Medical ethics teaching in the new undergraduate physiology competency-based curriculum in medical institutions in Delhi: A pilot, feasibility study

Background: Medical ethics teaching has received little attention in India's undergraduate medical curriculum, so the National Medical Commission’s formal inclusion of medical ethics in the new competency-based curriculum (CBME) is creditable. However, the policymakers have left out the most crucial stakeholders — the teachers. This study was conducted to find out how physiology educators in Delhi felt about the implementation of ethics teaching in physiology in the CBME. Methods: This was a pilot, cross-sectional, observational, feasibility study conducted using a questionnaire, involving faculty and senior residents (post-MD) in the departments of Physiology at nine medical colleges in Delhi, conducted over the period from February to October 2020. Results: The response rate was 76% (60/79), of which 40% (24/60) were senior residents and 60 (36/60) were faculty. Around 55% (n=33) felt bioethics and clinical ethics are not synonymous; 53% (n=32) believed ethics education can be accomplished in a large group setting; 75% (n=45) believed it should be the responsibility of the physiology faculty, rather than the clinical faculty, and 61.7% (n=37) wanted it to be included in the formative assessment. The respondents shared ethical concerns that should be included in the physiology curriculum and the best candidates to teach them to achieve integration. Despite the challenges, the majority 65% (n=39) felt ethics in the physiology CBME should be an inseparable part of teaching in all instructional modalities. Conclusion: Early clinical exposure was considered preferable to the Attitude, Ethics, and Communication (AETCOM) programme. Using the five W’s and one H method, we talk about how our findings can be used as a road map to help physiologists teach ethics to medical students in the new CBME.

Age and autonomy: An ethical dilemma in community mental health

Mental illnesses are proven to have their onset in the mid-teens, making early mental healthcare interventions necessary among adolescents. While school-based mental health awareness programmes have gained prominence in recent years, adolescents identify issues around confidentiality, privacy and the need for parental consent impinging on their autonomy, as barriers to accessing mental healthcare, for their perceived needs. We aim to discuss the various ethical dilemmas faced by community mental health providers in using age as a sole marker for determining autonomy for adolescents, focusing on the potential impact of these challenges on adolescent mental healthcare and wellbeing.

Pacing lead endocarditis due to Aspergillus fumigatus.

Invasive aspergillosis is an opportunistic infection with a high mortality rate that usually occurs in the immunocompromised host. Several cases of fungal infections have been reported after cardiac surgery. We present here a case of Aspergillus fumigatus tricuspid valve endocarditis associated with permanent pacemaker leads. Tricuspid valve vegetectomy was done and the pacing leads were also removed. Culture from the excised vegetation grew Aspergillus fumigatus. The patient was started on IV Amphotericin B for eight weeks. The patient was subsequently followed up in the out-patient clinic, and remains afebrile after one year, with no evidence of any vegetation.

Ten-year experience with the arterial switch operation.

BACKGROUND: Arterial level repair is considered the most appropriate procedure for transposition of the great arteries. This report describes our experience with the arterial switch operation over the past decade. METHODS AND RESULTS: From January 1991 to January 2001, a total of 299 patients underwent an arterial switch operation for transposition of the great arteries or double-outlet right ventricle. Group I (n=169, 56.5%) comprised patients with transposition of the great arteries in whom the ventricular septum was essentially intact. Group II patients (n=130, 43.5%) had transposition of the great arteries with an additional significant ventricular septal defect or had double-outlet right ventricle with a subpulmonic ventricular septal defect. Of the total, 245 (82%) were males and 54 (18%) were females. In group I, the ages ranged from 2 days to 18 years (median 19 days) and weight ranged from 1.7 to 68 kg (median 2.5 kg). In group II, the ages ranged from 4 days to 4 years (median 90 days) and weight ranged from 2.5 to 17 kg (median 4 kg). Fifteen percent of the patients (25/169) in group I and 30% of the patients (39/130) in group II had features of bacteriologic infection. Arterial switch operation was performed on standard lines. In group I, 141 patients (83.4%) had a primary arterial switch operation while 28 (16.6%) underwent a rapid two-stage repair. Twenty-three patients required concomitant relief of associated anatomic left ventricular outflow tract obstruction. Operative mortality was 8.8% (15/169) in group I and 33% (44/130) in group II with an overall mortality of 19% (59/299). The major causes of operative mortality included pulmonary arterial hypertensive crisis (n=21), sepsis and related complications (n=16), and left ventricular failure (n=8). Coexisting arch anomalies, longer cross-clamp time, late presentation, and preoperative bacteriologic infections were incremental risk factors. Follow-up ranged from 1 to 10 years and was 87% complete. On follow-up, 91% of the patients were asymptomatic and off all medications. There were 3 late deaths and 5 patients required reoperation. CONCLUSIONS: Excellent long-term results are obtained in operative survivors following the arterial switch operation. However. operative mortality remains a concern in our set-up.

