Can inpatient psychiatric care help teens amid a depressive crisis?

There has been a troubling rise in adolescent mental health struggles and suicide rates over the past decade, with a dramatic increase following the start of the COVID-19 pandemic. This crisis has been accompanied by an increased demand for pediatric inpatient psychiatry units (IPUs) across the United States. However, despite the growing need, which has reached the point of bed shortages, the effectiveness of IPUs on teen mental health outcomes remains understudied.

This study, led by Dr. Patricia Ibeziako from Boston Children’s Hospital, reviewed the electronic medical records and self-report questionnaires of over 200 adolescents (ages 12–17) admitted to the IPU between September 2021 and September 2023. Their study was published in the journal Psychiatric Research and Clinical Practice on April 21, 2025. They found one of the highest lifetime rates of suicide attempts ever reported in adolescents, with more than 75% of teens reporting at least one suicide attempt in their lifetime. Furthermore, nearly 70% of participants reported having suicidal thoughts within two weeks before admission, highlighting the severity of this mental health crisis. Depression was the most common diagnosis, with 93% of adolescents meeting the diagnostic criteria. This was often accompanied by other conditions such as anxiety disorders, attention deficit hyperactivity disorder, and trauma-related disorders.

At the hospital, the teens received daily care from doctors, therapists, nurses, and counsellors. They also had access to group therapy, school support, and help with any physical health problems. The team used special tools to assess suicide risk and conduct safety planning. They also used proven therapies like Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT), which are known to help people with depression and suicidal thoughts.

Most importantly, the study focused on the teens’ own voices by using Patient-Reported Outcomes (PROs)—surveys that asked the teens how they were feeling and functioning. This helped the care team understand what was working and what needed more attention.

But despite the high severity of symptoms upon admission, the study found that the patients showed significant improvement by the time they were discharged. “Self-reported measures on depression, anxiety, emotional regulation, family functioning, and overall life satisfaction all improved significantly”, says Dr. Ibeziako. “In fact, the largest treatment effect was seen in depressive symptoms, and improvements were observed across all subscales of depression, including mood, suicidal ideation, and energy levels.”

Perhaps most strikingly, the study found that adolescent scores for suicidal thoughts decreased by more than half. “The implementation of enhanced suicide screening and treatment that aligns with the Zero Suicide framework has made a meaningful difference in these young people’s lives,” adds Dr. Ibeziako. This framework, which was introduced during the first year of the pandemic, takes a comprehensive, system-wide approach to suicide prevention. The findings showed that when paired with other treatments for depression, the intervention led to significant improvements in symptoms and emotional regulation. “Pediatric IPUs play a crucial role in delivering these life-saving interventions,” emphasizes Dr. Ibeziako.

The results of this study show that timely and targeted psychiatric care can be lifesaving. With adolescent depression and suicidal thoughts at an all-time high, these results are a clear call to action for healthcare systems to prioritize resources and access to pediatric IPUs and further research into their outcomes.

Reference:

Patricia Ibeziako, Inpatient Psychiatry Patient Reported Outcomes: Adolescent Emotional Distress, Suicidal Thoughts and Behaviors, Psychiatric Research and Clinical Practice, https://doi.org/10.1176/appi.prcp.20240127.

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Buccal and Intranasal Midazolam Effective for Managing Uncooperative Children in Dental Treatment: Study

Researchers have found in a new research that both buccal (85%) and intranasal (80%) midazolam proved effective in calming uncooperative children during dental procedures.

Behavioral management techniques are not always sufficient, and then it is necessary to use pharmacological management methods. The aim of this study is to compare the effectiveness of buccal midazolam sedation with intranasal midazolam in non-cooperative children during dental treatment. A randomized single blinded comparative clinical study consisted of 40 children aged 3–6 years who were divided randomly into two groups: Group A intranasal midazolam and Group B buccal midazolam. The onset time of action and recovery time from sedation were compared between the two groups, and the efficacy of sedation was evaluated by Houpt behavior scale. The independent student’s T test, Mann–Whitney U test, the Wilcoxon test and the Chi-square test were used. Results: There were no statistically significant differences in the onset time of action (p = 0.458) and recovery time from sedation (p = 0.148). There were no statically significant differences between the two groups in sleeping, crying, and movement categories (p = 0.747), (p = 0.183), (p = 0.732), respectively, or in the overall Houpt scale (p = 0.393), there were statistically significant differences in the sleep variable between the two studied phases in the intranasal group (p = 0.014) and in the movement variable in the buccal group (p = 0.039). Both buccal midazolam and intranasal sedation were effective in the management of uncooperative children during dental treatment at 85% and 80%, respectively.

