A pilot study of the implementation and evaluation of a leadership program for medical undergraduate students: Lessons learned.

BACKGROUND: Most Indian medical schools lack formal leadership training though students are expected to evolve into leaders. The Student Leadership Program (SLP) was designed and evaluated with an objective to incorporate and strengthen leadership skills in undergraduates and to initiate change in organizational practice through the development of a Student Leadership Society. METHODS: The SLP was designed using best evidence guidelines in medical education. Competencies and learning outcomes were identified in four domains: reflective writing, self-management, team management, and experiential learning. A stepwise program was implemented over 6 months in which participants wrote reflections at the end of each program session. So as to gain objective evidence of behavioral change in participants in relation to the leadership training, their reflections were qualitatively analyzed and corresponding codes and themes were derived. RESULTS: We describe the content and stepwise process of implementation of our pilot leadership program, which included 24 final-year students. Results of qualitative analysis are presented in relation to the domains of self-management, team management, and evaluation of experimental learning. Among the findings were: students viewed assertive skills training as the most powerful learning experience within self-management, and in team management, the session on "Myers-Briggs Type Indicator for understanding one's own leadership style" was seen as the most powerful learning tool, while the session on conflict management was the most difficult in this domain. A Student Leadership Society was instituted. DISCUSSION: In this study, students' reflections helped us better understand factors (the "how" and "why") that make leadership training more effective. The SLP, with a strong evidence base, achieved the intended learning outcomes. A Student Leadership Society was constituted as a networking platform to explore the long-term effects of leadership training on organizational practice. The content and process of our pilot leadership program and lessons learned through understanding of students' perspectives should be applicable to subsequent iterations of student leadership development programs here and in other settings.

SIGNIFICANCE OF ISCHEMIA-MODIFIED ALBUMIN AS A SIMPLE MEASURE OF OXIDATIVE STRESS AND ITS DISCRIMINATORY ABILITY IN DIABETIC RETINOPATHY: Literature Review and Meta-Analysis.

PURPOSE: Oxidative stress (OXS) plays critical role in the development of diabetic retinopathy (DRP). Increased concentrations of serum ischemia-modified albumin (IMA) have been demonstrated as a novel and inexpensive measure of oxidative stress. Although few pilot studies have reported increased IMA in DRP, the available literature is limited to comprehensively describe the potential significance of IMA in predicting DRP. METHODS: The authors performed a meta-analysis to investigate IMA in DRP compared with control and diabetes mellitus subjects. The authors also performed a meta-analysis of area under curve for IMA. PubMed (Medline), Embase, Scopus, Web of Science, Science Direct, Springer Link, and Google Scholar databases were searched for relevant studies in serum IMA in DRP. The authors obtained five observational studies. Meta-analysis was performed using Review Manager 5.3 and MEDCALC 15.8 software to present the pooled-overall effect size as standardized mean difference and overall area under curve value of IMA. RESULTS: Random-effects meta-analysis indicated a significant increase in serum IMA in patients with DRP compared with control (standardized mean difference = 2.48, P < 0.0001) and diabetes mellitus groups (standardized mean difference = 1.43, P < 0.0001). Our results also show that IMA can significantly predict the development of DRP (area under curve = 0.86, P < 0.001). CONCLUSION: Serum IMA may be useful as a simple marker in monitoring of oxidative stress status in DRP and showed significant discriminatory ability in DRP. Future comparative studies in large are needed to further investigate IMA in different types of DRP; proliferative and nonproliferative.

Expression of P-glycoprotein in human retinoblastoma and its clinical significance.

Retinoblastoma is the most common malignant intraocular tumor of childhood. Drug resistance and relapses are major problems with chemotherapy, which is regarded as the mainstay of globe preserving treatment in retinoblastoma. P-glycoprotein (P-gp) expression has been reported to be associated with chemoresistance and poor prognosis in various malignancies. We analyzed P-gp expression in retinoblastoma specimens, enucleated either primarily or after neoadjuvant chemotherapy by immunohistochemistry and immunoblotting, and correlated with the histopathological findings. Variables were statistically analyzed by Fischer's exact and chi-square tests. Tumor tissues were collected from enucleated eyes of 24 children. Fifteen of these were primarily enucleated (group I), and nine (group II) had received chemotherapy prior to enucleation. P-gp was expressed in 4/15 (26.7 %) eyes in group I and in 5/9 (55.6 %) eyes in group II. P-gp was highly expressed in group II as compared to group I. There was no correlation between P-gp expression and tumor differentiation, invasion, or laterality. In conclusion, there was markedly high expression of P-gp in eyes with retinoblastoma enucleated after chemotherapy. This may possibly play a role in chemoresistance or it may be that chemotherapy might have induced high expression. These findings may have important implications for the treatment of retinoblastoma patients but need further prospective investigations in a larger patient population.