Total anomalous pulmonary venous connection: surgical experience in Indians.

BACKGROUND: We report a retrospective analysis of the demographic. morphological and clinical profiles of patients along with results of operative repair for total anomalous pulmonary venous connection. METHODS AND RESULTS: In the last 15 years, 248 patients (168 boys, 80 girls) underwent repair for total anomalous pulmonary venous connection. Their ages ranged from I day to 24 years (median 8 months) and 145 of them were < or = 1 year of age. The patients' weight ranged from 2 to 52 kg (median 5 kg). About 70% of patients (n = 174) were less than the 50th percentile of predicted weight for age and sex. The anomalous connection was supracardiac in 134 (54%), cardiac in 80 (32.2%), infracardiac in 9 (3.6%) and mixed in 25 (10.1%) patients. Fifty (20.2%) patients had obstructed drainage and 76 patients (30.2%) had moderate or severe pulmonary arterial hypertension. Forty-five patients (18.1%) had to be operated upon on an emergency basis. All the patients were operated upon using moderately hypothermic cardiopulmonary bypass. In 114 patients, circulatory arrest was used. There were 45 (19.1%) in-hospital deaths. The major causes of early death were pulmonary arterial hypertensive crisis in 19 (7.7%) and low cardiac output syndrome in 17 (6.9%) patients. Age < or = 1 year (odds ratio 2.16; 95% confidence interval: 1.22-3.82, p=0.008), severe pulmonary arterial hypertension (odds ratio 5.86; 95% confidence interval: 2-17, p=0.001), and need for emergency surgery (odds ratio 3.65; 95% confidence interval: 1.59-8.38, p=0.002) were independent risk factors for early death. Follow-up ranged from 1 to 180 months (median 48 months). There were 4 lake deaths. Actuarial survival at 12 years was 92.6% +/- 2.8%. CONCLUSIONS: In Indian circumstances, mortality continues to be high in infants with total anomalous pulmonary venous connection. Severe pulmonary arterial hypertension appears to be the most important predictor of operative mortality. Severe malnutrition, delayed diagnosis and late referrals possibly contribute to the high mortality.

Surgical experience with dissecting and nondissecting aneurysms of the ascending aorta.

BACKGROUND: Patients who underwent replacement of the ascending aorta with a prosthetic graft for treatment of ascending aortic aneurysm and dissection between January 1992 and December 2000 were studied. METHODS AND RESULTS: Bentall's operation, using a composite aortic valve and prosthetic graft. was performed in 82 patients (70 males). Indications for the procedure included ascending aortic aneurysm (n=54 including 16 patients with Marfan's syndrome): DeBakey Type I or II aortic dissection (n=26 including 10 patients with Marfan's syndrome) and ascending aortic aneurysm with severe aortic stenosis (bicuspid aortic valve disease) (n=2). Bentall's procedure with the inclusion technique was performed in 72 patients and a Cabrol fistula created in 63 patients. In 10 other patients, coronary button transfer was done without a Cabrol fistula. There were 6 early deaths (7.3%) and 8 patients required re-exploration for excessive bleeding. Eighteen patients showed low cardiac output while the wound of 8 became infected. Postoperative arrhythmia and renal failure was seen in 26 and 6 patients, respectively. Four patients had pericardial effusion. Follow-up ranged from 1 month to 8 years. There were 8 late deaths, the causes of which include congestive heart failure (n=3). cerebral hemorrhage (n=3) and sudden cardiac death (n=2). Two patients reported back with dissection of the descending thoracic aorta and await surgery. CONCLUSIONS: Bentall's operation is a safe procedure with an acceptable mortality and morbidity.

Infective complications of central venous catheters in cardiac surgical patients.

