Journal of Gandaki Medical College-Nepal

Clinical educators of the medical colleges of South Asia need to be trained for educating clinical reasoning skills to medical students

2023-11-30T10:32:30+00:00

Clinical reasoning is the process of reasoning to decide for managing the patient using data and applying medical knowledge and experience. Clinical reasoning skills are essential skills for the novice learner of medical education to learn the process of clinical diagnosis, thereby providing safe and effectual health care. These skills learning help clinicians arrive at a diagnosis and prevent making diagnostic errors which are reported to occur in five to 15% of cases. Poor clinical reasoning leads to a diagnostic error which may jeopardize the patient’s safety.

The clinical reasoning skills are not generally explicitly imparted to the learners especially during their undergraduate learning period even though these may be documented in the curriculum of medical undergraduate study. The key elements in the clinical reasoning process are the patients’ story, data acquisition, problem representation, hypothesis generation, search and selection of illness script, differential diagnosis, and a leading diagnosis.

Clinical reasoning is a complex process, difficult to teach learners and assess their skills, consumes clinical medical educators’ time, and requires resources for teaching and learning. There must be educational strategies both at the undergraduate and postgraduate levels to promote diagnostic reasoning skills; for this, clinical medical educators must be acquainted/trained in how to convey the reasoning approaches to beginners. The clinical medical educator has to a play dual role; provide quality care to the patients, teach clinical reasoning skills to the learners, and assess their skills to make them independent decision-makers and problem solvers in clinical settings.

Clinical reasoning skills are among the core competencies to be learned by medical learners to become competent clinicians. The clinical competence of the clinician cannot be superseded by the advancement of technology and evidence-based medicine. All these three need to be integrated to minimize the errors in diagnosis. Clinical educators must unequivocally nurture and enhance the capacity of learners to include and integrate both analytical and non-analytical clinical reasoning strategies into their approach to arrive at diagnosis. The clinical medical educator must identify the learners’ approach to clinical reasoning and enable them to follow the right approaches towards clinical reasoning. Clinical reasoning skills are better learned/imparted during clinical encounters and deliberate practice enriches learning of these skills.

Enhancement of clinical reasoning skills learning can be achieved through deliberate practice. The clinical medical educator may organize and supervise the simulation-based deliberate practice sessions for the learners to boost their clinical reasoning skills. For the deliberate practice of clinical reasoning skills, The New England Journal of Medicine (NEJM) has developed an application NEJM Healer, a screen-based interactive patient encounter (Virtual Bedside Encounter) through which learners are involved in each element of clinical reasoning process. Virtual Reality (VR) is also gaining popularity in educating the medical students and has been demonstrated to be beneficial in enhancing students’ comprehension and memory as well as in the development of transferable skills like surgical methods. The medical schools in South Asian countries need to reiterate the development/enhancement of clinical reasoning skills of both medical undergraduate and postgraduate learners. To achieve this objective, medical colleges must regularly organize training for clinical medical educators to facilitate students’ learning in reasoning skills, and for assessing their skills, and provide feedback to the learners. The institutes should also invest in infrastructure to pursue the use of modern technologies like VR, skills labs, etc. to attain this objective.

Rare cystic lesion of pancreas : A case report

2023-10-16T17:33:59+00:00

Hydatid disease also known as Hydatidosis or echinococcosis, the cause of which is the larval stage of Echinococcus granulosus. Pancreatic hydatidosis is very rare, with an incidence ranging from 0.14 to 2%. In this report we present a case of 51 years old female patient admitted in our hospital with a cystic lesion in the body of pancreas. Pre-operative computed tomography findings were suggestive of mucinous cystademona for which radical antegrade modular pancreatosplenectomy procedure was done.

Perceived stress among newcomer students in Gandaki Medical College: A cross-sectional study

2023-05-11T06:29:44+00:00

Introduction: Medical students perceive medical education as stressful, which has both positive and negative effects on physical and psychological health. The mental health of a medical student remains affected throughout training due to long study and working hours, extensive course content, examinations, peer competition, uninspiring environments, sleep deprivation, and loneliness. Hence, the objective of this research was to assess the prevalence of stress among newcomer students at Gandaki Medical College.

Methods: A descriptive cross-sectional study was conducted among 195 newcomer students at Gandaki Medical College in Kaski, District. Data was collected on orientation dated May 21,2021 at the GMC. A complete enumerative technique was used. Data was collected using the self-administered Perceived Stress Scale (PSS-10) tool. Descriptive (mean, frequency, percentage, and standard deviation) and inferential (chi-square test) statistics were applied for data analysis in Statistical Package for Social Science (SPSS) version-16.0.

