Perspectives of Community Nurses on Treatment Engagement of Persons with Severe Mental Illnesses (PwSMI): A Qualitative Study from South India

Background

There is increasing evidence of the need for treatment engagement between Persons with Severe Mental Illnesses (PwSMIs) and Mental Health Professionals (MHPs). This therapeutic process involves collaborative work between patients and MHPs, which improves the condition. Community nurses are uniquely positioned to facilitate this process as they act as the focal point of interaction between patients and the health system.

Methods

This qualitative study explored the community nurses' experiences in treatment engagement with PwSMI through eight group interviews of 35 community nurses from District Mental Health Programs (DMHPs) across Karnataka (South India) from February 2020 to March 2020. The audio recordings of the interviews were transcribed and coded to arrive at themes and subthemes.

Results

The major themes identified were factors influencing treatment engagement, strategies to tackle treatment nonengagement, and challenges in dealing with nonengagement. The reasons for nonengagement were lack of insight and lack of knowledge of sociocultural, logistic, and treatment-related factors. The DMHP teams contacted patients through phone calls, home visits, and liaisons with health workers and intervened with them through education and depot injections. The major challenges were difficulty conducting home visits, distances, the unavailability of medications, and the need for adequate infrastructure and human resources.

Conclusion

Community nurses address a few factors of nonengagement, such as insight, sociocultural factors, and treatment-related factors. Addressing the systemic challenges and adequate training of nurses in intervening in the dropped-out PwSMIs would help to reduce the treatment gap.

Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Impact of incentivizing ASHAs on the outcome of persons with severe mental illness in a rural South Indian community amidst the COVID-19 pandemic

BACKGROUND & OBJECTIVES

Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs). We examined the impact of incentivizing ASHAs on the outcome of persons with severe mental illness (SMI) amidst the pandemic.

METHODS

One hundred eighty-four adults with SMI from Jagaluru taluk were enrolled and followed up for a year. They were assessed for disability, work performance, internalized stigma, and illness severity at baseline, six months, and 12 months follow-up. ASHA workers were incentivized to ensure follow-up consultations, address concerns regarding illness/ medication side effects and monitor medication adherence.

RESULTS

Out of the 184 recruited patients, 7 died (non-COVID-19 causes), 22 stopped treatment and did not report for follow-up consultations, 11 shifted to treatment from other centers, and in 1 case, there was a change in diagnosis. 143 (78%) patients with SMI completed the study amidst the COVID-19 pandemic. At one year follow-up, there was a significant reduction in disability, illness severity, self-stigma, and improved work performance.

CONCLUSION

Incentivization of ASHAs helped ensure continuity of care to persons with SMI despite lockdowns and COVID-19 exigencies. It is feasible to involve ASHAs in the treatment of persons with SMI.

Impact of Technology Driven Mental Health Task-shifting for Accredited Social Health Activists (ASHAs): Results from a Randomised Controlled Trial of Two Methods of Training

Mental health task shifting is a potential way to address the burgeoning treatment gap for mental illness. Easily available and accessible digital technology can be utilised to continuously engage grassroot level health workers (for example, Accredited Social Health Activists (ASHAs). However, the impact of such a strategy is not yet systematically evaluated. In this randomised controlled trial, longitudinal hybrid training of ASHAs [1 day in-person classroom training and seven online sessions (ECHO model), aimed to screen and refer to commonly prevalent mental health issues in communities] was compared with traditional one-day in-person classroom training. ASHAs (n = 75) from six Primary Health Centres in Ramanagara district, Karnataka, India were randomized into study (SG-ASHAs) and control (CG-ASHAs) groups. After excluding drop-outs, 26 ASHAs in each group were included in the final analysis of the scores on their Knowledge, attitude, and practices (KAP) in mental health. Two house-to-house surveys were conducted by both groups to identify and refer possible cases. The number of screen positives (potential persons with mental illnesses) and the KAP scores formed the outcome measures. Online sessions for SG-ASHAs were completed over 18 months, the COVID-19 pandemic being the main disruptor. SG-ASHAs identified significantly higher number of persons with potential alcohol use disorders [n = 873 (83%); p ≤ 0.001] and common mental disorders [n = 96(4%); p = 0.018], while CG-ASHAs identified significantly higher number of those with potential severe mental disorders [n = 61(61.61%); p ≤ 0.001]. As regards KAP, after controlling for baseline scores, the time effect in RMANOVA favoured SG-ASHAs. Mean total KAP score increased from 16.76 to18.57 (p < 0·01) in SG-ASHAs and from 18.65 to 18.84 (p = 0.76) in CG-ASHAs. However, the Time-group interaction effect did not favour either (F = 0.105; p = 0.748). Compared to traditional training, mentoring ASHAs for extended periods is more impactful. Easily accessible digital technology makes the latter feasible. Scaling up such initiatives carry the potential to considerably improve treatment access for those in need.

