To study the survival outcomes of uncommon recurrences among patients with cervical cancer compared with loco-regional and nodal recurrences at a tertiary care center in North East India - Bridging the knowledge gap in the existing literature

Background

Recurrence rates of FIGO stage IB-IIA and IIB-IVA cervical cancer  28-64  respectively. There is a scarcity of data on the recurrence recurrence pattern for unusual sites and theirrecurrence pattern for unusual sites and its association with survival and prognosis.

Objective

To study overall survival in patients with distant metastasis compared to local and regional nodal metastasis.

Methods

A retrospective study was done from 1/1/2017 to 30/12/22. Cervical cancer patients post primary treatments were included. Survival was analyzed with respect to 3 groups local, regional nodalconducted from 1/1/2017 to 30/12/22. Cervical cancer patients who had received primary post-primary treatments were included. Survival was analyzed with respect to three groups: local, regional nodal, and distant metastasis.

Results

225 patients had recurrences   post-completion of primary treatment, of which 105 (46.6%)(46.6 %) had local, 46 (20.4%)(20.4 %) had regional nodal, and 74 (33.3 %) had distant recurrences. The median time for recurrence in local, regional nodal, and atypical recurrences were 9, 9, and 13 months (p value - <0.05), respectively. Treatment included systemic chemotherapy 122 (54.2 %), metronomic therapy 19 (8.4 %), palliative radiotherapy 44 (19.5 %), palliative surgery 8 (3.5 %) and best supportive care 30 (13.3 %) patients. Median Time to treatment-death of patients after recurrence in local, nodal and distant recurrences was 17.0 months, 18.0 months and 10.0 months respectively (p value - < 0.05). Overall Survival of patients after primary treatment with local, nodal and distant recurrences was 35.0 months, 47.0 months and 50.0 months respectively (p value <0.05).

Conclusion

Local recurrence is most common, followed by regional, nodal, and distant recurrences. Overall survival post recurrence was lowest for distant recurrences and highest for local recurrences however overall survival after primary treatment completion was highest for distant recurrence due to the late presen; however, tation of distant recurrences.

FIGO 2023 endometrial staging: a leap of faith into the new "prognostic based' rather than "anatomical based" staging-too fast too furious??

BACKGROUND

In 2023 FIGO revised the endometrial cancer staging system after 13 years. There is a lacuna of data regarding the performance and practicality of the revised 2023 FIGO staging schema for endometrial cancer from Low Middle-Income Countries (LMIC).

OBJECTIVE

To estimate the shift of stage and adjuvant management of endometrial cancer based on the FIGO 2023 system compared to the FIGO 2009 system and assess the predictive potential of the FIGO 2023 system.

MATERIAL AND METHODS

A retrospective study was conducted from 1st January 2017 to 31st December 2022. All patients with endometrial cancer were staged according to the FIGO 2023 and FIGO 2009 staging system. Follow-up of patients was done to determine recurrence.

RESULTS

A total of 152 patients were included. Aggressive histology was seen in 66 (45%) patients. Eighteen (11%) had subserosal involvement. Substantial LVSI was noted in 23 (15%) of patients. Twenty-four (47%) patients of FIGO 2009 Stage IA and 26 patients (63%) of FIGO 2009 Stage IB were upstaged. Eleven (50%) patients of FIGO 2009 Stage IIIA were down staged to IA3. Overall 23 patients (15%) had a shift of stage. Fifteen out of 152 patients (15%) would have had a possible risk stratification change which would imply 23 patients (15%) would have needed a more radical treatment. Molecular classification was done in 32 patients; however, only 2 patients could afford POLE testing. Kaplan-Meier curves showed significant PFS differences in FIGO 2009 Stage IB and Stage IIIA when restaged according to the FIGO 2023 system.

CONCLUSION

The FIGO 2023 endometrial staging is a more robust prognosticator; however, the practicality of molecular classification in LMICs is still a distant dream.

Relational solidarity and conflicting ethics in dementia care in urban India

OBJECTIVE

Using the concept of relational solidarity, we examine how autonomy, equality, dignity, and personhood are practiced in the care of people living with dementia at home in urban India.

METHODS

Video interviews with 19 family carers and 25 health providers conducted in English, Hindi, and Kannada in Bengaluru between March to July 2022. Data were translated into English and thematically analyzed.

RESULTS

Family carers and providers unanimously agreed that people with dementia should be respected and cared for. Concurrently, they perceived people with dementia as being 'like a kid' and used the analogy of a parent-child relationship to understand their care responsibilities. This analogy informed how ethical principles such as personhood and equality were reframed in the relationships between family carers and people with dementia, as well as how carers and providers maintained the safety but undermined the autonomy of people with dementia through restricting their movements inside and outside the home.