Results: Most of the respondents 163(83.58%) reported moderate stress, 18(9.23%) reported high stress and 14(7.19%) reported low stress. Stress among students was found to be significantly associated with residence (p=0.02) and type of family
(p=0.04).

Conclusions: Most respondents reported moderate stress. The research findings highlight counselling is an integral part of newcomer students to prevent stress.

Distribution of ABO and Blood Groups among various Caste and Ethnic Groups – A cross-sectional Hospital Based Study in a Teaching Hospital of Western Nepal

2023-07-28T06:44:04+00:00

Introduction: Red blood cells contain antigens on its membrane which are inherited according to Mendelian Law. Despite the identification of more than 400 red blood cell antigens, ABO and Rhesus blood group systems are clinically most significant. The current study aimed at determining the distribution of blood groups among different caste and ethnic groups of Western Nepal.

Methods: A descriptive cross-sectional study conducted among individuals in the Blood Bank of Department of Pathology of a Teaching Hospital from January 2018 to July 2019. Ethical approval was taken from the Institutional Review Committee (Ref. 384). Convenient sampling was done. Data were entered in Microsoft Excel and analysed using Statistical Package for the Social Sciences version 21.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results: In ABO system, the frequency of O, A, B and AB blood groups were found to be 960(33.9%) (95% Confidence Interval= 32.15-35.64), 930(32.8%) (95% Confidence Interval= 31.11-34.57), 716(25.3%) (95% Confidence Interval= 23.68-26.88) and 226(8.0%) (95% Confidence Interval=6.98-8.98) respectively. Rh positive was the dominant Rhesus blood group, 2758(97.4%) (95% Confidence Interval=96.73-97.94). Blood group O was dominant in Brahmin, Bishwakarma, Gurung, Pariyar, Tamang, Terai Brahmin and Limbu.

Conclusions: The frequency distribution pattern of ABO blood group was observed as blood group O>A>B>AB. Variation in the blood group distribution was observed in different ethnic groups.

Clinical characteristics and outcome of tibial pilon fractures treated with open reduction and plating in a tertiary medical college

2023-12-14T06:35:14+00:00

Introduction: Tibial pilon fracture possess a challenge to achieve optimum outcome because of soft tissue related complications and intra-articular nature of the fracture. Surgical treatments and outcomes vary in literature. The objective of this study was to assess the functional and radiological outcome of tibial pilon fractures treated with open reduction and internal fixation with plate and screws.

Methods: This was a descriptive study of retrospective data of displaced tibial pilon fractures treated with open reduction and internal fixation with plate and screws. Functional outcome was assessed by American Orthopaedic Foot and Ankle Society (AOFAS) score and fracture union with plain radiography.

Results: There were total of 20 cases of tibial pilon fractures with mean age of 41.4 years (SD±14.36). The mean AOFAS score was 81.60 (range 42-100) at mean follow up of 18.2 months (range 9-48). Good to excellent results was found in 12(60%) and fair results in 6(30%) cases. All the fractures united at mean of 5.8 months (range 5-7). Partial wound dehiscence was seen in 1(5%) case and marginal skin necrosis occurred in 3(15%) of the cases.

Conclusions: Current study showed favorable radiological and functional outcome in most of the tibial pilon fractures treated with open reduction and internal fixation with plate and screws with acceptable rate of minor wound related complications

Evaluation of the relationship between the interpupillary distance and mesiodistal width of maxillary anterior teeth in Nepalese population

2023-10-19T05:58:57+00:00

Introduction: For pleasing aesthetic appearance, the maxillary anterior teeth must be in proportion to facial morphology. Among the different facial measurements used to determine mesiodistal width of maxillary anterior teeth, the interpupillary distance remains constant irrespective of age changes. The objective of this study was to determine the relationship between the inter-pupillary width and mesiodistal width of maxillary anterior teeth.

Methods: This was a hospital-based cross sectional study conducted at outpatient department of College of Dental Surgery, Gandaki Medical College, Pokhara, Nepal. The study comprised of 199 participants of age group 18 to 35 years. The inter-pupillary distance and mesiodistal width from maxillary right canine to left canine (R3L3) were measured with a digital vernier caliper (Aero-space company, India) with accuracy of 0.01mm. Independent t-test was used to compare inter-pupillary distance and R3L3 between males and females while Pearson correlation was used to see the inter-relationship between these two parameters. Regression analysis was used to predict the mesiodistal width of right central incisor and R3L3.

Results: The overall IPD was 66.09 + 4.00 mm and R3L3 was 54.27 ± 4.47 mm. There were no significant differences in IPD and R3L3 in males and females. The IPD and R3L3 showed moderate positive correlation, r=0.47, p-value <0.001.Prediction equation was calculated to predict the R3L3 and mesiodistal width of right central incisors.

