Dose-Dense Docetaxel-Cyclophosphamide and Epirubicin-Cisplatin(ddDCEP): Analysis of an Alternative Platinum-Containing Regimen in 116 Patients with Early Triple Negative Breast Cancer.

We assessed the efficacy, tolerability, and cost-effectiveness of a novel neoadjuvant regimen comprising docetaxel-cyclophosphamide alternating with epirubicin-cisplatin (ddDCEP) administered biweekly for 16 weeks in 116 patients with early triple-negative breast cancer. This regimen achieved a high pathological complete response (ypT0/TisN0) rate of 55.2% and favorable survival outcomes (30-month event-free survival, 91.2%; overall survival, 97%). Febrile neutropenia was observed in 4.3% of patients, and 98% completed at least six of eight cycles. ddDCEP was more cost-effective than contemporary carboplatin-based regimens. This novel approach offers an economically viable and effective alternative to current chemoimmunotherapy regimens, and merits further investigation.

Costs & outcomes of hospitalized scrub typhus infection in a tertiary hospital in south India.

Background & objectives: Scrub typhus is a rickettsial infection seen along the Asian-Pacific rim and imposes a considerable burden on affected people in low- and middle-income countries. The present study was aimed to determine the direct cost of hospitalization of scrub typhus and its trend over six years. Methods: This was a retrospective, observational, hospital based study of individuals admitted to the hospital, diagnosed with scrub typhus over six years, from January 2013 to December 2018. The potential out of pocket expenditure was evaluated. Results: A total of 198 patients were included in the study. The median cost of admission (adjusted to INR 2020) for the six years (2013 to 2018) was found to be ₹ 37,026 (US $ 490) [interquartile range (IQR) 22,996-64,992]. The median cost for patients admitted to the intensive care unit (ICU) was ₹ 128,046 (US $ 1695) (IQR 71,575-201,171), while the cost for patients admitted to the ward-alone was ₹ 33,232 (US $ 440) (IQR 19,609-45,373). The multivariable analysis showed that ARDS and SOFA score were the independent predictors of ICU admission. Interpretation & conclusions: Hospitalisation for scrub typhus is associated with a substantial healthcare expense. The predictors of increased cost were the presence of acute respiratory distress syndrome (ARDS), shock, increasing sequential organ failure assessment (SOFA) score and duration of hospital stay.

Renal outcomes among snake-envenomed patients with acute kidney injury in southern India.

Background: . Acute kidney injury (AKI) is a common complication of snake envenomation. However, the long-term renal outcomes of such patients are not well defined. We aimed to determine the proportion of patients who developed AKI, characterize the presenting syndromes and ascertain the long-term resolution of AKI. Methods: . We did a cohort study with prospective follow- up from two centres in southern India. All admitted patients >15 years of age with snake envenomation and serum creatinine ≥1.5 mg/dl over the past 10 years were identified through their discharge summaries. These patients were prospectively contacted, interviewed telephonically and requested to come for a hospital review. Results: . Of the 866 patients screened, 1 84 developed AKI (21.2%). Among these, 53% had combined renal, haematological and neurological manifestations; 33.6% required admission to the intensive care unit and 38% were dialysed. On follow-up of hospital records the creatinine of 49% of patients had normalized. Of those admitted, 36% were contacted and none had a known renal disease or were on dialysis. Among these, 16 patients came to the hospital for review and only 2 had an elevated creatinine. The total mortality was 1 4. Conclusion: . AKI is an important cause of morbidity with snake envenomation and a proportion will require dialysis. The mortality in our study was low and long-term renal outcomes were relatively good.

Rethinking the Postgraduate Teaching Program and Examinations in Today's India.

Postgraduate medical education has undergone drastic changes in the developed and developing countries on par with advancements in technology. The Indian examination system which we imbibed from the British requires a rethinking and restructuring to keep pace with the changing trends shown by the Federation of the Royal Colleges of UK. In this manuscript we look at the strengths and weaknesses of different examination systems. We suggest changes in the theory examination which should be objectively based rather than the outdated essay and short notes. We discuss positive and proactive changes to reform our clinical examination system to enable a just and fair assessment of the candidate in a strictly time bound fashion.

Association between a prolonged corrected QT interval and outcomes in patients in a medical Intensive Care Unit.

