The Parallel Arts Festival at the 14th World Congress of Bioethics and the 7th National Bioethics Conference, Bengaluru

The theme of the 14th World Congress of Bioethics (WCB) was “Health for All in an Unequal World; Obligations of Global Bioethics”. The Parallel Arts Festival was embedded within the programme of the Congress and curated to reflect its theme.

The ethics of teaching in medicine: A personal view

While there is considerable literature on the teaching of medical ethics, much less has been written about the ethics of medical teaching. This article is a personal reflection on the latter. The devaluation of medical teaching, in part, but not only because of the difficulties of objectively assessing it, has serious ethical implications. Teaching, including medical teaching is a moral enterprise. The most serious consequence of inadequate medical teaching/learning is the graduation of incompetent and unethical medical students. Medical teachers have multiple functions and are positive or negative role models to the students they teach. Senior faculty have a moral imperative to continue to teach while mentoring their junior colleagues. Faculty and institutions need to be aware of the ethical consequences of a hidden and null curriculum that is at odds with the values and goals of medical teaching. Remedial measures are needed; there are several steps that medical teachers and administrators can take to address this issue

Perceptions of stigma among medical and nursing students and tuberculosis and diabetes patients at a teaching hospital in southern India.

Stigma has a significant impact on the diagnosis of a variety of illnesses, patients’ compliance with treatment and their recovery from these diseases. However, the Indian medical and nursing curriculum has given relatively little attention to recognising and addressing the issue of stigma. This study compared the perception of stigma with respect to tuberculosis (TB) and diabetes mellitus (DM) among medical and nursing students to that among patients with these diseases. The Explanatory Model Interview Catalogue (EMIC) questionnaire was used for all patients and student groups. Focus group discussions were held with only the students to understand their concept of stigma and the challenges they face while addressing stigma, and to explore their role in addressing stigma. The data showed that patients with TB prefer not to disclose their illness, while DM is not perceived of as stigmatising by patients. As a group, medical and nursing students attached excessive stigma to patients with both DM and TB, and this may mean that medical professionals subconsciously do harm through their interactions with patients and the attitudes they project to society. The perceptions of stigma were linked to the patient’s socioeconomic background, apart from the medical condition itself. The students recognised that they lacked the skills to understand and address stigma. We recommend that the subject of stigma be integrated into the curriculum of medical and nursing students.

Aerobic Fitness, Heart Rate Recovery and Heart Rate Recovery Time in Indian School Children.

Data on aerobic fitness and heart rate recovery in children are limited. This study was done to evaluate the relation between them in Indian school going children. Three hundred children of 7 to 10.5 years were recruited and their aerobic fitness was predicted using modified Harvard’s step test (VO2max) and 20 meter shuttle test (VO2peak). The heart rate was monitored for 12 minutes post modified Harvard’s step test. The difference between the maximum and the 1st minute HR was noted as HRR1 and the time taken to reach the resting heart rate was also recorded. VO2max was inversely correlated with HRR1 (r = –0.64, p<0.001). However, the partial correlation of the two was not significant (rpartial = –0.037, p=0.55), indicating children with higher basal HR had higher HRR1 and that accounted for the observed association with aerobic fitness. Cox regression analysis showed that the recovery rate per unit time was 3% greater with increasing VO2max (HR=1.03, 95% CI:1.01 to 1.05, p=0.013). The heart rate parameters did not show any associat with VO2peak. This study demonstrates that there is no relation between VO2max and HRR1 after 3 minutes of modified Harvard’s step test in Indian children of 7 to 10.5 years. However, aerobic fitness is a positive predictor of heart rate recovery time in this group.

Listening to the voices of the general public in India on biomedical research – an exploratory study.