A camp approach of community psychiatry in India: Past, present, and the future

Camps are a popular approach to deliver medical care in India. While it is usually a one-off event for physical ailments, it is a long-term affair in Psychiatry. One of the first camps in psychiatry was rolled out as early as in 1967 at Mandar, Ranchi, followed by Raipur Rani (Haryana) in 1976 and at Gunjur, Karnataka in 1977. This camp approach became extremely popular and got expanded across India as they were thought to be synonymous with community-based outreach for mental illnesses. In the past 5 years, however, newer models of community care have emerged, necessitating a relook at this traditional approach. In this paper, the authors trace the origin, utility and future directions of these camps, taking data from community psychiatry camps conducted by the National Institute of Mental Health and Neurosciences, Bengaluru, a premier neuropsychiatric tertiary care institute in India. Data have been collated from the annual reports of the Institute, database from the District Mental health Program, Government of Karnataka, India, and compared with published literature on the same field. While camps remain as one of the important avenues to reach the unreached, there is a need to change the approach of their functioning by incorporating training (primary care providers) aspects and collaborative care. The latter may make the initiative more meaningful and sustainable.

Care at door-steps for persons with severe mental disorders: A pilot experience from Karnataka district mental health program

BACKGROUND

Public funded outreach services for persons with severe mental disorders (SMDs), a norm in developed nations, is non-existent in India. We share our pilot experience with an indigenous model named 'Care at Doorsteps' (CADs) for persons with SMDs who dropped out from clinical care of District Mental Health Program (DMHP) at three sites of Karnataka, a south Indian state.

AIM

The objectives of this study were to identify the reasons for drop outs from routine care and to assess the burden of illness and disability after the intervention.

METHODOLOGY

Six-month prospective observational study on patients aged 18-60 years, diagnosed as Schizophrenia or bipolar disorder was conducted. Three home visits were made by the team and provided medications, also offered brief psychoeducation and counselling. Care-givers were interviewed to identify the reasons for drop outs and their expectations from the treating team. Patients were also assessed using the Clinical Global Impression Scale (CGI), Indian Disability Evaluation and Assessment Scale (IDEAS) and Burden Assessment Schedule (BAS) during each visit.

RESULTS

Ninety-six patients (50 males and 46 females) were followed up, of which 85 had a diagnosis of schizophrenia and 11 with bipolar illness. Common reasons for drop out were: single caregiver (breadwinner) unable to accompany the patient, loss of faith in medical treatment and financial constraints. Symptomatic improvement and restoration of productive work were the priority expectations. Over the course, the mean CGI-S showed significant reduction (4.81 ± 1.57, 4.46 ± 1.32 and 4.11 ± 1.39 respectively; p = 0.001). Mean score on BAS showed a significant reduction (85.76 ± 12.15, 83.46 ± 11.30, 84.27 ± 11.82; p = 0.04). Mean total IDEAS scores did not show significant change (13.27 ± 4.78, 12.82 ± 4.24, 13.17 ± 4.40; p = 0.16).

CONCLUSION

Meaningful assertive outreach care is feasible in India and is found to be useful for persons with SMDs by utilising the already existing public sector resources.

Postoperative respiratory depression caused by iatrogenic hypermagnesaemia

Hypermagnesaemia is an uncommon electrolyte disorder which can be fatal if not recognised and treated promptly. The signs and symptoms of hypermagnesaemia are non-specific, making it an under-diagnosed cause of cardiovascular dysfunction, hypocalcaemia, and neurological and respiratory depression. Since magnesium homeostasis is handled almost exclusively by the kidneys, symptomatic hypermagnesaemia seldom occurs in the context of normal renal function; when it does, it is usually iatrogenic. Here, we report a case of iatrogenic hypermagnesaemia which presented as respiratory depression, preventing weaning from mechanical ventilation following cardiac surgery in a patient in the early stages of chronic kidney disease. On investigation he was found to have isolated severe hypermagnesaemia, following an intravenous bolus of magnesium sulphate administered intra-operatively to treat tachyarrhythmia. Before administering intravenous magnesium therapeutically, it is important for clinicians to assess renal function and baseline serum magnesium along with other possible risk factors for hypermagnesaemia, and to actively look for signs and symptoms of magnesium toxicity when the patient is receiving therapeutic magnesium.

