Table of Contents : Journal of clinical and diagnostic research : 2009 - August - 3

The Impact of Two Diabetes Educational Programs on Patients with Diabetes in Malaysia

AL-HADDAD MA*, IBRAHIM M I M ** , SULAIMAN S A S ***, MAARUP N **** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Aims: This study was conducted to measure the effectiveness of 2 different diabetes educational programs (less structured vs structured). Setting: Universiti Sains Malaysia Health Center. Design: Prospective observational study design. Methods and Materials: Patients were invited to attend one monthly session of an educational program for a period of 4 months. The first group attended the less structured program while the second group attended the structured program. Patients’ glycated hemoglobin (HbA1c), Body Mass Index (BMI) and Blood Pressure (BP) were compared at the baseline, end of the program and after four months of the end of the program. Statistical Analysis: Repeated Measures ANOVA test was used to compare the three periods while Mann Whitney U test was used to compare between both groups. All data were analyzed using SPSS version 12 at a significance level of less than 0.05. Results: Results showed that HbA1c level significantly increased in the less structured group while significantly reduced in the structured group. BMI showed a slight increase in both groups, but was not statistically significant. On the other hand, systolic BP showed a significant reduction in the less structured group while no significant reduction was found in the structured group. Diastolic BP reduced slightly in both groups but was not statistically significant. Structured diabetes educational program was shown to be more effective than the less structured program. Patients’ BMI has been increased slightly which requires further research to find the reasons behind that. Most other results showed improvements even though some of them were not statistically significant. Conclusion: This study provides evidence on the effectiveness of diabetes educational program as well as the importance of communication skills in developing any patient-educational programs. As result, it can be used as a guideline for the policymakers in Malaysia for developing diabetes educational programs at the national level.

The Effect Of Dexamethasone On Morbidity Related To Vomiting, Pain and Oral Intake In Children After Tonsillectomy

KHANI A*,JAAFARPOUR M**,KHAJAVIKHAN J***,DYREKVANDMOGADAM A** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Background and Aim: Morbidity related to postoperative nausea and vomiting, pain, poor oral intake, dehydration and fever is a concern in children undergoing tonsillectomy. The aim of this study was to investigate the effects of preoperative 0.5 mg/kg i.v. dexamethasone on postoperative quality oral intake, vomiting and pain in paediatric patients undergoing tonsillectomy with or without adenoidectomy, during the first 8 hours of the postoperative period. Material and Methods: This is a quasi-experimental study that was performed at the Ilam Imam Khomeini hospital, IR, during the year 2008-2009. In a randomized, double-blind trial, 66 paediatric patients undergoing tonsillectomy received IV placebo (saline) or 0.5mg/kg IV dexamethasone, after the induction of anaesthesia before surgery. The incidence of vomiting, the time to the first oral intake, the quality of oral intake and the pain score were compared in both groups during the first 8 hours of the postoperative period. Pain was assessed using a five-point ‘‘faces’’ scale (1 = smiling face: no pain, 5 = crying face: highest pain score). The quality of the oral intake was judged as follows: excellent = child requests it, good = child accepts it when offered, fair = child accepts it when coaxed, and poor = child refuses. All collected data were analyzed using the statistical software (SPSS, Ver.11.5), descriptive statistics, Student t test, Mann-Whitney test and the χ2 or Fisher’s exact tests. p < 0.05 was considered significant. Results: The overall incidence of vomiting was significantly less in the Dexamethasone group as compared to the Saline group (p<0.001). The time of the first oral intake was shorter in the Dexamethasone group as compared to the Saline group (P<0.05). The quality of oral intake was better in the Dexamethasone group than in the Saline group (P<0.001). When compared with placebo, the patients who received preoperative dexamethasone had a significantly less pain score during the first 8 hours postoperatively ( p < 0.05). Discussion and conclusion: In the paediatric patients undergoing tonsillectomy, preoperative dexamethasone use significantly reduced posttonsillectomy pain, improved oral intake and decreased vomiting without any significant side effects. This report confirms the beneficial effect of IV dexamethasone on postoperative morbidity related to vomiting, pain and oral intake in children after tonsillectomy and is recommended for routine use.

