Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial.

BACKGROUND: History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents. METHODS: Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time. RESULTS: The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group. CONCLUSION: VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Estimation of population variance under ranked set sampling method by using the ratio of supplementary information with study variable.

In biological and medical research, the cost and collateral damage caused during the collection and measurement of a sample are the reasons behind a compromise on the inference with a fixed and accepted approximation error. The ranked set sampling (RSS) performs better in such scenarios, and the use of auxiliary information even enhances the performance of the estimators. In this study, two generalized classes of estimators are proposed to estimate the population variance using RSS and information of auxiliary variable. The bias and mean square errors of the proposed classes of estimators are derived up to first order of approximation. Some special cases of one of the proposed class of estimators are also considered in the presence of available population parameters. A simulation study was conducted to see the performance of the members of the proposed family by using various sample sizes. The real-life data application is done to estimate the variance of gestational age of fetuses with supplementary information. The results showed that RSS design is a more accurate method than simple random sampling, to determine the population variance of hard-to-measure or destructive sampling units.

A comparison of SRK/T formula with Hill RBF 2 and Barrett Universal II in the calculation of intraocular lens power.

OBJECTIVE: To compare the accuracy of SRK/T, Barrett Universal II and Hill radial basis activation function-2 formulas in intraocular lens power calculation using different axial lengths. METHODS: The retrospective study was conducted at the Lahore General Hospital, Lahore, Pakistan, and comprised data from June to December 2020 of patients who underwent phacoemulsification with non-toric, monofocal intraocular lens implantation. Data was sorted in 3 groups on the basis of axial length; group 1 22-25mm, group 2>25mm, and group 3 <22mm. Intraocular lens power was calculated using SRK/T with IOL Master, while online calculators were used for Barrett Universal II and Hill radial basis activation function-2 formulas. Data was analysed using SPSS 21. RESULTS: Of the 100 patients, 47(347%) were males and 53(53%) were females. There were 49(49%) diabetics, and 57(57%) were right eyes. There were 77(77%) patients with mean age 62.38±9.5 in group 1, 17(17%) patients with mean age 52.59±12.78 in group 2, and 6(6%) patients with mean age 61.33+7.61 years in group 3. Mean axial length in group 1 was 23.55±0.81mm with anterior chamber depth of 3.1± 0.37mm. In group 2, mean axial length was 27.54±2.8mm, with anterior chamber depth of 3.4±0.15mm. In group 3, mean axial length was 21.74mm, with anterior chamber depth of 3.14±0.44mm. Mean prediction error of SRK/T versus Barrett Universal II was 0.092±0.041D (p=0.078), SRK/T versus Hill radial basis activation function-2 was 0.066±0.037D (p=0.221) and Barrett Universal versus Hill radial basis activation function-2 was -0.025±0.019D (p=0.553). Mean prediction error of group 1 versus group 2 was -0.105±0.14D, group 2 versus group 3 was 0.046±0.216D and group 2 versus group 3 was 0.151±0.243D (p=1.0). In 74% eyes, absolute prediction error was within ±0.5D in group 1, 64% in group 2 and 50% in group 3 for all formulas. CONCLUSIONS: SRK/T formula was found to be as reliable as Barrett Universal II and Hill radial basis activation function-2 in terms of calculating intra ocular lens power for all axial lengths.

Role of serum VEGF-A biomarker for early diagnosis of ovarian cancer instead of CA-125.

OBJECTIVE: To assess the significance of serum vascular endothelial growth factor-A (VEGF-A) as a potential biomarker for the diagnosis of ovarian cancer instead of cancer antigen-125 (CA-125). METHODS: The case-control study was conducted at the obstetrics departments of Sir Ganga Ram Hospital and Jinnah Hospital, Lahore, Pakistan, from April to September 2018, and comprised cases of epithelial ovarian tumour and healthy female controls. Serum VEGF-A and CA-125 levels were evaluated using Luminex multi-analyte profiling technology and enzyme immunoassays technique. Age, stage, grading, metastasis and ascites of ovarian cancer patients were investigated and compared with serum VEGF-A and CA-125 levels. Data was analysed using SPSS 20. RESULTS: Of the 89 subjects, 44(49.4%) were cases and 45(49.6%) were controls. Among the cases, 13(29.5%) were benign and 31(70.5%) were malignant. The mean serum VEGF-A values were inversely proportional to the stages of ovarian cancer i.e. stage I, II, III and IV showed 762.2pg/ml, 267.3pg/ml, 233.1pg/ml and 125.5pg/ml VEGF-A levels respectively. A steady increase in the mean serum CA-125 values with the progression of the disease was observed i.e. in stage I, II, III and IV the levels of CA-125 were 146.2U/ml, 268.5U/ml and 477.2U/ml and 844.4U/ml respectively. CONCLUSIONS: The detection of high concentrations of serum VEGF-A level supported its use as one of the diagnostic parameters in the timely investigation of ovarian cancer.

Optimization of antibacterial activity of ethanolic extracts of Eucalyptus tereticornis and Nigella sativa: Response surface Methodology.