Medical research, from clinical trials to novel research on stored samples, is growing rapidly in India. Ethical regulations largely reflect standard international guidelines and the norms of “good clinical practice”. Through in-depth interviews, this study aimed to explore the perceptions, motivations and concerns of the public with respect to participation in clinical trials and biobanking-related research. It was found that the expectation of therapeutic benefit reflects “therapeutic misconception” and this, along with a poor understanding of research, leads to favourable participation in clinical trials. A relatively low level of awareness and knowledge of health matters and research (health literacy), along with the differences in the power of the doctor and the participant, lead to an unquestioning trust in the physician or the institution conducting the research. “Informed consent” is thought to protect the interests of the researcher and the institution rather than the participants’ rights. Biobanking research was very new to the participants and relatively unknown. Thus, it has not yet filtered into the public consciousness. As a result, the perceptions of the general public do not appear to be sufficiently evolved.

Ethical blind spots: John Cutler's role in India and Tuskegee

The Tuskegee experiment has become an essential case study in the discussion of medical research ethics. The lessons learnt from it continue to be debated and written about. Briefly, the Tuskegee experiment, carried out over three decades till the early 1970’s, was an observational study of African Americans who had syphilis. They were never told that they had the disease, nor were they provided with penicillin when the drug became available. The efficacy of penicillin in treating syphilis had already been established, initially among soldiers during World War II. The news of the Tuskegee experiment gave rise to widespread outrage. It led to the formulation of the Belmont Report (1979) and President Clinton publicly apologised for the incident.

Heart rate variability responses to standing are attenuated in drug naive depressed patients.

Depression has been linked to altered cardiac autonomic regulation. Previous studies have been inconsistent in terms of measurement of heart rate variability (HRV), selection of depressed patients with cardiac disorders and not controlling for co-morbid conditions such as substance use and anxiety disorders. The objective of this study is to compare the effect of posture on spectral measures of HRV in drug naive healthy patients with major depression with age and gender matched healthy controls. Spectral measures of HRV in supine position and with active standing were obtained (using Task force recommendations). Repeated measure ANOVA revealed an attenuated response in HRV parameters (HF normalized units & LH/HF ratio) to active standing in depressed subjects compared to healthy controls. We conclude that there is an impaired parasympathetic modulation in response to physiological maneuver (orthostatic challenge) in drug naive subjects with major depression (co-morbid medical or psychiatric conditions) compared to healthy controls.

Longitudinal trends in physical activity patterns in selected urban south Indian school children.

Background & objectives: There are very few studies describing the pattern of physical activity of children in India. This study was carried out to document patterns of physical activity in south Indian school children aged 8 to 15 yr and examine changes over a one year period. Methods: Physical activity was assessed using interviewer-administered questionnaires at baseline (n=256) and at follow up (n=203) in 2006 and 2007. Frequency and duration of each activity was recorded and metabolic equivalents (MET) assigned. Sedentary activity included activities with MET < 1.5, and moderate-to- vigorous physical activity (MVPA) with >3.0. For each activity, daily duration, intensity (MET), and the product of the two (MET-minutes) were computed. Children were categorized by age group, gender and socio-economic status. Height and weight were measured. Results: At baseline, sedentary activity was higher in children aged >11 yr, while intensity of MVPA was higher in boys than girls. Over one year, physical activity at school significantly decreased (P<0.001). There was also a significant decrease in MVPA MET-min (P<0.001) with interaction effects of age group (P<0.001) and gender (P<0.001). Interpretation & conclusions: There was a significant decline in moderate-to-vigorous physical activity over a single year follow up, largely due to a decrease in physical activity at school. There appears to be a gap between State educational policies that promote physical well-being of school-going children and actual practice.

Prevalence of health related disability among community dwelling urban elderly from middle socioeconomic strata in Bangaluru, India.

