Equity issues in gender-affirming medical care in Kerala: a reflective commentary.

Gender-affirming medical care is the provision of transition-related medical services that support a transgender person's own gender identity. Gender transitioning is a process that requires not only social support but also psychological and medical support, This paper attempts to document the challenges faced by transgender individuals (TG) especially in the context of gender affirming medical care in the Kerala context. The transition process is extremely complex as the preference for such process is varied. Some transgender individuals preferred social transition and/or medical transition to align their gender expression with their gender identity, while others chose to have a gender expression or identity outside the traditional gender binary. In Kerala, despite proactive policy and positive legal support, transgender individuals face many challenges in gender-affirming medical care which include lack of family support and equity-related issues with respect to a number of social support institutions including health services. A few possible interventions are suggested such as changes in medical curriculum, more active State support and sensitization of the society including health workers.

Clinico-epidemiological profile and outcomes of adults with COVID-19: A hospital-based retrospective study in Kerala, India.

Introduction: The clinical and epidemiological presentations of patients with coronavirus disease 2019 (COVID-19) in India is still not well explored. We studied the epidemiological and clinical profile and outcomes of COVID-19 patients admitted to a tertiary care private hospital in Kerala, India. Methods: In this retrospective study, we analyzed data of 476 adult (≥18 years) COVID-19 patients admitted to a tertiary care hospital in Kerala from September 1, 2020 to March 31, 2021. The patients were categorized into mild, moderate, and severe cases and followed till discharge or death. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23.0 with a significance set at P < 0.05. Results: The median age was 57 years (56% men). Mild, moderate, and severe cases accounted for 17%, 65%, and 18%, respectively. Around 75% had at least one comorbidity, and 51% had multiple comorbidities. The most common comorbidities were diabetes (45%), hypertension (44%), dyslipidemia (15%), and cardiac problems (12%). The elevated D-dimer values among patients in different categories were significantly different, with 74% in severe, 46% in moderate, and 19% in mild category patients. Serum ferritin, C-reactive protein, lactic acid dehydrogenase, and neutrophil to lymphocyte ratio values were significantly higher for severely ill patients. Thirty deaths (67% men) occurred during the study period, with a case fatality rate of 6.3%. Mortality mainly happened in the older age group (80%) and those with multimorbidity (90%). Conclusion: Age and multimorbidity are the major contributing factors for death in hospitalized COVID-19 patients. Generalization of the findings necessitates well-designed large-scale studies.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care.

BACKGROUND: India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders' perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India. METHODS: We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar. RESULTS: The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process. CONCLUSION: Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

India needs a resilient cancer program.

BACKGROUND: We analyzed the trends for two important cancers affecting females, breast cancer and cervical cancer, using the Indian cancer registry data and correlated the findings with selected relevant sociodemographic and behavioral indicators. METHODS: We examined National Family Health Survey data for the respective states in which registries are located, on relevant indicators like multiparity, early childbearing, cervical examination, multiple sexual partners/high-risk sexual behavior, and HIV prevalence (for cervical cancer), multiparity, early childbearing, duration of breastfeeding, overweight, alcohol use, and clinical breast examination (for breast cancer). We used Global Adult Tobacco Survey smoking data. RESULTS: The top four positions in cancer cervix were all in registries from northeast India with a higher proportion of multiparous women (≥3 births; around 40%), whereas three major metros in the south and the national capital of Delhi, all with a relatively low proportion of multiparous women (11-25%) topped the chart for breast cancer. Overweight/obesity was higher in states with a higher incidence of breast cancer (23.3-31%) compared to states with a lower incidence (12.2-16%). No clear patterns emerged with regard to alcohol consumption, duration of breastfeeding or clinical breast examination. CONCLUSION: The shift in the childbearing age group explains the increasing breast cancer rates in urban areas, whereas the persisting higher rate of multiparity explains higher cervical cancer rates especially in underserved states in the northeast. India needs to invest in transforming its cancer control program to be a more resilient one with a focus on screening and prevention.

COVID-19 and Mass Fatality Management: A Public Health Challenge.