Reference:

Arnaout, Doaa, Altinawi, Mohamed, Katbeh, Imad, Tuturov, Nikolay, Saleh, Ahmad, Evaluation of the Efficacy of Buccal Midazolam in Comparison With Intranasal Midazolam Sedation in Uncooperative Children During Dental Treatment, International Journal of Dentistry, 2025, 4269519, 6 pages, 2025. https://doi.org/10.1155/ijod/4269519

Keywords:

Buccal, Intranasal, Midazolam, Effective, Managing, Uncooperative, Children, Dental Treatment, Study , Arnaout, Doaa, Altinawi, Mohamed, Katbeh, Imad, Tuturov, Nikolay, Saleh, Ahmad

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AI Matches Radiologists in Detecting TB and Chest X-Ray Abnormalities, Finds Multi-Site Study

USA: In a significant step toward enhancing tuberculosis (TB) screening efforts, a recent multi-site prospective study has validated the use of artificial intelligence (AI) for detecting active pulmonary TB and other chest X-ray (CXR) abnormalities. Conducted in settings with high TB and HIV prevalence, the study found that AI tools performed comparably to radiologists in triaging suspected TB cases.

“AI matched the performance of radiologists in detecting active tuberculosis and also showed promise in identifying other chest X-ray abnormalities effectively,” the researchers wrote in NEJM AI.

To enhance TB screening in resource-limited settings, researchers explored using artificial intelligence to interpret chest X-rays as a potential triage tool for active pulmonary tuberculosis. Sahar Kazemzadeh, Google, Mountain View, CA, and colleagues aimed to evaluate the effectiveness of a commercially available CXR-based AI system in detecting active TB in real-world clinical settings.

For this purpose, the researchers assessed two cloud-based chest X-ray AI tools—one for detecting tuberculosis and the other for identifying general CXR abnormalities—in a high-TB and HIV burden population. The study included 1,978 adults with TB symptoms, recent TB exposure, or newly diagnosed HIV across three clinical sites.

The TB AI scores were evaluated using two thresholds: one for high sensitivity and another to mirror radiologist performance. Ten radiologists reviewed the X-rays independently, blinded to the reference results. The primary aim was to test whether the TB AI was noninferior to radiologists, while secondary analyses compared its performance with WHO targets. The abnormality AI was also evaluated against triage-appropriate sensitivity and specificity benchmarks.

Key Findings:

  • Among the 1,910 patients analyzed, 1,827 (96%) had a conclusive TB diagnosis. Of these, 649 patients (36%) were HIV positive, and 192 patients (11%) were TB positive.
  • The TB AI demonstrated 87% sensitivity and 70% specificity at the high-sensitivity threshold.
  • At the balanced threshold, the TB AI showed 78% sensitivity and 82% specificity.
  • Radiologists had a mean sensitivity of 76% and a mean specificity of 82%.
  • At the high-sensitivity threshold, TB AI was noninferior to the average radiologist’s sensitivity but not to specificity.
  • TB AI exceeded the WHO target for specificity but did not meet the sensitivity benchmark.
  • At the balanced threshold, the performance of TB AI was comparable to that of radiologists.
  • The abnormality AI achieved 97% sensitivity and 79% specificity, meeting both predefined performance targets.

The study concluded that the chest X-ray-based AI system for tuberculosis detection performed on par with radiologists when used for triaging active pulmonary TB in populations with high TB and HIV prevalence. However, neither the AI tool nor the radiologists met the World Health Organization’s recommended sensitivity levels in this setting. The AI system also showed promise in identifying other chest X-ray abnormalities, highlighting its potential for broader clinical use.

