Clinical skill learning for tomorrow’s doctors - a step towards better obstetric care

Background: Female urethral catheterization is the most commonly performed procedure in obstetrics and gynecology, for the assessment of urinary output. Many times catheterization is done by junior colleagues with improper technique resulting in improper catheterization and urethral injury. It is a must to know skill for every graduating medical student to avoid devastating consequences of performing it poorly. The objectives of this study are to evaluate the effectiveness of four step method of skill learning of bladder catheterization in female patients by interns and demonstrate the competency in the proper insertion and removal of an indwelling urinary catheter and also the study aimed to determine the effectiveness of bladder simulator training for medical interns.Methods: A prospective, observational and skill imparting study done using a specially designed model, after ethical committee approval. 30 Interns were divided in to six groups of five each for skill learning. It was done with Kirkpatrik model using specially designed objective structured clinical examination forms and scoring sheets. Sample paired t test was used.Results: 80% of the interns could perform the skill with maximum scores.Conclusions: It is an innovative teaching learning method for incoming interns which will help them to improve knowledge and practice and finally reduce the risk of complications and injury.

A 2-Year Follow-Up After a 2-Year RCT with Vitamin D and Exercise : Effects on Falls, Injurious Falls and Physical Functioning Among Older Women

Background: Both exercise and vitamin D are recommended means to prevent falls among older adults, but their combined effects on fallinduced injuries are scarcely studied. Methods: A 2-year follow-up of a previous 2-year randomized controlled trial with vitamin D and exercise (Ex) of 409 older home-dwelling women using a factorial 2 x 2 design (D(-)Ex(-), D(+)Ex(-), D(-)Ex(+), D(+)Ex(+)). Besides monthly fall diaries, femoral neck bone mineral density (fn-BMD), and physical functioning were assessed at 1 and 2 years after the intervention. Results: After the intervention, S-25OHD concentrations declined to baseline levels in both supplement groups. The groups did not differ for change in fn-BMD or physical functioning, except for leg extensor muscle strength, which remained about 10% greater in the exercise groups compared with the reference group (D(-)Ex(-)). There were no between-group differences in the rate of all falls, but medically attended injurious falls reduced in D+ Ex-and D(-)Ex(+) groups compared with D(-)Ex(-). However, all former treatment groups had less medically attended injured fallers, HRs (95% CI) being 0.62 (0.39-1.00) for D+ Ex-, 0.46 (0.28-0.76) for D(-)Ex(+), and 0.55 (0.34-0.88) for D(+)Ex(+), compared with D(-)Ex(-). Conclusions: Exercise-induced benefits in physical functioning partly remained 2 years after cessation of supervised training. Although there was no difference in the rate of all falls, former exercise groups continued to have lower rate of medically attended injured fallers compared with referents even 2 years after the intervention. Vitamin D without exercise was associated with less injurious falls with no difference in physical functioning.Peer reviewe

A STUDY ON ASSESSMENT OF GENETIC DIVERSITY AND RELATIONSHIPS OF MEDICINAL PLANTS USING RAPD MARKERS

ABSTRACT Molecular genetic fingerprints of medicinal species were developed using Randomly Amplified Polymorphic DNA (RAPD) marker to elucidate the genetic diversity among the 18 species. DNA was isolated using the CTAB method. The amplification was accomplished by using 10 primers and the specific PCR working program. Three decamer-primers generated 250 RAPD fragments, of which 232 fragments were polymorphic with 96.84% of polymorphism. Some of the RAPD markers were useful for species discrimination and identification. Most of the RAPD markers studied showed different level of genetic polymorphism. Amplified fragment sizes ranged from 300 to 5000 bp. Pairwise Nei and Li's similarity coefficient value ranged from 0.00-0.72 for 18 species of medicinal plants. A dendrogram was constructed based on the Unweighted pair group method using arithmetic averages. Cluster analysis of data using the UPGMA algorithm placed the 18 species of medicinal plants into four groups that are somewhat congruent with classification based on morphological characters proposed by earlier works. This analysis grouped all species into different clusters and clearly differentiated the medicinal plants into separate groups. This method of analysis can be helpful in selecting diverse parents and give broadness to the germplasm base of medicinal plants breeding programs in the future

Association of methylenetetrahydrofolate reductase C677T gene polymorphism and polycystic ovary syndrome in the South Indian cohort