Conclusions: There was a positive correlation between inter-pupillary distance and mesiodistal width of maxillary six anterior teeth. Prediction equation will be useful to determine the mesiodistal width of the maxillary six anterior teeth based on interpupillary distance.

Side effects of AZD 1222 COVISHIELD vaccine among front-line health care workers in a tertiary care hospital: A descriptive cross-sectional study

2023-12-14T08:18:13+00:00

Introduction: Coronavirus disease vaccination has been accepted as a global health measure to prevent severity,transmission and mortality. Vaccine frequently cause adverse effects which is supposed to be due to protective immune response induced by the vaccine. The study aimed to find out the prevalence of side effects of first dose of AZD 1222 COVISHIELD vaccine among front line health care workers receiving vaccination in a tertiary care hospital.

Methods: This was a descriptive cross-sectional study among front line health workers who received the first dose of COVISHIELD vaccine. The study was conducted from February 2021 to March 2021 in a tertiary care hospital after receiving ethical approval from the Institutional Review Committee. Convenience sampling was used for data collection and data was analyzed using SPSS version 17 was used for analysis. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.

Results: Among 629 participants, 344(54.7%) participants reported one or other side effects following vaccination. The major side effects reported were fever 152(19.6%), myalgia 144(22.9%), pain at injection site 123(19.6%), headache 75(11.9%) and in one reactivation of Herpes Zoster.

Conclusions: After the first dose of COVISHIELD vaccine, mild symptoms were seen which resolved within few days. Some cases of reactivation of Herpes Zoster was found. The adverse effects were seen more in patients who had history of COVID-19 infection.

Prescription pattern of antibiotics in urinary tract infection based on antimicrobial susceptibility test at a tertiary care hospital

2023-12-14T08:52:00+00:00

Introduction: Urinary tract infection is a common bacterial infection associated with significant morbidity, mortality, and financial burden. This study aimed to identify the causative bacteria, assess their antimicrobial susceptibility patterns and evaluate empirical and definitive antibiotic therapy for urinary tract infection.

Methods: A hospital-based crosssectional study was conducted at the outpatient medicine department at a teaching hospital in Nepal from February 15 to July 14, 2022. Two hundred participants with positive urine cultures and antimicrobial susceptibility testing were included. The microorganism causing urinary tract infection and prescription pattern of antibiotics pre-and post-AST report were analyzed.

Results: The majority of isolated pathogens were gram-negative bacteria (73%), with Escherichia coli being the most common (53.5%), followed by Staphylococcus aureus among gram-positive bacteria (14.5%). Female patients had a higher incidence of urinary tract infection (59.5%) than males (40.5%). The age group above 60 years had the highest occurrence (34%). Antibiotic susceptibility testing revealed that Escherechia coli exhibited higher sensitivity to nitrofurantoin, amikacin, and meropenem, while resistance was observed against ampicillin, cefixime, and norfloxacin. Empirical antibiotics were commonly prescribed, with levofloxacin and ceftriaxone being the most frequent choices. After antibiotic susceptibility testing, nitrofurantoin and levofloxacin were frequently prescribed.

Conclusions: This study provides valuable insights into the etiology of urinary tract infection and antibiotic susceptibility patterns, aiding in selecting appropriate antimicrobial therapy based on local resistance patterns.

Burn first aid knowledge, attitude, and practice among medical interns of a tertiary care center: A descriptive cross-sectional study

2023-11-01T09:11:18+00:00

Introduction: Burn injuries are a significant public health concern with immediate and long-term consequences. This study assessed the knowledge, attitude, and practice of burn first aid among medical interns in a tertiary care center.

Methods: A descriptive cross-sectional study was conducted among medical interns at a tertiary care center. A structured questionnaire was used to collect data on the burn first aid knowledge, attitude, and practical skills of medical interns. The data were analyzed using appropriate statistical methods.

Results: The study involved 89 medical interns aged between 23 and 29 years, with 60.7% male participants. Of them, 51(57.3%) reported no prior exposure to burn and 17(19.1%) received formal training in burn first-aid priorly. The study found that 85 participants had good knowledge (95.5%), with only 4.5% having poor knowledge. Attitude assessment revealed 66(74.16%) participants had unfavorable attitudes, while 25.84% had a favorable attitude towards burn first aid. All participants had a good level of practice.

Conclusions: The study emphasizes the need for targeted interventions to enhance burn first aid KAP among medical interns in tertiary care centers, including structured training programs, continuing medical education, positive attitudes, and hands-on practical skills training.

