Cholangiocarcinoma- A Case Series Study

Original Article

Abstract

Cholangiocarcinoma is a grave malignancy with 85-90% patients presenting to healthcare at advanced stage of disease. Best treatment for this condition is surgery and without surgery median survival is only 5-8 months. The most important prognostic factor is complete resection and absence of lymph node metastasis both of which require early detection. In our study there were total 39 (66%) hilar, 13 (22%) distal and 7 (12%) intrahepatic cholangiocarcinomas. 20 (34%) patients had distant metastasis at presentation itself. Only 3 (5%) patients underwent curative resection and rest of the patients mainly underwent only palliative interventions. This is an important concern as the only chance for cure in cholangiocarcinoma is surgery and hence more studies are urgently required to focus on early detection and better treatment of this condition.

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Outcome of Patients Undergoing Treatment for Cellulitis/Lymphangitis

Abstract

A lot of patients come to surgery outpatient department with persistentlymphedema following an attack of cellulitis/lymphangitis. Many of the patients undergo conservative management with antibiotics analgesics and supportive measures. Some patients undergo fasciotomy for the same. Objective of this observational study is to look for the incidence of persistent lymphedema in patients undergoing fasciotomy for cellulitis/lymphangitis and patients undergoing conservative management for the same.

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Assessment of Serum CEA Levels in Different Radiological stages and Histopathological Grades of Colorectal Malignancy

Abstract

The study assessed the usefulness of serum CEA in predicting radiological stages and histopathological grades of colorectal malignancy in 202 patients admitted with radiologically and histopathologically proven colorectal malignancy. Histopathology, 68.96% were well differentiated; 42.55% moderately differentiated and 60% poorly differentiated adenocarcinoma. Patients had high serum CEA levels (>5ng/m1). On analyzing radiological staging, 72.7% with high serum CEA (> 5ng/ml) were node positive [stage III & 1\7]; 68.47% patients with low serum CEA (<5ng/m1) were node positive. Considering serum CEA, 80.2% patients had serum CEA value more than 2.5ng/ml and 54.45% patients had elevated serum CEA value more than 5ng/ml. It is concluded that serum CEA has got statistically little value in predicting histopathological grading and staging of colorectal malignancy.

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A Study On Triple Negative Breast Cancer

Abstract

Estrogen (ER), progesterone (PR), and human epidermal growth factor receptor2 (HER-2/neu) receptors are known as triple negative breast carcinomas (TNBC). They are extremely aggressive with poor prognosis. Here describe the clinical pathological and epidemiological characters of triple negative breast carcinomas in a tertiary care hospital in Kerala and compare with non-TNBC.

Clinical, pathological and epidemiological characteristics of 75 cases of TNBC were compared with that of 225 cases of non-TNBC. ER, PR, HER-2/neu status were determined by immunohistochemical staining. Data obtained were statistically analyzed using SPSS software.

Triple negative carcinoma was significantly associated with a younger age( mean age 43.67 yrs), early age of menarche. Commonly seen in premenopausal age group(78.7%). Patients with the triple-negative carcinoma had relatively large tumors(mean size 4.45cm compared to 3.14cm) and a high rate of node positivity(86.67%). More advanced stage at diagnosis with high grade tumour charecteristics. Most common histopathology was invasive ductal carcinoma (98.7%)but no statistical difference was noted with non- TNBC. No significant difference was noted between TNBC and non TNBC on comparing family history, parity, age at 1st child birth, OCP use.

Keywords:

Triple Negative Breast Cancer; TNBC; non-TNBC; lymphnode status in TNBC; epidemiology of TNBC

Introduction

Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women. There is an ever increasing incidence of breast cancer in developing countries for which no definitive cause is found. In India Ca breast is the second most commonest cancer and in Kerala around 30% of cancer affected women have Ca breast.Over the past decade, our understanding and treatment of breast cancer has undergone a metamorphosis, shifting from a generally homogeneous approach to a more sophisticated view as guided by gene expression analysis. In the year 2000, Perou et al. published a noval classification based on gene-expression analysis that considered four breast cancer subtypes: Luminal, HER2- positive, normal breast, and basal-like1. Within these groups, basal-like cancer emerged as a unique subtype because of its absence of expression of estrogen receptor (ER), progesterone receptor (PR), and HER2, also showing the worst outcome and having no known therapeutic target. Despite triple-negative breast cancer (TNBC) is universally used as a surrogate marker, triple negative and basal-like are not equivalent terms.

