Investigating the internal structure of multiple mini interviews-A perspective from Pakistan

BACKGROUND

Healthcare professionals require many personal attributes in addition to cognitive abilities and psychomotor skills for competent practice. Multiple Mini- Interviews are being employed globally to assess personality attributes of candidates for selection in health professions education at all level of entry; these attributes are namely, communication skills, critical thinking, honesty, responsibility, health advocacy, empathy and sanctity of life. Considering the high stakes involved for students, faculty, institutions and the society, rigorous quality assurance mechanisms similar to those used for student assessment must be employed for student selection, throughout the continuum of medical education. It is a difficult undertaking as these psychological constructs are difficult to define and measure. Though considered to yield reliable and valid scores, studies providing multiple evidences of internal structure especially dimensionality of Multiple Mini-Interviews are sparse giving rise to questions if they are measuring a single or multiple constructs and even if they are measuring what they are purported to be measuring.

OBJECTIVE

The main objective is to provide statistical support of the multi-dimensional nature of our Multiple Mini Interviews, hypothesized a-priori, through CFA. Another objective is to provide multiple evidences for the internal structure. Our study highlights the link between content and internal structure evidences of the constructs, thus establishing that our Multiple Mini Interviews measure what they were intended to measure.

METHOD

After securing permission from the Institutional review board, an a-priori seven factor-model was hypothesized based on the attributes considered most essential for the graduating student of the institution. After operationally defining the attributes through extensive literature search, scenarios were constructed to assess them. A 5-point rating scale was used to rate each item on the station. A total 259 students participated in the multiple mini interviews over a period of three days. A training workshop had been arranged for the participating faculty.

RESULTS

The reliability coefficient using Cronbach's alpha were calculated (range from 0.73 to 0.94), Standard Error of Measurement (ranged from 0.80 to1.64), and item to station-total correlation ranged from 0.43-0.50 to 0.75-0.83. Inter-station correlation was also determined. Confirmatory factor analysis endorsed the results of Exploratory factor analysis in the study revealing a seven model fit with multiple indices of Goodness-of-fit statistics such as Root mean square error of approximation (RMSEA) value 0.05, Standardized root mean square residual (SRMR) value with less than 0.08. All these indices showed that model fit is good. The Confirmatory factor analysis confirmed the multi-dimensional nature of our MMIs and also confirmed that our stations measured the attributes that they were supposed to measure.

CONCLUSION

This study adds to the validity evidence of Multiple Mini-Interviews, in selection of candidates, with required personality traits for healthcare profession. It provides the evidence for the multi-dimensional structure of Multiple Mini interviews administered with multiple evidences for its internal structure and demonstrates the independence of different constructs being measured.

Transforming professional identity of medical teachers in Pakistan by a certificate program in health professions education: a thematic analysis of reflective essays

Introduction

A teacher's professional identity development is a dynamic and continuous process that requires rigorous, longitudinal, faculty development initiatives which are designed to work on individual professional growth. Impact of such programs must be evaluated by qualitative means to identify the process of change; The purpose of our study was to investigate whether and how our thoughtfully designed 6-month certificate program has transformed the professional identity of medical teachers.

Methods

The study was conducted in National University of Medical Sciences, Pakistan using thematic analysis, wherein a weekly task of guided reflective writing, on Moodle, was given. Data was analyzed in six phases to achieve credibility and transferability.

Results

By analyzing 202 reflective writings, seven subthemes were identified which manifest transformation in certain aspects of identity of participants and grouped under three major themes. The seven subthemes represent transformative journey of participants and include recognizing millennial learners' dilemma, identifying learning gaps and overcoming barriers, discovering a newer version of self, alternative frame of thinking, transforming traditional classroom, conducive learning environment and Community of Practice. Three major themes identified were Awareness, Modeling and Socialization which represent three processes bringing transformation in participants.

Conclusion

Our faculty development program has transformed certain aspects of professional identities of medical teachers by incorporating informal teaching strategies of experiential learning, professional socialization, reflections, and role modeling. Participants' beliefs and practices on teaching were challenged by giving a disorienting dilemma of millennial learners and learning theories. They underwent critical discourse with professional peers and mentors in community of practice, reflected on their traditional teaching practices, acquired new insight, underwent self-discovery, and introduced digitalization and interactive learning strategies within their classrooms.

Negative faculty role modelling - is it a reflection of deteriorating societal values?

BACKGROUND

Negative faculty role modelling is an area of growing concern especially due to its implications on medical professionalism. The study aims to explore the impacts of negative role modelling on professionalism of medical students in the context of Pakistan.

METHODS

This qualitative study is part of a larger study exploring impacts of role modelling on professionalism of students. It is based on Constructivist Grounded Theory involving six semi-structured interviews with clinical faculty and three focus group discussions with 22 students. Initial, focused, selective coding and thematic analysis was used to find the core category.

RESULTS

Three overarching categories were developed: traits observed with negative role models; impact of negative role modelling; factors promoting negative role modelling. Subcategories of impacts included negative impact on professionalism, emotional impact, and its paradoxical positive impact. Negative role modelling, a manifestation of declining professionalism, was attributed to deteriorating societal values; further compounded by the lack of required mechanisms by institutions and the regulatory authority at their respective levels.

CONCLUSIONS

In the absence of a strong moral platform at societal level, the burden of responsibility rests with the faculty and more importantly with institutions and regulatory bodies to discourage negative role modelling and educate students to recognize, reflect on and avoid negative behaviours and adopt strong professional values.

