A BSTRACT Introduction: Theory papers have been the most commonly employed method to assess learning outcomes in medical education. In these papers, both recall abilities and higher-order cognitive functions need to be assessed giving proper weightage as per relevance. Hence it becomes necessary that valid assessment methods are employed to evaluate the required objectives/competencies. The objective of the study was to develop a method for analyzing postgraduate question papers of various specialties. Methodology: A rubric matrix was created with three broad objective criteria to assess framing and layout of the questions in each paper, analysis of different sets for same examination, and finally an overall assessment of all the papers for each subject. Results: A total of 28 specialty papers were available. A total number of papers analysed = 340. The overall mean score out of total 60 marks was 38.64 ± 4.5. It was seen that the majority (60%) of the departments have been graded as fair on analysis of the theory papers. None of the departments were graded as very good, while 7% of them were graded as good. Although a very minuscule percentage of the papers had grammatical errors and duplication of questions in the sets, only 57% of the departments had done a proper moderation and 21% had used higher domains of learning for assessment. Conclusion: Analysis of postgraduate question papers showed that the questions asked for postgraduates are more recall-based instead of higher taxonomy of cognitive domain.

Parasitic infections of the intestine are a major health problem, which is found more prevalent in developing countries such as India. They are one of the important causes of morbidity and mortality among people all over the world. Acute amoebic appendicitis is a rare entity. We came across a case of acute appendicitis in a young pregnant woman, which revealed colonies of Entamoeba histolytica trophozoites in the mucosal epithelium and submucosal layer of the appendix with marked evidence of acute appendicitis. This report highlights acute appendicitis of amoebic origin and emphasises the importance of thorough examination of the appendix at various levels during histopathology and about the combined treatment of appendicectomy combined with antimicrobials as the treatment of choice. Appendicectomy removes the focus of infection, and antimicrobials reduce the incidence of septic complications.

Background:Fasting is practiced by various religions in the world. The previous studies show the effect of fasting on biochemical markers in healthy subjects; however, no study is available on its effect on gene expression or epigenetic markers. In the present study, miR126, a microRNA, was measured in serum samples of healthy adult subjects, and their correlation with biochemical profile was carried out during the short-term fasting of the Navratri festival.Methods:A total of 30 subjects who underwent fasting for 07 days during the Navratri festival were recruited for the study. The fasting blood samples were obtained at three different time points; day 1 of fasting, day 7 of fasting, and day 7 after completion of fasting period. The miR126 expression, fasting plasma glucose, and lipid profile were measured in all the three samples.Results:The miR126 levels showed a decreasing trend with a significant difference across the three time points (p-value = 0.006). Fasting plasma glucose increased continuously across three time points without showing any statistical significance. Serum total cholesterol (p = 0.001) and triglycerides (p = 0.001) levels were decreased initially and then increased after resuming normal diet. There was a medium-level negative correlation (-0.332) between baseline fasting glucose level and miR126 level (p = 0.068).Conclusion:The study revealed that serum levels of total cholesterol and triglyceride were more dynamic than the miR126 levels. A significant decrease in the miR126 expression across three time points is a promising outcome of this pilot study and indicates its role in short-term fasting. However, the fasting plasma glucose showed heterogeneous values without significant correlation with miR126 levels.

BACKGROUND:Antibody response to SARS-CoV may be estimated to give trends and patterns emerging in a population during an evolving epidemic. The novel coronavirus has opened a new chapter in the history of pandemics and understanding the disease epidemiology.METHODS:The study was a cross-sectional descriptive study. Institutional Ethical clearance and informed consent were taken for participation in the study. The study population included all personnel reporting to the institute for training courses, permanent posting or joining back from leave during the study period of 2 months (16 June to 16 August 2020). The sample size was calculated assuming the prevalence of COVID-19 to be 1% with the absolute precision of 0.5% and 5% level of significance, and finite correction for population size of 500, and the calculated sample size was 377. Inclusion criteria were all personnel reporting to the institute from different states and districts. Exclusion criteria-Any personnel reported for a short visit of lesser than 14 days. Demographic details and details of any likely exposure to a confirmed COVID-19 case were noted. A blood sample was collected, and serological tests were done using ErbaLisa COVID-19 IgG kit by Calbiotech, as per the manufacturer's instructions.RESULTS:Overall seropositivity of IgG COVID-19 antibodies was 7.5% (31/413) (95% CI: 5.3-10.4%). Study population (n = 413) comprised of an adult population in the age range of 21 years-53 years, and the mean age was 31.4 years (SD = 6.2 years).CONCLUSION:As the personnel joining the institute have come from various parts of the country the study provides an estimation of antibodies against COVID-19.

