Issues and remedies related to learning environment of students during maternal, neonatal and child health clerkship

Objective: To gain insight into learning-environment of Maternal Neonatal and Child Health community clerkship, using Dundee Ready Educational Environment Measure questionnaire and focus group discussion to improve students' quality of learning. Study Design: Sequential Mixed Method Study. Place and Duration of Study: Primary Centers [Aga Khan Health Services, Pakistan] and Secondary Center [Aga Khan University], from Nov 2014 to Oct 2015

Material and Methods: All consenting third-year MBBS students after completing maternal neonatal and child health [MNCH] rotation anonymously filled the Dundee Ready Educational Environment Measure [DREEM] questionnaire. Data was entered in MS Excel 2013 and SPSS version 21. Descriptive statistics were calculated such as frequencies, mean and standard deviation of the total/subscale scores. Independent samples t test was used to identify gender-related differences among DREEM scores with p-value of < 0.05 as statistically significant. Focus Group Discussion [FGD] was conducted with all consenting facilitators [Faculty/Lady Health Visitors]. Thematic analysis of qualitative data was done using constant iterative approach

Results: From a total of 99 students, 78 [78.8%] consented, of which 36 [46.2%] were males and 42 [53.8%] females. Mean total DREEM score was 126.26/200 [63.13%] indicating a more positive learning environment. Total means with percentages and interpretation of subscale scores showed 'Students Perception of Learning [SPOL]', 28.92/ 48 [60.25%] indicating more positive approach; 'Students Perception of Teachers [SPOT]', 28.58/ 44 [64.95%] indicating teachers are moving in right direction; 'Students Academic Self-Perception [SASP]', 20.64/32 [64.5%] indicating students felt positive academically; 'Students' Perception of Atmosphere [SPOA]' 31.17/48 [64.93%] indicating positive learning-atmosphere and Students' Social Self-Perception [SSSP], 16.93/28 [60.46%] showing not-too-bad social-environment. Thus, DREEM results showed, students perceived their learning environment to be overall positive. As a composite score in the five domains of educational environment no statistically significant difference was found between males and females. [SPOL: p value 0.655; SPOT: p value 0.760; SASP: p value 0.685; SPOA: p value 0.245; SSSP: p value 0.280]. Common issues identified through DREEM and student-facilitators through FGD were grouped into three themes; 'Challenges faced', 'Student-learning facilitation' and 'Way-forward'. Triangulation of data from DREEM questionnaire and FGD indicated validation of outcomes

Conclusion: MNCH clerkship is a rotation, in a low/middle income country, in early years of inception. Students are satisfied but there is scope for improvement. This evaluation helped = identify problem areas to enable improvement of program and inspire other institutions to arrange community clerkships

Frequency of thyroid peroxidase antibody and its association with miscarriages among pregnant women

Objective: To measure the frequency of thyroid peroxidase antibody [TPO Ab] among clinically euthyroid pregnant women during first trimester and determine its association with pregnancy outcome as miscarriage or live birth by estimating the relative risk. Study Design: Cohort study. Place and Duration of Study: Section of Chemical Pathology, Department of Pathology and Laboratory Medicine and the Gynaecology and Obstetric outpatient clinics of the Aga Khan University Hospital, Karachi, from July to December 2012

Methodology: The study subjects comprised of apparently euthyroid pregnant women, who were tested for TPO Ab during first trimester of pregnancy and followed till pregnancy outcomes Pregnancy outcome was noted and relative risk was determined

Results: TPO Ab was found positive in 127 [13.5%] pregnant women from a cohort of 943 subjects. A 2.03% increased risk of miscarriages was observed in TPO Ab positive subjects

Conclusion: There was a positive association of presence of TPO Ab with loss of pregnancy

Recommendation for use of vitamin 'D' treatment during pregnancy

To look into the significant controversy existing about the safety and the dose of vitamin D supplementation in pregnant women with a pandemic of vitamin D deficiency. We searched PubMed for information on Vitamin D, with special emphasis on reviews and studies regarding pregnancy. Recent clinical research sheds doubt on the prevalent guidelines, by proposing that the circulating 25 hydroxy vitamin D should be 40-60ng/ml [100-150 nmol] during pregnancy and a daily intake of 4000IU vitamin D3 is required to attain this circulating level. A search of the existing literature shows Vitamin D supplementation well above the current guidelines to be not just safe in pregnant patients, but also beneficial in preventing various adverse outcomes. There is a pressing need for further studies in this field in different populations, to establish accurate guidelines on Vitamin D levels in pregnancy.

change in trainee physicians' knowledge and comfort levels with obstetric emergencies following ALSO training

The Advanced Life Support in Obstetrics [ALSO] is a course in emergency obstetrics to help physicians and other health care providers develop and maintain the knowledge and skills to effectively manage potential obstetric emergencies. This course was held for the first time in Pakistan at the Aga Khan University in September 2003. This study was conducted to evaluate the improvement in knowledge and comfort level of physicians-in-training [interns, family medicine, obstetric and emergency room residents] in dealing with emergency obstetrics after undergoing the course. After informed consent, study subjects were administered a written test and asked to complete a questionnaire 10 days before and immediately after taking the ALSO course. Level of comfort in handling obstetric emergencies was assessed using a three-point Likert scale. A total of 38 trainees participated in pretest, ALSO course and subsequent post-test. Eleven were males and 27 were females. The comparison of the pre-test and post test showed a significant increase in the knowledge. The mean difference between the scores was 24 and the paired t-test done showed there was a highly significant difference between the scores [t=18.8, p= <0.001]. There was also a significant improvement in the comfort level for handling emergency obstetrics. Following the ALSO course all participants said they would recommend the course to others. The ALSO course is a valuable teaching intervention that improves not only knowledge but also perceived comfort levels of emergency obstetrics among interns and residents in a developing country

Frequency and diagnosis of bacterial vaginosis

To determine the frequency of bacterial vaginosis [BV] in women with vaginal discharge, and to compare different diagnostic tests for its diagnosis. Cross-sectional study. The Aga Khan University Hospital from June 1998 to May 2000. All women attending the Obstetrics and Gynecology clinics at The Aga Khan University Hospital, with the complaints of vaginal discharge, were examined with the help of a speculum. The vaginal pH was measured, samples for bacterial cultures were obtained. A slide was prepared for the gram's stain and Whiff-test was also performed. BV was diagnosed, when the vaginal discharge fulfilled at least three of the composite clinical criteria [Amsel's criteria], a st and ard method for the diagnosis of bacterial vaginosis: homogenous [pasty] discharge, pH more than 4.5, positive Whiff-test and the presence of clue cells. The frequency of BV was observed to be 16.1%. The culture for Gardnerella vaginalis was compared with the composite clinical criteria. The sensitivity, specificity, positive and negative predictive values of the culture, calculated for the diagnosis of BV were 93.8%, 70%, 37.7% and 98% respectively. The use of laboratory tests in conjunction with clinical findings is necessary for diagnosis of BV. The composite clinical criteria for the diagnosis of BV are rapid, reliable and inexpensive method