Assessment of Predictors for Severity in Scrub Typhus-A Case-Control Study

Objective: Scrub typhus is a rickettsial febrile condition caused by bacteria called Orientia tsusugamushi. It spreads to people through bites of infected larval mites. The objective of this study was to predict the severity of scrub typhus. Methods: A case-control study was done at Kasturba Medical College Hospital (2012-2015) retrospectively on patients admitted with scrub typhus. Patient demographics, lab parameters, investigations and treatment courses were noted. Subjects were divided into two groups, non-severe and severe group. Patient clinical details and laboratory parameters were compared in both the groups. The lab parameters associated with the severity of disease and mortality were also analyzed. A total of 210 patients out of which 140 controls (non-severe group) and 70 were cases (severe group). Results: The overall mortality due to scrub typhus infection was 14.3%. Eschar was present in 21.4% of the patients. Among the cases, the common symptoms were cough, chest pain, abdominal pain and distension, pedal edema and facial puffiness. Lymphadenopathy was observed with non-severe cases of scrub typhus and was statistically significant whereas, icterus, maculopapular rash, and hepatomegaly were associated with severe scrub typhus infection. Hemoglobin, platelet count and serum albumin were considerably lower in patients who died, whereas AST, aPTT, serum urea and creatinine were higher in them. Conclusion: Lower levels of hemoglobin, platelet count, serum albumin and higher levels of total leucocyte count, hepatic transaminases and serum creatinine correlated with severity. Doctors need to be watchful for such lab parameters and act quickly.

Clinical – microbiological characterization and risk factors of mortality in infective endocarditis from a tertiary care academic hospital in Southern India

Aims To dissect the clinical-microbiological profile of Infective endocarditis (IE) population and to determine the risk factors for IE related mortality. Methods A cohort study was conducted using relevant data from clinical records of patients (≥12 years) with definite/possible IE from December 2007 to December 2013 and was analyzed using appropriate statistical tests. Results In the cohort of 139 IE patients, mean age was 47.9 ± 15.8 years, with male preponderance (68.3%). Rheumatic heart disease was the commonest (30.9%) underlying cardiac lesion followed by mitral valve prolapse with mitral regurgitation (23.7%), degenerative valvular disease (23%), congenital heart disease (15.8%) and prosthetic valves (3.6%). Vegetations were detected in 94.2% cases. Blood cultures were positive in 69.8% cases, commonest organism isolated was α – hemolytic streptococci (30.9%) followed by Enterococcus (12.9%) and methicillin sensitive Staphylococcus aureus (10.8%). Complications observed were congestive cardiac failure (31.2%), acute kidney injury (25.9%), stroke (21.6%), septic shock (16.5%), embolic phenomenon non-stroke (8.6%), atrial fibrillation (5%) and ring abscess (2.9%). Mortality rate was 17.3%. Congestive cardiac failure, increase in the peak leucocyte count and stroke were the independent predictors of mortality. Conclusions This study reiterates the persistent dominance of rheumatic heart disease in the population studied and α – hemolytic Streptococci as the commonest responsible microorganism.

Standard setting of objective structured practical examination by modified Angoff method: A pilot study.

Background.The undergraduate curriculum at our institution is divided system-wise into four blocks, each block ending with theory and objective structured practical examination (OSPE). The OSPE in Physiology consists of 12 stations, and a conventional minimum score to qualify is 50%. We aimed to incorporate standard setting using the modified Angoff method in OSPE to differentiate the competent from the non-competent student and to explore the possibility of introducing standard setting in Physiology OSPE at our institution. Methods. Experts rated the OSPE using the modified Angoff method to obtain the standard set cut-off in two of the four blocks. We assessed the OSPE marks of 110 first year medical students. Chi-square test was used to compare the number of students who scored less than standard set cut-off and conventional cut-off; correlation coefficient was used to assess the relation between OSPE and theory marks in both blocks. Feedback was obtained from the experts. Results. The standard set was 62% and 67% for blocks II and III, respectively. The use of standard set cut-off resulted in 16.3% (n=18) and 22.7% (n=25) students being declared unsuccessful in blocks II and III, respectively. Comparison between the number, who scored less than standard set and conventional cut-off was statistically significant (p=0.001). The correlation coefficient was 0.65 (p=0.003) and 0.52 (p<0.001) in blocks II and III, respectively. The experts welcomed the idea of standard setting. Conclusion. Standard setting helped in differentiating the competent from the non-competent student, indicating that standard setting enhances the quality of OSPE as an assessment tool. Natl Med J India 2016;29:160–2

Development of a Predictor Model for Quality of Life in Cancer Patients with Adverse Drug Reactions due to Cancer Chemotherapy.

