Epidemiology of antimicrobial resistance in bacteria isolated from inpatient and outpatient samples, Ecuador, 2018.

Objective: To compare the epidemiology of antimicrobial resistance in bacteria isolated from inpatient and outpatient samples in Ecuador. Methods: A secondary analysis was done of data on bacteria isolated from inpatient and outpatient samples. Data were taken from the 2018 national antimicrobial resistance surveillance database of the National Reference Center for Antimicrobial Resistance. The variables included were: age, sex, inpatient versus outpatient setting, type of specimen, bacterial species identified, pattern of resistance to antibiotics, and geographic area. Results: Data from 57 305 bacterial isolates were included in the study: 48.8% were from hospitalized patients, 55.7% were from women, and 60.1% were from patients older than 45 years. Urine (42.9%) and blood (12.4%) were the most common clinical samples. Overall, 77.1% of bacterial isolates were gram-negative (83% and 71% in outpatients and inpatients, respectively). The most common gram-positive and gram-negative species were Staphylococcus aureus and Escherichia coli, respectively. Antimicrobial resistance levels were high (up to 80% for some antimicrobial drugs), and were higher in hospitalized patients compared with outpatients. A variety of carbapenemases were found to confer resistance to carbapenems (antibiotics of last resort) in gram-negative bacteria. Conclusions: The study findings provide an important baseline on antimicrobial resistance in Ecuador. This will allow the strengthening of guidelines of the surveillance system, the creation of public policies for standardization of laboratory methodologies, the proper handling of information, and the development of empirical therapy guidelines based on local epidemiology.

Polycystic Ovarian Syndrome among Young Women of a University in Central Gujarat - A Cross-sectional Study.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is one of the most common reproductive endocrinological disorders affecting 6%-8% of women in reproductive years. An early liberal PCOS screening appears to be a cost-effective strategy, benefiting earlier diagnosis and intervention. OBJECTIVES: The objectives are to measure the prevalence of PCOS and factors associated with PCOS among young girl students of a University in Central Gujarat. MATERIALS AND METHODS: All consenting girl medical students enrolled in MBBS curriculum during 2013-2017 were given a self-administered questionnaire (for signs and symptoms of PCOS), taking due prior permissions; during January 2018-June 2019. Using Rotterdam (2006) criteria, those who were screened for PCOS were subjected to abdominal ultrasonography (USG) and if required, laboratory investigations (random blood sugar, thyroid-stimulating hormone, and free testosterone). The proportion of young women having PCOS as per the Rotterdam and European Society for Human Reproduction and Embryology (EHSRE) Criteria are reported. RESULTS: The study enrolled 308 girl medical students. More than one-tenth of the study participants (11.7%, 36/308) had confirmed PCOS (Rotterdam Criteria). As per the EHSRE criteria, 24/36 had classic PCOS, 11/36 had ovulatory phenotype, and 01/36 had the non-hyperandrogenic phenotype PCOS. USG was required in 123/308 (39%); of which 91 consented and 16/91 (18%) had conclusive PCOS. Twenty-three girls required laboratory investigations, of which two had abnormal values suggestive of PCOS. Irregular menses and hirsutism were significantly associated with the PCOS (P < 0.05). CONCLUSION: The proportion of young medical students with PCOS was 12%. Irregular menses and hirsutism were significantly associated with PCOS.

Screening for gestational diabetes, Ahmedabad, India.

