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PurposeRelationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries.Materials and methodsThis was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used.ResultsThe survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (pConclusionMedical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries.

Background: Ethics and professionalism are an integral part of medical school curricula; however, medical students’ views on these topics have not been assessed in many countries. Objective: The study aimed to examine medical students’ perceptions toward ethics and professionalism teaching, and its learning and assessment methods. Design: A self-administered questionnaire eliciting views on professionalism and ethics education was distributed to a total of 128 final-year medical students. Results: A total of 108 students completed the survey, with an 84% response rate. Medical students reported frequently encountering ethical conflicts during training but stated only a moderate level of ethics training at medical school (mean = 5.14 ± 1.8). They noted that their education had helped somewhat to deal with ethical conflicts (mean = 5.39 ± 2.0). Students strongly affirmed the importance of ethics education (mean = 7.63 ± 1.03) and endorsed the value of positive role models (mean = 7.45 ± 1.5) as the preferred learning method. The cohort voiced interest in direct faculty supervision as an approach to assessment of knowledge and skills (mean = 7.62 ± 1.26). Female students perceived greater need for more ethics education compared to males (p =

We aimed to systematically review the literature on the educational impact of Advanced Trauma Life Support (ATLS) courses and their effects on death rates of multiple trauma patients. All Medline, Pubmed, and the Cochrane Library English articles on the educational impact of ATLS courses and their effects on trauma mortality for the period 1966–2012 were studied. All original articles written in English were included. Surveys, reviews, editorials/letters, and other trauma courses or models different from the ATLS course were excluded. Articles were critically evaluated regarding study research design, statistical analysis, outcome, and quality and level of evidence. A total of 384 articles were found in the search. Of these, 104 relevant articles were read; 23 met the selection criteria and were critically analyzed. Ten original articles reported studies on the impact of ATLS on cognitive and clinical skills, six articles addressed the attrition of skills gained through ATLS training, and seven articles addressed the effects of ATLS on trauma mortality. There is level I evidence that ATLS significantly improves the knowledge of participants managing multiple trauma patients, their clinical skills, and their organization and priority approaches. There is level II–1 evidence that knowledge and skills gained through ATLS participation decline after 6 months, with a maximum decline after 2 years. Organization and priority skills, however, are kept for up to 8 years following ATLS. Strong evidence showing that ATLS training reduces morbidity and mortality in trauma patients is still lacking. It is highly recommended that ATLS courses should be taught for all doctors who are involved in the management of multiple trauma patients. Future studies are required to properly evaluate the impact of ATLS training on trauma death rates and disability.

I1 The 9th Annual Dubai Medical Education Symposium 2015 addresses the recent strides in medical education and clinical practice Fouzia Shersad, Hajer Sheikh S1 Acute lower limb ischaemia — Snow White and the Seven "Ps" Munther I. Aldoori S2 Learning styles in medical education Mohammed Galal El Din Ahmed S3 Reflection and feedback in teaching in clinical settings Joseph Michael Muscat-Baron S4 Medical Education in the Millennial Era Dima Abdelmannan S5 Current trends in the assessment of clinical competency at the workplace Hossam Hamdy S6 Influence of culture in delivering education Syed Tanzeem Haider Raza S7 Medical education – its day-to-day value in caring for patient Parveen J Kumar S8 IgG-4 related diseases (IgG-4 RD): what the clinician needs to know Fatheia Ali Bayoumy S9 From fetus to infant: the pediatric surgical care come into its own Gloria Pelizzo S10 20 minutes to know rheumatic disease Mike Irani S11 Research trends at Dubai Medical College Fouzia Shersad, Doaa Sultan P1 The Clinical Skills & Simulation Center (CSSC): Facing challenges in implementing the standardized program during OSCE (Objective Structured Clinical Examination) for undergraduate medical students Sumaiah Ali Abdulwahab P2 Informed consent education in a multicultural medical environment: clinical clerks’ perspectives Tahra AlMahmoud, M. Jawad Hashim, Margaret Ann Elzubeir, Frank Branicki P3 Effectiveness of information literacy on the information retrieval activity of medical students Bushra Parveen P4 Opportunistic infections in AIDS R. Subha Parameshwaran, Shubhangi Pathak P5 From transactional to transformative learning: engaging early-stage students in community engagement activities Ghazala Khan, Sabeena Salam, Nabeerah Aftab P6 A study of drug utilization of over the counter (OTC) drugs in private pharmacies of a residential area of Dubai, UAE Tasneem Sandozi, Aksha Memon, Maira Khalid Mehmood, Nayyab Mohammed Tayyab Mustafa, Almas Parker, Kawther Hamdi P7 General education matters for envisioning holistic integrative thinking in healthcare professionals Sabeena Salam P8 Course report: multidimensional imaging and capturing the quality of offered courses Eman Abu-Gharbieh, Sabeena Salam P9 Recent advances in medical education M. Jawad Hashim