Breast carcinomas which do not express oestrogen(ER), progesterone(PR), and Human Epidermal growth factor Receptor 2(HER-2/neu) receptors are known as triple negative breast carcinomas(TNBC). They have been found to be aggressive with poor prognosis. There is paucity of data on TNBC from the state of Kerala. Our objectives were to study the clinicopathological and epidemiological characteristics of our patients with TNBC and to compare with non-TNBC.

Materials and Methods

The study conducted was a Cross sectional comparative study among the patients undergoing surgery for carcinoma breast in the Department of General Surgery, Government Medical college, Kozhikode. The study was conducted for a period of 20 months, between March 2014 and October 2015. A total of 300 patients were included in the study of which 75 cases of TNBC were compared with 225 cases of non-TNBC. The inclusion criteria being all female patients with carcinoma breast who underwent primary surgery(modified radical mastectomy or breast conservation surgery) and those who underwent surgery after neoadjuvant chemotherapy. Exclusion criteria included

  1. Male patients with carcinoma breast
  2. Patients with inoperable carcinoma breast
  3. Patients with metastasis to breast

Patients were recruited after obtaining an informed consent in local dialect. All necessary relevant details were collected by direct clinical examination, contacting patients over telephone, inpatient case sheets, operation registers maintained in respective surgery units and histopathology and IHC registers maintained in the Dept. of Pathology in our institution. The presence of ER, PR and HER2/neu receptors were determined by immunohistochemical staining from Pathology department in our college. For this study, triple negative breast cancers(TNBC) were defined as those that were ER negative, PR negative, and HER-2 neu negative. “Other”/ non-TNBC were defined as those that were positive for any of these IHC markers. Epidemiological, clinical and pathological parameters were compared between these two groups. The obtained data were statistically analyzed using SPSS software and arrived at the results.

Results

75 cases of TNBC were compared with 225 cases of non-TNBC. The mean age at diagnosis of TNBC patients were significantly lower than non-TNBC group(43.67years vs. 55.74 years, p= 0.000). The mean age of menarche in TNBC patients were significantly lower than of non-TNBC patients (13.44years vs. 14.24years, p=0.000)(Table 1). 78.7% cases of Triple negative group were premenopausal where as only 16.9% cases of non-TNBC were pre menopausal(Chart 1). The results were statistically significant (p=0.000).

No significant difference was noted between TNBC and Non- TNBC group for a positive family history of breast cancer (5.3% vs. 7.6%, p=0.514), history of oral contraceptive use(9.3% vs. 4.4%, p=0.113), history of breast feeding for more than 6 months(81.3% vs. 86.2%, p=0.304). Mean age at 1st child birth and mean parity also had no significant difference between the two groups(Table 1).

The mean size of the lump at the time of diagnosis of TNBC cases were significantly larger than non-TNBC (4.45cm vs. 3.14cm, p=0.000) (Table 1). Lymph node involvement was noted in 86.67% of cases of triple negative carcinoma of which 81.3% had N1 node and 5.3% had N2 node status (Chart 2). In other group 68.44% of cases had lymph node involvement of which 64% had N1 node status and 4.4% had N2 node status(p=0.009). Infiltrating Duct Carcinoma(IDC) was the histopathological report in 98.7% cases of TNBC and 95.6% of non-TNBC. Patients with TNBC had a significantly higher proportion of high-grade tumors as compared to the non- TNBC group(Chart 3)(60% grade 3 vs. 24.9% grade 3, p=0.000). 45.3% cases of TNBC had stage 3a disease where as 49.3% of non-TNBC had stage 2b disease, p=0.001 (Chart 4).

