Health-related quality of life and its determinants among cancer patients: evidence from 12,148 patients of Indian database

BACKGROUND

Cancer survivors experience a decrement in health-related quality of life (HRQoL) resulting from the disease as well as adverse effects of therapy. We evaluated the HRQoL of cancer patients, stratified by primary cancer site, stage, treatment response and associated adverse events, along with its determinants.

METHODS

Data were collected from 12,148 patients, sampled from seven purposively chosen leading cancer hospitals in India, to elicit HRQoL using the EuroQol questionnaire comprising of 5-dimensions and 5-levels (EQ-5D-5L). Multiple linear regression was used to determine the association between HRQoL and various socio-demographic as well as clinical characteristics.

RESULTS

Majority outpatients (78.4%) and inpatients (81.2%) had solid cancers. The disease was found to be more prevalent among outpatients (37.5%) and inpatients (40.5%) aged 45-60 years and females (49.3-58.3%). Most patients were found to be in stage III (40-40.6%) or stage IV (29.4-37.3%) at the time of recruitment. The mean EQ-5D-5 L utility score was significantly higher among outpatients [0.630 (95% CI: 0.623, 0.637)] as compared to inpatients [0.553 (95% CI: 0.539, 0.567)]. The HRQoL decreased with advancing cancer stage among both inpatients and outpatients, respectively [stage IV: (0.516 & 0.557); stage III (0.609 & 0.689); stage II (0.677 & 0.713); stage I (0.638 & 0.748), p value < 0.001]. The outpatients on hormone therapy (B = 0.076) showed significantly better HRQoL in comparison to patients on chemotherapy. However, palliative care (B=-0.137) and surgery (B=-0.110) were found to be associated with significantly with poorer HRQoL paralleled to chemotherapy. The utility scores among outpatients ranged from 0.305 (bone cancer) to 0.782 (Leukemia). Among hospitalized cases, the utility score was lowest for multiple myeloma (0.255) and highest for testicular cancer (0.771).

CONCLUSION

Older age, lower educational status, chemotherapy, palliative care and surgery, advanced cancer stage and progressive disease were associated with poor HRQoL. Our study findings will be useful in optimising patient care, formulating individualized treatment plan, improving compliance and follow-up.

Cost-Effectiveness of Novel Agent Regimens for Transplant-Eligible Newly Diagnosed Multiple Myeloma Patients in India

BACKGROUND

Survival outcomes for multiple myeloma have improved dramatically since the introduction of novel therapeutic agents. While these drugs are highly effective in improving survival outcomes and quality of life in patients with multiple myeloma, they come at a significant cost. We assessed the cost-effectiveness of bortezomib-based triplet or quadruplet drug regimens in isolation and followed by autologous hematopoietic stem cell transplantation (AHSCT) for the treatment of newly diagnosed multiple myeloma (NDMM) in the Indian context.

METHODS

A Markov model was developed to assess the health and economic outcomes of novel drug regimens with and without AHSCT for the treatment of NDMM in India. We estimated the lifetime quality-adjusted life-years (QALYs) and costs in each scenario. The incremental cost-effectiveness ratios (ICERs) were computed and compared against the current willingness-to-pay threshold of a one-time per capita gross domestic product of ₹146,890 (US$1,927.70) for India. Parameter uncertainty was assessed through Monte Carlo probabilistic sensitivity analysis.

RESULTS

Among seven treatment sequences, the VCd (bortezomib, cyclophosphamide, dexamethasone) alone arm has the lowest cost and health benefits as compared to four treatment sequences, namely VTd (bortezomib, thalidomide, dexamethasone) alone, VRd (bortezomib, lenalidomide, dexamethasone) alone, VRd plus AHSCT and DVRd (Daratumumab, bortezomib, lenalidomide, dexamethasone) plus AHSCT. It was found that VTd plus AHSCT and VCd plus AHSCT arms were extendedly dominated (ED) by combination of two alternative treatments. Among the five non-dominated strategies, VRd has a lowest incremental cost of ₹ 2,20,093 (US$2,888) per QALY gained compared to VTd alone followed by VRd plus AHSCT [₹3,14,530 (US$4,128) per QALY gained] in comparison to VRd alone. None of the novel treatment sequences were found to be cost-effective at the current WTP threshold of ₹1,46,890 (US$1,927.7).

CONCLUSION

At the current WTP threshold of one-time per capita GDP (₹ 146,890) of India, VRd alone and VRd plus AHSCT has 38.1% and 6.9% probability to be cost-effective, respectively. Reduction in current reimbursement rates of novel drugs, namely VRd, lenalidomide, and pomalidomide plus dexamethasone under national insurance program and societal cost of transplant by 50%, would make VRd plus AHSCT and VTd plus AHSCT cost-effective at an incremental cost of ₹40,671 (US$34) and ₹97,639 (US$1,281) per QALY gained, respectively.

Cost-Effectiveness Analysis of Denosumab in the Prevention of Skeletal-Related Events Among Patients With Breast Cancer With Bone Metastasis in India

PURPOSE

Denosumab is clinically superior to zoledronic acid (ZA) for preventing and delaying time to first and subsequent skeletal-related events (SREs) among patients with breast cancer (BC) with bone metastases. We evaluated the cost and health benefits of denosumab and ZA (once every 4 weeks and once every 12 weeks) among four different molecular subtypes of BC with bone metastases in India.

MATERIALS AND METHODS

A Markov model was developed in Microsoft Excel to estimate lifetime health consequences and resulting costs among cohort of 1,000 patients with BC with bone metastasis, for three intervention scenarios, namely denosumab (once every 4 weeks), ZA (once every 4 weeks), and ZA (once every 12 weeks). The health outcomes were measured in terms of SREs averted and quality-adjusted life-years (QALYs) gained. The cost of each intervention scenario was measured using both the health system and the patient's perspectives. Indirect costs because of lost productivity were not included. The future costs and outcomes were discounted at the standard rate of 3%.

RESULTS

Over a lifetime, the incremental number of SREs averted with use of denosumab once every 4 weeks (compared with ZA once every 4 weeks and once every 12 weeks) among patients with luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple negative breast cancer were estimated as 0.39, 0.26, 0.25, and 0.19, respectively. The number of QALYs lived were slightly higher in the denosumab arm (1.45-2.80) compared with ZA once every 4 weeks and once every 12 weeks arms (1.44-2.78). However, denosumab once every 4 weeks was not found to be a cost-effective alternative for either of the four molecular subtypes of breast cancer. ZA once every 12 weeks was found to be a cost-effective option with an average cost-effectiveness ratio ranging between ₹68,254 and ₹73,636.

