SUBLINGUAL VITAMIN D3 EFFECTIVE IN A PATIENT RESISTANT TO CONVENTIONAL VITAMIN D SUPPLEMENTATION.

OBJECTIVE: Vitamin D deficiency is prevalent worldwide and is usually treated with oral supplementation. Bioavailability of vitamin D may differ among individuals due to variable absorption and metabolism in the body. METHODS: A 66-year-old woman presented for evaluation of low 25-hydroxyvitamin D (25[OH]D) level. She had no known prior history of gastric or intestinal surgeries or malabsorptive conditions. She had previously been treated with oral vitamin D3 at 2,000 IU daily with poor response. She was then treated with oral vitamin D2 at 50,000 IU weekly, with persistently low 25(OH)D level at 14 ng/mL after 8 weeks of treatment. RESULTS: Celiac screen was negative and duodenal biopsy was normal. Due to demonstration of poor oral absorption, she was prescribed vitamin D2 at 50,000 IU sublingually for 8 weeks and then changed to over-the-counter vitamin D3 drops sublingually (1,000 IU/drop) at 4,000 IU twice daily due to suboptimal response with vitamin D2. 25(OH)D level improved gradually to 28 ng/mL after 12 weeks on this regimen and was at 37 ng/mL at 1 year. CONCLUSION: Sublingual vitamin D3 may be an effective alternative mode of vitamin D supplementation in patients who demonstrate poor oral vitamin D absorption despite adequate supplementation for various reasons.

TB case notification by private health-sector; retrospective study in 13 metro districts of Pakistan.

OBJECTIVE: To evaluate the impact of structured engagement of private providers in tuberculosis case notification and to investigate demographic profile, disease pattern and treatment outcome of tuberculosis patients seeking care from private care providers. METHODS: This retrospective study was carried out in 13 districts of Pakistan with the data of tuberculosis patients registered and diagnosed from July 2015 to June 2016 at directly observed treatment, short-course trained private providers. These facilities in collaboration with Greenstar Social Marketing Pakistan, a private organisation and the National Tuberculosis Control Programme, Pakistan, provided free anti-tuberculosis drugs and sputum smear microscopy. Study variables included socio-demographic character, disease patterns and treatment outcomes of patients along with details of the registering facility. Data was analysed using SPSS 23. RESULTS: There were 1317 directly observed treatment, short-course trained private health facilities and 123 private laboratories. Of the health facilities, 880(67%) reported 13769 tuberculosis patients. Of them, 7388(53.65%) were females and 6381(46.34%) were males. Overall, 10232(74.31%) were diagnosed with pulmonary tuberculosis and 3537(25.68%) were extra pulmonary tuberculosis patients. Among the pulmonary patients, 4195(41%) were diagnosed through sputum smear microscopy as bacteriologically confirmed (B+ve), while the remaining 6037(59%) were diagnosed through X-ray or other tests. Out of all the diagnosed patients 13218(96%) were treated successfully.. CONCLUSIONS: Private healthcare sector has great potential of supporting tuberculosis control. Gender and age had critical implications in service utilisation.

Effectiveness of outreach chest camps in detection of missed TB cases in Pakistan.

OBJECTIVE: To determine the effectiveness of outreach chest camp intervention for detection of missed tuberculosis cases in Pakistan and to evaluate the demographic profile of those who are dependent on such doorstep healthcare services. METHODS: This retrospective study was carried out using data from the outreach chest camp intervention organised by Greenstar Social Marketing company from August 2015 till December 2016 in Lahore, Gujrat and Sheikhupura districts of Pakistan's Punjab province. The intervention involved a set of community mobilisation events in hard-to-reach areas and in healthcare facilities which are deprived of suitable settings, followed by free medical camps where medical consultation and tuberculosis diagnostic facility of sputum smear microscopy were provided to the camp attendees. The data was taken as per set variables and analysed using SPSS 23. RESULTS: A total of 399chest camps were conducted, where 22,399 patients were clinically assessed for the presence or absence of tuberculosis. Overall, 12,319(55%) of the attendees were females and 10,080(45%) were males. Of the total, 5,226(24.6%) had signs and symptoms of tuberculosis and were declared as tuberculosis presumptive cases. After diagnostic investigations, 831(3.7%) individuals were declared confirmed tuberculosis patients. Amongst the total confirmed cases, 439(52.8%) were diagnosed through sputum smear microscopy with percent bacteria positivity of 8. (95% confidence interval [CI] 7.54 - 9.02). CONCLUSIONS: Chest camp intervention was found to have great potential to detect missed tuberculosis cases, thus limiting the spread of disease in the community.

