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The best feeding method for infants during the rst few months of life is exclusively breastfeeding, which has signicant advantages for both mothers and their infants. Despite all of its advantages, exclusive breastfeeding is very low and there is little knowledge about the determining factors, particularly from slum areas. The objective was to determine what percentage of lactating mothers in urban slum practice exclusive breastfeeding and estimate its prevalence and identify the obstacles to exclusive breastfeeding in Jamnagar, Gujarat's urban slums. Methods-A cross-sectional study was conducted among 420 lactating mothers for a period of six months in the urban slums of Jamnagar. Results- The prevalence found in our study for exclusive breastfeeding was 59.76%. Conclusion- Insufcient maternal secretions (48.52%), an inverted or sore nipple (21.89%), and early introduction of formula or additional lacteal feeds for the baby's growth were the biggest barriers to exclusive breastfeeding in this study. 17.16% of working women cited their jobs as the reason for early weaning.

Remote sensing based various land surface and bio-physical variables like Normalized Difference Vegetation Index (NDVI), Land Surface Temperature (LST), surface albedo, transmittance and surface emissivity are useful for the estimation of spatio-temporal variations in evapotranspiration (ET) using Surface Energy Balance Algorithm for Land (SEBAL) method. These variables were estimated under the present study for Ozat-II canal command in Junagadh district, Gujarat, India, using Landsat-7 and Landsat-8 images of summer season of years 2014 and 2015. The derived parameters were used in SEBAL to estimate the Actual Evapotranspiration (AET) of groundnut and sesame crops. The lower values NDVI observed during initial (March) and end (May) stages of crop growth indicated low vegetation cover during these periods. With full canopy coverage of the crops, higher value of NDVI (0.90) was observed during the mid-crop growth stage. The remote sensing-based LST was lower for agricultural areas and the area near banks of the canal and Ozat River, while higher surface temperatures were observed for rural settlements, road and areas with exposed dry soil. The maximum surface temperatures in the cropland were observed as 311.0 K during March 25, 2014 and 315.8 K during May 31, 2015. The AET of summer groundnut increased from 3.75 to 7.38 mm.day-1, and then decreased to 3.99 mm.day-1 towards the end stage of crop growth. The daily AET of summer sesame ranged from 1.06 to 7.72 mm.day-1 over different crop growth stages. The seasonal AET of groundnut and sesame worked out to 358.19 mm and 346.31 mm, respectively. The estimated AET would be helpful to schedule irrigation in the large canal command.

Surgery is the primary treatment of phyllodes tumor of the breast, and margins are the most important risk factor associated with local recurrence. We conducted a retrospective audit of 433 patients treated at our center.Women who presented with phyllodes tumors between 1999 and 2017 were included in the analysis. Data was collected from the hospital medical records, telephonic interviews, and electronic mail.Of the 433 women included in this study, 177 (40.9%) had benign phyllodes tumors, 84 (19.4%) were borderline, 131 (30.3%) were malignant, and 41 (9.5%) had sarcoma. A history of previous excision was noted in 154 (35.6%) patients, of which 104 presented with local recurrence. Of the total patients, 209 (48.3%) underwent breast conservation surgery; the median pT was 6 cm. At a median follow-up of 37.9 months, the 5-year disease-free survival (DFS) was 82.9%. On multivariate analysis, the factors that impacted DFS were histology (hazard ratio, 4.1; 95% confidence interval [CI], 1.5-10.9; P = .005) and history of previous excision biopsy (hazard ratio, 3.39; 95% CI, 1.76-6.52; P .001). We analyzed 231 women who presented without any prior excision separately, wherein at a median follow-up of 44.1 months, the DFS was 92.1% (95% CI, 92.05%-92.15%). In addition, less recurrences were noted in this cohort (5.6% [13/231] in no-excision biopsy vs. 12.5% with surgery done prior to presentation to our institute).A previous history of excision and the histologic subtype of phyllodes tumor are factors that have an impact on DFS, thus emphasizing the need for appropriate surgical planning and en bloc excision of the phyllodes at presentation.

