Presentation, Diagnosis and Treatment Delays in Breast Cancer Care and Their Associations in Sri Lanka, a Low-resourced Country

AIMS

Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation.

MATERIALS AND METHODS

We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance.

RESULTS

Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays.

CONCLUSIONS

Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

Curative-Intent Radiotherapy for Squamous Cell Carcinoma of the Head and Neck in Sri Lanka: The Impact of Radiotherapy Technique on Survival

AIMS

We conducted a retrospective analysis of patients with squamous cell carcinoma of the head and neck (SCCHN) treated with curative-intent radiotherapy at the National Cancer Institute of Sri Lanka to determine the impact of the treatment technique on disease-free survival (DFS).

MATERIALS AND METHODS

SCCHN patients treated with radical radiotherapy or adjuvant postoperative radiotherapy from 2016 to 2017 were included in the study. Data on the following variables were collected by reviewing clinical and radiotherapy treatment records: age, gender, tumour site, stage, time to delivery of radiotherapy, use of neoadjuvant chemotherapy, use of concurrent radiosensitising chemotherapy and treatment technique. DFS, defined as the time to death, tumour recurrence or loss to follow-up, was the primary end point and outcomes were compared between patients treated with intensity-modulated radiotherapy (IMRT) in linear accelerators and those treated with conventional radiotherapy in cobalt teletherapy units. Univariate and multivariate analyses were carried out on known prognostic variables.

RESULTS

In total, 408 patients were included in the study, with 138 (34%) being treated with IMRT in the linear accelerator. More than 75% of patients were of stage III or IV at diagnosis. The 2-year DFS of the whole cohort was 25% (95% confidence interval 21-30%). Patients treated with IMRT in the linear accelerator had a superior DFS in comparison with those treated with conventional radiotherapy in the cobalt teletherapy units (P < 0.001, hazard ratio 0.64, 95% confidence interval 0.5-0.82). Higher stage, cobalt treatment and use of neoadjuvant chemotherapy were adversely associated with DFS on multivariate analysis.

CONCLUSION

A large proportion of patients with SCCHN treated with curative-intent radiotherapy in Sri Lanka had locally advanced disease and DFS was superior in patients treated with IMRT in the linear accelerator.

Appraisal of national and international uterine fibroid management guidelines: a systematic review

BACKGROUND

Guidelines standardise high-quality evidence-based management strategies for clinicians. Uterine fibroids are a highly prevalent condition and may exert significant morbidity.

OBJECTIVES

To appraise national and international uterine fibroid guidelines using the validated AGREE-II instrument.

SELECTION STRATEGY

Database search of PubMed and EMBASE from inception to October 2020 for all published English-language uterine fibroid clinical practice guidelines.

DATA COLLECTION AND ANALYSIS

In all, 939 abstracts were screened for eligibility by two reviewers independently. Three reviewers used the AGREE-II instrument to assess guideline quality in six domains. Recommendations were mapped to allow a narrative synthesis regarding areas of consensus and disagreement.

MAIN RESULTS

Eight national guidelines (AAGL, SOGC 2014, ACOG, ACR, SOGC 2019, CNGOF, ASRM and SOGC 2015) and one international guideline (RANZOG) were appraised. The highest scoring guideline was RANZOG 2001(score 56.5%). None of the guidelines met the a priori criteria for being high-quality overall (score ≥66%). There were 166 recommendations across guidelines. There were several areas of disagreement and uncertainty. There were only three areas of consensus. Supporting evidence was not evident for many recommendations; 27.7% of recommendations were based on expert opinion only.

CONCLUSIONS

There is a need for high-quality guidelines on fibroids given their heterogeneity across individuals and the large range of treatment modalities available. There are also areas of controversy in the management of fibroids (e.g. Ulipristal acetate, power morcellation), which should also be addressed in any guidelines. Future guidelines should be methodologically robust to allow high-quality decision-making regarding fibroid treatments.

TWEETABLE ABSTRACT

Current national fibroid guidelines have deficiencies in quality when appraised using the validated AGREE instrument.