DISCUSSION

There can be relational solidarity in dementia care at home in urban India but also contradictions in the interpretations and applications of the ethical principles of autonomy, equality, dignity, and personhood. As such, a more organic, grassroots model of ethical practice is needed to frame care and provide material support to families in India.

An evaluation of treatment response and remission definitions in adult obsessive-compulsive disorder: A systematic review and individual-patient data meta-analysis

INTRODUCTION

Expert consensus operationalized treatment response and remission in obsessive-compulsive disorder (OCD) as a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) reduction ≥35% and score ≤12 with ≤2 on Clinical Global Impressions Improvement (CGI-I) and Severity (CGI-S) scales, respectively. However, there has been scant empirical evidence supporting these definitions.

METHODS

We conducted a systematic review and an individual participant data meta-analysis of randomized-controlled trials (RCTs) in adults with OCD to determine optimal Y-BOCS thresholds for response and remission. We estimated pooled sensitivity/specificity for each percent reduction threshold (response) or posttreatment score (remission) to determine response and remission defined by a CGI-I and CGI-S ≤ 2, respectively.

RESULTS

Individual participant data from 25 of 94 eligible RCTs (1235 participants) were included. The optimal threshold for response was ≥30% Y-BOCS reduction and for remission was ≤15 posttreatment Y-BOCS. However, differences in sensitivity and specificity between the optimal and nearby thresholds for response and remission were small with some uncertainty demonstrated by the confidence ellipses.

CONCLUSION

While the empirically derived Y-BOCS thresholds in our meta-analysis differ from expert consensus, given the predominance of data from more recent trials of OCD, which involved more refractory participants and novel treatment modalities as opposed to first-line therapies, we recommend the continued use of the consensus definitions.

Our Experience of Distal and Total Urethrectomies in Post Irradiated Vulvar Malignancies in Low Resource Settings: A Single Centre Study

Introduction

At diagnosis, women with vulvar cancer often present in locally advanced stage especially in developing countries, owing to the associated ignorance and social stigma. Generally tumour is seen involving adjacent organs, like the vagina, anus, and urethra. Damage to the sphincter system leads to urinary incontinence. Available evidence regarding urethral resections, subsequent lower urinary tract dysfunction and neo-meatus reconstruction in radical vulvar surgeries is scarce and conflicting.

Methodology

Considering, the lack of literature on outcomes of partial and total urethrectomies post chemoradiation in advanced vulvar malignancies from India, in the current study, we analysed our experience of such cases that have been operated post chemoradiation over a span of 2 years (from January 2019 to January 2021).

Results

DFS ( disease free survival) of more than 6 months was seen in 5 of our patients, however in view of local wound complications after primary closure, we recommend reconstruction with myocutaneous flaps. Also in view of incontinence observed in two of our patients who had undergone more than 1⁄2 of urethral resection, as a result of failed suprapubic catheterisation, further plan of urethral reconstruction should be considered especially in patients who have received prior radiation.

Conclusion

Our small group of patients represents a unique cohort of patients in whom surgery was attempted after radiation therapy. We have seen that surgery is a feasible option after radiotherapy in patients with advanced disease.

Attitudes to long-term care in India: a secondary mixed-methods analysis

BACKGROUND

India is the world's most populous country, and overseas Indians the world's largest diaspora. Many of the more than 1·4 million UK-based Indians will be providing care at a distance for parents living in India. Globalisation has contributed to a shift in India from traditional joint family systems to more nuclear structures. We investigated how commonly Indian parents consider and use long-term care facilities and attitudes to their use.

METHODS

We did a secondary mixed-methods statistical analysis of the LASI (Longitudinal Ageing Study in India), a national, cross-sectional household survey administered in 2017-18 to 73 396 randomly selected adults aged 45 years and older in all Indian states and Union Territories (42 261 [58%] women, 31 135 [42%] men). We report the proportion and sociodemographic predictors of respondents' parent(s) living in a care home. We also did a secondary thematic analysis of the qualitative interviews from the Moving Pictures India Study, exploring attitudes to long-term care in 2022. These interviews included 19 carers (nine [47%] women; age range 31-79 years) for people with dementia and 25 professionals (19 [76%] women; age range 24-56 years) purposively selected for diversity from networks of the team based at a Bangalore hospital, India.

FINDINGS

24 LASI participants reported that their parent was living in a long-term care facility (father [n=8], mother [n=15], both parents [n=1]). Although rare overall, use and consideration of use of long-term care were more frequently reported in urban areas (n=14, 58%), by people in middle-income quintiles (n=17, 71%) with higher levels of education (n=7, 29%), who rated their health as good or very good (n=15, 63%). The themes identified in qualitative interviews were the use of long-term care facilities as a last resort, social expectations, and limited availability of long-term care facilities.

