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

The Vanishing Adrenal Glands: A transient regression of adrenal lymphoma after a single dose of 1 mg dexamethasone

Objective: Dexamethasone is a known treatment for lymphoma, but it’s potency and rapidity of its effect has not been recognised. Our objective is to present a case of bilateral adrenal lymphoma, which significantly reduced in size after a single dose of dexamethasone. Methods: Clinical course and investigations including Adrenocorticotropic hormone (ACTH), cortisol, short synacthen test, computed tomography (CT) and adrenal biopsy are presented. Results: A 52-year-old man had a fall and was incidentally found to have bilateral adrenal masses (6 cm on left and 5 cm on right) on CT. His adrenal function tests included plasma metanephrines (normetanephrine 830 pmol/L (0-1180); metanephrine <100 pmol/L (0-510); 3-methoxytyramine <100 pmol/L (0-180), aldosterone 270 pmol/L( 90-700) and random cortisol 230 nmol/L (160-550). Overnight dexamethasone suppression test (ONDST), with 1 mg of dexamethasone, showed cortisol of <28 nmol/L (0-50).. A repeat CT, eight days following ONDST, showed adrenal masses of 4.5 cm and 3.5 cm on left and right respectively. He had a follow-up CT three months later, which showed adrenal lesions measuring 8 cm (left) and 9 cm (right). He subsequently presented with fatigue and dizziness. Morning cortisol of 201 nmol/L (160-550) with ACTH of 216 ng/L (10-30) indicated primary adrenal insufficiency. Mineralocorticoid and glucocorticoid replacement was commenced. Adrenal biopsy showed abnormal enlarged B-cells consistent with a diagnosis of diffuse large B-cell lymphoma. Conclusion: A diagnosis of lymphoma should be considered when adrenal lesions shrink, following even a single low dose of dexamethasone administered as a part of a diagnostic test

COVID-19 catalysing assessment transformation: A case of the online open book examination

Under COVID-19 lockdown conditions, the imposition of social distancing and restricted mobility, disrupted the traditional way of assessment in higher education. The closed book examination, conducted under proctored conditions, had to be substituted for the online open book examination (OOBE), posing challenges to both conventional and Open Distance Learning (ODL) institutions. The OOBE became a new experience to lecturers and students. Considering COVID-19 as a potential catalyst for educational transformation, the experiences gained in this format of assessment presents a valuable frame of reference for future learning. The aim is to extract lessons from this innovative learning experience to inform future assessment practices. The study is set in the context of a B.Ed. (Hons) compulsory module, offered at an Open Distance Learning (ODL) institution in South Africa. It is guided by the research question: “what were students’ experiences of their first online, open-book final examination and what are the implications for policy, practice and research?” This is a qualitative study, using as data, student emails on their experiences of the OOBE. The results show that the OOBE is an innovative assessment practice in higher education, in need of deeper understanding and (re)training. We conclude that the OOBE offers transformational opportunities in higher education assessment practices, to replace the traditional closed-book examination. We make recommendations to assist lecturers and students in approaching the OOBE in future

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

Study about the Effectiveness of Serial Stretching in Post Burn Elbow and Knee Flexion Contracture

