Gross Anatomy Teaching for Medical Undergraduates Through Computer-Based Simulation: Introduction and Evaluation of Effectiveness

Background Cadaveric teaching has been the gold standard for gross anatomy instruction through the ages and across the geographic spectrum, but with issues of availability faced in many medical schools, there is a need to look for other options. Digital tools like virtual dissectors that simulate the cadaver have been around for some years now, but their acceptability to the teachers and students and effectiveness need to be validated in the settings where applied. Aim To evaluate the acceptability, feasibility and effectiveness of using computer-based simulation tools for teaching gross anatomy via online mode to undergraduate medical students. Methodology A prospective crossover randomized controlled study was conducted online on 200 (120 males (60%) and 80 females (40%), Year 1 medical undergraduates (mean age males: 19.67 years and females: 19.52 years), wherein two broad topics of head and neck region were taught by didactic lectures delivered online via Zoom. Dissection videos were prepared for both cadaveric and computer-based simulation teaching. Groups were divided by random allocation and pre- and post-tests and feedback surveys were conducted online. Results A significant increase from pre- to post-test scores was found in both cadaveric and computer-based simulation techniques. However, more change was found in the computer technique as its t-value was more than the cadaveric technique. The feedback from the students was that the computer-based simulation teaching method gave them a good insight into 3D understanding of the human body, increased understanding of relations of body structures and capacity to grasp surface anatomy. Conclusion The study concluded that teaching gross anatomy through computer-based simulation techniques is acceptable to both the students and faculty. The study also concluded that it is an effective and feasible method that can be used to complement cadaveric teaching to revisit areas already dissected and for quick revision.

Simulated patient videos to supplement integrated teaching in competency-based undergraduate medical curriculum

The competency-based undergraduate medical curriculum in the preclinical years requires clinical topics to be taught using a linker clinical case for students to appreciate the clinical application of basic sciences. The objective of this study was to evaluate student and faculty satisfaction regarding the construct and delivery of an aligned and integrated curriculum that involved the use of linker clinical cases. We aimed at evaluating the perceptions and performance of students when paper cases were supplemented with a simulated patient (SP) video. This interventional study was conducted by inviting 250 medical students from the first professional phase from the 2020-2021 batch. Integrated modules were prepared for two clinical conditions: myocardial infarction (MI) and nephrotic syndrome (NS). The topic NS was taught with a paper-based case while the topic MI was supplemented with an SP video. Feedback from students and faculty was collected using a newly developed and validated questionnaire and focused group discussions. The students performed significantly better in the assessment conducted after the topic MI compared to NS. The majority of the students (80%) expressed a preference for the video to understand the clinical relevance when compared to the paper case. Overall, the students (83-87%) expressed satisfaction with integrated teaching sessions using clinical cases. Using linker clinical cases in an aligned and integrated preclinical curriculum allowed students to interrelate the subjects and apply them to clinical contexts. The SP videos prepared from an authentic setting facilitated learner engagement with a better understanding of the clinical relevance of the basic sciences.NOTE & NOTEWORTHY In this study, we have introduced linker cases to teach clinical correlation of basic sciences for integrated modules in the competency-based undergraduate medical curriculum. The novelty of our study is the inclusion of simulated patient video that was internally prepared and validated to supplement linker clinical paper cases in integrated modules.

Implementation of One-Minute Preceptor for Clinical Teaching in Obstetrics and Gynaecology

Background

In absence of a dedicated teaching curriculum for non-PG residents in Obstetrics and Gynecology department, a concise teaching learning method, One-Minute Preceptor (OMP) with feedback being its core component may be introduced to translate their theoretical knowledge into clinical practice.

Methods

This descriptive cross-sectional study included four faculty members and 20 residents. Each resident was exposed to three OMP sessions pertaining to common gynecological case scenarios with a gap of at least two days in between the sessions with faculties acting as preceptor and as observer. After three OMP sessions, feedback from residents and faculty regarding their teaching and learning experience after implementing this tool was obtained through separate pre-validated questionnaires graded on Likert's scale.

Results

The satisfaction index of the residents and faculties for OMP was found to be 96.3% and 95%, respectively. All residents and faculty members had consensus that OMP addressed the learning gaps (mean score 4.45 ± 0.51 and mean score 4.5 ± 0.57, respectively) and expressed being highly satisfied with OMP in busy clinical settings as compared to traditional method of teaching with mean score of 4.9 ± 0.30 and 4.75 ± 0.5, respectively. The faculties had consensuses that OMP can assess all domains of learning (mean score 4.75 ± 0.5). All residents and faculties opined that the time allotted to address all micro-skills was less and 60% residents advocated allotting at least 5 min time to the teaching encounter.

Conclusion

Our study indicates the beneficial role of OMP in time-constraint clinical environment and warrants further research to review the time frame keeping in view the learners' needs and the discipline.