Common Stressors And Coping Of Stress By Medical Students

SHAH C *, TRIVEDI R S **, DIWAN J ***, DIXIT R ****, ANAND A K***** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Everyone experiences stress. It is a natural reaction that everyone experiences at one time or the other. It is a part of human nature. Stress is the body’s response to danger or perceived threat. Many things in life can bring us stress. Adrenalin is released through our body, causing our body pressure to rise and the outward muscles to tighten. Elevated levels of stress can put a toll on our system but we can develop ways to cope with stress or to make attempts in our lives to avoid it. The participants in this study were 126 undergraduate medical students of Shree M P Shah Medical College, Jamnagar. Systemic random sampling was used for the selection of the participants. A majority of the 1st year medical students at Shri M.P Shah Medical College perceived stress. The stress profiles were as follows. 18-25% stressors were environmental. 21-40% stressors were due to office relationships. 18-25% stressors were due to social factors. 35-70% stressors were due to academic factors. As stress has a detrimental effect both on health as well as academic performance, the college administration should incorporate stress management plans as a co-curricular activity. The stressors at the campus should be identified, discussed with, and proper coping assistance should be provided to individual students. As stress in our colleges cannot be eliminated, we can and should do a better job and provide life satisfaction to our students.

The Cardio-Vascular Effects Of Topical Timolol, Levobunolol And Betaxolol In Patients Of Chronic Simple Glaucoma

SHARMA R *, KOHLI K* *, KAPOOR B***, MENGI RK****, SADHOTRA P*****. Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Background: β–adrenergic antagonists are the most commonly prescribed drugs for glaucoma. However, these drugs can be absorbed into the systemic circulation through the naso-lacrimal duct to produce various systemic side effects. Aims: The present study was conducted to evaluate the effects of topical timolol, levobunolol and betaxolol on the cardiovascular system in Indian patients of chronic simple glaucoma. Settings And Design: This prospective randomized single-blind parallel study was conducted in the Department of Pharmacology and Therapeutics in collaboration with the Department of Ophthalmology of a teaching institute. Methods And Material: Forty newly diagnosed patients of chronic simple glaucoma were included in the study. 16 patients (23 eyes), 12 patients (19 eyes) and 12 patients (20 eyes) were randomized to receive 0.5% timolol maleate, 0.5% levobunolol hydrochloride and 0.5% betaxolol hydrochloride respectively, as one drop twice a day instillation for 12 weeks. Blood pressure, pulse rate and intraocular pressure of each patient were recorded at 0, 6 and 12 weeks. Statistics: Effects of the individual drug on various study parameters were analysed using the paired t–test. P values <0.05 were taken as significant. A comparative analysis of the effects of the three drugs on the above parameters was done by using the analysis of variance test. Inter-group comparison was done using the Turkey test. Results: Topical timolol, levobunolol and betaxolol lowered IOP by 13.05 ± 1.53, 14.05 ±1.47 and 7.58 ± 0.90 mm of Hg respectively, at 6 weeks and by 16.12±1.67, 16.28 ±1.85 and 8.53±0.98 respectively, at 12 weeks (P<0.001) .Both topical timolol and levobunolol produced more reduction in IOP than topical betaxolol, with P-values of 0.004 and 0.002 at 6 and 12 weeks respectively. All the three drugs produced a statistically significant reduction in the pulse rate and systolic and diastolic blood pressure, indicating the systemic absorption of β-blockers in a concentration enough to alter the cardiovascular parameters of the patients .On comparative analysis using analysis of variance, a statistically insignificant difference for change in the three parameters was observed among the three groups . Conclusion: The results of our study necessitate an urgent need for ophthalmological physicians to exclude all the possible cardiovascular problems in the patients before prescribing a topical β-blocker.