INTERPRETATION

Although interviews were only conducted in Bangalore and respondents could misrepresent living arrangements due to ongoing societal stigma, the data show that very few people reside in old age homes across India, with strong preference towards intergenerational and community care. With the UK home to a growing diaspora of nuclear Indian families, our findings illustrate the contexts in which they provide care at a distance, navigating cross-cultural attitudes and social norms around long-term care.

FUNDING

Alzheimer's Association US.

Intraoperative frozen section in gynaecology cancers with special reference to ovarian tumours: time to "unfreeze" the pitfalls in the path of the Derby horse of Oncology

PURPOSE

In an oncological set up the role of frozen section biopsy is undeniable. They serve as an important tool for surgeon's intraoperative decision making but the diagnostic reliability of intraoperative frozen section may vary from institute to institute. The surgeon should be well aware of the accuracy of the frozen section reports in their setup to enable them to take decisions based on the report. This is why we had conducted a retrospective study at Dr B. Borooah Cancer Institute, Guwahati, Assam, India to find out our institutional frozen section accuracy.

METHODS

The study was conducted from 1st January 2017 to 31st December 2022 (5 years). All gynaecology oncology patients who were operated on during the study period and had an intraoperative frozen section done were included in the study. Patients who had incomplete final histopathological report (HPR) or no final HPR were excluded from the study. Frozen section and final histopathology report were compared and analysed and discordant cases were analysed based on the degree of discordancy.

RESULTS

For benign ovarian disease, the IFS accuracy, sensitivity and specificity are 96.7%, 100% and 93%, respectively. For borderline ovarian disease the IFS accuracy, sensitivity and specificity are 96.7%, 80% and 97.6%, respectively. For malignant ovarian disease the IFS accuracy, sensitivity and specificity are 95.4%, 89.1% and 100%, respectively. Sampling error was the most common cause of discordancy.

CONCLUSION

Intraoperative frozen section may not have 100% diagnostic accuracy but still it is the running horse of our oncological institute.

Utilizing Condoms in Laparoscopic Gynecologic Cancer Surgeries: A Profitable Safeguard?

Minimally invasive approach is a well-established strategy in the initial exploration or definitive management of the eligible gynecological cancers. It provides the benefits of improved surgical recovery to the patients. However, the last step of the specimen extraction through the smallest incision possible is always challenging for most of the surgeons. The in-bag retrieval of specimen needs utmost attention in most of the malignancies for the preservation of tumor integrity to avoid tumor seedling and upstaging of the disease. The various kinds of commercially available bags are already being utilized for the retrieval of specimens. However, the venture into innovative methods of development of novel and economical specimen retrieval system is desirable owing to the high cost of the commercial endobags. Here, we have described a very simple, safe, and cost-effective technique of specimen retrieval using the ETO sterilized condoms for smaller specimens' extraction in gynecological cancer surgeries.

Pattern of Care of Recurrent Cervical Cancer in Low-resource Settings: Challenges and Patient-initiated Follow-up as a Novel Opportunity

Introduction

The availability of optimum diagnostic strategies remains a major problem in resource-constraint countries. This technique of patient-initiated follow-up (PIFU) has been recently adopted in the UK for gynecological cancers and has proven cost benefits. However, no study from the Indian subcontinent has ever been reported.

Aims and Objectives

The primary objective was to study the pattern of care of recurrent cervical cancer in low-resource settings. The secondary objective was to compare the reliability of symptomatology/clinical evaluation and imaging methods on follow-up to detect recurrence and thus explore the feasibility of symptom-based PIFU.

Materials and Methods

This was a single-institutional retrospective analysis of recurrent cervical cancer cases for a period of 3 years from January 2019 to January 2022. Patients who followed up for minimum of 6 months were included in the study.

Results

In 57 of the total 69 patients, symptoms alone were the index diagnostic method. Interestingly, neither of the methods of recurrence detection had impact on overall survival (OS). Cox regression analysis revealed adverse impact of erratic/lost to follow-up (hazard ratio [HR] = 3.8) and pelvic side wall disease (HR = 1.33) on survival. Patients with positive para-aortic nodes had significantly shorter disease-free interval of 11 months, so adding systemic therapy to adjuvant treatment in this cohort needs to be further investigated.

Conclusion

Our analysis showed that patients with recurrence who were diagnosed with clinical manifestations alone vis-à-vis the ones who were diagnosed primarily on routine follow-up visit by some imaging or diagnostic test had comparable oncologic outcomes. PIFU can be a "practice changing modality" in patient management system, especially in low-resource settings. It will prove to be a simple cost-effective method to detect recurrence and prevent fallouts. Our study points to the feasibility of PIFU in Indian scenario.