Objective: To implement a community-based screening and awareness-raising project for gestational diabetes in Ahmedabad, India. Methods: The project took place between April 2016 and August 2019 in Ahmedabad. Medical college faculty members and medical officers trained 3582 paramedical staff on screening for gestational diabetes. These paramedical staff tested all pregnant women 24-28 weeks gestation, who were attending village health and nutrition days - also called mamta days - in urban and rural health centres for routine antenatal care, for gestational diabetes. An oral glucose tolerance test was used and blood sugar ≥ 7.8 mmol/L was the cut-off for gestational diabetes. Women with gestational diabetes were referred for counselling and treatment and all women were followed until 6 weeks after delivery. Findings: Of 53 522 pregnant women screened, 6786 (12.7%) had gestational diabetes and were referred for nutritional therapy or medication; 836 (12.3%) of these women started medication. There was no significant difference in the prevalence of stillbirths between women with gestational diabetes (0.8%; 54/6786) and women without (0.7%; 338/46 736; P-value: 0.51). Of the women on treatment, 38 had abnormal blood glucose after delivery and continued with the medication. Two women with gestational diabetes died; they had other associated co-morbidities - pre-eclampsia and anaemia. Conclusion: We found a high prevalence of gestational diabetes, indicating the need for gestational diabetes screening and implementation of this project on a larger scale. Gestational diabetes screening at the community level is operationally feasible using the existing human resources and infrastructure of the reproductive health programmes.

Strategies to detect and manage latent tuberculosis infection among household contacts of pulmonary TB patients in high TB burden countries - a systematic review and meta-analysis.

OBJECTIVE: To summarise latent tuberculosis infection (LTBI) management strategies among household contacts of bacteriologically confirmed pulmonary tuberculosis (TB) patients in high-TB burden countries. METHODS: PubMed/MEDLINE (NCBI) and Scopus were searched (January 2006 to December 2021) for studies reporting primary data on LTBI management. Study selection, data management and data synthesis were protocol-driven (PROSPERO-CRD42021208715). Primary outcomes were the proportions of LTBI, initiating and completing tuberculosis preventive treatment (TPT). Reported factors influencing the LTBI care cascade were qualitatively synthesised. RESULTS: From 3694 unique records retrieved, 58 studies from 23 countries were included. Most identified contacts were screened (median 99%, interquartile range [IQR] 82%-100%; 46 studies). Random-effects meta-analysis yielded pooled proportions for: LTBI 41% (95% confidence interval [CI] 33%-49%; 21,566 tested contacts); TPT initiation 91% (95% CI 79%-97%; 129,573 eligible contacts, 34 studies); TPT completion 65% (95% CI 54%-74%; 108,679 TPT-initiated contacts, 28 studies). Heterogeneity was significant (I2 ≥ 95%-100%) and could not be explained in subgroup analyses. Median proportions (IQR) were: LTBI 44% (28%-59%); TPT initiation 86% (60%-100%); TPT completion 68% (44%-82%). Nine broad themes related to diagnostic testing, health system structure and functions, risk perception, documentation and adherence were considered likely to influence the LTBI care cascade. CONCLUSION: The proportions of household contacts screened, detected with LTBI and initiated on TPT, though variable was high, but the proportions completing TPT were lower indicating current strategies used for LTBI management in high TB burden countries are not sufficient.

A structured mentorship program for medical college faculty on health research.

BACKGROUND: A paradigm shift is required in faculty development programs on research skills, from theory-driven to hands-on practical approach. The objective of this study was to develop and implement a structured mentorship model for training of medical faculties in research skills. METHODS: An interventional study using functional mentorship and experiential learning based on a research project was conducted over a period of one year through two prevalidated modules: protocol and manuscript writing. We included early and mid-career medical faculty as mentees (mentor:mentee ratio-1:2). Module 1 consisted of eight days of active learning and 25 days of refinement period-the end point being submission of research proposal to the ethics committee. Module 2 consisted of six days of active learning and 15 days of refinement period with the end point being manuscript submission to a peer-reviewed journal. Context, Input, Process and Product model of evaluation was used for this program. RESULTS: All eight faculty who participated as mentees in this program completed the first module, developed protocols under this program and processed them through the ethics committee. Six of the eight participants of this original cohort attended the second module and five could submit their manuscript to a peer-reviewed journal within the stipulated date. Participants expressed improvement in their self-rating of research skills, satisfaction with the program and an overall favourable change in attitude towards research. CONCLUSION: Structured mentorship program with the help of local mentors could enhance research skills of medical faculty.

Pretreatment Out-of-Pocket Expenses for Presumptive Multidrug-Resistant Tuberculosis Patients, India, 2016-2017.

