Improving Undergraduate Ophthalmology Education in the Time of COVID-19 Pandemic by Video-Assisted Online Learning

Introduction

The COVID-19 pandemic had given an immediate challenge to traditional undergraduate medical education methods, and in-person clinical clerkships, including ophthalmology rotation for medical students, had been suspended to prevent the threat of disease transmission. This rotation cancellation could lead to a lack of patient’s exposure and, eventually, inadequate basic ophthalmology knowledge and clinical skills. The lack of ophthalmology case exposures in medical students will contribute to the misdiagnosis and mismanagement of ocular diseases and inappropriate referral to ophthalmologist [1,2]. This condition forced the need to develop virtual clinical learning. The online learning method is not a substitute for traditional face-to-face learning method and is not without its shortcoming, but it can help to ensure that the medical students would not lose their precious time and could continue with their academics in these uncertain times [3,4].

Our university had developed an online learning platform named iLearn before the outbreak of COVID-19, but its use was still limited. The COVID-19 pandemic then allows us to explore a new approach for teaching-learning techniques using this online learning platform. Adequate evidence-based research must be provided to encourage the faculty to implement this alternative learning method during this pandemic period [5,6]. Therefore, we conducted this study to evaluate the online learning method’s effectiveness during the COVID-19 pandemic for undergraduate medical students in ophthalmology clinical clerkships. This study will give an insight into the efficacy of online learning in undergraduate ophthalmology education.

Methods

This study was conducted from June to November 2020 at the Department of Ophthalmology of Faculty of Medicine Andalas University, Indonesia. This study design was an interventional study. The online learning platform we used to conduct the online learning was the iLearn. This study enrolled 64 medical students who enter virtual clerkship in ophthalmology rotation during the COVID-19 pandemic for about four weeks. The students had never been undergone face-to-face clinical clerkship in the Department of Ophthalmology previously. Another inclusion criteria were clinical clerkship students who still registered as medical students and clinical clerkship students who had iLearn platform personal account. Exclusion criteria were clinical clerkship students who did not complete the multiple-choice test and the student perception questionnaire.

The students were instructed to enter the iLearn platform and do several tasks, including watching the clinical skill video and making a report about the case presented in the video, filling the multiple-choice question (MCQ) test and the student perception questionnaire through the iLearn platform. The clinical skill video topics include:

a) Visual acuity examination and introduction of ophthalmology examination tools.

b) History taking and subjective refractive examination.

c) Eyelid infection case presentation.

d) Conjunctival infection case presentation.

After watching the clinical skill videos, making the case reports, and answering the multiple-choice test, the students fill a questionnaire comprising ten questions about their perception of online learning. After two weeks of online learning, the students then undergo two weeks of in-person clinical clerkship in the university hospital wearing personal protective equipment, which is mandatory. At the end of the ophthalmology rotation, the students undergo an objective structured clinical examination (OSCE) test with the simulated patients, including visual acuity and subjective refractive examination. All data were collected and analyzed computerized using the descriptive statistic method. The authors then withdraw the conclusion from the result. This project was deemed quality improvement and research ethics approval was waived.

Results

The demographic data of the medical students are following. Among 64 students, 52 were female (81,25%) and 12 were male (18,75%). The range of students ages was 19 years old to 28 years old with a mean age was 22,66 years old. Assessment and evaluation of the online learning method are done by observing the MCQ and OSCE test scores and the students’ perception questionnaire results. By assigning this type of assessment, we can know the medical students’ level of basic knowledge and skills in ophthalmology. Table 1 shows the mean score of the MCQ and OSCE tests Table 1. Mean score of multiple choice and objective structured clinical examination test. From the test result, it can be seen that the students get good test scores both in MCQ and OSCE tests. However, in the MCQ test, the knowledge about visual acuity and subjective refractive examination still poor, shown by the low mean score. Nevertheless, later in the OSCE test, the student’s skill in visual acuity and subjective refractive examination had improved a lot, shown by the increase of the mean score.

Table 1: Mean score of multiple choice and objective structured clinical examination test.

Figure 1 shows the perception of the medical student about online learning methods. From the questionnaire results, the majority of the students agree that the videos were well-prepared, and the contents were easily understood. The videos also help the students to achieve learning objectives in clinical ophthalmology clerkship. However, some students prefer the face-to-face learning methods, especially in acquiring basic ophthalmology skills, with the direct supervision of an ophthalmologist. A clinical skill directly demonstrated by the instructor will be easier to understand and perform according to most students.

Figure 1: Students’ perception about online learning.

Discussion

The decline in undergraduate ophthalmology education level for medical students, which was further severed by the COVID-19 pandemic, could lead to a lack of essential basic skills in ophthalmology examination among medical students. The applied physical distancing and lockdown strategy had interfered with the learning-teaching process in most countries in the world. The medical students have been targeted to achieved some competencies in ophthalmology, but the current situation made it difficult because there were diminished opportunities and times to encounter real patients in the hospital. Modification of the ophthalmology teaching method must take place to accommodate this task within a shorter period. The advancement of information technology had brought online learning as one of the best alternative teaching methods during this pandemic era to get sufficient competencies in ophthalmic skills and knowledge [7-9].

Before the pandemic period, undergraduate ophthalmology rotation took four weeks in our department. The learningteaching process involves face-to-face case discussion and direct observation of patient examination in the outpatient clinic. During the COVID-19 pandemic, the education process had shifted into half of online learning and half of in-person clerkship. This change is to reduce the number of students in our department where the student’s group was split into halves so the physical distancing is still can be applied. This study result gives a promising result about the implementation of online learning in undergraduate ophthalmology education. Overall, both MCQ and OSCE tests show good mean scores of the students. A concern must be given to basic ophthalmology skill which is more complicated for medical students to master such as subjective refractive examination. In the online learning period, the students still difficult to comprehend this issue, shown by a low mean score of the MCQ test (55,55 + 22,20). However, after undergoing two weeks of in-person clinical clerkship in the university hospital, the skill of the students in the subjective refractive examination had improved significantly. Comprehensive management of simple refractive errors is one of the basic competencies in ophthalmic skill, which is mandatory to primary care physicians according to the National Standard of Indonesian Medical Doctor Competencies [10]. Unfortunately, the subjective refractive examination is quite difficult to master by the medical students. This examination needs patience and repetitive practice in order to do it well and get an accurate refractive error measurement. Besides that, this examination needs a cooperative patient and does not enough by only watching an educational video. In the in-person clinical clerkship period, the students had an opportunity to practiced it under the supervision of an ophthalmologist and directly get feedback after the examination. Feedback holds an important role in improving the student’s clinical skill as it guides them to do the procedure according to the standards. Therefore, face-to-face learning methods are still a more effective means of teaching for this particular ophthalmic skill [7,11].

Overall, the student’s perception was good about online learning, where more than 85% of students were satisfied with the quality of online learning. About 85,94% of students also can comprehend the learning material in the video and achieved the learning objectives which were expected. More than 90% of the students agreed that the topic presented in online learning was an essential topic to learned and very useful in clinical practice as a primary care physician. However, many of the students (93,75%) stated that face-to-face learning methods were more effective than online learning methods, especially in learning clinical skills such as subjective refractive examination. About 95,31% of them considered that clinical skills that the instructor directly demonstrated will be easier to understand and can rehearse to perform under the direct supervision of an ophthalmologist. Few studies about perception about online undergraduate ophthalmology teaching during the COVID-19 pandemic had shown positive feedback from students. Majority of the students perceived that online learning was a favorable alternative to the conventional face-to-face learning method with the ease of flexibility of the learning process to time and place, repeatability of the learning material at own pace, and the more courage to ask and interact with the instructor. The shortcomings of online learning were mainly the lack of clinical training and patient encounter, the learning process was not as interactive as traditional face-to-face learning, and limited facilities include poor internet connectivity [2,12-14].