Prospective randomised study was conducted over a 24 months period in a cardiac surgical intensive care unit to determine the incidence of infection associated with multilumen venous catheters. The influence of various factors including fever, peripheral blood culture, catheter site, catheter usage for monitoring central venous pressure and/inotrope therapy on infection rates were statistically evaluated. A total of 100 catheters submitted to the Microbiology laboratory were bacteriologically examined. Forty-nine of these were inserted into upper body sites, and 51 were inserted into the femoral vein. Twenty-one were triple-lumen catheters. Catheters were removed when a central line was no longer necessary. Catheter tips were cultured by semiquantitative technique for aerobic and anaerobic bacteria. Bacteremia occurred in 3% of catheter insertions; (Enterococcus faecalis, one; Enterobacter spp. One; Acinetobacter spp., one); and catheter colonisation developed in 24%. Neither catheter colonisation nor catheter related infection were associated with any of the risk factors evaluated. Our data indicates that central venous catheters are safe to use in our patients. The inability to identify "risk factors" for catheter infection emphasise the need to maintain a high index of suspicion.

Does inhaled nitric oxide improve survival in operated congenital disease with severe pulmonary hypertension?

BACKGROUND: The present study aimed to assess the impact of inhaled nitric oxide on survival following correction of congenital heart defects with residual pulmonary arterial hypertension. METHODS AND RESULTS: Inhaled nitric oxide was utilized for the management of residual pulmonary hypertension in 24 children following surgical correction of their underlying heart defects. Their ages ranged from 15 days to 14 months (median 5 months). Pulmonary artery hypertension was diagnosed either by direct pulmonary artery pressure monitoring or by echocardiography. Inhaled nitric oxide was used electively in 22 patients when the ratio of the mean pulmonary arterial pressure and mean systemic arterial pressure exceeded 0.5. In the remaining 2 patients, nitric oxide was used only to manage a pulmonary hypertensive crisis. Inhaled nitric oxide was also used a second time in 2 patients who developed delayed pulmonary hypertensive crisis. Twenty-two patients showed an initial response to therapy and the pulmonary artery pressures dropped significantly. Of the patients on direct pulmonary artery pressure monitoring, a pulmonary artery to systemic artery pressure ratio below 0.3 on prolonged therapy was associated with a survival ratio of 4/6 (including 1 neurological death and one reoperation); that between 0.3 and 0.5 with a survival ratio of 3/4. Three out of four patients with sustained echocardiographic and clinical response also survived and were discharged from the hospital. All the patients who showed a lack of response to (n=2), tolerance to (n=1), or dependence on (n=6) the use of inhaled nitric oxide died. In addition, all 5 patients who had a pulmonary hypertensive crisis died, 3 in spite of successful resuscitation with nitric oxide. Thus, excluding one neurological death and one re-operation, only 9 (41%) out of 22 patients survived. CONCLUSIONS: Though inhaled nitric oxide is effective in lowering pulmonary pressure, it does not appear to improve the survival rate following repair of congenital heart disease in those with associated severe pulmonary hypertension. A randomized trial between the use and non-use of inhaled nitric oxide is warranted to determine its exact role in influencing survival in patients with residual pulmonary hypertension following surgical repair.

Cardiac arrhythmias in surgically repaired total anomalous pulmonary venous connection: a follow-up study.

Twenty-five patients with diagnosis of total anomalous pulmonary venous connection, who had undergone corrective surgery, were studied at variable time period after surgery with 24-hour ambulatory electrocardiographic monitoring (Holter) and echocardiography. The aim of this study was to record arrhythmias, if any, and to correlate occurrence of arrhythmia with adequacy of repair and other related variables. All the patients were clinically asymptomatic. Twenty-four hours ambulatory electrocardiographic monitoring of these patients showed the presence of significant arrhythmias in 21 of the 25 patients. These included supraventricular ectopics in 19 patients, ventricular ectopics in 8, atrioventricular block in 2, right bundle branch block and atrial fibrillation 1 each and atrial tachycardia in 2 patients. There was no correlation between development of arrhythmia and age at repair, type of connection, operative approach and adequacy of repair. The study indicates that cardiac arrhythmias can occur in otherwise asymptomatic patients after correction for total anomalous pulmonary venous connection. Thus, these patients require long-term follow-up, even if they are asymptomatic.

Non-myxomatous cardiac tumours: twenty-year experience.

