Medical student competence in ophthalmology assessed using the Objective Standardized Clinical Examination

Purpose: To assess pre?clerkship and clerkship medical student performance in an ophthalmology Objective Standardized Clinical Examination (OSCE) station. Methods: One hundred pre?clerkship medical students and 98 clerkship medical students were included in this study. The OSCE station consisted of a common ocular complaint – blurry vision with decreased visual acuity – and students were asked to take an appropriate history, provide two or three differential diagnoses to explain the symptoms, and perform a basic ophthalmic examination. Results: Generally, clerks performed better than pre?clerks in the history taking (P < 0.01) and ophthalmic examination (P < 0.05) sections, with few specific exceptions. In the history?taking section, more pre?clerkship students asked about patient age and past medical history (P < 0.00001) and for the ophthalmic examination, more pre?clerkship students performed the anterior segment examination (P < 0.01). Interestingly, more pre?clerkship students were also able to provide two or three differential diagnoses (P < 0.05), specifically diabetic retinopathy (P < 0.00001) and hypertensive retinopathy (P < 0.00001). Conclusion: The performance of both groups was generally satisfactory; however, many students in both groups had scores that were unsatisfactory. Notably, pre?clerks also outperformed clerks in certain areas, which emphasizes the importance of revisiting ophthalmology content through clerkship. Awareness of such knowledge can allow medical educators to incorporate focused programs into the curriculum

Atypical Multiple Myeloma Case: Atypical Clinical Presentation, in Female and at Young Age

Background: Multiple myeloma (MM) is ranked as the 14th most prevalent cancer, making up 1.8% of all cancers and 10% of blood cancers, rarely seen below 35 years. MM presented aggressively in the young age group, including greater incidences of extramedullary plasmacytomas, plasma cell leukemia (11%), osteolytic lesions, kidney failure (25%), and Bence Jones proteinuria (81%). Though youngsters have an aggressive presentation, their response to treatment is as similar to older patients. Case: We reported a case of a young female from the rural Konkan region of Maharashtra with complaints of right limb radicular pain and back pain diagnosed with MM with acute kidney injury and hypercalcemia. First-line treatment for her included conventional chemotherapy mixed with a proteasome inhibitor (bortezomib) and intravenous hydration for acute kidney injury and hypercalcemia with injection (inj) zoledronate. Conclusion: The case study shows how MM must be ruled out before being considered as a possible diagnosis for a young child who has neurological problems and mass lesions.

Mental health status of healthcare providers during the Covid-19 pandemic: A cross-sectional study across India

BACKGROUND From the beginning of the Covid-19 pandemic, studies have observed an increased prevalence of psychological symptoms in the general population and healthcare providers. We studied the prevalence of psychological symptoms among the latter. METHODS We did this study using a self-administered questionnaire among healthcare providers across India who were involved in caring/treating patients. The questionnaire collected information on demographics, Depression, Anxiety and Stress Scales (DASS-21) and semi-structured questions related to the Covid-19 pandemic. RESULTS A total of 612 healthcare providers participated in the study; 254 were doctors of various specialties and 358 were nursing care-providers. According to the DASS-21 assessment, the prevalence of depression was 12.4%, anxiety was 19.1% and stress was 10.8%. The prevalence of psychological problems was more among nursing staff compared to doctors (depression risk ratio [RR] 2.4, anxiety RR 1.73 and stress RR 2.93) and they were equal among both genders (depression RR 1.05, anxiety RR 1.06 and stress RR 1.21). CONCLUSIONS Our study shows that there is a higher prevalence of depression, anxiety and stress among healthcare providers, particularly among nursing care-providers. We suggest psychological interventions to nursing care-providers and also those who are vulnerable among doctors, to improve their mental health status.