Provision of learning materials included clinical skill videos before undergraduate ophthalmology clinical clerkship had shown to significantly improved subjective and objective measures of knowledge and skill performance. This effect is likely due to the specified topics and the higher efficacy of selected materials provided by the instructor relative to student-selected materials so the students can focus and concentrate on achieving the learning objectives and clinical skills expected [15]. Computerassisted learning modules using virtual patients have been applied to enhance teaching and learning by allowing medical students to sharpen their clinical reasoning skills by formulating a diagnosis and treatment plan on virtual patients with simulated eye conditions in a safe learning environment before practicing on real patients. The application of virtual patients resulted in increased academic performance and sustained retention over traditional teaching alone [16]. However, such particular skills, such as refractive error correction and direct ophthalmoscopy, still need real patients to practice in order to understand the correct angle of approach and the necessary adjustments to be made during the examination. A hybrid learning model of virtual didactics, simulation, telemedicine, self-directed learning, and in-person clinical encounters will provide students with various experiences, including new opportunities in patient care and technical skill development [1,17]. This study shows that despite the excellent score of the overall multiple-choice test, the students still have inadequate knowledge about visual acuity and subjective refractive examination topics during the online learning period. However, after their encounter real patients and practiced directly in the clinic during the in-person clinical clerkship period, their knowledge and skill about visual acuity and subjective refractive examination topic have improved dramatically in the OSCE test at the end of the period.

Before the pandemic, the learning process in medicine is still commonly based on a conventional clerkship approach where learners observe clinical practice and learn from hands-on activity when permitted by the clinical instructor. We are forced to use online learning to teach clinical ophthalmology during the pandemic to limit unnecessary face-to-face exposure. Nevertheless, online learning cannot permanently replace in-person clinical clerkship. In-person ophthalmology clerkship enhances our ability to observe students and evaluate clinical performance, including students’ integration into the healthcare team, skills in interacting with patients, professionalism, and clinical and surgical skills. To overcome the shortcomings of online learning in clinical ophthalmology, we transformed our undergraduate ophthalmology curriculum into blended learning, where online learning is combined with traditional face-to-face learning. In the online learning period, the students enrolled in the iLearn platform and were assigned to watch the clinical skill videos, complete the multiple-choice test, and make a case report. In the clinical clerkship period, the students came to the teaching hospital wearing personal protective equipment, which is mandatory. The students can observe the real patient examination directly in the outpatient clinic. Afterward, the instructor gives an explanation and discussion about the patient examined before. The students were also performed basic ophthalmology examinations under the supervision of the instructor. As an adjunct to conventional learning method, however, online learning may be beneficial and may have a significant impact on future medical students, including new opportunities in patient care and technical skill development [1,18-21].

This study’s limitations include the relatively small sample size and the self-reported nature of the questionnaire in which participants may be subject to reporting bias affected by student confidence and the degree to which they did not want to disappoint teaching staff. This study also does not compare the blended learning method’s outcome with the conventional full-time clinical clerkship. However, with reasonable satisfaction from most students in this study, we hope that online learning can supplement the in-person clinical clerkship method, especially in this pandemic period, to ensure that the students would not lose precious time and could continue with their academics.

Conclusion

This study results can encourage that a blended learning model, which combines video-assisted online learning with the inperson clinical clerkship, can be useful for acquiring clinical skills by health students. Learning process flexibility to time and place was the most advantage of online learning and lacking to perform clinical skills was the main shortcoming. Quality assurance of the video resource should be done to enable students to understand the context and engage with video resources so in time they encounter real patients, they are already prepared and gain sufficient competencies. The advanced development of information and communication technology will further be improved and established online learning as a more time- and resource-effective model for the interactive and integrated learning process.

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Home-Based Mirror Therapy with Individual Set of Exercises Improves Phantom Limb Pain and Phantom Limb Sensation of Lower Extremity Amputees

Introduction

Lower limb amputation could be the final decision to solve uncurable disorders due to trauma, infection and other general diseases [1,2]. However, the amputees might suffer lasting phantom limb phenomenon (PLPh) (including phantom limb pain (PLP) and phantom limb sensation PLS [3]) with many negative impacts on their life such as the increasing demand of pain killer, depression and impairment of daily activities and social functions [4]. The rate of PLPh is about 85% [5,6]. A study found that more than 50% of patients with PLP suffered daily pain with the significant intensity rated from moderate to severe [7]. The treatment mainly includes three main groups: pharmacology, non-pharmacology and surgery. Each approach has its own advantages and disadvantages relating to complications and cost benefit. Recently, mirror therapy is emerging and considered as a safe, economic and effective procedure in treatment of PLPh [9-11], although it was first used by Ramachandran VS in 1996 [8]. By placing a mirror parasagittally between the arms or legs and viewing the reflected movements of the intact limb while attempting simultaneous movements with the phantom limb, the intention is that the patient perceives the reflection to be their amputated limb. This phenomenon possibly addresses incongruence between proprioceptive and visual inputs caused by cortical reorganization. Currently, the method is improved with many kinds of exercises so that the patients could do at home by themselves. However, one of the key for success is to select the appropriate exercise for individual.

Objectives

Our study was designed to investigate the improvement of PLP and depression after home-based mirror therapy with personalized exercises for lower limb amputee amputation.

Methods

We conducted the study with any patient who did not reduced the PLP symptoms after a month of surgery

Criteria

Inclusion Criteria

a) Unilateral lower limb amputation

b) Phantom limb pain score (40-100 on VAS)

c) Either gender.

Exclusion Criteria

a) Amputees with psychological/neurological impairments.

b) Amputees having neuropathic pain other than phantom limb pain.

c) Patients having visual-spatial impairments.

d) Patients having residual limb pain.

e) Inability to give informed consent.

f) Infectious stump

g) Severe hearing loss

h) Any condition that restricts the movement of opposite limb, pain or limited range of motion in the intact limb

i) Infectious and systematic diseases.

Research Design

Case -Series Study

Procedures

The patients were initially recorded information and assessed about pain with VAS and their use of pain killer and depression with CESD(Center for Epidemiologic Studies Depression Scale. Each patient also received an appropriate mirror and a booklet that contains guides of basic eleven exercises. In general, the exercise program was based on Netherlands guidelines [12] and the Ministry of Health’s guidelines on mirror therapy for PLPh [13] and included three groups: facilitation of visual illusion, sensory exercises, and basic motor exercises. However, each patient had individual exercises according to their preferences. The patients were asked to try every exercise, note which one made them comfortable and select at least one exercise of each group. That meant each patient had a personal set of exercise.

In this study, we used a 3mm thick acrylic glass with a cushion and a wooden frame to enhance its stability and prevent the injuries caused by the edge of the mirror. It had the enough length and width so that the reflection of the normal legs during exercise was complete and clear in the mirror (Figure 1). We recommended they would finish their set twice a day, at least 15 minutes per one time. The investigator would perform video call to check their adherence every two days of the first week and then once a week for 3 weeks. After finishing the one month program, the patients would be reassessed.

Figure 1: Exercises with mirror (Source: Actual pictures).

Data Analysis

All analytical procedures use Stata 14.2 software.

Results

20 patients were recruited in the study from January 2020 to August 2020 at HCMC Hospital for Rehabilitation and Occupational Diseases. More than half of them were 35 years or older (55%). Male was the majority (90%). The cause of amputation mainly was trauma. The level of amputation around knee was met in 60% (Table 1A). The point of time to start the mirror therapy was about 35.5 days after amputation. The average follow-up time was 4 months. The pain characteristics were illustrated in Table 1B. The chief complain was both phantom limb pain(PLP) and phantom limb sensation (PLS). Its onset appeared rather soon from 1 to 3 days after amputation. The pain intensity was significant from moderate to severe. The sorrow lasted long with 150 minutes per day in average (Table 2). The depression condition was illustrated in Table 3. Two third of patients had signs and symptoms of depression with CESD more than 16. 19/20 patients demonstrated their adherence at the time of call. One half said they could finished all the exercises with interesting;nearly50% did not prefer Hip abduction and adduction , picking up gravel with toes into a cup and writing letters with your feet in the air (Table 2).

Table 1A: Demographic of the patients (n=20).

Table 1B: Pain characteristics.

Table 2: The patient’s preference of exercise.

Table 3: PLPh results at the time end of study (n=20).

The intensity and the total daily time experiencing pain(TDTEP) of PLP significantly decreased after training mirror exercises in both groups of patients with PLP and PLS (Table 4). The extent of drug use also decreased up to ‘no use’ in patients with PLP and to a rather small extent in patients with PLS (p < 0.05 Table 4). The results was still kept maintenance or improved (Table 3) after finishing the therapy program. Depression scores also decreased after treatment and continued to decline (p <0,001 Table 5). The study results did not find a statistical significance relationship between the effect of reducing the intensity, duration of PLPh, depression score CESD with factors such as age, gender, cause of amputation, degree of amputation with p-values > 0.05 (Table 5). We did not find the relationship between pain and depression improvement with the factors such as age, gender, cause of amputation, level of amputation (Table 6).

