An insight into the clinical learning environment of dental institutes: a study in the twin cities of Pakistan

OBJECTIVE

To assess the perceptions of dental students regarding their clinical learning environment in an urban setting.

METHODS

This descriptive, cross-sectional survey was conducted from March 2020 to May 2021 after approval from the ethics review committee of Islamic International Dental College, Islamabad, Pakistan. It comprised of clinical year students, house officers and postgraduate trainees from 6 dental teaching hospitals of Rawalpindi and Islamabad. Data was collected using a pre-validated instrument assessing the dental clinical learning environment. Data was analysed using SPSS 24.

RESULTS

Of the 1030 students approached, 561(54.4%) responded. Of them, 448(80%) were girls, 234(41.7%) were 3rd year students, 110(19.6%) were 4th year students, 120(21.4%) were house officers and 97(17.3%) were postgraduate trainees. Female students had a better patient attitude and were more confident in their abilities to keep up with their peers (p<0.05). The students were content with the performance of their clinical teachers, with a mean score of 70.99+/-16.0, while the lowest score of 54.67+/-22.9 was for clinical infrastructure and materials. Students of Islamabad pointed out the lack of clinical materials and maintenance of equipment but noted better research opportunities compared to their Rawalpindi counterparts (p<0.05).

CONCLUSIONS

The clinical learning environment for Islamabad and Rawalpindi cities individually was good. Overall, students were satisfied with their clinical teachers, learning and training experience. Dental materials, infrastructure and maintenance factors scored the lowest.

Questionable research practices of medical and dental faculty in Pakistan - a confession

PURPOSE

Intellectual honesty and integrity are the cornerstones of conducting any form of research. Over the last few years, scholars have shown great concerns over questionable research practices (QRPs) in academia. This study aims to investigate the questionable research practices amongst faculty members of medical and dental colleges in Pakistan.

METHOD

A descriptive multi-institutional online survey was conducted from June-August 2022. Based on previous studies assessing research misconduct, 43 questionable research practices in four domains: Data collection & storage, Data analysis, Study reporting and Collaboration & authorship were identified and investigated. Descriptive (Frequencies, Percentages, Mean, SD) and Inferential (chi square) statistics were calculated.

RESULTS

A total of 654 faculty members responded. Every respondent reported committing at least one QRP in their career. The most common QRPs included deliberately failing to mention funding, publishing program evaluation data not meant for research purposes or approved by an ethical body, inappropriately storing identifiable information and non-disclosure of any conflicts. There was significant association of age, gender and academic rank with QRPs in 'Data collection and storage' and 'Data Analysis' domains.

CONCLUSION

Medical and dental faculty members participating in this study are involved in a range of questionable research practices (QRPs) in Pakistan. Their confession might have contributed to the faculty developing self-awareness and reinforcing academic integrity. There is a need for reviewing policies and practices to improve research culture. Future research should explore the factors resulting in such practices.

Impact of emotional intelligence in resolving clinical conflicts among postgraduate residents of surgery

Background & Objective

Emotional intelligence (EI) can become a vital tool for resolving clinical conflicts (CC) in surgery. The postgraduate residents focus on the technical skills and undermine the soft skills required for their better training. Our aim was to determine the EI of postgraduate resident (PGR) years one & two in General and Orthopedic Surgery. The CC in their workplace and how they use their EI to resolve these conflicts.

Methods

This mixed-method study was conducted from March 10, 2019 to May 28, 2020 at Departments of General and Orthopedic Surgery, Mayo Hospital, Lahore. The study was conducted in two phases 1 & 2. In Phase-1, one hundred PGR years one & two were administered the Mayor-Salovey-Caruso Emotional Intelligence test (MSCEIT) to measure EI. In phase-2, semi-structured in-depth interviews of 10 PGRs five with high and five with low EI were conducted to determine the CC and use of EI to resolve the CC at the workplace. A thematic analysis was done.

Results

Out of 100 PGR, the mean EI score was 46.25±14.8 with a maximum score of 75.4, and a minimum score of 18.16 (p-value =0.775). Ninety-one (91%) have not improving EI, and 09 (09%) have considered developing EI. Five themes in four settings, including emergency, ward, elective operation theatre, and outpatient department (OPD) were determined. The emerged themes for the CC were nepotism, gender biases, burnout, lack of professionalism, and toxic culture. The following were CC management strategies: self-study, deceit, gender affinity, performing attention-attaining work, aggrieved reaction and being disgruntled when alone.

Conclusion

None of the PGR was emotionally intelligent in overall grades, as well as a particular aspect of MSCEIT.

Variation in partial direct costs of treating clinical mastitis among 37 Wisconsin dairy farms

The objective of this observational study was to describe variations in partial direct costs of clinical mastitis (CM) treatments among 37 dairy herds using data obtained from herd management records. Animal health and drug purchase records were retrospectively collected from 37 Wisconsin dairy herds for a period of 1 yr. Each farm was visited to verify case definitions, recording accuracy, and detection criteria of CM cases. Descriptive statistics were used to summarize cost of drugs and milk discard. Differences in costs among protocols, intramammary (IMM) products, parities, days in milk, and recurrence were analyzed using ANOVA. Of 20,625 cases of CM, 31% did not receive antimicrobial treatment. The average cost of drugs and milk discard (including cases that were not treated) was $192.36 ± 8.90 (mean ± SE) per case and ranged among farms from $118.13 to $337.25. For CM cases treated only with IMM antimicrobials, milk discard accounted for 87% of total costs and was highly influenced by duration of therapy. Differences in costs were observed among parities, recurrence, and stage of lactation at case detection. Eight different treatment protocols were observed, but 64% of cases were treated using only IMM antimicrobials. Treatment costs varied among protocols; however, cases treated using both IMM and injectable antimicrobials as well as supportive therapy had the greatest costs as they were also treated for the longest duration. Ceftiofur was used for 82% of cases that received IMM antimicrobials while ampicillin was used for 51% of cases treated using injectable antimicrobials. With the exception of ceftiofur and pirlimycin IMM products, many IMM products were given for durations that exceeded the maximum labeled duration. For cases treated using only IMM therapy, as compared with observed costs, we estimated that partial direct costs could be reduced by $65.20 per case if the minimum labeled durations were used. Overall, partial direct costs per case varied among herds, cow factors, and treatment protocols and were highly influenced by the duration of therapy.

'We work together as a group': implications of jigsaw cooperative learning

BACKGROUND

Modern clinical practice increasingly relies on collaborative, cooperative and team-based approaches for effective patient care. Recently, Jigsaw cooperative learning has gained attention in medical education. There is a need for studies in Southeast Asian context to establish its effectives in developing various core competencies expected of health professionals such as interpersonal, communication, collaborative, and teamwork skills. This current study explores the impact of using Jigsaw Cooperative Learning on undergraduate medical students.

METHOD

An explanatory mixed method research design was carried out on first year medical students at a private university in Malaysia. In Phase I, a survey was conducted to explore the effectiveness of jigsaw learning. Descriptive and inferential statistics were calculated using SPSS. In Phase II, a focus group interview was conducted to explore their in-depth experiences. Qualitative data were thematically analysed.

RESULTS

Fifty-seven students participated in the survey and seven students took part in the focus group interview. Quantitative data analysis showed a statistically significant improvement in the student's individual accountability, promotive interaction, positive interdependence, interpersonal skill, communication skill, teamwork skill, critical thinking and consensus building after jigsaw learning sessions. Qualitative data explained their experiences in-depth.

CONCLUSION

Jigsaw cooperative learning improves collaboration, communication, cooperation and critical thinking among the undergraduate medical students. Educators should use jigsaw learning methods to encourage effective collaboration and team working. Future studies should explore the effectiveness of the jigsaw cooperative learning technique in promoting interprofessional collaboration in the workplace.