Design and development of heater control circuit without temperature sensor for monitoring hydrogen in argon

A thin film based tin oxide sensor is developed to monitor low levels of hydrogen (concentration ranging from 5 to 75 ppm) in the cover gas plenum of the fast breeder test reactor. The heater and the sensor patterns are integrated on a miniature alumina substrate, and necessary electrical leads are incorporated into it. For proper functioning of the sensor, the heater has to be maintained at a constant temperature of 350 °C. This paper gives an outline of the electronics developed to measure the sensor signal and to control the heater temperature. The major challenge in this work is that there was no provision for embedding a temperature sensor on the heater surface due to physical constraints. This constrained the maintenance of a constant heater temperature for the proper functioning of the sensor. This led us to develop and demonstrate a heater control circuit without a temperature sensor to maintain a fixed temperature for monitoring hydrogen in argon, and electronics for the above-mentioned circuitry is discussed.

Bio inspired growth factor loaded self assembling peptide nano hydrogel for chronic wound healing

Self assembling peptidebased hydrogel has been explored for delivering growth factors, anticancer drugs, antibiotics etc. Here, RADA 16-I (RADARADARADARADA), an ionic self complementary peptide that forms a well defined nanohydrogel has been studied for its ability to deliver PDGF-BB in a sustained manner and to destruct biofilm formed by wound specific pathogens. Results of the structural analysis of the nanohydrogel studied through AFM, FeSEM, CD, FT-IR and Rheometry, revealed the hydrogel forming ability of RADA 16-I with stable β-sheet structure at room temperature. The nanohydrogel was also found to destruct the biofilm formed under in vitro condition using S. aureus, E. coli and P. aeruginosa. The growth factor incorporated in the nanohydrogel followed first order release kinetics and showed sustained release up to 48 h. Angiogenic potential and wound healing ability of PDGF-BB incorporated nanohydrogel was confirmed in both in vitro and in vivo conditions. The animals treated with PDGF-BB incorporated nanohydrogel exhibited 99.5% wound closure at day 21. The content of hydroxyproline and ascorbic acid was significantly high in the treated animals when compared to control and untreated animals. Overall, the study provides the essential information and data for using RADA 16-I for treating chronic wounds.

Addressing the mental health concerns of migrant workers during the COVID-19 pandemic: An experiential account

The COVID pandemic has affected the world in a drastic manner taking a toll of not only human lives but also the economy and lifestyle. Of all the population suffering, the underprivileged and vulnerable groups have faced the maximum economic burden. Within India, an ample quota of people migrates annually for elementary occupations in service, sales, building and domestic industries. Generally, they are exposed to discrimination, work-rights exploitation and job insecurity. The onset of COVID 19 has accentuated these issues in unprecedented ways. The Apex Court of the country took note of this plight and gave directions to the governments to take care of the immediate needs of the migrant workers. This article attempts to reflect the mental health concerns of the migrant workers who were temporarily sheltered at relief camps across Bengaluru city in the state of Karnataka, during the ongoing COVID pandemic. The article ends with giving recommendations.

Embracing Technology for Capacity Building in Mental Health: New Path, Newer Challenges

Technology driven capacity building initiatives are the way to break the barrier of shortage of mental health human resources in India. This new path, while is a welcome step, comes with its own set of challenges. In one prototypic project that is being implemented in Ramanagara District of Karnataka, a south Indian state, we encountered many such issues. They ranged from issues related to availability of dedicated space to set up the hub-studio, inconsistent internet connectivity (particularly in remote areas) and inadequate digital literacy among the grassroot community health workers who hail from villages. This article summarises these challenges and ends by looking into ways and means of overcoming them.

Accredited Social Health Activist (ASHA) and Her Role in District Mental Health Program: Learnings from the COVID 19 Pandemic

COVID 19 pandemic has posed challenges for public mental healthcare delivery, particularly in LAMI countries such as India. However, this unique situation has also brought in opportunities to revisit the health system and optimally utilize the available resources. In this brief report, we report one such new initiative in which existing community health workers (CHWs), known as ASHAs (Accredited Social Health Activist) acted as a bridge between patients with mental illness and the District Mental Health Program (DMHP) of Ramanagara district of Karnataka State, India. They maintained continuity of care of 76 patients by delivering mental healthcare services to the patients' doorstep. This has paved the way to rethink and revisit their role in public mental healthcare delivery not only during COVID 19 times, but also beyond.

Mental health issues among health care workers during the COVID-19 pandemic - A study from India

Mental health issues among health care workers (HCWs) in treatment settings during COVID-19 remains understudied in India. This study examines its prevalence and correlates among HCWs in Karnataka State, India. HCWs who attended a workshop to improve mental health well-being during COVID-19 completed an anonymous online questionnaire. In addition to socio-demographics, domains assessed include occupational characteristics, COVID-19 related concerns, anxiety/depression, substance use, suicidality, lifestyle and family functioning. Of the 3083 HCWs who completed the survey (response rate-51.4 %), anxiety disorder and depression was highest among those with frontline COVID-19 responsibilities (anxiety disorder-26.6 %, depression-23.8 %). Prevalence was significantly higher among those with clinical responsibilities compared to those with supportive responsibilities (anxiety disorder: 23.9 % vs 15.5 %), (depression: 20.0 % vs 14.2 %). In the backward step-wise logistic regression analysis, HCWs with anxiety disorder were more likely to be doctors/nurses/hospital assistants, older, female, unmarried, without a leisure activity, report increased alcohol use and suicidal thoughts after pandemic onset, and having a history of receiving mental health interventions. Participants with depression additionally had family distress and hardly ever exercised. To conclude, mental health issues are common among HCWs in India. Interventions need to ensure that HCWs are protected from mental health consequences of working in COVID-19 treatment settings.

