A Review of Corporate Social Responsibility Programmes Conducted in a Large Public Hospital in a Metropolitan City

Background: Through Corporate Social Responsibility (CSR), a company achieves a balance of economic, environmental andsocial objectives and is also mandated by Indian law. CSR can help in strengthening healthcare in public hospitals catering to theneedy population. Aims: This study documents the various CSR activities going on in a large tertiary care teaching and publichospital in a metropolitan city, challenges in their implementation and effectiveness of such activities. Materials and Methods:Cross sectional questionnaire based descriptive study in a large public hospital in Mumbai, India. A questionnaire was distributedto nine departments which had received CSR support in the year 2017-18. Details recorded were the kind of initiatives andamount received, difficulties faced in implementation, mode of implementation, its effectiveness and number of people benefittedby the activity. Results: In all, companies have provided a total funding of Rs.10,18,24,940 in a year. Difficulties were faced dueto lack of knowledge of the procedure and clear guidelines for CSR implementation. Approximately 84,251 indoor patients and20,77,146 OPD patients were directly or indirectly benefited by these activities. Conclusions: Public hospitals are best settingswhere companies can implement their CSR activities for healthcare of the poorer sections of society, thus fulfilling their socialobligations in a fruitful way. In view of the advantages of CSR, a dedicated CSR department and guidelines for CSR utilisationneed to be set up with adequate expertise and responsibilities.

Re-entry NEET (National Eligibility-cum-Entrance Test): Opportunity and concerns.

The recent judgment on NEET will go a long way in reducing gross malpractice and corruption in admissions to MBBS and postgraduate medical courses. It is also an opportunity to improve the quality of the tests conducted. Currently, medical schools in India have different policies for admission to government-run and privately-run institutions. There are 200 government medical schools (27 180 seats) and 212 private medical schools (25 535 seats), with a total capacity to admit 52 715 students.1 In 2013, the Medical Council of India (MCI) notified the National Eligibility-cum-Entrance Test (NEET) for admission to MBBS and postgraduate medical courses.2 Through NEET, aspirants could appear for a single examination and apply for admission to any college of their choice across the country, except in the states of Andhra Pradesh, and Jammu and Kashmir. NEET also specified that students would be admitted on the basis of the examination scores alone and no extraneous factors would come into play. NEET has been held only once in 2013, following which it was struck down by the Supreme Court. On 11 April 2016, a Constitution bench of the Supreme Court recalled its controversial 2013 judgment which struck down the common entrance examination for all medical colleges in India. NEET was introduced with the purpose of reducing the mental and financial burden on medical aspirants, who had to appear in a number of entrance examinations across the country—at the allIndia level, state level or private medical school level. Students had the option to appear for 17 different examinations, each set at various levels of difficulty. The process was costly, cumbersome and confusing, with students of varying academic capabilities being admitted to medical schools through a long-drawn admission process. Another important reason was to prevent financial malpractices, such as compulsory donations, profiteering and capitation fees. NEET would emphasize merit as the only criterion for the selection of students for medical admissions. Private medical schools were permitted an approved fee structure that could be higher than public-funded medical schools. Private institutions would definitely be affected by this judgment, and would argue that it violated their right to practise any profession and that their admission procedure was fair, transparent and nonexploitative.

Medical humanities in the undergraduate medical curriculum.

The medical humanities have been introduced in medical curricula over the past 30 years in the western world. Having medical humanities in a medical school curriculum can nurture positive attitudes in the regular work of a clinician and contribute equally to personality development. Though substantial evidence in favour of a medical humanities curriculum may be lacking, the feedback is positive. It is recommended that medical humanities be introduced into the curriculum of every medical school with the purpose of improving the quality of healthcare, and the attitudes of medical graduates.

Where do I publish my paper.

To teach is an art. Medical Education is a field in which novice require direction in which he should go. In Continuation of editorial in previous volume, here is a second editorial from Dr. Avinash Supe- Editor NJIRM

How to select a topic for research in medical education.

To teach is an art. Medical Educaiton is a field in which novice require direction in which he should go. Here is the editorial from Dr. Avinash Supe, who is the legend in the filed of Medical Education. We look forward to get a series of editorial from him- Editor NJIRM

Asymptomatic gall stones – revisited.

