Using technology to deliver cost-effective Continuing Professional Development (CPD).

The work is based on engineering the audio video contents of the didactic presentations at the Regional Symposium on Sleep Medicine delivered to the target audience at NAMSCON 2013. The audio was extracted and then synchronized with Power Points, re-synthesized as SCORM (Sharable Content Object Reference Model) compliant packages and integrated with Moodle (Modular Object-Oriented Dynamic Learning Environment) as Learning Management System (LMS). The preliminary evaluation results showed high satisfaction with the content, its short loading time and smooth playback. These attributes were demonstrated to be effective in enhancing learning. The Moodle as LMS also allows tracking the participants' progress, involving them in social groups and open discussion forum for further enriching the online content and also helps in statistical analysis through its inbuilt web analytics. The technology is not only flexible and economical but also an effective delivery method for Continuing Professional Development Programmes.

Exploring the scope of sleep medicine in current medical teaching and utility of CD Based Learning Resource Material.

Background: Only recently health professionals have started recognizing sleep disorders as one of the commonest cause of morbidity. Only in the last 50 years have scientists and physicians attempted a systematic study of the physiology and disorders of sleep. The situation is changing in India too. About a decade ago the sleep medicine started developing but remained in the domain of Pulmonary Medicine. Through various societies, meetings, workshops it has now percolated to physiologists, neurologists, psychiatrists and allied specialists. However, there is still a gap in the awareness about sleep and its disorders among health professionals. Limited information is available regarding sleep education in current medical curriculum in India and globally. Aims: (i) To find out the existence of a course or module on sleep medicine in any of Government medical colleges in India. (ii) To explore feasibility of using Learning Resource Material (LRM) on CDs for Continuing Medical Education. Methods: As an outcome of Sleep Symposium held at National Academy of Medical Sciences (India) conference at AIIMS, Jodhpur, a survey was carried out among 100 Government Medical Colleges in India along with Resource Material consisting of didactic teaching material distributed through Compact Disc (CD) to explore utility of the method. Results: Response rate from medical colleges was 41 %. Ninety five percent of medical colleges denied of having any structured course or module on sleep medicine. Fifty percent felt that such module should be included for both UG and PG while 70 % agreed for PG only. Regarding cost effective delivery methods for the content of such a module, majority responded in favour for an online or DVD based with one of the content experts as a resource person with his physical presence. All respondent were highly satisfied by the content of CD. Conclusion: Sleep education is almost non-existent in most of medical schools in India. Survey elicited average response from academic community. However, sleep education has been perceived by 70 % participants to be included in PG curriculum. The content of PowerPoint presentations was considered highly satisfying and using multi-modal technology for sleep education is regarded to be an effective delivery method by majority. It can be concluded that there is felt but unmet need of a course on sleep medicine in our existing medical curriculum using information technology.

Comparative effectiveness of non-print media and live CME.

Continuing Medical Education is an integral ingredient of professional development of health care providers. The educational activity can be delivered by different modes. Here we share our experience of using Digital Video Disc (DVD) of a CME on Sleep Medicine as an alternative and cost effective mode. Objective: To assess improvement in knowledge and competencies in terms of comparative effectiveness of a model CME program using validated non-print medium for medical education. Methods: Recorded and validated DVD of talks delivered at NAMS-AIIMS Regional Symposium on Sleep Medicine was played to the participants in presence of one of the content experts. Video scripts of talk were also distributed to the participants. The assessment of participants and program evaluation of this CME was compared to the previously held live CME. Results: Eighty nine participants completed both pre and post test. Mean score increased from 9.91± 3.5 to 14.09 ± 2.85. Pass percentage based on an arbitrary cut off of 50%, increased from 8.3 to 43.8 (p< 0.001). Among the live CME group, mean score improved from 12.1±4.6 to 18.3 ± 3.8. Comparative analysis between live and DVD based CME showed improvement in scores of 6.17 and 4.18 respectively while pass percentage of 84.7 and 43.8 post CME among two modes were significant. The program evaluation showed identical level of satisfaction in all parameters except they were less satisfied vis-a-vis 'organizers made use of any critical comments I made' since all locally available resource persons were not present. Activity could be completed at just half the cost of live CME. Conclusions: The educational background and selection process of UG students between two medical institutes were strikingly different. While students at one institute were selected by highly competitive exam at All India level, the students at other institute were selected through state level competitive examination. In spite of that, results showed comparative impact on knowledge and competencies among the participants and hence proves this to be a cost-effective mode of delivery of educational assignment.

Optimizing the Effectiveness of CME Program: NAMS Experience.

