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1.  Patients’ and healthcare providers’ perceptions of a mobile portal application for hospitalized patients 
Hospital-based patient portals have the potential to better inform and engage patients in their care. We sought to assess patients’ and healthcare providers’ perceptions of a hospital-based portal and identify opportunities for design enhancements.
We developed a mobile patient portal application including information about the care team, scheduled tests and procedures, and a list of active medications. Patients were offered use of tablet computers, with the portal application, during their hospitalization. We conducted semi-structured interviews of patients and provider focus groups. Text from transcribed interviews and focus groups was independently coded by two investigators using a constant comparative approach. Codes were reviewed by a third investigator and discrepancies resolved via consensus.
Overall, 18 patients completed semi-structured interviews and 21 providers participated in three focus groups. Patients found information provided by the portal to be useful, especially regarding team members and medications. Many patients described frequent use of games and non-clinical applications and felt the tablet helped them cope with their acute illness. Patients expressed a desire for additional detail about medications, test results, and the ability to record questions. Providers felt the portal improved patient engagement, but worried that additional features might result in a volume and complexity of information that could be overwhelming for patients. Providers also expressed concern over an enhanced portal’s impact on patient-provider communication and workflow.
Optimizing a hospital-based patient portal will require attention to type, timing and format of information provided, as well as the impact on patient-provider communication and workflow.
Electronic supplementary material
The online version of this article (doi:10.1186/s12911-016-0363-7) contains supplementary material, which is available to authorized users.
PMCID: PMC5031299  PMID: 27653854
Patient-centered care; Patient portal; Personal health record; Hospitalized patient; Patient engagement
2.  Male-female patient differences in association between end-of-life discussions and receipt of intensive care near death 
Cancer  2015;121(16):2814-2820.
Patient gender plays a significant role in patient-physician communication, patient illness understanding and aggressiveness of end of life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The present study aims to determine if gender differences exist in receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and receipt of ICU EoL care.
Multi-site, prospective, cohort study of patients (N=353) with metastatic cancers, identified as terminally ill at study enrollment and interviewed a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life.
Patients who received ICU care at the EoL were more likely to be male than those who did not (73% male vs. 52% male, p=0.02). Adjusting for potential confounds, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (AOR=0.26, 95% CI 0.07–0.91; p=0.04). There was no association between EoL discussions and ICU stays near death among female patients.
Men with advanced cancers are more likely than women to receive aggressive, non-beneficial, ICU care near death. Gender differences in effects of EoL discussions on EoL care likely contribute to, and may even explain, gender differences in receipt of ICU care in the last week of life.
PMCID: PMC4529758  PMID: 25975179
3.  Evaluation of Skill-oriented Training on Enhanced Syndromic Case Management (ESCM) of Reproductive Tract Infections / Sexually Transmitted Infections (RTI/STIs) of Care Providers from Three-tier Health-care System of Gujarat 
Enhanced syndromic case management (ESCM) deals with reproductive tract and sexually transmitted infections. Capacity building of service providers not only boosts the program but also inputs from them improve the quality of services.
To (1) identify problem areas from providers' perspectives and the gaps in knowledge and application and (2) assess the gains (if any) through pre and post-training evaluation.
Materials and Methods:
A total of 121 participants (medical/para medical) from various medical colleges, district/sub-district hospitals/ community health centers, and urban dispensaries across Gujarat were trained at a teaching institute. Trainings were of 2-3 days duration involving different learning methodology. Pre- and post-training evaluation were done on a designed pro forma and data were entered in MS office Excel 2007. Gains in knowledge/skills if any were assessed by comparing pre-/post-evaluation responses and applying test of significance (x2 test).
Out of total 121 participants, half (60) were doctors and the rest were paramedics [staff nurse (SN) and lab technicians (LT)]. Doctors revealed significant gain in basics of reproductive tract infections (RTI) and sexually transmitted infections (STI), syndrome identification, STI/HIV co-infection, and ESCM and less gain in asymptomatic STI/ complications, vulnerability, male reproductive organs, causes of vaginal/urethral discharge, STI complications, cervical cancer screening, and limitation of syndromic management. Gain was statistically significant in basics of RTI/STI amongst adolescent in paramedics; lab technicians showed significant gain in knowledge of laboratory-related areas.