India has a large burden of individuals harboring asymptomatic gallstones. Based on Markov model decision and cost analysis, selective and concomitant cholecystectomy is recommended for special indications like hemolytic disorders and stones in endemic areas. Expectant management should be adopted in all others. The evolution of laparoscopy should not alter the indications of cholecystectomy. Since more than 90% patients with asymptomatic gallstones remain clinically “silent”, routine laparoscopic cholecystectomy is not indicated for the vast majority of subjects with asymptomatic cholelithiasis. Although laparoscopic cholecystectomy has become much safer, there remains associated morbidity and mortality. The risks of the operation outweigh the complications if stones are left in-situ. Patients should be counseled about the natural history and available management options, their advantages and disadvantages, and should be part of the decision making process. Prophylactic routine cholecystectomy for asymptomatic stones is not recommended. However, laparoscopic cholecystectomy should be performed selectively or concomitantly in a specific subgroup of patients.

Evaluating the efficacy of tumor markers CA 19-9 and CEA to predict operability and survival in pancreatic malignancies.

Aim: Using CA 19-9 and CEA (elevated >2times of normal) as predictors in determining operability and survival in pancreatic tumors. Methods: Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. Results: 16/24 (67%) patients with CA 19-9 levels (<2times) and 19/24 (79%) patients with CEA levels (<2times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p=0.0002-t) and 17/25(70%) patients having elevated CEA levels (p =0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels >1000U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. Conclusion: Elevated levels of CA 19-9 and CEA (>2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels >3times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (>1000U/ml) indicate a dismal survival in non-resectable group of patients.

Laparoscopic training in India: Need for criterion-based training and objective assessment of surgical skills.

Over the past 2 decades, laparoscopic techniques have evolved from diagnostic laparoscopy to more complex procedures. Minimally invasive techniques are routinely used for bariatric, colonic and advanced gastrointestinal surgical procedures. These new techniques require highly developed psychomotor skills and place an extra demand upon surgeons to acquire, maintain and develop a wide range of operative skills in the middle of their careers. In developed countries, training is imparted in skills centres, which use various models not only to teach a skill, but also as a means of assessment, both of technical competence and of decision-making. In addition, these centres are playing an expanding role in providing credentials to surgeons and maintaining the standards of skills. In India, laparoscopic training for community surgeons is unstructured and opportunistic, while resident’s training is not uniform. There is a need for structured training programmes that include giving residents and community surgeons experience in skills laboratories, along with an objective assessment of acquired skills.

Health services responses to disasters in Mumbai sharing experiences.

In mass disaster situations, demands frequently exceed the capacity of personnel and facilities. In the last few years, there has been an increased incidence of civil disasters; the spectrum of possible catastrophes has also dramatically increased as a result of an increasingly technologically sophisticated society. During the last 15 years, varied terrorist activities have become increasingly common as expressions of the opinions of extreme political groups, especially in India. In Mumbai itself, we have witnessed disasters such as widespread riots, terrorist bomb blasts, floods, and fires. There have been other disasters in India, such as earthquakes, floods, cyclones, as well as tsunamis Though most of the hospitals in India manage the medical problems associated with these disasters fairly efficiently, an analysis of the situation is presented so that this may form the basis for future planning in disaster preparedness and provide a template for other communities that may want to implement preparedness protocols. We present our experience with disaster management in Mumbai, India. A successful medical response to multi-injury civilian disasters, either natural or man-made, dictates formulation, dissemination, and periodic assessment of a contingency plan to facilitate the triage and treatment of victims of disaster.

Multiple choice questions: a literature review on the optimal number of options.

BACKGROUND: Single, best response, multiple choice questions (MCQs) with 4 options (3 distractors and 1 correct answer) or 5 options (4 distractors) have been widely used as an assessment tool in medical education in India and globally. Writing plausible distractors is time consuming and the most difficult part of preparing MCQs. If the number of options can be reduced to 3, it will make preparing MCQs less difficult and time consuming, thus reducing the likelihood of flaws in writing MCQs. We reviewed the literature to find out if the number of options in MCQ test items could be reduced to 3 without affecting the quality of the test. METHODS: A systematic database search was done using the following question as a framework: How many options are optimal for multiple choice questions? Theoretical, analytical and empirical studies, which addressed this issue, were included in the review. RESULTS: There was no significant change in the psychometric properties of the 3 options test when compared with 4 and 5 options. MCQs with 3 options improved the efficiency of the test as well as its administration compared with 4- or 5-option MCQs. MCQs with 3 options had a higher efficiency because fewer distractors needed to be prepared, took up less space and required less reading time, decreased the time required to develop the items and the time to administer, and more items could be administered in a given time thus increasing the content sampled. CONCLUSION: Our review of the literature suggests that MCQs with 3 options provide a similar quality of test as that with 4- or 5-option MCQs. We suggest that MCQs with 3 options should be preferred.

