Use of Mini-CEX as Formative Assessment Tool in the Training of Undergraduate Medical Students in ENT Situation Analysis and the Way Forward.

Background: Mini-CEX assesses clinical competency and is mainly used as a formative assessment tool. Its use in postgraduate training is well documented. However, Mini-CEX would play a significant role in training undergraduate medical students, especially with the commencement of competency-based medical education in India. This work reports the situational analysis of the Mini-CEX implementation in the department of ENT. Methods and Material: The Department of ENT is using Mini-CEX for formative assessment of students' clinical competence since 2017. Each student had to complete a minimum of five Mini-CEX encounters before the summative assessment. We reviewed the Mini-CEX assessment records of 149 undergraduate medical students who appeared for the summative exam in 2018. Results: We analysed the records of 874 Mini-CEX encounters. Each Mini-CEX encounter took 11 min on average. Each student completed five such assessments, which accounted for 55 min of one-to-one teacher-student interaction focused on clinical skills learning. The feedback time varied from 1 to 30 min. Feedback was focused on the cognitive (46%) and psychomotor (42%) domains. However, the majority of students reflected that they learned psychomotor skills during the Mini-CEX. Students selected only a few skills for the Mini-CEX, ignoring many must-know skills. Conclusions: Mini-CEX is feasible as a formative assessment tool for medical undergraduates' ENT training. It improves the assessor-student interaction, provides effective feedback, and develops the practice of reflection among students. However, regular review and training of the assessors and students are needed as a quality assurance measure.

Diagnostic Utility of NLR, PLR and MLR in Early Diagnosis of Gastric Cancer: an Analytical Cross-Sectional Study.

PURPOSE: Inflammatory markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR) are linked with the pathogenesis of gastric cancer (GC). However, the clinical significance of the combination of these markers is unclear. Hence, this study was carried out to determine the individual and combined diagnostic accuracy of NLR, PLR and MLR among patients with GC. METHODS: In this prospective, cross-sectional study, patients were recruited into three groups, GC, precancerous lesions and age and gender-matched controls. The primary outcome was to determine the diagnostic accuracy of inflammatory markers in the diagnosis of GC. The secondary outcome was to determine the correlation of inflammatory markers with the stage of gastric cancer, nodal involvement and metastasis. RESULTS: A total of 228 patients, 76 in each group, were enrolled. The cut-off value of NLR, PLR and MLR were 2.23, 146.8 and 0.26, respectively, for the diagnosis of GC. The diagnostic abilities of NLR, PLR and MLR were significantly high at 79, 75 and 68.4, respectively, to predict GC compared to precancerous and control groups. All the models of inflammatory markers showed excellent discrimination between GC and the controls with an AUC > 0.7. The models also showed acceptable discrimination between GC and the precancerous lesion group with AUC between 0.65 and 0.70. No significant difference was found in correlating inflammatory markers with clinicopathological features. CONCLUSION: The discrimination capacity of the inflammatory markers could be used as screening biomarkers in diagnosing GC, even in its early stages.

Adherence to iron and folic acid supplementation among antenatal mothers attending a tertiary care center, Puducherry: A mixed-methods study.

BACKGROUND: Iron-deficiency anemia in pregnancy is a major public health problem despite the efforts taken by the Ministry of Health and Family Welfare for the past five decades. Adherence to iron and folic acid supplementation (IFAS) is the key factor for the prevention and management of nutrition anemia. AIM: The aim of this study was to assess the adherence to its associated factors and to explore the reasons for the non-adherenc among pregnant women attending a tertiary care center. MATERIALS AND METHODS: It is an explanatory mixed-methods design (quantitative cross-sectional analytical design and qualitative descriptive design). STATISTICAL ANALYSIS USED: Results presented as proportion with 95% confidence interval (CI). Chi-square test was done to assess the association of the factors to adherence. Qualitative data were transcribed verbatim, translated to English, and analyzed by manual content analysis. RESULTS: A total of 340 pregnant women were included, and the adherence to IFAS among the antenatal mothers was 63.8 (95% CI [58.61-68.6]). The factors associated with adherence to IFAS (prevalence ratio with 95% CI) were primigravida status [1.22 [1.02-1.45]), nonanemic in the first trimester (1.27 [1.09-1.49]), and absence of side effects (3.16 [1.95-5.12]). Conceptual framework was constructed using the emerging themes: (i) knowledge-related factors, (ii) behavior-related factors, and (iii) facilitating factors. CONCLUSION: About three-fourth of the participants were adherent to IFAS. Compliance is directly influenced by the gravida status, anemic status, and absence of side effects. Based on qualitative results, measures to improve palatability and the quality of IFAS are recommended.

