Virtual Reality Simulation for the Acquisition and Retention of Electrocardiogram Interpretation Skills: A Randomized Controlled Trial Among Undergraduate Medical Students.

Introduction The electrocardiogram (ECG) is one of the most important tools in diagnosing cardiac abnormalities, particularly arrhythmias and myocardial infarction. It is one of the certifiable competencies for final-year medical undergraduate students. We determined virtual reality's effectiveness in acquiring and retaining ECG interpretation skills among medical students compared to traditional teaching. Methods One hundred and forty students were randomized into two groups. Seventy-one students (immersion group) were trained using virtual reality simulation to acquire and retain interpretation skills of normal and abnormal ECG. Sixty-nine students (traditional group) were trained in the classroom using chalk and board. The primary outcome of change in acquiring knowledge of the interpretation of ECG was determined by comparing pre and post-test scores. The secondary outcome of retention of knowledge was determined by comparing pre-test and second post-test scores conducted after eight weeks of intervention. The p-value of <0.05 was considered significant. Results Out of 140 students, 50 (35.7%) were males and 90 (64.3%) were female. The mean age of the students was 22.1 (SD 1.1), with 69.3% of them between the ages of 21 and 22 years. Mean pre-test scores for the interpretation of normal ECG among immersion and traditional groups were 9.8 (SD 8.4) and 8.3 (SD 7.5), respectively, and post-test scores for the acquisition of knowledge were 24.3 (SD 5.5) and 24.8 (SD 6.3), respectively. The post-test scores for retention skills were 25.3 (SD 5.6) and 20.7 (SD 6.9) respectively (p<0.001). The mean pre-test scores for the interpretation of abnormal ECG of both groups were 7.0 (SD 6) and 8.3 (SD 6.6), respectively. Mean post-test scores for acquiring knowledge to interpret abnormal ECG were 23.5 (SD 6.2) and 17.7 (SD 9), respectively (p<0.001), and mean post-test scores for retention of interpretation skills of abnormal ECG were 19.2 (SD - 6.9) and 13.3 (SD 10.2) respectively (p=0.001). The pairwise comparison of the immersion group indicates that all the combinations that changed in score from the pre to post-intervention time points, from pre-to-retention time, and from the post-to-retention time were significant (p<0.001). Conclusion Virtual reality teaching had a better impact on acquiring and retaining the skill for interpreting normal and abnormal electrocardiograms.

Alternate day versus daily oral iron for treatment of iron deficiency anemia: a randomized controlled trial.

Oral iron is the mainstay of treating iron deficiency anemia. Recent studies indicate better fractional iron absorption with alternate day supplementation. However, the optimal supplementation strategy is unclear. We compared effectiveness of daily versus alternate day supplementation of oral iron for treatment of iron deficiency anemia. This double blind, active control, randomized controlled trial was conducted on two hundred adults having hemoglobin 10 g/dL or less with microcytic hypochromic anemia and/or serum ferritin below 50 ng/mL. They were randomized to receive either two Ferrous sulfate tablets containing 60 mg elemental iron (120 mg total) on alternate days or single tablet of 60 mg elemental iron daily for 8 weeks. Primary outcome was mean change in hemoglobin at week 8 from baseline. Mean hemoglobin was 6.53 (± 1.89) and 6.68 (± 1.89) g/dL in the alternate day and daily arms respectively. Mean change in hemoglobin was + 1.05 ± 1.34 g/dL in alternate day arm and + 1.36 ± 1.51 g/dL in daily arm (p = 0.47) at week 8. There were no statistically significant differences between the arms with respect to any secondary outcome. There is no significant difference between alternate day and daily iron administration in improving hemoglobin. Randomized controlled trials enrolling more participants for longer periods of supplementation and evaluating clinically relevant outcomes like change in hemoglobin may be useful in identifying the ideal dosing strategy.Trial Registration: Clinical Trial Registry of India (CTRI/2019/01/017169).

Immunoglobulin G Antibodies to SARS-CoV-2 Among Healthcare Workers at a Tertiary Care Center in South India.