Summary Background/Objective To review published pediatric trauma research from the Gulf Cooperation Council (GCC) countries so as to identify research fields that need to be enhanced. Methods A MEDLINE search for articles on pediatric trauma from GCC countries during the period 1960 to 2010 was performed. The content of articles was analyzed, classified and summarized. Results Fifty-three articles were found and retrieved of which 18 (34%) were published in the last 5 years, 42 (79.2%) were original articles. The first author was affiliated to a university in 29 reports (54.7%), to a community hospital in 13 (24.5%) and to a military hospital in 10 (18.9%). All articles were observational studies that included 18 (34%) case-control studies, 18 (34%) case reports/case series studies, 8 (15.1%) prospective studies, and 7 (13.2%) cross sectional studies. The median (range) impact factor of the journals was 1.3 (0.5–3.72). No meta-analysis studies were found. Conclusion A strategic plan is required to support pediatric trauma research in GCC countries so as to address unmet needs. Areas of deficiency include pre-hospital care, post-traumatic psychological effects and post-traumatic rehabilitation, interventional studies focused on a safe child environment and attitude changes, and the socioeconomic impact of pediatric trauma.

The concept of structured Postgraduate Medical Education (PGME) and residency training gained widespread support from Emirati regional health authorities and has become a national priority in the United Arab Emirates (UAE). In cosmopolitan countries, such as the UAE, residents/ trainees are tutored and supervised by trainers from diverse cultural, ethnic and religious backgrounds. The roles and responsibilities of trainees are defined, thereby ensuring the appropriateness and safety ofpatient care countrywide in situations where trainees are involved. The aim of this project was to develop guidelines for a Code of Ethics that would govern the conduct and activities of postgraduate trainees in various medical specialties countrywide. Elements of Residency training involving ethics and professionalism highlighted by various international organizations with recognized high ethical standards and the opinions scholars who have published in this field were reviewed and adapted, with preservation of core Islamic values. This document focuses on professional responsibilities in several domains: professional practice standards, professional community standards, research standards, professional relationships with colleagues, physician duties towards society, physician duties towards workplace establishment, the relationships between trainees and industry, reporting responsibilities, and lists of some behaviors that are considered unacceptable. A formal document is now available to all postgraduate trainees (Residents) to emphasize the importance and relevance of ethical considerations and professionalism in PGME with a strong sense of obligation to patients’ best interests.

Purpose Limited information exists regarding students' routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments. Materials and methods A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks. Results 84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item "being treated in professional manner" and "endorsement of educational needs for care of adolescents" (p = 0.05). Conclusion There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education.

Aim To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to investigate factors affecting postoperative complications of PPU. Background The incidence of PPU has remained constant, simple closure with omental patch repair being the mainstay of treatment. Patients and Methods One hundred and nineteen patients admitted to Al-Ain Hospital with PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were excluded from the analysis. Logistic regression was used to define factors affecting postoperative complications. Results The mean age of patients was 35.3 years (range, 20–65). 45.7% of patients were Bangladeshi, and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perforated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%). Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic health evaluation (APACHE) II score ( p = 0.047) and a reduced white blood cell count (0.04) were highly significant for the prediction of postoperative complications. Conclusion Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time.

