Radical reform of the undergraduate medical education program in a developing country: the Egyptian experience

Medical educators are in a continuous quest to close the gap between the needs of medical practice and the rising expectations of the communities in their countries. During the past two decades, competency-based medical education has been evolving as an appealing strategy to close this gap. In 2017, the Egyptian medical education authorities mandated all medical schools to change their curricula to comply with revised national academic reference standards, which changed from outcome-based to competency-based. In parallel, they also changed the timeline of all medical programs for six years of studentship and one-year internship to five years and two years, respectively. This substantial reform involved the assessment of the existing situation, an awareness campaign for the proposed changes and an extensive national faculty development program. Monitoring the implementation of this substantial reform was performed through surveys, field visits and meetings with students, teaching staff and program directors. In addition to the expected challenges, the COVID-19-associated restrictions presented a significant further challenge during the implementation of this reform. This article presents the rationale for and steps of this reform, the challenges faced and how they were addressed.

Predictors of enablers and barriers to community pharmacists' management of minor ailments in a developing setting: A theory-driven assessment

BACKGROUND

The clinical and financial burdens associated with minor ailments are well documented, but published evidence suggests that minor ailment services led by community pharmacists have a remarkable positive impact, mainly in developed settings. There is a paucity of evidence on community pharmacists' self-perceived enablers and barriers to the effective management of minor ailments.

OBJECTIVES

The objective of the study was to identify community pharmacists' self-perceived enablers and barriers to the effective management of minor ailments as well as their significant predictors.

METHODS

A Kurt Lewin's theory-driven cross-sectional survey of 305 community pharmacists was conducted in Qatar using a pretested 25-item structured questionnaire developed with an adapted conceptual framework focused on 4 key areas: education, regulation, practice, and research. Bivariate logistic regression was used to identify significant predictors of community pharmacists' self-perceived enablers and barriers.

RESULTS

The response rate was 92.5% (282/305). Most of the respondents (68.1%) were males, who were 31-40 years of age (55.3%) and worked for pharmacy chains (77.3%). Community pharmacists identified a higher proportion of enablers (positive force) (82.4%) relative to only 3 barriers (negative force) (17.6%). The barriers identified included insufficient private or semiprivate space for patient counseling, the paucity of invitations to participate in practice-based research, and lack of feedback regarding the results and recommendations of previous research in which they were participants. The significant predictors of self-perceived enablers and barriers were female gender (odds ratio [OR], 2.21; 95% CI, 1.25-3.91; P = 0.007) and age group of ≤40 years (OR, 4.74; 95% CI, 3.50-7.16; P = 0.006).

CONCLUSION

Community pharmacists' perceptions of the factors that enhance their effective management of minor ailments were overwhelmingly positive, as 14 enablers were identified relative to only 3 barriers. Female and young community pharmacists were significantly more likely to perceive enablers than barriers. The insights provided are potentially useful in developing pharmacy-based schemes to improve the effective management of minor ailments.

Community pharmacists' management of minor ailments in developing countries: A systematic review of types, recommendations, information gathering and counselling practices

AIMS

To conduct a systematic review of the management of minor ailments by community pharmacists in developing countries, and to identify the specific minor ailments encountered, the medications recommended or requested and the information gathering and counselling practices.

METHOD

Observational studies from developing countries published in English language from inception to 2019 and report the management of minor ailments by community pharmacists were systematically searched in PubMed, ScienceDirect and Cochrane Library.

RESULTS

Thirty full-text studies, out of 7876 retrieved and screened, were included in the systematic review. Minor ailment-induced encounters by patients with community pharmacists are generally pervasive and involve mainly verbal request for specific medicines by name (60%). The most frequent minor ailments reported were respiratory, gastrointestinal and musculoskeletal conditions, and the most common medicines recommended or requested for were cough/cold preparations, antimotility and oral rehydration preparation, and analgesic/antipyretic. Inappropriate recommendation of antibiotics were reported for acute diarrhoea and cough/colds (40%) (10/25). Community pharmacists encountered 11-30 customers with minor ailments per day, with an average of about 4.8 (1.3-20.5) minutes per encounter. None of the studies reported the availability and/or use of a specific protocol to guide the management of minor ailments. There was wide variation in the type and depth of information gathered and used for the management of minor ailments; and the counselling information provided by community pharmacists, and there was no evidence of the documentation activities related to the management of minor ailments.