BACKGROUND:The first dose of the ChAdOx1 nCoV- 19 Corona Virus Vaccine (Covishield) was administered to the eligible beneficiaries of tertiary care institute of Western Maharashtra on 16 Jan 21 and in the past three months almost 97% of the staff has been vaccinated. The present study analyses the incidence of COVID cases in the unvaccinated and vaccinated population of the institute. METHODS:All Covid 19 infections (RT-PCR positive) from 01 February 21 to 25 April 21 were included in the study and analyzed as per their vaccination status. To assess the COVID 19 transmission in contacts, Secondary Attack Rates (SAR) of the pre-vaccination period (Jun-Oct 20) was compared with the present SAR. RESULTS:A total of 113 cases occurred in the study period (01 Feb to 25 Apr 21). Lower number of infections were observed among the fully vaccinated as compared to partially vaccinated and non-vaccinated. The overall vaccine effectiveness was found to be 88.6% (81.55-92.37) and 44.1% (4.55-67.3) in completely and partially vaccinated individuals respectively. Hazard Ratios for getting infected dropped significantly after 28 days of the second dose. The SAR in high risk contacts (HRCs) was found to be 4.25%, which was lower than SAR (20.6%) of pre-vaccination period. CONCLUSION:This is one of the earliest studies in India to report the impact of COVID-19 vaccination. The results indicate that the vaccine provides effective protection against COVID-19 infection. However, given the complex dynamics of vaccination, the role of NPIs and implementation of COVID appropriate behavior cannot be undermined.

Precision medicine has brought in many changes to the practise of medicine. The omics-based development of biomarkers and pharmaco-omics-based drug development programmes are evidences for the advancement. However, the field where it has proved to be most useful is in the development of various modalities of treatment in oncology. Various drugs targeting vascular endothelial growth factor, epidermal growth factor, tyrosine kinase receptor and rat sarcoma mutations have come to the forefront proving to be beneficial in many cancers. Some of the classic drugs developed using this concept include trastuzumab, bevacizumab, cetuximab and panitumumab among others. Precision medicine has been put to best use in the COVID-19 pandemic through use of various biomarkers such as IL-6 and c-reactive protein in assessing severity of disease, for development of various therapies and also to judge efficacy of vaccines. Precision medicine is also finding its place in management of infectious diseases, chronic diseases such as asthma, connective tissue diseases, cardiovascular diseases, diabetes and obesity. India has also made its presence felt in the field by launching various initiatives such as the Indian genome project and Indian cancer genome atlas. Numerous challenges still exist to the future of precision medicine such as cost involved, ethics, security of the Big data, merger of various platforms to integrate data and also availability of trained manpower to manage the data and algorithms. This new age medicine is a big step forward for mankind and hopefully it will bring more benefits for both patients and the caregivers in the near future.