Discussion

The mean age at diagnosis was significantly younger in TNBC patients (43.67 years) as compared to non-TNBC group (55.74 years) (P = 0.000). Similar results were seen in a study conducted by Bauer et al2 with mean age of 54 years in TNBC compared to 60 years in non TNBC. Dent et al3 in her study noted mean age of 53.0 versus 57.7 years respectively in TNBC
and non TNBC which was also comparable with our study. Similarly, Krishnamurthy et a4, Rao et al5 also reported that mean age of diagnosis of TNBC was significantly younger compared to non TNBC. The mean age at menarche in TNBC group was 13.44 years and in other group was 14.24 years and the difference was statistically significant. In a pooled analysis of 34 studies from breast cancer association consortium, Yang et al6 concluded that there was no statistically significant difference in the age of menarche between TNBC and other breast cancers, which was against the observations in our study.

Majority of cases of TNBC were premenopausal(78.7%) compared to non-TNBC cases in our study. This statistically significant observation was consistent with studies by Carey LA et al7 Carolina breast cancer study). A positive family history of breast cancer was noted in 5.3% cases of triple negative and 7.6% cases of other group in the current study which was not statistically significant. In the meta analysis by Yang et al6 a positive family history increased the risk for all the subtypes of breast cancer, though possibly somewhat more for basal like tumors(identified by gene expression analysis). But this difference was absent when the tumor subtypes were defined only by immunohistochemistry. No statistically significant difference was observed in OCP use between TNBC and non-TNBC in our study. Kwan et al8 observed that 72% cases of TNBC in his study had history of OCP use. 55% of cases of TNBC had used OCP in Phipps et al.9 study. Population based study by Dolle JM et al10 observed that OCP use was associated with a 3.1-fold increased risk of triple-negative breast cancer and not related to risk of non-triple-negative breast cancer. No statistically significant difference was noted between TNBC and non TNBC in the mean age of 1st pregnancy(19.71years and 19.01years respectively) and parity(2.43 and 2.71 respectively) in the study. Yang et al6 suggested that nulliparity and increasing age at first birth do not increase risk for triple-negative tumors.

Millikan et al.11 reported that parity and early age at first fullterm birth were not protective for TNBC and suggested that these factors may actually increase the risk for TNBC. 18.7% cases of TNBC and 13.8% cases of non TNBC had short duration of breast feeding. But the observations were statistically not significant. Elevated risk of TNBC with short duration of breast feeding was demonstrated in Millikan et al11, Ma et al12. Patients
in the triple negative group had relatively large tumors (4.45 cm compared to 3.14cm) and the difference was statistically significant. This observation was consistent with the findings in the studies of Dent et al3 and Bauer et al2. Lymph node involvement was more in TNBC group(86.67%) as compared to non TNBC group(68.44%) which was statistically significant.

Results of the present study was consistent with Studies by Dent et al.3, and Li et al.13 which also showed a higher propensity for Lymph node involvement in TNBC in 54.4% and 71.3% patients respectively. Tumour grade was found to be significantly higher in TNBC, with majority having grade 3 tumour compared to the non-TNBC, similar observations

Table 1: Demographic and clinical characteristics
CharacteristicsTNBCNon-TNBCP value
Mean age43.6755.74.000
Mean age at menarche13.4414.24.000
Age at 1st pregnancy19.7119.01.434
Mean parity2.432.71.179
Mean size of lump(cm)4.453.14.000
Family history of Ca breast(%)5.3%7.6%.514
OCP use(%)9.3%4.4%.113
Breast feeding >6 months(%)81.3%86.2%.304
Choice of surgery96%92.9%.338
4%7.1%

were noted by Dent et al3, Bauer et al2, Gogia et al16 and Carey et al7. Stage 3a was the commonest stage at presentation in TNBC comprising 45.3% of cases followed by stage 2b, 32%. Whereas only 13.3% cases of non-TNBC group had stage 3a disease and the observation was statistically significant. This means that triple negative cancer was diagnosed at a higher stage compared to non TNBC revealing the aggressiveness of the TNBC. In a Japanese study by Ishikawa et al14 86.5% of cases of TNBC had stage 1 and 2 while only 10.3% had stage 3 disease.

