Preparing faculty for problem-based learning curriculum at Patan Academy of Health Sciences, Nepal

Introduction: Patan Academy of Health Sciences (PAHS) in Nepal has adopted problem-based learning (PBL) as principal pedagogy to foster attributes predefined for its medical graduates. This study evaluates reaction of participants in PBL tutor-training program focused on PBL process and its assessment. Methods: An orientation program was organized separately for 24 faculty members and 45 higher secondary science majoring students prior to conduction of real-time PBL tutorial sessions. Faculty’s reaction as PBL tutors was collected before and after the orientation program using a 13-item self-administered questionnaire. Internal consistency reliability of the questionnaire items and outcome of the training program were assessed using Cronbach’s alpha, coefficient of variation, Shapiro-Wilk test, paired t-test and adjusted effect size for dependent samples. Results: The pre-test internal consistency reliability was high (0.89) whereas it was acceptable (0.69) for post-test. The average score increased from 26.50 to 34.55 and standard deviation decreased from 5.39 to 2.70 between pre- and post-test. Difference between post- and pre-tests total scores followed normal distribution and suitable parametric test (paired t-test) revealed the difference was highly significant (p< 0.0001). The adjusted effect size was high (1.65) for small dependent samples. Conclusions: The faculty training for PBL and assessment was helpful  in implementing PBL pedagogy at PAHS.  Keywords: Nepal, PAHS, Problem based learning, Process assessment, Tutor training program Â

Validating a problem-based learning process assessment tool in a Nepalese medical school

Introductions: The newly established Patan Academy of Health Sciences (PAHS) has incorporated the measurement of non-cognitive skills and behaviors into the summative assessment in the setting of problem based learning (PBL). This study was conducted to validate a PBL process assessment tool for PAHS.Methods: A list of 72 items of student behaviors observable in PBL tutorials was compiled from literature review. They were categorized under ten broad dimensions consistent with predefined PAHS Graduate Attributes. A series of PBL project committee meetings and expert inputs refined the list of 72 items to 47 and categorized them under eight dimensions. These 47 items, each with a 4-point rating scale, formed the Tutor Assessment of Student Tool (TAS-Tool). Twenty-four trained faculty members used the TAS-Tool to evaluate the performance of 41 senior high school students in PBL tutorials. Results: The internal-consistency of the TAS-Tool was very high rona’s .. eoal of to inonsistent ites furter increased it to 0.975. Principal components analysis with varimax rotation applied to the remaining 45 items gave seven components and explained 69.47% of the variation between the components. These seven components (% variation) were: Immersed in the Tutorial Process (20.16%); Professional (12.71%); Communicator and Team Leader (11.25%); Critical Thinker (8.77%); Reflector (6.22%); Creative (5.95%), and Sensitive (4.41%).Conclusions: TAS-Tool was found to be reliable and valid instrument deemed applicable in formative PBL process assessment at PAHS starting with the pioneer cohort of medical students. Further validation of TASTool through longitudinal study with PAHS students is required for summative purpose.Keywords: factor analysis, problem based learning, summative assessment, tool validation, Nepa

Critical care bed capacity in Asian countries and regions

Objective: To assess the number of adult critical care beds in Asian countries and regions in relation to population size. Design: Cross-sectional observational study. Setting: Twenty-three Asian countries and regions, covering 92.1% of the continent’s population. Participants: Ten low-income and lower-middle–income economies, five upper-middle–income economies, and eight high-income economies according to the World Bank classification. Interventions: Data closest to 2017 on critical care beds, including ICU and intermediate care unit beds, were obtained through multiple means, including government sources, national critical care societies, colleges, or registries, personal contacts, and extrapolation of data. Measurements and Main Results: Cumulatively, there were 3.6 critical care beds per 100,000 population. The median number of critical care beds per 100,000 population per country and region was significantly lower in low- and lower-middle–income economies (2.3; interquartile range, 1.4–2.7) than in upper-middle–income economies (4.6; interquartile range, 3.5–15.9) and high-income economies (12.3; interquartile range, 8.1–20.8) (p = 0.001), with a large variation even across countries and regions of the same World Bank income classification. This number was independently predicted by the World Bank income classification on multivariable analysis, and significantly correlated with the number of acute hospital beds per 100,000 population (r2 = 0.19; p = 0.047), the universal health coverage service coverage index (r2 = 0.35; p = 0.003), and the Human Development Index (r2 = 0.40; p = 0.001) on univariable analysis. Conclusions: Critical care bed capacity varies widely across Asia and is significantly lower in low- and lower-middle–income than in upper-middle–income and high-income countries and regions

