Predictors Associated with In-hospital Mortality among COVID-19 Patients during the Second Wave in a Tertiary Care Hospital, Gujarat, India: A Retrospective Observational Study.

BACKGROUND: Fatalities due to coronavirus disease 2019 (COVID-19) have already crossed to more than 5 million globally so far. Hence, it is crucial for us to identify the risk factors associated with hospital deaths starting from first contact which can help to give timely treatment to the targeted population. OBJECTIVES: This retrospective cohort study was conducted to identify various factors related to in-hospital mortality related to COVID-19 in our region. MATERIALS AND METHODS: The present study was a single-center, retrospective cohort study of 675 adult patients, admitted with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection between 1st April and 25th May 2021 in our tertiary care hospital. Baseline demographic profile, comorbidities, clinical characteristics, and investigatory findings were analyzed for increased odds of mortality. RESULTS: A total of 181 (26.8%) patients died and 494 (73.2%) survived. There were 65.4% of males and no difference was found between genders in terms of mortality. Comorbidities associated with in-hospital death in our cohort were age group ≥50 years (p<0.001), diabetes (p<0.0007), and renal injury (p<0.0001). More than half of the patients died during the first week of admission. Breathlessness (83%) was the most common symptom in non-survivors. Neutrophil-to-lymphocyte ratio (NLR), S. creatinine, D-dimer, ferritin, and C-reactive protein (CRP) were increased significantly among the patients who died. Multivariate logistic regression revealed age ≥50 years [adjusted odds ratio (AOR) 2.30, 95% confidence interval (CI) 1.45-3.64] and oxygen (O2) saturation <94% at the time of admission (AOR 2.62, 95% CI 1.75-3.93) were associated with mortality. CONCLUSION: Overall in-hospital mortality was 26.8%. Higher age and low O2 saturation were the major risk factors associated with in-hospital mortality.

A structured mentorship program for medical college faculty on health research.

BACKGROUND: A paradigm shift is required in faculty development programs on research skills, from theory-driven to hands-on practical approach. The objective of this study was to develop and implement a structured mentorship model for training of medical faculties in research skills. METHODS: An interventional study using functional mentorship and experiential learning based on a research project was conducted over a period of one year through two prevalidated modules: protocol and manuscript writing. We included early and mid-career medical faculty as mentees (mentor:mentee ratio-1:2). Module 1 consisted of eight days of active learning and 25 days of refinement period-the end point being submission of research proposal to the ethics committee. Module 2 consisted of six days of active learning and 15 days of refinement period with the end point being manuscript submission to a peer-reviewed journal. Context, Input, Process and Product model of evaluation was used for this program. RESULTS: All eight faculty who participated as mentees in this program completed the first module, developed protocols under this program and processed them through the ethics committee. Six of the eight participants of this original cohort attended the second module and five could submit their manuscript to a peer-reviewed journal within the stipulated date. Participants expressed improvement in their self-rating of research skills, satisfaction with the program and an overall favourable change in attitude towards research. CONCLUSION: Structured mentorship program with the help of local mentors could enhance research skills of medical faculty.

Atypical Presentation of Primary Hyperparathyroidism as Recurrent Pancreatitis: A Case Report With a Review of the Literature.

The majority of the patients with primary hyperparathyroidism (PHPT) are asymptomatic. The most common organ systems involved in PHPT are the kidneys and the skeletal system. In rare instances, acute or chronic pancreatitis may be presenting feature in PHPT patients. The association between these both diseases is still the topic of debate. Here, we put forth a case of a 52-year-old female with three episodes of pancreatitis in the last six months who was diagnosed with PHPT during the fourth episode of pancreatitis based on raised serum amylase and serum lipase levels along with ultrasonography (USG) findings of the abdomen. Pancreatitis in the absence of additional risk factors such as gallstones and alcohol abuse along with raised parathyroid hormone (PTH), hypercalcemia and osteolytic bone lesions led us towards the diagnosis of PHPT. On radio imaging such as MRI and CT scans of the neck, parathyroid adenoma was found in the posterior aspect of the right lobe of the thyroid. She was treated with parathyroidectomy. Serum calcium and PTH levels normalised postoperatively. As can be seen from our case, recurrent pancreatitis with hypercalcaemia should be evaluated for PHPT.

Role of Insulin Resistance in Patients of Acne Vulgaris and Hirsutism in the Western Part of India- A Cross-Sectional Study.

