Movement disorder in a patient with Human Immunodeficiency Virus on an anti-retroviral therapy: A Case Report.

Human Immunodeficiency Virus associated neurocognitive dysfunction can present as a case of movement disorder in a patient with prolonged antiretroviral therapy. Diagnosis was made after ruling out space occupying lesions, nutritional deficiencies and infectious causes through brain imaging and cerebrospinal fluid analysis. With multidisciplinary care and change of antiretroviral therapy to drugs with higher cerebrospinal fluid penetration, symptoms of the patient improved over a span of six months. Delayed neurological damage due to Human Immunodeficiency Virus can present with isolated cerebellar symptoms.

Beyond the classroom, 'pro-active teaching methods--a must for today's CPD movement'.

Non-traditional teaching approaches are not recent innovations in the field of continuing medical and professional development; however, there is a lack of employing such methods in our context. The reasons could include lack of awareness, recognition and overlapping and adoption of these approaches, peculiarly academic detailing, by the pharmaceuticals. Nevertheless these methods have proven to be useful in changing physicians' behaviour and attitudes towards patient care and health safety. Moreover, it guides, promotes and derives the self-directedness of the physicians to acquire current knowledge, skills and generic attributes that are required for lifelong learning.

Professionalism in medical students at a private medical college in Karachi, Pakistan.

OBJECTIVE: To determine levels of professionalism in undergraduate medical students at a private medical college and assess how changes emerge during their training. METHODS: The study was conducted at Aga Khan University, a tertiary care teaching hospital, during November and December 2011. Freshmen, Year 3 and Year 5 students were requested to fill out a questionnaire. It was designed to assess the participants' levels of professionalism and how they perceived the professional environment around them by incorporating previously described scales. The questionnaire was re-validated on a random sample of practising clinicians at the same hospital. SPSS 17 was used for statistical analysis. RESULTS: The study sample comprised 204 participants. The mean score for level of individual professionalism was 7.72+/-3.43. Only 13 (6.4%) students had a score one standard deviation above the faculty mean. About 24 (11.8%) were one standard deviation and 35 (17.2%) were 2 standard deviations below the faculty mean. The remaining 130 (63.7%) were >2 standard deviations below the faculty mean. Considering the level of education, the mean score for level of professionalism was 8.00+/-3.39 for freshmen, 6.85+/-3.41 for year 3 students, and 8.40+/-3.34 for year 5 students. CONCLUSION: The currently employed teaching practices inculcating the values of professionalism in medical students are serving as a buffer to maintain the pre-training levels of professionalism from declining.

Evaluating neurology CME in two educational methods using Patton's utilization focused model.

BACKGROUND: Generally in continuing education medical education (CME) the most time is consumed for in the planning and preparation of the event. This planning and preparation, however, needs recognition through an evaluative process. The purpose of this study was to evaluate neurology CME in two educational methods, lecture vs task-based learning, using Patton's utilisation focused model. METHODS: This was an observational, cross-sectional inquiry. The questionnaire evaluated the educational elements such as learning objectives met, content covered, presentations at the level of understanding, level of interaction, knowledge gained, time management, queries responded, organisation, quality of learning material and overall grading of the educational event. General Practitioners were the key participants in this evaluation and consisted of 60 self-selected physicians distributed equally in both the TBL and lecture groups. Patton's utilization focused model was used to produce findings for effective decision making. The data were analysed using Mann-Whitney U test to know the value of the learning method that satisfied the most participants. RESULTS: A total of 58 evaluations were returned, 29 from the TBL group and 29 from the lecture. The analysis of the elements showed higher mean ranks for TBL method ranging between 32.2 and 38.4 versus lecture (20.6-26.8). Most of the elements assessed were statistically significant (p > 0.05), except time management (p = 0.22). However, elements as 'objectives of the activity met' (p = 0.07), 'overall grading of the event' (p = 0.06) and 'presentations at the level of understanding' (p = 0.06) were at border line. Of the 29 respondents in the TBL group, 75% rated all the elements of the program above very good. In the lecture group, 22 (75%) respondents out of 29 rated almost half of the elements above very good. CONCLUSION: Majority of respondents in the TBL group rated all program elements as exceptional compared to the lecture group in which only half of the elements were rated above very good. Task-based learning method made the most impact on participants' satisfaction.

How does self-efficacy affect performance of learner?

