National Medical Journal of India

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The undergraduate virtual grand teaching ward round: Perceptions from the subcontinent
(All India Institute of Medical Sciences, 2024-01) Gooneratne, T; Wijeyaratne, M.
Background Grand ward rounds are an integral component of undergraduate medical education. Covid-19 prevented the conduct of conventional grand ward rounds (CWRs) prompting a ‘virtual’ grand ward round (VWR). With restrictions lifted should future grand ward rounds remain virtual? Undergraduate perceptions on the two formats were sought to explore the feasibility of the VWR as a teaching ward round for medical students. Methods Our study was done during April 2021 to April 2022. The weekly grand ward round was converted to a VWR during April–November 2021. Following lifting of restrictions, it was reverted to a CWR. All patients provided informed consent. A Zoom-based, secure, online platform was created with the use of smartphones to share audiovisuals and patient discussions. An online anonymised feedback survey was conducted for undergraduates during both VWR and CWR phases. Results The response rate was 71% (182/258). VWR was considered more advantageous than the CWR in terms of time efficiency (p=0.03), space restrictions (p=0.01), improved audibility (p=0.02) and better opportunity to engage in discussions (p=0.1). Most students (80%) felt that the VWR provides a more ‘ideal’ grand ward. Overall preference was towards VWR across safety (92%), efficacy (72%), communication (85%), information availability (84%) and training opportunity (73%). Again 80% of students preferred future ward rounds to be virtual. Conclusions VWR is an innovative approach. While not a substitute for bedside teaching it appears safer, efficient, thought/discussion-provoking and more satisfactory. Successful elements of the VWR can be adopted in future, to develop a more ideal undergraduate grand ward round.
Pseudo-subarachnoid haemorrhage: An unusual presentation of hyperviscosity syndrome
(All India Institute of Medical Sciences, 2024-01) Thomas, A; Jose, H; Jacob, L; Koshy, JM; Sebastian, GM
Hyperviscosity syndrome can present with haematological, neurological or cardiovascular manifestations. The common differential diagnoses for severe headache and altered sensorium in a patient with Eisenmenger syndrome include brain abscess, meningitis, cortical venous thrombosis and subarachnoid haemorrhage (SAH). We report a patient with Eisenmenger syndrome with hyperviscosity, presenting as pseudo-SAH, which was successfully treated with phlebotomy.
Epidemiology and clinical spectrum of melioidosis: Analysis of cases from a tertiary care centre in southern Tamil Nadu
(All India Institute of Medical Sciences, 2024-01) Ganesan, V; Sundaramurthy, R.
Background We studied the clinical features and treatment outcome of patients with melioidosis in our hospital. Methods We did this retrospective observational chart review over a period of 7 years between December 2014 and February 2022. Results There were 59 cases and 23 deaths attributable to melioidosis over the study period. The age range was 5 to 74 years and 48 (81.3%) were men. The comorbid conditions included diabetes mellitus (68%), alcoholism (11.8%), pulmonary tuberculosis (6.7%) and chronic kidney disease (5%). Over three-fourths of patients (78%) presented during the rainy season (June to December) and were acute presentations (44 [75%]). The most common sites were liver and spleen, followed by the musculoskeletal system, skin, soft tissues, lungs and brain. Of the 21 (36%) patients with septic shock, 16 (76%) died. On the contrary, of 38 (64%) patients without septic shock, only 11% died. Of the 27 (47%) admitted to ICU, 11 (41%) died. In ICU, 18 (67%) were ventilated. Of the 23 (39%) deaths overall, median time from admission to death was 4 days. There were no relapses in the 42% patients followed up for 2–6 months. Conclusions The epidemiology of melioidosis is similar to other endemic areas with preponderance of men. There was a temporal association with the monsoon season and a higher number of acute cases. The differences included a higher proportion of deep visceral abscesses and musculo-skeletal involvement compared to lung involvement.
Macrolipasemia variant of macroenzymes: An endocrine laboma
(All India Institute of Medical Sciences, 2024-01) Sharma, LK; Datta, RR; Aggarwal, A; Sharma, N; Dutta, D.