Usage Pattern of Fixed-dose Combinations at ICMR Network of Rational Use of Medicine Centres across India: Recommendations for Policymakers and Prescribers

AIM

Irrational use of medicines is a global problem. In India, one contributing factor is the availability of a large number of fixed-dose combinations (FDCs). To improve rational use and to strengthen policies, it is important to assess the usage patterns and rationality of FDCs.

METHODS

This study was conducted as part of a 1-year prospective cross-sectional analysis of prescriptions in the outpatient clinics of broad specialities from 13 tertiary care hospitals across India. Five most commonly prescribed FDCs in each center were analyzed. In addition, all the prescribed FDCs were classified as per the Kokate Committee classification and it was noted whether any of the FDCs were irrational or banned as per the reference lists released by regulatory authorities.

RESULTS

A total of 4,838 prescriptions were analyzed. Of these, 2,093 (43.3%) prescriptions had at least one FDC. These 2,093 prescriptions had 366 different FDCs. Of the 366 FDCs, 241 were rational; 10 were irrational; 14 required further data generation; and the remaining 96 FDCs could not be categorized into any of the above. Vitamins and minerals/supplements, antibacterial for systemic use, and drugs for gastroesophageal reflux disease (GERD) and peptic ulcer were the most used FDCs.

CONCLUSION

Based on the finding that some prescriptions contained irrational FDCs, it is recommended that a rigorous, regular, and uniform method of evaluation be implemented to approve/ban FDCs and that prescribers be periodically notified about the status of the bans.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Safety of hydroxychloroquine in healthcare workers for COVID-19 prophylaxis

BACKGROUND & OBJECTIVES

Hydroxychloroquine (HCQ), reported to inhibit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication in in vitro studies, has been recommended for prophylaxis of COVID-19 in healthcare workers (HCWs). The objective of this study was to assess short-term adverse events (AEs) of HCQ in HCWs.

METHODS

This cross-sectional study among consenting HCWs taking prophylaxis and working in hospitals with COVID-19 patients used online forms to collect details of HCWs, comorbidities, prophylactic drugs used and AEs after the first dose of HCQ. Verification of dose and AEs was done by personal contact. Multivariate logistic regression analysis was done to determine the effect of age, gender and dose of HCQ on AE.

RESULTS

Of the 1303 HCWs included, 98.4 per cent (n=1282) took HCQ and 66 per cent (n=861) took 800 mg as first day's dose. Among the 19.9 per cent (n=259) reporting AEs, 1.5 per cent (n=20) took treatment for AE, none were hospitalized and three discontinued HCQ. Gastrointestinal AEs were the most common (172, 13.2%), with less in older [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.35-0.89], with more in females (OR 2.46, 95% CI 1.78-3.38) and in those taking a total dose of 800 mg on day one compared to a lower dose. Hypoglycaemia (1.1%, n=14), cardiovascular events (0.7%, n=9) and other AEs were minimal.

INTERPRETATION & CONCLUSIONS

HCQ prophylaxis first dose was well tolerated among HCWs as evidenced by a low discontinuation. For adverse effects, a small number required treatment, and none required hospitalization. The study had limitations of convenience sampling and lack of laboratory and electrocardiography confirmation of AEs.

Simulated Patients for Competency-Based Undergraduate Medical Education Post COVID-19: A New Normal in India

The conventional medical curriculum in India needed more focus on explicit teaching and assessment of interpersonal and communication skills, professionalism, team-work and reflection for prevention and better management of increasing incidences of violence against doctors by building good doctor-patient relationships. Increasing number of seats in Indian medical colleges, decreasing hospital stay of patients, and decrease in faculty requirements will hamper adequate supervised authentic clinical experiences of undergraduates for developing clinical skills. The recent COVID-19 pandemic has led to a significant decrease in student-patient encounters. Simulated patients are being used in many countries to address many of these issues. To make the Indian medical graduates competent to function as primary physician of first contact, competency-based medical education along with guidelines for use of skill-lab and simulation has been introduced from 2019. The current review is focused on the need and use of simulated patients; their advantages, limitations and role in students' teaching and assessment. It also gives a brief outline of their training process. Simulated patients should be used to supplement day-to-day learning, help in transition to attending real patients and also save enormous faculty time in the post-COVID-19 new normal. However, simulated patients are unlikely to completely replace real patients' experiences.

Faculty's perspective on skill assessment in undergraduate medical education: Qualitative online forum study

BACKGROUND

India is at the nascent stage of competency-based medical education. Faculties trained in medical education are the main driving force for change. The present study explores the perception of faculties about the current practices and problems in medical/dental/nursing undergraduate assessment, barriers to adoption of best practices, and solutions for addressing them.

METHODOLOGY

A qualitative study was designed and data collected through an asynchronous online discussion forum. A group of 31 health professionals (FAIMER fellows selected on the basis of active participation in department of medical education of respective colleges) participated in the forum. An open-ended topic guide with prompts was designed. The forum was initiated by release of discussion topics (threads) at the start of the month and remained in forum throughout the month. Researchers moderated and recorded day-to-day events. All online forum data were coded line by line and analyzed using conventional content analysis.

