National Medical Journal of India

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On the quarter-millennial anniversary of the Madras General Hospital
(All India Institute of Medical Sciences, 2022-02) RAMAN, RAMYA; RAMAN, ANANTANARAYANAN
The General Hospital (GH) of Madras (presently Chennai) grew out of a hospital intended for the personnel attached to the Madras army—a Military Hospital (MH)—established within the Fort St George in 1664. Although the GH grew out of this MH, its relocation at its present Périamét (then known as Narimédu, Hog’s Hill) site in 1772, bearing the name ‘General Hospital’ marks its 250th anniversary in 2022. From being MH that serviced the ‘white’ residents of Madras, it opened to locals in 1899. In 2011, it was renamed as the Rajiv Gandhi Government General Hospital. Today, it has grown into a stunning medical facility in India treating about 12 000 patients a day. We chronicle the growth of the MH into the GH. Notable that the first formally conducted medical forensic examination in the whole of India occurred in this facility in August 1693, when this institution was MH. Surgeon Samuel Browne’s erroneous dispensation of a medication resulted in the death of James Wheeler, a prominent English-East India Company (EEIC) civil servant in Madras. Following an order to execute an investigation by the Governor, Fort St George, an autopsy of the body of Wheeler was carried out by Surgeon Edward Bulkley. Further to referring to such landmark historical details of early time segments of the MH and GH, we briefly refer to the remarkable medical work of Charles Donovan, William Niblock and Mysore Ramaswami Guruswami Mudaliar, who worked at the GH in the early decades of the 20th century.
Depressive and generalized anxiety symptoms in adults awaiting cataract surgery in India
(All India Institute of Medical Sciences, 2022-12) KUMAR, S.G. PREM; RANPISE, DHANAJI; CHAVAN, SHOBHANA; VISHWAKARMA, PANKAJ; KRISHNAN, RADHIKA; KURIAN, ELIZABETH
BACKGROUND Systematic data on mental health issues among adults awaiting cataract treatment are not readily available in India. We explored the prevalence and predictors of depressive and generalized anxiety (GA) symptoms in a cohort of adults awaiting cataract surgery. METHODS Our study is based on data from baseline assessments which were conducted as part of a multicentre prospective, longitudinal cohort study. Subjects were recruited from four eye hospitals to assess depression and GA and associated risk factors using standardized scales, i.e. Center for Epidemiologic Studies–Depression Scale (CES-D) and Generalised Anxiety Disorder (GAD-7). Variation in the intensity of depression and GA was assessed using multiple classification analysis (MCA). RESULTS A total of 813 adults awaiting cataract surgery participated, of whom 456 (56.1%) were men. The mean (SD) CES-D and GAD-7 scores were 24.6 (7.8) and 6.3 (SD 4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively. The overall prevalence of depression score of >16 was 87.4% (95% confidence interval [CI] 84.7%– 89.6%), and GA score of >10 was 57.1% (95% CI 53.5%–60.7%). The prevalence of comorbid depressive and anxiety symptoms was 56.6% (95% CI 52.9%– 60.2%). MCA showed that being neglected and mistreated by family/friends because of vision condition and facing difficulty and requiring help with daily tasks had the highest effect on the intensity of both depression (beta=0.254 and 0.238, respectively) and GA (beta=0.219 and 0.211, respectively). CONCLUSION The majority of adults with untreated cataract had both depressive and GA symptoms. These findings could be used for planning mental health interventions for adults awaiting cataract surgery.
