Competency Based Medical Education (CBME) in India: Clinicians' Multifaceted Challenges.

In the recent past, in order to achieve our national goal of 'health for all', National Medical Commission and Government of India made competency based medical education (CBME) mandatory in all Indian medical colleges. By undergoing CBME, the Indian Medical Graduate is expected to achieve the five roles of Clinician, Communicator, Leader and Member of the health care, Professional and Lifelong learner. This article is an overview of CBME, its relevant terminologies and knowledge-gaps. The purpose is to share these changes in medical education with practicing Otolaryngologists of India. It also discusses the various challenges regarding this already- suggested implementation process for clinical academicians, which could be counterproductive to the expected national aim and goal.

Adenoidectomy: Anatomical Versus Clinical Success.

Endoscopic adenoidectomy with powered instruments,a challenge in resource-constraint developing countries, has been on the rise. To evaluate conventional curettage as compared to endoscopic assisted adenoidectomy in the successful management of adenoid enlargement. A randomized controlled double-blinded study among children undergoing adenoidectomywas done. Primary outcomes were assessed by pre- and postoperative evaluation with a symptoms questionnaire and fiberoptic nasal endoscopy. There were 71 children aged 3-15 years, majority having grade III adenoids. Conventional adenoidectomy was done by the surgeon who was blinded to preoperative adenoid status. Patients were randomized to two groups, 35in conventional curettage where no further on-table intervention was done. Check endoscopyof the remaining 36 patients, formingthe second group, revealed residual grade III adenoidsin 5.6%. They underwentcompletion adenoidectomyendoscopically. By the 12th postoperative week, nasal endoscopy noted that 39.3% had grade I/II and 8.8% had grade I in the conventional and endoscopic groups respectively. Thoughstatistically significant, all pre-op symptoms settled except sleep-related ones which persisted in both groups (25% versus 14.7) with no complications in either group. Relief of all symptoms other than sleep-related ones, was achieved despite residual adenoids being up to grade II in both conventional and endoscopic group. This suggests non-obstructive causes in a subset of these patients. Conventional adenoid curettage is comparable to endoscopic adenoidectomy by cold method among children aged three and above. Complete adenoidclearance for achieving 'anatomical success' appears not to be necessary for 'clinical success'.

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).

Utility of Pecs Block for Perioperative Opioid-Sparing Analgesia in Cancer-Related Breast Surgery: A Randomized Controlled Trial.

Multidisciplinary treatment and multimodal analgesia are the approach to reduce mortality and morbidity of breast cancer. Pectoral nerve block (PECS I and II) is one of the modes of analgesia advocated. The primary aim is to find the risks and benefits of the block in providing analgesia for intraoperative and immediate postoperative cancer-related breast surgery and total morphine consumption. The secondary aim is to evaluate, any additional knowledge acquired, in the reduction of persistent chronic pain state and cancer recurrence, during the time frame studied. The study was conducted after the approval of the ethics committee and National Registry, and included patients of ASA I and II undergoing mastectomy surgery with axillary clearance, under general anesthesia, during the period of 2017 to 2018. A total of 60 patients were recruited, randomizing them into two groups: group 1 (n = 30): ultrasound-guided PECS I (0.2 ml/kg) and PECS II (0.4 ml/kg) block, post-induction with 0.25% levobupivacaine, maximum dose of 2 mg/kg; group 2 (n = 30): no block, only general anesthesia. Intraoperatively, vitals were monitored at regular intervals and analgesics given as per response. Postoperatively, pain was assessed using the numerical pain score and arm abduction score, until discharge. Data collected was analyzed and interpreted using statistical methods. Patients were followed up telephonically, until six months for any chronic pain and cancer recurrence instances. The PECS block group used less morphine intra and postoperatively, which was statistically significant (p = 0.0001). Group 1- Had a significant decrease in the mean intraoperative systolic blood pressure (p = 0.03). There was significant improvement in the arm abduction in the test group as compared to that in the control group (p = 0.001). The average time for block performance was 7.9 min and no complications were observed. No patients in the study groups reported chronic pain or cancer recurrence issues. The two-level PECS block is safe, effective, reliable, and easy to perform. Clinical Trial Registration Number: CTRI/2017/11/010630.

