Competency based medical education as an accelerator to end tuberculosis (End TB) in India.

Tuberculosis is a major public health challenge in India and has been targeted for elimination. The National Tuberculosis Elimination Program (NTEP), in its all-previous forms has been one of the leading national health programs with the institutionalized engagement of medical colleges. This article outlines the mechanisms for medical college engagement in NTEP and discusses how the recent adoption of competency based medical education (CBME) for graduate medical education provides an opportunity for strengthening medical college participation in NTEP. The authors propose that for an accelerated progress towards 'End TB' in India, there is need for scaling up faculty development programs, focusing upon operational and implementation research, adopting a practical approach in designing curriculum for graduate medical teaching and creation of online repository of training material as well as the data bank of post-graduate theses, and other published and unpublished research work. Alongside, these efforts need to be supplemented by the professional associations of medical specialties and the governments through organizing annual national scientific and policy forum; and the capacity building of postgraduate students and faculty members in operational research, amongst others. The adoption of CBME has-arguably- created an opportunity for innovations at medical college level to support End TB. The learnings could also be utilized for enhanced engagement of medical colleges in other national health programs. India's experience on medical college engagement in tuberculosis elimination could serve as a 'good practice' for TB endemic countries in other parts of the world.

Collaboration with medical colleges and public health institutions for implementation of national health programs: The way forward.

Health system strengthening is a much-needed priority to achieve the major public health goals of control, elimination, and eradication of various diseases. It depends on improving the country's ability to successfully perform essential functions while focusing on sustainability, equity, effectiveness, and efficiency. Medical colleges and public health institutions play an integral role in health system strengthening by educating and training the current and the future generations of health-care workforce with a vision to achieve the global standards in public health. This discussion focuses on the role of medical colleges and public health institutions in the success of various national health programs with a focus on challenges and improvement areas for the same.

Finding the most cost-effective option from commonly used Dipeptidyl peptidase-4 inhibitors in India: a systematic study.

OBJECTIVE: To identify a preferred and cost-effective drug among Dipeptidyl peptidase-4 inhibitors (DPP4Is) for Indian patients with T2DM. METHODS: We performed a systematic literature search using standard databases for relevant literature. Original studies comparing the efficacy and/or safety of different DPP4Is were included. Two authors independently performed the literature search, screening, and collected relevant data from the selected studies. The costs of all brands of individual DPP4Is were noted and compared for lowest, highest, and average cost. Finally, we summarized the information with respect to Efficacy, safety, suitability, and cost to find the most cost-effective DPP4I. RESULTS: We found 13 eligible studies containing data on 15,720 subjects. These studies showed similar efficacy (or better) and safety with teneligliptin as compared to other DPP4Is. Teneligliptin also showed additional benefits other than the glycemic control. The average cost per tablet of teneligliptin 20 mg was markedly lower as compared to sitagliptin, vildagliptin, and other commonly used DPP4Is. Teneligliptin also outscored other commonly used DPP4Is in India in suitability and seems to have better patient compliance. CONCLUSIONS: Teneligliptin 20 mg could be considered as the preferred and most cost-effective agent among commonly used DPP4Is for the effective management of patients with T2DM in India.

Self-Medication with Modern and Complementary Alternative Medicines in Patients with Chronic Pain.

Objective: The study aimed to assess the prevalence, pattern, and determinants of the self-medication practices with modern and/or complementary and alternative medicine (CAM) therapies in patients with chronic pain. Methods: The descriptive cross-sectional study was conducted between August 2021 and January 2022 and assessed a representative sample of chronic pain patients visiting outpatient departments in India by administering a semi-structured questionnaire. The survey questionnaire consisted of forty multiple response items, including ten questions that assessed the subjects' sociodemographic profile, for example, age, sex, education, marital status, employment status, residence, and distance of home from any health care facility. The next part of the questionnaire evaluated the practice and determinants of self-medication for chronic pain with modern or CAM therapies. It included thirty questions assessing the reasons, duration, sources of information, procurement methods, preference for a particular system of medicine, knowledge about risks or drug interactions, rationality, perception of the subject, and communication with the physician, among other aspects of self-medication for pain. Findings: Out of the 325 respondents with chronic pain, those who practiced self-medication (237) were significantly more in number than those who did not (P < 0.05). Among those who self-medicated, the practice was significantly higher in urban participants living closer to healthcare facilities, with better economic backgrounds and higher education (P < 0.05). Modern medicine was the predominant choice of self-treatment for chronic pain compared to various CAM therapies (P < 0.05). Among the alternatives, homeopathic and ayurvedic systems of medicines were preferred. The main reasons for self-medicating were urgency, ease, previous prescriptions, and presumed mildness of the underlying disease. More than one-third of the respondents opined in favor of continuing self-medication in the future. Conclusion: The prevalent practice of self-medication for chronic pain may not be hazardous, but it can turn into a serious problem if not based on correct information. The inherent risks need to be minimized by increasing awareness, health education, and pharmacy regulations.