Background: As the world battles the coronavirus disease 2019 (COVID-19) pandemic, rapid detection is the key to contain the spread of the disease. Although real-time polymerase chain reaction (RT-PCR) remains the gold standard for the diagnosis of severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection, it demands specialized equipment and technical expertise. SARS-CoV-2 rapid antigen detection test (RAT) is the user-friendly alternative, which needs evaluation in the hospital setting. Materials and Methods: This cross-sectional study was carried out at the Indian Council of Medical Research approved COVID-19 diagnostic molecular laboratory between November and December 2020. Nasopharyngeal swabs in viral transport medium (VTM) were received from suspected SARS-CoV-2 infected individuals were processed for SARS-CoV-2 RT-PCR and a rapid antigen detection test, COVID-19 Ag Respi-Strip. Results: A total of 342 samples were assessed for this study by RT-PCR and Rapid Antigen Test. The sensitivity of RAT was found to be 41% at an RT-PCR cycle threshold of 35 or below. Sensitivity of RAT improved to 81.2% when a RT-PCR cycle threshold of 25 or below was considered as positive. Specificity of RAT was 99% to 100%. Conclusion: Rapid antigen test is a cost-effective alternative for screening of symptomatic individuals in the hospital setting. However, due to low sensitivity, the negative results need to be interpreted with caution.

Precision medicine is the new age medicine and refers to tailoring treatments to a subpopulation who have a common susceptibility to a particular disease or similar response to a particular drug. Although the concept existed even during the times of Sir William Osler, it was given a shot in the arm with the Precision Medicine Initiative launched by Barack Obama in 2015. The main tools of precision medicine are Big data, artificial intelligence, the various omics, pharmaco-omics, environmental and social factors and the integration of these with preventive and population medicine. Big data can be acquired from electronic health records of patients and includes various biomarkers (clinical and omics based), laboratory and radiological investigations and these can be analysed through machine learning by various complex flowcharts setting up an algorithm for the management of specific subpopulations. So, there is a move away from the traditional “one size fits all” treatment to precision-based medicine. Research in “omics” has increased in leaps and bounds and advancements have included the fields of genomics, epigenomics, proteomics, transcriptomics, metabolomics and microbiomics. Pharmaco-omics has also come to the forefront with development of new drugs and suiting a particular drug to a particular subpopulation, thus avoiding their prescription to non-responders, preventing unwanted adverse effects and proving economical in the long run. Environmental, social and behavioural factors are as important or in fact more important than genetic factors in most complex diseases and managing these factors form an important part of precision medicine. Finally integrating precision with preventive and public health makes “precision medicine” a complete final product which will change the way medicine will be practised in future.

Central venous catheterization is one of the most prevalent procedures in the Intensive Care Unit. Complications are reported in about 15% of the patients and usually comprise of infection, arterial puncture, malpositioning, pneumothorax, local hematoma, hemothorax, and so on. Chylothorax is a rare complication of this procedure. We present a 42-year-old lady, who developed bilateral massive chylothorax after cannulation of her left internal jugular vein (IJV), due to direct injury to the thoracic duct during the procedure. The patient was successfully managed with bilateral chest tube drainage and omission of oral feeds for four days. Development of bilateral chylothorax as a complication of IJV cannulation is rare, but merits reporting, in view of a large number of central venous cannulations being undertaken. Critical care professionals should be aware of this rare complication of a common procedure to facilitate early identification and institute appropriate therapy.