National exit test: The medical faculty perspective—A pilot study
(All India Institute of Medical Sciences, 2022-02) DULLOO, PUJA; KANITKAR, MADHURI
BACKGROUND Implementation of the exit examination for medical graduates in India has been debated for many years. The national exit test (NEXT), under the construct of the National Medical Commission Act, would serve two purposes: first, it will be a common exit/licentiate examination for all Indian medical graduates, and second, it will be a test for postgraduate selections for all specialties. There has been no research or evidence on stakeholders’ opinion on this test. We aimed to assess the perspective of medical faculties, nationwide, regarding the implementation of NEXT. METHODS We conducted a nationwide, cross-sectional, questionnaire-based pilot survey. The Google survey form with close- and open-ended questions was forwarded via email and WhatsApp to various groups. RESULTS Two hundred and forty-five medical teachers participated, of which 35.9% were from Gujarat, 44.9% were working in government colleges, 91.43% had MD/MS as the highest professional degree, 50% had >15 years of experience and were from different medical specialties. The majority felt that the NEXT examination was a positive step, 82.5% suggested that a national selection/testing authority should conduct it, 36.3% suggested having the test after internship while 32.7% expected some weightage for each year of the medical programme, and 84.1% agreed that all the learning domains should be assessed by various strategies. DISCUSSION Faculties welcomed the NEXT examination under a national testing authority. The necessity of this examination is to have uniform standards and quality for medical graduates irrespective of their institutes. Assessment of all the domains will make the Indian medical graduate more competent for the job or residency programmes.
Transactions of the Medical and Physical Society of Calcutta: The first English language medical journal in India
(All India Institute of Medical Sciences, 2022-02) SINHA, SAVITRI DAS
Essential medicines for cardiovascular diseases in India: Rapid appraisal of policies and processes at the subnational level
(All India Institute of Medical Sciences, 2022-12) GARG, ANKUR; MURPHY, ADRIANNA; KRISHNA, ASHISH; SAHOO, SWAGATA KUMAR; HUFFMAN, MARK D; KISHORE, SANDEEP P; SHIVASHANKAR, ROOPA
BACKGROUND The burden of cardiovascular diseases (CVDs) and response to health systems vary widely at the subnational level in India. Our study aimed to assess the variation in state-level access to medicines for CVDs by comparing the essential medicines lists (EMLs) at the national and subnational levels in India and by rapid appraisal of the existing policies and processes of drug procurement. METHODS We assessed the inclusion of six classes of medicines for CVDs in the recent and publicly available national and subnational EMLs from July to September 2018 in the states of Telangana and Madhya Pradesh. We examined the drug procurement and distribution policies and processes using documentary review and five key informant interviews between March and June 2018. RESULTS The WHO’s EML, India’s national EML, and 21 of 28 publicly available (75%) Indian state and Union Territory EMLs included all six classes of essential medicines for CVDs. However, some medicines were not included in the policy packages of essential medicines meant for primary health centres. Both the states used centralized tendering and decentralized distribution as part of the public sector drug procurement process. The requirement was based on the previous year’s consumption. The approximate time between procurement planning and distribution was 7–8 months in both the states. CONCLUSION Substantial variation exists in the selection of drugs for CVDs in EMLs at the subnational level in India. Improving forecasting techniques for requirement of medicines and reducing time lags between forecasting and distribution to health facilities may allow for better access to essential medicines.
Role of male partners in birth preparedness and complication readiness: A qualitative study
(All India Institute of Medical Sciences, 2022-12) CHACKO, MAYA; GEORGE, LEYANNA SUSAN; RETNAKUMAR, CHARUTHA
BACKGROUND In familial and societal matters, men are the decision-makers and economic resource providers in many patriarchal societies. It is important to assess the involvement of men in birth preparedness and complication readiness (BPCR), as men act as gatekeepers to women’s health. We examined the role, motivators and barriers for participation of male partners of pregnant women in BPCR. METHODS This qualitative study was based on the grounded theory approach. Data were collected through 29 in-depth interviews conducted among husbands (n=8), mothers (n=8), mothers-in-law (n=8), health professionals (n=5) and focus group discussions (FGDs) with pregnant women (FGD, n=3). Interviews and FGDs were transcribed; themes and sub-themes were generated and conclusions were drawn by triangulation of the data. RESULTS Men were found to have a major role in BPCR. They supported their pregnant wives by maintaining their health, providing financial support and helping them in the decision-making process regarding treatment. They also provided complication readiness support by arranging transportation and facilitating the process of hospital admission. CONCLUSIONS Our study emphasizes how changes have occurred in the attitudes and practices over generations regarding men’s role in BPCR and their participation during delivery. However, there is a long way to go for which transference of knowledge and cultural transformation have become necessities.