Adapted ERAS Pathway vs. Standard Care in Patients with Perforated Duodenal Ulcer-a Randomized Controlled Trial.

OBJECTIVES: The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency simple closure of perforated duodenal ulcer (PDU). METHODS: This single-center, prospective, open-labeled, superiority, RCT was carried out from August 2014 to July 2016. Patients of PDU undergoing open simple closure were randomized preoperatively in 1:1 ratio into standard care and adapted ERAS group. Patients with refractory shock, ASA class ≥3, and perforation size ≥1 cm were excluded. Primary outcome was the length of hospitalization (LOH). Secondary outcomes were functional recovery parameters and morbidity. RESULTS: Forty-nine and 50 patients were included in standard care and ERAS group, respectively. Patients in ERAS group had a significantly early functional recovery (days) for the time to first flatus (1.47 ± 0.18; p < 0.001), first stool (2.25 ± 0.20; p < 0.001), first fluid diet (2.72 ± 0.38; p < 0.001), and solid diet (3.70 ± 0.44; p < 0.001). LOH in ERAS group was significantly shorter (mean difference of 4.41 ± 0.64 days; p < 0.001). There was a significant reduction in postoperative morbidity such as superficial SSI (RR 0.35, p = 0.02), postoperative nausea and vomiting (RR 0.28, p < 0.0001), and pulmonary complications (RR 0.24, p = 0.04) in the ERAS vs. standard care group with similar leak rates (1/50 vs.2/49). CONCLUSION: ERAS pathways are safe and feasible in select patients undergoing emergency simple closure of PDU.

External validation of scoring systems in risk stratification of upper gastrointestinal bleeding.

AIM: The aim of this study was to externally validate the four commonly used scoring systems in the risk stratification of patients with upper gastrointestinal bleed (UGIB). METHODS: Patients of UGIB who underwent endoscopy within 24 h of presentation were stratified prospectively using the pre-endoscopy Rockall score (PRS) >0, complete Rockall score (CRS) >2, Glasgow Blatchford bleeding scores (GBS) >3, and modified GBS (m-GBS) >3 scores. Patients were followed up to 30 days. Prognostic accuracy of the scores was done by comparing areas under curve (AUC) in terms of overall risk stratification, re-bleeding, mortality, need for intervention, and length of hospitalization. RESULTS: One hundred and seventy-five patients were studied. All four scores performed better in the overall risk stratification on AUC [PRS = 0.566 (CI: 0.481-0.651; p-0.043)/CRS = 0.712 (CI: 0.634-0.790); p<0.001)/GBS = 0.810 (CI: 0.744-0.877; p->0.001); m-GBS = 0.802 (CI: 0.734-0.871; p<0.001)], whereas only CRS achieved significance in identifying re-bleed [AUC-0.679 (CI: 0.579-0.780; p = 0.003)]. All the scoring systems except PRS were found to be significantly better in detecting 30-day mortality with a high AUC (CRS = 0.798; p-0.042)/GBS = 0.833; p-0.023); m-GBS = 0.816; p-0.031). All four scores demonstrated significant accuracy in the risk stratification of non-variceal patients; however, only GBS and m-GBS were significant in variceal etiology. Higher cutoff scores achieved better sensitivity/specificity [RS > 0 (50/60.8), CRS > 1 (87.5/50.6), GBS > 7 (88.5/63.3), m-GBS > 7(82.3/72.6)] in the risk stratification. CONCLUSION: GBS and m-GBS appear to be more valid in risk stratification of UGIB patients in this region. Higher cutoff values achieved better predictive accuracy.