Sir, In tropical countries, multiple infectious diseases are prevalent within the population at the same time. There exists a strong possibility for an individual to be affected by two or more organisms. We describe a case of concomitant infection with dengue and influenza-SOIV H1N1 (H1N1) and discuss the clinic-lab picture and the problems associated with the successful management of the case. A 27-year-old male presented with moderate grade fever with headache, myalgia of 4 days; dry cough, running nose, sore throat and progressively increasing breathlessness of 1 day duration. He had blood pressure (BP) of 90/52 mmHg; pulse of 112/min; respiratory rate (RR) of 20/min, spO2 of 92% on room air with examination of respiratory and other systems being normal. His investigations showed hemoglobin (Hb) of 15.6 gm/dL, leucocyte count (TLC) 2200/mm3, platelets 90,000/mm3 and hematocrit 43%. His other biochemical and laboratory profile were normal. His NS1 and IgM dengue ELISA was positive and real-time polymerase chain reaction (RT PCR), done later, was also positive for dengue (DEN1 serotype). His x ray chest (CXR) showed mild left pleural effusion. He was managed as a case of severe dengue (dengue shock syndrome) using oral and intravenous (IV) fluids, antipyretics and other supportive therapy. His cough and breathlessness worsened with tachypnea, spO288% and left interscapular crackles. His arterial blood gas analysis (ABG) showed pH of 7.40, pCO231 mmHg, pO262 mmHg, and bicarbonate of 16 mmol/L, PaO2/FiO2:310 and a repeat CXR showing interstitial shadows in the left lower zone. He was given CVP-guided fluids, oxygen (4 L/min), IV ceftriaxone and levofloxacin, and other therapy continued. In view of upper respiratory tract (URT) symptoms with an interstitial pneumonia like picture, H1N1 pneumonia was also considered. His nasopharyngeal swab-antigen assay and RT PCR for H1N1 were positive. He was isolated and started on oral oseltamivir 150 mg twice daily. By second day, he progressively deteriorated with diffuse crackles up to mid interscapular level and worsening of opacities on CXR. He was intubated and placed on ventilator support (low tidal ventilation of 6 mL/kg and plateau pressure of 26-30 cm of water, FiO2 less than 0.6 and PEEP <10 cm of water). Three days later, he showed signs of pneumonia (with CXR showing bilateral diffuse infiltrates as shown in Figure 1 and tracheal aspirate growing pseudomonas sensitive only to meropenem) with features of sepsis and multiorgan dysfunction, which was aggressively managed with IV meropenem and other measures. Gradually by 7th day, the patient[Single Right-Pointing Angle Quotation Mark]s ventilator parameters and laboratory parameters showed improvement. The weaning process was started and the patient was extubated by 12th day. With good physiotherapy and supportive measures, he was off all respiratory support by 14th day [Figure 2] and subsequently discharged on 20th day.Figure 1: Chest x ray picture on day 5 of illness showing bilateral parenchymal infiltrates with bilateral pleural effusionFigure 2: Chest x ray picture on day 16 of illness showing improvement in radiological pictureIn tropical countries where peak dengue season often coincides with that of influenza; co-infections of dengue with influenza may be seen. Such cases are very rare and have been reported by Perez, et al.[1] and by Borthakur, et al.[2] The H1N1 virus is known to cause damage to respiratory epithelium. As the respiratory epithelium may also be afflicted by dengue virus, a mixed infection may lead to fulminant lung involvement.[3] On the contrary, some researchers postulate that dengue may improve outcomes in influenza by causing apoptosis of infected respiratory cells, thereby limiting spread of H1N1 infection. The clinical syndrome produced by these infections can be mimicked by each other. Dengue may cause pulmonary features like parenchymal infiltrates, pleural effusion, pneumonitis, pulmonary hemorrhage and acute respiratory failure.[4] Influenza may cause a febrile illness with headache, myalgias, hemorrhagic manifestations, leucopenia or thrombocytopenia resembling dengue infection.[5] In such a scenario of mixed clinical picture, dengue can be confirmed by NS1, IgM, and IgG ELISA test which are sensitive, quick and simple; and H1N1 may be diagnosed by rapid antigen detection assays or RT PCR as shown in Table 1.Table 1: Common diagnostic tests of dengue and H1N1Distinguishing dengue and influenza by clinical features alone can be difficult but certain clinical clues can help in diagnosis. Cough, sore throat, and other URT symptoms are common in H1N1 while headache, myalgias, arthralgias and hemorrhagic manifestations are commoner in dengue. A dengue patient may also have hemoconcentration (high Hb and PCV), leucopenia or thrombocytopenia, hypoalbuminemia, mild transaminitis, or mild ascites and acalculous cholecystitis. The diagnosis can be confirmed by serology.[6] The management of such a co-infection needs aggressive treatment of both as discussed in this case which includes appropriate fluid hydration, antipyretics, oseltamivir for H1N1, antibiotic therapy for secondary bacterial infection, oxygen support and aggressive critical care support. Both dengue and H1N1 influenza are potentially fatal diseases and a high index of suspicion is necessary among the treating physicians for early diagnosis and best outcomes.

