The Covid-19 effect on medical students’ perceptions of their profession: A mixed methods study from South India

Covid-19 has devastated human lives and stretched the limits of the medical profession and health systems. Using the mixed methods of online survey and online focus group discussions, we assessed how medical students and interns of two medical colleges in South India viewed the profession they had chosen. Of the 900 participants, 571(63.4%) had a positive perception of the medical profession, 77(8.6%) a negative perception and 252(28%) were undecided. The year of study in medical school was significantly associated with their perception of the medical profession, with interns more likely to have a negative perception (p<0.001). An overwhelming 823(91.4%) participants remained confident of their career choice, but a higher proportion of interns were less confident or regretful about their choice of profession compared to first to fourth year students (p<0.001). Most participants experienced moral distress; they acknowledged a duty to care but were troubled by personal risk, inadequate protection, and limited resources. Gaps were identified in medical and ethics training particularly regarding uncertainties and coping with deficiencies of the health system as encountered in the pandemic. The essential role played by doctors with its required competence, care and ethics cannot be assumed or expected without investment in the making of the future doctor through more socially embedded medical education imparting the skills of understanding the public, responding to them and being the advocate for their equitable and optimal care. An ethics of responsiveness emerges as important for healthcare, also for medical education in preparation for future health crises.

Reflective narratives during the Covid-19 pandemic: an outlet for medical students in uncertain times

Reflective narratives on personal experiences, observations, thoughts and concerns were used as a method of helping medical students process the Covid-19 pandemic and their lives. This involved individual writing, anonymous submission, on-line group reading of selected narratives on a voluntary basis and facilitated discussions. Students felt that this was a safe method to voice their feelings and thoughts, to understand themselves better and to gain new perspectives. Though small numbers of students participated, there appears to be a greater potential to use reflective narrative writing coupled with facilitated group discussions in medical education to help students cope with external and internal stress, to better understand themselves, to relate to others and possibly to become more empathic. Keywords: Education, medical, reflective narrative, Covid-19, wellbeing strategies, humanities, medical students.

Sonda uretral flexível como método alternativo para aferição invasiva da pressão intracraniana em trauma cranioencefálico induzido em coelhos / Flexible urethral catheter as alternative method to invasive measurement of intracranial pressure in induced head trauma in rabbits

O objetivo deste estudo foi utilizar a sonda uretral flexível como método alternativo para aferição da pressão intracraniana em coelhos com trauma cranioencefálico induzido pelo cateter de Fogarty 4 Fr (balão epidural) e comparar os dados obtidos com o método convencional de cateter de ventriculostomia. Foram utilizados 12 coelhos, machos, adultos, distribuídos aleatoriamente em dois grupos, denominados de G1: mensuração da PIC com cateter de ventriculostomia (n=6) e G2: mensuração com sonda uretral (n=6). Foram realizadas duas craniotomias na região parietal direita e esquerda para a implantação do cateter de ventriculostomia ou sonda uretral flexível e o balão epidural, respectivamente. A PAM, a PPC, a FC, a FR e a TR foram mensurados antes e após a craniotomia. A PIC foi avaliada após a craniotomia e a cada 10 minutos depois do preenchimento do balonete com 0,3mL de NaCl 0,9%, durante 40 minutos, e com 0,6mL, pelo mesmo período de tempo, totalizando 80 minutos. A PIC aumentou em ambos os grupos, sendo menores os valores registrados com a sonda uretral flexível. Foi possível reproduzir o aumento da PIC com o modelo experimental de TCE utilizando o cateter de Fogarty 4 Fr na região epidural e, embora haja a necessidade de outros estudos, a sonda uretral flexível demonstra ser um método alternativo de mensuração da PIC em coelhos com trauma cranioencefálico.(AU)

