National Medical Journal of India最新文献

Background Device closure of atrial septal defect (ASD) has emerged as a treatment modality for the past 3 decades and has changed the natural history of ASD compared to that of surgical closure. Early intervention in ASD retards the geometrical and electrical remodelling of the atrium that contributes to the development of atrial tachyarrhythmias. We studied the incidence of atrial arrhythmias in patients undergoing surgical and device closure of ASD. Methods We did this retrospective observational study at a tertiary referral centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. Patients of all age groups undergoing surgical and device closure of ASD between 1 January 2003 and 31 December 2008 were included to compare the incidence and nature of atrial arrhythmias and also analyse the difference in new-onset atrial arrhythmias between the two arms. Results Of 277 patients, 144 with surgical closure and 133 with device closure were followed up for 10-15 years. A larger number of men underwent surgical closure (41.7%) compared to device closure (25.6%). The mean (SD) follow-up was 12.6 (3.7) years in the surgical closure group and 10.9 (2.6) years in the device closure arm. There were a larger number of patients with atrial tachyarrhythmias in the surgical closure group (6.3%) compared to the device closure group (0.8%) at baseline (p=0.02). A significantly larger number of patients had atrial fibrillation in the surgical closure group (5.6%) compared to the device closure group (0.7%) at baseline (p=0.003). Pulmonary hypertension at baseline was present in 38.9% of patients in the surgical closure group and in 23.3% of patients in the device closure group (p=0.006). New-onset atrial arrhythmias occurred in patients ≥30 years of age (p=0.006) and exclusively in patients with pulmonary hypertension in the surgical group (3.7%) and in the device closure group (6.6%). This was statistically significant in the device closure group (p=0.05) but not in the surgical closure group (p=0.13). The incidence of new-onset arrhythmias was not statistically significant in both groups. Conclusions Atrial arrhythmias were significantly more common in patients who underwent surgical or device closure at ≥ 30 years of age and in patients with pulmonary hypertension. There was no difference in new-onset atrial arrhythmias between the surgical and device closure groups. Our study results suggest that surgical or device closure before 30 years of age and before the development of atrial arrhythmias may be beneficial with respect to the development of atrial arrhythmias.

Background Palliative care for children is an innovative approach that helps improve the quality of life of children suffering from life-limiting illnesses, and their family members. The WHO recognized palliative care as a part of universal health coverage. However, there is inadequate availability and inequitable distribution of palliative care services for children in most parts of the world. We reviewed the existing literature to assess (i) the challenges in providing palliative care services for children suffering from life-limiting illnesses and (ii) the strategies or opportunities to overcome these challenges. Methods We conducted systematic searches in the PubMed and Scopus databases to find articles published in the past 10 years (January 2011 to December 2020). The population, concept and context (PCC) framework was used to devise a search strategy in an electronic database. Results A total of 1562 articles were found by searching the database and other sources. Title and abstracts of articles were screened, and 206 articles were selected for full-text review. After scrutiny 28 articles met the inclusion criteria. Barriers to and opportunities in the provision of palliative care services for children were identified at policy, organizational, healthcare provider, and patient/family levels. Conclusion We found that the majority of barriers to provision of palliative care services for children with life-limiting illnesses can be addressed by adopting research-driven strategies. Adequate and equitable distribution of palliative care services is required for improving children and their family members' quality of life.

The Covid-19 pandemic affected undergraduate medical education worldwide. By March 2020, colleges in India had to close following a national lockdown. Most of the colleges including ours started using e-platforms. Our earlier studies highlighted concern for lack of patient examination in clinical settings and successes of the online teaching programmes were limited to didactic teaching. The year 2020 also was the year in which the National Medical Commission (NMC) introduced a competency-based system, which was new to all stakeholders. We assessed the impact of Covid-19 on the ongoing teaching pattern in our institute. Actual coverage of theory classes and practical/clinical teaching sessions were gathered from departments across all years of undergraduate medical education and the gap percentage was calculated against the NMC/ Medical Council of India requirements. The gap percentage was calculated as missing classes divided by required classes multiplied by hundred. The heads of departments were consulted, and details of theory, practical and clinical classes taken for each batch before and after lockdown were gathered using a questionnaire. These were compared against the mandated teaching by the NMC guideline for theory, practical and clinics. The results showed a gap ranging from 2% to 83% for theory classes, the least being in anatomy and the highest being in medicine. As there were no practical or clinical sessions during the lockdown, the gap was zero. Various challenges were faced due to online medical education. There was a dilemma over choosing the type of training that would produce adequate numbers with low quality or a delayed training but of assured quality. Various solutions including suspending the ongoing course and converting it to short-term skill training sessions to deal with pandemic care and strategies to improve online teaching were considered.

Background Hyperglycaemia and hypoglycaemia in hospitalized patients are associated with poor clinical outcomes. We assessed whether administration of an online educational course for medicine residents improves the glycaemic management of hospitalized patients with diabetes. Methods We conducted this quasi-experimental, pre-post study from January 2019 to April 2019. The contents of the course were in compliance with the American Diabetes Association Guidelines 2018. After participating in the online course, the change in the knowledge of residents was assessed by pre- and post-test questionnaire and changes in the inpatient diabetes care were assessed by case record review of the hospitalized patients with diabetes managed by them before and after the participation in the course. Results Fifty-six residents participated and completed the online course. Their average post-test scores increased by 11.6%. One hundred and eighteen patients managed by the residents in the same wards before and after the participation in the course were studied. After attending the course, glycaemic targets were predetermined in 75.4% of patients compared to 32.2% before and adequacy of glucose monitoring improved. The total hypoglycaemic event rate reduced significantly by 45.8% and this was accompanied by a trend towards improved glycaemic control. At the time of discharge, the patient awareness on insulin injection technique, hypoglycaemic symptoms and its home remedies were significantly increased. Conclusion The administration of an online course increases the knowledge level of residents, improves patient safety and may improve glycaemic control in hospitalized patients with diabetes.

Background The traditional coronary calcium score (CCS) is a time-tested tool for the evaluation of coronary atherosclerosis and predictor of future cardiovascular events. Non-traditional tools can also have a value in predicting and detecting subclinical coronary artery disease (CAD). Methods We studied the role of CCS, the traditional CAD risk predictor, and the less-recognized, non-traditional risk factors, i.e. epicardial fat volume (EFV) and thoracic extracoronary calcium (ECC), to assess the degree of subclinical CAD. In this cross-sectional observational study, we included 950 Indian patients (suspected to have CAD). Coronary computed tomography angiography was performed. Estimation of CCS, EFV and thoracic ECC was done. Results A CCS of 0 was seen in 583 patients (61.4%). Of these, 492 patients had normal coronary angiogram but 91 patients had CAD. The median values of EFV were statistically significantly higher in the 'CAD present and CCS 0' group compared to the 'CAD absent and CCS 0' group (p<0.001). The presence of thoracic ECC involving at least a single site was seen in only 6 of these 91 patients. When both EFV and CCS were considered together for the detection of CAD, the sensitivity and negative predictive value (NPV) were improved compared to either of these in isolation. When ECC was taken together with CCS and EFV, no further improvement in sensitivity or NPV was observed. Conclusion The combined use of traditional CCS along with non-traditional EFV may guide us in better profiling cardiovascular risk and supplement the various traditional cardiovascular risk factors/scores.