Table 4: PLPh results at the time of finishing mirror training (n=20).

Table 5: The results of depression after mirror treatment (n=20).

aAccredit Wilcoxon signed-rank, bAccredit Fisher, cAccredit Chi square.

Table 6: The relation between improved difference PLPh, CESD and other factors (n=20).

Discussion

Post-amputation phantom limb pain (PLP) is highly prevalent and might be very difficult to treat. The high-prevalence, high-pain intensity levels, and decreased quality of life associated with PLP compel scientists to find out the ways to prevent, manage, and reverse this chronic pain condition. Currently, Nonoperative and non-drug PLP interventions include targeted muscle reinnervation (TMR), repetitive transcranial magnetic stimulation (rTMS), imaginal phantom limb exercises, mirror therapy (MT), virtual and augmented reality, and eye movement desensitization and reprocessing (EMDR) therapy. They are reported to be effective , however, no one is widely accepted or clearly superior to the others. Moreover, not one intervention has been found to be consistently effective [16]. Mirror therapy seems to be an suitable way for developing countries with their high rate of amputation because mirror could be available with low cost in anywhere. Mirror therapy is expected to be widely used for the treatment of phantom limb pain since it is easy to use at both home and in outpatient departments.

There are many theories to explain the mechanism of mirror therapy. Despite how the therapy has effect on central nervous system and reduce pain, one of the most important keys for success is the patient’s adherence. It is much easy to strictly follow the treatment program if the program includes simple and feasible exercises. It is also more significant if the patients experience the exercises at least one time and that makes them comfortable. That is the reason why we built a set of exercises basing on the patient’s preference. To our knowledge few study have similar treatment approach. Our encouraging results reinforce the previous studies in which mirror therapy reduced PLP in lower extremity amputees [9-11,16]. However, the “rebound phenomenon” after stopping practicing mirror exercises might be a big concern. In order to evaluate the stability of the effectiveness we still followed up our patients for about 4 months . We found that the intensity and TDTEP of PLPh continued to decrease. We also found some accompanying positive effects such as the decrease of the demand of pain killer and improvement of depression condition. The Darnall BD study also gave similar results [10].

Conclusion

Home based Four- week practice of mirror therapy with an individual set of exercises based on the patient’s result in significant reduction of PLP and PLPh and their improvement of depression condition in lower limb amputees. The interventions are simple and cost- benefit thus appropriate to the low-resource communities.

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Phototheraputic Keratectomy for a Patient with Corneal Intraepithelial Dysplasia

Introduction

Intraepithelial neoplasia and squamous cell carcinoma of the cornea and conjunctiva are the most common tumors of the ocular surface [1] with a reported incidence of 0.13 to 1.9/100,000, depending on geographic location [2]. This tumor is classified as an in situ form, known as conjunctival and/or Corneal Intraepithelial Neoplasia (CIN), or invasive squamous cell carcinoma. CIN encompasses entities that were previously referred to as dysplasia and carcinoma in situ. Corneal epithelial dysplasia occurs in elderly patients. Although the etiology remains unknown, it has been suggested that excess ultraviolet exposure and human papilloma virus infection may cause the lesion [3,4]. The pathogenesis of corneal epithelial neoplasia usually commences at the limbal region in that abnormal epithelium grows towards the central cornea and often associates with neovascularization into the lesion. The most common treatment for conjunctival and corneal neoplasia is radical excision in combination with cryotherapy [5]. Newer chemotherapeutic modalities, such as mitomycin C (MMC) [6] 5-fluorouracil (FU) [7] and interferon,8 are now being used to avoid the operating room altogether and decrease the potential risk of limbal stem cell loss and scarring. There has been only one case of recurrent corneal intraepithelial dysplasia treated with Phototherapeutic Keratectomy (PTK) [8,9]. In this report, we describe a case of primary corneal intraepithelial dysplasia after PTK.

Case Report

A 68-year-old woman presented with blurred vision in the right eye for 6 months before the initial visit to the clinic. We did not obtain a medical history of the etiologic factors associated with induction of the neoplasm. Her Corrected Distance Visual Acuity (CDVA) was 20/40 and 20/20 in the right and left eyes, respectively. Central pachymetry measured 564 μm in the right eye and 530 μm in the left eye. Biomicroscope demonstrated plaque-like isolated epithelial corneal lesions extending from the paracentral cornea into the central visual axis in her right eye. The cornea of her left eye also showed translucent epithelial corneal lesions at the paracentral cornea, but no symptoms occurred. The cornea was avascular, and the corneal stroma seemed to be uninvolved. The anterior chamber was quiet, and the remainder of the ocular examination was unremarkable. Anterior Segment Optical Coherence Tomography (AS-OCT) (CASIATM, Tomey Corporation, Nagoya, Japan) was performed and demonstrated thickening and highly increased reflectivity of the corneal epithelial layer extending from the paracentral to central cornea of the right eye. In accordance with the thickening lesions, anterior corneal steepening was observed in the keratometric map using AS-OCT. Based on these morphological characteristics, we diagnosed corneal intraepithelial dysplasia in both eyes in this patient.

We conducted PTK with the NIDEK EC-5000 excimer laser system and used the following parameters: wavelength, 193 nm; fluency, 165 mJ/cm2; repetition rate, 40 Hz; ablation zone diameter, 7.0 mm; transition zone, 1.0 mm; and ablation depth, 200 μm based on the AS-OCT. We used the transepithelial technique for removal of the corneal epithelium. No histological examination was performed on the ablated tissue after PTK. Postoperatively, steroidal (0.1% fluorometholone) and antibiotic (1.5% levofloxacin) medications were topically administered 4 times daily for 1 week after insertion of a soft contact lens, and the dose was steadily reduced thereafter. The patient returned at the 1-month follow-up examination with subjective improvement in vision and no subjective complaints. The preceding epithelial corneal lesions had diminished. Her CDVA had improved to 20/20 in the affected eye, with mild punctate epithelial erosions at the inferior cornea. AS-OCT was again performed, demonstrating normal epithelium without the lesions previously observed. The anterior corneal astigmatism also improved to 1.2 diopters in the AS-OCT keratometric map. The CDVA remained at 20/20, and no recurrence of epithelial corneal lesions occurred at the 6-month follow-up.

Discussion

Current treatment modalities include excision with or without adjuvant cryotherapy, topical chemotherapy (e.g., MMC, 5-FU, or interferon), radiation therapy, and in extreme cases, exenteration of the orbit [10]. Surgical excision alone of CIN has been associated with higher rates of recurrence, ranging from 17% to 24% for dysplasia and from 30% to 41% for squamous cell carcinoma [2,11]. In the current case, the corneal lesion was diagnosed as corneal intraepithelial dysplasia of the ocular surface before treatment with PTK. Although histological examination might be helpful in determining the confirmed diagnosis, a dysplastic tissue sample was not obtained because of excimer laser ablation. To our knowledge, this is the first reported case of PTK in primary corneal intraepithelial dysplasia. Our case demonstrated isolated neovascularized corneal epithelial dysplasia compared to a previous case report by Dausch, et al [9]. We conclude that PTK is an appropriate technique for mild to moderate cases of corneal intraepithelial dysplasia. Excimer laser ablation may be effective in the treatment of corneal intraepithelial dysplasia. High-resolution AS-OCT is emerging as an important noninvasive technique that can help diagnose and evaluate the efficacy of treatment. AS-OCT was performed to look for evidence of recurrence in the present case. We are conducting imaging using an AS-OCT described in many patients.

