Team-based learning versus interactive lecture in achieving learning outcomes and improving clinical reasoning skills: a randomized crossover study.

BACKGROUND: This study aimed to investigate the impact of interactive lecture (IL) and team-based learning (TBL) on improving clinical reasoning skills (CRSs) and achieving learning outcomes (LO). Students' feedback was obtained about the strategies. METHODS: This study was carried out at the Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia. Two modules, endocrinology, and emergency were selected. Students of each batch in both modules were divided into two arms. With a randomized crossover design, IL & TBL were used for two separate topics in each module. After each topic, a quiz in the form of well-structured MCQs was taken. A questionnaire was designed to obtain students' feedback. SPSS version 23 was used to analyse results. The difference between the mean values was calculated by Student's t-test. Feedback data is presented as frequency. P-value ≤ 0.05 was considered statistically significant. RESULTS: Learning outcomes were achieved by all groups in two modules, with both instructional strategies, IL and TBL. Students attempted >70% correct answers. However, in the emergency module, the groups with TBL as the instructional strategy performed better in quiz1 and quiz 2 (p = 0.026 and p = 0.016, respectively). Similarly, in the endocrinology module (3rd year), although the groups with TBL as the instructional strategy performed better in both quizzes, it was significant in quiz1 (p = 0.02). The difficulty indices of the clinical reasoning questions (CRQ) were used as the parameters for comparison. In the emergency module, group1, in quiz1, with TBL as an instructional strategy performed better in the CRQ (p = 0.017), while in quiz2, group2 with TBL as the instructional strategy performed better (p < 0.001). Group1 of the third-year students (endocrinology module) performed better in the CRQ in quiz 1 with TBL as an instructional strategy than group 2 with IL (p = 0.04). Mostly, students in both modules preferred TBL over IL, and especially they liked team application. Students perceived that TBL was a better strategy to learn CRS. CONCLUSIONS: Students achieved LOs and CRS better with TBL as an instructional strategy. They preferred TBL over IL. It is suggested to include TBL, or increase its percentage, in the curriculum.

23-gauge transconjunctival sutureless vitrectomy in treatment of post-operative endophthalmitis.

PURPOSE: To report the safety and efficacy of 23-gauge (23-G) transconjunctival vitrectomy (TSV) in the surgical management of postoperative endophthalmitis. MATERIALS AND METHODS: Ten consecutive patients underwent a 23-G TSV in 2008-2010 after cataract surgery (n = 5) or filtrating surgery (n = 5), and were prospectively studied with a minimum follow-up of 6 months. TSV was performed within a median delay of 1 day after the diagnosis, after one or two injections of intravitreal antibiotics (vancomycin, ceftazidime). Conventional cultures (brain heart infusion media) and/or panbacterial PCR were performed on aqueous humor and/or vitreous samples. RESULTS: Initial visual acuity was less than or equal to hand motion in all cases, and clinical findings included hypopyon (80%), pupillary fibrin membrane (80%), and dense vitreitis (4+, 100%). The bacteria identified were Gram-positive cocci in 60% of the cases (coagulase-negative staphylococci, 20%; streptococcus, 40%) and Gram-negative bacilli in 10% (moraxella lacunata). All patients had central and peripheral vitrectomy (mean duration, 58.6 ± 16 min). No intraoperative complications were noted. Two patients developed retinal detachment postoperatively and were reoperated. The final visual vision was 20/400 for two patients and 20/50 or better for the other patients. CONCLUSION: 23-G TSV allows the surgeon to meet the same objectives as the 20-G technique for the treatment of endophthalmitis.

Awareness and knowledge about glaucoma among patients visiting the screening clinic in Jeddah Eye Hospital, Saudi Arabia.