The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials.

OBJECTIVE: To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence. METHODS: Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I2 statistics determined the impact of heterogeneity. RESULTS: Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9). CONCLUSION: PN is effective to increase screening rates and complete care events. PRACTICE IMPLICATIONS: PN is an effective intervention for use in healthcare.

Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial.

OBJECTIVES: To describe (1) cardiac rehabilitation (CR) referral across cardiac units in a tertiary centre with eReferral; (2) characteristics associated with CR referral and enrolment and (3) the effects of peer navigation (PN) on referral and enrolment. This pilot was a 2 parallel-arm, randomised, single-blind trial with allocation concealment. SETTING: 3 cardiac units (ie, interventional, general cardiology, and cardiac surgery) in 1 of 2 hospitals of a tertiary centre. PARTICIPANTS: CR-eligible adult cardiac inpatients were randomised to PN or usual care. 94 (54.7%) patients consented, of which 46 (48.9%) were randomised to PN. Outcomes were ascertained in 76 (80.9%) participants. INTERVENTION: The PN (1) visited participant at the bedside, (2) mailed a card to participant's home reminding about CR and (3) called participant 2 weeks postdischarge to discuss CR barriers. OUTCOME MEASURES: The primary outcome of enrolment was defined as participant attendance at a scheduled CR intake appointment (yes/no). The secondary outcome was referral. Blinded outcome assessment was conducted 12 weeks postdischarge, via CR chart extraction. RESULTS: Those who received care on the cardiac surgery unit (77.9%) were more likely to be referred than those treated on the general cardiology (61.1%) or interventional unit (33.3%; p=0.04). Patients who had cardiac surgery, hypertension and hyperlipidaemia were significantly more likely, and those with congenital heart disease, cancer and a previous cardiac diagnosis were less likely to be referred. Participants referred to a site closer to home (76.2% of those referred) were more likely to enrol than those not (23.7%, p<0.05). PN had no effect on referral (77.6%, p=0.45) or enrolment (46.0%, p=0.24). CONCLUSIONS: There is wide variability in CR referral, even within academic centres, and despite eReferral. Referral was quite high, and thus, PN did not improve CR utilisation. Results support triaging patients to the CR programme closest to their home. TRIAL REGISTRATION NUMBER: NCT02204449; Results.

Resilience Through Squamous Cell Carcinoma and Rhabdomyosarcoma of Oral Cavity: A Unique Case Report.

Rhabdomyosarcoma (RMS) is a soft tissue neoplasm of mesenchymal origin. It is a commonly encountered malignant tumor amongst pediatric patients, yet relatively rare in adults. It usually involves the head and neck region, genitourinary organs and retroperitoneal structures. In adults, the most commonly affected area is the head and neck region. We present here a case of a 30-year-old male patient with a primary squamous cell carcinoma of the tongue (T1, N0, M1), successfully cured with surgery and chemoradiotherapy and later on development of metachronous ipsilateral lesion on the left lower alveolus. Biopsy was consistent with spindle cell RMS. Immunohistochemistry demonstrated positivity for desmin, vimentin and myogenin, thus confirming the mesenchymal origin. With the best of our literature search, this is an exceptional case presenting two malignant lesions with diverse genetic origins, diagnosed at stage 1 and giving a favorable outcome.