RESULTS

Four categories generated were: (1) Low utility of current skill assessment system due to low validity and reliability; (2) Barrier in adopting newer assessment tool due to the absence of felt need of faculties and students, mistaken beliefs, and limited resources; (3) Poor implementation of newer assessment tools such as formatives and objective structured clinical examination with no blueprinting; and (4) Solutions proposed were regular formative assessment, criterion-based examination, quality-assured faculty development programs, and administrative support.

CONCLUSIONS

Barriers in adopting newer assessment tools are related to the faculty's perception and resource constraint. This can be addressed by quality-assured faculty development programs and effective implementation of competency-based education.

Acceptability and feasibility of mini-clinical evaluation exercise as a formative assessment tool for workplace-based assessment for surgical postgraduate students

Background:

Despite an increasing emphasis on workplace-based assessment (WPBA) during medical training, the existing assessment system largely relies on summative assessment while formative assessment is less valued. Various tools have been described for WPBA, mini-clinical evaluation exercise (mini-CEX) being one of them. Mini-CEX is well accepted in Western countries, however, reports of its use in India are scarce. We conducted this study to assess acceptability and feasibility of mini-CEX as a formative assessment tool for WPBA of surgical postgraduate students in an Indian setting.

Methods:

Faculty members and 2^nd year surgical residents were sensitized toward mini-CEX and requisite numbers of exercises were conducted. The difficulties during conduction of these exercises were identified, recorded, and appropriate measures were taken to address them. At the conclusion, the opinion of residents and faculty members regarding their experience with mini-CEX was taken using a questionnaire. The results were analyzed using simple statistical tools.

Results:

Nine faculty members out of 11 approached participated in the study (81.8%). All 16 2^nd year postgraduate surgical residents participated (100%). Sixty mini-CEX were conducted over 7 months. Each resident underwent 3–5 encounters. The mean time taken by the assessor for observation was 12.3 min (8–30 min) while the mean feedback time was 4.2 min (3–10 min). The faculty reported good overall satisfaction with mini-CEX and found it acceptable as a formative assessment tool. Three faculty members (33.3%) reported mini-CEX as more time-consuming while 2 (22.2%) found it difficult to carry the exercises often. All residents accepted mini-CEX and most of them reported good to high satisfaction with the exercises conducted.

Conclusions:

Mini-CEX is well accepted by residents and faculty as a formative assessment tool. It is feasible to utilize mini-CEX for WPBA of postgraduate students of surgery.

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.

Impact of immediate feedback on the learning of medical students in pharmacology

INTRODUCTION

Providing feedback to students is an essential component in medical education and has been shown to improve the students' learning. The purpose of this study is to evaluate the effect of computer-based immediate feedback on the medical students' learning in a pharmacology course.

METHODS

In this prospective intervention study some feedback modules in pharmacology (FMP) were prepared in two topics: the cardiovascular system (CVS) and chemotherapy, using blank templates on "Hot Potatoes" software. The FMP included MC-based questions and two versions were developed: one with feedback (FMP-1) and the other without feedback (FMP-2). The FMP-1 module provided immediate feedback for each option the student chose. The students (n=48) were randomized by computer generated random number table to two groups A and B to receive the module in CVS, i.e., FMP-1 and FMP-2, respectively. A cross-over design was adopted to expose all students to immediate feedback modules. The test scores were compared and feedback was obtained from students and faculty using a validated questionnaire. A focus group discussion was conducted to clarify the issues raised by the students.

RESULTS

The module with immediate feedback was much better appreciated by the students than the module without feedback. The students spent more time on FMP-1 (42±7.00 minutes vs 27±12.36 minutes; p<0.001 in chemotherapy and 40±12.11 minutes vs 24±6.01 minutes; p<0.001 in CVS). However, there was no statistically significant difference in mean test scores. The qualitative data collected provided important information on the value of immediate feedback. The students believed that immediate feedback was an excellent way for self-assessment and improved their deeper understanding of content areas. They also felt that it supplemented their traditional learning habits and stimulated them to read more. The students enjoyed its non-threatening nature.

CONCLUSION

Immediate feedback improved the deeper understanding of pharmacology and its relevance to medicine for the two topics although immediate feedback did not improve test scores. Overall, immediate feedback had a positive impact on the students' self-directed learning.

A Study of Cutaneous Adverse Drug Reactions in a Tertiary Care Center in Punjab

CONTEXT

Cutaneous adverse drug eruptions are the most common adverse reactions attributed to drugs in which any type of skin reaction can be mimicked, induced, or aggravated.

AIMS

To study the pattern of various types of cutaneous adverse drug reactions (CADRs), to find out the causative drug(s) involved and to determine the response to treatment and outcome in patients with CADRs.

