Validity of very short answer versus single best answer questions for undergraduate assessment

Background Single Best Answer (SBA) questions are widely used in undergraduate and postgraduate medical examinations. Selection of the correct answer in SBA questions may be subject to cueing and therefore might not test the student’s knowledge. In contrast to this artificial construct, doctors are ultimately required to perform in a real-life setting that does not offer a list of choices. This professional competence can be tested using Short Answer Questions (SAQs), where the student writes the correct answer without prompting from the question. However, SAQs cannot easily be machine marked and are therefore not feasible as an instrument for testing a representative sample of the curriculum for a large number of candidates. We hypothesised that a novel assessment instrument consisting of very short answer (VSA) questions is a superior test of knowledge than assessment by SBA. Methods We conducted a prospective pilot study on one cohort of 266 medical students sitting a formative examination. All students were assessed by both a novel assessment instrument consisting of VSAs and by SBA questions. Both instruments tested the same knowledge base. Using the filter function of Microsoft Excel, the range of answers provided for each VSA question was reviewed and correct answers accepted in less than two minutes. Examination results were compared between the two methods of assessment. Results Students scored more highly in all fifteen SBA questions than in the VSA question format, despite both examinations requiring the same knowledge base. Conclusions Valid assessment of undergraduate and postgraduate knowledge can be improved by the use of VSA questions. Such an approach will test nascent physician ability rather than ability to pass exams

Sheehan's like syndrome in a man

An 84-year-old physician self-diagnosed that he had a pituitary tumour when he was found to have a bilateral upper quadrantanopia on routine eye testing. Magnetic resonance imaging (MRI) confirmed a large non-functioning pituitary macroadenoma associated with chiasmal compression. Investigation showed partial hypopituitarism with disconnection hyperprolactinaemia [prolactin 1095 mU/L (60–300)]. He was treated with hormonal replacement consisting of thyroxin 100 µg and prednisolone 3 mg and was offered transphenoidal hypophysectomy, but chose a conservative approach. Two years later, his visual fields worsened (Figure 1A) corresponding to an increase in macrodenoma size. Subsequently, he fell and fractured his left shoulder, which became infected, requiring surgery. Immediately after the shoulder surgery, he became hypotensive and vomited several times, and his visual fields became restricted. MRI showed pituitary infarction (Figure 1B), and he did not require surgical intervention. A few weeks later, he noticed dramatic improvement in his vision. His prolactin level dropped from a peak level of 1095 to 48 mU/L (60–300), suggesting lactotroph infarction. Repeated pituitary MRI showed dramatic reduction in the height of the pituitary macroadenoma consistent with the improvement in his visual fields (Figure 1C)

A Study to Assess the Effectiveness of Ice Cube Application on Oral Mucositis, Associated with Injection 5 – Flurouracil among Cancer patients in Amala Cancer Centre and Research Institute at Trichur District.

Cells are the building blocks of our body, the dreaded disease cancer begins from these cells. Cancer is not just one disease but many diseases. There are more than 100 different types of cancer. As cancer is one of the leading cause of mortality and morbidity globally leads to long hospital stays, higher cost of treatments with various side effects causing huge burden to the family and reduces the quality of life. Among side effects of chemotherapy oral mucositis is an important and big burden to the patient. Hence the researcher planned to conduct a research study to asses the effectiveness of ice cube application on oral mucositis associated with injection 5 Flurouracil among cancer patients. OBJECTIVES: 1. To assess the severity of oral mucositis associated with injection 5-flurouracil among cancer patients in experimental and control group. 2. To evaluate the effectiveness of ice cube application on oral mucositis associated with injection 5-Flurouracil in experimental and control group. 3. To determine the association between the post level severity of oral mucositis associated with injection 5-Flurouracil among cancer patients with their selected demographic variables in experimental and control group. The study was conducted in Amala cancer center and research institute, Thrissur. In this study Quasi experimental; research design was adopted with non randamaised purposive sampling technique. The sample size was 60. The data collection tool consists of demographic variables and oral mucositis assessment scale and visual analogue pain scale. The intervention is done with oral ice cubes 5 minutes prior to, 5 minutes during and 20 minutes after chemotherapy. CONCLUSION: The main conclusion drawn from the study was the practice of oral ice cube application is helpful in reducing the severity of oral mucositis. This result can potentially employed as one of the complementary therapy in the reduction of severity of oral mucositis associated with chemotherapy with inj-5 flurouracil. After the application of ice cubes orally, the subjects found themselves comfort and expressed satisfaction

Silymarin Protects Epidermal Keratinocytes from Ultraviolet Radiation-Induced Apoptosis and DNA Damage by Nucleotide Excision Repair Mechanism