In India, under the National Tuberculosis Elimination Programme, the government provides free treatment for multidrug-resistant tuberculosis; however, many patients seek care elsewhere, which is costly. To determine those out-of-pocket expenses, we interviewed 40 presumptive patients and found that they spent more than their median annual income before registering for the government program.

"Side effects--part of the package": a mixed methods approach to study adverse events among patients being programmatically treated for DR-TB in Gujarat, India.

BACKGROUND: High rates of Adverse Events (AEs) during treatment is one of the leading causes of unsuccessful treatment outcomes among patients with drug resistant tuberculosis (DR-TB). However, information related to AEs is not systematically collected and managed under programmatic setting. The present study assessed the a) incidence and pattern of adverse events in first three months of DR-TB treatment initiation; b) treatment seeking behaviour for AE management; and c) explore the challenges in seeking treatment and reporting AEs. METHODS: This mixed methods study included all patients diagnosed and initiated on treatment under RNTCP during July-September 2018 at Ahmedabad DR-TB centre. The patients were interviewed telephonically and assessed for all AEs experienced by them. In-depth interviews and key-informant interviews were conducted among patients, DOTS supervisors and programme staff (treatment supervisors, medical officer and district program managers). RESULTS: Total 207 AEs were reported by the 74 DR-TB patients. All patients experienced at least one AE during initial treatment period. Incidence rate of AEs (experienced) was 3.11 (1st month-4.6, 2nd month-2.7, 3rd month-2.02) per 100 person days. Of the 207 AEs, gastro-intestinal (59, 28.3%), ophthalmic (32, 15.4%) and otolaryngology (25, 11.9%) system related AEs were commonly experienced. Treatment was not sought in two-fifths of the AEs. Themes and sub-themes related to challenges in treatment seeking or reporting of AEs were 1) Patient related-Misconceptions, accessibility and affordability of management, lack of counselling support, stigma and discrimination, and past treatment experience; 2) Health system related- lack of guidelines and training for AE management, 3) Poor coordination between hospital and tuberculosis centre. CONCLUSION: The incidence of AEs was high among patients with DR-TB in the first three months of treatment and treatment seeking/reporting was low. Adequate health education and counselling of the patient and orientation of the health systems is the need of the hour. An efficient real-time reporting and management of AE should be developed and tested for effective DR-TB control.

Improved survival among oral cancer patients: findings from a retrospective study at a tertiary care cancer centre in rural Kerala, India.

BACKGROUND: Oral cancer is very common in India. The reported 5-year survival of such patients is around 50% after treatment with surgery and radiotherapy, much lower than most of the developed countries. METHODS: A retrospective study of a prospective database of oral cancer patients undergoing surgery from June 2009 to June 2013 was conducted. Follow-up details were updated from case records and by phone calls. Data were double entered in EpiData Entry version 3.1 and were analysed using EpiData Analysis software 2.1.0.73. RESULTS: Two-hundred and twenty patients were analysed (136 males); 85% were consuming tobacco, mainly in chewable form. The majority (51.1%) had tongue cancer, of whom 75 patients (34.1%) had T4 tumours. Postoperative radiotherapy was given to 108 patients (49.1%). Forty had recurrence, of which 23 were in early stage. Of these, 19 showed node positivity (p < 0.01). Node-negative patients had 79% 5-year survival while node positive had 59% which is comparable to that reported in developed countries. Median disease-free survival duration was 48.2 months. CONCLUSIONS: Node positivity is the single factor affecting recurrence and survival. The overall survival and disease-free survival is better in patients without lymph node involvement and in patients with early stage of cancer as compared to the patients with node involvement and in advanced stages.

Counseling intervention improves treatment adherence among newly diagnosed drug sensitive Tuberculosis patients of Ahmedabad city - A mixed methods approach.