Anaesthetic management of a patient with multiple acetyl CoA dehydrogenase deficiency: A case report

Multiple acetyl CoA dehydrogenase deficiency is a rare autosomal recessive disorder of amino acid, fatty acid, and choline metabolism. It is a mitochondrial disorder with defective electron transfer flavoproteins or electron transfer flavoprotein dehydrogenases. They are vital for β-oxidation of fatty acids, an essential fuel for skeletal and cardiac muscles. It is also an important source of energy during starvation for the brain. Acute deterioration of these patients can occur during stressful periods like starvation, surgery, infection, and exercise. The anaesthetic management is a challenge with special emphasis on minimizing starvation, ensuring hydration and glucose supplementation, and considering the various effects of anaesthetic agents on the mitochondrial function. The anaesthetic management of a patient with multiple acetyl CoA dehydrogenase scheduled for modified radical mastectomy is described. General anaesthesia can be administered safely in these patients with special emphasis on hydration, glucose supplementation, avoidance of stressors, and monitoring of metabolic status.

Two manoeuvres to facilitate the oral insertion of LMA CTrach™

Background and Aims:

LMA CTrach^TM, a new intubating conduit, has a thicker shaft compared to that of the intubating laryngeal mask airway (ILMA) due to the embedded optical fibres of the system. This causes difficulty during insertion despite normal mouth opening. Utility of two manoeuvres to overcome this was evaluated.

Methods:

From our experience with LMA CTrach^TM we found that two manoeuvres can be helpful to facilitate the insertion of LMA (a) dorsal and downward pressure over the shaft at the point where it hinges against the incisors while continuing the one handed rotational insertion of LMA (b) Lateral insertion of the LMA till the cuff is inside the oral cavity and then rotation of the LMA by 90° and then complete the insertion. A retrospective analysis of 200 insertions of LMA CTrach^TM was done to evaluate the utility of these manoeuvres.

Results:

Out of 200 insertions, 15 were found to be difficult. Manoeuvre “a” was applied in 13 cases to facilitate the insertion and manoeuvre “b” was applied in 2 cases where insertion was not possible despite manoeuvre “a'. Insertion was successful in these cases after the application of the described manoeuvres.

Conclusion:

The two manoeuvres described above can be useful when LMA CTrach^TM insertion into the oral cavity is obstructed by the incisor teeth.

Evaluation of segmental epidural blockade following standard test dose versus test dose with addition of saline in abdominal surgeries

Background and Aims

Epidural analgesia is widely used for pain relief but confirmation of accurate epidural placement is poorly understood. We proposed that sensory blockade to cold sensation would predict the accurate placement of epidural. The primary outcome was the assessment of sensory blockade at 5 and 10 min with a standard epidural test dose versus test dose with additional saline. We looked at haemodynamic changes following administration as secondary outcomes.

Methods

Following Ethics Committee approval, 161 patients presenting for elective abdominal surgery needing epidural analgesia with general anaesthesia were randomly allocated into Group 1 receiving standard test dose (3 ml of 2% lignocaine with 1:2,00,000 adrenaline) or Group 2 (standard test dose with 6 ml of saline) epidurally. The blockade to cold sensation was assessed at 5 and 10 min. The heart rate (HR), systolic blood pressure (SBP), and mean arterial pressure (MAP) were recorded at baseline, 1, 5, and 10 min following epidural dosing. Statistical analysis was performed with Chi-square test for categorical and Student's t-test for continuous variables.

Results

The sensory blockade at 5 min was 69.5% versus 82.3% (P = 0.059), and at 10 min 85.4% versus 97.5% (P = 0.01) in Groups 1 and 2, respectively. The MAP at 5 min (P = 0.032) and the HR and MAP at 10 min (P = 0.015, 0.04) were significantly lower in Group 2.

Conclusion

An epidural test dose of 3 ml followed by additional 6 ml saline accurately predicted sensory blockade to cold at 10 min in comparison to the standard dose of 3 ml but was associated with a decrease in the HR and MAP.