Background & objectives: Research has shown that health related conditions and socio-economic factors influence disability in the elderly. We examined the prevalence of health related disability in community dwelling elderly (≥65 yr) residents in a suburb of Bangaluru, Karnataka, India, and assessed the association of disability with various socio-economic variables and current health status. Methods: Using the International Classification of Functioning, Disability and Health (ICF) disability was measured in 356 elderly in the Koramangala suburb of Bangaluru city. Various socio-economic and health related factors associated with disability were documented. Results: A total of 85 per cent of the respondents reported current medical problems. Based on a total disability score computed from the participation section of the ICF, 27 per cent of the respondents had mild disability while 37 per cent had higher level of disability. Disablement was significantly associated with age > 75 yr and impairment in cognitive and sensory functions especially hearing. Interpretation & conclusion: In this urban elderly population while majority had current medical conditions, a significant proportion did not experience any difficulties in activities of daily living. Restriction in participation in activities of daily living was more influenced by increasing age and impairment in cognitive functions and not current health status. A multidimensional measure of disability as captured by the ICF needs to be applied to other populations such as urban poor and rural elderly to get a more comprehensive picture of disability among the elderly in India.

Stress analysis of cantilever-fixed partial denture connector design using the finite element method / Análise de tensões de desenhos de conectores de pontes cantilever pelo método dos elementos finitos

Purpose: To analyze the stress distribution on a cantilever-fixed partial denture after simulation of maximum mastication loads in order to optimize its design. Methods: A cantilever-fixed partial denture framework was designed in the CAD-CAM system Everest®Kavo v2.0 using two materials, titanium and zirconium, with connectors of 5.28 mm² and 9.05 mm², respectively. A finite element model was built for stress analysis using simulations of mastication load. Results: For zirconia, only the molar cantilever with the smaller connector area and a 0.5-mm fillet exceeded the considered threshold resistance value of 575 MPa. All the other designs yielded resistances below this value. For titanium, only cantilevers with 9.05 mm² connector area and fillets of 1 or 1.4 mm presented stress values inferior to titanium yield strengh. Conclusion: Within the limitations of this study, it can be concluded that titanium cantilever-fixed partial denture frameworks with a 5.28 mm² connector area cannot support maximum mastication loads; frameworks of this material require larger connectors with fillets introduced in the gingival embrasure. Zirconia, however, supports maximum bite forces in most situations with both molar and premolar design cantilevers. Precaution should be taken when dealing with smaller connectors of 5.28 mm².

Objetivo: Analisar a distribuição de tensões em próteses parciais fixas em cantilever após aplicação de cargas simuladoras da mastigação, de forma a otimizar o seu desenho. Metodologia: Obteve-se a infra-estrutura de uma prótese parcial fixa em cantilever no sistema CAD-CAM Everest®Kavo v2.0, considerando dois materiais: titânio e zircônia, com conectores de 5,28 mm² e 9,05 mm², respectivamente. Gerou-se um modelo de elementos finitos, onde foram efetuadas análises de tensões com cargas simuladoras da mastigação. Resultados: Para zircônia, apenas o cantilever molar com área de conector mais reduzida, e concordância de 0,5 mm, excedeu o valor de resistência 575 MPa. Para o titânio, apenas o cantilever de 9,05 mm², com concordâncias de 1 e 1,4 mm, apresentou valores inferiores à tensão do titânio. Conclusão: Dentro das limitações deste estudo pode-se concluir que as infra-estruturas de titânio em cantilever não suportam cargas mastigatórias máximas com uma área de conector de 5,28 mm² e requerem conectores de áreas superiores, com concordâncias introduzidas na embrasura gengival. A zircônia geralmente suporta forças mastigatórias máximas com cantilever molar ou pré-molar. Deve-se ter precaução quando a área dos conectores é reduzida para 5,28 mm².

A pilot study on hyperinsulinaemic euglycaemic clamp based insulin sensitivity in young adult Indian males with low body mass index.