The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohort-median pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.

Background: Breast cancer is the most common cancer worldwide. There has been emerging interest in studying differences in breast tumor phenotypes between South Asian and South American women given that racial/ethnic disparities in incidence and mortality have been demonstrated in multiple studies. South Asian women are more likely to be diagnosed with an advanced stage breast tumor despite lower incidence than in North American women. There is evidence that computer-extracted nuclear morphological features on H&E slide images may be associated with breast cancer aggressiveness, specifically recurrence and disease free survival. However, studies have mostly focused on North American women. In this work, we evaluated whether there is a difference in computer extracted features of nuclear morphology from H&E tissue slide images between South Asian (SA) and North American (NA) women and we also investigated how these differences could impact the development of population specific breast cancer prognostic models. Methods: H&E slides of breast tumors from patients who were diagnosed with ER+ early stage invasive breast cancer from Tata Memorial Centre, India (SA: 69 (20 recurrence)) and from University Hospitals Cleveland Medical Center (NA: 121 (20 recurrence)), along with outcome information were collected. All slides were digitized on either a Ventana DP 200 or a Roche Ventana iScan HT slide scanner. For each image, a conditional Generative Adversarial Network model was employed to segment the individual nuclei, which were used to generate 241 nuclear features including nuclear architecture, shape, orientation disorder, and texture features. Half of the patients (95) were randomly selected as the training set (Stra) with the remaining patients as the hold-out validation set (Stest). Three elastic net regularized Cox regression models (MSA, MNA, MSA+NA) were trained fitting between the nuclear features and disease free survival (DFS) respectively for SA subset, NA subset, and SA & NA set in Stra. The top five prognostic features were identified respectively from each of the three models (MSA, MNA, MSA+NA) which were further validated on Stest to evaluate their prognostic value in prediction of DFS. Results: We found that the prognostic features identified by MNA and MSA+NA were mostly shape features (three out of five for MNA, four out of five for MSA+NA), while the prognostic features identified by the model specifically trained with the SA population (MSA) were mostly texture features (three out of five), possibly reflecting chromatin patterns in the cell. MSA yielded a better performance (Hazard Ratio=4.99 (p=0.00928, CI=1.32-18.9) from log-rank test between model derived high and low risk categories) on SA population in Stest compared to MNA and MSA+NA. Conclusion: We found that nuclear histomorphometry features were different between breast cancer patients from South Asia and those from North America. The prognostic capability of the computational pathology-based models for South Asian women could be significantly improved by taking into account population-specific information. An additional independent validation set is needed to confirm the preliminary findings presented here. Citation Format: Haojia Li, Kaustav Bera, Paula Toro, Pingfu Fu, Vidya Rao, Shabina Siddique, Aparna Harbhajanka, Haley Sechrist, Zelin Zhang, Sangeeta Desai, Vani Parmar, Anant Madabhushi. Computerized image analysis of nuclear morphological features reveals differences in phenotype and prognosis of disease free survival of early stage ER+ breast cancers for South Asian and North American women [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-45.

