Evaluation of delays during diagnosis and management of lung cancer in India: A prospective observational study.

OBJECTIVE: The majority of lung cancers are diagnosed at an advanced stage; the reasons for which are variable and unclear. METHODS: Lung cancer patients were evaluated prospectively to quantify various timelines and establish reasons for delays. Timelines were defined as time intervals between symptom onset, first physician visit, first specialist visit, date of diagnosis and treatment. RESULTS: A total 410 patients were included, majority having advanced disease. The median period for a first visit to a physician was 30 days (interquartile range [IQR] 20-90), 50 days (IQR 20-110) for referral to our centre, 23 days (IQR 14-33) to reach diagnosis, and 24 days (IQR 14.5-34) to initiate treatment. Administration ofanti-tuberculosis treatment further delayed referral to specialist centre. Treatment delays were related to performance status, disease stage and treatment type. On multivariate analysis, education and histology affected diagnosis delay and treatment delay. Treatment delay was less in those who received targeted therapy compared to chemotherapy. Various time delays did not affect the overall survival. CONCLUSION: Poor education status and inappropriate anti-tubercular treatment were primary factors associated with longer diagnostic delays. Creating disease awareness and high clinical suspicion are essential to overcome these lacunae in lung cancer care.

Prognostic factors for treatment response and survival outcomes after first-line management of Stage 4 non-small cell lung cancer: A real-world Indian perspective.

Background: Indian data on treatment outcomes and survival in advanced non-small cell lung cancer (NSCLC) remain scarce. Materials and Methods: A retrospective review of 537 advanced NSCLC patients treated at a tertiary care facility in North India from January 2008 to March 2018 was done to assess treatment response and survival in terms of objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Results: Median age of enrolled patients was 60 years (range: 26-89 years). The majority were males (78.2%) and smokers (66.5%). Adenocarcinoma (51.2%) was the most common pathological type. Most patients had good performance status (PS) (the Eastern Cooperative Oncology Group [ECOG] 0 or 1 in 55.7%) and received conventional chemotherapy (86.6%). ORR and DCR after 3-4 months of first-line treatment were 55.2% and 71.75%, respectively (n = 223). Never smokers had better ORR as well as DCR compared to chronic smokers whereas treatment with tyrosine kinase inhibitors achieved significantly better ORR, and patients with good PS had better DCR compared to those with poor PS. Median PFS (n = 455) was 7.0 months (95% confidence interval [CI]: 3.7-14.0) and median OS was 11.7 months (95% CI: 5.5-29.9 months). Good PS and nonsmoking status were independent predictors of better PFS on multivariate analysis. For OS, good PS, nonsmoking behavior, and treatment with epidermal growth factor receptor inhibitors were independent predictors. Conclusion: In advanced NSCLC, never-smokers, and patients with good baseline ECOG have favorable treatment and survival outcomes. Treatment with targeted therapy results in better ORR and OS but did not affect PFS.

Spectrum of magnetic resonance imaging findings in post-COVID-19 patients presenting with rhino-orbito-cerebral mucormycosis in a teaching hospital in Malwa region of Punjab.

Background: Rhino-orbito-cerebral-mucormycosis (ROCM) associated with COVID-19 infection was at its peak during and immediately after the second wave of the pandemic in India during 2021. Many of the risk factors were implicated in the development of this deadly fungal infection, when there was a sudden surge of cases, especially who had a history of COVID-19 infection. Objectives: The objective of the study was to describe the characteristic magnetic resonance imaging (MRI) findings in invasive mucormycosis and to evaluate the extent and severity of invasive mucormycosis. Materials and Methods: A retrospective study was carried out for 4 months which included 60 patients who underwent MRI using a Siemens Avanto 1.5 Tesla scanner. During our study, 68 cases were selected based on clinicoradiological features suspected of ROCM. However, 8 patients were excluded on the basis of exclusion criteria as either there was no definitive evidence of COVID infection or were proven to be negative for mucormycosis on microbiological examination. Results: On the basis of the spectrum of MRI findings, post-COVID-19 related ROCM was broadly categorized into three stages. Out of total of 60 patients, the disease was localized to the nasal and paranasal sinus region (Stage I) in 7 patients (11.66%), extending to adjacent extrasinus orofacial soft tissue structures (Stage II) in 36 patients (60%), and intracranial extension of disease (Stage III) was seen in 17 patients (28.33%). Conclusion: In post-COVID-19 patients presenting with clinical features suspected of ROCM, MRI imaging helps in early diagnosis and staging/severity of ROCM, so that timely intervention can be planned to reduce mortality as well as morbidity.

To study heterogeneity in SARS-CoV-2 IgG response titre in patients recovered from COVID-19.

The COVID-19 pandemic caused a serious health challenge to the entire mankind. The association between clinical characteristics of disease and formation of neutralizing antibodies have not well studied. A prospective study was conducted for patients recovered from confirmed SARS-CoV-2 infections from 1st August 2020 to 28th February 2021, to study the association between SARS-CoV-2 IgG antibody response titres and clinical characteristics of the disease. A total 92 patients were included in the study. Median age was 52 years; majority were male and middle or old aged.  About 48% patients required hospitalization and 38.3% had moderate CT severity score. Positive SARS-CoV-2-IgG was detected in all patients except one. On comparing the antibody titres among various sub-groups of COVID-19 recovered patients, old age was the only factor associated with statistically significant higher antibody response (28 AU/ml for age<35 years, 53 AU/ml for age group 35-60, and 71 AU/ml for age group >60 years, p=0.01). Severity of infection, worse CT severity scores, need of hospitalization, oxygen or ventilatory support were associated with higher antibody titres but were not statistically significant. There was a strong correlation of antibody titres when analysed for age of study population (Spearman correlation=0.39, p<0.001); whereas a weak correlation (Spearman correlation=0.03, p=0.753) was seen when analysed for CT severity score. Elderly patients had higher antibody titre after recovery from Covid-19 infection. Severity of disease, need of hospitalisation or oxygen/mechanical ventilation did not influence the antibody titre.