Macroenzymes, formed by polymerization of physiological enzymes with immunoglobulins, have slower renal clearance rates due to their higher molecular mass. They are usually incidentally detected, have no pathophysiological importance, and can potentially lead to over-treatment and iatrogenic morbidity. We present, possibly for the first time, a macro-lipasemia variant of macroenzyme, detected in a 14-year-old girl with type-1 diabetes admitted with severe hyperglycaemia and pain abdomen. Raised lipase levels (414 U/L), initially raised the suspicion of underlying pancreatitis, which was ruled out by the clinical symptoms and normal ultrasound and CT imaging of the pancreas. Upper gastrointestinal endoscopy revealed pangastritis, which could explain the mild upper abdominal pain in the child. She improved with proton pump inhibitor therapy and was discharged after 5 days of hospital admission after good glycaemic control using multiple subcutaneous injections of insulin. Post-polyethylene glycol (PEG) precipitation, the recovery of lipase activity in PEG treated serum sample was 30.6% (127 U/L), which confirmed the presence of macrolipase. An increased clinical suspicion and performing a cheap reliable test (PEG precipitation), whenever there is clinical biochemical discordance can help us in diagnosing more patients with macroenzymes and macrolipasemia.
Regional patterns in minimum diet diversity failure and associated factors among children aged 6–23 months in India
(All India Institute of Medical Sciences, 2024-07) Gunnal, G; Bagaria, D; Roy, S.
Background About 35% of the global child deaths and 11% of the total disease burden are due to inadequate nutrition. While in India, 1 in 3 children are underweight and stunted, and 1 in 5 children are wasted. Methods Using multivariate and descriptive statistical analysis, we examined the prevalence, determinants of minimum diet diversity failure (MDDF) and trends of MDDF across different regions of India among children aged 6–23 months. Dietary pattern in 8 food groups was also examined using the National Family and Health Survey (NFHS) data from 2005–06 to 2019–21. Results Overall, MDDF in India has decreased from 87.4% (2005–06) to 77.1% (2019–21). The central region (84.6%) reported the highest prevalence of MDDF in 2019–21. Children of illiterate and rural residing mothers with no mass media exposure, children of the first birth order and children not exposed to counselling and health check-ups at Anganwadi/Integrated Child Development Services (ICDS) centres, children with low birth weight and anaemic, and who belonged to a large family had greater likelihood for MDDF. Conclusion To tackle the high prevalence of MDDF, a holistic action is needed from the government, i.e. improved public distribution system (PDS), intensified Integrated Child Development Scheme (ICDS) programme, use of social media, and nutrition counselling through local self-governance.
Credit hours and continuing medical education (CME) programmes
(All India Institute of Medical Sciences, 2024-05) Bhattacharya, S; Bhattacharya, K.
Continuing medical education (CME) credits has been mandated by the National Medical Commission for registered medical practitioners in India as a part of continuing professional development and a minimum of 30 credits in 5 years is required for the renewal of the medical license. Undoubtedly, credit hours for CME attendance is an essential yardstick for professional and career growth, the modus operandi adopted to grant these credit hours needs a serious look. Targeted learning with adequate feedback either with a post CME examination or questionnaire should become the norm and every publication in high impact indexed journal deserve a higher credit point than the rest of the publications.
Mid-level healthcare providers: Making a fresh case for modern Indian healthcare
(All India Institute of Medical Sciences, 2024-07) Bhaduri, SD
To compensate for physician shortage, many countries around the world have introduced a cadre of mid-level healthcare providers (MLHPs) into their health systems to shoulder many of the conventional responsibilities of a physician. Besides backing their clinical competence and service quality, evidence and experience on MLHPs also supports their lower turnover and higher rural retention rates. In India, mainstreaming of MLHPs has time and again been met with resistance from organized medicine. We explore a fresh case for MLHPs in India in view of some recent developments and the probable future contours that Indian healthcare is likely to assume. Aided by global precedents, we broaden the rationale for mainstreaming MLHPs, address some common misunderstandings, and describe the conducive emergent legal and policy landscape. We also explain how a possible reorganization of Indian healthcare, highly likely under expanded publicly financed health insurance and value-based healthcare regimes, can warrant greater health workforce differentiation and an expanded role of MLHPs in mainstream healthcare delivery. We also touch upon important political economy considerations, including the need for navigating organized medical opposition, involving medical stakeholders in the MLHP mainstreaming process, autonomous regulation of MLHP professions, streamlining MLHP competencies, and inclusive health financing systems.