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Diaphragmatic Eventration in Nf1 Microdeletion Syndrome: A Rare Association Unmasked by Pregnancy

Introduction

Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is a neurocutaneous condition with an estimated prevalence between 1 in 2000 to 1 in 4000, characterized by a great variability in its clinical presentation. Clinical hallmarks such as café au-lait macules, neurofibromas, axillar or inguinal freckling, optic pathway glioma and iris hamartomas (Lisch nodules) represent the main NF1 diagnostic criteria set by the U.S. National Institutes of Health (NIH) in 1988 [1]. Beside these typical signs, the possible association with skeletal, endocrine, cardiovascular and oncologic complications make NF1 a multi-systemic disorder [2]. A similar broad spectrum of clinical manifestation is caused by mutations occurring in the Neurofibromin on co suppressor gene, on chromosome band 17q11.2, and inherited in an autosomic dominant manner [3]. In about 5–10% of cases takes place a large deletion involving the NF1 gene and its flanking regions which results in the “NF1 microdeletion syndrome” [4]. Despite the lack of genotype–phenotype correlations in NF1, patients with Type 1 microdeletion (1.4 Mb encompassing about 14 genes) typically present a serious illness, mainly characterized by dysmorphic facial features and developmental delay [5]. During pregnancy, NF1 women should be monitored because they are more prone to complications such as hypertension, preeclampsia, fetopelvic disproportion, poor fetal growth and oligohydramnios [6]. Furthermore, pregnancy for NF1 women is related to an increased number and size of cutaneous neurofibromas [7]. Regarding pregnancy in women with NF1 microdeletion, no specific literature data are available, possibly due to their low fitness and to the rarity of the condition.

Diaphragmatic defects have never been described before as a pregnancy complication in NF1 women. Similar conditions are also unusual in general population, with only 56 reported cases until 2018 [8]. The increased abdominal pressure experienced by women during pregnancy might represent a risk factor for unmasking hidden congenital diaphragmatic defects (CDD). Among these defects, diaphragm eventration (DE) represents an uncommon finding, defined as the upward displacement of a portion or the entire diaphragm, otherwise intact. Congenital DE (CDE) diagnosis is often an incidental finding in adults, as it can remain completely asymptomatic. Even if scarcely described first presentation of CDD during pregnancy, owing to the risk of rupture, represents a lifethreatening complication both for mother and fetus [9]. Here we report a case of (CDE) complicating the pregnancy of a 30-year-old patient with NF1 Type 1 Microdeletion Syndrome.

Case Report

The patient is a 30-year-old pregnant woman, affected by NF1 type 1 microdeletion syndrome, followed since the age of 24 at our Clinical Reference Centre for NF1. She has undergone numerous clinical and instrumental evaluations over the years; the main clinical issues that have emerged are summarized here: mild intellectual disability, typical NF1 cutaneous features (cafè au laits spots and diffuse cutaneous neurofibromas) and two plexiform neurofibromas on the scalp and on the left hemiabdomen. Furthermore, multiple spinal neurofibromas were reported at the age of 26, involving all the conjugation foramina, especially in the thoracic and lumbar tracts of the spine. At the age of 28 due to a suspected diagnosis of pheochromocytoma, the patient underwent left adrenalectomy; histological examination diagnosed a ganglioneuroma and steroid replacement therapy was therefore introduced. In addition, a nonfunctioning pituitary microadenoma was detected on routine brain magnetic resonance imaging (MRI), steady in size on control MRI in the following years. In view of these comorbidities, as the patient got pregnant, she was followed by a multidisciplinary team, consisting of gynecologists, endocrinologists, neurologists and medical geneticists. Regular ultrasound evaluations were performed throughout the entire pregnancy. The patient and her partner decided not to proceed with any invasive tests for prenatal diagnosis.

The pregnancy progressed regularly. In preparation of spinal anesthesia, a spine MRI was performed to monitor the wellknown spinal neurofibromas that appeared to be steady in size and number. Serendipitously, three round-shaped images at the base of right chest were reported and interpreted as possible diaphragmatic hernia (DH) with partial displacement of the liver to the chest. A right-sided pleural effusion was also reported, which retrospectively appeared to be present and unchanged since the previous control. An echocardiogram and an abdominal ultrasound were performed as follow-up investigations. The former reported mild mitral and tricuspid insufficiency, but no pericardial effusion was observed. The second examination showed a moderate pleural effusion on the right side with thin fibrinous septae and gross outpouchings of the liver parenchyma, the largest of almost 4cm. Thus, the previous suspicion of DH was confirmed. In view of the numerous comorbilities, a caesarean section was performed and the patient gave birth to a female newborn. Genetic NF1 analysis performed after birth revealed the transmission of the maternal NF1 microdeletion to the baby. Since both the mother and the newborn were in good health, they were discharged five days after delivery, once DH-related complications were excluded. Computed Tomography (CT) of the upper abdomen performed two months later showed three diaphragmatic bulges, with a maximum diameter of 4.2cm on the VIII segment of the liver and of 4.8-2.8cm on the VII segment. The right-sided pleural effusion was still present and, as the diaphragm was not clearly visible over hepatic protrusions and appeared worsen from previous imaging, the hypothesis of hernias was corroborated (Figure 1). Therefore, surgical correction of the defect was planned after the weaning of the child. The patient underwent video-assisted thoracoscopic surgery (VATS), which revealed an intact but very thin diaphragm, consistent with a diagnosis of DE. There was no evidence of occult neurofibromas nearby, nor adjacent lesions that might be the very first cause of the diaphragmatic eventration. In addition, a voluminous pleuro-pericardial cyst was found, explaining the pleural effusion previously reported. Finally, a diaphragm plication and cyst excision were performed. The removed tissue was biopsied and this examination revealed the presence of a cystic wall, covered by a single stratified cubic-cylindrical epithelium. No atypia was found. The post-operative course was uneventful.

Figure 1: Chest MR Imaging:

A. Two round shape images with partial liver shift in right pleural space (red arrow) and surrounding fluid collection (yellow X);

B. Coronal plane;

C. MR imaging three years before pregnancy.

Discussion

Diaphragmatic weakness became clinically relevant during pregnancy, when the rising abdominal pressure pushes the diaphragm upwards while the muscle itself contracts downwards. In our patient, these two opposing forces probably enlarged a preexisting diaphragmatic defect, resulting in liver herniation. To our knowledge this is the first reported case of a patient with NF1 microdeletion showing a DE and a pericardial cyst, three extremely rare conditions. Fortunately, the liver was the only organ involved in herniation and the patient remained asymptomatic, even during pregnancy. As mentioned, among NF1 population, patients with type 1 microdeletion generally display a more severe phenotype. This is possibly due to the deletion not only of the NF1 gene, but also of its flanking genes, which could partially influence the clinical manifestation of the disease. In particular, NF1 type 1 microdeleted patients are more likely to develop malignant peripheral nerve sheath tumors (MPNSTs), cardiovascular anomalies [5] and connective tissue abnormalities [10]. Although the precise molecular basis of connective tissue involvement in NF1 is still unclear, neurofibromin has been shown to play a regulatory role in mesenchymal stem cell differentiation [10]. Moreover, during embryogenesis, this protein also takes part to axons’ elongation in order to ensure the correct activity of the nervous system [11]. The involvement of NF1 gene in proper neuronal and mesenchymal development must be particularly stressed as neurons and connective tissue, together with several other structures from different embryonic origins, participate to the complex sequence of events that leads to diaphragm development [12]. In particular, CDE has been related to defects in migration and proliferation of muscle fibres, two steps leaning on the regulatory action of connective tissue cells [13].

Whether the association between NF1 and CDE is causal or is in fact a possible associated complication, the management of our case demonstrates the crucial importance of a multidisciplinary approach to pregnant women affected by a rare disease. NF1 microdeletion syndrome is associated with numerous comorbidities, most of which are just barely known. Particularly, knowledge about pregnancy-related complications in NF1 microdeleted women is still lacking and even more about possible urgent events; as a consequence, no specific management guidelines are available yet. As shown by our case report, pregnancy in these women can turn out to be a challenging moment and should be carefully supervised, as it represents an event in which the delicate equilibrium of such fragile patients might unbalance, possibly leading to unexpected, unknown and potentially serious complications. In our opinion the complexity of this condition, the unpredictability of complications’ onset and severity can be properly managed only by gaining a wider and multifaceted vision of the disease, which can be obtained only by means of a dedicated multidisciplinary team. A well-coordinated multi-specialized equipe could represent the primary step towards widening our perspective of the condition and towards implementing tools for personalized care and follow-up, with the ultimate aim of ensuring early diagnosis and prompt management of possible upcoming emergencies, especially during pregnancy in these vulnerable women.