Reference:

Kazemzadeh S, Kiraly AP, Nabulsi Z, Sanjase N, Maimbolwa M, Shuma B, Jamshy S, Chen C, Agharwal A, Lau CT, Sellergren A, Golden D, Yu J, Wu E, Matias Y, Chou K, Corrado GS, Shetty S, Tse D, Eswaran K, Liu Y, Pilgrim R, Muyoyeta M, Prabhakara S. Prospective Multi-Site Validation of AI to Detect Tuberculosis and Chest X-Ray Abnormalities. NEJM AI. 2024 Oct;1(10):10.1056/aioa2400018. doi: 10.1056/aioa2400018. Epub 2024 Sep 26. PMID: 39823016; PMCID: PMC11737584.

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Antibiotics Identified as Leading Cause of Anaphylaxis in Children in new study

A new study published in the European Journal of Pediatrics showed that antibiotics, particularly ceftriaxone, were the most commonly related to anaphylactic reactions in children. This highlights the need for heightened awareness and careful monitoring when prescribing antibiotics to pediatric patients.

Drugs are the most common etiological agents in deadly anaphylaxis in most areas where data is available. Data on drug-induced anaphylaxis in children are sparse, with most case studies including adult populations. Azize Pınar Metbulut and crew conducted this study to understand demographics, clinical manifestations, risk factors, causative agents, and therapy options for drug-related anaphylaxis in the pediatric population.

Pediatric patients between the ages of 1 month and 18 months, who were admitted to the Pediatric Allergy and Immunology outpatient clinics of 11 participating centers between January 2017 and December 2022 with a presumptive diagnosis of drug-induced anaphylaxis and who met the standard criteria for anaphylaxis were included in this multicenter retrospective study.

A total of 293 anaphylactic incidents that occurred in 265 individuals were included, of which 48.1% (n 141) were female. During the index event, the median age of the patients was 107 months. When compared to home surroundings, hospital settings had a higher rate of anaphylaxis. In 40.3% of the instances, the administration was peroral, and in 59.7%, it was parenteral.

The most often suspected medication classes were antibiotics, non-steroidal anti-inflammatory medicines, and chemotherapeutics; nevertheless, the most prevalent culprits among antibiotics were the cephalosporin group, particularly ceftriaxone. 39.6% of the events had severe anaphylaxis, whereas 54.9% had mild anaphylaxis.

5 of the patients experienced a biphasic response. Adrenaline therapy was administered to only 72% of patients. A total of 39 individuals were confirmed by diagnostic tests, comprising skin prick, intradermal, and drug provocation tests, conducted between 1 and 120 months following the index response.

The results showed positive results in 23.4%, 17.2%, and 20.3% of instances, respectively. Protocols for possible drug desensitization were performed on four individuals. Overall, algorithmic assessment is necessary for pediatric patients suffering from drug-related anaphylaxis in order to guarantee a precise diagnosis, stop recurrence, and find safe substitute therapies.

Source:

Metbulut, A. P., Haci, İ. A., Can, D., Bekiş Bozkurt, H., Cavkaytar, Ö., Arga, M., Özçeker, D., Kavas Yildiz, Y., Vezir, E., Arikoğlu, T., Kuyucu, S., Azkur, D., Güvenir, H., Kendirci, N., Orhan, F., Usta Güç, B., Bahçeci, S., & Dibek Misirlioğlu, E. (2025). Evaluation of drug-related anaphylaxis in children: multi-center study. European Journal of Pediatrics, 184(3), 230. https://doi.org/10.1007/s00431-025-06068-x

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Seeking MBBS at AFMC Pune this year! Here’s complete admission guide

Pune- Armed Forces Medical College (AFMC), Pune has released the information brochure for its MBBS course for 2025. Admission is based on NEET UG 2025 scores, and candidates must apply separately through the DGHS portal.

A total of 145 seats are available (115 for boys and 30 for girls), with up to 10 seats reserved for SC/ST candidates and 5 seats for foreign nationals sponsored by the Government of India. Applicants must be Indian citizens (with exceptions for certain foreign candidates), unmarried, medically fit, and between 17 and 24 years of age as of 31 December 2025. Candidates must have passed the qualifying exam in the first attempt with specific subject and mark requirements. Document verification and timely reporting are mandatory; any discrepancies or delays may lead to cancellation of admission.

As per the information bulletin, the duration of the MBBS course is 4½ years followed by compulsory rotating internship training of one year. All medical cadets after completing final MBBS examination will undergo internship training in selected service hospitals recognized by the National Medical Commission (NMC).