Comparison of cross-legged sitting position with the traditional sitting position for the ease of insertion of an epidural catheter in parturient for providing labour analgesia: A randomised control trial

Background and Aims:

The patient's position during the insertion of the epidural catheter plays a major role in the success of labour analgesia. In our study, we compared the ease of insertion of the epidural catheter in either traditional sitting position (TSP) or crossed-legged sitting position (CLSP). The primary objective was to compare the number of successful first attempts at epidural placement between the groups. Secondary objective included patient comfort, ease of landmark palpation and the number of needle-bone contacts.

Methods:

The prospective non-blinded randomised control study was conducted on 50 parturient with uncomplicated pregnancy during active labour. Patients were randomly assigned into two groups using a computer-generated random sequence of numbers by closed envelope technique. Group TSP received epidural in a traditional sitting position and group CLSP received an epidural in a crossed-legged sitting position with knee and hip flexed.

Results:

The parturient in both groups were comparable with respect to the distribution of age, height, weight and parity. The baseline visual analogue score (VAS) and VAS scores at 15 min were comparable between groups. Percentage of a parturient with successful epidural placement in the first attempt was higher in CLSP group than in TSP group (88% versus 44%, P = 0.004). The landmark, needle-bone contact and comfort during positioning were comparable between the two groups.

Conclusion:

Cross-legged sitting position is a better position than the traditional sitting position for the ease of insertion of labour epidural catheter.

Effects of Preoxygenation with Tidal Volume Breathing Followed by Apneic Oxygenation with and without Continuous Positive Airway Pressure on Duration of Safe Apnea Time and Arterial Blood Gases

Background:

Application of continuous positive airway pressure (CPAP) helps to recruit collapsed areas of the lung, which improves the oxygen reserve.

Aim of the Study:

To compare the time to desaturate to 90% during apnea following preoxygenation and apneic ventilation with tidal volume breathing for 3 min with and without the application of CPAP.

Settings and Design:

This prospective randomized study was conducted in a tertiary care institution.

Subjects and Methods:

Twenty adult surgical patients were allocated into two groups. Group C patients were preoxygenated with 100% oxygen with CPAP of 20 cm H₂O for 3 min. Group P patients were preoxygenated for 3 min without CPAP. In Group C, apneic oxygenation was initiated following induction and neuromuscular blockade with CPAP of 20 cm H₂O. In Group P, no CPAP was applied. The study was terminated when the patient desaturated to 90%.

Statistical Analysis Used:

Chi-square test and Mann–Whitney test.

Results:

Group C had a significantly longer apnea time as compared to Group P (816.00 ± 30.98 vs. 348.00 ± 122.64 s). Three patients in Group P desaturated to <90% by 3 min and the remaining soon after 6 min. No patient in Group C desaturated till 12 min of apnea. PaO₂ was significantly higher in Group C at 3 and 6 min of apnea. At 3 and 6 min, Group P had significantly lower saturation as compared to Group C.

Conclusion:

Preoxygenation with CPAP significantly delayed desaturation during apnea with significantly higher arterial partial pressure of oxygen as compared to preoxygenation without CPAP.

Comparison of Arterial Oxygenation and Acid-Base Balance with the use of Transnasal Humidified Rapid-insufflation Ventilatory Exchange versus Tidal Volume Breathing with Continuous Positive Airway Pressure for Preoxygenation and Apneic Ventilation

Background:

Preoxygenation and apneic ventilation prolong apnea time without desaturation.

Aims:

The primary objective of this study is to compare arterial oxygenation during the periods of apnea following preoxygenation and apneic ventilation with tidal volume breathing for 3 min with continuous positive airway pressure (CPAP) versus with transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).

Settings and Designs:

This prospective randomized study was conducted in 20 adult patients at a tertiary care institution.

Subjects and Methods:

Group C patients (n = 10) were preoxygenated with 100% oxygen using a face mask at a rate of 6 L/min for 3 min with CPAP of 15 cm of H₂O. In Group H, oxygen was administered using THRIVE at 30 L/min for 3 min. Apneic ventilation was given in Group C with 10 L/min oxygen with CPAP of 15 cm H₂O and in Group H with THRIVE at 60 L/min. The endpoint was desaturation to 90% or maximum duration of 12 min.

Statistical Analysis Used:

Chi-square test and Mann–Whitney test.