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The Era of Online Education in Indian Physiotherapy: A Boon or Curse

Introduction

Education is an enlightening experience. It is the process that facilitates learning or training of the young minds by imparting knowledge, imbibing values, and morals, encouraging self-thinking and beliefs and most importantly acquiring life lessons and survival skills. To put it in simple terms – education aims to develop completeness in a being by probing the individual to think, feel and act in various situations. The aim of this review is to highlight the road travelled for physiotherapy education during the past year under the influence of the COVID 19 pandemic. The objectives of the study are to enumerate the various methods adopted during these challenging times to ensure continuity of the teaching-learning process on the way to train students from novices to professional physiotherapists.

Ancient Indian Medical Education

India has been the hub of education since ancient times. The Indian education system being culturally advanced and spiritually enriched operated under both formal and informal settings were built on the sole purpose of promoting individual self-realization. The religion-based system slowly evolved to formulate the Gurukul system which were residential schools of learning usually at the teacher’s house or spiritual places. Students gained knowledge through listening, memorizing, assimilation and interpreting fundamental concepts followed by the last stage which included deeper understanding, formulating self-theories and application in daily life. Earliest medicine practiced by sages of ancient India was Ayurveda and Siddha. The other fields and faculties developed consequently. The surgeon Sushruta practiced techniques which are now the base of physiotherapy in India. Medical students completed 7 years of training and vigorous testing before independent practice. This system modified over the following years to accommodate to the changing era and development, leading to the formulation of the modern education system ever advancing to face the digital and global frontiers [1-3].

Physiotherapy in India

Physiotherapy is one of the noble health professions working to improve human movement and function. Therapeutic knowledge and approaches are used by physiotherapists to evaluate, diagnose, and treat patients holistically to improve their physical and mental health, thereby enhancing their quality of life [4]. An epidemic of Poliomyelitis in Mumbai during 1952, initiated the establishment for the first Physiotherapy school in 1953 as a joint collaboration between Indian Government and WHO [5]. With establishment of the Indian association of Physiotherapy in 1962, the field was promoted with many teaching institutes established all across India dedicated to training more and more students. Rules and regulations were established, curriculums were formulated, and the field is blossoming by the day.

Online Physiotherapy Teaching/Learning in India

COVID 19 pandemic has forced countries to adopt measures of safety, social distancing, stay at home directive etc. This has impacted the Indian education system quite hard. Institutes were forced to look out of the box to continue the education process leading teachers to adopt virtual learning tools. Online learning is any learning experience attained by using whichever device with internet access in synchronous or asynchronous environments [6]. Teachers were introduced to various online apparatus, trained to use them, and made to connect with students in this format. This transition from traditional environment to remote virtual format has led to the emergence of blended and hybrid classrooms [7]. Online Pedagogy has become the need of the hour. The pandemic has brought the near future online training to the current now. The anytime-anywhere feature of this mode has proved to be highly beneficial in these trying times. The student educational experience was also open to the fact that each one can now learn at their own pace. Self-directed learning was gaining more importance now more than ever. Connectivity across the globe for various purposes is now possible smoothly. The scope of learning has advanced tremendously breaking geographical, language and many other plausible barriers. Students can learn using devices such as smart phones, tablets, laptops etc. from their place of comfort.

Modes Used for Online Education

The quest for the best mode of delivering information and educating students begins here forth. Both asynchronous and synchronous objectives must be addressed. Multiple platforms and software’s are being currently used to deliver sessions. Few of them are Webinars, Zoom Meetings, Microsoft Teams, Google Meet, Telegram, WebEx, Skype you tube video interactions etc with assignments given on google classroom, WhatsApp, Emails etc. Videos can be uploaded to repositories such as Google drive and shared with the entire class for improving student understanding and thus, learning. A study done by Munjal and Zutshi, using webinar to educate physiotherapy interns showed that students preferred webinar-based teaching to classroom atmosphere with practical skills being a limitation for its regular use [8].

Barriers

Challenges identified during online teaching/learning are quite alarming too. Modifying the environment and getting accustomed to virtual models while feeling equally overwhelmed about the pandemic is one of the biggest trials. The problems range from technology support, infrastructure, funding, curriculum and syllabus planning and designing, universal education programs and reforms, research and innovations etc. The objective of education goals is somewhere lost in understanding and perception and further implementation in actual society. Digital inequality is also a rising factor that needs to be considered. Negative attitudes of both students and teachers towards acceptance of new technology is a serious issue. Kaur et al in their study concluded that even on eliminating various barriers, online learning is not a replacement for traditional teaching methods [9].

Teacher’s Concerns

Physiotherapy is a profession which relies very much on hands on skill which has become difficult to achieve due to a virtual environment. The entire skill based psychomotor domain is now being converted to virtual models. It is a constant worry for the teacher to understand whether the students have actually grasped the concept required to implement both preclinical and clinical skills. Lack of personal and eye to eye contact with students makes it tough to gauge their level of understanding. Guided practise, communication with patients and working with community becomes essential [10]. Dhawan in his study coined the term “Panicgogy” to summarize the situation of the educators who have converted the existing material available into online framework as soon as possible leading to chaos [11]. Creative and innovative teaching to grasp the student attention specially to learn skillbased activities still pose a major concern. It was becoming more and more tiresome to monitor each and every students’ progress over the screen. There is also high level of stress and exhaustion due to lack of a technology enabled environment conducive for conducting sessions. Creating online student appropriate material for independent learning requires meticulous planning and designing. Some teachers find it difficult to construct meaningful content, patient scenarios, practical simulations etc. to complete the learning objectives. The main challenge is to capture and retain the students’ attention. Educators find it hard to connect to students due to lack of face-to-face interactions. Digital divide and digital illiteracy also add to the anguishes for senior faculty who find it difficult to adapt to the technology.

Student’s Woes

Though initially the concept of studying while enjoying the comforts of home was very exciting, soon bitter truths of reality set in. The loss of formal institutional environment affected student concentration, attention, seriousness and eventually learning. Thakur in her study on undergraduate health science students deduced that majority of them were not studying regularly. Selfstudy and self-learning were not achieved during the lockdown period [12]. Home environment though comfortable became a route cause of multiple distractions. The enjoyable learning experience with peers was immensely becoming a burden. Social isolation is an unintended by-product. Kumar et al in their study found that though students were comfortable with online classes, majority of them were eager to begin regular classes once the lockdown was lifted indicating that classroom teaching was more effective especially for learning skill-based lessons [13]. Moreover, the increased screen time is affecting their health as well with symptoms such as eye irritation, headaches, body pains due to sedentary and abnormal postures etc. Sheer boredom to attend sessions are side effects to this mode of learning. They are also losing confidence to develop physical contact and rapport with the patients by the day. Students’ perceptions and mental health need to be considered as well.

Physiotherapy in India - Towards the Bright Future

Physiotherapy is a humble profession providing service to mankind. Learning is a lifelong, continuous process. The pandemic opened the pandora of technology available at our disposal for enriching the teaching/learning. There is a radical transformation observed in all aspects of education. Verma et al in their interaction with academicians, found that majority of the teachers have gracefully accepted online modes of teaching and acknowledge the fact that it is boon in the current situation [14]. Many complex concepts in physiotherapy, biomechanics and biological conditions can be explore and understood better with use of 3-D models and other applications. Smart boards and technology enabled learning solutions need to be encouraged. The entire unexplored arena of telehealth and telerehabilitation can be explored further. We need to remember that education not only increases knowledge but also brings about personality and behavioural changes. We as educators, mentors and policy makers should form an all-inclusive curriculum for professional practice which is built on the roots of the Indian eternal morals and values augmenting all the aspects of education such as intellectual, ethical, biological, socio-cultural, spiritual etc. The ideal system would reflect the perfect incorporation traditional and modern methods with perfect balance between the digital and the human world. It is time to embrace the tech savvy world. E-Learning complements traditional teaching facilitating lifelong learning [15].

Conclusion

A digitalized education system though welcomed with open arms, needs to be streamlined to achieve definitive and positive results. An ideal curriculum should include an amalgamation of online education as well as offline practices to ensure superior student learning. Constant student feedback and digitally evolving faculty are the key features responsible to implement an effective E-Learning System. Teachers need to hone their skills and stay abreast with the recent advances making the classroom technology enabled. With awareness and proper facilities at grassroot levels, online education will flourish exponentially.

