A survey of awareness, knowledge, attitude, and skills of telemedicine among healthcare professionals in India.

Background: Telemedicine Practice Guidelines were promulgated in India in 2020. There is little information about the awareness, knowledge, attitude and skills (AKAS) of the healthcare professionals regarding telemedicine and its practice guidelines a year after. The aim of the study was to study the awareness, knowledge, attitudes and skills of the healthcare workers of the country about telemedicine especially in the context of telemedicine practice guidelines 2020. Methods: An online survey was conducted over 12 weeks from active healthcare workers in India. A standard AKAS Questionnaire for telemedicine and other close and open ended questions were used. Results: A total of 602 active healthcare workers participated in the study. It was seen that a majority of participants had high scores for awareness, knowledge, and attitude toward telemedicine but a mere 39.53% scored high for skills related to telemedicine. A majority of the respondents had no knowledge of the existence of telemedicine practice guidelines and very few had seen or read them. A majority of the respondents were keen to attend a course or training to enhance their understanding and practice of telemedicine. Conclusion: The results of the study show that the basic awareness and background knowledge regarding telemedicine exists in the healthcare professionals in the country. The requirement is to train and educate them about the skills and provisions of the telemedicine practice guidelines 2020 to ensure optimal use of telemedicine and to avoid medico-legal issues.

Characterization of the ability of a, second-generation SST-DA chimeric molecule, TBR-065, to suppress GH secretion from human GH-secreting adenoma cells.

CONTEXT: Somatostatin (SST) and dopamine (DA) inhibit growth hormone (GH) secretion and proliferation of GH-secreting pituitary adenomas (GHomas) through binding to SSTR2 and D2R receptors. Chimeric SST-DA compounds (Dopastatins) display increased potency in inhibiting GH secretion, as compared with individual SST or DA analogs (alone or combined). OBJECTIVE: To assess the efficacy of a second-generation dopastatin, TBR-065, in suppressing GH secretion from human GH- and GH/prolactin(PRL)-omas. DESIGN: We compared the ability of TBR-065 to inhibit GH secretion from primary cultures of human GH- or GH/PRLoma cells to that of the first generation dopastatin, TBR-760 (formerly BIM-23A760), octreotide (OCT) and cabergoline (CAB), the later either alone or combined. We investigated whether there was any impact of BIM-133, the metabolite of TBR-065, on the ability of TBR-065 to inhibit GH in these cultures. METHODS: 17 GH- and GH/PRLomas were included in this study. Inhibition of GH secretion by TBR-065, TBR-760, OCT and CAB (0.1 pM to 0.1 µM) was assessed over a period of 8 h. RESULTS: All tumors expressed SSTR2 and D2R mRNAs. GH suppression was higher with TBR-065 as compared with TBR-760 (Emax = 57 ± 5.6% vs. 41.1 ± 12.5%, respectively, p < 0.001) or with OCT + CAB (Emax = 56.8 ± 7.2% vs. 44.4 ± 9.4%, p < 0.001). BIM-133 did not have any impact on the activity of TBR-065. CONCLUSION: TBR-065 has significantly improved efficacy in suppressing GH secretion as compared to current available therapies and may represent a new promising option for the treatment of acromegaly.

Entrustable Professional Activities (EPAs) and milestones for MD sports medicine: A proposed portfolio.

BACKGROUND: Sports Medicine is an upcoming postgraduate speciality in India. A MD Sports Medicine specialist is expected to contribute in the prevention of sports injuries, sportsmen training and enhancement of performance apart from being involved in planning of conduct of sports events amongst many other roles and responsibilities. This requires hands-on training and acquisition of skill sets required to perform these roles. The National Medical Council of India highlights the need for a competency based curriculum and has laid down guidelines for the course. There was a felt need to develop Entrustable Professional Activities (EPAs) and milestones based on the prescribed curricula and develop a portfolio for continuous monitoring of the achievement of these EPAs. METHODS: A five step model was done by experts in the field to prepare the EPAs, milestones and portfolio. This consisted of faculty development, identification of the EPAs and milestones and portfolio preparation. RESULTS: 114 EPAs and 961 milestones were identified by the subject experts. The portfolio was developed with the help of specialists and faculty of the field of sports medicine, and medical educationists. CONCLUSION: Post graduate medical education is mandated to be competency based. A portfolio has been developed in the current exercise for use in a competency based post-graduate curriculum in sports medicine. This will help in the better implementation of CBME in the country.