Assessing the risk for development of Venous Thromboembolism (VTE) in surgical patients using Adapted Caprini scoring system.

AIM: To determine the incidence, morbidity and mortality due to Venous Thromboembolism (VTE) in surgical patients, and to assess the validity and reliability of Adapted Caprini scoring in risk stratification for VTE prophylaxis. METHODOLOGY: This was a prospective observational study in a tertiary care hospital of South India on patients who underwent both elective and emergency surgeries over a period of 9 months. An Adapted Caprini score was devised which included only the clinical criteria. The patients were scored by two persons independently at admission and followed up till the 30th post-operative day and primary and secondary end points were statistically analyzed. RESULTS: Three hundred and one patients were included and the overall incidence of VTE at 30 days was 7.3%. The risk of developing VTE was found to be significantly higher among the >8 score group as compared to 3-4 group (OR = 153.5, p < 0.001), or the 5-6 group (OR = 52.9, p < 0.001) or the 7-8 group (OR = 2.3, p = 0.002). Patients with a score of 7-8 were more likely to develop VTE as compared to 3-4 group (OR = 67.5, p < 0.001) or the 5-6 group (OR = 23.2, p < 0.001). CONCLUSION: The risk of developing VTE is less significant in the 5-6 score group compared to 7-8 or more score group. Further stratification of the highest risk groups is recommended to provide appropriate prophylaxis only to the patients with high scores, thereby reducing complications due to VTE prophylaxis.

Decolonisation of MRSA and its effect on surgical site infections--a study in a tertiary care institute.

BACKGROUND: Two-thirds of surgical site infections (SSI) because of Staphylococcus aureus are caused by Methicillin resistant Staphylococcus aureus (MRSA). This study was done to assess the efficacy of topical 2% mupirocin with 2% chlorhexidine gluconate body wash in decolonizing MRSA and its impact in preventing SSI because of MRSA. The various risk factors associated with MRSA carriers and SSI were also studied because of paucity of data in the developing world. METHODS: We did a non-randomised interventional trial in 602 patients undergoing elective general surgical operations. All patients in case (297) group were screened for MRSA and those positive were decolonised with topical 2% mupirocin calcium ointment and daily baths with 2% chlorhexidine antiseptic solution for 5 days. Control (305) group patients underwent surgery without decolonisation. Postoperatively, all patients were followed up for SSI for 30 days. RESULTS: Prevalence of MRSA carriers was 7.5% with decolonisation rate of 95.2%. The SSI incidence was 21.3%. The significant risk factors for SSI were type of anaesthesia (p = 0.002), duration of surgery (p = 0.001) and preoperative hospital stay (p = 0.001). There was a significant association between MRSA carrier positivity at the time of surgery and SSI (p = 0.041). CONCLUSIONS: There was no reduction in rate of SSI or other nosocomial infections in patients undergoing elective general surgical operations following preoperative MRSA decolonisation with 2% mupirocin and 2% chlorhexidine gluconate in MRSA carriers. MRSA carrier status was a significant risk factor for SSI but not for other nosocomial infections.

Quality of life and its determinants in people living with human immunodeficiency virus infection in puducherry, India.