The COVID-19 pandemic has posed a serious question over preparedness to deal with mass fatality. The current trend shows that there would be more bodies than the capacity and resources to handle them. The international agencies have alerted governments that the number of deaths may overwhelm the local capacity to handle dead bodies properly. Mass fatality management and planning are important to respecting the dignity of the deceased and surviving family. Inadequate capacity to deal with dead bodies may affect the psychological well-being of survivors which may result in distress to families and community.

Debate: COVID-19 and children in India.

The COVID-19 pandemic impact on children is a growing concern. The United Nations and its agencies (the World Health Organization and UNICEF), Indian Association For Child and Adolescent Mental Health and National Institute of Mental Health and Neuroscience in India warn about the broader impacts on children and call for urgent action to support the world's children amidst the pandemic which may have lasting consequences. The COVID-19 pandemic and unprecedented control measures to prevent its spread have disrupted nearly every aspect of children's lives - their health, development, learning, behaviour and their families' economic security, including protection from violence and abuse. Given this background, there is an urgent need for action through screening to minimize the mental health issues of children in India who constitute a substantial proportion of the population.

COVID-19: Challenges and its consequences for rural health care in India.

This commentary highlights the potential consequences of the COVID-19 pandemic for India's rural population. The rural health care system in India is not adequate or prepared to contain COVID-19 transmission, especially in many densely populated northern Indian States because of the shortage of doctors, hospital beds, and equipment. The COVID-19 pandemic creates a special challenge due to the paucity of testing services, weak surveillance system and above all poor medical care. The impacts of this pandemic, and especially the lockdown strategy, are multi-dimensional. The authors argue for the need to take immediate steps to control the spread and its aftereffects and to use this opportunity to strengthen and improve its primary health care system in rural India.

Does IgG4 level at the time of diagnosis correlate with disease outcome in IgG4-Related disease?

BACKGROUND/OBJECTIVES: Serum IgG4 level is used as a diagnostic criterion for immunoglobulin G4-related disease (IgG4-RD) but whether it predicts disease progression is unclear. Aim of the study was to investigate if serum IgG4 level at the time of diagnosis correlates with disease outcome. METHODS: Patients with a definitive diagnosis of IgG4-RD were included in this study. They were divided into two groups - Group 1: Elevated serum IgG4 at diagnosis and Group 2: Normal serum IgG4 at diagnosis. Outcome parameters including multiple organ involvement, exocrine and endocrine dysfunction, relapse and mortality were compared. Data was subanalysed for outcomes on 2 levels of serum IgG4 cut-off - A: The upper limit of normal (ULN) and B: Twice the ULN. RESULTS: Of 47 patients, 31 (66%) patients had elevated serum IgG4 at diagnosis. There was no statistically significant difference between the two groups in any of the outcome parameters. Data analysed with the serum IgG4 levels > ULN showed no difference between the 2 groups for any of the outcome parameters. However, when the serum IgG4 cut-off was set to twice the ULN, there was a significantly higher rate of disease relapse (42.9% vs 11.5%, p = 0.02) and pancreatic exocrine insufficiency (PEI) (76.2% vs 42.3%, p = 0.041). CONCLUSION: Raised serum IgG4 greater than two times the ULN was significantly associated with disease relapse and PEI in patients with IgG4-RD. Larger multicentre studies with longer follow-up are required to corroborate these findings and define the role and cut-off value of serum IgG4 in outcomes of IgG4-RD.

Universalizing health services in India: the techno-managerial fix.

The non-universal nature of health services in India can also be the result of many reforms and milestones the health services had passed through since independence. The reform era during the post-nineties is replete with many new trends in organizational strategies which could have led to crises in health services. The salient crises need to be dissected from a larger societal crisis and the specific crises in the health services system. It is evident that non-accessibility and non-availability and the sub-optimal functioning of the primary health centers are perennial issues which could not be addressed by indigenous, imposed or cocktail reforms (such as National Rural Health Mission) and by targeting as these only tinker with the health services. Needless to reiterate that there is a need to address the social dimensions which fall outside the technical sphere of health services. This paper based on an analytical review of relevant literature concludes that any efforts to universalize health and health-care can not only focus on technical components but need to address the larger social determinants and especially the societal crisis, which engender ill-health.

Role of EUS/EUS-guided FNA in the management of proximal biliary strictures.

