Pulmonary Hydatid without Liver Involvement: A Case Series

Pulmonary hydatid is not a rare disease. But raising a suspicion for its diagnosis is limited. There are limited approaches for the diagnosis and treatment of the same. We present here four cases of pulmonary hydatid, without liver involvement, with emphasis on how it was misdiagnosed and received multiple treatment and landed into complications. Most of our cases presented with cough, sputum and hemoptysis. For these nonspecific signs and symptoms, patient is generally treated on a different line of diagnosis. Two of the cases were already treated for abscess and fungal infection. One of the patients was on antitubercular treatment. One of our cases was secondarily infected with aspergilloma. One of the cases was referred to oncologist to start chemotherapy. Interestingly, to raise a suspicion, none of our cases had liver involvement. A detailed history revealed expectoration of white salty material in sputum, living with sheep and dog and expectorating grape-like vesicles in sputum. History helped us to put hydatid as one of our differentials. Echinococcal serology was positive in three cases. Only three cases had on-table appearance of hydatid cyst. All four cases underwent surgical management for complete cure. There is need for strong suspicion and a detailed history and proper set of investigations help in timely diagnosis and management of pulmonary hydatid disease.

Anticonvulsant property of celecoxib in maximal electroshock seizure: Correlating the role of inflammation in pathophysiology of epileptic seizures

Background: Epilepsy is an abnormal excessive electric neuronal activity and always represents by recurrent seizures. There is positive feedback cycle between epileptogenesis and brain inflammation. It has been proved that an inflammatory enzyme, cyclooxygenase (COX) (especially isoform-2, a constitutive enzyme), expressed in some important parts of the central nervous system and is responsible to induced inflammation locally and having seizurogenic property. Aim and Objective: The goal of this study was to see if celecoxib (a selective COX-2 inhibitor) could reduce the maximal electroshock seizure (MES)-induced seizures in mice. Materials and Methods: Celecoxib injected intraperitoneally in two different doses 5 mg/kgb/w and 10 mg/kg b/w, in albino Swiss mice and in two different phases. MES was elicited and length of different phases was noted. Length of tonic hindlimb extension was considered as indicator of anti-epileptic activity. Results: Celecoxib, when given intraperitoneally, exert significant reduction in the duration of THLE. This action of celecoxib strongly suggests the involvement of inflammation in the pathophysiology of epilepsy. Conclusion: The findings are suggestive of the therapeutic significance of celecoxib, as a future antiepileptic agent for seizure management.

Identifying high risk patients post myocardial infarction with reduced left ventricular function using loop recorders INSPIRE-ELR clinical study

Aims: Sudden cardiac death (SCD) continues to be a devastating complication amongst survivors of myocardial infarction (MI). Mortality is high in the initial months after MI. The aims of the INSPIRE-ELR study were to assess the proportion of patients with significant arrhythmias early after MI and the association with mortality during 12 months of follow-up. Methods: The study included 249 patients within 14 days after MI with left ventricular ejection fraction (LVEF) _x0001_35% at discharge in 11 hospitals in India. Patients received a wearable external loop recorder (ELR) 5 ± 3 days after MI to monitor arrhythmias for 7 days. Results: Patients were predominantly male (86%) with a mean age of 56 ± 12 years. In 82%, reperfusion had been done and all received standard of care cardiovascular medications at discharge. LVEF was 32.2 ± 3.9%, measured 5.1 ± 3.0 days after MI. Of the 233 patients who completed monitoring (7.1 ± 1.5 days), 81 (35%) experienced significant arrhythmias, including Ventricular Tachycardia/Fibrillation (VT/ VF): 10 (4.3%); frequent Premature Ventricular Contractions (PVCs): 65 (28%); Atrial Fibrillation (AF): 8 (3.4%); chronic atrial flutter: 4 (1.7%); 2nd or 3rd degree Atrioventricular (AV) block: 4 (1.7%); and symptomatic bradycardia: 8 (3.4%). In total, 26 patients died. Mortality was higher in patients with clinically significant arrhythmia (at 12 months: 23.6% vs 4.8% with 19 vs 7 deaths, hazard ratio (HR) ¼ 5.5, 95% confidence interval (CI) 2.3 to 13.0, p < 0.0001). Excluding 7 deaths during ELR monitoring, HR ¼ 4.5, p < 0.001. Conclusion: ELR applied in patients with acute MI and LV dysfunction at the time of discharge identifies patients with high mortality risk.