The aim of this study was to evaluate the use of flexible urethral catheter as an alternative method for measuring intracranial pressure in rabbits with head trauma induced by 4 F Fogarty catheter (epidural balloon) and compare the data obtained with the conventional method of ventriculostomy catheter. In this study, New Zealand rabbits were randomly distributed into two groups, G1: measuring the ICP with ventriculostomy catheter (n=6) and G2: measuring the ICP with urethral catheter (n=6). Two craniotomies were performed in the right and left parietal region for the implantation of a ventriculostomy catheter and/or flexible urethral catheter and epidural 4 Fr Fogarty arterial embolectomy catheter, respectively. MAP, CPP, HR, RF and RT values were measured before and after of the craniotomy. The ICP value was measured after craniotomy, every five minutes during 40 minutes after the balloon was inflated with 0.3 ml with NaCl and further 40 minutes after the balloon was inflated with 0.6 ml. The ICP value increased in both groups; however, the ICP values were lower in the flexible urethral catheter. The flexible urethral catheter can be used as an alternative method to measure ICP values in rabbits with head injury.(AU)

X-ray pelvimetry in common marmoset (Callithrix jacchus - LINNAEUS, 1758) / Pelvimetria radiográfica em sagui-de-tufo-branco (Callithrix jacchus - LINNAEUS, 1758)

The common marmoset is an important Neotropical primate for biomedical research. With the intention of providing pelvimetric values that allow the selection of animals with better characteristics for reproduction, we studied the X-ray of the pelvis, in ventro-dorsal projection of 12 adult animals, six males and six females, belonging to the National Center of Primates - CENP. The measurements were made to right diagonal diameters (RDD), left diagonal diameter (LDD), bi-iliac middle diameter (BIMD), bi-iliac upper diameter (BIUD), bi-iliac lower diameter (BILD), sacrum-pubic diameter (SPD), and the input area of the pelvis (IAP), which were compared in relation to sex and bodily correlated with the biometrics. The results of the means and standard deviations regarding pelvimetry (cm) were: for the RDD in males of 1.91±0.14 and in the females of 2.05±0.08; LDD in males of 1.85±0.16 and in females of 2.03± 0.08; BIMD in males of 1.46±0.12 and in the females of 1.5±0; BIUD showed in males 1.3±0.1 and in females of 1.3±0.06; BILD in males of 1.35±0.15 and in females of 1.25±0.08; SPD in males of 1.68±0.09 and in females of 1.93±0.13; IAP in males of 1.9±0.26 and in the females of 2.23±0.13. It was concluded that the pelvis of Callithrix jacchus could be classified as dolicopelvic type, there is sexual dimorphism in relation to the pelvis of adult animals and that the bodily measurements have low positive correlation with pelvic measurements.(AU)

O sagui-de-tufo-branco se destaca como um importante primata neotropical para as pesquisas biomédicas. Com o intuito de fornecer valores pelvimétricos que permitam a seleção de animais com melhores características para a reprodução, estudaram-se radiografias da pelve, em projeção ventrodorsal, de 12 animais, sendo seis machos e seis fêmeas, adultos, pertencentes ao Centro Nacional de Primatas - CENP. As mensurações realizadas foram referentes aos diâmetros diagonal direito (DDD), diagonal esquerdo (DDE), bi-ilíaco médio (DBIM), bi-ilíaco superior (DBIS), bi-ilíaco inferior (DBII), sacropúbico (DSP), além da área de entrada da pelve (AEP), os quais foram comparados em relação ao sexo e correlacionados com a biometria corpórea. Os resultados de médias e desvios-padrão com relação à pelvimetria (cm) foram: para o DDD nos machos de 1,91±0,14 e nas fêmeas de 2,05±0,08; DDE nos machos de 1,85±0,16 e nas fêmeas de 2,03±0,08; DBIM nos machos de 1,46±0,12 e nas fêmeas de 1,5±0; DBIS nos machos de 1,3±0,1 e nas fêmeas de 1,3±0,06; DBII nos machos de 1,35±0,15 e nas fêmeas de 1,25±0,08; DSP nos machos de 1,68±0,09 e nas fêmeas de 1,93±0,13; AEP nos machos de 1,9±0,26 e nas fêmeas de 2,23±0,13. Concluiu-se que a pelve de Callithrix jacchus pode ser classificada como do tipo dolicopélvica, existe dimorfismo sexual em relação às pelves de animais adultos e que as medidas corpóreas apresentam baixa correlação positiva com as medidas pélvicas.(AU)