INTRODUCTION: Patients admitted into a medical Intensive Care Unit (ICU) have varying illnesses and risk factors. An electrocardiogram (ECG) is a useful tool to assess the cardiac status. The aim of the study was to determine the prevalence of QT prolongation of the ECG in patients admitted to a medical ICU in a tertiary hospital, to assess outcomes in terms of mortality, cardiovascular events, and duration of ICU stay. MATERIALS AND METHODS: Prospective observational study, 6 months duration, assessing the prevalence of prolonged corrected QT interval (QTc) at admission into a medical ICU. A QTc calculated by Bazett's formula, of >440 ms for males and >460 ms for females was considered prolonged. Details of illness, clinical and lab parameters were monitored. RESULTS: The total number of patients screened was 182. There was a high prevalence of prolonged QTc (30%) on admission to the ICU. This reduced to 19% on day 3 (P = 0.011). In patients with a prolonged QTc the odds ratio of adverse outcome from ICU was 3.17 (confidence interval [CI]: 1.52-6.63) (P = 0.001) and of adverse outcome for hospital stay was 2.27 (CI: 1.11-4.66) (P = 0.014). In the study, 35% of all patients received drugs with QT prolonging action. Of patients with a prolonged QTc at admission 18 (35%) received a QT prolonging drug. CONCLUSIONS: We found that prolonged QTc is common (30%) in our medical ICU at admission and a large proportion (35%) received drugs capable of prolonging QT interval. These patients with QTc prolongation have a higher odds ratio for adverse outcomes.

Severe methemoglobinemia due to insecticide poisoning.

Methemoglobinemia is an altered state of hemoglobin resulting in impaired oxygen delivery to the tissues. Deliberate ingestion of certain insecticides and pesticides may result in this condition. We report a case of severe methemoglobinemia after deliberate ingestion of an insecticide marketed to be safe and containing only biological extracts and fillers. Methemoglobinemia should be suspected with low oxygen saturation on pulse oxymetry and the presence of chocolate colored blood. The methemoglobin level of 91% in our patient is the highest level reported among methemoglobinemia survivors.

Development of a Choice-framework for Covid vaccines in India using a multi-criteria decision analysis approach.

BACKGROUND: Vaccines were crucial in controlling the Covid-19 pandemic. As more vaccines receive regulatory approval, stakeholders will be faced with several options and must make an appropriate choice for themselves. We proposed a multi-criteria decision analysis (MCDA) framework to guide decision-makers in comparing vaccines for the Indian context. METHODS: We adhered to the ISPOR guidance for the MCDA process. Seven vaccine options were compared under ten criteria. Through three virtual workshops, we obtained opinions and weights from citizens, private-sector hospitals, and public health organisations. Available evidence was rescaled and incorporated into the performance matrix. The final score for each vaccine was calculated for the different groups. We performed different sensitivity analyses to assess the consistency of the rank list. RESULTS: The cost, efficacy and operational score of the vaccines had the highest weights among the stakeholders. From the six scenario groups, Janssen had the highest score in four. This was driven by the advantage of having a single dose of vaccination. In the probabilistic sensitivity analysis for the overall group, Covaxin, Janssen, and Sputnik were the first three options. The participants expressed that availability, WHO approvals and safety, among others, would be crucial when considering vaccines. CONCLUSIONS: The MCDA process has not been capitalised on in healthcare decision-making in India and LMICs. Considering the available data and stakeholder preference at the time of the study, Covaxin, Janssen, and Sputnik were preferred options. The choice framework with the dynamic performance matrix is a valuable tool that could be adapted to different population groups and extended based on increasing vaccine options and emerging evidence. *ISPOR - The Professional Society for Health Economics and Outcomes Research.

The economic impact of a COVID-19 illness from the perspective of families seeking care in a private hospital in India.

Background: The Covid-19 pandemic had a tremendous impact that caused significant morbidity, mortality, and financial stress for families. Our study aimed to determine the Out-of-pocket expenses and economic impact of a Covid-19 illness for households where patients were admitted to a private hospital in India. Methodology: This was a cost-of-illness study from a tertiary care academic institute where adult patients diagnosed with COVID-19 from May 2020 to June 2021 were included. Patients with an admission of less than one day or who had any form of insurance were excluded. The clinical and financial details were obtained from the hospital information system and a cross-sectional survey. This was stratified across three clinical severity levels and two epidemiological waves. Results: The final analysis included 4445 patients, with 73 % admitted in Wave 1 and 99 patients interviewed. For patients with severity levels 1, 2 and 3, the median admission days were 7, 8 and 13 days respectively. The total cost of illness (general category) was $934 (₹69,010), $1507 (₹111,403) and $3611 (₹266,930) and the direct medical cost constituted 66%, 77% and 91% of the total cost for each level respectively. Factors associated with higher admission costs were higher age groups, male gender, oxygen use, ICU care, private admission, increased duration of hospital stay and Wave 2. The median annual household income was $3247 (₹240,000) and 36% of families had to rely on more than one financial coping strategies, loans with interest being the commonest one. The lockdown period affected employment and reduced income for a considerable proportion of households. Conclusion: A Covid admission of higher severity was a significant financial burden on families. The study reaffirms the need for collaborative and sustainable health financing systems to protect populations from hardships.$-US Dollar; ₹- Indian Rupees.