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Freshwater Snails Infection Status and Predisposing Risk Factors to Schistosomiasis in Doma Local Government Area, Nasarawa State, Nigeria

Introduction

Schistosomiasis is also referred to as snail fever or bilharziasis. It is a tropical parasitic disease caused by schistosome (blood fluke) [1-4]. The disease is known to be endemic in many countries especially in West Africa [5]. Reports by the World Health Organization (WHO) estimated 243 million people in 52 countries require treatment against the disease [6]. Nigeria has the heaviest burden of the disease in sub-Saharan Africa, with a total of 29 million cases [7]. The transmission of the disease is correlated with freshwater snail intermediate host and requires human contact with the parasite infective stage found in contaminated freshwater bodies. Therefore, communities that live close to snail infested water bodies are mostly at risk of schistosomiasis [8]. Several factors such as social, cultural, environmental and behavioural are known to have direct influence on the prevalence and intensity of schistosomiasis. The role played by various epidemiological factors in the transmission and intensity of the infection has been studied widely using different methods. Distance from the transmission site, migration and emergence of new foci, urbanization, socioeconomic status, sanitation, water supply patterns and disposal of human wastes (faeces and urine) are among the epidemiological factors [9]. Hence, this study investigated freshwater snails intermediary status and risk factors of schistosomiasis in Doma Local Government Area (LGA) of Nasarawa State, Nigeria.

Materials and Methods

Study Area

The study was carried out in Doma LGA in Nasarawa state, Nigeria. Doma has an area of 2,714 km2 and had a population of 139,607 in the 2006 census. Its geographical coordinate is 8.4009° N and 8.3581° E. Agriculture (farming and fishing), craftwork and civil service are the major occupations in Doma. It is located in the Guinea savannah region where they experience rainfall from May to October and cold dry season from the month of November.

Freshwater Snail Collection and Identification

Freshwater snail search and collection was done from the month of August to October, 2019. Samples were collected weekly from the water bodies according to the method described by Abe et al. [10]. A hand-held scoop net (18cm and 0.2mm mesh) was used for collecting/scooping and also hand-picking was also employed along the length of the waterbodies at various sites for 30 minutes. Each sampling site was visited in the morning for snail search and collection. Snails collected were put in specimen bottles containing water and then labelled before being transported to the Department of Zoology laboratory at the Federal University of Lafia. In the laboratory, the snails were washed with water to remove dirt and identified using standard keys by Brown and Christensen [11] and Danish Bilharziasis Laboratory (DBL) [12].

Screening for Cercaria Infection in Snails

Collected snails were put individually in petri dishes containing distilled water. They were then covered with net to prevent the snails from crawling out of the container. The petri dishes containing the snails were then exposed to light for 2 hours to induce shedding of cercaria if present [13]. Where no cercaria was shed, the snails were gently crushed in a container containing distilled water. The fleshy part of each snail was dissected and examined microscopically for unshed cercaria and rediae [14].

Questionnaire Administration

A well-structured questionnaire was administered to people seen around the water bodies, in order to collect data relating to their occupation, water contact activities, environmental sanitation, living conditions (like type of water supply, toilets, presence of domestic animals) and health conditions (blood in urine). The individuals involved were those who are resident around the studied water sources. The respondents were both males and females as well as both young and adults.

Data Analysis

Data obtained was analyzed using R Console software (Version 3.6.1). Pearson’s Chi-square test was used to compare snails abundance between the species encountered. Descriptive simple percentages was used for the information generated from administered questionnaires. The level of significance was set at P < 0.05.

Results

Composition and Abundance of Snails in Doma LGA, Nasarawa State

A total of 308 snails were collected from the 17 water bodies sampled which cut across five species: Bulinus globosus, Bulinus forskalii, Biomphalaria pfeifferi, Lymnea natalensis and Melanoides tuberculata as shown in Table 1. B. globosus was the most abundant 182 (59.1%) snail species encountered followed by Biomphalaria pfeifferi 57 (18.5%) then Lymnea natalensis 32 (10.4%) while the least was Melanoides tuberculata 11 (3.6%). Therefore, the abundance between snail species collected at Doma LGA showed a very high significant difference (χ2 = 312.03, df = 4, P < 0.0001).

Table 1: Composition and abundance of snails in Doma LGA, Nasarawa State, Nigeria between August and October 2019.

Prevalence of Parasites in Vector Snails

Of the 308 snails examined for parasites using the light and crushing techniques none was found to be infected with trematode cercaria (Table 2).

Table 2: Prevalence of parasites in vector snails in relation to two screening techniques.

Socio-demographic Status of Respondents in Relation to Schistosomiasisis Risk Factors

Out of the 510 questionnaires administered, 383 (75.1%) were males while females were 127 (24.9%). More adults 289 (56.7%) participated than children 221 (43.3%). Also, the respondents are resident in Doma LGA and familiar with the water bodies sampled. In overall, 225 (44.1%) of the participants had secondary education, followed by 149 (29.2%) who had primary education then the uneducated 84 (16.5%) while only 52 (10.2%) of the respondent had a tertiary education. Majority of the respondents were unemployed 231 (45.3%), self-employed (trade) were 96 (18.2%), 13 (2.6%) were civil servants (official), 103 (20.2%) were farmers, 12 (2.4) were into fishing while those into other forms of commercial activities (driving, construction) were 55 (10.8%) as shown in Figure 1.

Figure 1: Occupational status of respondent around water bodies in Doma LGA, Nasarawa State, Nigeria.

Schistosomiasisis Risk Factors

Information gotten from respondents on their knowledge of the disease showed that 211 (41.4%) of the participant had contact with contaminated water, 89 (17.5%) and 61 (12%) respondents wash in surface water and walk without shoe respectively, while 102 drinks unsafe water. A high number of the respondents 232 (45.5%) use pipe-borne water for domestic purposes in their homes whereas 87 (17.0%) of them utilized well water as the main source of water for domestic purposes while 191 (37.5%) accessed water from rivers, streams and pools (Figure 2). Figure 3 showed that pit latrine was the most widely used type of toilet in this study with 233 (45.7%) respondents. 143 (28%) of the respondents make use of modern flush toilet (water system) in their homes while 76 (14.9%) respondents utilize other forms of latrine (including the use of buckets, nylons) and 58 (11.4%) in nature (bush).

Figure 2: Proportion of respondents sources of water in the study area: a predisposing schistosomiasisis risk factor.

Figure 3: Types of latrine in the study area a predisposing schistosomiasis is risk factor.

Also, 313 (61.4%) of the respondents had domestic animals present in their homes and 197 (38.6%) do not. While 326 (63.9%) of the respondents stay in close proximity to water bodies as compared to 184 (36.1%) who reside at a distance (>250 m) to waterbodies. One hundred and sixty-four (32.2%) respondents have contact with water mostly in the morning followed by those who have contact with water in the evening 114 (22.4%) while only a few 41 (8%) have water contact in the afternoon (Figure 4). The frequency of water contact also indicates that 138 (27.1%) respondent come in contact with water bodies daily, 210 (41.2%) had contact weekly, 118 (23.1%) had water contact monthly, while 44 (8.6%) only come in contact with water body at most once or twice in a year. The reasons for water contact varies among respondents, 189 (37.1%) come in contact with water bodies for the purpose of washing/laundry, 97 (19%) for the purpose of swimming/bathing, 17 (3.3%) go for fishing, 11 (2.2%) and 94 (18.4%) source the water for cooking and gardening/farm purposes, 7 (1.4%) for the purpose of waste disposal while 95 (18.6%) come in contact with the water bodies for other reasons.

Figure 4: Time of day when respondents have contact with water bodies around.

Blood in urine and bloody stool was experienced by 197 (38.6%) and 86 (16.9%) respondents respectively. Also, 227 (44.5%) have experienced abdominal pain. However, only 122 (23.9%) of the respondent have previously been treated for schistosomiasis, while an ample number of the respondents 388 (76.1%) have never been treated for the disease and are unaware of their status.

Discussion

The snail species reported in this study (Table 1) had earlier been reported in different parts of Nigeria. Omudu and Iyough [15] reported the presence of B. globosus, Lanistes libycus, L. natalensis and Nepa cinerea in Makurdi, Benue State. Similarly, Okafor and Ngang [16] found B. globosus, B. truncatus, B. senegalensis, B. forskalii, Bi. pfeifferi. Lanistes varicus and L. natalensis in their studies in Niger-cem, Nkalagu Eastern Nigeria. Abe et al. [10] studies in almost all Local Government Areas (LGAs) of Nasarawa State showed that snail species were present in all the selected LGAs covered. Interestingly, a species of snail, M. tuberculata found in Doma was not reported in the study by Abe et al. [10]. Alternatively, Indoplanorbis exutus reported by Abe et al. [10] was absent in Doma LGA. The result of this study is therefore additional information on snail species of medical importance in Nasarawa State which before now has not been documented.