Assessing Success Of Vaginal Birth After Cesarean By FLAMM Model In A Retrospective Observational Design

Background: After year 2000 cesareanrates have increased from 15% to 30-50% worldwide. Practice of Trial of labor after cesarean has decreased from last two decades of 20thcentury. Predictors of vaginal birth after cesarean are not uniform and not suitable equally for all populations. FLAMM model was tested in this study for its predictability for a successful vaginal birth after previous one cesarean. Material And Methods:For an observational, retrospective study 72 patient files admitted in 2018 in Obstetric Department of C R Gardi Hospital were included which fulfille d criteria of having second pregnancy after cesarean for non recurrent indications like fataldistress, failure of induction of labor, pre-eclampsia, eclampsia, twins and others. Indication of contracted pelvis, rupture uterus, previous classical cesarean section; and multiple pregnancy, medical complications and obstetric complications in this pregnancywere excluded. FLAMM scoreparameters; cervical dilatation, effacement, presence of previous vaginal birth before cesarean, indication of it and age of woman wereused. Observations of successful and failed trial were done by scoring system. Chi square test was used to compare data. Study variables were success of trial in various FLAMM parameters. Result:Higher scores in cervical dilatation (p<0.001), effacement (p<0.001) and prior vaginal delivery (p=0.03) were significantly associated with a successful outcome. Higher theaggregate FLAMM score, higher were chances of successful trial. A non-recurrent indication other than non-progress of labor for previous cesarean had no statistical association with success of trial. Aggregate score of 6 and more has 100 % predictability for a successful vaginal birth. Conclusion:Prediction by FLAMM model resulted in 62. 5%successful trial. FLAMM model maybe used for near to accurate prediction of successful trial of labor after cesarean.

Estimation Dynamic Distance Direct Ophthalmoscopy (eDDDO): A novel, objective method for the quantitative assessment of accommodation in young children

Purpose: To describe estimation dynamic distance direct ophthalmoscopy (eDDDO) and compare it with the monocular estimation method of dynamic retinoscopy (eDR) for the assessment of accommodation in children. Methods: In this prospective observational cohort study, an ophthalmologist performed eDDDO followed by eDR in children with normal eyes, and then under the partial effects of cyclopentolate and tropicamide to assess performance of eDDDO with eDR under the condition of pharmacologically induced accommodation failure. Only one eye of each child was recruited in the study. To study the inter-observer variation, two masked pediatric ophthalmology fellows performed eDDDO in the similar manner. Results: For the comparison of eDDDO with eDR, 60 eyes of 60 patients were recruited. The mean age of the patients was 10.4 years. The mean accommodation on eDDDO was 3.0D, 5.1D, 9.8D, and 11.3D at 40 cm, 25 cm, 10 cm, and 8 cm, respectively and 3.0D, 5.0D, 9.5D, and 11.0D on eDR. The eDDDO overestimated accommodation by a mean 0.17D (95% CL 0-0.48D, P = 0.5). The correlation of eDDDO with eDR was excellent (Pearson r 0.98, T value 76.0). The inter-observer difference with eDDDO was not significant (mean 1D, 95% CL 0-2.6D, P = 0.9) and the correlation between two observers was excellent (Pearson r 0.9, T value 12.7). The eDDDO and eDR were also performed on 12 eyes of 6 children with a mean age of 8.5 years (range 8-12 years) under the partial effect of cyclopentolate and tropicamide, where eDDDO overestimated the accommodation by a mean 0.3D (95% CL 0- 1.2D, P = 0.7) and the correlation was excellent (Pearson r 1.0, T value 45). Conclusion: eDDDO is a simple, reliable, quantitative, and objective technique of accommodation assessment for children. Further studies with larger sample are required to assess its performance in disorders of accommodation affecting younger children and in children with ocular comorbidities.