Background & objectives: Indians have decreased insulin sensitivity (IS) and a greater adiposity at a lower body mass index (BMI) when compared with other ethnic groups. Despite this, IS has not been studied in Indians of low BMI. This study thus used the hyperinsulinaemic euglycaemic clamp (HEC) technique to compare IS in young normal weight (NW) and low BMI (LBMI) Indian males. Clamp IS was also compared with convenient indices of insulin sensitivity such as the homeostatic model assessment (HOMA). In the NW group, clamp IS was compared with published data of similarly measured IS in other studies and ethnic groups. Methods: Ten NW [body mass index (BMI): 18.5-25 kg/m2] and ten LBMI (BMI < 18.5 kg/m2) young healthy Indian males aged between 19-32 yr were recruited through advertisements from Bangalore slums. Fasting plasma glucose and insulin, glucose disposal rates (GDR) and IS were the parameters measured during the HEC technique. Results: The NW group had a Clamp IS of 4.5 (3.8, 5.3) (median, lower, upper quartile, mg/(kg. min)/μU/ml) that was close to half that of the LBMI group; 9.9 (7.1, 13.4: P<0.001). Clamp IS in the NW group was significantly lower than that observed in published studies involving other ethnic groups (P<0.05). Clamp IS and per cent body fat (% BF), were significantly and negatively correlated (n=20, ρ = -0.7, P<0.001). Correlations between Clamp IS and other IS indices ranged from ρ = -0.5 for HOMA2-%B to ρ = 0.5 for HOMA2-%S (P<0.05); however, the correlation with HOMA1-IR was not significant (ρ = 0.4). Interpretation & conclusions: The significantly lower Clamp IS of the NW group compared with the LBMI group and other ethnic groups indicated that IS was impaired in Indians at relatively low BMIs. Most of the convenient indices of IS were significantly correlated with Clamp IS, however, the Clamp IS was more sensitive method with greater discriminatory power, since IS differences between LBMI and NW groups were only apparent with Clamp IS.

Finite element analysis of the mechanical behavior of a partially edentulous mandible as a function of cancellous bone density / Análise por elementos finitos do comportamento mecânico de uma mandíbula humana parcialmente edêntula em função da densidade óssea trabecular

Purpose: To present a methodological procedure to obtain the geometric and discrete models of a human mandible for numerical simulation of the biomechanical behavior of a partially edentulous mandible as a function of cancellous bone density. Methods: A 3D finite element method was used to assess the model of a partially edentulous mandible, Kennedy Class I, with dental implants placed at the region of teeth 33 and 43. The geometric solid model was built from CT-scan images and prototyping. In the discrete model a parametric analysis was performed to analyze the influence of cancellous bone density (25 %, 50 %, 75 %) on the development of mandibular stress and strain during simulation of masticatory forces in the anterior region. Results: Maximum von Mises stress and equivalent strain values in cancellous bone were found close to the loading area (masticatory forces). The peak stress and strain values occurred in the mandibular anterior region, and for the same masticatory force the equivalent stresses increased with bone density. Conclusion: The results suggest that the stresses and strains developed in the mandibular model were affected by cancellous bone density during the simulation of masticatory activity.

Objetivo: Apresentar uma metodologia para modelamento geométrico de uma mandíbula humana e obtenção de um modelo discreto para simular numericamente o comportamento biomecânico de uma mandíbula parcialmente edêntula em função de diferentes densidades do osso trabecular. Metodologia: Utilizou-se o método de elementos finitos 3D para realizar um estudo numérico sobre um modelo de mandíbula humana, desdentada parcial tipo Classe I de Kennedy, com implantes nas regiões dos dentes 33 e 43. O modelo sólido geométrico foi determinado por tomografia computorizada e prototipagem. No modelo discretizado foi realizada uma análise paramétrica para verificar a influência da densidade óssea do osso trabecular (25 %, 50 %, 75 %) no desenvolvimento de tensões e deformações da mandíbula durante a aplicação de forças mastigatórias na região anterior. Resultados: As tensões máximas de von Mises e deformações equivalentes no osso trabecular foram desenvolvidas próximo às regiões de aplicação das forças de mordida. Os picos de valores de tensões/deformações localizaram-se na região anterior da mandíbula, sendo que, para o mesmo valor de esforço de mordida, as tensões equivalentes aumentaram com a densidade óssea. Conclusão: Os resultados sugerem que as tensões e deformações desenvolvidas no modelo mandibular testado foram afetadas pelo grau de densidade do osso trabecular durante simulação de atividade mastigatória.