Emphysematous pyelonephritis (EPN) is a group of potentially life-threatening conditions seen particularly in diabetics, leading to high morbidity and mortality. Our aim was to study the profile of emphysematous infections of the kidney and urinary tract and evaluate the effect of early surgical intervention on mortality. This is an observational study conducted in a tertiary care hospital between January 2009 and January 2013, in which the clinical, laboratory, microbiological and radiological profiles of patients with EPN (diagnosed based on clinical, laboratory and imaging findings) was studied. A total of 12 patients were studied, including 10 with diabetes. A total of 66.6% had pyelonephritis, 25% had both cystitis and pyelonephritis and 8.3% had only cystitis; involvement of the left kidney was more common and bilateral involvement was seen in two cases. The clinical features seen in the patients included fever (100%), features of urinary infection (66.6%) and flank pain (50%). Culture positivity was seen in only 50% of the cases. Ten patients underwent percutaneous drainage (PCD) within 24 h, and two of these patients required nephrectomy subsequently. All patients were followed-up for one month. There was one death (mortality 8.3%), and all other patients responded well and recovered. Our study suggests that EPN is a potentially life-threatening condition that requires aggressive and prompt medical therapy with early PCD to reduce morbidity and mortality. Nephrectomy should be reserved for cases that do not respond to PCD.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a drug reaction commonly occurring in association with aromatic anticonvulsants and allopurinol. It is characterized by triad of fever, skin eruption, and systemic involvement. DRESS is rare with beta-lactam antibiotics and even rarer with ceftriaxone. We describe a case of pneumonia who developed ceftriaxone-induced rash, bicytopenia, eosinophilia, transaminitis and was eventually diagnosed and managed successfully as a case of DRESS.

BACKGROUND:Human immunodeficiency virus (HIV) management has witnessed paradigm changes over the past decade. In the early era, Absolute lymphocyte counts (ALC) were used as an inexpensive, indirect marker of immunity status. With time, CD4 lymphocyte counts and HIV RNA levels have become a standard of care for follow up of people living with HIV/AIDS (PLHA). Wide disparities between resource rich and poor countries, rekindles the need for an inexpensive surrogate marker for CD4 lymphocyte counts. Multiple studies in the past including one by Sen S et al, in 2011 did not validate ALC as a surrogate marker of CD4 lymphocyte counts and had recommended a similar study at another centre to validate the same.(1) Recently few publications have suggested that ALC may be used as a proxy marker to CD4 lymphocyte counts in resource poor areas.(2) With this backdrop we decided to evaluate the association if any, of ALC as a surrogate marker to CD4 lymphocyte counts. METHODS:ALC and CD4 lymphocyte counts measurements of 241 patients at our HIV/AIDS referral centre were assessed over a period of 13 months. RESULTS:Pearson correlation coefficient, coefficient of determination and standard statistical methods revealed modest linear correlation between ALC and CD4 lymphocyte counts which was statistically significant but did not have clinical significance. CONCLUSION:We recommend that time has come to call curtains down on ALC as a surrogate marker for CD4 lymphocyte count.

Tuberculosis affects almost every organ of the body, and the breast is no exception. However, tuberculosis of the breast is rare, and the varied presentation requires a high index of suspicion, especially in middle-aged women for whom a clinical diagnosis of malignancy is likely to be made. We report two cases of primary tuberculosis of breast with different manifestations. One case presented as tuberculous mastitis and the other presented with a lump masquerading as breast carcinoma. The diagnosis in both cases was based on demonstration of acid-fast bacilli on histopathological examination. Resolution was complete with antitubercular therapy, and major surgical intervention was not necessary.

Tuberculosis of the scapula is a rare clinical entity. Few cases have been reported in the literature so far. We report a case of tuberculosis of the scapula in a HIV positive patient, which was managed successfully with antitubercular drugs. This case illustrates the difficulties in diagnosing tubercular osteomyelitis of the scapula as it has an insidious onset, paucity of constitutional symptoms and frequent absence of associated pulmonary involvement. Pitfall in diagnosis is the delay in considering the diagnosis of bony tuberculosis, especially in patients who have normal chest radiographs.