Relationships between dendritic morphology, spatial distribution and firing patterns in rat layer 1 neurons

The cortical layer 1 contains mainly small interneurons, which have traditionally been classified according to their axonal morphology. The dendritic morphology of these cells, however, has received little attention and remains ill defined. Very little is known about how the dendritic morphology and spatial distribution of these cells may relate to functional neuronal properties. We used biocytin labeling and whole cell patch clamp recordings, associated with digital reconstruction and quantitative morphological analysis, to assess correlations between dendritic morphology, spatial distribution and membrane properties of rat layer 1 neurons. A total of 106 cells were recorded, labeled and subjected to morphological analysis. Based on the quantitative patterns of their dendritic arbor, cells were divided into four major morphotypes: horizontal, radial, ascendant, and descendant cells. Descendant cells exhibited a highly distinct spatial distribution in relation to other morphotypes, suggesting that they may have a distinct function in these cortical circuits. A significant difference was also found in the distribution of firing patterns between each morphotype and between the neuronal populations of each sublayer. Passive membrane properties were, however, statistically homogeneous among all subgroups. We speculate that the differences observed in active membrane properties might be related to differences in the synaptic input of specific types of afferent fibers and to differences in the computational roles of each morphotype in layer 1 circuits. Our findings provide new insights into dendritic morphology and neuronal spatial distribution in layer 1 circuits, indicating that variations in these properties may be correlated with distinct physiological functions.

Low-frequency fatigue at maximal and submaximal muscle contractions

Skeletal muscle force production following repetitive contractions is preferentially reduced when muscle is evaluated with low-frequency stimulation. This selective impairment in force generation is called low-frequency fatigue (LFF) and could be dependent on the contraction type. The purpose of this study was to compare LFF after concentric and eccentric maximal and submaximal contractions of knee extensor muscles. Ten healthy male subjects (age: 23.6 ± 4.2 years; weight: 73.8 ± 7.7 kg; height: 1.79 ± 0.05 m) executed maximal voluntary contractions that were measured before a fatigue test (pre-exercise), immediately after (after-exercise) and after 1 h of recovery (after-recovery). The fatigue test consisted of 60 maximal (100 percent) or submaximal (40 percent) dynamic concentric or eccentric knee extensions at an angular velocity of 60°/s. The isometric torque produced by low- (20 Hz) and high- (100 Hz) frequency stimulation was also measured at these times and the 20:100 Hz ratio was calculated to assess LFF. One-way ANOVA for repeated measures followed by the Newman-Keuls post hoc test was used to determine significant (P < 0.05) differences. LFF was evident after-recovery in all trials except following submaximal eccentric contractions. LFF was not evident after-exercise, regardless of exercise intensity or contraction type. Our results suggest that low-frequency fatigue was evident after submaximal concentric but not submaximal eccentric contractions and was more pronounced after 1-h of recovery.

Insulin sensitivity and cardiac autonomic function in young male practitioners of yoga.

BACKGROUND: While yoga is thought to reduce the risk of chronic non-communicable diseases such as diabetes, there are no studies on insulin sensitivity in long term practitioners of yoga. We assessed insulin sensitivity and cardiac autonomic function in long term practitioners of yoga. METHODS: Fifteen healthy, young, male practitioners of yoga were compared with 15 young, healthy males who did not practice yoga matched for body-mass index. Fasting insulin sensitivity was measured in the fasting state by the hyperinsulinaemic-euglycaemic clamp. RESULTS: There were no significant differences between the groups in their anthropometry or body composition. However, the fasting plasma insulin was significantly lower in the yoga group. The yoga group was also more insulin sensitive (yoga 7.82 [2.29] v. control 4.86 [11.97] (mg/[kg.min])/(microU/ml), p < 0.001). While the body weight and waist circumference were negatively correlated with glucose disposal rate in the controls, there were no similar correlations in the yoga group. The yoga group had significantly higher low-frequency power and lower normalized high-frequency power. CONCLUSION: Long term yoga practice (for 1 year or more) is associated with increased insulin sensitivity and attenuates the negative relationship between body weight or waist circumference and insulin sensitivity.