Inhaled iloprost as an add-on therapy for advanced pulmonary arterial hypertension: An Indian perspective
(All India Institute of Medical Sciences, 2022-12) BOBHATE, PRASHANT; GUPTA, RAJAT KUMAR; KARANDE, TANUJA; KULKARNI, SNEHAL
BACKGROUND Pulmonary arterial hypertension (PAH) is a progressive disease with high morbidity and mortality. Risk stratification and initiation of dual or triple combination therapy has a better clinical response, especially in high-risk patients. Unfortunately, prostacyclin analogues are not marketed in India; hence, the use of these medications is limited. We report the benefits and difficulties of using iloprost inhalation in patients with advanced PAH in India. METHODS In this prospective observational study, we included patients with group 1 PAH. Inhaled iloprost was initiated as an add-on therapy for patients who had clinical, echocardiographic or laboratory deterioration on dual oral medications. Patients with clinical instability were excluded. All patients underwent thorough clinical evaluation, detailed echocardiogram and laboratory investigations. Patients were started on inhaled iloprost 2.5 ?g six times daily and closely followed up. The dose was escalated if necessary. On follow-up, clinical echocardiographic and laboratory evaluation was done on all patients. RESULTS Fourteen patients (11 women) with a median age of 32 years (2–66 years) with group 1 PAH were started on inhaled iloprost as an add-on therapy. Improvement in clinical parameters, WHO functional class, echocardiographic-derived right ventricular function, and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels were observed in 10 of 14 patients. A median increase of 31% (4.2, 106%) in the distance travelled during 6-minute walk test, a median increase of 45% (–20, 120%) in right ventricular fractional area change, a median increase of 27% (–16.7, 60%) in tricuspid annular peak systolic excursion and a median decrease of 36.7% (–69.6, 17.2%) in NT-pro-BNP levels were observed after initiation of medication. Three patients had progression of symptoms and were then referred for lung/heart–lung transplant. One patient developed progression of symptoms after an excellent initial response and transitioned to subcutaneous treprostinil. Improvement in clinical, echocardiographic and laboratory features allowed us to successfully perform surgical Potts shunt in 2 patients. The medications were well tolerated with minimal and transient side-effects. There were no deaths. CONCLUSION Inhaled iloprost can be used with acceptable benefits and minimal side-effects in patients with PAH.
Perspectives of women on availing antenatal services in urban poor areas of Rishikesh, Uttarakhand
(All India Institute of Medical Sciences, 2022-12) SHARMA, ANUSHA; KHAPRE, MEENAKSHI; KUMAR, SANTOSH; KISHORE, SUREKHA
BACKGROUND Antenatal care (ANC) is the essential regular care of women that prevents potential health problems during pregnancy. In India, the proportion of women who received four or more antenatal visits was only 51% (National Family Health Survey, 2015–2016). An even worse situation prevails in urban areas where women from poor communities face greater health risks. We assessed various barriers women residing in these areas come across in availing ANC services. METHODS This study is a part of a mixed-methods, community-based study, and we report its qualitative component. We conducted the study at the residence of the study participants in September–October 2019. The study participants were women who had less than four antenatal visits throughout the pregnancy. Twelve in-depth interviews were conducted based on data saturation. Data were transcribed and themes were drawn concerning the gender analysis framework. RESULTS Through this study, we found how gender relations affect the utilization of antenatal services concerning access to resources, division of labour, social norms including the belief of husband and other family members towards pregnancy and decision-making power of women. CONCLUSION Our findings underline the importance of making the urban health system gender-sensitive and responsive to the needs of women during pregnancy. There is a need to educate men regarding maternal health so as to allay such social norms that label pregnancy as a woman’s responsibility and encouraging them to accompany their wives during pregnancy visits, thus making men a part of antenatal services.