This paper presents an update of the role of minimally invasive surgery (MIS) in gastrointestinal malignancy. A review of indications, surgical technique, and radicality of laparoscopy in the field of gastrointestinal cancer surgery is discussed. The feasibility and safety of laparoscopic procedures are compared with established and implemented standards in the diagnosis and treatment of oncological disorders. It is important to appreciate that only the "access" is different with all its attendant advantages. The use of laparoscopy in tumor staging and palliative and curative resection is evaluated on review of the literature, and special indications for a laparoscopic approach in gastrointestinal malignancy in different organs are discussed. In conclusion, MIS is safe and feasible, with many short-term advantages; long-term results should be further assessed in randomized controlled studies. Until the outcomes of such studies are available MIS for malignant disease should be performed by experienced surgeons in specialized centers.

To analyze the role of multidetector CT (MDCT) in the management of abdominal highenergy trauma patients using CT classification of organ injury. During the past 2 years, 451 patients with abdominal trauma were examined by MSCT. Most were victims of RTA, 400 men and 51 women, between 18 and 80 years old (mean age 38 years). In 78 patients injury to abdominal organs was diagnosed by MDCT. MDCT (GE Light Speed) was performed using 2.5 mm collimation and 7.5 mm table movement with dynamic IV injection of iohexol 350 mg iodine/ml. A workstation was used for 2D and 3D reconstructions. We detected 24 patients with liver rupture. The spleen was ruptured in 20 cases, kidneys in 14 cases; urinary bladder rupture occurred in 4 cases and urethral rupture in 1 case. In 19 patients, more than one organ injuries were observed. In only 23 patients (30% of all injured with grades 3–4), surgery was an imperative treatment, but the majority of victims with abdominal injuries, grades 1–2, were treated conservatively. MDCT plays a crucial role in the management of patients with abdominal trauma. A team approach (traumatologist, surgeon and radiologist) is mandatory in high-energy trauma.

Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma. This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions.Review and commentary on pertinent articles in the English language literature are presented.Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting. In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard.As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired. A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application. When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease. Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty. Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair. Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.

The aim of the present study was to define the factors that affect passing the assessments for successful completion of the Advanced Trauma Life Support (ATLS) Provider Courses in the United Arab Emirates (UAE). The ATLS Provider Course has been taught in three medical centers in the UAE since 2004. A total of 1,041 doctors completed the course during the period 2004–2010. A special protocol was designed to enter data accrued for each course, participants’ demographics, and assessments, including the final results. Direct logistic regression was performed to define factors affecting success in multiple choice questions (MCQ) and in the practical initial assessment station exam. The studied variables included the year, the course site, speciality, level of practice, and pre-test score. The majority of participants were surgeons (33.2 %), followed by Emergency Medicine physicians (27.3 %). The logistic regression model showed that having a low pre-test score (p

This article reviews substantial progress made in the past decade in the management of patients with portal hypertension who present with major upper gastrointestinal bleeding. Variceal and portal pressure measurements and endoscopy facilitate a reasoned approach to management, and several treatment options are available to gain control of ongoing or recurrent haemorrhage. These encompass endoscopic therapy (sclerotherapy, endoscopic variceal ligation), radiological intervention with transjugular intrahepatic systemic shunt (TIPS) procedures, and a variety of surgical procedures for devascularization or shunting from the high-pressure portal system to low-pressure systemic venous connections. In most prospective randomized trials endoscopic variceal ligation has proved superior to sclerotherapy, and TIPS has found a role in the salvage of patients with further haemorrhage, sparing them surgical intervention. Advances in pharmacotherapy for the control of initial bleeding and secondary prophylaxis hold promise. Liver transplantation has become an option for selected patients with end-stage liver disease.