CONCLUSION

ZA once every 12 weeks is the cost-effective treatment option for BC with bone metastases in India. The present study findings hold significance for standard treatment guidelines under India's government-funded health insurance program.

Financial toxicity of cancer treatment in India: towards closing the cancer care gap

Background

The rising economic burden of cancer on patients is an important determinant of access to treatment initiation and adherence in India. Several publicly financed health insurance (PFHI) schemes have been launched in India, with treatment for cancer as an explicit inclusion in the health benefit packages (HBPs). Although, financial toxicity is widely acknowledged to be a potential consequence of costly cancer treatment, little is known about its prevalence and determinants among the Indian population. There is a need to determine the optimal strategy for clinicians and cancer care centers to address the issue of high costs of care in order to minimize the financial toxicity, promote access to high value care and reduce health disparities.

Methods

A total of 12,148 cancer patients were recruited at seven purposively selected cancer centres in India, to assess the out-of-pocket expenditure (OOPE) and financial toxicity among cancer patients. Mean OOPE incurred for outpatient treatment and hospitalization, was estimated by cancer site, stage, type of treatment and socio-demographic characteristics. Economic impact of cancer care on household financial risk protection was assessed using standard indicators of catastrophic health expenditures (CHE) and impoverishment, along with the determinants using logistic regression.

Results

Mean direct OOPE per outpatient consultation and per episode of hospitalization was estimated as ₹8,053 (US$ 101) and ₹39,085 (US$ 492) respectively. Per patient annual direct OOPE incurred on cancer treatment was estimated as ₹331,177 (US$ 4,171). Diagnostics (36.4%) and medicines (45%) are major contributors of OOPE for outpatient treatment and hospitalization, respectively. The overall prevalence of CHE and impoverishment was higher among patients seeking outpatient treatment (80.4% and 67%, respectively) than hospitalization (29.8% and 17.2%, respectively). The odds of incurring CHE was 7.4 times higher among poorer patients [Adjusted Odds Ratio (AOR): 7.414] than richest. Enrolment in PM-JAY (CHE AOR = 0.426, and impoverishment AOR = 0.395) or a state sponsored scheme (CHE AOR = 0.304 and impoverishment AOR = 0.371) resulted in a significant reduction in CHE and impoverishment for an episode of hospitalization. The prevalence of CHE and impoverishment was significantly higher with hospitalization in private hospitals and longer duration of hospital stay (p < 0.001). The extent of CHE and impoverishment due to direct costs incurred on outpatient treatment increased from 83% to 99.7% and, 63.9% to 97.1% after considering both direct and indirect costs borne by the patient and caregivers, respectively. In case of hospitalization, the extent of CHE increased from 23.6% (direct cost) to 59.4% (direct+ indirect costs) and impoverishment increased from 14.1% (direct cost) to 27% due to both direct and indirect cost of cancer treatment.

Conclusion

There is high economic burden on patients and their families due to cancer treatment. The increase in population and cancer services coverage of PFHI schemes, creating prepayment mechanisms like E-RUPI for outpatient diagnostic and staging services, and strengthening public hospitals can potentially reduce the financial burden among cancer patients in India. The disaggregated OOPE estimates could be useful input for future health technology analyses to determine cost-effective treatment strategies.

GC-MS and NMR spectroscopy based metabolite profiling of Panchvalkal kwath (polyherbal formulation)

Panchvalkal kwath (PK) is a bark formulation of five pharmacologically important plants, i.e., Ficus benghalensis, Ficus racemosa, Ficus religiosa, Thespesia populnea, and Ficus lacor. The Ayurvedic formulation is being used since ancient times to cure diabetes, bacterial infections and heal wounds. The present study aims to identify the metabolite profiles of PK which could explain its properties and its mode of action against specific diseases and disorders. The aqueous extract of Panchvalkal is prepared through a hot maceration process. The extract is subjected to preliminary identification of phytoconstituents and FTIR spectroscopy to recognize functional groups. GC-MS analysis reveals that the extract is enriched with 24-Norursa-3,12-diene (25.16%); Lup-20(29)-en-3-one (16.76%); 2-methyl-3-(4-propan-2-ylphenyl) propanal (7.04%); 2-(hydroxymethyl)-2-nitropropane-1,3-diol (11.21%) and 3,5-dihydroxy-6-methyl-2,3-dihydropyran-4-one (4.15%). The presence of three new phytocompounds that are 4-(hydroxymethyl)-7-methyl-1,3-dioxepane-5,6-diol; 1-(4-isopropylphenyl)-2-methylpropylacetate and 4,4,6 A,6B,8A,11,11,14B-octamethyl-1,4,4A,5,6,6A,8,8a,910,11,12,12a,12b,13,14,14a,14b-ctadecahydro-3(2H)-picenone are detected in the extract. Metabolite profiles of the extract also constitute isoeugenol, stigmasterol, ergosterol, ocimene, myrcene, squalene, sphingosine, betulin, methyl ferulate and cis-jasmone, which are unraveled by 1 D ¹H and 2 D ¹H-¹³C HSQC NMR spectroscopy. This article focuses on the presence of different phytocompounds in PK in order to demonstrate its efficacy as a therapeutic formulation for a variety of diseases.

Diagnostic Accuracy of Screening of Lip and Oral Cavity Cancers or Potentially Malignant Disorders (PMD) by Frontline Workers: A Systematic Review and Meta-Analysis

BACKGROUND

Oral cancer screening strategies help reduce associated mortality and could be performed by a trained frontline health worker (FHW). The present review aims to assess the diagnostic accuracy of commonly used screening modalities for oral cancer performed by FHW in apparently healthy individuals.

METHODS

Electronic databases PubMed, Scopus, Embase, Cochrane Library, and Google Scholar, were searched. The review included studies conducted where apparently healthy adult individuals were screened by the FHW for cancer or PMD of the lip and oral cavity by any of the four commonly used techniques - Conventional Oral Examination (COE), toluidine blue staining (TBS), Oral Cytology (OC), and Chemiluminescent Illumination (CLI).