The rationale and guiding principles to design a psychiatry curriculum for primary care doctors of India
(All India Institute of Medical Sciences, 2022-02) DINAKARAN, DAMODHARAN; MANJUNATHA, NARAYANA; KUMAR, CHANNAVEERACHARI NAVEEN; MATH, SURESH BADA; THIRTHALLI, JAGADISHA
BACKGROUND Integrating psychiatric care into the general practice of primary care doctors (PCDs) is necessary to overcome the shortage of human resources to cater to the burgeoning public mental health needs of India. The traditional psychiatry curriculum is often top–down and specialist-based that contributes little in terms of skill quotient. We designed an innovative, digitally driven, distance education-based, part-time, modular-based Primary Care Psychiatry Programme (PCPP, skill-based). It is being implemented across many states of India to equip PCDs with skills to provide first-line psychiatry treatment. We discuss the rationale and guiding principles behind designing the curriculum of PCPP. DISCUSSION There are nine guiding principles behind designing and implementing PCPP to provide pragmatic, acceptable, feasible modules of higher translational quotient (TQ) that are essential to upskill PCDs. There is a shift in training the location of PCDs in their live brief general consultations utilizing innovative telemedicine-based ‘on-consultation training’ (OCT) augmented with collaborative video consultations. A monolithic treatment protocol-driven, trans-diagnostic approach is used to design a concise, all-inone, point-of-care manual containing a culturally sensitive, rapid, validated screener and taxonomy, called ‘Clinical Schedules for Primary Care Psychiatry’. This incorporates the PCDs’ style of clinical practice that helps in picking up the most commonly prevalent adult psychiatric disorders presenting to primary care. CONCLUSION This PCPP curriculum contains pragmatic modules with higher TQ. This curriculum is dynamic as the learning is bi-directional. This can be used by policy-makers, innovators and academia for integration with national health programmes such as those for non-communicable diseases and reproductive and child health.
Mapping the distribution and trends of co-circulating dengue virus serotypes in Odisha, India: A retrospective facility-based analysis
(All India Institute of Medical Sciences, 2022-12) LABALA, SALONI; SINHA, ABHINAV; PANDA, SAILENDRA; TURUK, JYOTIRMAYEE; PATI, SANGHAMITRA; SAHOO, PRAKASH KUMAR
BACKGROUND Dengue, caused by mosquito bite, is an emerging disease of international concern. Evidence regarding the prevalent dengue serotypes is scarce, but essential for its management during the outbreaks. Hence, we mapped the distribution and trends of currently prevalent dengue virus (DENV) serotypes in Odisha. METHODS We conducted a facility-based retrospective study from referral samples sent for the diagnosis/confirmation of dengue in 2018. The samples were serologically tested for enzyme-linked immunosorbent assay (ELISA) IgM antibody and NS1. Only NS1-positive samples were chosen for sero-typing. A pool of 8–10 NS1-positive samples were analysed for district-wise serotypes. Ribonucleic acid extraction and nested polymerase chain reaction (PCR) was done from NS1-positive samples. The PCR products were then subjected to gel electrophoresis. RESULTS A total of 2892 samples were screened for dengue virus across various districts of Odisha where 763 samples were found to be NS1-positive. Thirteen of 18 districts covering all topographies of Odisha predominantly had DENV2 serotype. Only few districts such as Balangir, Kalahandi and Rayagada had mixed serotypes. CONCLUSION Although DENV2 is predominantly prevalent, mixed serotypes too exist in Odisha. Evidence based on variations of dengue serotypes across topographies, seasons, gender and age groups may support public health efforts in preventing the disease.