Eligible candidates who are interested to join AFMC, Pune to pursue the MBBS course will have to mandatorily register and apply for AFMC, Pune on DGHS official website during the registration window provided by the DGHS. Below are the details-

DOCUMENT SCRUTINY

1 The candidates who have made it to the final merit list/wait list as published on DG-1D website & AFMC website and thereafter called for admission will have to produce the original Admit card for NEET UG – 2025 containing the NEET Roll number, original mark sheets of their qualifying examination and other documents, details of which will be given in the joining instructions. If their results and mark sheets are not received by the date of reporting for admission to AFMC, their candidature will be cancelled and no representation in this respect will be entertained. No candidate will be admitted provisionally awaiting result of the qualifying examination. If at any point of time in the process of interview, admission, or MBBS course the documents of the candidate are found to be false/not authentic or any other discrepancy is observed, the candidature / selection / admission of the candidate will be cancelled forthwith.

2 Wait list will be released along with the merit list only. The waitlisted candidates will be called in blocks and will be offered seats in order of merit. Candidates are required to report strictly by 1400 hrs on the day of reporting. Anyone reaching AFMC Pune after the cut off time will not be entertained in any circumstances. Candidates should keep certificates and fees ready and be ready to move at short notice on receipt of intimation by telephone, letter or e-mail.

3 No intimation about non-selection or correspondence in this regard will be entertained. No seats will be kept vacant for candidates higher in merit in waiting list if they fail to report on the date and time on which they have been called for reporting.

4 Candidates MUST preserve the NEET UG–2025 admit card till the admission to AFMC is over. Admit card along with NEET UG–2025 Roll number, will be required during the interview and final admission to college.

ELIGIBILITY

A candidate seeking admission to the MBBS Course in AFMC is eligible if he / she fulfils the following criteria-

1 The candidate should be a citizen of India. Foreign nationals of Indian origin may be admitted into AFMC only after they have acquired Indian Citizenship or in respect of whom the Ministry of Home Affairs issues a certificate of eligibility. This however does not apply to the 05 Govt Sponsored Candidates from Friendly Foreign Countries.

2 Must be unmarried. Marriage during the course is not permitted.

3 Should be medically fit.

4 The candidate should have attained the age of 17 years at the time of admission or should be completing that age on or before 31 Dec of the year of admission of the first year of MBBS course but must not have attained the age of 24 years on that date, i.e., must have been born not earlier than 01 January 2002 and not later than 31 December 2008.

NON-ELIGIBILITY

The following categories of candidates are not eligible to apply-

1 Candidates who have passed in Domestic Science, Domestic Arithmetic, and Lower Math separately or in combination with other subjects like General Science / Social studies in High School / Higher Secondary (Multipurpose) or equivalent examination.

2 Candidates who have passed only Pre-University / Pre-Degree (one-year course) or PreProfessional in Agriculture / Veterinary / Dental Examination.

3 Candidates who have passed the Pre-professional or equivalent qualifying examination as a private candidate or from Open schools.

4 Candidates who have secured the requisite percentage but in subsequent attempts or compartment examination.

ACADEMIC QUALIFICATIONS

Candidates must have passed one of the qualifying examinations below in the first attempt with English, Physics, Chemistry and Biology/ Bio-technology taken simultaneously and securing not less than 60% of the aggregate marks in these three science subjects taken together and not less than 50% marks in English and 50% marks in each of the science subjects. They must have also passed an examination in Mathematics of the tenth standard. The examinations are-

1 The Higher Secondary (10+2) or equivalent examination in science of a statutory Indian University/board or other recognized examination body with English, Physics, Chemistry & Biology/ Bio-technology which shall include practical test in all of these science subjects.

2 The Pre-professional/pre-medical examination with English, Physics, Chemistry and Biology/ Bio-technology (after passing either Higher Secondary School examination or pre- University or equivalent examination) which shall include practical test in these science subjects.

3 1st year of three years Degree course of a recognized University with English, Physics, Chemistry, and Biology/ Bio-technology including practical test in science subjects provided the examination is a University Examination.

4 Senior Secondary of a statutory Examination Board of Indian School Certificate examination of 12 years of study, last two years of study comprising of Physics, Chemistry, Biology/ Bio-technology and Mathematics or any other elective subject with English at higher level.