Solar ultraviolet (UV) radiation is a well recognized epidemiologic risk factor for melanoma and non-melanoma skin cancers. This observation has been linked to the accumulation of UVB radiation-induced DNA lesions in cells, and that finally lead to the development of skin cancers. Earlier, we have shown that topical treatment of skin with silymarin, a plant flavanoid from milk thistle (Silybum marianum), inhibits photocarcinogenesis in mice; however it is less understood whether chemopreventive effect of silymarin is mediated through the repair of DNA lesions in skin cells and that protect the cells from apoptosis. Here, we show that treatment of normal human epidermal keratinocytes (NHEK) with silymarin blocks UVB-induced apoptosis of NHEK in vitro. Silymarin reduces the amount of UVB radiation-induced DNA damage as demonstrated by reduced amounts of cyclobutane pyrimidine dimers (CPDs) and as measured by comet assay, and that ultimately may lead to reduced apoptosis of NHEK. The reduction of UV radiation-induced DNA damage by silymarin appears to be related with induction of nucleotide excision repair (NER) genes, because UV radiation-induced apoptosis was not blocked by silymarin in NER-deficient human fibroblasts. Cytostaining and dot-blot analysis revealed that silymarin repaired UV-induced CPDs in NER-proficient fibroblasts from a healthy individual but did not repair UV-induced CPD-positive cells in NER-deficient fibroblasts from patients suffering from xeroderma pigmentosum complementation-A disease. Similarly, immunohistochemical analysis revealed that silymarin did not reduce the number of UVB-induced sunburn/apoptotic cells in the skin of NER-deficient mice, but reduced the number of sunburn cells in their wild-type counterparts. Together, these results suggest that silymarin exert the capacity to reduce UV radiation-induced DNA damage and, thus, prevent the harmful effects of UV radiation on the genomic stability of epidermal cells

Inadvertent treatment of hypoadrenalism with prednisolone in pemphigus: a case report

Pituitary and adrenal insufficiency must not be overlooked when weaning patients down from high‐dose steroids. Prednisolone can be used as glucocorticoid replacement therapy, with most patients needing 3‐4 mg once daily

Utility of cannulated prolactin to exclude stress hyperprolactinemia in patients with persistent mild hyperprolactinemia

Background: Stress-induced hyperprolactinemia can be difficult to differentiate from true hyperprolactinema and may result in patients having unnecessary investigations and imaging. We report the results of cannulated prolactin tests with serial prolactin measurements from an indwelling catheter to differentiate true from stress-induced hyperprolactinemia in patients with persistently mildly elevated prolactin levels in both referral and repeat samples. Methods: Data were collected for 42 patients who had a cannulated prolactin test between January 2017 and May 2018. After cannula insertion, prolactin was measured at 0, 60, and 120 minutes. Normalization is defined as a decline in prolactin to gender-defined normal ranges. Results: The mean age was 33.8 years (SD ± 9.9), and 37 (88%) were female. Menstrual irregularities were the main presenting symptom in 28.57% of the patients. Prolactin normalized in 12 (28.6%) patients of whom cannulated prolactin test was done. Repeat random prolactin levels were significantly higher in patients whose prolactin did not normalize during the cannulated prolactin test. MRI of the pituitary gland showed an abnormality in 23 out of 28 (82%) patients who did not normalize prolactin, a microadenoma in the majority of patients (18 patients). Conclusion: The cannulated prolactin test was useful in excluding true hyperprolactinemia in 28.6% of patients with previously confirmed mildly elevated random prolactin on two occasions, thus avoiding over-diagnosis and unnecessary imaging

Optimising prednisolone or prednisone replacement in adrenal insufficiency

CONTEXT: Patients with adrenal insufficiency (AI) have higher mortality than the general population, possibly because of excess glucocorticoid exposure at inappropriate times. The cortisol circadian rhythm is difficult to mimic with twice or thrice-daily hydrocortisone. Prednisolone is a once-daily alternative which may improve patient compliance and convenience. OBJECTIVES: Prednisolone day curves can be used to accurately down-titrate patients to the minimum effective dose. We aimed to review prednisolone day curves and determine therapeutic ranges at different timepoints after administration. METHODS: Between August 2013 and May 2021, 108 prednisolone day curves from 76 individuals receiving prednisolone replacement were analysed. Prednisolone concentrations were determined by ultra-high performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). Spearman's correlation coefficient was used to determine the relationship between 2-, 4- and 6-hour prednisolone levels compared to the validated standard 8-hour prednisolone level (15-25 μg/L). RESULTS: The median dose was 4mg prednisolone once daily. There was strong correlation between the 4-hour and 8-hour (R=0.8829, p ≤0.0001), and 6-hour and 8-hour prednisolone levels (R=0.9530, p ≤ 0.0001). Target ranges for prednisolone were 37-62 μg/L at 4-hours, 24-39 μg/L at 6-hours and 15-25 μg/L at 8-hours. Prednisolone doses were successfully reduced in 21 individuals and of these, three were reduced to 2mg once daily. All patients were well upon follow-up. CONCLUSION: This is the largest evaluation of oral prednisolone pharmacokinetics in humans. Low dose prednisolone of 2-4mg is safe and effective in most patients with AI. Doses can be titrated with either 4-hour, 6-hour, or 8-hour single timepoint drug levels