The presence of five freshwater snails in these studies is a clear indication of that the water bodies are potential transmission sites of schistosomiasis and other snail-borne diseases based on observed anthropogenic activities such as fishing, swimming/quick bath by farmers, washing, fetching, watering points for animals and channeling of water for irrigation in the sites. Such activities often result in decrease in the availability of water and could lead to pollution/contamination which affects freshwater snails. This is in tandem with research findings from Okafor and Ngang [16] which gave an update on freshwater snails of medical and veterinary importance and Ugochukwu et al. [9] where they reported higher frequency of schistosomiasis in farmer and fishermen due to their water contact activities.

The absence of shedded cercaria from the snail could possibly be attributed to good sanitation and hygiene practices in the area, therefore, suggests that human prevalence status in the area should be carried out so as to really ascertain the prevalence rate within the human population. Also, the absence of cercaria infection in the snails implies that schistosomiasis may not be endemic in the study area. This is accordance with the finding of Abe et al. [10] who reported that from 105 sites surveyed, no developing stage of trematodes was observed in 977 snail intermediate host examined. Another study by Rabi [17]in three parts of Jakara dam in Kano State indicated that none of the snails collected was found to be shedding any schistosome cercaria but cyclops was found. Similar observations were also made by Diakité et al. [18] in Cote d’ivoire and Ejehu et al. [19] in Oguta Lake in Nigeria.

Responses from respondents to questions intended to determine the existence of social factors that predisposes the community to schistosomiasis supports the observation made earlier on lack of endemicity of the infection in the area due to the absence of infected snails. Although about 45.5% of the respondents have access to tap water, however, the contact with snail infested water bodies by about 37% of the respondents is quite alarming and concurs with Ugochukwu et al. [9] who documented that occupational risk in relation to schistosomiasis arises from water contact. The very low defecation rate (11.4%) in bushes and the proper practice of faecal disposal in the area either via the use of water system (28%) or pit latrine (45.7%) accounts for the absence of schistosomiasis in the area. This is line with Dawaki et al. [2] who reported that one of the factor known to aid endemicity of the disease is good refuse disposal system most especially feaces.

Conclusion

This study has added to already existing checklist of freshwater snails in Nasarawa State based on the finding of the snail, M. tuberculata in Doma LGA. None of the snails’ shedded cercaria. Hence, the communities should maintain the good level of hygiene and sanitation thus far recorded in order to perpetually remain free from schistosomiasis infection.

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Hematological and Biochemical Alterations at Different Stages in Cattle Affected with Foot and Mouth Disease in Bangladesh

Hematological and Biochemical Alterations at Different Stages in Cattle Affected with Foot and Mouth Disease in Bangladesh

Introduction

Foot and mouth disease (FMD) is one of the most devastating disease of farm animals in the world that can destroy food supplies and farmer’s livelihoods almost overnight of the wide number of cloven-hoofed animals include cattle, buffalo, pigs, sheep and goat [1]. The disease Foot and mouth disease (FMD) is generally characterized by the rapid appearance of high body temperature, respiratory and pulse rate following by the formation of vesicles on the tongue epithelium and skin particularly on the inter-digital space epithelium of the foot [2,3]. Even after recovery from the acute infection, most animals act as a carrier for each serotypes of the virus and the agent can be isolated from their esophagus and throat fluid after 2-3 years of post-infection [4-6] with a moderate raised values (p≤0.05) were recorded in rectal temperature, respiratory and pulse rate, where highest values were during 3 to 7 days of post infection which subsequently reduced after passing the days of infection [7]. Although FMD does not cause high mortality in adult animals, the disease has debilitating effects, including weight loss, decrease in milk production, reproductive failures and loss of draught power resulting in reduced productivity. Mortality, however, can be high in young animals up to 100%, wherein the virus causes myocardial degeneration, known as Tiger Heart disease [8]. It is estimated that 25% productivity of individual recovered animals are lost due to FMD [9]. It causes low production for the affected countries; severe restrictions are placed on international trade of animal and animal products (meat, milk, hide and butter) due to its transboundary nature of transmission [10]. Studies conducted by Bangladesh Livestock Research Institute (BLRI) revealed that during an outbreak the morbidity, in cattle to be around 36%, in buffaloes 23%, in sheep and goat 5% and case fatality rate, especially in calves, has been found to be about 51% in outbreak area (www.blri.gov.bd). Annual losses due to the outbreak of FMD in Bangladesh have been estimated to be US$ 10.92 million per year [11].

The causal agent, FMD virus belongs to the genus Aphthovirus, under the family Picornaviridae, of which there are seven immunologically distinct serotypes; O, A, C, South African Territories (SAT)-1, SAT-2, SAT-3 and Asia-1, and at least 65 subtypes have been identified [10]. Chowdhury et al. [12] reported that Foot and mouth disease (FMD) is endemic both in Bangladesh and its neighboring countries like India, Nepal, Bhutan and Myanmar. In Bangladesh during 2007 to 2008, Serotypes A, O, C and Asia-1 have been identified where A, O and Asia-1are very common, while type C has been identified scarcely. The pathogenicity in case of FMDV type O is always severer than type A, C and Asia-1. However, recently FMDV types A and Asia-1 are also found as severe as FMDV type O [13]. The disease is often transmitted from the infected to the apparently healthy susceptible animals through air or direct contact and disease outbreak is high in the winter (December- February) and in monsoon (June-September) of a year in tropical and subtropical country of the world [14-16]. The outbreak of this disease has become a regular event throughout the country in every year, while the exact reason for this frequency is not very clear, but it is assumed that the outbreak of the disease may be due to new introduction of mutant viruses. Moreover, a significant number of cattle and buffaloes have been entering from India to Bangladesh in every year either through proper or improper channels which directly or indirectly serves as a source of new virus introduction [17].

Laboratory based works on FMD specially it’s isolation; identification and vaccine development were carried out in Bangladesh as well as only few studies reported on the hematological and biochemical alterations at different stages of bovine FMD. Moreover, almost no reports are available on the hematological and biochemical changes at different stages in naturally infected cattle with FMD in Bangladesh. Therefore, the aim of this present research was to determine the possible alterations in hematological and biochemical parameters in cattle with Foot and Mouth Disease at primary, advanced and recovery stages in Bangladesh.

Materials and Methods

This research was performed in the laboratory of the Department of Anatomy & Histology, Bangladesh Agricultural University, Mymensingh-2202 during the outbreak report from June to November in 2016. Clinically FMD affected cattle and some healthy cattle (for control group) over 1 year of age were selected for the evaluation of effective hematological and biochemical changes at different outbreak areas of Rajshahi, Mymensingh and Bandarbon each of these districts shares common boundaries with the neighboring country India (Figure 1).

A. Study Design

A total number of 20 cattle were used in this study, of these 15 cattle showed characteristic clinical sign of FMD. The remaining 5 cattle were apparently healthy and selected as a control group. Peripheral blood samples, 20 samples each were collected directly from the jugular vein with the help of 10ml sterile syringe and put into blood collecting vial (Vacuum Tube, K3EDTA, REF Ko3oEDE) containing anticoagulant EDTA (ethylene diamine tetra acetic acid at 2 mg/ml) to investigate the WBC, RBC, Hb. conc., PCV, MCV and MCH for hematological study (Figure 2). Another 20 samples from the jugular vein were collected and put into blood collecting vial (Vacuum Tube, K3EDTA, REF Ko3oEDE) without anticoagulant for total serum protein, albumin, globulin, BUN, calcium, glucose, phosphorus and cholesterol test for biochemical study. These collected samples were divided into four groups:
a) Group A (Control group): Group A is control group with normal physiological condition and no clinical findings.
b) Group B (Primary stage): Group B is referred to as primary stage group where animal are affected with FMD disease of 1st to 2^nd days of post infections.
c) Group C (Advanced stage): Group C is referred to as advanced stage group where animal are affected with FMD disease of 3rd to 7^th days of post infections.
d) Group D (Recovery stage): Group D is referred to as recovery stage group where animal are affected with FMD disease of 8th to 14^th days of post infections.

