Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India.

The discrepancy in the demand for palliative care and distribution of specialist palliative care services will force patients to be eventually cared for by primary care/family physicians in the community. This will necessitate primary care/family physicians to equip themselves with knowledge and skills of primary palliative care. Indian National Health Policy (2017) recommended the creation of continuing education programs as a method to empower primary care/family physicians. With this intention, a taskforce was convened for incorporating primary palliative care into family/primary care practice. The taskforce comprising of National and International faculties from Palliative Care and Family Medicine published a position paper in 2018 and subsequently brainstormed on the competency framework required for empowering primary care/family physicians. The competencies were covered under the following domains: knowledge, skills and attitude, ethical and legal aspects, communication and team work. The competency framework will be presented to the National Board of Examinations recommending to be incorporated in the DNB curriculum for Family Medicine.

Joint position statement Indian Association of Palliative Care and Academy of Family Physicians of India - The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations.

PURPOSE: This joint position statement, by the Indian Association of Palliative Care (IAPC) and Academy of Family Physicians of India (AFPI), proposes to address gaps in palliative care provision in the country by developing a community-based palliative care model that will empower primary care physicians to provide basic palliative care. EVIDENCE: India ranks very poorly, 67th of 80 countries in the quality of death index. Two-thirds of patients who die need palliative care and many such patients spend the last hours of life in the Intensive care unit. The Indian National Health Policy (NHP) 2017 and other international bodies endorse palliative care as an essential health-care service component. NHP 2017 also recommends development of distance and continuing education options for general practitioners to upgrade their skills to provide timely interventions and avoid unnecessary referrals. METHODS: A taskforce was formed with Indian and International expertise in palliative care and family medicine to develop this paper including an open conference at the IAPC conference 2017, agreement of a formal liaison between IAPC and AFPI and wide consultation leading to the development of this position paper aimed at supporting integration, networking, and joint working between palliative care specialists and generalists. The WHO model of taking a public health approach to palliative care was used as a framework for potential developments; policy support, education and training, service development, and availability of appropriate medicines. RECOMMENDATIONS: This taskforce recommends the following (1) Palliative care should be integrated into all levels of care including primary care with clear referral pathways, networking between palliative care specialist centers and family medicine physicians and generalists in community settings, to support education and clinical services. (2) Implement the recommendations of NHP 2017 to develop services and training programs for upskilling of primary care doctors in public and private sector. (3) Include palliative care as a mandatory component in the undergraduate (MBBS) and postgraduate curriculum of family physicians. (4) Improve access to necessary medications in urban and rural areas. (5) Provide relevant in-service training and support for palliative care to all levels of service providers including primary care and community staff. (6) Generate public awareness about palliative care and empower the community to identify those with chronic disease and provide support for those choosing to die at home.

Risk factors for MDR and XDR-TB in a tertiary referral hospital in India.

BACKGROUND: India has a high burden of drug resistant TB, although there are few data on XDR-TB. Although XDR-TB has existed previously in India, the definition has not been widely applied, and surveillance using second line drug susceptibility testing has not been performed. Our objective was to analyze clinical and demographic risk factors associated with isolation of MDR and XDR TB as compared to susceptible controls, at a tertiary center. METHODOLOGY/FINDINGS: Retrospective chart review based on positive cultures isolated in a high volume mycobacteriology laboratory between 2002 and 2007. 47 XDR, 30 MDR and 117 susceptible controls were examined. Drug resistant cases were less likely to be extrapulmonary, and had received more previous treatment regimens. Significant risk factors for XDR-TB included residence outside the local state (OR 7.43, 3.07-18.0) and care costs subsidized (OR 0.23, 0.097-0.54) in bivariate analysis and previous use of a fluoroquinolone and injectable agent (other than streptomycin) (OR 7.00, 95% C.I. 1.14-43.03) and an initial treatment regimen which did not follow national guidelines (OR 5.68, 1.24-25.96) in multivariate analysis. Cavitation and HIV did not influence drug resistance. CONCLUSIONS/SIGNIFICANCE: There is significant selection bias in the sample available. Selection pressure from previous treatment and an inadequate initial regimen increases risk of drug resistance. Local patients and those requiring financial subsidies may be at lower risk of XDR-TB.