BACKGROUND/AIMS: Optimal management of proximal biliary strictures depends on staging and adequate tissue diagnosis of suspected malignant lesions. Sensitivity of ERCP brush cytology is poor. EUS/EUS-FNA of these lesions is challenging with limited data on its diagnostic accuracy. We report our experience of EUS/ EUS guided FNA of proximal biliary strictures in a tertiary referral centre. METHODOLOGY: All patients who underwent EUS guided FNA of hilar lesions between October 2003 to July 2007 were identified. The final diagnosis was determined by surgical pathology, results of EUS-FNA or follow-up. RESULTS: 32 patients underwent 36 procedures for hilar lesions during the study period. EUS detected a mass in 9/14 patients who did not have a mass seen on imaging. The mean followup period was 39.43 months. The cytological specimen was adequate in 26 patients. The final diagnosis was adenocarcinoma (24) and benign (8). The overall accuracy, sensitivity, specificity, positive predictive value and negative predictive value of EUS-FNA were 68%, 52 %, 100%, 100% and 54%, respectively. If only adequate aspirates were included in the analysis, the values were 74%, 60%, 100%, 100% and 55% respectively. CONCLUSIONS: EUS guided FNA is a useful modality in the diagnosis and management of hilar lesions.

The use of traditional, complementary and alternative medicine in Sri Lankan cancer care: results from a survey of 500 cancer patients.

OBJECTIVES: While the introduction of biomedicine within the Sri Lankan healthcare system has resulted in reduced reliance on traditional, complementary and alternative medicine (TCAM) over the last century in Sri Lanka, treatment modalities such as Ayurveda, Sinhala and traditional religious practices still receive considerable public support. Cancer is an increasing burden in Sri Lanka, and whilst Sri Lankans are known to use TCAM for everyday ailments, there has been no research examining the role of TCAM in the context of cancer. The aim of this study was to evaluate the prevalence and patterns of TCAM use by cancer patients. STUDY DESIGN: Cross-sectional survey. METHODS: Data were obtained from two Sri Lankan hospitals using a consecutive convenience sample of 500 cancer patients currently receiving biomedical treatment, over a 10-week period in 2008. RESULTS: Analyses showed that 67.4% of those surveyed used one or more TCAM in conjunction with biomedicine for cancer treatment. The most common were Sinhala, Ayurveda and traditional religious practices. Of those patients who used TCAM, 95.0% gave the main reason for usage as 'they thought it would cure their cancer'. The strongest reason for not using TCAM was on advice from their doctor (80.5%). CONCLUSIONS: The high use of TCAM amongst cancer patients in Sri Lanka raises numerous important issues, including those related to patient safety, potential benefit, interactions with biomedical cancer treatments, and delays in seeking biomedical cancer care. Further research is needed to explore the decision-making processes of cancer patients, including the perceived benefits/limitations of key processes in biomedical and TCAM care.

Social exclusion, caste & health: a review based on the social determinants framework.

Poverty and social exclusion are important socio-economic variables which are often taken for granted while considering ill-health effects. Social exclusion mainly refers to the inability of our society to keep all groups and individuals within reach of what we expect as society to realize their full potential. Marginalization of certain groups or classes occurs in most societies including developed countries and perhaps it is more pronounced in underdeveloped countries. In the Indian context, caste may be considered broadly as a proxy for socio-economic status and poverty. In the identification of the poor, scheduled caste and scheduled tribes and in some cases the other backward castes are considered as socially disadvantaged groups and such groups have a higher probability of living under adverse conditions and poverty. The health status and utilization patterns of such groups give an indication of their social exclusion as well as an idea of the linkages between poverty and health. In this review, we examined broad linkages between caste and some select health/health utilization indicators. We examined data on prevalence of anaemia, treatment of diarrhoea, infant mortality rate, utilization of maternal health care and childhood vaccinations among different caste groups in India. The data based on the National Family Health Survey II (NFHS II) highlight considerable caste differentials in health. The linkages between caste and some health indicators show that poverty is a complex issue which needs to be addressed with a multi-dimensional paradigm. Minimizing the suffering from poverty and ill-health necessitates recognizing the complexity and adopting a perspective such as holistic epidemiology which can challenge pure technocentric approaches to achieve health status.