Evaluating the suitability of prediction equations for lung function in Indian children: a practical approach.

OBJECTIVE: Although several prediction equations to evaluate peak expiratory flow rate (PEFR) of Indian children are available in literature, clinicians and researchers need to make a logical choice of which equation to use as reference. The aim was to demonstrate a practical approach to making such a logical choice by using prediction equations on our study population. METHODS: Eighteen linear regression equations generated on Indian children were chosen from available literature. PEFR measured on a Wright peak flow meter on 81 boys and 60 girls, aged between 8 and 13 years, was compared with the predicted values obtained from the equations. Data was systematically analyzed for the extent of over-estimation and under-estimation, correlation between the predicted and measured values and bias and limits of agreement using Bland-Altman plots. RESULTS: The correlation between observed and predicted values using the eighteen equations ranged between 0.616 and 0.797 (for all P < 0.001). The Bland-Altman plots indicated that for all but three equations in boys and three equations in girls, lower measured values of PEFR were associated with higher predicted values. A final choice of a reference prediction equation was based on a combination of factors which included a high correlation between actual and predicted PEFR values, the bias of the estimate, the limits of agreement and the extent to which equations over or under-estimated PEFR. CONCLUSION: A practical approach to evaluate the applicability of prediction equations on an independent data set has been demonstrated.

A study of stress and autonomic nervous function in first year undergraduate medical students.

Psychological stress is a risk factor for hypertension and coronary artery disease. The purpose of this study was to assess the impact of real life stressor, that of stress among first year medical students on cardiac autonomic regulation. Stress levels in 36 non-smoking, healthy first year medical students of either gender were assessed on a self-rating scale. Cardiac autonomic regulation was tested using both conventional tests and spectral analysis of heart rate variability (HRV). Nine subjects who obtained scores on the stress scale in the upper quartile were classified as the "stress" group and the rest constituted the "no stress" group (n = 27). There were no significant differences between the two groups on any of the conventional tests of autonomic nervous activity. The low frequency power in normalized units and low frequency high frequency ratio of heart rate variability in supine posture was significantly higher in the "stress" group compared to the "no stress" group. The low frequency power in normalized units was significantly positively correlated with total stress score. The changes were suggestive of a tilt in the resting cardiac autonomic balance towards increased sympathetic activity.

Use of rice bran oil in patients with hyperlipidaemia.

BACKGROUND: The quantity and type of dietary fat is known to affect plasma lipid concentration and hence the choice of cooking oil is important to lower the risk of coronary heart disease. Rice bran oil, which was not popular worldwide, is slowly being recognized as a 'healthy' oil in India. We assessed if rice bran oil had hypolipidaemic effects in subjects with elevated lipid levels. METHODS: The study had a cross-over design with subjects (n = 14) randomly assigned to consume either rice bran oil or refined sunflower oil in their homes, for a period of 3 months (period 1). After a washout period of 3 weeks, they were crossed over to the other oil (period 2). The serum lipid values were estimated at the beginning, on day 45 and day 90 of each phase. Additional parameters assessed included anthropometry, dietary and physical activity patterns. RESULTS: The use of rice bran oil significantly reduced plasma total cholesterol and triglyceride levels compared with sunflower oil. The reduction in plasma LDL-cholesterol with rice bran oil was just short of statistical significance (p = 0.06). HDL-cholesterol levels were unchanged. CONCLUSION: The use of rice bran oil as the main cooking oil significantly reduced serum cholesterol and triglyceride levels. The use of rice bran oil together with dietary and lifestyle modifications may have implications for reducing the risk of cardiovascular disease.