Serum Vitamin D Levels and Dry Eye Disease in Postmenopausal Women: A Case-Control Study at a Tertiary Care Center in Rural Haryana.

Background: Despite the high prevalence of Vitamin-D insufficiency and high susceptibility to dry eye disease (DED) in postmenopausal women (PMW), correlation between DED and Vitamin D has not been explored in PMW in any Indian study. Aims and Objectives: To explore the correlation between serum Vitamin D levels in PMW with and without DED, in a hospital-based population in rural Haryana. Materials and Methods: Subjective (ocular surface disease index [OSDI] questionnaire) and objective clinical tests were undertaken for DED diagnosis. 25(OH) Vitamin D was measured in serum using enzyme-linked immunosorbent assay; insufficient (10-30 ng/ml) and deficient (<10 ng/ml). Descriptive statistics were analyzed by mean ± standard deviation for continuous and frequencies for the categorical variables; Student's t-test used to find out mean difference in Vitamin D levels; P < 0.05 was considered statistically significant. Results: One hundred and forty PMW (60.1 ± 5.32 years) were included; Group-A (Controls; no DED; n: 70); Group-B (Cases; DED diagnosed by OSDI scores; n: 70); Subgroup-B1 (clinical tests negative; n: 30) and B2 (clinical tests positive; n: 40). There was no statistically significant difference in OSDI scores between B1 and B2. Significantly lower mean Vitamin D levels were found in cases (14.36 ± 4.08 ng/ml) as compared to controls (19.19 ± 6.4 ng/ml) (P = 0.001) and in B2 (13.15 ± 3.51 ng/ml) as compared to B1 (15.57 ± 4.66 ng/ml) (P = 0.01). Conclusion: There were significantly low levels of Vitamin-D in clinically established DED. Evaluating Vitamin D levels as a part of the dry eye workup in PMW is recommended. OSDI scores were not aligned with the clinical test scores; questionnaire-based tests alone may not be sufficient for diagnosing DED.

Learning Preference of Medical Undergraduate Students: A Multi-Institutional Survey.

This cross-sectional multi-institutional study was conducted to analyze learning preference among medical undergraduate students (n=1659) in four colleges in Haryana. VARK questionnaire (v8.01) was administered through designated study leaders of the respective institutes. The most preferred learning modality was kinesthetic (21.7%), which favors experiential form of learning, most suited for teaching-learning of skills in medical curriculum. More information on the learning preference of medical students is needed to optimize learning outcomes.

Clinical predictors of high risk histopathology in retinoblastoma.

BACKGROUND: Previous studies show that clinical features at presentation, in retinoblastoma patients, like glaucoma and neovascularization of iris are associated with a higher incidence of high risk histopathology findings (HRF) in enucleated eyes. Herein, we analyze association between clinical features at time of enucleation and occurrence of HRF including invasion of anterior chamber, iris, ciliary body, choroid (massive), sclera, extrascleral tissue, optic nerve beyond lamina cribrosa, and optic nerve cut end, in a large series of eyes enucleated for retinoblastoma. PROCEDURE: We retrospectively studied demographic, clinical, and histopathology findings in all retinoblastoma patients who underwent primary enucleation at our center, over a 5 years duration. Statistical analysis was done to find any association between clinical features at presentation and the presence of HRF. RESULTS: Three hundred twenty-six eyes were studied. Median age of presentation was 2 years. Glaucoma was the most common clinical finding at presentation apart from leucocoria. Out of 326 enucleated eyes, 28 (8.6%) had extrascleral and/or optic nerve transection invasion. Among remaining 298 eyes, with completely resected tumor, 115 (38.6%) had massive choroidal invasion, 54 (17%) had retrolaminar optic nerve invasion, and 24 (7%), 29 (9%), and 23(7%) had anterior chamber, iris, and ciliary body invasion, respectively. Age more than 2 years, lag period more than 3 months, hyphema, pseudohypopyon, staphyloma, and orbital cellulitis were associated with occurrence of three or more HRF on univariate analysis. CONCLUSIONS: Clinical variables including older age, longer lag period, hyphema, pseudohypopyon, staphyloma, and orbital cellulitis were strongly associated with occurrence of HRF in this study.

