Preparing tutors for problem-based learning: an experience from B. P. Koirala Institute of Health Sciences, Nepal

BACKGROUND

Problem based learning (PBL) has made major impact on curricular designing and practice in medical education for the last forty years. Incorporation of PBL approach in medical education has been a challenge and opportunity for both educationists on how to impart change and medical teachers on how to internalise the change.

OBJECTIVES

This paper aimed to investigate experiences, achievement and responses of medical teachers at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal.

MATERIALS AND METHODS

There were 25 heterogeneous groups of teachers, majority of them were entry level. Pre- and Post-test question were taken from various topics relevant to PBL such as learning strategy and principles of adult learning, PBL practice at BPKIHS, tutorial session and role of a tutor, making resource session interactive, designing PBL problems, planning educational objectives in PBL, formulation of problem for PBL. In addition to it participants' perception on development and dissemination of PBL manual and effectiveness of workshop were also included in the questionnaire.

RESULTS

There was significant gain in knowledge following the workshop (p<0.001). The perception of the teacher found quite relevant and useful for adopting new role as tutor. The respondent teachers noted that skills they learned during the training will be applicable to their job situation. They stressed for an additional training for reinforcement and update with new trends and tools in PBL.

CONCLUSION

Therefore, such trainings for faculty development would be highly beneficial to inculcate new competencies in PBL.

Drde-07: a possible antidote for sulphur mustard toxicity

Chemical Warfare Agents are classified in various categories and vesicating agents are one among them. Vesicating agents are mostly mustard agents. Sulphur mustard which is chemically known as bis(2-chloro ethyl) sulphide (SM), was first used in World War-I and in recent past in Iran-Iraq war. Its possible use by the terrorist groups can't be overlooked in the present scenario. As the mode of its action is still lacking, no specific treatment is so far known against SM induced systemic toxicity. The major drawback with the development of antidote against sulphur mustard is low efficacy of the potential compounds in vivo models. This review summarizes the current update about the work done so far and the future strategies.

Controlled novel route to synthesis and characterization of silver nanorods

Silver nanorods were synthesized by burning out the as prepared Ag-PVA nanocomposite films at 300 degrees C in air. Aqueous PVA solution is acts as stabilizing agents for silver nanorods. The formation of silver nanorods was confirmed from the appearance of two surface plasmon absorption maxima at 425 and 465 nm due to transverse and longitudinal mode of vibration of electrons. SEM micrograph showed the resultant nanorods were 500-600 nm in length and 50-70 nm in diameter. It is supported by TEM with more 1000 nm in length and 40-60 nm diameters. The XRD demonstrated that the nanorods were present in fcc crystal of pure silver. Finally the X-ray photoelectron spectroscopy (XPS) also confirmed the formation of silver nanorods with 3d(5/2) and 3d(3/2) band at 368.6 and 374.6 eV respectively.

Final results of a phase I study of daily PI-88 as a single agent and in combination with dacarbazine (D) in patients with metastatic melanoma

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Background: PI-88 is a heparan sulfate mimetic that inhibits angiogenesis and metastasis directly and via release of tissue factor pathway inhibitor (TFPI). PI-88 has shown some efficacy in an intermittent dosage regimen (250 mg/day 4 days/week) in melanoma (Thomson et al, ASCO 2005). This study tested PI-88 7 days per week alone (group 1) and in combination with 3 weekly D (group 2). Methods: Eligibility included inoperable metastatic melanoma, no prior chemotherapy, PS 0–1, adequate organ function, no recent use of heparin, negative anti-heparin antibody (AHA), no concurrent use of anti-coagulants or anti-platelet agents, no history of GI bleeding. Group 1 cohorts received daily PI-88 in doses of 140 mg, 190 mg and 250 mg. Group 2 received PI-88 commencing at the level below the single agent MTD plus D 1,000 mg/m2 every 21 days. Group 1 pts who had PD could continue PI-88 with the addition of D. FDG-PET scans were performed prior to and after 6 weeks PI-88 in Group 1. Free TFPI was measured in serum prior to and up to 2hr post first dose PI-88 in group 1. Results: Group 1 - DLT occurred in 0/3 (140 mg), 0/3 (190 mg) and 2/3 (250 mg) pts. Group 2 - DLT occurred in 1/6 (140 mg) and 0/4 (190 mg) pts. All DLTs were AHA positive grade III/IV thrombocytopenia with in 1 pt (250 mg) cerebral venous sinus thrombosis. No other major toxicities and no increase in expected DTIC toxicities were observed. 4 group 1 pts had pre/post PET scans. One pt had 50% fall in SUVmax with radiologic SD for 4 months. No radiologic responses occurred with PI-88 alone. 3/9 pts in group 2 had radiologic PR. 2/5 group1 pts who had D added to PI-88 had PR. Free TFPI increased from 6.9 ± 1.9 ng/ml just prior PI-88 to 56.1 ± 19.4 30 min post PI-88. The elevated levels were maintained at 60 and 120 min. Elevation of free TFPI did not correlate with PI-88 dose. Conclusion: The recommended phase II dose of continuous daily PI-88 is 190mg alone and in combination with D 1,000 mg/m2 every 3 weeks. An ongoing randomised study is comparing D 1,000 mg/m2 plus PI-88 190mg/day to single-agent D.

