Establishing links between assessments and expected learning outcomes through curriculum mapping in a dental physiology curriculum.

Background: . The relevance of curriculum mapping to determine the links between expected learning outcomes and assessment is well stated in the literature. Nevertheless, studies confirming the usage of such maps are minimal. Methods: . We assessed links through curriculum mapping, between assessments and expected learning outcomes of dental physiology curriculum of three batches of students (2012-14) at Melaka-Manipal Medical College (MMMC), Manipal. The questions asked under each assessment method were mapped to the respective expected learning outcomes, and students' scores in different assessments in physiology were gathered. Students' (n = 220) and teachers' (n=15) perspectives were collected through focus group discussion sessions and questionnaire surveys. Results: . More than 75% of students were successful (≥50% scores) in majority of the assessments. There was moderate (r=0.4-0.6) to strong positive correlation (r=0.7-0.9) between majority of the assessments. However, students' scores in viva voce had a weak positive correlation with the practical examination score (r=0.230). The score in the assessments of problem-based learning had either weak (r=0.1-0.3) or no correlation with other assessment scores. Conclusions: . Through curriculum mapping, we were able to establish links between assessments and expected learning outcomes. We observed that, in the assessment system followed at MMMC, all expected learning outcomes were not given equal weightage in the examinations. Moreover, there was no direct assessment of self-directed learning skills. Our study also showed that assessment has supported students in achieving the expected learning outcomes as evidenced by the qualitative and quantitative data.

An Unusual Cause of Recurrent Syncope - A Large Free-Floating Left Atrial Thrombus.

Rheumatic heart disease is the most common valvular heart disease in developing countries. Recurrent syncope due to a large, free-floating left atrial thrombus is a rare presentation of rheumatic mitral stenosis. We report this uncommon finding on echocardiogram in an elderly woman presenting to the emergency department with giddiness for the past few months.

Optical coherence tomography characterization of spontaneous recanalized coronary thrombus - Single center experience.

Introduction: Recanalized thrombus is an under diagnosed clinical entity. Aim was to investigate the utility of optical coherence tomography (OCT) in identifying spontaneously recanalized thrombi (SRCT) for management in clinical practice. Methods: This was a retrospective study analyzing 2678 coronary angiograms over a 4-year period which included intravascular imaging guidance in 75.8% of the percutaneous coronary interventions (PCI). Angiographic suspicion of SRCT has hazy appearance seen in 34 patients. Results: Eight patients (7 males and 1 female) were confirmed with SRCT on OCT and two underwent intravascular ultrasound (IVUS). Median age was 52 years (range 33-67 years). Based on clinical symptoms, diagnosis was STEMI-2, NSTEMI-1, unstable angina-3 and chronic stable angina-2. Angiographic patterns were veiled/hazy appearances in 3; braided in 2; pseudo dissection in 2; and near occlusion in 1 patient. OCT findings displayed multiple small cavities, signal-rich with high backscattering and thin septa with smooth inner borders dividing the lumen and intercommunications. Presence of multiple holes conferred typical "Swiss cheese" or 'lotus root' like appearance, characteristic of recanalized thrombi. SRCT lesion length was (median interquartile ranges [IQR], 16.5[12.07-21.5] mm) and minimal luminal area (median [IQR], 1.77 [0.93-3.26] mm2) with significant stenosis (median [IQR], 74.0[67.0-81.0] %). Minimum/maximum number of channels were (median [IQR], 2.0[2.0-2.0]) and (median [IQR], 4.50[4.0-6.75]) respectively. Lipid rich plaque was predominant. IVUS demonstrated echo-lucent channels with small cavities. All but one patient underwent PCI. Conclusion: Intravascular imaging by OCT delineates the characteristics of recanalized thrombi and distinguishes ambiguous lesions. Majority of the lesions involving SRCT were significant both symptomatic and stenosis severity wise on OCT requiring PCI.

Unusual Presentation of a Rapidly Progressive Coronary Artery Pseudoaneurysm after Drug Eluting Stent Placement.