The Effect Of VC On Immunoendocrine And Oxidative Stress Responses To Exercise

BABAEI P * , RAHMANI-NIA F**, NAKHOSTIN B ***, BOHLOOLI S H **** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X The depression of the immune system function that is typically observed after strenuous exercise is believed to be possibly mediated by stress hormones, cytokines and oxidative stress. The aim of this study was to measure immunoendocrine and oxidative stress responses after the ingestion of two different doses of Vitamin C (VC) supplementation. Twenty-four healthy untrained males participated in a 30-min exercise at 75%Vo2max. Immediately pre-exercise, the participants received either of the following regimens: placebo, 500 mg and 1000 mg of VC. Blood samples were obtained prior to ingestion, immediately after ingestion, 2hrs after ingestion and also 2hrs and 24hrs after exercise. Vitamin C used in doses of 500 mg and 1000 mg could significantly increase the plasma VC concentration and antioxidant capacity in both vitamin receiving groups. The increase in total antioxidant capacity (TAC) followed a significant decrease in post-exercise oxidative stress markers like malondialdehyde (MDA) (P<0.05). Markers of inflammation (total leukocytes, neutrophils and IL-6), muscle damage, creatine kinase (CK) and stress hormone (cortisol) were found to significantly increase in response to the exercise (P<0.05), but VC supplementation failed to decrease these factors significantly. The results suggest that acute supplementation with moderate and high doses of VC might prevent exercise-induced lipid peroxidation but not inflammatory markers.

AmpC Beta Lactamases Among ESBL Producing Escherichia Coli And Klebsiella Pneumoniae- If You Don’t Look, You Won’t Find.

VANDANA K E *, HONNAVAR P** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Amp C beta lactamases confer resistance to a wide variety of beta lactams and pose both diagnostic and therapeutic challenges, as their presence goes undetected in the presence of ESBLs. We evaluated 52 ESBL positive clinical isolates of E.coli (n=41) and K.pneumoniae (n=11) for AmpC production by a phenyl boronic acid disc (PBA) and the 3 dimensional enzyme test (3DET). The PBA method detected 24 (58.5%) and 9 (82%) E.coli and K.pneumoniae isolates as AmpC positive, while detection by the 3DET increased the numbers to 29 (70.7%) and 10 (91%) isolates, respectively. We conclude that a large number (75%) of ESBL producers are also found to produce AmpC and that the PBA disc method is a very useful and reliable method for routine use in laboratories.

Factors Associated with Warfarin Therapy Knowledge and Anticoagulation Control among Patients Attending a Warfarin Clinic in Malaysia

YAHAYA A H M *, HASSALI M A **, AWAISU A***, SHAFIE A A **** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Objective: To determine the factors that correlated with the patient’s knowledge of warfarin therapy, the level of medication adherence and INR control. Methods: A cross-sectional survey was conducted at the Warfarin Clinic of Hospital Teluk Intan, Malaysia. The systematic random sampling method was used in sample selection and face-to-face interviews using standard questionnaires were administered to determine the demographic characteristics, the patient’s knowledge of warfarin therapy and medication adherence. Medical records were reviewed to determine anticoagulation control during the study period. Results: A total of 52 patients were enrolled in the survey (mean ± SD age of 58.73  9.55 years), with a response rate of 95%. A large proportion (63.5%) of the respondents had only primary school education and 71.2% were low-income earners (below RM500 per month). About 69% of the respondents were able to read and 53.8% were able to understand Malay (the national language of the country). A majority of the patients (98%) had verbal medication education through medical or nursing officers. Only 44.2% of patients knew about their medications, but the medication adherence was fairly good at 76.1%. The study showed that age, income level, level of education, and literacy in various languages were significantly associated with the patient’s knowledge on warfarin therapy (p< 0.05). The study also showed a significant difference between those patients who knew/did not know about their medications in terms of warfarin therapy knowledge (p<0.05). Conclusion: Age, income, educational level, literacy and race were significantly correlated with the patient’s knowledge of anticoagulation. The study did not find any association between anticoagulation control and the knowledge of anticoagulation. Practice Implications: The disadvantaged groups receiving anticogulation therapy, including the low-income earners, the elderly, the less-educated and the illiterate, should be given utmost care and attention.

Effect Of Aqueous Fruit Extract Of Emblica Officinalis On Haloperidol Induced Catalepsy In Albino Mice

