Incidence and attributes of chemotherapy induced myelotoxicity, anemia and neutropenia in adults with cancer in Nepal: A cross-sectional observational study.

BACKGROUND: Myelosuppression remains a major toxicity in cancer patients receiving chemotherapy, and is associated with considerable morbidity, mortality and cost. OBJECTIVE: The present study aims to investigate the prevalence and incidence of myelotoxicity, anemia and neutropenia in the adult cancer population, and further to determine the factors influencing them. METHODS: This was a cross-sectional observational study conducted at National Academy of Medical Sciences, Bir Hospital, Kathmandu. A total of 170 subjects eligible for the study were enrolled for analysis. Prevalence and incidence of myelotoxicity anemia, neutropenia and myelotoxicity at enrollment and during study were investigated. Factors influencing development of myelotoxic event were determined. RESULTS: Of 170 enrolled patients, the prevalence of myelotoxicity, anemia and neutropenia at enrolment was 54 (31.8%), 20 (11.8%) and 28 (16.6%), respectively, with 27 (16%) mild and 12 (7.1%) moderate type of anemia. Incidence of myelotoxicity, anemia and neutropenia during treatment was 90 (52.94%), 44 (26%) and 53 (31.2%) respectively, with 70 (41.2%) mild, 39 (22.9%) moderate and 5 (2.9%) severe type of anemia. Age (OR: 0.49; p < 0.047), and baseline Hb (OR: 1.29; p < 0.01) were found to be independent predictors associated with anemia. Hb (OR: 2.42, CI: 1.79-3.28; p < 0.001) and smoking (OR: 0.49: p = 0.03) were found to be independent factors associated myelotoxicity. CONCLUSION: Our study confirmed a high incidence rate of myelotoxicity, neutropenia and anemia in a considerable number of Nepalese cancer patients receiving chemotherapy, and that baseline Hb, smoker and older adults are at more risk, these patients should be evaluated carefully and a prophylactic measure should be adopted accordingly so as to prevent toxicity and improve quality of life during cancer treatment.

Try Before You Buy: Are There Benefits to a Random Trial Period before Students Choose Their Collaborative Teams?

The cognitive and performance benefits of group work in undergraduate courses depend on understanding how to structure groups to promote communication and comfort while also promoting diversity and reducing conflict. The current study utilized social network analysis combined with self-reported survey data from 555 students in 155 groups to understand how students identified group members whom they wished to work with. Students' willingness to work with their peers was positively associated with behavioral traits pertaining to attention, participation, and preparedness in class. We tested whether preventing students from choosing their group members until completing a multiweek period of random assignment to different groups each week influenced group selection criteria, and we found little effect. Students continued to depend on demographic similarities such as gender and ethnicity when selecting groupmates and enforcing random interactions before the group formation did not influence group satisfaction and/or grades. Random interactions before group formation did influence the willingness of students to continue working with peers who were persistently poorly rated based on behavioral attributes and contribution to the group work. Thus, the effort of random assignment could be beneficial to identify struggling students and improve collaboration.

Outcome of Epidermal Growth Factor Receptor Mutated and Non Mutated Adenocarcinoma Lung to Standard Therapy.

BACKGROUND: Asian patients with adenocarcinoma of lung have higher incidence of epidermal growth factor receptor mutations which predict increased response and survival in patients to oral tyrosine kinase inhibitors. This study was conducted to study the frequency of epidermal growth factor receptor mutation in patients in Nepal and compare the outcome in epidermal growth factor receptor mutated versus non-mutated patients receiving standard therapy. METHODS: This is an observational study conducted among newly diagnosed patients with stage IV adenocarcinoma of lung in Bir Hospital from April 2017 to June 2018. Demographic and clinical data collection along with epidermal growth factor receptor mutation testing was done. Patients with epidermal growth factor receptor mutations received Gefitinib while non-mutated patients received systemic chemotherapy. Response evaluation, progression free survival at 1 year, objective response rate and quality of life were compared. Follow up period was for 1 year. RESULTS: Eighty three (33%, n=253) patients were diagnosed with adenocarcinoma of the lung with mean age at diagnosis being 59.4 years. epidermal growth factor receptor mutations were found in 29% patients. Complete response was achieved in 9.1% vs 3.0 % (p=0.46), objective response rate was 27.3% versus 15.2% (p=0.23), progression free survival at 1 year was 39% vs 27%, (p = 0.29) and mean score of global health status was 68.1 versus 61.6 in epidermal growth factor receptor mutated versus non-mutated (p = 0.036). CONCLUSIONS: The frequency of epidermal growth factor receptor mutation in patients with adenocarcinoma of the lung was lower than in Eastern Asian studies, but higher than in western populations. epidermal growth factor receptor mutated patients had improved survival, better treatment response and quality of life in comparison with non-mutated.