Psychosocial distress, perceived social support, and coping in women survivors of domestic violence seeking help from a women's helpline in urban India

BACKGROUND

Domestic violence against women is a worldwide phenomenon and a major public health concern. The adverse effects on the physical and mental health of the women survivors of domestic violence are influenced by various psychosocial factors. This study aimed to understand psychological distress, perceived social support, and coping strategies among women survivors of domestic violence and its implications.

MATERIALS AND METHODS

It is a cross-sectional study conducted with 30 women survivors of domestic violence from urban Bengaluru who were registered with a women's helpline. Data were collected using a socio-demographic schedule, a self-reporting questionnaire assessing psychological distress, perceived social support scale, and ways of coping scale. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Psychological distress was the highest among participants facing violence due to perpetrator using alcohol (M = 11.6, SD = 3.9) and (M = 11.73, SD = 3.5) dowry harassment. Perceived social support from family (M = 14.76, SD = 4.54) and friends (M = 11.85, SD = 4.7) was the highest among participants who reported that alcohol use was not a reason for violence.

CONCLUSION

It can be noticed that alcohol use, dowry harassment, and poor coping strategies were the main reasons for domestic violence, which has led to severe psychosocial distress among the women survivors.

Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Neuropalliative Care in India - Barriers, Challenges and Future Directions

Neuropalliative care is an emerging sub-specialty of neurology and palliative care that aims to relieve suffering from symptoms, reduce distress and improve the quality of life of people with life-limiting neurological conditions and their family caregivers. As advances are being made in the prevention, diagnosis, and treatment of neurological illnesses, there is an increasing need to guide and support patients and their families through complex choices involving immense uncertainty and important life-changing outcomes. The unmet need for palliative care in neurological illnesses is high, especially in a low-resource setting like India. This article discusses the scope of neuropalliative care in India, the barriers and challenges that impede the specialty's development, and the factors that could facilitate the development and scale-up delivery of neuropalliative services. The article also attempts to highlight priority areas for advancing neuropalliative care in India which include context-specific assessment tools, sensitization of the healthcare system, identification of intervention outcomes, the need for developing culturally sensitive models based on home-based or community-based care, evidence-based practices, and development of manpower and training resources.

Carcinoid ovary with synchronous carcinoid tumour of the appendix: report of a rare occurrence with review of literature

Carcinoid tumours are present in a wide range of organs but most frequently involve the gastrointestinal tract and rarely reported in gynaecological organs. Literature reports that the prevalence of ovarian carcinoid is 0.3%-1% of ovarian neoplasms and accounts for only 5% of ovarian teratomas. The pathogenesis of neuroendocrine tumours associated with synchronous primaries is undetermined and many theories have been proposed, such as existence of a common carcinogenic effect or a common stem cell undergoing similar genetic mutation. Paracrine or autocrine growth loop effect by the secretory peptides of the neuroendocrine cell tumours is also suggested. Since carcinoids are variably positive in neuroendocrine and organ-specific markers, there are no immunohistochemistry markers to delineate the definite primary site of origin versus metastasis. We report a rare case of carcinoid ovary with synchronous carcinoid tumour of the appendix. In our case, the presence of contralateral teratomatous elements may hint primary struma carcinoid instead of being metastatic from the appendix. A strumal carcinoid component was also highlighted by PAX8 positivity. This led us to conclude the case as concurrent appendix carcinoid with struma carcinoid as two independent primaries with uncertain pathogenesis. Histologically, as both tumours are well differentiated with Ki-67 of less than 3%, the decision of the joint tumour board was to keep the patient on surveillance, with no adjuvant treatment needed. The patient is currently on surveillance and the follow-up period of 24 months to date has been uneventful.

Using digital media to improve dementia care in India: A pilot randomised control trial (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

International Registered Report Identifier (IRRID)

Adaptation of an online training and support program for caregivers of people with dementia to Indian cultural setting

Support for caregivers of people with dementia has been identified as an action area in the Global Action Plan on the Public Health Response to Dementia 2017-2025 by the World Health Organization (WHO). As a step towards that, WHO developed iSupport - an online program to provide support and training for caregivers of people with dementia. To address the need of caregivers in India, the iSupport program was adapted to the Indian cultural setting. The process of adaptation consisted of four phases: (a) information gathering (review of literature and focus group discussions), (b) preliminary adaptation design (modifications using an adaptation guide), (c) preliminary adaptation tests (face-to-face interviews and online test run), and (d) adaptation refinement (final modifications to the intervention and study process). The initial adaptation was carried out by effecting changes in words, names, resources, caregiving scenarios and audio files to make the English version of iSupport suitable to the Indian cultural context. The results of the qualitative adaptation tests provided additional recommendations like changing the links to India specific websites, revising the eligibility criterion for caregiving duration, re-wording of e-mail texts, inclusion of a time estimate required to complete the assessments and decreasing the numbers of screens that the caregivers had to navigate in the program, which were incorporated in the final phase. Preliminary data showed that the caregivers who participated in the adaptation process found the changes acceptable. Translation of iSupport to different Indian languages could be undertaken after initial effectiveness of the program is established.