Results:

Both groups tolerated apnea for 12 min without desaturation. PaO₂ in Group C was significantly higher than Group H from 3 min of apnea to 12 min. The PaCO₂ was significantly lower in Group C from 6 min. The pH was comparable in both groups except at 12 min with Group H having significantly lower pH.

Conclusion:

Tidal volume breathing with CPAP resulted in significantly higher arterial oxygen levels than THRIVE, though both modalities were equally effective in prolonging apnea time without desaturation up to 12 min. Group C showed an added advantage of lower PaCO₂ with less acidemia.

Effectiveness of transnasal humidified rapid-insufflation ventilatory exchange versus traditional preoxygenation followed by apnoeic oxygenation in delaying desaturation during apnoea: A preliminary study

Background and Aims:

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) during apnoea has shown to delay desaturation. The primary objective was to compare time to desaturate to <90% during apnoea with THRIVE versus traditional preoxygenation followed by apnoeic oxygenation.

Methods:

This prospective, randomised, single-blinded study was conducted in 10 adult patients presenting for direct laryngoscopy under general anaesthesia without endotracheal intubation. Group P patients were preoxygenated with 100% oxygen, and in Group H, high-flow humidified oxygen was delivered using nasal cannula for 3 min. After induction and neuromuscular blockade, time to desaturate to 90%, while receiving apnoeic oxygenation, was noted. Chi-square test and Mann–Whitney tests were used.

Results:

Group H had a significantly longer apnoea time as compared to Group P (796.00 ± 43.36 vs. 444.00 ± 52.56 s). All patients in Group H continued to have nearly 100% saturation even at 12 min of apnoea. However, in Group P, 80% of patients desaturated to <90% after 6 min of apnoea. Baseline blood gases, that following preoxygenation and at 3 min of apnoea time were comparable in both groups. At 6 min, Group H had a significantly higher PaO₂ (295.20 ± 122.26 vs. 135.00 ± 116.78) and PaCO₂ (69.46 ± 7.15 vs. 59.00 ± 4.64). Group H continued to have a PaO₂ of >200 mmHg even at 12 min of apnoea with a significant rise in PaCO₂ along with fall in pH after 6 min.

Conclusion:

During apnoeic periods time to desaturate to <90% was significantly prolonged with use of THRIVE.

Effects of Body Mass Index on Parasympathetic Nervous System Reactivity and Recovery Following Orthostatic Stress

Vagally mediated heart rate variability (vmHRV), defined as the beat-to-beat fluctuations in a heart series mediated by the vagus nerve, serves as a non-invasive index of parasympathetic nervous system (PNS) activity. Lower resting state vmHRV is associated with greater body mass index (BMI), providing a psychophysiological pathway linking obesity with health and disease. However little research has been conducted to examine how BMI may influence PNS reactivity to orthostatic stress. The present study sought to explore this in a sample of 59 individuals (44 females, mean age = 24.37 years, age range 19-65 years). VmHRV was measured throughout the 5-minute baseline (sitting), orthostatic (standing), and recovery (sitting) conditions. Individuals were stratified into low (BMI < 20), moderate (BMI 20-25), and high (BMI > 25) BMI groups. Results indicate that the high BMI group had a greater decrease in vmHRV from baseline to standing in comparison to the moderate BMI group. Furthermore, the low BMI group showed lower vmHRV during recovery compared to baseline, suggesting that these individuals did not fully recover from the standing position. Taken together, these results extend previous literature showing that those with low and high BMI can show different yet maladaptive patterns of vmHRV in response to orthostatic stress.

Efficacy of oral tolvaptan versus 3% hypertonic saline for correction of hyponatraemia in post-operative patients

Background and Aims:

Hyponatraemia is frequent in post-operative patients and may be corrected with hypertonic saline (HTS). Oral tolvaptan is used to treat hypervolaemic or euvolaemic hyponatraemia. This study was performed to assess the efficacy of oral tolvaptan in correcting postoperative hyponatraemia compared to HTS.