INTRODUCTION: Counselling sessions based on the health behaviour module for patients on TB treatment may help improve the level of understanding of tuberculosis and its treatment, importance of adherence to therapy, possible side effects, dietary habits and to address any misconceptions; leading to better adherence and improved outcome. Hence, study attempted to assess the impact of brief counselling intervention through treatment adherence supportive activist (TASA) in improving adherence to treatment among drug sensitive TB patients. METHODS: An explanatory mixed methods design (QUAN-Qual) was carried out. Out of 23 Tuberculosis units (TUs) in Ahmedabad Municipal Corporation (AMC) two were selected, one interventional group where trained counsellor was recruited while other was the control group. All drug sensitive TB patients diagnosed at both selected TUs during January to March 2020 were included in the study. Among all patients who were non-adherent in both the TUs, 14 were selected to explore factors contributing to non-adherence to treatment. RESULTS: At the end of intensive phase, drug adherence in the study TU was 85.71% while it was 67.5% in the control TU. At the end of one month of treatment, the proportion of patients having better level adherence was more among counselled patients as compared to non-counselled patients. Marital status, religion, gender did not affect the level of adherence. Reasons for non-adherence as well as perceived barriers to adherence to TB treatment were treatment related, patient related and social barriers. CONCLUSION: Dedicated NTEP counsellor (TASA) can help improve the treatment adherence and impact of physical counselling.

Treatment outcomes and associated factors among patients with drug-sensitive tuberculosis on daily fixed-dose combination drugs: A cohort study from Ahmedabad, India.

Background and Aim: The National Tuberculosis Elimination Program (NTEP) has been progressive in addressing the issues related to tuberculosis (TB) control in the country, with constant programmatic changes based on evidence available from operational research. Our objectives were 1. to assess the sociodemographic and clinical characteristics, and the treatment outcomes of patients on fixed-dose combination (FDC) daily regimen and 2. to assess the factors associated with unsuccessful treatment outcomes among patients with DS-TB. Materials and Methods: A retrospective cohort study was conducted based on record review. The study population included all patients with drug-sensitive TB, registered and initiated on treatment under NTEP "new category" from January to June 2018 and under "previously treated category" from January to March 2018. Quantitative data downloaded from Nikshay in Excel format was imported. Results: A total of 8301 patients with DS-TB registered under NTEP. Mean (standard deviation [SD]) age of DS-TB patients was 35.3 + 16.9 years, and 63.2% were in the age group of 15-44 years. Also, 60.1% were male, 2.5% were human immunodeficiency virus (HIV) positive, 65.3% were pulmonary TB cases, and 70.4% obtained treatment from public providers. Proportion of "successful" and "unsuccessful" outcomes was 87.9% and 12.1%, respectively, in the new treatment category and 78.3% and 21.7%, respectively, in the previously treated category. Among the patients classified under new category, the unsuccessful treatment outcome remained significantly high after adjustments with known confounders among patients aged 45-54 years (adjusted relative risks [aRR] 1.59, 95% confidence interval [CI] 1.31-1.93) and 55-64 years (aRR 1.67, 95% CI 1.36-2.05) compared to patients aged <15 years. Conclusion: Unsuccessful treatment outcome was significantly high among patients aged 45-54 years. Various adherence mechanisms implemented can be evaluated for further upscaling and improving the program effectiveness.

Effects of Ultrasound-Guided Lower Extremity Nerve Blocks for Below-Knee Procedures in the Emergency Department of a Tertiary Care Hospital, Central Gujarat.

Background and objectives Ultrasound-guided femoral and popliteal sciatic nerve blocks are useful adjuncts for many below-knee procedures like debridement, amputation, etc. The objectives of the study were to find the efficacy and feasibility of the ultrasound-guided combined femoral and popliteal sciatic nerve block for below-knee procedures in the Emergency Medicine Department (ED). Methodology This prospective clinical study was carried out over three months in ED. A total of 30 patients undergoing below-knee procedures were included in the study. Femoral and popliteal sciatic nerve blocks were administered to each patient using the high-frequency linear ultrasound probe by emergency physicians trained in ultrasound. The effect of blocks, amount of local anesthetic (LA) used, duration of the procedure, and post-block analgesia were recorded. Patients were monitored for possible complications, if any. Data were entered and analyzed using a Microsoft Excel worksheet. Results The average volume of LAs required was around 34.5 cc for both blocks combined. No complications like vascular puncture or nerve injury were reported during the study. The time taken to complete the procedure was around 33 minutes, and the average time to achieve sensory block was around 9 minutes after completing the procedure. Conclusions An ultrasound-guided combined femoral and popliteal sciatic nerve block is an effective and feasible procedure and thus should be considered in ED for below-knee procedures.