Infected coronary artery aneurysm (CAA) is a rare complication of percutaneous coronary intervention (PCI) and is associated with high morbidity and mortality. The management of infected CAA is unclear and is based on the clinical and imaging features. We report an interesting case of a giant infected right CAA secondary to Pseudomonas aeruginosa within four weeks of a drug eluting stent (DES) implantation. Chronological analysis of the coronary angiograms and computed tomography coronary angiography revealed rapid progression in the size of the aneurysm from small to a giant CAA over a period of four weeks. Patient remained afebrile throughout the hospital stay without any signs of septicaemia. In view of the rapid progression in size, surgical aneurysmal ligation with distal revascularisation was done with good post-operative recovery. Afebrile presentation of an infected CAA is very rarely reported in the literature as in our case. Early diagnosis using multimodality imaging and immediate surgical intervention are the cornerstone in the management of giant infected CAAs.

Gender-based in vivo comparison of culprit plaque characteristics and plaque microstructures using optical coherence tomography in acute coronary syndrome.

Introduction: Women perform worse after acute coronary syndrome (ACS) than men. The reason for these differences is unclear. The aim was to ascertain gender differences in the culprit plaque characteristics in ACS. Methods: Patients with ACS undergoing percutaneous coronary intervention for the culprit vessel underwent optical coherence tomography (OCT) imaging. Culprit plaque was identified as lipid rich,fibrous, and calcific plaque. Mechanisms underlying ACS are classified as plaque rupture, erosion,or calcified nodule. A lipid rich plaque along with thin-cap fibroatheroma (TCFA) was a vulnerable plaque. Plaque microstructures including cholesterol crystals, macrophages, and microvessels were noted. Results: A total of 52 patients were enrolled (men=29 and women=23). Baseline demographic features were similar in both the groups except men largely were current smokers (P <0.001). Plaque morphology,men vs. women: lipid rich 88.0% vs. 90.5%; fibrous 4% vs 0%; calcific 8.0% vs. 9.5% (P = 0.64). Of the ACS mechanisms in males versus females; plaque rupture (76.9 % vs. 50 %), plaque erosion (15.4 % vs.40 %) and calcified nodule (7.7 % vs. 10 %) was noted (P = 0.139). Fibrous cap thickness was (50.19 ±11.17 vs. 49.00 ± 10.71 mm, P = 0.71) and thin-cap fibroatheroma (96.2% vs. 95.0%, P = 1.0) in men and women respectively. Likewise no significant difference in presence of macrophages (42.3 % vs. 30%, P = 0.76), microvessels (73.1% vs. 60 %, P = 0.52) and cholesterol crystals (92.3% vs. 80%, P = 0.38). Conclusion: No significant gender-based in-vivo differences could be discerned in ACS patients' culprit plaques morphology, characteristics, and underlying mechanisms.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India.

OBJECTIVES: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography. METHODS: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography. RESULTS: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels. CONCLUSIONS: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Impact of plaque burden and composition on coronary slow flow in ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: intravascular ultrasound and virtual histology analysis.

AIM: Coronary slow flow (SF) is an important complication of percutaneous coronary intervention (PCI) associated with poor prognosis. The aim was to assess grey-scale intravascular ultrasound (IVUS) and virtual histology (VH-IVUS) characteristics of culprit lesion in ST-elevation myocardial infarction (STEMI). METHODS: A total of 295 consecutive patients with STEMI underwent coronary angiogram and IVUS. Following PCI, patients divided into two groups; SF (thrombolysis in myocardial infarction [TIMI] flow ≤ 2, n = 74) and normal flow (NF) (TIMI flow >2, n = 221). Coronary plaque burden and its composition in relation to SF were evaluated. RESULTS: On grey-scale IVUS, the plaque area (12.3 mm2 vs. 11.5 mm2, p = .01), plaque volume (110.7 mm3 vs. 99.8 mm3, p < .001), lesion external elastic membrane (EEM) cross-sectional area (14.9 mm2 vs. 14.0 mm2, p = .011) and remodelling index (1.3 vs. 1.2, p = .043) were significantly higher in SF group. On VH-IVUS, absolute fibrous volume (48.1 mm3 vs. 41.5 mm3, p ≤ .001), fibrofatty volume (23.8 mm3 vs. 18.6 mm3, p = .015), necrotic core volume (8.3 mm3 vs. 5.5 mm3, p < .001), dense calcium volume (1.2 mm3 vs. 0.6 mm3, p = .003) and thin cap fibroatheroma either single (30.1% vs. 16.1%, p < .001) or multiple (9.6% vs. 1.8%, p < .001) were higher in SF arm. In multivariable analysis, absolute necrotic core volume (odds ratio = 1.159; 95% CI 1.030-1.305, p = .015) was the only independent predictor of SF. CONCLUSIONS: Higher necrotic core volume as detected by VH-IVUS may be a potential risk factor for the development of coronary SF phenomenon in patients with STEMI after PCI.