Assessment revealed (1) poor baseline knowledge and (2) gains following training sometimes significant and other times not significant even in core areas. Quality monitoring and contents/ methodologies modification are essential for robust trainings. Gains in skills could not be assessed through this evaluation.
PMCID: PMC4919930  PMID: 27385870
Enhanced syndromic case management (ESCM); reproductive tract infections (RTI); sexually transmitted infections (STIs); training evaluation
4.  Impact Evaluation of Domains of Learning on Universal Work Precautions (UWP) Amongst Nursing Staff in a Tertiary Care Hospital, Western India 
Second key strategy of National AIDS Control Program (NACP IV) is comprehensive care and support by providing quality services through zero stigma and discrimination. Quality of services can be improved by eliminating stigma and discrimination and making health care provider aware of associated occupational hazards. Nursing staff play crucial role and are more at risk therefore their understanding, perception and skill must be assessed in different domains of learning to improve the contents and methodology of trainings.
Material and Methods:
Total 85 nursing staff underwent 1 day training in 3 batches focusing on Universal Work Precautions (UWP), Post Exposure Prophylaxis (PEP) and sensitization of the participants towards PLHA (People living with HIV/AIDS). Their learning was evaluated under different domains (cognitive, psychomotor and affective) using structured questionnaire.
In pretest evaluation scores showed minor and statistically not significant variations in terms of participant's gender, age, designation work experience and status of having received any similar training in the past. Impact of the training was visible as overall mean scores increased from 10.6 ± 2.7 to 13.8 ± 5.8; gain being statistically highly significant (P value < 0.001). Gain was highest in cognitive (from 58% to 77%) followed by psychomotor (from 48% to 62%) and minimal in affective domain (from 75% to 76%).
After undergoing the training, participants were benefitted more in cognitive domain than psychomotor and affective domain. Acquired knowledge, skill and communication skill if evaluated as done in this study will improve the methodology of such trainings making them more effective.
PMCID: PMC4799637  PMID: 27051089
Domains of learning; nursing staff; post exposure prophylaxis (PEP); universal work precautions (UWP)
5.  Racial/Ethnic Differences in Inpatient Palliative Care Consultation for Patients With Advanced Cancer 
Journal of Clinical Oncology  2015;33(32):3802-3808.
Inpatient palliative care consultation (IPCC) may help address barriers that limit the use of hospice and the receipt of symptom-focused care for racial/ethnic minorities, yet little is known about disparities in the rates of IPCC. We evaluated the association between race/ethnicity and rates of IPCC for patients with advanced cancer.
Patients and Methods
Patients with metastatic cancer who were hospitalized between January 1, 2009, and December 31, 2010, at an urban academic medical center participated in the study. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and IPCC.
A total of 6,288 patients (69% non-Hispanic white, 19% African American, and 6% Hispanic) were eligible. Of these patients, 16% of whites, 22% of African Americans, and 20% of Hispanics had an IPCC (overall P < .001). Compared with whites, African Americans had a greater likelihood of receiving an IPCC (odds ratio, 1.21; 95% CI, 1.01 to 1.44), even after adjusting for insurance, hospitalizations, marital status, and illness severity. Among patients who received an IPCC, African Americans had a higher median number of days from IPCC to death compared with whites (25 v 17 days; P = .006), and were more likely than Hispanics (59% v 41%; P = .006), but not whites, to be referred to hospice.
Inpatient settings may neutralize some racial/ethnic differences in access to hospice and palliative care services; however, irrespective of race/ethnicity, rates of IPCC remain low and occur close to death. Additional research is needed to identify interventions to improve access to palliative care in the hospital for all patients with advanced cancer.
PMCID: PMC4979133  PMID: 26324373
6.  Development of mRuby2-Transfected C3H10T1/2 Fibroblasts for Musculoskeletal Tissue Engineering 
PLoS ONE  2015;10(9):e0139054.