Status of glycemic control and lipid profile in type 2 diabetes mellitus: A descriptive cross-sectional study

2023-07-05T16:17:38+00:00

Introduction: Dyslipidemia in diabetes mellitus is commonly seen in the form of high total cholesterol (TC), high lowdensity lipoprotein (LDL), high triglyceride (TG) and low high-density lipoprotein (HDL) levels. This study was done to study the association of glycemic control with lipid profile in Type 2 Diabetes Mellitus (T2DM) patients.

Methods:This was a cross sectional, observational study conducted from December 2018 to June 2020 at Universal College of Medical Sciences and Teaching Hospital, Bhairahawa. It involved 125 patients of type 2 diabetes mellitus (68 males and 57 females), who visited in outpatient department of Internal Medicine. Laboratory tests [(Fasting Blood Sugar(FBS), Post Prandial Blood Sugar (PPBS), Glycosylated Hemoglobin (HbA1c), Renal Function Test (RFT) and Fasting Lipid Profile] were noted. The data was analyzed with SPSS Version 25. Descriptive statistics like frequency, percentage,
mean and standard deviation (SD) were calculated. Independent t-test was used to measure the association between glycated hemoglobin with blood glucose level and glycated hemoglobin with lipid profile.

Results: The study patients were categorized into two groups on the basis of HbA1C level [(good glycemic control ≤7 (n=33) and poor glycemic control >7 (n=92)]. In good glycemic control the mean TC was 143.30, LDL 71.88, HDL 43.70, VLDL 29.55, TG 134.39 mg/dl while in poor glycemic control the mean TC was 182.47, LDL 114.85, HDL 32.03. VLDL 36.61, TG 179.33 mg/dl with p-value <0.05.

Conclusions: There was significant positive association of HbA1c with TC, LDL, VLDL, TG and significant negative association with HDL.

Evaluation of renal arteries in hypertensive patients by multi-detector computed tomography

2023-10-17T08:19:02+00:00

Introduction: Among various causes of hypertension, only 1 to 2% is renovascular hypertension which may be characterized by the various reasons in renal vascular supply. Multi-detector computed tomography is used to know about the details of the vascular structures in patients. This study aims to evaluate the renal arteries in hypertensive patients.

Methods: A prospective observational study was conducted among 93 hypertensive patients. Contrastenhanced computed tomography of the abdomen and pelvis was conducted, and measurements were obtained from the axial section of the maximum intensity projection image. Data were analyzed using SPSS version 23.0. Independent t-test and Pearson’s Correlation were used. The level of statistical significance was set at p<0.05.

Results: The study found mean lengths for the right and left main renal arteries to be 40.33±10.26 mm and 32.36±9.55 mm, and diameters were 4.31±0.86 mm and 4.16±0.81 mm. No significant sex-based differences were observed. However, a significant age-related difference was noted in the length (p=0.012) and diameter (p=0.036) of the right main artery within the 20 to 29 and 80 to 89 years age groups. Weak correlations were observed between left renal artery length and age (r=0.221, p=0.33) and mean right renal artery diameter and age (r=-0.218, p=0.036). Prevalence of accessory renal arteries and early branches was 19.35% and 16.10% respectively.

Conclusions: This study found that there were no statistically significant differences in renal arteries dimensions of hypertensive patients with different age groups and genders. Although the proportion of early renal artery branching and accessory arteries are found to be similar to previous studies there may be other associated factors for all hypertensive patients who don’t have early renal branches or accessory arteries.

Assessing the quality of multiple-choice questions in allied health science summative exams: A retrospective analysis

2023-06-19T10:20:06+00:00

Introduction: Multiple-choice questions are feasible, reproducible and cost-effective; hence, they are widely embraced in health professions education. The quality of multiple-choice questions is monitored statistically by item analysis. Item analysis confirms whether the questions measure the intended learning outcomes, ensuring fair and equitable assessments. To promote quality assessment, we analyzed the quality standards of multiple-choice questions in a summative examination using item analysis.

Methods: The multiple choice questions answered by 38 students in the first semester of the allied health science programme of Madan Bhandari Academy of Health Sciences in Bagmati Province were collected, examined, and analyzed. The data gathered were subjected to the performance of each multiple choice question by analysis of difficulty index, discrimination index, and distractor effectiveness.

Results: Items of most courses were acceptable (30% to 70%) as per the difficulty index with only three courses having (>70%) easy items. Poor discriminatory index <0.20=poor) was noted in seven courses, particularly discipline-specific courses. A significant proportion of excellent distractors were identified in two courses: 50% each in Medical Terminology & Musculoskeletal and Fundamentals of Pharmacy. Most of the courses had more than 50% of functional distractors.

Conclusions: The multiple-choice questions in most of the courses had poor discrimination index. These outcomes highlight the need for careful formulation of multiple-choice questions for authentic assessment.