Kinetics of viral RNA, immunoglobulin-M & G antibodies in Kyasanur forest disease

Background & objectives: Kyasanur forest disease (KFD) is an infectious disease discovered in Karnataka State of India in 1957; since then, the State has been known to be enzootic for KFD. In the last few years, its presence was observed in the adjoining five States of the Western Ghats of India. The present study was conducted to understand the kinetics of viral RNA, immunoglobulin M (IgM) and IgG antibody in KFD-infected humans for developing a diagnostic algorithm for KFD. Methods: A prospective follow up study was performed among KFD patients in Sindhudurg district of Maharashtra State, India. A total of 1046 suspected patients were tested, and 72 KFD patients were enrolled and followed for 17 months (January 2016 to May 2017). Serum samples of KFD patients were screened for viral RNA, and IgM and IgG antibodies. Results: KFD viral positivity was observed from 1st to 18th post-onset day (POD). Positivity of anti-KFD virus (KFDV) IgM antibodies was detected from 4th till 122nd POD and anti-KFDV IgG antibodies detected from 5th till 474th POD. A prediction probability was determined from statistical analysis using the generalized additive model in R-software to support the laboratory findings regarding viral kinetics. Interpretation & conclusions: This study demonstrated the presence of KFD viral RNA till 18th POD, IgM antibodies till 122nd POD and IgG till the last sample collected. Based on our study an algorithm was recommended for accurate laboratory diagnosis of KFDV infection. A sample collected between 1 and 3 POD can be tested using KFDV real-time reverse transcriptase polymerase chain reaction (RT-PCR); between 4 and 24 POD, the combination of real-time RT-PCR and anti-KFDV IgM enzyme-linked immunosorbent assay (ELISA) tests can be used; between POD 25 and 132, anti-KFDV IgM and IgG ELISA are recommended.

Morphological and anatomical aberrations induced by waterlogging in sugarcane

Aim: The present investigation was carried out to study root anatomy of sugarcane cultivars (CoLk 94184 and CoJ64) planted under waterlogged condition through Scanning Electron Microscopy (SEM). Methodology: Two sugarcane (Saccharum spp. hybrid) cultivars, CoLk 94184 and CoJ 64 were evaluated for changes in root anatomy in response to waterlogging during 2017-2018. For waterlogging treatment, crop was grown in deep plot which was waterlogged upto a depth of 1 m during active grand growth stage (monsoon season) along with untreated control plot. After three months of waterlogging, the plants were uprooted to study the root morphology and anatomy through SEM. Results: Waterlogged plants showed aerial root formation in both the cultivars but number and mass were higher in CoJ64. Aerenchyma was formed in the cortical region of both control and waterlogging roots but the size was relatively increased in waterlogged. Irregular and damaged surface cells with longer root hairs were observed in waterlogging treatment. Waterlogged roots exhibited cell distortion, loss of uniformity in endodermis and pericycle regions and higher number of metaxylem vessels. Interpretation: The study concluded that waterlogging treatment caused structural anomalies and induced anatomical and surface ultra-structural changes in both the cultivars, but the level of deformation was relatively higher in genotype CoJ 64, indicating sensitivity towards waterlogging as compared to cultivar CoLk 94184.

Why road safety is the need of the hour? A study among youth of District Dehradun, Uttarakhand

Background: Road traffic injuries are the eighth leading cause of death globally, and the leading cause of death for young people aged 15–29 years. Each year, almost 400,000 young people under 25 years old are killed in a road traffic crash - about 1049 youngsters every day. Aims and objectives: To find out the prevalence of road safety related health risk behaviours and its determinants amongst young males of District Dehradun. Methodology: It was a cross sectional study conducted over 12 months of duration. The study sample comprised of 1800 male youth aged 15-24years studying in various schools and colleges of District Dehradun. A pre-tested and pre-structured questionnaire (YRBSS) was used. The data was entered and analysed using SPSS-version 20.0. Results: Approximately three-fourth of youth reported never using seat-belt while driving and only 4.4% reported always using helmet whereas 24.0% accepted never use of helmet. Approximately one-fourth of the total 1168 at risk subjects in past 30 days, accepted driving a vehicle while drunk and 39.9% reported use of mobile phones while driving. Personality traits (extrovert, neuroticism and lack of direction) turned out to be the major factor in road safety related health risk behaviour. Conclusion: Although, road safety related health risk was found to be more among urban youth as compared to their rural counterparts, yet it was found alarmingly high for both rural and urban study population.