Near-peer-assisted learning for training undergraduate medical students in clinical ophthalmology skills.

OBJECTIVE: This study aims to formally evaluate near-peer-assisted learning (NPAL) for teaching clinical ophthalmology skills to second-year undergraduate medical students through their fellow medical interns. METHODS: Interns posted at the department of ophthalmology were included as tutors after an initial sensitization and assessment. Second-year undergraduate students were included as tutees. Sessions were conducted for pre-identified clinical skills in batches of 3-5 tutees each. Perceptions of tutors and tutees were captured on a 5-point Likert scale (Kirkpatrick level-1) and evaluated. Tutors were assessed by directly observed procedural skills (DOPS) and tutees by pre- and post-session scores and performance of the respective clinical skills (Kirkpatrick level-2). RESULTS: A total of 21 of 24 tutors and 82 of 100 tutees responded to the evaluation questionnaire. Tutors perceived themselves as knowledgeable and useful as instructors; scores of second DOPS session significantly improved compared to the first (p = 0.001) for all clinical skills. Tutees found the NPAL sessions effective for learning clinical skills. Pre- and post-test scores significantly improved (p = 0.001), and all clinical skills were satisfactorily performed in the end-of-term exam. CONCLUSION: NPAL was perceived as an effective teaching-learning method by both tutees and tutors, and all clinical skills were performed successfully. NPAL can serve as a useful adjunct to traditional teaching for clinical training of small groups and can help alleviate teaching pressures on already burdened clinical faculty in Indian Medical colleges.

Overexpression of Separase induces aneuploidy and mammary tumorigenesis.

Separase is an endopeptidase that separates sister chromatids by cleaving cohesin Rad21 during the metaphase-to-anaphase transition. Conditional expression of Separase in tetracycline-inducible diploid FSK3 mouse mammary epithelial cells with both p53 WT and mutant (Ser-233-234) alleles of unknown physiological significance develops aneuploidy within 5 days of Separase induction in vitro. Overexpression of Separase induces premature separation of chromatids, lagging chromosomes, and anaphase bridges. In an in vivo mouse mammary transplant model, induction of Separase expression in the transplanted FSK3 cells for 3-4 weeks results in the formation of aneuploid tumors in the mammary gland. Xenograft studies combined with histological and cytogenetic analysis reveal that Separase-induced tumors are clonal in their genomic complements and have a mesenchymal phenotype suggestive of an epithelial-mesenchymal transition. Induction of Separase resulted in trisomies for chromosomes 8, 15, and 17; monosomy for chromosome 10; and amplification of the distal region of chromosomes 8 and 11. Separase protein is found to be significantly overexpressed in human breast tumors compared with matched normal tissue. These results collectively suggest that Separase is an oncogene, whose overexpression alone in mammary epithelial cells is sufficient to induce aneuploidy and tumorigenesis in a p53 mutant background.

Phthisis bulbi in retinoblastoma.

BACKGROUND: Phthisis bulbi is a relatively uncommon and atypical clinical presentation of retinoblastoma. DESIGN: Retrospective study conducted at a tertiary care hospital. PARTICIPANTS: Eighteen consecutive retinoblastoma patients with primary phthisis bulbi. METHODS: Retrospective analysis of clinical, imaging and histopathological features of all retinoblastoma patients with primary phthisis bulbi, treated at our centre between January 2005 and December 2009. MAIN OUTCOME MEASURE: Clinical and histopathology features. RESULTS: Eighteen (3.5%) retinoblastoma patients developed primary phthisis bulbi. The median age of presentation was 1.5 years. The median duration of symptoms before presentation was 6 months. In total, 15 out of 18 (83%) cases had bilateral disease. Among these, 80% (12/15) had advanced intraocular disease in the fellow eye. Most common first symptom was white reflex. History of orbital inflammation was present in 12/18 cases. Computed tomographic scan of orbit showed intraocular mass with calcific densities in 16 eyes. In two cases, hyperdense mass was seen without any calcification. On histopathology, residual viable tumour cells with characteristics of poorly differentiated retinoblastoma were found in 67% (12/18) eyes. High-risk factors were present in six cases with microscopic residual disease in three cases. CONCLUSIONS: This is the largest case series of retinoblastoma patients with primary phthisis bulbi. Phthisis bulbi in retinoblastoma may be associated with bilateral disease in most cases and advanced intraocular disease in the fellow eye in a significant number of cases. Regression is incomplete in majority of these cases; therefore, enucleation must definitely be done in all cases of retinoblastoma presenting with phthisis bulbi.