Very short answer questions: a novel approach to summative assessments in pathology

Background A solid understanding of the science underpinning treatment is essential for all doctors. Pathology teaching and assessment are fundamental components of the undergraduate medicine curriculum. Assessment drives learning and the choice of assessments influences students’ learning behaviours. The use of multiple-choice questions is common but is associated with significant cueing and may promote ‘rote learning’. Essay-type questions and Objective Structured Clinical Examinations (OSCEs) are resource-intensive in terms of delivery and marking, and do not allow adequate sampling of the curriculum. To address these limitations, we used a novel online tool to administer Very Short Answer questions (VSAQs) and evaluated the utility of the VSAQs in an undergraduate summative pathology assessment. Methods A group of 285 medical students took the summative assessment, comprising 50 VSAQs, 50 single best answer questions (SBAQs), and 75 extended matching questions (EMQs). The VSAQs were machine-marked against pre-approved responses, and subsequently reviewed by a panel of pathologists, with the software remembering all new marking judgements. Results The total time taken to mark all 50 VSAQs for all 285 students was 5 hours, compared to 70 hours required to manually mark an equivalent number of questions in a paper-based pathology exam. The median percentage score for the VSA test (72%) was significantly lower than that of the SBAQs (80%) and EMQs (84%), p <0.0001. VSAQs had a higher Cronbach alpha (0.86) than SBAQs (0.76), and EMQs (0.77). VSAQs, SBAQs and EMQs had a mean point-biserial of 0.35, 0.30 and 0.28, respectively. Conclusions VSAQs are an acceptable, reliable and discriminatory method for assessing pathology, and may enhance students’ understanding of how pathology supports clinical decision-making and clinical care by changing learning behaviour

Understanding concepts of generalism and specialism amongst medical students at a research-intensive London Medical School

Background Many prominent UK medical organisations have identified a need for more generalist clinicians to address the complex requirements of an aging society. We sought to clarify attitudes towards “Specialists” and “Generalists” amongst medical students and junior doctors at Imperial College School of Medicine. Methods A survey exploring medical students’ beliefs was followed up by qualitative analysis of focus groups of medical students and Imperial-graduate foundation year doctors. Results First year medical students associated specialists with academia and higher income, and generalists with ease of training and job availability. Senior (Years 5/6) medical students associated specialists even more firmly with broader influence and academic work, whilst generalists were assigned lower prestige but the same workload as specialists. The medical student focus group discussed concepts of Generalism pertaining only to Primary Care. In contrast, the foundation year doctor focus group revealed that Generalism was now seen to include some hospital care, and the perception that generalists sat lower in a knowledge hierarchy had been challenged. Conclusion Perceptions that Generalism is associated with lower prestige in the medical profession are already present at the very start of medical school and seem to be reinforced during undergraduate training. In early postgraduate clinical practice, the perceived knowledge and prestige hierarchy lessens. These findings can help inform curriculum redesign and the promotion of Generalism as a rewarding career aspiration

HISTORIC REVIEW ON MODERN HERBAL NANOGEL FORMULATION AND DELIVERY METHODS

Chemistry deals with herbal constituents are often coined as phytochemistry. Herbal constituents have profound improvements in drug discovery for several existing diseases. Many of these constituents are restricted from pharmaceutical discoveries due to two important reasons: pharmacodynamics and pharmacokinetics. There are many new technological strategies and comparisons have been studied to improve the herbal discoveries in the pharmaceutical market. This review paper will highlight historical evidence of nanogels which is the most important strategy applied to several herbal medicines with high patience compliance, delivery rate, and efficiency. Nanogels are nanoparticles combined with cross-linked polymer networks with desirable features to carry hydrophilic or hydrophobic drugs in a more stable condition. Nanogels are highly preferred substances for herbal medicine in terms of stability and rapid response to the external stimuli factors. Nanogel can facilitate the herbal products with higher cellular penetration than existing and hence, it proves to be the new dimension for both oral and transdermal drug delivery for several unmet diseases like cancer, diabetes, and chronic disorders. By the way, including the recent technological constituents to herbal drugs, it can possess high bioavailability, low toxicity and enhance the sustained release