Introduction Healthcare workers (HCWs) are at risk of exposure to SARS-CoV-2. Seroprevalence in this group may offer insights into trends to monitor and revise strategies to prevent transmission. Methods A cross-sectional study was conducted in two phases among healthcare workers at a tertiary care center to detect IgG antibodies to SARS-CoV-2. Seropositivity was calculated during both phases, and possible associations were determined using regression analysis. Results A total of 382 and 168 HCWs took part in the two phases, respectively. IgG antibodies were detected in 13 of 382 (3.4%; 95% confidence interval (CI): 2%-5.7%) and 71 of 168 (42.3%) participants in the first and second phases, respectively. Receiving at least one dose of vaccine (p < 0.001) and age (p = 0.028) were factors associated with the presence of antibodies, while gender, job type, exposure to COVID-19 cases, and comorbidities were not associated with seropositivity. Conclusion Serosurveys among HCWs may help identify transmission patterns and redesign infection control practices in the healthcare setting.

National Early Warning Score 2 (NEWS2) to predict poor outcome in hospitalised COVID-19 patients in India.

BACKGROUND: While several parameters have emerged as predictors of prognosis of COVID-19, a simple clinical score at baseline might help early risk stratification. We determined the ability of National Early Warning Score 2 (NEWS2) to predict poor outcomes among adults with COVID-19. METHODS: A prospective study was conducted on 399 hospitalised adults with confirmed SARS-CoV-2 infection between August and December 2020. Baseline NEWS2 score was determined. Primary outcome was poor outcomes defined as need for mechanical ventilation or death within 28 days. The sensitivity, specificity and Area under the curve were determined for NEWS2 scores of 5 and 6. RESULTS: Mean age of patients was 55.5 ± 14.8 years and 275 of 399 (68.9%) were male. Overall mortality was 3.8% and 7.5% had poor outcomes. Median (interquartile range) NEWS2 score at admission was 2 (0-6). Sensitivity and specificity of NEWS 2 of 5 or more in predicting poor outcomes was 93.3% (95% CI: 76.5-98.8) and 70.7% (95% CI: 65.7-75.3) respectively [area under curve 0.88 (95% CI: 0.847-0.927)]. Age, baseline pulse rate, baseline oxygen saturation, need for supplemental oxygen and ARDS on chest X ray were independently associated with poor outcomes. CONCLUSIONS: NEWS2 score of 5 or more at admission predicts poor outcomes in patients with COVID-19 with good sensitivity and can easily be applied for risk stratification at baseline. Further studies are needed in the Indian setting to validate this simple score and recommend widespread use.

Empiric antibiotic and in-vitro susceptibility of urosepsis pathogens: do they match? The outcome of a study from south India.

INTRODUCTION: Urosepsis is life threatening, unless treated immediately. Empirical treatment with appropriate antibiotics lowers the risk of a poor outcome. However, with increasing resistance among common uropathogens, there is a need for continuous review of the existing protocol to determine whether there is a correlation between empirical antibiotic therapy and in-vitro susceptibility pattern of the pathogens causing urosepsis. METHODOLOGY: A prospective study was carried out on 66 confirmed cases of urosepsis from January 2017 to December 2018 after obtaining ethical clearance. Demographic details, risk factors, length of hospital stay, bacteriological profile, empirical antibiotic given, and change in antibiotic following susceptibility report and outcome was recorded. RESULTS: Among the 66 urosepsis cases 63 of them were started on empiric antibiotic. The correlation between the empirical antibiotic given and the in-vitro antimicrobial susceptibility was found to be significant with a p value < 0.0001. Among the 63 for whom empiric antibiotics was started further escalation of antibiotic was done in 46 patients. The remaining 20% of cases were changed over to a different antibiotic, in line with susceptibility report. The mortality rate was (15.1%) with a confidence interval of (CI = 15 ± 3.5). The association between the risk factors for urosepsis and their effect on mortality rate was analyzed. Diabetes mellitus and chronic kidney disease were identified as important independent risk factors and had direct influence on the mortality rate with significant p value of 0.0281 and 0.0015 respectively. CONCLUSIONS: A significant correlation was identified between the empirical antibiotic given and in-vitro antibiotic susceptibility pattern.

Melioidosis: distinctive clinico-epidemiological characteristics in southern India.

As it is increasingly being reported from India, we carried out a prospective study of patients with culture-proven melioidosis from south India, examining clinical, laboratory features, epidemiological data, risk factors, treatments, outcomes at three and six months, and factors associated with mortality.Between 2014 and 2018, 31 cases were identified. Diabetes (83.9%) and alcohol abuse (58.1%) were common risk factors. Musculoskeletal, skin and soft tissue manifestations together constituted 48.4% of presentations, while 29% had pneumonia. During the intensive phase, 74.2% received one of three recommended antibiotic regimes, but 51.6% did not receive continuation treatment. Pneumonia and lack of continuation treatment were independently associated with a high mortality of 25.8%. Hot spots for melioidosis exist in India, and there is considerable diversity of presentation, including skin, soft tissue, musculoskeletal and neurological involvement. High rates of bacteraemia are shown.