Acute Coronary Syndrome after 17 Years of Bare Metal Stent Implantation: "Very" Very Late Stent Thrombosis.

Very late stent thrombosis (VLST) is a catastrophic and life-threatening complication after percutaneous coronary intervention which presents as an acute coronary syndrome with significantly high mortality and morbidity. VLST is a rare entity with drug-eluting stents and even rarer with bare metal stents. The exact pathophysiologic mechanism of VLST after BMS implantation is not known although various mechanisms have been proposed. Recently, in-stent neoatherosclerosis with intimal plaque rupture has been proposed as a potential mechanism of VLST after BMS. We report a rare case of VLST occurring 17 years after BMS implantation with angiographic and intravascular imaging evidence which provides insight into the mechanisms of VLST.

Association of culprit lesion plaque characteristics with flow restoration post-fibrinolysis in ST-segment elevation myocardial infarction: an intravascular ultrasound-virtual histology study.

BACKGROUND: Not every patient achieves normal coronary flow following fibrinolysis in STEMI (ST-segment elevation myocardial infarction). The culprit lesion plaque characteristics play a prominent role in the coronary flow before and during percutaneous coronary intervention. The main purpose was to determine the culprit lesion plaque features by virtual histology-intravascular ultrasound (VH-IVUS) in patients with STEMI following fibrinolysis in relation to baseline coronary angiogram TIMI (thrombolysis in myocardial infarction) flow. Pre-intervention IVUS was undertaken in 61 patients with STEMI after successful fibrinolysis. After the coronary angiogram, they were separated into the TIMI1-2 flow group (n = 31) and TIMI 3 flow group (n = 30). Culprit lesion plaque composition was evaluated by VH-IVUS. RESULTS: On gray-scale IVUS, the lesion external elastic membrane cross-sectional area (EEM CSA) was significantly higher in the TIMI 1-2 groups as compared to the TIMI 3 group (15.71 ± 3.73 mm2 vs 13.91 ± 2.94 mm2, p = 0.041) with no significant difference in plaque burden (82.42% vs. 81.65%, p = 0.306) and plaque volume (108.3 mm3 vs. 94.3 mm3, p = 0.194). On VH-IVUS, at the minimal luminal area site (MLS), the fibrous area (5.83 mm2 vs. 4.37 mm2, p = 0.024), necrotic core (NC) area (0.95 mm2 vs. 0.59 mm2, p < 0.001), and NC percentage (11% vs. 7.1%, p = 0.024) were higher in the TIMI 1-2 groups in contrast to the TIMI 3 group. The absolute necrotic core (NC) volume (8.3 mm3 vs. 3.65 mm3, p < 0.001) and NC percentage (9.3% vs. 6.0%, p = 0.007) were significantly higher in the TIMI 1-2 groups as compared to the TIMI 3 group. Absolute dense calcium (DC) volume was higher in TIMI 1-2 groups with a trend towards significance (1.0 mm3 vs.0.75 mm3, p = 0.051). In multivariate analysis, absolute NC volume was the only independent predictor of TIMI 1-2 flow (odds ratio = 1.561; 95% CI 1.202-2.026, p = 0.001). Receiver operating characteristic curves showed absolute NC volume has best diagnostic accuracy (AUC = 0.816, p < 0.001) to predict TIMI 1-2 flow with an optimal cutoff value of 4.5 mm3 with sensitivity and specificity of 79% and 61%, respectively. CONCLUSIONS: This study exemplifies that the necrotic core component of the culprit lesion plaque in STEMI is associated with the coronary flow after fibrinolysis. The absolute necrotic core volume is a key determinant of flow restoration post-fibrinolysis and aids in prognostication of less than TIMI 3 flow.