Methods:

This prospective, randomised study was conducted in 40 symptomatic patients with serum sodium level ≤130 mEq/L. In Group H (n = 20), 3% HTS was infused at 20–30 mL/h aiming for correction of 6 mEq/L/day. Group T received oral tolvaptan 15 mg on the 1^st day. If daily correction was <4 mEq/L, the dose was increased by 15 mg/day to a maximum of 45 mg. The primary outcome was serum sodium concentration 48 hours after starting treatment. Paired t-test was used to compare changes in sodium levels.

Results:

Baseline sodium and values at 12, 24 and 48 h were comparable in both groups. At 72 h, Group T had significantly higher sodium levels as compared to Group H (133.4 ± 1.9 vs. 131.3 ± 2.4 mEq/L). Intragroup analysis had shown a significant increase in sodium levels from baseline values in both groups at 12, 24, 48 and 72 h. Group H had a significantly lower potassium level and lower negative fluid balance on day 3.

Conclusion:

Oral tolvaptan and 3% HTS were equally effective in correcting hyponatraemia at 48 hours, but serum sodium levels were higher at 72 hours after oral tolvaptan.

Awareness on Hypertension and its Self-Management Practices Among Hypertensive Patients Attending Outreach Clinics of a Medical College in South India

Background Recent data suggest that hypertension is a significant public health problem in India. The success strategies for hypertension management depend upon clients' awareness on hypertension and its self-management practices. Objective To determine awareness, self-management practices and compliance with treatment among hypertensive patients. Method This cross-sectional study was done in January 2012 at four health centres in Mangalore. All confirmed cases of hypertension attending the outpatient department were interviewed using a semi-structured interview schedule. Result Majority (58.7%) of the 315 participants were of the age group 41 to 60 years and majority (53.6%) were males. Most patients (69.5%) were educated up to high school level. The awareness level about hypertension was average or good in majority (52.4%) of the participants. Self-management practices were found to be average or good among 60.6% cases. Good compliance with treatment was seen in 78.7% cases and blood pressure was in control in 72.4% cases. Quality of self-management practices was found to influence control of blood pressure (p=0.021). Awareness, self-management practices and compliance were found to be significantly poor among aged (above 50 years), males, less educated, unemployed, unskilled or retired patients. Conclusion Awareness on hypertension and self-management practices were average or above among majority of the studied population. However this study identified groups who need to be better educated and further monitored to achieve universal blood pressure control among hypertensive population during the routine health care services in this settings.

Association between occupational history of exposure to tobacco dust and risk of carcinoma cervix: A case-control study

CONTEXT

Cervical cancer is the second most common malignancy among women in India. There is thus a need to identify unexplored risk factors such as occupational exposure to tobacco dust to justify its increasing trend so as to recommend suitable preventive measures.

AIMS

The aim was to study the association between occupational exposure to tobacco dust with development of carcinoma cervix.

SETTINGS AND DESIGN

Case-control study done in two tertiary care hospitals in Mangalore.

METHODOLOGY

239 histologically confirmed new cases of cervical cancer and the equivalent number of age-matched controls from 2011 to 2012 were interviewed about occupational history of beedi rolling and related factors.

STATISTICAL ANALYSIS

Chi-square test, unpaired t-test, logistic regression.

RESULTS

Exposure rate to tobacco dust following beedi rolling was 63 (26.4%) among cases and 38 (15.9%) among controls (P = 0.005, odds ratio [OR] =1.893). The latent period from occupational exposure of tobacco dust subsequent to beedi rolling and development of cervical cancer was found to be 26.5 ± 8.5 years. Adjusted OR of beedi rolling with development of cervical cancer was found to be 1.913 (P = 0.005) after controlling the confounding effect of tobacco usage and was 1.618 (P = 0.225) after controlling the effects of all confounders. Three-quarters of beedi rollers were working in conditions of inadequate ventilation and hardy anybody used face mask during work. About a quarter of participants underwent voluntary screening for cervical cancer.

CONCLUSION

Occupational exposure to tobacco dust was found to be associated with risk of developing cervical cancer. Measures to promote awareness, timely screening of this disease along with the improvement in working conditions is required for improving the health status of beedi rollers and to minimize the incidence of carcinoma cervix in the community.