CONTEXT: With anti-retroviral therapy (ART) for human immunodeficiency virus infection (HIV) coming into picture, quality of life (QOL) has gained importance. Knowledge on the factors affecting QOL would be helpful in making important policy decisions and health care interventions. AIMS: The aim of this study is to assess the quality of life of people living with HIV (PLWH) and to identify the factors influencing their QOL. MATERIALS AND METHODS: The study was done among 200 PLWH attending a tertiary care hospital, and three Non Governmental Organizations at Puducherry, India, from November 2005 to May 2007. QOL was assessed using HIV specific World Health Organization Quality Of Life scale (WHOQOL-HIV) - BREF questionnaire which has six domains (physical, psychological, level of independence, social relationships, environment and spirituality/religiousness/personal belief). Social support and stigma were measured using "Multidimensional Scale of Perceived Social Support" and "HIV Stigma Scale," respectively, using Likert Scale. Factors influencing QOL were identified using backward stepwise multiple linear regression with the six domain scores as the dependent variables. RESULTS: MALE: Female ratio was 1:1 and 58% were in early stage of the disease (stage I/II). Psychological and SRPB (Spirituality Religiousness and Personal Beliefs) domains were the most affected domains. All the regression models were statistically significant (P<0.05). The determination coefficient was highest for the social relationship domain (57%) followed by the psychological domain (51%). Disease stage and perceived social support significantly influenced all the domains of WHOQOL. Younger age, female gender, rural background, shorter duration of HIV, non-intake of ART and greater HIV related stigma were the high risk factors of poor QOL. CONCLUSION: Interventions such as ART, family, vocational and peer counseling would address these modifiable factors influencing QOL, thereby improving the QOL of PLWH.

Epidemiology of injury in rural Pondicherry, India.

BACKGROUND: To find out the prevalence of "all" injuries, its nature, outcome and sources of treatment among rural population of Pondicherry. METHODS: It was a triangulated study of quantitative (survey) and qualitative (Focus Group Discussion, FGD) methods. The trained second year medical undergraduate students paid house visits to all houses in five feasibly selected villages of our field practice area. The students interviewed the housewife and obtained information for all injuries for each family member in last one year and its sources of treatment. We could obtain information for 1,613 (96.7%) households. Post-survey, FGDs were undertaken to explore the various traditional treatments for the common injuries. The data was entered and analyzed using Epi_info 6.04d software package. RESULTS: Overall, the prevalence of all injury among all age groups was 30.6% in last one year. Injuries were significantly more after 18 years of age and among men (p was less than 0.001). About 99.2% injuries reported were accidental and majority (58.2%) went to government doctor for treatment. Most common causes of injuries were fall on the ground from height or due to slip (7.4%), road traffic accidents (5.6%), agriculture related injuries (5%) and bites by scorpion/insects/snakes /dogs (4.1%). FGDs explored some potentially harmful traditional remedial measures at village level such as application of mud or cow dung on the injury and burning the site of thorn prick on foot sole. CONCLUSIONS: Considering the high prevalence of all injuries related to road traffic accidents, fall from height and agriculture work related injuries across all age groups, especially among men and some potentially harmful traditional treatments, an intervention in the form of targeted injury prevention program for different age and sex group, focusing health education efforts based on local epidemiology and behavioral practices is needed.

Correlates of human immunodeficiency virus (HIV) related knowledge among HIV infected people.

BACKGROUND: The current adult prevalence of HIV in India is 0.34%. HIV infected persons should have adequate knowledge about the modes of transmission of infection. This is essential for reducing the risk of secondary infection, preventing coinfection from other viruses such as hepatitis B and for protecting the uninfected. Identification of the correlates of poor knowledge among HIV positive subjects will aid in planning effective measures to improve their health knowledge about HIV. AIMS: To explore HIV related knowledge among HIV positive subjects and to determine the correlates of their knowledge. METHODS: The study was conducted between November 2005 and May 2007. Two hundred HIV positive subjects attending a tertiary care hospital and three non-governmental organizations in Puducherry, South India, were recruited for the study. They were interviewed using a pre-tested structured questionnaire regarding their knowledge about HIV and were divided into those with HIV knowledge score > 90% and those with score ≤ 90%. The data were analyzed using Chi-square test and logistic regression. Odds ratio (OR) and 95% confidence intervals were also calculated. RESULTS: The median knowledge score was 90%. Knowledge on the modes of HIV transmission was better than that on the modes by which it does not spread. Subjects who had received counseling (OR: 16.78), studied above class 10 (OR: 4.13), and those with duration of more than 1 year since diagnosis (OR: 3.12) had better HIV knowledge score (>90%). Persons counseled by HIV positive peers had a better knowledge. CONCLUSION: This study revealed the importance of counseling in improving the HIV related knowledge among HIV positive individuals. It also highlights the beneficial effect of peer counseling.

Epidemiology of childhood injuries in rural Puducherry, South India.