Infiltrating duct carcinoma(IDC) was the histopathology of 98.7% cases of TNBC and 95.6% of non-TNBC group. This finding was consistent with studies by Livasy et al15, Ishikawa et al14, Carey et al7. 86.7% of cases with TNBC underwent primary surgery compared to 89.8% with non-TNBC. 96% cases with TNBC underwent modified radical mastectomy(MRM) and 4% underwent breast conservation surgery(BCS) compared to 92.9% and 7.1% of MRM and BCS respectively in cases with non-TNBC. These observations were not statistically significant.

Despite the fact that TNBC tends to be more aggressive, surgical decision making likely rests on more traditional clinicopathological variables and patient preference17. Studies also showed that the type of surgery, either breast-conserving or total mastectomy, had no significant impact on the rate of locoregionalrecurrence18. In our study the outcome of the disease following treatment were not assessed due to the short time frame of the study.

Conclusion

Triple negative carcinoma is significantly associated with younger age, early age of menarche. Commonly seen in premenopausal age group. Patients with the triple-negative carcinoma will have relatively large tumors and a high rate of node positivity and more advanced stage at diagnosis with high grade tumour charecteristics. No significant difference was noted in the influence of a positive family history, oral contraceptive use, parity or age of 1st child birth between TNBC and non-TNBC. The patients who had all the three receptors available are included. Triple negative breast cancer represents a unique subgroup, with a specific molecular profile, an aggressive behavior pattern, a relative lack of effective therapies and a poor prognosis. More studies around the world are on the way to tackle this unique and aggressive disease.

References

  1. Perou CM, Sørlie T, Eisen MB, van de Rijn M, Jeffrey SS, Rees CA, Pollack JR, Ross DT, Johnsen H, Akslen LA, et al. Molecular portraits of human breast tumours. Nature 2000;406:747– 752.
  2. Bauer KR, Brown M, Cress RD, et al., Descriptive analysis of estrogen re- ceptor (ER)-negative, progesterone receptor (PR)-negative, and HER2- negative invasive breast cancer, the so called triple-negative phenotype: a populationbased study from the California cancer registry. Cancer 2007:109:1721- 1728.
  3. Dent R, Trudeau M, Pritchard KI, et al., Triple-negative breast cancer: clinical features and patterns of recurrence. Clin Cancer Res 2007: 13:4429- 443
  4. Krishnamurthy S, Poornima R, Challa VR, Goud YG. Triple negative breast cancer – our experience and review. Indian J Surg Oncol 2012;3:12-6.
  5. Rao C, Shetty J, Prasad KH. Immunohistochemical profile and morphology in triple-negative breast cancers. J Clin Diagn Res 2013;7:1361-5.
  6. Yang XR, Chang J, Goode EL, et al., Associations of breast cancer risk factors with tumor subtypes: a pooled analysis from the Breast Cancer Association Consortium studies, J. Natl. Cancer Inst.2011:103: 250- 263.
  7. Carey LA, Perou CM, Livasy CA, et al., Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study, JAMA. 2006:295(21):2492-2502.
  8. Kwan M.L., Kushi L.H., Weltzien E. Epidemiology of breast cancer subtypes in two prospective cohort studies of breast cancer survivors. Breast Cancer Res. 2009;11:R31
  9. Phipps A.I., Chlebowski R.T., Prentice R. Body size, physical activity, and risk of triple-negative and estrogen receptor positive breast cancer. Cancer Epidemiol Biomarkers Prev. 2011;20(March 3):454–463.
  10. Dolle JM, Daling JR, White E, et al. Risk factors for triple negative breast cancer in women under the age of 45 years. Cancer Epidemiol Biomarkers Prev. 2009;18:1157– 66.
  11. Millikan RC, Newman B, Tse CK, et al. Epidemiology of basal-like breast cancer. Breast Cancer Res Treat. 2008;109(1):123–139. Ma H, Wang Y, Sullivan-Haley J, et al. Use of four biomarkers to evaluate the risk of breast cancer subtypes in the Women’s contraception and reproductive experiences study. Breast feeding and contraception use. Cancer Res 2010; 70: 575–87
  12. Li CY, Zhang S, Zhang XB, Wang P, Hou GF, Zhang J. Clinicopathological and prognostic characteristics of triple- negative breast cancer (TNBC) in Chinese patients: A retrospective study. Asian Pac J Cancer Prev 2013;14:3779- 84.
  13. Ishikawa Y, Horiguchi J, Toya H. Triple-negative breast cancer: histological subtypes and immunohistochemical and clinicopathological features. Cancer Sci. 2011;102(March 3):656–662
  14. Livasy CA, Karaca G, Nanda R, et al., Phenotypic evaluation of the basal-like subtype of invasive breast carcinoma. Mod. Pathol. 2006:19: 264-271.
  15. Gogia A, Raina V, Deo SVS, et al. Triple-negative breast cancer: An institutional analysis. Indian journal of cancer 2014:51:2: 163-166.
  16. Crutcher CL, Cornwell LB, Chagpar AB. Effect of triple negative status on surgical decision making. ASCO 2010.
  17. Lowery AJ, Kell MR, Glynn RW, et al. Locoregional recurrence
  18. after breast cancer surgery: a systematic review by receptor
  19. phenotype. Breast Cancer Res Treat. 2012;133:831–841.