Identifying entrustable professional activities for post-graduation in ENT: What should an ENT specialist be able to do?

BACKGROUND: Though regulatory bodies of medical education in India mandate post graduate medical education to be competency based, the implementation of the same has not kept pace. The present study aims to develop and propose a set of entrustable professional activities for a masters degree in the discipline of ENT. It also attempts to present it in the form of a portfolio. METHODS: Experts in the subject went through a series of activities including brainstorming, discussions and internal peer review to shortlist and enumerate EPAs. RESULTS: 335 EPAs were identified and are presented. They were further classified as per need and expected expertise. CONCLUSION: The EPAs may serve as a guideline to medical colleges/institutions aiming to adopt competency based medical education in the post graduate curriculum in the subject of ENT.

Development of a portfolio framework for implementation of an outcomes-based healthcare professional education curriculum using a modified e-Delphi method.

BACKGROUND: The explicit declaration of Entrustable Professional Activities (EPA) and milestones are an essential component of a competency based medical education curricula. The present study attempts to develop a portfolio framework to document them for adaptation in any healthcare professional education curriculum development. METHODS: A modified e-Delphi method was used after incorporation of a study group of medical education experts (MEDEX-G). Consensus was defined as 75% agreement. Both qualitative and quantitative data was collected and analysed to conduct three rounds of the Delphi. RESULTS: The draft template was prepared by the core faculty of medical education centre. The final template was approved by the experts after 03 iterations of anonymous online voting and presentation of summary results by the moderator. The final template lists out the milestones of each EPA separately with provision for expected expertise and level, suggestive teaching learning activities and assessments, reflections by the students and feedback by facilitator for each EPA. CONCLUSION: The MEDEX-G consensus template is an important development to encourage the adoption of portfolios in a competency based medical education curriculum. It can be freely adopted by various healthcare professional education bodies in various disciplines.

The infodemics of COVID-19 amongst healthcare professionals in India.

BACKGROUND: There is a deluge of information and misinformation about COVID-19. The present survey was conducted to explore the sources of information /misinformation for healthcare professionals from India. METHODS: A cross-sectional online survey using snowballing technique was conducted from 24 Mar to 10 Apr 2020. The questionnaire was pretested and developed using standard techniques. It was circulated among medical students and physicians. Data were analysed using the STATA software. RESULTS: Data of 758 participants were analysed. A total of 255 (33.6%) medical students, 335 (44.2%) nonspecialists and 168 (22.1%) specialists participated. The most common source of formal and informal information was official government websites and online news, respectively. A total of 517 (68.2%) participants accepted receiving misinformation. Social media and family and friends were the most common sources of misinformation. Seventy-two percent of participants agreed that spread of information helped to contain COVID-19, but more than that 75% agreed to having received inaccurate information. Seventy-four percent of respondents felt the need for regulation of information during such times; 26% and 33% felt that information about COVID-19 made them feel uncomfortable and distracts routine decision-making, respectively, and 50% felt it was difficult to differentiate correct from incorrect information about COVID-19. CONCLUSION: The study explored the sources of information and misinformation and found a high prevalence of misinformation, especially from social media. We suggest the need to better manage the flow of information so that it can be an effective weapon against SARS-CoV2. There is a need for doctors to adapt to the changing times of infodemics accompanying pandemics.

Leadership challenges in multinational medical peacekeeping operations: Lessons from UNIFIL Hospital.