Effect of surgical stress on neutrophil function.

The present study was undertaken to find out the effect of surgical stress on nonspecific immune response. Twenty patients posted for various elective surgeries participated in the study (male : 17, female : 3, age : 43.4 +/- 2 yrs). The blood samples were taken preoperatively (4 to 6 days prior to surgery) and the following parameters were assessed: phagocytic index of neutrophils, avidity index of neutrophils and percentage of neutrophils in differential count. These were compared with the respective parameters assessed in the blood samples taken 24 hours after surgery. There was a significant (P = 0.0001) decrease in the phagocytic index of neutrophil and a significant (P = 0.003) increase in the percentage of neutrophils in differential count in the postoperative blood samples. However, the avidity index did not show a significant change. It could be tentatively concluded that surgical stress causes depression of nonspecific immunity in the early postoperative period.

1-Triacontanol cerotate; isolated from Marsilea quadrifolia Linn. ameliorates reactive oxidative damage in the frontal cortex and hippocampus of chronic epileptic rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Marsilea quadrifolia Linn. (MQ) has been used for insomnia and epileptic disorders in traditional Indian medicine. The present study is to isolate the active component responsible for antiepileptic property of MQ by evaluating its ability to minimize the reactive oxidative damage in brain due to chronic epilepsy in rat. MATERIALS AND METHODS: 1-Triacontanol cerotate (1TAC) was isolated after chromatography on a silica gel from dried petroleum ether fraction of methanolic extract of MQ. Acute oral toxicity studies of 1TAC were carried out and efficacy of 1TAC on malondialdehyde (MDA) and reduced glutathione (GSH) production in different brain areas of chronic pentylenetetrazole (PTZ) induced epileptic rats were evaluated. RESULTS: Our results showed that PTZ-kindled chronic epileptic rats had an increase MDA and decreased GSH concentration in the frontal cortex as well as hippocampus, compared to the normal control. MDA and GSH concentrations in those brain areas were normalized after treatment with sodium valproate (SV) in 200 mg kg(-1)bw; as well as 1TAC in 40 and 80 mg kg(-1)bw doses. CONCLUSION: Production of reactive oxygen species (ROS) is known to worsen epileptogenesis. The isolated component 1TAC which reduced the reactive oxidative damage in hippocampus and frontal cortex of PTZ kindled rats could be responsible for antiepileptic property of MQ. Its action is found to be dose dependent, with 80 mg kg(-1)bw showing even better efficacy than 200 mg kg(-1)bw of SV.

The effectiveness of self-directed learning (SDL) for teaching physiology to first-year medical students.

BACKGROUND: Self-directed learning (SDL) has become popular in medical curricula and has been advocated as an effective learning strategy for medical students to develop competence in knowledge acquisition. AIMS: The primary aim was to find out if there was any benefit of supplementing self-directed learning activity with a traditional lecture on two different topics in physiology for first-year medical students. METHOD: Two batches of first-year Bachelor of Medicine and Bachelor of Surgery (MBBS) (Batch A and Batch B) comprising 125 students each, received an SDL session on Morphological classification of anaemia. The students belonging to Batch A received a one-hour lecture on the same topic three days prior to the SDL session. The students were given a 10 multiple choice questions (MCQ) test for a maximum of 10 marks immediately following the SDL session. The next topic, Conducting system of the heart, disorders and conduction blocks was taught to both batches in traditional lecture format. This was followed by an SDL session on the same topic for Batch A only. The students were evaluated with a MCQ test for a maximum of 10 marks. RESULTS: The mean test scores on the first topic were 4.38±2.06 (n=119) and 4.17±1.71 (n=118) for Batch A and Batch B, respectively. The mean test scores on the second topic were 5.4± 1.54 (n=112) and 5.15±1.37 (n=107) for Batch A and Batch B, respectively. There was no significant difference between the groups. CONCLUSION: For first-year medical students, SDL is an effective teaching strategy for learning physiology. However, no additional benefit is gained by supplementing SDL with a lecture to facilitate learning physiology.