No significant financial relationships to disclose.

Generation of autoreactive CTL by tumour vaccines containing foreign T helper epitopes

The aim of this study was to evaluate the effect of including a foreign T helper cell epitope in vaccines designed for generation of CTL against self-antigens and for inhibition of tumour growth. Two different vaccine designs were composed, a minimal epitope vaccine and a modified full length self-antigen, both based on OVA containing either a colinearily synthesized or an inserted Th-epitope, respectively. These vaccines were used for immunization of tolerant OVA transgenic mice (RIP-OVA(low)) and non-tolerant C57BL/6 mice. First, it was shown that transgenic mice were tolerant to OVA in the CD4 compartment. Secondly, only the vaccines containing the foreign Th-epitope and not the wild-type constructs were able to induce self-reactive CTL in the transgenic mice. Thirdly, these self-reactive CTL induced by the Th-epitope modified constructs also inhibited tumour growth in the OVA transgenic mice. Overall, these results demonstrate that inclusion of a foreign Th-epitope circumvents the tolerance in this OVA transgenic strain. In addition, these results show the importance of including strong T-cell help in cancer vaccines.

Validation of the LC-MS/MS method for the quantification of mevalonic acid in human plasma and determination of the matrix effect

A simple, specific, and sufficiently sensitive liquid chromatography-tandem mass spectrometry (negative-ion electrospray ionization) methodology to determine mevalonic acid (MVA) in human plasma is described, and its application to the analysis of rat plasma MVA levels after rosuvastatin administration is demonstrated. The method was validated over the linearity range of 0.5-50.0 ng/ml (r(2) > 0.99) using deuterated MVA as an internal standard. The lower limit of quantification was 0.5 ng/ml. The assay procedure involved the isolation of MVA from plasma samples using solid-phase extraction. Chromatographic separation was achieved on a HyPurity Advance column with a mobile phase consisting of ammonium formate buffer (10 mM, pH 8.0) and acetonitrile (70:30, v/v). Excellent precision and accuracy were observed. MVA and deuterated mevalonolactone were stable in water and plasma under different storage and processing conditions. The recovery observed was low, which was attributable to a significant matrix effect. A significant decrease (30-40%; P < 0.05) was observed in rat plasma MVA levels after rosuvastatin administration.

Excess risk of renal allograft loss and early mortality among elderly recipients is associated with poor exercise capacity

BACKGROUND

Successful renal transplantation in the elderly offers substantial benefits in quality and life expectancy. However, in this group of patients there is an early increased risk of death compared with those remaining on dialysis.

MATERIALS AND METHODS

Graft and patient outcomes in 64 older transplant recipients were compared with 338 patients aged 18 - 59 years. We identified potential risk factors that may predict clinical outcomes in older transplant recipients. A log-rank test and Cox regression analyses were performed to assess the impact of various patient characteristics on graft and patient survival.

RESULTS

Among older patients, graft survival was 76.6% and 67% at 1 and 3 years, respectively. When graft survival was censored for death with functioning graft, the 1- and 3-year graft survival was 83% and 82%, respectively. Patient survival was 78% and 71% at 1 and 3 years, respectively. These survival rates were significantly lower than those of younger recipients. Pretransplant inactivity, delayed graft function, smoking history and longer waiting time predicted poor graft and patient survival. A history of chronic obstructive pulmonary disease, and peripheral vascular disease also predicted a higher mortality among older recipients.

CONCLUSION

Older kidney transplant recipients are at high risk for allograft failure and early death. Poor functional capacity predicts a poor outcome for older patients undergoing renal transplantation. Therefore, careful patient selection is paramount, and every effort should be made to initiate timely interventions aimed at increasing physical activity in those with low fitness level.