Networking in medical education: Creating and connecting.

Social networking is being increasingly used as a tool of choice for communications and collaborations in business and higher education. Learning and practice become inseparable when professionals work in communities of practice that create interpersonal bonds and promote collective learning. Individual learning that arises from the critical reconstruction of practice, in the presence of peers and other health professionals, enhances a physician's capability of clinical judgment and evidence-based practice. As such, it would be wise for medical schools, whose responsibility it is to prepare students to make a transition to adult life with the skills they need to succeed in both arenas, to reckon with it.

Training of medical teachers in India: need for change.

India has the highest number of medical colleges in the world and consequently the highest number of medical teachers. The unprecedented growth of medical institutions in India in the past two decades has led to a shortage of teachers and created a quality challenge for medical education. In recent years, though medical advances have been understood and adopted by many institutions, the same is not true for educational planning and implementation. There is a need for well-trained faculty who will help improve programs to produce quality graduates. The existing teachers' training programs are insufficient, both in number and the aspects that they cover, to meet this demand. The globalization of education and India's potential as a destination for higher education have brought the issue into sharper focus. Medical educators must stand up to meet this challenge. This paper briefly describes the current status of training programs for medical teachers in India, outlines an approach for developing future programs and defines key content areas to focus on in order to enhance faculty development efforts.

Spectrum and outcome of pancreatic trauma.

BACKGROUND AND AIMS: Pancreatic trauma is associated with high morbidity and mortality. Diagnosis is often difficult and surgery poses a formidable challenge. METHOD: Data from 17 patients of pancreatic trauma gathered from a prospectively maintained database were analysed and the following parameters were considered: mode of injury, diagnostic modalities, associated injury, grade of pancreatic trauma and management. Pancreatic trauma was graded from I through IV, as per Modified Lucas Classification. RESULTS: The median age was 39 years (range 19-61). The aetiology of pancreatic trauma was blunt abdominal trauma in 14 patients and penetrating injury in 3. Associated bowel injury was present in 4 cases (3 penetrating injury and 1 blunt trauma) and 1 case had associated vascular injury. 5 patients had grade I, 3 had grade II, 7 had grade III and 2 had grade IV pancreatic trauma. Contrast enhanced computed tomography scan was used to diagnose pancreatic trauma in all patients with blunt abdominal injury. Immediate diagnosis could be reached in only 4 (28.5%) patients. 7 patients responded to conservative treatment. Of the 10 patients who underwent surgery, 6 required it for the pancreas and the duodenum. (distal pancreatectomy with splenectomy-3, pylorus preserving pancreatoduodenectomy-1, debridement with external drainage-1, associated injuries-duodenum-1). Pancreatic fistula, recurrent pancreatitis and pseudocyst formation were seen in 3 (17.05%), 2 (11.7%) and 1 (5.4%) patient respectively. Death occurred in 4 cases (23.5%), 2 each in grades III and IV pancreatic trauma. CONCLUSIONS: Contrast enhanced computed tomography scan is a useful modality for diagnosing, grading and following up patients with pancreatic trauma. Although a majority of cases with pancreatic trauma respond to conservative treatment, patients with penetrating trauma, and associated bowel injury and higher grade pancreatic trauma require surgical intervention and are also associated with higher morbidity and mortality.

Mucormycosis of the bile duct: a case report.

A case of isolated localised mucormycosis of the bile duct in an immuno-competent 54 year old female patient is described. Mucormycosis is rare in immuno-competent patients. Isolated localised mucormycosis of the bile duct has not yet been described in the literature.

Immunomodulatory role of Tinospora cordifolia as an adjuvant in surgical treatment of diabetic foot ulcers: a prospective randomized controlled study.