Acknowledgements: None.
Conflict of Interest: None
Address for Correspondence:
Arun Ajay
Senior Resident, Dept of General Surgery,
Govt Medical College Kozhikode

Conundrum of MBBS Admissions

Preamble

Year after year, medical admissions in Kerala are becoming murkier and murkier, thanks to the inefficiency, corruption and lack of vision among all the parties involved. The problem can be solved very easily. The Hon. Supreme Court or the Central Government should issue orders accordingly.

Dr. YM Fazil Marickar,
Principal, Mount Zion Medical College, Adoor

Preamble

Year after year, medical admissions in Kerala are becoming murkier and murkier, thanks to the inefficiency, corruption and lack of vision among all the parties involved. The problem can be solved very easily. The Hon. Supreme Court or the Central Government should issue orders accordingly.

The Problems

Several problems in UG and PG admissions have been created in the recent past.

  1. Medical Council of India is expected to ensure the effectiveness and competence of institutions all over the country to conduct the MBBS course. For this purpose, the Council is conducting inspections every year. However, the norms of the Medical Council are outrageous and
    completely out of perspective in the light of realities. Several ambiguities exist in the rules and regulations regarding the minimum standard requirements for creating Medical Colleges.
  2. The post of Junior Resident is meant for post graduate students after getting admission to a post graduate degree course in a Medical College. There is no place for such post in an institution, where there is no post graduate course running. They should be named as Tutors.
  3. Senior Resident is the name of the trainee who gets admitted for post-doctoral courses namely MCh and DM. There is no point in giving designation for posts as senior resident in an institution, where the post-doctoral degree courses do not exist. They should be designated as assistant professors.
  4. Eligibility for appointment as Assistant Professor is pass in the post graduate examination, whereas the requirement for the post of Senior Resident is completing 3 years of training as Junior Resident. In realistic terms, the difference between a qualification for Assistant Professor and Senior Resident is just a pass in the post graduate examination. It is really unscientific to apply such posts to new Medical Colleges, which are not granted permission to conduct the post graduate – MS, MD courses or the post-doctoral DM, MCh courses.
  5. The solution is to abolish the post of Senior Resident and rename the Junior Resident post as tutors. The requirement of Assistant Professors can be increased to fill the number of Senior Residents posts also.
  6. Unrealistic numbers of Faculty. In a new institution starting an MBBS course, the super speciality departments like Urology, Plastic Surgery, Thoracic Surgery, Neurosurgery, Paediatric Surgery, Gastro-enterology
    Surgery, Nephrology, Cardiology, Gastro-enterology and Neurology are not required. However in the present day, in the urban and semi-urban areas, a Medical College, which is supposed to be a tertiary hospital is expected to have most of these super speciality departments as well. In the absence of super speciality departments, the number of patients with different illnesses will be very low. Under the circumstances, it is not possible for the budding Medical Colleges, without the speciality and super speciality degree courses to have sufficient number of patients as required by the MCI.
  7. The quality of patients is another controversial aspect. The question of which patient with what diagnosis is to be admitted depends on the geographical location, of the Medical Council says that the inspection should not be conducted on a public holiday of national or local level. When this situation is brought to the notice of the assessors, they say that they had to just follow their rules and that they should be continuing with the assessment.
  8. During the initial talk with the co-ordinator, one of the assessors disappears. After a few minutes, the assessor is traced to a ward and the Principal goes and greets him in the ward. The assessor confronts the Principal by asking the demeaning questions like “why are you here?, did I invite you?” and derogating statements like “you are not wanted here”. It may be pointed out that the Principal or Dean has got the right to visit any place of the hospital and no assessor can restrain the Principal from reaching any part of the hospital.
  9. One assessor walks into the operating theatre without changing to theatre dress to take count of the number of surgeon working inside! The assessors would not consider faculty members working in other theatres in casualty and minor theatres where surgeons were working. Rejection of such faculty create discomfiture to the institutions.
  10. The rule stating that the inspectors can come at any time till 11’0’ clock and insist for an attendance register at 11’0’ clock is totally unscientific. In certain institutions, at certain times, the inspectors accept Faculty members till the time they leave the College. When the need of the MCI is to reject permission to a College, the inspectors are asked to come in at 10:30 and close the attendance at 11’0’ clock and find out “DEFICIENCIES”. When the College is waiting for first renewal of permission for 2015-2016, the Faculty for the five Para-clinical Departments of Pharmacology, Pathology, Microbiology, Forensic Medicine and Community Medicine are to be shown during the inspections in September 2014 to June 2015. The majority of Faculty members of the above Departments have no work till the II MBBS class starts in November 2015.