Analysis of Germin-like protein genes family in Vitis vinifera (VvGLPs) using various in silico approaches

Abstract Germin-like proteins (GLPs) play an important role against various stresses. Vitis vinifera L. genome contains 7 GLPs; many of them are functionally unexplored. However, the computational analysis may provide important new insight into their function. Currently, physicochemical properties, subcellular localization, domain architectures, 3D structures, N-glycosylation & phosphorylation sites, and phylogeney of the VvGLPs were investigated using the latest computational tools. Their functions were predicted using the Search tool for the retrieval of interacting genes/proteins (STRING) and Blast2Go servers. Most of the VvGLPs were extracellular (43%) in nature but also showed periplasmic (29%), plasma membrane (14%), and mitochondrial- or chloroplast-specific (14%) expression. The functional analysis predicted unique enzymatic activities for these proteins including terpene synthase, isoprenoid synthase, lipoxygenase, phosphate permease, receptor kinase, and hydrolases generally mediated by Mn+ cation. VvGLPs showed similarity in the overall structure, shape, and position of the cupin domain. Functionally, VvGLPs control and regulate the production of secondary metabolites to cope with various stresses. Phylogenetically VvGLP1, -3, -4, -5, and VvGLP7 showed greater similarity due to duplication while VvGLP2 and VvGLP6 revealed a distant relationship. Promoter analysis revealed the presence of diverse cis-regulatory elements among which CAAT box, MYB, MYC, unnamed-4 were common to all of them. The analysis will help to utilize VvGLPs and their promoters in future food programs by developing resistant cultivars against various biotic (Erysiphe necator and in Powdery Mildew etc.) and abiotic (Salt, drought, heat, dehydration, etc.) stresses.

Ethnomedicinal uses of plants for various diseases in the remote areas of Changa Manga Forest, Pakistan

Abstract This study aims at reporting the indigenous knowledge of the medicinal flora from the inhabitants of surroundings of the World’s largest artificial planted forest “Changa Manga”, Pakistan. Data were collected by direct interviews and group meetings from 81 inhabitants including 32 local healers having information regarding the use of indigenous medicinal plants over a period of one year. Different statistical tools were applied to analyze the data including Frequency citation (FC), Relative frequency citation (RFC), Use Value, Factor of informants consensus and fidelity level. This study reported 73 plant species belonging to 37 plant families and 46 genera. The majority of plant species belong to compositae family. The most commonly used medicinal plants were P. hysterophorus L., P. dactylifera L., S. indicum L, P. harmala L., P. emblica L., and A. indica A.Juss. The greatest number of species was used to cure gastrointestinal disorders. The highest fidelity level (68.18%) was of E. helioscopia to cure gastrointestinal disorders. Maximum fresh uses (17) were reported by C. dactylon (L.) Pars. While the highest number of species reporting fresh uses in similar number was 13. In this study, five novel plants are being reported for the first time in Pakistan for their ethnomedicinal worth. Our data reflect unique usage of the medicinal plants in the study area. The statistical tools used in the study proved useful in pointing the most important and disease category specific plants. High use value plant and the new reported medicinal plants might prove an important source of the isolation of pharmacologically active compounds.

Comparison of the effect of zinc oxide nanoparticles and extract of Acorus calamus applied topically on surgical wounds inflicted on the skin of rabbits

Antibiotics are used for postsurgical wound healing purposes but unfortunately, resistance against them demands some alternatives for quick recovery. Sepsis of wounds is a challenge for medical as well as veterinary professionals. Nanoparticles have significant advantages in wound treatment and drug resistance reversal. This study was conducted to appreciate emerging alternates of antibiotics like zinc oxide nanoparticles and plant extracts in topical application. Zinc oxide is considered a good wound healer and its nanoparticles are easy to access. So, the efficacies of zinc oxide nanoparticles and sweet flag plant extract ointments were tested to compare modern and traditional therapeutics as sweet flag is considered a pure medicinal plant. Rabbits were selected for this study due to the healing properties of their skin. Wounds were inflicted on the thoracolumbar region and treated for 29 days post-surgically daily with normal saline and the ointment of zinc oxide nanoparticles and sweet flag extract ointment, prepared in a hydrophilic solvent. Wound shrinkage was observed daily and histopathological analysis was made and results were compared. Zinc oxide nanoparticles ointment showed the most satisfactory results for every parameter included in the study. No side effects of its topical application were observed. Healing was normal without any complications. The preparations of zinc oxide nanoparticles may help in the era of antibiotic resistance as topical drugs in the future.

Development and validation of a questionnaire about hidden curriculum in medical institutes: A pilot study

The goal of the current study was to develop and validate a questionnaire that would reveal characteristics of medical hidden curricula. It is an extension of the qualitative research that was done by researchers on hidden curriculum, and a second part of the qualitative was the creation of a questionnaire by a panel of experts. Using both exploratory factor analysis (EFA) and the quantitative portion, the questionnaire was verified. The sample size was 301, and the participants, who were from medical institutes, were both genders and between the ages of 18 and 25. First, a thematic analysis of the qualitative portion was used to create a 90-item questionnaire. The validity of the questionnaire's content was certified by the expert panel. A 39-item questionnaire was subsequently created after the items that overlapped and the items that did not represent the particular theme were eliminated. After that, we validated the survey. A total of 39 high-loading components made up the six variables of EFA, which explained 62% of the variance. The 33-item questionnaire, from which six items were deleted, was found to have satisfactory psychometric qualities. As a result, the accountability of faculty and students in curricula and extracurricular activities combined with equal opportunity is one factor, communication and relationships with stakeholders combined with evidence-based reforms and implementations are the second factors, and student-centeredness and empowerment as the third main factor of the hidden curriculum are all considered to be important factors. All these three main constructs were collectively used to measure hidden curricula in medical institutes.