The screening of plants for medicinal purposes represents an effort to discover newer, safer, and possibly more effective drugs. Design of the present study was made aiming to the optimization of the antibacterial activity of ethanolic extracts of Eucalyptus tereticornis (leaves) and Nigella sativa (seeds) against bacteria belongings to both Gram-positive (Bacillus subtilis and Staphylococcus aureus) and Gram-negative (Escherichia coli) spectrum by using response surface methodology. 20 g powder of each E. tereticornis (leaf) and N. sativa (seeds) were mixed with 200ml of ethanol at room temperature, and then it was centrifuged at 4000 rpm for 10 min to separate the supernatants, and allowed to dry in order to obtain ethanol free extracts. A fresh bacterial culture of 100µl of test microorganism was inoculated onto media and spread homogeneously. The antimicrobial activity of ethanolic extracts showed that all the concentrations tested were effective against the test microorganisms. The diameters of zones of inhibition exhibited by S. aureus PCSIR-83 were in the range of 0-28mm, E. coli PCSIR-102 (0-28mm) and B. subtilis PCSIR-05 (15-26mm). The combination of N. sativa (15mg/µl) and E. tereticornis (20mg/µl) were found most effective at pH 9.0 and temperature 35°C. Our results clearly indicate that Gram positive bacteria showed more sensitivity than Gram-negative bacteria.

Evidence of male hypogonadism at an early age as a familial risk of type 2 diabetes.

OBJECTIVE: Previous investigations provide evidence of an association of hypogonadism with type 2 diabetes in men, and low testosterone levels have been regarded a risk factor for the disease. Since a strong genetic predisposition to type 2 diabetes has been demonstrated, here we investigate a possible tendency towards hypogonadism in young male offspring of diabetic parents. MATERIAL AND METHODS: The study compares 32 male offspring of diabetic parents with 31 male offspring of nondiabetic parents matched by age. The subjects comprised boys (9-17 years) and young adults (19-25 years). Anthropomorphic measurements were made in all subjects. Fasting blood samples were analyzed for glucose and serum concentrations of testosterone (T), sex hormone-binding globulin (SHBG), luteinizing hormone (LH), insulin and leptin were measured by ELISA. Free testosterone (FT) was calculated using T and SHBG levels. RESULTS: Serum T, FT and bioavailable T (BAT) levels in offspring of diabetic parents were significantly lower than those of offspring of nondiabetic parents across all age groups. Mean serum LH levels were also lower in offspring of diabetic parents compared to the controls. Although LH levels in young adults with diabetic parents, tended to be lower than those of age-matched controls but the difference was not statistically significant. Serum insulin and leptin, and insulin resistance measured by HOMA-IR were significantly raised in older offspring of diabetic parents but were within the normal range. CONCLUSION: Whereas hypogonadism was the only indicator of a possible predisposition to metabolic dysfunction in peripubertal children of diabetic parents, a significant change in other metabolic markers becomes apparent at a more advanced age.

Assessment of biochemical and antioxidative status in patients suffering from dengue fever.

A multi-centred study was designed to collect dengue epidemiologic data from government and registered private hospitals/clinics and maintained archive of frozen specimens in bio-bank to be used for future dengue epidemic control program, and assess the epidemiology of dengue fever (DF) by evaluating biochemical and oxidative status of patients. ELISA IgM antibodies test was done to confirm DF. From August 2010 to December 2011, 101 confirmed blood samples of DF patients referred to pathology lab of Jinnah Hospital Lahore were subjected to the epidemiologic assessment by evaluating the biochemical and physiological indices and alterations of circulating antioxidants. Clinical features of DF patients and effect of fever on blood components and serum proteins of liver were recorded. The hospital stay in DF, dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) showed significant difference. Significant increases in serum alanine amino transferase (ALT) (P=0.000), aspartate amino transferase (AST) (P=0.000), alkaline phosphatase (ALP) (P=0.000), malondialdehyde (MDA) along with significant decreases in total protein (TP) (P=0.000), reduced glutathione (GSH) (P=0.000), superoxide dismutase (SOD), catalase (CAT) (P=0.000), and sialic acid contents (P=0.016) were observed. A positive correlation existed between bound sialic acid levels, liver enzymes and circulating antioxidants (r=0.656, P=0.016). In the present study, alterations of circulating antioxidants in DF suggest that DF might be a metabolic response to an acute, self-limiting tropical viral infection, and a consequence of the viral inflammatory process.