Histopathological study of prostatic lesions in correlation with serum prostate specific antigen levels in elderly men

Background: Prostatic lesions are common among elderly men with urinary complaints. Variety of prostatic lesions range from inflammatory, benign to malignant pathologies. The Prostate specific antigen (PSA) is secreted by glandular epithelium of prostate shows raised serum levels in these pathologies. Usually significant rise is commonly associated with Prostatic adenocarcinomas (PCa) with exceptions.Methods: In this retrospective study, total 63 diagnosed cases of prostatic lesions over a one-year period for which serum PSA levels were available, were selected. Cases without serum PSA levels & inadequate biopsies were excluded. Histological diagnosis of prostatic lesions reconfirmed and its correlation with serum PSA was done.Results: Study included patients with mean age 67.84 years (range: 48-60) at the time of diagnosis. Benign lesions were commonest prostatic lesions accounting for total 54 cases (85.71%) out of which 38 were of Benign prostatic hyperplasia (BPH), 14 cases of BPH with prostatitis while single case each for BPH with granulomatous prostatitis and basal cell hyperplasia. Mean PSA value for benign lesions was 6.57 ng/ml. Total 8 were malignant which included 7 (11.11%) PCa while single (1.59%) case of metastatic transitional cell carcinoma. Mean PSA for PCa were 35.05 ng/ml. Single case (1.59%) of high grade prostatic intraepithelial neoplasia also detected.Conclusion: Common age group at the time of presentation of prostatic pathologies is 60-70 years. The most common prostatic lesions are benign predominantly BPH. PCa are commonest malignancies. Elevated PSA levels >20 ng/ml are commonly observed in PCa. However lower or normal values don’t rule out PCa.

Management of urinary tract infections in children: antimicrobial sensitivity pattern, efficacy and pharmacoeconomics

Background: Urinary tract infections are commonly seen in febrile children, high incidence of Vesico Ureteral Reflux (VUR) is frequently seen in paediatric patient which is of concern as it may lead to renal scarring. Despite presence of established clinical guidelines there is disparity amongst physician in the diagnosis and treatment of UTI, some physician prescribes taking into consideration the symptoms, some prescribe on the basis of smell and colour and some rely on urine culture and sensitivity report. There is dearth of studies in many tertiary health care centers regarding antimicrobial use. Authors conducted this study to evaluate antimicrobial sensitivity pattern, efficacy and cost effectiveness of antimicrobials used for UTI in children.Methods: Patients of urinary tract infection <13 years of age were included in the study. Symptoms of patient i.e. pain in abdomen, haematuria, increased frequency of urination and degree of fever were recorded. Efficacy was measured through calculating degree of defervescence per hour. Cost effective model was prepared by calculating cost effective ratio i.e. dividing cost of antimicrobial required to bring down the fever and degree through which fever came down.Results: E. coli was the most common pathogen isolated from urine positive culture (69.07%). Nitrofurantoin has shown highest sensitivity to all uropathogens (72.73%). Cotrimoxazole, ciprofloxacin and nitrofurantoin were found to be most cost effective.Conclusions: In this current study authors found E coli is the most common uropathogen isolated. Ceftriaxone, cefixime, cotrimoxazole and amikacin were found to be most efficacious. Cotrimoxazole, ciprofloxacin and nitrofurantoin were found to be most cost effective.

Comparison of health supplement on strength, stamina and growth of rats

Background: Children require more nutrition as organs grow fast in this age group. Due to abundance of various commercial health supplements in market, parents are often confused about selection of health supplements. Traditional foods are rich source of various nutrients required by growing children. We conducted a study to compare strength, stamina and growth enhancing ability of commercial health supplement and natural health supplement on wistar rats.Methods: Total of 24 wistar rats were included. Animals were divided in four groups. Each group of rats except control group were receiving health supplements. Group I, group II, group III and group IV were receiving health supplement I, health supplement II, natural health supplement and no health supplement (control group) for 60 days. Strength and stamina of wistar rats in each group were analysed using grip strength meter and swim stress test, growth of rats in each group were analysed by measuring body length, tail length and body weight. Group of rat showing maximum growth (body length, tail length and body weight), strength and stamina were analysed.Results: Group II rats showed greater strength and stamina followed by group I, group III and group IV respectively. Group I rats showed maximum growth followed by group II, group III and group IV respectively.Conclusions: In the current study we found that strength and stamina were greater in group II rats followed by group I, group III and group IV respectively also group I rats showed maximum growth followed by group II, group III and group IV respectively.