Chemical divergence of the Juglans Regia L. across districts Swat and Dir, Khyber Pakhtunkhwa, Pakistan

Juglans regia L. are nutritious fruit bearing plants mostly found in Northern areas of Pakistan. The population of walnuts was explored from district Dir and Swat Khyber Pakhtunkhwa, Pakistan for their geographical, climatic and chemical divergence. The geographical differences such as altitude, latitude and longitude whereas climatic differences viz. soil EC, soil pH, precipitations, intensity of light, temperature and soil temperature. In both districts TPC ranged from 211.2±0.6 to 227.8±0.4 mg/100g, RSA ranged from 43.32±1.5% to 52.18±0.4%, conductivity ranged from 296.43±0.6 to 312.22±0.3 S/m and elemental composition such as iron, copper, calcium, zinc and magnesium in Dir differs from 0.312±0.032, 0.209±0.13, 20.0±0.313, 0.406±0.10 and 10.2±0.030 mg/L to 0.543±0.65, 0.698±0.82, 28.7±0.234, 0.685±0.15 and 17.6±0.015 mg/L respectively. Altitude and temperature showed a correlation with total phenolics contents and radical scavenging activity while soil pH, precipitations, soil temperature, soil Ec and light intensity indicated a weak correlation with chemical traits of walnuts. Further studies of walnuts are needed to explore their therapeutically important phytochemicals to succeed naturally pharmaceutical nutrients of the maximum significance for the health of human beings.

A comprehensive review on the documented characteristics of four Reticulitermes termites (Rhinotermitidae, Blattodea) of China

Termites are known as social insects worldwide. Presently in China 473 species, 44 genera and 4 families of termites have been reported. Of them, 111 Reticulitermes species are widely spread in different zones of China. The dispersion flight season of these Chinese Reticulitermes species are usually started from February to June, but in some regions different species are distributed, sharing their boundaries and having overlapping flight seasons. These reasons become important sources of hybridization between two different heterospecific populations of termites. It was confirmed that the fertilized eggs and unfertilized eggs of some Reticulitermes termites have the capacity of cleavage. While the unfertilized eggs of R. aculabialis, R. chinensis and R. labralis cleaved normally and the only R. aculabialis unfertilized eggs develop in embryos. While, the R. flaviceps and R. chinensis were observed with their abnormal embryonic development, and not hatching of eggs parthenogenetically. They were reported more threatening to Chinese resources as they propagate with parthenogenesis, hybridization and sexual reproduction. Eggshell and macrophiles of eggs play important roles in species identification and control. Although, they are severe pests and cause a wide range of damages to wooden structures and products in homes, buildings, building materials, trees, crops, and forests in China's Mainland.

Pachypodol attenuates Perfluorooctane sulphonate-induced testicular damage by reducing oxidative stress

Perfluorooctane sulfonate (PFOS) is an endocrine disruptor chemical (EDC) with potentially adverse effects on the male reproductive system. Pachypodol (5,4'-dihydroxy-3,7,3'-trimethoxyflavone) is a promising flavonoid isolated from Pogostemon cablin (Blanco) Benth that shows a broad range of pharmacological properties. However, the potential curative effects of pachypodol on testicular toxicity are not available until now. Therefore, this research was proposed to examine the efficiency of pachypodol against PFOS-induced testicular toxicity in adult male rats. The experiments were conducted on Sprague-Dawley rats (n = 48), which were equally distributed into four groups: control, PFOS (20 mg/kg), PFOS + Pachypodol (20 mg/kg + 10 mg/kg respectively), and Pachypodol (10 mg/kg). After 56 days of treatment, testes were excised by slaughtering rats, weighed, and stored till further analysis. The estimated parameters include biochemical markers, spermatogenic indices, hormonal and histopathological profiles. PFOS exposure disturbed the biochemical profile by altering the antioxidant/oxidant balance. For instance, it decreased the activities of catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx), and glutathione reductase (GSR) while increasing the concentration of reactive oxygen species (ROS) and level of thiobarbituric acid reactive substances (TBARS). PFOS intoxication also led to a notable decline in viability, motility, epididymal sperm count, and the number of HOS coiled-tail sperms, whereas the higher level of abnormality in the head, mid-piece, and tail of sperms were observed. Besides, it lowered luteinizing hormone (LH), follicle-stimulating hormone (FSH), and plasma testosterone. In addition, PFOS exposure led to histopathological damages in testicles. However, pachypodol treatment potently alleviated all the illustrated impairments in testes. Conclusively, our results demonstrate the promising free-radical scavenging activity of pachypodol, a novel phytochemical, against the PFOS-instigated testicular dysfunctions.

Ethnomedicinal and traditional uses of the Ferns of Khyber Pakhtunkhwa, Pakistan

Ferns are often used by indigenous people in Khyber Pakhtunkhwa, Pakistan. This study was designed to collect the ethnomedicinal and traditional knowledge of these locals about this group of vascular plants. Forty taxa belong to nineteen genera and ten families are used in the treatment of different diseases. The Pteridaceae was the most representative family with twelve taxa (30%), followed by Athyriaceae and Dryopteridaceae with six taxa each (30%), and Thelypteridaceae with five taxa (12.5%). Regarding the genera, Adiantum, Asplenium and Dryopteris ranked first with four taxa each (30%), followed by Aleuritopteris, Diplazium, Pteris and Equisetum with three taxa each (30%), followed by Athyrium, Oeosporangium, Polystichum and Pseudophegopteris with two taxa each (20%). These taxa were commonly used in the treatment of respiratory disorders i.e. asthma, bronchitis, emphysema, pneumonia; intestinal ulcer, stomach, urinary ailments and skin disorders by the methods of decoction and infusion. Traditional knowledge about ethnomedicinal plants is a valuable and essential source for the discovery of allopathic, herbal and homeopathic medicines.

1242 A Surfacing Staghorn: Spontaneous Expulsion of a Large Renal Calculus from A Nephrocutaneous Fistula

An 83-year-old lady presented to the urology department with right flank pain in the context of a previously known right renal staghorn calculus. On examination, she was found to have a visible discharging sinus in her right flank, and the renal calculus had become visible at the skin surface. Non-contrast CT imaging confirmed that her staghorn calculus had eroded through the skin via a nephrocutaneous fistula. The stone was manually extracted percutaneously on the ward, and she was treated with intravenous antibiotics. She subsequently passed a further stone through the tract and made a good recovery.