Background: Despite being common and easy to treat conditions, acne and hirsutism may have a striking consequence on one's perception of self. Though understanding the pathogenesis of acne and hirsutism has undergone a major paradigm shift, one of them being insulin resistance (IR), extensive research is still underway. The purpose of the study is to establish causal relationship linking IR with acne vulgaris and hirsutism, as well as to assess severity of the two with increasing IR. Materials and Methods: A cross-sectional observational study was conducted in the dermatology department. Patient's detailed clinical history and necessary parameters like height, weight, body mass index (BMI), etc., were recorded in predefined proforma, noting signs and symptoms of underlying IR, along with acne severity calculated by global acne grading system (GAGS) and hirsutism severity by modified Ferriman Gallwey score (mFG), then analyzing using Pearson's correlation test to establish correlation between IR and acne with/without hirsutism and hirsutism alone. Results: A total of 349 patients included in our study were divided into three groups, (i) Acne-only (N = 308) group showed statistically significant correlation of IR with acne severity (P < 0.0001) and recurrence (P < 0.0001). (ii) In hirsutism-only (N = 24) group, homeostatic model assessment for insulin resistance (HOMA-IR) was strongly associated with modified Ferriman-Gallwey score and recurrence suggesting raised insulin resistance with increased severity of hirsutism (P < 0.0001) and recurrence (P < 0.007). (iii) In acne + hirsutism (N = 17) group, raised BMI was found to be positively associated with IR but not with severity of both conditions. Conclusion: IR has emerged as an important contributory, if not, causative event in pathogenesis of severe, resistant acne, and hirsutism. These conditions have great deal of impact on the psychological health of those affected necessitating different approach to manage such cases.

Cash transfer scheme for people with tuberculosis treated by the National TB Programme in Western India: a mixed methods study.

OBJECTIVES: This study aimed to assess the coverage and explore enablers and challenges in implementation of direct benefit transfer (DBT) cash incentive scheme for patients with tuberculosis (TB). DESIGN: This is a mixed methods study comprising a quantitative cohort and descriptive qualitative study. SETTING: The study was conducted in City TB Centre, Vadodara, Western India. PARTICIPANTS: We used routinely collected data under the National TB Programme (NTP) on patients with TB notified between April and September 2018 and initiated on first-line anti-tuberculosis treatment (ATT) to assess the coverage of DBT. We interviewed NTP staff and patients to understand their perceptions. PRIMARY AND SECONDARY OUTCOME MEASURES: The study outcomes are receipt of DBT (primary), time to receipt of first instalment of DBT and treatment outcome. RESULTS: Among 1826 patients, 771 (42.2%) had received at least one instalment. Significantly more patients from the public sector had received DBT (at least one instalment) compared with those from private sector (adjusted relative risk (adjRR)=16.3; 95% CI 11.6 to 23.0). Among public sector patients, 7.3% (49/671) had received first instalment within 2 months of treatment initiation. Median (IQR) time to receipt of first instalment was 5.2 (3.4, 7.4) months. Treatment in private sector, residing outside city limits and being HIV non-reactive were significantly (p<0.001) associated with longer time to receipt. Timely and sufficient fund release, adequate manpower and adequate logistics in TB centre were the enablers. Inability of patients to open bank accounts due to lack of identity/residence proof, their reluctance to share personal information and inadequate support from private providers were the challenges identified in implementation. CONCLUSION: During the early phase of DBT implementation, the coverage was low and there were delays in benefit transfer. Facilitating opening of bank accounts for patients by NTP staff and better support from private providers may improve DBT coverage. Repeat assessment of DBT coverage after streamlining of implementation is recommended.

'M-TRACK' (mobile phone reminders and electronic tracking tool) cuts the risk of pre-treatment loss to follow-up by 80% among people living with HIV under programme settings: a mixed-methods study from Gujarat, India.