Feasibility and preliminary effectiveness of an online training and support program for caregivers of people with dementia in India: a randomized controlled trial

OBJECTIVES

Internet-based interventions involving elements of cognitive behavior therapy, psychoeducation, relaxation and skills training for caregivers of people with dementia have been found to be promising in Western countries. Given these outcomes, the adapted version of a multi-component online caregiver skills training and support program of the World Health Organization, called iSupport, was tested for feasibility and preliminary effectiveness in India.

METHODS

One hundred fifty-one caregivers of family members with a diagnosis of Alzheimer's disease or dementia were randomized to either the intervention arm (iSupport; n = 74) or to the control group (an education-only e-book program; n = 77). Participants were assessed using self-rated measures of depression and perceived burden, which were the primary outcome measures, at baseline and 3-month follow-up. Person-centered attitude, self-efficacy, mastery and self-rated health were also assessed.

RESULTS

Fifty-five caregivers (29 in the iSupport group and 26 in the control condition) completed the study. The recruitment and retention rate of the study were 44.67% and 36.42% respectively. No significant differences were found between the two groups at 3-month follow-up on the primary outcomes. Among the secondary outcomes, significant improvement was only seen in caregivers' person-centered attitude towards persons with dementia in the iSupport group (t = 2.228; p < 0.05).

CONCLUSIONS

Despite efforts to recruit and retain participants to the online program, this study had a low recruitment and retention rate, which require closer attention and indicates a need for further adaptations of the Indian version of the iSupport program to improve its acceptability and accessibility. The lessons learned from this study will guide the further development of caregiver training and support interventions in India. The trial was registered with the Clinical Trials Registry-India (Trial Registration No. CTRI/2017/02/007876).

Choriocarcinoma in post-menopausal women- 3 case reports with review of literature

Gestational trophoblastic neoplasia is of uncommon occurrence in postmenopausal women, unlike in the reproductive age group. The diagnosis is based on levels of beta-human chorionic gonadotropin (hCG) in serum. The management is similar to that in premenopausal women. First case, fifty-two-year-old, P8 L4A3 postmenopausal female, presented with postmenopausal bleeding. Diagnosis of choriocarcinoma was made in view of raised serum betah-CG levels with uterine lesion with lung metastasis. The patient started on Multi-agent chemotherapy. The patient succumbed to death due to Grade III hematological toxicity while on the first cycle of the EMA/CO regimen. Second case, forty-two-year-old, P2 L2, postmenopausal, with a history of Choriocarcinoma 20 years, back presented with postmenopausal bleeding. After metastatic workup, the patient started on EMACO regimen. She is asymptomatic and on regular follow-up after 8 cycles of chemotherapy. Third case, forty-seven-year-old, P4 L4, postmenopausal, presented with histopathology report suggestive of choriocarcinoma after hysterectomy. After evaluation, lung metastasis was detected. The patient responded to eight cycles to Multi-agent chemotherapy and is on regular follow-up. Choriocarcinoma is a rare gynecological malignancy in postmenopausal women. High index of suspicion is required for its diagnosis. The prognosis of the disease is not encouraging as compared to the premenopausal woman

Perspectives on Components of an Online Training and Support Program for Dementia Family Caregivers in India: A Focus Group Study

OBJECTIVES

There is a considerable need for support interventions for caregivers of people with dementia in developing countries, such as India. The purpose of the study was to identify the components and understand the acceptability of an online training and support program for dementia caregivers in India.

METHODS

Three focus group discussions were carried out with dementia caregivers (2) and health professionals (1) to understand the requirements of an online training and support program from their perspective. The commonly recurring themes were identified and defined using thematic content analysis.

RESULTS

The expectations from an online training and support program were wide-ranging from information about identification and management of dementia to support caregiver well-being. Use of simple language, cultural relevance, and an interactive design were suggestions to facilitate the use of the support program. Lack of time, difficulty in accessing the internet, lack of awareness about the portal, difficulty in reaching the rural population were anticipated as challenges in using the program.

CONCLUSIONS

The study highlights the requisite components of a first of its kind online training and support program in India by integrating the experiences, motivations, challenges, and expectations of caregivers and professionals involved in dementia care.

CLINICAL IMPLICATIONS

The focus group discussions in the current study provide a road map for the development of an online caregiver training and support program underlying the perspectives of the stakeholders for the consolidation of an effective dementia care program for lower resourced settings.

