Intangibility of the invisible hand - Analysing the micro-dynamics of novice mentoring program based upon one institutional experience

Although mentoring has been regarded as an essential component in the developmental phase of medical students, it is the nature of hierarchical relationship and the quality of emotional exchange which determine its sustainability. With great enthusiasm, we had launched our mentoring program for the new entrants of our medical school. After an initial faculty development workshop on mentoring, we framed our guidelines for implementing the program. To measure the relationship satisfaction on both sides and self-efficacy, we used relationship satisfaction scales. As the winds offered us the beginner's fortune, our program went on well for the first six months. Slowly, the colour of the mentorship program began to fade. Students began to find excuses for not meeting their mentors and the sessions truncated into a "hay- how do you do - bye" meetings. Through this commentary, we would like to introspect the factors which would have dampened the interest. Would it be the asynchronous agency support or lack of motivation / self-efficacy or roadblocks in Communication Bridge or lack of adequate matching or lack of need? The outcomes of our introspection would be of help for others who run the mentorship programs or who wish to install in their own institutes.

Snake envenomation: is the 20 min whole blood clotting test (WBCT20) the optimum test for management?

BACKGROUND

The 20 min whole blood clotting test (WBCT20) is a simple bedside test recommended by World Health Organization (WHO) to assess hemotoxic envenomation and guide administration of polyvalent anti-snake venom (ASV). However, reliability and validity of this test has not been well documented in literature.

METHODS

Sixty consecutive patients with history of snake bite were prospectively evaluated at a teaching hospital in India over 2 years. Envenomation was established by clinical and laboratory criteria. WBCT20 was done at 0, 4 and 12 h using standardized protocol. Prothrombin time (PT) with international normalized ratio (INR) was estimated at similar intervals to detect venom-induced consumption coagulopathy. Sensitivity, specificity and likelihood ratios (LR) were determined for WBCT20 using envenomation criteria as gold standard. WBCT20 was compared with PT/INR at cutoff values of ≥1.4 and ≥1.2. Two observers performed test-retest correlation to determine inter-observer variability of WBCT20.

RESULTS

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Seventeen of 60 patients had evidence of hemotoxic envenomation. Four patients had combined neurotoxicity and hemotoxicity. Sensitivity and specificity of WBCT20 were 94 and 76%; positive and negative LR were 3.9 and 0.08, respectively. No inter-observer variability was noted.

CONCLUSIONS

WBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom.

The patient is king: But does the king accept wise counsel?

Trust is the most important component of the doctor-patient relationship. This relationship has evolved substantially from a sacred paternalistic bond to a very prejudiced, consumeristic link. Changes in legal systems have brought medicine into the purview of consumer litigation and therefore the patient is the king akin to the consumer. In this short paper, the implications of the rights of the patient from a consumer point of view and the issues related to its use/misuse in daily interactions is discussed. How patients could potentially participate in decision making is stressed. At the same time, the fallout of their unnecessary intrusions into the doctor's clinical expertise and advisory capabilities needs to be recognised and tactfully countered to build and maintain trust in the doctor-patient relationship.

Comparing Curricular Reform in Medical Schools and the Ship of Theseus: Insights Regarding Philosophical and Ideological Characteristics

Most of the curricular reforms are either imprecise, lacking appropriate contextualization or keen in "lifting" the solution from one context and fixing it in some other context. The greatest obstacle for curricular reform is something intrinsic [philosophical and ideological] and related to the general disposition of educators to resist the change and love status quo. We would like to put forth that viewing reforms under these lenses is the ultimate requirement and when winds of reform begin to blow in curriculum, definitely it would become unstoppable and one reform would give birth to the necessity for other reform. This commentary intends to discuss the under emphasized intricacies related to curricular reform by comparing it with analogy of "The Ship of Theseus."