Accuracy of Xpert® MTB/RIF in diagnosing extrapulmonary tuberculosis in Indian children
(All India Institute of Medical Sciences, 2022-12) SHAH, IRA; BHAMRE, RASIKA; SHETTY, NAMAN S
BACKGROUND Diagnosing extrapulmonary tuberculosis (EPTB) can be challenging because of a variety of presentations. We assessed the accuracy of the Xpert MTB/RIF assay in diagnosing EPTB in children. METHODS Of the 255 children diagnosed to have tuberculosis (TB) who underwent testing by the Xpert MTB/ RIF assay at the TB clinic from December 2014 to April 2017, 182 had EPTB and were included in the study. The diagnostic accuracy, specificity and sensitivity of the Xpert assay were calculated with Mycobacterium growth indicator tube (MGIT) as a reference standard. RESULTS Lymph node TB was present in 58 (32%) children, 37 (20%) had neurological TB, 36 (20%) had bone TB, 31 (17%) had pleural TB, 15 (8%) had abdominal TB, 2 (1%) had abscess, 2 (1%) had congenital TB and disseminated TB was seen in 1 (0.4%) child. Xpert MTB/RIF assay was positive in 84 (46.2%) patients. The sensitivity and specificity of the Xpert MTB/RIF assay were 72% and 72.04%, respectively. Compared to MGIT, a kappa coefficient of 0.44 shows moderate agreement between the Xpert assay and MGIT. The sensitivity of Xpert MTB/RIF assay in abdominal TB, bone TB, lymph node TB, neurological TB and pleural TB was 50% (15%–85%), 72.7% (15.9%– 86.9%), 80.8% (62.1%–91.5%), 75% (50.5%–90%) and 25% (4.6%–70%), respectively. The specificity of abdominal TB, bone TB, lymph node TB, neurological TB and pleural TB was 83.3% (43.7%–97%), 69.2% (42.4%– 87.3%), 55.2% (37.6%–71.6%), 85% (64%–94.8%) and 82.6% (62.9%–93%), respectively. Forty-seven (26%) patients had drug-resistant TB (DR-TB), of which 15 (8%) were rifampicin-resistant (RR), 2 (1%) were polyresistant, 14 (8%) had multi-DR (MDR), 15 (8%) had pre-extremely DR (XDR) and 1 (1%) had XDR-TB. Of the 15 patients with MDR-TB, Xpert MTB/RIF assay detected only 10 (71%) as RR (p=0.06). Of the 15 pre-XDR cases, Xpert MTB/RIF detected only 8 (53%) as RR (p=0.02). CONCLUSION Xpert MTB/RIF assay is useful in the diagnosis of EPTB. It shows good concordance with MGIT. However, it may be negative in patients with DR-TB.
Willingness of medical students to volunteer during the Covid-19 pandemic: Assessment at a tertiary care hospital in India
(All India Institute of Medical Sciences, 2022-08) SRA, MANRAJ; GUPTA, AMULYA; JAISWAL, ABHISHEK; YADAV, KAPIL; GOSWAMI, ANIL; GOSWAMI, KIRAN
BACKGROUND The involvement of medical students in strategies to control Covid-19 might be considered to cope with the shortage of healthcare workers. We assessed the knowledge about Covid-19, willingness to volunteer, potential areas of involvement and reasons for hesitation among medical students towards volunteering. METHODS We did this cross-sectional study among undergraduate students at a tertiary care teaching hospital in New Delhi. We used a web-based questionnaire to elicit demographic information, knowledge of Covid-19, willingness to volunteer and reasons deterring them from working during the Covid-19 pandemic, and self-declared knowledge in six domains. RESULTS A total of 292 students participated in the study with a mean (SD) age of 19.9 (3.1) years. The mean (SD) knowledge score of Covid-19 was 6.9 (1.1) (maximum score 10). Knowledge score was significantly different among preclinical (6.5), paraclinical (7.18) and clinical groups (7.03). Almost three-fourth (75.3%) participants were willing to volunteer in the Covid-19 pandemic, though 67.8% had not received any training in emergency medicine or public health crisis management. Willingness to work was maximum in areas of social work and indirect patient care (62.3% each). Lack of personal protective equipment was cited as a highly deterring factor for volunteering (62.7%) followed by fear of transmitting the infection to family members (45.9%), fear of causing harm to the patient (34.2%) and the absence of available treatment (22.2%). CONCLUSIONS A majority of the students were willing to volunteer even though they had not received adequate training. Students may serve as an auxiliary force during the pandemic, especially in non-clinical settings.