Cancer is one of the leading causes of morbidity and mortality worldwide. There are various detrimental symptoms experienced by a cancer patient due to the disease and the undergoing treatment which adversely affects the Quality of Life (QOL) in these patients. Therefore, QOL and its evaluation have turned out to be progressively vital in the health care system. Hence, the aim of our study was to develop a predictor model to predict the QOL in cancer patients receiving chemotherapy. The study was carried out in the Department of Radiotherapy and Oncology, Kasturba hospital, Manipal, a tertiary care hospital. Predictor model was developed to predict the Quality of Life Scores (QOLS) using multivariate regression analysis. A total of 387 patients participated in the study. Mean age of the patients was 50.85 ± 11.82 years (95% CI, 49.66-52.03). In our study, 16.54% had poor global health status/QOL, 72.35% had average and 11.11% had a high global health status/QOL. A significant difference was found in the QOLS based on the age group, site of cancer, drugs used in treatment of cancer, age as a predisposing factor and organ system affected due to ADRs (respiratory system, sensory system, skin and appendages). In the predictor model, the Coefficient of determination R-square (R2) was found to be 0.3267 indicating that 32.67% of the variation in the ‘quality of life score’ is explained by the independent variables included in the model. The F (45, 341) = 3.67, p < 0.001 indicating the overall significance of the regression model. Thus, the study showed that there are various predictors that can assess the QOL in cancer patients which can further serve as a guide to implement timely interventions to improve patients QOL.

Work related musculoskeletal disorders among medical laboratory professionals: a narrative review.

Work related musculoskeletal disorders are common health problem and increasing cause of disability. Laboratory professionals are unique group of healthcare professionals who play an essential part in diagnosis and therapy planning and often their work is associated with potential health hazards. Objective of current study was to review literature on prevalence of work-related musculoskeletal disorders among medical laboratory professionals. Electronic databases and bibliographies were searched and identified papers evaluated against inclusion criteria. The searching strategy uncovered 13 reports. Total 7 studies were included for the review. A high degree of heterogeneity among studies was observed. The overall prevalence’s ranges from 40-60%. With neck being more prevalent 18-78%. However additional high quality studies are required in this area.

Fall related self-efficacy among elderly: a comparison of resistance training with balance exercise.

Aims: To evaluate the effectiveness of individualized progressive resistance strength training (PRT) program in improving the confidence level among the institutionalized elderly with balance impairment, in comparison with traditional balance exercise (TBE), and combination of both (COMBI). Place and Duration of Study: The study was conducted between June 2008 and December 2012 in the geriatric care homes, Mangalore, India. Methodology: The eligible subjects were assigned to 3 groups (TBE, PRT and COMBI) using block randomization technique and allocation concealment was done. PRT group received strength training for the key muscles (hip flexors, extensors and abductors, knee flexors and extensors, ankle dorsiflexors and plantar flexors) essential for maintenance of balance. TBE group received conventional balance training and the participants of the COMBI group received TBE and PRT interventions alternately. All the three groups received their respective interventions 4 times a week for 6 months. The data was collected at baseline, 3rd and 6th month and the analysis was performed using Statistical Package for Social Sciences (SPSS) version 15. Both per-protocol and intention to treat methods of analyses were used. Results: Mean age of the 54 elderly participants (18 in each group) was 75.17 years and the comparison of the baseline variables revealed homogeneity between the groups. Between the baseline and six months, all the three groups showed notable reduction in Falls Efficacy Scale (FES) scores. The change scores (pre-post intervention) of FES were notable for all the three groups, but the statistical test did not reveal any significant differences between the groups. Conclusion: Individualized structured PRT intervention targeting the key muscles of lower limbs for balance maintenance, for a period of 6 months, is comparable to TBE in improving the falls efficacy. This in turn reduces self-induced functional restrictions among the non-frail elderly people living in geriatric homes.