Eighty-eight patients underwent surgery for various cardiac tumours from January 1978 to June 1998 at our Institute. Seventy-seven tumours were myxomas, 10 were non-myxomatous and one was secondary cardiac tumour. Case records of the patients with non-myxomatous primary cardiac tumours and one secondary tumour were reviewed. Six of these primary tumours were benign and four, malignant. Age of the patients ranged from 26 days to 47 years. Among patients (3 children, 8 adults) with non-myxomatous primary cardiac tumours, dyspnoea on exertion was the commonest symptom and was the cause of presentation in seven out of 11 patients. Of the eight adults, six were in New York Heart Association functional class II/III and two in class IV. Echocardiographic diagnosis was possible in all the patients. Complete excision of the tumour was possible in all benign and two of the four malignant tumours. Incomplete resection was done in the secondary tumour. Of the six benign tumours, three were rhabdomyomas and one each of fibroma, haemangioma and lipoma. The malignant tumours were one each of fibrosarcoma, angiosarcoma, unclassified sarcoma and malignant mesothelioma. The secondary tumour was a malignant thymoma. Follow-up ranged from 1 to 10 years (mean 7.2 years). Of the patients with benign tumours, four out of six are alive; one patient died on the first post-operative day and one lost to follow-up. Two of the four patients with malignant cardiac tumours died, one was lost to follow-up and one is alive two years after surgery. The patient with secondary malignant thymoma to the superior vena cava was lost to follow-up three months after an uneventful recovery from surgery.

Surgical considerations of univentricular heart with total anomalous pulmonary venous connection.

Out of the 600 patients undergoing univentricular repair during the last 11 years, 20 children had associated total anomalous pulmonary venous connection. The objective was to outline the clues to establish the diagnosis of this rare disease combination and the various surgical options available to manage the same. Bidirectional Glenn, bilateral bidirectional Glenn, total cavopulmonary connection and atriopulmonary connection were performed in combination with rechannelling of various types of total anomalous pulmonary venous connection in 20 children aged 6 months to 36 months (mean +/- SD 17.65 +/- 9.02 months). Diagnosis could be established pre-operatively in only 13 (65%) patients. Out of 6 early deaths (30%), 4 were directly attributable to missed diagnosis. No late deaths occurred over a follow-up period ranging from 1 month to 132 months. None of the surviving children required reoperation and all are in NYHA functional class I. Doppler echocardiography of the surviving children revealed unrestricted atrio/cavopulmonary anastomosis and pulmonary vein to atrium connection in all survivors. Our own experience, coupled with a review of the literature, indicates that a missed diagnosis increases the hospital mortality. Cross sectional 2D echocardiography is a superior method of detection of associated total anomalous pulmonary venous connection compared to angiocardiography. Exclusion of the diagnosis of anomalous pulmonary venous connection is imperative in all univentricular hearts pre-operatively and on operation table. Failure to recognise this disease combination results in formation of a closed systemic circuit after bidirectional Glenn or a modified Fontan of connection and is lethal as happened in our early experience. It is suggested that one-stage Fontan operation should be performed only if other criteria for Fontan procedure are satisfied.

Management of tetralogy of Fallot with absent pulmonary valve: early and mid-term results of a uniform approach.

The operative management of absent pulmonary valve syndrome remains controversial regarding palliative or one-stage correction, the need for pulmonary valve implantation and pulmonary arterioplasty. This retrospective report summarises the experience of a single centre with a view to provide some answers to this controversy. Forty-six consecutive patients including five infants, aged 2 months to 43 years, underwent primary surgical correction during the last 8.5 years. All the patients underwent two-dimensional echocardiography and cardiac catheterisation. Nine patients had mild and 10 moderate pulmonary artery hypertension. Repair consisted of patch closure of the ventricular septal defect and reconstruction of the right ventricular outflow tract. A valve was incorporated in the pulmonary position in 19 patients. Pulmonary arterioplasty was performed only in infants. Overall hospital mortality was 4 out of 46 patients (8.6%). Two out of five infants died accounting for 40 percent mortality. Forty-two survivors were followed up from 4 to 101 months; 40 patients are in functional class I and two in class II. Actuarial survival at 8.5 years was 91 percent. It is concluded that reconstruction of the right ventricular outflow tract with a transannular patch is sufficient in majority of patients. A selective approach to pulmonary valve insertion is recommended in patients with pulmonary hypertension or other anomalies. Pulmonary arterioplasty should be performed as the primary treatment in infants.

Profound hypothermic circulatory arrest in management of aortic aneurysms.

