Spatial analysis of food and water-borne diseases in Ahmedabad, India: Implications for urban public health planning

Spatial analysis of infectious diseases can play an important role in mapping the spread of diseases and can support policy making at local level. Moreover, identification of disease clusters based on local geography and landscape forms the basis for disease control and prevention. Therefore, this study aimed to examine the spatial-temporal variations, hotspot areas, and potential risk factors of infectious diseases (including Viral Hepatitis, Typhoid and Diarrhea) in Ahmedabad city of India. We used Moran's I and Local Indicators of Spatial Association (LISA) mapping to detect spatial clustering of diseases. Spatial and temporal regression analysis was used to identify the association between disease incidence and spatial risk factors. The Moran's I statistics identified presence of positive spatial autocorrelation within the considered diseases, with Moran's I from 0.09 for typhoid to 0.21 for diarrhea (p < 0.001). This indicates a clustering of affected wards for each disease, suggesting that cases were not randomly distributed across the city. LISA mapping demonstrated the clustering of hotspots in central regions of the city, especially towards the east of the river Sabarmati, highlighting key geographical areas with elevated disease risk. The spatial clusters of infectious diseases were consistently associated with slum population density and illiteracy. Furthermore, temporal analysis suggested illiteracy rates could increase risk of viral hepatitis by 13 % (95 % Confidence Interval (CI): 1.01-1.26) and of diarrhea by 18 % (95 % CI: 1.07-1.31). Significant inverse association was also seen between viral hepatitis incidence and the distance of wards from rivers. Conclusively, the study highlight the impact of socio-economic gradients, such as slum population density (indicative of poverty) and illiteracy, on the localized transmission of water and foodborne infections. The evident social stratification between impoverished and affluent households emerges as a notable contributing factor and a potential source of differences in the dynamics of infectious diseases in Ahmedabad.

First Measurement of the Nuclear-Recoil Ionization Yield in Silicon at 100 eV

We measured the nuclear-recoil ionization yield in silicon with a cryogenic phonon-sensitive gram-scale detector. Neutrons from a monoenergetic beam scatter off of the silicon nuclei at angles corresponding to energy depositions from 4 keV down to 100 eV, the lowest energy probed so far. The results show no sign of an ionization production threshold above 100 eV. These results call for further investigation of the ionization yield theory and a comprehensive determination of the detector response function at energies below the keV scale.

Model-based online implementation of spike detection algorithms for neuroengineering applications

Traditional methods for the development of a neuroprosthesis to perform closed-loop stimulation can be complex and the necessary technical knowledge and experience often present a high barrier for adoption. This paper takes a novel Model-Based Design approach to simplifying such closed-loop system development, and thereby lowering the adoption barrier. This work implements a computational model of different spike detection algorithms in Simulink® and compares their performances by taking advantage of synthetic neural signals to evaluate suitability for the intended embedded implementation. Clinical Relevance--- Closed-loop systems have been demonstrated to be suitable for brain repair strategies. Coupling two different brain areas by means of a neuroprosthesis can potentially lead to restoration of communication by inducing activity-dependent plasticity.

El Niño Southern Oscillation, monsoon anomaly, and childhood diarrheal disease morbidity in Nepal

Climate change is adversely impacting the burden of diarrheal diseases. Despite significant reduction in global prevalence, diarrheal disease remains a leading cause of morbidity and mortality among young children in low- and middle-income countries. Previous studies have shown that diarrheal disease is associated with meteorological conditions but the role of large-scale climate phenomena such as El Niño-Southern Oscillation (ENSO) and monsoon anomaly is less understood. We obtained 13 years (2002-2014) of diarrheal disease data from Nepal and investigated how the disease rate is associated with phases of ENSO (El Niño, La Niña, vs. ENSO neutral) monsoon rainfall anomaly (below normal, above normal, vs. normal), and changes in timing of monsoon onset, and withdrawal (early, late, vs. normal). Monsoon season was associated with a 21% increase in diarrheal disease rates (Incident Rate Ratios [IRR]: 1.21; 95% CI: 1.16-1.27). El Niño was associated with an 8% reduction in risk while the La Niña was associated with a 32% increase in under-5 diarrheal disease rates. Likewise, higher-than-normal monsoon rainfall was associated with increased rates of diarrheal disease, with considerably higher rates observed in the mountain region (IRR 1.51, 95% CI: 1.19-1.92). Our findings suggest that under-5 diarrheal disease burden in Nepal is significantly influenced by ENSO and changes in seasonal monsoon dynamics. Since both ENSO phases and monsoon can be predicted with considerably longer lead time compared to weather, our findings will pave the way for the development of more effective early warning systems for climate sensitive infectious diseases.

Spectacle wear and refractive errors in Dutch children

Background

Myopia is a refractive error that is increasing dramatically all over the world. Early onset is associated with a significant visual burden later in life, but little is known about refractive errors in preschool children. The aim of this study was to assess prevalence of spectacle wear, visual acuity and refractive errors in young Dutch children and to make global comparisons.

Methods

We analyzed data of three prospective population-based studies: 99,660 3- to 5-year-olds undergoing vision screening at preventive child healthcare organizations, 6,934 6-year-olds from the Generation R study, and 2,974 7-year-olds from the RAMSES study. Visual acuity was measured with Landolt-C or LEA charts, spectacle wear was assessed, and refractive errors at age 6 and 7 were measured with cycloplegic refraction. Spectacle wear was compared with international studies.