  11. Surprise inspection is another farce. There are instances, where the inspections are held several times to suit the convenience of the MCI designs. The first inspection is done in a scientific way and no deficiencies are recognized. Action is not taken on the findings of the inspection for more than a month and at the end of the period on the day, executive committee of Medical Council of India is meeting, a new set of inspectors is sent to the same colleges as surprise inspection and the inspectors are asked to report by the hour to the executive committee members of the Medical Council on the number of patients, the type of patients, the presence of faculty at 11.00’ clock and so on with the only intention of harassing as the types of diseases vary from place to place. In many western countries, the non-availability of actual patients has instigated medical teaching based on dummy (standardized) patients, where normal people are trained to present with various complaints of a particular disease and brought in as subjects to present to the student as suffering from that particular disease at the time of examinations and clinical classes. These subjects with the knowledge of the disease give more insight to the topic to the students, who are studying for this course and appearing for the examination. Scientific teaching of modern medicine depends more on the approach towards diagnosis and treatment rather than the number of patients with a particular diagnosis. With the enforcement of skill labs and newer technologies in teaching, it is possible to reduce the minimum requirement of number of patients in the new Medical Colleges. Experience shows that with the progress of the medical institutions, most to the Medical Colleges become high profile full-fledged hospitals as time passes by and post graduate courses and super speciality courses are started and the number of patients automatically increases. Thus, it is not the number of patients and type of disease that matter in the training of the medical student, but proper professional training of the students and giving information on what diseases are likely to come in the local situations.
  12. The Medical Council of India has been uncertain with the numbers of Faculty members in the colleges starting the MBBS course. From the 1st July 2015, the number of Faculty members in various pre and para-clinical departments has been reduced unscientifically, whereas the number of faculty in various clinical departments still is more than
    the minimum requirement.
  13. The MCI inspection is a farce. On one fine morning, three people walk into the Principal’s room at 10.45 am and claim they are assessors from Medical Council of India coming for a surprise inspection. They tell the Principal that all the faculty members should come to the Principal’s office within 15 minutes and sign the attendance register before 11.00 am. (They don’t even care to show the authority letter from the Medical Council to convince the Principal that they are genuine assessors of the Council. Out of dignity and consideration for the said inspectors, the Dean does not demand any papers from them.) Any faculty member who did not sign the attendance register before 11.00 am is not counted for the faculty positions. The fact that one of the days of the inspection happens to be local holiday declared by the Government does not matter to the assessors. The rule the Colleges. This is simple intimidation of the staff and management of the Medical Colleges.
  14. During such surprise inspections, natural situations like duty off, weekly off and leave for various medical and other considerations are not being considered by the assessors. It is very clear that the assessors are interested only in creating some comments based on which the executive committee can reject the permission for the
    admission for the next academic year. This approach is very unscientific.
  15. Many of the inspectors who come for the inspection do not know the rules. They are guided by various regulations to suit their own convenience. For example: the minimum standard requirements of Medical Council of India contain ambiguities in the different pages of the book. The various forms to be filled up, namely Form A, Form A1, Form A2, Form A3, B Form and so on are contradictory. The large number of Forms is totally unnecessary and makes it confusing particularly in the light of facts that various aspects of inspection are given differently in the different Forms. All the forms could be made into one and all the aspects required to be filled in the inspection form should be according to the minimum standard requirement scheme given by the Medical Council of India. There are several disparities and errors in the minimum standard requirement and the guidelines issued by the Medical Council of India from time to time.
  16. The arrogance shown by some of the Medical Council inspectors in the days of inspection is deplorable, unacceptable, unscientific and unethical. An inspector from one subject does not appear to be competent of deciding which patent should be admitted in another
    Department. The genuinity of the patients and the diagnosis of the patients are not to be questioned by the inspectors. This outrageous attitude of some inspectors is responsible for the instigation to the Medical College management to conduct foul play. They cannot be
    blamed.
  17. For the academic year 2015-2016, over 100 colleges were denied permission by the MCI for renewal. When the file was sent to the Union Government, the Central Government decided that all the Government colleges can be granted renewal of permission for admitting students, whatever be the deficiency. All the private Medical Colleges were left in the dark. The private Medical Colleges were forced to approach the judiciary. Ultimately in the last week of September, many of the private Medical Colleges got permission for renewal of permission for admission. These created unnecessary disturbances and destabilization of the educational pattern of the whole country. All these can be totally avoided if the solutions which are presented in these columns are approved by the Government or the Supreme Court of India and implemented in the country.
  18. The solution to these problems is possible, if regulations are maintained realistic in consultation with the college managements both in the government and private sector and formulate programmes, by which the sanctity of medical education can be retained by proper organization of the courses and with proper review.