All types of attribution based on which learners make their judgement (i.e., self efficacy), about academic success or failure or about a specific task usually affect their performance and their capabilities to deal with different realities. It is perhaps the most distinctive capability of self-reflection. Many of the cognitive theorists have defined it as a meta-cognitive capability. This judgement influence learners choose what to do, how much effort to be invested in the activity, how long to carry the phase of disappointment, and whether to approach the task anxiously or with assurance.

Post-dural puncture posterior reversible encephalopathy syndrome.

We report the case of a young patient with 36 weeks pregnancy, and an acute respiratory infection with severe bronchospasm, who developed an occipital headache and neck pain on the third day of inadvertent dural puncture during placement of combined epidural spinal anaesthesia for caesarian section. It was diagnosed as post-dural puncture headache until generalised tonic clonic seizures occurred the next day raising the suspicion of postpartum eclampsia or meningitis. Posterior reversible encephalopathy syndrome was diagnosed on MRI of the brain which showed features of reversible ischemia in the posterior region of the brain. With anticonvulsant therapy and antibiotics there was complete resolution of neurological symptoms. We highlight the importance of high index of suspicion of this reversible encephalopathy in obstetric cases with intentional or inadvertent dural puncture, with headache similar to post-dural punctural headache, and the essential role of neuroradiology in confirmation of the diagnosis, as placement of an epidural blood patch would be highly detrimental in these cases.

Experiences from an international tele-epilepsy collaboration.

OBJECTIVE: Our main objective was to use videoconferencing as a primary means to: a) assist in launching an epilepsy surgery program in Pakistan; 2) participate in case conferences on complex epilepsy patients in each country. METHODS: Extensive testing using both point to point and bridged integrated service digital network (ISDN) and internet protocol (IP) connections was carried out using bandwidths of 384-768 kilobits per second (kbps). Videoconferences between sites were arranged two to three weeks in advance and connections were tested a day prior to the scheduled conference. Sharing of PowerPoint presentations, neuroimaging and video-EEG was available to all sites. Discussions centered on patients with medically refractory epilepsy. RESULTS: Between July 2006 and June 2008, 17 sessions were booked. Five of these conferences bridged in specialists from West Virginia University. Most successful connections occurred using IP point to point calls or a bridge connecting end points through IP at 512 kbps. We conducted three surgeries for medically refractory temporal lobe epilepsy in Pakistan. At follow-up in January 2009, two patients have been seizure free and one had two breakthrough seizures after sudden unsupervised discontinuation of Levetiracetam. CONCLUSION: Our international tele-epilepsy collaboration has proven feasible and valuable to all participants. Our experience suggests considerable thought and preparation are needed before a teleconference to ensure its success. We provide a recipe to set-up similar telemedicine collaborations. Considerations include time zone differences, equipment type, interoperability between endpoints, connection capabilities, bandwidth availability, and backup plans for unsuccessful connections. Telemedicine can facilitate epilepsy care around the world, identifying with the concept of a "Global Health Village".

Brain death: concepts and knowledge amongst health professionals in province of Sindh, Pakistan.

OBJECTIVE: Last few decades have seen improved resuscitative measures and use of life saving machines like ventilators. Due to these dramatic interventions, end of life decisions, including brain death and organ transplantation, have become more complex and a major problem in our clinical practice. This study was done to find the opinion and awareness of physicians regarding issues surrounding brain death in this region. METHODS: A total of 259 questionnaires were analyzed that encompassed physicians at different level of training and students in the final year of their training, from five major tertiary care centres, located at Karachi and Hyderabad and who are involved in decision making about brain death and related issues. RESULTS: One hundred and forty one (54 percent) respondents did not have a clear idea regarding the definition of brain death. Majority of doctors 122 (47 percent) would therefore not turn off the ventilator even in a brain dead patient. Sixty seven (26 percent) actually considered it Euthanasia. Most considered 24 hrs as optimal period before confirming the diagnosis of brain death. Most of the doctors favoured a confirmatory test, like an electroencephalogram, to confirm the diagnosis of brain death. Majority of the doctors (68 percent) would not consider stopping ventilatory support of a patient in a persistent vegetative state. CONCLUSION: This study highlights the lack of understanding and confusion regarding issues surrounding brain death in this region especially among junior doctors and highlights the importance of including these issues in the medical curricula.