Results

The prevalence of spectacle wear was 1.5%, 2.3%, 6.6%, 8.2% and 11.8% at 36, 45, 60, 72 and 84 months, respectively, with no major sex differences. Among children with spectacle wear at 72 months (N = 583) and 84 months (N = 351) 29.8% and 34.6% had myopia respectively, of which 21.1% and 21.6% combined with astigmatism, 19.6% and 6.8% had hyperopia, 37.2% and 11.1% hyperopia and astigmatism, and 12.5% and 33.3% astigmatism only. The prevalence of spectacle wear globally varied between 1.5% to 21%.

Conclusions

Spectacle wear in these European children started early in preschool and increased to substantial figures at school age. Among children with spectacle wear, &gt;30% were already myopic, illustrating the urgency to implement myopia prevention strategies in child health centers.

Key messages

Early onset myopia is a public health issue. Of the 6- to 7-year-olds with spectacles 30-34% were already myopic. Monitoring of refractive errors and preventive lifestyle interventions are warranted.

Increased Incidence of Thrombotic Complications With Non-small Cell Lung Cancer Necessitates Consideration of Prophylactic Anticoagulation in Young Individuals

Venous thromboembolism (VTE) is a common complication in cancer patients and is associated with increased morbidity and mortality. Lung cancer is commonly associated with VTE including pulmonary embolism. We did a retrospective analysis from the 2013 Healthcare Cost and Utilization Project data to determine the role of age as a factor in the development of VTE in this patient group. Patients were selected using the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for metastatic lung cancer and VTE. The patients were stratified by age, sex, race/ethnicity, and site of VTE. There was a total of 16,577 VTE events detected out of a total of 182,863 cases of metastatic lung cancer, representing 9% of the total cases. In patients under 65 years of age, there were 356.82 more cases of pulmonary embolism per 100,000 individuals compared to those older than 65 years (p<0.0001). The same age group also showed 374.83 more upper extremity VTE, 286.94 more non-pulmonary thoracic VTE, and 263.97 more abdominal VTE events per 100,000 individuals (p<0.0001). In conclusion, we found that patients under the age of 65 years had a significantly higher incidence of VTE, pulmonary embolism, upper extremity VTE as well as abdominal and non-pulmonary VTE.

Constraints on Lightly Ionizing Particles from CDMSlite

The Cryogenic Dark Matter Search low ionization threshold experiment (CDMSlite) achieved efficient detection of very small recoil energies in its germanium target, resulting in sensitivity to lightly ionizing particles (LIPs) in a previously unexplored region of charge, mass, and velocity parameter space. We report first direct-detection limits calculated using the optimum interval method on the vertical intensity of cosmogenically produced LIPs with an electric charge smaller than e/(3×10^{5}), as well as the strongest limits for charge ≤e/160, with a minimum vertical intensity of 1.36×10^{-7}  cm^{-2} s^{-1} sr^{-1} at charge e/160. These results apply over a wide range of LIP masses (5  MeV/c^{2} to 100  TeV/c^{2}) and cover a wide range of βγ values (0.1-10^{6}), thus excluding nonrelativistic LIPs with βγ as small as 0.1 for the first time.

Light Dark Matter Search with a High-Resolution Athermal Phonon Detector Operated above Ground

We present limits on spin-independent dark matter-nucleon interactions using a 10.6 g Si athermal phonon detector with a baseline energy resolution of σ_{E}=3.86±0.04(stat)_{-0.00}^{+0.19}(syst)  eV. This exclusion analysis sets the most stringent dark matter-nucleon scattering cross-section limits achieved by a cryogenic detector for dark matter particle masses from 93 to 140  MeV/c^{2}, with a raw exposure of 9.9 g d acquired at an above-ground facility. This work illustrates the scientific potential of detectors with athermal phonon sensors with eV-scale energy resolution for future dark matter searches.

Comparison of peak wall stress and peak wall rupture index in ruptured and asymptomatic intact abdominal aortic aneurysms

BACKGROUND

Previous studies have suggested that finite element analysis (FEA) can estimate the rupture risk of an abdominal aortic aneurysm (AAA); however, the value of biomechanical estimates over measurement of AAA diameter alone remains unclear. This study aimed to compare peak wall stress (PWS) and peak wall rupture index (PWRI) in participants with ruptured and asymptomatic intact AAAs.

METHODS

The reproducibility of semiautomated methods for estimating aortic PWS and PWRI from CT images was assessed. PWS and PWRI were estimated in people with ruptured AAAs and those with asymptomatic intact AAAs matched by orthogonal diameter on a 1 : 2 basis. Spearman's correlation coefficient was used to assess the association between PWS or PWRI and AAA diameter. Independent associations between PWS or PWRI and AAA rupture were identified by means of logistic regression analyses.

RESULTS

Twenty individuals were included in the analysis of reproducibility. The main analysis included 50 patients with an intact AAA and 25 with a ruptured AAA. Median orthogonal diameter was similar in ruptured and intact AAAs (82·3 (i.q.r. 73·5-92·0) versus 81·0 (73·2-92·4) mm respectively; P = 0·906). Median PWS values were 286·8 (220·2-329·6) and 245·8 (215·2-302·3) kPa respectively (P = 0·192). There was no significant difference in PWRI between the two groups (P = 0·982). PWS and PWRI correlated positively with orthogonal diameter (both P < 0·001). Participants with high PWS, but not PWRI, were more likely to have a ruptured AAA after adjusting for potential confounders (odds ratio 5·84, 95 per cent c.i. 1·22 to 27·95; P = 0·027). This association was not maintained in all sensitivity analyses.