SUDHAKAR PEMMINATI*, V NAIR**,DORABABU.P**, GOPALAKRISHNA HN***, PAI MRSM ****. Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Neuroleptic drugs used in the treatment of schizophrenia and other affective disorders are known to produce extrapyramidal side effects. Catalepsy was induced by these drugs in animals and these have been used as models for the extrapyramidal side effects associated with antipsychotic agents in human beings. In the present study, we have attempted to evaluate the protective effect of the aqueous extract of the fruits of Emblica officinalis (EO) on haloperidol (1.0mg/kg intraperitoneal administration) induced catalepsy in mice by employing the standard bar test. Mice were allocated to seven groups, each group containing six animals. The effects of the test drug EO (0.8, 2.0 and 4.0mg/kg doses) and the standard drugs scopolamine (1.0mg/kg) and ondansetron (0.5 and 1.0mg/kg doses) were assessed after single and repeated dose administration for seven days, 30 minutes prior to the haloperidol. Mice were sacrificed on the seventh day and super oxide dismutase (SOD) activity in the brain tissue was estimated by using the Beauchamp and Fridovich method. A significant (P<0.001) reduction in the cataleptic scores was observed in all the test drug treated groups as compared to the control, with maximum reduction in the dose 4.0mg/kg group. Similarly, the maximum reduction in SOD activity (P<0.01) was observed in the dose 4.0mg/kg group. Our study suggests that EO has significantly reduced oxidative stress and the cataleptic score induced by haloperidol. It could be used to prevent drug- induced extrapyramidal side effects.

The Diagnostic Value of Hyperbilirubinemia and Total Leucocyte Count in the Evaluation of Acute Appendicitis

KHAN S* Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Background: Acute appendicitis (AA) is a common abdominal emergency encountered in general surgery. In most of the cases, the diagnosis can be made clinically by assessing the symptoms and physical findings and can be confirmed by laboratory tests and ultrasonography. However, diagnosis is difficult sometimes even after all these tests and in such doubtful cases, either the diagnosis is missed or the patient’s normal appendix is operated on, leading to increase in mortality and morbidity. Aims: It is to evaluate the importance of total leukocyte count (TLC) and total serum bilirubin (TSB) in the diagnosis of clinically suspected cases of AA. Settings And Design: This is a prospective study conducted at the Department of Surgery at NGMC, Teaching Hospital, Nepalgunj, Nepal, from December 2004- Jan 2008. Methods And Material: 122 patients suspected of having appendicitis at clinical evaluation underwent prospective evaluations which included laboratory tests (TLC, LFT, Urine analysis) and ultrasonography (USG) of the abdomen. They were operated on and their diagnosis was confirmed per-operatively and post-operatively by histo-pathological examination. Laboratory results, operative findings and histo-pathological findings were compiled, analyzed and compared with reference values. The TLC and total serum bilirubin (TSB) were considered positive for appendicitis when their values were greater than 1010cell/cmm and > 1.1 mg/dL, respectively. Results: The ages ranged from 8-73 years with a mean of 29.36 years. Out of 122 patients, 21(17.81%) cases belonged to the early group of cases (reported <24hours after the onset of the symptoms), while 101(82.78%) cases belonged to the delayed group of cases (reported >24 hours after the onset of the symptoms). The histological examination revealed that of the 122 specimens, 118(96.72%) had a positive histology for AA, while 4 (3.22%) had normal histology. TLC was elevated in 93 (76.22%) cases and it was normal in 29 (23.77%) cases. Among the cases that had elevated TLC, only 91(97.84%, CI 14010±254) had a positive histology for AA, while the remaining 2 (2.15%) had normal histology. Among 29 cases that had normal TLC, 27 had positive histology for AA, while the remaining 2 had normal histology. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy are 50%, 77%, 97.8%, 7.4% and 76.22%, respectively. TSB was elevated in 95 cases (77.86%, CI 2.06±0.73), while it was within normal limits in 27 (22.13%) cases. Among the cases that had elevated TBS, all had positive histology for AA, while in cases with normal TBS, 23 had a positive histology for AA, while 4 had normal histology. The specificity, sensitivity, PPV, NPV, and overall diagnostic accuracy are 100%, 80%, 100%, 14% and 81.14%, respectively Liver enzyme changes if any, were not helpful in the diagnosis. Conclusion: Elevated TSB (without severe changes in liver enzymes) was found to be a better laboratory test with 100% specificity, 80% sensitivity and 81.14% overall diagnostic accuracy than TLC with 50% specificity, 77% sensitivity and 76.22% overall diagnostic accuracy in the diagnosis of AA. But the diagnosis can be further improved if positive results of either tests alone or in combination are taken into consideration. This will reduce the missing rate of AA without increasing the rate of negative appendicectomies.