Scrub typhus presenting as mitral valve infective endocarditis
(All India Institute of Medical Sciences, 2024-07) Devi, S; Das, D; Acharya, D; Das, T; Singh, S; Gupta, JD; Pramanik, S
Scrub typhus presenting as infective endocarditis of the mitral valve is rare. There are few reports of infective endocarditis by scrub typhus with just one previous report of involvement of the aortic valve. An 18-year-old woman presented with prolonged fever for 1 month. Her repeated blood cultures were negative. She was finally diagnosed to have scrub typhus with scrub typhus IgM being positive and became afebrile with prolonged oral doxycycline monotherapy. Although atypical organisms such as Legionella, Mycoplasma and Coxiella are described to cause culture-negative endocarditis, vegetations were present on both the anterior and posterior mitral valve leaflets in our patient.
Learning medical sociology through an innovative ‘Elective study module’ integrating humanities with medicine for undergraduate students of a medical college in Bengaluru, India
(All India Institute of Medical Sciences, 2024-07) Gomes, N; Harikumar, V; Joseph, J; Mohapatra, A; Rai, A; Senthil, S; Varughse, N; Mony, P
Background The newly introduced ‘Elective programme’, a voluntary special study module in the final phase of the undergraduate medical curriculum, offers scope for new immersive, self-directed learning opportunities. We describe a programme of study for learning ‘medical sociology’ through the innovative use of humanities in medicine. Methods Our elective module, called ‘Community Health and Rock Music’ (CHaRM), was a 2-week programme, merging the curricular subject of community health with ‘rock music’ as an exposure to the ‘counter-culture’ outside of the medical world. The half-day sessions consisted of: (i) watching/listening to a rock song-video without reading its lyrics; (ii) listening to the same song again but with lyrics; (iii) undertaking an emotionally stimulating activity (watching a movie, making a site-visit, etc.); and (iv) debriefing, to identify/discuss the underlying social determinants of health and their relevance in the grooming of a socially aware medical student. Formative assessment was intended to gauge levels of expression of the affective domain (attitude/emotions). Results Seven of 143 students volunteered for this programme. Key learnings were a clear appreciation of the societal determinants of health (such as deprivation/discrimination/social structures); multi-level causation of diseases; social issues not addressed in traditional medical curriculum; personal growth; teamwork; and the role of empathy in medical practice. Additional learning was the exposure to the ‘counter-culture of arts’. All 7 student assessments ‘met expectation’, with 4 of them ‘exceeding expectation’. Conclusion An ‘elective programme’ combining humanities with medicine is potentially an innovative, student-centric and replicable model of learning that impacts the affective domain critical for doctors-in-training.