Novel Hptlc-Densitometric Method For The Estimation Of Teriflunomide In Tablet Dosage Form

Objective: The current work is intended towards the development of a novel, simple and precise high-performance thin layer chromatographic (HPTLC) method coupled with a densitometer for the estimation of teriflunomide (TEF) present in the marketed formulation. Methods: The chromatographic development was performed on aluminum plates coated with silica gel 60 F254 using toluene: ethyl acetate: glacial acetic acid (7.5:2: 0.5 v/v/v) as the mobile phase. Densitometric scanning was achieved at the absorbance maxima, UV 284 nm. Results: Well separated band was observed with Rf value 0.46. The calibration curve plotted in the concentration range 100-700ng/band exhibited an excellent linear relationship with the r2 value of 0.9928. The method was found to comply with all the validation parameters as per the ICH guidelines. Conclusion: The method ensures minimal use of mobile phase with minimal run time compared to other reported analytical methods. This validated method can be used by quality control laboratories for the routine quantitative analysis of tablets consisting of Teriflunomide.

Sexual Risk Behavior: A Perilous Journey By Unmarried Youth Of District Dehradun, Uttarakhand

Background: Sexual health is an integral part of overall health and well-being and determination of sexuality of the youth is an important milestone in understanding their behavior, associated risks and outcomes. The declining age at puberty and increasing age at marriage has created a longer growing period in which youth may engage in sexual health risk behaviors. This research focuses attention on estimation and involvement of the most dynamic & valuable segment of a nation’s population towards sexual risk behaviors. Aims & objectives: The aim of this study is to find out the prevalence and determinants of sexual health risk behaviors amongst youth in District Dehradun. Material and methods: It was a cross-sectional study conducted over a period of 06 months in rural and urban area of District Dehradun. The study surveyed 1800 male youth aged 15-24 years using a self-administered questionnaire (YRBSS & Big five inventory). After collection, the data was entered using the SPSS software and analyzed using SPSS and Microsoft Excel 2010. Results: Out of 1800 participants, 19% were found to be at risk of sexual health risk behavior and reported having had sex. Out of these 342 at-risk, 43.5% accepted involving in sexual activity even before adulthood, 31% reported having multiple sexual partners and 21.1% accepted not using condoms. Place of residence and personality trait were found to be important determinants of sexual health risk behaviors. Conclusion: Our study documented the high prevalence of sexual risk behavior among male youth of rural and urban area of District Dehradun.

Allergic reactions to atropine eye drops for retardation of progressive myopia in children

Purpose: To report clinical manifestations of ocular allergy to atropine eye drops used for retardation of progressive myopia in children. Methods: Myopic children, who developed bothersome itching that subsided promptly after cessation of atropine eye drops, were included. History of systemic or ocular allergy, preexisting ocular conditions, and clinical features of allergy were noted. Results: Six children, age 5–15 years, were included. Four developed allergy to 1% atropine sulfate eye drops and two to 0.01% concentration of atropine sulfate. The onset of allergy was within a month to as late as 4 years after using atropine eye drops. The severity of allergy was higher with 1% concentration. The most common symptoms of atropine allergy were itching and burning. The most common signs were lid swelling and hyperemia. The allergic manifestations promptly reversed with the stoppage of eye drops. Reintroduction was possible in three patients, either by reducing the concentration of atropine or using benzalkonium free formulation. Conclusion: Allergy to atropine eye drops in children may develop within a few weeks or after many years of usage. Prompt cessation followed by a reintroduction and continuation of therapy may be possible in few patients.

Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation

Purpose: The aim of this study is to describe a modified surgical technique of continuous intraoperative optical coherence tomography (iOCT)-guided shield ulcer debridement with tuck-in multilayered Amniotic membrane transplantation (ML AMT) in vernal keratoconjunctivitis (VKC) with shield ulcer with plaque. Methods: Seven eyes of seven patients presenting with VKC with shield ulcer with plaque were enrolled in this prospective case series and planned for shield ulcer debridement with ML AMT. Debridement of the ulcer base with double-layered AMT was done under the continuous guidance of iOCT. The main outcome measure was the time for complete reepithelialization. Statistical analysis was performed using the Stata-14.0 program for Windows. Data were presented as mean � standard deviation/median (minimum-maximum) and frequency percentage as applicable. Results: The surgery could be completed successfully in all cases and iOCT could provide real-time assessment of the depth of dissection during the entire procedure. The duration of complete healing and disintegration of amniotic membrane varied from 7 to 12 days. Recurrence was not seen in any case till 2 months follow-up. Conclusion: iOCT provides continuous monitoring of the depth of dissection and allows for a safe and complete debridement of the shield ulcer with plaque.

Is a diagnostic lumbar puncture indicated in intraocular retinoblastoma?