Diagnostic utility of bone marrow examination in evaluation of fever: a descriptive study on 98 immunocompetent adults from a tertiary care institute in south India

Five-year clinico-laboratory data from 99 (one HIV seropositive) adults (mean age = 41.3 ± 20.4 years) who underwent bone marrow examination for fever persisting for ≥ 1 week were analysed and correlated with microbiological characteristics. Infections, reactive marrow changes and haematolymphoid malignancies were most commonly associated with fever. A high concordance rate of 71% was noted between aspiration and trephine biopsies. Bone marrow granulomas (BMG) were seen exclusively on sections and were most commonly of tubercular and typhoidal in origin (two Salmonella Typhi, one Salmonella Paratyphi A). The common aetiologies associated with fever and cytopenia(s) were BMG, acute leukaemia and haemophagocytic lymphohistiocytosis (HLH; n = 3). The yield from bone marrow culture was inferior compared to other body fluids. In conclusion, bone marrow histology is superior to smears in the evaluation of prolonged fever. Marrow culture may not be useful in immunocompetent individuals other than if Salmonellosis is suspected.

Introducing a course on Evidence Based Medicine for undergraduate medical students – experience from an Indian medical school

This article was migrated. The article was not marked as recommended. Introduction: Although evidence based medicine (EBM) is part of undergraduate training in several countries, Indian medical schools are yet to make a meaningful start. We report our experience with EBM training for undergraduate. Methods: Third year students undergoing clinical clerkship at a teaching hospital underwent an 8 week course on EBM with modules on concepts, formulating questions, searching for evidence and critical appraisal. Feedback was taken and assessment done on knowledge and searching skills. Results: 90% of students had poor awareness of EBM. 92% considered evidence the most important component of EBM; 5% considered clinical expertise and patient values as part of EBM. At baseline majority cited Google the most reliable search tool. Only 27% felt EBM relevant to their curriculum. 66% rated the course good, very good or excellent. Hands-on training enhanced learning lack of background knowledge of diseases hindered it. Conclusion: Awareness of EBM is low among undergraduates and most find it irrelevant to their curriculum. Our experience suggests that it is feasible to integrate EBM training into undergraduate curriculum. More studies reporting knowledge and skills before and after EBM courses would strengthen the cause for making it part of undergraduate medical curriculum in India.

Hemophagocytic lymphohistiocytosis: An unusual complication in disseminated Mycobacterium tuberculosis

Background:

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of disseminated Mycobacterium tuberculosis (MTB). The clinical course of tuberculosis-associated HLH (TB-HLH) has been reported to be unpredictable.

Materials and Methods:

Here we describe the clinicopathological features, laboratory parameters, management, and outcome data of a patient who satisfied the 2004 diagnostic criteria for HLH secondary to disseminated MTB; we also do a systematic review of the international literature on TB-HLH. The literature review (January 1975–March 2014) found that HLH complicated the clinical course of 63 tuberculosis patients (41 males, 22 females, mean age = 45 ± 23.5 years) with a high mortality rate of 49% (31/63 died). The mean serum ferritin level (n = 44/63) was 5963 ng/mL (range 500–38,539 ng/mL); and a higher proportion (54.2%) of patients had pancytopenia at presentation. On univariate analysis (n = 53/63), age >30 years [hazard ratio (HR): 2.79, 95% confidence interval (CI):1.03–7.56, P = 0.03], presence of comorbidities (HR 4.59, CI: 1.08–19.52, P = 0.04), marked hemophagocytosis in bone marrow (HR: 2.65, CI: 1.16–6.05, P = 0.02), and nonusage/delayed usage of antitubercular therapy (ATT) (HR: 3.44, CI: 1.51–7.87, P = 0.003) were associated with decreased survival, though none of these parameters attained statistical significance (P > 0.05) in multivariate analysis. Usage of corticosteroids and/or immunomodulator drugs (HR 1.00, CI: 0.66–3.22, P = 0.35) did not alter the outcome in these patients.