Commanding a military multinational and multilingual healthcare facility can be a formidable task with very little margin for error. The authors were in leadership positions of UNIFIL Hospital, unique in its diversity of both staff and clientele. Experience about the challenges faced and methods adopted to overcome them will be shared. Troops from diverse backgrounds differ in their competency, and also in their attitudinal approach to situations. It is imperative for the medical commanders to identify these differences, and work towards harnessing individual strengths to form a cohesive unit. Frequent rotation of team members and thereby difficulty in adapting to new environment makes the tasks more challenging. Challenges can be broadly categorized in those dealing with functional roles (providing medical support) and command and control issues. Linguistic challenges especially in situations where professionals have to work as a coordinated unit remains a major challenge. The threat of medical errors arising out of misunderstandings is very real. Gender sensitization is essential to avoid potential unpleasant situations. Interpersonal conflict can easily go out of hand. The leadership has to be more direct and deliberate relying less on hierarchy and more on direct communication. A strict enforcement of UN standards for equipment and competence, frequent joint medical drills help to overcome interoperability issues and develop mutual confidence. Leadership in multinational UN hospitals is a demanding task with its peculiar set of challenges. A systematic and deliberate approach focused on mutual respect, flexibility and direct leadership can help medical commanders in such situations.

Evaluation of interactive teaching for undergraduate medical students using a classroom interactive response system in India.

BACKGROUND: The classical didactic lecture has been the cornerstone of the theoretical undergraduate medical education. Their efficacy however reduces due to reduced interaction and short attention span of the students. It is hypothesized that the interactive response pad obviates some of these drawbacks. The aim of this study was to evaluate the effectiveness of an interactive response system by comparing it with conventional classroom teaching. METHODS: A prospective comparative longitudinal study was conducted on 192 students who were exposed to either conventional or interactive teaching over 20 classes. Pre-test, Post-test and retentions test (post 8-12 weeks) scores were collated and statistically analysed. An independent observer measured number of student interactions in each class. RESULTS: Pre-test scores from both groups were similar (p = 0.71). There was significant improvement in both post test scores when compared to pre-test scores in either method (p < 0.001). The interactive post-test score was better than conventional post test score (p < 0.001) by 8-10% (95% CI-difference of means - 8.2%-9.24%-10.3%). The interactive retention test score was better than conventional retention test score (p < 0.001) by 15-18% (95% CI-difference of means - 15.0%-16.64%-18.2%). There were 51 participative events in the interactive group vs 25 in the conventional group. CONCLUSIONS: The Interactive Response Pad method was efficacious in teaching. Students taught with the interactive method were likely to score 8-10% higher (statistically significant) in the immediate post class time and 15-18% higher (statistically significant) after 8-12 weeks. The number of student-teacher interactions increases when using the interactive response pads.

Contact Endoscopy of mucosal lesions of oral cavity - Preliminary experience.

BACKGROUND: Contact Endoscopy is a non invasive tool to visualise alterations in cell architecture in vivo. In this study we investigated the diagnostic accuracy of Contact Endoscopy in detecting malignancy in oral mucosal lesions. METHODS: 76 patients with oral mucosal lesions requiring biopsy were included. Contact Endoscopy was performed by Otolaryngologist before biopsy and findings recorded. The lesion was then biopsied and sent for histopathological examination by Pathologist who was blinded to Contact Endoscopy findings. Findings of Contact Endoscopy were compared with histopathological findings taking the latter as the gold standard. Two biopsies were reported as 'inconclusive' on histopathological examination and hence excluded from the final analysis. Data of the remaining 74 patients is presented here. RESULTS: Clinically lesions were diagnosed as ulcero-proliferative lesions in 34 patients, Leukoplakia in 19, Erythroplakia in 9, Lichen planus in 5 and Submucous fibrosis in 7 patients. Histopathological examination revealed presence of malignancy in 97.06% of ulcero-proliferative mucosal lesions, 10.53% of leukoplakia and 33.33% of erythroplakia while corresponding figures on Contact Endoscopy were 94.12%, 5.26% and 11.11% respectively. No malignancy was detected in lichen planus and submucous fibrosis by either technique. When compared with histopathological examination, CE showed sensitivity of 84.21%, specificity of 94.44% and accuracy of 89.19%. No adverse effects on the patients were seen due to the procedure or stain. CONCLUSION: Contact Endoscopy may be useful in determining cellular structure in vivo without biopsy to detect oral malignancy early. Further studies are suggested.