CONCLUSION

High aortic PWS had an inconsistent association with greater odds of aneurysm rupture in patients with a large AAA.

Role of extreme weather events and El Niño Southern Oscillation on incidence of Enteric Fever in Ahmedabad and Surat, Gujarat, India

INTRODUCTION

Enteric Fever (EF) affects over 14.5 million people every year globally, with India accounting for the largest share of this burden. The water-borne nature of the disease makes it prone to be influenced as much by unsanitary living conditions as by climatic factors. The detection and quantification of the climatic effect can lead to improved public health measures which would in turn reduce this burden.

METHODOLOGY

We obtained a list of monthly Widal positive EF cases from 1995 to 2017 from Ahmedabad and Surat Municipalities. We obtained population data, daily weather data, and Oceanic Niño Index values from appropriate sources. We quantified the association between extreme weather events, phases of El Niño Southern Oscillations (ENSO) and incidence of EF.

RESULTS

Both cities showed a seasonal pattern of EF, with cases peaking in early monsoon. Risk of EF was affected equally in both cities by the monsoon season -- Ahmedabad (35%) and Surat (34%). Extreme precipitation was associated with 5% increase in EF in Ahmedabad but not in Surat. Similarly, phases of ENSO had opposite effects on EF across the two cities. In Ahmedabad, strong El Niño months were associated with 64% increase in EF risk while strong La Niña months with a 41% reduction in risk. In Surat, strong El Niño was associated with 25% reduction in risk while moderate La Niña with 21% increase in risk.

CONCLUSIONS

Our results show that the risk of EF incidence in Gujarat is highly variable, even between the two cities only 260 kms apart. In addition to improvements in water supply and sewage systems, preventive public health measures should incorporate variability in risk across season and phases of ENSO. Further studies are needed to characterize nationwide heterogeneity in climate-mediated risk, and to identify most vulnerable populations that can benefit through early warning systems.

Perceptions of quality of care during birth at private Chiranjeevi facilities in Gujarat: lessons for Universal Health Coverage

The Indian national health policy encourages partnerships with private providers as a means to achieve universal health coverage. One of these was the Chiranjeevi Yojana (CY), a partnership since 2006 with private obstetricians to increase access to institutional births in the state of Gujarat. More than a million births have occurred under this programme. We studied women's perceptions of quality of care in the private CY facilities, conducting 30 narrative interviews between June 2012 and April 2013 with mothers who had birthed in 10 CY facilities within the last month. The commonly agreed upon characteristics of a "good (sari) delivery" were: giving birth vaginally, to a male child, with the shortest period of pain, and preferably free of charge. But all this mattered only after the primary outcome of being "saved" was satisfied. Women ensured this by choosing a competent provider, a "good doctor". They wanted a quick delivery by manipulating "heat" (intensifying contractions) through oxytocics. There were instances of inadequate clinical care for serious morbidities although the few women who experienced poor quality of care still expressed satisfaction with their overall care. Mothers' experiences during birth are more accurate indicators of the quality of care received by them, than the satisfaction they report at discharge. Improving health literacy of communities regarding the common causes of severe maternal morbidity and mortality must be addressed urgently. It is essential that cashless CY services be ensured to achieve the goal of 100% institutional births.

Determinants of Breastfeeding Practices and Its Association With Infant Anthropometry: Results From a Prospective Cohort Study in South India

Introduction

Despite national efforts for promoting exclusive breastfeeding (EBF) during the first 6 months of the infants' life, breastfeeding rates are low in India. Evidence on the interference of supplementary food on optimal nourishment and growth of the infant has also been well-established. Our study was undertaken to assess the effect of breastfeeding practices on infant anthropometry and determine the various factors affecting breastfeeding practices.

Methods

A prospective cohort study - Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI) was conducted at a tertiary care public hospital in Bengaluru, South India. From the consenting women, data such as obstetric history, infant feeding practices, anthropometry of mother and child, the psychosocial status of the women using the Edinburgh Postnatal Depression Scale (EPDS), was collected at baseline and subsequent follow-up: post-delivery and 14 weeks after birth. In this study, we analyzed data collected from April 2016 to April 2018, with descriptive statistics presented in mean and standard deviation, and logistic regression adjusting for confounders.

Results

Among the 240 women enrolled in the study, 33% (n= 80) were using supplementary food for their infants at 14 weeks of infants age. Infants who received supplementary feeding at age 14 weeks had nearly 2.5 times higher odds of being wasted (OR: 2.449, p-value: 0.002) as compared to exclusively breastfed infants.

Conclusion

Infants between 14 to 16 weeks of age who received supplementary feeding were at risk of wasting as compared to exclusively breastfed infants. Despite strong evidence in support of the benefits of exclusive breastfeeding, awareness in urban women in India is low. Increased focus on promoting exclusive breastfeeding is necessary to ensure proper nutritional intake and healthy growth of infants.

Nodal recurrences after stereotactic body radiotherapy for early stage non-small-cell lung cancer

Lobectomy is considered the standard of care for early stage non-small-cell lung cancer. However, for those patients who remain unfit to undergo surgery due to advanced age, poor performance status, comorbidities, poor pulmonary reserve or a combination of these are now treated with stereotactic body radiation therapy (SBRT). Due to its noninvasive nature, lower cost, lower toxicity, reduced recovery time and equivalent efficacy, even medically operable patients are attracted to the option of SBRT despite the lack of level I evidence. Thus, studying the incidence and patterns of recurrence after SBRT help in understanding the magnitude of the problem, risk factors associated with the different patterns of recurrence, and aid in devising strategies to prevent them in future. Nodal recurrences are not uncommon after SBRT and can potentially lead to further seeding for distant metastases and ultimately poor survival. This review is aimed at reviewing the published data on the incidence of nodal recurrences after SBRT and compare it to surgery, identify potential risk factors for recurrence, salvage treatment options and prevention strategies.