This is a highly unusual presentation of nephrolithiasis in a developed country in the 21st century. Review of the literature suggests that surgical management is almost always indicated in patients with staghorn calculi. However surgical management options are not without risk and conservative management of staghorn disease may be appropriate in select patient groups: those with multiple co-morbidities at high risk for GA, in cases of patient refusal of surgery, or in patients with aberrant anatomical factors

Our case highlights a potential complication of conservatively managed staghorn stone disease. To our knowledge our case is the first of spontaneous expulsion of renal stone of this size to be reported in the developed world.

Traditional knowledge about medicinal plant in the remote areas of Wari Tehsil, Dir Upper, Pakistan

Traditional medicine is cheaper and easily available to local people, to care for most frequent diseases in the Northern parts of Pakistan. Our study aimed at inventorying medicine from local plants, documenting their uses, and assessing their market value in 2015-2018 during spring, summer, and winter seasons. A total of 15 trips were made, 5 in each season. Semi-structured interviews with 165 inhabitant's age range between 20-80 years were conducted, analyzed the data is analyzed using Relative frequency of citation(RFC), Use Value(UV), Fidelity Level(FL), Informants consensus factor(ICF), and Jaccard index(JI) to find the most frequent and well-known used species in the area. A total of 86 species belonging to 39 vascular plant families, 33 genera were documented as medicinally important. Family Asteraceae was observed as the dominant family among all the families with 10 species, the leaf was the most used parts and decoction 36% was the most preferred preparation type. Herb was the predominant life form (67%). The maximum UV (0.92) was demonstrated by J. adhatoda L. species, while A. sativum L. shows maximum RFC (0.58), the highest ICF value represented by diarrhea and dermatitis 0.92, and high FL value is recorded 100%. According to our collections, wild species were 45%, invasive species were 38% and cultivated 17% recorded, dicots species were recorded more 81%. Seven 7 medicinal species is being economically important and export to the local and international market of the world, whereas P. integrima L. species were the most exported species according to the local dealers. The investigated area is rural and the local people depend on the area's plants for their health needs, and other uses like a vegetable, fuelwood, fodder, etc. The current result of RFC, UV, ICF, FL, and JI shows that medicinal flora needs to be pharmacologically and phytochemically investigated to prove their efficacy. The documentation of medicinal knowledge is important to preserve this precious old knowledge before it is lost forever, due to technological and environmental changes in the world.

POS1056 COMPARATIVE EFFICACY OF TNF INHIBITORS VERSUS OTHER CYTOKINE INHIBITOR bDMARDs ON PSORIATIC ARTHRITIS IMPACT OF DISEASE (PsAID) SCORE AND DOMAINS

Background:

Psoriatic arthritis (PsA) has many consequences, reflecting musculoskeletal and skin inflammation, with the potential to adversely affect overall quality of life. Patient reported outcome measures (PROM) assess a holistic range of aspects of quality of life, including physical and mental components, and provide broad detailed information of the impact of disease. Biologic DMARDs (bDMARDs) targeting TNF have been used to treat PsA for over 10 years whereas inhibitors of IL-17, IL-12/23 and Janus kinases (JAK) have only been available more recently. They all target differing cytokines, including JAK inhibitors which inhibit IL-12 and IL-23 signaling but not TNF signaling. Their relative impact on PROMs is unknown.

Objectives:

To assess, in routine care, the relative impact in PsA of TNF inhibitors (TNFi) versus non-TNFi bDMARDs, targeting IL-17, IL-12/23 and JAK, on PROMs.

Methods:

We performed a cross section analysis of PsA patients with established disease treated with bDMARDs and JAKi, under routine care at St George’s University Hospital, London, UK. Patients completed the 12-item psoriatic arthritis impact of disease (PsAID) tool. The total PsAID score was calculated using the on-line EULAR toolkit (see reference). The PsAID total and individual domain scores were compared between TNFi and non-TNFi groups using the Mann Whitney U test. A total PsAID score below 4 out of 10 is considered a ‘patient-acceptable state’.

Results:

A total 95 patients (female n= 53, 56%) completed the PSAID; TNFi n=72 (female 50%, adalimumab n=41, Etanercept n= 24, Golimumab n=4, Infliximab n =2, Certolizumab n=1) and non-TNFi n= 23 (female 74%, Secukinumab n=9, Ixekizumab n=1, Ustekinumab n=9, Tofacitinib n=4). The mean age was 53.6 (TNFi 53.5, non-TNFi 53.7) years, and duration of time on bDMARD treatment was TNFi 49.5 (range 1- 141) months, non-TNFi 25.3 (range 4 -59) months. The total and individual domain PsAID scores are shown in the Table 1. A ‘patient acceptable state’ total score <4 was recorded in TNFi 36/72 (50%) and non-TNFi 11/23 (48%). There was no significant difference between TNFi and non-TNFi groups in the mean total PsAID score, or proportion achieving a patient acceptable state. Patients on TNFi had lower (better outcome) mean scores for all 12 domains except skin, and the differences, versus non-TNFi treated patients, were significant for pain, functional capacity, discomfort and depression.

PSAID domainTNFiNon-TNFiP valueTotal score3.314.64N.S.Pain3.675.430.02Fatigue4.045.65N.S.Skin problems3.112.78N.S.Work/leisure activities3.564.78N.S.Functional capacity3.295.040.02Discomfort3.885.650.02Sleep disturbance3.424.78N.S.Coping3.014.09N.S.Anxiety, fear, uncertainty2.644.17N.S.Embarrassment/shame2.283.39N.S.Social participation2.63.48N.S.Depression2.113.910.03

Conclusion:

In PsA, TNFi appear to have a greater impact over non-TNFi bDMARDs on some aspects of quality of life, including pain and functional capacity. TNFi and non-TNFi were no different with respect to patients’ perspective on skin disease, embarrassment or shame, despite less good cutaneous responses in clinical trials from TNFi agents. Overall, the PsAID tool reveals an unmet burden on quality of life in PsA patients treated with all classes of bDMARDs and JAKi, as 50% fail to achieve a ‘patient acceptable state’. This should prompt scrutiny of the high scoring domains and utilization of additional treatment modalities to achieve better holistic outcomes for PsA patients in routine care.