Stress and coping among final year medical students

Background: Medical School is challenging as medical students have to confront varied stressors such as academic pressures, work over load, and issues pertaining to professional competence. Stress can be more during the final year of study as students have to deal with pressure of graduating and making career decisions. Efficient coping protects students against stress. Gender differences may exist in stress and coping. Aims: The present study aimed to examine stress, coping and gender differences in final year medical students. Prediction of stress by coping was also examined. Methods: This cross-sectional study consisted of 117 final year medical students from a medical college in coastal Karnataka . Professional Student Stress Survey to measure stress and Carver’s Brief COPE to measure coping were administered. Results: An almost similar amount of mild and moderate degree of stress was experienced by majority of the sample. Academic performance and professional identity issues caused greater stress. Among the major coping approaches, problem coping was used more by the group. The coping subtypes frequently used were planning, active coping, acceptance, and self-distraction. There were no gender differences in stress. With regard to coping, females used more emotional coping strategies, specifically, self-blame and seeking emotional support. Venting, an emotional coping strategy repeatedly emerged as a positive predictor of overall stress and various stress domains. Avoidant coping also positively predicted over all stress and stress in two stress domains. Positive re-framing negatively predicted stress and religion positively predicted stress in two stress domains respectively. Conclusion: The findings point towards the crucial need for stress management programs in medical school. Though students used problem coping frequently, the evident role of maladaptive coping in increasing stress warrants the need for coping skills training. Research on effectiveness of such programs in India needs to be improved.

Immunophenotyping of normal individuals classifi ed on the basis of human dosha prakriti.

Background: Human variations related to immune response and disease susceptibility is well-documented in Ayurveda. Prakriti (body constitution) is the basic constitution of an individual established at the time of birth and distinguishes variations, into three broad phenotype categories such as vata, pitta and kapha. Variation in immune response is often attributed to and measured from the difference in cluster differentiation (CD) markers expressed in lymphocytes. Currently, there are no reports available on the expression of CD markers related to prakriti. Objective: This is a pilot study performed to evaluate a panel of lymphocyte subset CD markers in dominant prakriti individuals. Materials and Methods: Immunophenotyping was carried out using whole blood from a total of healthy 222 subjects, who are grouped into kapha (n = 95), pitta (n = 57) and vata (n = 70) prakritis. CD markers such as CD3, CD4, CD8, CD14, CD25, CD56, CD69, CD71 and HLA-DR were analyzed using fl ow cytometry method. Differences between groups were analyzed using one-way ANOVA or Kruskal-Wallis analysis of variance (ANOVA) and multiple comparisons between groups were performed by Bonferroni or Mann-Whitney U test with corrections for type I error respectively. Signifi cance was evaluated by ANOVA and Pearson’s correlation. Results: We observed a signifi cant difference (P < 0.05) in the expression of CD markers such as CD14 (monocytes), CD25 (activated B cells) and CD56 (Natural killer cells) between different prakriti groups. CD25 and CD56 expression was signifi cantly higher in kapha prakriti samples than other prakriti groups. Similarly, slightly higher levels of CD14 were observed in pitta prakriti samples. Conclusion: Signifi cant difference in the expression of CD14, CD25 and CD56 markers between three different prakriti is demonstrated. The increased level of CD25 and CD56 in kapha prakriti may indicate ability to elicit better immune response, which is in conformity with textual references in Ayurveda.

Exploring attributes of effective teachers - student perspectives from an Indian medical school.