Correlation of Intraoperative Frozen Section Report and Histopathological Diagnosis of Central Nervous System Tumors - A Six-Year Retrospective Study.

OBJECTIVES: To evaluate the degree of agreement between the intraoperative frozen section (FS) reporting of central nervous system (CNS) tumors and final histopathological diagnosis based on permanent paraffin section. METHODS: All CNS tumor cases with a diagnosis at FS and subsequent permanent section (n = 261) taken from 2007 to 2012 were retrospectively reviewed. Twenty percent of FS were double-checked by a senior pathologist as part of the study and the intraobserver agreement between the pathologist and the agreement between final report, and initial FS report was estimated by the intraclass correlation coefficient (ICC). RESULTS: A total of 261 cases were reviewed. The most common diagnosis was glioblastoma (grade IV) and meningioma (grade I-II) forming 45.6% of cases. Fifty-three cases were subjected to intraobserver agreement of histological diagnosis. There was nearly perfect intraobserver agreement on histopathology (ICC = 0.9). Out of 261 cases, 224 cases showed a strong agreement between the FS diagnosis and final histological diagnosis (ICC = 0.747). A discrepancy between the FS and final diagnosis were found in eight cases. The disagreement did not relate to any specific tumor type. However, in three cases, the discrepancy was in the grading of the glioma. In 29 cases, a definite opinion could not be given on FS as the samples examined were nonrepresentative. CONCLUSIONS: Histopathological slides classified by World Health Organization criteria of CNS tumors had excellent intraobserver agreement. Our results show a moderate to high degree of agreement in the intraoperative diagnosis of CNS lesions using FS. However, there are limitations, and some lesions are a diagnostic challenge. There is a need to improve our diagnostic skills and knowledge of possible errors and establish better communication with neurosurgeons.

Increased endothelial and macrophage markers are associated with disease severity and mortality in scrub typhus.

OBJECTIVES: Scrub typhus is endemic in the Asia-Pacific region. Mortality is high even with treatment, and further knowledge of the immune response during this infection is needed. This study was aimed at comparing plasma levels of monocyte/macrophage and endothelial related inflammatory markers in patients and controls in South India and to explore a possible correlation to disease severity and clinical outcome. METHODS: Plasma levels of ALCAM, VCAM-1, sCD163, sCD14, YKL-40 and MIF were measured in scrub typhus patients (n = 129), healthy controls (n = 31) and in infectious disease controls (n = 31), both in the acute phase and after recovery, by enzyme immunoassays. RESULTS: Patients had markedly elevated levels of all mediators in the acute phase, differing from both healthy and infectious disease controls. During follow-up levels of ALCAM, VCAM-1, sCD14 and YKL-40 remained elevated compared to levels in healthy controls. High plasma ALCAM, VCAM-1, sCD163, sCD14, and MIF, and in particular YKL-40 were all associated with disease severity and ALCAM, sCD163, MIF and especially YKL-40, were associated with mortality. CONCLUSIONS: Our findings show that scrub typhus is characterized by elevated levels of monocyte/macrophage and endothelial related markers. These inflammatory markers, and in particular YKL-40, may contribute to disease severity and clinical outcome.

Diagnosis of adult chronic rhinosinusitis: can nasal endoscopy predict intrasinus disease?