Mouse C3H10T1/2 fibroblasts are multipotent, mesenchymal stem cell (MSC)-like progenitor cells that are widely used in musculoskeletal research. In this study, we have established a clonal population of C3H10T1/2 cells stably-transfected with mRuby2, an orange-red fluorescence reporter gene. Flow cytometry analysis and fluorescence imaging confirmed successful transfection of these cells. Cell counting studies showed that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells proliferated at similar rates. Adipogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for Oil Red O and showed increased expression of adipogenic genes including adiponectin and lipoprotein lipase. Chondrogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for Alcian Blue and showed increased expression of chondrogenic genes including aggrecan. Osteogenic differentiation experiments demonstrated that untransfected C3H10T1/2 cells and mRuby2-transfected C3H10T1/2 cells stained positive for alkaline phosphatase (ALP) as well as Alizarin Red and showed increased expression of osteogenic genes including alp, ocn and osf-1. When seeded on calcium phosphate-based ceramic scaffolds, mRuby2-transfected C3H10T1/2 cells maintained even fluorescence labeling and osteogenic differentiation. In summary, mRuby2-transfected C3H10T1/2 cells exhibit mRuby2 fluorescence and showed little-to-no difference in terms of cell proliferation and differentiation as untransfected C3H10T1/2 cells. These cells will be available from American Type Culture Collection (ATCC; CRL-3268™) and may be a valuable tool for preclinical studies.
PMCID: PMC4583363  PMID: 26407291
7.  Evaluation of patients’ knowledge on warfarin in outpatient pharmacy of a tertiary care cardiac center 
BMC Research Notes  2015;8:429.
Warfarin is widely used for the prevention and treatment of cardiac, thromboembolic and hypercoagulable diseases. Since warfarin is a narrow therapeutic index medicine, it requires close monitoring when used in the outpatient setting and on long term basis. Warfarin has been found to be associated with a number of complications especially bleeding. Patients’ knowledge on warfarin can improve anticoagulation control with decrease in adverse drug reaction and other associated complications. The objective was to assess knowledge level of warfarin therapy among its users and to provide adequate education and counseling to the patients.
In the present cross sectional study, 34 patients on warfarin were interviewed. Patients’ knowledge on warfarin was assessed using a validated Anticoagulation Knowledge Assessment (AKA) questionnaire comprising 29 questions. Each correct answer scored 3.45 points whereas an incorrect answer scored zero point. Patient who answered at least 21 questions correctly or scored (21 × 3.45 = 72.4 %) was considered to have adequate level of knowledge or have obtained a passing score. Association between independent variables and AKA score was assessed using Pearson Chi square test or Fisher’s exact test for categorical variables. Patients were counseled regarding proper warfarin use by the researcher pharmacists at the end of each data collection schedule.
Of the 34 patients, only 5.8 % (n = 2) achieved a passing score whereas 94.1 % (n = 32) failed to achieve the passing score. 67.6 % of the patients (n = 23) achieved a score below 50 %. More than 50 % of the patients incorrectly answered 15 questions in the questionnaire. None of the patients scored 100 %. No significant association was found between age, gender of patients and total warfarin score. A significant association (p < 0.05) was found between duration of warfarin therapy and total warfarin score.
Warfarin knowledge was poor among the patients. Hence, regular counseling with timely assessment of their understanding was felt necessary.
PMCID: PMC4566289  PMID: 26358332
Warfarin; Anticoagulation knowledge assessment; Adverse drug reaction; Narrow therapeutic index
8.  A comparative study of effects of glycopyrrolate and ondansetron on nausea and vomiting in cesarean section under spinal anesthesia 
Background and Aim:
Nausea and vomiting causes distress to patients and increases surgical complications. Though various antiemetics are available, their effectiveness and fetal safety profile when used in parturient remains debatable. This randomized, double-blind, comparative study was designed with an aim to compare the antiemetic effects of ondansetron and glycopyrrolate during cesarean section.
Sixty-six parturients (American Society of Anesthesiologist physical status I-II) scheduled for elective cesarean section were randomized to receive intravenous ondansetron 4 mg (Group O, n = 32) or glycopyrrolate 0.2 mg (Group G, n = 31) before spinal anesthesia. Outcome measures studied were emesis, episodes of hypotension and bradycardia and pain, till 10 h postoperative. Statistical software used was Epi Info 7 and Microsoft Excel.
There was no significant difference in nausea and vomiting at all the study intervals between the two groups statistically. There was no difference in episodes of hypotension, but episodes of bradycardia were significantly less in glycopyrrolate group (26%) than in ondansetron group (56%) (P = 0.027). There was no difference in additional analgesic requirements. However, the incidence of dry mouth was significantly greater in glycopyrrolate group (21 [68%]) as compared to ondansetron group (5 [16%]) (P = 0.00).
