An advisory by the association of radiation oncologists of India for radiation therapy patients and staff among COVID 19 pandemic

Covid19 has become a major public health problem in India and the rest of the world. The dramatic rise in the incidence of COVID 19 cases has severely challenged our healthcare system and forced us to work with limited infrastructure, resources, and workforce. However, even in this time of adversity, we as oncologists cannot neglect the seriousness of cancer care and the utmost attention it requires for the timely management of our patients. Hence, the Association of Radiation Oncologists of India has come up with an advisory for radiation therapy keeping in mind such aspects.

Study of epidemiological aspects and hormone receptor status of meningiomas

Background: Meningiomas account for about a third of all central nervous system tumours worldwide. Though very common, quite less is known about its epidemiology. This study aims to establish the epidemiological parameters and hormone receptor status (Progesterone Receptor-PR) involved in the development of Meningiomas.Methods: This observational study included 50 patients. Epidemiological parameters studied included age, sex, symptoms, history of hormone intake, smoking, recurrence, family history, history of other hormone related tumours and radiological assessment of tumour site. Surgical samples were grossed and typed according to the WHO standards. Immunohistochemical staining was done using PR to establish the role of hormonal receptors in the development of meningiomas.Results: The mean age was 46.84±13.54 years. The ratio of male and female (Male:Female) was 1.0:2.3. 48.5% of females had history of hormonal pill intake and 28.6% had hormone related tumours, of which fibroid was most common. Amongst the sites involved cerebral convexity was most common (56%). Chi-square (χ2) test showed that there was a significant association between histological grade and PR expression of the patients (p=0.0002).Conclusions: Positivity for hormone receptors like PR, increased intake of hormonal pills by females and association of meningioma with hormone related tumours indicates that hormonal milieu plays a significant role in the growth of meningiomasχχ. This could thus provide an insight to the pathogenesis of meningiomas. In addition, mifepristone, an anti-progestin could be a player in the medical management of meningiomas.

Sacrum metastasis in carcinoma gall bladder: an unusual presentation

Disseminated blood-borne metastases from carcinoma of the gall bladder are uncommon and usually occur late. The most common site of extra-abdominal metastasis is lung followed by brain. Skeletal metastases in carcinoma gall bladder are very rare. To date there have only been a few case reports of bone metastasis in carcinoma gall bladder at the time of presentation. Authors here present a rare case of carcinoma gall bladder that progressed to isolated sacrum metastasis.

Computerized tomography based evaluation of level I and II axillary lymph nodes by high conventional tangential fields in carcinoma breast

Background: Axillary radiation and surgery have provided equivalent local control in early breast cancer patients. It is believed that tangential field (TF) radiation that was used to treat the breast coincidently delivered radiation treatment to the lower axilla and eradicated the disease. In the era of CT-based three dimensional- (3D) radiotherapy planning, however concerns have been raised about the adequacy of coverage of the axillary levels in the tangential fields. In this study, author evaluated the coverage of the axillary nodal levels I and II using high conventional tangential fields in patients with or without axillary dissection.Methods: A prospective study was conducted which included 18 cases for a period of one year, radiation therapy was planned to the chest wall or whole breast by using the high conventional tangential field using 2D radiation portals. Central lung distance (CLD) and the distance of superior border was measured form the head of the humerus and were recorded. CECT chest was done in the same position alike during conventional simulation. All the images were shifted to the treatment planning system. The Contouring of Axillary lymph nodes level I and II was done on Oncentra contouring software.Results: The coverage of the axillary nodes was not related to central lung distance (CLD). However, some with CLD of 1cm had more coverage of the level I nodes than with CLD of 2 cm and the maximum CLD in the field was 2.5 cm. Of the 18 patients in the study, 13 patients had <2 cm distance from the humeral head and all the axillary level II LN covered in the field. Whereas 5 patients having distance >2 cm did not have adequate coverage of level II axillary LN’s.Conclusions: The distance of the cranial border of the tangent portal from the head of the humerus shows a relationship with coverage of level II nodes cranially. As the distance decreases the coverage of level II nodes cranially keeps increasing. In majority of the patients a distance of 2 cm or less than 2 cm ensured good coverage of level II nodes cranially. Similarly, no correlation was found between volumetric coverage of the axillary nodes with central lung distance.