[Responsible use of screens: recommendations to limit myopia in children and young people]

The excessive use of screens is a contemporary problem that can have a number of effects on health. It is of particular influence on the onset and exacerbation of myopia, and for these reasons a group of professionals decided to draw up recommendations on a more sensible use of screens. The group comprised an ophthalmologist-epidemiologist, an orthoptist, paediatric and adolescent physicians, a youth health care nurse, an orthopaedic surgeon, a movement therapist-epidemiologist, health scientists and psychologists. They recommend that on history-taking, standard questions concerning screen use and its associated problems should be asked. The parents can then be given targeted lifestyle advice for the child, i.e. after 20-30 minutes continuous screen use there should be a change of activity, and that the child should spend 2 hours a day outdoors. These recommendations will promote the health of children's eyes as well as their general development.

Antimicrobial Resistance Surveillance in Typhoidal Salmonella in Ahmedabad in an Era of Global Antimicrobial Resistance Surveillance Systems

Introduction:

India possibly carries the highest burden of antimicrobial resistant typhoidal salmonellae in the world. We report on the health-care ecosystem that produces data on antimicrobial resistance (AMR) testing and the resistance patterns of typhoidal Salmonella isolates in the city of Ahmedabad.

Materials and Methods:

Through municipality records and internet searches, we identified 1696 private and 83 public laboratories in the city; 4 medical colleges, 4 health-care institution attached laboratories, and 4 corporate laboratories (CLs) were performing culture and antibiotic sensitivity testing (AST), but only 2 medical colleges and 1 CL shared their data with us. There was considerable variation in culturing and sensitivity testing methodology across laboratories.

Results:

Out of 51,260 blood cultures, Salmonella isolates were detected in only 146 (0.28%). AST was conducted on 124 isolates, of which 67 (54%) were found resistant. Multidrug resistance was absent. Concurrent resistance to more than one antibiotic was very high, 88%, among the 67 resistant isolates. Ciprofloxacin resistance varied widely between the private and public sector laboratories. Notably, isolates from the private sector laboratory showed complete resistance to azithromycin.

Conclusions:

High resistance to ciprofloxacin and azithromycin observed in Ahmedabad may be due to the increased use of these two antibiotics in the public and private sectors, respectively. The need of the hour is to identify a representative sample of laboratories from both the public and the private sectors and encourage them to participate in the national AMR surveillance network.

POT1 germline mutations but not TERT promoter mutations are implicated in melanoma susceptibility in a large cohort of Spanish melanoma families

BACKGROUND

Germline mutations in telomere-related genes such as POT1 and TERT predispose individuals to familial melanoma.

OBJECTIVES

To evaluate the prevalence of germline mutations in POT1 and TERT in a large cohort of Spanish melanoma-prone families (at least two affected first- or second-degree relatives).

METHODS

Overall, 228 CDKN2A wild-type melanoma-prone families were included in the study. Screening of POT1 was performed in one affected person from each family and TERT was sequenced in one affected patient from 202 families (26 families were excluded owing to DNA exhaustion/degradation). TERT promoter sequencing was extended to an additional 30 families with CDKN2A mutation and 70 patients with sporadic multiple primary melanoma (MPM) with a family history of other cancers.

RESULTS

We identified four families with potentially pathogenic POT1 germline mutations: a missense variant c.233T>C (p.Ile78Thr); a nonsense variant c.1030G>T (p.Glu344*); and two other variants, c.255G>A (r.125_255del) and c.1792G>A (r.1791_1792insAGTA, p.Asp598Serfs*22), which we confirmed disrupted POT1 mRNA splicing. A TERT promoter variant of unknown significance (c.-125C>A) was detected in a patient with MPM, but no germline mutations were detected in TERT promoter in cases of familial melanoma.

CONCLUSIONS

Overall, 1·7% of our CDKN2A/CDK4-wild type Spanish melanoma-prone families carry probably damaging mutations in POT1. The frequency of TERT promoter germline mutations in families with melanoma in our population is extremely rare.

Erratum: First Dark Matter Constraints from a SuperCDMS Single-Charge Sensitive Detector [Phys. Rev. Lett. 121, 051301 (2018)]

This corrects the article DOI: 10.1103/PhysRevLett.121.051301.

First Dark Matter Constraints from a SuperCDMS Single-Charge Sensitive Detector

We present the first limits on inelastic electron-scattering dark matter and dark photon absorption using a prototype SuperCDMS detector having a charge resolution of 0.1 electron-hole pairs (CDMS HVeV, a 0.93 g CDMS high-voltage device). These electron-recoil limits significantly improve experimental constraints on dark matter particles with masses as low as 1  MeV/c^{2}. We demonstrate a sensitivity to dark photons competitive with other leading approaches but using substantially less exposure (0.49 g d). These results demonstrate the scientific potential of phonon-mediated semiconductor detectors that are sensitive to single electronic excitations.