Survival in general surgery: The female surgeons' perspective

Objective

Specialty choices in health profession has long been influenced by gender. The field of General Surgery remains the least preferred specialty by females, especially in Pakistan. The objective of this study was to identify the factors leading to success and retention of females in General Surgery in Pakistan.

Methods

Qualitative case study was conducted from February to May 2020 at Khyber Medical University, Peshawar. Ten semi-structured interviews were conducted with purposive sample of female surgeons at various academic position in different tertiary care hospitals of Pakistan. Data were thematically analyzed.

Results

Participants were driven by their passion for surgery, which led them to choose this specialty in the beginning. Their survival in male dominant workplace was made possible by their own personality traits and conducive environment provided by the supervisors and peers. However, a structured mentorship program for females was found lacking.

Conclusion

The necessary ingredients for success are passion and personality traits in any field but attention to nurturing and supportive environment for females in the General Surgery is paramount in determining success. Due consideration to the factors identified in the current study will enhance the retention and success of females in General Surgery.

Use of situational judgment tests for assessing non-cognitive attributes of final year dental students

OBJECTIVE

Situational judgment tests (SJT) have been previously used in the admission process of medical and dental undergraduate programs, but their utilization as an assessment tool is fairly new. The objective of this study was to explore essential non-cognitive attributes of dental graduates. We also aimed to assess the attributes of final year dental students utilizing SJT and later collected participants' reactions on the test.

METHODS

A mixed-method exploratory sequential study was conducted. One-on-one and group discussions were done with subject matter experts (SMEs) to explore the essential attributes of fresh dental graduates. Based on the thematic analysis, 10 SJT items per domain were constructed by one group of SMEs and expert validated by a different group of SMEs and vice versa. The final dental-SJT was piloted online on final year dental students and their perceptions were collected using a five-point Likert scale questionnaire. Descriptive statistics and Cronbach's alpha were calculated for the test.

RESULTS

The consultation with SMEs generated three main themes, namely, Conventional skills, Tribal skills, and Occupational skills. The 70-item dental-SJT piloted on 150 final year dental students revealed data were normally distributed. The internal reliability of test was good (0.738). Students scored highest in "management skills" (>70%) and lowest in "professional ethics" (56%) and "diverse experiences" (58%). The overall student perception about the test was good.

CONCLUSION

SJT is an effective tool to assess non-cognitive attributes of dental students. It has an overall positive perception about perceived predictive validity, perceived fairness, face and content validity.

Exploring challenges and mitigation strategies towards practicing Teledentistry

BACKGROUND

Since the beginning of the COVID-19 pandemic, many dentists have opted for Teledentistry as a mechanism for patient consultation, oral lesion evaluation, diagnosis, and monitoring. The current study explores the challenges faced and potential solutions proposed by dentists practicing Teledentistry in a developing country like Pakistan.

METHODS

A qualitative case study was carried out from January to December 2021. A purposive maximum variation sample of 10 dentists was interviewed in two focus groups. The interview guide was developed using the technology-organization-environment framework. The data was transcribed verbatim using otter.ai. The analysis involved immersion in the data and open coding. The conceptually related codes were synthesized into themes and subthemes.

FINDINGS

The study found various Personnel, Technological and Organizational challenges, and potential solutions from those practicing Teledentistry. The challenges included operational cost, minimal financial returns, lack of awareness, hardware and software support, and other challenges related to the availability of specialization, accessibility, and institutional encouragement. They suggested Institutional Based Practice, staff training, hiring, development of government regulations, and supporting infrastructures such as designated space, central registry, internet, and using/building software to provide 3D images as solutions.

CONCLUSION

Teledentists face Personnel, Technological and Organizational challenges and related potential solutions from those practicing Teledentistry in Pakistan. Government should encourage Teledentistry to reduce long-term costs, encourage preventive services and enable rural access to dental care. They should also involve all stakeholders to develop regulations for practicing Teledentistry in Pakistan.

The Perceptions of Non-native Medical Students Towards Language Barrier on Clinical Teaching and Learning: a Qualitative Study from Saudi Arabia

BACKGROUND

Patient-doctor communication is essential for achieving the best healthcare quality for the patients. Saudi Arabia hosts a variety of healthcare providers from diverse cultures and languages, making language barriers distinctive towards effective communication for a predominantly Arab population. There is limited research on the challenges associated with language barriers among non-native medical students. The current qualitative study aims to explore the perceptions and experiences of non-native medical students during clinical encounters with Arabic speaking patient population at a private university in Riyadh, Saudi Arabia.

METHODS

This is a qualitative case study employing non-native medical students in clinical years to explore their perceptions and experiences towards language barriers. Participants attended four focus group discussions, following a brief regarding the concept of the challenges that language barriers pose. All interviews were recorded and transcribed verbatim. A thematic framework analysis was employed to analyze the data.

RESULTS

Twenty-two non-native medical students participated in the study. We identified four broad themes constituting problems in patient interaction, development of clinical skills, managing and overcoming language barriers, and student recommendations to overcome language barrier. Participants suggested improvements in available Arabic language courses and the introduction of a professional skills course in Arabic for non-native students.

CONCLUSION

Non-Native medical students perceived language barriers as an obstacle to a meaningful clinical experience. They identified implications for clinical learning environment, professionalism, empathy, and patient care. Recommendations for advanced occupation-related Arabic language courses to facilitate doctor-patient interactions were made to improve patient-student interactions between native patients and non-native medical students.

P-799 To evaluate the effect of Intra-ovarian platelet rich plasma instillation on the clinical outcome of women with diminished ovarian reserve: A prospective interventional study

Study question

Does intra-ovarian instillation of platelet rich plasma (PRP) improves the clinical outcome of IVF cycles in women with Diminished Ovarian reserve (DOR)?

Summary answer

PRP instillation leads to consistent improvement in Antral follicle count (AFC), thus achieving clinical pregnancy rate of 33.3% per cycle in women with DOR.

What is known already

There is rising incidence of females with diminished ovarian reserve (DOR) especially among Asian ethnicity. With the emergence of regenerative medicine, multiple studies have evaluated the role of intra-ovarian PRP, demonstrating a beneficial role in improving ovarian reserve parameters (serum Follicular stimulating hormone (FSH), serum anti-Mullerian hormone (AMH), AFC). Despite its’ favorable effects on biochemical markers and AFC, data regarding improvement in clinical outcome remains elusive and led to inception of this study.

Study design, size, duration

A prospective interventional study was conducted at Division of Reproductive Medicine of a tertiary care institute. 41 infertile females aged 20-39 years with DOR (AMH &lt;1.2 ng /ml; AFC&lt;5) were enrolled in the study during a 6-month period beginning from August 2021.

Participants/materials, setting, methods

After informed consent, patients received fresh autologous PRP, prepared from 30 ml venous blood. 1.5ml of PRP instilled in each ovarian stroma between day 7-10 of menstrual cycle under sedation. Patients were followed up for three-consecutive months to assess ovarian reserve parameters including serum FSH, AMH and AFC. Patients showing significant improvement in parameters were recruited for fresh IVF cycles using Antagonist protocol with 1% transdermal testosterone. Outcomes were analysed using linear mix effect model.