Temporomandibular joint dysfunction and trapezius muscle fatigability

INTRODUCTION: It has been suggested that pain increases trapezius muscle activation in patients with temporomandibular joint dysfunction (TMD). Changes in muscle activation might change muscle resistance to fatigue. The purpose of this study was to evaluate the fatigability of the trapezius muscle in patients with TMD. METHOD: Fourteen patients with TMD (clinically diagnosed and referred by a dentist) and eleven healthy subjects performed a fatigue test consisting of shoulder elevation performed at 70 percent of the maximal voluntary isometric contraction, which was maintained for 30 seconds. Electromyographic signals were obtained from the upper portion of the trapezius muscle (sampling frequency: 2000 Hz/channel). Consecutive segments of three seconds in duration each were extracted from the electromyographic signal and analyzed in the frequency domain using a Fast Fourier Transform algorithm. Linear regression analysis was applied to the consecutive median frequencies for each subject. The slope of the regression line was used to describe muscle fatigability. RESULTS: No changes were observed in fatigability between the right and left trapezius of either group or between the left trapezius of the healthy and TMD groups. The linear regression for median frequencies in the right trapezius of the TMD group showed a slope of -0.15 ± 0.33 (mean ± SD), which was smaller than the slope for the healthy group (-0.44 ± 0.46; p= 0.049). These results suggested that the fatigability of the right trapezius was lower in the TMD group than in the healthy group.

INTRODUÇÃO: Tem sido sugerido que a dor aumenta a ativação do músculo trapézio em pacientes com disfunção temporomandibular (TMD). Mudanças na ativação do músculo podem alterar a resistência à fadiga. O objetivo do estudo foi investigar a fatigabilidade do músculo trapézio em pacientes com TMJ. MÉTODOS: Quatorze indivíduos com TMD (diagnosticados clinicamente e encaminhados pelo especialista odontólogo) e onze indivíduos saudáveis realizaram um protocolo de fadiga que consistiu em uma contração isométrica submáxima de elevação do ombro, em um nível de 70 por cento da contração voluntária máxima, mantida por um período de 30 segundos. O sinal eletromiográfico (EMG) foi obtido da porção superior do músculo trapézio, (taxa de amostragem de 2000Hz/canal). Três segundos consecutivos do sinal EMG foram analisados no domínio da freqüência usando a Transformada Rápida de Fourier (FFT). Uma análise de regressão linear foi aplicada para valores consecutivos da freqüência mediana (MF) de cada sujeito, e a inclinação da regressão linear foi utilizada para descrever a fatigabilidade muscular. RESULTADOS: Nenhuma diferença foi observada na fatigabilidade do músculo trapézio direito e esquerdo para ambos os grupos e entre o trapézio esquerdo do grupo saudável e com TMD. A MF do músculo trapézio direito do grupo com disfunção apresentou valores de inclinação da reta de regressão linear de -0,15 ± 0,33 (média ± SD), os quais foram menores que os valores do grupo saudável (-0,44 ± 0,46; média ± SD; p= 0,049). Esses resultados sugerem que a fatigabilidade do trapézio direito é menor no grupo com TMD do que no grupo saudável.

HIV-1 viremia during the first 28 weeks of pregnancy is not associated with mother-to-child transmission

