemented to assess the clinical skills of medical students in a resource-limited setting in the developing world.

Low haemoglobin levels, its determinants and associated features among pregnant women in Islamabad and surrounding region.

OBJECTIVE: To estimate the haemoglobin levels in pregnant women and to determine the socio-demographic factors associated with anaemia in pregnancy. PATIENTS AND METHODS: In this cross-sectional survey, a total of 200 patients visiting prenatal clinic of Shifa International Hospital/Shifa Foundation Community Health Centres, Islamabad over the period of six months, both booked and non-booked were included. A detailed questionnaire was filled and complete blood count, peripheral smear and absolute values were performed in all cases. Haemoglobin levels (Hb) of women below 10.5g/dl were considered to be low (anaemia) and were further subjected to urine/stool routine examination. Cases of thalasaemia trait were excluded from the study. All the data was entered in SPSS v 10.0. Descriptive analysis was done obtaining frequencies for socio-demographic factors. Mean haemoglobin levels along with standard deviation and confidence interval were reported. Frequency of helminthic infestation of suspected cases was also reported. Analysis included any significant differences in mean haemoglobin levels of booked versus non-booked cases. RESULTS: Mean haemoglobin of our study population was 11.0 +/- 1.64 g/dl. Frequency of decreased haemoglobin was found to be in 42.5%. Mean haemoglobin of patients having income less than Rs5000 was 10.5 +/- 1.24 g/dl and those with income more than Rs5000/month had a mean Haemoglobin of 11.5 +/- 1.44g/dl. Mean haemoglobin of patients with history with or without pica eating was 10.1 +/- 1.31g/dl and 11.9 +/- 1.56g/dl respectively. CONCLUSION: Low haemoglobin was commonly seen in our population among pregnant women irrespective of their socioeconomic status. The severity of anaemia was significantly associated with lower socioeconomic status and odd eating habits.

Intralobar pulmonary sequestration: a masqurader in tuberculosis prevalent population.

Intra pulmonary sequestration is a rare congenital disorder that is characterized by malformation of pulmonary tissue having no connection to normal tracheobronchial tree and pulmonary arteries. This is a case history of 20 years old man initially misdiagnosed as Tuberculosis and later diagnosis of intra-lobar pulmonary sequestration was confirmed. There are few reports of this rare disorder globally and we are reporting the first case of Intrapulmonary Sequestration in Pakistan.

The structure and function of a new clinical skills and medical informatics laboratory (SCIL) in a developing country--a two year institutional experience.

OBJECTIVE: To combine clinical skills and medical informatics learning by offering a combined 'SCIL' rotation to third year medical students and to determine its long-term impact. METHODS: A combined clinical skills and medical informatics laboratory (SCIL) was set up at our institution with international collaboration. Nine months to one year after formal third year SCIL rotations were conducted, a questionnaire rated on (1-5) Likert Scale was administered to the inaugural class undergoing this rotation. RESULTS: The rotation was rated positively in terms of both acquisition of clinical skills as well as medical informatics skills. (overall rotation rating: 3.32 +/- 0.53) CONCLUSION: Our results have shown the positive long-term impact on undergraduate medical students of a combined clinical skills and medical informatics rotation.

Efficacy and safety of total dose infusion of low molecular weight iron dextran in the treatment of iron deficiency anemia during pregnancy.

OBJECTIVE: To determine the efficacy and safety of Total Dose Infusion (TDI) of low molecular weight iron dextran for the treatment of iron deficiency anemia compared to oral iron replacement during pregnancy through improvement in hemoglobin (Hb) after intervention. STUDY DESIGN: Non-randomized control trial. PLACE AND DURATION OF STUDY: Section of Gynaecology and Obstetrics, Shifa International Hospital and Shifa Community Health Centre, Islamabad during January 2005 to January 2006. PATIENTS AND METHODS: A group of 100 pregnant women with gestational age greater than 12 weeks with confirmed diagnosis of iron deficiency anemia attending the antenatal clinics were enrolled in this study. Total dose iron infusion of low molecular iron dextran was given to these patients after calculating iron deficit, in a monitored in-patient setting. Control comprised of a second group of 50 pregnant females matched for age, parity and baseline hemoglobin, tolerant to oral iron supplementation (ferrous sulphate 200 mg three times a day) attending the antenatal clinics during the same period. Post-treatment hemoglobin levels of study group as well as the oral control group were determined between 3 to 4 weeks. RESULTS: In the intervention group, mean pre-infusion hemoglobin level was 8.57 +/- 0.9 gm/dl (range 5-10.5 gm/dl) and mean post-infusion Hb was 11.0 +/- 1.1 (range 8.4-14.3 gm/dl). In control group, mean pre-oral intake Hb level was 9.5 +/- 0.9 gm/dl (range 7-10.5 gm/dl) and mean post-oral intake Hb was 10.2 +/- 1.2 gm/dl (range 6.4-12.8 gm/dl). Mean increase of Hb in intervention group was 2.43 gm/dl (95% CI 2.4 - 3.8) and for controls it was 0.7 gm/dl (95% CI 0.6-2.3). Flushing and palpitations were observed in 4% of interventional group patients and none in the control group. No significant adverse reactions were observed in either group. CONCLUSION: We conclude that the total parenteral iron replacement with low molecular weight iron dextran is an effective and safe method for the treatment of iron deficiency anemia in a selected group of pregnant women.