Introduction: Attributes of an effective teacher is a passionate area of research for medical educators. Teaching at Melaka Manipal Medical College (MMMC), Manipal University, India, is assessed periodically as a part of the institution’s program evaluation process. The present study was undertaken to determine the highly rated attributes of a medical teacher, as felt by three batches (preclinical, para-clinical and clinical batch) of medical students at MMMC. Methods: A questionnaire focusing on twelve attributes of effective teaching was developed and administered to three batches of students. Students were requested to select the five most important attributes from the questionnaire and rank them accordingly as 1st, 2nd, 3rd, 4th and 5th. The responses were analyzed using cross tabulation and percentages of the grades provided by the participants were reported for each of the batch. Results: The ability of a teacher to motivate and inspire students was rated to be the best attribute of an effective teacher. Students also felt that defining objectives and clarifying concepts was an important quality that medical teachers should possess. The importance of being an effective communicator was also emphasized. Discussion: The present study underpins the need for a healthy teacher-student relationship in medical schools. Communication with international students in an Indian scenario may be a challenging task, keeping in mind the diverse cultural background of students. Probing qualities that students identify with an effective teacher may help us respond to these challenges.

Student and faculty perspectives on Laboratory Based Learning (LBL) sessions in Physiology.

Objective: To explore students’ and faculty members’ perspectives regarding LBL sessions-the gaps/pitfalls- to explore possibilities for improvement. Method: Two sets of questionnaires, one each for students and faculty members were developed and administered to the students of first year MBBS (n=113) and Faculty members of physiology department (n=13) of MMMC, Manipal. Both questionnaires had closed-ended questions (no negative statements) inviting responses in the form of Likert scale. Open-ended questions were included in the questionnaire distributed to faculty members. Quantitative analysis was done using SPSS version 16. Results: Students agreed to all items, with a median score of 4. Students’ responses clearly indicated that, in general, they were satisfied with conduction of LBL sessions in physiology, while, faculty members concurred with them with a median score of 4 for items other than student related and expressed that current LBL sessions were adequate for MBBS curriculum. Faculty members were of the opinion that students need to practice more in LBL sessions. They also suggested inclusion of additional teaching aids in LBL sessions. Conclusion: Majority of students and faculty members were satisfied with the content and methodology employed in the current laboratory based sessions in physiology. Some of the suggestions given by students and faculty members could be easily implemented for improving the process, while others require additional infrastructure and logistic support.

The involvement of amygdala nucleus in chronic stress induced changes on ingestive behavior of wistar rats.

Organisms are constantly subjected to stimuli that can be construed as stressors. Stress regulation is a highly integrated process controlled largely by the brain. The role of amygdala in stress tolerance has attracted continued interest because of its central role in processing emotional information. In the present study, the Wistar albino rats were subjected to chronic swimming (physical) stress and chronic immobilization (psychological) stress for 60 days with or without bilateral lesions of the nucleus of amygdala. Their food intake, water intake and body weight were measured. Exposure to stressors significantly decreased the body weight, food and water intake whereas amygdala lesioning significantly increased the body weight (P<0.001), food intake (P<0.001) and water intake (P<0.001).However, the stress induced decrease observed in the body weight and food intake of the amygdala lesioned groups was significantly more (P<0.001) during immobilization stress than swimming stress. It can be concluded that amygdala nucleus appears to play a prominent role in minimizing the stress induced changes in the food intake and body weight; and this role was more evident in immobilization stress than a physical stress. Thus, the present study support the notion that the amygdala nucleus play a definite role in minimizing stress induced changes in the ingestive behavior and its role in psychological stress is more prominent.

Metformin - A convenient alternative to insulin for Indian women with diabetes in pregnancy.

Objective : To compare the use of metformin with that of insulin for the treatment of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) unresponsive to diet therapy. Materials and Methods : In this prospective observational study, maternal glycemic control and perinatal outcome in diabetic pregnancies were compared between 2 obstetric units, one using insulin therapy and the other using metformin therapy. Baseline pretreatment glycemic profile was done and then repeated weekly throughout pregnancy. The outcome measures studied were glycemic control, maternal complications and perinatal outcome. Results :Sixty women with gestational and type 2 diabetes were enrolled, 30 each for metformin and insulin. Both groups were comparable with respect to age, body mass index (BMI), parity and pretreatment plasma glucose levels. Glycemic control was better with metformin after 1 week of therapy and also throughout gestation (P = 0.03-0.007). There were no major complications or perinatal deaths in this study. Mean gestational age and birth weight (2.9 ± 0.4 kg versus 3.1 ± 0.4 kg, P = 0.30) were comparable. However, there was a significant increase in neonatal intensive care unit (NICU) admission and stay for babies born in the insulin group. The cost of treatment was tenfold higher in thethe insulin group. Conclusion :Metformin is clinically effective, cheap and a safe alternative to insulin therapy in pregnant diabetic women.