The Solution

  1. All the MBBS admissions in the country should be completed before the 31st of May every year.
  2. Classes for MBBS should start all over the country on the 1st of June every year.
  3. The procedures for granting permission to institutions for admission to the MBBS courses should be completed by the Medical Council, the Central Government, the State Governments and the various Hon. Courts of India before 31st of March every year. No cases should be accepted by the courts after that date.
  4. All the entrance examinations, national and regional approved by the MCI should be completed before the 30th of April every year.
  5. Examinations approved by the MCI shall not be questioned by any authority after 1st of April every year.

STANDARDS OF MEDICAL EDUCATION

If only more effort is taken by the Medical Council of India, it will be possible to improve the standards of medical education by incorporating smart classrooms and connecting the various colleges and having unified classes by expert teachers. The students of all the institutions in the country will ultimately benefit.

For example: There are several agencies which conduct post graduate entrance training classes in All India level which students in various parts of country sitting in different lecture halls and attending. Excellent satellite classes are taken by genuine teachers of caliber and simplicity. This sort of lectures can be made official, probably with a fee to be transmitted to various Medical Colleges. If the classes are regulated by electronic online versions, all the courses in the country can be started on a same day and all the examinations can be conducted on the same day and irregularities and disparities in the timing of the courses can be avoided. With the starting of online classes, the websites of the Medical Colleges can be updated with lessons presented by the various teachers and each class can become a module on the subject. Such modules can be incorporated in all the websites for the students to learn the subjects the electronic way. The modules that are being taught (5330 modules) in a span of 8975 hours in MBBS course have to be equated to the 300 common diseases (diagnosis) which are likely to be seen by the undergraduate student during the period of the MBBS course. By equating modules to diagnosis, the learning process can be simplified and made more realistic in the line of Vertical Integration. Module to diagnosis will also be incorporated as a part of an Electronic Medical Record System, whereby all the medical colleges can be involved in a proper Electronic Medical Records maintenance program. In this set up, all the diagnoses are pre-planned and set by the Doctors concerned in their own way in different combinations and in different grades of disease and all the investigations, laboratory, endoscopic and operative procedures can be incorporated in to the system using the suggested new Electronic Medical Recording Program. The national grid should be created for the maintenance of the teaching materials in servers which can be transmitted to various Medical Colleges for improving medical education. The whole system of the Medical Council has to be redrawn in order to make these implementations effective. Telemedicine should be incorporated in the teaching process of all the medical colleges so that the clinical pathological conferences, immortality conferences, the CME programs of various Medical Colleges can be clubbed and made available to all the other Medical colleges. This will enhance the opportunity for the students to see what is happening in other parts of the country and also to be aware of the rare diseases which are occurring in various parts of the country. This facility can be extended to international levels also to incorporate teachers of international repute in the teaching of under graduate, post graduate medical institutions in the country.