Our Experience with Sinonasal Glomangiopericytoma in North India: A Case Series.

Glomangiopericytoma (GPC) is a rare benign sinonasal tumor originating from Zimmerman's Pericytes surrounding capillaries and accounting for less than 0.05% of all sinonasal tumors. Glomangiopericytoma has low malignant potential (5-10%) and is mostly diagnosed in the 6th or 7th decade of age with slight female preponderance. We presented here a case series of 5 patients with sinonasal GPC. This research was conducted at a tertiary healthcare centre in North India. In our case series, all the patients were evaluated and underwent endoscopic surgical resection. All patients underwent digital subtraction angiography (DSA) and preoperative embolization. The coblation technique used for haemostasis proved very effective and time-saving. All patients exhibited cytoplasmic SMA positivity (a marker of GPC) and CD34 negativity, while one patient exhibited a high Ki-67 index (> 10%), which is a predictor of aggressive tumor behavior. None of the patients showed any recurrence in follow-up. We recommend performing complete endoscopic surgical excision to prevent recurrence. The use of DSA, preoperative embolization, and intraoperative use of the coblation technique provides a cleaner surgical field and reduced operating time.

The novel somatostatin receptor 2/dopamine type 2 receptor chimeric compound BIM-23A758 decreases the viability of human GOT1 midgut carcinoid cells.

The majority of neuroendocrine tumors (NETs) of the gastroenteropancreatic system coexpress somatostatin receptors (SSTRs) and dopamine type 2 receptors (D2R), thus providing a rationale for the use of novel SSTR2/D2R chimeric compounds in NET disease. Here we investigate the antitumor potential of the SSTR2/D2R chimeric compounds BIM-23A760 and BIM-23A758 in comparison to the selective SSTR2 agonist BIM-23023 and the selective D2R agonist BIM-53097 on human NET cell lines of heterogeneous origin. While having only minor effects on human pancreatic and bronchus carcinoid cells (BON1 and NCI-H727), BIM-23A758 induced significant antitumor effects in human midgut carcinoid cells (GOT1). These effects involved apoptosis induction as well as inhibition of mitogen-activated protein kinase and Akt signaling. Consistent with their antitumor response to BIM-23A758, GOT1 cells showed relatively high expression levels of SSTR2 and D2R mRNA. In particular, GOT1 cells highly express the short transcript variant of D2R. In contrast to BIM-23A758, the SSTR2/D2R chimeric compound BIM-23A760 as well as the individual SSTR2 and D2R agonistic compounds BIM-23023 and BIM-53097 induced no or only minor antitumor responses in the examined NET cell lines. Taken together, our findings suggest that the novel SSTR2/D2R chimeric compound BIM-23A758 might be a promising substance for the treatment of NETs highly expressing SSTR2 and D2R. In particular, a sufficient expression of the short transcript variant of DR2 might play a pivotal role for effective treatment.

A Randomised Controlled Trial on the Efficacy of Topical Application of Autologous Platelet Rich Plasma (PRP) on Graft Uptake Rate in Adults Undergoing Type 1 Tympanoplasty for Inactive COM Mucosal Disease.