PATIENTS AND METHODS

This prospective study was done in the department of dermatology. Patients with suspected drug rash, of either sex and all age groups were included in the study.

STATISTICAL ANALYSIS

Frequencies and proportions were calculated using Chi-square test and t-test as the tests of significance. Data was analyzed using SPSS version 21.

RESULTS

A total of 258 patients were enrolled in the study. The most common CADR observed in the study was exanthematous drug eruption in 42.63% patients followed by drug induced urticaria in 21.32% patients. Antimicrobials were the most common offending drugs in 64.73% of patients, followed by non-steroidal anti-inflammatory drugs (NSAIDs) in 15.50% patients. In the study, 12 patients (4.65%) were found to have severe cutaneous adverse drug reactions (SCADRs). Stevens-Johnson syndrome (SJS) - Toxic epidermal necrolysis (TEN) was the most common SCADR (50%) and antituberculous drugs were the most common causative group of drugs causing SCADRs.

CONCLUSION

The most common CADR observed in the study was exanthematous drug eruption and antimicrobials were the most common causative drugs.

Evolution of pharmacology education in India: Past and future

Pharmacology education has passed through various stages in the evolution sequence due to ever-changing type and repository of drugs as well as technological advancements in the educational processes. This article reviews the journey of evolution of pharmacology education. Pharmacology is relevant component of various curricula in medical, dental, and paramedical courses. A huge number of students learn pharmacology as a subject. Important milestones in evolutionary sequence included revisions and updates in learning objectives, teaching-learning material/methods and assessment in undergraduate (UG) and postgraduate (PG) levels. During this period, a number of pharmacology organizations and associations were formed for the progress of the subject. The inception of Indian Pharmacological Society and International Union of Pharmacology is worth mentioning. There are standardization and unification efforts being done in pharmacology education at national and international levels. The era of animal experimentation is struggling to survive in the new era of animations and simulations. There is increasingly more emphasis on the relevant clinical pharmacy and clinical pharmacology components in the education. The past evolutionary sequences provide leads for future evolutions. New courses and innovations are being designed and implemented to make pharmacology education more meaningful and useful to the new technology-savvy students. A number of innovations in the form of case-based learning, objective-structured practical examination, small group learning, interactive, and integrated methods are being implemented. There is a lot of work being done to introduce a competency-based intergraded curriculum in medical UG and PG courses. All these evolutionary sequences require changing and evolving role of teachers as facilitators.

Construct validity and predictive utility of internal assessment in undergraduate medical education

BACKGROUND

Internal assessment is a partial requirement of all medical college examinations in India. It can help teachers provide remedial action and guide learning. But its utility and acceptability is doubted because, with no external control, internal assessment is considered prone to misuse. It is therefore not used as a tool for learning. There is no study on the validity of internal assessment from India.

METHODS

We use multiple methods and multiple teachers to assess students and our records are well maintained. We analysed the internal assessment scores at our institute. We correlated the internal assessment marks with the university marks obtained by students in one of the subjects in each of the four professional examinations.

RESULTS

There was a positive correlation of university marks with internal assessment marks. The r values ranged from +0.426 to +0.685 and were statistically significant (p<0.01). The percentage of internal assessment marks was higher than the university percentage in all professional examinations except the first.

CONCLUSIONS

Internal assessment marks correlate well with marks in university examinations. This provides evidence for construct validity and predictive utility of internal assessment. Internal assessment can predict performance at summative examinations and allow remedial action.

Opinion of stakeholders on existing curriculum for postgraduate (MD) course in Pharmacology: A survey

Objectives:

To survey the opinion about various curricular components of Doctor of Medicine (MD) pharmacology curriculum in India by stakeholders, including faculty and students.

Materials and Methods:

An online survey was done to evaluate the various curricular components of MD pharmacology curriculum being used in India. A total of 393 respondents including faculty, MD students, and other stakeholders completed the survey. The survey was developed using SurveyMonkey platform and link to survey was E-mailed to stakeholders. The results were expressed as percentages.

Results:

There was a balanced representation of respondents from various designations, teaching experience, regions, and age groups. Most of the respondents (83%) were aware of the MD pharmacology curriculum. However, they reported that it is more inclined to knowledge domain. About half of respondents (53%) said that animal experiments are being used. The most common teaching methods mentioned are seminars (98.5%), journal clubs (95%), and practical exercises by postgraduates (73%), but there is less use of newer methods (25%) in theory and less of clinical pharmacology exercise (39%) in practical classes. The log books are maintained but not assessed regularly. Internal assessment is sparingly used.

Conclusion:

The MD pharmacology curriculum needs to be made uniform at the national level and updated to include the newer methods in teaching-learning and assessment. There should be sharing of newer methods at a common platform implemented at the national level.