B. Hematological Study

The anticoagulant added samples were examined for hematological study of red blood cells count (RBCs, 106/ μl), white blood cells count (WBCs, 103/ μl), hemoglobin (Hb, g/dl), packed cell volume (PCV%) as per method described by Mohan et al. [18]. The mean corpuscular volume (MCV,fl), and the mean corpuscular hemoglobin (MCH, pg) were calculated as mentioned by Gökçe et al. [19].

C. Biochemical Study

Through the non-anticoagulant added samples, the concentration of different serum biochemical constituents such as the average value of total protein, albumin, globulin, blood urea nitrogen (BUN), cholesterol, calcium, phosphorus and glucose were examined by standard method.

D. Statistical Analysis

All the collected data were analyzed by using IBM SPSS Statistics (version 20) software and revealed the results in necessary forms. Statistical analysis was performed using one-way analysis of variance (ANOVA) followed by post hoc Duncan’s test. Results were expressed as mean ± standard error (S.E). Differences between groups were considered significant at p<0.01 and p<0.05 level.

Figure 1: Location of study area inside Bangladesh. Rajshahi, Mymensingh and Bandanban districts share common boundaries with the neighboring country India.

Figure 2: Collected blood sample for hematological and biochemical examination.

Results and Discussion

E. Hematological Study

The concentration of different hematological indices (mean ± SE values) are presented in the Table 1. In this present study, the total number of red blood cells (RBC) count in foot-and-mouth disease cattle at primary, advanced, recovery stage groups (Group B, Group C, Group D) and apparently healthy animals (Group A) were 4.98±1.48 x10⁶/μl, 4.60±0.48** x10⁶/μl, 5.14±1.36 x10⁶/ μl and 5.5±0.29 x10⁶/μl respectively. Similarly, the hemoglobin concentration were 8.85±1.25 g/dl, 8.32±0.78** g/dl, 9.25±2.02 g/dl and 9.57±1.08 g/dl at the primary, advanced, recovery stage groups (Group B, Group C, Group D) and control group (Group A) respectively Table 1. Statistical analysis revealed that the RBCs count and Hb conc. specially at the advanced stage (group C) was significantly (p<0.01) lower than the other groups that might be due to reduction of the process of erythropoesis and hemolysis [20]. Similar findings are also observed by different workers in FMD infection [18,19,21]. On the other hand, FMD infected animals showed significant production of mean corpuscular volume (MCV) (p≤0.05) at advanced (64.27±3.94* fl) stage group as compared to the primary (60.65±2.67 fl) stage, recovery (56.20±2.48 fl) stage and control (51.80±2.86 fl) group Table 1 same findings are recorded by Gokce et al. [19], Ghanem et al. [21], Mohapatra et al. [22], Krupakaran et al. [23] and Gattani et al. [24]. These results could be attributed to endocrinopathy is reported previously by Radostits et al. [20].

Table 1: Hematological parameters (mean ± SE values) in FMD at primary, advanced, recovered stage group and control group with normal range.

Results are Mean ± SE (Standard Error) in each group. One-way analysis of variance (ANOVA) followed by post hoc Duncan’s test was performed as the test of significance. The difference was considered to be significant when **p<0.01, *p<0.05 compared to FMD control group.
NS = Not significant

Besides these, the total white blood cells (WBC) count, the mean value of packed cell volume (PCV), and the value of mean corpuscular hemoglobin (MCH) in FMD affected animals at primary, advanced, recovery stage groups did not show any significant alteration along with the control group and our findings also are corroborated with the observation made by Mohan et al. [18], Gokce et al. [19] and Al-Rukibat et al. [25].

F. Biochemical Study

The concentration of different biochemical indices (mean ± SE values) are presented in the Table 2. This study demonstrated that the average value of total serum protein were 6.20±0.65 g/dl, 4.32±0.17** g/dl, 5.95±0.57 g/dl and 7.07±0.72 g/dl and albumin concentration were 2.99±0.23 g/dl, 2.17±0.11** g/dl, 3.96±0.18 g/ dl and 4.65±0.18 g/dl in FMD at the primary, advanced, recovery stage groups and control group respectively Table 2. The total serum protein and albumin concentration were significantly (p<0.01) decreased at advanced stage rather than the other groups. Roussel et al. [26] reports that the decrease level of total protein concentration is associated with hepatic and renal damage, starvation, enteropathies that resulting in protein loss and the presence of infection or any lesion in the body is also recorded by Meyer et al. [27]. which was inconsonance with our observation. Low albumin and protein concentrations may also be due to alterations in pancreatic β-cell functions that might have developed during the clinical course of FMD is reported by Barboni et al. [28]. As well as, serum globulin concentration showed a significant decrease (p<0.05) at the advanced stage as compared to primary, recovery stage groups and control group. The serum globulin concentration at the primary, advanced, recovery stage groups and control group were 2.40±0.08 g/dl, 2.14±0.14* g/dl, 2.35±0.30 g/dl and 2.78±0.30 g/dl respectively Table 2, that might be due to hypoglobulinemia in the affected animals, coming in parallel with mention by Gokce et al. [19], Ghanem et al. [21], Mohapatra et al. [22], Krupakaran et al. [23] and Gattani et al. [24].

Table 2: Biochemical parameters (mean ± SE values) in FMD at primary, advanced, recovered stage group and control group with normal range.

Results are Mean ± SE (Standard Error) in each group. One-way analysis of variance (ANOVA) followed by post hoc Duncan’s test was performed as the test of significance. The difference was considered to be significant when **p<0.01, *p<0.05 compared to FMD control group.
NS = Not significant

Though the blood urea nitrogen (BUN) concentrations were decreased significantly (p<0.01) at the advanced stage group (18.44±0.34** mg/dl) as compared with the primary (16.92±0.44 mg/dl), recovery (18.94±0.33 mg/dl) and control group (20.19±0.68 mg/dl). It might be due to hypoproteinemia in the affected group. As well as the mean value of cholesterol in FMD at the primary, advanced, recovery stage groups and control group were 170.51±5.27 mg/dl, 156.45±3.64** mg/dl, 184.33±4.97 mg/dl and 192.69±5.77 respectively Table 2, while the normal range is 65- 220 mg/dl. This study was revealed a significant (p<0.01) reduction of cholesterol level at the advanced stage group (Group C) and may be due to dysfunction of pancreatic β-cell is suggested by Gokce et al. [19] and Ghanem et al. [21]. Nevertheless, the mean value of calcium level at the primary, affected, recovered stages and control group was reported very little significant which is also mentioned by Mohapatra et al. [22], Krupakaran et al. [23] and Gattani et al. [24]. This research also revealed a significant (p<0.01) production of phosphorus (P) concentration between the affected and control groups. The mean value of phosphorus (P) in foot-and-mouth disease cattle at primary, advanced, recovery stage groups and control group were 6.98±0.37, 8.55±0.57**, 5.7±0.24 and 5.3±0.86 g/dl respectively. Hyperphosphatemia recorded in our result is also noted by Gokce et al. [19], Ghanem et al. [21], Mohapatra et al. [22], Krupakaran et al. [23] and Gattani et al. [24]. Similarly, Glucose concentration was significantly (p<0.01) increased at the advanced stage (73.94±2.17** mg/dl) group in analogy with the primary (67.39±4.07 mg/dl), recovered (52.91±3.27 mg/dl) stage groups and control group (51.28±3.67 mg/dl) Table 2. An increased concentration of glucose was well documented in cattle affected with FMD is recorded by Elitok et al. [29] and also a common finding in cattle affected by the stress in systemic disease is described by Gokce et al. [19], Paalberg et al. [30] and Yeotikar et al. [31].

Conclusion

From this present study, it can be concluded that the concentration of different hematological constituents revealed a significant reduction (p≤0.01) of red blood cells (RBC), hemoglobin (Hb) and significant production (p≤0.05) of mean corpuscular volume (MCV) especially at the advanced stage (group B) rather than the control groups. Similarly, at 3rd to 7th days of post infection that is in advanced stage, the serum biochemical concentration of total protein, albumin, globulin, blood urea nitrogen, cholesterol are significantly decreased and significant increase (p≤0.01) of glucose and phosphorus in FMD affected animals in comparison to the other respective groups.

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