Main results and the role of chance

The average platelet concentration in PRP was ∼10,00,000 platelets/µL. The mean age of enrolled patients was 31.22±4.16 years. Linear improvement in AFC (3.63 vs 6.98 vs 7.97 vs 6.90, p&lt;0.001) was observed from baseline to three consecutive follow-up months with maximal response witnessed in second month in 57.1% of those undergoing IVF cycle. However, there was no significant difference in Serum FSH (p=0.11) and AMH (p=0.16) from the baseline post intervention. Of the 41 patients, 35 (85.3%) responded to the treatment and underwent IVF antagonist cycle. 5 out of 35 IVF cycles were cancelled mid-cycle due to poor ovarian response. The mean dose of gonadotropin requirement was 2667.5±281.1 IU (Follicular stimulating hormone) and 1400±337.3 IU (Human menopausal gonadotropin). The average number of oocytes retrieved was 5.7±2.2 whereas mean number of MII oocytes was 4.63±1.85. The fertilization rate and the cleavage rate were 92.4% and 74.1% respectively. Of the thirty patients, eight patients underwent day 2 transfer due to poor grade of embryos. Mean number of grade 1- day 3 embryos was 1.25±0.55 with surplus embryos available for cryopreservation in 14 patients. The overall clinical pregnancy rate per transfer was 33.33%. No adverse events were reported.

Limitations, reasons for caution

This was a prospective single arm study. A randomized controlled trial comprising a “no-treatment” arm would establish a Level-I evidence. However, “no-treatment” arm in a developing country like ours, imposes financial burden on the couple with no guaranteed clinical success and thus raising ethical concern and need for ovarian rejuvenation.

Wider implications of the findings

With the impetus to provide a biological child to these DOR women, intra-ovarian PRP instillation as a method of ovarian rejuvenation holds promising results. Evidently, PRP is not only effective in improving ovarian reserve but this translates into an improved reproductive outcome in a population, previously limited to oocyte donation.

Trial registration number

REF/2022/01/051033

P-656 Effect of COVID-19 vaccination on clinical outcome in fully vaccinated infertile women undergoing IVF/ICSI cycles at tertiary care centre: prospective observational study

Study question

Does immune response to COVID-19 vaccination affect the clinical outcome in fully vaccinated infertile women undergoing IVF/ICSI cycles?

Summary answer

COVID-19 IgG antibodies are present in follicular fluid post vaccination and higher immune response increases duration of gonadotrophins required and negatively impacts the IVF outcome.

What is known already

Recent studies assessed the influence of COVID-19 infection and mRNA COVID-19 vaccine on the stimulation cycle characteristics and embryological variables of patients undergoing IVF cycle and found no effect on the IVF outcome in their immediate IVF cycle after recovery, except for a decreased number of top quality embryos. One study reported infection or mRNA vaccine results in rapid formation of anti-COVID IgG which can be detected in follicular fluid. This immune response did not lead to any significant negative effect on ovarian follicular function. There is a possibility that COVID-19 infection might affect numerous fertility-linked proteins.

Study design, size, duration

Prospective observational study, conducted at Division of Reproductive Medicine of tertiary care institute. After taking informed consent, 32 patients who satisfy the inclusion and exclusion criteria with history of receiving two doses of Covishield or Covaxin vaccine with at-least 2 weeks from last dose, were recruited for IVF/ICSI cycles from December 2021 to January 2022, for assessing COVID-19 IgG antibodies in their follicular fluid.

Participants/materials, setting, methods

Women of 21-40 years with normal ovarian reserve and normal uterine cavity were included, those with history of COVID infection were excluded. All patients underwent GnRH antagonist protocol. Follicular fluid was collected at time of oocyte retrieval. After collecting oocytes, 400 microlitre of follicular fluid was stored at -80 and later thawed and analysed for SARS-CoV-2 IgG antibodies (ADVIA Centaur COV2G assay, Germany) which are expressed in index value and reported as reactive (≥1 index).

Main results and the role of chance

Out of 32, 21 (65.6%) of the participants had received COVISHIELD (V1)and 11 (34.3%) received COVAXIN (V2). The mean gap between vaccine and the IVF cycle was 84.94 ± 52.65 days. The mean COVID IgG antibody titres (Index) were significantly higher in V1, 28.77±33.50 (0.34 -100), than V2 2.28±3.74(0.05-13.23), p<0.001. Patients with higher antibody titres, required longer duration of ovarian stimulation, rho=0.42, p = 0.017. Patients with higher COVID IgG antibodies were negatively correlated with clinical pregnancy rate (20.9 0± 29.68 vs 4.60 ± 6.28, p = 0.153). The time gap from the last dose of vaccine to IVF cycle had moderate negative correlation with percentage of grade-I embryos out of the total embryos fertilised (%), rho= -0.33, p = 0.068. Furthermore, higher gonadotropins doses were required in patients with high antibody titres, rho=0.25, p = 0.160, and amongst V1 vs V2, total dose of gonadotropins required was 3802.38±742.92 vs 3422.73±564.52, respectively, p=0.115. COVID IgG antibody titres had weak negative correlation with number of grade-I embryos, rho= -0.16, p = 0.396. The time gap from the last dose of vaccine to IVF cycle had a weak negative correlation with number of grade-I embryos, rho=-0.28, p = 0.124.

Limitations, reasons for caution

The main limitation of this study is small sample size. However, the study is currently ongoing, and these are the interim results of the same. As prospective studies with larger sample size would be required to assess the effect of different COVID-19 vaccines in different populations on the IVF outcomes.

Wider implications of the findings

The present study confirms the presence of COVID IgG antibodies in follicular fluid in vaccinated women, and proves that COVISHIELD vaccinated patients had higher antibody titres. Higher antibody titres require longer duration of stimulation and result in poorer outcomes so a longer interval from vaccine to IVF should be recommended.

Trial registration number

NA

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

How does postgraduate diploma in Family Medicine impact on primary care doctors?

BACKGROUND

Over the last decade, the emphasis on improving the education and training of family physicians has increased. World Health Organization has also emphasized the importance of a trained primary care workforce. In 2017, Khyber Medical University (KMU) Peshawar initiated a one-year Postgraduate Diploma in Family Medicine for doctors working in primary care, to upgrade their skills and knowledge as Family Physicians. To justify the allocation of resources, there is a need for research on the impact of such programs. This study explores the impact of Diploma in Family Medicine (DFM) on primary care doctors in Khyber Pakhtunkhwa. It also identifies the barriers associated with learning and its translation to practice.

METHODS

A mixed-method explanatory study was conducted from February 2019-2020. Forty-five graduates from the DFM program at KMU were invited to participate in this study. The quantitative data was collected through questionnaires (n=30) and the results were then explained further through qualitative focus group interviews (n=24). Descriptive statistics were calculated for the quantitative data and thematic analysis was performed for the qualitative data.

RESULTS

The respondents (n=30/45) were satisfied from the course content and delivery. They agreed that the course is useful (93.3%), relevant to their learning needs (86.7%) and they were able apply it to their clinical practice (100%). The qualitative findings also corroborated that the course improved both the clinical and consultation skills of the participants. The learning environment encouraged them to identify their learning needs and attain new competencies. They reported being more patient-centered and evidence-based, which increased patients' satisfaction. The program also resulted in increased career opportunities and other monetary benefits. Despite the blended nature of the program, the participants found it challenging to balance training with the provision of services.

CONCLUSION

One-year Postgraduate Diploma in Family Medicine is focused, practical and relevant to the learning needs of primary healthcare physicians. The policymakers should consider provision of such training opportunities in both public and private-sector. Future research should explore the long-term impact of such programs on healthcare outcomes.

Impact of implementing multisource feedback on behaviors of young doctors

Objectives:

Multisource feedback (MSF) is a workplace-based assessment tool that offers 360-degree evaluation of the trainee doctor. Little is known about its receptiveness among stakeholders in Pakistan. This study explores house officers’ perceptions regarding MSF since its implementation in Eye Unit-II, Institute of Ophthalmology, King Edward Medical University/ Mayo Hospital, Lahore.

