Factor structure of the Jefferson Scale for Empathy among medical undergraduates from South India.

Background: Empathy is a multidimensional construct and is considered an essential attribute among healthcare professionals. The Jefferson Scale for Empathy (JSE) is a commonly used tool to measure physician empathy and has been used in medical students as well; however, the psychometric properties have not been well studied in India. We aimed to study the factor structure of JSE among medical undergraduates. Methods: This was a secondary analysis of baseline data obtained from the Stigma, Empathy and Attitude module study among medical undergraduates (N = 157). The scores obtained on the 20-item JSE Medical Student Version were subjected to principal component analysis with varimax rotation. Eigenvalues greater than unity, scree plot, and Horn's parallel analysis were used for identifying the factors. Items with loading more than 0.4 were included based on Steven's recommendation. Results: The sample was adequate for factor analysis (Kaiser-Meyer-Olkin (KMO) measure 0.832). Five factors were extracted using principal component analysis, which explained 60% of the variance. The first three appeared as stable factors, and the last two factors had two items each. The first factor was the strongest (explained 18.8% of variance) with loadings from nine items. The second factor (explained 15.6% of variance) had loadings from six items, and two of the items showed correlation with the first factor. Conclusions: JSE has a multidimensional structure with five factors in our sample of medical undergraduates.

A prospective study to assess the role of paraoxonase 1 genotype and phenotype on the lipid-lowering and antioxidant activity of statins.

Human paraoxonase 1 (PON1) enzyme protects against atherosclerosis by preventing low-density lipoprotein from oxidative modification. Upregulation of PON1 enzymatic activity is suggested to contribute to atheroprotective potential of statins. Glutamine (Q) to arginine (R) at site 192 and leucine (L) to methionine (M) substitution at site 55 polymorphisms influence the PON1 activity. The study assessed the role of PON1 polymorphisms on lipid-lowering and PON1-modulating activity of statins in a Western Indian cohort of patients with dyslipidemia. Lipid profile and PON1 activity were determined at baseline and 3 months after initiation of statin treatment. PON1 genotypes (QQ, QR, RR; LL, LM, and MM) were determined by PCR-RFLP. Paraoxon was used as a substrate for assessing PON1 activity by spectrophotometry. A total of 140 statin-naïve patients were enrolled; of them, 116 were available for final analysis. Fifty-seven (50%) had QQ, 39 (35%) had QR, and 17 (15%) had RR genotypes. Seventy-six (67%) patients had LL, 35 (31%) had LM, and 2 (2%) had MM genotypes. We observed no impact of PON1 polymorphisms on lipid parameters posttreatment. A significant increase was observed in the serum PON1 activity from a median (range) of 47.92 U/L (9.03-181.25) to 72.22 U/L (7.64-244.44) (P < 0.05) following statin treatment, which was independent from high-density lipoprotein (HDL) concentration. This increase was significantly greater in QQ compared to QR and RR genotypes (P = 0.01). To conclude, the important antioxidant properties of statins are exerted via the rise in serum PON1 activity, independent of HDL cholesterol concentrations. The increase was greater in individuals with QQ genotype. Future large-scale studies will validate the premise that QQ homozygotes see added benefits from statin treatment compared to R carriers. In the meantime, PON1 enzymatic activity remains an important marker to be measured while assessing pleotropic effects of statins in CAD.

A Questionnaire-based Study on Perceptions, Attitudes, and need Assessment regarding Geriatric Healthcare among Geriatric Outpatients at a Tertiary Care Hospital in India.

BACKGROUND: The lack of specialized geriatric healthcare in India, coupled with an aging population, has resulted in longer wait times, communication barriers, and a potential increase in unmet needs in a demographic that is already financially and socially vulnerable. This raises the need for exploring the perspectives and needs of the geriatric patient population to improve the quality and accessibility of the healthcare they receive. OBJECTIVES: This study was conducted to assess the perceptions and perceived needs of geriatric patients regarding current healthcare and their attitudes toward specialized geriatric healthcare. MATERIALS AND METHODS: Following the Institutional Ethics Committee (IEC), a cross-sectional study was carried out among 262 geriatric patients (age >60) from seven outpatient departments (OPD). A structured 10-item questionnaire was administered to assess the perceptions and perceived needs of the study population. RESULTS: A total of 165 (63%) patients were not satisfied with the healthcare being provided to them. Around 96.1% of patients felt the need for a separate geriatric OPD/department. A total of 98% of patients had optimistic attitudes toward the possibility of specialized geriatric healthcare. A total of >80% of the patients were willing to spend more time for checkups and follow-ups regularly if that would improve their quality of life. CONCLUSION: This study showed a low satisfaction rate of geriatric patients with the current healthcare and a high felt need for specialized geriatric facilities. There was an overall positive attitude of patients toward the implementation of various facilities of specialized geriatric healthcare.