FINDINGS

A total of 2,413 potentially relevant articles were retrieved from the search, among which five studies for COE were included in the review. Four out of those five studies were done before the year 2000. None of the studies fitted the inclusion criteria for TBS, OC, and CLI. Pooled sensitivity of oral screening by COE performed by an FHW (n=5) was 88.8% (95% CI: 71.6-96.1), whereas pooled specificity was 91.9% (95% CI: 78.3-97.3). On subgroup analysis, the pooled sensitivity and specificity of studies where the prevalence of disease was <50% (n=4) was 84.5% (95% CI: 62.6 - 94.7) and 94.1% (95% CI: 82.2 - 98.2), respectively.

INTERPRETATION

COE by trained FHW had high pooled sensitivity and specificity for screening of oral cancer and PMDs. The screening techniques TBS, OC, and CLI, were not studied for mass screening by trained FHW. COE by trained FHW could be utilized for oral screening in limited-resource settings. However, the FHW should be sufficiently trained to get the desired benefits of early detection.

FUNDING

Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Sensing of mercury ion using light induced aqueous leaf extract mediated green synthesized silver nanoparticles of Cestrum nocturnum L

In this study, a simple, one-pot, and eco-friendly biosynthesis of silver nanoparticles (AgNPs) was accomplished with the use of aqueous leaves extract of Cestrum nocturnum L.(AECN). Different techniques like ultraviolet-visible (UV-Vis) spectrophotometry, Fourier transform infrared (FTIR), X-ray diffraction (XRD), transmission electron microscopy (TEM), and scanning area electron diffraction were used to investigate the optical, operational, and physical properties of the green synthesized AECN-AgNPs.The AECN-AgNPs were further used for the detection of Hg²⁺ by UV-Vis and electrochemical methods. The disintegration of the AECN-AgNPs solution caused the formation of an Ag-Hg amalgam, which caused discoloration of the solution. Sensing performance for a variety of metals such as Na⁺, K⁺, Mg²⁺, Ca²⁺, Ni²⁺, Cu ²⁺, Fe³⁺, Zn²⁺, Co²⁺, Cd²⁺, Pb²⁺, As³⁺, and Mn²⁺ at 10-mM concentrations was measured in order to determine the selectivity of the sensor towards the Hg²⁺. For the electrochemical determination of 2 + Hg²⁺ , AECN-AgNPs were immobilized on a glassy carbon (GC) electrode, and the resulting modified electrode (GC/AECN-AgNPs) was characterized by cyclic voltammetry. This phenomenon is advantageously used for the sensitive determination of trace level Hg²⁺. GC/AECN-AgNPs demonstrated a linear calibration range of 100 nM to 10 μM and a limit of detection of 21 nM for Hg²⁺ determination.

Efficient Catalytic Degradation of Selected Toxic Dyes by Green Biosynthesized Silver Nanoparticles Using Aqueous Leaf Extract of Cestrum nocturnum L

In the present study, the catalytic degradation of selected toxic dyes (methylene blue, 4-nitrophenol, 4-nitroaniline, and congo red) using biosynthesized green silver nanoparticles (AgNPs) of Cestrum nocturnum L. was successfully performed. These AgNPs are efficiently synthesized when a reaction mixture containing 5 mL of aqueous extract (3%) and 100 mL of silver nitrate (1 mM) is exposed under sunlight for 5 min. The synthesis of AgNPs was confirmed based on the change in the color of the reaction mixture from pale yellow to dark brown, with maximum absorbance at 455 nm. Obtained NPs were characterized by different techniques, i.e., FTIR, XRD, HR-TEM, HR-SEM, SAED, XRD, EDX, AFM, and DLS. Green synthesized AgNPs were nearly mono-dispersed, smooth, spherical, and crystalline in nature. The average size of the maximum number of AgNPs was 77.28 ± 2.801 nm. The reduction of dyes using a good reducing agent (NaBH₄) was tested. A fast catalytic degradation of dyes took place within a short period of time when AgNPs were added in the reaction mixture in the presence of NaBH₄. As a final recommendation, Cestrum nocturnum aqueous leaf extract-mediated AgNPs could be effectively implemented for environmental rehabilitation because of their exceptional performance. This can be utilized in the treatment of industrial wastewater through the breakdown of hazardous dyes.

Burden of Group A Streptococcal Pharyngitis, Rheumatic Fever, and Rheumatic Heart Disease in India: A Systematic Review and Meta-Analysis

OBJECTIVE

To estimate the burden of group A streptococcal pharyngitis (GAS) pharyngitis, rheumatic fever (RF), and rheumatic heart disease (RHD) in India using existing data sources, as well as to recognize the most serious gaps in GAS disease burden data.

METHODS

Four electronic databases-PubMed, Scopus, Embase, and Web of Science were searched using a comprehensive search strategy. Data were identified primarily from observational studies including school surveys, community-based and hospital-based studies. The standard methodological procedures as per Cochrane guidelines were used. Eligible studies were pooled for estimating prevalence, incidence, and case fatality rate using R software version 3.3.3. The protocol was registered with PROSPERO; registration number CRD42018075742.

RESULTS

The pooled prevalence of GAS pharyngitis among asymptomatic children and pharyngitis cases aged 5 to 15 y was estimated as 2.79 percent [95% Confidence interval (CI): 1.58-4.89] and 13 percent (95% CI: 3.18-41.97), respectively. The prevalence rate of rheumatic fever was found to be 0.04% (95% CI: 0.01-0.17). The pooled prevalence rate of RHD among children aged 5-15 y using clinical auscultation and echocardiography was estimated as 0.36 percent (95% CI: 0.02-7.52) and 0.28 percent (95% CI: 0.08-1.03), respectively.

CONCLUSION

The study emphasizes the importance of developing a population-based surveillance framework to track patterns, management strategies, and outcomes in order to develop informed recommendations for launching contextual measures to regulate RF and RHD.

Cost Effectiveness of Ribociclib and Palbociclib in the Second-Line Treatment of Hormone Receptor-Positive, HER2-Negative Metastatic Breast Cancer in Post-Menopausal Indian Women

BACKGROUND

In this study, we evaluate the cost and outcomes of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) plus fulvestrant, fulvestrant alone, and conventional chemotherapy as the second-line therapy for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in India.

METHODS

Using a Markov model, the clinical effectiveness of managing HR+, HER2- MBC in postmenopausal women with either a CDK4/6i (either ribociclib or palbociclib) and fulvestrant, fulvestrant alone, and chemotherapy (single-agent paclitaxel or capecitabine) was measured in terms of quality-adjusted life-years (QALYs). The costs were estimated from two different points of view: scenario I, as per the prevailing market prices of the drugs; and scenario II, as per the reimbursement rates set up by the publicly financed national health insurance scheme. Incremental cost per QALY gained with a given treatment option was compared against the next best alternative and was assessed for cost effectiveness using a threshold of 1-time the per capita gross domestic product (GDP) in India from a societal perspective.