We report a case of a 36-year-old lady who presented with a huge fungating tumour that involved the entire right breast. The tumour was diagnosed histologically as undifferentiated primary stromal tumour of the breast with axillary lymph node metastasis. We review the literature of this rare malignant tumour. Stromal sarcomas of the breast lack epithelial participation, and diagnosis of these tumours can be difficult. Genome-wide expression profiling is currently used to determine the cell of origin of most sarcomas. Surgery offers the best therapeutic option. Adjuvant radiotherapy is not very beneficial, while chemotherapy has, to date, no established role in the management of this disease. The prognosis is dismal for patients with lymph node involvement. The size of the tumour has a lesser bearing on outcome.

Camel-related injuries have been less well studied than other animal-related injuries. We aimed to study prospectively the incidence, mechanism, distribution of injury, and outcome of patients admitted to hospital with camel-related injuries in Al-Ain, United Arab Emirates. All patients who were admitted to Al-Ain Hospital with a camel-related injury were prospectively studied during the period of October 2001 to January 2010. Patient’s demography, time of injury, mechanism of injury, and distribution and severity of injury were studied. A total of 212 patients, all male, with a median age of 28 years (5–89 years) were studied. The estimated incidence of hospitalized camel-related injured patients in Al-Ain City was 6.88 per 100,000 population per year. Camel kicks were most common (36.8 %) followed by a fall from a camel (26.4 %) and camel bites (25.0 %). Camel kicks and falling from a camel were more common during the hot month of August, and camel bites were more common during the rutting season (November to February). Patients with a kick-related injury had a significantly higher rate of maxillofacial fractures compared with other mechanisms. Spinal injuries occurred significantly more often in vehicle occupants who collided with camels compared with other mechanisms (3/7 compared with 7/205, p = 0.0022, Fisher’s exact test). Twelve patients (5.7 %) were admitted to the intensive care unit. The mean hospital stay was 8.6 days (1–103 days). Two patients died (overall mortality 1 %). Understanding the biomechanisms and patterns of injury and correlating them with the behavior of the camel is important for identification and prevention of camel-related injuries.

To study the effects of a law banning children from taking part in camel racing on child camel jockey injuries in Al-Ain City, United Arab Emirates.Prospective study.University Teaching Hospital.All patients who were admitted to Al-Ain Hospital and were injured while riding camels were prospectively studied between January 1, 2002, and December 31, 2009.Two periods, before the law and after its introduction, were compared.Pediatric injuries, their anatomical distribution, and severity of injury.Fifty-four patients were studied, and all were males. There were 13 children and 41 adults. All children were camel jockeys except 1 child who was riding a camel for fun. None of the adult camel riders was a camel jockey. The median (range) age of patients admitted before the law was 12.5 (5-45) years, which was significantly less compared with 27.2 (20-40) years after its introduction (P = 0.001, Mann-Whitney test). All 13 children sustained their injuries before the law was implemented, whereas 12 of 41 adults sustained their injuries before the legislation was in place (P0.0001, Fisher exact test). The total length of hospital stay of patients was significantly reduced after the law enforcement (P0.01, Mann-Whitney test).Our findings emphasize the important role of law enforcement in injury prevention, illustrated by the replacement of children by robot substitutes. This is possibly one of the few examples where child injury has been completely prevented by legislation.

Gastric cancer is the fourth most commonly diagnosed malignancy and the second leading cause of cancer-related mortality worldwide. Recent research suggests that tissue stem cells and the self renewal transcription factor, octamer-binding transcription factor 4 (Oct4), could be involved in the development of certain tumors. The aim of this study was to investigate the expression pattern of Oct4 in normal human stomach and during multistep gastric carcinogenesis. Pyloric antral mucosal tissues were obtained from consenting individuals undergoing endoscopy (due to upper gastrointestinal symptoms) and gastrectomy (due to pyloric antral adenocarcinoma). Some tissue samples were processed to assemble an array of tissue sections representing multistep carcinogenesis and probed using anti-Oct4 antibodies and lectins specific for α-L-fucose or N-acetyl-D-glucosamine. Some tissue samples were processed for subcellular fractionation and western blot analysis using the same antibodies. The results revealed that Oct4-expressing cells were found in the proliferative cell compartment of the pit-gland units of microscopically normal gastric mucosal biopsies. Mucosal tissues with evidence of severe gastritis, metaplastic/dysplastic transformation and gastric cancer showed a significant increase in the expression of Oct4 (the labeled area increased from 2% in the control to 6 and 16% in the gastritis and cancerous tissues, respectively), suggesting a role for Oct4 in the early stages of cancer development. Furthermore, the data revealed an alteration in the subcellular distribution of Oct4, possibly due to the inhibition of cytoplasm-to-nucleus translocation during carcinogenesis. In conclusion, this study demonstrates an alteration in the expression pattern and nuclear translocation of Oct4 during gastric carcinogenesis and may be helpful in designing new modalities for the early detection and/or therapy of gastric cancer.

