Is there need for a transformational change to overcome the current problems with postgraduate medical education in India.

In spite of the existence of a dual system of postgraduation, one under the Medical Council of India (MCI) and the other on a parallel track under the National Board of Examinations, postgraduate medical education in India is beset with several problems. For example, the curriculum has not been revised comprehensively for several decades. The diploma course under the MCI has become unpopular and is largely a temporary refuge for those who do not get admission to degree courses. The level of skills of the outgoing graduate is falling and the increase in the number of seats is taking place in a haphazard manner, without reference to the needs. In spite of increase in seats, there is a shortage of specialists at the secondary and tertiary care levels, especially in medical colleges, to share teaching responsibilities. Further, the distribution of specialists is skewed, with some states having far more than others. To remedy these ills and fulfil the requirements of the country over the next two decades, a working group appointed by the erstwhile governors of the MCI was asked to suggest suitable modifications to the existing postgraduate system. After an extensive review of the lacunae in the present system, the needs at various levels and the pattern of postgraduate education in other countries, it was felt that a competency-based model of a 2-year postgraduate course across all specialties, the use of offsite facilities for training and a criterion-based evaluation system entailing continuous monitoring would go a long way to correct some of the deficiencies of the existing system. The details of the proposal and its merits are outlined for wider discussion and to serve as a feedback to the regulatory agencies engaged in the task of improving the medical education system in India. We feel that the adoption of the proposed system would go a long way in improving career options, increasing the availability of teachers and dissemination of specialists to the secondary and primary levels, and improving the quality of outgoing postgraduates.

Effect of temperature on the potency & pharmacological action of insulin.

Background & objectives: Since proper storage of insulin is necessary for its action, the present study was undertaken to determine the extent to which improper temperature storage conditions could have contributed to the potency of the three insulin formulations tested. Methods: Two human insulin formulations (regular and biphasic) from three different manufacturers were stored at 5 different temperatures. In vitro potency of insulin was determined by high performance liquid chromatography on every seventh day for a period of 28 days. For the in vivo study, insulin tolerance test was done by injecting human regular insulin intraperitoneally to rabbits on the 25th day of storage. Blood glucose was determined at 0, 15, 30 and 60 min after insulin injection using glucometer. Results: Storage at 32 and 37ºC showed 14-18 per cent decrease in potency of insulin in both the formulations on 28th day for all the three brands. Also the rabbits receiving insulin stored in 32 and 37ºC did not show a significant decrease in blood sugar level when compared to those receiving insulin stored at 5ºC. Interpretation & conclusions: Improper storage of insulin decreases the potency and hence the pharmacological action of insulin. Patients should be educated on the proper methods of storage, and free supplies of insulin for more than two weeks use should not be dispensed.

Academic dishonesty in Indian medical colleges.

Integrity is a necessary attribute expected in practitioners of medicine. Unfortunately there is evidence on hand that academic dishonesty is widely prevalent in many Indian medical colleges and that a proportion of students seem to think that there is nothing wrong in participating in such acts. This practice needs to be discouraged as those indulging in unethical acts during student days are likely to indulge in similar practices while dealing with their patients. It is, therefore, necessary that teachers in medical colleges show 'zero tolerance' to such acts. There is a need for faculty and administrators to be above board in their actions and be role models for ethical behaviour. Hence, acts of academic misconduct committed by faculty and administrators should also be dealt with quickly, fairly and firmly. A milieu of transparency, fairness and student awareness will go a long way in minimizing this pervasive malady.

Effect of occupational noise on the nocturnal sleep architecture of healthy subjects.