Patient adherence to tuberculosis treatment in the Indian subcontinent: systematic review and meta-synthesis of qualitative research.

OBJECTIVES: How well patients adhere to their tuberculosis (TB) treatment influences their recovery and development of drug resistance, but influences on adherence are multiple and often competing. We synthesised qualitative studies from our setting in the Indian subcontinent to understand the dimensions and dynamics involved to help inform service provision. DESIGN: Qualitative synthesis comprising inductive coding, thematic analysis and forming a conceptual framework. DATA SOURCES: Medline (OVID), Embase (OVID), CINAHL (EBSCOHost), PsycINFO (EBSCOHost), Web of Science Core Collection, Cochrane Library and Epistemonikos were databases searched on 26 March 2020 for studies published since 1 January 2000. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included reports in English from the Indian subcontinent that used qualitative or mixed-methodology designs and reported findings around adherence to TB treatment. Full texts meeting eligibility were sampled based on 'thickness' (the richness of the qualitative data reported). DATA EXTRACTION AND SYNTHESIS: Two reviewers used standardised methods to screen abstracts and code. Included studies were assessed for reliability and quality using a standard tool. Qualitative synthesis was performed by inductive coding, thematic analysis and developing conceptual framework. RESULTS: Of 1729 abstracts screened from initial search, 59 were shortlisted for full-text review. Twenty-four studies that qualified as 'thick' were included in the synthesis. Studies were set in India (12), Pakistan (6), Nepal (3), Bangladesh (1) or in two or more of these countries (2). Of the 24 studies, all but one included people who were taking TB treatment (1 study included only healthcare providers), and 17 included healthcare workers, community members or both.We identified three themes: (1) personal influences on the people with TB include interconnections between their social role in the family unit, their own priorities in day-to-day living and their experience to date with the disease; (2) adherence is profoundly influenced by how individual healthcare providers interact with patients on treatment and address their needs; (3) adherence is influenced across communities by structural, social, economic and cultural factors related to treatment. CONCLUSION: Staff in TB programmes require an understanding of the various competing influences on individuals undergoing treatment. Programmes need to have more flexible and people-centred approaches to service provision in order to achieve adherence, and thus improve treatment outcomes. PROSPERO REGISTRATION NUMBER: CRD42020171409.

Assessment of Challenges and Opportunities and Identification of Approaches and Innovations in COVID-19 Pandemic Management by Different States in India: A Qualitative Approach.

OBJECTIVE: The primary objective of the study was to compare the challenges in implementing various COVID-19-related public health strategies and activities between the selected high health index and low health index states. The secondary objective was to identify the differently managed mechanisms adopted by the health-care delivery system across the states to maintain their functioning during the COVID-19 pandemic. SETTING: Eight states were divided into two groups; based on their health index and vulnerability index ranking-Kerala, Maharashtra, Gujarat, and Karnataka in top four (Group 1) and Delhi, Tripura, Rajasthan, and Orissa in bottom four states (Group 2). RESULTS: There was lack of private sector involvement in both the groups of the states, more so in Group 2. Although transport-related issues were similar in both groups, lack of provision of vehicles for transport for carrying out various COVID and non-COVID activities seemed to be more prominent in Group 2. More obstacles related to infrastructure were observed in Group 1 states. In terms of innovations, commonalities lay in convergence of multiple departments for monitoring, contact tracing, essential supplies, and transportation. Both groups managed routine health services and fund allocation with nearly equal vigour. Major challenges faced were related to human resource, policy management, transportation, routine health services, data management, and infrastructure. HR-related challenges in top four states included confusion due to frequent change in guidelines, unclear micro-containment, and testing guidelines. Discharge guidelines and SOPs related to home isolation of slum dwellers, inter-departmental cooperation and coordination issues faced in greater proportion in top four states; issues with fund allocation for local needs were faced by the Group 2 states. Innovations implemented to meet hurdles faced during the pandemic could be categorized under heads of 'human resource', 'community actions', 'policy management', 'inter-departmental coordination', 'use of technology and media', and 'fund allocations'. There was private-public partnership; use of other human resource for health-care delivery; use of technology for health-care delivery was seen in all states but more so in Group 1 states. CONCLUSION: States with higher health index and lower vulnerability index, i.e., Group 1 states faced fewer challenges than those in Group 2. Innovative measures taken at local level to tackle problems posed by the pandemic were unique to the situations presented to them and helped control the disease as effectively as they could.