Physicians' Knowledge, Attitudes, Practices and Perceived Needs Regarding Specialised Geriatric Healthcare: A Nation-wide Survey in India.

Background& : The geriatric population in India is projected to increase from 8% to a staggering 20% by 2050. The combination of a population boom along with advances in medicine resulting has resulted in an increase in life span, leaving India with a potential geriatric healthcare crisis in its hands leaves India with a potential geriatric healthcare crisis in its hands. India currently produces as few as 20 geriatricians per year due to limited PG seats and has only a handful of fully functioning Geriatric Departments in the public healthcare sector. Thus, there is a need to fully assess the knowledge, attitudes and current practices in geriatric healthcare among medical professionals and interns across the country. OBJECTIVE: To investigate the knowledge, attitudes and practices and perceived needs of physicians towards specialised geriatric healthcare and to assess the views towards geriatric medicine as a career option among medical interns in India. DESIGN: Cross-sectional, web-based survey by forwarding the link via social media platforms. SETTING: MBBS graduates undergoing their rotatory internship and residents/postgraduate doctors in specialties relevant to the care of older persons throughout India. PARTICIPANTS: A total of 800 Indian medical interns and professionals. MEASUREMENTS: Demographic characteristics of medical professionals and interns included age, gender, branch of practice, working sector, availability of any geriatric facility in their workplace, etc. Responses were weighted to maintain nationwide representativeness. Knowledge, attitudes, current practices and perceived needs regarding specialised geriatric healthcare were the primary outcome measurements. RESULTS: Insufficient knowledge (48.5% of professionals) regarding any specialised branch of geriatric healthcare was found. Only 9.0% medical professionals performed 'Comprehensive Geriatric Assessment' and even the mean score of practice of CGA was low. 96% professionals and 92% interns felt the need for specialised geriatric services throughout India with majority feeling the need for specialised OPDs. 32.7% of Interns were willing to opt for post-graduation in Geriatrics, if given a choice and those with any specialised geriatric facility available at their institute were more willing. More than 85% professionals and interns had affirmative attitudes towards the possible benefits of specialised healthcare. CONCLUSION AND IMPLICATIONS: There is poor practice of specialised geriatric healthcare throughout India and also a high prevalence of perceived needs among professionals and interns regarding facilities like OPDs, wards and departments. Highly affirmative attitudes were observed among both interns and professionals indicating the acceptance of suggested strategies. Majority of interns were convinced of opting for post-graduation in geriatrics when incentivized, indicating the need for prioritizing interns for capacity building in the future.

Comprehensive Geriatric Assessment (CGA) Screening of Geriatric Patients in a Tertiary Care Hospital: a Cross-sectional Study in India.

BACKGROUND: Within the next few decades, India will witness a staggering increase in its elderly population owing to advancements in health care. However, an increase in life span is not mutually inclusive with high quality of living. Old age is associated with multiple ailments which decreases functionality and increases dependency, several of which go undiagnosed while catering to primary complaints. This prompts the need for a comprehensive approach to the healthcare of the elderly for which Comprehensive Geriatric Assessment (CGA is widely practiced in the west. OBJECTIVES: This study was conducted to estimate the prevalence of undiagnosed medical problems by Comprehensive Geriatric Assessment (CGA) Screening and explore its applicability in Indian tertiary healthcare setup. METHODOLOGY: Following ethical approval of the institute, a cross-sectional study was conducted among 262 geriatric patients with age over 60 years, from seven out-patients departments. A Comprehensive Geriatric Assessment (CGA) inventory was prepared by compiling screening instruments for Visual acuity, Hearing acuity, Dependency, Functionality, Depression, Cognitive impairment, Fall risk, Urinary incontinence, Nutritional Status and Insomnia. The participants were administered the screening inventory once they had already undergone a normal check-up in the OPDs. RESULTS: Overall, 262 geriatric patients underwent CGA screening (Female: 57.3%, Male: 42.7%). There was a high prevalence of problems going undiagnosed ranging from 58.65% to 95.45% in various OPDs. Some problems had a significantly greater overall prevalence and were also prevalent in going undiagnosed in particular OPDs (urinary incontinence in Gynaecological OPD, p=0.003; insomnia in surgical OPD, p<0.005). Many patients who screened positive for certain problems were found to have a few other problems as well (dependency and cognitive impairment, p=0.003; insomnia and depression, p=0.0001). CONCLUSION: This study showed a high prevalence of problems going undiagnosed along with their associations with particular OPDs and other problems. Participants of this study showed a considerable acceptability for CGA. This reaffirmed the need for CGA in every geriatric patient in our tertiary care setup.