Acute porphyrias: clinical spectrum of hospitalized patients.

OBJECTIVE: To determine characteristics, clinical features and triggers of acute porphyria in hospitalized patients presenting to a tertiary care center in Pakistan. DESIGN: Case series. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from 1988 to 2003. PATIENTS AND METHODS: Case records of 26 patients hospitalized with diagnosis were identified through computerized hospital patients' data. The diagnosis of acute porphyria was based on pertinent clinical features and laboratory investigations after exclusion of other alternative diagnosis and patients previously diagnosed as porphyric. The data was analyzed through SPSS software version 11.0. RESULTS: Twelve patients (46.2%) were males. Mean age was 21 years. Most common manifestation were gastrointestinal (n=22; 88.5%) followed by neurological symptoms (n=14; 54%). Neurological manifestations included seizures (n=9; 34.6%) and neuropathy (n=6; 23%). One patient presented with depression and insomnia. Family history was positive in (n=8; 30.8%). Eighteen (69%) had history of previous attacks at their presentation to the hospital. Most common precipitating factor was 'eating outside' (n=18; 69%). CONCLUSION: Porphyrias are uncommon and cryptic group of diseases. This study shows a slightly different gender distribution, earlier onset of symptoms, higher number of neuropsychiatric symptoms (especially seizures), more distal neuropathies and different precipitant in the studied subset of patients than described previously in the western studies.

Oral contraceptives and cerebral venous thrombosis: case report and a brief review of literature.

Cerebral venous thrombosis remains an important and sometimes an elusive cause of strokes. Oral contraceptives seem to have a strong causative association with this entity. We describe a case that highlights the importance of asking specific questions about oral contraceptive use in patients with strokes due to cerebral venous sinus thrombosis, especially, where the cause remains cryptic.

Neuroleptic malignant syndrome: need for early diagnosis and therapy.

BACKGROUND: Neuroleptic Malignant Syndrome (NMS) is a medical entity that has received little attention in the clinical settings in Pakistan. The aim of our study was to review the predisposing factors, outcomes and characteristics of in-patients diagnosed with NMS. METHODS: We performed a retrospective chart review of all cases (age >15 years) at a tertiary care center in Karachi between January 01, 1990 and November 30, 2001, diagnosed using ICD 10 coding. Data was collected using a standardized data entry form and statistical analysis was performed using Epi Info 6, Version 6.02. RESULTS: There were a total of 20 patients diagnosed with NMS (11 male and 9 female) in our study with a mean age of 46.6 +/- 15.9 years. Haloperidol was the most frequently responsible neuroleptic. Of the 18 patients on a neuroleptic, most developed NMS after 8 weeks of therapy. There were 5 mortalities all of which were associated with septic shock. Fourteen patients recovered completely from the episode and did not have any neurologic sequelae. CONCLUSIONS: NMS is an important preventable clinical entity. Early diagnosis and judicious use of antipsychotics is warranted to prevent mortality and heightened morbidity.

Herpes simplex encephalitis: analysis of 68 cases from a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: To evaluate clinical presentation, radiological and cerebrospinal fluid findings and outcome of patients with Herpes simplex encephalitis (HSE). METHODS: The charts of all the patients (n = 88), who were admitted to The Aga Khan University, Karachi with diagnosis of HSE, from 1990-2002, were retrospectively reviewed. Sixty eight patients were included in the study. The variables were identified (including demographic data, signs and symptoms at presentation and laboratory investigations such as CSF analysis including, PCR, serum IgM antibodies, EEG and neuroimaging). The patients were included in the study if they had any three of the five criteria positive in addition to clinical features suggestive of herpes encephalitis. RESULTS: Sixty eight patients, that fulfilled the criteria, were included in the study. Clinical findings included fever, seizures, altered mental status, aphasia and hemiparesis. CSF, analysed in all the patients, was abnormal in 65 patients (96%) and EEG was abnormal in 82% patients. All patients underwent CT or MRI of the brain, 66% patients had abnormal scans. Temporal lobe involvement was seen in 34 patients (50%) and 11 patients had purely extra temporal lesions. All patients were treated with standard Acyclovir. Seven patients died. At the time of discharge, 17 patients showed normal neurological examination, 29 were ambulatory with assistance and 15 were bedridden. CONCLUSION: Our study suggests that large number of patients with HSE have extra temporal involvement on CT or MRI. Majority of patients had complete or good recovery after completion of therapy.