AIM: To explore levels and determinants of awareness and knowledge about glaucoma among patients. METHODS: This was a cross-sectional study that included adult patients from October to the end of December 2018. A semi-structured questionnaire was designed by the researchers to measure the levels of awareness and knowledge about 18 basic information about glaucoma. The sheet was divided into 4 domains: types of glaucoma, risk factors, clinical features, and management. A knowledge score (KS, range=0-18) was calculated, with higher scores indicating higher levels. RESULTS: A total of 383 patients responded to the questionnaire, 61.9% males, mean±SD age was 38.5±12.94 years old, and 61.6% had a university degree or higher. Of them, 6.3% and 23.2% reported personal and family history of glaucoma, respectively. The most frequently reported source of information about glaucoma was another person with glaucoma (28.2%), followed by physicians (24.8%) and TV (19.6%). Knowledge by item ranged from 3.1% to 82.5% correctness rate, while KS showed mean=5.91 and median=5; and reliability testing of the knowledge scale showed Cronbach's alpha=0.782. Higher KS were found among respondents with higher educational level (P=0.036), diabetes history (P=0.025), and personal (P<0.001) and family (P<0.001) history of glaucoma. CONCLUSION: This study reveals low awareness and knowledge levels about glaucoma among the attendees of a local eye care hospital, where several misconceptions about disease risk factors, clinical features, and management are identified.

Choroidal blood flow after the first intravitreal ranibizumab injection in neovascular age-related macular degeneration patients.

PURPOSE: To analyse choroidal blood flow (ChBF) changes after the first intravitreal ranibizumab injection in naïve, age-related macular degeneration (ARMD) patients. METHODS: Subfoveal ChBF was assessed by laser Doppler flowmetry (LDF) in newly diagnosed ARMD patients. Both treated and untreated eyes were assessed in each subject at each visit before the first intravitreal ranibizumab injection as well as 24 hr (day 1) and 7 days after (day 7). Central macular thickness (CMT), best-corrected visual acuity (BVCA), systemic haemodynamic parameters and LDF parameters were evaluated at each visit. Nonparametric tests were used to compare data between visits and between treated and untreated eyes. RESULTS: Seventeen ARMD patients were included (12 women and five men, 78 ± 8 years old). At day 7 postintravitreal ranibizumab injection, the normalized choroidal blood velocity (ChBVel) change in the treated eye group was significant (-10.2%; p = 0.006). The choroidal blood volume (ChBVol) did not change significantly after intravitreal injection of ranibizumab. There was a trend for a reduction in ChBF at day 7 (-9.1%, p = 0.08). The sensitivity of the experiment was 12% for ChBVel, 16% for ChBVol and 9% for ChBF. CONCLUSION: In conclusion, the laser Doppler technique provides feasible and noninvasive measurements of blood flow parameters before and after intravitreal injection of antivascular endothelial growth factor (anti-VEGF) in patients with exudative ARMD. Choroidal blood velocity decreased as early as 7 days after intravitreal ranibizumab injection, suggesting a vasoconstriction effect of anti-VEGF in large choroidal vessels in front of choriocapillaris (the site of LDF measurement).

Twenty-four-hour rhythm of ocular perfusion pressure in non-arteritic anterior ischaemic optic neuropathy.

PURPOSE: In non-arteritic anterior ischaemic optic neuropathy (NAAION) patients, circulatory insufficiency within the optic nerve has previously been hypothesized to be related to nocturnal systemic hypotension. The main objective of this prospective cohort study was to investigate the nyctohemeral variations in ocular perfusion pressure (OPP) in NAAION patients. METHODS: In 20 patients with NAAION, the intraocular pressure (IOP) was measured using the Tono-Pen XL(™) electronic tonometer every hour for 24 hr. Blood pressure (BP) was evaluated over 24 hr. Mean OPP was calculated with the following formula: OPP sitting position = (0.74 × mean BP) - IOP and OPP lying position = (0.84 × mean BP) - IOP. A nonlinear least squares dual-harmonic regression analysis approach was used to model the 24-hr rhythms of OPP data. RESULTS: On average, a 24-hr amplitude of 4.7 ± 2.6 mmHg was found for OPP. The patients were classified as either having a diurnal OPP rhythm (i.e. with a diurnal acrophase, 10% of the cases), a nocturnal OPP rhythm (45%) or absence of OPP rhythm (45%). Four patients had a nocturnal reduction in OPP (mean, -11%). CONCLUSION: The physiological nocturnal rhythm of OPP was maintained in 45% of the NAAION patients. The nocturnal reduction in OPP seen in 20% of the patients was within the range of OPP where optic nerve blood flow autoregulation is still fully operative. A high prevalence of obstructive sleep apnoea syndrome in our population (71%) may explain the low frequency of systemic nocturnal hypotension.