Pre-treatment lymphocytopaenia is an adverse prognostic biomarker in muscle-invasive and advanced bladder cancer

BACKGROUND

Pre-treatment lymphocytopaenia may result from cytokines secreted by the tumour microenvironment in association with aggressive tumour biology. We sought to establish the prognostic significance of lymphocytopaenia in muscle-invasive and advanced bladder cancer.

PATIENTS AND METHODS

Seventy-four patients with muscle-invasive bladder cancer treated with radical chemoradiotherapy and 131 patients with advanced bladder cancer treated with palliative chemotherapy were included in the study. The absolute lymphocyte count on the first day of treatment was recorded. Invasive local or systemic recurrence in the muscle-invasive bladder cancer cohort and all-cause mortality in the advanced bladder cancer cohort were defined as survival end points. Receiver operating characteristic (ROC) curve analysis was utilized to determine the cut-off for defining lymphocytopaenia in the muscle-invasive bladder cancer cohort followed by multivariable analysis in a model evaluating the following variables: anaemia, neutrophilia, tumour stage, hydronephrosis and neoadjuvant chemotherapy. Subsequently, lymphocytopaenia was assessed in a multivariable model of the advanced bladder cancer cohort analysing the following prognostic variables: neutrophilia, anaemia, performance status and presence of bone or visceral metastases. A further analysis was carried out evaluating absolute lymphocyte count as a continuous variable.

RESULTS

An absolute lymphocyte count of 1.5 × 10(9)/l was determined as the cut-off on ROC curve analysis in the muscle-invasive bladder cancer cohort, and multivariate analysis revealed that only lymphocytopaenia was predictive for inferior outcome in this cohort. In the advanced bladder cancer cohort, lymphocytopaenia [hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.1-2.4; P = 0.02] and performance status (HR 1.7, 95% CI 1.0-2.7; P = 0.047) were adverse prognostic factors in the binary variable multivariate model. Absolute lymphocyte count was the sole significant factor when analysed as a continuous variable (HR 0.66, 95% CI 0.5-0.87; P = 0.003).

CONCLUSION

Pre-treatment lymphocytopaenia is an independent adverse prognostic factor in both muscle-invasive and advanced bladder cancer. It may be a manifestation of cancer-induced immune suppression driving tumour progression.

Perception of Simulation-based Learning among Medical Students in South India

Background:

Traditional methods of educating medical students are no longer sufficient in the current era largely influenced by multimedia. Simulation-based techniques may play a pivotal role in bridging this educational gap.

Aim:

This study was conducted to explore the perception of medical students towards simulation based learning (SBL).

Subjects and Methods:

This cross-sectional study was conducted in May 2013 in a private medical college in Mangalore, Karnataka, India. A total of 247 participants from fourth, sixth, eighth semester and internship were chosen by convenience sampling method. Attitudinal data on perception towards SBL were collected using a self-administered questionnaire with responses in a 5-point Likert's scale.

Results:

The mean age of students was 21.3 (standard deviation 1.9) years, and males constituted 55.5% (137/247). Most participants 72.5% (179/247) had favorable perceptions of SBL, with scores of92–118 out of a possible 118 points. Favorable perception towards SBL was seen significantly more among female students (P = 0.04) and senior MBBS students of sixth and eighth semesters (P = 0.05). Nearly, all students (90.7%; 224/247) agreed that simulation supports the development of clinical skills. As many as 29.6% (73/247) agreed that real patients might be replaced with simulated patients in practical examinations.

Conclusion:

SBL was perceived as favorable by a large number of participants in this study indicating a bright prospect for its implementation in the medical curriculum.

Kinetically Selective Inhibitors of Histone Deacetylase 2 (HDAC2) as Cognition Enhancers

Kinetically selective inhibitors of HDAC2 enhanced learning and memory in a CK-p25 mouse model of neurodegeneration.