Methods:

A qualitative case study was conducted from July 2019 to February 2020 in Eye Unit II. A purposive (maximum variation) sample of 12 house surgeons was taken. Two focus group discussions were conducted. Data were transcribed and analyzed thematically.

Results:

The study identified the impact of MSF on house surgeons. Most participants reported positive experiences. The feedback they received increased their motivation, management skills and team working. A number of factors affecting the receptiveness of MSF were also identified which mainly included characteristics of raters and emotional response to MSF.

Conclusion:

Multisource Feedback is a useful tool for feedback that impacts the young doctors in many ways. It contributes to increasing their sense of responsibility, management skills and self-directed learning. The improvement in individual abilities and teamwork also helped in improving patient care.

Trends in the use of mechanical and bioprosthetic aortic valve replacement in the era of transcatheter aortic valve replacement

Background

The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and co-morbidities, since bioprosthetic AVR (bAVR) as compared to mechanical AVR (mAVR), are associated with a more rapid structural deterioration. However, refinements in bioprosthetic valves and the introduction of transcatheter aortic valve replacement (TAVR) (potential for valve-in-valve procedures), will most likely influence valve selection in the future. The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined.

Purpose

The goal of our study was to assess trends in utilization of bAVR and mAVR in the United States while, assessing in-hospital mortality over time.

Methods

The National Inpatient database (2009–18) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 700,896 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older, [bAVR (69.8 years) vs mAVR (62.7 years) p&lt;0.001]. Heart failure, cardiac arrhythmias, hypertension, diabetes with complications and renal failure were more common in those undergoing a bAVR. Through the course of the study period, the rates of mAVR decreased across all age groups (p trend &lt;0.001), including patients younger than 50 years (p trend &lt;0.001). Both crude (OR = 1.20 95% CI 1.13–1.27) and adjusted (OR = 1.34 95% CI 1.25–1.44) inpatient mortality was higher amongst mAVR recipients.

Conclusions

In the contemporary TAVR era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with significantly less co-morbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding the causes accounting for the higher mortality after mAVR, future research should focus on developing TAVR friendly bAVR; possibly enhancing our ability to perform percutaneous valve-in-valve procedures in the future.

Funding Acknowledgement

Type of funding sources: None.

Gender disparities in the treatment of aortic stenosis – an analysis of the united states national inpatient sample (2009–2018)

Introduction

Gender disparity in the management of a variety of cardiovascular disorders has been well established. Studies have shown that women are less likely to undergo surgical aortic valve replacement (SAVR), and have higher mortality and health care cost in the management of aortic stenosis (AS). The impact of transcatheter aortic valve replacement (TAVR) on this gender disparity has not been well established.

Purpose

We sought to examine the impact of gender on outcomes following aortic valve replacement for AS in the era of routine transcatheter valve replacement.

Methods

We used the National Inpatient Sample (2009–18), a representative probability sample of the United States, to study visits for all aortic valve replacements and in-hospital outcomes as a function of gender. Survey estimation commands were used to provide national estimates.

Results

There were an estimated 431,344 SAVR and 189,137 TAVR inpatient visits during the periods of 2009–18 and 2011–18, respectively with a higher representation of women in the TAVR cohort (46.4% [95% CI, 45.9%-46.9%]) than SAVR (36.8% [95% CI, 36.4%-37.2%]). Women were slightly older with higher prevalence of uncomplicated hypertension (HTN) and pulmonary circulation disorders. However, women exhibited a lower prevalence of complicated HTN, complicated diabetes mellitus, prior percutaneous coronary intervention, prior coronary artery bypass grafting, peripheral vascular disease and renal failure. In-hospital mortality was higher in women after SAVR (3.8%±0.1 vs 2.7%±0.07, p&lt;0.001) and TAVR (2.4%±0.1 vs 1.7%±0.1, p&lt;0.001) compared to men. Female SAVR patients had higher rates of permanent pacemaker (PPM) implantation, stroke and significant bleeding (5.9%±0.1 vs 5%±0.1, 2.8%±0.1 vs 2.3%±0.07, and 37.8%±0.8 vs 29.8%±0.6; p&lt;0.001, respectively) but lower rates of acute kidney injury (AKI) (16.4%±0.3 vs 20.3%±0.3, p&lt;0.001). In addition, women undergoing TAVR had higher rates of stroke and significant bleeding (2.4%±0.1 vs 1.6%±0.09 and 28.7%±0.6 vs 22%±0.5; p&lt;0.001 respectively) but lower rates of PPM and AKI (9.5%±0.3 vs 10.7%±0.2 and 11.3%±0.3 vs 13.4%±0.3; p&lt;0.001, respectively). There was a reduction in mortality, compared to the early TAVR era, for all groups during the study period, particularly in female TAVR patients (from approximately 5.2% to 1.7%). In-hospital mortality for women was lower after TAVR than SAVR, both after multivariable adjustment (OR = 0.33, 95% CI 0.24–0.45) and propensity matching (mean difference 1.28%±0.49).

Conclusions

TAVR appears to have narrowed the gender disparity in the management of AS. Although women continue to have a higher in-hospital mortality following both TAVR and SAVR compared to men, TAVR is associated with a lower inpatient mortality in women compared to SAVR. Thus, TAVR may represent a bridge for the gender gap in aortic valve replacement.

Funding Acknowledgement

Type of funding sources: None.

Does the availability of transcatheter aortic valve replacement impact inpatient outcomes after surgical aortic valve replacement? Analysis of the national inpatient sample

Background

With the introduction of transcatheter aortic valve replacement (TAVR), the treatment of aortic stenosis (AS) has experienced a paradigm shift, altering patient selection for surgical aortic valve replacement (SAVR) over the past decade. What remains to be determined is the impact of a hospital's ability to offer TAVR, in the contemporary era, on inpatient outcomes following SAVR.

Purpose

The goal of this study was to assess inpatient mortality and the use of mechanical aortic valve replacement (mAVR) in patients undergoing SAVR at TAVR versus non-TAVR centers in the United States.

Methods

The National Inpatient Sample (2011–18), a probability sample of inpatient visits in the United States, was used to study trends in admissions for SAVR at TAVR and non-TAVR centers; in-hospital mortality was trended over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 559,365 inpatient visits for SAVR with 75.2% (95% CI 74.2%-76.2%) and 24.7% (95% CI 23.8%-25.8%) receiving bioprosthetic SAVR (bAVR) and mAVR, respectively at TAVR centers and 64.5% (95% CI 63.3%-65.6%) and 35.5% (95% CI 34.4%-36.7%) receiving bAVR and mAVR, respectively at non-TAVR centers. SAVR recipients at non-TAVR centers were older when compared to recipients at TAVR centers (68.3±0.09 vs 66.9±0.11 years p&lt;0.001). Heart failure, cardiac arrhythmias, peripheral vascular disorders, complicated hypertension and diabetes, renal failure and liver disease were more common in patients undergoing SAVR at TAVR-centers. During the study period, both crude (OR = 0.78 95% CI 0.73–0.83) and adjusted (OR = 0.79 95% CI 0.73–0.86) inpatient mortality was lower amongst SAVR recipients at TAVR centers. The utilization rates of mAVR at both TAVR and non-TAVR centers decreased over time amongst all age groups (p trend &lt;0.001).

