Flipped pedagogical approach in teaching skeletal muscle physiology for undergraduate medical students

Objectives: Medical teachers need to use different pedagogical approaches to enhance student learning. Students are exposed to the flipped classroom (FC) in addition to the other teaching approaches which may enhance the comprehension, interpretation, and analytic skills of the students. The objective of this study was to compare the test scores obtained after the FC teaching session with the test scores obtained after a traditional classroom teaching session on a topic in skeletal muscle physiology delivered to 1st-year undergraduate medical students. Materials and Methods: Twenty-one 1st-year undergraduate medical students, undergoing a musculoskeletal system module at a private medical college were involved in this study. Students in the flipped pedagogical method were required to read the notes and power-point slides provided in addition to watching the prerecorded lecture videos before class. During the class, there was a topic review session followed by a small case discussion in groups. In the traditional classroom, students were advised to attend the lectures but there were no recorded videos to watch before the session. The effectiveness of the two types of pedagogical approaches was tested through pre-test and post-test using multiple-choice questions. The students’ perception of FC was collected through a semi-structured validated questionnaire. Results: The pre-test mean score was higher for FC (5.48 ± 1.44) when compared to the traditional classroom (3.19 ± 1.4). In our study, the scores from pre-test to post-test in a traditional classroom showed statistically significant improvement (P = 0.0014) but were not statistically significant in the FC. In the flipped pedagogical approach, the difference between mean correct responses for question number 5 (P = 0.031) in pre-test and post-test was statistically significant. There was an improvement in the mean scores in all the eight questions between pre-test and post-tests in the traditional pedagogical method of teaching. About 79.6% of students agreed that they watched all the assigned videos and 78.6% of students completed reading the assigned power-point presentation slides before coming to the FC. About 78.5% agreed to learn more topics in FC format and 78.6% of students agreed that FC was more engaging and interesting in comparison to a traditional class. Conclusion: Our study showed that flipped and traditional pedagogical approaches both enhance student learning

Casting made simple using modified sprue design: An in vitro study.

Background: Success in dental casting restorations for fixed partial dentures (FPDs) depends on the castability. Castability is described as the ability of an alloy to faithfully reproduce sharp detail and fine margins of a wax pattern. The goal of a prosthodontist is to provide the patient with restorations that fit precisely. Regardless of the alloy used for casting, the casting technique should yield a casted alloy, which should possess sufficient mass, surface hardness and minimal porosity after casting. Materials and Methods: Twenty patterns for casting were made from three‑dimensional printed resin pattern simulating a 3 unit FPD and casted using modified sprue technique. Later test samples were cemented sequentially on stainless steel model using pressure indicating paste and evaluated for vertical marginal gap in eight predetermined reference areas. Marginal gap were measured in microns using Video Measuring System (VMS2010F‑CIP Corporation, Korea). A portion of the axial wall of the cast abutments depicting premolar and molar were sectioned and embedded in acrylic resin and tested for micro hardness using Reichert Polyvar 2 Met Microhardness tester (Reichert, Austria) and porosity using Quantimet Image Analyzer (Quantimet Corporation London, England). Results: The results obtained for marginal gap, micro hardness, and porosity of all test samples were tabulated, descriptive statistics were calculated and the values were found to be within the clinically acceptable range. Conclusion: The new sprue technique can be an alternative and convenient method for casting which would minimize metal wasting and less time consuming. However, further studies with same technique on various parameters are to be conducted for its broad acceptance.

Unusual presentation of keratocystic odontogenic tumor in the mandible with imaging features – a case report

Keratocysytic Odontogenic tumor is a lesion occurring in the oral cavity that has a high recurrence rate. This lesion has an ability to mimic other lesions affecting the jaw. The tumor has a varied clinical and radiographic presentation. This article presents a case report of a 45 year old male patient presenting with an asymptomatic swelling on the right lower jaw associated with an impacted tooth and depicts an unusual radiographic picture.

Unusual occurrence of Epidermolysis bullosa with Amelogenesis Imperfecta – a rare case

Epidermolysis bullosa is an inherited disorder which is characteristically presented as skin blisters developing in response to minor injury. Junctional variety of Epidermolysis bullosa is associated with enamel hypoplasia. Amelogenesis imperfecta presents with abnormal formation of the enamel both in deciduous and permanent dentition. This is a case report of amelogenesis imperfecta with complete loss of enamel in a young female patient with epidermolysis bullosa.

Influence of timing on performance of laparoscopic cholecystectomy for acute biliary pancreatitis.