Effects of COVID-19 pandemic lockdown on medical advice seeking and medication practices of home-bound non-COVID patients.

BACKGROUND: Many countries are implementing measures for social distancing to contain the spread of the coronavirus disease 2019 (COVID-19) pandemic. The Indian government also issued an order for complete lockdown of the country, with all the nonessential services, including most of the services for nonemergency health issues, being temporarily suspended. OBJECTIVES: This study aimed to understand the effect of pandemic lockdown on medical advice-seeking behavior and the medication practices of the non-COVID Indian patients confined to homes, who would have normally visited the outpatient departments (OPDs) for medical advice. MATERIALS AND METHODS: It was a questionnaire-based, cross-sectional study conducted online during the lockdown period. The questions dealt with medical advice-related practices, self-medication, the sources of medical advice, and the need to visit emergency department. Evaluation of data was done as for descriptive studies. RESULTS: A total of 106 people (34%) out of the 312 participants had either old or new health problems. Ninety-six of such people (90.5%) tried to manage their sufferings by either continuing the drugs prescribed earlier or by making phone calls to doctors along with taking the help of home remedies, if needed. Ten (9.5%) of the symptomatic participants did not consult any doctor waiting for natural course of relief. None of the participants practiced self-medication of modern medicine therapy. Only one participant (of the total 312) took hydroxychloroquine as self-medication for assumed prophylactic therapy against the COVID-19 infection. CONCLUSION: Most of the people with medical conditions, confined at home due to national lockdown, are coping with their problems without any irrational self-medication with modern medicines or any misuse of prophylactic therapy against the COVID infection. This seemingly positive trend may also have been due to the strict enforcement of the lockdown rules by the law enforcement agencies.

The Hindi Version of the Breastfeeding Self-Efficacy Scale-Short Form: Reliability and Validity Assessment.

BACKGROUND: Despite the cultural sanctity and elevation of breastfeeding practices, nearly one in two Indian women nationwide are unable to practice exclusive breastfeeding (EBF). Early identification of mothers at risk of reduced breastfeeding through a suitable instrument can enable targeted interventions for breastfeeding support. OBJECTIVES: We conducted this study with the objectives of translation into Hindi and to psychometrically test the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) and to ascertain the sociodemographic and other correlates of breastfeeding self-efficacy. METHODS: The BSES-SF was translated into Hindi using a back and forth translation process to ensure linguistic validity. We enrolled a total of 210 married women who were mothers of infants at an urban primary health center in Delhi, India. RESULTS: The Cronbach's alpha for the Hindi translation of the BSES-SF was 0.87 with all except one correlation coefficient <0.3. We conducted an exploratory factor analysis using principal component analysis that revealed a two-component solution, which explained 47.9% and 16.7% of the total variance, respectively. Mothers perceiving higher social support registered significantly higher mean BSES-SF scores, indicating a greater confidence in their breastfeeding abilities (P = 0.01). However, breastfeeding self-efficacy was unrelated to the mother's age, parity, and education. The women planning to breastfeed partially had lower BSES-SF scores compared to the woman adhering to EBF norms (P < 0.001). CONCLUSION: The Hindi version of the BSES-SF demonstrates good reliability and validity and can also explain previous and planned breastfeeding behavior in mothers of infants.

Knowledge, attitude, and perception of Indian population toward coronavirus disease (COVID-19).