Prophylactic low dose ketamine infusion for prevention of shivering during spinal anesthesia: A randomized double blind clinical trial.

BACKGROUND AND AIMS: Regional anesthesia is known to produce perioperative hypothermia and shivering. We aimed to evaluate if prophylactic low dose ketamine bolus followed by infusion would prevent intraoperative and postoperative shivering under spinal anesthesia. MATERIAL AND METHODS: Sixty patients belonging to American Society of Anaesthesiologists (ASA) 1 and 2 undergoing abdominal and lower limb surgery were randomized to receive either 0.2 mg/kg iv of ketamine bolus followed by infusion 0.1 mg/kg/hr (Group K) or5 ml of saline followed by 0.1 ml/kg/hr solution (Group S) as an infusion throughout the period of surgery. The incidence of shivering was the primary outcome of the study with degree of sedation and the hemodynamic profile between the two groups being the secondary outcomes. Hemodynamics (Heart rate, Mean Blood Pressure and temperature), Grade of shivering and grade of sedation were assessed intraoperatively and for grade of shivering and sedation two hours postoperatively. Repeated measures Analysis of Variance (ANOVA) was used to compare the hemodynamic variables and Chisquare test/Fisher's exact test to compare the grades of shivering and sedation between the two groups. RESULTS: Intraoperative shivering was seen in eighteen patients in saline group (58.06%) and only with four patients (13.79%) with ketamine group (P < 0.001). Post operative shivering was also significantly less in ketamine group compared to saline (P = 0.01). Also, patients who received ketamine had significant sedation in the intraoperative period (P < 0.001). CONCLUSION: Prophylactic low dose ketamine administered as a small bolus followed by an infusion was effective in preventing both intraoperative and postoperative shivering.

Simulation-Based Training in Measurement of Blood Pressure: A Randomized Study of Impact in Real-Life Settings.

INTRODUCTION: Simulators are used for training competencies including blood pressure (BP) measurement. Whether such training translates to competency in real life is unclear. METHODS: We randomized 145 first-year undergraduate medical students to train on a BP simulator or arms of colleagues. After training, all students were assessed for accuracy (within 4 mm Hg above or below assessor's simultaneous recording) and methodology of BP recordings by an objectively structured clinical examination on real patients. RESULTS: Overall, 67 (46.2%) and 92 (63.4%) students accurately measured systolic and diastolic BP, respectively. Forty-three (58.1%) of 74 students in the conventional training recorded systolic BP accurately compared with 24 (33.8%) of 71 students in simulator training (P = 0.005). Diastolic BP was accurately recorded by 56 (75.7%) of 74 students in conventional group as against 36 (50.7%) of 71 students trained on simulator (P = 0.002). Median (interquartile range) objectively structured clinical examination score in conventional group was 8 (7-9) compared with 6 (5-7) in simulator group (P < 0.001). CONCLUSIONS: Simulator-based training did not translate to clinical competence in terms of accuracy and methodology of BP recordings in real-life settings. Notwithstanding its advantages, simulator-based BP training needs integration with human element to make it meaningful and relevant to clinical practice.

Comparison of Nebulized Ketamine with Nebulized Magnesium Sulfate on the Incidence of Postoperative Sore Throat.

BACKGROUND: Postoperative sore throat (POST) is a known complication following general anesthesia requiring endotracheal intubation. Its incidence ranges from 21% to 65% and remains the eighth most undesirable postoperative event. Various measures have been tried to decrease the incidence of sore throat with various success rates. AIM: This study aimed at reducing the incidence of POST with ketamine and magnesium sulfate nebulization. SETTINGS AND DESIGN: This study is a prospective randomized, double-blinded study. MATERIALS AND METHODS: After Institutional Ethics Committee approval and written informed consent, 80 patients who fulfilled the inclusion and exclusion criteria were randomly divided into two groups to receive magnesium sulfate 250 mg in 5 ml saline in Group A and ketamine 50 mg in 5 ml saline nebulization in Group B before the start of general anesthesia. All patients received standard anesthesia protocol. After extubation, all patients were enquired about the incidence and severity of sore throat at 0, 2, 4, 6, and 24 h. STATISTICAL ANALYSIS USED: Paired t-test and Wilcoxon signed-rank test were used to compare hemodynamic variables and Chi-square test to compare the incidence and severity of sore throat. RESULTS: There were no differences in the demographic profile, duration of laryngoscopy, time taken to intubate, and duration of surgery between the two groups. The incidence and severity of sore throat were significantly decreased in ketamine group at 4 and 6 h when compared to magnesium sulfate group. CONCLUSION: Nebulization with ketamine 50 mg significantly decreases the incidence of POST when compared to magnesium sulfate 250 mg.