BACKGROUND: Cancer treatment during nationwide lockdown due to the COVID-19 pandemic has posed several challenges in the delivery of cancer care and carries tremendous potential sequel of impoverishing the households. This study aims to examine the economic distress faced by breast cancer patients receiving treatment at Tata Memorial Center (TMC) Mumbai, India during the nationwide lockdown initiated in March 2020 following the outbreak of COVID-19. METHODS: A total of 138 non-metastatic breast cancer patients who were accrued in this study at TMC before imposing of lockdown, and their treatment was impacted because of the COVID-19 outbreak, were interviewed. Telephonic interviews were conducted using a structured schedule which contained information on household and demographic characteristics of the patients, knowledge about COVID-19, their daily expenditure for treatment, difficulties faced during lockdown and how they met expenditures. Descriptive statistics and logistic regression were used in the analyses. RESULTS: The average monthly expenditure of cancer patients had increased by 32% during the COVID-19 period while the mean monthly household income was reduced by a quarter. More than two-thirds of the patients had no income during the lockdown. More than half of the patients met their expenditure by borrowing money, 30% of the patients used their savings, 28% got charity and 25% used household income. About 81% of the patients had reported shortage of money, 32% reported shortage of food and 28% reported shortage of medicine. The distress financing was significantly higher among patients receiving treatment in Mumbai compared to those receiving treatment at their native cities (67% vs. 46%), patients under 40 years of age, illiterate, currently married, Muslim and staying at a rented house. CONCLUSION: The incremental expenditure coupled with reduced or no income due to the closure of economic activities in the country imposed severe financial stress on breast cancer patients.

Background Therapeutic decisions in breast carcinoma are being made on the basis of tumor cell proliferation using exorbitant genomic tests. The 2013 St Gallen meeting advocated surrogate definitions for classifying tumors into luminal subtypes on the basis of immunohistochemical (IHC) markers. We studied the classification of estrogen receptor (ER)-positive tumors using these definitions as well as different methods for Ki-67 labeling index (LI) estimation. Patients and Methods A total of 541 ER+ invasive breast carcinoma cases from January 2012 to December 2012 were evaluated for Ki-67 LI by the average and hot spot methods. The IHC results of ER, PR, and human epidermal growth factor receptor 2 (HER2) were noted. HER2 IHC equivocal (2+) samples were subjected to HER2 fluorescence in-situ hybridization testing. Luminal subgroups created on the basis of the 2013 St Gallen meeting guidelines were correlated with clinicopathologic variables and disease-free survival. Results The distribution of luminal subtypes was as follows: luminal A–like, 13.3%; luminal B–like (HER2−), 57.9%; and luminal B–like (HER2+), 28.8%. Approximately 6% of cases were recategorized into different subgroups when the average method was used instead of the hot spot method for Ki-67 LI assessment. Younger patients (≤ 50 years), grade 3 tumors, positive axillary nodes, recurrence, and distant metastasis had a positive statistical correlation with luminal B–like (HER2−) subtype. Patients with luminal B–like (HER2−) tumors had a shorter disease-free survival compared to patients with luminal A–like tumors. Conclusion Ki-67 LI, irrespective of the method of assessment, along with PR, can be efficiently used to divide ER+ tumors into prognostic subgroups in Indian patients.

Background Severe acute respiratory syndrome coronavirus 2 has caused substantial disruptions in routine clinical care. Emerging data show that surgery in coronavirus disease (COVID)‐positive cases can be associated with worsening of clinical outcomes and increased postoperative mortality. Hence, preoperative COVID‐19 testing for all patients before elective surgery was implemented in our institution. Materials and Methods Two hundred and sixty‐two asymptomatic cancer patients were preoperatively tested for COVID‐19 using reverse‐transcription polymerase chain reaction technique with nasopharyngeal and oropharyngeal swabbing. All negative patients were operated within 72 hours, and positive patients were quarantined for a minimum 14 days before re‐swabbing. Results In our cohort, 21 of 262 (8.0%) asymptomatic preoperative patients, who were otherwise fit for surgery, tested positive. After adequate quarantine and a negative follow‐up test report, 12 of 21 (57%) had an operation. No major postoperative morbidity due to COVID‐19 was noted during the immediate postoperative period before discharge from the hospital. Conclusion Routine preoperative COVID‐19 testing was successful in identifying asymptomatic viral carriers. There was no incidence of symptomatic COVID‐19 disease in the postoperative period, and there was no incidence of morbidity attributable to COVID‐19. These data suggested a beneficial role for mandatory preoperative COVID‐19 testing.

