Leptospirosis following heavy rains in 2017 in Mumbai: Report of large-scale community chemoprophylaxis.

Background: Globally, cities get flooded due to heavy rains. As the incidence of leptospirosis increases after such flooding in Mumbai, community chemoprophylaxis to selected individuals was a consensus recommendation by experts. Methods: We surveyed a total of 1 499 293 houses in severely affected areas of Mumbai (where there was waterlogging or high incidence of leptospirosis in the past) as well as in all slum areas. A total of 6 714 210 people (>50% of the population) were screened. A total of 156 934 adults, 4465 children, 359 pregnant women and 4957 high-risk adults were given prophylaxis with doxycycline or azithromycin by paramedical staff (n = 9526) under the supervision of medical staff. Social media and newspaper advertisements were used to create public awareness. Results: Compared with previous floods, there were reduced number of cases of leptospirosis due to community chemoprophylaxis (432 confirmed cases in 2005 v. 128 [59 confirmed] in 2017). Conclusions: Selective, time-bound chemoprophylaxis following floods is likely to reduce the incidence of leptospirosis, as well as associated morbidity and mortality.

Impact of a fellowship program for faculty development on the self-efficacy beliefs of health professions teachers: a longitudinal study.

BACKGROUND: Teachers' belief in their ability to teach influences how much of the new knowledge and skills gained during faculty development (FD) programs are actually implemented at the workplace. AIM: To study the effect of a longitudinal FD program on the self-efficacy beliefs (SEB) of teachers of health professions using quasi-experimental methodology. METHODS: The SEB of 70 teachers of health professions enrolling for a longitudinal FD program at three sites in India and one site in South Africa and an equal number of comparable controls were measured using the "teacher efficacy belief systems-self" (TEBS-self) scale. The scale was re-administered at 6 and 12 months to both the groups. RESULTS: Teachers enrolled in the program had lower scores than controls at the beginning of the program but demonstrated a significant increase at 6 months with an effect size of 0.56. The 12-month scores demonstrated a further rise in the participating teachers. The control group maintained the scores but did not show any significant change either at 6 or at 12 months. CONCLUSION: Longitudinal FD program has positive effect on SEB of teachers.

FAIMER Global Faculty Development: A Sustainable Partnership Model to Advance Health Professions Education.

The Foundation for Advancement of International Medical Education and Research (FAIMER), a member of Intealth, offers longitudinal faculty development programs (LFDPs) in health professions education (HPE) and leadership through its International FAIMER Institute (IFI) in the United States and FAIMER Regional Institutes (FRIs) globally. FAIMER fosters mutual collaboration and delineates shared responsibilities for FRI development in partnership with local institutions, using an adapted hub-and-spoke organizational design. This paper describes FAIMER's model, its sustainability, and its impacts at individual, institutional, and national levels. IFI was launched in 2001 in Philadelphia, Pennsylvania, as a 2-year part-time hybrid LFDP; with the COVID-19 pandemic onset, IFI transitioned to a fully online program. Since FAIMER's launch, 11 FRIs developed in Brazil, Chile, China, Egypt, India, Indonesia, and South Africa, each modeled on the IFI curriculum and adapted to local context. The more than 1,600 IFI and FRI graduates (fellows) from over 55 countries now form a global community of health professions educators who have shared exposure to HPE methods and assessment, leadership and management, educational scholarship and research, and project management and evaluation. Across all global locations and program formats, fellows self-reported a similar increase in knowledge and skills in HPE. All programs center on the fellows' institutional projects as experiential learning; these projects have focused primarily on educational methods and curriculum revisions. An increased quality of education was reported as the top impact resulting from fellows' projects. As a result of these programs, fellows have influenced education policy in their countries and established academic societies for HPE, thus contributing to recognition of the HPE academic specialty. FAIMER has successfully developed a sustainable model for advancing HPE globally, creating a vibrant network of health professions educators who have influenced country-specific educational policy and practice. FAIMER's model offers one approach to building global capacity in HPE.

Asymptomatic gall stones--revisited.

India has a large burden of individuals harboring asymptomatic gallstones. Based on Markov model decision and cost analysis, selective and concomitant cholecystectomy is recommended for special indications like hemolytic disorders and stones in endemic areas. Expectant management should be adopted in all others. The evolution of laparoscopy should not alter the indications of cholecystectomy. Since more than 90% patients with asymptomatic gallstones remain clinically "silent", routine laparoscopic cholecystectomy is not indicated for the vast majority of subjects with asymptomatic cholelithiasis. Although laparoscopic cholecystectomy has become much safer, there remains associated morbidity and mortality. The risks of the operation outweigh the complications if stones are left in-situ. Patients should be counseled about the natural history and available management options, their advantages and disadvantages, and should be part of the decision making process. Prophylactic routine cholecystectomy for asymptomatic stones is not recommended. However, laparoscopic cholecystectomy should be performed selectively or concomitantly in a specific subgroup of patients.

Framework to Incorporate Leadership Training in Competency-Based Undergraduate Curriculum for the Indian Medical Graduate.

The new competency-based curriculum recognized the importance of leadership skills in physicians and has outlined competencies that would lead to attaining this goal. To prepare the Indian medical graduates as effective healthcare leader, there is no universal approach; it is desirable that the institutes organize the leadership competencies into an institutional framework and integrate these vertically and horizontally in their curriculum in a longitudinal manner. We describe the rationale for incorporating formal leadership training in the new competency-based undergraduate curriculum and propose a longitudinal curricular template utilizing a mixed/multi-modality approach to teach and apply leadership competencies.