References:

[1]PsAID tool: http://pitie-salpetriere.aphp.fr/psaid/raid_psaid_quest_home.php

Disclosure of Interests:

Atif Rauf: None declared, Catherine Hughes: None declared, Diane Hill: None declared, Patrick Kiely Speakers bureau: Abbvie.

POS1262 A COHORT STUDY OF COVID-19 RELATED MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN AND ADOLESCENTS FROM MULTIPLE TERTIARY CARE CENTRES IN SOUTH INDIA

Background:

After the peak of COVID 19 pandemic, a surge of cases with multi-system involvement and hyperinflammatory state was reported in children, at multiple tertiary care centers across the world. (1) This COVID-19 associated multisystem inflammatory syndrome in children and adolescents is also known as multisystem inflammatory syndrome in children (MIS-C). There is a paucity of literature of clinical profile of MIS-C patients from India.

Objectives:

To study the clinical manifestations and treatment outcomes of COVID-19 related multisystem inflammatory syndrome in children (MIS-C) and adolescents.

Methods:

It was a cohort study including cases defnied as per the case definitions of MIS-C by World Health Organisation (WHO) or Centre for Disease Control and Prevention(CDC).(2)The clinical parameters, laboratory parameters (including inflammatory markers, D dimer and NT ProBNP), electrocardiogram, 2D echocardiogram, course in hospital, and immediate outcomes were noted.

Results:

Twenty five patients (male-14) with a mean age of 6.22 ±4.25 years and a mean body mass index of 16.21 ±3.36 kg/m2 were enrolled on the study. Average length of hospital stay was 8.12±5.76 days. Associated comorbidities were present in 4 of our patients (16%). Figure 1 shows the frequency of clinical features in our study patients. Table 1 shows the clinical, laboratory, imaging findings, disease course and outcomes.

Figure 1.

Frequency of clinical features in our MIS-C cohort patients

Table 1.

Clinical characteristics of MIS-C patients (n)=25

Clinical Phenotypes:Incomplete/ Atypical Kawasaki Disease (KD)18 (72%)Macrophage activation syndrome (MAS)11 (44%)Unexplained Shock13 (52%)Fever with gastrointestinal symptoms17 (68%)Fever with neurological symptoms9 (36%)Fever with respiratory symptoms5 (20%)COVID chronology:MISC with acute COVID 19 with MAS1 (4%)MISC with acute COVID 19 with incomplete/atypical KD1 (4%)COVID 19 tests:COVID 19 RTPCR positive2 (8%)COVID 19 RTPCR negative23 (92%)COVID 19 IgG positive20 (80%)COVID 19 IgM positive6 (24%)COVID 19 IgG and IgM both positive2 (8%)COVID 19 IgG and IgM not done4 (16%)Other laboratory investigations(Peak/ trough values):Anaemia20 (80%)Leukopenia2 (8%)Thrombocytopenia6 (24%)Pancytopenia2 (8%)Positive CRP23 (92%)High Procalcitonin9 (36%)High ferritin10 (40%)High D- dimer17 (68%)High NT ProBNP23 (92%)Hypoalbuminemia14 (56%)Sterile pyuria7 (28%)Proteinuria4 (16%)Cardiac assessment:Abnormal Electrocardiogram (ECG)5 (20%)Abnormal Echocardiography15 (60%)Coronary dilation/prominence/non-tapering9 (36%)Coronary aneurysm1 (4%)LAD Z score (Mean±SD)2.12 ± 1.11Decreased Ejection fraction (EF)5 (20%)Systolic Dysfunction5 (20%)Pericardial effusion9 (36%)Global/septal hypokinesia4 (16%)Mitral Valve regurgitation3 (12%)Complete heart block1 (4%)

Twenty patients (80%) had severe illness requiring intensive care. Fourteen patients (56%) required inotropic support, 8 patients (32%) required supplemental oxygen, 5 patients (20%) required mechanical ventilation and 2 patients (8%) expired. A total of 23 patients (92%) received pulse steroids followed by oral/iv steroids, 22 patients (88%) received IVIG (2g/kg) and 3 patients (12%) required anticoagulation.

Conclusion:

Our MIS-C cohort had varied clinical manifestations ranging from the mild cutaneous and gastrointestinal symptoms to fatal multiorgan dysfunctions. In contrast to western cohorts, our study cohort had higher number of patients from younger age group and lower BMI.

References:

[1]Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K et al. Multisystem inflammatory syndrome in children: A systematic review. EClinicalMedicine. 2020;26:100527.

[2]Jiang L, Tang K, Levin M, Irfan O, Morris S, Wilson K et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. The Lancet Infectious Diseases. 2020;20(11):e276-e288.

Disclosure of Interests:

None declared

Fatty acid composition and antioxidant activity of Angelica glauca and Chenopodium album seed extracts from Kashmir

Angelica glauca Edgew. and Chenopodium album Linn. are medicinally important plants with aromatic, nutritious and flavor-enhancing properties. In this study the fatty acid composition of petroleum ether seed extracts (PE) of processed plants were analyzed by gas chromatography-mass spectrometry (GC-MS). The PE consisted mainly of unsaturated fatty acids, such as petroselinic acid 74.26% and oleic acid 7.37% for A. glauca and linoleic acid 53.05% and oleic acid 20.74% for C. album. The de-fatted seed extracts were screened for their antioxidant activities using 2,2-di-phenyl-1-picrylhydrazyl (DPPH), nitroblue tetrazolium (NBT), hydrogen peroxide (H2O2) and 2,2'-azino-bis (3-ethylbenzothiazoline-6-sulphonic acid) (ABTS) radical scavenging assay. Almost all the assays resulted in defatted seed extracts showing powerful radical scavenging activity. These findings suggest that the processed plants could be used as ingredients (as a source of natural antioxidants and unsaturated fatty acids) for the formulation of functional foods.