Skill up; gradation of anganwadi workers pertaining to growth chart plotting and interpretation in rural areas of Varanasi district, India

Background: The task of using the growth chart by Anganwadi Workers (AWWs) for growth monitoring requires technical skill. It was hypothesized that skill up-gradation can make a difference in the performance of AWWs in regard with growth monitoring. The aim of the study was to evaluate the effect of intervention in improving skill of AWWs regarding growth chart plotting and interpretation.Methods: It was a field based interventional study, which was conducted in rural areas of Varanasi district, India. A total of 66 AWWs each from Chiraigaon (intervention) and Cholapur (control) community development blocks of Varanasi district was selected for the study. Each AWW was provided 3 weight readings of different ages for plotting and 4 filled growth charts for interpretation. Chi square test has been applied to assess the significant difference.Results: Only around 10% of AWWs could correctly plot all 3 growth charts and similar proportion of AWWs could also correctly interpret all 4 filled growth charts. The planned intervention could significantly improve their skill of growth chart plotting and interpretation and during end line survey 41% and 77% of AWWs could correctly plot all 3 growth charts and interpret all the four growth charts, respectively.Conclusions: The developed hypothesis is proved, and intervention was found effective in significantly improving the skills of AWWs in regard with growth monitoring.

Concurrent chemoradiation in head and neck cancers with weekly cisplatin: analysing toxicities

Background: Head and neck cancers constitute 6% of cancers worldwide. The management requires a multidisciplinary approach. Concomitant chemoradiotherapy with cisplatin is the standard approach for locally advanced head and neck cancers. The most commonly used regime uses three weekly cisplatin which is more toxic. Low-dose once-a-week cisplatin is substituted because of perceived lower toxicity and convenience.  Methods: Squamous cell carcinoma of stage III, IVA and IVB of oropharynx, hypopharynx and larynx were studied for one year. 82 patients were studied. Total dose of radiation was 66Gy/33#/6 ½ weeks from Monday to Friday with inj. Cisplatin 40mg/m2 i.v. infusion weekly.Results: 88% of patients were able to complete five or more weekly chemotherapy cycles with cumulative dose of 200mg/m2. Grade 2 and 3 acute toxicities were seen in weekly cisplatin arm but were conservatively managed.Conclusions: Weekly cisplatin can be used with concurrent radiotherapy as the acute toxicities are manageable and is well tolerated.

Four percent formalin application for the management of radiation proctitis in carcinoma cervix patients: An effective, safe, and economical practice

Context: Radiotherapy is a very effective treatment modality for pelvic malignancies such as carcinoma of the cervix. However, it is quite common for chronic radiation proctitis (CRP) to manifest after radical radiotherapy. CRP is a source of significant morbidity, and there is a lack of effective treatment modalities. There also exists a general lack of guidelines on management of CRP. Aims: To assess the benefit from 4% formalin application for the treatment of Grade >2 CRP among patients previously treated with radical radiotherapy for cervical carcinoma. Settings and Design: This retrospective descriptive study involved 29 eligible patients who were treated from November 2010 - November 2015 for CRP with 4% formalin application. Materials and Methods: Of the 1864 patients of carcinoma cervix treated during the said patients, 29 patients fulfilled the eligibility criteria. Eligible patients were invited telephonically for follow-up and were assessed for response and complications of the procedure. Results: The treatment of hemorrhagic radiation proctitis with local formalin instillation is effective, well tolerated and safe procedure. The procedure is inexpensive, technically simple and can be done on an outpatient basis. 62% patients had complete freedom from rectal bleed, while 34.5% patients had partial benefit. Only one patient required diversion colostomy for persistent bleeding.

Medical tourism: a new growth factor for Indian healthcare industry.

Epidemiological transition has given the opportunity to grow the traditional system of medicine across the world. Indian healthcare system which is already famous for providing quality of medical services at affordable cost as compared to developed countries took advantage of this opportunity and created a ‘basket of services’ by merging traditional medicines in existing allopathic system to attract patients across the borders. Government has made efforts in the direction of promoting medical tourism in the country and this has been fuelled by the private players both nationally and internationally. Recently this medical tourism has proved a major growth factor for expansion of Indian economy. However, the growth in this sector is underscored in terms of market share and cost advantages due to various challenges. There is also a need for proper diversion of revenue by a clear cut mechanism to strengthen the nation’s healthcare sector.