To Study the Prevalence of Cognitive Impairment in Alcohol Dependence

Introduction: Present study aimed to evaluates the cognitive status among dependent patients and effect of abstinence from alcohol for one month. Materials and methods: Study included 50 alcohol dependent male inpatients and a similar number of age and education matched controls. Specially designed semi-structured proforma was used to collect demographical data. Cognitive functions were evaluated by Post Graduate Institute of Medical Education and Research, Chandigarh Battery of Brain dysfunction (PGI-BBD). Assessment by similar method was done in both cases (at baseline and 1 month after abstinence/treatment) and controls. Data was analyzed by SPSS ver. 21.0. Results: Significant cognitive dysfunction was seen in all domains among alcoholics as compared to controls (p<0.05). Post-treatment/ abstinence improvement was seen in all domains except recent memory, mental balance, immediate and delayed recall, retention for similar and dissimilar pairs. Performance quotient impairment was seen in 40 (80%), 18 (36%) and 12 (24%) in pre-treatment, post-treatment and control group respectively. Further PQ evaluation revealed that mean scores of 69.54, 82.82 and 91.08 (p<0.05; all groups). Increase in years of consuming alcohol of study group is associated with more cognitive impairment in memory and intelligence. Conclusion: Present study had validated the assumption that there is significant cognitive impairment among alcohol dependent cases. These deficits can be detected with formal neuropsychological assessment Awareness of alcohol’s effects on cognition can help health-care providers in addressing the problem and instituting appropriate treatment.

Cost effective analysis of tab. nitrofurantoin vs. inj. ceftriaxone as an empirical therapy in patients of urinary tract infection at a tertiary health care centre

Background: Urinary tract infections (UTI) are commonly seen in adults, Urinary tract infection and asymptomatic bacteriuria in adults are a significant health care burden. In a developing country it is necessary to minimize the cost of therapy while giving maximum health benefits to the patient. Appropriate antimicrobial selection is clearly important, as treatment failures will increase the cost of care and result in additional morbidity for patients. Empirical treatment of urinary tract infection is common at tertiary health care center, authors conducted a pharmacoeconomic study to evaluate cost effectiveness of the empirical treatment.Methods: Patients with similar symptoms suffering from UTI were divided into 5 groups with 10 patients in each group. Each group was subdivided into two subgroups with subgroup A having five patients receiving tab nitrofurantoin and subgroup B having 5 patients receiving inj ceftriaxone. Out of the total cost of therapy, percentage of cost attributed to tab nitrofurantoin was compared with inj ceftriaxone. Most cost-effective antibiotic was analysed. Average number of admission days for groups of UTI patients receiving tab nitrofurantoin and inj ceftriaxone were calculated and compared. Group of UTI patients receiving antibiotic with least number of admission days was calculated.Results: Percentage of cost attributed to Nitrofurantoin therapy out of total cost in urinary tract infection patient was less than percentage of cost attributed to inj Ceftriaxone in all five groups of patients and was found to be statistically significant (p <0.05). However, there was no statistically significant difference in average number of admission (IPD) days between groups of patients receiving tab nitrofurantoin and inj ceftriaxone (p>0.05).Conclusions: In current study authors found tab nitrofurantoin to be more cost effective than inj ceftriaxone as an empirical therapy in UTI patients.

Effects of Cognitive Behavior Therapy on Heart Rate Variability in Young Females with Constipation-predominant Irritable Bowel Syndrome: A Parallel-group Trial