BACKGROUND: In 2016, the National AIDS Control Programme (NACP) in Gujarat, India implemented an innovative intervention called 'M-TRACK' (mobile phone reminders once every week for four weeks after diagnosis and electronic patient tracking tool) to reduce pre-treatment loss to follow-up (LFU) among people living with HIV (PLHIV) in Vadodara district while other districts received standard of care. OBJECTIVES: To assess the effectiveness of M-TRACK in reducing pre-treatment LFU (proportion of diagnosed PLHIV not registering for HIV care by four weeks after diagnosis) and to explore the implementation enablers and challenges from health care providers' and PLHIV perspective. METHODS: An explanatory mixed-methods study design was used wherein the quantitative phase (cohort study with two groups: Vadodara district exposed to M-TRACK and Rajkot district as unexposed) was followed by a qualitative phase (descriptive study involving group interview with 16 health care providers, personal interviews with two programme managers and telephonic interviews with 16 PLHIV). Data were collected during October 2016 to February 2017. RESULTS: During the pre-M-TRACK period (July-September 2016), the LFU proportion was similar [13% (25/191) in Vadodara; 15% (21/141) in Rajkot (p = 0.8)]. During the M-TRACK period (October-December 2016), LFU decreased to 4% (9/209) in Vadodara (exposed), whereas it remained similar at 16% (18/113) in Rajkot (unexposed) district (p = 0.02). PLHIV exposed to M-TRACK had an 80% lower risk of LFU (aRR 0.2; 95% CI: 0.1-0.5) compared with standard care, after adjusting for socio-demographics, time and clustering at district level. During interviews, M-TRACK was welcomed by both PLHIV and the counsellors. The latter felt it saved time by obviating the need for home visits and helped in documentation. Inconvenience of using landline phone available at the health facility, lack of budgets for reimbursement of mobile call expenses and internet connectivity problems were the key implementation challenges. CONCLUSION: M-TRACK was highly effective in reducing the gap between diagnosis and treatment. It may be considered for scale-up after addressing the challenges noted.

Process evaluation of child health services at outreach sites during health and nutrition day (Mamta Day) in urban slums of Western India.

INTRODUCTION: Health indicators of rural and urban India show a wide variation. Rural areas have received large focus in child health services, but on the flip side, urban areas have been the last to receive such attention. MATERIALS AND METHODS: A cross-sectional study was conducted to include one randomly selected outreach session from all the 19 urban primary health centers of Vadodara city from April 2013 to May 2014. Nineteen session sites were observed for the process evaluation of three components of child health care, namely, "planning of Health and Nutrition Day," "availability of vaccines/logistics," and "direct observation of actual immunization process" at the site using a structured checklist. RESULTS: Most of the vaccines and logistics were present at all 19 sites visited, but adverse events following immunization kit were observed at ten sites (52%) only. Open vial policy, no-touch technique, and immediate cutting of syringe with hub cutter were implemented at all sites; however, completely filled Mamta Card was observed at 9 (47%) sites only. All four key messages were given at 5 (26%) sites only. CONCLUSION: Immunization services such as proper vaccine administration with no-touch technique and open vial policy were mainly focused; however, other services such as biomedical waste management, record keeping, and delivery of all four key messages need to be strengthened during Mamta Divas. Strengthening of other child health care services such as growth monitoring, Integrated Management of Neonatal and Childhood Illnesses, and referral services is required in urban areas.

Is "modular" the way to go for small group learning in community medicine in undergraduate clinical postings?

CONTEXT: There is a need to shift from the didactic lecture-based instruction to more student-centered active learning methods for undergraduate teaching in community medicine. AIMS: To compare didactic and modular method of learning on Level 1 and 2 on Kirkpatrick's training evaluation model. SETTINGS AND DESIGN: This was a two-arm educational intervention study for a small group of the 2(nd) year MBBS students in their 4(th) semester during clinical posting in the subject of community medicine. SUBJECTS AND METHODS: The topic chosen was "rabies prophylaxis" in the 2(nd) clinical posting during 4(th) semester. With permission from Institutional Ethics Committee, first batch of 17 students was taught this topic by didactic method. Next batch of 22 students was taught by the modular method. A self-reading module was prepared for this study and validated by three teachers. What was different in modular teaching was a circular sitting arrangement, module reading by students, video presentation, and exercise using case vignettes. STATISTICAL ANALYSIS USED: Student's t-test was used for pre- and post-test score comparison and Mann-Whitney U-test for students' responses on Likert scale. RESULTS: The mean gain in obtained marks after modular learning (7.9/15) was significantly higher as compared to gain after didactic teaching (5.9/15) (P = 0.0038); more students asserted to be confident to manage a case in modular group compared to the didactic group (P < 0.05) indicating a higher level of learning through modular teaching. CONCLUSIONS: Modular teaching fares better than didactic method and hence should be used more frequently in community medicine clinical posting.