Prevalence of menopausal symptoms among women in Vadodara, Central Gujarat: The urban-rural divide.

Aim: The aim of this article is to estimate prevalence of menopausal symptoms among women in the menopausal age group and study the urban-rural differences. Methods and Design: Analytical cross-sectional study conducted in rural and urban field practice areas of a tertiary care center affiliated to Medical College, where 290 women (145 each from urban and rural areas) were interviewed to measure prevalence of menopausal symptoms. Forty-one symptoms were divided into 'Psycho-somatic' (17 symptoms), 'genito-urinary (9 symptoms)' and musculo-skeletal (5 symptoms) domains. The prevalence of each of these symptoms is reported as proportion and the differences in the median scores in the two groups were tested using Mann-Whitney U test. Results: From among 145 women each, in urban and rural settings, most common psychosomatic symptoms were physical exhaustion-fatigue (73.1%), difficulty climbing stairs (59.3%), sleep problems (45.2%), body ache (43.4%), and hot flushes (41.4%). Among the urban participants, most common was physical exhaustion (42.1%), difficulty climbing stairs (62.1%), anger (46.9%), sleep problems (45.5%), and irritability (42.1%), while among the rural participants they were physical exhaustion (66.2%), difficulty climbing stairs (56.6%), insomnia (54.5%), and body ache (46.2%). Most common genito-urinary symptoms overall and in rural areas were urinary urgency (35.9% and 38.6%), increased frequency of urine (31.7% and 37.2%) and incontinence (30% and 35.2% respectively). Among the urban women, common symptoms were urinary urgency (33.1%) followed by itching of private parts (30.3%) and increased frequency of urination (26.2%). Among musculo-skeletal symptoms, joint pain (74.1%, 74.5%, 73.8%) was the most common symptom followed by joint and muscular discomfort (71.7%, 73.8%, 69.7%) among the overall, urban and rural participants. There was a significant difference in the median psychosomatic score as per the symptoms experienced by the urban and rural participants (U = 36, Z statistic = 2.31, and P = 0.02). However, there was no significant difference in the scores for genito-urinary and musculo-skeletal symptoms; thereby, median scores under both these domains were almost similar in both urban and rural groups. Conclusion: There was significant difference in the median psychosomatic score as per the symptoms experienced by the urban and rural participants however; there was no significant difference in genito-urinary and musculo-skeletal symptom scores.

Early implementation challenges in electronic referral and feedback mechanism for patients with tuberculosis using Nikshay - A mixed-methods study from a medical college TB referral unit of Delhi, India.