BACKGROUND/AIMS: The relation between heart rate variability (HRV) as non-invasive biomarkers of autonomic function and cognitive behavior therapy (CBT) as non-pharmacological treatments has rarely been examined in patients with constipation-predominant irritable bowel syndrome (IBS-C). The purpose of this study is to evaluate the efficacy of an 8-week CBT intervention on HRV and IBS symptoms, and the correlation of changes in HRV with changes in IBS symptoms among young female nursing students with IBS-C. METHODS: This study consisted of an exploratory subgroup analysis of 43 participants with IBS-C who had been randomly assigned to receive either 8 weeks of CBT (n = 23) or general medical information (control, n = 20). At baseline and 8, 16, and 24 weeks, participants completed a questionnaire assessing their gastrointestinal (GI) symptoms, anxiety, depression, and stress, and their HRV was measured via electrocardiography. RESULTS: At the 8-week follow-up, the high-frequency (HF) power was significantly higher, and the low-frequency (LF)/HF ratio was lower in the CBT group than in the control group (P < 0.001 for both), and the severity of GI symptoms (P = 0.003), anxiety (P < 0.001), depression (P < 0.001), and stress (P < 0.001) was significantly lower in the CBT group than in the control group. Changes in the HF power were significantly and inversely associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from −0.37 to −0.68). Changes in the LF/HF ratio were also significantly and positively associated with changes in GI symptoms, anxiety, depression, and stress at 16 and 24 weeks (P < 0.05 for all; range of r from 0.38 to 0.60). CONCLUSIONS: CBT was effective in managing symptoms in young IBS-C patients and the improvement of symptoms was sustained at 24 weeks following the completion of CBT. Furthermore, indirect measurement of autonomic function using HRV may be a useful objective parameter for assessing response to CBT in young IBS-C patients.

Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm.

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease‑related complications.

Rectifying calibration error of Goldmann applanation tonometer is easy.

Purpose: Goldmann applanation tonometer (GAT) is the current Gold standard tonometer. However, its calibration error is common and can go unnoticed in clinics. Its company repair has limitations. The purpose of this report is to describe a self‑taught technique of rectifying calibration error of GAT. Materials and Methods: Twenty‑nine slit‑lamp‑mounted Haag‑Streit Goldmann tonometers (Model AT 900 C/M; Haag‑Streit, Switzerland) were included in this cross‑sectional interventional pilot study. The technique of rectification of calibration error of the tonometer involved cleaning and lubrication of the instrument followed by alignment of weights when lubrication alone didn’t suffice. We followed the South East Asia Glaucoma Interest Group’s definition of calibration error tolerance (acceptable GAT calibration error within ±2, ±3 and ±4 mm Hg at the 0, 20 and 60‑mm Hg testing levels, respectively). Results: Twelve out of 29 (41.3%) GATs were out of calibration. The range of positive and negative calibration error at the clinically most important 20‑mm Hg testing level was 0.5 to 20 mm Hg and ‑0.5 to ‑18 mm Hg, respectively. Cleaning and lubrication alone sufficed to rectify calibration error of 11 (91.6%) faulty instruments. Only one (8.3%) faulty GAT required alignment of the counter‑weight. Conclusions: Rectification of calibration error of GAT is possible in‑house. Cleaning and lubrication of GAT can be carried out even by eye care professionals and may suffice to rectify calibration error in the majority of faulty instruments. Such an exercise may drastically reduce the downtime of the Gold standard tonometer.

Profile of Patients Attending an Animal Bite Management Clinic in Rural Pondicherry, India.