Primary Small Intestinal Angiosarcoma: Epidemiology, Diagnosis and Treatment

Angiosarcoma is an aggressive mesenchymal sarcoma of endothelial cell origin with high mortality. Its occurrence in the small intestine is exceedingly low. In addition to the rarity of small intestine angiosarcoma, the nonspecific early clinical symptoms obscure the suspicion of such tumors and thereby delay the diagnosis. In a hope to improve the knowledge of this rare but fatal neoplasm, we report one case of angiosarcoma of duodenum and jejunum in a 73-year-old man. Furthermore, we summarize and analyze the common clinical features, tumor markers, treatment, and survival of previous reported cases of this malignancy. Small bowel angiosarcoma occurs more often in men than women (1.6:1). The median age at diagnosis is 68.5 years. The overall median survival time is 150 days; the median survival time in female (300 days) is longer than that of male patients (120 days). Von Willebrand factor (vWF), CD31, CD34, vimentin, and Ulex europaeus agglutinin 1 appear to be the most useful markers for the diagnosis. The majority of the patients underwent surgical resection alone or surgery with subsequent chemotherapy. The patients treated with surgery plus chemotherapy survive longer than those underwent surgical resection only (median 420 days, n = 7 vs. 96.5 days, n = 26, respectively; P = 0.0275). Further studies of more cases are needed for a better understanding of this rare entity, as well as the development of effective strategies for prevention, early diagnosis, and treatment.

Results from the Super Cryogenic Dark Matter Search Experiment at Soudan

We report the result of a blinded search for weakly interacting massive particles (WIMPs) using the majority of the SuperCDMS Soudan data set. With an exposure of 1690 kg d, a single candidate event is observed, consistent with expected backgrounds. This analysis (combined with previous Ge results) sets an upper limit on the spin-independent WIMP-nucleon cross section of 1.4×10^{-44} (1.0×10^{-44})  cm^{2} at 46  GeV/c^{2}. These results set the strongest limits for WIMP-germanium-nucleus interactions for masses >12  GeV/c^{2}.

Characteristics of private partners in Chiranjeevi Yojana, a public-private-partnership to promote institutional births in Gujarat, India - Lessons for universal health coverage

Background

The Chiranjeevi Yojana (CY) is a Public-Private-Partnership between the state and private obstetricians in Gujarat, India, since 2007. The state pays for institutional births of the most vulnerable households (below-poverty-line and tribal) in private hospitals. An innovative remuneration package has been designed to disincentivise unnecessary cesareans. This study examines characteristics of private facilities which participated in the program.

Methods

We conducted a cross-sectional survey of all facilities which had conducted any births between June 2012 and April 2013 in three districts. We identified 111 private and 47 public facilities. Ninety of the 111 private facilities did caesarean sections in the last three months and were eligible to participate in the CY program. Of these, 40 (44%) participated in the CY program. We conducted descriptive and bivariate analyses followed by a Poisson regression model to estimate prevalence ratios of facility characteristics that predicted participation.

Results

We found that facilities participating in the CY program had a significantly higher likelihood of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of cesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0). But none of these factors retained significance in a multi variable model.

Conclusion

Private obstetricians who participate in the CY program tend to be new to private practice, provide general services, conduct fewer caesareans and are also less expensive. This is advantageous to the PPP and widens the target beneficiary groups that can be serviced by the PPP. The state should design remuneration packages with the aim of attracting relatively new obstetricians to set up practices in more remote areas. It is possible that the CY remuneration package design is effective in keeping caesarean rates in check, and needs to be studied further.

Occult myeloproliferative neoplasms: not so occult any more

Non-cirrhotic, non-malignant portal vein thrombosis (PVT) is commonly secondary to inherited or acquired prothrombotic states. However, even after extensive workup, 25% of patients with PVT have no apparent prothrombotic aetiology identified (idiopathic PVT). Inherited conditions include factor V Leiden, PT mutation and protein C/S/AT deficiency. Acquired conditions include APS, PNH and BCR-ABL 1-negative myeloproliferative neoplasms (MPN). BCR-ABL-1 negative MPNs are the most frequent underlying prothrombotic risk factor for PVT (15%-30%). However, peripheral blood counts often remain within normal ranges in these patients with MPN because of portal hypertension sequel. Despite suggestive features of MPN in bone marrow, these patients lack adequate diagnostic criteria and are classified as occult MPN. The discovery of recurrent molecular abnormalities such as CALR gene exon 9 mutation presented a crucial advance in the diagnosis of occult MPNs. In our patient, the diagnosis of MPN was made on this basis, despite lack of peripheral evidence of MPN.

Temporal trend in the use of surgery in the management of stage IIIa non-small cell lung cancer (NSCLC) between 2000-2013: A SEER analysis