It is currently recommended that antiretroviral prophylaxis to prevent mother-to-child transmission (MTCT) of HIV be initiated at 14 weeks of gestation. However, the relevance of early-gestation HIV viral load level for intrauterine MTCT is unknown. The objective of this study was to determine the relationship between prenatal maternal viral load and intrauterine MTCT. Records of HIV-infected pregnant women in two centers in Brazil, from 1999 to 2004 were analyzed. Three pregnancy periods were considered: earlier than 14 weeks, 14 to 27 6/7 weeks, and 28 weeks of gestation or more. Peripartum HIV exposure was also computed. Maximum viral load in each period was the measure of HIV exposure. Four hundred fifty-seven HIV-infected pregnant women were evaluated, but 53 were excluded. The MTCT rate was 0.49 percent (2/404-95 percent confidence interval (CI95) = 0.14-1.79 percent). Newborns were not breast-fed. Median viral load for the earlier-than-14-week period was 9,900 copies/mL (P25-75 1,000-50,775 copies/mL), 8,350 copies/mL (P25-75 707-42,000 copies/mL) for the 14 to 27 6/7-week period, and 435 copies/mL (P25-75 90-7,775 copies/mL) after the 28-week period. The peripartum median viral load was 400 copies/mL (P25-75 80-500 copies/mL). MTCT in mothers with VL > 1,000 copies/mL during the first 14 weeks (0.67 percent, 2/298) was not different from those with VL =1,000 copies/mL (0.0 percent, 0/96, P=1). Analogously, in the 14 to 27 6/7-week period, MTCT was similar in groups with VL higher (0.68 percent, 2/292) or lower (0 percent, 0/106) than 1,000 copies/mL (P=1). Regarding VL >1,000 copies/mL at 28-weeks-or-later and at peripartum periods, MTCT rates were 1.15 percent (2/173, P = 0.18) and 2.8 percent (2/71, P = 0.03), respectively. Intrauterine transmission does not seem to be influenced by HIV viremia during the first 28 weeks of pregnancy.

Sindrome do tunel do carpo / carpal tunnel syndrome

A sindrome do tunel do carpo (STC) e a neuropatia de maior incidencia no membro superior e consiste na compressao do nervo mediano no interior do tunel do carpo.Atualmente, essa alteracao neuromuscular tem atingido um numero de pessoas cada vez maior, principalmente trabalhadores que desempenham atividades de intensa movimentacao do punho. Uma serie de estudos tem procurado investigar a fisiopatologia, o diagnostico e o tratamento para a STC. No entanto, os mecanismos neuromusculares envolvidos em seu desenvolvimento ainda n'ao sao totalmente compreendidos, o que dificulta um diagnostico mais sensivel e capaz de detectar inclusive a presenca de dupla compressao (coluna cervical e tunel carpo), assim como o tratamento adequado...

Perceptions of the intensity of specific physical activities in Bangalore, South India: implications for exercise prescription.

OBJECTIVE: To assess perceptions of the intensity of specific physical activities in urban Indians and to determine whether these perceptions are dependent on age, gender, body mass index and actual physical patterns. METHOD: A self-administered questionnaire in a convenience sample of 782 adults (441 women) aged 17 to 70 years in the city of Bangalore. RESULTS: Women rated the intensity of carpentry, jogging, manual labour and walking uphill significantly higher than men. These differences persisted when they were adjusted for total daily physical activity levels and levels of discretionary exercise. In contrast, while men rated household activities such as manual washing of clothes and sweeping at higher levels than women, these differences disappeared when they were adjusted for actual levels of daily activity related to household chores. There were clear age-related changes in the perception of intensity of physical activities and these persisted even after adjustment for overall physical activity patterns. CONCLUSIONS: This study demonstrates clear age and gender-related differences in the perception of physical activities. This is important to know while motivating individuals to change physical activity patterns and assumes added importance given the recent evidence that perceived intensity of habitual activity is predictive of coronary heart disease, even at levels of activity that are below standard recommendations.

Practices and perceptions of physical activity in urban, employed, middle-class Indians.

The aim of this study was to describe the detailed physical activity profiles of educated, employed, urban Indians and to ascertain their knowledge about the benefits of exercise, their concept of 'ideal' exercise, and the constraints in achieving it. To this end, 401 subjects (193 males, 208 females) between the ages of 25 and 58 years were studied. Women were significantly more active than men (p < 0.05), largely due to enhanced household activity (p < 0.05), which was not offset by the higher leisure time-related exercise of males (p < 0.05). Over 50 percent of subjects were aware of the benefits of exercise in preventing heart disease. The subjects' perceptions of 'ideal' exercise, based on exercise programmes they had drawn up for themselves, were adequate in terms of frequency and duration, but inadequate in intensity, when compared with the current recommendations for exercise in primary prevention of coronary heart disease. Lack of time (men 53.4%, women 68.3%) and lack of motivation (men 26.4%, women 28.4%) were the most-often cited reasons for being unable to achieve 'ideal' exercise goals. The data provides an important framework for understanding physical activity profiles of urban, educated and employed Indians on the basis of which behavioural strategies can be formulated to enhance physical activity and reduce cardiovascular risk.

