Lasitha Samarakoon

Learning styles and approaches to learning among medical undergraduates and postgraduates

BackgroundThe challenge of imparting a large amount of knowledge within a limited time period in a way it is retained, remembered and effectively interpreted by a student is considerable. This has resulted in crucial changes in the field of medical education, with a shift from didactic teacher centered and subject based teaching to the use of interactive, problem based, student centered learning. This study tested the hypothesis that learning styles (visual, auditory, read/write and kinesthetic) and approaches to learning (deep, strategic and superficial) differ among first and final year undergraduate medical students, and postgraduates medical trainees.MethodsWe used self administered VARK and ASSIST questionnaires to assess the differences in learning styles and approaches to learning among medical undergraduates of the University of Colombo and postgraduate trainees of the Postgraduate Institute of Medicine, Colombo.ResultsA total of 147 participated: 73 (49.7%) first year students, 40 (27.2%) final year students and 34(23.1%) postgraduate students. The majority (69.9%) of first year students had multimodal learning styles. Among final year students, the majority (67.5%) had multimodal learning styles, and among postgraduates, the majority were unimodal (52.9%) learners.Among all three groups, the predominant approach to learning was strategic. Postgraduates had significant higher mean scores for deep and strategic approaches than first years or final years (p < 0.05). Mean scores for the superficial approach did not differ significantly between groups.ConclusionsThe learning approaches suggest a positive shift towards deep and strategic learning in postgraduate students. However a similar difference was not observed in undergraduate students from first year to final year, suggesting that their curriculum may not have influenced learning methodology over a five year period.

A meta-analysis of magnesium for tetanus.

Uncontrolled studies suggest that magnesium sulphate controls spasms in patients with established tetanus. We performed a meta‐analysis of controlled trials that compared magnesium sulphate with placebo or diazepam for the treatment of patients with tetanus. We searched PubMed, Scopus, Embase and the Cochrane clinical trials registry. Three studies met the inclusion criteria, containing 275 participants (199 male patients, 72.4%). Magnesium sulphate did not reduce mortality, relative risk (95% CI): vs placebo, 0.80 (0.41–1.58); vs diazepam, 1.11 (0.70–1.75). The data on duration of total intensive care unit stay, total hospital stay and the need for ventilatory support were conflicting and pooling of results could not be done due to methodological differences of individual trials. More controlled trials are needed to assess the effect of magnesium sulphate on reducing autonomic instability, spasms, duration of intensive care and hospital stays and the need for mechanical ventilation.

Anatomical relations of the superficial sensory branches of the radial nerve: a cadaveric study with clinical implications

BackgroundAnatomically, it is difficult to give a systematic description of the superficial branch of the radial nerve (SBRN). Our aim was to describe the exact relationship of the SBRN to fixed bony points of radial styloid and Listers tubercle, and to the cephalic vein. We also compared our data with other international studies.MethodsThe study was a descriptive anatomical study. Twenty-five forearms were dissected. Measurements were made from predefined fixed reference points.ResultsThe mean distance to the point of emergence of the nerve from the radial styloid was 8.54 cm (SD = 1.32). The nerve branched at a mean distance of 5.57 cm (SD = 1.43) from the radial styloid. The mean distance to the point where the most medial and most lateral branches of the nerve crossing the wrist joint, measured from the Listers tubercle were 2.51 cm (SD = 0.53) and 3.90 cm (SD = 0.64). In 17 specimens(68%) cephalic vein crossed the SBRN superficially once. Mean distance from the radial styloid to the most distal point where the vein crossed the nerve was 5.10 cm. Diffefrence between mean distance to the point of emergence and branching point, when compared with other international studies were not statistically significant. (P value > 0.05)ConclusionsWe recommend avoiding transverse incisions in the snuffbox region between 2.51 cm and 3.90 cm from the Listers tubercle. We also recommend avoiding cannulation of the cephalic vein in the distal forearm.