8524

Background: The optimal treatment of patients with Stage IIIA NSCLC, a heterogeneous group comprised of T1-T4, N0-N2 disease, is controversial. Lack of clear data and guidelines allows several options for treatment, and hence there has been significant variability in clinical practice. The purpose of this study was to evaluate the nationwide trends in rates of surgery for Stage IIIA lung cancer diagnosed between 2000-2013. Methods: The study included patients with Stage IIIA NSCLC, 18 years and older diagnosed between 2000 and 2013. We used Z-tests in SEER*Stat to compare relative survival rates for patients diagnosed between 2000-2010. Results: Among the 27,697 patients with Stage IIIA NSCLC, 45% were females and median age was 67. 35% were treated with surgery. Multivariate analysis demonstrated that year of diagnosis, race, marital status, geographic region, tumor size, tumor grade, nodal status all were significantly associated with the use of surgery. Relative survival at 24 months (RS24) was 62% for patients who had surgery and 29% for patients without surgery (z = -47.3). The proportion of patients receiving surgery decreased from 55.6% in 2000 to 32.6% in 2010 and 29.7 in 2013 (p < 0.0001) while the relative survival at 24 months (RS24) from 2000 to 2010 rose from 34.7% to 43.2% (z = -4.89). The RS24 for patients who received surgery rose from 55.3% in 2000 to 77.6 % in 2010 (z = -3.58). Change in RS24 for patients who did not have surgery also improved from 19.6% to 31.2%. The median RS of the surgical cohort changed from 28 m to 44 m. Conclusions: Based upon reporting within the SEER database, the proportion of stage IIIA NSCLC patients undergoing surgery has decreased over the study time period. However, the relative survival rates have improved significantly for both the overall group and those having surgery, suggesting that significant strides have been made both in selecting the group of patients who would benefit from surgical resection and in the overall management of this group of patients.

Conditional survival estimates for patients with plasma cell leukemia: An analysis of the SEER database

e19533

Background: Plasma cell leukemia (PCL) is an aggressive malignancy with poor prognosis. Retrospective studies have suggested improved outcomes with stem cell transplant and use of novel agents. Methods: We used the Surveillance, Epidemiology, and End Results database to identify 480 patients with PCL from 1973 to 2009. Kaplan Meier method was used to calculate 3-year Cancer Specific Survival (CSS) estimates, conditional on 1 to 3 years of survival (CS3). Covariates included age, sex, race and geographic location. The cohort was divided into three time frames, 1973-95, 1996-2005 and 2006-2009, to account for use of transplant from 1995 and novel agents from 2005. Results: 398 patients were selected for analysis from the initial cohort. Median age was 65. 50.75% were female and 65.8% were white. The 3-year CSS for patients with PCL was 19.6% and conditional probability of surviving additional 3 years (CS3) at 1, 2, 3 and 5 years from diagnosis was 36.9%, 51.5%, 58.5% and 71.2% respectively. CSS rates at 3 years during 1973-95, 1995-2005 and 2006-2009 were 14.7%, 12.4% and 32.9% respectively and the CS3 improved from 37.4% / 27.9% / 44.5% at 1 year to 72.7% / 46.3% / 57.5% at 3 years. 3-year CSS rates of patients aged < 50, 50-59, > 70 years was 19.9%, 19.7% and 18.7% respectively. The CS3 with each year survived increased for all age groups, with the most dramatic increase for those > 70 years (45.8% at 1 year to 80.5% at 3 years). Hispanics had the lowest 3-year CSS rate (5.5%). Improvement in CS3 from 1 to 3 years for races was as follows – Whites: 35.8% to 57.9%, Blacks: 41.9% to 50.10%, Asians: 28.6% to 67% and Hispanics: 18.7% to 33.3%. 3-year CSS rate for patients from metropolitan/non-metropolitan areas was 19.5%/18%. CS3 for metropolitan/non-metropolitan areas increased from 38.2%/27.3% at 1 year to 63%/33.3% at 3 years. Conclusions: The risk profile of patients with PCL changes as they survive past the diagnosis. Improvements in survival are more substantial in older patients and patients from metropolitan areas.

Prophylactic anticoagulation to benefit younger patients under 65 years of age with metastatic lung cancer: An analysis of the 2013 Healthcare Cost and Utilization Project (HCUP) data

6581

Background: Cancer patients have increased risk of venous thromboses. Venous thromboembolism (VTE) is reported to be a leading cause of death in cancer patients. It has been hypothesized that prophylactic anticoagulation for VTE might improve prognosis and quality of life. Based on our analysis of the 2013 HCUP data, we propose that prophylactic anticoagulation should be considered for patients younger than 65 years with metastatic lung cancer. Methods: Patients were selected using ICD-9 diagnoses codes for metastatic lung cancer and VTE. Diagnoses were stratified by site including upper extremity, lower extremity, pulmonary, abdominal and nonpulmonary thoracic VTE. Patients were stratified by age, sex, race and ethnicity. Differences in incidence of VTE among groups were calculated by the Chi-Square method using the SAS software. Results: There were a total of 16,577 VTE events amongst 182,863 cases of metastatic lung cancer. Subgroup analyses showed that patients younger than 65 years of age had 356.82 more PE events per 100,000 individuals compared to those at or older than 65 years (p < 0.0001). The same age group also showed 374.83 more UE, 286.94 more nonpulmonary thoracic and 263.97 more abdominal (Abd) VTE events per 100,000 individuals (p-values, p < 0.0001). There was no statistically significant difference in the incidence of LE VTE’s between the subgroups. Conclusions: Prophylactic anticoagulation should be considered in patients < 65 years of age with metastatic lung cancer. Increased incidence of VTE in these patients may contribute towards greater morbidity and mortality associated with metastatic lung cancer in this subgroup. [Table: see text]

Blocking the PD-1/PD-L1 pathway in glioma: a potential new treatment strategy

Gliomas are the most common type of primary brain tumor in adults. High-grade neoplasms are associated with poor prognoses, whereas low-grade neoplasms are associated with 5-year overall survival rates of approximately 85%. Despite considerable progress in treatment modalities, the outcomes remain dismal. As is the case with many other tumors, gliomas express or secrete several immunosuppressive molecules that regulate immune cell function. Programmed death-ligand 1 (PD-L1) is a coinhibitory ligand that is predominantly expressed by tumor cells. The binding of PD-L1 to its receptor PD-1 has been demonstrated to induce an immune escape mechanism and to play a critical role in tumor initiation and development. Encouraging results following the blockade of the PD-1/PD-L1 pathway have validated PD-L1 or PD-1 as a target for cancer immunotherapy. Studies have reported that the PD-1/PD-L1 pathway plays a key role in glioma progression and in the efficacy of immunotherapies. Thus, progress in research into PD-L1 will enable us to develop a more effective and individualized immunotherapeutic strategy for gliomas. In this paper, we review PD-L1 expression, PD-L1-mediated immunosuppressive mechanisms, and the clinical applications of PD-1/PD-L1 inhibitors in gliomas. Potential treatment strategies and the challenges that may occur during the clinical development of these agents for gliomas are also reviewed.