Stigma, Empathy, and Attitude (SEA) educational module for medical students to improve the knowledge and attitude towards persons with mental illness.

OBJECTIVE: The objective was to develop an educational module on stigma, empathy, and attitude towards mental illness and evaluate its effectiveness among undergraduate medical students. METHODS: In phase I, the authors developed the Stigma, Empathy, and Attitude (SEA) module consisting of interactive teaching-learning components through an experts-based consensus (two rounds of Delphi). In phase II, the effectiveness of the module was evaluated. SEA module (one-hour interactive lecture and three hours' small group teaching) was delivered to the fifth-semester undergraduate medical students (N = 240) once during their psychiatry rotation. Students were assessed with the Mental Health Knowledge Schedule (MHKS), Mental Illness: Clinician's Attitudes (MICA) scale, Jefferson Scale for Empathy (JSE), and Social Distance scale (SDS), to measure mental health knowledge, attitude, empathy, and stigma, at baseline and after delivery of the module. Feedback on the module was obtained from the participating students and faculty. RESULTS: Baseline data was obtained for 157 students, and post-intervention assessment was completed for 66 students. There was a significant increase in MHKS score (p < 0.001, Cohen's d = 0.59) and a significant reduction in the MICA score (p = 0.016, Cohen's d = 0.31) after the intervention. However, there was no change in empathy and social distance, as measured by JSE (p = 0.23) and SDS (p = 0.31). A majority of the faculty and students were satisfied with the module and felt it should be part of the psychiatry curriculum. CONCLUSIONS: The SEA module was found to improve medical students' knowledge and attitude towards mental illness and could be integrated as part of the psychiatry curriculum. However, it was ineffective in changing empathy and stigma in the students.

Clinical Utility of 24-h Ambulatory Blood Pressure Monitoring in Hospitalized Patients with Chronic Kidney Disease.

INTRODUCTION: Hypertension leads to rapid progression of kidney disease. Hypertension (HTN) is the second most common cause for CKD after diabetes. Ambulatory blood pressure monitoring (ABPM) helps in accurate and early diagnosis of HTN along with measurements of other variables, namely nondippers, reverse dippers, hyperbaric index (HBI), percentage time elevation (PTE), and early morning surge. METHODOLOGY: After obtaining the institution ethics committee approval total 192 cases, of 12-80 years age group, who were diagnosed with CKD were included in the study. ABPM was done for patients using Meditech ABPM-05 machine. RESULTS: Study showed male predominance. Maximum patients were in the age group of 41-60 years. Prevalence of Hypertension in patients with CKD was 88.02%. The systolic BP, diastolic BP, and mean arterial pressure (MAP) were significantly higher by clinic BP measurement than ABPM in all stages of patients with CKD especially in stage IV than stage V CKD. Systolic, diastolic, MAP, HBI and PTE at nighttime were significantly higher than daytime in all patients with CKD, especially in patients with resistant hypertension. Prevalence of whitecoat HTN (4.1%), whitecoat effect (16.1%), resistant hypertension (39.6%), masked HTN (1%), and masked uncontrolled HTN (10.4%) was noted. Systolic and diastolic HBI was lower in patients on hemodialysis as compared to those not on hemodialysis. Non-dippers were more than dippers. CONCLUSION: Apart from mean systolic and diastolic BP, ABPM gives the extent of end-organ damage and insights into the need for control of 24 h BP in patients of CKD.

