Management of thromboembolic disorders during pregnancy in resource-constrained settings: An Indian perspective

Venous thromboembolism (VTE) in pregnancy and resulting thrombotic disorders are increasingly being recognized as an important cause of maternal morbidity and mortality. The diagnosis of VTE during pregnancy has an impact on current as well as future foeto-maternal outcomes. Whereas algorithms to manage VTEs during pregnancy in developed countries exist, these are difficult to implement in resource-constraint settings. In this narrative review, we discuss strategies that can be applied in daily clinical practice by obstetricians and haematologists dealing with these disorders in the country

Perspectives of nursing students on challenges of e-learning during early stages of the COVID-19 pandemic

Background: E-learning is becoming an important approach to teaching and learning in higher education institutions, including nursing training. Despite that, there are students who were never introduced to e-learning prior to the coronavirus disease 2019 (COVID-19) pandemic. Their challenges in relation to e-learning could differ from those of other students who had experienced the platform before, especially against the backdrop of the COVID-19 pandemic that brought an abrupt change in the approach to teaching, learning and assessment. Objectives: This study explored and described university nursing students' challenges in relation to e-learning during the early stages of the COVID-19 pandemic in a resource-constrained setting. Method: Qualitative exploratory and contextual design was used. The sample consisted of 17 participants who were conveniently selected, and data were collected by means of two focus groups and five individual interviews. Data analysis followed a qualitative content analysis process. Results: The five categories emanated from analysis are e-learning mode not suitable for practical components, challenges related to assessment of learning, connectivity issues, e-learning is a lonely journey and computer illiteracy and limited skills for the use of e-learning. Conclusion: Nursing students' challenges regarding e-learning during the early stages of the COVID-19 pandemic related to the learning of practical components, assessment, connectivity, a lack of interaction with peers and a lack of the skills required to operate e-learning tools.

Survival outcomes with 12 weeks of adjuvant or neoadjuvant trastuzumab in breast cancer

Background: There is limited access to 1 year of adjuvant trastuzumab in resource-constrained settings. Most randomized studies have failed to prove non-inferiority of shorter durations of adjuvant trastuzumab compared to 1 year However, shorter durations are often used when 1 year is not financially viable. We report the outcomes with 12 weeks of trastuzumab administered as part of curative-intent treatment. Methods: This is a retrospective analysis of patients treated at Tata Memorial Centre, Mumbai, a tertiary care cancer center in India. Patients with human epidermal growth factor receptor (HER2)-positive early or locally advanced breast cancer who received 12 weeks of adjuvant or neoadjuvant trastuzumab with paclitaxel and four cycles of an anthracycline-based regimen in either sequence, through a patient assistance program between January 2011 and December 2012, were analyzed for disease-free survival (DFS), overall survival (OS), and toxicity. Results: A total of 102 patients were analyzed with a data cutoff in September 2019. The median follow-up was 72 months (range 6–90 months), the median age was 46 (24–65) years, 51 (50%) were postmenopausal, 37 (36%) were hormone receptor-positive, and 61 (60%) had stage-III disease. There were 37 DFS events and 26 had OS events. The 5-year DFS was 66% (95% Confidence Interval [CI] 56–75%) and the OS was 76% (95% CI 67–85%), respectively. Cardiac dysfunction developed in 11 (10.7%) patients. Conclusion: The use of neoadjuvant or adjuvant 12-week trastuzumab-paclitaxel in sequence with four anthracycline-based regimens resulted in acceptable long-term outcomes in a group of patients, most of whom had advanced-stage nonmetastatic breast cancer.

INCLEN Diagnostic Tool for Neuromotor Impairments (INDT-NMI) for Primary Care Physician: Development and Validation.

Objectives: To develop and validate a diagnostic tool for use by primary care physicians for diagnosing neuro-motor impairment among 2-9 year old children in primary care settings. Study design: Modified Delphi technique involving national (n=49) and international (n=6) experts was used for development of INDT-NMI. The tool was then validated through a cross sectional study. Setting: Neurology specialty clinics of three tertiary care pediatric centers in New Delhi, India. Participants: 454 children aged 2-9 years [mean (SD) age: 60.4 (23.7) mo], selected through systematic random sampling, underwent assessment for identification and classification of neuromotor impairments (NMI). Intervention: All study subjects were first administered INDTNMI (candidate test) by a trained physician followed by expert assessment for NMI and other neurodevelopment disorders (NDD) by team of two pediatric neurologists (Gold standard). Results: According to expert evaluation, 171 (37.8%) children had neuromotor impairments. There were four categories of subjects: NMI alone (n=66); NMI+other NDDs (n=105); Other NDDs without NMI (n=225) and ‘Normal’ group (n=58). Using expert evaluation as gold standard, overall sensitivity of the INDTNMI was 75.4% and specificity was 86.8%. INDT-NMI helped graduate physicians to correctly classify 86.6% (112/129) children with NMI into different types (cerebral palsy, neuromotor diseases and other NMI). Graduate physicians assigned 40 children (8.8%) as ‘indeterminate’, 38 (95%) of whom had either NDD and/or NMI and thus merited referral. Misclassification of NMI occurred in those with mild changes in muscle tone, dystonia, or ataxia and associated NDDs. Conclusion: Graduate primary care physicians with a structured short training can administer the new tool and diagnose NMI in 2-9 year old children with high validity. INDT-NMI requires further evaluation in actual primary care settings.

Diagnosis and Management of Ureterovaginal Fistula in a Resource-Constrained Setting: Experience at a District Hospital in Northern Nigeria

During 2007 we were invited at different times to review and manage four women with ureterovaginal fistula following caesarean section performed in different rural hospitals. We describe our experience of a simple technique of diagnosis and management of these indigent patients in a resource-constrained hospital. The condition was diagnosed by the three-swab test in all four patients; and abdominopelvic ultrasound was employed to help find the ureter involved. Transvesical ureteral implantation with a stent was carried out. Stent was removed after 2 weeks. All four patients were dry. Amidst the complexity of and sophistication of modern health care; it is important to remind ourselves of the common occurrence of this distressing condition following caesarean section and the use of a well known simple diagnostic technique and subsequent management in resource-poor communities