A total of 15 patients having aneurysms of aorta were operated from June 1997 to December 1998 using deep hypothermic circulatory arrest as a modality of brain protection. There were 12 males and 3 females. The age ranged from 19 years to 74 years and the mean age was 44.9 years. Nine patients had aneurysms of ascending aorta (group I), one had aneurysm of ascending aorta and arch of aorta (group II), four had aneurysm of the distal aortic arch (group III) and one patient had thoracoabdominal aortic aneurysm (group IV). In group I, six patients underwent Bentall procedure, two underwent Wheat procedure and one patient had repair of pseudoaneurysm of ascending aorta. The only patient in group II had his ascending aorta and arch replaced, with reimplantation of left common carotid and innominate artery. In group III, three patients had interposition Gelseal graft and one had repair of the tear in distal aortic arch. The lone patient in group IV had interposition Gelseal graft of thoracoabdominal aorta. The hypothermic circulatory arrest was used in all of them for brain and/or spinal cord protection. Retrograde cerebral perfusion was used in two patients. There were two (13%) operative deaths. One patient died of cerebrovascular accident on eighth post-operative day and second died of inadequate surgical repair. There was one instance of left hemiparesis secondary to an infarct in right frontoparietal region. To conclude, hypothermic circulatory arrest could provide an adequate brain protection for aortic aneurysm surgery. Retrograde cerebral perfusion could be an adjuvant when the anticipated time of hypothermic circulatory arrest is likely to exceed 45 minutes.

A comparison of esmolol and diltiazem for heart rate control during coronary revascularisation on beating heart.

This prospective study compared control of heart rate and haemodynamics during coronary artery revascularization without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 groups. Group A (n=30) received a 50 microg/kg/ loading dose of esmolol followed by a 100 microg/kg/hr infusion, for control of heart rate during surgical anastomosis of the coronary vessel. Group-B (n=30) received 0.15 mg/kg of diltiazem as a loading dose followed by a 5 mg/hr infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in group A, 51.4 +/- 1.3 beats/min, (p <0.01) than in group B, 69.6 +/- 3.0 beats/min (p <0.05), as compared to baseline values of 80.6 +/- 12.1 beats/min in group A and 82.4 +/- 10.6 beats/min in group B respectively. Systemic vascular resistance and pulmonary artery wedge pressure were unchanged in group A but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic vascular resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index at the time of distal coronary anastomosis. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.

A comparison of esmolol & diltiazem for heart rate control during coronary revascularisation on beating heart.

This prospective study was done to compare the control of heart rate and haemodynamics during coronary artery revascularisation without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 equal groups. Group A received a 500 micrograms/kg loading dose of esmolol followed by a 100 micrograms/kg/h infusion, for control of heart rate during surgical anastomosis of the coronary vessel. While Group B received 0.15 mg/kg diltiazem as a loading dose followed by a 5 mg/h infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in Group A, 51.4 (+/- 1.3) beats/min, than in Group B, 69.6 (+/- 3.9) beats/min but the decrease in heart rate was significant in both the groups at peak effect compared to respective predrug values. Group A patients had unchanged systemic resistance and pulmonary artery wedge pressure but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.

Post-infarction ischaemic mitral regurgitation: what determines the outcome.

Ischaemic mitral regurgitation is an important determinant of survival in patients with coronary artery disease. A retrospective analysis was performed to evaluate the overall outcome and its determinants in patients with ischaemic mitral regurgitation. Over a period of 10 years, 72 patients underwent operations for mitral regurgitation of ischaemic origin. Age ranged from 37 to 68 years (mean 54.6 +/- 10.4 years), and 62 (86.1%) were male. Thirteen (18%) patients had acute and 59 (82%) had chronic ischaemic mitral regurgitation. Twenty-one patients were in New York Heart Association class II, 32 in class III and 19 in class IV. Moderate to severe left ventricular dysfunction was present in 42 patients. Valve prolapse was present in 35 (48.6%) patients and restricted leaflet motion secondary to myocardial dysfunction was present in 37 (51.4%) patients. All the patients were operated using standard cardiopulmonary bypass technique. Mitral valve was replaced in 33 patients and repaired in 39. Repair included a combination of techniques: chordal transposition (n = 2), chordal shortening (n = 18), leaflet resection (n = 2), posterior collar annuloplasty (n = 35) and annuloplasty with flexible Duran's ring (n = 3). Operative mortality was 18.1 percent (13/72). Low cardiac output was the cause of death in the majority (n = 10). Acute presentation and presence of restricted leaflet motion were the significant predictors of early mortality. Follow-up ranged from 3 to 84 months (mean 41.6 +/- 10.2 months). Late mortality was 46.2 percent. Actuarial survival in operative survivors at five years was 44.4 +/- 8.8 percent. To conclude, ischaemic mitral regurgitation carries a poor early and late outcome, with left ventricular dysfunction and presence of restricted leaflet motion being important contributors to it. In addition, acute presentation also reflects greater early mortality.