UDHAVI Community Support During India's Second COVID-19 Wave: A Descriptive Study on a Tertiary Care Center's Pandemic Response Helpline.

BACKGROUND: In April 2021, during the peak of the second wave of the COVID-19 pandemic in India, hospitals overflowed with COVID-19 patients, and people hesitated to seek necessary care due to fear of contracting the disease. The UDHAVI helpline was set up by a tertiary care hospital in Vellore with the help of district administration, nongovernmental organizations, and various supporting agencies to provide general information, medical advice, counseling, and logistics support to the community. METHODS: This is a retrospective study of all the phone calls made to the UDHAVI helpline between mid-May and mid-June 2021 during the second wave of the COVID-19 pandemic. The calls were electronically captured as part of the process, and the information was subsequently retrieved and analyzed. RESULTS: In all, 677 calls were received. The lines for general information, medical advice, counseling, and logistics support received 168 (25%), 377 (56%), 15 (2%), and 117 (17%) calls, respectively. Home care kits, oxygen concentrators, and food were delivered by volunteers from local nongovernmental organizations and hospitals. CONCLUSION: We believe the details of our experience would be useful in the preparedness and mobilization of resources in the event of any public health emergency. As a result of this initiative, we propose an integrated partnership model for emergency response to any pandemic situation.

Community-acquired fungal pyelonephritis with renal infarction and gangrene of the colon: an uncommon diagnosis.

A 54-year-old male farmer with a history of long-standing uncontrolled type 2 diabetes mellitus (HbA1c 10.8) presented with a 3-week history of fever, intermittent vomiting, malaise and left flank pain for which he was treated with broad-spectrum antibiotics and oral antifungals for Candida isolated from urine culture. CT of the abdomen revealed predominant involvement of the left kidney and retroperitoneal structures. Nephrectomy was performed due to worsening abdominal pain and features of bowel perforation found on imaging. Pus culture from the necrotic kidney grew aseptate fungal hyphae, and the histopathological examination was suggestive of zygomycosis. He received amphotericin B postoperatively, but his condition deteriorated and he succumbed to nosocomial gram-negative septicaemia.

Good survival rate, moderate overall and good respirator quality of life, near normal pulmonary functions, and good return to work despite catastrophic economic costs 6 months following recovery from Acute Respiratory Distress Syndrome.

Introduction: Long-term quality of life, return to work, economic consequences following Acute Respiratory Distress Syndrome (ARDS) are not well described in India. This study was aimed to address the question. Methods: A prospective cohort study of 109 ARDS survivors were followed up for a minimum of 6 months following discharge. Quality of life was assessed using the SF-36 questionnaire. Respiratory quality was assessed using the St Georges Respiratory Questionnaire. Time to return to work was documented. Costs-direct medical, as well as indirect were documented up to 6 months. Results: At 6 months, 6/109 (5.5%) had expired. Low energy/vitality and general heath were noted in the SF-36 scores at 6 months; overall a moderate quality of life. Pulmonary function tests had mostly normalized. Six-min walk distance was 77% of predicted. Respiratory quality of life was good. It took at the median of 111 days to go back Interquartile range (55-193.5) to work with 88% of previously employed going back to work. There were no significant differences in the severity of ARDS and any of these outcomes at 6 months. The average total cost from the societal perspective was ₹ 231,450 (standard deviation 146,430-, 387,300). There was a significant difference between the 3-ARDS severity groups and costs (P < 0.01). There were no independent predictors of return to work. Conclusion: ARDS survivors have low 6-month mortality. Pulmonary physiology and exercise capacity was mostly normal. Overall, quality of life is average was moderate, while respiratory quality of life was good. Return to work was excellent, while cost of care falls under a catastrophic heath expense.

