Journal of postgraduate medicine最新文献

Abstract: Lipedema is a chronic adipose tissue disorder primarily affecting women, marked by abnormal, symmetrical, and disproportionate accumulation of subcutaneous fat in the lower limbs and sometimes in the arms, with hands and feet typically spared. Frequently misdiagnosed as lymphedema or obesity, lipedema presents with pain, easy bruising, bilateral nonpitting edema, and swelling that worsens throughout the day. We present two cases: Two middle-aged women reported longstanding bilateral lower limb swelling, pain, and varicose veins, without significant comorbidities. Clinical examination revealed characteristic disproportionate fat distribution and negative Stemmer's sign. Laboratory investigations and lymphoscintigraphy excluded other causes of edema. Imaging confirmed subcutaneous thickening, fat stranding, and varicosities. Both patients were advised to have conservative management including compression therapy, limb elevation, physiotherapy and dietary counseling; one exhibited significant limb volume reduction. Our report underscores the importance of recognizing lipedema for early diagnosis and effective management to prevent progression and complications.

Introduction: Antimicrobial resistance (AMR) represents a global public health crisis. The WHO Global Action Plan and India's National Action Plan on AMR underscore the rational use of antibiotics in healthcare settings as a critical strategy for mitigating AMR. Intensive Care Units (ICUs) are high-risk environments for development of AMR. This study analyzes baseline antibiotic utilization data in ICUs by applying the defined daily dose (DDD) metrics in the context of the 'Access', 'Watch', 'Reserve' (AWaRe) classification framework.

Materials and methods: This prospective observational study was conducted over a 12-month period. Data from patients prescribed antibacterials for systemic use during their stay in the medicine, surgery, and neurosurgery ICUs were included. Antibiotic utilization was analyzed using daily dose metrics and the WHO AWaRe framework.

Results: Data from 359 eligible ICU patients were analyzed. The DU75% segment included 'Watch' category antibiotics, ceftriaxone, meropenem, and 'Access' category antibiotics, metronidazole and doxycycline. 'Watch' category antibiotics were used most frequently, with a cumulative DDD/100 patient days of 71.8. This was followed by the 'Access' category with a cumulative DDD/100 patient days of 48. The use of 'Watch' category antibiotics in the NSICU was significantly higher than in other ICUs ( P < 0.005, χ2 = 7.8). Antibiotics were used mostly for prophylaxis (59%), followed by empirical (28.4%) and definitive therapy (13%).

Conclusions: The study demonstrates excessive use of 'Watch' antibiotics and a relative underuse of 'Access' agents in ICUs, emphasizing the scope for implementing robust stewardship measures including culture-guided de-escalation, formulary restriction of broad-spectrum agents, and implementing stringent surgical prophylaxis protocols.

Abstract: This scoping review aimed to map the landscape of medical education research (MER) in India from 2016 to 2021, focusing on teaching-learning methodologies. The objectives were to identify demographic trends, analyze research methodologies and their shifts, and inform future research priorities. It was conducted following updated Joanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A systematic search was performed across MEDLINE, Education Resources Information Center (ERIC), and Google Scholar, supplemented by hand-searched journals to select original English-language research articles that addressed teaching-learning methodologies within Indian medical colleges. Data on pertinent variables were extracted. The methodological quality of these studies was assessed using the Mixed Methods Appraisal Tool. From 348 articles screened, 238 met the inclusion criteria. Publication output showed a peak in 2021 (n = 60). A majority of studies originated from private medical colleges (n = 137, 57.6%). The department of Physiology was the most frequent contributor. Undergraduate students were the main participants (n = 205, 86.1%). Most studies were classroom-based (n = 172, 72.3%) and used quantitative, perception-based methods (n = 208, 87.4%). Only 56 studies (23.5%) were rated as high quality. Ethical approval and informed consent were reported in 79.4% (n = 189) and 66.0% (n = 157) of studies, respectively. MER in India has grown in volume since 2016, but significant improvements are needed in methodological rigor, ethical transparency, and instrument validation. It is dominated by quantitative, perception-based studies focusing on undergraduates. Future progress requires in-depth training in research methodologies, improved reporting standards, and stronger institutional support.

Abstract: Sample size is among the most common concerns while planning an empirical research study in health and medicine. Its role in rigorous conclusions is well known. The procedure for determining the sample size is different for the estimation of a population parameter than for testing a hypothesis on a parameter. The former requires specification of the tolerable margin of error, and the latter the minimum clinically important effect to be not missed when present. But all research studies must be subjected to the highest rigor, and several other factors, such as inter-subject variability and the design, need to be considered for determining the adequate sample size. This communication compiles all these considerations together at one place. This also provides a general method for computing sample size for the two types of statistical inferences, which is not generally available in the literature. This may sensitize the reader to the ingredients required for calculating the correct sample size and the intricacies involved. The sources and tools for the calculation of sample size are also presented. This may enable the researchers and statisticians to determine the right sample size for rigorous results in their study.