Karnataka telemedicine mentoring and monitoring program for complete integration of psychiatry in the general health care

The National Mental Health Survey of India reported a higher prevalence and treatment gap of psychiatric disorders among the general population. Task shifting is one of the important solutions to meet this requirement. The prevalence of psychiatric disorders among primary care is about 30%-50%. Digitally driven primary care psychiatry program (PCPP) designed to innovate different module to upscale the skills of primary care doctors (PCDs) in live consultation of PCDs in their general patients. To exponential coverage of PCDs, Karnataka Telemedicine Mentoring and Monitoring (KTM) Program is been implemented across all districts of Karnataka. It is the training of trainer version of PCPP where psychiatrists serving in District Mental Health Program of all districts of Karnataka become trainers to implement of two digital modules (Telepsychiatric On-Consultation Training and Collaborative Video Consultations) of PCPP with the target to train all PCDs of Karnataka. This paper aims to provide a glimpse of this innovative KTM program and current progress with a preliminary analysis of translational quotient indicating skill transfer and retention.

Establishing Performance Indicators of Telemedicine-Based "On-Consultation Training" of Primary Care Doctors: An Innovation to Integrate Psychiatry at Primary Care

Background

A "functional treatment gap" exists in primary care of India despite the higher prevalence of psychiatric disorders at primary care. Traditional classroom training for primary care doctors (PCDs) fails to translate into adequate clinical skills to provide basic psychiatric treatment. An innovative telepsychiatric on-consultation training (Tele-OCT) is designed exclusively for practicing PCDs where a telepsychiatrist trains PCDs in live video streaming of their own real-time general consultations of primary health centres. The aim of this study is to establish performance indicators of Tele-OCT for its effective implementation.

Methodology

The data collected using a file review method from a naturalistic design of the implementation of Tele-OCT for 73 PCDs from August-2016 to October-2018 across Mandya district, Karnataka, India.

Results

Flexibility in the scheduling of Tele-OCT sessions is key to success. Personal smartphones of PCDs with available videoconference applications are the popular choice. Four consecutive Tele-OCT sessions are planned for each PCD with a gap of 2-4 weeks over two months. The first three sessions are considered the "optimum Tele-OCT training package" for each PCD, followed by the fourth one as a 'Tele-OCT impact evaluation session' in a live, real-time general consultation. Each Tele-OCT is conducted in an average ten general patients in about two hours per session, totalling about 30 patients in 6 hours of Tele-OCT training package per PCD. Patient's profiles especially common mental disorders are reflective of a true picture of Indian primary care.

Conclusions

Performance indicators of Tele-OCT for future implementation are established. Tele-OCT appears to be a path-breaking training model for PCDs to integrate psychiatric care in their general practice.

Identification of Psychiatric Disorders by Rural Grass-Root Health Workers: Case Series & Implications for the National Mental Health Program of India

Auxiliary Nurse Midwife (ANMs) and Accredited Social Health Activists (ASHAs) are well suited to cater to the mental health needs of the communities. Integrating primary mental health care into the general healthcare is one of the important objectives of the District Mental Health Program (DMHP) to reduce the treatment gap. As a part of an ICMR funded trial to evaluate the effectiveness of NIMHANS-ECHO blended training program, the ASHAs and ANMs were trained to identify and refer cases from the community. We aim to describe a series of cases identified by those workers from the community, highlighting their importance in our health care system.

Impact Evaluation of VKN-NIMHANS-ECHO Model of Capacity Building for Mental Health and Addiction: Methodology of Two Randomized Controlled Trials

BACKGROUND

Bridging the alarming treatment gap for mental disorders in India requires a monumental effort from all stakeholders. Harnessing digital technology is one of the potential ways to leapfrog many known barriers for capacity building.

AIM AND CONTEXT

The ongoing Virtual Knowledge Network (VKN)-National Institute of Mental Health and Neurosciences (NIMHANS)-Extension of Community Health Outcomes (ECHO) (VKN-NIMHANS-ECHO: hub and spokes model) model for skilled capacity building is a collaborative effort between NIMHANS and the University of New Mexico Health Sciences Centre, USA. This article aims to summarize the methodology of two randomized controlled trials funded by the Indian Council of Medical Research (ICMR) designed to evaluate the effectiveness of the VKN-NIMHANS-ECHO model of training as compared to training as usual (TAU).