BACKGROUND: Diagnosis, notification and timely initiation of treatment is an important cornerstone for the elimination of tuberculosis (TB). The referral and feedback mechanism under National Tuberculosis Programme of India has been changed from paper-based to web-based electronic system (Nikshay) since 2018. The current study was carried out to assess the effect of Nikshay in referral and receipt of feedback on treatment initiation and to understand the early implementation challenges. METHODS: A mixed-methods study was conducted in a medical college referral unit (MCRU) of Delhi, India. The electronic TB notification data for July 2018-March 2019 were abstracted from Nikshay portal and analysed. Unadjusted and adjusted relative risk (aRR) was calculated to assess the factors associated with the receipt of feedback. Themes and subthemes were generated from qualitative data obtained through key-informant interviews of healthcare providers. RESULTS: Of the total 4395 patients handled by MCRU during the study period, 3315 (75.4%) were referred out within and outside Delhi for treatment. Feedback was received among 797 (24.0%) of the patients who were referred out. Patients with extrapulmonary TB (aRR: 1.3, confidence interval (CI): 1.1-1.8), previously treated (aRR: 1.2, CI: 1.2-1.3) and registered for drug-resistant TB care (aRR: 1.4, CI: 1.1-1.8), had high chance of receiving feedback. Four broad themes emerged, namely, (a) awareness of programme and Nikshay; (b) tracking of patients; (c) user-friendly portal and (d) workload. CONCLUSION: The low feedback on treatment initiation of patients with TB needs further research after health system-level quality improvement interventions. Real-time tracking of patients is the need of the hour towards the path for TB elimination.

Clinical Outcomes of Head and Neck Cancer Patients Treated with Palliative Oral Metronomic Chemotherapy at a Tertiary Cancer Center in Kerala, India.

BACKGROUND: Cetuximab-based chemotherapy is the standard palliative chemotherapy in head and neck cancers, but there is a limitation due to financial and logistic reasons, and where oral metronomic chemotherapy can be a successful alternate. Oral metronomic chemotherapy (MCT) can either be with Methotrexate alone or a combination of Methotrexate and Erlotinib. The study was aimed to assess the clinical outcome of oral MCT in head and neck cancer patients. MATERIALS AND METHODS: This was a retrospective review done at a tertiary cancer centre in India. The clinical outcomes of head and neck cancers patients started on palliative oral MCT from 1st August 2016 to 31st December 2017 were analyzed. The demographic details, toxicity profiles, response to MCT, disease progression status were analyzed. Univariate analysis was done to assess the factors associated with disease progression. Kaplan Meier curve was used for estimating progression free survival (PFS). RESULTS: Of the total 104 patients, the most common primary site of head and neck cancer was oral cavity (52%). MCT scheduled with Methotrexate and Erlotinib in 80 patients. Toxicity rate was 61%, with Grade 3-4 toxicity in 21%. Response rate was 56% and clinically meaningful response rate was 69%. Disease progression was observed in 55% patients. Median PFS rate was 134 Days. Oral MCT was permanently stopped in 73%, the most common reason being disease progression. DISCUSSION: Patients who underwent palliative oral MCT had a median PFS of 134 days which is considered as promising treatment method. Results confirmed more than 50% response rate with lower Grade 3-4 toxicities. CONCLUSION: Palliative oral MCT either with Methotrexate and Erlotinib or Methotrexate alone will be a feasible treatment option in patients with head and neck cancers treated with palliative intent.

Patient treatment pathways of multidrug-resistant tuberculosis cases in coastal South India: Road to a drug resistant tuberculosis center.

Background: Delays in initiating multidrug-resistant tuberculosis (MDR TB) treatment adds risk to individual patients and the community due to disease progression, and on-going transmission. The Government of India offers free TB diagnosis and treatment, however many presumptive MDR TB patients wander within the Indian healthcare system and delay accessing the programme. To improve access to care, it is imperative to understand the treatment pathways taken by MDR TB patients. We aimed to describe the diagnostic and treatment pathway taken by presumptive MDR TB patients registered under Programmatic Management of Drug-resistant TB Program. Methods: We conducted a cross-sectional study amongst patients registered during August 2016 - April 2017 at one District Drug Resistance Tuberculosis centre of Dakshina Kannada district in Karnataka, India. A semi-structured questionnaire was used to collect the number, type (private and public sector), and dates of healthcare facilities (HCFs) visits prior to the initiation of MDR TB treatment. Delays in pathway were measured in days and summarised as median and interquartile range (IQR), from the date of onset of illness until the initiation of MDR TB treatment. Results: We found that patients preferred private HCFs; however, due to lack of treatment and unaffordability they shifted to public HCFs. Median delay to register under the program was more in private HCFs (180 days) in comparison with public HCFs (120 days). We also found that the detection rates were much higher in public HCFs (80%). Conclusion: The present study found that there was substantial patient delay and total delay in diagnosis and treatment of MDR TB patients. Private HCF was first point of contact for most of the patients; however the diagnostic rate was high in public HCF. The government should involve private HCFs to provide standard diagnostics and treatment to the patients seeking a private facility.

