Ethical challenges faced by community mental health workers in urban Chennai

Background: Delivery of mental health interventions to youth in schools requires a cadre of community mental health workers (CMHWs) in addition to psychiatrists. Literature is sparse in the India context on the ethical and professional challenges faced by CMHWs, especially those working with youth. Hence, the aim of the study was to understand these challenges faced by CMHWs working in schools in urban Chennai and explore ways to overcome them. Methods: A qualitative study was done with CMHWs involved in the delivery of youth mental health (YMH) interventions, including mental health literacy, screening for mental disorders and mental health support to youth in schools in urban Chennai. Focus group discussions (FGDs) were conducted with the study participants and audio recorded. Transcription of the recording was done verbatim and coded for themes using a thematic analysis approach. Results: Two FGDs were conducted with a total of eight participants. The mean (± standard deviation) age of the participants was 27 ± 3.7 years; all having a master’s degree in either psychology, social work, or public health. The major themes that emerged were the meaning of ethics and professionalism, confidentiality, dilemma in decision making, incongruence between the requirements of student and school administration, and personal and professional challenges faced by CMHWs. Recommendations to overcome these challenges were also explored. Conclusion: The results indicate CMHWs face significant ethical challenges with confidentiality, and decision making while delivering YMH interventions in schools, highlighting the need for designing and implementing a framework to address these challenges.

Treatment of circumscribed choroidal hemangioma using CyberKnife: A viable alternative

Circumscribed choroidal hemangioma is a benign vascular hamartoma without systemic associations. For symptomatic cases, treatment options are photodynamic therapy (PDT), transpupillary thermotherapy (TTT), intravitreal injection of anti-vascular endothelial growth factor (VEGF), or radiation therapy. CyberKnife radiosurgery is an image-guided radiation therapy that delivers radiation to lesions anywhere in the body with an accuracy of 0.5 mm without damage to surrounding structures. We report a case of circumscribed choroidal hemangioma which was successfully treated with CyberKnife therapy. The literature search reveals cases of uveal melanoma, intraocular, and periocular lymphoma successfully treated with CyberKnife therapy. To the best of our knowledge, this is the first report on such treatment for choroidal hemangioma.

Development and validation of a questionnaire to measure preferences and expectations of patients undergoing palliative chemotherapy: EXPECT questionnaire.

OBJECTIVE: The objective was to design and validate the questionnaire for capturing palliative chemotherapy‑related preferences and expectations. DESIGN: Single arm, unicentric, prospective observational study. METHODS: EXPECT questionnaire was designed to capture preferences and expectations of patients undergoing palliative chemotherapy. This questionnaire underwent a linguistic validation and then was tested in patients. Ten patients are undergoing chemotherapy for solid tumors who fulfilled the inclusion and exclusion criteria self‑administered the EXPECT questionnaire in regional language. After filling this questionnaire, they self‑administered quick questionnaire‑10 (QQ‑10). SPSS version 16 (IBM New York) was used for analysis. Completion rate of EXPECT questionnaire was calculated. The feasibility, face validity, utility and time taken for completion of EXPECT questionnaire was also assessed. RESULTS: The completion rate of this questionnaire was 100%. All patients completed questionnaire within 5 min. The QQ‑10 tool confirmed the feasibility, face validity and utility of the questionnaire. CONCLUSION: EXPECT questionnaire was validated in the regional language, and it’s an effective tool for capturing patient’s preferences and expectation from chemotherapy.

Retrospective audit of clinico‑pathologic features and treatment outcomes in a cohort of elderly non‑Hodgkin’s lymphoma patients in a tertiary cancer center.

INTRODUCTION: There is limited data from India regarding elderly non‑Hodgkin’s lymphomas (NHL) patients. Hence, this audit was planned to study the clinic‑pathological features and treatment outcomes in elderly NHL patients. METHODS: Retrospective analysis of all NHL patients above age of 59 years treated at the author’s institute, between December 2010 and December 2013 was done. Case records were reviewed for baseline details, staging details, prognostic factors, treatment delivered, response, toxicity and efficacy. SPSS version 16 (IBM, Newyork) was used for analysis. Descriptive statistics was performed. Kaplan–Meir survival analysis was done for estimation of progression‑free survival (PFS) and overall survival (OS). Univariate analysis was done for identifying factors affecting PFS and OS. RESULTS: Out of 141 NHL patients, 67 patients were identified subjected to the inclusion criteria. The median age was 68 years (60–92). Majority were B‑cell NHL (86.6%). The commonest subtype in B‑cell was diffuse large B‑cell lymphoma (55.2%). Fifty‑four patients took treatment. The treatment intent was curative in 41 patients (61.2%). Among the patients receiving curative treatment, 16 patients couldn’t receive treatment in accordance with NCCN guidelines due to financial issues. Two years PFS was 55%. Two years PFS for B‑cell NHL and T‑cell NHL were 55% and 50% respectively (P = 0.982). Two years PFS for standard Rx and nonstandard Rx were 62% and 50% respectively, but it didn’t reach statistical significance (P = 0.537). Two years OS for the entire cohort was 84%. CONCLUSION: Standard treatment in accordance with guidelines can be delivered in elderly patients irrespective of age. There is a need for creating financial assistance for patients, so that potentially curative treatments are not denied.

Patterns of care in geriatric cancer patients – An audit from a rural based hospital cancer registry in Kerala.