Assessment of biochemical and antioxidative status in patients suffering from dengue fever / 华中科技大学学报（医学）（英德文版）

A multi-centred study was designed to collect dengue epidemiologic data from government and registered private hospitals/clinics and maintained archive of frozen specimens in bio-bank to be used for future dengue epidemic control program, and assess the epidemiology of dengue fever (DF) by evaluating biochemical and oxidative status of patients. ELISA IgM antibodies test was done to confirm DF. From August 2010 to December 2011, 101 confirmed blood samples of DF patients referred to pathology lab of Jinnah Hospital Lahore were subjected to the epidemiologic assessment by evaluating the biochemical and physiological indices and alterations of circulating antioxidants. Clinical features of DF patients and effect of fever on blood components and serum proteins of liver were recorded. The hospital stay in DF, dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) showed significant difference. Significant increases in serum alanine amino transferase (ALT) (P=0.000), aspartate amino transferase (AST) (P=0.000), alkaline phosphatase (ALP) (P=0.000), malondialdehyde (MDA) along with significant decreases in total protein (TP) (P=0.000), reduced glutathione (GSH) (P=0.000), superoxide dismutase (SOD), catalase (CAT) (P=0.000), and sialic acid contents (P=0.016) were observed. A positive correlation existed between bound sialic acid levels, liver enzymes and circulating antioxidants (r=0.656, P=0.016). In the present study, alterations of circulating antioxidants in DF suggest that DF might be a metabolic response to an acute, self-limiting tropical viral infection, and a consequence of the viral inflammatory process.

Changes in levels of peripheral hormones controlling appetite are inconsistent with hyperphagia in leptin-deficient subjects.

Congenital leptin deficiency, a rare genetic disorder due to a homozygous mutation in the leptin gene (LEP), is accompanied by extreme obesity and hyperphagia. A number of gastrointestinal hormones have been shown to critically regulate food intake but their physiological role in hyperphagic response in congenital leptin deficiency has not been elucidated. This study is the first to evaluate the fasting and postprandial profiles of gut-derived hormones in homozygous and heterozygous carriers of LEP mutation. The study subjects from two consanguineous families consisted of five homozygous and eight heterozygous carriers of LEP mutation, c.398delG. Ten wild-type normal-weight subjects served as controls. Fasting and 1-h postprandial plasma ghrelin, glucagon-like peptide (GLP) 1, peptide YY (PYY), leptin and insulin levels were measured by immunoassays. Fasting plasma ghrelin levels in homozygotes remained remarkably unchanged following food consumption (P = 0.33) in contrast to a significant decline in heterozygous (P < 0.03) and normal (P < 0.02) subjects. A significant postprandial increase in PYY was observed in heterozygous (P < 0.02) and control subjects (P < 0.01), but not in the homozygous group (P = 0.22). A postprandial rise in GLP-1 levels was significant (P < 0.02) in all groups. Interestingly, fasting leptin levels in heterozygotes were not significantly different from controls and did not change significantly following meal. Our results demonstrate that gut hormones play little or no physiological role in driving the hyperphagic response of leptin-deficient subjects. In contrast, fasting and postprandial levels of gut hormones in heterozygous mutation carriers were comparable to those of normal-weight controls.

Comparative Study of Alterations in Tri-iodothyronine (T3) and Thyroxine (T4) Hormone Levels in Breast and Ovarian Cancer.

Objective : The present study was designed to investigate variations in the levels of thyroid hormones (T3, T4) in breast and ovarian cancers patients. Methods : A total 120 subjects were recruited (without thyroid history) divided into three groups; A, B and C. Group A as control with healthy individuals. While group B and group C were consisting of breast cancer and ovarian cancer patient respectively. Blood samples (5 ml) were taken and analyzed to estimate the levels of serum T3 (tri-iodothyronine) and T4 (thyroxin) hormones. R esults : Statistically significant difference (P=0.000* and P=0.017*) was obtained among all groups. A significant increase in T3 (P=0.000*) and T4 (0.005*) levels was observed among breast cancer patients as compared to healthy controls. While for ovarian cancer patients conflicting results were found for T3 and T4 levels in the serum i.e. insignificant difference was found in T3 (P=0.209) and T4 (P=0.050) as compared to control. Our results showed that in the breast cancer and ovarian cancer patients the thyroid hormone (T3 and T4) level has been altered from the normal ranges as compared to the normal healthy individuals. Conclusion : We conclude that hyperthyroidism has profound effects on breast cancer and ovarian cancer cells proliferation.

Tooth loss in institutionalized coronary heart disease patients of Punjab Institute of Cardiology, Lahore, Pakistan.

OBJECTIVE: To observe frequency and possible association of tooth loss with prevalent coronary heart disease in Pakistani population. METHODOLOGY: Angiographically determined coronary heart disease (CHD) patients of Punjab Institute of Cardiology, Lahore, Pakistan, and healthy individuals were enrolled for status of tooth loss. RESULTS: Nine hundred and thirty six CHD patients and 595 healthy subjects with mean age of 51.9±8.4years were examined. Mean (±SD) tooth loss was significantly (P⩽0.001) higher in cardiac patients (9.8±9.2) than healthy subjects (6.8±6.9) with odds ratio (OR)=1.543 (95%CI=1.985-2.851). Tooth loss was significantly (P⩽0.001) associated with CHD males and females and cardiac patients with diabetes and smoking. After adjustment of age, gender, diabetes and smoking, subjects with CHD were more likely to have higher tooth loss. CONCLUSION: Tooth loss was significantly associated with prevalent CHD independent of classic risk factors of age, gender, smoking and diabetes in this study sample.