BACKGROUND: Coronavirus disease (COVID-19) has spread very fast worldwide as a pandemic causing unprecedented morbidity and mortality. Most countries in the world have undergone emergency lockdown in an attempt to flatten the curve and reduce the load on healthcare systems. OBJECTIVE: This study was done to assess the knowledge, attitude, and perception toward the disease among the home-bound Indian population during the lockdown. METHODOLOGY: This was a questionnaire-based descriptive cross-sectional study conducted online. Compilation and assessment of the online data in the form of responses were done as for descriptive studies. RESULTS: Among the 320 participants of the study, the awareness about the epidemiological features, including the signs and symptoms of the disease, was very good (more than 99% in some aspects). The attitude toward the measures for prevention of disease at home and outside was also very good (more than 97%) in some aspects, with a scope of improvement in a few others. Only one-third had the knowledge of online (e-consultation) services floated by governments and hospitals for medical advice. Ten percent had the potential to misuse drugs as prophylaxis. Most of the participants perceived that they had no predictable idea about the shape of disease epidemiology in the near future and only hoped for things to get better. CONCLUSION: This study reflects that aggressive awareness drives have played an important role in the dissemination of knowledge and the development of informed positive attitude toward COVID-19. Few gaps in knowledge and practices related to disease epidemiology, safe practices, mobile app for tracking and the availability of e-resources for medical advice, still remain. These should be addressed more aggressively, to strengthen the efforts to overcome this unprecedented crisis.

Impact of increased focus on pharmacovigilance on knowledge and attitude towards adverse drug reaction reporting among medical students in India.

BACKGROUND: Recent years have seen a surge in pharmacovigilance (PV) related activities in India. In the present study the impact of these initiatives on medical students from across the country was evaluated to identify their effectiveness, lacunae and arrive at remedial measures. METHODS: A cross-sectional, questionnaire based study was conducted. The survey questionnaire consisted of 28 multiple response items. The areas covered included subject knowledge (theoretical and practical), attitude and awareness towards pharmacovigilance. RESULTS: The survey participants (n = 253) were from 71 medical colleges and 17 states across India. While 60% of the participants were familiar with the term 'Pharmacovigilance', many could not distinguish side effect and adverse drug reaction. The majority was unaware that 'Periodic Safety Update Report' (PSURs) is a mandatory pharmacovigilance activity by the industry. 91% felt reporting is a useful practice and causes for under-reporting are a lack of awareness followed by attitude, misconceptions about what to report, fear of litigation and interestingly the least important is lack of time. However, most were reluctant to have reporting as mandatory tool; they would rather use it voluntary. CONCLUSION: In spite of collaborative and synchronized efforts by various agencies there is a need to further improve the PV milieu in India by confidence building exercises, imparting training on PV programme, updating of the current knowledge on PV and also sustaining motivation.

Stability of non-metal dopants to tune the photo-absorption of TiO2 at realistic temperatures and oxygen partial pressures: A hybrid DFT study.

TiO2 anatase is considered to play a significant importance in energy and environmental research. However, for developing artificial photosynthesis with TiO2, the major drawback is its large bandgap of 3.2 eV. Several non-metals have been used experimentally for extending the TiO2 photo-absorption to the visible region of the spectrum. It's therefore of paramount importance to provide theoretical guidance to experiment about the kind of defects that are thermodynamically stable at a realistic condition (e.g. Temperature (T), oxygen partial pressure ([Formula: see text]), doping). However, disentangling the relative stability of different types of defects (viz. substitution, interstitial, etc.) as a function of charge state and realistic T, [Formula: see text] is quite challenging. We report here using state-of-the-art first-principles based methodologies, the stability and meta-stability of different non-metal dopants X (X = N, C, S, Se) at various charge states and realistic conditions. The ground state electronic structure is very accurately calculated via density functional theory with hybrid functionals, whereas the finite T and [Formula: see text] effects are captured by ab initio atomistic thermodynamics under harmonic approximations. On comparing the defect formation energies at a given T and [Formula: see text] (relevant to the experiment), we have found that Se interstitial defect (with two hole trapped) is energetically most favored in the p-type region, whereas N substitution (with one electron trapped) is the most abundant defect in the n-type region to provide visible region photo-absorption in TiO2. Our finding validates that the most stable defects in X doped TiO2 are not the neutral defects but the charged defects. The extra stability of [Formula: see text] is carefully analyzed by comparing the individual effect of bond-making/breaking and the charge carrier trapping energies.

A pharmacoeconomic analysis to compare cost-effectiveness of metformin plus teneligliptin with metformin plus glimepiride in patients of type-2 diabetes mellitus.