Evaluation of a novel method for teaching drawing of histology diagrams to first year MBBS students
(All India Institute of Medical Sciences, 2024-07) Sreenivasan, S; Nakhate, MS
Background The challenge faced by an undergraduate medical student to draw factually correct histology diagrams needs to be addressed by the use of innovative teaching strategies. We introduced a new method to teach drawing of histology diagrams and compared its outcome with two preexisting methods. We obtained feedback from the students and faculty. Methods We introduced an innovation (method 3): A validated hand-drawn pencil sketch of a histology diagram was provided to the students. Students drew on the pencil sketch with haematoxylin and eosin (H&E) pencils and coloured it. They then drew the same diagram afresh. Three diagrams of systemic histology were chosen and the evaluation criteria shared with students. The students drew all three diagrams once, each by a different method. The scores of method 3 were compared with the other two methods, copying from standard atlas (method 1) and from hand-drawn colour chart made by teacher (method 2). Feedback was sought from students and faculty by means of a google form. Results A total of 112 students (of 167 who volunteered) completed the study. The mean (SD) score obtained by method 3 (4.83 [0.298]) was higher than the mean score by method 1 (3.91 [0.95]) and method 2 (4.82 [0.27]). There was a statistically significant difference between method 3 and method 1 (p<0.01), and method 2 and method 1 (p<0.01). However, the difference in scores between methods 3 and 2 was not statistically significant (p>0.05). Conclusion We found method 3 (the innovation) to be better than one of the pre-existing methods (method 1) but not better than method 2. The quality of diagrams produced by methods 2 and 3 were better than those by method 1, and equally so. The ease of drawing and time taken to draw were the best for method 2. Hence, overall, method 2 may be adjudged the best method.
Camphor poisoning in an adult: Seizures manifesting as ‘mis-purposed’ drug effect
(All India Institute of Medical Sciences, 2024-01) Sahu, AK; Rathoor, S.
Camphor, a common aromatic hydrocarbon, is known to be potentially hazardous due to its acute harmful effects primarily on the central nervous system. Contrastingly, camphor is an integral component of various indigenous medicinal potions owing to its medicinal value. Camphor neurotoxicity has been reported in children. However, accidental or voluntary ingestion in adults is rare. We report a patient with voluntary ingestion of camphor, in a relatively large dose for alleviation of a medical condition.
Scrub typhus presenting with massive splenomegaly and lobar pneumonia
(All India Institute of Medical Sciences, 2024-07) Vihari, J; Aditya, A; Krishna, AV; Roja, T; Elika, M; Pooja, U.
Scrub typhus is still an underdiagnosed disease despite an increase in incidence as the clinical presentation is often different, leading to a low index of suspicion among doctors. Scrub typhus, an acute febrile disease, is a cause of prolonged fever and pyrexia of unknown origin. It can have varied clinical presentations ranging from mild asymptomatic disease to fatal multi-organ dysfunction. Splenomegaly in scrub typhus has been rarely reported. We report a 30-year-old man presenting with fever, hepatomegaly, massive splenomegaly, lymphadenopathy and lobar pneumonia. Tests for malarial parasite and enteric fever were negative. Bone marrow aspiration showed normal haematopoiesis. IgM scrub was positive. Upon serological confirmation, doxycycline therapy was started followed by a rapid and complete resolution of pneumonia (both clinically and radiologically), splenomegaly and lymphadenopathy. This highlights the importance of recognizing rare clinical manifestations of this common tropical disease. An early diagnosis is required as a delay may lead to complications and a poor outcome.
V.R. Khanolkar’s initial years as pathologist and researcher in India: 1924–1941
(All India Institute of Medical Sciences, 2024-05) Pai, SA; Lanjewar, DN; Joshi, AS.
Vasant Ramji Khanolkar was the first Indian pathologist and a pioneering researcher who was at the forefront of the diverse fields of cancer research, blood group genetics, epidemiology and leprosy research, etc. in the mid-twentieth century. All his cutting-edge research took place after he joined Tata Memorial Hospital, Bombay (now Mumbai), as Director of Laboratories. There is little evidence of his research in the first 17 years of his career in India, at J.J. Hospital and K.E.M. Hospital, Bombay. We tried to address this gap by attempting to obtain information on Khanolkar’s papers from PubMed, prior to his having joined Tata Memorial Hospital. We evaluated the abstracts of the presentations that he made at the meetings of the Teaching Pathologists Association, Bombay. Finally, we extracted from the autopsy registers at the two hospitals, any useful information about the autopsies that he had performed. Khanolkar performed preliminary laboratory research in anaemia as well as some experimental pathology in his stint at K.E.M. Hospital. Further, surprisingly, histology was not performed on most autopsies at J.J. Hospital for the period that he was Professor, but was done at K.E.M. Hospital. Why Khanolkar was a late bloomer and did not perform much research or publish in the first two institutions that he was Professor at, remains a mystery.