RESULTS

In scenario I, an MBC patient was found to incur a lifetime cost of Indian Rupees (₹) 2.54 million ($34,644), ₹2.53 million ($34,496), ₹512,598 ($6,984), ₹326,026 ($4,442) and ₹237,115 ($3,230) for the ribociclib and palbociclib combination arms, fulvestrant monotherapy, single-agent paclitaxel and the single-agent capecitabine treatment arms, respectively. The lifetime cost for CDK4/6i (ribociclib and palbociclib) combination therapy, fulvestrant monotherapy, paclitaxel, and capecitabine arms was estimated to be ₹1.94 million ($26,459), ₹1.92 million ($26,220), ₹315,387 ($4,296), ₹187,392 ($2,553) and ₹153,263 ($2,088), respectively, in scenario II. The mean QALYs lived per MBC patient with CDK4/6i (either ribociclib or palbociclib) combination therapy, fulvestrant, paclitaxel and capecitabine were estimated to be 1.4, 1.0, 0.9 and 0.7, respectively. None of the treatment arms are cost effective at current prices and reimbursement rates at a threshold of 1-time the per capita GDP of India. However, a 78% reduction in the current market price or a 72% reduction in the reimbursement rate of fulvestrant in the government-funded insurance program will make it a cost-effective treatment option for HR+, HER2- MBC patients in India.

CONCLUSION

CDK4/6i (ribociclib and palbociclib) therapy is not a cost-effective treatment option for MBC patients. A 72% reduction in the reimbursement rate for fulvestrant monotherapy will make it a cost-effective treatment option in the Indian context.

AB0586 OCULAR ISCHEMIC SYNDROME CAUSING ACUTE BINOCULAR VISION LOSS IN THREE PATIENTS WITH TAKAYASU ARTERITIS TYPE V: A THERAPEUTIC QUANDARY

Background

Ocular Ischemic syndrome (OIS) is a rare manifestation in Takayasu Arteritis (TA) which can cause irreversible retinal ischemia and neovascular changes. Ocular Ischemic syndrome denotes hypoperfusion of both anterior and posterior segments of eye and orbital structures as a result of common/internal carotid artery occlusion1,2. Although described as a chronic phenomenon, we report three young female patients, diagnosed Takayasu Arteritis Type V (Angiographic Classification) who presented to us with acute binocular loss of vision which were managed with individually tailored approaches to restore vision.

Objectives

1.To elaborate on three patients diagnosed Takayasu Arteritis type V presenting with acute onset binocular vision loss and discuss critical aspects of management in OIS.

Methods

Case series of three patients of TA satisfying 1990 ACR classification criteria.

Results

18-year-old female presented with acute onset painless loss of vision in both eyes and severe vertigo. She appreciated hand motion on visual acuity testing. She was started on Methotrexate (MTX)and Prednisolone (PSL). In view of acute vertebrobasilar and carotid insufficiency, she underwent bilateral carotid and vertebral angioplasty. She tested 20/80 on visual acuity in both eyes and ambulated without support by two weeks after procedure.

15-year-old female presented with episodic vertigo, amaurosis fugax and claudication of both upper and lower limbs. She was kept on MTX and tapering doses of PSL and when dose of PSL reached less than 0.25mg/kg, she developed acute binocular vision loss with absent pupillary reflexes. Visual acuity testing revealed perception of hand motion in both eyes which improved to 20/40 within 2 weeks after increasing steroid dose to 0.5mg/kg and tocilizumab.

14-year-old female presented with acute binocular painless vision loss with previous history of limb claudication. Examination revealed no light perception on visual acuity testing in both eyes with absent pupillary reflexes. She was started on tapering doses of PSL and MTX. Also, she underwent a bilateral carotid and vertebral artery angioplasty. By first week, she could identify hand motion in both eyes and is continued on inpatient care.

Conclusion

We suggest that combining vascular surgical and pharmacological intervention in acute vision loss in TA may restore vision, even in active disease. Prompt follow-up and wider sample size is needed to draw insights into ocular involvement in TA.

References

[1]Peter J, David S, Joseph G, Horo S, Danda D. Hypoperfusive and hypertensive ocular manifestations in Takayasu arteritis. Clin Ophthalmol 2010;4:1173-1176.

[2]Peter J, David S, Danda D, Peter JV, Horo S, Joseph G. Ocular manifestations of Takayasu arteritis: a cross-sectional study. Retina. 2011 Jun;31(6):1170-8

Figure 1. Picture attached showing a)Fundus angiogram – increased foveal avascular zone

b)Fundus image -ischemic changes

c)CT Aortogram -Bilateral Carotid and subclavian stenosis

Table 1.

Characteristics of patients of TA with acute binocular vision loss

AgeDuration(years)Absent peripheral pulseHypertensionCRP levelsCT aortogram involvementTA typeFundus angiogram findingsFundus examination181Both brachial and radialNoHighBoth proximal subclavian arteries, common carotid, Infrarenal aorta, coeliac and superior mesenteric arteriesVcapillary non perfusion areasNormal152Both brachial, radial, right popliteal and Dorsalis pedis.YesHighBoth subclavian arteries, common carotid, renal and iliac arteries with >50% narrowing of abdominal aortaVcapillary non perfusion areasGrade II Hypertensive retinopathy144Left Brachial and radialYesNormalBoth subclavian, renal, iliac arteries and > 70% diffuse stenosis of bilateral carotidsVincreased foveal avascular zone, capillary non perfusion areasCotton wool spots, venous engorgements

Disclosure of Interests

None declared

AB1501 EFFECT OF SARS-COV-19 PANDEMIC ON RHEUMATOLOGY TRAINING IN INDIA

Background

The current study aims to gauge the magnitude of the effect the pandemic has had on Rheumatology training (including the effect on clinical, academic and research training) in India, their physical, mental and social wellbeing during the pandemic and the perceived changes in Rheumatology training and care during the pandemic from the trainee’s view

Objectives

1.To asses the Impact of COVID-19 Pandemic on the training of Rheumatology Residents (DM, DNB and Fellows)

2.Understand the issues faced by trainees and the extent of affection.

Methods

Study design: We conducted an observational cross-sectional study using an online survey sent to rheumatology trainees in India.