Professionalism and ethics: A proposed curriculum for undergraduates

Professionalism is the attributes, behaviors, commitments, values, and goals that characterize a profession. In medical professional, it encompasses strong societal role and involves emotional component too. On the other hand, ethics is the study of morality – careful and systematic analysis of moral decisions and behaviors and practicing those decisions. Medical ethics focuses primarily on issues arising out of the practice of medicine. It is generally believed that professionalism and ethics are caught by watching your teachers and seniors and not taught formally. Professionalism and ethics are previously diffused passively to the students through “the hidden curriculum,” leaving a lot to chance. However, over the time, it has been advocated that graduates need to be formally trained in the concepts of professionalism and ethics. In this paper, we propose a formal curriculum on professionalism and ethics, tailor-made for Indian medical graduates.

Postgraduate pharmacology curriculum in medical institutions in India: time for need-based appraisal and modifications

The need to revise the curriculum for the postgraduate course (M.D.) in Pharmacology has been perceived by the academicians in India since quite some time. The changing professional requirements of the graduating students, the current scenario vis a vis animal experimentation and the emphasis of the Medical Council of India on a competency based curriculum has triggered this felt need. In spite of the fact that most medical institutions and universities in India offer postgraduate courses in pharmacology, the curriculum lacks uniformity with extreme variations observed at some places. This article attempts to analyze the existing curricula in pharmacology in India and suggest modifications that could be recommended to the suitable regulatory bodies for implementation. A revision of objectives in the three domains of learning, development of skills that help develop suitable competencies, adoption of teaching learning methods in addition to the conventional methods, and a rethink on the assessment methods have been recommended. Development and validation of alternatives skill-based modules in lieu of animal experiments are recommended. Additional skills like medical writing and communication skills, professionalism and ethics, multi and inter-disciplinary integration and collaboration and a wider exposure of students to the pharmaceutical, academic, regulatory and research institutions for onsite learning were also recommended to fulfill their future career requirements.

Teaching of the basic sciences in medicine: Changing trends

A number of medical schools throughout the world have tried to downsize the basic sciences, but studies have shown that teaching of basic sciences is of importance for the clinical years that lie ahead. While some students endorse this finding, others want instruction in these sciences to be limited in terms of content and time. With the increasing cost of medical education and healthcare, medical schools the world over are trying to contain expenditure on the teaching of the basic sciences. In India, too, instruction in these sciences has been curtailed. This trend may need to be reviewed and the new challenges in this area must be addressed.

Animal use in education in India: confusion continues

In India, there is an urgent need to get a single directive on the appropriate and relevant use of animals in education and research which is equally applicable in all institutions

Animal use in pharmacology education and research: the changing scenario

The use of animals in research and education dates back to the period when humans started to look for ways to prevent and cure ailments. Most of present day's drug discoveries were possible because of the use of animals in research. The dilemma to continue animal experiments in education and research continues with varied and confusing guidelines. However, the animal use and their handling vary in each laboratory and educational institution. It has been reported that the animals are being subjected to painful procedures in education and training unnecessarily. The extensive use of animals in toxicity studies and testing dermatological preparations has raised concerns about the ways animals are sacrificed for these “irrelevant experiments”. On the other side of the coin are scientists who advocate the relevant and judicious use of animals in research so that new discoveries can continue. In this review, we discuss the evolution of the use of animals in education and research and how these have been affected in recent times owing to concerns from animal lovers and government regulations. A number of computer simulation and other models have been recommended for use as alternatives to use of animals for pharmacology education. In this review we also discuss some of these alternatives.

Cost of stroke from a tertiary center in northwest India

AIM

We aimed to study the cost of stroke, its predictors, and the impact on social determinants of the family.

SETTINGS AND DESIGN

This prospective study was done in the Stroke unit and Neurology clinic between April 2009 and October 2011.

MATERIALS AND METHODS

All first ever stroke patients during the study period were enrolled. Direct and indirect costs at admission, at 1 and 6 months follow-up were obtained. The follow-up included information about the patient's poststroke outcome using modified Rankin Scale (mRS), work status, modifications made at home, loan requirement, etc.,

RESULTS

Two hundred patients were enrolled in this study and final analysis was performed on 189 patients. The mean age was 58 ± 13 years and 128 (67.7%) were men. Majority (54%) were living in a joint family. The mean overall cost of stroke per patient was rupees (INR) 80612 at 6 months. Higher income (P = 0.008), poor outcome (mRS >2) (P = 0.001), and length of hospital stay (P = 0.001) were the cost driving factors of total cost of stroke at 6 months. There was a decline in the requirement of help (P < 0.0001) and need for loan (P = 0.003) at 6 months follow-up.

CONCLUSIONS

Direct medical cost or acute care of stroke accounted for a major component of cost of stroke. Poor outcome, length of hospital stay, and higher income were the cost driving factors. The socioeconomic impact on the family decreased at follow up probably due to joint family system.

