Development of a hybrid undergraduate portfolio for the AETCOM module.

Background: A structured Attitude Ethics and Communication (AETCOM) module for undergraduates exists. For ensuring that the module achieves what it is intended to achieve, there was a felt need to develop a learning portfolio with an emphasis on reflections and with a scope for assessment. Methods: The AETCOM module by NMC has laid out objectives, lesson plans, and case-based scenarios. Hybrid portfolio development was necessary to align the sessions to the objectives and lesson plans and to help students capture their learning process with self-reflection, and at the same time, ensure the scope of assessment of these activities. Hence, writing reflections was considered the most important step. Measures were taken to train students in writing reflections, and faculty development workshops were also conducted. An evaluation was done using Kirkpatrick model level I-III using student's feedback form, scores of rubric matrix for assessment of reflections and one-on-one interaction with students by trained faculty. Faculty perspectives on portfolio development were collected. Results: A significant improvement in students' self-assessment scores on AETCOM module was seen (p <0.05). An assessment of reflections using a rubric matrix showed that all the students reached at least grade B by the end of three months. More than 90% of faculty members felt that the faculty is vital for assessing AETCOM. Conclusion: The development of a hybrid portfolio for AETCOM requires faculty development and special sessions for students on writing reflections. The hybrid portfolio provides the learner to self reflect, and a rubric matrix can be used to assess reflections.

An unusual presentation of pulmonary nodules.

A pulmonary nodule is a common radiological finding encountered in routine medical practice. It needs to be extensively evaluated as the differential diagnosis can range from sinister malignancies to fully treatable infectious causes. Here, we present a rare case of pulmonary paragonimiasis presenting as pulmonary nodule. This case report aims to sensitise the medical practitioner regarding pulmonary paragonimiasis which is completely treatable but carries a high risk of being under diagnosed.

Development of a Machine learning image segmentation-based algorithm for the determination of the adequacy of Gram-stained sputum smear images.

Background: Machine learning (ML) prepares and trains a model through supervised or unsupervised learning methods. Sputum, a respiratory tract secretion, is a common laboratory specimen that aids in diagnosing respiratory diseases, including pulmonary tuberculosis (TB). Gram stain is an easy, cost-effective stain, which may be applied to sputum smears to screen out an unsatisfactory sample. ML model may help in screening sputum smears. Methods: This collaborative project was carried out from June 2020-July 2021. In this study, a color-based segmentation ML algorithm using K-Means clustering was developed. A library of stained sputum smears was built. The Bartletts criteria (based on neutrophil and squamous cell count) for screening and selecting satisfactory sputum smears were used. A smartphone camera was used to take several photographs of satisfactory, as well as unsatisfactory, smears. The image segmentation algorithm was applied to medical image analysis, color-segmentation of sputum images was done. The hue saturation value (HSV) color ranges were defined on a prototype image. Then, all connected pixels were identified as a single object, and morphological operations were applied. Results: Usage of AI-driven model on the slide-image revealed the slide adequacy as the cell count was acceptable based on Bartlett's criteria. Both the manual cell counts (Range: 126-203 neutrophils, 14-47 squamous cells) and the model counts (Range: 117-242 neutrophils, 14-37 squamous cells) are within acceptable limits. Conclusion: The use of a model to screen a large number of sputum slides may be a boon in resource-limited settings where trained microscopists may not be easily available.

Post vaccination antibody titres of hepatitis B surface antigen (anti-HBs) in a mixed cohort of health care workers.

Background: Hepatitis B (HepB) is an important vaccine preventable infection among healthcare workers (HCWs). Vaccination against Hep B virus, remains the foremost preventive approach. This study aims to measure the antibody titres to Hep B surface antigen (anti-HBs) in a mixed cohort of HCWs. It also aims to study the association between time since vaccination and the anti-HBs titres thus evaluating the duration of seroprotection. Methods: A total of 200 HCWs, including nursing students (n = 112), nursing staff (n = 49), laboratory technicians (n = 30) and doctors (n = 9) who had received all three doses of the Hep B vaccine and met the inclusion criteria of having taken all three doses of vaccine were included in this study. Anti-HBs titres were estimated by bioMérieux mini VIDAS® automated immunoassay based on the principle of enzyme-linked fluorescence assay. Results: Two hundred subjects aged 19 to 52 years were included in the study; mean age was 27.29 ± 0.568 years. Duration since vaccination in the study cohort was ≤ 5 years in 149 (74.5.0%), 6-10 years in 20 (10.0%) and >10 years in 31 (15.5%) subjects. Postvaccination antibody titres were > 100 mIU/ml in 85.0%, 10-100 mIU/ml in 11.0% and ≤ 10 mIU/ml in 3.5%. There was a decline noted in antibody titres as duration after vaccination increased. Increasing age was associated with falling protective titres. Conclusion: The study revealed that majority of the HCWs had adequate anti-HBs titres and were protected after vaccination.

