Assessment of Knowledge, Attitude and Practice of Pharmacovigilance among the Interns in a Tertiary Care Hospital in Northern India-A Questionnaire Based Study

Background: The use of drugs and occurrence of its ADRs go hand in hand. Spontaneous reporting of ADRs is an effective method and needs to be encouraged. Objective: The study was planned to know the perception of interns towards pharmacovigilance and to make them aware of the importance of ADR reporting. Materials and Methods: A cross sectional observational questionnaire based study conducted on 100 interns to gather information about the knowledge of Pharmacovigilance, attitude towards reporting and factors in practice which could act as a deterrent to the reporting of ADRs. Results: Out of the 100 interns, 90 responded. 50 % participants knew the purpose of PV. 67% agreed that it should be mandatory. 59% and 67% said that medical students and nurses have a role to play in PV. Half of the interns had seen an ADR, only 42% knew how and where to report. Very few (9%) were aware of what happens to the information submitted by them. Conclusion: There is a huge gap between knowledge of ADR reporting and pharmacovigilance and the practical reporting of ADRs. Our health care providers need to be well equipped to detect, manage, report ADRs. For this, educational intervention, regular training programmes are the need of the hour to create awareness and take care of the factors responsible for under reporting. Pharmacovigilance programme needs to be strengthened by increasing the rate of ADR reporting by active participation of health care providers.

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.

Fatal rabies despite post-exposure prophylaxis.

Only sporadic reports of failure of post-exposure prophylaxis for rabies exist in the published literature. We are reporting such a case in a 3-year-old boy. The child had Category III dog bite on his right thigh. He presented with progressive ascending paralysis, finally developing quadriplegia and respiratory paralysis. Typical hydrophobia and aerophobia were absent. He received four doses of antirabies cell culture vaccine. He did not receive antirabies immunoglobulin. The boy succumbed on the 23 rd day of the dog bite. Diagnosis of rabies was confirmed in the laboratory by demonstration of Negri bodies, direct fluorescent antibody test and reverse transcriptase-polymerase chain reaction either on impression smear of brain or a piece of brain taken during autopsy.

Epidemiology of cholera--a five year study.

A total of 286 strains of Vibro Cholerae were isolated and tested over a period of five years. The strains were identified by standard methods and confirmed by slide agglutination tests with polyvalent, Ogawa and Inaba antisera. The non-agglutinating strains were tested with O-139 antisera. The maximum number of cases were found in the age group of 0-10 years. The number of females affected was more than the males. V. cholerae O-139 was isolated in the year 1998 and then again in 2000. V. cholerae serotype Inaba was found only in the year 1999. All of the other isolates belonged to the serotype Ogawa. The periodic shift between O1 and O-139 serogoups is reminiscent of the shifts from the Ogawa to the Inaba serotypes periodically witnessed among V. cholerae, possibly mediated by the immune pressure in the population.

Trichosporon beigelii peritonitis in a HIV-positive patient on continuous ambulatory peritoneal dialysis.

Peritonitis, the commonest complication of peritoneal dialysis, is usually bacterial in origin. Fungal peritonitis is rarely encountered. We are reporting a rare case of fungal peritonitis caused by Trichosporon beigelii in a patient on continuous ambulatory peritoned dialysis (CAPD), who was HIV positive.

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.