Combating COVID-19 Pandemic in Nepal: Ethical Challenges in an Outbreak.

Pandemic outbreak of COVID-19 is the largest of its kind of this century. All countries throughout the globe are trying their best to contain the disease and eliminate at the earliest. Efforts are continuing to improve the outcome of the infection in terms of minimizing the morbidity and mortality. As a public health strategy every state has the responsibility of protecting the health of the community and such measures includes the preventive measures like social distancing or even lockdown of the state as a whole restricting the movement of the people, diagnostic measures like testing the suspects, contact tracing and isolation of the patients. Treatment of the infected requires decisions in resource constraint situation particularly ICU beds and ventilators. In the meantime, protecting doctors, nurses, other health workers as well as frontline workers need personal protective equipment which is a scarce commodity. While doing so there might be a compromise in the individual autonomy, privacy, confidentiality, and social justice for the beneficence for the larger community. This is an attempt to explore the ethical quandaries in relation to combating COVID-19 in Nepal by relating the issues with the principles of biomedical ethics.

Reliance on Self-Medication Increase Delays in Diagnosis and Management of GI Cancers: Results From Nepal.

PURPOSE: Patients with GI cancers in Nepal often present with advanced disease and poor outcomes. The purpose of the study was to determine the time to presentation, diagnosis, and treatment of GI cancer and the baseline factors that may be associated with delays. PATIENTS AND METHODS: An institutional review board-approved study was performed in Kathmandu, Nepal, from July 2018 to June 2019. Patients with newly diagnosed GI cancers were asked to fill out a standardized questionnaire. Baseline factors such as residence, literacy, and use of self-medication were recorded. Patients were asked to report the time from first symptom to presentation, time from primary care visit to pathologic diagnosis, and time from diagnosis to surgery and/or treatment. Baseline factors were analyzed using 2-tailed t tests (Prism 8.0; GraphPad, La Jolla, CA) to determine whether any factors were associated with longer time delays in these 3 intervals. RESULTS: The cohort comprised of 104 patients with a median age of 53.5 years (range, 22-77 years); 61.5% were men, 46.2% had upper GI cancers, and 83.7% presented with stage III or IV disease. The median time to presentation was 150 days, time to diagnosis was 220 days, and time to treatment was 50 days. There was no statistically significant difference in time intervals between upper and lower GI cancers. Use of self-medication (88.5%) was the only factor associated with longer time intervals to presentation, diagnosis, and treatment. CONCLUSION: Patients in Nepal have long time intervals to presentation, diagnosis, and treatment of GI cancer. Self-medication led to longer delays. Reasons for self-medication and other potential barriers will be explored in future studies in the hopes of improving outcomes.

Randomized Phase II Trial to Compare the Efficacy of Haloperidol and Olanzapine in the Control of Chemotherapy-Induced Nausea and Vomiting in Nepal.

PURPOSE: The purpose of the study was to compare efficacy and toxicity of olanzapine (OLN; a higher-cost drug) and haloperidol (HAL; a lower-cost drug) in the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients who receive highly emetogenic chemotherapy (HEC). PATIENTS AND METHODS: In a randomized, phase II trial, patients were randomly assigned to receive either OLN 10 mg orally on days 1 to 4 or HAL 1 mg orally on day 1 and 0.5 mg twice daily on days 2 to 4. Both groups received ondansetron 16 mg and dexamethasone 12 mg intravenously on day 1. Patients recorded their nausea using the Edmonton Symptom Assessment Scale (ESAS) and recorded daily episodes of vomiting from day 1 to day 5. The primary end point was complete nausea prevention (CNP; ie, ESAS of 0). Secondary end point was complete emesis prevention (CEP). RESULTS: Sixty-five patients were randomly assigned, and 64 received their allocated treatment (n = 32 in each arm). There was no difference in CNP during the overall period (days 1 to 5) between OLN and HAL (68.7% v 71.8%; P = .78). In the acute period (day 1) and the delayed period (days 2 to 5), CNP was similar between OLN and HAL (acute: 84.3% v 81.2%; delayed: 68.7% v 75%). No difference was identified in the rate of CEP during the overall period (81.2% with OLN v 78.1% with HAL; P = .75), during the acute period (93.7% with OLN v 90.6% with HAL), or during the delayed period (84.3% with OLN v 84.3% with HAL). No difference in toxicities was noted between treatment arms. CONCLUSION: In this study, HAL had comparable efficacy to OLN in the management of CINV, which suggests that it is the higher-value option in patients who receive HEC in resource-scarce countries.

Procalcitonin and C-Reactive Protein As Markers of Bacteremia in Patients With Febrile Neutropenia Who Receive Chemotherapy for Acute Leukemia: A Prospective Study From Nepal.