Prognostic evaluation of quick sequential organ failure assessment score in ICU patients with sepsis across different income settings

Background There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions. Methods This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study. Results Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00–1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h. Conclusions qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

Regional Anaesthesia in Clavicle Surgery

In routine practice, regional anaesthesia is less commonly used for clavicular fracture compared to general anaesthesia. We report two cases of clavicle fracture for which operative treatment was done under combined superficial cervical plexus andinterscalene brachial plexus block. Inboththe cases combination of ropivacaine anddexmeditomidine was used forblock. Both the patients exhibited comfort and there was no additional analgesic demand in both the cases.Thuscombination ofinterscalene and superficial cervical plexus block can prove to be useful in patients with clavicle fracture where administration of general anaesthesia and its adverse effects could be avoided. [PubMed

Comparative Study between Tramadol and Dexamethasone as an admixture to Bupivacaine in Supraclaivcular Brachial Plexus Block.

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Managing COVID-19 in resource-limited settings: critical care considerations

The 2019 coronavirus (COVID-19) pandemic has now involved numerous low-to-middle-income countries (LMICs). The healthcare systems in LMICs face serious constraints in capacity and accessibility during normal times. This would be aggravated during an outbreak, leading to worse clinical outcomes. Moreover, 69% of the global population aged 60 and above live in LMICs. These older persons are at increased risk of severe COVID-19 and mortality [1]. LMICs lack time and finances for swift uptake of new technologies (e.g., rapid test kits, vaccines, and antivirals). From a more urgent and pragmatic perspective, we believe creative use of existing resources and repurposing others for human medical care are needed (Table 1). We acknowledge that our suggestions may be perceived as controversial, and we wish to emphasize that maximization of conventional healthcare assets should always be done before turning to unconventional solutions

Critical care bed capacity in Asian countries and regions

Objective: To assess the number of adult critical care beds in Asian countries and regions in relation to population size.Design: Cross-sectional observational study.Setting: Twenty-three Asian countries and regions, covering 92.1% of the continent\u27s population.Participants: Ten low-income and lower-middle-income economies, five upper-middle-income economies, and eight high-income economies according to the World Bank classification.Interventions: Data closest to 2017 on critical care beds, including ICU and intermediate care unit beds, were obtained through multiple means, including government sources, national critical care societies, colleges, or registries, personal contacts, and extrapolation of data.Measurements and main results: Cumulatively, there were 3.6 critical care beds per 100,000 population. The median number of critical care beds per 100,000 population per country and region was significantly lower in low- and lower-middle-income economies (2.3; interquartile range, 1.4-2.7) than in upper-middle-income economies (4.6; interquartile range, 3.5-15.9) and high-income economies (12.3; interquartile range, 8.1-20.8) (p = 0.001), with a large variation even across countries and regions of the same World Bank income classification. This number was independently predicted by the World Bank income classification on multivariable analysis, and significantly correlated with the number of acute hospital beds per 100,000 population (r = 0.19; p = 0.047), the universal health coverage service coverage index (r = 0.35; p = 0.003), and the Human Development Index (r = 0.40; p = 0.001) on univariable analysis.Conclusions: Critical care bed capacity varies widely across Asia and is significantly lower in low- and lower-middle-income than in upper-middle-income and high-income countries and regions

Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study

10.1136/bmj.d3245BMJ-BRITISH MEDICAL JOURNAL342781