Planning organisation and delivery of educational program(s), culminating in purposeful learning require strong basis of principles of adult learning along with a sound knowledge and requisite skills in both psychology as well as technology of medical education. Assessing effectiveness of a CME program is as important as the organization of learning activities and delivery of academic program as these may provide further directions for enhancing the efficacy of the CME delivery system. Objective: (i) The purpose of this study was to investigate the effectiveness of well planned and conducted CME program in terms of enhancing knowledge and competence of the participants. (ii) To explore if the gain in knowledge and competence, if any, can be attributed to the interactive design of the educational process. Methods: The study was conducted during NAMS-AIIMS Regional Symposium on Sleep Medicine at AIIMS, Jodhpur as part of NAMSCON 2013. After explaining the objectives of the study to the participants and assurance of confidentiality, a validated and pre-tested questionnaire consisting of 30 multiple choice, single response questions, was administered to 103 participants. Following intervention consisting of didactic lectures by experts in different aspects of sleep medicine, interactive sessions and problem triggered sessions consisting of clinical data, participants were readministered post test questions which were, however, different from pre-test but had similar difficulty level. Result: The response rate of participants was 89%. Pre-intervention scores were 11.76 ± 4.4, with only 26 % of participants achieving an arbitrary pass score of 50 %. Comparison of paired score of participants who attempted both pre and post tests (n=59) showed improvement from 12.1 ±4.6 to 18.3 ± 3.8 which was significant (p <0.05). 84.7 % of participants secured above pre decided 50% score. The mean increase in the score was 6.2 with 95% CIs 4.8; 7.5 (P <0.001). Higher gain in knowledge and competencies is attributed to intense interactive involvement of participants during the problem triggered sessions, feedback provided during interaction and system of reward and incentive introduced at time of sessions. The study concludes that well designed educational intervention based on the principles of adult learning brings positive gain in the knowledge and enhances competence of the participants.

Determination of Satisfaction Index as a tool in evaluation of CME Program.

Continuing Medical Education is an indispensable part of physician's learning. Well designed program based on andragogy principles can enhance learning by motivating the learner and providing platform to encourage self directed learning. The present study aimed to explore the impact of program “NAMS-AIIMS Regional Symposium on Sleep Medicine” in changing the behavior and attitude of participants using “Satisfaction Index” and descriptive analysis of responses as evaluation tools for program effectiveness. This descriptive cross sectional study captured the response of participants through a pre-tested and validated questionnaire administered at the end of symposium. The result showed almost equal sex distribution (M: F- 27: 34) with majority being UG students (86%). Reliability of data showed Cronbach's Alpha of 0.98 indicating high reliability. Satisfaction index (SI) calculated as per WHO Educational Handbook for Health Personnel showed highest satisfaction for conducive environment of symposium (87.87 %) followed by provision for time to seek clarifications (87.21%), provision of appropriate Learning Resource material (85.90 %) and handling of critical comments by organizers (85.57%). Descriptive analysis showed majority responses as highly positive to our questionnaire with suggestions for more such activity, inclusion of clinical cases and other aspects of practical relevance.

Synergistic immunosuppression by candida in HIV infection: a cytokine based analysis.

Candida is a common opportunistic pathogen in HIV infection and is regarded a signal infection for progression to AIDS. Cytokine imbalances between Th1/Th2 groups have been described in both candida and HIV infections. A study was undertaken to assess the role of candida in furthering immunosuppression in HIV infection based on cytokine levels and CD4 cell counts. 30 Indian subjects were enrolled; 10 HIV positive patients with and 10 without mucosal candidiasis and 10 age matched controls. Th1 cytokines; interleukin (IL) 2, IL 12 and interferon (IFN) gamma, Th2 cytokines; IL 4, IL 6, IL 10 and tumor necrosis factor (TNF) alpha with CD 4 cell counts were estimated using ELISA in all subjects. CD4 cell counts were reduced in both patient groups as compared to controls; significantly more in patients with both HIV and candida infections. There was a decrease in Th1 cytokine levels in all patients; lower levels of Th1 cytokines were seen in patients with both infections. Among the Th2 cytokines, there was a significant increase in the levels of IL 6, IL 10 and TNF alpha in both patient groups; IL 10 and TNF alpha values were significantly raised in patients with dual HIV and candida infections as compared to the other patients. There was no difference in IL 4 values across the subject groups. A positive correlation between CD4 cell counts and Th1 cytokine levels and a negative correlation with Th2 cytokines were noted; these were stronger in patients with both HIV and candidiasis. Thus, there was a Th1/Th2 cytokine imbalance with CD4 cell count reduction in all HIV infected patients, which was more pronounced in patients with both infections. It can be concluded that, owing to the depressed CD4 cell count and Th1 response and increased Th2 cytokines in patients with both candidiasis and HIV as compared to patients with only HIV candidiasis may have a synergistic immunosuppressive effect with HIV in patients with dual infections.

