Introducing virtual classrooms for undergraduate physiology teaching during the COVID-19 pandemic: acceptance by students and subjective impact on learning.

The COVID-19 pandemic and worldwide lockdowns brought major changes in education systems. There was a sudden obligatory shift toward utilization of digital resources for teaching and learning purposes. Medical education, specifically physiology teaching, comprises hands-on training in the laboratory. It is challenging to offer a course like physiology in a virtual format. The objective of this study was to assess the effectiveness and influence of virtual classroom technology on online physiology education in a sample size of 83 first-year MBBS undergraduates. A questionnaire comprising questions related to technology accessibility and utilization, comprehensibility and effectiveness of instructions, faculty proficiency, and learning outcomes was administered to the group. The responses were collected and analyzed. Validation through principal components and factor analysis showed that online teaching is not very effective and has a limited application in the physiology education of undergraduate MBBS students. Our study also revealed that virtual physiology teaching of undergraduate medical students during the COVID-19 pandemic had a moderate level of effectiveness.NEW & NOTEWORTHY In the present qualitative study, we have conducted and validated an online physiology teaching platform at a medical college to continue medical education during the peak times of the COVID-19 pandemic and prolonged lockdowns. Furthermore, we have evaluated the effectiveness of online physiology teaching through multidimensional feedback from undergraduate MBBS students. It is experimental evidence of inadequate sustainability, moderate efficacy, limited application, and poor first-hand experience gained by the students in virtual physiology teaching in a preclinical and clinical setting.

Neuronavigation based 10 sessions of repetitive transcranial magnetic stimulation therapy in chronic migraine: an exploratory study.

INTRODUCTION: Chronic migraine is a disease of altered cortical excitability. Repetitive transcranial magnetic stimulation provides a novel non-invasive method to target the nociceptive circuits in the cortex. Motor cortex is one such potential target. In this study, we targeted the left motor cortex using fMRI-guided neuronavigation. MATERIALS AND METHODS: Twenty right-handed patients were randomized into real and sham rTMS group. Baseline subjective pain assessments were done using visual analog scale (VAS) and questionnaires: State-Trait Anxiety Inventory, Becks Depression Inventory, and Migraine Disability Assessment (MIDAS) questionnaire. Objectively, pain was assessed by means of thermal pain thresholds using quantitative sensory testing. For corticomotor excitability parameters, resting motor thresholds and motor-evoked potentials were mapped. For rTMS total, 600 pulses in 10 trains at 10 Hz with an intertrain interval of 60 s were delivered in each session. Ten such sessions were given 5 days per week over 2 consecutive weeks. The duration of each session was 10 min. Real rTMS was administered at 70% of Resting MT. All the tests were repeated post-intervention and after 1 month of follow-up. There are no studies reporting the use of fMRI-based TMS for targeting the motor cortex in CM patients. RESULTS: We observed a significant reduction in the mean VAS rating, headache frequency, and MIDAS questionnaire in real rTMS group which was maintained after 1 month of follow-up. CONCLUSION: Ten sessions of fMRI-based rTMS over the left motor cortex may provide long-term pain relief in CM, but further studies are warranted to confirm our preliminary findings.

Resuming outpatient services during COVID times: Our approach and experience at India's apex institute.

Healthcare services have been severely strained and stressed coping with the rising burden of COVID-19 patients. With the situation gradually worsening and the growing need to cater to Non-COVID patients, we ventured to reopen the OPDs. This was to be implemented in a staggered manner. The backbone to this endeavour was the specialised screening and sampling OPD for healthcare workers which had been earlier established. We would like to share our two-pronged approach in this unprecedented situation: establishment of a specialised screening and sampling clinic for healthcare workers and a high-volume "Influenza-like screening clinic" for the resumption of outpatient services.

Repetitive transcranial magnetic stimulation in chronic tension-type headache: A pilot study.