To assess the efficacy of topical use of autologous platelet rich plasma (PRP) as a packing material in type 1 tympanoplasty in Mucosal Inactive COM disease by conducting a Randomized Controlled Trial in 80 patients. Prospective Randomized Controlled Trial. Total 80 patients were enrolled for the study after fulfilling the inclusion and exclusion criterion. Written and informed consent was taken from all patients. After taking detailed clinical history, the patients were divided in to two groups of 40 patients each by block randomization. Group A was the interventional group where topical autologous platelet rich plasma was applied on the graft during type1 tympanoplasty. In Group B, PRP not applied. Graft uptake rate was observed postoperatively after 1 month and 6 months. Successful graft uptake at 1st month was noted in 97.5% patients in Group A and 92.5% in Group B with a corresponding failure rate of 2.5% and 7.5% respectively. Successful graft uptake at 6th month was noted in 95% patients in Group A and 90% in Group B with a corresponding failure rate of 5% and 10% respectively. As observed from our study status of graft uptake and reperforations at 1st and 6th months subsequent to surgery and rate of post-operative infections were similar in both the groups irrespective of the status of receiving autologous platelet rich plasma. Trial registration Trial registered with CTRI (Clinical Trial Registry -India) (Reg. no CTRI/2019/02/017468 dated 05/02/2019). Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03681-w.

Requirement of central ghrelin signaling for alcohol reward.

The stomach-derived hormone ghrelin interacts with key CNS circuits regulating energy balance and body weight. Here we provide evidence that the central ghrelin signaling system is required for alcohol reward. Central ghrelin administration (to brain ventricles or to tegmental areas involved in reward) increased alcohol intake in a 2-bottle (alcohol/water) free choice limited access paradigm in mice. By contrast, central or peripheral administration of ghrelin receptor (GHS-R1A) antagonists suppressed alcohol intake in this model. Alcohol-induced locomotor stimulation, accumbal dopamine release and conditioned place preference were abolished in models of suppressed central ghrelin signaling: GHS-R1A knockout mice and mice treated with 2 different GHS-R1A antagonists. Thus, central ghrelin signaling, via GHS-R1A, not only stimulates the reward system, but is also required for stimulation of that system by alcohol. Our data suggest that central ghrelin signaling constitutes a potential target for treatment of alcohol-related disorders.

The Use of a Low-Cost Gaming Platform as a Substitute to Medical-Grade Force Plate in Objective Evaluation of Balance.

Posturography is a tool for quantitative measurement of balance in various static and dynamic test conditions. Current medical grade Posturography systems are very costly and rare outside research institutes. The Wii Balance Board is an inexpensive gaming device which works on similar principles and uses the center of pressure of an individual as an input for motion-controlled gaming. The aim of this study was to assess the validity of using a gaming platform (Wii Balance Board) as a substitute to medical grade Posturography machine. The objectives were to compare the measures of postural sway obtained from a gaming platform with those from a medical grade Posturography machine and to demonstrate a low-cost method of analysis of balance using the gaming platform. Descriptive Observational study. Individuals aged 18-65 years and having no apparent dysfunction of balance were assessed objectively using Wii Balance Board and Medical-grade Posturography machine. A program was developed in Scilab for computation of sway parameters. The results were compared in terms of correlation coefficient, Bland-Altmann plots, and ability to detect abnormal sway. A Pearson's correlation coefficient ranging from 0.53-0.91 was observed in various test conditions, with an overall value of 0.62 between the results of the two machines. The sensitivity was 69.39%, specificity was 73.16%, positive predictive value 24.29%, negative predictive value 95.07%, and accuracy 72.75%. Thus, we can conclude that the Wii Balance Board can be used as a low-cost substitute to medical grade Posturography machine for quantification of balance in situations where precise measurement of balance is not required.

Combined effects of ghrelin and higher food intake enhance skeletal muscle mitochondrial oxidative capacity and AKT phosphorylation in rats with chronic kidney disease.