The future of CT: deep learning reconstruction

There have been substantial advances in computed tomography (CT) technology since its introduction in the 1970s. More recently, these advances have focused on image reconstruction. Deep learning reconstruction (DLR) is the latest complex reconstruction algorithm to be introduced, which harnesses advances in artificial intelligence (AI) and affordable supercomputer technology to achieve the previously elusive triad of high image quality, low radiation dose, and fast reconstruction speeds. The dose reductions achieved with DLR are redefining ultra-low-dose into the realm of plain radiographs whilst maintaining image quality. This review aims to demonstrate the advantages of DLR over other reconstruction methods in terms of dose reduction and image quality in addition to being able to tailor protocols to specific clinical situations. DLR is the future of CT technology and should be considered when procuring new scanners.

CHALLENGES OF E-LEARNING FACED BY MEDICAL TEACHERS AND STUDENTS DURING COVID-19 PANDEMIC

Objective: To explore perceptions of medical students and faculty, regarding challenges of e-learning they faced, during COVID-19 pandemic. Study Design: Mixed method study (Quantitative and Qualitative - Phenomenological approach). Place and Duration of Study: Army Medical College Pakistan, from Apr 2020 to Sep 2020. Methodology: A self-made questionnaire, having both qualitative and quantitative elements, was developed after interviews of participants. It was pilot tested, finalized and sent via Google forms. Total 318 students and 6 faculty members responded, data was transcribed verbatim, themes were identified, and qualitative inductive content analysis of participants‟ reports was done. Results: Twenty-seven subthemes were identified by analyzing students‟ and faculty perceptions. They were grouped under five major themes, namely, communicational, technological, institutional, related to educators and students. Conclusion: Despite limiting factors like communication gap, digital refugee faculty teaching digital native students, limited technical support, digital divide and unplanned curricular delivery, e-learning was found to be beneficial in terms of flexibility in timings, improving learners‟ self-efficacy, faculty transformation and gradual acceptance. Moreover, it provided opportunity for hybrid e-curriculum development.

Real-Time Label-Free Kinetics Monitoring of Trypsin-Catalyzed Ester Hydrolysis by a Nanopore Sensor

Trypsin is an important proteolytic enzyme in the digestive system and its activity is a major indicator for evaluating diseases such as chronic pancreatitis. Here, we present a novel label-free method to detect trypsin kinetics using a nanopore technique. A mutant α-hemolysin (M113R)₇ protein nanopore equipped with a polyamine decorated β-cyclodextrin (am₇β-CD) was employed as a sensing platform for the real-time monitoring of the process of trypsin enzymatic cleavage of a substrate Nα-benzoyl-l-arginine ethyl ester (BAEE) at the single molecule level. Significantly, this sensor can exclusively respond to the current modulation caused by the product and prevent interference from the substrate, thus improving detection sensitivity, and it provides a new scheme to detect enzyme activity for cleaving small molecules.

Genetics of the thrombomodulin-endothelial cell protein C receptor system and the risk of early-onset ischemic stroke

BACKGROUND AND PURPOSE

Polymorphisms in coagulation genes have been associated with early-onset ischemic stroke. Here we pursue an a priori hypothesis that genetic variation in the endothelial-based receptors of the thrombomodulin-protein C system (THBD and PROCR) may similarly be associated with early-onset ischemic stroke. We explored this hypothesis utilizing a multi-stage design of discovery and replication.

METHODS

Discovery was performed in the Genetics-of-Early-Onset Stroke (GEOS) Study, a biracial population-based case-control study of ischemic stroke among men and women aged 15-49 including 829 cases of first ischemic stroke (42.2% African-American) and 850 age-comparable stroke-free controls (38.1% African-American). Twenty-four single-nucleotide-polymorphisms (SNPs) in THBD and 22 SNPs in PROCR were evaluated. Following LD pruning (r2≥0.8), we advanced uncorrelated SNPs forward for association analyses. Associated SNPs were evaluated for replication in an early-onset ischemic stroke population (onset-age<60 years) consisting of 3676 cases and 21118 non-stroke controls from 6 case-control studies. Lastly, we determined if the replicated SNPs also associated with older-onset ischemic stroke in the METASTROKE data-base.

RESULTS

Among GEOS Caucasians, PROCR rs9574, which was in strong LD with 8 other SNPs, and one additional independent SNP rs2069951, were significantly associated with ischemic stroke (rs9574, OR = 1.33, p = 0.003; rs2069951, OR = 1.80, p = 0.006) using an additive-model adjusting for age, gender and population-structure. Adjusting for risk factors did not change the associations; however, associations were strengthened among those without risk factors. PROCR rs9574 also associated with early-onset ischemic stroke in the replication sample (OR = 1.08, p = 0.015), but not older-onset stroke. There were no PROCR associations in African-Americans, nor were there any THBD associations in either ethnicity.

CONCLUSION

PROCR polymorphisms are associated with early-onset ischemic stroke in Caucasians.

Anthelmintic Effect of Date Palm Fruit: A Systematic Review

Soil-transmitted helminth infections constitute a global affliction affecting people and livestock, resulting in a significant disease burden and economic losses in endemic regions. However, control has not been entirely successful and the problem is compounded by the development of resistance to available chemotherapy. Novel alternative compounds are urgently needed, encouraging the screening of largely plant-based sources for anthelmintic effects. Date palm fruit (Phoenix dactylifera) is a popular and nutritious food much coveted for its nutraceutical effect. There are convincing reports documenting the antibacterial, antiviral and antifungal effects of date palm fruit but evidence for any potential anthelmintic effect remains unclear. Here we conducted a systematic review of the published information through an electronic search using six scientific databases; SCOPUS, MEDLINE COMPLETE, OVID, EMBASE, WEB OF SCIENCE and CINAHL COMPLETE. Out of 58 studies that were initially identified only 2 manuscripts fitted our inclusion criteria. The first article reported on the anthelmintic effect of date palm fruit against the rodent nematodes Trichuris muris and Angiostrongylus cantonensis in vitro and in vivo while the second article was based only on in vivo assessment (with coconut) of the effect on the rodent cestode Hymenolepis microstoma. Our review revealed limited anecdotal reports of the anthelmintic effect of date palm fruit against parasitic helminths, however, the majority of reports were inconclusive due to mixed results, limited focus on date palm fruit and lack of any statistical analyses. Rigorous, systematic and fully controlled studies focusing on date palm fruit are needed to validate the anecdotal evidence.