Awareness, Attitude and Practices Concerning the Essential Medicines Concept among Malaysian Prescribers and Pharmacists

Ahmed H M A *, Ibrahim M I M **, Fathelrahman A I *** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X

Spectrum of Nocardiosis –A report of three cases

DIAS M* ,ANTONY B**, PINTO H*** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Nocardiosis is caused by soil borne aerobic actinomycetes in immunocompromised hosts as well as in persons without any predisposing factors. We report here, three cases of culture proven Nocardia asteroides infection. Two cases were reported from immunocompetent individuals and the last one from an HIV patient.

Parathyroid Cyst: A Rare Diagnosis Of A Neck Swelling

AGARWAL C S *, KAUR N **, SAHA S **, NITISH ANCHAL* Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Parathyroid cysts are rare clinical entities. They may mimic solitary thyroid nodules and frequently present as a clinical diagnostic problem. The case of a 43- year male is presented here, who had a left sided neck swelling which recurred after aspiration. The patient underwent excision of the swelling and the diagnosis of parathyroid cyst was established on the basis of the histopathological examination of the specimen. The diagnosis of parathyroid should be suspected in the case of any cystic anterior neck mass that yields a clear fluid on aspiration, especially if it is in the inferior position. The presence of elevated parathyroid levels in the fluid is diagnostic. Aspiration alone is curative in some cases.

Nearly Fatal Wild Honey Intoxication A Case Report of Seven Cases

JAUHARI A C *, JOHOREY A C **, BANERJEE I ***, SHRESTHA P ****, SINGHAL K C ***** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Honey is used as a common breakfast item all over the world. Honey is also used in cooking and baking, is used as a spread on breads and is added to beverages such as tea, or as a sweetener in commercial beverages. In Nepal, there is a fancy for the use of wild honey. Honey is also used in weight reduction. Studies reported elsewhere pinpoint that wild honey is poisonous. This poisoning is well known from ancient times, right from the time of Xenophon. This wild honey is derived from the flowers of Rhododendrons (the national flower of Nepal). Honey consumption toxicity was noted in a few medical students who were treated and the current paper describes the outcome and the cause of toxicity.

Romiplostim:A Novel c-Mpl/CD110 Receptor Ligand for the Management of Idiopathic Thrombocytopenic Purpura

PATEL H*, PATEL N**, VYAS A***, PATEL M ****, PANDEY S***** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X Idiopathic Thrombocytopenic Purpura (ITP) is an autoimmune disease characterised predominantly by an antibody mediated destruction of platelets. Few treatment options are available for ITP like corticosteroids, IV immunoglobulins, splenectomy, rituximab, danazole and cyclophosphamide. All these treatment options work by reducing the destruction of platelets by antibody. However recent evidence suggests that production of platelet is reduced in 75% of thrombocytopenic patient with ITP. Romiplostim is a novel thrombopoetin receptor agonist approved by USFDA in August 2008 that increases the platelet count in ITP patients unresponsive to corticosteroids, immunoglobulins or splenectomy. Romiplostim is not currently available in India. The addition of Romiplostim in the treatment options for ITP will surely improve the outcomes in ITP patients.

Academic Detailing as a Possible Source of Drug Information in the Context of Nepal: A short review

SAVAL KHANAL*, SUBISH PALAIAN**, P. RAVI SHANKAR***, PRANAYA MISHRA**, MOHAMED IZHAM MOHAMED IBRAHIM**** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X The source of unbiased drug information is an integral part of evidence based practice. The status of evidence based practice in Nepal is very poor. One of the major factors associated with it, is the limited availability of new literature, and poor documentation and dissemination of the little available information. Academic detailing is an educational outreach program in which a trained health professional visits clinicians in their offices to provide evidence based information. So, there is a huge scope for academic detailing as a means to disseminate the available information in the context of Nepal. Research done worldwide has already shown improvement in the clinicians’ knowledge, their attitude and practice, improvement in their prescribing patterns and an increase in their adherence to clinical guidelines, following academic detailing. In Nepal, there are many topics which can be selected for academic detailing. Topics covering the information regarding newer drugs, diarrhoea treatment guidelines, the rational use of antimicrobials, the rationality of fixed dose combinations, nonsteroidal antinflammatory drugs (NSAIDs) and specialized devices for the administration of drugs, will be more relevant. Lack of local health statistics, lack of awareness about evidence based practice, challenges from pharmaceutical representatives and a lack of financing capability may be the major limitations for academic detailing in Nepal.