Isolated pulmonary valve endocarditis with pulmonary annular abscess in a patient of Noonan syndrome
(All India Institute of Medical Sciences, 2022-10) RAO, SHIVANI; NEGI, PRAKASH CHAND
Right-sided endocarditis is a rare entity, with various series reporting an incidence of 5%–10%. Pulmonary valve (PV) is not only the least commonly involved valve in infective endocarditis (IE), with an incidence of 1.5%–2%, but ‘isolated’ pulmonic valve endocarditis (PVE) without tricuspid valve involvement is even rarer with limited published data. We report a middle-aged man with Noonan syndrome and a dysplastic PV with severe pulmonary stenosis. He presented with a large isolated mobile PV vegetation with moderate pulmonary regurgitation (PR). Initially, he was managed conservatively, but due to persistent fever, pulmonary regurgitation and evidence of pulmonary annular abscess extending into the right ventricular outflow tract, he required surgical intervention. Considering the low incidence of isolated PVE, it poses a challenge for physicians in prompt diagnosis and timely management of the infection.
Study of atrial arrhythmias after surgical or device closure of atrial septal defect
(All India Institute of Medical Sciences, 2022-10) MOHANKUMAR, NANDHINI; NAMBOODIRI, NARAYANAN; NAIR, KRISHNA KUMAR MOHANAN; RAGHURAM, KARTHIK; VALAPARAMBIL, AJITKUMAR; MAHADEVAN, KRISHNAMOORTHY KAVASSERY
BACKGROUND Device closure of atrial septal defect (ASD) has emerged as a treatment modality for the past 3 decades and has changed the natural history of ASD compared to that of surgical closure. Early intervention in ASD retards the geometrical and electrical remodelling of the atrium that contributes to the development of atrial tachyarrhythmias. We studied the incidence of atrial arrhythmias in patients undergoing surgical and device closure of ASD. METHODS We did this retrospective observational study at a tertiary referral centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. Patients of all age groups undergoing surgical and device closure of ASD between 1 January 2003 and 31 December 2008 were included to compare the incidence and nature of atrial arrhythmias and also analyse the difference in new-onset atrial arrhythmias between the two arms. RESULTS Of 277 patients, 144 with surgical closure and 133 with device closure were followed up for 10–15 years. A larger number of men underwent surgical closure (41.7%) compared to device closure (25.6%). The mean (SD) follow-up was 12.6 (3.7) years in the surgical closure group and 10.9 (2.6) years in the device closure arm. There were a larger number of patients with atrial tachyarrhythmias in the surgical closure group (6.3%) compared to the device closure group (0.8%) at baseline (p=0.02). A significantly larger number of patients had atrial fibrillation in the surgical closure group (5.6%) compared to the device closure group (0.7%) at baseline (p=0.003). Pulmonary hypertension at baseline was present in 38.9% of patients in the surgical closure group and in 23.3% of patients in the device closure group (p=0.006). New-onset atrial arrhythmias occurred in patients ?30 years of age (p=0.006) and exclusively in patients with pulmonary hypertension in the surgical group (3.7%) and in the device closure group (6.6%). This was statistically significant in the device closure group (p=0.05) but not in the surgical closure group (p=0.13). The incidence of new-onset arrhythmias was not statistically significant in both groups. CONCLUSIONS Atrial arrhythmias were significantly more common in patients who underwent surgical or device closure at ? 30 years of age and in patients with pulmonary hypertension. There was no difference in new-onset atrial arrhythmias between the surgical and device closure groups. Our study results suggest that surgical or device closure before 30 years of age and before the development of atrial arrhythmias may be beneficial with respect to the development of atrial arrhythmias.