Effect of glycopyrrolate on nausea and vomiting during cesarean section are comparable to ondansetron, but with an increased incidence of dry mouth. Glycopyrrolate has no effect on hypotension or additional analgesic requirements, but the incidence of bradycardia is significantly less.
PMCID: PMC4683504  PMID: 26712972
Cesarean section; glycopyrrolate; nausea; ondansetron; vomiting
9.  Making Progress with Code Status Documentation 
Journal of hospital medicine  2015;10(8):553-554.
PMCID: PMC4516597  PMID: 25873559
10.  Upper gastrointestinal bleed in a post menopausal woman due to combination of high first dose aspirin and clopidogrel prescribed for acute coronary syndrome 
Journal of Mid-Life Health  2015;6(3):129-131.
Combination of aspirin, clopidogrel and enoxaparin remains the standard treatment for acute coronary syndrome (ACS) but is known to increase the incidence of upper gastrointestinal bleed (UGIB). We hereby report an unusual case of gastrointestinal bleed (GIB) as it resulted inspite of proton pump inhibitor (PPI) prophylaxis within the second day of treatment in a post-menopausal woman (PMW) with high first dose of aspirin clopidogrel dual combination in a patient of ACS.
PMCID: PMC4604673  PMID: 26538991
Acute coronary syndrome; aspirin; clopidogrel; enoxaparin; gastrointestinal bleed
11.  Unpacking Resident-Led Code Status Discussions: Results from a Mixed Methods Study 
The quality of code status discussions (CSDs) is suboptimal as physicians often fail to discuss patients’ goals of care and resuscitation outcomes. We previously demonstrated that internal medicine residents randomized to a communication skills intervention scored higher than controls on a CSD checklist using a standardized patient. However, the impact of this training on CSD content is unknown.
Compare CSD content between intervention and control residents.
We conducted qualitative analysis of simulated CSDs. Augmenting a priori codes with constant comparative analysis, we identified key themes associated with resident determination of code status. We dichotomized each theme as present or absent. We used chi-square tests to evaluate the association between training and presence of each theme.
Fifty-six residents rotating on the internal medicine service in July 2010 were randomized to intervention (n = 25) or control (n = 31).
Intervention residents completed CSD skills training (lectures, deliberate practice, and self-study). Six months later, all 56 residents completed a simulated CSD.
Comparison of key themes identified in CSDs among intervention and controls.
Fifty-one transcripts were recorded and reviewed. Themes identified included: exploration of patient values/goals, framing code status as a patient decision, discussion of resuscitation outcomes and quality of life, and making a recommendation regarding code status. Intervention residents were more likely than controls to explore patient values/goals (p = 0.002) and make a recommendation (p < 0.001); and less likely to frame the decision as one solely to be made by the patient (p = 0.01). Less than one-third of residents discussed resuscitation outcomes or quality of life.
Training positively influenced CSD content in key domains, including exploration of patient values/goals, making a recommendation regarding code status, and not framing code status as solely a patient decision. However, despite the intervention, residents infrequently discussed resuscitation outcomes and quality of life.
PMCID: PMC4000342  PMID: 24526542
code status; resuscitation; physician–patient communication; palliative care; medical education
12.  Turning the tide or riding the waves? Impacts of antibiotic stewardship and infection control on MRSA strain dynamics in a Scottish region over 16 years: non-linear time series analysis 
BMJ Open  2015;5(3):e006596.
To explore temporal associations between planned antibiotic stewardship and infection control interventions and the molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA).
Retrospective ecological study and time-series analysis integrating typing data from the Scottish MRSA reference laboratory.
Regional hospital and primary care in a Scottish Health Board.
General adult (N=1 051 993) or intensive care (18 235) admissions and primary care registrations (460 000 inhabitants) between January 1997 and December 2012.
Hand-hygiene campaign; MRSA admission screening; antibiotic stewardship limiting use of macrolides and ‘4Cs’ (cephalosporins, coamoxiclav, clindamycin and fluoroquinolones).
Outcome measures
Prevalence density of MRSA clonal complexes CC22, CC30 and CC5/Other in hospital (isolates/1000 occupied bed days, OBDs) and community (isolates/10 000 inhabitant-days).