Abstract: Antimicrobial resistance (AMR) is a growing concern that can compromise clinical outcomes as well as increase the significant economic stress on healthcare systems. Antimicrobial stewardship programs (ASPs) have demonstrated promising results in improving treatment outcomes and reducing costs worldwide. However, the effectiveness of ASP in Indian hospital settings remains underexplored. This systematic review aimed to evaluate the effectiveness of implementing ASP in Indian hospital settings. Literature search was carried out in electronic databases such as PubMed, Clinical Trials Registry-India, Clinicaltrials.gov, and Google Scholar from January 2015 till April 2025 to identify published studies that explored the clinical outcomes in Indian hospital-based settings that implemented ASP. Studies that assessed at least one of the following outcomes-AMR pattern, infection rate, mortality rate, prescription pattern, costs, or barriers/challenges in ASP implementation-were eligible for screening. Two independent reviewers screened the articles for eligibility, with discrepancies resolved through discussion with a third reviewer. Out of the 1732 studies screened, 11 studies were found eligible for inclusion. Those studies were conducted in different Indian states. Each study implemented different ASP practices, including infection control, audit and feedback, and customized training. Most of the studies evaluated demonstrated improvements such as a reduction in inappropriate prescriptions, lower antimicrobial resistance rates, decreased infection and mortality rates, and reduced costs following the implementation of ASP. Despite the benefits, implementation challenges remain. This review highlights the need for strict ASP implementation and monitoring in Indian hospitals to combat AMR.

Introduction: Artemisinin combination therapy (ACT) is the World Health Organization (WHO) recommended first-line therapy for falciparum malaria. However, recent concern is ACT resistance. Arterolane-piperaquine is a synthetic alternative to ACT. Our objective was to determine the safety and efficacy of arterolane-piperaquine in comparison with artemether-lumefantrine for the treatment of falciparum malaria.

Material and methods: We conducted a systematic review and meta-analysis to determine the safety and efficacy of arterolane maleate and piperaquine phosphate for the treatment of uncomplicated falciparum malaria. We searched PubMed/MEDLINE, Cochrane Library, Google Scholar, Clinical Trials.gov and MedRxiv. Search results were screened by title, abstract, and full text before inclusion into the study. Meta-analysis of risk difference between arterolane-piperaquine and artemether-lumefantrine in regard to safety and efficacy was done using a random effects model.

Results: Four randomized controlled trials (RCTs) were included. One RCT had a high risk of bias, while the other three studies had a low risk of bias. The 28-day polymerase chain reaction (PCR) corrected risk difference between the artemether-lumefantrine and arterolane-piperaquine was 0 (95% confidence interval -0.02 to 0.02), whereas the PCR uncorrected risk difference was 0.11 (95% confidence interval -0.06 to 0.27). On 42-day follow-up, the PCR uncorrected risk difference was 0.17 (95% confidence interval -0.05 to 0.38), while the PCR-corrected risk difference was 0.01 (95% confidence interval -0.01 to 0.03). Adverse effect profile was similar with risk difference of at least one adverse effect being -0.01 (95% confidence interval -0.02 to 0.00). The commonly reported adverse effects of arterolane-piperaquine were vomiting, anemia, and pain abdomen.

Conclusions: Our study shows that arterolane-piperaquine is non-inferior to artemether-lumefantrine for the treatment of uncomplicated falciparum malaria.

Introduction: The combined impact of type 2 diabetes mellitus (T2DM), sarcopenia, and hypertension on incident cardiovascular disease (CVD) and mortality remains inconclusive. This study aimed to evaluate the additive effect of these co-morbidities on CVD and all-cause mortality among Chinese adults aged 45 years and older.

Materials and methods: A total of 12,398 participants were enrolled in the China Health and Retirement Longitudinal Study. Participants were categorized based on their T2DM, sarcopenia, and hypertension status. The study outcomes included incident CVD (including heart disease and stroke) and all-cause mortality. Multivariable logistic regression models and population attributable fractions (PAFs) were employed to investigate the associations between the coexistence of T2DM, sarcopenia, and hypertension with CVD incidence and mortality.

Results: Compared to those with none of T2DM, sarcopenia, or hypertension, participants with any one, any two, or all three of these conditions exhibited increased risks of incident CVD and higher odds of all-cause mortality. The ORs for CVD and all-cause mortality significantly increased in the groups with none, any one, any two, and all three co-morbidities. (P for trend < 0.001) These three co-morbidities collectively explained 19.1% (95% confidence interval [CI]: 15.7, 22.3) of PAF for CVD and 19.0% (95% CI: 13.5, 24.2) for mortality. The results remained generally consistent in the sensitivity analyses.

Conclusions: Participants with the coexistence of T2DM, sarcopenia, and hypertension faced a more than two-fold increase in the risk of CVD events and mortality. The estimated PAFs indicated that preventing these three co-morbidities could be beneficial in reducing CVD incidence and all-cause mortality.