Clinical and Laboratory Characteristics of Dengue-Orientia tsutsugamushi co-Infection from a Tertiary Care Center in South India.

BACKGROUND: Concurrent infection with multiple pathogens is common in tropics, posing diagnostic and treatment challenges. Although co-infections of dengue, malaria, leptospirosis and typhoid in various combinations have been described, data on dengue and scrub typhus co-infection is distinctly limited. METHODOLOGY: This study was a retrospective analysis of dengue and scrub typhus co-infection diagnosed between January 2010 and July 2014 at a tertiary care center. Clinical and laboratory features of these cases were compared with age and gender-matched patients with isolated dengue fever and isolated scrub typhus. Positive test for dengue non-structural 1 (NS1) antigen was considered diagnostic of dengue whereas scrub typhus was diagnosed by IgM scrub antibodies demonstrated by ELISA. RESULTS: There were 6 cases of dengue-scrub co-infection during the review period which fitted clinical and laboratory profile with a mean age of 42.5 years. Fever, headache, and arthralgia were common. Normal hemoglobin, significant thrombocytopenia, transaminitis, and hypoalbuminemia were identified in these patients. Compared to patients with isolated dengue, those with co-infection had higher pulse rate, lower systolic blood pressure, normal leucocyte counts, higher levels of liver enzymes, greater prolongation of partial thromboplastin time (aPTT) and lower serum albumin. Co-infection was characterized by a lower nadir platelet count compared to scrub typhus, and lesser time to nadir platelet count and longer duration of hospital stay compared to either isolated dengue or scrub typhus. CONCLUSION: Dengue-scrub typhus co-infection may be under-diagnosed in tropics, particularly confounded during dengue epidemics. Normal leukocyte counts, early drop in platelets and hypoalbuminemia in dengue patients could be clues to concurrent scrub typhus infection. Prompt recognition and treatment of scrub typhus in such cases may reduce unnecessary hospital stay and cost.

Impact of focused training on communication skills of final-year medical students in a medical school in India.

BACKGROUND: Although communication skills are important for a good physician-patient relationship, Indian medical curricula give very little emphasis on training medical students in this aspect. AIMS: To determine the change in communication skills of final-year medical students following focused training. METHODS: This was an educational interventional study done at Pondicherry Institute of Medical Sciences, a tertiary care teaching hospital in South India, to assess communication skills among final-year MBBS students. Fifty-two students (24 males and 28 females) participated in the study. A pre-test was conducted in the form of an objectively structured clinical examination (OSCE), followed by focused training for four hours. The same OSCE was administered as post-test. A comparison between the pre-test and post-test scores was done using Wilcoxon Signed Ranks Test. RESULTS: Ninety-six per cent of participants (50 out of 52) showed improvement in their performance after the focused training. The mean marks of the pre-test and post-test were 10.77± 3 and 18.04±2, respectively, out of a maximum mark of 20 (p<0.05). One out of 52 participants did not show any improvement, and one participant scored less in the post-test compared to the pre-test. There was no significant difference in the performance between male and female students. CONCLUSION: Focused training can enhance the communication skills of medical students. Hence, it may be included in the curriculum of undergraduate medical teaching programmes in India.

Synthesis, crystal structures and docking studies of 2,7-diphenyl-1,4-diazepan-5-one derivatives.