CONCLUSIONS

Community pharmacists' encounter with and management of minor ailments appear extensive in developing countries and probably present an opportunity to contribute significantly to reduce disease burden and enhance public health. However, the management process is currently unstructured, unguided by a specific protocol and vary in the quality of recommendations, information gathering and counselling practices.

Using Padé Approximant Method to Solve the Mathematical Model of Tumor-Immune Interactions

A mathematical model, in the form of a system of nonlinear ordinary differential equations, that describes the interaction between tumor cells and effective immune cells is proposed. An exact solution cannot be found to this system like many other nonlinear systems. Yet, approximate analytical solution is explored. This solution should have a large interval of convergence to be acceptable because the interaction can take many days to reach its steady state. Power series method is used to obtain a series solution. In this process, some auxiliary variables are used to transform the system of equations to polynomial form. However, this solution has a small radius of convergence, therefore, Padé approximant method is used to extend the domain of convergence. Hence, the obtained approximate analytical solution is valid over a large interval and has a remarkable accuracy when compared with numerical solution.

Mathematical Modelling for the Role of CD4+T Cells in Tumor-Immune Interactions

Mathematical modelling has been used to study tumor-immune cell interaction. Some models were proposed to examine the effect of circulating lymphocytes, natural killer cells, and CD8+T cells, but they neglected the role of CD4+T cells. Other models were constructed to study the role of CD4+T cells but did not consider the role of other immune cells. In this study, we propose a mathematical model, in the form of a system of nonlinear ordinary differential equations, that predicts the interaction between tumor cells and natural killer cells, CD4+T cells, CD8+T cells, and circulating lymphocytes with or without immunotherapy and/or chemotherapy. This system is stiff, and the Runge-Kutta method failed to solve it. Consequently, the "Adams predictor-corrector" method is used. The results reveal that the patient's immune system can overcome small tumors; however, if the tumor is large, adoptive therapy with CD4+T cells can be an alternative to both CD8+T cell therapy and cytokines in some cases. Moreover, CD4+T cell therapy could replace chemotherapy depending upon tumor size. Even if a combination of chemotherapy and immunotherapy is necessary, using CD4+T cell therapy can better reduce the dose of the associated chemotherapy compared to using combined CD8+T cells and cytokine therapy. Stability analysis is performed for the studied patients. It has been found that all equilibrium points are unstable, and a condition for preventing tumor recurrence after treatment has been deduced. Finally, a bifurcation analysis is performed to study the effect of varying system parameters on the stability, and bifurcation points are specified. New equilibrium points are created or demolished at some bifurcation points, and stability is changed at some others. Hence, for systems turning to be stable, tumors can be eradicated without the possibility of recurrence. The proposed mathematical model provides a valuable tool for designing patients' treatment intervention strategies.

Vaginal progesterone for prevention of preterm delivery in women with twin pregnancy: a randomized controlled trial

BACKGROUND

The aim of this study is to evaluate the efficacy of vaginal progesterone to prevent preterm delivery in twin pregnancies and its effect on perinatal outcome.

MATERIALS AND METHODS

A randomized, open label, controlled trial (NCT02350231) was carried out over 70 women, in three different hospitals in Egypt, between February 2015 and January 2017. All eligible pregnant women with twin pregnancies were randomly allocated in a 1:1 ratio into two groups. Group I (Progesterone group) was dispensed, 400 mg of progesterone through a vaginal pessary, each day at bedtime, from the 28th week of pregnancy until delivery. Group II (Control group) received no treatment other than the normal tonics taken during pregnancy. The two study groups were followed until delivery. The primary outcome was the rate of preterm delivery <37 weeks.