First operation in SPIDER and the path to complete MITICA

The requirements of ITER neutral beam injectors (1 MeV, 40 A negative deuterium ion current for 1 h) have never been simultaneously attained; therefore, a dedicated Neutral Beam Test Facility (NBTF) was set up at Consorzio RFX (Padova, Italy). The NBTF includes two experiments: SPIDER (Source for the Production of Ions of Deuterium Extracted from Rf plasma), the full-scale prototype of the source of ITER injectors, with a 100 keV accelerator, to investigate and optimize the properties of the ion source; and MITICA, the full-scale prototype of the entire injector, devoted to the issues related to the accelerator, including voltage holding at low gas pressure. The present paper gives an account of the status of the procurements, of the timeline, and of the voltage holding tests and experiments for MITICA. As for SPIDER, the first year of operation is described, regarding the solution of some issues connected with the radiofrequency power, the source operation, and the characterization of the first negative ion beam.

Neuro-hemodynamic endophenotypes of emotional interference in OCD: fMRI study using emotion counting stroop task

BACKGROUND

We sought to examine the endophenotype pattern of neuro-hemodynamic substrates of emotion counting Stroop (ecStroop) paradigm in patients with OCD, their unaffected siblings [first degree relatives-FDR] and healthy controls (HC).

METHODS

OCD patients (medication naïve)[N = 16], their unaffected siblings(FDR)[N = 16] and HC [N = 24] were compared using an established ecStroop paradigm in a 3-Tesla fMRI. The relative BOLD signals corresponding to the three types of conditions (neural words-N, words with negative emotional salience-E and words with salience for OCD-O) were examined in the apriori hypothesized brain regions.

RESULTS

Both in O minus N contrast and O minus E contrast, the groups demonstrated significant differential activation of right insula (BA 13). The post-hoc analyses showed in patients and FDRs relative to HC the following: significant hyperactivation of insula in O minus E contrast; significant hyperactivation of right insula and right DLPFC (BA 9) in O minus N contrast.

CONCLUSIONS

The neuro-hemodynamic responses corresponding to the obsessive words in insula and DLPFC could be potential endophenotypes. "Threat relatedness" might thus have a vulnerability meaning in the pathogenesis and neurobiological basis of OCD.

iSupport, an online training and support program for caregivers of people with dementia: study protocol for a randomized controlled trial in India

Background

Dementia has a huge physical, psychological, social and economic impact upon caregivers, families and societies at large. There has been a growing impetus to utilize Internet interventions given the potential scalability, and presumed cost-effectiveness and accessibility. In this paper, we describe the design of a randomized controlled trial (RCT) aiming to study the impact of online self-help programs on caregivers of people with dementia in India. The experimental group will receive an interactive training and support program and the comparison group will receive an education-only e-book. It will be among the first online support intervention RCTs for a mental health condition in a lower-middle income country.

Methods and design

Two hundred and eight participants are expected to be recruited via several strategies (email, Internet and social media, telephone and face-to-face) starting in the Bangalore region of India. The inclusion criteria for participation in the trial are: (1) being 18 years or older, (2) being a self-reported caregiver of a person with dementia, (3) self-report that a family member has a diagnosis of dementia (AD8 ≥ 2), and experience caregiver distress (≥ 4 on a 1-item burden scale ranging from 1 to 10 or ≥ 4 or < 20 on the Center for Epidemiologic Study-Depression (CES-D) scale (10-item) or ≥ 4 or < 15 on the Generalized Anxiety Disorder Scale (7-item).

The intervention group will be offered iSupport, an online self-help training and support program, enabling a personalized education plan with a maximum of 23 lessons. These modules present a range of topics from “what is dementia?” to “dealing with challenging behaviors like aggression.” The comparison group will receive an education-only e-book containing similar content. The outcomes of this trial are: caregiver burden as measured by the 22-item Zarit Burden Scale, depressive symptoms, anxiety symptoms (primary outcomes), quality of life, person-centered attitude, self-efficacy and mastery (secondary outcomes).

Discussion

Based on the findings of this trial, we will examine the potential use and scale up of iSupport for caregiver distress in India. This style of online self-help programs could be expanded to other regions or countries or to other suitable caregiver groups.

Trial registration

Clinical Trials Registry—India (CTRI), ID: CTRI/2017/02/007876.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2604-9) contains supplementary material, which is available to authorized users.

Role of radiological imaging and interventions in management of Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is a clinical condition resulting from impaired hepatic venous drainage, in which there is obstruction to the hepatic venous outflow at any level from the small hepatic veins to the junction of the inferior vena cava and the right atrium leading to hepatic congestion. The diagnosis of BCS is based on imaging, which can be gathered from non-invasive investigations such as ultrasonography coupled with venous Doppler, triphasic computed tomography (CT) and magnetic resonance imaging (MRI). Apart from diagnosis, various interventional radiology procedures aid in the successful management of this syndrome. In this article, we present various imaging features of BCS along with various interventional procedures that are used to treat this diverse condition.