Evaluating the efficacy of tumor markers CA 19-9 and CEA to predict operability and survival in pancreatic malignancies.

AIM: Using CA 19-9 and CEA (elevated > 2 times of normal) as predictors in determining operability and survival in pancreatic tumors. METHODS: Levels of CA 19-9 and CEA were measured (pre and post operatively) in 49 patients of pancreatic malignancy. CECT was performed for diagnosis and staging. An experienced surgeon determined the operability. The levels of tumor markers were correlated with the operability and the survival based on CECT and intra-operative findings. RESULTS: 16/24 (67%) patients with CA 19-9 levels (< 2 times) and 19/24 (79%) patients with CEA levels (< 2 times) were found to be resectable. 22/25 (88%) patients having elevated CA 19-9 levels (p = 0.0002-t) and 17/25 (70%) patients having elevated CEA levels (p = 0.003) were found to be non-resectable. Of the 27 patients, found resectable on CECT, 5 were non-resectable intra-operatively. All of these had elevated levels of CA 19-9 and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) non-resectable patients, with elevated levels of CA 19-9 reported at 1 year follow up. None of the non-resectable patients with CA 19-9 levels > 1000 U/ml reported at 6 month follow-up. None of the resectable patients pre-operatively showed evidence of recurrence. All achieved normal values post surgery. CONCLUSION: Elevated levels of CA 19-9 and CEA (> 2 times) predict increased chances of inoperability and poor survival in pancreatic tumors. Levels > 3 times had increased risk of inoperability even in patients deemed resectable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients. Levels of CA 19-9 (> 1000 U/ml) indicate a dismal survival in non-resectable group of patients.

Laparoscopic training in India: need for criterion-based training and objective assessment of surgical skills.

Over the past 2 decades, laparoscopic techniques have evolved from diagnostic laparoscopy to more complex procedures. Minimally invasive techniques are routinely used for bariatric, colonic and advanced gastrointestinal surgical procedures. These new techniques require highly developed psychomotor skills and place an extra demand upon surgeons to acquire, maintain and develop a wide range of operative skills in the middle of their careers. In developed countries, training is imparted in skills centres, which use various models not only to teach a skill, but also as a means of assessment, both of technical competence and of decision-making. In addition, these centres are playing an expanding role in providing credentials to surgeons and maintaining the standards of skills. In India, laparoscopic training for community surgeons is unstructured and opportunistic, while resident's training is not uniform. There is a need for structured training programmes that include giving residents and community surgeons experience in skills laboratories, alongwith an objective assessment of acquired skills.

Multiple choice questions: a literature review on the optimal number of options.

BACKGROUND: Single, best response, multiple choice questions (MCQs) with 4 options (3 distractors and 1 correct answer) or 5 options (4 distractors) have been widely used as an assessment tool in medical education in India and globally. Writing plausible distractors is time consuming and the most difficult part of preparing MCQs. If the number of options can be reduced to 3, it will make preparing MCQs less difficult and time consuming, thus reducing the likelihood of flaws in writing MCQs. We reviewed the literature to find out if the number of options in MCQ test items could be reduced to 3 without affecting the quality of the test. METHODS: A systematic database search was done using the following question as a framework: How many options are optimal for multiple choice questions? Theoretical, analytical and empirical studies, which addressed this issue, were included in the review. RESULTS: There was no significant change in the psychometric properties of the 3 options test when compared with 4 and 5 options. MCQs with 3 options improved the efficiency of the test as well as its administration compared with 4- or 5-option MCQs. MCQs with 3 options had a higher efficiency because fewer distractors needed to be prepared, took up less space and required less reading time, decreased the time required to develop the items and the time to administer, and more items could be administered in a given time thus increasing the content sampled. CONCLUSION: Our review of the literature suggests that MCQs with 3 options provide a similar quality of test as that with 4- or 5-option MCQs. We suggest that MCQs with 3 options should be preferred.

Networking in medical education: creating and connecting.

Social networking is being increasingly used as a tool of choice for communications and collaborations in business and higher education. Learning and practice become inseparable when professionals work in communities of practice that create interpersonal bonds and promote collective learning. Individual learning that arises from the critical reconstruction of practice, in the presence of peers and other health professionals, enhances a physician's capability of clinical judgment and evidence-based practice. As such, it would be wise for medical schools, whose responsibility it is to prepare students to make a transition to adult life with the skills they need to succeed in both arenas, to reckon with it.

Health services responses to disasters in Mumbai sharing experiences.

In mass disaster situations, demands frequently exceed the capacity of personnel and facilities. In the last few years, there has been an increased incidence of civil disasters; the spectrum of possible catastrophes has also dramatically increased as a result of an increasingly technologically sophisticated society. During the last 15 years, varied terrorist activities have become increasingly common as expressions of the opinions of extreme political groups, especially in India. In Mumbai itself, we have witnessed disasters such as widespread riots, terrorist bomb blasts, floods, and fires. There have been other disasters in India, such as earthquakes, floods, cyclones, as well as tsunamis Though most of the hospitals in India manage the medical problems associated with these disasters fairly efficiently, an analysis of the situation is presented so that this may form the basis for future planning in disaster preparedness and provide a template for other communities that may want to implement preparedness protocols. We present our experience with disaster management in Mumbai, India. A successful medical response to multi-injury civilian disasters, either natural or man-made, dictates formulation, dissemination, and periodic assessment of a contingency plan to facilitate the triage and treatment of victims of disaster.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis.

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis.

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos).

Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.