Conclusions

Patients undergoing SAVR at TAVR centers were younger and had more co-morbidities compared to patients undergoing SAVR at non-TAVR centers. Although patients undergoing SAVR at TAVR centers had significantly more co-morbidities, inpatient mortality was lower at TAVR centers compared to non-TAVR centers. Further research is needed to determine whether the impact of a multidisciplinary cardiac approach resulted in significant differences in patient selection for SAVR, due to the availability of TAVR, influencing patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Educational Environment In The Transition Phase Of Curriculum At Ayub Medical College Abbottabad, Pakistan

BACKGROUND

Evaluation of the educational environment is key to the delivery of high-quality medical education. Especially, when an institute is in the transition phase of curriculum. In curriculum transformation phase of Ayub Medical College Abbottabad, no such evaluation has been done. This study aimed to find the direction of Educational environment in the transition phase curriculum of Ayub Medical College Abbottabad and compare different domains of educational environment with gender, residency, pre-medical education's medium of instruction, and doctors among sibling or parents.

METHODS

This descriptive cross-sectional survey was conducted among students of integrated and traditional curriculum of Ayub Medical College, Abbottabad from 1st December 2019 to 29th February 2020. By Non-probability convenience sampling technique, pre-validated Dundee Ready Educational Environment Measure questionnaire was used. Descriptive and inferential statistics were calculated in SPSS v22.

RESULTS

A total 149 (100%) participants, 66 (44.3%) males and 83 (55.7%) females with mean age of 20.5±1.07 years responded. Among total, 76 (51%) were from integrated curriculum and 73 (49%) were of traditional curriculum. Significant difference was found among different aspect of education environments and both classes.

CONCLUSIONS

The current transitional phase of curriculum at Ayub Medical College Abbottabad is more positive than negative. Some areas like student social-self-perception still need improvement. Moreover, gender and place of birth affect student's perception about their learning environment.

Assessment of burnout and associated factors among medical educators

Objective

To assess burnout in medical educators and to identify factors associated with it.

Methods

A sequential mixed methods research study was conducted over eight months from July 2018 until February 2019. Participants included medical educators, who are studying for or graduated with a postgraduate qualification in medical education. An online questionnaire was developed using Maslach Burnout Inventory to collect quantitative data. The findings were explored in-depth qualitatively. Descriptive and inferential statistics were calculated for the quantitative data using SPSS 20. For qualitative data, we performed thematic analysis.

Results

Of total 160 medical educationists, 101 responded giving 63.1% response rate. Mean age was 41.4 years and majority 53.5% were females. Overall aggregate mean burnout level was 12.34 ± 7.36 whereas sub-domains of Maslach burnout inventory (MBI) like i) emotional exhaustion, ii) depersonalization and iii) personal accomplishment were found out to be 19.59, 10.42 and 11.21 respectively. Most respondents had moderate 71 (70.3%) emotional exhaustion and 8 (8.9%) had severe emotional exhaustion. Average level of depersonalization was suffered by 73 (72.3%) respondents and severe level was observed in 20 (19.8%) respondents. Personal accomplishment was found low in all 101 (100.0%) respondents. Selective in-depth interviews revealed that coping mechanisms like social gatherings, indoor and outdoor game facilities and outings and leisure time should be strategized for faculties.

Conclusion

In this study medical educators were found to have quite high level of burnout. The early career medical educators feels emotionally exhausted, with low sense of personal accomplishment.

Setting Agenda for Medical Education Research in Pakistan

Objective:

To justify the allocation of human and financial resources, this study aims to identify multiple stakeholders’ views of medical education research priorities in Pakistan for the next five years.

Methods:

This two-stage exploratory mixed-method study was conducted from Jan 2018 to Jun 2019. A purposively selected sample of 250 faculty members, research supervisors, postgraduate students, undergraduate students and policymakers actively involved in improving Medical Education were included. In Stage-I: An exploratory open-ended questionnaire asking about Medical Education Research (MER) priorities in Pakistan for the next five years was emailed. Data were thematically analyzed to identify MER areas. In Stage-II: Another questionnaire was developed based on MER areas. The participants were asked to rate their importance on a scale of one to five. Descriptive statistics were calculated using SPSS.v.24.

Results:

In Stage-I, 140 participants and in Stage-II, 130 participants from different stakeholder groups responded. We identified 20 research priorities grouped under eight themes: curriculum organization, content, delivery, assessment, workplace, students, faculty and educational management. Top three research priorities were identifying needs and developing effective provisions for continuous professional development of the faculty, improving assessment and communication skills.

Conclusion:

The study identified top MER priority areas as continuous professional development, assessment and communication skills. Some areas unique to the current study include admissions, fostering critical thinking, Islamic values in professionalism and ethics. The study provides evidence-base for decision-making about allocating time and funds for MER in Pakistan.

Quantification of antimicrobial usage in adult cows and preweaned calves on 40 large Wisconsin dairy farms using dose-based and mass-based metrics

Use of antimicrobials in animal agriculture is under increasing scrutiny, but the quantity of antimicrobials used on large US dairy farms has not been evaluated using data from large farms and different metrics. This study investigated total antimicrobial usage (AMU) in adult dairy cows and preweaned calves (PWC) and contrasted 2 metrics used for measurement of AMU. Wisconsin dairy farms were eligible if they had >250 lactating cows, maintained computerized animal health records, and were willing to allow researchers access to treatment records. Animal health data for a 1-yr period was retrospectively collected from computerized records, and a farm visit was performed to verify case definitions and recording accuracy. Both dose-based (animal daily doses; ADD) and mass-based (total mg of antimicrobials per kg of body weight; BW) metrics were calculated at the herd, cow, and PWC levels. Descriptive statistics for AMU were examined for both age groups. Mean AMU was compared among active ingredients and route of usage using ANOVA models that included farm as a random variable. At enrollment, farms (n = 40) contained approximately 52,639 cows (mean: 1,316 ± 169; 95% CI: 975, 1657) and 6,281 PWC (mean: 180 ± 33; 95% CI: 112, 247). When estimated using ADD, total herd AMU was 17.2 ADD per 1,000 animal-days (95% CI: 14.9, 19.5), with 83% of total herd-level AMU in adult cows. When estimated using the mass-based metric, total herd AMU was 13.6 mg of antimicrobial per kilogram of animal BW (95% CI: 10.3, 17.0), with 86% of total AMU used in adult cows. For cows, 78% of total ADD (15.8 ADD per 1,000 cow-d) was administered as intramammary (IMM) preparations. In contrast, when AMU was estimated using a mass-based metric, IMM preparations represented only 24% of total AMU (12.1 mg of antimicrobial/kg of cow BW). For cows, ceftiofur was the primary antimicrobial used and accounted for 53% of total ADD, with 80% attributed to IMM and 20% attributed to injectable treatments. When estimated using a mass-based metric, ampicillin was the predominant antimicrobial used in cows and accounted for 33% of total antimicrobial mass per kilogram of BW. When AMU was estimated for PWC using ADD, injectable antimicrobials represented 79% of total usage (28.3 ADD per 1,000 PWC-d). In contrast, when AMU was estimated for PWC using a mass-based metric, injectable products represented 42% of total AMU, even though more farms administered antimicrobials using this route. When AMU in PWC was summarized using ADD, penicillin represented 32% of AMU, and there were no significant differences in ADD among ampicillin, oxytetracycline or enrofloxacin. When a mass-based metric was used to estimate AMU in PWC, oral products (sulfadimethoxine and trimethoprim-sulfa) represented more than half of the total AMU given to this group. Overall, these results showed that choice of metric and inclusion of different age groups can substantially influence interpretation of AMU on dairy farms.

Curriculum integration: From Ladder to Ludo

This Personal View is based on our experiences with the levels of integration. We are concerned about the (mis) interpretation of 'integration ladder' in our context and propose directions for rethinking curriculum integration. We share the famous board game 'Ludo' as a metaphor to understand the concept of integration. Mughal emperors (educators) played (lead) Ludo (curriculum/teaching reforms) in which tokens (disciplines) move from their silos (departments) towards others (integrate) according to rolls of a dice (resources) and not stepwise (1-2-3…11) like in a ladder. There are safe spaces (timetable/minimum hours), double pieces (combination of different integration levels) and tokens (disciplines) can also be pushed back to their silos by opponents (challenges). The game (change management) involves skill (competence in medical education), strategy (planning), emotion (emotional intelligence) and luck. We found Ludo relevant to understanding integration and discuss three different systems with implications on the curriculum, assessment, organisational structure and timetable/schedules. We believe that a clear description of integration as three different systems will counter the issues with the integration ladder and make it easier for institutions and educationists to understand, opt for and implement curriculum integration.