Aiming towards the development of novel nootropic therapeutics to address the cognitive impairment common to a range of brain disorders, we set out to develop highly selective small molecule inhibitors of HDAC2, a chromatin modifying histone deacetylase implicated in memory formation and synaptic plasticity. Novel ortho-aminoanilide inhibitors were designed and evaluated for their ability to selectively inhibit HDAC2 versus the other Class I HDACs. Kinetic and thermodynamic binding properties were essential elements of our design strategy and two novel classes of ortho-aminoanilides, that exhibit kinetic selectivity (biased residence time) for HDAC2 versus the highly homologous isoform HDAC1, were identified. These kinetically selective HDAC2 inhibitors (BRD6688 and BRD4884) increased H4K12 and H3K9 histone acetylation in primary mouse neuronal cell culture assays, in the hippocampus of CK-p25 mice, a model of neurodegenerative disease, and rescued the associated memory deficits of these mice in a cognition behavioural model. These studies demonstrate for the first time that selective pharmacological inhibition of HDAC2 is feasible and that inhibition of the catalytic activity of this enzyme may serve as a therapeutic approach towards enhancing the learning and memory processes that are affected in many neurological and psychiatric disorders.

Knowledge of first aid skills among students of a medical college in mangalore city of South India

Background:

The adequate knowledge required for handling an emergency without hospital setting at the site of the accident or emergency may not be sufficient as most medical schools do not have formal first aid training in the teaching curriculum.

Aim:

The aim of this study is to assess the level of knowledge of medical students in providing first aid care.

Subjects and Methods:

This cross-sectional study was conducted during May 2011 among 152 medical students. Data was collected using a self-administered questionnaire. Based on the scores obtained in each condition requiring first aid, the overall knowledge was graded as good, moderate and poor.

Results:

Only 11.2% (17/152) of the total student participants had previous exposure to first aid training. Good knowledge about first aid was observed in 13.8% (21/152), moderate knowledge in 68.4% (104/152) and poor knowledge in 17.8% (27/152) participants. Analysis of knowledge about first aid management in select conditions found that 21% (32/152) had poor knowledge regarding first aid management for shock and for gastro esophageal reflux disease and 20.4% (31/152) for epistaxis and foreign body in eyes. All students felt that first aid skills need to be taught from the school level onwards and all of them were willing to enroll in any formal first aid training sessions.

Conclusion:

The level of knowledge about first aid was not good among majority of the students. The study also identified the key areas in which first aid knowledge was lacking. There is thus a need for formal first aid training to be introduced in the medical curriculum.

Curcumin, an active component of turmeric in the prevention and treatment of ulcerative colitis: preclinical and clinical observations

Inflammatory bowel disease (IBD) comprising of ulcerative colitis (UC) and Crohn's disease (CD) is a major ailment affecting the small and large bowel. In clinics, IBD is treated using 5-amninosalicylates, antibiotics, the steroids and immunomodulators. Unfortunately, the long term usages of these agents are associated with undue side effects and compromise the therapeutic advantage. Accordingly, there is a need for novel agents that are effective, acceptable and non toxic to humans. Preclinical studies in experimental animals have shown that curcumin, an active principle of the Indian spice turmeric (Curcuma longa Linn) is effective in preventing or ameliorating UC and inflammation. Over the last few decades there has been increasing interest in the possible role of curcumin in IBD and several studies with various experimental models of IBD have shown it to be effective in mediating the inhibitory effects by scavenging free radicals, increasing antioxidants, influencing multiple signaling pathways, especially the kinases (MAPK, ERK), inhibiting myeloperoxidase, COX-1, COX-2, LOX, TNF-α, IFN-γ, iNOS; inhibiting the transcription factor NF-κB. Clinical studies have also shown that co-administration of curcumin with conventional drugs was effective, to be well-tolerated and treated as a safe medication for maintaining remission, to prevent relapse and improve clinical activity index. Large randomized controlled clinical investigations are required to fully understand the potential of oral curcumin for treating IBD.

Future specialization interests among medical students in southern India

BACKGROUND

A consideration of the future specialization interests of undergraduate medical students might help to understand the needs of higher medical education and future manpower availability for healthcare.

METHODS

A cross-sectional study was conducted among 373 undergraduate students of a medical college in southern India using a self-administered questionnaire.