Background: Lumbar puncture (LP) is frequently performed in patients with advanced intraocular retinoblastoma. However, this may not be necessary in a significant proportion of patients. Materials and Methods: A file review of patients who were diagnosed with retinoblastoma over a 13-year-period was performed. Patients who underwent LP as part of staging were included in the study. Results: The study included 223 patients. One-third had bilateral retinoblastoma. The grouping was C, D, and E in 4 (2.9%), 41 (29.9%), and 92 (67.2%) patients, respectively. The stage was 0, I, II, III, and IV in 14 (6.3), 123 (55.2%), 13 (5.8%), 70 (31.4%), and 3 (1.3%) patients, respectively. Eight (3.6%) patients had a positive cerebrospinal fluid (CSF) cytology. None of the patients with intraocular disease and 7 (10%) patients with extraocular disease had a positive CSF. Conclusions: A diagnostic CSF is not indicated in patients with intraocular retinoblastoma.

Comparison of conventional dose and low dose infusion of dexmedetomidine on hemodynamic stress response, dose of induction agent and postoperative analgesia in patients undergoing laparoscopic cholecystectomy

Background and Aim: Anesthetic techniques are based on hemodynamic stability during anesthesia and surgery. Dexmedetomidine is centrally acting α2 agonist with sedative, sympatholytic and analgesic. Aim of this study was to compare effect of conventional dose with low dose infusion of dexmedetomidine on hemodynamic stress response, induction agent requirement & postoperative analgesia. Materials and methods: Single randomised prospective study done on 100 ASA Ι and ΙΙ patients aged 18-65 years scheduled for elective laparoscopy cholecystectomy under general anesthesia. Patients were divided in to two groups of 50 each, Group A: 1 µg/kg loading dose of Rolaniya SL, Dhawan S, Meera Kumari, Jain R, Pareek A, Sehtia S. Comparison of conventional dose and low dose infusion of dexmedetomidine on hemodynamic stress response, dose of induction agent and postoperative analgesia in patients undergoing laparoscopic cholecystectomy. IAIM, 2017; 4(7): 111-117. Page 112 dexmedetomidine I.V. started 15 min before procedure and infusion. 5 µg/kg/hr after induction and continued till end of surgery. Group B: 0.5 µg /kg/hr of dexmedetomidine I.V. started 15 min before procedure and continued till end of surgery. Results: Hemodynamic stability more in group B by avoiding complications like hypotension and bradycardia (p value < .05). Reduction of induction dose was more in group A than group B as compared to standard doses (P value <0.01). Hypotension and bradycardia were observed in 5 cases after 15 min of infusion in group A ( p value <.01). Mean VAS score in Group A was at 330 min was 3.10.39 and 3.150.94 at 210 min in group B. Conclusion: Low dose infusion of dexmedetomidine provides more hemodynamic stability. Requirement of induction agent was decreased more in group A than group B. Postoperative analgesia more in group A.

Development and validation of a Hindi language health-related quality of life questionnaire for melasma in Indian patients.

Background: Melasma, which is fairly common in Indians, causes signifi cant emotional and psychological impact. A Hindi instrument would be useful to assess the impact of melasma on the quality of life in Indian patients. Objective: To create a semantic equivalent of the original MELASQOL questionnaire in Hindi and validate it. Methods: A Hindi adaptation of the original MELASQOL (Hi-MELASQOL) was prepared using previously established guidelines. After pre-testing, the Hi-MELASQOL questionnaire was administered to 100 women with melasma visiting the out-patient registration counter of Safdarjung Hospital, Delhi. These women were also administered a Hindi equivalent of the Health Related Quality of Life (HRQOL) questionnaire. Melasma area severity index (MASI) of all the participants was calculated. Results: The mean MASI score was 20.0 ± 7.5 and Hi-MELASQOL score was 37.19 ± 18.15; both were highly, positively and signifi cantly correlated. Reliability analysis showed satisfactory results. Physical health, emotional well-being and social life were the most adversely affected life domains. Limitations: It was a single-center study and the number of patients studied could have been larger. Conclusion: Hi-MELASQOL is a reliable and validated tool to measure the quality of life in Indians with melasma.

Pathology of a H5N1, highly pathogenic avian influenza virus, in two Indian native chicken breeds and a synthetic broiler line.