493-497The polycystic ovarian syndrome is the utmost common endocrinopathy state in women. It is related to both reproductive and metabolic disorders. The MTHFR gene associated with the ovarian follicular action encodes the 5-MTHFR (methylenetetra-hydrofolate reductase) enzyme, tangled in folate metabolism. MTHFR gene C677T polymorphism declines the enzyme activity and thus folate deficit and increases the level of homocysteine, which affects the progress of oocytes. Here, we evaluated the association of MTHFR gene C677T polymorphism withPolycystic ovary syndrome (PCOS) inthe South Indian cohortof women. About 129 PCOS women with following Rotterdam criteria and 90 women controls were studied. PCR-RFLP technique was carried out on all PCOS women in this study. Dissimilarities in hormone levels in PCOS patients were detected. MTHFR gene polymorphism CC, CT, TT genotype was found to be 74, 16, 9.30% in patients correspondingly. However, in controls, it was 44.4, 24, 31%, respectively. A substantial difference was detected in the genotype frequency distributions among the patients and controls. Also, allele frequency was shown as 82.95% C allele and 17.83% T allele and 56.67%, 43.33% for C, and T allele in controls correspondingly. Our resultsindicate a possible association and suggest that MTHFR C677T polymorphism can be used as a potential biomarker for PCOS progress in the South Indian women

RADIOLOGICAL EVALUATION OF SINONASAL, INTRAORBITAL AND INTRACRANIAL EXTENSION OF MUCORMYCOSIS IN POSTCOVID PATIENTS

Background: Mucormycosis is a fatal and progressive condition that affects immunocompromised patients in the post-COVID state. Radiological assessment by computed tomography and magnetic resonance imaging is useful to determine the severity and extent of the disease. Objective: The objective of this research is to evaluate mucormycosis in post-COVID patients using radiological investigations like computed tomography and magnetic resonance imaging and also to study the extent of disease in patients with diabetes and with steroid/ immunosuppressant use. Methods: A prospective observational study was undertaken at Dr. D. Y. Patil Hospital and Medical College, Pimpri Pune from March-June 2021. All patients who presented with mucormycosis were either COVID-19 positive or recovered from COVID-19 infection. Computed tomography and magnetic resonance imaging were performed in these patients. Results: The association between the status of diabetes mellitus and extent of involvement, steroids/immunosuppressant use and extent of involvement was statistically significant with a p value of <0.001. Conclusion: Patients with post COVID-19 status and diabetic status with steroid therapy during the treatment of COVID-19 may increase the risk of developingopportunistic infections like mucormycosis. Post COVID-19 related mucormycosis on computed tomography and magnetic resonance imagin

Identification of QTLs and candidate genes for high grain Fe and Zn concentration in sorghum [Sorghum bicolor (L.)Moench]

Sorghum is a major food crop in the semi-arid tropics of Africa and Asia. Enhancing the grain iron (Fe) and zinc (Zn) concentration in sorghum using genetic approaches would help alleviate micronutrient malnutrition in millions of poor people consuming sorghum as a staple food. To localize genomic regions associated with grain Fe and Zn, a sorghum F6 recombinant inbred line (RIL) population (342 lines derived from cross 296B PVK 801) was phenotyped in six environments, and genotyped with simple sequence repeat (SSR), DArT (Diversity Array Technology) and DArTSeq (Diversity Array Technology) markers. Highly significant genotype environment interactions were observed for both micronutrients. Grain Fe showed greater variation than Zn. A sorghum genetic map was constructed with 2088 markers (1148 DArTs, 927 DArTSeqs and 13 SSRs) covering 1355.52 cM with an average marker interval of 0.6 cM. Eleven QTLs (individual) and 3 QTLs (across) environments for Fe and Zn were identified. We identified putative candidate genes from the QTL interval of qfe7.1, qzn7.1, and qzn7.2 (across environments) located on SBI-07 involved in Fe and Zn metabolism. These were CYP71B34, and ZFP 8 (ZINC FINGER PROTEIN 8). After validation, the linked markers identified in this study can help in developing high grain Fe and Zn sorghum cultivars in sorghum improvement programs globally

Identification of QTLs and Underlying Candidate Genes Controlling Grain Fe and Zn Concentration in Sorghum [Sorghum bicolor (L).Moench]