Estimating the proportion and IgG antibody response to SARS-CoV-2 in individuals joining a central educational institute from different parts of India by Enzyme-linked immunosorbent assay (ELISA) based serology.

BACKGROUND: Antibody response to SARS-CoV may be estimated to give trends and patterns emerging in a population during an evolving epidemic. The novel coronavirus has opened a new chapter in the history of pandemics and understanding the disease epidemiology. METHODS: The study was a cross-sectional descriptive study. Institutional Ethical clearance and informed consent were taken for participation in the study. The study population included all personnel reporting to the institute for training courses, permanent posting or joining back from leave during the study period of 2 months (16 June to 16 August 2020). The sample size was calculated assuming the prevalence of COVID-19 to be 1% with the absolute precision of 0.5% and 5% level of significance, and finite correction for population size of 500, and the calculated sample size was 377. Inclusion criteria were all personnel reporting to the institute from different states and districts. Exclusion criteria-Any personnel reported for a short visit of lesser than 14 days. Demographic details and details of any likely exposure to a confirmed COVID-19 case were noted. A blood sample was collected, and serological tests were done using ErbaLisa COVID-19 IgG kit by Calbiotech, as per the manufacturer's instructions. RESULTS: Overall seropositivity of IgG COVID-19 antibodies was 7.5% (31/413) (95% CI: 5.3-10.4%). Study population (n = 413) comprised of an adult population in the age range of 21 years-53 years, and the mean age was 31.4 years (SD = 6.2 years). CONCLUSION: As the personnel joining the institute have come from various parts of the country the study provides an estimation of antibodies against COVID-19.

M3: The military medicine module: A focussed competency-based program.

BACKGROUND: Military medicine is a unique and specific field for the armed forces doctors providing skill-based training on military specific injuries and diseases arising due to the unique occupational conditions. The current study retrospectively studied the planning and implementation of the military medicine module which was carried out with the aim of imparting the requisite skills to military doctors. METHODS: The study was a qualitative research, carried over two years, 2017-2019. The study population included two batches of recently graduated medical doctors about to be commissioned . The methodology included needs assessment and gap analysis which was carried out by consulting experts from the tri services. Feedback was taken by medical education experts from both the batches using surveys, and modifications were done after brainstorming with experts keeping feedback in mind. RESULTS: There was an improvement in the rating scores and an improved performance by participants was seen in the competencies. CONCLUSION: In conclusion the module was developed and implemented keeping in mind the important skills that military physicians need to learn through training as these are not been taught in any educational syllabus. To achieve such skills and capabilities, gap analysis is essential and programs should be implemented keeping scope for modification depending on the feedback after brainstorming. Feedback remains important in development of such modules and hence should be collected anonymously.

A pilot study on case-based learning (CBL) in medical microbiology; students perspective.

BACKGROUND: Traditional teaching of medical microbiology has revolved around an organism centric, didactic lecture approach, lacking clinical relevance and appeal. Studies have shown that case-based learning in comparison to didactic lectures leads to a greater comprehension and understanding of the subject. To conduct a pilot study in our medical. College for the current MBBS batch (2019) (following the old pattern of syllabus), on student perceptions on case based learning (CBL) before the new Competency based undergraduate curriculum is rolled out for 2021 batch coming to second year of MBBS. METHODS: This pilot study was conducted at a medical college. The study was designed as an observational study on educational research and was approved by the institutional ethical committee (IEC). Study participants were second MBBS students willing to participate in the study (n = 60). Four topics were chosen to be taught as casebased scenarios as per the new CBME syllabus. Six weeks after the first CBL session was conducted, a survey questionnaire was given to the students to share their perceptions anonymously. The questionnaire had questions framed to assess the students' perception about CBL. The evaluation was done on a 5-point Likert. The responses collected were compiled in Microsoft excel sheet and the data was analysed statistically. Faculty perspective was also gathered. RESULTS: Majority of the students perceived CBL positively. There was a shift in the student's perspective towards the subject of microbiology, from being perceived earlier as theoretical and non-clinical to being perceived as appealing and clinically relevant.

Prevalence of Human Papillomavirus (HPV) Genotypes in Cervicovaginal Secretions of Human Immunodeficiency Virus (HIV) Positive Indian Women and Correlation With Clinico-Virological Parameters.