Impact of Covid-19 lockdown on the emotional health of schoolchildren in an urban Indian setting
(All India Institute of Medical Sciences, 2022-08) MATHEW, DEEPA ELIZABETH; JOHN, CHERI MATHEWS; JOHN, NATASHA SUSAN; JOHNSON, JOE; PORCHELVAN, S; GEORGE, SANJU
BACKGROUND Public health measures taken to prevent the spread of the Covid-19 pandemic can potentially impact the mental health of children. We assessed the prevalence and risk factors for childhood depression during the Covid-19 lockdown. METHODS After 100 days of lockdown, we sent a survey questionnaire by WhatsApp to parents of school-aged children (5–16 years) in Chennai. The Short Mood and Feelings questionnaire was used as an objective screening tool to assess depression, with a score of 12 as the cut-off. RESULTS There were 874 responses. The prevalence of childhood depression was 13.7%. Girls were more likely to be depressed than boys; 11–16-year-olds were more likely to be depressed than 5–10-year-old children. Children who had more than 4 hours online education had a higher likelihood of depression. Those who used a cell phone for online classes had a higher likelihood of depression compared to other devices, such as tabs or laptops. Children who slept less than 8 hours a day had a higher likelihood of depression while those who either did not sleep in the afternoon or slept less than 1 hour had a lower likelihood of depression. Children who were interacting with family over 1 hour per day had a lower likelihood of depression. CONCLUSION Overzealous online education, lack of adequate sleep and failure to spend quality time with the family can negatively impact the mental health of children. The impact of Covid-19 on the emotional health of children should be addressed by public health policy-makers and healthcare professionals.
Large right-sided pneumothorax with Takotsubo cardiomyopathy
(All India Institute of Medical Sciences, 2022-10) MAHADEVAPPA, MANJAPPA; KULKARNI, PRASHANTH; POORNIMA, K.S.
Patients with left-sided pneumothorax presenting with electrocardiogram (ECG) changes resembling acute coronary syndrome (ACS) have been reported in the literature. Takotsubo cardiomyopathy (TCM) occurs predominantly in post-menopausal women with underlying intense emotional or physical stress. However, as this case report shows, it can complicate any acute illness leading to intense stress. We report a rare combination of ECG changes mimicking ACS in a man with a large right-sided pneumothorax and TCM.
Scoping review of published research on medical education in India during the Covid-19 pandemic
(All India Institute of Medical Sciences, 2022-08) KUMAR, DINESH; DONGRE, AMOL; VARMA, JAGDISH; PANDYA, HIMANSHU
BACKGROUND Medical educators in India made rapid adjustments to maintain continuity and integrity of medical education in the midst of disruption caused by the Covid-19 pandemic. However, there are concerns regarding achievement of competence by undergraduate medical students due to inadequate clinical exposure. We explored the focus of initiatives from medical educators in India by a scoping review of published articles on developments in medical education during the pandemic to map concepts, main sources and the literature available in PubMed. METHODS We did this scoping review of published articles in PubMed database in four steps: (i) identification of research questions; (ii) identification of relevant studies; (iii) selection of studies meeting inclusion and exclusion criteria, and charting of data; and (iv) collating the summary and reporting of results. Manual content analysis was done to derive frequencies of variables. RESULTS Of the 52 articles identified, 22 met the requirements. Most studies (68.2%) were published in 2020. Half of the studies were conducted among undergraduate students and the remaining among postgraduates (27.3%), faculty (18.2%) and interns (4.5%). All the studies were evaluations at Kirkpatrick level-1 (18; 81.8%) and level-2 (4; 18.2%). Most of the studies (9, 41%) focused on exploration of perspectives about online learning among students and faculty, 9 (27.3%) on teaching– learning, 4 (18.2%) on formative assessment and 3 (13.6%) on summative assessment. CONCLUSIONS Most studies were evaluations at Kirkpatrick level-1 and level-2 among undergraduate medical students with a focus on conceptual understanding.