OBJECTIVES: To define the role of endoscopic evaluation of middle meatus in adult patients clinically diagnosed to have chronic rhino-sinusitis and its ability to predict intra-sinus mucosal involvement as compared to CT scan. METHODS: This prospective analytical study was conducted on consecutive patients with diagnosis of chronic rhino-sinusitis who were symptomatic and fulfilled the American Academy of Otolaryngology - Head and Neck Surgery Task Force criteria. The patients were enrolled prospectively and were subjected to rigid diagnostic nasal endoscopy and classified as defined by the revised Sinus Allergy Health Partnership Task Force criteria. The patients then underwent non contrast CT sinuses on the same day. Results were analyzed as a diagnostic test evaluation using CT as a gold standard. RESULTS: Among the 75 study patients with symptom based chronic rhino-sinusitis, nasal endoscopy was abnormal in 65 patients (87%). Of these patients, 60/65 (92%) showed positive findings on CT scan. Ten patients had normal endoscopy, of these 6/10 (60%) had abnormal CT scan. Sensitivity and specificity of diagnostic nasal endoscopy against CT scan were 91% (95% CI: 81-97) and 44% (95% CI: 14-79), respectively. The likelihood ratio for positive nasal endoscopy to diagnose chronic rhino-sinusitis was 1.6 and the likelihood ratio to rule out chronic rhino-sinusitis when endoscopy was negative was 0.2. CONCLUSION: Nasal endoscopy is a valid and objective diagnostic tool in the work up of patients with symptomatic chronic rhino-sinusitis. When clinical suspicion is low (<50%) and endoscopy is negative, the probability of rhino-sinusitis is very low (<17%) and there is no need to perform a CT scan to reconfirm this finding routinely. Endoscopy alone is able to diagnose chronic rhino-sinusitis in >90% of patients when clinical suspicion is high (88%) as defined in this study by AAO-HNS Task Force criteria. Negative endoscopy, however, does not totally exclude the sinus disease in patients fulfilling task force criteria. CT scan may be needed on follow-up if there is clinical suspicion in 10% of these patients who are negative on endoscopy if symptoms persists. It is thus possible to reduce the number of CT scans if patients are carefully selected based on clinical criteria and endoscopy is done initially as part of their evaluation.

Fine needle aspiration in chronic tonsillitis: reliable and valid diagnostic test.

Fine needle aspiration (FNA) of the tonsil as a diagnostic tool in evaluating the microflora in chronic tonsillitis has not been popularized. A prospective study of 30 patients with chronic tonsillitis undergoing tonsillectomy was undertaken. FNA of the tonsil core was done under local/general anaesthesia. The reliability of the culture by FNA of the tonsil core was then validated with the reference (gold) standard which is the dissected tonsil core. The sensitivity of FNA culture as compared to core culture was 100 per cent and 93 per cent under general and local anaesthesia respectively. The positive predictive value of FNA culture as compared to core culture was 92 per cent and 82 per cent for general and local anaesthesia respectively. These factors indicate that FNA of the tonsil core is reliable and valid. It can safely be performed as an out-patient procedure under local anaesthesia. This is reported for the first time. Identifying the bacterial organism within the infected tonsil for appropriate antibiotic therapy could revolutionize the management of chronic tonsillitis.

Chronic adenoid hypertrophy in children - is steroid nasal spray beneficial?

OBJECTIVE: [corrected] To the efficacy of naial btvlomethosone spry in the treatmrnl of chronic adenoid hypertrophy in children. METHOD: .-1 randomized double-blind placebo-controlled study SETTING: Tertiary academic referral center Patients: Aged 3-12 years diagnosed to have chronic nasal obstruction due to hypertrophied adenoids. INTERVENTION: Intranasal beclomethasone at the dose of 200 microgramslday to one group and placebo to the other group in matched dispensers for 8 weeks. OUTCOME MEASURES: Reduction of symptoms due to hypertrophied adenoids and the size of enlarged adenoids. Variables were noted at the beginning and end of the study for symptoms score severity. X-ray and flexible nasal endoscopie findings. RESULTS: Analysis was done to find any significant improvement between the two groups. The Chisquare test was used to investigate the relationship between discrete variables. 26 children completed the study with 13 each in the drug and placebo group. There were 17 male and 9 female patients from 3 to 12 years of age. There was no significant difference in nasal obstruction, snoring or nasal discharge between the two groups. Comparison of x-rays and endoscopy also showed no significant difference between the 2 groups significant (P value =1.000 and P=0.0666 respectively). CONCLUSION: This study indicates that intranasal beclomelhasone therapy is not useful in treatment of ehronic adenoid hypertrophy in the general pediatrie population.