RESULTS

Of the 373 students, 188 (50.4%) were men. Almost all of them (370 [99.2%]) wanted to pursue postgraduation. Of these, 267 (72.4%) wanted to pursue postgraduation in India. Overall, the first choice subject was surgery (120 [32.2%]) followed by internal medicine (85 [22.8%]) and paediatrics (43 [11.5%]). The third preference for men and women differed, with men choosing orthopaedics and women choosing obstetrics and gynaecology. The factors that influenced the choice of specialization were interest in the speciality (Likert scale score 4.7), job satisfaction (4.6), employment opportunities (4.0), job security (4) and high income potential (3.9).

CONCLUSION

It was evident from the proportion of students desiring to do postgraduation and their choice of specialties that most of them will end up working at hospitals instead of at primary healthcare centres. The deficiencies of certain specialists such as ophthalmologists are likely to persist. This is a cause for concern as the majority of our population lives in rural areas and there is already a maldistribution of doctors.

Hypoxia-microRNA-16 downregulation induces VEGF expression in anaplastic lymphoma kinase (ALK)-positive anaplastic large-cell lymphomas

The anaplastic lymphoma kinase (ALK), tyrosine kinase oncogene is implicated in a wide variety of cancers. In this study we used conditional onco-ALK (NPM-ALK and TPM3-ALK) mouse MEF cell lines (ALK+ fibroblasts) and transgenic models (ALK+ B-lymphoma) to investigate the involvement and regulation of angiogenesis in ALK tumor development. First, we observed that ALK expression leads to downregulation of miR-16 and increased Vascular Endothelial Growth Factor (VEGF) levels. Second, we found that modification of miR-16 levels in TPM3-ALK MEF cells greatly affected VEGF levels. Third, we demonstrated that miR-16 directly interacts with VEGF mRNA at the 3'-untranslated region and that the regulation of VEGF by miR-16 occurs at the translational level. Fourth, we showed that expression of both the ALK oncogene and hypoxia-induced factor 1α (HIF1α) is a prerequisite for miR-16 downregulation. Fifth, in vivo, miR-16 gain resulted in reduced angiogenesis and tumor growth. Finally, we highlighted an inverse correlation between the levels of miR-16 and VEGF in human NPM-ALK+ Anaplastic Large Cell Lymphomas (ALCL). Altogether, our results demonstrate, for the first time, the involvement of angiogenesis in ALK+ ALCL and strongly suggest an important role for hypoxia-miR-16 in regulating VEGF translation.

A study of the knowledge and attitude towards pulse polio immunization in semi urban areas of South India

BACKGROUND

The government of India launched the pulse polio immunization (PPI) programme in 1995 with the aim of eradicating poliomyelitis by the end of 2000. Despite this, 733 children with polio were reported in 2009 alone. Therefore, there is a need to understand the reason underlying such high numbers of cases after so many years of programme implementation. This study was performed to assess the knowledge of the general population about poliomyelitis and PPI and their attitude and practice towards PPI.

METHOD

This cross-sectional study was undertaken in two semi- urban areas of Mangalore city. Only houses in which children under five lived were included in the study. Data was collected by interviewing any adult member of the household using a pretested questionnaire.

RESULTS

The literacy rate of study participants was 99%. Only 35(10.9%) participants knew the correct mode of transmission of polio. More than one quarter of the study population were under the misconception that polio is a curable disease. The primary source of information about PPI in majority of participants was the television (n = 192; 60%). Two-hundred and eighty eight (90%) participants knew that the purpose of PPI was to eradicate polio. Only 128 (40%) participants knew that polio drops can be given to children with mild illnesses and an identical number of participants knew that hot food stuff should not be given for at least half an hour following vaccination administration. Misconceptions such as PPI causing vaccine overdose was identified among 7 (2.2%) participants, it is a substitute for routine immunization was believed among 30 (9.4%) participants and that oral polio vaccine prevents other diseases was seen among 76 (23.7%) participants. The educational status of the participants was significantly associated with their awareness level (χ(2) =13.668, DF=6, P=0.033).

CONCLUSION

This study identified a few important misconceptions associated with polio and PPI which need to be addressed by large scale awareness campaigns in order to achieve polio eradication in the near future.