Biological Studies of Turmeric Oil, Part 3: Anti-Inflammatory and Analgesic Properties of Turmeric Oil and Fish Oil in Comparison with Aspirin

Turmeric and fish oil have been gaining interest as food supplements because of their beneficial properties. Turmeric oil contains sesquiterpenes and fish oil has eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), possessing anti-inflammatory activity. The present study is to evaluate and compare the anti-inflammatory and analgesic properties of these two natural food products with aspirin as a standard. The percent inhibition as a measure of paw edema for turmeric oil and fish oil at 100 mg/kg was 76% and 31%, respectively, while the percent inhibition by the combination of the two at 100 mg/kg was 62%, which was the same as that of aspirin at the same dose. The inhibitory activity of fish oil at 50 mg/kg was 86% and with an increase in dose the activity decreased. The analgesic activity measured by the tail flick method showed optimum activities for turmeric oil and fish oil at 60 and 90 minutes, respectively, whereas the combination of the two decreased the analgesic activity. Thus the two common food ingredients, oils from turmeric and fish, have desirable biochemical properties to develop further their use as food and medicine.

Biological studies of turmeric oil, part 3: anti-inflammatory and analgesic properties of turmeric oil and fish oil in comparison with aspirin

Turmeric and fish oil have been gaining interest as food supplements because of their beneficial properties. Turmeric oil contains sesquiterpenes and fish oil has eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), possessing anti-inflammatory activity. The present study is to evaluate and compare the anti-inflammatory and analgesic properties of these two natural food products with aspirin as a standard. The percent inhibition as a measure of paw edema for turmeric oil and fish oil at 100 mg/kg was 76% and 31%, respectively, while the percent inhibition by the combination of the two at 100 mg/kg was 62%, which was the same as that of aspirin at the same dose. The inhibitory activity of fish oil at 50 mg/kg was 86% and with an increase in dose the activity decreased. The analgesic activity measured by the tail flick method showed optimum activities for turmeric oil and fish oil at 60 and 90 minutes, respectively, whereas the combination of the two decreased the analgesic activity. Thus the two common food ingredients, oils from turmeric and fish, have desirable biochemical properties to develop further their use as food and medicine.

Evaluation of the in vivo anti-inflammatory and analgesic and in vitro anti-cancer activities of curcumin and its derivatives

Curcumin, obtained from turmeric, has several biological properties to make it a desirable template for drug development. A lipophilic derivative of curcumin, diacetyl curcumin (DAC) and a hydrophilic derivative, diglutaryl curcumin (DGC) were synthesized and their in vivo analgesic and anti-inflammatory activities were compared with those of curcumin and aspirin. The in vitro anti-cancer activities of curcumin and the two derivatives against three cell cancer lines were compared with those against a non-cancerous cell line. The inhibitory effects were comparable to each other and nearing that of curcumin while they showed low inhibitory effect towards the non-cancerous cell line. The mouse tail flick assay showed that curcumin, DAC and DGC increased latency time. DGC was most effective as an analgesic, even more so than aspirin. The maximum percentage effect (MPE) was highest with DGC at 3 hours. The carrageenan induced paw edema model indicated anti-inflammatory activity of all three curcumin formulations. The percentage inhibition of paw edema was maximum for DAC, followed by aspirin and curcumin.

Efficacy and safety of add on low-dose mirtazapine in depression

Objectives:

Although antidepressant medications are effective, they have a delayed onset of effect. Mirtazapine, an atypical antidepressant is an important option for add-on therapy in major depression. There is insufficient data on mirtazapine in Indian population; hence this study was designed to study the add-on effect of low-dose mirtazapine with selective serotonin reuptake inhibitors (SSRIs) in major depressive disorder (MDD) in Indian population.

Materials and Methods:

In an open, randomized study, 60 patients were divided into two groups. In Group A (n=30) patients received conventional SSRIs for 6 weeks. In Group B (n=30) patients received conventional SSRIs with low-dose mirtazapine for 6 weeks. Patients were evaluated at baseline and then at 1, 2, 3, 4, 5, and 6 weeks.

Results:

There was significant improvement in Hamilton Depression Rating Scale (HDRS), Montgomery and Asberg depression rating scale (MADRS) scores (P<0.05) in both groups. Mirtazapine in low dose as add on therapy showed improvement in scores, had earlier onset of action, and more number of responders and remitters as compared to conventional treatment (P<0.05). No serious adverse event was reported in either of the groups.

Conclusion:

Low-dose mirtazapine as add-on therapy has shown better efficacy, earlier onset of action and more number of responders and remitters as compared to conventional treatment in MDD in Indian patients.