5 Higher Secondary School Certificate examination of Maharashtra State Board of Higher Secondary Education with English at Higher level, anyone of the Modern Indian or Modern Foreign or Classical Languages, Physics, Chemistry, Biology/ Biotechnology and Mathematics or any other elective subject.

6 Any other examination which in scope and standard is found to be equivalent to the Higher Secondary Science/Pre-Professional/Pre-medical Examination of Indian University/ Board with English, Physics, Chemistry and Biology/ Bio-technology including practical test in each of these Science subjects.

7 B.Sc. Examination of a recognized Indian University provided that he/she has passed the B.Sc. Examination in not less than two of the subjects Physics, Chemistry, Botany, Zoology / Bio-technology and further that he/she has passed the qualifying examination with Physics, Chemistry, Biology and English.

8 Candidates who have appeared or will be appearing in qualifying examination may also apply. Admission, if selected, however, will be subject to passing and meeting the eligibility criteria.

9 Regarding the requirement of Mathematics, any candidate who has passed Higher Secondary, Senior Cambridge or Indian School Certificate Examination and had not offered Mathematics in the final year will be deemed eligible if he / she had studied Mathematics up to the pre-final year stage (X Class) and had passed an examination in the subject provided it was at least of Tenth standard. A certificate signed by the Head Master or Principal of the school in which candidate has studied should be produced at the time of interview in such cases. A candidate who had not taken Mathematics in the Tenth or an equivalent examination but had subsequently passed in Mathematics as an additional subject in I. Sc. / B.Sc. examination is also eligible.

SC/ST CANDIDATES

For the SC/ST category candidates, up to 10 seats out of 145 will be offered subject to fulfilling the following criteria-

1 The SC/ST candidates must have applied for AFMC, Pune and also qualified in the NEET UG-2025 written examination.

2 They must fulfil all other conditions/standards, as applicable to non-SC / ST candidates, like age eligibility, academic qualifications, medical fitness, etc.

3 These seats will be in addition to any vacancies secured by SC/ST candidates on the basis of their position in the main merit list.

4 In case of any SC / ST girl / boy, admitted against these vacancies the number of girls / boys to be admitted against the general seats will be reduced correspondingly.

5 All such candidates will have to sign a surety bond on the same lines and on the same conditions as Non-SC / ST candidates.

NUMBER OF SEATS

A total of 145 medical cadets (115 boys & 30 girls) will be admitted for the year 2025. In addition to the above 145 seats, Govt. of India at its discretion through Ministry of External Affairs & Ministry of Defence may sponsor and select five (05) NEET(UG) qualified foreign students from friendly foreign countries for MBBS training in AFMC, under their aid / collaboration programs. Up to 10 seats out of 145 are offered to candidates belonging to the Scheduled Castes/ Scheduled Tribes (SC/ST) subject to the provisions.

CANCELLATION OF ADMISSION

Any candidate, during the whole process of admission or subsequently after admission, if found to be having less marks in the qualifying examination or produces false certificates or conceals any disease to get admission, his / her admission will be treated as cancelled and fees / deposit will be forfeited.

To view the information bulletin, click the link below

https://medicaldialogues.in/pdf_upload/afmc-285484.pdf

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Batch of Tofajak Tablets earlier classified as NSQ now flagged as Spurious

New Delhi: Through a recent revised drug alert, the Central Drugs Standard Control Organization (CDSCO) has classified a batch of Tofacitinib Tablets IP 5 mg (TOFAJAK TABLETS) as spurious. The batch was earlier classified as Not of Standard Quality (NSQ).

The Medical Dialogues team had reported that 41 drug formulations were declared as Not of Standard Quality (NSQ) in November 2024, based on testing conducted by various CDSCO laboratories. Among these was a batch of Tofacitinib Tablets IP 5 mg (TOFAJAK TABLETS) (Batch No. 4F30009), listed under Cipla LTD , which was flagged by the Regional Drugs Testing Laboratory (RDTL) Chandigarh for failing identification and assay of Tofacitinib citrate calculated as Tofacitinib.

However, the same batch has now also been classified as “purportedly spurious” in CDSCO’s revised alert, with Cipla informing that it did not manufacture this batch.

The batch in question — Batch No. 4F30009, with a manufacturing date of May 2024 and expiry of April 2026 — carries Cipla’s name on the label. However, the company has officially clarified that it did not manufacture this particular batch.