Academic experiences of undergraduate post-registered BS nursing students in Islamabad, Pakistan

OBJECTIVE

To assess the academic experiences of undergraduate post-registered BS (Bachelor of Science) nursing students in Islamabad.

METHODS

This multisite cross-sectional study was conducted from February to May 2018. It included undergraduate nursing students from one public and three private-sector institutes of Islamabad. A pre-validated Undergraduate Nursing Students' Academic Satisfaction Scale (UNSASS) was used to collect data. Descriptive and Inferential statistics were calculated using SPSS 21, p< 0.05 was considered as significant.

RESULTS

Out of 220 nursing students, 198 responded. Nursing students from public-sector were significantly more satisfied than those in private. This satisfaction was significant for classroom teaching and clinical teaching. The students from private institutes reported significantly greater satisfaction towards institutional support and resources. Female students from private colleges were significantly more satisfied with the clinical education (p<0.042) and programme design and delivery (p<0.018) than their male counterparts. First year students from public-sector were significantly more satisfied from classroom teaching (p<0.003), support and resources (p<0.036), while those in private from clinical teaching (p<0.002). Students aged 31 years and above were generally more satisfied.

CONCLUSIONS

Post-registered BS nursing students are satisfied from their academic experiences during undergraduate training. Students in public-sector institutes are comparatively more satisfied.

Coronary computed tomography versus stress echocardiography-guided management of stable chest pain patients: a propensity matched analysis

Background

Recent recommendations by national and international societies advocate the use of coronary computed tomography (CCT) as the first-line test for the assessment of low-risk patients with suspected stable angina. However limited real-life data exist regarding its relative clinical value versus stress echocardiography (SE)-guided management.

Purpose

We aimed to assess in a real-life setting the clinical value of stress echocardiography (SE)-guided versus CCT-guided management in patients presenting with stable chest pain and no prior history of coronary artery disease (CAD).

Methods

We compared the relative feasibility, efficacy and the proportion of patients undergoing downstream testing including revascularisation and their impact on outcome (mortality and myocardial infarction) when CCT versus SE were used as the first line test for the assessment of stable chest pain.

Of the patients who underwent CCT (N=2192) or SE (N=2081) between October 2013 and October 2014 only those with suspected stable angina and without previous CAD were selected. The population was propensity-matched (total 1980 patients-990 patients each group) to account for differences in the baseline cardiovascular risk factors.

Results

The mean age of the population was 59±13.2 years and 949 (47.9%) patients were male. Inconclusive tests were 6% versus 3% (p&lt;0.005) in CCT versus SE. Severe (&gt;70%) luminal stenosis on CCT and inducible ischemia on SE detected obstructive CAD by invasive coronary angiography in 63% versus 57% patients (p=0.33). Over the entire follow-up period (median 717 (IQR 93–1069) days) significantly more patients underwent invasive coronary angiography (21.5% versus 7.3%, p&lt;0.005) and revascularisation (33.5% versus 3.5%, p&lt;0.005) respectively in the CCT versus the SE group. Following their initial assessment 336 (33.9%) patients in the CCT and 86 (8.7%) in the SE group underwent further functional testing (SE, stress cardiac MRI, exercise electrocardiography) (p&lt;0.005) (Figure 1A). There was no difference in all-cause mortality (p=0.26) or death and myocardial infarction (p=0.16) between the two groups (Figure 1B).

Conclusions

SE when used for the assessment of patients with stable angina and no prior CAD resulted in more conclusive tests, similar detection of obstructive CAD, less overall invasive coronary angiography and revascularization and less subsequent functional tests compared with CCT.

Figure 1

Funding Acknowledgement

Type of funding source: None

Learning Based On Principles Of Cognitivism

Sometimes, knowledge or information becomes difficult to understand and/or memorize. Cognitive load theory aids a learner to gain information effectively. It provides a scientific roadmap to the design of learning materials. Through a complex set of mental processes, information is acquiring, process, retain, and comprehend information. Applying mental effort for remembering is a very crucial phenomenon. The core of memory process is apprehending and saving of information into long term memory. Because of limited capacity of working memory, delivering or acquiring of information should not be overloaded with irrelevant materials. Based on cognitive load theory dozens of strategies can be intervened at different loci of cognitive process and every piece of information is easily remembered. Not only learners, but teachers can also get benefits from them. In this commentary, John Sweller ideology is further discussed and strategies are presented for better comprehension and memorization of difficult information.

Multicenter study on the diagnostic performance of multiframe volumetric laser endomicroscopy targets for Barrett's esophagus neoplasia with histopathology correlation

Volumetric laser endomicroscopy (VLE) has been shown to improve detection of early neoplasia in Barrett's esophagus (BE). However, diagnostic performance using histopathology-correlated VLE regions of interest (ROIs) has not been adequately studied. We evaluated the diagnostic accuracy of VLE assessors for identification of early BE neoplasia in histopathology-correlated VLE ROIs. In total, 191 ROIs (120 nondysplastic and 71 neoplastic) from 50 BE patients were evaluated in a random order using a web-based module. All ROIs contained histopathology correlations enabled by VLE laser marking. Assessors were blinded to endoscopic BE images and histology. ROIs were first scored as nondysplastic or neoplastic. Level of confidence was assigned to the predicted diagnosis. Outcome measures were: (i) diagnostic performance of VLE assessors for identification of BE neoplasia in all VLE ROIs, defined as accuracy, sensitivity, and specificity; (ii) diagnostic performance of VLE assessors for only high level of confidence predictions; and (iii) interobserver agreement. Accuracy, sensitivity, and specificity for BE neoplasia identification were 79% (confidence interval [CI], 75-83), 75% (CI, 71-79), and 81% (CI, 76-86), respectively. When neoplasia was identified with a high level of confidence, accuracy, sensitivity, and specificity were 88%, 83%, and 90%, respectively. The overall strength of interobserver agreement was fair (k = 0.29). VLE assessors can identify BE neoplasia with reasonable diagnostic accuracy in histopathology-correlated VLE ROIs, and accuracy is enhanced when BE neoplasia is identified with high level of confidence. Future work should focus on renewed VLE image reviewing criteria and real-time automatic assessment of VLE scans.

What problems make students struggle during their undergraduate medical education? A qualitative exploratory study

OBJECTIVE

To explore problems faced by struggling undergraduate medical students and their impact on student's academics.

METHODS

A qualitative case study was carried out from March to August 2019. Semi-structured interviews were conducted with a purposive sample of sixteen struggling students. The interview questions were validated and then piloted to ensure clarity. All interviews were audio recorded and transcribed verbatim. Due to sensitive nature of the data, confidentiality and anonymity was ensured. Thematic analysis was employed to get meaning with in the data set. All authors ensured analytical triangulation by independently analyzing the data before developing consensus on the codes and themes.

RESULTS

Eleven sub-themes under four major themes emerged from the transcripts. Participants were found to be struggling with emotional, academics and family related problems. Psychological distress was caused by factors such as fight with friends, one-sided love, and hard financial times. Time management, lack of attention and commitments at home were few of the other problems. Problems had an impact on students as they were demotivated, lost focus in their studies, could not perform good and few participants even failed in examinations.