Effect of Yoga Intervention in the Management of Hypertension: A Preventive Trial.

BACKGROUND: Noncommunicable diseases are on the rise in India. Hypertension is one of the major risk factors for cardiovascular diseases and also labeled as a chronic lifestyle disorder. Hence, non-pharmacological interventions leading to lifestyle modifications are of utmost importance to control and prevent hypertension. This trial aims to implement yoga intervention to the experimental group in addition to medicines, advice on diet and physical activity and to compare blood pressure and perceived stress scores with the control group. METHODS: It was an open-label, two-armed, non-randomized controlled trial, conducted at a tertiary care center on 145 patients with hypertension: 73 in the intervention group and 72 in the control group. The intervention group received yoga intervention for a period of 4 months on a weekly basis along with advice on physical activity, diet, and routine medicines. The control group did not receive yoga intervention. RESULTS: The mean age of the participants was 51.3 ± 9.4, females (58.2%) outnumbered males (41.3%). Following the intervention, perceived stress score and blood pressure showed a significant reduction between two groups (P < 0.001). Also, perceived stress and blood pressure were found to be reduced significantly within both groups (P < 0.001). CONCLUSIONS: Yoga proves to be an effective, safe, and less expensive adjunct therapy for hypertension management. Yoga was also found to be effective in reducing the level of stress. Diet modification and physical activity have got an important role to play in the control and prevention of hypertension.

Clinical Study of Use of Remdesivir and Tocilizumab in Severely Ill COVID-19 Patients.

Introduction: Remdesivir and Tocilizumab are two experimental drugs used in severely ill COVID-19 patients. Various clinical trials studying these drugs are giving conflicting results. Our aim is to study these two drugs and share the experience in our setting. Methods: Our Study is a retrospective analysis of Clinico-laboratory details and outcome of three groups of patients who were given either (i) Remdesivir or (ii) Tocilizumab or (iii)both Remdesivir and Tocilizumab . We compared the outcome of these patients with other patients who did not receive either of these drugs, when it was not available or not introduced as experimental drugs earlier in treatment guidelines. Results: Out of a total of 521 patients, in the above three groups who received either or both Remdesivir or Tocilizumab, 334 survived. Out of 214 patients who did not receive any of the two drugs only 74 survived. The outcome was better individually for all the three groups of patients receiving either or both of the drugs as compared to neither of the drugs.(p <0.01) Conclusion: Remdesivir and Tocilizumab were useful drugs in treatment of severely ill covid -19 patients as compared with the patients who did not receive any of the above drugs.

Risk Factors and Comorbidities in Young Indian Patients with Hypertension: REAL YOUNG (Hypertension) Study.

PURPOSE: To analyze the risk factors and comorbidities among the young Indian adults with hypertension. PATIENTS AND METHODS: This was a retrospective, multicentric real-world study which included patients diagnosed with and receiving treatment for hypertension. Data were collected from the medical records of clinics/hospitals across 623 study sites in India. Patients of either sex and aged 18-45 years were included. Demographic details (age, sex, anthropometric measurement), medical and family history, sedentary lifestyle, smoking status and alcohol consumption data were extracted. Descriptive and comparative analysis (Mann-Whitney U and chi-squared test) was done. RESULTS: Out of 15,006 young patients diagnosed with hypertension (men=63.6%), 65.7% belonged to the age group of >35-45 years. The median body mass index was 27.0 kg/m2. Patients diagnosed with only hypertension were 29.1% while other predominant comorbidities with hypertension were diabetes mellitus (42.4%) and dyslipidemia (7.8%). Hypertension with diabetes mellitus were prevalent in the age group of >35-45 years (43.8%). More than half of the patients with hypertension (n=7656) had a sedentary lifestyle. Overall, 35.6%, 47.3%, and 56.7% of the patients were alcoholic, smokers (present and former), and had a family history of hypertension, respectively. CONCLUSION: The results showed that among the young population, hypertension was common in the age group of >35-45 years and diabetes mellitus and dyslipidemia were common comorbidities. Family history, sedentary lifestyle, smoking, alcohol consumption, and body mass index may also contribute to hypertension.