INTRODUCTION: Human beings are unique creation of god, as they have an upper limb which is distinctly different from the lower limb. Evolution of human race has allowed us to have a complex amount of movements in the limbs. The hands are the eyes of the blind, the tongue of a dumb and the aid of the deaf to communicate. The upper limbs have to extend bend and hold. The lower limbs have to be straight, strong and move. Burn injury is a systemic illness and its severity is usually assessed, if not by patient’s survival, by the consequence of the burn injury i.e. scar hypertrophy, contracture and structural deformities due to loss of body components. Body deformity is closely related to the magnitude of the injuries i.e. extend and depth of injury, mode of intervention, physiotherapy and follow-up care. Formation of Scar tissue at the wound site and contraction of the scar tissue are the normal consequence of an injury. Although the exact mechanism accounting for the sequential change in wound healing and scar formation remain incompletely understood, wounds with infection and or allowed to heal spontaneously tend to form scar that are thickened and contracted circumferentially, mediated by various fibrogenic cytokines especially TGF β. The upper limbs which tried to rescue a burning victim needs the supportive care. Proper and timely care of the scar prevent, the formation of the deformity. This study is an effect to find out the effectiveness of stretching the scar both in the upper and lower limb at the level of elbow and knee. Though the act of stretching and splinting is tender, the results are dynamic in outcome. AIM OF THE STUDY: To study about the effectiveness of serial stretching in post burn elbow and knee flexion contracture. Objective: 1. To study about the amenability of the post burn scar to stretching, 2. Average time needed for full extension, 3. Relationship between age of scar and time needed for full extension, 4. Complications of Stretching, 5. Effectiveness as an adjunct procedure in a patient with multiple contracture, while the more important areas are getting surgical treatment. MATERIALS AND METHOD: From the patients admitted, or attending the out patient department, detailed history about the following are taken, 1. Information about the nature of the injury, 2. Date of the injury, 3. Treatment history of the wound, 4. Previously done Surgical procedure, 5. Whether splinting was done while wound was healing and after wound has healed and, 6. Follow up care. Local examination of the joint include assessing the, 1. Extent of the scar, 2. Maturity of the scar, 3. Presence of blister, raw area, ulceration or scar breakdown, if present is noted. 4. Degree of Contracture, 5. Active and passive range of joint mobility, 6. Condition of the proximal and distal joints and, 7. Associated other deformity. RESULTS: Total of 23 cases were selected for the study during the period, November 2006 – March 2009. All the 23 patients were corrected by serial stretching: 1. Average time at which the patients report to the hospital, after developing contracture was 4.31 months, and it ranges from 20 days to 10 months, 2. Flame burn was the commonest cause of burns, 3. Female gender was commonly affected and the age group was 16 - 25 years in Elbow contracture and 5 - 15 years in knee contracture, 4. Elbow contracture being the commonest one, account for 82.6% of the total contracture, 5. Degree of contracture commonly reported was, more than 60° for the elbow joint and 30-60° for the knee joint, 6. All patients had full correction of flexion deformity, 7. Average time taken for full correction of flexion deformity was 37.94 days for elbow contracture and 47.25 days for knee contracture. 8. 13 patients amounting to, 68.4% of the total elbow contracture patients and all the patients with knee contracture had associated deformity. 10 patients with elbow contracture and 2 patients with knee contracture had simultaneous correction of the associated deformity. 9. 5 patients with elbow contracture and 2 patients with knee contracture had developed blister. One patient with elbow contracture and one patient with knee contracture had scar break down. All of them settled with conservative management, 10. 6 patients with elbow contracture and 2 patient with knee contracture had discontinued the splint and had developed recurrence of contracture after correction by serial stretching, which was again corrected with serial stretching. CONCLUSION: Serial stretching is a good modality of treatment for correcting post burns flexion contracture of the knee and elbow. It can be used as an out-patient procedure without anesthesia and can be applied to all age group. Slow progressive and prolonged stretching helps in full correction without serious complication. Patients and their parents need good motivation, as prolonged follow up and after care, in the form of pressure garment, splint, scar massage and exercise are necessary. Cotton padding with elastocreep bandage helps in reducing blister formation which is very common with compression stocking. Blister formation is the commonest cause for discontinuation of pressure garment and splint. Serial stretching being another tool in the armamentarium of burns surgeon helps in the simultaneous correction of multiple deformities or in patients with high chance of hypertrophic scarring or when surgical correction is not possible. Early splinting, proper positioning and mobilization helps to prevent development of contracture. Splinting and pressure therapy has to be continued till the scar fully matures, to prevent scar hypertrophy and recurrence of contracture

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

Late night salivary cortisol and cortisone should be the initial screening test for Cushing’s syndrome

Endogenous Cushing’s syndrome (CS) poses considerable diagnostic challenges. Although late night salivary cortisol (LNSC) is recommended as a first line screening investigation, it remains the least widely used test in many countries. The combined measurement of LNSC and late-night salivary cortisone (LNS cortisone) has shown to further improve diagnostic accuracy1. We present a retrospective study in a tertiary referral centre comparing LNSC, LNS cortisone, overnight dexamethasone suppression test, low dose dexamethasone suppression test and 24-hour urinary free cortisol results of patients investigated for CS. Patients were categorised into those who had CS (21 patients) and those who did not (33 patients).LNSC had a sensitivity of 95% and a specificity of 91%. LNS cortisone had a specificity of 100% and a sensitivity of 86%. With an optimal cut-off for LNS cortisone of >14.5 nmol/l the sensitivity was 95.2%, and the specificity was 100% with an area under the curve of 0.997, for diagnosing CS. Saliva collection is non-invasive and can be carried out at home.We therefore advocate simultaneous measurement of LNSC and LNS cortisone as the first-line screening test to evaluate patients with suspected CS

Improving the interpretation of afternoon cortisol levels and SSTs to prevent misdiagnosis of Adrenal Insufficiency

Introduction Adrenal Insufficiency (AI), especially iatrogenic-AI, is a treatable cause of mortality. The difficulty in obtaining 9am cortisol levels means samples are taken at suboptimal times, including a substantial proportion in the afternoon. Low afternoon cortisol levels often provoke short Synacthen Tests (SSTs). It is important that this does not lead to patients misdiagnosed with AI, exposing them to the excess mortality and morbidity of inappropriate steroid replacement therapy. Methods This retrospective study collected 60,178 cortisol results. Medical records, including subsequent SSTs of initial cortisol results measured after midday were reviewed. Results ROC analysis (AUC- 0.89) on 6531 suitable cortisol values showed that a limit of 95% on the Abbott analyser platform. Conclusion An afternoon cortisol >234nmol/L excludes AI on Abbott analyser platforms. In patients who have an afternoon cortisol <234nmol/L, including both a 30-minute and a 60-minute SST cortisol values prevents unnecessary glucocorticoid replacement therapy in 22.3% of individuals in this study. The Abbott analyser SST cortisol cut-offs used to define AI should be 366.5nmol/L and 418.5nmol/L at 30- and 60-minutes respectively. All patients remained well subsequently with at least one year longitudinal follow up