Aims: In India, annual incidence of animal bite is estimated as 1.7 per 100 population and that of human rabies as 1.7 per 1,00,000 population. Since rabies is universally fatal it requires prevention through timely management by wound care, Anti-Rabies Vaccine (ARV) and rabies immunoglobulin. Study Design: Retrospective record review. Place and Duration of Study: Animal Bite Management (ABM) clinic of a Primary Health Centre in rural Pondicherry, south India, between January and December, 2011. Methodology: This study is a secondary analysis of data collected at an Animal Bite Management (ABM) clinic in a primary health centre in rural Pondicherry. The study population was mainly rural and agrarian. All victims of animal bite, who sought treatment from the ABM clinic between January and December, 2011 were included. Wound washing and administration of ARV through intramuscular route was provided for all victims. Data on factors like age, gender, place of residence, biting animal was collected. Means and proportions were calculated. Chi square test for categorical and t-test for continuous variables were applied. Results: A total of 767 victims sought treatment from ABM clinic. The mean age was 29 years (1 to 84 years). Mean distance of travel to ABM clinic was 2.1 km. About a third of all cases occurred during summer (March to May). Majority of victims were bitten by dog (85%) followed by cat (9%) and monkey (6%). Only 61.7%, 32.2%, 0.8% and 0% turned up for day 3, day 7, day 14 and day 28 doses of ARV schedule. Of those who came, only 70% came on due day. There was no statistically significant difference in treatment seeking based on gender and distance from ABM clinic. Conclusion: The high dropout rate for Day 3 and subsequent doses of the ARV and the delayed administration of Day 3 and Day 7 are worrying facts because only a full and timely ARV course will provide complete protection against rabies. Aims: In India, annual incidence of animal bite is estimated as 1.7 per 100 population and that of human rabies as 1.7 per 1,00,000 population. Since rabies is universally fatal it requires prevention through timely management by wound care, Anti-Rabies Vaccine (ARV) and rabies immunoglobulin. Study Design: Retrospective record review. Place and Duration of Study: Animal Bite Management (ABM) clinic of a Primary Health Centre in rural Pondicherry, south India, between January and December, 2011. Methodology: This study is a secondary analysis of data collected at an Animal Bite Management (ABM) clinic in a primary health centre in rural Pondicherry. The study population was mainly rural and agrarian. All victims of animal bite, who sought treatment from the ABM clinic between January and December, 2011 were included. Wound washing and administration of ARV through intramuscular route was provided for all victims. Data on factors like age, gender, place of residence, biting animal was collected. Means and proportions were calculated. Chi square test for categorical and t-test for continuous variables were applied. Results: A total of 767 victims sought treatment from ABM clinic. The mean age was 29 years (1 to 84 years). Mean distance of travel to ABM clinic was 2.1 km. About a third of all cases occurred during summer (March to May). Majority of victims were bitten by dog (85%) followed by cat (9%) and monkey (6%). Only 61.7%, 32.2%, 0.8% and 0% turned up for day 3, day 7, day 14 and day 28 doses of ARV schedule. Of those who came, only 70% came on due day. There was no statistically significant difference in treatment seeking based on gender and distance from ABM clinic. Conclusion: The high dropout rate for Day 3 and subsequent doses of the ARV and the delayed administration of Day 3 and Day 7 are worrying facts because only a full and timely ARV course will provide complete protection against rabies.

Scanning the macula for detecting glaucoma.

Background: With the advent of spectral domain optical coherence tomography (SDOCT), there has been a renewed interest in macular region for detection of glaucoma. However, most macular SDOCT parameters currently are thickness parameters which evaluate thinning of the macular layers but do not quantify the extent of area over which the thinning has occurred. We therefore calculated a new macular parameter, “ganglion cell complex surface abnormality ratio (GCC SAR)” that represented the surface area over which the macular thickness was decreased. Purpose: To evaluate the ability of SAR in detecting perimetric and preperimetric glaucoma. Design: Retrospective image analysis. Materials and Methods: 68 eyes with perimetric glaucoma, 62 eyes with preperimetric glaucoma and 165 control eyes underwent GCC imaging with SDOCT. SAR was calculated as the ratio of the abnormal to total area on the GCC signifi cance map. Statistical Analysis: Diagnostic ability of SAR in glaucoma was compared against that of the standard parameters generated by the SDOCT soft ware using area under receiver operating characteristic curves (AUC) and sensitivities at fi xed specifi cities. Results: AUC of SAR (0.91) was statistically signifi cantly bett er than that of GCC average thickness (0.86, P = 0.001) and GCC global loss volume (GLV; 0.88, P = 0.01) in diff erentiating perimetric glaucoma from control eyes. In diff erentiating preperimetric glaucoma from control eyes, AUC of SAR (0.72) was comparable to that of GCC average thickness (0.70, P > 0.05) and GLV (0.72, P > 0.05). Sensitivities at specifi cities of 80% and 95% of SAR were comparable (P > 0.05 for all comparisons) to that of GCC average thickness and GLV in diagnosing perimetric and preperimetric glaucoma. Conclusion: GCC SAR had a bett er ability to diagnose perimetric glaucoma compared to the SDOCT soft ware provided global GCC parameters. However, in diagnosing preperimetric glaucoma, the ability of SAR was similar to that of soft ware provided global GCC parameters.

Long-term change in central corneal thickness from a glaucoma perspective.