Sample: Convenience sampling was used, so the sample size was not calculated.

Inclusion and exclusion criteria: Rheumatology trainees from India including DM/DNB residents and fellows with the ability and desire to complete the survey were included.

Data collection and instruments: The link to the survey was sent to the rheumatology trainees through social media platforms like WhatsApp, Telegram and email.

Statistical analysis: Descriptive statistics were performed by calculating measures of central tendency for quantitative variables and using counts and percentages for qualitative and nominal variables.

Results

A total of 78 trainees from 24 institutes in 12 states participated in the study. Mean age of the participants was 31 with 70% of trainees being male and 30 % females. 56 (70%) participants were DM students, 15 (19%) participants were DNB students, 5 fellowship students and 2 Non- academic Senior Residents. An overwhelming majority of residents (84%) felt COVID-19 Pandemic Negatively impacted their residency and their Physical (65%), Mental(74%) and Social wellbeing (80%). 79% of trainees felt burnt-out due to the pandemic. Majority of trainee felt the pandemic negatively impacted their training with clinical teaching(91%), Clinical examination skill (74%), current(80%) and future(70%) research opportunities suffered during the pandemic. Most residents felt diminution and significant reduction of the overall footfall(99% & 72%) of patients in rheumatology including OPD(100% & 77%) and indoor(99% & 67%) admissions along with academics(85% & 35%), procedures(97% & 66%) and exposure to musculoskeletal ultrasound(96% & 71%). Almost 60% and 40% of trainees had their OPDs and indoor admissions stopped during COVID-19 pandemic of these 20% had their OPDs and Admissions closed for more than 6 months. 85% of the participants had one or the other psychological symptoms with almost half experiencing anxiety(44%), low mood(47%) or lack of sleep(41%); 85% were concerned about their family members being infected and 40% lost a close relative to COVID. 91% of the trainee were posted in COVID-duties 2/3rd of them in ICUs, 50% being posted for 1-3 months and 20% more than 3 months, a quarter of trainees got infected during their duties (COVID and Non-COVID) and though most had asymptomatic to mild COVID, 15% still had moderate to severe COVID. Teleconsultation was started by more than half of the respondents after COVID related lockdowns with greater than half not being happy with teleconsultations.

Conclusion

The COVID-19 Pandemic has completely altered the status quo for rheumatology trainees and has affected their physical, social and mental wellbeing. Academic and clinical training has reduced, Current and future Research has become difficult, disruptions in OPDs and Admissions, recurrent COVID postings and reduction in patient footfall, Procedures and MSK-US have been detrimental to trainees.

References

[1]Chandwar K, Dixit J, Kishor K, Ekbote D,Dogga P. COVID‑19 anniversary – The hits, the misses, and the wayforward: A resident’s view. Indian J Rheumatol 2021; 10.4103/injr.injr_97_21

Disclosure of Interests

None declared

AB1086 VACCINE HESITANCY AGAINST COVID-19 VACCINES IN PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASES AND EFFECT OF SPECIALIST COUNSELLING ON VACCINE HESITANT PATIENTS WILLINGNESS TO TAKE VACCINE

Background

Vaccination is one of the most significant public health achievements; however, the success has been marred with vaccine hesitancy. The reasons for vaccine hesitancy are neither singular nor straightforward and arise from a complex interplay between scientific, religious and political beliefs. This study aims to understand the possible reasons for vaccine hesitancy in patients with autoimmune rheumatic diseases and the effectiveness of Specialist counselling on vaccine-hesitant patients willingness to take the vaccine.

Objectives

1. To assess causes of Vaccine hesitancy against COVID-19 vaccines in patients with autoimmune rheumatic diseases.

2. To study the effect of specialist counselling on vaccine-hesitant patients willingness to take vaccine.

Methods

Study design: We conducted an observational survey-based in person cross-sectional study. Patients attending a tertiary care hospital’s outpatient department were asked about their vaccination status. Those unvaccinated were asked reasons for vaccine hesitancy The vaccine-hesitant patients were counselled by the treating rheumatologist and asked regarding their willingness to take the vaccine after the counselling. The patient responses were recorded.

Sample: Convenience sampling was used, so the sample size was not calculated.

Inclusion and exclusion criteria: All adults(>18yrs) with AIRD coming to the rheumatology OPD. Those vaccinated, recently infected(within 6 weeks), and non-AIRD patients were excluded.

Data collection: The questionnaire included patients’ demographic details, Diagnosis, medication details, and response to the reason for vaccine hesitancy.

Statistical analysis: Descriptive statistics were performed by calculating measures of central tendency for quantitative variables and using counts and percentages for qualitative and nominal variables.

Results

A total of 322 patients participated in the study with a mean age of 40 years(18-76), with 73%(234) females and 27%(88) males. Most patients had Rheumatoid Arthritis(40%) followed by SPA (27%), SLE(13%) and others and may were on immunosuppressive medications(95%). A significant proportion of patients(60%) had more than one reason for vaccine hesitancy. Almost 60% of the respondents feared their disease might flare post-vaccination, while almost half(44.4%) were hesitant to take the vaccine due to the fear of vaccine side effects and more than one third (35%) feared vaccine may not be effective on them as they were on immunosuppressive medications. Other major causes of vaccine hesitancy were the inability to get a chance to get vaccinated (18%), doubts about vaccine efficacy (15%), and fear of injections (10%).Most patients(91%) were willing to take the vaccine after specialist counselling and only 28 of the 322 (9%) were unwilling even after specialist counselling.

Conclusion

Vaccine hesitancy can be multifactorial. Major reasons for vaccine hesitancy in patients with autoimmune rheumatic diseases were fear of flare of disease post-vaccination, fear of vaccine side effects and doubts whether the vaccine would work in patients taking immunosuppressive medications. Most patients were willing to take vaccine after counselling by a rheumatologist.

Disclosure of Interests

None declared

Cost Effectiveness of Bevacizumab Plus Chemotherapy for the Treatment of Advanced and Metastatic Cervical Cancer in India-A Model-Based Economic Analysis

Patients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India.

Health related quality of life among Rheumatic Fever and Rheumatic Heart Disease patients in India

Background

Measurement of health-related quality of life (HRQOL) of people with chronic illnesses has become extremely important as the mortality rates associated with such illnesses have decreased and survival rates have increased. Thereby, such measurements not only provide insights into physical, mental and social dimensions of patient’s health, but also allow monitoring of the results of interventions, complementing the traditional methods based on morbidity and mortality.