Pulmonary arterial hypertension: advances in pathophysiology and management

Pulmonary arterial hypertension (PAH) is a heterogeneous, hemodynamic, and pathophysiological state which is commonly found throughout the world, but the disease burden is greater in India and in other developing countries. It is a disease characterized by vascular obstruction and vasoconstriction leading to progressive increase in pulmonary vascular resistance and right ventricular failure. PAH is a progressive disorder carrying a poor prognosis; however, dramatic progress has occurred in our knowledge of its pathogenesis and consequently, its treatment over the last two decades. In this article, we attempt to provide an overview of the etiology, pathophysiology, and current therapeutic modalities in the treatment of PAH. Patients suspected to have PAH should be submitted to a battery of investigations which help in establishing the diagnosis, identifying the etiology, guiding in treatment and informing the prognosis. All patients should be considered for standard therapy with oxygen, anticoagulation, and diuretics for right heart failure. Oral calcium channel blockers should be used in patients with a favorable response to acute vasodilator challenge. Disease targeted therapies include prostacyclines, endothelin receptor blockers, and phosphodiesterase-5 inhibitors. A brief mention of new and potential therapeutic strategies is also included.

Student evaluation of teaching and assessment methods in pharmacology

Background:

The students are in the best position to comment on the effectiveness of any teaching system and they may be regarded as the best judges to assess the teaching and evaluation methods.

Objective:

This study was designed to obtain student feedback on teaching and assessment methods in the subject of pharmacology and use it for improvement.

Materials and Methods:

Based on student feedback from batch 2006, innovative strategies were implemented. To know the effect of these strategies feedback was obtained from subsequent batch 2007 using a written validated questionnaire covering various aspects of teaching and assessment methods.

Results:

Students were satisfied with all teaching methods except lecture, seminars and pharmacy exercises. Majority of the students showed preference for tutorials, short answer questions and revision classes. All students felt that there should be more time for clinical pharmacology and bedside teaching. The performance score of the students (batch 2007) indicated improvement in their scores (12%) when earlier feedback suggestions were implemented. The pass percentage of the subsequent batch in university examinations improved from 90 to 100%.

Conclusion:

The implementation of suggestions obtained from students resulted in improvement in their performance. Hence, it is very essential to synchronize teaching and evaluation methods with special requirements of medical students.

Computer simulation models are implementable as replacements for animal experiments

It has become increasingly difficult to perform animal experiments, because of issues related to the procurement of animals, and strict regulations and ethical issues related to their use. As a result, it is felt that the teaching of pharmacology should be more clinically oriented and that unnecessary animal experimentation should be avoided. Although a number of computer simulation models (CSMs) are available, they are not being widely used. Interactive demonstrations were conducted to encourage the departmental faculty to use CSMs. Four different animal experiments were selected, that dealt with actions of autonomic drugs. The students observed demonstrations of animal experiments involving conventional methods and the use of CSMs. This was followed by hands-on experience of the same experiment, but using CSMs in small groups, instead of hands-on experience with the animal procedures. Test scores and feedback showed that there was better understanding of the mechanisms of action of the drugs, gained in a shorter time. The majority of the students found the teaching programme used to be good to excellent. CSMs can be used repeatedly and independently by students, and this avoids unnecessary experimentation and also causing pain and trauma to animals. The CSM programme can be implemented in existing teaching schedules for pharmacology undergraduate teaching with basic infrastructure support, and is readily adaptable for use by other institutes.

Effect of atorvastatin on hs-CRP in acute coronary syndrome

AIMS

To evaluate the effect of a lower dose (20 mg) of atorvastatin on hs-CRP concentrations in patients with ACS.

METHODS

Group A (n = 50) patients received atorvastatin 20 mg day(-1) for 4 weeks in addition to standard anti-anginal treatment. Group B (n = 50) patients received standard anti-anginal treatment without atorvastatin.

RESULTS

hs-CRP concentrations decreased in both groups, but the decrease was greater in group A. The decrease in hs-CRP was also significantly greater in the subgroups of smoking, hypertension and past history of cardiovascular disease with atorvastatin.

CONCLUSIONS

The use of a lower dose (20 mg) of atorvastatin can offer an attractive approach for early treatment of patients with ACS.

Effectiveness and acceptability of sertraline and citalopram in major depressive disorder: pragmatic randomized open-label comparison

OBJECTIVE

Citalopram and sertraline are widely prescribed selective serotonin reuptake inhibitors (SSRIs). There is no conclusive evidence to show superiority of citalopram or sertraline in terms of efficacy or tolerability. Hence this study was designed to compare short term efficacy and safety of citalopram and sertraline in major depressive disorder (MDD) in Indian patients.

METHODS

In an open, randomized study, 100 patients were divided into two groups. In Group A (n = 50) patients received citalopram (20-60 mg/day) for 6 weeks. In Group B (n = 50) patients received sertraline (50-150 mg/day) for 6 weeks. Patients were evaluated at baseline and then at 1, 2, 3, 4, 5, and 6 weeks.

RESULTS

There was significant improvement in Hamilton depression rating scale (HDRS), Montgomery and Asberg depression rating scale (MADRS) and Amritsar depressive inventory (ADI) scores (p < 0.05) with both the drugs. However, the decrease in score was more with citalopram (p < 0.05). Onset of action of citalopram was earlier as compared to sertraline (p < 0.05). The number of responders and remitters was also more with citalopram (p < 0.05). No serious adverse event was reported in either of the groups.