BACKGROUND & OBJECTIVES: Noise is considered to be a non-specific stressor which generally causes physiological and psychological effects in an individual. Many occupations involve workers being subjected to loud noise levels without adequate protective measures. The study was done to document the changes, if any, in the nocturnal sleep architecture of healthy persons exposed to loud occupational noise during daytime. METHODS: The study was a retrospective cohort design wherein three groups of eight subjects each, exposed to continuous occupational background noise levels of >75dB for 1-2 years, 5-10 years and >15 years were selected. Corresponding age and gender matched healthy controls (eight for each group) who worked in a quiet atmosphere was also recruited. All night sleep polysomnography was done on all subjects. In the morning, subjects rated their quality of sleep on a Visual Analogue Scale. RESULTS: There is a strong association between occupational exposure to loud noise and poor sleep efficiency (Relative Risk 2.49; Confidence Interval 1.12 to 5.57; P=0.01, Fisher's exact test). The group exposed to noise for 1-2 years had a decrease in Total Rapid Eye Movement Time, Non Rapid Eye Movement Time, Slow Wave Sleep Time, Sleep Onset Latency and Total Sleep Time. The other two groups showed lesser number of changes in sleep architecture. Subjectively there was a decrease for sleep continuity in Group I and an increase for sleep onset in Group II. There is no correlation between loudness of noise in the workplace and sleep efficiency. INTERPRETATION & CONCLUSION: It can be concluded that workers exposed to loud background occupational noise are at an increased risk of having poor quality sleep but adaptation to this effect probably takes place after a few years.

Effect of occupational noise on the nocturnal sleep architecture of healthy subjects.

BACKGROUND & OBJECTIVES: Noise is considered to be a non-specific stressor which generally causes physiological and psychological effects in an individual. Many occupations involve workers being subjected to loud noise levels without adequate protective measures. The study was done to document the changes, if any, in the nocturnal sleep architecture of healthy persons exposed to loud occupational noise during daytime. METHODS: The study was a retrospective cohort design wherein three groups of eight subjects each, exposed to continuous occupational background noise levels of > 75dB for 1-2 years, 5-10 years and > 15 years were selected. Corresponding age and gender matched healthy controls (eight for each group) who worked in a quiet atmosphere were also recruited. All night sleep polysomnography was done on all subjects. In the morning, subjects rated their quality of sleep on a Visual Analogue Scale. RESULTS: There is a strong association between occupational exposure to loud noise and poor sleep efficiency (Relative Risk 2.49; Confidence Interval 1.12 to 5.57; P = 0.01, Fisher's exact test). The group exposed to noise for 1-2 years had a decrease in Total Rapid Eye Movement Time, Non Rapid Eye Movement Time, Slow Wave Sleep Time, Sleep Onset Latency and Total Sleep Time. The other two groups showed lesser number of changes in sleep architecture. Subjectively there was a decrease for sleep continuity in Group I and an increase for sleep onset in Group II. There is no correlation between loudness of noise in the workplace and sleep efficiency. INTERPRETATION AND CONCLUSION: It can be concluded that workers exposed to loud background occupational noise are at an increased risk of having poor quality sleep but adaptation to this effect probably takes place after a few years.

Recruitment of subjects for clinical trials after informed consent: does gender and educational status make a difference?

CONTEXT: Researchers and investigators have argued that getting fully informed written consent may not be possible in the developing countries where illiteracy is widespread. AIMS: To determine the percentage of patients who agree to participate in a trial after receiving either complete or partial information regarding a trial and to find out whether there were gender or educational status-related differences. To assess reasons for consenting or refusing and their depth of understanding of informed consent. SETTINGS AND DESIGN: A simulated clinical trial in two tertiary health care facilities on in-patients. METHODS AND MATERIAL: An informed consent form for a mock clinical trial of a drug was prepared. The detailed / partial procedure was explained to a purposive sample of selected in-patients and their consent was asked for. Patients were asked to free list the reasons for giving or withholding consent. Their depth of understanding was assessed using a questionnaire. Chi-square test was used for statistical analyses. RESULTS: The percentages of those consenting after full disclosure 29/102 (30%) and after partial disclosure 15/50 (30%) were the same. There was a significant (p=0.043) gender difference with a lesser percentage of females (30%) consenting to participation in a trial. Educational status did not alter this percentage. Most patients withheld consent because they did not want to give blood or take a new drug. Understanding of informed consent was poor in those who consented. CONCLUSIONS: The fact that only one-third of subjects are likely to give consent to participate in a trial needs to be considered while planning clinical trials with a large sample size. Gender but not educational status influences the number of subjects consenting for a study. Poor understanding of the elements of informed consent in patients necessitates evolving better methods of implementing consent procedures in India.

Predictors of nocturnal oxygen desaturation in chronic obstructive pulmonary disease in a South Indian population.