Objective

The present study was conducted to describe the HRQOL of patients suffering from Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD), and to identify socio-demographic and clinical factors as predictors of HRQOL.

Methodology

A cross-sectional study was conducted to assess the HRQOL among 702 RF and RHD patients using EuroQol 5-dimensions 5-levels instrument (EQ-5D-5L), EuroQol Visual Analogue Scale and Time Trade off method. Mean EQ-5D-5L quality of life scores were calculated using EQ5D index value calculator across different stages of RF and RHD. Proportions of patients reporting problems in different attributes of EQ-5D-5L were calculated. The impact of socio-economic determinants on HRQOL was assessed.

Results

The mean EQ-5D-5L utility scores among RF, RHD and RHD with Congestive heart failure patients (CHF) were estimated as 0.952 [95% Confidence Interval (CI): 0.929–0.975], 0.820 [95% CI: 0.799–0.842] and 0.800 [95% CI: 0.772–0.829] respectively. The most frequently reported problem among RF/RHD patients was pain/discomfort (33.8%) followed by difficulty in performing usual activities (23.9%) patients, mobility (22.7%) and anxiety/depression (22%). Patients with an annual income of less than 50,000 Indian National Rupees (INR) reported the highest EQ-5D-5L score of 0.872, followed by those in the income group of more than INR 200,000 (0.835), INR 50,000–100,000 (0.832) and INR 100,000–200,000 (0.828). Better HRQOL was reported by RHD patients (including RHD with CHF) who underwent balloon valvotomy (0.806) as compared to valve replacement surgery (0.645).

Conclusion

RF and RHD significantly impact the HRQOL of patients. Interventions aiming to improve HRQOL of RF/RHD patients should focus upon ameliorating pain and implementation of secondary prevention strategies for reducing the progression from ARF to RHD and prevention of RHD-related complications.

Development of National Cancer Database for Cost and Quality of Life (CaDCQoL) in India: a protocol

INTRODUCTION

The rising economic burden of cancer on healthcare system and patients in India has led to the increased demand for evidence in order to inform policy decisions such as drug price regulation, setting reimbursement package rates under publicly financed health insurance schemes and prioritising available resources to maximise value of investments in health. Economic evaluations are an integral component of this important evidence. Lack of existing evidence on healthcare costs and health-related quality of life (HRQOL) makes conducting economic evaluations a very challenging task. Therefore, it is imperative to develop a national database for health expenditure and HRQOL for cancer.

METHODS AND ANALYSIS

The present study proposes to develop a National Cancer Database for Cost and Quality of Life (CaDCQoL) in India. The healthcare costs will be estimated using a patient perspective. A cross-sectional study will be conducted to assess the direct out-of-pocket expenditure (OOPE), indirect cost and HRQOL among cancer patients who will be recruited at seven leading cancer centres from six states in India. Mean OOPE and HRQOL scores will be estimated by cancer site, stage of disease and type of treatment. Economic impact of cancer care on household financial risk protection will be assessed by estimating prevalence of catastrophic health expenditures and impoverishment. The national database would serve as a unique open access data repository to derive estimates of cancer-related OOPE and HRQOL. These estimates would be useful in conducting future cost-effectiveness analyses of management strategies for value-based cancer care.

ETHICS AND DISSEMINATION

Approval was granted by Institutional Ethics Committee vide letter no. PGI/IEC-03/2020-1565 of Post Graduate Institute of Medical Education and Research, Chandigarh, India. The study results will be published in peer-reviewed journals and presented to the policymakers at national level.

Toxicity profiling and antioxidant activity of ethyl acetate extract of leaves of Premna integrifolia L. for its application as protective agent against xenobiotics

Premna integrifoliaL. (Lamiaceae) is widely used in herbal formulation “Dashmoolarishta” which is useful in postnatal care. Ethyl acetate extract obtained from the leaves was evaluated for phenolic content and its antioxidant activity. Acute and subacute toxicity of the extract was studied in mice of both sexes to get an idea about LD₅₀ value and assessed its safety profile before its application as a protective agent against different toxicities induced by xenobiotics. Phenol enriched extract (phenol content is 63.10 ± 1.26 mg/g of gallic acid equivalent and flavonoid content 75.33 ± 0.23 mg/g of rutin equivalent) showed good antioxidant activity. In acute toxicity studies it was observed that single different doses (300−5000 mg/kg b.wt.) of extract did not show any mortality of mice. Thus the LD₅₀ of the extract was determined, and it was higher than 5000 mg/kg. There was no major change in behavioral and general appearance of mice. External morphology of liver, kidneys, lungs, spleen and heart did not show any effect of treatment. In subacute toxicity no statistically significant change in body weight, relative organ weight, food intake and water uptake, hematological, biochemical parameters were reported after comparison with control. Extract did not show significant effect in the level of antioxidant enzymes in the liver of mice of treated groups. No histopathological changes were observed in liver and kidney tissues. Thus, extract did not show any sign of toxic effects, when administered orally to male and female mice at dose level up to 1000 mg/kg. So, it can be utilized as protective agent against toxicity produced by different xenobiotics.

Cost of Treatment of Valvular Heart Disease at a Tertiary Hospital in North India: Policy Implications

BACKGROUND

Lack of data on the cost of cardiac care is an impediment to evidence-based planning, especially for determining provider payment rates under publically financed health insurance schemes.

OBJECTIVE

This study estimates the unit costs of outpatient consultation, hospitalization, intensive care, selected surgical procedures and diagnostics for providing cardiac care for valvular heart disease at a tertiary hospital in India.

METHODS

We undertook an economic costing of cardiac care using both patient and health system perspectives. For the health system costs, a bottom-up costing methodology was used. Data on all resources (capital and recurrent) utilized for the delivery of cardiac care services for valvular heart disease for 1 year were collected. Data on out-of-pocket expenditures was collected from 100 cardiac patients who underwent valve replacement and balloon valvotomy procedures. All estimated costs represent the year 2016-2017.