Preemptive plasmapheresis and recurrence of FSGS in high-risk renal transplant recipients

Recurrent focal segmental glomerulosclerosis (FSGS) following transplantation is ascribed to the presence of a circulating FSGS permeability factor (FSPF). Plasmapheresis (PP) can induce remission of proteinuria in recurrent FSGS. This study addressed the efficacy of pre-transplant PP in decreasing the incidence of recurrence in high-risk patients. Ten patients at high-risk for FSGS recurrence because of rapid progression to renal failure (n = 4) or prior transplant recurrence of FSGS (n = 6) underwent a course of 8 PP treatments in the peri-operative period. Recurrences were identified by proteinuria >3 g/day and confirmed by biopsy. Seven patients, including all 4 with first grafts and 3 of 6 with prior recurrence, were free of recurrence at follow-up (238-1258 days). Final serum creatinine in 8 patients with functioning kidneys averaged 1.53 mg/dL. FSGS recurred within 3 months in 3 patients, each of whom had lost prior transplants to recurrent FSGS. Two of these progressed to end-stage renal disease (ESRD) and the third has significant renal dysfunction. Based on inclusion criteria, recurrence rates of 60% were expected if no treatment was given. Therefore, PP may decrease the incidence of recurrent FSGS in high-risk patients. Definitive conclusions regarding optimal management can only be drawn from larger, randomized, controlled studies.

Experience With Sirolimus for Calcineurin Minimization/Elimination in Pancreas-After-Kidney Transplantation

Pancreas after kidney (PAK) transplantation, associated with a persistent elevation in serum creatinine (defined as a >25% increase from baseline), was seen in 7 of 11 (64%) cases maintained on immunosuppressive therapy consisting of tacrolimus, mycophenolate mofetil, and prednisone. Patients were converted to sirolimus as a means of minimizing or eliminating exposure to tacrolimus, the presumed nephrotoxic agent. With the use of sirolimus-based immunosuppression, and with elimination or minimization of tacrolimus, renal function, as measured by serum creatinine, stabilized or improved in all cases.

Cryptosporidium infection in renal transplant patients

Cryptosporidium parvum, an intracellular protozoan parasite, is a significant cause of gastrointestinal disease worldwide. Transmission can occur from an infected person, animal or fecally contaminated environment. The clinical manifestations of cryptosporidiosis are dependent on the immunologic state of the host. Infection among immunocompetent hosts results in diarrhea that is typically self-limited. In immunocompromised hosts, however, the infection may be protracted and life-threatening with no reliable antimicrobial therapy. In transplant patients, a course of antimicrobial therapy along with concurrent reduction in immunosuppression optimize immunologic status and may potentially lead to resolution of the infection.

Factors Contributing to Acute Rejection in Renal Transplantation: The Role of Noncompliance

Early episodes of acute rejection after renal transplantation reflect inadequate immunosuppression at a time of heightened immune challenge. Late acute rejection episodes, however, are less likely related to inadequacy of immunosuppression and may be due to patient noncompliance or overzealous weaning of immunosuppression. We evaluated 443 consecutive renal transplant recipients to determine the incidence and etiology of acute rejection. All episodes were confirmed by ultrasound-guided biopsy. The cause of each acute rejection was determined by chart review. Medication compliance was determined by history at the time of admission for biopsy. Over a follow-up period of 42 +/- 22 months, 87 patients (20%) suffered acute rejection. There was a trend toward fewer episodes of acute rejection with thymoglobulin induction and tacrolimus-based immunosuppression. Younger recipients had an increased risk of acute rejection (odds ratio 0.47, range 0.24-0.91, P = .027). Patient noncompliance with immunosuppression was associated with late acute rejection (P = .0002). Acute rejection increased the risk of allograft failure (P < .0001). Modifiable factors, including the choice of immunosuppression, reduce the risk of acute rejection. More importantly, the transplant recipient plays a substantial role in the maintenance of their allograft health through compliance with immunosuppressive drug therapy. Future strategies to improve compliance, including increased vigilance in high-risk patient groups, frequent medication review, and laboratory testing, should be encouraged.

Keeping up with the Jones's: open donor nephrectomy in the laparoscopic era

Several new approaches have been developed to perform donor nephrectomy. These include laparoscopic donor nephrectomy and open donor nephrectomy performed through small incisions, herein referred to as "mini-open donor nephrectomy". In the past, we performed open donor nephrectomy via a standard flank incision. In October 2002, we introduced mini-open donor nephrectomy via an anterior, retroperitoneal approach. Contemporaneously, we offered the option of laparoscopic donor nephrectomy. Herein, we review our single-center experience with these three techniques. Mini-open donor nephrectomy was comparable to the laparoscopic approach for duration of narcotic requirement and donor length of stay. The laparoscopic procedure was more expensive. Both procedures demonstrated improvement over the flank approach by eliminating the risk of pneumothorax, neuropathy, and flank bulge. In addition, length of stay and narcotic requirements were higher with the flank approach. Mini-open donor nephrectomy provides a good alternative to laparoscopic surgery, offering the donor an equivalent convalescence at lower cost and potentially with reduced morbidity.