67% of all clinical MRSA isolates (10 707/15 947) were typed. Regional MRSA population structure was dominated by hospital epidemic strains CC30, CC22 and CC45. Following declines in overall MRSA prevalence density, CC5 and other strains of community origin became increasingly important. Reductions in use of ‘4Cs’ and macrolides anticipated declines in sublineages with higher levels of associated resistances. In multivariate time-series models (R2=0.63–0.94) introduction of the hand-hygiene campaign, reductions in mean length of stay (when >4 days) and bed occupancy (when >74 to 78%) predicted declines in CC22 and CC30, but not CC5/other strains. Lower importation pressures, expanded MRSA admission screening, and reductions in macrolide and third generation cephalosporin use (thresholds for association: 135–141, and 48–81 defined daily doses/1000 OBDs, respectively) were followed by declines in all clonal complexes. Strain-specific associations with fluoroquinolones and clindamycin reflected resistance phenotypes of clonal complexes.
Infection control measures and changes in population antibiotic use were important predictors of MRSA strain dynamics in our region. Strategies to control MRSA should consider thresholds for effects and strain-specific impacts.
PMCID: PMC4386222  PMID: 25814495
13.  Family Matters: Effects of Birth Order, Culture, and Family Dynamics on Surrogate Decision Making 
Cultural attitudes about medical decision making and filial expectations may lead some surrogates to experience stress and family conflict. Thirteen focus groups with racially and ethnically diverse English- and Spanish-speakers from county and Veterans hospitals, senior centers, and cancer support groups were conducted to describe participants’ experiences making serious or end-of-life decisions for others. Filial expectations and family dynamics related to birth order and surrogate decision making were explored using qualitative, thematic content analysis and overarching themes from focus group transcripts were identified. The mean age of the 69 participants was 69 years ± 14 and 29% were African American, 26% were White, 26% were Asian/Pacific Islander, and 19% were Latino. Seventy percent of participants engaged in unprompted discussions about birth order and family dynamics. Six subthemes were identified within 3 overarching categories of communication, emotion, and conflict: Communication – (1) unspoken expectations and (2) discussion of death as taboo; Emotion – (3) emotional stress and (4) feelings of loneliness; and Conflict – (5) family conflict and (6) potential solutions to prevent conflict. These findings suggest that birth order and family dynamics can have profound effects on surrogate stress and coping. Clinicians should be aware of potential unspoken filial expectations for firstborns and help facilitate communication between the patient, surrogate, and extended family to reduce stress and conflict.
PMCID: PMC4130561  PMID: 24383459
Advance care planning; Birth order; Decision Making; Aging; Qualitative research
14.  Scar endometriosis: Diagnosis by fine needle aspiration 
Endometriosis is defined as the presence of a functioning endometrium outside the uterus. Abdominal wall endometriosis is a rare entity. Most of the abdominal wall endometriosis occurs in or around surgical scars following caesarean section or hysterectomy. We report a case of scar endometriosis following caesarean section and diagnosed by fine needle aspiration cytology (FNAC). Excision biopsy confirmed the FNAC diagnosis of scar endometriosis.
PMCID: PMC4408687  PMID: 25948953
Abdominal wall endometriosis; FNAC; Scar endometriosis
15.  Documentation Quality of Inpatient Code Status Discussions 
Accurate documentation of inpatient code status discussions (CSDs) is important because of frequent patient care handoffs.
To examine the quality of inpatient CSD documentation and compare documentation quality across physician services.
This was a retrospective study of patients hospitalized between January 1 and June 30, 2011 with a new or canceled do-not-resuscitate (DNR) order at least 24 hours after hospital admission. We developed a chart abstraction tool to assess the documentation of five quality elements: 1) who the DNR discussion was held with, 2) patient goals/values, 3) prognosis, 4) treatment options and resuscitation outcomes, and 5) health care power of attorney (HCPOA).
We identified 379 patients, of whom 235 (62%) had a note documenting a CSD. After excluding patients lacking a note from their primary service, 227 remained for analysis. Sixty-three percent of notes contained documentation of who the discussion was held with. Patient goals/values were documented in 43%, discussion of prognosis in 14%, treatment options and resuscitation outcomes in 40%, and HCPOA in 29%. Hospitalists were more likely than residents to document who the discussion was held with (P < 0.001) and patient goals/values (P < 0.001), whereas internal medicine residents were more likely to document HCPOA (P = 0.04). The mean number of elements documented for hospitalists was 2.40, followed by internal medicine residents at 2.07, and noninternal medicine trainees at 1.30 (P < 0.001).