Effect of trace elements on surface hydrophobicity and adherence of Escherichia coli to uroepithelial cells.

Trace elements have significant effect on the physiology of bacteria. Variation in the concentration of trace elements may affect the expression of virulence by microorganisms. The effect of trace elements on hydrophobicity and adherence of E.coli to uroepithelial cells was studied. Increasing concentrations of Ca2+, Mg2+, Fe3+ and Zn2+ significantly decreased the surface hydrophobicity. Toxic trace elements like Co2+, Cu2+, Mn2+ and Ni2+ did not alter surface hydrophobicity. With regards to adherence of E.coli to uroepithelial cells, only Mg2+ had significant effect. Toxic trace elements decreased the rate of cell adherence. The pathogenic strains of E.coli showed higher surface hydrophobicity and better cell adherence compared to the nonpathogenic strains. There was good correlation between surface hydrophobicity and cell adherence at higher concentrations (0.1 to 0.2mM) of Fe2+ and Zn2+. The results indicated that trace elements can significantly affect surface hydrophobicity and adherence of E.coli to uroepithelial cells. Such effect may have a significant impact on the initial stages of bacterial infection.

Comparison of the immunogenicity and safety of two different brands of Salmonella typhi Vi capsular polysaccharide vaccine.

BACKGROUND: The recent emergence of multi-drug-resistant Salmonella strains highlights the need for better preventive measures, including vaccination. Safe and immunologic vaccines have been developed based on purified Vi polysaccharide. OBJECTIVE: To compare the immune response elicited by two different brands of Salmonella Vi capsular polysaccharide vaccine (ViCPS). SETTING AND DESIGN: Double blind, randomized (3:1), controlled, parallel, phase III study was conducted at two centres in India to compare the safety and immunogenicity of Typbar, the investigational vaccine with an already marketed vaccine "X", in healthy subjects aged between 12 -25 years. MATERIAL AND METHODS: A sample size of 184 subjects was calculated. Subjects were randomly distributed in two groups, immunized with single dose of Typbar or Vaccine "X". Serum samples were taken before 7 days and 4 weeks after immunization for the determination of antibodies to Vi polysaccharide, by ELISA method. Safety was assessed by physical examination, laboratory parameters before and after vaccination and by monitoring adverse events. Statistics: The geometric mean antibody titre (GMT) 4 weeks after vaccination was compared from respective pre-vaccination values by Wilcoxon signed rank test. Geometric mean of antibody levels before and after immunization and the ratio between them (Mann-Whitney test), the Seroconversion rates (Z test of proportions) and the adverse events (Fisher's exact test and Chi square test), were compared between two groups. P value < 0.05 was considered statistically significant. P values and 95% confidence intervals were estimated in two-tailed fashion. RESULTS: 153 subjects (Typbar =116 and Vaccine "X" =37) were studied. 71.6% (95% CI=63.4%-79.8%) and 75.7% (95% CI=64.9% - 89.5%) were the seroconversion rates with Typbar and vaccine "X" respectively. The GMT values for Vi antibodies induced after Typbar and vaccine "X" were 10.23 Typbar and 13.46 mg/mL respectively and these values showed high significance when compared to their respective pre-immunization GMT values (P<0.0001) at 95% CI (-10.49 to -7.19 mg/mL for Typbar and -14.69 to -8.86 mg/mL for Vaccine "X"). The induction of antibody response appeared to be slightly stronger (P=0.032) with vaccine "X" when compared to that of Typbar. This is justifiable as the same group also had high pre-immunization GMT values (P=0.021). CONCLUSION: The immunogenicity and safety of the investigational vaccine Typbar was found to be similar to that of already marketed brand of Vi CPS, Vaccine "X". The availability of a single dose of vaccine that is safe and effective enhances the prospective for control of typhoid fever.