RESULTS

No significant differences were observed among both groups of women in terms of delivery <37 weeks (16.9% versus 25.4%; p=0.06) and mode of delivery (vaginal versus cesarean; p=0.31). The mean gestational age at delivery was comparable between both groups (p=0.09). Additionally, no difference, regarding the neonatal outcome, was observed between both groups.

CONCLUSION

Dispensing vaginal progesterone [400 mg] after 28 weeks of gestation does not prevent preterm delivery in twin gestations.

Sulfatides in ovarian tumors: clinicopathological correlates

OBJECTIVES

To investigate the expression of sulfatides in the tissue homogenates of malignant ovarian tumors, benign ovarian tumors, and control tissues and to study the relation between this marker and other clinico-pathological criteria such as the tumor type, grade of differentiation, surgical stage and ovulatory years.

DESIGN

Cross-sectional study.

SETTING

Department of Obstetrics and Gynecology and Department of Biochemistry, Assuit university hospital.

SUBJECTS

Forty-six patients had malignant ovarian tumors. Sixteen patients had benign ovarian neoplasm. Thirty patients, with normal ovaries, represented the control group.

METHODS

A sample of the tumor or from the normal ovary (the control group) was sent for histopathological and biochemical examination. Sulfatides were measured by a rapid and sensitive spectrophotometric method.

RESULTS

There was a significant rise in benign tumors [median and range 43 (38-53)], than in the control group, 21 (18-31), P-value = 0.000. In malignant tumors, the median value of sulfatides was significantly higher than in benign tumors [127 (71-193), P-value = 0.000]. Sulfatides were significantly higher in patients with more ovulatory years and tumors of advanced stages (stage III/IV) and poor differentiation.

CONCLUSIONS

Sulfatides may play a role in the pathogenesis of benign and malignant ovarian tumors. It may also predict advanced stages in patients who are apparently early stage. It is also a candidate to study of their association with response to chemotherapy.

Second-trimester pregnancy termination: comparison of three different methods

The object of this study was to compare intravaginal misoprostol and dinoprostone (prostaglandin E2) for second-trimester pregnancy termination, and to examine the role of the nitric oxide donor, glyceryl trinitrate, as a possible alternative to prostaglandins to induce cervical ripening in second-trimester pregnancy termination. This was a randomised clinical trial. The trial involved pregnant women between 13 and 28 weeks' gestation admitted with clear medical or obstetric indications for pregnancy termination, and was carried out in the department of obstetrics and gynecology, Assiut University Hospital, Egypt. Patients were classified into Group A, where pregnancy termination was induced by vaginal misoprostol 100 micrograms every 4 hours with a maximum dose of 500 micrograms; Group B, where induction was by vaginal dinoprostone 6 mg every 6 hours with a maximum dose of 24 mg; and Group C, where induction involved vaginal glyceryl trinitrate 500 micrograms every 6 hours with a maximum dose of 2.5 mg. Twenty-four hours after the start of induction, the rate of complete abortion in the three groups was 100%, 66.67% and 0%, respectively. The rate of complete abortion was 100% in the nitric oxide (glyceryl trinitrate)-induced group after introducing a complementary procedure. The induction-abortion interval was significantly shorter, the number of doses needed was less and the maximum Bishop score reached was greater with misoprostol than with dinoprostone. A higher rate of side effects occurred with the misoprostol-induced group (74%) compared with the other two groups (46.6% and 0%). Misoprostol is a cheap, effective drug for second-trimester pregnancy termination with short induction abortion intervals but a higher rate of side effects. Prostin E2 is also effective in termination of second-trimester pregnancy but is expensive and may require high doses to be administered. Glyceryl trinitrate is an effective drug for cervical ripening (softening) but it has no role in the stimulation of uterine contractions.

Maternal and fetal serum nitric oxide (NO) concentrations in normal pregnancy, pre-eclampsia and eclampsia

OBJECTIVES

To measure the maternal and fetal serum concentrations of total nitrites and nitrates (as an index of nitric oxide production) in normal pregnancy, pre-eclampsia and eclampsia.