CONCLUSIONS

Students were struggling more with emotional and family related problems and less with academics related problems. They were impacting student's academics. The study site had a robust mentoring program however, struggling students need timely identification and more dedicated time to help them manage their problems. Stress relieving activities and counselling sessions may frequently be added, and academically underachieved students should also be given extra care, support, and guidance.

Impact of Coronavirus disease (COVID-19) pandemic on health professionals

Objective

Recognizing the huge potential ramifications of COVID-19 pandemic, this study explores its impact on health professionals personally and professionally along with the associated challenges.

Methods

A descriptive cross-sectional qualitative survey was conducted from March-April 2020. Participants included health professionals from various disciplines in both public and private-sector institutions of Pakistan. The sample size was not predetermined, and an iterative approach of simultaneous data collection and analysis was taken until data and time saturation were reached. Thematic analysis of the qualitative data was carried out by two analysts.

Results

Two hundred and Ninety health professionals responded. They reported an impact on their mental, physical and social well-being. The clinicians mentioned facing an unprecedented workload in overstretched health facilities, while those in academia become engaged with planning/providing emergency remote teaching for the students affecting work-life balance. Some challenges associated with work-from-home and in the hospitals were identified.

Conclusion

During COVID-19, the health professionals are anxious, overworked and financially unstable while planning, creating and caring for others and their families. We need to support them to do their jobs, be safe and stay alive. Future research should explore the fears and coping strategies of health professionals during pandemics.

Advantages, Limitations and Recommendations for online learning during COVID-19 pandemic era

OBJECTIVE

During COVID-19 pandemic, the institutions in Pakistan have started online learning. This study explores the perception of teachers and students regarding its advantages, limitations and recommendations.

METHODS

This qualitative case study was conducted from March to April 2020. Using maximum variation sampling, 12 faculty members and 12 students from University College of Medicine and University College of Dentistry, Lahore were invited to participate. Four focus group interviews, two each with the faculty and students of medicine and dentistry were carried out. Data were transcribed verbatim and thematically analyzed using Atlas Ti.

RESULTS

The advantages included remote learning, comfort, accessibility, while the limitations involved inefficiency and difficulty in maintaining academic integrity. The recommendations were to train faculty on using online modalities and developing lesson plan with reduced cognitive load and increased interactivities.

CONCLUSION

The current study supports the use of online learning in medical and dental institutes, considering its various advantages. Online learning modalities encourage student-centered learning and they are easily manageable during this lockdown situation.

Challenges towards quality assurance of Basic Medical Education in Pakistan

OBJECTIVE

There are growing concerns towards the quality of medical education in Pakistan. To help strengthen accreditation processes, this study identifies the challenges towards quality assurance of Basic Medical Education in Pakistan.

METHODS

A qualitative case study was carried out from March to August 2018. Participants included inspectors from various disciplines in both public and private medical colleges, and medical educationists from Pakistan. Semi-structured interviews were conducted with 12 inspectors, while focus group discussion included 10 medical educationists. All the interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted to capture the intricacies of meaning within the data.

RESULTS

Data identified 14 sub-themes grouped under three major themes. Challenges towards quality assurance included mounting political influence, commercialism in medical education, weak regulatory capacity of accrediting body, violation of rules, lack of valid accreditation standards and skilled inspectors.

CONCLUSION

Quality assurance of Basic Medical Education in Pakistan involves various systemic, resource and personnel related challenges. The accrediting body needs to bring major reforms in its accreditation system and strengthen its regulatory and technical educational capacity to ensure the quality of medical education in nearly 168 medical and dental colleges of the country.

P4599Strict versus no fasting prior to cardiac catheterization: a prospective evaluation of safety and clinical outcomes

Background/Methods

No studies have examined safety of a no fasting (NF) strategy as compared to current nil per os (NPO) practice in patients undergoing non emergent cardiac catheterization (CC). We compared these two strategies in this single center, prospective, randomized study. Fasting group was NPO for solids after midnight but could have clear liquids up to 2 hours prior to procedure. NF group had no restriction or oral intake.

Results

A total of 520 patients enrolled till December 2018 were included in this interim analysis. Both groups had similar baseline characteristics (figure 1). As compared to the fasting group (n=274), NF group (n=246) had similar rates of primary outcomes: CIN (0.02% in both groups), peri-procedural hypotension (0.02% vs 0.03%), aspiration pneumonitis (none vs 0.009%), nausea/vomiting (0.05 vs 0.07%), hypoglycemia (0.007% vs 0.008%) respectively [p=not significant for all].Secondary outcomes including patient's satisfaction and 30-day mortality were also similar in both groups. Cost of index hospitalization was significantly lower in NF group (table 1).

Outcome table Outcomes Fasting group (n=274) Non- Fasting group (n=246) p value Length of Stay (days)† 2.13±0.2 1.96±0.19 0.524 SBP post catheterization† 133.31±1.44 133.15±1.39 0.936 Hypotension peri procedurally 6 (2%) 7 (3%) 0.617 Fluid resuscitation required for hypotension 2 (0.7%) 3 (1%) 0.669 Pressor required for hypotension 1 (0.4%) 2 (0.8%) 0.603 Acute Kidney Injury 10 (4%) 9 (4%) 0.981 Contrast induced nephropathy 5 (2%) 6 (2%) 0.612 Hypoglycemia 2 (0.7%) 2 (0.8%) 1 Hyperglycemia 12 (4%) 4 (2%) 0.080 Symptomatic hypotension 1 (0.4%) 2 (0.8%) 0.603 Nausea/vomiting 12 (5%) 15 (7%) 0.344 Aspiration pneumonitis 0 (0%) 2 (0.9%) 0.219 Patient satisfaction score† 4.39±0.06 4.45±0.06 0.438 Alive on discharge 271 (98.9%) 240 (98%) 0.622 30-day mortality 4 (1.5%) 6 (2.4%) 0.417 30-day Cardiac readmission 32 (13%) 26 (11%) 0.557 Total Cost (US Dollars)† 10148.97±985.71 7710.914±648.33 0.040 Results are shown as number (%). †Expressed as mean ± standard error.

Conclusion

NF strategy is safe and cost effective as compared to traditional NPO practice in patients undergoing CC.

Acknowledgement/Funding

A financial grant of USD15,000 from Guthrie Research Foundation

World Federation for Medical Education: Appropriateness of Basic Medical Education standards in Pakistan

Objective:

To explore the appropriateness of WFME Basic Medical Education (BME) standards to Pakistani context.

Methods:

A descriptive cross-sectional survey of faculty, graduates and students of five Masters’ in Health Professions Education programmes was carried out from Jul-Dec 2017. Participants were asked to rate the appropriateness of WFME-BME basic standards to Pakistani context on a fourpoint Likert scale (Strongly Disagree through to Strongly Agree). They were also asked for additional comments, if any. Descriptive statistics were carried out for quantitative data, while content analysis for qualitative data.

Results:

A total of 127/200 participants responded (63.5%). For all major areas (106 standards), 97.7% responses (n=13,149) were positive while only 2.3% (n=313) were negative. Ninety-six standards got more than 95% positive response while only 10 standards in three major areas got more than five percent negative response. These include five standards from major area Mission and Outcomes, one from Educational Programme and four from Students.

Conclusions:

This is the first study exploring the appropriateness of WFME-BME standards for accreditation in Pakistan. We found that all the areas, sub-areas and standards are largely appropriate. We recommend further deliberation on 10 standards with more than five percent negative responses, regarding their contextualization to Pakistan and the development of guidelines and possible reconsiderations in WFME future revisions.