Anatomical landmarks for safer carpal tunnel decompression: an experimental cadaveric study

BackgroundCarpal tunnel syndrome is a common presentation to surgical outpatient clinics. Treatment of carpal tunnel syndrome involves surgical division of the flexor retinaculum. Palmar and recurrent branches of the median nerve as well as the superficial palmar arch are at risk of damage.MethodologyThirteen cadavers of Sri Lankan nationality were selected. Cadavers with deformed or damaged hands were excluded. All selected cadavers were preserved with the conventional arterial method using formalin as the main preservative. Both hands of the cadavers were placed in the anatomical position and dissected carefully. We took pre- determined measurements using a vernier caliper. We hypothesized that the structures at risk during carpal tunnel decompression such as recurrent branch of the median nerve and superficial palmar arch can be protected if simple anatomical landmarks are identified. We also hypothesized that an avascular area exists in the flexor retinaculum, identification of which facilitates safe dissection with minimal intra operative bleeding. Therefore we attempted to characterize the anatomical extent of such an avascular area as well as anatomical landmarks for a safer carpal tunnel decompression.Ethical clearance was obtained for the study.ResultsIn a majority of specimens the recurrent branch was a single trunk (n =20, 76.9%). Similarly 84.6% (n = 22) were extra ligamentous in location. Mean distance from the distal border of the TCL to the recurrent branch was 7.75 mm. Mean distance from the distal border of TCL to the superficial palmar arch was 11.48 mm. Mean length of the flexor retinaculum, as measured along the incision, was 27.00 mm. Mean proximal and distal width of the avascular area on TCL was 11.10 mm and 7.09 mm respectively.ConclusionWe recommend incision along the radial border of the extended ring finger for carpal tunnel decompression. Extending the incision more than 8.16 mm proximally and 7.75 mm distally from the corresponding borders of the TCL should be avoided. Incision should be kept to a mean length of 27.0 mm, which corresponds to the length of TCL along the above axis. We also propose an avascular area along the TCL, identification of which minimizes blood loss.

Why do doctors emigrate from Sri Lanka? A survey of medical undergraduates and new graduates

BackgroundMigration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka.MethodsA cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration.ResultsThere were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision.ConclusionsThe rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.

Fanconi anaemia with bilateral diffuse pulmonary arterio venous fistulae: a case report

BackgroundWe report a patient with cytogenetically confirmed Fanconi anaemia with associated diffuse bilateral pulmonary arterio-venous fistulae. This is only the second reported case of diffuse pulmonary arterio-venous fistulae with Fanconi anaemia.Case PresentationA 16 year old Sri Lankan boy, with a cytogenetically confirmed Fanconi anaemia was admitted to University Medical Unit, National Hospital of Sri Lanka for further assessment and treatment. Both central and peripheral cyanosis plus clubbing were noted on examination. The peripheral saturation was persistently low on room air and did not improve with supplementary Oxygen. Contrast echocardiography failed to demonstrate an intra cardiac shunt but showed early crossover of contrast, suggesting the possibility of pulmonary arterio-venous fistulae. Computed tomography pulmonary angiogram was inconclusive. Subsequent right heart catheterisation revealed bilateral diffuse arterio-venous fistulae not amenable for device closure or surgical intervention.ConclusionTo our knowledge, this is the second reported patient with diffuse pulmonary arterio-venous fistulae associated with Fanconi anaemia. We report this case to create awareness among clinicians regarding this elusive association. We recommend screening patients with Fanconi anaemia using contrast echocardiography at the time of assessment with transthoracic echocardiogram. Though universal screening may be impossible given the cost constraints, such screening should at least be performed in patients with clinical evidence of desaturation or when a therapeutic option such as haematopoietic stem cell transplantation is considered. Treatment of pulmonary arteriovenous fistulae would improve patient outcome as desaturation by shunting worsens the anaemic symptoms by reducing the oxygen carrying capacity of blood.

Anatomy of Teaching Anatomy: Do Prosected Cross Sections Improve Students Understanding of Spatial and Radiological Anatomy?