In this study, susceptibility to H5N1 virus infection was studied in two Indian native chicken breeds viz. Kadaknath and Aseel (Peela) and an Indian synthetic broiler strain (Synthetic dam line (SDL-IC). Fifty birds from each genetic group were infected intra-nasally with 1000 EID50 of a highly pathogenic avian influenza virus (HPAIV) strain A/chicken/Navapur/India/7972/ 06 (H5N1) and observed for a period of 10 days. Significant differences in severity of clinical signs, gross lesions and time for onset of symptoms were observed. The overall severity of clinical signs and gross lesions was less in SDL-IC broilers as compared to the other two genetic groups. The mortality percentages were 100, 98 and 92% with Mean Death Time (MDT) of 3.12, 5.92 and 6.96 days, respectively for the two native breeds Kadaknath and Aseel (Peela), the and SDL-IC broiler strain. Comparison of histological lesions revealed differences in disease progression among the genetic groups. Vascular lesions such as disseminated intravascular coagulopathy (DIC) were predominant on 3 days post infection (dpi) in Kadaknath, and on 5 and 6 dpi in Aseel (Peela) and SDL-IC broiler. The mean log2 HA titres of the re-isolated virus from various organs of H5N1 AIV infected birds of the three genetic groups ranged from 2.32 (lung, trachea and bursa) to 5.04 (spleen) in Kadaknath; 2.32 (lung) to 6.68 (brain) in Aseel (Peela); and 2.06 (liver) to 7.01 (lungs and kidney) in SDL-IC broiler. These results suggest that the susceptibility to H5N1 highly pathogenic avian influenza virus infection differed among the three breeds; Kadaknath being highest followed by Aseel (Peela) and synthetic SDL-IC broiler.This is possibly the first report on the differences in the susceptibility of the India native breeds to H5N1 virus infection and its severity.

Prevalence and Correlates of Alcohol Intake In a Rural Block of Haryana, India.

Alcohol consumption is today’s major public health concern in our country, which can be largely reduced solely by primordial and primary prevention. According to NFHS III, 31.9% of men and 2.2% of women drink alcohol in India. Aims & objectives: To determine the prevalence and correlates of alcohol intake among the rural community of block Beri, district Jhajjar, Haryana. Methods: This cross-sectional study was carried out during the period of September 2012 to August 2013. Multistage random sampling was used in this study. From each selected PHC, two subcentres were randomly selected and from each subcentre area, two anganwadis were also selected by simple random sampling technique. Hence a total of 6 sub-health centres and 12 anganwadis were included in the study. From each anganwadi, 90 individuals of 15-64 years age group who were further subdivided into 15-24, 25-34, 35-44, 45-54 and 55-64 years age-group were selected and interviewed. Thus, a sample size of 1080 was included in the study Appropriate statistical tests were used for analysis. Results: The overall prevalence of ever alcohol intake was found 25.7% (Males:49.1%; Females: 2.4%). The prevalence of current alcohol intake was found to be 18.8% (Males: 36.9%; Females: 0.7%). Conclusion: Our study confirmed the high burden of alcohol intake in rural areas and reiterated the need to address these issues comprehensively as a part of NCD prevention and control strategy.

Barriers to ART adherence & follow ups among patients attending ART centres in Maharashtra, India.

Background & objectives: Adherence to ART is a patient specific issue influenced by a variety of situations that a patient may encounter, especially in resource-limited settings. A study was conducted to understand factors and influencers of adherence to ART and their follow ups among patients attending ART centres in Maharashtra, India. Methods: Between January and March 2009, barriers to ART adherence among 32 patients at three selected ART centres functioning under national ART roll-out programme in Maharashtra, India, were studied using qualitative methods. Consenting patients were interviewed to assess barriers to ART adherence. Constant comparison method was used to identify grounded codes. Results: Patients reported multiple barriers to ART adherence and follow up as (i) Financial barriers where the contributing factors were unemployment, economic dependency, and debt, (ii) social norm of attending family rituals, and fulfilling social obligations emerged as socio-cultural barriers, (iii) patients’ belief, attitude and behaviour towards medication and self-perceived stigma were the reasons for suboptimal adherence, and (iv) long waiting period, doctor-patient relationship and less time devoted in counselling at the center contributed to missed visits. Interpretation & conclusions: Mainstreaming ART can facilitate access and address ‘missed doses’ due to travel and migration. A ‘morning’ and ‘evening’ ART centre/s hours may reduce work absenteeism and help in time management. Proactive ‘adherence probing’ and probing on internalized stigma might optimize adherence. Adherence probing to prevent transitioning to suboptimal adherence among patients stable on ART is recommended.