Change in action: using positive deviance to improve student clinical performance.

At our medical college many students have lower ratings in their clinical performance once they start their clinical years (third year). This is contrary to their results in other written exams. Some students demonstrate better clinical performance. We used the six-step Positive Deviance (PD) Conceptual Framework to identify and disseminate the strategies employed by the successful students to improve group clinical performance. Fifty 3rd year students (of a 5-year MBBS program) rotating through internal medicine were assessed mid-rotation with mini-CEX and 360° evaluations. Twenty students (40%) who performed well were invited for in depth interviews in order to identify positive deviant behavior in their clinical skills learning practices. The seven students (14%) who reported novel behaviors were asked to develop strategies for dissemination of their learning behavior in their peers. They decided to work in small groups with their peers, using the identified PD behaviors to encourage learning of history taking and examining skills in their peers. Group performance was assessed at the end of rotation, using mini-CEX and 360° evaluation in comparison to a subsequent group of students in the same year that did not work in PD peer learning groups. For the 360° evaluation the EP(2) (generalizability coefficient) was 0.92 and for the mini-CEX the EP(2) was 0.95, taking into account the variances between participants, groups, time and the interactions effects; thus indicating good reliability of both the assessment methods. A statistically significant difference (p < 0.05) was seen for improvement in medical interviewing skills and clinical judgment on the mini-CEX exam and 360 evaluation (p < 0.0001) in the PD group. Positive Deviance approach can help highlight behaviors among medical students, which contribute to success but may go unnoticed. Learning strategies based on the PD framework can improve student's group performance.

Risk of development of chronic kidney disease in patients with type 2 diabetes having metabolic syndrome.

OBJECTIVE: To measure the relation of creatinine clearance in type-2 diabetic patients with different components of metabolic syndrome and to quantify the relationship of frequency of incident CKD with increasing number of metabolic syndrome components while controlling for age, gender and duration of diabetes. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Diabetes Clinic, Fauji Foundation Hospital, Rawalpindi, from January to August 2006. METHODOLOGY: Patients having type-2 Diabetes for more than 5 years were enrolled. Information regarding age, gender, duration of diabetes , type of diabetes, treatment taking, complete fasting lipid profile, fasting blood glucose, Body Mass Index (BMI), 24 hours urinary proteins and creatinine clearance, co-existent risk factors like hypertension and ischemic heart disease was taken. Patients were divided into groups having one to all five metabolic syndrome traits. Progressive increase in the metabolic syndrome traits was compared with decline in creatinine clearance. Pearson correlation test and multiple logistic regression were applied to determine correlation with significance at 'r' and 'p' < 0.05. RESULTS: Out of 104 evaluated female and male patients, 70% had hypertension, ischemic heart disease and a family history of diabetes. While 20% had normal creatinine clearance, 37% had a creatinine clearance between 60-90 ml/min, 19% had a creatinine clearance of 30-59 ml/min, 18% had a creatinine clearance of less than 30 ml/min and 10% were already in stage 5 CKD. The decline in renal function was more severe in subjects evaluated who had a higher number of features of the metabolic syndrome. Age was the only significant determinant of development of CKD (p=0.05). CONCLUSION: The renal function progressively declined with 3 or more features of the metabolic syndrome.

Intrabiliary rupture of hepatic hydatid cyst: role of ERCP.

We report a case of hepatic hydatid cyst presenting with obstructive jaundice following cholecystectomy. ERCP showed intrabiliary cyst rupture with biliary obstruction due to cyst remnants. Endoscopic sphincterotomy was performed and cyst debris removed with complete resolution of symptoms.

Malignant hypertension in a patient with end of stage renal disease (ESRD) treated by renal transplant.

Control of hypertension is often a problem in the management of end stage renal disease (ESRD). Multiple modalities of treatment are required to prevent cardiovascular and cerebrovascular mortality and morbidity. These include fluid and salt restriction, multidrug regimes and dialysis. We report a case of young 25 years old patient, admitted with chronic renal failure, complicated by malignant and refractory hypertension, not responding to hemodialysis and antihypertensive agent. During stay in hospital, patient also had intracerebral hemorrhage, fits due to uncontrolled hypertension requiring ventilatory support followed. Renal transplant was considered to be the final therapeutic modality. After gradual recovery, a successful live-related renal transplant was performed. As soon as good graft was established, the blood pressure settled and 4 of the 5 antihypertensives were withdrawn. After 2 weeks, patient was discharged in a stable condition with a total stay of about 2 months.

Smear-negative pulmonary tuberculosis and lymphocyte subsets.

OBJECTIVE: To correlate and quantitate lymphocyte subsets with clinically diagnosed smear-negative pulmonary tuberculosis and severity of disease. DESIGN: Case-control study. PLACE AND DURATION OF STUDY: Military Hospital and Armed Forces Institute of Pathology Rawalpindi. 1999-2000. SUBJECTS AND METHODS: Freshly diagnosed, well-characterized smear-negative patients (n=15) of pulmonary tuberculosis were selected. Non-induced three-consecutive negative smears of sputum with simultaneous culture for AFB for 6-8 weeks, positive Mauntoux test (Z10 mm), blood complete picture with ESR and chest x-rays were done. Selected panel of monoclonal antibodies against specific CD markers were used. Statistical analysis done by student t-test or Mann-Whitney rank-sum test with the help of Sigma State software. RESULTS: Hemoglobin and total lymphocyte counts were significantly reduced whereas total leukocyte counts with absolute neutrophil counts were increased. Fraction of CD4+ and CD8+ T lymphocytes with HLA-DR expression was reduced while no significant change in rest of the TB and NK lymphocytes. CONCLUSION: Low hemoglobin level, high neutrophil count and low total lymphocytes suggest possible direct relationship with extent of disease. The number of activated CD4+, CD8+, ab and gd TCR T cells have tendency to increase during Mycobacterium infection. This seems to have a potential of being a good, non-invasive prognostic indicator for patients with pulmonary tuberculosis.