Task-based learning versus problem-oriented lecture in neurology continuing medical education.

OBJECTIVE: To determine whether general practitioners learned better with task-based learning or problem-oriented lecture in a Continuing Medical Education (CME) set-up. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: The Aga Khan University, Karachi campus, from April to June 2012. METHODOLOGY: Fifty-nine physicians were given a choice to opt for either Task-based Learning (TBL) or Problem Oriented Lecture (PBL) in a continuing medical education set-up about headaches. The TBL group had 30 participants divided into 10 small groups, and were assigned case-based tasks. The lecture group had 29 participants. Both groups were given a pre and a post-test. Pre/post assessment was done using one-best MCQs. The reliability coefficient of scores for both the groups was estimated through Cronbach's alpha. An item analysis for difficulty and discriminatory indices was calculated for both the groups. Paired t-test was used to determine the difference between pre- and post-test scores of both groups. Independent t-test was used to compare the impact of the two teaching methods in terms of learning through scores produced by MCQ test. RESULTS: Cronbach's alpha was 0.672 for the lecture group and 0.881 for TBL group. Item analysis for difficulty (p) and discriminatory indexes (d) was obtained for both groups. The results for the lecture group showed pre-test (p) = 42% vs. post-test (p) = 43%; pre- test (d) = 0.60 vs. post-test (d) = 0.40. The TBL group showed pre -test (p) = 48% vs. post-test (p) = 70%; pre-test (d) = 0.69 vs. post-test (d) = 0.73. Lecture group pre-/post-test mean scores were (8.52 ± 2.95 vs. 12.41 ± 2.65; p < 0.001), where TBL group showed (9.70 ± 3.65 vs. 14 ± 3.99; p < 0.001). Independent t-test exhibited an insignificant difference at baseline (lecture 8.52 ± 2.95 vs. TBL 9.70 ± 3.65; p = 0.177). The post-scores were not statistically different lecture 12.41 ± 2.65 vs. TBL 14 ± 3.99; p = 0.07). CONCLUSION: Both delivery methods were found to be equally effective, showing statistically insignificant differences. However, TBL groups' post-test higher mean scores and radical increase in the post-test difficulty index demonstrated improved learning through TBL delivery and calls for further exploration of longitudinal studies in the context of CME.

Establishment of a comprehensive epilepsy center in pakistan: initial experiences, results, and reflections.

Background. Developing countries, home to 80% of epilepsy patients, do not have comprehensive epilepsy surgery programs. Considering these needs we set up first epilepsy surgery center in Pakistan. Methods. Seventeen teleconferences focused on setting up an epilepsy center at the Aga Khan University (AKU), Karachi, Pakistan were arranged with experts from the University of Alberta Hospital, Alberta, Canada and the University of West Virginia, USA over a two-year period. Subsequently, the experts visited the proposed center to provide hands on training. During this period several interactive teaching sessions, a nationwide workshop, and various public awareness events were organized. Results. Sixteen patients underwent surgery, functional hemispherectomy (HS) was done in six, anterior temporal lobectomy (ATL) in six, and neuronavigation-guided selective amygdalohippocampectomy (SAH) using keyhole technique in four patients. Minimal morbidity was observed in ATL and, SAH groups. All patients in SAH group (100%) had Grade 1 control, while only 5 patients (83%) in ATL group, and 4 patients (66%) in HS group had Grade 1 control according to Engel's classification, in average followups of 12 months, 24 months and 48 months for SAH, ATL, and HS, respectively. Conclusion. As we share our experience we hope to set a practical example for economically constrained countries that successful epilepsy surgery centers can be managed with limited resources.

Continuing medical education and pharmaceutical industry.

Continuing medical education providers' (academia) and industrial relationship is drawing attention all over the world. To date, there are no national commercial support guidelines available in Pakistan to properly regulate cooperation between the two distinct entities. However, the fact is that the future of all continuing medical education depends on pharmaceutical support and the providers are heavily dependent on the pharmaceutical industry to remain in action. It should always be remembered that medical education and profession is regarded as a moral of enterprise based on a blind faith between the physician and the patient. The funding support by the industry should not bind or influence physician's prescription for any reason. To be trusted, medicine must be free of all such dependency; it should be accountable only to the society it serves and to its own professional standards.