METHODS

Both RCTs were conducted in Karnataka, a southern Indian state in which the DMHP operates in all districts. We compared the impact of the following two models of capacity building for the DMHP workforce (a) the VKN-NIMHANS-ECHO model and (b) the traditional method. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of these two trials.Trial 1 is to evaluate the "Effectiveness of addition of Virtual-NIMHANS-ECHO tele-mentoring model for skilled capacity building in providing quality care in alcohol use disorders by the existing staff of DMHP districts of Karnataka." Hub for trial 1 was set up at NIMHANS and the spokes were psychiatrists and other mental health professionals headquartered in the district level office. Trial 2 assesses the implementation and evaluation of the NIMHANS-ECHO blended training program for the DMHP workforce in a rural south-Indian district of Karnataka state. The hub for trial 2 was set up in the district headquarter of Ramanagaram. Hub specialists are DMHP psychiatrists, whereas spokes are the non-doctor workforce (including auxiliary nurse midwives [ANMs] and accredited social health activists [ASHA] workers) medical officers of primary health centers. The location of the HubHub differs in these two studies. Both trials are funded by the ICMR, Government of India.

DISCUSSION

Both these trials, though conceptually similar, have some operational differences which have been highlighted. If demonstrated to be effective, this model of telementoring can be generalized and widely merged into the Indian health care system, thus aiding in reducing the treatment gap for patients unable to access care.

Taluk Mental Health Program: The new kid on the block?

This article highlights the platform and framework for the new public mental health initiative, the Taluk Mental Health Program (TMHP), rolled out by the Government of India, as part of the expansion of the District Mental Health Program. In this initial phase, TMHP has been approved for ten taluks of Karnataka state. In the authors' collective opinion, few of the initiatives in the country could be considered as foundations for conceptualizing the TMHP (a) research programs and projects in the community, (b) community intervention programs running in two taluks of Karnataka since the past one and a half decade (Thirthahalli and Turuvekere taluks of Karnataka), and the (c) Primary Care Psychiatry Program of National Institute of Mental Health and Neurosciences. The article briefly describes the above initiatives and ends with further suggestions to scale up TMHP.

A Performance Audit of First 30 Months of Manochaitanya Programme at Secondary Care Level of Karnataka, India

Introduction:

Lifetime prevalence of psychiatric disorders in India is about 14%, and the treatment gap is huge necessitating large-scale public health efforts. Manochaitanya programme (MCP), one such innovative program, was launched by the Government of Karnataka in October 2014. MCP entails provision of outpatient psychiatric care in subdistrict (Taluk) hospitals and primary health centers under a public–private (Indian Psychiatric Society-Karnataka chapter) partnership model, at least one Tuesday of every month.

Aim:

The aim was to do a secondary care level performance audit of MCP of initial 2½ years at all Taluka general hospitals of Karnataka.

Methodology:

Data on MCP were collected and tabulated from all 31 districts using a specially designed semistructured pro forma. This includes the number of self-reported psychiatric consultations in each Tuesday's clinic, number of psychiatrists, and their visit details. Prospective data were obtained from monthly reports.

Results:

The district coverage was 100% during initial 2½ years over this period, i.e., MCPs were successfully covered in at least one Taluka hospital in all 31 districts. A total number of estimated consultations under this initiative were 73,663 with an average of 24.1 patients per psychiatrist consultation. One hundred and eleven psychiatrists participated in a total of 3,056 visits across the state. Patient footfall increased consistently over this time period.

Conclusions:

Psychiatrist-based Manochaitanya programme at secondary care level at Taluk hospitals has noticed substantial benefits to patient care. There is a need for psychiatrist-based secondary care at Talukas (subdistrict) level across the country.

Effects of Citrate Acid Concentrate on Hemodialysis Adequacy, Reuse, and Quality of Life: A Prospective Randomized Crossover Trial

We conducted a randomized crossover trial to identify whether the use of citrate dialysate (CD) for bicarbonate hemodialysis is beneficial compared to regular acetate dialysate (AD) in terms of adequacy, reuse, and quality of life. Thirty-two stable end-stage renal disease patients on twice-weekly maintenance hemodialysis were randomly assigned to CD or AD fluid in a single-blinded randomized prospective crossover trial of 1-year duration. The primary outcomes studied were the impact of CD in comparison with AD on hemodialysis adequacy, reuse of dialyzer, and quality of life. Secondary outcomes studied were the effect on intradialytic hypotension, acidosis correction, and episodes of symptomatic hypocalcemia. A total number of 28 patients underwent a total of 1456 sessions of hemodialysis with CD over 6 months and 1456 sessions with AD over 6 months. There was a significant increase in dialyzer reuse with the use of CD (P = 0.02). There was no difference in dialyzer adequacy as measured by Single pool Kt/V (spKt/V) (P = 0.840) and urea reduction ratio (%) (P = 0.90). Quality of life did not differ between the two groups. No statistically significant difference was observed in predialysis arterial pH (P = 0.23) serum bicarbonate (0.17) and calcium change (P = 0.16). CD is safe and equally effective as compared to AD. It significantly improves the reuse of dialyzer but it does not offer any added advantage in terms of improvement in hemodialysis adequacy and quality of care.