‘The actual manufacturer (as per label claim) has informed that the impugned batch of the product has not been manufactured by them and that it is a spurious drug.’ the CDSCO stated in its revised alert.

The matter is now under active investigation. While the product is currently listed as “purportedly spurious,” the final classification will depend on the outcome of the ongoing inquiry.

Drug Alert for the Month of November–2024 (Revised)

List of Drugs, Medical Devices, Vaccines and Cosmetics declared as Not of Standard Quality/Spurious/Adulterated/Misbranded for the Month of November–2024 (Revised)

S.

No

Name of Drugs/medical device/cosmetics

Batch No.

Date of

Manufacture

Date of Expiry

Manufactured

by

Reason for failure

Drawn By

Firms’s reply

Remarks

40.

Tofacitinib Tablets IP 5 mg (TOFAJAK TABLETS)

4F30009

05/2024

04/2026

Under Investigation

Identification and Assay of Tofacitinib citrate calculated as Tofacitinib

Drugs Control Officer, Gurugram

The actual manufacturer (as per label claim) has informed that the impugned batch of the product has not been manufactured by them and that it is a spurious drug.

The product is purported to be spurious; however, the same is subject to outcome of investigation.

Also Read:Cipla gets CDSCO Panel nod to study Revefenacin Inhalation solution

To view the official notice, click the link below:

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How does consciousness work? Dueling scientists test two big theories but find no winner

“Theories are like toothbrushes,” it’s sometimes said. “Everybody has their own and nobody wants to use anybody else’s.”

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Q&A: Two decades of research lead to treatment for rare, painful skin condition

Patients with severe dystrophic epidermolysis bullosa, or EB, have skin so fragile, the slightest touch can lead to blistering and, eventually, large, open wounds that never heal, causing immense pain.

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Skin-to-skin contact improves breastfeeding but not cognitive outcomes in very preterm infants: Clinical trial

Researchers led by the Trondheim University Hospital in Norway report that two hours of immediate skin-to-skin contact between mothers and very preterm infants after birth does not improve cognitive, motor, or language development by age 2 to 3 years. Infants receiving the intervention did show significantly improved breastfeeding outcomes.

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Odisha Govt appoints Principals, Superintendents at 2 Medical College Hospitals

Bhubaneswar: The Odisha Health and Family Welfare Department has appointed four doctors as the new principals and superintendents in Sundargarh Medical College and Hospital and Saheed Rendo Majhi Medical College at Bhawanipatna, respectively.  

A notification issued by the department in this regard on May 1st mentioned Professor Subhra Ghosh as the new Dean and Principal of the Government Medical College in Sundargarh. She is currently serving as a professor in the Department of Obstetrics and Gynaecology at Shree Jagannath Medical College and Hospital, Puri.

Similarly, Sarada Prasanna Swain, a professor of psychiatry at SCB Medical College and Hospital in Cuttack, has been appointed as the Superintendent of Government Medical College and Hospital at Sundargarh.

Also read- Gujarat appoints 4 senior doctors in Govt Medical Colleges hospitals

Professor Krishna Kar, who teaches community medicine at SCBMCH, Cuttack, has been appointed as the new Dean and Principal of Saheed Rendo Majhi Medical College in Bhawanipatna.

Alongside him, Professor Lity Mohanty from the pathology department of SCBMCH will take charge as the new Superintendent of the Bhawanipatna Medical College and Hospital, reports Sangbad English.

Medical Dialogues had previously reported that during a session of the Odisha Legislative Assembly, Health Minister Mukesh Mahaling announced that the State Government has directed the Odisha Public Service Commission (OPSC) to begin the recruitment process for 5,822 doctors.

Previously, the Odisha Cabinet announced to send a requisition to the Odisha Public Service Commission (OPSC) for the recruitment of over 5,000 medical officers, including 124 dentists, without delay to address the ongoing shortage of doctors in government hospitals.

Additionally, it approved the newly formulated Odisha Medical & Health Services (Method of Recruitment and Conditions of Service) Amendment Rules, 2025, following the decision to amend the Odisha Medical & Health Services (Method of Recruitment and Conditions of Service) Rules, 2017.

Also read- Odisha cabinet nod to amend OMHS Rules, to recruit over 5000 doctors

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