Training tutors for implementing problem-based learning at a private medical college of Nepal

Introductions: Problem based learning (PBL)  is an innovative approach of teaching learning methodology in which, instead of traditional lectures, students are divided in small groups and provided with a problem which they try to solve. It has been used in different medical schools, around the world, for over 50 years. In Nepal, the use of PBL methodology is gradually increasing. Methods: Three experts on PBL content and process provided interactive lectures, hands-on exercises and plenary discussion sessions. Effectiveness of the workshop was assessed by validated retro pre questionnaire at the end of the workshop. Paired t-tests were used to test the differences between before and after scores on knowledge, application and opinion on PBL. Effect size was also calculated to determine the size of the difference between before and after the workshop. Results: The PBL training was effective as it increased knowledge, application and opinion on PBL of most of the participants. The workshop benefitted the most to the experienced male basic sciences faculty. However, clinical sciences faculty were skeptical of its application and their opinion of PBL did not change much whereas nursing faculty had some reservation on their opinion about PBL only. Conclusions:  As PBL is implemented during the basic sciences years only, the concerned faculty benefitted the most from the workshop. Further such trainings are advocated to increase the pool of trained tutors for effective implementation of the PBL. Keywords: faculty training, Kathmandu University, Lumbini Medical College, Nepal, PBL problem-based learning, Â

Evaluation of core faculty development workshop: Experience from Patan Academy of Health Sciences, Nepal

Introductions: Faculty development is important to promote the core education principles/philosophies and instil the innovations planned and/or carried out in any educational program. Thus, Patan Academy of Health Sciences (PAHS) has carried out regular faculty development programs for its faculty in order to effectively implement an innovative curriculum, teaching/learning methods and student assessment.  Methods: Effectiveness of the workshop was assessed by validated retro-pre questionnaire at the end of the workshop. Paired t-test was used to test the differences between before and after scores on knowledge and application on various aspects of the program. Effect size was also calculated to determine the size of the difference between before and after the workshop. Results: The core faculty development program was effective as it significantly increased the overall knowledge and application scores among most of the participants. The workshop benefitted the most to the experienced male faculty as the effect size for these groups were very high (Cohen’s d>1.3). Conclusions:  As PBL is implemented during the basic sciences years only, the concerned faculty benefitted the most from the workshop. Further such trainings are advocated to increase the pool of trained tutors for effective implementation of the PBL. Key words: faculty development, innovation, medicine, PAHS Â

Evaluation of web-based self-assessment module administered in a medical school of Nepal

Introductions: Self-assessment enables medical students to self-evaluatetheir knowledge and seek timely assistance for effective learning fromtheir peers and faculties. Self-assessment is an integral part of the studentassessment system of School of Medicine, Patan Academy of HealthSciences.Methods: Multiple Choice Questions (MCQs) and Structured IntegratedShort Answer Questions (SISAQs) links were sent to the personal e-mail ofmedical students at the start of Principle of Human Biology I Block. Theseitems were created and selected from various disciplines as per theircurricular weightage in this block. Students’ scores and feedback wereanalysed once this 11-week long block was over.Results: The MCQ surveys had ideal difficulty levels and acceptablediscrimination indices but they had poor internal consistencies. Thecriterion-referenced cut-scores of MCQs and SISAQ were higher thanthe conventionally used 50% pass-mark in Nepal. Students’ suggested toincrease the MCQs and SISAQ numbers and match them in terms of theirdifficulty levels with the end-block and end-year summative assessments.Item analysis helped to identify the items to be retained, revised anddiscarded for the future use.Conclusions: Web-based self-assessment of knowledge was found to be anextremely useful tool to inculcate self-directed and life-long learning habitsamong medical students.Keywords: self-assessment, MCQ, SISAQ, angoff, borderline regression,standard settin

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

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Monitoring urban beaches with qPCR vs. culture measures of fecal indicator bacteria: Implications for public notification

Abstract Background The United States Environmental Protection Agency has established methods for testing beach water using the rapid quantitative polymerase chain reaction (qPCR) method, as well as “beach action values” so that the results of such testing can be used to make same-day beach management decisions. Despite its numerous advantages over culture-based monitoring approaches, qPCR monitoring has yet to become widely used in the US or elsewhere. Considering qPCR results obtained on a given day as the best available measure of that day’s water quality, we evaluated the frequency of correct vs. incorrect beach management decisions that are driven by culture testing. Methods Beaches in Chicago, USA, were monitored using E. coli culture and enterococci qPCR methods over 894 beach-days in the summers of 2015 and 2016. Agreement in beach management using the two methods, after taking into account agreement due to chance, was summarized using Cohen’s kappa statistic. Results No meaningful agreement (beyond that expected by chance) was observed between beach management actions driven by the two pieces of information available to beach managers on a given day: enterococci qPCR results ofsamples collected that morning and E. coli culture results of samples collected the previous day. The E. coli culture beach action value was exceeded 3.4 times more frequently than the enterococci qPCR beach action value (22.6 vs. 6.6% of beach-days). Conclusions The largest evaluation of qPCR-based beach monitoring to date provides little scientific rationale for continued E. coli culture testing of beach water in our setting. The observation that the E. coli culture beach action value was exceeded three times as frequently as the enterococci qPCR beach action value suggests that, although the beach action values for bacteria using different measurement methods are thought to provide comparable information about health risk, this does not appear to be the case in all settings

COVID-19 vaccine effectiveness and variants in Nepal: study protocol for a test-negative case–control study with SARS-CoV-2 genetic sequencing

Introduction Inactivated, viral vector and mRNA vaccines have been used in the Nepali COVID-19 vaccination programme but there is little evidence on the effectiveness of these vaccines in this setting. The aim of this study is to describe COVID-19 vaccine effectiveness in Nepal and provide information on infections with SARS-CoV-2 variants.Methods and analysis This is a hospital-based, prospective test-negative case–control study conducted at Patan Hospital, Kathmandu. All patients &gt;18 years of age presenting to Patan Hospital with COVID-19-like symptoms who have received a COVID-19 antigen/PCR test are eligible for inclusion. The primary outcome is vaccine effectiveness of licensed COVID-19 vaccines against laboratory-confirmed COVID-19 disease.After enrolment, information will be collected on vaccine status, date of vaccination, type of vaccine, demographics and other medical comorbidities. The primary outcome of interest is laboratory-confirmed SARS-CoV-2 infection. Cases (positive for SARS-CoV-2) and controls (negative for SARS-CoV-2) will be enrolled in a 1:4 ratio. Vaccine effectiveness against COVID-19 disease will be analysed by comparing vaccination status with SARS-CoV-2 test results.Positive SARS-CoV-2 samples will be sequenced to identify circulating variants and estimate vaccine effectiveness against common variants.Measuring vaccine effectiveness and identifying SARS-CoV-2 variants in Nepal will help to inform public health efforts. Describing disease severity in relation to specific SARS-CoV-2 variants and vaccine status will also inform future prevention and care efforts.Ethics and dissemination Ethical approval was obtained from the University of Oxford Tropical Ethics Committee (OxTREC) (ref: 561-21) and the Patan Academy of Health Sciences Institutional Review Board (ref: drs2111121578). The protocol and supporting study documents were approved for use by the Nepal Health Research Council (NHRC 550-2021). Results will be disseminated in peer-reviewed journals and to the public health authorities in Nepal