Prediction of COVID-19 Trend in India and Its Four Worst-Affected States Using Modified SEIRD and LSTM Models.

Since the beginning of COVID-19 (corona virus disease 2019), the Indian government implemented several policies and restrictions to curtail its spread. The timely decisions taken by the government helped in decelerating the spread of COVID-19 to a large extent. Despite these decisions, the pandemic continues to spread. Future predictions about the spread can be helpful for future policy-making, i.e., to plan and control the COVID-19 spread. Further, it is observed throughout the world that asymptomatic corona cases play a major role in the spread of the disease. This motivated us to include such cases for accurate trend prediction. India was chosen for the study as the population and population density is very high for India, resulting in the spread of the disease at high speed. In this paper, the modified SEIRD (susceptible-exposed-infected-recovered-deceased) model is proposed for predicting the trend and peak of COVID-19 in India and its four worst-affected states. The modified SEIRD model is based on the SEIRD model, which also uses an asymptomatic exposed population that is asymptomatic but infectious for the predictions. Further, a deep learning-based long short-term memory (LSTM) model is also used for trend prediction in this paper. Predictions of LSTM are compared with the predictions obtained from the proposed modified SEIRD model for the next 30 days. The epidemiological data up to 6th September 2020 have been used for carrying out predictions in this paper. Different lockdowns imposed by the Indian government have also been used in modeling and analyzing the proposed modified SEIRD model.

Not just skin deep: Multiple cutaneous nodules as first presenting sign of small cell cancer.

A 65 years old male, chronic smoker (30 pack years), presented with complaints of dyspnea (mMRC grade2), cough (dry in nature), loss of appetite, loss of weight ( > 5 kgs), weakness, bony pains, feverish feeling and easy fatigability for last 2-3 months.Contrast enhanced CT chest showed bilateral extensive paraseptal and centriacinar emphysematous changes, right upper lobe spiculated heterogeneously enhancing soft tissue lesion and significant conglomerate mediastinal lymphadenopathy encasing lower trachea and great vessels.As patient was high risk for development of pneumothorax related to image guided sampling of right upper lobe lesion in view of extensive emphysema; patient was referred to us for EBUS-TBNA (endobronchial ultrasound guided transbronchial needle aspiration) guided mediastinal lymph nodes sampling. But on head to toe examination revealed round, firm, non-tender, skin coloured, 2-3 cm size skin nodules (2 on left lateral chest wall, 1 on right lateral chest wall and 1 in proximity to umbilicus).Fine needle aspiration cytology (FNAC) was attempted from two of skin nodules which was suggestive of small cell lung cancerSkin metastasis as initial presentation is reported rarely in small cell lung cancer.The index case emphasize on importance of detailed physical examination in cases of lung cancer to look for any skin manifestation of the disease, although encountered rarely.Moreover detection of skin nodules helps in staging and prognosis of diseases.

Knowledge, anxiety and the use of hydroxychloroquine prophylaxis among health care students and professionals regarding COVID-19 pandemic.

INTRODUCTION: Data regarding knowledge and attitude about COVID-19, the prevalence of acceptance of hydroxychloroquine prophylaxis and anxiety amidst COVID-19 pandemic among health care students/professionals in India is scarce. MATERIAL AND METHODS: A cross-sectional study was conducted during May 2020, using an online survey via Google forms. A self-administered validated structured questionnaire was applied, which comprised 28 questions among health care students/professionals at a tertiary care centrein North India. RESULTS: A total of 956 respondents were included (10.2% nurses, 45.2% medical students, 24.3% paramedical students, 11.7% resident doctors and 8.6% consultant doctors). Overall knowledge score was 9.3/15; the highest for preventive practices (4/5), followed by clinical knowledge (2.7/5) and the use of personal protective equipment (PPE) (2.6/5). The overall score was the highest in consultant doctors (10.8) while the lowest in nurses (8.5) and paramedical students (8.4) (p < 0.001). Less than half of the respondents had knowledge about the correct sequence of doffing PPE and the use of N95 mask. About 21.8% of the participants experienced moderate to severe anxiety; higher among nurses (38%), followed by paramedical students (29.3%); and anxiety was higher when knowledge score was low (27.6% vs 14.7%); both factors were independent predictors on multivariate analysis (p < 0.001). Only 18.1% of the respondents applied HCQ prophylaxis - the highest proportion constituted consultants (42.7%), and the least - paramedical students (5.2%); (p < 0.001) and HCQ use was more frequently used if they had a family member of extreme age group at home (23.3% vs 12.2%; p < 0.001). CONCLUSIONS: The knowledge about correct PPE usage is low among all groups of HCWs and students, and there is a high prevalence of anxiety due to COVID-19. The lower COVID-19 knowledge scores were significantly associated with a higher likelihood of anxiety and inadequate use of HCQ prophylaxis. The appliance of HCQ prophylaxis had no significant association with anxiety levels of the respondents.