Introduction and Background: Both human papillomavirus (HPV) and the human immunodeficiency virus (HIV) are sexually transmitted. High-risk (HR) HPV types are a causal factor in cervical cancer. Persistent HPV infection in this subset of immunocompromised women results in faster disease progression. The study determined the prevalence of HPV genotypes in cervicovaginal secretions of HIV seropositive women and the correlation with CD4 counts and cytology. Method: One hundred, non-pregnant, HIV-positive women of 18 years of age and above were enrolled in this cross-sectional study following approval by the institutional ethical committee. A written consent, questionnaire, followed by sample collection including a Papanicolaou (Pap) smear for cytology was undertaken. Cervicovaginal secretion samples were collected in the Digene® specimen transport medium (STM) (Qiagen Gaithersburg Inc., MD, USA). HPV genotyping was carried out with PCR amplification of a 65-base pair (bp) fragment in the L1 region of the HPV genome using the short PCR fragment (SPF10) primers followed by reverse hybridization by line probe assay (LPA) using the INNOLiPA HPV Genotyping Extra kit (Fujirebio, Belgium). Quantitation of HPV-16 and-18 viral loads (VLs) was done by real-time PCR. Results of Pap smear cytology were correlated with CD4 counts and HPV-16 and-18 VLs. Results: Mean age of the subjects was 34.9 years ± 7.2 years (median 33.0 years, range 24-60 years). HPV was detected in 62 of 93 (66.6%) samples. Twenty (32.25%) of these 62 samples harbored a single HPV genotype. Multiple genotypes (more than two) were detected in 38 (61.3%) samples. HPV-16 was the commonest genotype detected in 26 (27.9%) of all samples and 41.9% of HPV positive samples. Pap smear cytology was reported for 93 women included in the study. Women who had normal cytology were reported as negative for intraepithelial malignancy or lesion (NILM; n = 62; 71.36%), two women had a high-grade squamous intraepithelial lesion (HSIL), low-grade squamous intraepithelial lesion (LSIL; n = 11), atypical squamous cells of undetermined significance (ASCUS; n = 12). Those smears with inadequate material were reported as scant (n = 6). The median CD4 count was 363/cu.mm (range 39-787) in HPV-positive women compared to 423/cu.mm (range 141-996) in those HPV-negative women. Quantitation of HPV-16 and-18 VL was done in duplicate for samples positive by PCR reverse hybridization (INNOLiPA). Of these 20 samples (65%), 12 samples were positive by real-time PCR. The normalized HPV-16 VL ranged between 18 and 240,000 copies/cell. The normalized HPV-18 VL in cervical samples ranged between ~24 and 60,000 copies/cell. Conclusion: HIV-positive women may be infected with multiple genotypes other than HPV-16 and-18. This may have implications on the vaccines available currently which target few specific genotypes only. Studies are required to determine the predictive role of HR HPV genotypes, in significant copy numbers especially in HIV seropositive women. It would be clinically relevant if the HPV VLs, cervical cytology, and CD4 counts are considered into cervical cancer screening programs for triage and follow-up of these women.

Molecular detection of blaNDM-1 (New Delhi metallobetalactamase-1) in nosocomial Enterobacteriaceae isolates by nested, multiplex polymerase chain reaction.

BACKGROUND: Carbapenems are considered "drugs of last resort" in many life-threatening infections. Advent of carbapenemases like KPC, OXA-48, VIM, IMP, and NDM have greatly affected the efficacy of these drugs, posing serious threat to global health and infection control. NDM bears special significance to the India subcontinent, labeled as place of origin and reservoir. NDM tends to escape detection by routine phenotypic methods, requiring molecular confirmation. This study utilizes nested, multiplex polymerase chain reaction (PCR) for reliable detection of blaNDM-1 in nosocomial Enterobacteriaceae isolates. METHODS: This study was conducted to detect prevalence of blaNDM-1, blaIMP, blaVIMand blaKPC genes by multiplex PCR among multidrug/carbapenem-resistant nosocomial Enterobacteriaceae isolates. From March 2013 to April 2014, 100 consecutive non-repeat isolates of Enterobacteriaceae from various inpatient clinical samples were analyzed. Imipenem-resistant isolates identified by Kirby Bauer disk diffusion method with Clinical and Laboratory Standards Institute guidelines were further subjected to nested, multiplex PCR to simultaneously detect blaNDM-1, blaIMP, blaVIMand blaKPC genes. RESULTS: Out of 100 isolates, 17 (17%) were found to be imipenem-resistant. blaNDM-1 was detected in all 17 isolates by nested, multiplex PCR. blaVIM was co-carried in 4 isolates while one isolate co-harbored blaIMP with blaNDM-1. Imipenem resistance and NDM-1 carriage was predominant amongst Klebsiella isolates. Maximum NDM-1 producers were isolated from the intensive care unit (70.6%). CONCLUSION: NDM-1 prevalence in nosocomial Enterobacteriaceae isolates in our hospital was found to be 17%. A nested, multiplex PCR was used for rapid detection of various carbapenemase genes with high sensitivity and specificity which is essential not only for favorable patient outcome but also for timely implementation of appropriate infection control practices to prevent further spread of such organisms.