Documentation quality of inpatient CSDs was poor. Our findings highlight the need to improve the quality of resident and attending CSD documentation.
PMCID: PMC4177509  PMID: 24681110
Documentation; advance care planning; resuscitation; DNR orders
16.  Orthodontic bracket designs and their impact on microbial profile and periodontal disease: A clinical trial 
Journal of Orthodontic Science  2014;3(4):125-131.
The aim of the present study was to compare the undisturbed plaque formation on teeth bonded with Preadjusted (Captain Ortho, Libral Traders, Mumbai, India) and Begg Brackets (Captain Ortho, Libral Traders, Mumbai, India) with nonbonded control sites via a de novo plaque growth over a period of 7 days.
Materials and Methods:
A clinical trial with the split-mouth design was set up enrolling 10 dental students. Within each subject sites with (Preadjusted) (P-site), Begg brackets (B-site) and control sites were followed. Plaque index and gingival index were recorded on days 3 and 7. Supra-gingival and sub-gingival plaque samples were taken from the brackets and the teeth on days 3 and 7, and were sent for aerobic and anaerobic culturing. The total number of bacterial colony forming units (CFU) was assessed for each sample using a colony counter. Tukeys and Dunnett test then statistically analyzed data.
The mean plaque index and gingival index increased on P-site and B-site on the third and 7th day. The shift from aerobic to anaerobic species was observed earlier in P-sites than in B-sites. The CFU were significantly higher for all sites on day 7 when compared with day 3. The aerobe/anaerobe CFU ratio was significantly lower in P-sites than in B-sites and then control showing an increase in the number of anaerobic species on the 3rd and 7th day (P < 0.05). Based on observed means, the mean difference was significant (P < 0.05).
The present data suggest that Preadjusted brackets accumulated more plaque than Begg brackets. Bracket design can have a significant impact on bacterial load and on periodontal parameters.
PMCID: PMC4238080  PMID: 25426456
Beggs; colony forming units; preadjusted
17.  Item and Test Analysis to Identify Quality Multiple Choice Questions (MCQs) from an Assessment of Medical Students of Ahmedabad, Gujarat 
Multiple choice questions (MCQs) are frequently used to assess students in different educational streams for their objectivity and wide reach of coverage in less time. However, the MCQs to be used must be of quality which depends upon its difficulty index (DIF I), discrimination index (DI) and distracter efficiency (DE).
To evaluate MCQs or items and develop a pool of valid items by assessing with DIF I, DI and DE and also to revise/ store or discard items based on obtained results.
Study was conducted in a medical school of Ahmedabad.
Materials and Methods:
An internal examination in Community Medicine was conducted after 40 hours teaching during 1st MBBS which was attended by 148 out of 150 students. Total 50 MCQs or items and 150 distractors were analyzed.
Statistical Analysis:
Data was entered and analyzed in MS Excel 2007 and simple proportions, mean, standard deviations, coefficient of variation were calculated and unpaired t test was applied.
Out of 50 items, 24 had “good to excellent” DIF I (31 - 60%) and 15 had “good to excellent” DI (> 0.25). Mean DE was 88.6% considered as ideal/ acceptable and non functional distractors (NFD) were only 11.4%. Mean DI was 0.14. Poor DI (< 0.15) with negative DI in 10 items indicates poor preparedness of students and some issues with framing of at least some of the MCQs. Increased proportion of NFDs (incorrect alternatives selected by < 5% students) in an item decrease DE and makes it easier. There were 15 items with 17 NFDs, while rest items did not have any NFD with mean DE of 100%.
Study emphasizes the selection of quality MCQs which truly assess the knowledge and are able to differentiate the students of different abilities in correct manner.
PMCID: PMC3968575  PMID: 24696535
Difficulty index; discrimination index; distractor efficiency; multiple choice question or item; nonfunctional distractor (NFD); teaching evaluation
18.  Code Status Discussion Skill Retention in Internal Medicine Residents: One-Year Follow-Up 
Journal of Palliative Medicine  2012;15(12):1325-1328.
Communicating with patients about goals of care is an important skill for internal medicine residents. However, many trainees are not competent to perform a code status discussion (CSD). A multimodality intervention improved skills in a group of first-year residents in 2011. How long these acquired CSD skills are retained is unknown.