DESIGN

Three groups of women were studied cross-sectionally: late pregnant women with pre-eclampsia and eclampsia (n=31); normal late pregnant women (n=32); and age-matched healthy non-pregnant women (n=21). Venous blood samples were collected from all women and both maternal and umbilical venous samples were collected from pregnant women.

METHODS

Blood samples were assayed for nitric oxide (NO) production by Greiss reaction which measures the combined oxidation products of NO (total nitrites and nitrates).

RESULTS

There was a significant increase in serum total nitrites and nitrates concentrations in normal pregnant women than in the serum of age-matched normal non-pregnant women (P<0.0001). Significantly higher total nitrites and nitrates levels were found in the maternal sera of the pre-eclamptic and eclamptic women compared with those of normal pregnant women (P<0.0001). Also, fetal blood levels of total nitrites and nitrates were significantly increased in pre-eclampsia and eclampsia compared with those of normal pregnancy (P<0.0001).

CONCLUSIONS

(1) Serum nitric oxide (NO) production is increased in normal pregnancy than in the normal non-pregnancy. (2) Maternal and fetal serum NO levels are increased significantly in pre-eclampsia and eclampsia, which possibly represents a compensatory/protective mechanism to maintain blood flow and limit platelets aggregation in the fetal-maternal circulations. (3) The increase in NO production is directly related to the severity of pre-eclampsia; this would be of diagnostic significance for the prediction of the severity of this syndrome.

Hysteroscopic myometrial biopsy in unexplained abnormal uterine bleeding

OBJECTIVES

To define the value of hysteroscopic myometrial biopsy in unexplained abnormal uterine bleeding not responding to hormonal treatment and to compare two hysteroscopic biopsy techniques.

DESIGN

A prospective cross-sectional comparative study.

SETTING

Gynecologic Endoscopy Unit, Assiut University Hospital, Egypt.

PATIENTS

It comprised 99 patients with abnormal uterine bleeding who underwent transvaginal ultrasonography, endometrial biopsy and diagnostic hysteroscopy, which revealed no local lesions.

INTERVENTIONS

Operative hysteroscopy was performed for 62 of them (group A). Hysteroscopic myometrial biopsies were taken using rigid biopsy forceps and the resectoscope successively guided by the previous ultrasonography of the myometrium. Thirty-seven patients (group B) underwent total abdominal hysterectomy followed by multiple full-thickness myometrial biopsies of the specimens.

RESULTS

Pathologic myometrium was diagnosed in 12 (19%), 27 (43%) and 21 (56.5%) biopsies taken with the rigid biopsy forceps and the resectoscope (group A) and full-thickness biopsies (group B) respectively. Thirty biopsies (48%) taken with the rigid biopsy forceps were inadequate for proper histopathologic assessment while thermal effect was excessive in only four biopsies (6%) taken with the resectoscope. Honeycomb sonographic appearance was specific in prediction of adenomyosis.

CONCLUSIONS

Resectoscopic myometrial biopsy can explain the cause of persistent abnormal uterine bleeding in about 43% of cases. Myometrial biopsy using the rigid biopsy forceps is inadequate and is not recommended.

Simplified biophysical profile: an antepartum fetal screening test

A total of 330 high-risk pregnant women with gestational ages of 32-42 weeks were followed until delivery using the biophysical profile (BPP) and a screening test consisting of the amniotic fluid index together with fetal acoustic stimulation under ultrasound M-mode scanning. The test was compared with the BPP and nonstress test (NST) for predicting abnormal outcome. The sensitivities of the BPP, NST and the proposed test were 100, 98.4 and 100%, respectively, the negative predictive values were 100, 99.4 and 100%, while the false-positive rates were 21.3, 39.3 and 67%. Our simplified biophysical testing method is suggested to be a good negative preliminary screening test, while positive results require further fetal testing methods. This test reduced the need for BPP in many high-risk patients and had the advantages of simplicity, low cost and less time consumption.