An Unusual Association of Renal Cell Carcinoma and Renal Malakoplakia with Focal Segmental Glomerulosclerosis in an Elderly Patient

The association of malignancy and glomerulonephritis may be missed, especially in elderly patients. Here, we report a case of eosinophilic variant of renal cell carcinoma and renal parenchymal malakoplakia discovered on renal biopsy in a patient with steroid-dependent nephrotic syndrome. The presence of malakoplakia in our biopsy was probably due to systemic steroid therapy for glomerulonephritis, presence of concomitant asymptomatic urinary tract infection, and/or history of diabetes mellitus. The patient had remission of proteinuria following laparoscopic removal of the tumor, indicating probable remission of glomerulonephritis.

Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours

BACKGROUND

Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial.

METHODS

Patients with periampullary cancers were randomized to either laparoscopic or open pancreatoduodenectomy. The outcomes evaluated were hospital stay (primary outcome), and blood loss, radicality of surgery, duration of operation and complication rate (secondary outcomes).

RESULTS

Of 268 patients, 64 who met the eligibility criteria were randomized, 32 to each group. The median duration of postoperative hospital stay was longer for open pancreaticoduodenectomy than for laparoscopy (13 (range 6-30) versus 7 (5-52) days respectively; P = 0·001). Duration of operation was longer in the laparoscopy group. Blood loss was significantly greater in the open group (mean(s.d.) 401(46) versus 250(22) ml; P < 0·001). Number of nodes retrieved and R0 rate were similar in the two groups. There was no difference between the open and laparoscopic groups in delayed gastric emptying (7 of 32 versus 5 of 32), pancreatic fistula (6 of 32 versus 5 of 32) or postpancreatectomy haemorrhage (4 of 32 versus 3 of 32). Overall complications (defined according to the Clavien-Dindo classification) were similar (10 of 32 versus 8 of 32). There was one death in each group.

CONCLUSION

Laparoscopy offered a shorter hospital stay than open pancreatoduodenectomy in this randomized trial. Registration number: NCT02081131( http://www.clinicaltrials.gov).

Culturally Relevant Family Therapy Practice with Parents of Children and Adolescents

BACKGROUND

India is diverse in culture, with multiple aspects that may not match with the Western societal picture. Hence, it has often been seen that therapists encounter unique aspects of therapy that is faced during actual practice, which is never written in any textbook or research papers. Substantial information is present through both outcome (efficacy and effectiveness) studies and process research, but it has very little impact of actual Marital and Family Therapy (MFT) practice. This paper throws light into "how" and "what" of family therapy with parents of children/adolescents having psychiatric disorders.

MATERIALS AND METHODS

Focused group discussion was conducted with practicing family therapists and mental health professionals working in Psychiatric Tertiary Hospital (National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India). Qualitative analysis was done to disseminate process issues in therapy.

RESULTS

Aspects that are vital for families having children and adolescent with psychiatric disorders include: Academic decline and loss of parental control as main reasons for seeking help, integration of models is noted to be beneficial, therapeutic alliance, intake sessions, conjoint sessions and individual sessions are important, cultural issues like gender of therapist, their cultural belief model, therapist's cultural competence need to be taken into consideration.

CONCLUSIONS

Challenges and way-outs to overcome these has been mentioned and implications discussed.

Dominant {100} facet selectivity for enhanced photocatalytic activity of NaNbO3 in NaNbO3/CdS core/shell heterostructures

Facet-selective synthesis of NaNbO₃ crystals in cubic and orthorhombic phases and enhanced photocatalytic activity depending on the surface energy of the facets.

The Use of Ginseng as an Adjunct in Treatment-Resistant Depression

The treatment of depression has evolved over the past several years since the evolution of tricyclic antidepressants (TCAs) to the serotonin selective reuptake inhibitors (SSRIs). However, some patients are resistant to various medications, and various adjunctive medications have been added to the original medication, to promote a therapeutic response. This case report describes a woman, with a long history of treatment-resistant depression, who was treated with a combination of an SSRI and ginseng.