The scientific content of the post graduate medical entrance examinations is absolutely unscientific. There is no point in asking post graduate level of questions to students who have just completed the MBBS course. The questions should be set in such a way that they are based on an undergraduate level rather than a postgraduate level. Several students are forced to waste years of their precious life’s preparing for entrance examination. Most of the postgraduate knowledge is gained before the admission rather than after the admission. The purpose of selection is to identify the best group of students. There is no need to waste years of a student’s life for the sake of getting admission for the next course. Every year at the end of the MBBS course during before House Surgeoncy starts, the admission process to the post graduate degree courses should be completed. The House Surgeon will be able to perform his work in a way beneficial to himself and the institution.

Epilogue

It is the basic rights of the new generation of young budding medical professionals to get justice in our country. If the prenursery classes, the junior school, senior school and all the educational systems of one academic year can start on the 1st of June, why not the medical education also starts on the 1st of June? Precious man days of the budding doctors are lost because of the inefficiencies, irregularities and corruption in the medical education sector in this country. Irregularities lead to corruption and corruption leads to a vicious circle, whereby the ultimate sufferers are the students. If the rules and regulations are clear, there is no scope for corruption and all the admission processes are streamlined, the fees of the Management quota students can also be regulated. Capitation fees can then be controlled. The teaching processes can be unified and streamlined to be completed within the stipulated span of 4 years and 187 days.

Acknowledgements: None.
Conflict of Interest: None
Address for Correspondence:
Dr. YM Fazil Marickar,
Principal, Mount Zion Medical College, Adoor

Total Contact Casting (TCC) in Diabetic Plantar Ulcers

Original Article

Abstract

Total contact casting is the choice of treatment in neuropathic diabetic ulcers. We took 50 cases of diabetic ulcers to study the effect of total contact casting in healing of Neuropathic diabetic foot ulcers.A total of 50 patients with plantar diabetic ulcers with Wagner’s grade 1 and 2 were included in the inclusion criteria and patients with peripheral vascular disease and wagners grade 3 and 4 were excluded. The study was conducted based on the ulcer healing time and followed up for 8 weeks. Our results found out that 87.3% of foot ulcers healed in our study group. The mean ulcer healing time was 3 weeks.

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Robotics and Surgery

Dr. R Dayananda Babu,
Prof of Surgery and HOD, Sree Gokulam Medical College

Invited Article

LINDBERG SURGERY

7th September 2001 was a landmark memorable day in the history of surgery. Michale Gagner performed the first transatlantic surgery – a robotic system was utilised to perform a cholecystectomy on a patient in Strasbourg while the surgeon was comfortably positioned in New York. However Rome was not made in a days work.

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