Aberrant regeneration of third nerve with characteristic lid signs: operating the normal fellow eye.

A young female with old traumatic third nerve palsy presented with characteristic lid signs of aberrant regeneration of third nerve. There was noticeable disparity in the lid aperture and surgery on the normal fellow eye was undertaken to offer the patient a satisfactory aesthetic appearance.

Framework to Incorporate Leadership Training in Competency-Based Undergraduate Curriculum for the Indian Medical Graduate.

The new competency-based curriculum recognized the importance of leadership skills in physicians and has outlined competencies that would lead to attaining this goal. To prepare the Indian medical graduates as effective healthcare leader, there is no universal approach; it is desirable that the institutes organize the leadership competencies into an institutional framework and integrate these vertically and horizontally in their curriculum in a longitudinal manner. We describe the rationale for incorporating formal leadership training in the new competency-based undergraduate curriculum and propose a longitudinal curricular template utilizing a mixed/multi-modality approach to teach and apply leadership competencies.

Abnormal ocular electrophysiology in Sjögren-Larsson syndrome.

Two siblings who were born out of consanguineous marriage in an Indian family and had typical clinical manifestations of Sjögren-Larsson syndrome were found to have normal electroretinogram and abnormal visual evoked potential results. Abnormal visual evoked potential results along with the presence of distinctive foveal and parafoveal deposits, which could have a prognostic bearing on the visual acuity of the patients, emphasize the importance of a complete ophthalmological and electrophysiological evaluation in all patients with Sjögren-Larsson syndrome.

Clinical procedural skills assessment during internship in ophthalmology.

INTRODUCTION: Directly observed procedural skills (DOPS) is a unique method for assessment since it tests the trainee's ability to apply his knowledge and skills in performing a particular procedure and provides an assessment of the practical work performed by the trainee on a 'real' patient under supervision of an experienced faculty. The study aims to make use of DOPS rating for assessment and further improvement in procedural skills in interns in Ophthalmology rotational posting. METHODS: A prospective study was planned and 15 interns on 2 weeks' rotational posting in the department of Ophthalmology were included by purposive sampling over a duration of 2 months. Four clinical procedural skills were identified and in the second week of posting, the interns were assessed by three DOPS encounters at an interval of 2 days for each clinical skill. The DOPS ratings were analyzed quantitatively using R-statistical software by repeated measure ANOVA and Banfuroni test. RESULTS: A total of 180 DOPS were undertaken for 15 interns in 4 core areas of ophthalmic examination. The mean overall DOPS rating for DOPS-1 was 3.70±0.82, DOPS-2, 3.83±1.82 and DOPS-3, 4.93±1.65; the difference in DOPS rating between the first and second encounter was not statistically significant (p=0.497), between the second and the third and between the first and the third were statistically significant (p=0.000 in both cases) using Banfuroni test. The overall difference was also statistically significant (p=0.000) using repeated measure ANOVA. Both the assessor and intern satisfaction increased significantly from the first to the third DOPS, but not statistically significant between the first and the second and between the second and the third DOPS. CONCLUSIONS: We found significant improvement in interns' clinical skills through repeated DOPS and the method was well accepted by both the students and the faculty. Internship period can be well utilized for improving clinical skills and novel performance assessment methods like DOPS might prove to be highly beneficial in ensuring adequacy of learning during internship and also to assess their readiness for accepting professional responsibilities in future.

Myopic Shift After Intraocular Lens Implantation in Children Less Than Two Years of Age.