Late toxicities among laryngopharyngeal cancers patients treated with different schedules of concurrent chemoradiation at a rural tertiary cancer care center.

BACKGROUND: Concurrent chemoradiation is the treatment of choice for laryngeal-pharyngeal cancers. Apart from survival organ preservation remains major aims of the treatment. Advanced radiation techniques like VMAT have shown to reduce morbidity. The purpose of our study is to assess the late toxicities in patients treated with concurrent chemoradiation and its association with dose to organs at risk. AIMS: Assessment of late toxicities following concurrent chemoradiation in patients with laryngopharyngeal cancers. MATERIALS AND METHODS: Retrospective study at a tertiary cancer centre on patients with laryngeal and pharyngeal cancers treated with concurrent chemoradiation with VMAT upto a total dose of 69.3 -70 Gy in 33-35 fractions and concurrent chemotherapy with Cisplatin was done. Severe late toxicities and its association with demographic and clinical parameters and dose to OAR were studied. Data was analysed using EpiData analysis v2.2.2.182. RESULTS: Of the 93 patients studied majority were males above 55 years. Oropharynx was the commonest site (58%) with T3 and N2 in majority. Late dysphagia and odynophagia was seen in 18(21%) and 23(27%) patients respectively. 16 (17%) had tube dependence and nine (9.6%) had aspiration pneumonia. D60, V50 and V60 along with site, node positivity and weight loss were found to be significantly associated with severe late toxicity. CONCLUSION: Oropharyngeal cancers, node positivity and weight loss were found to have significant grade III and above toxicities including tube dependency. Dose to larynx showed association with severe late toxicities, though dose to constrictors could not.

Pain Management in Children With Cancer Using World Health Organization Guidelines at a Tertiary Cancer Center in Rural India.

Management of cancer pain among children is a difficult process due to the way they perceive pain, their dependence on parents, complexity of assessment, and limited availability of safe analgesics. Pain among children with cancer is still a less explored problem in India. This descriptive study was carried out in a tertiary cancer center to explore the characteristics of pain and its management among the children with cancer. We analyzed children diagnosed with hematologic malignancies, aged 4-18 years, admitted between January 2013 and December 2017. This retrospective cohort study involved the review of patient records available at the medical records department. During the study period, there were 290 admission episodes, of which 93 (32.1%) episodes were associated with pain. Of these 93 episodes, 14 (15%) were primarily for pain management. Step I analgesic was utilized in the majority (83%) of the admission episodes involving younger age group (4-9 years) children, whereas for the older age group (10-18 years) Step 2 analgesic (tramadol) was utilized in 29 (58%) episodes, and this was found to be statistically significant (P < .001). Only in 9 (9.7%) episodes Step 3 analgesic was utilized. A significant proportion of children with hematologic malignancies had pain episodes, and these episodes in older age group children were managed with weak opioids.

Limiting factors for autologous transplantation among transplant-eligible multiple myeloma patients: Lesson from a Tertiary Cancer Centre in rural India.

There is limited data from low and middle income countries on the exact proportion of Myeloma patients undergoing transplant even if they are eligible for the same. In this retrospective analysis of all newly diagnosed transplant eligible Myeloma treated between January 2011 to June 2017, number of patients undergoing transplant were recorded and among those not opting for transplant, reasons for the same were noted. Among 89 eligible patients, 23 (26%) patients could undergo transplantation. Most common reasons for not undergoing transplant were fear of the complications in 42 (47%) and financial reasons in 41 (46%) of patients. The transplanted group had better progression free survival when compared against the non-transplanted group (3 year PFS of 80% versus 36%, HR = 0.09, 95%CI 0.02-0.4, p = 0.001). Future studies may be conducted to arrive at measures, for correcting the transplant related concerns and fears, through psycho-social interventions.