Alteration in steroid hormone and Her-2/neu receptor status following neoadjuvant chemotherapy in locally advanced breast cancer: Experience at a tertiary care centre in India

CONTEXT

Use of neoadjuvant chemotherapy (NACT) in locally advanced breast cancer (LABC) enables tumor reduction and conservative surgery. It is proposed in some studies that there may be an alteration in the hormonal receptor (HR) status and human epidermal growth factor receptor 2 (Her-2)/neu immune-expression following NACT.

AIMS

To study the status of estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu receptor before and after NACT in LABC.

MATERIALS AND METHODS

HR and Her-2/neu status were evaluated by immunohistochemistry on 100 core needle biopsy of primary tumors and surgical specimens after receiving NACT (NACT group); fifty patients without NACT served as non-NACT group, and discordance was compared between the two groups.

RESULTS

In the NACT group, discordance of 17%, 13%, and 11% was noted in ER, PR, and Her-2/neu status, while in non-NACT group, discordance seen in ER, PR, and Her-2/neu was 8%, 8%, and 4%, respectively.

CONCLUSIONS

There was a significant alteration in ER and Her-2/neu status from the core biopsy to the treated resected tumor in the study group. As these changes may impact treatment, HR and Her-2/neu expression reanalysis in final surgical specimens is recommended.

Molecular Pathophysiology of Congenital Long QT Syndrome

Ion channels represent the molecular entities that give rise to the cardiac action potential, the fundamental cellular electrical event in the heart. The concerted function of these channels leads to normal cyclical excitation and resultant contraction of cardiac muscle. Research into cardiac ion channel regulation and mutations that underlie disease pathogenesis has greatly enhanced our knowledge of the causes and clinical management of cardiac arrhythmia. Here we review the molecular determinants, pathogenesis, and pharmacology of congenital Long QT Syndrome. We examine mechanisms of dysfunction associated with three critical cardiac currents that comprise the majority of congenital Long QT Syndrome cases: 1) IKs, the slow delayed rectifier current; 2) IKr, the rapid delayed rectifier current; and 3) INa, the voltage-dependent sodium current. Less common subtypes of congenital Long QT Syndrome affect other cardiac ionic currents that contribute to the dynamic nature of cardiac electrophysiology. Through the study of mutations that cause congenital Long QT Syndrome, the scientific community has advanced understanding of ion channel structure-function relationships, physiology, and pharmacological response to clinically employed and experimental pharmacological agents. Our understanding of congenital Long QT Syndrome continues to evolve rapidly and with great benefits: genotype-driven clinical management of the disease has improved patient care as precision medicine becomes even more a reality.

Six months versus nine months anti-tuberculous therapy for female genital tuberculosis: a randomized controlled trial

OBJECTIVE

To compare six months versus nine months anti-tuberculous therapy in patients of female genital tuberculosis.

STUDY DESIGN

It was a randomized controlled trial in a tertiary referral center teaching institute on 175 women presenting with infertility and found to have female genital tuberculosis on clinical examination and investigations. Group I women (86 women) were given 9 months of intermitted anti-tuberculous therapy under directly observed treatment short course (DOTS) strategy while Group II (89 women) were given 6 months of anti-tuberculous therapy under DOTS. Patients were evaluated for primary end points (complete cure, partial response, no response) and secondary end points (recurrence rate, pregnancy rate) during treatment. All patients were followed up further for one year after completion of therapy to assess recurrence of disease and further pregnancies.

RESULTS

Baseline characteristics were similar between two randomized groups. There was no difference in the complete clinical response rate (95.3% vs 97.7%, p=0.441) between 9-months and 6-months groups. Four patients in 9-months group and two patients in 6-months group had recurrence of disease and required category II anti tuberculous therapy (p=0.441). Pregnancy rate during treatment and up to one year follow up was also similar in the two groups (23.2% vs 21.3%, p=0.762). Side effects occurred in 27(31.4%) and 29(32.6%) in 9-months and 6-months of therapy and were similar (p=0.866).

CONCLUSIONS

There was no difference in complete cure rate, recurrent rate and pregnancy rate for either 6-months or 9-months of intermittent directly observed treatment short course anti-tuberculous therapy in female genital tuberculosis.

CLINICAL TRIAL REGISTRATION

The trial was registered in clinicaltrials.gov with registration no: CTRI/2009/091/001088.

The value of routine bone marrow biopsy in patients with diffuse large B-cell lymphoma staged with PET/CT: a Danish-Canadian study

BACKGROUND

The added diagnostic and prognostic value of routine bone marrow biopsy (BMB) in patients with diffuse large B-cell lymphoma (DLBCL) undergoing positron emission tomography combined with computed tomography (PET/CT) staging is controversial.