BACKGROUND: 1,4-Diazepine derivatives are the seven membered, nitrogen containing heterocyclic ring systems possessing a wide range of therapeutic applications. 1,4-Diazepines attracted the attention of chemists and druggists due to their biological and medicinal properties, such as antimicrobial, anti-HIV and anticancer activities. Herein, we report the preparation, crystal structure determined by X-ray crystallographic methods and docking of the molecules with the potential target protein NS5B RNA polymerase. RESULTS: The crystal structures and conformational studies of 1,4-diazepine [t-3, t-6-dimethyl-r-2,c-7-diphenyl-1,4-diazepan-5-one(DIAZ1)] and its nitroso derivative [t-3, t-6-dimethyl-1-nitroso-r-2,c-7-diphenyl-1,4-diazepan-5-one(DIAZ2)] are reported. The analyses of the molecules reveal that the seven membered diazepine ring systems adopt chair and boat conformations in compounds DIAZ1 & DIAZ2, respectively. In DIAZ2, the oxygen O2A is disordered over two positions with the refined occupancies of 0.792(7): 0.208(7) in the nitroso group. In both DIAZ1 & DIAZ2, the symmetry related molecules form a hetero/homo-dimer through N-H…O hydrogen bonds. CONCLUSION: In this study, the crystal structures of two new 1,4-diazepines, namely t-3, t-6-dimethyl-r-2,c-7-diphenyl-1,4-diazepan-5-one and t-3, t-6-dimethyl-1-nitroso-r-2,c-7-diphenyl-1,4-diazepan-5-one were synthesized and characterized by X-ray crystallographic methods. The docking studies show that the compounds inhibit at the active site of the target protein and can be utilized as potential drug molecules. In both the compounds, N-H…O hydrogen bonds lead to dimer formation. In DIAZ2, additionally a couple of C-H…O interactions are noted between the molecules. Graphical AbstractStructure and docking studies of 1,4-diazapine derivatives.

Prevalence and patterns of hearing loss among chronic kidney disease patients undergoing haemodialysis.

BACKGROUND: The prevalence, degree, and patterns of hearing loss associated with chronic kidney disease (CKD) reported by various studies differ significantly. The effects of haemodialysis and duration of disease on hearing loss remain unclear. AIMS: The aim of this study was to determine the prevalence and degree of hearing loss in CKD patients on haemodialysis. METHODS: This study included 120 CKD patients on haemodialysis. Information regarding age, gender, duration of disease, subjective hearing loss, exposure to ototoxic drugs, comorbidities like diabetes, hypertension, and hypothyroidism, renal functions, electrolytes and number of haemodialysis sessions received were obtained. An equal number of age and sex matched controls were used to determine prevalence of hearing loss in CKD patients after subjecting both groups to pure tone audiometry. We compared CKD patients with and without hearing loss for association of hearing loss with disease duration, number of haemodialysis, and blood parameters. RESULTS: Hearing loss was present in 41.7 per cent of CKD patients, significantly higher than controls (p=0.001), and was mild in the majority of patients. Impairment was noted across high and low frequencies of audiometric testing. Median duration of disease was the same (18 months) among CKD patients with and without hearing loss (p=0.62). CKD patients with hearing loss received 72 haemodialysis compared to 122 sessions by those without hearing loss (p=0.04). CONCLUSION: Mild sensorineural hearing loss is common in CKD. Hearing loss has no specific pattern as it prevails at high and low frequencies. Hearing loss may be inversely associated with the number of haemodialysis sessions but not with duration of disease.

Pattern of craniofacial anomalies seen in a tertiary care hospital in Saudi Arabia.

BACKGROUND AND OBJECTIVE: To date, there are no published studies from Saudi Arabia on the incidence or etiology of craniofacial anomalies. This study aimed to report the patterns of craniofacial anomalies in Saudi Arabia. DESIGN AND SETTING: Hospital-based, descriptive study conducted during 2002 to 2009 in the Cleft Lip/Palate and Craniofacial Anomalies Registry at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. PATIENTS AND METHODS: Data was collected on craniofacial patients in the registry. RESULTS: Of the 447 craniofacial patients (male, 242; female, 205), 109 (24.4%) had only cranial anomalies, 261 (58.4%) had only facial anomalies and 77 (17.2%) had both of these conditions. Craniosynostosis was seen in 33.3% of the total patients (81 males and 68 females). Of the 65 craniosynostosis syndromic patients, 25 (38.5%) had Apert syndrome and 18 (27.7%) had Crouzon syndrome. Among facial anomalies, 47 (19.4%) had dysmorphic features, followed by 35 (14.5%) with micrognathia. Among facial syndromes, 72 (59.0%) were observed to have Pierre-Robin sequence, 17 (13.9%) had Goldenhar syndrome and another 17 (13.9%) had Van der Woude syndrome. Cleft palate was more common in 171 (56.8%) patients as an associated deformity, followed by cleft lip with cleft palate in 99 (32.9%) and cleft lip in 23 (7.6%) patients. Of the 224 patients having other congenital anomalies, the cardiovascular system was most commonly affected, with 46 (20.5%) children diagnosed with congenital heart disease. A family history of anomalies was observed more in children born to parents of a consanguineous marriage than in those whose parents were unrelated (P=.01). CONCLUSIONS: Additional efforts should be made towards creating awareness among the general population about these deformities in relation to consanguinity.