India’s role in the odyssey of medical training in South Africa
(All India Institute of Medical Sciences, 2024-07) Singh, B; Singh, JP; Ebrahim, S; Naidoo, NM.
Apartheid had a devastating impact on medical education in South Africa. Until the development of the University of Natal Medical School in 1951, there were minimal opportunities for blacks (collectively Africans, Indians and so-called coloureds) to undertake undergraduate and postgraduate medical training in South Africa. At the height of apartheid (1968–1977), whites who had constituted 17% of the population, accounted for up to 87% of all medical graduates. The African majority, constituting 70% of the population had less than 5% of all medical graduates in South Africa. The global isolation of South Africa from the late 1940s further impacted negatively on the medical training for blacks in South Africa. During apartheid, the Government of India provided full scholarships to the marginalized in South Africa to study medicine in India. This initiative, coming at a time when India was grappling with its post-colonial challenges, was a remarkable yet seldom appreciated gesture.
Haemodiafiltration or haemodialysis in kidney failure
(All India Institute of Medical Sciences, 2024-05) Modi, GK; Kumar, S
Exchange transfusion as a therapeutic modality for aniline dye-induced methaemoglobinaemia
(All India Institute of Medical Sciences, 2024-07) Gupta, N; Dhagia, S; Kelaiya, A; Sama, R; Padhy, K
Methaemoglobinaemia and a Heinz-body haemolytic anaemia are uncommon but potentially treatable complications of aniline poisoning. Management of aniline poisoning is mainly removing the source of aniline exposure and management of methaemoglobinaemia. Management of methaemoglobinaemia is guided by blood methaemoglobin levels and patient symptoms. Blood methaemoglobin level <30% requires only supplemental oxygen while for methaemoglobin level >30%, intravenous methylene blue is the mainstay of treatment. All patients treated with methylene blue should be observed for delayed haemolysis, acute renal failure and cardiac complications. In patients with contraindication to methylene blue, exchange transfusion can be used while haemodialysis is reserved for complicated cases. We successfully managed 6 patients of methaemoglobinaemia due to aniline poisoning by methylene blue. Two of these patients who developed Heinz-body haemolytic anaemia with acute renal failure as a complication also required exchange transfusion.
Health impact of screen addiction: A cross-sectional comparative study
(All India Institute of Medical Sciences, 2024-01) Rao, SR; Mhatre, PP; Ambike, AA; Adarkar, SA; Gupta, V; Paranjape, RM; Saraf, PH; Raul, SK; Kadam, ES
Background Prevalence-based, non-comparative studies have been done to assess psychological and physical consequences of social media and gaming addiction. However, similar studies are lacking for binge-watching, especially in India. We compared the physical and psychological health impact between screen addicted and healthy screen users, by minimizing bias due to confounding factors. Methods We did this cross-sectional comparative study among 120 participants (60 cases and 60 matched controls) consisting of gamers, social media users and binge-watchers, who were recruited from schools and colleges of Mumbai based on their scores on the Digital Addiction Scale (DAS). Levels of depression, anxiety and stress; sleep quality; and dry eye disease were assessed using pre-validated scales such as DASS-21, Pittsburgh Sleep Quality Index (PSQI), and Ocular Surface Disease Index (OSDI), respectively, while the other variables were assessed using a self-designed questionnaire with a content validity ratio (CVR) >0.65. Results The mean (SD) age of the participants was 19.3 (3.2) years, one-third were women; 68% were from medical colleges and 16% each from engineering colleges and high schools. The prevalence and scores of depression, anxiety and stress; poor sleep quality; and dry eye disease; and prevalence of loneliness, aggression and musculoskeletal pain in the wrist, thumb, neck and back were significantly higher in the screen addicted group (p<0.05). Conclusions There was a significant difference in the prevalence and levels of physical and psychological health impact between screen addicted and healthy screen users.