Aim: Gallstone disease is the most common cause of acute pancreatitis. Cholecystectomy is mandatory to avoid recurrence of pancreatitis. Our objective was to evaluate the results of laparoscopic cholecystectomy (LC) in patients with gall-stone induced pancreatitis . Methods: All patients presenting to us within the time frame from February 2004 to June 2008 with acute biliary pancreatitis were included in the study. The severity of pancreatitis was assessed by Ranson’s criteria. ERCP and endoscopic sphincterotomy was performed when the common bile duct (CBD) was dilated (>6 mm) with either calculi or sludge as seen on imaging. Patients with successful ERCP with predicted demanding laparoscopic cholecystectomy were discharged instead for an elective LC, 4-6 weeks later. Patients with mild pancreatitis (with Ranson’s score of 3 or less) and predicted uncomplicated LC underwent surgery at the same admission. The difficulty of the procedure was determined by the presence of adhesions in the gallbladder area, dissection in Calot’s triangle, tackling the dilated cystic duct, intra-operative bleeding, and the need for a drain. Results: A total of 26 patients (12 male and 14 female; age range 23-75 years) with acute biliary pancreatitis comprised the study group. Eleven patients with suspected choledocholithiasis underwent ERCP and clearance of the CBD was done in all of them. Nine patients (2 ERCP and 7 non-ERCP) underwent early LC in the same admission. Seventeen patients (9 ERCP and 8 non-ERCP) were predicted as difficult cases for LC and underwent delayed LC. No patient had recurrent pancreatitis in the interval period. Conclusion: There was no significant difference in the operative difficulty between early and delayed LC when patients were selected for timing of LC based on pre-defined criteria.

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Carcinoid tumor of bile duct.

We report a 38-year-old lady with carcinoid tumor of the extrahepatic biliary tract who presented with recurrent obstructive jaundice and previous surgery for suspected choledocholithiasis. MRCP revealed a large bile duct tumor extending from the confluence up to the superior aspect of the pancreas; this was completely excised, with bilio-enteric anastomosis. These tumors are characteristically slow growing and, therefore, are amenable to aggressive surgical excision, which offers the best chance of cure.

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis.

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Laparoscopic orchidectomy for undescended testis in adults.

BACKGROUND: Impalpable testis is a significant diagnostic and therapeutic challenge in adults, for both radiologist and surgeons, with few reports in literature addressing this problem in adults. Laparoscopy is a reliable and definitive procedure obviating the necessity of advance investigation and subsequent inguinal exploration in adults. AIMS: To study the utility of laparoscopy as combined diagnostic and therapeutic modality for undescended testis in adults. SETTINGS AND DESIGN: Prospective study from a single surgical unit of a large tertiary referral centre during August 2000 to January 2002. METHODS AND MATERIAL: Nine patients of unilateral undescended testis with average age 22.7 years (range 13-31 years) underwent diagnostic laparoscopy and orchidectomy subsequent to detailed clinical, ultrasound and examination under anaesthesia (EUA) procedure. All patients were operated with one 10 mm umbilical camera port, one suprapubic port and 1 lateral port. RESULTS: None of the patients had palpable testis or an inguinal cough impulse on clinical examination and during EUA. In only 3(33.3%) patients, the ultrasound could locate the testis situated at the deep ring. On laparoscopy all testes were identified, 4 were present at the deep ring, 3 were intra-abdominal and 2 had blind ending vas entering the deep ring. Mesh plug was inserted in the internal ring in these 2 patients, after dissecting the peritoneum. None of the patients had intra or post-operative complications and all were discharged on the next day. CONCLUSION: Laparoscopy is one of the most satisfactory methods for the diagnosis and management of non-palpable testis in adult cryptorchid patients.

Pre-transplant risk factors for renal allograft dysfunction at one year in Indian patients.

BACKGROUND: Only a few patients with end-stage renal disease in the Indian subcontinent receive optimal treatment. Of these only a minority can afford a second renal transplant. Awareness of modifiable pre-transplant risk factors that influence allograft function is crucial before embarking on the first transplant. There are no reports from the Asian subcontinent describing the pre-transplant risk factors. METHODS: We studied the effect of donor age, gender, and relation with the recipient, patient age, gender, HLA matching, native kidney disease and immunosuppression on one-year allograft function using data from 1177 consecutive primary living related donor renal transplants at the Christian Medical College Hospital, Vellore. We performed a univariate followed by a multivariate analysis using a logistic regression model to calculate the odds ratio for the effect of the above factors on two levels of graft function (serum creatinine > 1.4 mg/dl and > 2 mg/dl) at one year. RESULTS: On univariate analysis, older donors, women donors, mother being the donor, men recipients, < 1 HLA antigen match, cyclosporine-based immunosuppression and patient age between 16 and 40 years were associated with serum creatinine levels > 1.4 mg/dl at one year. Multivariate analysis showed that donor-related factors, namely mother as donor, older donors, and a < or = 1 HLA antigen match, were risk factors for graft dysfunction (serum creatinine level > 1.4 mg/dl) at one year. Recipient-related risk factors were male patients and those between the age of 16 and 40 years. CONCLUSION: In patients undergoing living related donor renal transplants from large extended families, a younger haplomatched donor, for instance, a brother, is a better choice than an older haplomatched donor, for instance, the mother, particularly in young male recipients at a higher risk of renal dysfunction.