RESULTS

The health system cost of an outpatient cardiac consultation was estimated as 182.4 Indian rupees (INR) (US$2.8) and INR334.8 (US$5.2) in the cardiology, and cardio-thoracic and vascular surgery (CTVS) departments, respectively. The cost of hospitalization per bed-day in cardiology, CTVS and the intensive care unit (ICU) was INR1040 (US$16), INR3853 (US$60) and INR12,635 (US$197), respectively. The median out-of-pocket expenditure for valve replacement surgery using mechanical and bio-prosthetic valves was estimated to be INR107,800 (US$1684) and INR154,000 (US$2406), respectively, and for balloon valvotomy was estimated to be INR14,456 (US$367). Overall package cost per mechanical and bio-prosthetic single valve replacement surgery and balloon valvotomy procedure was estimated as INR127,919 (US$1999), INR148,919 (US$2372) and INR14,456 (US$226), respectively.

CONCLUSION

Our findings are useful for planning expansion of public sector cardiac care services, developing package rates for publically financed insurance schemes in India and for undertaking research on cost effectiveness of various models of cardiac care.

A comparative study on the level of satisfaction among regular and contractual health-care workers in a Northern city of India

Introduction:

Job satisfaction greatly determines the productivity and efficiency of human resources for health. The current study aims to assess the level of satisfaction and factors influencing the job satisfaction among regular and contractual health-care workers.

Materials and Methods:

A cross-sectional quantitative study was conducted from January to June 2015 among health care workers (n = 354) at all levels of public health-care facilities of Chandigarh. The correlation between variables with overall level of satisfaction was computed for regular and contractual health-care workers. Stepwise multiple linear regression was done to elucidate the major factors influencing job satisfaction.

Results:

Majority of the regular health-care staff was highly satisfied (86.9%) as compared to contractual staff (10.5%), which however was moderately satisfied (55.9%). Stepwise regression model showed that work-related matters (β = 1.370, P < 0.01), organizational facilities (β = 1.586, P < 0.01), privileges attached to the job (β = 0.530, P < 0.01), attention to the suggestions (β = 0.515, P < 0.01), chance of promotion (β = 0.703, P < 0.01), and human resource issues (β = 1.0721, P < 0.01) are strong predictors of overall satisfaction level.

Conclusion:

Under the National Rural Health Mission, contract appointments have improved the overall availability of health-care staff at all levels of public health facilities. However, there are concerns regarding their level of motivation with various aspects related to the job, which need to be urgently addressed so as to improve the effectiveness and efficiency of health services.

Prevalence of KRAS mutations in metastatic colorectal cancer: A retrospective observational study from India

BACKGROUND

One of the genetic alterations implicated in tumor progression in colorectal cancers (CRCs) are abnormalities in Kristen Rat Sarcoma (KRAS) gene. Evaluation of KRAS mutation status is an important prognostic factor and has predictive value in deciding first line therapy based on monoclonal antibodies such as Cetuximab and Panitumumab in metastatic CRCs.

MATERIALS AND METHODS

In this retrospective study, we analyzed 7 different somatic mutations in Exon 2 of KRAS gene in 299 unselected incidental CRC patients who visited the hospital for clinical management during the period 2009-2013. Most of the tumors were primarily originating from colon and rectum; nevertheless, there were a few from rectosigmoid, sigmoid, ceacum and anal canal in the study group. Genomic DNA extracted from paraffin embedded tumor tissues was screened for 7 point mutations located in Codons 12 and 13 of KRAS gene, using Scorpions amplified refractory mutation system real time polymerase chain reaction technology. Statistical analysis was performed to assess bivariate relationship between different variables that includes: mutation status, mutation type, tumor location, tumor morphology, age and sex.

RESULTS

Prevalence of mutation in Codons 12 and 13 was 42.8% in the study group. Well-differentiated tumors had significantly more mutation positivity than moderately and poorly differentiated tumors (P = 0.001). 92% of the mutations were from Codon 12 and 8% in Codon 13. Glycine to Arginine was relatively more common in rectosigmoid followed by ceacum, while Glycine to Alanine mutation was relatively more prevalent in sigmoid, followed by rectum and rectosigmoid.

CONCLUSION

The results suggest a prevalence of KRAS mutation at 42.8% in Indian population indicating that this testing is very crucial for targeted therapy management in metastatic CRC in India. Further analysis on mutation status of other homologues such as NRAS and downstream partner, v-raf murine sarcoma viral oncogene homolog B1, would add value to understanding the role of anti-epidermal growth factor receptor therapy in CRC management.

COX-2 gene polymorphisms and risk of chronic periodontitis: a case-control study and meta-analysis

OBJECTIVE

Cyclooxygenase-2 (COX-2) enzyme is a major mediator of inflammation in periodontitis, leading to loss of gingival tissues and alveolar bone supporting the teeth. Previous studies have explored the role of COX-2 polymorphisms with the risk of periodontitis in different ethnic groups; however, findings are inconsistent. So, we aimed to investigate the association of COX-2 polymorphisms (rs20417, rs689466, and rs5275) in susceptibility to chronic periodontitis (CP) in northern Indian population. Meta-analysis was also carried out to precisely estimate the effect of COX-2 polymorphisms in CP.

MATERIALS AND METHODS

Genotyping of COX-2 polymorphisms was carried out through PCR-RFLP in 200 CP cases and 200 controls. For risk estimation, binary logistic regression was applied using SPSS, version 15.0, while meta-analysis was carried using MIX 2.0 software.

RESULTS

None of the COX-2 polymorphisms independently were associated with the risk of CP. Meta-analysis suggested a significant reduced risk of CP with rs5275+8473 C allele and rs20417 in Chinese population.

CONCLUSIONS

No association was observed in any of the studied COX-2 polymorphisms with CP in North India. But, the study should be replicated in larger sample size to arrive at a definitive conclusion. Meta-analysis suggested a role of rs5275 COX-2 polymorphisms in susceptibility to overall CP, and on ethnic basis, rs20417 showed reduced risk of CP in Chinese population.

Levels of lipid peroxides and antioxidants in smokers and nonsmokers

BACKGROUND AND OBJECTIVE

The aim of the study was to evaluate the relationship between cigarette smoking and periodontal damage in terms of the levels of free radicals and antioxidants.

MATERIAL AND METHODS

Thirty-five healthy subjects in the age group 25-56 yr and with chronic moderate inflammatory periodontal disease (attachment loss of 3-4 mm) were selected. All subjects were matched with respect to the clinical parameters plaque index, gingival index and attachment loss. Of the 35 subjects, 25 were smokers (smoking a minimum of 15 cigarettes/day) and 10 were nonsmokers. Smokers were subdivided into three subgroups: group I (10 subjects smoking 15-20 cigarettes/day); group II (10 subjects smoking 21-30 cigarettes/day) and group III (five subjects smoking > 50 cigarettes/day). Gingival tissue (obtained during Modified Widman surgery) and blood samples were collected from each of the subjects and analyzed for the following parameters: lipid peroxide, superoxide dismutase, catalase, glutathione and total thiol.