Reflective writing by final year medical students: lessons for curricular change.

BACKGROUND: Reflective writinghas been used in undergraduate medical curricula to inculcate empathetic attitudes in medical students. Journal writing has been used to enhance reflection in a confidential space. We aimed to introduce our medical students to reflective writing of their daily experiences, both to enhance empathetic attitudes as well as to use the entries to Inform curricular changes. METHODS: We invited 16 final year medical students posted in the Department of Medicine to record their emotional experiences during a 6-week posting. Freedom to abstain without prejudice was emphasized, yet all 16 students complied. RESULTS: According to the principle of grounded theory, the entries were grouped into 8 themes: (i) doctor-patient relationship; (ii) personal inadequacy; (iii) empathy; (iv) communication skills; (v) doctor's competence; (vi) patient behaviour; (vii) hospital practices; and (viii) personal feelings. There were 179 entries which were evaluable under the above categories, with no significant gender differences. Based on the entries, the following curricular suggestions were made: (i) use of diaries by medical students to express their emotional reactions and make value judgements, followed by guided discussion by experienced facilitators; (ii) introduction of communication skills courses at appropriate points to enhance Interview skills, empathetic listening, conflict resolution and breaking bad news; (iii) encourage reflection on healthcare delivery and its inequities and suggest methods of dealing with individual patients; and (iv) use of positive feedback and encouragement by faculty. Conclusions. Reflective journal writing by medical students in India gives valuable insights into improving communication skills and professionalism. Appropriate curricular changes should be made to meet the challenges posed by the existing healthcare system.

Early hypocaloric enteral nutritional supplementation in acute organophosphate poisoning--a prospective randomized trial.

INTRODUCTION: Early institution of enteral feeds may be associated with improved outcomes in the critically ill. This study evaluated the effect of hypocaloric enteral nutritional supplementation in acute organophosphate(OP)-poisoned patients requiring invasive mechanical ventilation. SETTINGS AND DESIGN: Prospective randomized controlled trial conducted in the medical intensive care unit (ICU) of a tertiary care university teaching hospital. PATIENTS AND METHODS: During a 13-month period, 87 OP-poisoned patients were admitted. Twenty-seven patients who were not ventilated were excluded. Thirty patients were randomized to the control arm and 29 to the intervention arm. The intervention arm received hypocaloric nasogastric feeds within 48 h of intubation whilst the control arm received intravenous fluids. Primary outcome was infectious complications. Secondary outcomes included hospital mortality, duration of ventilation, ICU stay, and hospital stay. RESULTS: An infectious complication occurred in 14 patients (48%) in the intervention group and 15 patients (50%) in the control group (p = 0.898). Three patients in each group died (p = 0.965). Duration of ventilation (p = 0.19) and ICU stay (p = 0.41) were similar. Duration of hospital stay was shorter in the control group (p = 0.05). Gastric stasis occurred in two patients (6.9%) receiving enteral feeds. Feeding related complications were less frequent than in other published trials. CONCLUSIONS: In OP-poisoned patients, early hypocaloric enteral feeding was not associated with improvements in clinical endpoints, albeit longer hospital stay was observed in the enterally fed group. Feeding related complications were infrequent. Further studies would help define the status of early enteral feeding in this subset of patients.

Disseminated cysticercosis.

Cysticercosis is a common public health problem in the Tropics. However, disseminated cysticercosis is rare. We report a patient with chronic liver disease and seizures, in whom a simple plain radiographic examination helped in narrowing down the differential diagnosis to disseminated cysticercosis. The diagnosis was confirmed by serum cysticercal antibody enzyme-linked immunosorbent assay (ELISA) and computerized tomography of the brain.