Conclusion:

HLH should be considered as a differential diagnosis in patients with tuberculosis who present with cytopenias, organomegaly, and coagulopathy. Strong clinical suspicion and early usage of ATT might be useful in reducing the morbidity and mortality. The utility of immunosuppressive/immunomodulator therapy lacks general concensus among treating physicians, and warrants further studies.

Impact of focused training on communication skills of final-year medical students in a medical school in India

BACKGROUND

Although communication skills are important for a good physician-patient relationship, Indian medical curricula give very little emphasis on training medical students in this aspect.

AIMS

To determine the change in communication skills of final-year medical students following focused training.

METHODS

This was an educational interventional study done at Pondicherry Institute of Medical Sciences, a tertiary care teaching hospital in South India, to assess communication skills among final-year MBBS students. Fifty-two students (24 males and 28 females) participated in the study. A pre-test was conducted in the form of an objectively structured clinical examination (OSCE), followed by focused training for four hours. The same OSCE was administered as post-test. A comparison between the pre-test and post-test scores was done using Wilcoxon Signed Ranks Test.

RESULTS

Ninety-six per cent of participants (50 out of 52) showed improvement in their performance after the focused training. The mean marks of the pre-test and post-test were 10.77± 3 and 18.04±2, respectively, out of a maximum mark of 20 (p<0.05). One out of 52 participants did not show any improvement, and one participant scored less in the post-test compared to the pre-test. There was no significant difference in the performance between male and female students.

CONCLUSION

Focused training can enhance the communication skills of medical students. Hence, it may be included in the curriculum of undergraduate medical teaching programmes in India.

Selective myelosuppression following yellow phosphorus ingestion

Toxicity from accidental and intentional ingestion of yellow phosphorus, ubiquitously present in fireworks and rodenticides, has recently become more frequent. Gastrointestinal, renal, neurologic, and cardiovascular manifestations are common, with mortality of 23 per cent to 73 per cent. Reports of haematological abnormalities are rare. We report only the second case of severe neutropenia secondary to selective myelosuppression in a 14-year-old girl following intentional ingestion of yellow phosphorus. Leucocyte counts recovered spontaneously without further complications. Our case indicates that, besides hepatic and renal function monitoring, physicians should meticulously monitor blood counts in such cases for early detection of marrow suppression. Further studies are required to elucidate the complex mechanisms and significance of this unusual toxicity of yellow phosphorus.

Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.

Prevalence and patterns of hearing loss among chronic kidney disease patients undergoing haemodialysis

BACKGROUND

The prevalence, degree, and patterns of hearing loss associated with chronic kidney disease (CKD) reported by various studies differ significantly. The effects of haemodialysis and duration of disease on hearing loss remain unclear.

AIMS

The aim of this study was to determine the prevalence and degree of hearing loss in CKD patients on haemodialysis.

METHODS

This study included 120 CKD patients on haemodialysis. Information regarding age, gender, duration of disease, subjective hearing loss, exposure to ototoxic drugs, comorbidities like diabetes, hypertension, and hypothyroidism, renal functions, electrolytes and number of haemodialysis sessions received were obtained. An equal number of age and sex matched controls were used to determine prevalence of hearing loss in CKD patients after subjecting both groups to pure tone audiometry. We compared CKD patients with and without hearing loss for association of hearing loss with disease duration, number of haemodialysis, and blood parameters.

RESULTS

Hearing loss was present in 41.7 per cent of CKD patients, significantly higher than controls (p=0.001), and was mild in the majority of patients. Impairment was noted across high and low frequencies of audiometric testing. Median duration of disease was the same (18 months) among CKD patients with and without hearing loss (p=0.62). CKD patients with hearing loss received 72 haemodialysis compared to 122 sessions by those without hearing loss (p=0.04).

CONCLUSION

Mild sensorineural hearing loss is common in CKD. Hearing loss has no specific pattern as it prevails at high and low frequencies. Hearing loss may be inversely associated with the number of haemodialysis sessions but not with duration of disease.