RESULTS

The level of lipid peroxide was lowest in nonsmokers (2.242 +/- 0.775 in tissue and 1.352 +/- 0.414 in blood) and highest in smokers smoking > 50 cigarettes/day (6.81 +/- 1.971 in tissue and 4.96 +/- 0.890 in blood), both in tissue and in blood. The increase was statistically significant in all groups, except in tissue of group I smokers. Catalase showed a similar trend, where the levels increased from 0.245 +/- 0.043 in controls to 0.610 +/- 0.076 in group III smokers for tissue, and from 0.231 +/- 0.040 in controls to 0.568 +/- 0.104 in group III smokers for blood. The increase was statistically significant for all groups. Total thiol levels were also higher in smokers than in controls (0.222 +/- 0.050 in controls vs. 0.480 +/- 0.072 in group III smokers in tissue; 0.297 +/- 0.078 in controls vs. 0.617 +/- 0.042 in group III smokers in blood). Except for group I in both tissue and blood, the increase was statistically significant. The superoxide dismutase (SOD) level was higher in nonsmokers (2.406 +/- 0.477 in tissue and 2.611 +/- 0.508 in blood) than in group III smokers (1.072 +/- 0.367 in tissue and 0.938 +/- 0.367 in blood), both in tissue and in blood, but this was significant only in the case of blood and for group III smokers in tissue. The glutathione level in tissue was consistently lower in smokers than in controls, showing a decrease from 121.208 +/- 37.367 in controls to 46.426 +/- 14.750 in group III smokers, but the decrease was not significant in group I smokers. In the case of blood, the glutathione level dropped from 262.074 +/- 68.751 in controls to 154.242 +/- 51.721 in group III smokers, but was statistically significant only for group III smokers.

CONCLUSION

The study results show that smoking increases the level of free radicals in periodontal tissues, which in turn may be responsible for the destruction seen in periodontal diseases.

Behavior of human periodontal ligament cells on CO2 laser irradiated dentinal root surfaces: an invitro study

OBJECTIVE

The aim of this study was to investigate the in vitro attachment behavior of human periodontal ligament fibroblasts on periodontally involved root surface after conditioning with CO2 laser and to compare its efficacy with chemical conditioning agents, namely tetracycline hydrochloride, citric acid, hydrogen peroxide (H2O2) and EDTA, using scanning electron microscopy.

METHODS

A total of 84 scaled and root-planed specimens from periodontally involved single-rooted human teeth showing hopeless prognosis were selected and assigned to two groups. One group was lased with a CO2 laser (from 5 cm at 3 W for 0.8, 1.0 and 1.2 s), and the other group was treated with either tetracycline hydrochloride (2.5%), citric acid (saturated solution, pH 1), H2O2 (6%) or EDTA (5%; pH 7.4) for 3 min. The specimens were then seeded with human periodontal ligament fibroblasts, incubated for either 12 h or 24 h, and then the cell attachment behavior was observed.

RESULTS

CO2 laser irradiation for 1.0 s was found to be the most efficient, showing consistently good cell attachment with the highest mean value (15.00 +/- 3.41 cells/10,000 microm2 after incubation for 12 h and 29.17 +/- 2.04 cells/10,000 microm2 after 24 h), followed by irradiation for 0.8 s (13.11 +/- 3.04 cells/10,000 microm2 after incubation for 12 h and 22.91 +/- 7.10 cells/10,000 microm2 after 24 h). Charring was observed following irradiation for 1.2 s. Amongst chemical conditioning agents, citric acid was found to be the most efficient, with a mean cell attachment of 17.82 +/- 2.16 cells/10,000 microm2 after incubation for 12 h and 23.62 +/- 1.94 cells/10,000 microm2 after 24 h. EDTA and H2O2 did not do well in the study.

CONCLUSION

The results suggest that CO2 laser irradiation for 1.0 s may promote comparatively better attachment of periodontal ligament fibroblast on dentinal root surfaces than the conventional chemical conditioning agents used in the study.

Effect of a carbon dioxide laser on periodontally involved root surfaces

BACKGROUND

The purpose of this in vitro study was to evaluate the effect of CO2 laser on the periodontally involved root surface, and to compare its efficacy with citric acid, EDTA and hydrogen peroxide in removal of root surface smear layer after root planing.

METHODS

The study was conducted on 50 periodontally involved single rooted human teeth with poor prognosis. Immediately after extraction the teeth were scaled and root planed with Gracey curets; 50 specimens were obtained from the proximal side of each tooth which were assigned randomly to 1 of the 4 groups. Group A (35 specimens) was divided into 7 subgroups of 5 specimens each and irradiated with CO2 laser using a defocused mode at 3-watt power for 0.2, 0.4, 0.6, 0.8, 1.0, 1.2, or 1.4 seconds, respectively. Groups B, C, and D (5 specimens each) were treated with 6% hydrogen peroxide, EDTA solution (pH 7.4), or saturated citric acid solution (pH 1), respectively for 3 minutes. The specimens were then fixed and scanned using SEM.

RESULTS

It was observed that surface smear layer was present on root surfaces of teeth that were root planed; the CO2 laser was not able to remove the smear layer on the sites that were irradiated for 0.2, 0.4 or 0.6 seconds at 3W power. Irradiation time of 0.8 seconds at 3W power was able to remove the smear layer, but the dentinal tubules were partially exposed. The surface irradiated for 1 second showed a flat appearance with many clear orifice of dentinal tubules. No change in diameter of exposed dentinal tubules was observed and their diameter was nearly equal that of normal dentinal tubules. Irradiation time of 1.2 and 1.4 seconds produced surface charring and carbonization and was totally ineffective in exposing the dentinal tubules; 6% hydrogen peroxide did not remove the smear layer completely and the exposed dentinal tubules orifice was not clear. EDTA (pH 7.4) and citric acid (pH 1) were found to be effective in removing the smear layer and exposing the dentinal tubules, which showed funnel shaped widening.

CONCLUSIONS

Surface smear layer was present on root surfaces of teeth that were root planed. Laser irradiation of 1 second at 3W completely removed the smear layer with minimal change in the diameter of the dentinal tubules. EDTA and citric acid were also effective in removing smear layer, but the exposed dentinal tubules showed funnel-shaped widening.