Introduction. Cadaveric dissections and prosections have traditionally been part of undergraduate medical teaching. Materials and Methods. Hundred and fifty-nine first-year students in the Faculty of Medicine, University of Colombo, were invited to participate in the above study. Students were randomly allocated to two age and gender matched groups. Both groups were exposed to identical series of lectures regarding anatomy of the abdomen and conventional cadaveric prosections of the abdomen. The test group (n = 77, 48.4%) was also exposed to cadaveric cross-sectional slices of the abdomen to which the control group (n = 82, 51.6%) was blinded. At the end of the teaching session both groups were assessed by using their performance in a timed multiple choice question paper as well as ability to identify structures in abdominal CT films. Results. Scores for spatial and radiological anatomy were significantly higher among the test group when compared with the control group (P < 0.05, CI 95%). Majority of the students in both control and test groups agreed that cadaveric cross section may be useful for them to understand spatial and radiological anatomy. Conclusion. Introduction of cadaveric cross-sectional prosections may help students to understand spatial and radiological anatomy better.

Spontaneous intracranial hypotension presenting as thunderclap headache: a case report

BackgroundSpontaneous intracranial hypotension is a rare but treatable cause of a disabling headache syndrome. It is characterized by positional orthostatic headache, pachymeningeal enhancement and low cerebrospinal fluid pressure. However, the spectrum of clinical and radiographic manifestations is varied and misdiagnosis is common even in the modern era of magnetic resonance imaging. Spontaneous intracranial hypotension presenting as thunderclap headache is recognized but rare.Case presentationA 41-year-old Sri Lankan female presented with thunderclap headache associated with nausea and vomiting, but the headache was characterized by positional variation with aggravation in the upright posture and relief in the supine posture. Gadolinium-enhanced cranial magnetic resonance imaging demonstrated generalized meningeal enhancement and normal magnetic resonance angiography while lumbar puncture revealed a cerebrospinal fluid opening pressure of less than 30 millimetres of water. Magnetic resonance myelography failed to identify the site of cerebrospinal fluid leak. The patient was managed conservatively with bed-rest, intravenous hydration, analgesics and an increased intake of oral coffee which led to a gradual relief of headaches in the upright posture.ConclusionsSpontaneous intracranial hypotension can rarely present as thunderclap headache. Awareness of its varied spectrum of presentations would avoid inappropriate investigations, misinterpretation of imaging results and ineffective treatment.

Unusual case of recurrent thigh lump in a girl: a case report

IntroductionLipofibromatosis is a rare fibro-fatty tumour with a predilection to involve distal extremities. It has only recently been described as a distinctive clinicopathologic entity, and subsequently only a few cases have been published in the literature. To address the clinicopathologic significance of this rare entity, we here describe a case of lipofibromatosis occurring on the left thigh of a Sri Lankan girl who developed a recurrence following excision.Case presentationA 15-year-old previously healthy girl of Sri Lankan ethnicity presented with a painless progressively enlarging mass in her left thigh. Magnetic resonance imaging of her thigh lump, revealed a septated mass arising from subcutaneous tissue of anterolateral and medial aspects of her thigh. Histological assessment revealed evidence of lipofibromatosis, and the lesion was excised followed by split-skin grafting. She presented again with a local recurrence at the same site.ConclusionsAdequate surgical excision leads to complete cure of this benign lesion, but recurrences are common following incomplete excision. Therefore awareness among clinicians of this rare entity is vital in offering the best possible care to the patients.

Electrocardiographic and echocardiographic manifestations of cardiac involvement in leptospirosis

BACKGROUND Cardiac involvement is known to occur in leptospirosis, however, data on the significance of electrocardiographic and echocardiographic findings is very limited. METHODS Electrocardiographic and echocardiographic changes were studied in serologically confirmed patients with leptospirosis. RESULTS Of 22 patients, 45% (10) had cardiac symptoms; 59% (13) had abnormalities on the ECG; 90% (9/10) of patients with cardiac symptoms had at least one electrocardiographic abnormality. Echocardiographic abnormalities were seen in 41% (9). Clinical and echocardiographic evidence of myocarditis was seen in two patients, but left ventricular function was preserved. CONCLUSIONS Echocardiographic changes may be useful in identifying patients with myocarditis in leptospirosis, especially in symptomatic patients.