Palliative radiotherapy in esophageal cancer

The present study was undertaken to evaluate the efficacy of radiotherapy in palliation of dysphagia in patients with squamous cell carcinoma (SCC) of esophagus and to see the quality of life (QoL) following radiotherapy. This was a prospective clinical study done between September 2006 and May 2008. All consecutive patients with SCC of the esophagus, who are not candidates for definitive treatment, were included in the study. Dysphagia and QoL were assessed using modified Takita's grading and modified questionnaire based on EORTC QLQ 30 respectively. External beam radiotherapy (EBRT) was delivered to all patients using linear accelerator 6 Mv photons. Patients who had good response with EBRT were further subjected to intraluminal brachytherapy (ILBT) at 700 cGy using Iridium-192. The cumulative dose each patient received was 65 Gy. Patients were followed up at 6 weeks from completion of treatment to look for any difference in dysphagia grade and QoL following therapy. Thirty-three patients were included in the study. The mean age among males and females was 60.9 and 49.8 years, respectively. Nineteen patients (57.6 %) received EBRT followed by ILBT; the remaining patients received only EBRT. Seven were lost during follow-up, and seven (21.2 %) died during the study period of 6 weeks. Nineteen (57.6 %) were followed up. On follow-up endoscopy, evidence of residual stricture was observed in 57.9 %, and growth in 36.8 %. Of the patients, 27.8 % had biopsy-confirmed residual disease. The median dysphagia score decreased from 4 to 3 after treatment (p = 0.002) in 17 (89.5 %) patients. The mean QoL score improved from 107.5 to 114.1 at 6-week follow-up. Following radiotherapy, 26.3 % had persistent chest pain, increased cough with expectoration in 15.8 %, and hyperpigmentation of skin in 10.5 %. Radiotherapy gives significant relief of dysphagia and improves QoL in 90 % of patients with SCC of esophagus. However, following radiotherapy, a number of patients will have persistent stricture, ulceration, and residual disease.

A combined light sheet fluorescence and differential interference contrast microscope for live imaging of multicellular specimens

We describe a microscope capable of both light sheet fluorescence microscopy and differential interference contrast microscopy (DICM). The two imaging modes, which to the best of our knowledge have not previously been combined, are complementary: light sheet fluorescence microscopy provides three-dimensional imaging of fluorescently labelled components of multicellular systems with high speed, large fields of view, and low phototoxicity, whereas differential interference contrast microscopy reveals the unlabelled neighbourhood of tissues, organs, and other structures with high contrast and inherent optical sectioning. Use of a single Nomarski prism for differential interference contrast microscopy and a shared detection path for both imaging modes enables simple integration of the two techniques in one custom microscope. We provide several examples of the utility of the resulting instrument, focusing especially on the digestive tract of the larval zebrafish, revealing in this complex and heterogeneous environment anatomical features, the behaviour of commensal microbes, immune cell motions, and more.

Polymerization behavior of hydrophilic-rich phase of dentin adhesive

The 2-fold objectives of this study were 1) to understand whether model hydrophobic- and hydrophilic-rich phase mimics of dentin adhesive polymerize similarly and 2) to determine which factor, the dimethacrylate component, bisphenol A glycerolate dimethacrylate (BisGMA) or photoinitiator concentration, has greater influence on the polymerization of the hydrophilic-rich phase mimic. Current dentin adhesives are sensitive to moisture, as evidenced by nanoleakage in the hybrid layer and phase separation into hydrophobic- and hydrophilic-rich phases. Phase separation leads to limited availability of the cross-linkable dimethacrylate monomer and hydrophobic photoinitiators within the hydrophilic-rich phase. Model hydrophobic-rich phase was prepared as a single-phase solution by adding maximum wt% deuterium oxide (D2O) to HEMA/BisGMA neat resins containing 45 wt% 2-hydroxyethyl methacrylate (HEMA). Mimics of the hydrophilic-rich phase were prepared similarly but using HEMA/BisGMA neat resins containing 95, 99, 99.5, and 100 wt% HEMA. The hydrophilic-rich mimics were prepared with standard or reduced photoinitiator content. The photoinitiator systems were camphorquinone (CQ)/ethyl 4-(dimethylamino)benzoate (EDMAB) with or without [3-(3, 4-dimethyl-9-oxo-9H-thioxanthen-2-yloxy)-2-hydroxypropyl]trimethylammonium chloride (QTX). The polymerization kinetics was monitored using a Fourier transform infrared spectrophotometer with a time-resolved collection mode. The hydrophobic-rich phase exhibited a significantly higher polymerization rate compared with the hydrophilic-rich phase. Postpolymerization resulting in the secondary rate maxima was observed for the hydrophilic-rich mimic. The hydrophilic-rich mimics with standard photoinitiator concentration but varying cross-linker (BisGMA) content showed postpolymerization and a substantial degree of conversion. In contrast, the corresponding formulations with reduced photoinitiator concentrations exhibited lower polymerization and inhibition/delay of postpolymerization within 2 h. Under conditions relevant to the wet, oral environment, photoinitiator content plays an important role in the polymerization of the hydrophilic-rich phase mimic. Since the hydrophilic-rich phase is primarily water and monomethacrylate monomer (e.g., HEMA as determined previously), substantial polymerization is important to limit the potential toxic response from HEMA leaching into the surrounding tissues.