Treatment of COVID-19 Acute Respiratory Distress Syndrome With a Tabletop Noninvasive Ventilation Device in a Respiratory Intermediate Care Unit.

Objective: To study the outcomes of noninvasive ventilation (NIV) administered through a tabletop device for coronavirus disease 2019 acute respiratory distress syndrome in the respiratory intermediate care unit (RIMCU) at a tertiary care hospital in India. Patients and Methods: We retrospectively studied a cohort of hospitalized patients deteriorating despite low-flow oxygen support who received protocolized management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy from July 30, 2020 to November 14, 2020. Treatment was commenced on the continuous positive airway pressure mode up to a pressure of 10 cm of H2O, and if required, inspiratory pressures were added using the bilevel positive air pressure mode. Success was defined as weaning from NIV and stepping down to the ward, and failure was defined as escalation to the intensive care unit, the need for intubation, or death. Results: In total, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via a tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were men. Diabetes mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77% (129/168) of the patients; of them, 41% (69/168) received treatment with continuous positive airway pressure alone and 36% (60/168) received additional increased inspiratory pressure via the bilevel positive air pressure mode. Conclusion: Respiratory support using the tabletop NIV device was an effective and economical treatment for coronavirus disease 2019 acute respiratory distress syndrome. Further studies are required to assess the appropriate time of initiation for maximal benefits and judicious utilization of resources.

Factors associated with the opposition to COVID-19 vaccination certificates: A multi-country observational study from Asia.

BACKGROUND: There are ongoing calls to harmonise and increase the use of COVID-19 vaccination certificates (CVCs) in Asia. Identifying groups in Asian societies who oppose CVCs and understanding their reasons can help formulate an effective CVCs policy in the region. However, no formal studies have explored this issue in Asia. METHOD: The COVID-19 Vaccination Policy Research and Decision-Support Initiative in Asia (CORESIA) was established to address policy questions related to CVCs. An online cross-sectional survey was conducted from June to October 2021 in nine Asian countries. Multivariable logistical regression analyses were performed to identify potential opposers of CVCs. RESULTS: Six groups were identified as potential opposers of CVCs: (i) unvaccinated (Odd Ratio (OR): 2.01, 95% Confidence Interval (CI): 1.65-2.46); vaccine hesitant and those without access to COVID-19 vaccines; (ii) those not wanting existing NPIs to continue (OR: 2.97, 95% CI: 2.51-3.53); (iii) those with low level of trust in governments (OR: 1.25, 95% CI: 1.02-2.52); (iv) those without travel plans (OR: 1.58, 95% CI: 1.31-1.90); (v) those expecting no financial gains from CVCs (OR: 2.35, 95% CI: 1.98-2.78); and (vi) those disagreeing to use CVCs for employment, education, events, hospitality, and domestic travel. CONCLUSIONS: Addressing recurring public health bottlenecks such as vaccine hesitancy and equitable access, adherence to policies, public trust, and changing the narrative from 'societal-benefit' to 'personal-benefit' may be necessary and may help increase wider adoption of CVCs in Asia.

Trainee doctors in medicine prefer case-based learning compared to didactic teaching.

BACKGROUND: Sustaining interest and promoting deep learning is a challenge in any teaching method. The purpose of the study is to find the perception of trainee doctors in Internal Medicine and teaching faculty on the usefulness of case-based learning (CBL) and to compare assessment knowledge outcome with didactic seminars. METHODS AND MATERIALS: We developed and conducted a CBL teaching program on eight topics in infectious diseases. First group had CBL and second group had didactic seminars. In step 1, a clinical case was introduced in stages. Learning objectives were formulated and topics were divided among the trainees. At step 2, trainees shared what they had learnt from self-directed learning. Faculty summarized the case and learning points. In the seminar group, trainees made presentations on the given topics. Trainees who had CBL underwent a questionnaire survey. Multiple choice questions-based test was administered for both the groups. RESULTS: The trainee doctors and staff overwhelmingly found CBL to be more interesting, stimulating, and useful compared to didactic seminars. There was no statistical difference in the test scores. CONCLUSIONS: CBL is a useful and interesting method of learning and should be employed more often in teaching for trainee doctors.

The impact of demonetisation on the utilisation of hospital services, patient outcomes and finances: a multicentre observational study from India.