CONTEXT: Nocturnal Oxygen Desaturation (NOD) in patients with chronic obstructive pulmonary disease (COPD) is associated with a poor prognosis. AIMS: To document the occurrence of NOD in COPD and to identify factors which might predict NOD in COPD patients with daytime arterial oxygen tension (PaO2) > or =60 mm Hg. SETTINGS AND DESIGN: This prospective study was conducted in patients attending the special respiratory clinics or admitted in JIPMER, Pondicherry. METHODS AND MATERIAL: Thirty consecutive patients with COPD were divided into two groups, desaturators and non-desaturators on the basis of nocturnal oxygen saturation. Statistical analysis used: Unpaired 't' test, Karl Pearson's correlation equation and stepwise multiple regression analysis was done. RESULTS: Fourteen patients (46.6%) experienced NOD. Desaturators had lower awake oxygen saturation, PaO2, forced vital capacity, forced expiratory volume in one second and peak expiratory flow rate. There was positive correlation between nocturnal O2 saturation and PaO2 (r=0.638 and P value =0.014) and awake SPO2 (r=0.901 and P value <0.001). CONCLUSIONS: The rate of occurrence of NOD in COPD was 46.6%. Awake SPO2 is the only single predictor of nocturnal oxygen desaturation in these patients.

Effect of hyoscine butylbromide and atropine on heart rate during nocturnal sleep.

This is a single blind crossover study designed to test the effects of hyoscine butylbromide (HBB), an anticholinergic which does not cross the blood brain barrier (BBB), on the temporal changes in heart rate during nocturnal sleep. The effects were compared with atropine sulphate which is known to cross the BBB. Ten healthy male volunteers slept in the JIPMER sleep disorders laboratory for three nights and received either saline, atropine sulphate (0.4 mg, i.v.) or HBB (10 mg, i.v.) just prior to sleep onset. All night polysomnography recording was done to monitor heart rate during the specific stages of sleep. The normal physiological fall in heart rate is blunted by both drugs during slow wave sleep whereas only HBB prevented the fall in rapid eye movement sleep. Therefore, HBB may be a better choice as pre-anaesthetic medication for patients with cardiac abnormalities since it does not alter heart rate during both slow wave sleep and rapid eye movement sleep.

Comparative effects of hyoscine butylbromide and atropine sulphate on sleep architecture in healthy human volunteers.

The changes in sleep architecture, heart rate and respiratory rate to hyoscine butylbromide (HBB), a peripherally acting anticholinergic was studied. These effects were compared with that of atropine sulphate, a drug known to cross the blood brain barrier. The study followed a single blind cross over design with a one week washout period. Atropine sulphate (0.4 mg) and HBB (10 mg) were given intravenously to ten adult healthy male volunteers before sleep onset. Normal saline was used as control. All night sleep polysomnography was done with the standard montage for sleep staging. Respiration and airflow were also monitored. Rapid eye movement (REM) latency was significantly increased with both the drugs whereas the duration of REM sleep was decreased only with atropine. Slow wave sleep (SWS) was also increased significantly by atropine. There was no change in heart rate, or respiratory rate during any of the sleep stages. HBB affects the initiation of REM sleep whereas atropine affects both its initiation and maintenance.

Effect of the Karnatic music raga "Neelambari" on sleep architecture.

The raga Nelambari in the classical Indian Karnatic system of music is said to be able to induce sleep and also have some sleep promoting qualities. This hypothesis was scientifically tested using sleep polysomnography with eight healthy subjects who listened to either Neelambari (test) raga or Kalyani (control) raga. There was no difference in sleep architecture or in subjective feeling of quality of sleep. The anecdotal references to the quality of sleep promoting effects of Neelambari probably reflect a conditioned response since most lullabies in South India are sung in Neelambari raga.

Ascorbic acid delays the development of tolerance to amphetamine induced anorexia but does not affect the reverse tolerance which develops to the locomotor activity.

Ascorbic acid (1 g/kg) accentuated anorectic and locomotor effects of amphetamine (5 mg/kg) and delayed development of tolerance to anorectic effect. On the contrary, it did not alter the pattern of reverse tolerance to increased locomotor activity. The results suggest that modulation of dopamine receptor sensitivity by ascorbic acid may be the reason for the delay in development of tolerance to amphetamine induced anorexia.