BACKGROUND: With the available evidence of early combined oral drug therapies being more effective in lowering blood glucose levels than maximal doses of a single drug, many clinicians are taking the aggressive approach of adding a sulfonylurea or a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin as the initial therapy in type 2 diabetes mellitus (T2DM). Pharmacotherapy for a chronic disease like diabetes has substantial economic implications for patients especially in a developing country like India. So it is important to scientifically evaluate the cost-effectiveness of these commonly practiced combination therapies in the management of T2DM. MATERIALS AND METHODS: This was a prospective observational randomized comparative study conducted over 8 weeks on patients of T2DM who were prescribed either of the two therapies of metformin (500 mg) plus glimepiride (1 mg) or metformin (500 mg) plus teneligliptin (20 mg). Cost-effectiveness analysis was done by calculating the expense incurred on 0.1% reduction in HbA1 c and 1 mg/dl reduction in fasting plasma glucose (FPG)/post-prandial plasma glucose (PPG) levels after 8 weeks and compared for both the groups. The same was also evaluated for differences in BMI levels. RESULTS: The cost-effectiveness for per unit reduction in HbA1c and FPG was significant in metformin plus glimepiride group as compared to the metformin plus teneligliptin group though it was comparable for both the groups for per unit PPG reduction. There was no significant change in BMI levels between the groups. CONCLUSION: Compared to metformin plus teneligliptin, metformin plus glimepiride is a significantly cost-effective therapy when used as an initial combination therapy in patients of T2DM in lowering HbA1c and FPG.

Impact of antiepileptic drugs on bone health: Need for monitoring, treatment, and prevention strategies.

Epilepsy is the most common neurological disorder affecting approximately 50 million people worldwide. In India, overall prevalence of epilepsy is reported to be 5.59/1000 population. Antiepileptic drugs (AEDs) constitute the main-stay of treatment with a large number of AEDs available in the market. High incidence of adverse effects is a major limitation with AEDs. One of the major concerns is significant metabolic effects on the bone. However, little attention has been paid to this issue because most of the bone effects remain subclinical for a long time and may take years to manifest clinically. The main effects include hypocalcemia, hypophosphatemia, reduced serum levels of Vitamin D, increase in parathormone (PTH) levels, and alterations in bone turnover markers. The CYP450 enzyme-inducing AEDs such as phenytoin, phenobarbital, carbamazepine, and primidone are the most common AEDs associated with bone disorders while the data regarding the effect of valproate and newer AEDs such as lamotrigine, gabapentin, vigabatrin, levetiracetam, and topiramate on bone metabolism and bone density are scanty and controversial. Deficiency of Vitamin D is commonly described as a cause for the bone loss in epileptic patients while others being decreased absorption of calcium, increased PTH levels, and inhibition of calcitonin secretion, etc. However, there are no formal practical guidelines for the management of bone disease among those taking AEDs. Evidence-based strategies regarding monitoring, prevention, and treatment of bone diseases in patients on AED therapy are needed.

Vedolizumab: A novel anti-integrin drug for treatment of inflammatory bowel disease.

Inflammatory bowel disease (IBD) is the chronic inflammatory disorder of gastrointestinal tract consisting of two subtypes: Ulcerative colitis and Crohn's disease. IBD occurs due to infiltration of leukocytes in intestinal mucosa and derangements in intestinal barrier function. One of the most important steps in pathogenesis of IBD is the interactions between integrins on the surface of leukocyte. The α4ß7 integrin expressing T-cell is an important leukocyte involved in pathogenesis and represents a new drug target for the treatment of IBD. Vedolizumab is a humanized monoclonal antibody, which acts against α4ß7 integrin heterodimer and blocks the interaction of α4ß7 integrin with MAdCAM-1. It prevents leukocyte binding to endothelial surface and its extravasation into affected tissue. The efficacy and safety of the vedolizumab have been established in many clinical studies. It has shown promising results in various clinical studies where a greater percentage of patients as compared to a placebo achieved and maintained clinical response, clinical remission, and corticosteroid-free clinical remission. Vedolizumab has been shown to be well tolerated with slightly higher risk of infections, headache, naspharyngitis as compared to placebo. This review focuses on the potential role of vedolizumab for the treatment of IBD.

4-hydroxy-benzoic acid (4-diethylamino-2-hydroxy-benzylidene)hydrazide: DFT, antioxidant, spectroscopic and molecular docking studies with BSA.

The Schiff base 4-hydroxy-benzoic acid (4-diethylamino-2-hydroxy-benzylidene) hydrazide (SL) was synthesized and characterized. Its antioxidant activity was evaluated using 1,1-diphenyl-2-picrylhydrazyl (DPPH) free radical scavenging action. Being a potent antioxidant its binding ability to the transport protein bovine serum albumin (BSA) was studied using fluorescence quenching and circular dichroism (CD) studies. The binding distance has been calculated by fluorescence resonance energy transfer (FRET) to be 1.85 Å and the Stern-Volmer quenching constant has been calculated to be (3.23 ± 0.45) × 10(5) M(-1). Quantum chemical analysis was carried out for the Schiff base using DFT with B3LYP and 6-311G** and related to the experimentally obtained results. For a deeper understanding of the mechanism of the interaction, the experimental data were complemented by protein-Schiff base docking calculations using Argus Lab.