Aim: To investigate the longitudinal change in central corneal thickness (CCT) over 3 years in patients with glaucoma. Materials and Methods: The Chennai Glaucoma Follow‑up Study, an offshoot of the Chennai Glaucoma Study, was designed to evaluate the progression of glaucoma. A cohort of participants in the Chennai Glaucoma Study that were suffering from glaucoma or were at a higher risk for glaucoma underwent comprehensive ophthalmic evaluation at the base hospital at 6‑month intervals during the years 2004 to 2007. The CCT (average of 10 readings) was measured between 11 am and 1 pm on any given day using an ultrasonic pachymeter. Patients with a history of ocular surgery, corneal disease and usage of topical carbonic anhydrase inhibitor were excluded. No patient was a contact lens wearer. Results: One hundred and ninety‑six patients (84 male, 112 female) met the inclusion criteria. We analyzed data from the right eye. The mean age of the patients was 59.97 ± 9.06 years. Fifty‑nine (30.1%) of the patients were diabetic. The mean change in CCT (CCT at first patient visit – CCT at last patient visit) was 3.46 ± 7.63 µm. The mean change in CCT was 0.75 µm per year (R2 = 0.00). Age, gender, intraocular pressure at the first patient visit and diabetic status had no significant influence on the magnitude of change in CCT. Conclusion: A carefully obtained CCT reading by a trained examiner need not be repeated for at least 3 years as long as the ocular and systemic factors known to affect the measurement of CCT are constant.

Epidemiology of keratoconus.

Prevalence of keratoconus is variable in different parts of the world. Environmental and ethnic factors and the cohort of patients selected for such studies may explain the wide variation in the reported rates. Family history, gender differences, asymmetry in the two eyes, association with ocular rubbing, and natural history of disease are discussed.

Inadvertent rupture of iridociliary cyst following transscleral Diode laser.

Primary iridociliary cysts can induce plateau iris configuration and angle closure glaucoma. We report a patient with bilateral, primary, ring-shaped, solitary iridociliary cysts. The right eye displayed normal intraocular pressure, oppositional iridocorneal angle closure, and healthy optic nerve head. The left eye had advanced chronic angle closure glaucoma. The management strategy varied between eyes and is discussed. This, to the best of our knowledge, is the first report of transscleral Diode laser application in an eye with a large iridociliary cyst.

Our experience of fibrin sealant-assisted implantation of Ahmed glaucoma valve.

Aim: To report our experience with the fibrin sealant as a suture substitute for securing the human scleral patch graft during implantation of Ahmed glaucoma valve (AGV). Materials and Methods: A retrospective, non-comparative study of 12 eyes of 12 patients who underwent an AGV implantation with fibrin sealant for part of the procedure during June 2009 to September 2010. Results: The mean patient age was 21.5 ± 20.6 years. Male: Female ratio was 2 : 1. Seven (58.3%) patients were monocular. The indications for AGV were varied. The mean number of intra-ocular surgeries prior to an implantation of AGV was 1.8. The mean follow-up duration was 24.5 ± 17.9 weeks. There was a statistically significant reduction in the mean IOP and in the mean number of anti-glaucoma medications at the final visit compared to the pre-operative values (P < 0.01, paired t test). Conjunctival retraction was seen in 1 (8.3%) case. The scleral patch graft was retracted posteriorly in another (8.3%) case. There was no case of AGV tube exposure, tube-cornea touch, or conjunctival erosion. Vision threatening complication viz. late post-operative rhegmatogenous retinal detachment, unlikely to be related to the use of the fibrin sealant, occurred in 2 (16.6%) eyes. Conclusion: The fibrin sealant offers the advantages of safety and convenience to the placement of a scleral patch graft during an AGV implantation.

Oral cyclosporine therapy for refractory severe vernal keratoconjunctivitis.

We report the success of oral cyclosporine therapy in a patient with severe vision-threatening vernal keratoconjunctivitis. A child presented with severe allergy which was not controlled with topical steroids, cyclosporine and mast cell stabilizers. Oral steroids were required repeatedly to suppress inflammation. Child showed a dramatic improvement and stabilization with oral cyclosporine therapy. Oral cyclosporine therapy can be tried in severe vision-threatening allergy refractory to conventional therapy.