To study CSD skill retention one year after a multimodality intervention.
This was a longitudinal cohort study.
Thirty-eight second-year internal medicine residents in a university-affiliated internal medicine residency program participated in the study. Nineteen completed the intervention and 19 served as controls.
Mean CSD clinical skills examination (CSE) scores using an 18-item checklist were compared after the intervention (2011) and one year later (2012).
Intervention group residents performed significantly better than residents in the control group (71.9% (standard deviation [SD]=16.0%) versus 54.7% (SD=17.1%; p<0.001) at one-year follow-up. Intervention group residents retained their CSD skills at one year as performance was 75.1% in 2011 and 71.9% in 2012 (p=0.46). Control group residents did not develop additional CSD skills as 2011 checklist performance was 53.2% and 2012 performance was 54.7% (p=0.78).
CSD skills taught in a rigorous curriculum are retained at one-year follow-up. Residents in the control group did not acquire new CSD skills despite an additional year of training and clinical experience. Further study is needed to link improved CSD skills to better patient care quality.
PMCID: PMC3509358  PMID: 23045991
19.  Improving Residents' Code Status Discussion Skills: A Randomized Trial 
Journal of Palliative Medicine  2012;15(7):768-774.
Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents.
This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests.
Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly.
A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.
PMCID: PMC3387757  PMID: 22690890
20.  EGFR Mutations in Indian Lung Cancer Patients: Clinical Correlation and Outcome to EGFR Targeted Therapy 
PLoS ONE  2013;8(4):e61561.
Screening for EGFR mutation is a key molecular test for management of lung cancer patients. Outcome of patients with mutation receiving EGFR tyrosine kinase inhibitor is known to be better across different ethnic populations. However, frequency of EGFR mutations and the clinical response in most other ethnic populations, including India, remains to be explored. We conducted a retrospective analysis of Indian lung cancer patients who were managed with oral tyrosine kinase inhibitors. Majority of the patients in the study had adenocarcinoma and were non-smokers. 39/111 patients tested positive for EGFR kinase domain mutations determined by Taqman based real time PCR. The overall response to oral TKI therapy was 30%. Patients with an activating mutation of EGFR had a response rate of 74%, while the response rate in patients with wild type EGFR was 5%, which was a statistically significant difference. Progression free survival of patients with EGFR mutations was 10 months compared to 2 months for EGFR mutation negative patients. Overall survival was 19 months for EGFR mutation patients and 13 months for mutation negative patients. This study emphasizes EGFR mutation as an important predictive marker for response to oral tyrosine kinase inhibitors in the Indian population.
PMCID: PMC3631198  PMID: 23620765
21.  Author fee: not a great idea 
PMCID: PMC2853409  PMID: 20382899
22.  Traditional Expectations Versus US Realities: First- and Second-Generation Asian Indian Perspectives on End-of-Life Care 
Although end-of-life care preferences vary across racial/ethnic groups, little is known about how cultural values affect end-of-life care preferences among South Asian immigrants and their offspring in the US.
To examine the perspectives of first- and second-generation South Asians living in the US regarding end-of-life care.
Focus group study. Discussions explored participant preferences and experiences with family members facing the end of life.
Twelve first-generation and 11 second-generation self-identified Asian Indians living in the mid-Atlantic region.
Content analysis of focus group transcripts.
First-generation participants ranged in age from 41 to 76 years and were evenly split by gender. Second-generation participants ranged in age from 23 to 36 years and included seven women and four men. All participants were highly educated, and two thirds were either studying or working in a health care field. All but two subjects were Hindu. Several themes emerged that highlighted cultural differences and challenges for this population in the context of end-of-life care: attitudes toward death and suffering; family duty; and preferences for information disclosure and decision making. Participants described cultural challenges due to the evolution of traditional roles, lack of explicit discussion between patients and family members about preferences and care expectations, and a tension between wanting to meet traditional expectations and the challenges in doing so given US social realities.
Traditional cultural values, such as duty to family, greatly influenced end-of-life care preferences and retained importance across generations. Clinicians caring for Asian Indian patients at the end of life may be better able to assess care preferences after exploring the complex interplay between traditional expectations and specific social realities for each patient. Particular attention should be given to attitudes toward death and suffering, family duty, and preferences for information disclosure and decision making.