Emerging organisms in a tertiary healthcare set up.

BACKGROUND: One-tenth of all infectious diseases are attributable to emerging organisms. As emerging organisms sporadically affect a relatively small percentage of population they are not studied at large. This study was aimed at studying the characteristics of emerging organisms encountered from various clinical samples in an apex tertiary care multispeciality teaching and research hospital. METHODS: 16,918 positive isolates obtained from 66,323 culture samples processed in the clinical microbiology lab of an apex multispeciality hospital during 2011-2012 were included after a pilot study. Both manual and automated systems were used for identification and antimicrobial susceptibility. The frequency of isolation, sources, referring centers, resistance and susceptibility profiles, phenotypic characteristics and number of reports in PubMed were studied. RESULTS: Out of 16,918 isolates, 13,498 (79.78%) were Gram negative bacteria, 3254 (19.23%) were Gram positive bacteria and 166 (0.98%) were yeasts. A total of 483 (2.85%, 95% CI 2.6%-3.1%) emerging organisms including 116 (0.69%, 95% CI 0.57%-0.81%) emerging species were identified comprising 54 genera. CONCLUSION: Emerging organisms are likely to evade routine identification or be disregarded as non-contributory. Astute efforts directed at identification of emerging isolates, decisions by clinical microbiologists and treating physicians and containment of infection are required.

Prevalence of inducible clindamycin resistance in Staphylococcus aureus isolated from clinical samples.

BACKGROUND: Therapy for Staphylococcal infections may be complicated by the possibility of inducible macrolide-lincosamide-streptogramin B resistance (MLSBi). We studied the prevalence of MLSBi in community associated (CA) and hospital associated (HA) Staphylococcus aureus isolates from clinical samples. METHODS: A total of 305 strains of S. aureus comprising 140 (45.9%) [95% CI 40.36-51.52] methicillin resistant S. aureus (MRSA) and 165 (54%) [95% CI 48.48-59.64] methicillin-sensitive S. aureus (MSSA) were identified by conventional methods. The double disc test (D test) was applied by placing erythromycin and clindamycin discs to investigate inducible and constitutive MLSBi resistant phenotypes. RESULTS: 16.6% of MRSA showed constitutive resistance and 37.5% inducible MLSBi resistance. Community associated MRSA (CA-MRSA) represented 10% of all isolates and had lower prevalence of MLSBi than hospital associated MRSA (HA-MRSA). CONCLUSION: Routine screening for inducible MLSBi resistance by double disc test can screen for potential treatment failures such that clindamycin can be used effectively and judiciously when indicated for staphylococcal infections especially for treating skin and soft tissue infections (SSTIs) in CA-MRSA due to low prevalence of MLSBi among CA-MRSA.

Pleuropulmonary paragonimiasis: mimicker of tuberculosis.

Infection caused by the lung fluke is endemic in north eastern parts of India. Paragonimus westermani and Paragonimus heterotremus are known to be endemic in eastern Indian states of Manipur and Nagaland. The infection is related to eating habits of the locals and is acquired by ingestion of raw, inadequately cooked crabs or crayfish containing encysted metacercariae which act as second intermediate hosts during the life cycle of the lung fluke. Diagnosis is generally delayed due to lack of suspicion and presentation similar to tuberculosis which is endemic in the population. We report pleuropulmonary paragonimiasis in a soldier from eastern India who presented with chest pain, haemoptysis, and eosinophilia. He gave history of consumption of raw crabs while on leave at his native village in Nagaland. Ova morphologically resembling Paragonimus heterotremus were detected in sputum and bronchoalveolar lavage specimen. Symptoms resolved with praziquantel treatment.

Profile of primary resistance in HIV-1-infected treatment-naive individuals from Western India.

The majority of the HIV drug resistance (HIVDR) testing studies have focused on subtype B virus. The predominance of subtype C in the Indian subcontinent along with greater access to antiretroviral therapy (ART) necessitates studies on HIVDR genotyping. We determined the prevalence of mutations associated with protease inhibitors (PI), nucleoside reverse transcriptase inhibitors (NRTI), and nonnucleoside reverse transcriptase inhibitors (NNRTI) from plasma of 40 antiretroviral drug-naive study participants in Indian HIV-1 pol gene sequences. Of these, 36 sequences belonged to subtype C, two to subtype A1, and two were subtype A1C recombinants. The heterosexual route was the most common route of transmission. Drug resistance-associated mutations were observed in 10% (4/40) of the study participants. The resistance mutation observed in the protease gene was V82A, whereas in the RT gene, M41L, D67N, M184V, and A98G were documented. This is the first study reporting major protease mutations by genotyping in ART-naive individuals from western India.