Background & objectives: Tension-type headache (TTH) is the most common type of primary headache disorder. Its chronic form is often the most ignored and challenging to treat. Transcranial magnetic stimulation (TMS) is a novel technique in the treatment of chronic pain. The aim of this pilot study was to explore the effect of low-frequency repetitive TMS (rTMS) on pain status in chronic TTH (CTTH) by subjective and objective pain assessment. Methods: Patients (n=30) diagnosed with CTTH were randomized into rTMS (n=15) and placebo (n=15) groups in this study. Pre-intervention detailed history of patients was taken. Numerical Rating Scale (NRS) for Pain and questionnaires [Headache Impact Test-6 (HIT-6), McGill Pain Questionnaire, Pain Beliefs Questionnaire, Coping Strategies Questionnaire, State-Trait Anxiety Inventory Test, Hamilton Rating Scale for Depression and WHO-Quality of Life Questionnaire-Brief version] were filled, and objective assessments such as nociceptive flexion reflex (NFR) and conditioned pain modulation were done. The tests were repeated after 20 sessions (5 days/week). In the rTMS group, 1200 pulses in eight trains of 150 pulses each were given at 1Hz over the right dorsolateral prefrontal cortex (RDLPFC). In the placebo group, the rTMS coil was placed such that magnetic stimulation did not reach the cortex. Results: The NRS score decreased significantly (P<0.001) and NFR thresholds increased significantly (P=0.011) in the rTMS group when compared to placebo group. Interpretation & conclusions: Subjective improvements in the NRS, HIT-6, McGill Present Pain Intensity, trait of anxiety and psychological pain beliefs were observed. The increase in the thresholds of NFR served as an objective marker for improvement in pain status. Further studies need to be done to confirm our preliminary findings.

Planning, implementation, and evaluation of multicomponent, case-based learning for first-year Indian medical undergraduates.

Didactic lecture is an effective method to quickly pass on a high volume of information to a large number of students. However, if not well designed, lectures can be monotonous and provide only passive learning, with little scope for higher order learning skills. To address this drawback of lectures, we supplemented it with case-based learning (CBL), which has been shown to promote self-learning. After giving an overview of gastrointestinal physiology through lectures, CBL on peptic ulcer disease was implemented for first-year Bachelor of Medicine, Bachelor of Surgery students. The present study aimed to evaluate the students' and teachers' opinions on the notion of supplementing lectures with CBL. In previous reports, discussion using clinical cases was primarily employed as the solitary component for conducting CBL. In the present study, three different but mutually exclusive components, such as case discussion, concept map, and critical thinking exercise on a specific topic in gastrointestinal pathophysiology, were integrated to form the multicomponent CBL (MC-CBL). Students reported that MC-CBL could promote application of the knowledge learned in lectures in a more appropriate context (92.42% positive response), enhance their learning efficiency (98.46% positive response), promote their active participation in the learning process (98.48% positive response), and help them in integrating physiological concepts with clinical science (98.46% positive response). Teachers observed that MC-CBL could promote active learning, analytic, and problem-solving skills of students. In conclusion, MC-CBL appeared to be an effective supplement for the lectures, providing an opportunity for the students to relate the knowledge learned during lectures.

Exploring pathogenic pathways in carpal tunnel syndrome: sterile inflammation and oxidative stress.

OBJECTIVES: The main objective of the current study was to find the association between oxidative stress, inflammatory markers, and electrophysiological profile with symptom severity in patients of carpal tunnel syndrome (CTS). METHODS: Thirty-two carpal tunnel syndrome patients and 32 controls were included in the study. Boston CTS questionnaire along with plasma oxidative stress markers including superoxide dismutase, malondialdehyde, and nitric oxide and inflammatory markers including IL-6 and TNF-α were compared with the electrophysiological parameters derived from nerve conduction studies. Statistical significance of the levels between groups was calculated using unpaired-t test after checking for normality with D'Agostino & Pearson omnibus normality test. RESULTS: We found that the median nerve conduction velocity was prolonged, amplitude was decreased, while the levels of oxidative stress markers like malondialdehyde (MDA), superoxidase dismutase (SOD), and nitric oxide (NO) were increased in CTS patients compared to controls. Inflammatory markers like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) were also increased in CTS patients. We found that plasma SOD and TNF-α correlated well with the median motor amplitude. There was no other significant correlation between oxidative stress markers and inflammatory markers with nerve conduction studies or disease severity. Patients with mild disease also showed lesser levels of SOD, NO, IL-6, and TNF-α markers than patients with severe disease. CONCLUSIONS: CTS is probably a disease of sterile inflammation and disbalance of oxidative stress, with higher inflammatory and oxidative stress markers pointing to a more severe disease.

Repetitive transcranial magnetic stimulation of the prefrontal cortex for fibromyalgia syndrome: a randomised controlled trial with 6-months follow up.

OBJECTIVES: Fibromyalgia Syndrome (FMS), is a chronic pain disorder with poorly understood pathophysiology. In recent years, repetitive transcranial magnetic stimulation (rTMS) has been recommended for pain relief in various chronic pain disorders. The objective of the present research was to study the effect of low frequency rTMS over the right dorsolateral prefrontal cortex (DLPFC) on pain status in FMS. METHODS: Ninety diagnosed cases of FMS were randomized into Sham-rTMS and Real-rTMS groups. Real rTMS (1 Hz/1200 pulses/8 trains/90% resting motor threshold) was delivered over the right DLPFC for 5 consecutive days/week for 4 weeks. Pain was assessed by subjective and objective methods along with oxidative stress markers. Patients were followed up for 6 months (post-rTMS;15 days, 3 months and 6 months). RESULTS: In Real-rTMS group, average pain ratings and associated symptoms showed significant improvement post rTMS. The beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In Sham-rTMS group, no significant change in pain ratings was observed. CONCLUSION: Right DLPFC rTMS can significantly reduce pain and associated symptoms of FMS probably through targeting spinal pain circuits and top-down pain modulation . TRIAL REGISTRATION: Ref No: CTRI/2013/12/004228.