PMCID: PMC3286568  PMID: 21948206
cultural differences; end-of-life care; advance directives; immigrant health; qualitative research
23.  Discovery of a Novel Class of Boron-Based Antibacterials with Activity against Gram-Negative Bacteria 
Gram-negative bacteria cause approximately 70% of the infections in intensive care units. A growing number of bacterial isolates responsible for these infections are resistant to currently available antibiotics and to many in development. Most agents under development are modifications of existing drug classes, which only partially overcome existing resistance mechanisms. Therefore, new classes of Gram-negative antibacterials with truly novel modes of action are needed to circumvent these existing resistance mechanisms. We have previously identified a new a way to inhibit an aminoacyl-tRNA synthetase, leucyl-tRNA synthetase (LeuRS), in fungi via the oxaborole tRNA trapping (OBORT) mechanism. Herein, we show how we have modified the OBORT mechanism using a structure-guided approach to develop a new boron-based antibiotic class, the aminomethylbenzoxaboroles, which inhibit bacterial leucyl-tRNA synthetase and have activity against Gram-negative bacteria by largely evading the main efflux mechanisms in Escherichia coli and Pseudomonas aeruginosa. The lead analogue, AN3365, is active against Gram-negative bacteria, including Enterobacteriaceae bearing NDM-1 and KPC carbapenemases, as well as P. aeruginosa. This novel boron-based antibacterial, AN3365, has good mouse pharmacokinetics and was efficacious against E. coli and P. aeruginosa in murine thigh infection models, which suggest that this novel class of antibacterials has the potential to address this unmet medical need.
PMCID: PMC3591879  PMID: 23295920
24.  Epidemiological and Investigative Study of Premature Graying of Hair in Higher Secondary and Pre-University School Children 
Hair pigmentation is one of the most conspicuous phenotypes in humans ranging from black, brown, and blonde to red. Premature graying of hair occurs more commonly without any underlying pathology but is said to be inherited in autosomal dominant pattern. Premature graying has been shown to be associated with a few of the autoimmune disorders. A role for environmental factors and nutritional deficiencies has also been postulated. However, to date the exact etiology of premature graying has not been established.
The objective of our study was to conduct an epidemiological and investigative study of premature graying of hair in higher secondary and pre-university school children of the semi-urban area.
Materials and Methods:
A total of 35 cases and controls were investigated for various parameter such as Hemoglobin, total iron binding capacity, serum ferritin (S. Ferritin), serum calcium (S. Ca), serum iron (S. Iron), vitamin B12, and vitamin D3 after taking informed consent. Epidemiological and investigations correlation was established using the Chi-square and Mann Whitney test and P < 0.05 values were considered significant.
Among the various laboratory parameters S. Ca, S. Ferritin and vitamin D3 were low in patients with premature graying of hair. There was significant high number of vitamin D3 deficient and insufficient among the cases compared to the controls.
According to our study S. Ca, S. Ferritin, vitamin D3 may play a role in premature graying of hair in our society.
PMCID: PMC3746220  PMID: 23960391
Calcium; ferritin; premature graying of hair; vitamin D3
25.  Characterization and Phylogenetic Diversity of Carboxymethyl Cellulase Producing Bacillus Species from a Landfill Ecosystem 
Indian Journal of Microbiology  2011;51(4):531-535.
Total population of cellulose degrading bacteria was studied in a landfill ecosystem as a part of microbial diversity study. Samples were obtained from 3 and 5 feet depth of a local landfill being operated for past 10 years. Among many isolates, 22 bacterial strains were selected based on their capability to decompose carboxymethyl cellulose (CMC). These isolates were cultivated on agar medium with CMC as the carbon source. All isolates were Gram positive, endospore forming and alkalophilic bacteria with optimum growth pH 9–10. They were grouped based on the phenotypic and chemotaxonomic characters and representative strains of different groups along with high carboxymethyl cellulase (CMCase) producing strains were included for further characterization. Analysis of 16S rRNA gene indicated that these strains belong to different species of the genus Bacillus. Maximum CMCase activity of 4.8 U/ml at 50°C was obtained by strain LFC15. Results in the present study indicated the potential of waste land ecosystems such as landfill are potential source for isolation of industrially important microorganisms.
PMCID: PMC3209942  PMID: 23024419
Landfill ecosystem; Bacillus; CMCase; 16S rRNA gene phylogeny

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