Onlay bone grafts from iliac crest: a retrospective analysis

This study was performed to address the outcomes of patients treated with onlay grafts from the iliac crest to augment the deficient jaw. The results of 173 consecutive patients who underwent bone grafting prior to implant surgery are presented. The grafts were taken from the anterior iliac crest to repair alveolar bone deficiencies that were too large to be corrected using intraoral bone grafts. Three months postoperatively, 869 implants were placed into 190 onlay grafts (167 grafts in the maxilla, 23 in the mandible). The follow-up ranged from 3 months to 23 years post implantation. All patients received a fixed prosthesis. Parameters examined included healing of the donor site and bone grafts, implant survival, peri-implant condition, and donor site morbidity. The overall survival rate for all implants was calculated to be 95%±2.7% according to Kaplan-Meier analysis. The implant survival rate compares favourably with those reported in studies using intraoral and extraoral bone.

Efficacy and safety of liraglutide in Indian adolescents with obesity

AIM

The aim of this study was to evaluate the efficacy and safety of liraglutide in adolescents with obesity.

MATERIALS AND METHODS

Patients (n = 41) received injection liraglutide for at least 12 weeks and their pre-baseline and post-baseline characteristics were recorded and analysed. The key parameters analysed were weight, height, body mass index (BMI), fasting insulin and sugar, 1 h insulin and glucose, 2 h insulin and glucose, HbA1c, cholesterol, triglycerides, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, thyroid stimulating hormone and bone.

RESULTS

There was a significant decrease (p < 0.001) in body weight, BMI, fasting, 1 h post-glucose tolerance and 2 h glucose tolerance. The changes from baseline to the end of study were for body weight - 6.5 ± 4.2 kg and BMI -2.35 ± 1.30 kg m-2. Systolic blood pressure decreased from 119.25 ± 12.50 to 114.53 ± 9.53 mmHg and diastolic blood pressure from 70.69 ± 14.52 to 70.82 ± 8.85 mmHg. Liver enzymes had improved from 34.36 ± 12.23 (serum glutamic oxaloacetic transaminase), 38.08 ± 21.02 (serum glutamic pyruvic transaminase) to 33.52 ± 11.23 (p = 0.03) and 33.99 ± 13.16 (p = 0.01), respectively. Cholesterol and triglyceride had improved from 152.46 ± 24.74 and 124.41 ± 33.27 to 151.71 ± 23.46 (p = 0.14) and 120.76 ± 26.22 (p = 0.009), respectively.

CONCLUSION

In conclusion, treatment with liraglutide in adolescents with obesity offers an efficacious and safe alternative to patients who are not responding to other available modalities.

Emergent Vibronic Excitations in the Magnetodielectric Regime of Ce_{2}O_{3}

The strong coupling between spin, lattice, and electronic degrees of freedom in magnetic materials can produce interesting phenomena, including multiferroic and magnetodielectric (MD) behavior, and exotic coupled excitations, such as electromagnons. We present a temperature- and magnetic field-dependent inelastic light (Raman) scattering study that reveals the emergence of vibronic modes, i.e., coupled vibrational and crystal-electric-field (CEF) electronic excitations, in the unconventional rare-earth MD material Ce_{2}O_{3}. The energies and intensities of these emergent vibronic modes are indicative of enhanced vibronic coupling and increased modulation of the dielectric susceptibility in the Néel state (T_{N}≈6.2  K). The field dependences of the energies and intensities of these vibronic modes are consistent with a decrease of both the vibronic coupling and the dielectric fluctuations associated with these modes below T_{N}. These results suggest a distinctive mechanism for MD behavior in Ce_{2}O_{3} that is associated with a field-tunable coupling between CEF and phonon states.

Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.

Abstract P3-08-14: Quantifying intrinsic subtype admixture in luminal A breast cancer and its relationship to clinical outcomes

Background/Objectives: PAM50 gene profiling assigns each cancer to a single intrinsic subtype. However, individual cancers vary in their adherence to a prototype, and some may exhibit expression patterns that indicate intra-tumor admixture of multiple subtypes. Our objective was to develop admixture metrics from PAM50 gene expression profiles in order to stratify Luminal A cases according to their degree of subtype admixture, and then relate such admixture to clinical and molecular variables.

Methods: We re-constructed scaled, normalized PAM50 profiles for 1,980 cases (674 LumA) in the METABRIC cohort and for each case we computed its Mahalanobis (M-) distance from its assigned centroid and its M-distance from all other centroids. We used t-SNE plots to visualize overlaps in subtype clustering. With Normal-like cases excluded, Median Distance Criteria (MDC) classified a case as Pure if it was located within the 50th percentile of the LumA centroid and &gt;50th percentile from any other centroid. Distance Ratio Criteria (DRC) was computed as the ratio of M-distances from the LumA centroid to the nearest non-assigned centroid; cases were grouped by DRC tertile. Pure and admixed LumA cases were compared on clinical, molecular and survival traits. TCGA LumA cases (n=509) were used for independent validation.

Results: Compared to admixed cases in METABRIC, pure ones by MDC had younger age at diagnosis, smaller tumor size, lower grade and lower stage. Comparisons of the highest (T3, most admixed) to lowest tertile (T1) for DRC revealed even stronger associations. Admixed cases, by both metrics, were more likely to show HER2 gain, high proliferation by AURKA expression, higher PAM50 Risk of Recurrence scores, more frequent TP53 mutation, and less frequent mutation of PIK3CA and CBFB. Similar results were observed in the TCGA validation cohort. LumA-LumB confusion was predominant, but other combinations with LumA were also present. Degree of admixture was associated with overall survival in both cohorts, as was disease-free survival in TCGA, independent of age, grade and stage. (See table for adjusted hazard ratios).

Conclusions: Luminal A breast cancers subgrouped based on PAM50 subtype purity support the hypothesis that admixed cases have worse clinical features and survival. Future analyses will explore more extensive genomic metrics for admixture and their spatial significance within a single tumor.

Multivariable hazard ratios for overall (OS) and disease-free survival (DFS) for Luminal A breast cancer, according to degree of subtype admixture. METABRIC and TCGA cohorts. Distance ratio tertile T1 (pure)T2T3  HRadj95% CIHRadj95% CIHRadj95% CIP trendMETABRIC - OS*1.00-1.200.91-1.591.421.07-1.88&lt;0.001TCGA - OS^1.00-1.340.69-2.621.901.02-3.540.04TCGA - DFS^1.00-1.140.48-2.742.851.39-5.850.002* Adjusted for age, tumor size, grade and stage; ^ adjusted for age, size and stage only

Citation Format: Kumar N, Zhao D, Sethi A, Gann PH. Quantifying intrinsic subtype admixture in luminal A breast cancer and its relationship to clinical outcomes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-14.

The influence of postgraduate qualifications on educational identity formation of healthcare professionals

Demand for postgraduate qualifications in medical education can be judged by the increase in providers worldwide over the last two decades. However, research into the impact of such courses on identity formation of healthcare professionals is limited. This study investigates the influence of such programmes on graduates' educational identities, practices and career progression. Informed by constructivist grounded theory (CGT), semi-structured interviews were conducted with 27 graduates (2008-2012) from one postgraduate programme, who were at different stages in their careers worldwide. The audio data were transcribed and analysed using a CGT approach. Participants enrolled in award-bearing medical education courses for various intrinsic and extrinsic reasons. The findings from this study highlight their development as educators, and educational researchers, leaders and learners, as their self-efficacy in educational practices and engagement in scholarly activities increased. Graduates attributed career progression to the qualification, with many being promoted into senior positions. They also described substantial performance attainments in the workplace. The findings contribute to understanding the complexity and nuances of educational identity formation of healthcare professionals. A qualification in medical education encouraged transformational changes and epistemological development as an educator. Awareness of these findings will inform both those considering enrolment and those supporting them of potential benefits of these programmes.