Isolated splenic lymphoma: an elusive preoperative diagnosis.

Four patients underwent splenectomy for various clinical and radiological diagnoses and were found to have primary splenic lymphoma at surgery and histology. The diagnosis was classical Hodgkin's lymphoma, mixed cellularity type (one case); marginal zone B-cell non-Hodgkin's lymphoma (one case); and large B cell type non-Hodgkin's lymphoma (two cases). The first two patients had multiple nodules in the spleen measuring 0.1-0.5 cm while large cell lymphomas had large nodules (largest measuring 11 cm x 7 cm x 4 cm). The diagnoses were confirmed by immunohistochemical analysis. Mean follow up of these patients was 11 months; all patients received chemotherapy. One patient died, of causes not related to the disease process.

Paraesophageal mediastinal drainage with diversion for delayed presentation of esophageal perforation.

Esophageal perforation is a serious condition; a delay of more than 48 hours in initiation of treatment leads to increased morbidity and mortality. Management of such patients is a surgical dilemma. We successfully managed 4 patients (2-iatrogenic, 1-tuberculous, 1-Boerhaave's syndrome) with delayed presentation of esophageal perforation by esophageal exclusion and paraesophageal mediastinal drainage, achieving good control of mediastinal sepsis, healing of perforation and at the same time avoiding thoracotomy and subsequent second surgery.

Laparoscopic management of hydatid cyst of liver.

We describe the laparoscopic excision of a hydatid cyst in the liver. During the procedure, done after treatment with the scolicidal agents praziquantel and albendazole, care was taken to prevent spillage of scolices during evacuation of contents and to excise the entire germinal epithelium. The patient had no immediate or short-term complications and is asymptomatic 3 months later.

Giant prosthesis for reinforcement of visceral sac for complex bilateral and recurrent inguinal hernias: a prospective evaluation.

AIMS: To evaluate giant prosthesis for reinforcement of visceral sac (GPRVS) as a treatment for complex bilateral and recurrent inguinal hernias. SUBJECTS AND METHODS: The prospective study carried out in a single surgical unit at a tertiary health care center involved consecutive series of 31 patients with complex bilateral and recurrent inguinal hernias who underwent GPRVS. All were men and the mean age was 58 years (range 49-95 years). Factors predicting high risk for recurrence included a large hernia ( greater, similar5cms, 32%, 10/31 patients), failure of one or more previous repairs (45%, 14/31 patients), chronic obstructive pulmonary disease (25%, 8/31 patients) and poor muscle tone (70%, 22/31 patients). Operative time, length of postoperative stay, complications and death were the main outcome measures. RESULTS: Mean -/+ SEM operative time was 65 -/+ 11 minutes (range 45-115 minutes). Mean -/+ SEM length of stay was 3.5 -/+ 0.7 days (range 2-5 days). There were 4 minor complications, but no mesh infections and death. Follow up was obtained for a mean period of 14.6 months (range 12-23 months); there were no recurrences. CONCLUSION: GPRVS provides a definitive and safe cure for repair of complex bilateral and recurrent inguinal hernias because of its simplicity, ease of the procedure, good results and low recurrence rate.

Isolation of emetine resistant clones of Entamoeba histolytica by petri dish agar method.

Emetine resistant clones of Entamoeba histolytica strain HM1:IMSS were isolated by using petri dish agar method after mutation with ethyl-methanesulphonate. Two emetine resistant clones were obtained and both were resistant to emetine at a concentration of 24 micrograms/ml of emetine. The 50 per cent inhibitory concentration (IC50) for both emetine sensitive and resistant clones was 5 and 14 micrograms/ml respectively. The colony forming efficiency of E. histolytica strain HM1:IMSS varied from 44 to 54 per cent. This method is useful for isolating clones from different strains of the parasite for molecular and immunological studies.