The gaps in undergraduate medical education due to the ongoing pandemic: An experience from a private medical college in Kerala
(All India Institute of Medical Sciences, 2022-10) RAFI, ABOOBACKER MOHAMED; NAIR, PADMAKUMAR KRISHNANKUTTY; KUTTICHIRA, PRAVEENLAL
The Covid-19 pandemic affected undergraduate medical education worldwide. By March 2020, colleges in India had to close following a national lockdown. Most of the colleges including ours started using e-platforms. Our earlier studies highlighted concern for lack of patient examination in clinical settings and successes of the online teaching programmes were limited to didactic teaching. The year 2020 also was the year in which the National Medical Commission (NMC) introduced a competency-based system, which was new to all stakeholders. We assessed the impact of Covid-19 on the ongoing teaching pattern in our institute. Actual coverage of theory classes and practical/clinical teaching sessions were gathered from departments across all years of undergraduate medical education and the gap percentage was calculated against the NMC/ Medical Council of India requirements. The gap percentage was calculated as missing classes divided by required classes multiplied by hundred. The heads of departments were consulted, and details of theory, practical and clinical classes taken for each batch before and after lockdown were gathered using a questionnaire. These were compared against the mandated teaching by the NMC guideline for theory, practical and clinics. The results showed a gap ranging from 2% to 83% for theory classes, the least being in anatomy and the highest being in medicine. As there were no practical or clinical sessions during the lockdown, the gap was zero. Various challenges were faced due to online medical education. There was a dilemma over choosing the type of training that would produce adequate numbers with low quality or a delayed training but of assured quality. Various solutions including suspending the ongoing course and converting it to short-term skill training sessions to deal with pandemic care and strategies to improve online teaching were considered.
Non-operative treatment for low back pain: A review of evidence and recommendations
(All India Institute of Medical Sciences, 2022-02) GARG, BHAVUK; GEORGE, JAIBEN; MEHTA, NISHANK
BACKGROUND Low back pain (LBP) is a healthcare problem with high global prevalence, with non-operative management being the first line of treatment in the majority of patients. This literature review summarizes the current evidence for various modalities of non-operative treatment for LBP. METHODS We did a literature search to elicit high-quality evidence for non-operative treatment modalities for LBP, including Cochrane Database reviews and systematic reviews or meta-analysis of randomized controlled trials. Only when these were not available for a particular treatment modality, other level 1 studies were included. The quality of evidence was categorized in accordance with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method—a globally adopted tool for grading the quality of evidence and making treatment recommendations. RESULTS The treatment modalities that were reviewed included: general measures, medications/pharmacotherapy, exercises, electromagnetic therapies, alternative treatment modalities and interventional therapies. We found that high-quality evidence is lacking for most non-operative treatment modalities for LBP. The majority of interventions have small benefits or are similar to placebo. CONCLUSION The current evidence for non-operative treatment modalities for LBP is insufficient to draw conclusions or make recommendations to clinicians. High-quality trials are required before widespread use of any treatment modality. Considering that non-operative treatment is usually the first line of therapy for most patients with LBP, it deserves to be the focus of future research in spinal disorders.
Covid-19 presenting as isolated severe thrombocytopenia in an HIV-lymphoma survivor
(All India Institute of Medical Sciences, 2022-08) MADAN, MANU; SHAREEF, IMTIYAZ; RAJA, ARUN; DWIVEDI, TANIMA; MITTAL, SAURABH; SAHOO, BISWAJEET; MEENA, VED PRAKASH; TIWARI, PAWAN; MOHAN, ANANT; MALLICK, SAUMAYARANJAN
Coronavirus disease has myriad manifestations and can present with predominantly extrapulmonary manifestations. We describe a 50-year-old man, a person living with HIV (PLHA), a non-Hodgkin lymphoma survivor, who presented with isolated severe thrombocytopenia. He was found to have immune-mediated thrombocytopenia, and showed excellent response to intravenous immunoglobulins.

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