Aberrant pain modulation in trigeminal neuralgia patients.

Objectives The present study attempts to understand the role of supraspinal nociceptive pain modulation in typical trigeminal neuralgia (TN) patients by using a conditioned pain modulation paradigm and estimation of plasma levels of two important neuromodulators; Calcitonin Gene-Related Peptide and ß-endorphin. Methods Twenty TN patients and 20 healthy, age and gender-matched subjects participated in the study. The participants' hot pain thresholds (HPT) were measured over their affected side on the face. Testing sites were matched for healthy controls. For the conditioned pain modulation their contralateral foot was immersed in noxious cold (5 °C) water bath (conditioning stimuli) for 30 s and HPT (testing stimuli) was determined before, during and till 5 min after the immersion. Plasma Calcitonin Gene-Related Peptide and ß-endorphin levels were estimated to understand their role in disease pathogenesis and pain modulation. Results Change in HPT during foot immersion was significantly higher in healthy controls compared to TN patients (p<0.0001). The changes recorded in HPT in patients, were significant only in 2nd and 3rd minute post immersion. While in healthy controls, the effect lasted till the 4th minute. The concentration of beta-endorphin was significantly lower in TN patients (p=0.003) when compared to healthy controls. Conclusions The results suggest that there is an impairment in supraspinal pain modulation also known as Diffuse Noxious Inhibitory Controls in typical TN and that the reduced levels of ß-endorphin may contribute to the chronic pain state experienced by patients.

Can aberrant spinal nociception be a marker of chronicity of pain in fibromyalgia syndrome?

Pain sensitivity is a recognized feature of fibromyalgia syndrome (FMS) but the contribution of spinal nociceptive circuitry to this phenomenon is unknown. Therefore, the objectives were to study the changes in spinal nociception i.e. nociceptive flexion reflex (NFR) in patients with FMS and to investigate correlation if any, between NFR threshold, pain duration and tender points in FMS. One hundred and three patients with FMS and 74 healthy volunteers participated in the study. To record NFR, sural nerve was stimulated in the retro malleolar region and the reflex response was recorded from the short head of biceps femoris muscle. NFR was elicited at significantly lower [21.0(18.0-25.0)V] thresholds in FMS group when compared to healthy subjects [30.0(24.75-35.0)V; p = 0.001] indicating hyperalgesic response to electrocutaneous stimulation in FMS patients. The latency and other parameters of NFR were comparable in both the groups. No significant correlation was found among NFR threshold and pain duration or tender points. On the basis of results of present study, it may be concluded that the functional deficit of the spinal nociceptive system can contribute to hyperalgesia in FMS. This is first study that correlates a marker of central hyper-excitability (NFR threshold) with clinical symptoms (pain duration and tender points) of FMS.

Repetitive transcranial magnetic stimulation of the prefrontal cortex for fibromyalgia syndrome: a randomised controlled trial with 6-months follow up

Abstract Objectives Fibromyalgia Syndrome (FMS), is a chronic pain disorder with poorly understood pathophysiology. In recent years, repetitive transcranial magnetic stimulation (rTMS) has been recommended for pain relief in various chronic pain disorders. The objective of the present research was to study the effect of low frequency rTMS over the right dorsolateral prefrontal cortex (DLPFC) on pain status in FMS. Methods Ninety diagnosed cases of FMS were randomized into Sham-rTMS and Real-rTMS groups. Real rTMS (1 Hz/1200 pulses/8 trains/90% resting motor threshold) was delivered over the right DLPFC for 5 consecutive days/week for 4 weeks. Pain was assessed by subjective and objective methods along with oxidative stress markers. Patients were followed up for 6 months (post-rTMS;15 days, 3 months and 6 months). Results In Real-rTMS group, average pain ratings and associated symptoms showed significant improvement post rTMS. The beneficial effects of rTMS lasted up to 6 months in the follow-up phase. In Sham-rTMS group, no significant change in pain ratings was observed. Conclusion Right DLPFC rTMS can significantly reduce pain and associated symptoms of FMS probably through targeting spinal pain circuits and top-down pain modulation . Trial registration: Ref No: CTRI/2013/12/004228.(AU)