Biofortification is one of sustainable options for combating micronutrient-malnutrition. For identifying genomic regions associated with grain Fe and Zn in sorghum, RIL population (342 individuals) from cross 296B × PVK 801 was phenotyped for two years at three locations and genotyped with SSRs and DArTs. Highly significant genotype×environment interactions were observed for both micronutrients; grain Fe showed greater variation than Zn. Sorghum genetic map was constructed with 2088 markers (1148 DArTs, 927 DArT Seqs and 13 SSRs) covering 1355.52 cM with an average marker interval of 0.6cM. A total of 18 QTLs controlling Fe and Zn were found stable across environments. Three QTLs for Fe and 15 for Zn were identified with phenotypic variance explained (PVE) values ranging from 3.94 to 5.09% and 3.17 to 9.42%, respectively. Of these 18 stable QTLs, 11 were located on chromosome SBI-07. Favorable alleles for 11 QTLs (co-located) for Fe and Zn on chromosome SBI-07 were contributed by parent PVK801-P23. QTLs were analyzed in-silico to identify underlying candidate genes, 62 candidate genes involved in Fe/Zn metabolism were identified within QTL interval; twenty-three were found in QTL with highest phenotypic effect (PVE 9.42%). Sorghum genes underlying Fe/Zn QTLs were used to analyze gene synteny with rice and maize. Synteny sequence level between sorghum-rice ranged from 44% to 97%, while sorghum-maize ranged from 49% to 99%. QTLs/candidate/novel genes along with the marker/genetic resources identified through this study can help in developing high Fe and Zn lines in cost-effective and efficient manner

Study protocol for prevention of falls: A randomized controlled trial of effects of vitamin D and exercise on falls prevention

Peer reviewe

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Iäkkäiden naisten liikunta: vaikutukset kaatumisiin, kuntoon, kaatumispelkoon ja kustannuksiin