Purpose To prospectively study the incidence, mechanism, distribution of injury, and outcome of patients admitted to Al-Ain Hospital with camel bite injuries in Al-Ain, United Arab Emirates. Methodology All patients admitted to Al-Ain Hospital with a camel bite were prospectively studied during the period of October 2001–October 2007. Patient's demography, mechanism of injury including behaviour of the camel, distribution and severity of injury, and outcome were studied. Results 33 patients were studied having a median (range) age of 27 (10–58), all were males. 97% were from the Indian subcontinent. A majority of injuries (73%) occurred during the camel rutting season (November–March). Twenty-five patients were camel caregivers whilst five were camel jockeys. All camel jockeys were children. Seven patients were raised up by the camel's mouth and thrown to the ground whilst 26 patients were only bitten. Most injuries were in the upper limb (64%) and head and face (15%). 48% of upper limb injuries had associated fractures. Two patients who were bitten at the neck were admitted to the ICU. One of these died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. The median hospital stay was 6 days. There was only one death (3%). Conclusion The behaviour of the camel is occasionally unpredictable, especially during the rutting season. The mechanism of camel bite injuries, which are usually severe, are complex including penetrating and crushing injuries by the camel jaw and blunt injuries when patients are picked up and thrown away. Care should be taken when handling camels, particularly in the rut.

Background We established a trauma registry in 2003 to collect data on trauma patients, which is a major cause of death in the United Arab Emirates (UAE). The aim of this paper is to report on the long term effects of our early analysis of this registry. Methods Data in the early stages of this trauma registry were collected for 503 patients during a period of 6 months in 2003. Data was collected on a paper form and then entered into the trauma registry using a self-developed Access database. Descriptive analysis was performed. Results Most were males (87%), the mean age (SD) was 30.5 (14.9). UAE citizens formed 18.5%. Road traffic collisions caused an overwhelming 34.2% of injuries with 29.7% of those involving UAE citizens while work-related injuries were 26.2%. The early analysis of this registry had two major impacts. Firstly, the alarmingly high rate of UAE nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. Second, the equally alarming high rate of work-related injuries led to collaboration with a Preventive Medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention. Conclusion Analysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention.

Purpose: To study the mechanism, management and outcome of patients who had sustained pancreatic trauma. Methodology: Patients who were treated for pancreatic trauma in Al-Ain hospital between October 2002 and August 2007 were retrospectively studied. Results: All eleven patients were males having a median age of 30 years (range 24–52 years). Nine had blunt trauma while two had suffered penetrating injury. Three presented with shock. Associated injuries were present in nine patients (head, chest, and extremities) while seven had other intra-abdominal injuries. Only one patient had isolated pancreatic injury. Early serum amylase was elevated in six patients. CT abdomen was diagnostic for pancreatic injury in seven patients. Two cases were missed by early CT scan (sensitivity of 78%) while the remaining two patients were taken immediately to the operating theater. All patients underwent laparotomy. Five patients were treated by drainage alone, four had distal pancreatectomy, abdominal packing was performed in one patient and in another gastrocystostomy was carried out. Pancreatic fistula occurred in three patients. Median hospital stay was 25 days (range 12–152 days). Two patients (18%) died. Conclusions: Blunt trauma is the main cause of pancreatic injury in our country. Early CT scan may miss pancreatic injury in almost a quarter of the patients. Thin sliced CT scan, with special views in a dedicated abdominal pancreatic study, is recommended. A high index of clinical suspicion, depending on the mechanism of injury, is important for diagnosis of pancreatic injury. Mortality is mainly attributable to other associated injuries so simple procedures should initially be adopted for pancreatic injury, especially in haemodynamically unstable patients.