BACKGROUND: This study assessed trends in healthcare utilisation in relation to the implementation of an economic policy in India wherein 500 and 1000 rupee notes were demonetised. METHODS: In this ambidirectional observational study of private not-for-profit hospitals, data on hospital outpatient and inpatient numbers, surgeries, emergency department (ED) visits, obstetric admissions and mortality were obtained for pre-demonetisation (September/October 2016), early (November/December 2016) and late demonetisation (January/February 2017), and post-demonetisation periods (March/April 2017) and compared with the control period (2015-2016) from 11 centres (three tertiary hospitals; eight secondary). A Bayesian regression analysis was performed to adjust for seasonal (winter) effect. Monthly financial data, including the proportion of cash versus non-cash transactions, were collected. FINDINGS: Overall, at the pooled all-hospital level, Bayesian analysis showed non-significant increase in outpatients (535.4, 95% CI -7097 to 8116) and decrease in deaths (-6.3 per 1000 inpatients, 95% CI -15.45 to 2.75) and a significant decrease in inpatients (-145.6, 95% CI -286.4 to -10.63) during demonetisation. Analysis at the level of secondary and tertiary hospitals showed a variable effect. For individual hospitals, after adjusting for the seasonal effect, some hospitals observed a significant reduction in outpatient (n=2) and inpatient (n=3) numbers, ED visits (n=4) and mortality (n=2) during demonetisation, while others reported significantly increased outpatient numbers (n=3) and ED visits (n=2). Deliveries remained unchanged during demonetisation in the hospitals that provided the service. There was no significant reduction in hospital incomes during demonetisation. In tertiary hospitals, there was a significant increase in non-cash component of transactions from 35% to 60% (p=0.02) that persisted beyond the demonetisation period. CONCLUSIONS: The effect of demonetisation on healthcare utilisation was variable. Some hospitals witnessed a significant reduction in utilisation in some areas, while others reported increased utilisation. There was an increase in non-cash transactions that persisted beyond the period of demonetisation.

Lupus cystitis: unusual cause of renal failure in systemic lupus erythematosus.

A 42-year-old woman presented with chronic fever, abdominal pain, intermittent loose stools and dysuria for 3 months. She had recently developed acute dyspnoea with acute kidney injury. She was found to have a contracted, thick-walled bladder with bilateral hydroureteronephrosis. She underwent bilateral percutaneous nephrostomies, following which her renal function recovered. She satisfied the clinical and immunological features of the Systemic Lupus International Collaborating Clinics criteria for systemic lupus erythematosus (SLE). She was initiated on immunosuppression. Lupus cystitis with a contracted bladder is an uncommon presentation of SLE.

Extended spectrum ß-lactamase producing Shigella flexneri serotype-2 causing bacteremia in a patient with uncontrolled diabetes mellitus.

We report a case of Shigella flexneri serotype-2 causing bacteremia in an elderly gentleman with uncontrolled diabetes mellitus, who had no other apparent risk factors. Antibiotic susceptibility testing revealed that the organism was a multidrug resistant extended spectrum beta-lactamase producing straian, which was confirmed by molecular characterization. This rare case alerts both the clinician and microbiologist to a previously unaddressed risk factor of Shigella spp. causing bacteremia, as well as emerging resistant strains that are on the rise in immunocompromised patients.

Etiology and Outcomes of ARDS in a Rural-Urban Fringe Hospital of South India.

Objectives. Etiology and outcomes of acute lung injury in tropical countries may be different from those of western nations. We describe the etiology and outcomes of illnesses causing acute lung injury in a rural populace. Study Design. A prospective observational study. Setting. Medical ICU of a teaching hospital in a rural-urban fringe location. Patients. Patients ≥13 years, admitted between December 2011 and May 2013, satisfying AECC criteria for ALI/ARDS. Results. Study had 61 patients; 46 had acute lung injury at admission. Scrub typhus was the commonest cause (7/61) and tropical infections contributed to 26% of total cases. Increasing ARDS severity was associated with older age, higher FiO2 and APACHE/SOFA scores, and longer duration of ventilation. Nonsurvivors were generally older, had shorter duration of illness, a nontropical infection, and higher total WBC counts, required longer duration of ventilation, and had other organ dysfunction and higher mean APACHE scores. The mortality rate of ARDS was 36.6% (22/61) in our study. Conclusion. Tropical infections form a major etiological component of acute lung injury in a developing country like India. Etiology and outcomes of ARDS may vary depending upon the geographic location and seasonal illnesses.

Scrub typhus meningitis in South India--a retrospective study.

BACKGROUND: Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports. METHODS: A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness--a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits. RESULTS: Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol. CONCLUSION: Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.