BACKGROUND: Chronic diabetic patients with wounds have deficient growth factors and impaired local and systemic cellular immunity. Treatment with growth factors is expensive with risk of infection transmission and these factors may not achieve optimum wound concentration. We evaluated the role of generalized immunomodulation in diabetic ulcers by using Tinospora cordifolia as an adjuvant therapy and studied its influence on parameters/determinants of healing, on bacterial eradication and on polymorphonuclear phagocytosis. MATERIALS AND METHODS: A prospective double-blind randomized controlled study lasting for over 18 months in 50 patients. The ulcer was classified by wound morphology and severity with Wound Severity Score (Pecoraro-Reiber system). Mean ulcer area, depth and perimeter were measured and swabs taken for culture. Blood was collected to assess polymorphonuclear % phagocytosis (PMN function by Lehrer-Cline C. albicans method). Medical therapy, glycemic control, debridement, wound care were optimized. At 4 weeks, parameters were reassessed. PMN function was reviewed at 3 months. RESULTS AND ANALYSIS: Forty-five patients completed the trial: study group - 23 (M:F = 17:1; mean age = 56.3 years; mean ulcer duration = 21.1 days); control group 22 (M:F = 19:3; mean age = 56.3 years; mean ulcer duration = 30.4 days). Net improvement was seen in 17 patients (73.9%) in the study group; while in the control group, in 13 patients (59.1%); P = 0.292. Specific parameters included rate of change of ulcer area - cm(2) /day (study - 0.15; control - 0.07; P = 0.145); rate of change of ulcer perimeter - mm/day (study - 0.09; control = - 0.07; P = 0.089); change of depth - mm (study - 2.2; control - 1.4; P = 0.096); change of wound score (study - 14.4; control - 10.6; P = 0.149); total number of debridements (study - 1.9; control - 2.5; P = 0.03) and change in % phagocytosis (study - 3.9; control - 2.3; P = 0.048). CONCLUSION: Diabetic patients with foot ulcers on T. cordifolia as an adjuvant therapy showed significantly better final outcome with improvement in wound healing. Reduced debridements and improved phagocytosis were statistically significant, indicating beneficial effects of immunomodulation for ulcer healing.

Carcinoid tumor of bile duct.

We report a 38-year-old lady with carcinoid tumor of the extrahepatic biliary tract who presented with recurrent obstructive jaundice and previous surgery for suspected choledocholithiasis. MRCP revealed a large bile duct tumor extending from the confluence up to the superior aspect of the pancreas; this was completely excised, with bilio-enteric anastomosis. These tumors are characteristically slow growing and, therefore, are amenable to aggressive surgical excision, which offers the best chance of cure.

Cadaver as a model for laparoscopic training.

BACKGROUND: Though minimally invasive techniques now are routine world over, there is need to develop facilities for training surgeons. Laparoscopy performed on anesthetized animals is an established model but is costly and is not easily available. We report on human cadaver as a training modality for surgeons participating in a laparoscopic training course. METHODS: Unembalmed cadavers were used for training surgeons to appreciate anatomy, practice laparoscopic techniques, and deploy equipment and instruments during a laparoscopic training course. Trainees carried out procedures such as cholecystectomy, appendicectomy, splenectomy, intestinal explorations, mesenteric lymph node biopsy, and varicocele-vein occlusion. We analyzed the trainees' perspective regarding cadaver as a model using the 5-point Likert scale. RESULTS: Thirty-two trainees from five consecutive training courses held at our institution expressed general satisfaction over cadaver as a training model, and 96.9% (31/32) rated the training model as highly satisfactory. The trainees ranked as highly satisfactory their understanding of surgical anatomy (29/32; 90.6%), understanding of laparoscopic technique (29/32; 90.6%) and use of instruments (32/32; 100%). The trainees thought such an approach improved spatial perception of anatomy and they perceived it as a valuable educational experience. CONCLUSIONS: Human cadaveric laparoscopy may offer an ideal surgical environment for laparoscopy training courses, allowing dissection and performance of complicated procedures.

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis.

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Pre-operative prediction of difficult laparoscopic cholecystectomy using clinical and ultrasonographic parameters.

BACKGROUND: Pre-operative prediction of a difficult laparoscopic cholecystectomy (LC) can help the patient as well as the surgeon prepare better for the intra-operative risk and the risk of conversion to open cholecystectomy. METHODS: In 105 eligible patients who underwent LC during May 2001 to January 2003, patient characteristics, clinical history, laboratory data, ultrasonography results and intra-operative details were prospectively analyzed to determine predictors of difficult LC. RESULTS: Of 105 patients, 12 (11.4%) required conversion to open cholecystectomy. Significant predictors of conversion were body mass index> 30 Kg/m2, male gender, past history of acute cholecystitis or acute pancreatitis, past history of upper abdominal surgery, and gall bladder wall thickness exceeding 3 mm. CONCLUSION: Clinical and ultrasonograpic factors can help predict difficult LC and likelihood of conversion of LC to open surgery.