PATIENTS AND METHODS

Patients with newly diagnosed DLBCL who underwent both staging PET/CT and BMB were retrospectively identified in British Columbia, Aalborg, and Copenhagen. Original written PET/CT and pathology reports were retrospectively reviewed to determine Ann Arbor stage and outcomes, with and without the contribution of BMB.

RESULTS

A total of 530 patients were identified: 146 (28%) had focal bone marrow (BM) lesions on PET/CT and 87 (16%) had positive BMB. Fifty-two of 146 patients (36%) with positive PET/CT had a positive BMB [39 DLBCL, 13 indolent non-Hodgkin lymphoma (iNHL)], while 35 of 384 patients (9%) with negative PET/CT had positive BMB (12 DLBCL, 23 iNHL). BMB upstaged 12/209 (6%) of stage I/II patients to stage IV, although this was the case for only 3 (1%) patients with DLBCL in the BMB. PET/CT identified BM involvement by BMB with sensitivity 60%, specificity 79%, positive predictive value 36%, and negative predictive value 91%. Concordant histological involvement of the BM by DLBCL was associated with worse overall survival and progression-free survival than discordant or no involvement in univariate and multivariate analyses.

CONCLUSIONS

In patients with DLBCL, staging PET/CT can miss BM involvement with concordant DLBCL (less common) or discordant iNHL (more common). Routine BMB does not add relevant diagnostic or prognostic value over PET/CT alone in the majority of patients with DLBCL.

Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program

BACKGROUND

The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program.

METHODS

Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012-2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed.

RESULTS

Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector.

CONCLUSIONS

CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government's efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector's ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.

Infectious disease burden in Gujarat (2005-2011): comparison of selected infectious disease rates with India

Background

India is known to be endemic to numerous infectious diseases. The infectious disease profile of India is changing due to increased human environmental interactions, urbanisation and climate change. There are also predictions of explosive growth in infectious and zoonotic diseases. The Integrated Disease Surveillance Project (IDSP) was implemented in Gujarat in 2004.

Methods

We analysed IDSP data on seven laboratory confirmed infectious diseases from 2005–2011 on temporal and spatial trends and compared this to the National Health Profile (NHP) data for the same period and with other literature. We chose laboratory cases data for Enteric fever, Cholera, Hepatitis, Dengue, Chikungunya, Measles and Diphtheria in the state since well designed vertical programs do not exist for these diseases. Statistical and GIS analysis was done using appropriate software.

Results

Our analysis shows that the existing surveillance system in the state is predominantly reporting urban cases. There are wide variations among reported cases within the state with reports of Enteric fever and Measles being less than half of the national average, while Cholera, Viral Hepatitis and Dengue being nearly double.

Conclusions

We found some limitations in the IDSP system with regard to the number of reporting units and cases in the background of a mixed health system with multiplicity of treatment providers and payment mechanisms. Despite these limitations, IDSP can be strengthened into a comprehensive surveillance system capable of tackling the challenge of reversing the endemicity of these diseases and preventing the emergence of others.

Drinking Water Quality Surveillance in a Vulnerable Urban Ward of Ahmedabad

The World Bank estimates that 21% of all communicable diseases in India are related to unsafe water with diarrhoea alone causing more than 0.1 million deaths annually. The WHO drinking water surveillance parameters of quality, quantity, accessibility, affordability and continuity were assessed in one vulnerable ward of Ahmedabad—a fast growing city in Western India. Interviews with key informants of the ward office, health centre and water supply department, secondary analysis and mapping of field test reports and a questionnaire-based survey of different household types were conducted. We found that Ahmedabad Municipal Corporation (AMC) supplies water to the ward intermittently for two hours during the day. Housing society clusters supplement their AMC water supply with untested bore-well water. The water quality surveillance system is designed for a twenty-four-hour piped distribution of treated surface water. However, in order to maintain surveillance over an intermittent supply that includes ground water, the sampling process should include periodic surveys of water actually consumed by the citizens. The laboratory capacity of the Central Water Testing Laboratory should expand to include more refined tests for microbial and chemical contamination.

Female health workers in Gujarat: Examining human resource actions and workforce objectives-an exploratory mixed methods study

Background. Female health workers (FHWs), posted at subcentres, each serving a rural population of 3000 to 5000, are the final points of contact between the people and the health system. This study assesses a selected sample of FHWs using the 'managing for performance' framework. Methods. Twenty-two FHWs and their supervisors at five primary health centres near Ahmedabad were purposively selected for this mixed methods study. They were administered a semi-structured questionnaire, which also guided 12 individual interviews and four focus group discussions. Quantitative data were analysed using Epi Info and Excel. Content analysis of the qualitative data was done using Microsoft Word. Results. In spite of increased FHW strength due to recent recruitments, one-third of these FHWs were carrying out additional responsibilities of another FHW or supervisor. Planning of tasks was the most popular activity while the chief demotivating factor at work was meeting targets. Recent trainings have been useful but failed to build specific competence as required. About 37% of routine person-tasks carried out by FHWs were graded below 60 points by supervisors. They rated the FHWs highly for their collaboration with community leaders although FHWs themselves did not consider community leaders to be a helpful resource. Conclusion. Mapping age, skill levels and locations of existing FHWs and soon-to-be retirees would be useful when planning future expansion of the FHW cadre. The natural elasticity of base populations due to migration as well as unpredictability of their work schedules need to be taken into account when monitoring the work performance of FHWs. District training centres need to be developed to provide a wide range of competencies.