CONCLUSION

Citalopram had shown better efficacy, earlier onset of action and more number of responders and remitters as compared to sertraline in MDD in Indian patients.

Combination therapy of low-dose atorvastatin and fenofibrate in mixed hyperlipidemia

Mixed hyperlipidemia is a major cause of coronary artery disease. Monotherapy with statins is considered the gold standard for treatment of mixed hyperlipidemia. But greater benefit may be expected by combination therapy. Combination may allow lower doses of statins and less adverse effects. Hence, this preliminary study was designed to evaluate the efficacy and safety of low-dose atorvastatin in combination with fenofibrate in patients with mixed hyperlipidemia. Ninety patients were assigned into three groups and received atorvastatin (10-40 mg/day) or fenofibrate (160-200 mg/day) or combination of low-dose atorvastatin (5 mg/day) and fenofibrate (160 mg/day). There was a significant decrease in low-density lipoprotein (LDL), triglycerides (TG) and total cholesterol (TC), and a significant increase in high-density lipoprotein (HDL) in all the groups at the end of therapy. Combination therapy produced maximum decrease in LDL, TG and TC, and maximum increase in HDL when compared with monotherapies. No significant difference was reported in safety profile between the two groups. To conclude, the results suggest that combination therapy with low-dose atorvastatin and fenofibrate is more efficacious, with no increase in adverse effects when compared with monotherapies with individual drugs for mixed hyperlipidemia. The results are preliminary and suggestive only, as the study was open and nonrandomized.

A multicentric study to evaluate efficacy and safety of cefetamet pivoxyl in lower respiratory tract infections in Indian patients

This multicentric, open label, non-comparative study was designed to evaluate the extended spectrum of third generation oral cephalosporin, cefetamet pivoxyl in the treatment of patients with lower respiratory tract infections. This study was conducted among 111 patients with clinical, radiological and bacteriological findings consistent with the diagnosis. After obtaining written informed consent, patients were given cefetamet 500 mg tablet twice a day for 7 days. Cefetamet consistently decreased all clinical signs and symptoms at post-therapy visit. All the treated patients were either cured or improved. Cefetamet was well tolerated with a low incidence of drug related adverse events. The findings of this study indicate that cefetamet pivoxyl was well tolerated and is suitable option for the treatment of patients with lower respiratory tract infection.

Effect of clarithromycin on the pharmacokinetics of carbamazepine in rhesus monkeys

Clarithromycin, an advanced-generation macrolide antimicrobial, is less prone to drug interactions as compared to erythromycin. Based on two case reports in which increased carbamazepine (CBZ) plasma concentrations were observed in patients receiving clarithromycin, a crossover multiple dose study was designed to find out the pharmacokinetic interaction between CBZ and clarithromycin in rhesus monkeys. CBZ (46 mg/kg/d) was administered to the monkeys alone and along with clarithromycin (20 mg/kg/d). Blood samples were collected from 0-24 h. Plasma concentrations of CBZ were measured by HPLC technique. Pharmacokinetic data revealed an increase in plasma concentrations, AUC(0-24) and t1/2e of CBZ when coadministered with clarithromycin, but the increase was not statistically significant. These findings suggest careful administration and plasma monitoring of CBZ concentrations when coadministered with clarithromycin.

Pharmacokinetics of phenytoin: unaltered by enalapril and amlodipine in rhesus monkeys

A cross over single and multiple dose study was carried out to find out pharmacokinetic interactions between diphynylhydantoin (DPH) (35 mg/kg, p.o.) and antihypertensives enalapril (1.6 mg/kg; p.o.) and amlodipine (0.4 mg/kg, p.o.) in rhesus monkeys. Neither the plasma concentrations nor the pharmacokinetic parameters of DPH were altered by coadministration of enalapril or amlodipine, suggesting that enalapril and amlodipine can be safely administered to epileptic patients receiving phenytoin.

Antimicrobial prescribing pattern in an Indian tertiary hospital

550 prescriptions of the indoor patients receiving antimicrobial drugs in the Departments of Internal Medicine, Surgery, Urology and Paediatrics were analysed for drug utilization studies. The prescribing frequency of one antimicrobial per prescription was maximum in Surgery and Urology (52.52%) and Internal Medicine (50.51%) whereas prescribing frequency of two antimicrobials was maximum in Paediatrics (59.9%). In all the departments, quinolones, aminoglycosides, cephalosporins and penicillins were frequently prescribed among which amikacin, ciprofloxacin, cefotaxime and cloxacillin were most preferred drugs, with a general tendency of prescribing newer antimicrobials. In majority of cases selection of antimicrobials was not based on microbiological confirmation. It is suggested that the use of newer and expensive antimicrobials should be kept reserved only for serious and life threatening situations.