Effect of solvent polarity and extraction time on in vitro antioxidant properties of Brassica oleracea Convar Capitata Var L. seeds

Effect of solvent polarity and extraction time on antioxidant properties of Brassica oleracea seeds was optimized by response surface methodology using central composite design. A significant linear negative effect of solvent polarity on total extractable components (TEC), total phenolic acids (TPA), linoleic acid reduction capacity (LARC) and hydroxyl radical scavenging capacity (HRSC) and significant positive effect on iron chelating activity (ICA), reducing power (RP) and (DPPH RSC). Linear effect of solvent polarity on total antioxidant activity (TAOA) was also found to be positive but not significant. Significant linear negative effect of extraction time was observed on ICA and HRSC. Only RP was found to be significantly increased with increase in extraction time. Quadratic effect of solvent polarity was found to be negative on TAOA, DPPH RSC and HRSC. However, quadratic effects of both variables were found to be positive on TEC, TPA, ICA and LARC. The polarity dependent increase in TAOA indicates the extraction of phytochemicals with comparatively stronger antioxidant properties in polar solvents. The decrease in antioxidant properties in response to increase in extraction time may be attributed to the time dependent loss of antioxidant activity of extracted compounds.

Relationship between Student Performances in Non-Cognitive Skills in Multiple Mini Interview and Integrated Practical Examination

OBJECTIVE

To investigate the relationship between the performances of students in non-cognitive skills in Multiple Mini Interview (MMI) and Integrated Practical Examination (IPE) of the first year of medical school.

STUDY DESIGN

Cross-sectional observation study with statistical support.

PLACE AND DURATION OF STUDY

Shifa College of Medicine/Shifa Tameer-e-Millat University, Islamabad between December 2015 and March 2016.

METHODOLOGY

Student performance in communication skills, domain of the 8-station Multiple Mini Interview, was compared with their scores in communication skills in the first Integrated Practical Examination taken at the end of first block. Descriptive statistics were calculated for student demographics, scores in communication skills in MMI as well as IPE. Pearson's Correlation was calculated to investigate the relationship between the two scores. A p-value of <0.05 was taken as significant.

RESULTS

The mean score in MMI was 130.38 ±9.90 as compared to a score of 79.96 ±19.74 in the IPE. This relationship has a statistically significant (p<0.001) positive correlation, with a Pearson's correlation of 0.52.

CONCLUSION

Student performance shows a positive correlation in non-cognitive skills between Multiple Mini Interview and Integrated Practical Examination.

Effect of antibiotic, probiotic, and human rotavirus infection on colonisation dynamics of defined commensal microbiota in a gnotobiotic pig model

We developed a gnotobiotic (Gn) pig model colonised with defined commensal microbiota (DMF) to provide a simplified and controlled system to study the interactions between intestinal commensals, antibiotics (ciprofloxacin, CIP), probiotics (Escherichia coli Nissle 1917, EcN) and virulent human rotavirus (VirHRV). The DMF included seven gut commensal species of porcine origin that mimic the predominant species in the infant gut. Gn piglets were divided into four groups: DMF control (non-treated), DMF+CIP (CIP treated), DMF+CIP+EcN (CIP/EcN treated), DMF+EcN (EcN treated) and inoculated orally with 10⁵ cfu of each DMF strain. The pig gut was successfully colonised by all DMF species and established a simplified bacterial community by post-bacteria colonisation day (PBCD) 14/post-VirHRV challenge day (PCD) 0. Overall, Bifidobacterium adolescentis was commonly observed in faeces in all groups and time points. At PCD0, after six days of CIP treatment (DMF+CIP), we observed significantly decreased aerobic and anaerobic bacteria counts especially in jejunum (P<0.001), where no DMF species were detected in jejunum by T-RFLP. Following HRV challenge, 100% of pigs in DMF+CIP group developed diarrhoea with higher diarrhoea scores and duration as compared to all other groups. However, only 33% of pigs treated with EcN plus CIP developed diarrhoea. EcN treatment also enhanced the bacterial diversity and all seven DMF species were detected with a higher proportion of Bifidobacterium longum in jejunum in the DMF+CIP+EcN group on PBCD14/PCD0. Our results suggest that EcN increased the proportion of B. longum especially in jejunum and mitigated adverse impacts of antibiotic use during acute-infectious diarrhoea. The DMF model with a simplified gut commensal community can further our knowledge of how commensals and probiotics promote intestinal homeostasis and contribute to host health.

Multi-platform metabolomics analyses of a broad collection of fragrant and non-fragrant rice varieties reveals the high complexity of grain quality characteristics

The quality of rice in terms not only of its nutritional value but also in terms of its aroma and flavour is becoming increasingly important in modern rice breeding where global targets are focused on both yield stability and grain quality. In the present paper we have exploited advanced, multi-platform metabolomics approaches to determine the biochemical differences in 31 rice varieties from a diverse range of genetic backgrounds and origin. All were grown under the specific local conditions for which they have been bred and all aspects of varietal identification and sample purity have been guaranteed by local experts from each country. Metabolomics analyses using 6 platforms have revealed the extent of biochemical differences (and similarities) between the chosen rice genotypes. Comparison of fragrant rice varieties showed a difference in the metabolic profiles of jasmine and basmati varieties. However with no consistent separation of the germplasm class. Storage of grains had a significant effect on the metabolome of both basmati and jasmine rice varieties but changes were different for the two rice types. This shows how metabolic changes may help prove a causal relationship with developing good quality in basmati rice or incurring quality loss in jasmine rice in aged grains. Such metabolomics approaches are leading to hypotheses on the potential links between grain quality attributes, biochemical composition and genotype in the context of breeding for improvement. With this knowledge we shall establish a stronger, evidence-based foundation upon which to build targeted strategies to support breeders in their quest for improved rice varieties.