PURPOSE: The purpose of this study was to evaluate the clinical significance of the biomarkers procalcitonin (PCT) and C-reactive protein (CRP) in patients with febrile neutropenia (FN) undergoing chemotherapy for acute leukemia. METHODS: We conducted a prospective, observational study in patients who developed FN while undergoing chemotherapy for acute leukemia. PCT and CRP were obtained in patients who presented with FN. Blood cultures also were obtained. The primary goals were to evaluate the ability of PCT and CRP to predict bacteremia in patients with FN. The secondary goals were to assess the prognostic role of PCT and CRP and to assess the microbiologic profile and culture sensitivity patterns in the study population. RESULTS: A total of 124 episodes of FN that involved 67 patients with acute leukemia occurred in the study. PCT was superior to CRP in the prediction of bacteremia. The median PCT level in the bacteremia group was 3.25 ng/mL compared with 0.51 ng/mL in the group without bacteremia (P < .01). The median values of CRP in the bacteremia and without-bacteremia groups were 119.3 mg/L and 94.5 mg/L, respectively (P = .07). There were no differences in median PCT and CRP in patients who died and those who improved. Of the 42 positive cultures, Gram-negative bacteremia was common (86%), and Escherichia coli was the most frequent organism isolated. Carbapenem resistance was seen in 39% of positive cultures. CONCLUSION: PCT is an effective biomarker to predict bacteremia in patients with FN undergoing chemotherapy for acute leukemia.

Evidence of HPV subtypes linked with cervical cancer in Nepal.

OBJECTIVES: Cervical cancer is the commonest malignancy among women in Nepal but data are limited on which subtypes of human papillomavirus (HPV) are associated with cancer in this population. Now that vaccines against HPV types 16 and 18 are available, this evidence is of vital importance in obtaining further support for a vaccination programme. METHODS: Cervical swabs from 44 histologically confirmed invasive cervical cancer cases were obtained from two tertiary referral hospitals in Nepal. Evidence of HPV subtypes was identified using an HPV multiplex polymerase chain reaction (PCR), and confirmed at the Scottish HPV Virus Reference Laboratory. RESULTS: HPV types 16 and 18 were present in 70% of samples, along with other high-risk subtypes. HPV 6 and 11 were not observed. Epidemiological data assessment appeared to indicate that patient age, age of marriage and age of first pregnancy were associated with increased HPV infection in patients. CONCLUSIONS: This study provides further evidence of the importance of HPV types 16 and 18 in cervical cancer in Nepal and adds support to a nationwide vaccination programme and the use of HPV detection in screening programmes.

Human papillomavirus infection and cervical cancer prevention in India, Bangladesh, Sri Lanka and Nepal.

Although one-third of the world cervical cancer burden is endured in India, Bangladesh, Nepal and Sri Lanka, there are important gaps in our knowledge of the distribution and determinants of the disease in addition to inadequate investments in screening, diagnosis and treatment in these countries. Prevalence of human papillomavirus (HPV) infection among the general populations varies from 7-14% and the age-specific prevalence across age groups is constant with no clear peak in young women. This observation may be the result of a low clearance rate of incident infections, frequent re-infection/reactivation, limited or no data in target high-risk age groups (teenagers), and sexual behavioural patterns in the population. High-risk HPV types were found in 97% of cervical cancers, and HPV-16 and 18 were found in 80% of cancers in India. Beyond research studies, demonstration projects and provincial efforts in selected districts, there are no serious initiatives to introduce population-based screening by public health authorities in these countries. Cervical cancer is a relatively neglected disease in terms of advocacy, screening and prevention from professional or public health organizations. Cytology, HPV testing and visual screening with acetic acid (VIA) or Lugol's iodine (VILI) are known to be accurate and effective methods to detect cervical cancer and could contribute to the reduction of disease in these countries. While HPV vaccination provides hope for the future, several barriers prohibit the introduction of prophylactic vaccines in these countries such as high costs and low public awareness of cervical cancer. Efforts to implement screening based on the research experiences in the region offer the only currently viable means of rapidly reducing the heavy burden of disease.

Genital prolapse in women of Bhaktapur, Nepal.

Genital prolapse is one of the commonest reproductive morbidity in developing country. Common predisposing factors are multiparity, early postpartum sternous activity, advanced age and menopause. This study conducted in Bhaktapur district in five months included 1337 women aged 20 and above. The prevalence of female genital prolapse found to be 7.55%. Maximum numbers of women were having children eight and more (48.51%). Only 1.9% of women with genital prolapse were nulliparous. Home delivery is still common in Bhaktapur, 79% of women with genital prolapse had all children born at home without help. Regarding post partum activity majority of them (64.3%) told that they took rest at least one month after delivery but 26.73% started working in field in 2-3 weeks after delivery. The use of pessary is 25% among female with genital prolapse but only a few were following medical advice to change the ring. Nine women were having impacted ring in situ for years.