Preliminary Observations and Experiences of Physiotherapy Practice in Acute Care Setup of COVID 19: A Retrospective Observational Study.

BACKGROUND: The rapid outbreak of coronavirus disease 2019 (COVID-19), a public health emergency of grave concern, warranted hospital admissions with almost 90,000 cases in June 2020 in city of Mumbai. 3-10% of the patients with moderate to severe involvement required intensive care unit (ICU) admission with respiratory support. Patients admitted in ICU with an acute COVID event present with respiratory dysfunction and are more likely to have critical illness myopathy and neuropathy (CIMN). Physiotherapy services being integral part of non-pharmacological management of any ICU was implemented for patients with COVID 19; a novel viral disease. OBJECTIVE: This retrospective study was undertaken to explore the physiotherapy practices that could be implemented in patients admitted with COVID 19 in the ICU and its effect on mobility and oxygen requirement as an outcome. METHODOLOGY: Following ethical permission of institute, the data was extracted from electronic data record sheet in which daily parameters for physiotherapy intervention were recorded. Data from a single ICU and step down unit (SDU) from 5th June to 5th July 2020 was analysed. Records of patients diagnosed with COVID 19 and admitted in ICU or SDU were studied. Those in the age group of 18 to 90 years, of either gender were included. Demographic characteristics, disease severity, oxygen requirement, mobility status, physiotherapy intervention were studied. RESULTS: 278 record sheets (110 ICU and 168 SDU) were retrospectively analysed for demographics. 44.55% of patients improved with side lying position, 37.27% with prone position and 10.91% with quarter prone position. 4.55% of patient maintained oxygenation in propped up sitting. 2.73% could not be positioned. Chest physiotherapy techniques applied were deep breathing, ACBT, paced breathing and diaphragmatic breathing. Deep intercostal pressure on NIV along with vibrations was given to 12.72% of patients in the ICU. Group therapy sessions were conducted in SDU where 50.59% patients participated. ICU mobility score showed significant improvement on Wilcoxon Signed Ranks test status on day 7 in the ICU (z=-5.99, p=0.00) and SDU (z= 7.676, p=0.00) compared to day 1. Descriptive analysis showed a definitive reduction in oxygen support requirement. CONCLUSION: Most common form of physiotherapy interventions in patients with Covid 19 were therapeutic positioning, early mobilization and breathing exercises. Physiotherapy intervention appears promising in facilitating early patient ambulation and discharge. This study shows that it is safe and feasible to provide early physiotherapy treatment techniques in patients with COVID-19 using appropriate measures of infection prevention and cross contamination.

Clinical Utility of Ambulatory Blood Pressure Monitoring (ABPM) in Newly Diagnosed Hypertensive Patients.

BACKGROUND: Ambulatory Blood Pressure Monitoring (ABPM) has an upper hand in diagnosing hypertension accurately. Parameters obtained by ABPM helps us in diagnosing white coat hypertension, BP variability, dipping status and blood pressure load on organs (Hyperbaric Index) reflecting possible end organ damage. OBJECTIVES: To evaluate clinical utility of ABPM in stage 1 newly diagnosed hypertensive subjects, to compare ABPM readings with clinic blood pressure (Clinic BP), to study dipping pattern and White Coat Hypertension (WCH) in newly labeled hypertensives. METHODOLOGY: After institutional ethics committee approval and written informed consent from participants, an observational cross sectional prospective study was conducted in hypertension clinic of tertiary care hospital over a period of one and half years on 138 newly diagnosed stage I hypertensive patients. ABPM results were analyzed and compared with clinic BP. RESULTS: 86/138 (62.32%) patients were diagnosed to have true HT by ABPM. WCH was detected in 52/138 (37.68%) which is higher than that reported in international studies (21%). The mean pulse, mean systolic/diastolic BP, mean pulse pressure and MAP were significantly higher (p<0.0001) by clinic BP than ABPM. True hypertensive patients were having higher weight (p <0.001), had higher fasting blood sugar values (p=0.008) and BUN levels (p=0.034) than WCH patients. Hyperbaric Index was significantly higher for systolic and diastolic BP in true hypertensive patients as compared to WCH patients. Patients with WCH were predominantly males (71.15%), were younger (41.82 ± 12.77 years) than true hypertensives (46.45 ± 12.20years), (p =0.037). Dipping was detected in 33 (38.37%), non-dipping in 44 (51.16%) and reverse dipping in 9 (10.47%) patients. CONCLUSION: Our study reflects the clinical utility of ambulatory blood pressure monitoring not only for accurate diagnosis of hypertension but also for assessing the various parameters of blood pressure.