Hyvä liikkumis- ja toimintakyky ovat keskeisiä ikäihmisille päivittäisistä toiminnoista selviytymisen ja elämänlaadun kannalta. Toimintakyvyn heikkeneminen altistaa iäkkäät kaatumisille ja vammoille, joista puolestaan aiheutuu huomattavia kustannuksia sekä yksilölle että yhteiskunnalle. Väitöskirja ja sen osajulkaisut perustuvat UKK-instituutissa vuosina 2010‒2013 tehtyyn satunnaistettuun kontrolloituun väestöpohjaiseen tutkimukseen. Väitöskirjatutkimuksessa arvioitiin kotona asuvien iäkkäiden naisten kaatumisten vaaratekijöitä mukaan lukien sarkopenia (lihaskato), toimintakyvyn aleneminen ja kaatumispelko. Lisäksi arvioitiin liikuntaharjoitteluohjelman vaikutuksia toimintakykyyn, kaatumisiin ja kaatumisvammoihin sekä kaatumispelkoon. Lisäksi arvioitiin harjoitusohjelman toteutettavuutta ja kustannusvaikuttavuutta kyseisessä ryhmässä. Neljäsataayhdeksän 70‒80-vuotiasta tamperelaisnaista satunnaistettiin liikuntaryhmään (EX) tai vertailuryhmään (CON). Liikuntaryhmä harjoitteli ohjatusti kahdesti viikossa ensimmäisen vuoden ajan ja kerran viikossa toisen vuoden ajan. Liikuntaryhmä sai lisäksi kotiharjoitteet, joita he tekivät kotona 3-5 päivänä viikossa. Harjoittelu oli progressiivista ja koostui lihasvoimaa, tasapainoa, ketteryyttä ja liikkuvuutta parantavista osioista. Vertailuryhmään kuuluvia pyydettiin jatkamaan entisiä liikuntatottumuksiaan koko tutkimuksen ajan. Tutkittavien henkilöiden fyysinen toimintakyky (lihasvoima, kävelynopeus, TUG, tuolilta ylösnousu, takaperinkävely), kaatumispelko (FES-I, kaatumishuolestuneisuus) ja fyysinen aktiivisuus arvioitiin puolivuosittain (0, 6, 12, 18 ja 24 kk) ja kehon koostumus mitattiin vuosittain (0, 12 ja 24 kk). Tutkittavat pitivät kaatumispäiväkirjaa, joka palautettiin kuukausittain postitse. Kaatumisten aiheuttamat terveydenhuollon käynnit tarkistettiin Tampereen kaupungin ylläpitämästä potilastietokannasta (Pegasos) ja Tampereen yliopistollisen sairaalan potilaskertomuksista. Poikkileikkauksena alkutilanteessa määritettiin konsensuskriteerien mukaisesti sarkopenian vallitsevuus (prevalenssi) ja toimintakyvyn yhteyttä sarkopeniaan ja kaatumispelkoon tarkasteltiin regressiomalleilla. Yleistettyjä lineaarisia sekamalleja (LMM ja GLMM) käytettiin tarkasteltaessa intervention vaikutusta toimintakykyyn. Ryhmien välisiä eroja kaatujien ja kaatumisten määrässä arvioitiin Coxin suhteellisen vaaran ja Poissonin regressiomallien avulla. Kustannusvaikuttavuutta arvioitiin lisäkustannuksena suhteessa ohjelman vaikuttavuuteen vammakaatumisten ehkäisyssä. Tutkimuksen lähtötilanteessa sarkopenian vallitsevuus oli vain 1‒3 %. Sen sijaan 69 % tutkittavista raportoi kaatumisen huolestuttavan melko paljon. Vaikeudet asioimistoimintakyvyssä (IADL), tasapainossa ja kyvyssä liikkua ulkona olivat yhteydessä suurempaan kaatumispelkoon. Harjoitusohjelma toteutui hyvin. Liikuntaryhmäläiset osallistuivat keskimäärin 73 % ryhmäharjoituksista (yksilöllinen vaihteluväli 0‒97 %) ja 66 % kotiharjoittelusta (yksilöllinen vaihteluväli 0‒100 %). Osallistujat eivät raportoineet harjoittelun aikana vakavia vammoja tai haittavaikutuksia. Kehon lihasmassa väheni kummassakin ryhmässä intervention aikana, mutta CON-ryhmässä hieman enemmän kuin EX-ryhmässä (p=0,048) (ryhmien välinen ero muutoksessa oli 0,5 % intervention päättyessä). EX-ryhmäläiset harrastivat vähintään kohtuullisesti rasittavaa liikuntaa enemmän kuin vertailuryhmä (p=0,003). Vertailuryhmään verrattuna liikuntaharjoittelu paransi alaraajojen ojentajalihasten isometristä voimaa (suurin eroavuus 15,5 % 18 kk kohdalla) (p<0,001), nopeaa kävelyvauhtia (suurin eroavuus 4,3 % 24 kk kohdalla) (p=0,003) ja tuolilta ylösnousuaikaa (suurin eroavuus 5,0 % 24 kk kohdalla) (p=0,016). Lähtötilanteeseen verrattuna useampi EX-ryhmään kuuluva suoriutui takaperin kävelytestistä virheettömästi (p<0,001). Sen sijaan harjoittelu ei vaikuttanut TUG-testiin eikä perus- tai asiointitoimintakykyyn eikä liikkumiskykyyn ulkona. Ryhmien välillä ei ollut eroa kaatumisten ilmaantuvuudessa (insidenssi), mutta liikuntaryhmässä oli 55 % vähemmän vammakaatumisia (riskisuhde IRR 0,45; 95 % luottamusväli 0,27‒0,78, p=0,004). Tulos oli samanlainen tarkasteltaessa kaatujia. Kaatumispelossa ei ollut ryhmien välistä eroa (p=0,082). Tutkimus osoitti 63,4 % todennäköisyydellä, että yhden kaatumisvamman ehkäiseminen aiheuttaa 191 euron lisäkustannuksen. Jos yhteiskunnalla on halukkuutta maksaa 2240 euroa yhden kaatumisvamman ehkäisemisestä, tämä liikuntainterventio olisi 95 % todennäköisyydellä kustannustehokas tässä väestössä. Sarkopenian vallitsevuus on matala kotona asuvien iäkkäiden naisten keskuudessa, eikä lihasmassa tai sarkopenian määritelmän mukaiset tekijät olleet yhteydessä toimintakykyyn. Kaatumispelko sen sijaan on melko yleistä. Kohtuullisen rasittava monipuolinen liikuntaharjoittelu paransi toimintakykyä ja oli turvallista ja toteuttamiskelpoista iäkkäille naisille. Vaikka kaatumiset eivät vähentyneet, monipuolinen liikuntaharjoittelu osoittautui tehokkaaksi keinoksi vähentää hoitoa vaativia kaatumisvammoja. Liikuntaharjoittelu voi kohtuullisin kustannuksin aikaansaada säästöjä terveydenhuollossa.Functional decline predisposes