The development & characteristics of a physical activity questionnaire for epidemiological studies in urban middle class Indians.

A single page physical activity questionnaire was designed for use in epidemiological studies. The questionnaire estimates 24 h energy expenditure as well as components of occupation and discretionary leisure time activities. Estimates of physical activity were highly repeatable, when the questionnaire was re-administered within a 4 wk period (e.g., r = 0.86, P < 0.01 for 24 h energy expenditure). Relative validity was assessed by comparing energy intake (using repeated 24 h dietary recalls) and expenditure (using the physical activity questionnaire) over the same period. A correlate of r = 0.33, P < 0.05 between the two measures compared well with reports from literature. The discriminatory power of the questionnaire was assessed by comparing the physical activity patterns of young (18-30 yr) and older (> 60 yr), free living healthy subjects. The questionnaire provides a tool for the assessment of physical activity patterns of urban middle class Indians, which despite its importance has been inadequately studied so far.

Skeletal muscle endurance is reduced in chronically energy deficient adults.

Fifty eight adult males (well nourished; WN = 25, underweight; UW = 13, chronically energy deficient; CED = 20), aged 18 to 30 yr underwent an assessment of skeletal muscle function using a load cell based handgrip dynamometer coupled to a polygraph. WN subjects had higher handgrip strengths than either the UW or CED subjects (P < 0.05), though not when corrected for forearm muscle area or forearm volume. CED subjects fatigued faster than WN subjects during sustained maximal isometric contraction (P < 0.05) as well as during prolonged isotonic exercise (P < 0.05). During the latter, the onset of fatigue in the CED subjects was also faster than that in their anthropometrically similar UW controls. These data are consonant with reports of decreased productivity in undernourished adults during real life tasks.

The characteristics and determinants of maximal expiratory pressure in young, healthy, Indian males.

Maximal expiratory pressure (MEP) can be used as an index of respiratory muscle strength and of the ability of an individual to cough effectively. The influence of anthropometry, nutritional status and ethnicity on MEP was studied in 113 young healthy Indian males and 53 Tibetans between 18 and 30 years of age. All subjects underwent an anthropometric assessment. Anthropometric variables (BMI, log BMI) explained only 12.5% of the variance in MEP. MEP was significantly lower in chronically undernourished subjects when compared with anthropometrically similar underweight subjects (P < 0.05). The Indian subjects had significantly lower MEP's than BMI matched Tibetan subjects (P < 0.01). This difference may have been due to the higher chest circumferences in the Tibetans (P < 0.01). While general muscle strength (maximal hand grip) and MEP were significantly correlated (r = 0.26, P < 0.01), the strength of the correlation was relatively low, suggesting that the determinants of the two measures were considerably different.

Gender differences in muscle strength & endurance in young Indian adults.

Muscle strength was studied in 70 males and 53 females between the ages of 17-30 yr, using a handgrip dynamometer. In a subset group of 31 males and 20 females, muscle endurance during sustained isometric contraction was studied using a load cell based handgrip dynamometer coupled to a polygraph. The males had a significantly greater muscle mass and lower body fat as compared to the females. Males had close to twice the handgrip strength of females in absolute terms (P < 0.01) and this difference persisted after correction for forearm muscle area (P < 0.05). In contrast, the rate of decline of muscle strength during sustained isometric contraction was lower in females as compared to males (P < 0.05), suggestive of greater skeletal muscle endurance in females. Physical activity patterns were not a determinant of skeletal muscle function. These findings are consistent with gender specific muscle fibre characteristics reported in literature in other racial groups.