A Prospective, Observational Study to Determine the Prevalence and Clinical Profile of Patients of Hypertensive Crisis in a Tertiary Care Hospital.

BACKGROUND: Hypertension can present in crisis form as 'hypertensive urgency'(HU) or as 'hypertensive emergency' (HE). Both the conditions are associated with significant morbidity and mortality. AIM: To evaluate the clinical characteristics, course of illness, end-organ damage and survival outcome in patients with hypertensive crisis. METHODOLOGY: This prospective observational year-long study was conducted after due ethical considerations on 120 adult non-pregnant patients who presented with blood pressure of >180/120 mm Hg in the emergency medical services of a tertiary care hospital. The available data was statistically analyzed using the t-test for continuous variables and chi-square test for categorical variables. RESULTS: Sixty two (51.67%) patients presented with hypertensive urgency and fifty eight (48.33%) with hypertensive emergency. Together they constituted 0.59% of total medical admissions and 18.04% of ICU admissions. Mean age of patients was 48.34 years and 52.48 years in HU and HE groups respectively. Headache (49.2%) and giddiness (43.3%) were the common presenting symptoms. Focal neurological deficit (p=0.001), psychomotor agitation (p=0.024), visual disturbances (p=0.048), oliguria (p=0.036) were noted significantly in patients with HE. Systolic and diastolic blood pressures were significantly elevated (p=0.001) in HE as compared to HU. Circadian peaks were noted between 2pm - 4 pm followed by 2am - 4 am and circannual peaks were noted in hot and humid months of May and October. Occurrence of HE was significantly linked with male gender (p=0.037), alcoholism (p<0.001), dyslipidemia (p<0.001) and diabetes mellitus (p<0.001). Cardiac and cerebrovascular end organ involvement was noted in 67.2% each and majority of subjects (69.9%) had more than one organ involvement. Out of total 120 study subjects, 19 (15.83%) died within first 72 hours of admission with mean age of 52.47 years. Negative survival outcome was associated with hypertensive emergencies (p=0.021), smoking (p=0.05), dyslipidemia(p=0.002), diabetes mellitus(p=0.003), cardiovascular (p=0.002) and cerebrovascular involvement(p=0.015). CONCLUSIONS: This study showcases the characteristic features of hypertensive crises in Indian subjects, thus allowing us a better understanding of the natural history of this medical emergency.

Left ventricular non-compaction with viral myocarditis: a rare presentation of a rarer disease.

We report an unusual case of a 22-year-old male who was incidentally diagnosed with isolated noncompaction of the left ventricle (LV) when he was admitted with viral myocarditis. Left ventricular noncompaction (LVNC) is a congenital cardiomyopathy which presents with ventricular dysfunction, cardioembolic manifestations or with arrhythmias. A diagnosis can be made with the commonly available modality of echocardiography but is still often overlooked. There is no specific treatment directed at isolated noncompaction. Treatment is focused on the cause of presentation, with medication aimed at improving ventricular dysfunction, as well as treating and preventing thrombosis and arrhythmia. This is, we feel, the first case report of isolated LVNC presenting with viral myocarditis.

Recurrent cardiac tamponade in a young woman.

A young woman presented with recurrent pericardial effusion, she had previously been treated with antitubercular medications. She had clinical features of systemic sclerosis (SSc) which was subsequently confirmed on further workup. She was also found to be profoundly hypothyroid. Cardiac tamponade is uncommon in both SSc as well as hypothyroidism, unlike in our patient who was found to have both of these disorders. In her case, the pericardial involvement probably ante-dated the other features of SSc.

HTLV infection and strongyloidal hyperinfection syndrome.

Strongyloides stercoralis can affect humans in the form of asymptomatic infections, Strongyloidal hyperinfection syndrome and disseminated Strongyloidiasis depending on the immune response of the host. We report a case of strongyloidial hyperinfection syndrome that subsequently tested positive for HTLV infection.