Continuous response of optic nerve head blood flow to increase of arterial blood pressure in humans.

PURPOSE: This study investigates the effect of increased ocular perfusion pressure (OPP) on optic nerve head (ONH) hemodynamics. METHODS: In 21 healthy subjects, the increase in arterial blood pressure (BP), measured continuously using a pneumatic transcutaneous sensor, was produced by isometric exercise consisting of 2 minutes of hand-gripping. ONH blood flow parameters-namely the velocity (Vel), number (Vol), and flux (F) of red blood cells-were measured using the laser Doppler flowmeter (LDF). RESULTS: In those 14 healthy subjects who exhibited a similar increase in BP to handgrip superior to 30% of baseline BP, group average increases of BP and OPP amounted to 34% ± 3% (SEM) and 43% ± 3%, respectively. The increase in F of 19% ± 8%, resulting from an increase in Vel (17% ± 7%) and Vol (6% ± 7%), was significantly less than predicted for a passive autoregulatory response, as revealed also by the increase in vascular resistance (R = OPP/F). Spearman test of linear correlations between F and time during handgrip led to the identification of one group of eight subjects (with a stable F) and one group of six subjects (with an increase in F). A closed-loop gain (G) of the regulatory process, defined as G = 1 - {(F - Fbl)/Fbl}/{(OPP - OPPbl)/OPPbl}, was found to be rather independent from the OPP, with an average value 0.7 ± 0.07. G was 0.83 ± 0.06 for the group of eight subjects with stable F and 0.3 ± 0.15 for the group of six subjects with F increasing with the OPP. CONCLUSIONS: The continuous recording of both BP and LDFs represents a novel and more precise approach to the characterization of ONH hemodynamics during isometric exercise, especially useful in the future for patients with ocular diseases. The efficiency of the ONH blood flow autoregulation appears to vary significantly between healthy subjects. (ClinicalTrials.gov number, NCT00874913.).

Frequent loss of nyctohemeral rhythm of intraocular pressure restored by nCPAP treatment in patients with severe apnea.

OBJECTIVE: To assess 24-hour intraocular pressure (IOP) and ocular perfusion pressure rhythms in newly diagnosed apneic patients before and after nasal continuous positive airway pressure (nCPAP) treatment. METHODS: Intraocular pressure (using a Tonopen XL) and ambulatory blood pressure, measured hourly for 24 hours, were analyzed in 18 consecutive patients with obstructive sleep apnea for nyctohemeral rhythmicity (cosinor model). Twelve of 18 patients were reassessed after nCPAP use. RESULTS: Before treatment, 28% of the patients with obstructive sleep apnea demonstrated a nocturnal acrophase, 22% a diurnal acrophase, and 50% absence of 24-hour rhythm of IOP. The ocular perfusion pressure rhythm was nocturnal in 78% of cases and absent in 22%. Using nCPAP, the mean (standard error of the mean) nocturnal IOP increased from 14.8 (0.8) to 18.3 (1.2) mm Hg (P < .03). Among patients with initial abnormal IOP rhythm (ie, rhythm with diurnal acrophase or absence of rhythm), 67% shifted to a normal 24-hour IOP profile after treatment. CONCLUSIONS: Normal IOP nyctohemeral rhythm is lost in most patients with severe apnea. Nasal continuous positive airway pressure use restored a normal 24-hour IOP profile in most cases.