older adults to falls and resulting injuries, which are serious and common medical problems experienced by older adults. The costs of falling are high, both to the individual and to society. The thesis and its original publications are based on a randomized, controlled trial conducted between April 2010 and March 2013 at the UKK Institute for Health Promotion Research, Tampere, Finland. The purpose of the study was to examine risk factors for falling, including body composition, physical functioning and fear of falling in home-dwelling older women. The study evaluated the effects of supervised multimodal group exercise on physical functioning, falls, fall-related injuries and fear of falling, and its cost-effectiveness from a societal perspective. Of all 70‒80-year old women from Tampere invited for the study (n = 9730), 409 women who fulfilled the inclusion criteria were randomly assigned to exercise (EX) or control (CON) groups. EX attended supervised group training classes 2 times a week for the first 12 months, and once a week for the subsequent 12 months of the 24-month intervention, with home exercises to be practiced on the remaining days. Training was progressive and consisted of strength, balance, agility and mobility exercises. CON were asked to maintain their pre-study levels of physical activity throughout the trial. Physical functioning (isometric leg extension strength, walking speed, Timed Up and Go (TUG), chair stand time, backwards walking), fear of falling (FES-I) and physical activity were assessed at baseline, at 6, 12, 18 and 24 months. Activities of daily living (ADL), instrumental ADL (IADL) and outdoor mobility were assessed at baseline and 24 months. Body composition was measured at baseline, 12 and 24 months. Falls were monitored with fall diaries returned monthly. Fall-related health services utilization was assessed from patient medical records over 24 months. Prevalence of sarcopenia was determined using consensus diagnostic criteria. Cross-sectional analysis of baseline data included independent samples t-tests and multinomial logistic regression. Intervention effects on physical functioning were estimated by LMM and GLMM. Negative binomial regression and Cox-regression models were used to evaluate falls and fallers in each group. Cost-effectiveness was expressed in terms of the incremental cost-effectiveness ratio, with bootstrapping techniques to estimate uncertainty. All analyses were done according to the ITT principle. Sarcopenia prevalence was only 1‒3% in this cohort, while 69% reported at least a moderate fear of falling. Muscle mass and derived indices of sarcopenia were not significantly related to measures of physical functioning. Difficulties in IADL, balance and outdoor mobility contributed independently to a greater fear of falling. Training compliance for group and home exercise was 73% (range 0% to 97%) and 66% (range 0% to 100%) respectively, with no severe adverse effects or injuries due to the training. At the end of the intervention, there were no significant changes in ADL, IADL or mobility scores, nor were there significant differences between groups. The mean total body lean mass decreased slightly in both groups, but more in CON compared with EX (p=0.048) (peak difference 0.5% at 24 months). EX engaged in a significantly greater amount of at least moderate-intensity physical activity per week (p=0.003). Isometric leg extension strength improved significantly (p<0.001) in EX (peak difference 15.5% at 18 months) compared with CON. Fast walking speed improved in EX, and declined in CON (p=0.003) (peak difference 4.3% at 24 months). There were no significant changes or differences between the groups in the TUG test. Chair stand time reduced significantly (p=0.016) in EX compared with CON (peak difference 5% at 24 months). EX showed a significantly greater probability of completing the backwards walking test compared with CON (p<0.001). There was no significant difference between groups in the total falls incidence rate (IRR 1.0, 95% CI 0.79 to 1.26). However, the number of medically-attended injurious falls (IRR 0.45, 95% CI 0.27 to 0.78, p=0.004), and medically-attended fallers (HR 0.45, 95% CI 0.26 to 0.77, p=0.004) was significantly lower in EX compared with CON. There were no overall changes or differences between groups in FES-I scores (p=0.082). The data suggested 63.4% probability that each injurious fall avoided per person-year required an additional cost of € 191. At a willingness to pay of € 2,240 per injurious fall prevented, there was a 95% chance of the exercise intervention being cost-effective in this population. In conclusion, sarcopenia prevalence is low in community-dwelling older Finnish women, while fear of falling is common. Multimodal group exercise improved physical functioning and prevented age-related functional decline. Although the intervention did not result in a reduced rate of falls, it reduced fall-related injuries requiring medical treatment. Exercise training was safe and feasible, required only modest investments for preventing injurious falls, and in some cases may even be cost saving