Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic.

Background The Covid-19 pandemic has posed a challenge to organizing a safe clinical assessment for postgraduate degree candidates completing the residency programmes in various specialties. Although minimizing the risk of Covid-19 transmission is a priority, fulfilling the objectives of the assessment is equally important. Methods We conducted this study in the Department of Internal Medicine at our institute. Instead of physically examining patients, case scenarios that included history, clinical and investigational data of the cardiovascular system (CVS) were presented to the candidates. Performance was scored by both the conventional and the CVS objective-structured clinical examination (CVS-OSCE) method and compared. Results Clinical assessment examination of 27 candidates for the degree of Doctor of Medicine showed that the median cumulative score gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50% [interquartile range-IQR 39%-64%] v. 79% [IQR 64%-100%], p<0.01). Most of the candidates agreed that case scenarios were good alternatives to the conventional physical examination amidst the pandemic. Conclusion CVS-OSCE-based assessment using structured case scenarios is a feasible and effective alternative for clinical skill assessment in high-stake examinations.

One-Hour Postload Plasma Glucose in Obese Indian Adults with Nonalcoholic Fatty Liver Disease: An Observational Study from North India.

Background: Metabolic perturbations and hyperglycemia are increasingly identified as causal factors for nonalcoholic fatty liver disease (NAFLD). Insulin resistance, an indirect marker for initiation of NAFLD can be promptly diagnosed with standard oral glucose tolerance test (OGTT). One-hour postOGTT plasma glucose measurement can have a significant impact on early identification of dysglycemia with NAFLD and may be superior to fasting and 2-hour plasma glucose. Objective: To assess 1-hour post OGTT plasma glucose levels and presence of NAFLD in obese adults. Materials and Methods: In this observational study, we included 101 consecutive obese (body mass index >25 kg/m2) participants of age 20-50 years without known illness of diabetes mellitus. Their anthropometric and laboratory characteristics were recorded and a standard OGTT was performed. Plasma glucose (PG) levels were measured during fasting, 1-hour (1-hour-PPG), and 2-hour (2-hour-PPG) intervals. All participants underwent ultrasound of the abdomen by a single, experienced observer for fatty liver (FL) grade assessment. Comparison of the PG and FL was done by the Chi-square test and a P value <0.05 was considered statistically significant with a 95% confidence interval. Data analysis was done using SPSS version 24.0 (IBM® SPSS Statistics Inc., Chicago, Illinois, USA). Results: The result demonstrated that 53 adults had 1-hour-PPG values above the cutoff (≥155 mg/dl), whereas only 20 individuals had raised PG at 2 hours (≥140 mg/dl). All study subjects (100%) had an evidence of FL disease on ultrasound scan. Among these, 33 had grade I and 68 participants had grade II or III FL. About 41.6% of individuals had deranged 1-hour-PPG levels and higher FL grades as compared to 11.9% individuals with raised 2-hour-PPG values and FL of same grades. The relationship between 1-hour-PPG and FL grades was also statistically significant (P value <0.05). Conclusions: 1-hour-PPG levels were more deranged in obese adults without diabetes, and had more consistent and significant relationship with higher FL grades than the 2-hour-PPG levels.

Short-term outcome of local pancreatic complications in a public hospital from North India.

INTRODUCTION: Dearth in the literature pertaining to natural history of acute pancreatitis (AP) necessitates further studies to evaluate the outcome of local pancreatic complications using the revised Atlanta classification. OBJECTIVE: To evaluate the outcomes of local pancreatic complications after first episode of AP, risk factors for their development and predictors of need for intervention. METHODOLOGY: A prospective study was carried out on 50 consecutive cases of AP who developed local pancreatic complications from January 2015 to July 2016. After imaging, they were categorised into acute pancreatic fluid collection (APFC) and acute necrotic collection (ANC). The risk factors for their development and the need for intervention were assessed. RESULTS: Of 50 patients, 20 developed APFC and 30 ANC. Of ANC cases, 27 progressed into walled-off necrosis (WON), of which 4 were managed conservatively and 18 collections were drained percutaneously, 3 underwent endotherapy (transmural drainage and endoscopic necrosectomy) and 2 died following percutaneous drainage (PCD) and surgery. Ten WON collections persisted at the end of 3rd month. Collections resolved in 6 of 20 APFC patients, 14 formed pseudocysts, of which 10 showed resolution with or without intervention and only 4 of them persisted at the end of study. Size of collection ≥6 cm was independent predictor of intervention irrespective of type of collections while in cases of ANC, extensive necrosis (>30%) and multiple collections were more likely to require intervention. CONCLUSION: Incidence of ANC is more common than APFC when local pancreatic fluid collections develop most of which develop WON and require intervention.

Cytological diagnosis of amyloidosis presenting as a supraclavicular swelling.

Amyloidosis is a well-recognized entity, that can present as a systemic disease, or, uncommonly, as a localized mass. We report here, a rare presentation of amyloidosis presenting as a supraclavicular swelling, diagnosed on fine-needle aspiration cytology. Subsequent bone marrow examination led to the diagnosis of multiple myeloma. This case highlights the need to be aware of cytological characteristics of amyloidosis, which can have unusual presentation posing a diagnostic dilemma.

Fine needle aspiration diagnosis of isolated pancreatic tuberculosis. A case report and review of literature.

CONTEXT: Tuberculosis is a common disease in the developing world and its incidence is slowly increasing in developed countries where a resurgence has been seen subsequent to the AIDS epidemic. Tuberculosis, in its extrapulmonary form, though emerging as a clinical problem, rarely affects the pancreas. The pancreas is biologically protected from being infected by Mycobacterium tuberculosis. Pancreatic tuberculosis presents with a wide spectrum of symptoms such as abdominal pain, constitutional symptoms, obstructive jaundice, iron deficiency anemia, pancreatic abscess, massive gastro-intestinal bleeding, acute/chronic pancreatitis, secondary diabetes, splenic vein thrombosis and a pancreatic mass mimicking malignancy. It should be suspected clinically in patients having a pancreatic mass, particularly if the patient is young, not jaundiced, coming from an area of high tuberculosis endemicity and having a normal endoscopic retrograde cholangio-pancreatography. Its indolent course and vague symptomatology along with non-specific laboratory and radiological findings call for greater vigilance. CASE REPORT: We report a case of pancreatic tuberculosis which presented with pancreatic pain. Imaging techniques revealed a mass located in the head of the pancreatic gland. Fine needle aspiration cytology revealed caseating granulomas. The diagnosis of pancreatic tuberculosis was made and the patient was put on anti-tubercular therapy. Five months later, a repeat CT scan of the abdomen revealed resolution of the pancreatic lesion. CONCLUSION: The diagnosis of pancreatic tuberculosis is usually not suspected prior to laparotomy. Most patients have been diagnosed at laparotomy, thus fine needle aspiration cytology/biopsy is useful in obviating the need for major surgery with its accompanying morbidity. Exploratory laparotomy may be required in technically difficult cases due to risk of injury to the vessels in the vicinity of the mass.