Background: The primary goal of any assessment of students is to provide valid and reliable evaluations of students' knowledge and skills as well as provision of accurate feedback to students about their performance. Contrary to best practice guidelines for development of multiple choice questions (MCQs), however, items used within medical schools are often flawed. This disappoints students and discourages examiners from using in-house MCQ databases. Vetting and reviewing items can improve the quality of MCQs. In this paper, we describe our approach to standardize the format used for MCQ assessment and provide recommendations for quality enhancement of high-stakes assessment. Methods: A collaborative enhancement-focused vetting and review approach to development of high quality single best answer MCQs has been described. Results: Implementation of a collaborative strategy to blueprint, vet, review and standard set MCQ items for high stakes examinations can effectively contribute to assessment quality assurance. Similarly, shared responsibility for post examination analyses of items may reveal the psychometric properties of items in need of improvement and contribute to closure of the assessment outcomes feedback loop. Discussion: Devolving responsibility for implementation of assessment processes as an integral part of educational practices and values can maximize reliability and standards of assessment processes. We contend that while logistics and time constraints are of concern to busy faculty members, judicious utilization of resources to develop well-written MCQ items are well worth the effort to produce reliable and valid examinee scores. An enhancement-focused approach can be institutionally rewarding and lead to improved quality of high stakes assessments.

Recurrent gastrointestinal bleeding from hepatocellular carcinoma HCC invading the duodenum is very rare. We present a case of 50-year-old male who was admitted with a history of recurrent upper gastrointestinal tract UGIT bleeding, weight loss and anemia. The patient was known to have a chronic hepatitis C. Endoscopic examination showed grade-2 non-bleeding esophageal varices, and a large ulcerated duodenal mass partially obstructing the duodenal bulb outlet and causing recurrent UGIT bleeding. Pathological evaluation of the mass revealed HCC.

The clinical course and sequel of the life-threatening gastrointestinal (GI) bleeding during the treatment of strongyloides helmintic hyperinfection induced by immunosuppression in a patient with multiple myeloma is presented. A 55-year old male patient was diagnosed with strongyloides infection with stool analysis and intestinal biopsy shortly after his combined chemotherapy for myeloma. He was commenced on albendazole anthelmintic therapy. However, after initiation of the treatment he suffered life-threatening GI bleeding. Repeated endoscopies, including intraoperative enteroscopy, concluded to diffuse multifocal intestinal bleeding. The patient required huge amounts of red blood cells and plasma transfusions and correction of haemostasis with recombinant activated factor VII. Abdominal aorto-angiography showed numerous microaneurysms ("berry aneurysms") in the superior and inferior mesenteric arteries' territories. While the biopsy taken prior to the treatment with albendazole did not show evidence of vasculitis, the biopsy taken after initiation of therapy revealed leukoclastic aggregations around the vessels which was also consistent with vasculitis. These findings suggest that--in addition to direct destruction of the mucosa-vasculitis could be an important additive factor to the massive GI bleeding during the anthelmintic treatment. This might result from substances released by the worms that have been killed with anthelmintic drugs. Current guidelines advise steroids to be tapered and stopped in case of systematic parasitic infections as they reduce immunity and precipitate parasitic hyperinfection. In our pinion, steroid therapy might be of value in the management of strongyloides hyperinfection related vasculitis--in addition to the specific anthelmintic treatment. Indeed, steroid therapy of vasculitis with other means of supportive care yielded in sequel of the bleeding and in recovery of the patient.

A case of an anomalous extrahepatic biliary system is reported in which the right hepatic duct was found to enter the infundibulum of the gallbladder. In this case, a selective intraoperative cholangiography has prevented a possible major iatrogenic injury.