A randomized controlled study of brief family-based intervention in obsessive compulsive disorder

BACKGROUND

Cognitive behaviour therapy (CBT) for Obsessive Compulsive Disorder (OCD) is therapist-intensive and prolonged making it less accessible to patients, particularly in resource-constrained situations. We examined the efficacy of a brief psychotherapeutic intervention as an adjunct to serotonin reuptake inhibitors (SRIs) in OCD.

METHOD

We randomized 64 adult OCD patients stabilized on SRIs to either the 6-session brief family-based intervention (BFBI; n = 30) that included psychoeducation, exposure and response prevention and family intervention or to a control arm of relaxation exercises (RE). Assessments were conducted at baseline and at 1- and 3- months post-intervention. Primary outcome measure was response to treatment defined as ≥ 35% reduction in the Yale-Brown Obsessive Compulsive Scale total score relative to baseline score plus a Clinical Global Impression- Improvement rating of very much improved or much improved. Family accommodation and expressed emotions were also assessed.

RESULTS

At 3- month follow-up, the BFBI group responded better than the RE group (53% vs. 12%, p < 0.001). Illness severity, family accommodation and expressed emotion declined significantly over time in the BFBI group compared to the RE group. The BFBI (OR = 13.17, p < 0.001) and baseline illness severity (OR = 0.746, p < 0.011) predicted treatment response.

LIMITATIONS

Sample size was small and follow-up duration was short. Control group had less time with the therapist although number of sessions was identical in both the groups.

CONCLUSION

Briefer intervention is effective in treating OCD. Briefer and inclusive format of intervention has important implications for clinical practice in resource-constrained circumstances.

Neoadjuvant chemotherapy in advanced epithelial ovarian cancer: A survival study

Context:

Patients with advanced ovarian cancer have a poor prognosis in spite of the best possible care. Primary debulking surgery has been the standard of care in advanced ovarian cancer; however, it is associated with high mortality and morbidity rates as shown in various studies. Several studies have discussed the benefit of neoadjuvant chemotherapy in patients with advanced ovarian cancer.

Aims:

This study aims to evaluate the survival statistics of the patients who have been managed with interval debulking surgery (IDS) from January 2007 to December 2009.

Materials and Methods:

During the period from January 2007 to December 2009, a retrospective analysis of 104 patients who underwent IDS for stage IIIC or IV advanced epithelial ovarian cancer at our institute were selected for the study. IDS was attempted after three to five courses of chemotherapy with paclitaxal (175 mg/m² ) and carboplatin (5-6 of area under curve). Overall survival (OS) and progression free survival (PFS) were compared with results of primary debulking study from existing literature. OS and PFS rates were estimated by means of the Kaplan-Meier method. Results were statistically analyzed by IBM SPSS Statistics 19.

Results:

The median OS was 26 months and the median PFS was 18 months. In multivariate analysis it was found that both OS and PFS was affected by the stage, and extent of debulking.

Conclusions:

Neoadjuvant chemotherapy, followed by surgical cytoreduction is a promising treatment strategy for the management of advanced epithelial ovarian cancers.

Comparison of clinical characteristics of familial and sporadic obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition with evidence of familiality in a considerable proportion of patients. A classification into familial and sporadic forms has been proposed to explain the heterogeneity. The current study aims to compare the demographic, clinical and comorbidity patterns of patients with and without a family history of OCD in first-degree relatives.

METHOD

802 consecutive patients who consulted a specialty OCD Clinic at a tertiary care psychiatric hospital in India were evaluated with the Mini-International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression Scale. Family history was assessed by interviewing patients and at least one first-degree relative.

RESULTS

Family history of OCD was seen in 152 patients (19%). Family history was associated with juvenile onset (Χ(2)=19.472, p<0.001), obsessions of contamination (Χ(2)=6.658, p=0.01), hoarding (Χ(2)=4.062, p=0.032), need for symmetry (Χ(2)=3.95, p=0.047), washing compulsion (Χ(2)=7.923, p=0.005), ordering compulsions (Χ(2)=6.808, p=0.009), repeating compulsions (Χ(2)=4.950, p=0.026) and compulsions by proxy (Χ(2)=7.963, p=0.005). Family history was also associated with greater severity of OCD (t=-2.31, p=0.022) and compulsions (t=-3.09, p=0.002) and longer duration of illness at presentation (t=-2.93, p=0.004).

CONCLUSION

Our findings suggest that familial OCD may have distinctive clinical features. Studying familial forms of OCD may offer unique insight in to understanding the genetic basis of OCD.