PURPOSE: The purpose of this study was to evaluate the myopic shift over a period of 2 years following implantation of intraocular lens (IOL) in children less than 2 years of age with axial length less than 22 mm. METHOD: A retrospective analysis of records of children below 2 years of age with axial length less than 22 mm who had undergone cataract surgery with primary IOL implantation over a period of 7 years was undertaken. Mean myopic shift was analyzed at 6 months, in first year, second year and end of 2 years following surgery. RESULTS: Total 40 eyes of 23 children were included (mean age 13.55±7.38 months); with mean myopic shift at end of 2 years -2.35±2.15. Myopic shift in eyes with undercorrection in range of 3-4 D (group-I) and 5-7 D (group-II) was compared using Mann-Whitney test. Mean myopic shift at end of 2 years was -2.93±2.55 in group-I and -1.88±1.77 in group-II (p value not significant). There was no significant difference in myopic shift between two groups at 6 months and 1 year; a borderline significant difference was found in second year (p= 0.04). CONCLUSION: In our study amount of myopic shift in first two years in children with axial length less than 22 mm is below the expected normal. There was not much significant difference in the myopic shift over a period of 2 years in eyes, which were undercorrected by 3-4 D against those with 5-7 D. Thus aiming for less residual hyperopia by less undercorrection did not increase myopic shift. Thus high-level hyperopic glasses in the early years could be avoided and help in prevention of amblyopia after paediatric cataract surgery.

Anomalous Lateral Rectus Muscle Band in a Case of Duane Retraction Syndrome.

Anomalous orbital structures are suspected in restrictive strabismus with features of severe globe retractions, overshoots, or synergistic movements. We report a case of suspected Duane syndrome that was found to have an anomalous band beneath the lateral rectus muscle. Such abnormal structures are rare, but it is important to identify and manage them to optimize outcomes.

Ischemia modified albumin (IMA) and albumin adjusted-IMA (AAIMA) as biomarkers for diabetic retinopathy.

INTRODUCTION: Oxidative stress has important role in the pathophysiology of diabetic retinopathy (DR). Ischemia modified albumin (IMA) has been recently considered as a marker of oxidative damage in diabetes. However, there is scarcity of published information about both IMA and albumin adjusted-IMA (AAIMA) in DR patients. OBJECTIVES: To evaluate the serum levels of IMA and AAIMA in patients with DR and in healthy controls. MATERIAL AND METHODS: This was a cross sectional study. Serum was obtained to measure lipids, albumin and IMA from the the patients with DR and non-diabetic subjects. The IMA level was measured by a colorimetric albumin cobalt binding (ACB) assay and the values were presented as absorbance units (ABSU). The IMA levels were adjusted for albumin interference and the AAIMA by using a formula [Individual serum albumin/median albumin concentration of the population X IMA]. RESULTS: This study was done on 18 DR and 20 non- diabetic patients. The mean Serum IMA values in DR group and controls were 0.50±0.17 and 0.32±0.17, respectively (P=0.002). The mean serum AAIMA values in DR group and controls were 0.48±0.20 and 0.32±0.17, respectively (P=0.01). The albumin and HDL- Cholesterol levels were significantly lower in DR patients compared to controls (p=0.004 and p=0.01, respectively). CONCLUSIONS: The level of IMA and AAIMA were higher in cases of DR compared to that of non-diabetic subjects. The levels of albumin and HDL-Cholesterol were lower in DR patients compared to controls.

Correlation between Central Corneal Thickness and Refractive Error: A Pilot Study in Rural Population of Haryana

Central corneal thickness (CCT) is an essential tool in the assessment and management of corneal disease. CCT has thus become very important for the interpretation of intraocular pressure and prerefractive procedure assessment; however little is known about its distribution within a population with wide range of refractive errors. Therefore the objective is to study the correlation of CCT with a broad range of refractive errors in rural population of Haryana. Methods: Prospective analysis of patients with refractive error presenting to the Ophthalmology outpatient services were included as cases. Age and sex matched emmetropic subjects were included as controls. Both cases and controls were undertaken for CCT measurements by ultrasonic pachymetry. Results: A total of 187 eyes as cases, 101 as controls. Among cases, 122 eyes myopic (Group- 1) (Mean CCT= 531.80±37.83 μ) and 65 hypermetropic (Group- 2) (Mean CCT=549.66±45.66 μ). The results shows that the central corneal thickness was decreased in the myopic eyes in comparison to the normal eyes which was statistically significantly (p=0.001). However in the hypermetropic group, no correlation was found between central corneal thickness and degree of hypermetropia. Conclusion: This study provides pilot data of CCT in different types of refractive errors in our set of rural population which helps us in understanding the variation of CCT with refractive errors.