Skeletal muscle mitochondrial dysfunction and insulin resistance occur in chronic kidney disease. Ghrelin is a gastric hormone previously shown to enhance muscle mitochondrial enzyme activities and AKT-mediated insulin signaling independent of food intake in healthy rats. Here we determined the impact of ghrelin treatment on anorexia, skeletal muscle mitochondrial oxidative capacity, AKT phosphorylation as a measure of insulin signaling, and lean body mass in a rat model of chronic kidney disease. Ghrelin infusion promoted higher food intake and lean body mass. Further, although muscle mitochondrial enzyme activities were low in the rats with CKD (chronic kidney disease), they normalized with ghrelin treatment, a change that was consistent with the increase in the transcript levels of regulators of mitochondrial biogenesis and lipid metabolism. This was associated with a lower muscle triglyceride content and higher AKT phosphorylation. Pair-feeding showed that mitochondrial effects of ghrelin are independent of changes in food intake, whereas combined ghrelin treatment and higher food intake were needed to enhance AKT phosphorylation. Thus, ghrelin-induced muscle mitochondrial changes and lower tissue triglycerides could favor insulin action and muscle anabolism in the presence of improvement in food intake. Our study shows that combined effects of ghrelin on appetite and muscle mitochondria improve muscle metabolic and nutritional alterations in chronic kidney disease. This could have potential beneficial impact on patient morbidity and survival.

Vestibular Dysfunction in Children Suffering from Otitis Media with Effusion: Does Grommet Help? An Observational Study Using Computerized Static Posturography.

Otitis media with effusion (OME) has a detrimental effect on balance, which may not present as a clear symptom in children. This effect can be improved by the insertion of ventilation tubes. This study assesses balance in children suffering from OME pre and post operatively using computerized static posturography. 50 children of 3-6 years, suffering from OME were included in this observational descriptive study. These patients underwent myringotomy and grommet insertion. The balance was evaluated pre and post operatively after 3 months using computerized static posturography with Modified Clinical Test of Sensory Interaction on Balance under four conditions, namely eyes open/closed on firm surface/foam. Posturography mean sway velocity was deranged in these children preoperatively and it showed statistically significant improvement post operatively at 3 months. There is occult vestibular dysfunction in children with OME as assessed by static posturography which improves significantly 3 months after myringotomy and grommet insertion.

Unilateral Sudden Sensorineural Hearing Loss: A Rare Presentation of Cerebral Venous Thrombosis.

Sudden sensorineural hearing loss (SNHL) is postulated to be caused due to a multitude of factors, but a definitive cause is seldom found despite extensive investigations. We present a rare case of sudden SNHL in which central venous thrombosis was found on magnetic resonance imaging. The case highlights the importance of neuroimaging in all cases of sudden SNHL before being labelled as "idiopathic" so that targeted therapy can be given.

Voice Quality in Cochlear Implant Recipients: An Observational Cross Sectional Study.

Children with hearing loss are more likely to suffer from voice and speech disorders than with normal hearing due to their poor and less robust auditory feedback mechanisms. Prelingually deaf children are not able to supervise their own voice due to lack of auditory feedback. Cochlear implanted children achieve better hearing and consequently enhanced speech intelligibility. Various parameters of voice improve with continous usage of cochlear implant. However all the vocal parameters do not show similar degree of change. Previous studies have assessed the voice quality of cochlear implantees and have given inconsistent results. The aim of the study is to compare the voice quality of cochlear implant children with normal subjects using objective and subjective methods. The study was undertaken after obtaining clearance from the Institutional Ethics committee. Written informed consent for carrying out voice analysis was taken from the parents. The voice analysis of 42 normal and 42 cochlear implant children were done using the Dr Voice software by Tiger Inc. All the children were age and sex matched. The parameters assessed were fundamental frequency, maximum phonation time, jitter%, shimmer% and harmonics to noise ratio. The findings of both the group were compared. The cochlear implanted children showed significant deviation of all the measured parameters as compared to the normal children. The voice quality of the implanted children is poor and deviant from the normal. Even after continuous usage of cochlear implant for 1 year the voice quality of these children did not reach to the levels of their normal hearing peers.