Continuous low-dose oral chemotherapy in recurrent and persistent carcinoma of cervix following chemoradiation: a comparative study between prolonged oral cyclophosphamide and oral Etoposide

Aim:

To compare the efficacy and toxicities of low-dose oral cyclophosphamide and oral etoposide in patients with persistent and recurrent cervical cancer with gross pelvic disease following full course of chemoradiation therapy.

Materials and Methods:

30 patients with recurrent and persistent cervical cancer with gross pelvic disease were enrolled in this trial. The patients were randomly divided into two groups of 15 patients each with one group receiving low dose oral cyclophosphamide (100 mg/day) and the other group receiving low-dose oral etoposide (50 mg/day). Results were statistically analysed by IBM SPSS Statistics 19.

Results:

Oral etoposide was not well tolerated with grade 2 neutropenia occurring in 33.3% and grade 3 neutropenia in 6.6% and thrombocytopenia occurring in 13.3%. Oral cyclophosphamide group on the other hand was better tolerated with none of the patients having thrombocytopenia and 6.6% patients having grade 2 neutropenia. There were two complete response (15.38%) and one partial response at the end of study (7.6%) in the cyclophosphamide group whereas there was no complete response and two partial response (16.6%) in the oral etoposide group.

Conclusion:

Long-term, low-dose oral etoposide was found to be less tolerated without any significant effect with patients with persistent and recurrent cervical cancer with gross pelvic disease following full course of chemoradiation therapy in contrast to oral cyclophosphamide which was found to be effective and well-tolerated by the patients.

Hybrid capture 2 assay based evaluation of high-risk HPV status in healthy women of north-east India

BACKGROUND

High risk HPV (HR-HPV) testing has been recommended as an effective tool along with cytology screening in identification of cervical intraepithelial lesions (CINs) and prevention of their progress towards invasive cervical cancer. The aim of this study was to assess the HR-HPV DNA status by Hybrid Capture 2 (HC2) assay in healthy asymptomatic women of North-East India.

MATERIALS AND METHODS

This study examined cervical cell samples of forty three (n=43) healthy women by HC2 assay. A High Risk HPV DNA kit (Qiagen) was used which can detect 13 high risk HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68.

RESULTS

The mean relative light units (RLU) for samples was in the range of 141-5, 94, 619. HR-HPV DNA was confirmed in 16% (7/43) of participant women samples. Among demographic and clinical parameters, menstrual irregularity (p=0.039) and infection history (p=0.028) has shown statistically significant differences between the HR-HPV-positive and negative groups. In the HR-HPV positive group, two women were confirmed for CINs after colposcopy and histopathologic examination.

CONCLUSIONS

We suggest that there may be an association between irregular menstruation and infection history of the urogenital tract with HR-HPV DNA prevalence in North-East Indian asymptomatic women. HC2 assay can be a valuable tool for HR-HPV screening.

Neurohemodynamic Correlates of Washing Symptoms in Obsessive-compulsive Disorder: A Pilot fMRI Study Using Symptom Provocation Paradigm

BACKGROUND

Obsessive-compulsive disorder (OCD) is increasingly being viewed as a multidimensional heterogeneous disorder caused due to the dysfunction of several closely related, overlapping frontostriatal circuits. A study investigating the dimensional construct in treatment naïve, co-morbidity free patients with identical handedness is likely to provide the necessary homogeneity and power to elicit neural correlates of the various symptom dimensions, and overcome the limitations of previous studies.

MATERIALS AND METHODS

Nine DSM-IV OCD patients with predominant contamination-related obsessive-compulsive symptoms (age=29.8±7.1 years; five males: four females; years-of-education=13.9±1.6, YBOCS total score=28.8±4.7, DYBOCS Contamination dimension score=10.7±1.8) and nine healthy controls matched one to one with the patients for age, sex, and years of education (age=27.8±5.4, five males: four females; years-of-education=14.9±3.0), were examined during symptom provocation task performance in 3TMRI. Paired samples t test of brain activation differences (contamination relevant pictures - neutral pictures), limited to apriori regions of interest was done using SPM8 (uncorrected P<0.005).

RESULTS

Patients found significantly more pictures to be anxiety provoking in comparison to healthy controls. Patients were found to have deficient activation in the following areas in comparison with healthy controls: bilateral anterior prefrontal, dorsolateral prefrontal, orbitofrontal, anterior cingulate, insular and parietal cortices, precuneus, and caudate.

CONCLUSIONS

Results underscore the importance of frontal, striatal, parietal, and occipital areas in the pathophysiology of OCD. Divergence of findings from previous studies might be attributed to the absence of confounding factors in the current study and may be due to production of intense anxiety in patients.