Caecal diverticulitis: a rare cause of right iliac fossa pain

We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.

Formative assessment in undergraduate medical education: concept, implementation and hurdles

Formative assessment, described as "the process of appraising, judging or evaluating students' work or performance and using this to shape and improve students' competence", is generally missing from medical schools of Pakistan. Progressive institutions conduct "formative assessment" as a fleeting part of the curriculum by using various methods that may or may not include feedback to learners. The most important factor in the success of formative assessment is the quality of feedback, shown to have the maximum impact on student accomplishment. Inclusion of formative assessment into the curriculum and its implementation will require the following: Enabling Environment, Faculty and student Training, Role of Department of Medical Education (DME). Many issues can be predicted that may jeopardize the effectiveness of formative assessment including faculty resistance, lack of motivation from students and faculty and paucity of commitment from the top administration. For improvement in medical education in Pakistan, we need to develop a system considered worthy by national and international standards. This paper will give an overview of formative assessment, its implications and recommendations for implementation in medical institutes of Pakistan.

Exploring the trustworthiness and reliability of focus groups for obtaining useful feedback for evaluation of academic programs

BACKGROUND

At Shifa College of Medicine, evaluation is an integral part of the curriculum. We used focus groups as a tool to obtain in-depth information regarding students' experience with the new integrated, system- based curriculum. The purpose of this study was to explore the usefulness of focus groups in identifying important issues for curriculum improvement and to explore the trustworthiness and representativeness of data obtained through this strategy.

METHODS

In 2012, we used focus groups to seek feedback from students regarding their experience with the integrated curriculum. One course of each of the three preclinical years was selected for this purpose. Three parallel focus groups were conducted for each selected course. Each focus group was audio recorded, and the moderator and a volunteer student took additional notes during the session. The audio recordings were transcribed and data obtained from the three sources were analyzed, coded, and categorized independently by three investigators. Both manifest and latent themes were identified, using an inductive approach. Final agreement on themes was reached by comparison of the independently done thematic analysis by the three researchers. Reliability of data was established by comparing responses from the three parallel focus groups of each course. Trustworthiness of inferences was ensured by multiple coding, audit trail and member checking with focus group participants who reviewed the themes for validity.

RESULTS

Most of the data on students' perceptions of their courses from each of the parallel groups were in agreement: Similar themes were seen within groups of the same class as well as across the three preclinical years.

CONCLUSION

Focus groups can be a useful tool for collecting trustworthy and reliable information through a process that promotes interaction among student participants. They can support quantitative data from students and be used to support curriculum reform.

First Report of Iris yellow spot virus Infecting Green Onion in Indonesia

Green onion (Allium fistulosum L.) is an important vegetable crop for small-holder farmers for domestic consumption in Indonesia. Iris yellow spot virus (IYSV; family Bunyaviridae, genus Tospovirus) transmitted by Thrips tabaci is an economically important viral pathogen of bulb and seed onion crops in many onion-growing areas of the world (1,3). In Asia, IYSV has been reported in India and Sri Lanka (2,4). In April 2013, symptoms suspected to be caused by IYSV were observed on a 1-month-old green onion crop grown for their leaves in a farmer's field in Cipendawa, Pacet, Cianjur District, West Java. Symptoms consisted of elliptical to spindle-shaped, straw colored, irregular, chlorotic lesions with occasional green islands on the leaves. Approximately 25% of the field had plants with these symptoms. The presence of the virus was confirmed with an IYSV-specific Agdia Flash kit. IYSV infection was confirmed by RT-PCR with primers specific to the nucleoprotein (N) gene of IYSV. Primers 465c: 5'-AGCAAAGTGAGAGGACCACC-3' and IYSV-239f: 5' TGAGCCCCAATCAAGACG3' (3) were used as forward and reverse primers, respectively, using total nucleic acids eluted from FTA cards that were previously coated with freshly prepared sap extracts from field samples. Amplicons of approximately 240 bp were obtained from four symptomatic plants tested but not from healthy and water controls. The amplicons were cloned and sequenced. Consensus sequence was derived from three clones. Comparison with IYSV N gene sequences available in GenBank showed sequence identity of 95 to 99% confirming the identity of the virus as IYSV. To our knowledge, this is the first report of IYSV infecting onion in Indonesia. The finding in Java underscores the need for conducting surveys in Java as well as other onion-growing regions of Indonesia to gain a better understanding of its incidence, distribution, and potential impact. References: (1) D. H. Gent et al. Plant Dis. 88:446, 2004. (2) B. Mandal et al. Plant Dis. 96:468, 2012. (3) H. R. Pappu et al. Virus Res. 141:219, 2009. (4) K. S. Ravi et al. Plant Pathol. 55:288, 2006.

Prevalence of parvoviruses in commercial turkey flocks

Turkey parvovirus belongs to the family Parvoviridae, subfamily Parvovirinae, Genus parvovirus. Since the initial report on turkey parvovirus in the United States appeared in 1983, there had been no further reports of parvovirus in turkeys until 2008. The aims of our study were to determine the prevalence of parvovirus in commercial turkey flocks using PCR; to determine their genetic relationship to previous strains identified in North America and Europe; and to test samples for enteric viruses by transmission electron microscopy (TEM). A total of 169 fecal samples collected from 42 turkey farms in four different states within the United States between 2000 and 2010 were examined. We found that the most frequently detected viruses by TEM were small round viruses, accounting for 52% of the examined samples; however, the PCR detected parvoviruses in 71% of the samples. The phylogenetic analysis of partial nonstructural gene sequences showed a certain degree of variability among the turkey samples tested in the study. Moreover, there was a clear dichotomy in the phylogenetic tree between chicken and turkey samples, with the exception of one turkey isolate from 2000, which clustered together with the chicken group.