BACKGROUND: There is deficit of data from India on elderly patients with cancer. Comprehensive geriatric assessment may lead to a better decision making capacity in this population. However, routine implementation of such assessment is resource consuming. AIM: The aim of this study was to determine the patterns of care in elderly patients treated at a tertiary rural cancer center in India. MATERIALS AND METHODS: All patients with age 70 or above with solid tumors without any definitive treatment prior to the registration at our center and registered between 01/01/2010 and 31/12/2011 were selected for this study. The baseline demographic pattern and the pattern of care of treatment were analyzed. SPSS version 16 (IBM Inc, Armonk, New York, U.S.) was used for analysis. Descriptive data are provided. RESULTS: A total of 761 patients were evaluable subject to the aforementioned inclusion criteria. The median age of this cohort was 75 years (70‑95 years). The most frequent primary sites of malignancies in 451 males were head neck (32.4%), lung (23.3%) and gastrointestinal (23.3%). In 310 females, the most common sites were head neck (31.6%), gynecological (18.4%) and gastrointestinal (24.5%). 228 (30%) of the patients had localized disease, 376 (49.4%) had loco‑regionally advanced disease and 145 (19.1%) had distant metastases at presentation. 334 (46.32%) of patients were treated with curative intent. On logistic regression analysis the factors that predicted use of curative intent treatment were age <75 years, performance status 0‑1, primary site and clinical extent of disease. CONCLUSION: Routine comprehensive geriatric assessment needs to be implemented in our setting as almost 50% of our geriatric patients undergo curative intent treatment.

Immunoregulatory pathways in pregnancy.

Murine pregnancy is characterized by transient thymic atrophy and splenomegally. Several laboratories are investigating the immunoregulatory mechanisms during pregnancy, and the majority of these studies are primarily focused on the immunological changes either in the uterus or the thymus and not much information is available on the immunological changes in the spleen that result in transient splenomegally. An attempt has been made in this review to understand the significance of thymic atrophy, splenomegally and local immune changes in the uterus to understand the overall immunomodulatory mechanisms in pregnant mother. The most significant change which occurs soon after mating is the infiltration of immune cells such as macrophages and gammadelta-T cells into the uterus indicating that the mother's immune system detects the presence of foreign antigens in the reproductive tract. The sensitized cells appear to migrate to the secondary lymphoid organs including the spleen. The microenvironment in the spleen is conducive for the cell-cell contact and generation of immune response. The major changes that occur in the spleen are, the induction of T-cell dependent B-cell response on day-1 post-coitum (P.C.), generation of antibody producing B-cells on day-3 and also proliferation of CD8+ T-cells that peaks on day-3 of pregnancy. The weight of the spleen reaches a peak on day-10 in mice. Thereafter, on day-15 of pregnancy, lymphocyte apoptosis is seen in the spleen indicating the deletion of peripheral sensitized cells. This results in decrease in spleen weight to that of normal non-pregnant mice. The decrease in thymic weight after day-5 pregnancy was associated with the increased apoptosis of cortical thymocytes. This perhaps is due to negative selection of self-reactive thymocytes. Our studies have demonstrated that the pregnancy associated monoclonal antibodies react with antigens of sperm indicating that the mother's immune system recognizes and responds to the constituents of the semen to produce non-precipitating asymmetric auto antibodies (NPAA) or blocking antibodies which have favourable effects on pregnancy. It is postulated that the mother's immune response could be directed to some antigens of sperm along with some conserved antigens such as heat shock proteins (HSP) that are present both in sperm and in the mother. It may be speculated that after the initial priming to some conserved antigens of sperm and due to the presence of similar antigens in the mother, these activated clones are eliminated both in the primary and secondary lymphoid organs to prevent autoimmunity in the mother during pregnancy.

Characterization and localization of estrogen and progesterone receptors of human fallopian tube.

The cellular distribution of estrogen and progesterone receptors (ER and PR) in the human fallopian tube was investigated by immunohistochemical localization with specific monoclonal antibodies. Nuclear immunostaining was observed. Intense PR immunostaining was seen in tissues obtained at mid cycle and luteal stages of the normal menstrual cycle. On the other hand, enhanced staining for ER was seen in early follicular phase and mid cycle. Menopausal tissues showed negligible staining for both ER and PR. The ER and PR were characterized for their molecular size, anatomical distribution and levels during the menstrual cycle and in menopause. ER protein was present throughout the cycle and also during menopause. Western blot analysis revealed two forms of ER approximately 66 kDa and a truncated from approximately 49 kDa in hFT. Presence of A [approximately 90 kDa] and B [approximately 120 kDa] isoforms of human PR was detected. Follicular and early luteal tissue possessed relatively high concentration of immunoreactive PR whereas it was almost undetectable in menopausal tissues. These results suggests that ER and PR are regulated by the changing ovarian steroid hormones.

Effect of estrogen and progesterone on newly synthesised and released human fallopian tube specific proteins.

Current study was carried out to identify the profile of newly synthesized and released proteins by human fallopian tube (hFT). Results indicated that hFT during menopause synthesised and released only 2-3 proteins as against several proteins ranging from molecular weight (MW) approximately 20 to approximately 130 kD during normal menstrual cycle. In vitro addition of estradiol-17 beta (E2) resulted in synthesis and release of a number of proteins including specific protein of MW 110-130 kD. Addition of progesterone (P) however, led to inhibition of protein synthesis and a combination of E2 and P negated the effect of the latter. An alteration in oviductal secretory protein-profile following addition of E2 in vitro were similar to that observed during normal menstrual cycle.