Clustering of impaired glucose tolerance, hyperinsulinemia and dyslipidemia in young north Indian patients with coronary heart disease: a preliminary case-control study.

Metabolic insulin resistance syndrome is a critical factor in the pathogenesis of atherosclerosis and coronary heart disease in Indians. In a preliminary case-control study, 44 young patients (age < 40 years) with coronary heart disease (angina, myocardial infarction), not previously diagnosed to have diabetes mellitus, were recruited seven days to six weeks after the cardiac event (group I), and compared to 20 healthy subjects (group II). After recording history and anthropometric data, they were subjected to oral glucose tolerance test. Each group was divided into A and B subgroups according to the magnitude of impaired glucose tolerance. Hypertension was recorded in 11 (25%) patients in group I, while all the subjects in group II were normotensive (p < 0.05). Groups IB and IIB, consisting of subjects with impaired glucose tolerance displayed significantly high post-load blood glucose values. After excluding patients with the family history of diabetes mellitus, there were 13 (39%) and 3 (17%) patients with impaired glucose tolerance in groups I and II, respectively. Total cholesterol and low-density lipoprotein cholesterol levels were higher in group I as compared to group II (p < 0.01). Group IB showed highest mean values of total cholesterol, triglycerides, low-density lipoprotein cholesterol and lowest level of high-density lipoprotein cholesterol as compared to other subgroups. Serum insulin levels at 30 and 90 minutes were significantly higher in group I (p < 0.05). Group IB and IIB showed higher insulin values at 90 minutes when compared to group IA (p < 0.05) and IIA (p < 0.05). Elevated serum insulin values at 90 minutes during oral glucose tolerance test could differentiate among both groups and subgroups, except IB versus IIB. The study demonstrates significantly high prevalence of hypertension, obesity, impaired glucose tolerance, hyperinsulinemia and dyslipidemia, suggesting fully developed metabolic insulin resistance syndrome in young north Indian patients with manifest coronary heart disease.

Metabolic factors in the development of retinopathy of juvenile-onset type I diabetes mellitus.

Thirty-five patients of insulin-dependent diabetes mellitus (IDDM) were investigated for the effect of various metabolic factors on retinopathy. The severity of retinopathy increased with duration and age of onset of IDDM. Degree of glycaemia (fasting blood sugar, FBS) was similar in patients with or without retinopathy. All IDDM patients as a group showed severe carbohydrate intolerance with lower basal and post glucose serum immunoreactive insulin (IRI) levels and serum C-peptide radioimmunoreactivity (CPR) as compared to controls. The insulin secretory response was similar in no retinopathy, mild retinopathy and severe retinopathy groups. Patients with retinopathy had higher incidence of hyperlipidemia but mean serum levels of cholesterol and triglyceride were similar. This study does not suggest a direct relationship between the various metabolic factors studied and retinopathy due to IDDM.

Anti-insulin antibodies and retinopathy in juvenile onset type-1 diabetes.

Juvenile diabetics have severe loss of beta cell function and require replacement therapy with insulin. Insulin antigenicity can produce anti-insulin antibodies resulting in allergic reactions and insulin resistance. The role of insulin-anti-insulin antibody complexes in the development and progress of chronic diabetic complications like microangiopathy is not very clear. In the present study, there was statistically a significant trend of higher insulin antibody binding levels in IDDM patients who developed retinopathy. Though there was a trend of higher insulin antibody in IDDM patients with retinopathy, there was no association between insulin antibody and HLA antigen which some authors have reported.

Genetic marker in juvenile diabetic retinopathy.

Thirty five patients with insulin dependent diabetes mellitus (IDDM) were investigated for development of retinal microangiopathy by fluorescein angiography. HLA typing (A,B.C antigens) was done as a genetic marker. There was no statistically significant difference in the frequency of HLA antigens between patients without retinopathy (Gr.I) and with retinopathy (Gr.II) Frequency of various HLA antigens did not differ significantly in the mild and severe retinopathy groups or in comparison with controls. HLA B8 was significantly over represented in the patients of IDDM as a single group (GrI + II) when compared with controls (26% vs 8%). HLA profile was not a predictor of either the development or the severity of retinopathy in IDDM.