OBJECTIVE: To study the epidemiology of injuries among children (<14 years) in a rural population. METHODS: The present Cross Sectional Study was undertaken in rural Pondicherry. The trained second year medical undergraduate students paid house visits to all houses in five feasibly selected villages. The students interviewed the mother of children aged < 14 years and obtained information on injuries in last 1 year and its sources of treatments. The authors could obtain information for 1,613 households (96.7%). The data was entered and analyzed using Epi_info 6.04d software package. RESULTS: Overall, prevalence of injuries among below 14 years was 23% in the last 1 year. The prevalence of injuries among infants, 1-4 years children and 5-14 years children was 32 (15.2%), 110 (24.5%) and 274 (23.7%) respectively. Prevalence of injury was significantly higher among male children (p = 0.001). All injuries were accidental and 68.2% injuries occurred in home environment followed by that in school. Source of treatment for majorities of injuries (58.4%) were government doctors. Notably, village level Anganwadi workers (AWW) or Auxiliary Nurse Midwife (ANM) were not consulted for the treatment. Falls were the leading cause of injury. Fall on ground from height, burns, bite by scorpion/insect/snake/dogs, and road traffic accidents were the four leading causes of injury among children. CONCLUSIONS: There is a need for community based health education intervention for mothers, caregivers, school teacher and capacity building of village level health workers such as ANM and AWW. Health education message should include preventive measures for the leading causes of childhood injuries.

The benefits to medical undergraduates of exposure to community-based survey research.

INTRODUCTION: In India, there has been little effort to teach medical students about public health research. Few medical institutions in India and nearby Nepal formally offer exposure to field surveys or projects to medical undergraduates as a part of their training in community medicine. Little is known about the effect of such activity on students or how they apply what they learn. We implemented a systematic, hands-on experience in the public health research process with medical undergraduates in Puducherry, India to evaluate its effect on students. MATERIAL AND METHODS: Two groups, each with 30 third-semester (second year) medical undergraduates, participated in a 15-day, two and one-half hours per day course on the public health research process. At the end of course, a retrospective post-then-pre self-assessment of students skills was obtained. One year later, we resurveyed students with open-ended questions to assess their impressions of what they had gained from learning about the field survey process. RESULTS: Out of the 60 students, 55 (91.6%) provided complete responses for analysis. The mean post-exposure Likert scores of students self-perceived skills and knowledge were significantly higher than their retrospective assessments of themselves prior to the course in areas such as being aware of the public health research process, their skills in interviewing and communicating with local villagers, and ability to collect, enter via computer and present gathered information (p < 0.005). Six categories of common responses, all positive, emerged from the open-ended feedback: 1) ability to apply learning to research work, 2) communication skills, 3) awareness about local epidemiology of injury, 4) awareness of local first-aid practices and health care seeking behavior, 5) awareness of survey techniques, and 6) anticipated application of this learning in the future and its effect on the student. CONCLUSIONS: Overall, the initial implementation of a program exposing medical students to the community survey research process was well received. Early exposure of medical undergraduates to the survey research process appears to help them be better clinicians, who are able to understand and use field level data.

Rheumatic fever and rheumatic heart disease: primary prevention is the cost effective option.

OBJECTIVE: To measure the economic output/input ratios for the various options of prevention of rheumatic fever/rheumatic heart disease (RF/RHD) and check the viability of primary prevention vis-à-vis secondary and tertiary preventions. METHODS: Cost accounting of the various prevention options was calculated for each variable as available in literature. Actual data as obtainable for the financial year ending March 2006 were computed for the Pondicherry population. Both direct and indirect costs (including community/social costs) were worked out using mostly primary data and wherever necessary, secondary data. Certain scientific assumptions were used where exact data was not available. RESULTS: Primary prevention is the definite viable economic option (1:1.56) compared to secondary (1: 1.07) and tertiary (1: 0.12) preventions. In fact, the current stress on only secondary and tertiary preventions is found to be economically unviable. CONCLUSION: It is postulated that primary prevention as a practical policy in tackling RF and RHD can be recommended.