Development of a semi-adiabatic isoperibol solution calorimeter

A semi-adiabatic isoperibol solution calorimeter has been indigenously developed. The measurement system comprises modules for sensitive temperature measurement probe, signal processing, data collection, and joule calibration. The sensitivity of the temperature measurement module was enhanced by using a sensitive thermistor coupled with a lock-in amplifier based signal processor. A microcontroller coordinates the operation and control of these modules. The latter in turn is controlled through personal computer (PC) based custom made software developed with LabView. An innovative summing amplifier concept was used to cancel out the base resistance of the thermistor. The latter was placed in the dewar. The temperature calibration was carried out with a standard platinum resistance (PT100) sensor coupled with an 8½ digit multimeter. The water equivalent of this calorimeter was determined by using electrical calibration with the joule calibrator. The experimentally measured values of the quantum of heat were validated by measuring heats of dissolution of pure KCl (for endotherm) and tris (hydroxyl methyl) amino-methane (for exotherm). The uncertainity in the measurements was found to be within ±3%.

Integración de habilidades para la crianza de adolescentes: Intervención para el reforzamiento de la relación padres-adolescentes

Las destrezas o habilidades parentales son un aspecto importante del desarrollo infantil. El adiestramiento de los padres en la adquisición y cultivo de estas destrezas es un proceso reciente orientado a su capacitación apropiada en el manejo del niño dentro de su cultura y su comunidad utilizando principios didácticos específicos para tal cultura. En la India han comenzado a emerger una serie de presentaciones sistemáticas de modelos basados en evidencias en el desarrollo de habilidades parentales. El presente artículo describe uno de estos programas (Habilidades Integrales para padres de adolescents, ISPA, sigla en ingles) orientado al reforzamiento del vínculo padre-adolescente y a la descripción de sus componentes. Luego de una evaluación inicial de las necesidades de los padres de niños adolescents, 13 padres siguieron sistemáticamente el programa de once sesiones, cada una de ellas enfocando temas diferentes.Los resultados antes y después de la intervención muestran cambios estadísticamente significativos en las actitudes de los padres respecto a una relación positiva con sus hijos adolescentes. Se describen los “pros y contras” de tales enfoques.

Swelling equilibrium of dentin adhesive polymers formed on the water-adhesive phase boundary: experiments and micromechanical model

During their application to the wet, oral environment, dentin adhesives can experience phase separation and composition change, which can compromise the quality of the hybrid layer formed at the dentin-adhesive interface. The chemical composition of polymer phases formed in the hybrid layer can be represented using a ternary water-adhesive phase diagram. In this paper, these polymer phases are characterized using a suite of mechanical tests and swelling experiments. The experimental results were evaluated using a granular micromechanics-based model incorporating poro-mechanical effects and polymer-solvent thermodynamics. The variation in the model parameters and model-predicted polymer properties was studied as a function of composition along the phase boundary. The resulting structure-property correlations provide insight into interactions occurring at the molecular level in the saturated polymer system. These correlations can be used for modeling the mechanical behavior of the hybrid layer, and are expected to aid in the design and improvement of water-compatible dentin adhesive polymers.

OA01.05. Effectiveness of simple and logical treatment in complete disc prolapse

Purpose:

To explain the effectiveness of 21 days inpatient treatment on a 46 year old male patient with complete disc proplapse who was suggested an emergency discectomy in a leading hospital.

Method:

To explain the case history with complete details of medicines used and treatments given with the responses observed before, during & after treatment with substantiating 3 MRI digital films & reports that were taken before, immediately after treatment and 3 months later. Also to have a small video of the patient sharing his experience. Treatments given were Abyangam, Elakkizhi, Navarakizhi, Matravasthi, Vaitarana vasthi, Madhu thailika vasthi & Pichu with 8 internal medications during the treatment course.

Result:

The patient who was unable to stand, sit & walk properly with the threat to lose his bladder & bowel control without discectomy had a dramatic recovery during discharge and 100 percent recovery in 3 months with ayurveda treatments alone, with out any supportive allopathic care.

Conclusion:

Though it is a well known fact that Ayuvreda work wonders with such conditions, this is an attempt to explain that these are not only because of specialized & sophisticated treatments but a simple and logical treatment can also be miraculous and also to emphasize that documentations like MRI reports before and after treatments helps is proper evaluation of the treatment results in addition to patients feedback.