Sutureless, Glueless, Scleral Fixation of Single-Piece and Toric Intraocular Lens: A Novel Technique.

Sutureless, glueless, scleral fixation of an intraocular lens is a known technique of fixing a lens in the scleral pockets. However, this technique is applied to single-piece and toric lenses instead of 3-piece lenses, allowing the advantage of the use of premium lenses in patients with poor capsular support. Favourable results without complications of pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage and cystoid macular edema with a well-centered, stable intraocular lens have been observed in the 3-month postoperative period in both cases.

Hypersensitivity reaction with deferasirox.

Thalassemias comprise a group of hereditary blood disorders. Thalassemia major presents with anemia within the first 2 years of life requiring frequent blood transfusions for sustaining life. Regular blood transfusions lead to iron overload-related complications. Prognosis of thalassemia has improved because of the availability of iron-chelating agents. Oral iron chelators are the mainstay of chelation therapy. Deferasirox is a new-generation oral iron chelator for once daily usage. We herein describe a patient of beta thalassemia major who developed an allergic manifestation in the form of erythematous pruritic skin rashes to the oral iron chelator deferasirox. This is a rare adverse reaction reported with deferasirox that led to a therapeutic dilemma in this particular case.

To evaluate efficacy and safety of Caralluma fimbriata in overweight and obese patients: A randomized, single blinded, placebo control trial.

AIM: The aim of the following study is to evaluate the efficacy and safety of Caralluma fimbriata extract (CFE) in overweight and obese individuals in a prospective, randomized, placebo controlled trial. MATERIALS AND METHODS: Commercially available CFE was assessed in overweight and obese individuals. A total of 89 patients were randomized into a treatment group (n = 47) and placebo group (n = 42) to receive either CFE in the form capsules/oral 500 mg b.d. for 12 weeks or matching placebo in similar way. Patients were evaluated clinically and biochemically at 4, 8 and 12 weeks for anthropometric measurements, appetite, biochemical investigations and other safety parameters. RESULTS: At the end of study period both CFE and placebo for 12 weeks caused only numerical reduction in weight, body mass index, waist circumference, hip circumference and waist hip ratio in overweight and obese individuals. However, these parameters failed to attain significant statistical levels (P ≥ 0.05). CFE and placebo both failed to elucidate any modification of the appetite. There were no significant changes in the biochemical and clinical parameters in both the test and placebo group. However, CFE was well-tolerated and adverse events noted were mild and transient in nature. CONCLUSION: A commercially available extract of CFE in an oral dose of 1 g/day claimed to have anti-obesity effect failed to yield any positive results on anthropometry and appetite in overweight and obese individuals beyond placebo. There were also no significant differences in the clinical and biochemical parameters. However, CFE was well tolerated. Thereby, underscoring the need to carry more research before CFE is recommended as an anti-obesity drug.

Comparative evaluation of aliskiren, ramipril, and losartan on psychomotor performance in healthy volunteers: A preliminary report.

AIM: To compare the effects of aliskiren, ramipril, and losartan on the psychomotor performance in healthy volunteers. MATERIALS AND METHODS: In this preliminary, single-dose, open-label, cross-over study conducted in 12 healthy volunteers, psychomotor assessment was carried out by four tests: Simple reaction time (SRT), multiple choice reaction time test (MCRT), critical flicker fusion frequency threshold test (CFFT), and tracking performance test (TPT). Each volunteer received a single dose of each of the three test drugs with a washout period of 10 days between different test sessions and then evaluated for post-drug scores at 2-h intervals up to 12 h and then at 24 h. The changes from the baseline scores by the test drug were statistically analyzed. RESULTS: All the three antihypertensive drugs caused significant improvement in a similar fashion on SRT, MCRT calculated as error index, CFFT, and TPT. Aliskiren caused numerically more improvement than the other two test drugs, suggesting better cognitive profile. However, inter-drug comparisons were nonsignificant. CONCLUSION: The results of the study highlight improvement of the cognitive functions equally by ramipril, losartan, and aliskiren. The results of the study could be of immense clinical utility in ambulatory hypertensive patients especially engaged in sensory-motor coordination tasks like driving and operating on mechanical tools.