Empowerment and engagement of SHGs against RTI/STI in Karnataka, India: an interventional study.

Background: Reproductive Tract Infections (RTIs) including Sexually Transmitted Infections (STIs) are ‘silent’ epidemics and are recognized as public health problem and rank second as the cause of healthy life lost among women of reproductive age after maternal morbidity and mortality in developing countries. Development and use of IEC material along with active participation by the community ensures delivery of appropriate information and knowledge to people which in turn empowers them to make informed decisions about their health. Methods: This was a ‘Multi-centric action research demonstration study’ to empower and engage the Self Help Groups (SHGs) women by creating awareness and sustaining interest through lesson plans in the IEC material regarding prioritized problem, required interventions and their access for syndromic recognition of the RTI/STIs. As an intervention, series of workshops were conducted with the help of pre-developed IEC material. 400 households (200 from each intervention and control sites) of SHG women were interviewed for baseline and endline each. Results: Intervention was found effective in the form of a significant improvement in the level of awareness about RTI/STI, correct knowledge about white discharge, capability to identify the symptoms of RTI/STI and health seeking behavior of the respondents. Conclusion: This study provides experience of the feasibility, efficacy and impact of health education interventions and point out that cost-effective strategies for prevention of RTI/STI are needed through information, education, and behavior change.

Retinoblastoma: A Curse to Childhood.

Retinoblastoma is the most common intraocular malignancy in children. With the improvement in diagnostic and treatment modalities, early diagnosis and prompt treatment have remarkably improved the survival and salvageable vision in retinoblastoma patients. We report a case of a 14-month-old female child who presented to us with intermittent deviation of both eyes and white reflex in both eyes along with redness and photophobia in right eye, she was diagnosed to liver bilateral retinoblastoma.

Huge uterine-cervical diverticulum mimicking as a cyst.

Here we report an incidental huge uterine-cervical diverticulum from a total abdominal hysterectomy specimen in a perimenopausal woman who presented with acute abdominal pain. The diverticulum was mimicking with various cysts present in the lateral side of the female genital tract. Histopathological examination confirmed this to be a cervical diverticulum with communication to uterine cavity through two different openings. They can attain huge size if left ignored for long duration and present a diagnostic challenge to clinicians, radiologists, as well as pathologists because of its extreme rarity. Therefore, diverticula should also be included as a differential diagnosis. Its histopathological confirmation also highlights that diverticula can present as an acute abdomen, requiring early diagnosis with appropriate timely intervention. Immunohistochemistry CD 10 has also been used to differentiate it from a mesonephric cyst.

Abdominal packing for surgically uncontrollable haemorrhage.

Background: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. Patients and methods: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years) . The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were : liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). Results: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <340C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. Conclusion: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.

Calculating prevalence of hepatitis B in India: Using population weights to look for publication bias in conventional meta-analysis.

Publication bias can result from the propensity of researchers to document what is unusual. This can distort the inferences drawn in systematic reviews. To measure the distortion, it has been suggested that a second analysis be done; using weights proportional to the size of the population from which the samples are drawn. We re-evaluate data from a published meta-analysis on prevalence of hepatitis B in India, to see how this approach alters the results. Prevalence of hepatitis B among tribal and non-tribal populations in different States was analyzed. Weights were then assigned according to population of the State. The overall country prevalence was then calculated. Using population-weights it is estimated that the point-prevalence of hepatitis B among non-tribal populations is 3.07% [95% CI: 2.5 - 3.64]. Among tribal populations it is 11.85% (CI 10.76 -12.93). Overall prevalence was 3.70 (CI: 3.17 -4.24) (corresponding to a chronic carrier rate of 2.96%). The present analysis using population-weights has resulted in the estimated prevalence among non tribal populations increasing by 24% and that among tribal populations decreasing by 25.5% when compared to figures of the metaanalysis published earlier. The advantages and drawbacks of this procedure are discussed.