Giant Congenital Melanocytic Naevus

K SHREEDHARA AVABRATHA*, DAMBALKAR G **, AGNIDEVI L** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X

Reply to 'Generic Medicines as a way to Improve Access and Affordability: A Proposed Framework for Pakistan'

SHANKAR P R Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X

Pattern Of Potential Drug-Drug Interactions In The Intensive Care Unit Of A Teaching Hospital In Nepal: A Pilot Study

BISTA D*, SAHA A**, MISHRA P ***, PALAIAN S ****, PATHIYIL R S***** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X

Evaluation of the Relationship between Systemic Osteoporosis, Dietary Ca Intake and the Reduction Of Residual Ridges In An Edentulous Patient: An In Vivo Pilot Study

DESHPANDE S S*, SARIN S P** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X In recent years, there has been an obvious increase in the elderly population. Osteoporosis, a systemic disease in the elderly, shows a decrease in the skeletal mass without alteration in the chemical composition of bone. In edentulous patients, reduction of the residual ridge (RRR) is one of the most important factors affecting denture support, retention, stability and masticatory function. The aetiology can be multifactorial, eg: dietary Ca intake, hormonal, etc. This study investigated the relationship between systemic osteoporosis,dietary Ca intake and RRR in elderly edentulous patients. Systemic osteoporosis was evaluated by measuring BMD by ultrasound. Residual Ridge Resorption was evaluated by OPG (Wical and Swoop Analysis) and Dietary case history was taken to evaluate Ca intake. Residual ridge resorption was found to be directly proportional to the age of the patient and to the degree of osteoporosis, inversely proportional to dietary Ca intake and was found to be more common in females.

Conducting Problem-Stimulated Learning In A Nepalese Medical School

SHANKAR PR*,JHA N**,BAJRACHARYA O***,SHRESTHA RK****,THAPA HS*****,PIRYANI RM****** Journal of clinical and diagnostic research : 2009 - August - 3:0973-709X The problem-based learning of Pharmacology and Therapeutics has been recommended as a key intervention towards promoting the more rational use of medicines (1). Problem stimulated learning (PSL) sessions in Pharmacology had been conducted at the Manipal College of Medical Sciences, Pokhara, Nepal (2). In this manuscript, the authors describe the initial experiences with problem-stimulated learning in Pharmacology in a new Nepalese medical school. KIST Medical College KIST Medical College is a new medical school in Lalitpur, Nepal, which is committed to excellence in holistic healthcare, education and research. The college admits 75 students to the MBBS course every year on the first of the Nepalese month of Magh (around mid-November). The department of Clinical Pharmacology and Therapeutics has the vision of creating doctors who can use essential medicines rationally and to inculcate in them the capacity to keep up to date with new developments in medicine and therapeutics. This department collaborates with the department of Medicine for achieving these objectives. PSL sessions were started right from the beginning and their aim is to develop in students, the capacity for self-directed learning, problem solving and working together in small groups. In Nepal, Pharmacology is taught during the first two years of the undergraduate medical (MBBS) course in an integrated, organized, system based manner with other basic science subjects. Comfortable Working Environment Creating a comfortable ‘working’ environment for the students was vital. Students were divided into two batches (each of around 37 students) for the Pharmacology PSL sessions. Each batch was further divided into five groups, each containing 7 or 8 students. The groups worked around an oval table (6 feet by 2 feet). Seating was provided in the form of plastic armless chairs which could be rotated and moved around freely. Chairs with arms were not used as these would occupy too much space and the arms could create a barrier between the group members. The sessions are usually held on Thursday and Friday afternoon for the two batches from 2 pm to 4 pm. The Groups We decided to keep the groups constant for a year in order to facilitate group dynamics. Each group had been named after an eminent scientist or personality in Medicine/Pharmacology. The group names are Oslers (after Sir William Osler, the famous Canadian physician), Lasagnas (after Louis Lasagna, the American Clinical pharmacologist), Paracelsians (after Paracelsus), Abels (after John Abel, the father of American pharmacology) and Ehrlich (after Paul Ehrlich, the father of chemotherapy). The group name was prominently displayed on the work table along with the names of the group members. At the beginning of the year, each group had to prepare a biographical sketch of their ‘group scientist’. These write ups were prominently displayed in the lab. We believe that this helped to create a sense of identification and belonging among the group members. They also felt pride in their group being named after a prominent scientist.