Evaluation of 3-year tuberculosis external quality assessment results of public health laboratories
(All India Institute of Medical Sciences, 2024-07) Bozkurt, ENN; Uçarman, SN; Arslantürk, A; Saribas, A; Altun, D; Özsaraç, H; Simsek, H
Background We aimed to evaluate the 3-year participation status of tuberculosis (TB) laboratories in public health laboratories (PHL) tuberculosis external quality assessment (EQA) and EQA results. Method During 2018–2020, PHLs participated in the EQA programme organized annually by the National Tuberculosis Reference Laboratory (NTRL). Five kinds of EQA samples were sent to the participating laboratories on three parameters, including microscopy, culture and phenotypic first-line drug susceptibility testing and they were asked to perform according to the standard protocol. The results were taken over by the Tuberculosis Laboratories Surveillance Network (TULSA) web system and analysed. Results A total of 24 PHLs participated in the EQA in 2018; 30 in 2019 and 23 in 2020. In terms of sensitivity, specificity, accuracy and reproducibility in microscopy, respectively, in 2018, 20 of the laboratories were 100%, 4 of them 80%, and in culture 16 of them were 100% and 2 of them 80%; in 2019, 28 of them were 100%, 2 of them 80%, and in culture 11 of them were 100%, 6 of them 80%, 1 of them 60%; in 2020, 20 of them were 100%, 3 of them 80%, and in culture 13 of them were 100% and 3 of them 80%. Conclusion It is beneficial for laboratories working on TB to participate in EQA in terms of evaluating the accuracy and reliability of the method used.
Sensitizing nursing faculty about formation of professional identity: Exploration of lessons learnt at a nursing institute in India
(All India Institute of Medical Sciences, 2024-05) Pandya, H; Dongre, A; Ghosh, S; Prabhakaran, A; Prakash, RH; Panchal, S; Varma, J
Background We initiated a conversation regarding the concept of professional identity formation (PIF) with faculty of Institute of Nursing at our university through a participatory workshop. We report the planning and conduct of the workshop, as well as lessons learnt from the discussions in the workshop. Methods We designed and implemented a day-long workshop for 28 nursing faculty at Institute of Nursing, Bhaikaka University, Gujarat. The expected learning outcomes of the workshop were to: (i) understand the concept of PIF and process of socialization; (ii) identify factors influencing socialization; and (iii) discuss strategies to support PIF. The workshop included a series of four small group discussions, each followed by debriefing. We collected feedback using a questionnaire with 4 open-ended questions and written reflections on the learnings, within 2 days of the workshop. We carried out manual content analysis of text data generated during group work, reflections and feedback. Results Twenty-six of the 28 participants responded to the questionnaire. Thirteen mentioned interactions during group activities and discussions with facilitators as a good part of the workshop. Constructive suggestions on improving the workshop were received from 13 respondents. Twenty-three respondents reported they would make changes in their practice after the workshop. Five respondents found the activity on roles and responses during socialization as needing more discussion. Key themes identified from the participants’ reflections were: (i) their different views about professional identity, (ii) experiences and reactions and (iii) their future action plan. Conclusions The workshop was well received by the participants. Our approach to the workshop might help other institutions design and implement similar activities as a part of their faculty development programme.
Co-WIN and Ayushman Bharat Digital Mission: The way forward
(All India Institute of Medical Sciences, 2024-05) Athavle, P.
As Covid-19 becomes, for better or worse, an endemic disease, the future of the revolutionary Covid-19 Vaccine Intelligence Network (Co-WIN) platform needs to be considered seriously. Rather than being made obsolete, the Co-WIN platform can serve as a stepping stone to catalyse a true digital healthcare revolution in India if steps are taken to harness its features and data for varied uses as part of the Ayushman Bharat Digital Mission. By bringing these features to other vaccinations, as well as integrating outbreak data from the Integrated Health Information Platform for public knowledge and awareness, disease responses can become faster and more public-driven (rather than government-driven as currently). This will also create a data pool that will be of value in post-vaccination monitoring.

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