Introduction : In the context of an alarming increase in the magnitude of type 2 diabetes mellitus in Indian population, the prevailing perceptions & practices of diabetics assume immense importance in the control of disease. Objectives: To determine level of knowledge, attitude and practices of patients with regard to the disease. Method: A cross sectional study was conducted among 70 patients, aged more than 30 years, diagnosed with types 2 diabetes more than year back & visiting G.G. Govt. Hospital, Jamnagar for follow up from July to August 2019. Pre-tested Pre-designed questionnaire used to interview the patients regarding their sociodemographic characteristic, knowledge, attitude & practices related to disease. Results: Study revealed that knowledge regarding symptoms & complications of the disease was poor except for frequent urination (42.85%) & eye complication (61.42%); however, only 24.2% patients had gone for eye examination during the last 1 year of their treatment. Awareness on complications of diabetes like periodic eye examination, BP monitoring, hypoglycemia, foot care were found to be poor. Attitude toward regular exercise & dietary modification was found to be favorable in the majority; however while compliance to dietary modification was reported to be high (82.85%) it was low with regular exercise (30%) Conclusion: Diabetic patients rely mostly on drugs & dietary modification for disease control while neglecting other lifestyle modification. Promotion of healthy lifestyle modification & self -care should be incorporated as part of diabetes education in all treatment facilities.

Background: Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots. Methods: A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020. Findings: Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV – VI). Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in

Aim Efficient, succinct, and salient handover of current issues of surgical inpatients between doctors is an essential process which, if done ineffectively can contribute to patient harm. It was recognised that existing junior neurosurgical handover could be improved and using the Royal College of Surgeons’ and NICE guidelines for clinical handover we aimed to improve the existing handover system, improving doctor’s satisfaction with handover and patient safety. Method 19 junior doctors on the SHO rota were surveyed to establish their perspective on the existing handover process. Based on this feedback, we redesigned handover combining national bodies’ guidance and local ideas. We resurveyed following these changes to measure improvement. Results Initial results showed only 36 % of junior doctors were satisfied with the existing handover procedure and only 50.5% felt the existing handover was safe. After these changes there was a 44% improvement in satisfaction with handover and a 24% improvement in the perceived safety of the handover process. Conclusions Handovers should be optimised to improve patient care and doctors working environment. We have improved our existing handover procedure increasing the perceived safety and doctor’s satisfaction of the handover process.

Aim Assess and improve the proportion of inappropriate acute clinic referrals being made to our local ENT department via a telephone referral system with regards to nature and suitability for a junior grade doctor run clinic with senior supervision. Additionally, to make a more efficient, timely and failproof booking system with an auditable trail by transitioning to an electronic referral system. Method A guideline was created using based on common protocols from major Trusts within the UK which was then used to assess 101 acute clinic referrals taken from February 2021 to our local service. An electronic referral system was created, and guidelines disseminated to departments commonly making referrals to the acute clinic in anticipation for re-audit in September 2021 alongside introduction of the guideline to new doctors rotating to the specialty at induction in August. Results Initial audit revealed 29% of referrals were inappropriate, 50% of which were too complex, 45% were not acute and 5% were due to accidental double-bookings. Additionally, nasal fracture reviews were seen within 10 days only one third of the time, 37% of patients referred did not have a recorded contact number and 13.8% of all referrals were made with incorrect or unclear clinical information. Conclusions The lack of clear clinical guidance on referrals to an acute ENT service at our local centre with an outdated telephone referral system is associated with a large proportion of inappropriate referrals, delays to timely care and transcription errors potentially putting patients at risk of harm.

Dupilumab is a monoclonal antibody against interleukins 4 and 13 currently FDA approved for the treatment of moderate to severe atopic dermatitis (AD) in adults and adolescents and severe AD in children aged 6-11 years. It is reported to be safe with the most common side effects described from clinical trials being conjunctivitis, nasopharyngitis and injection site reactions. Outside the clinical trial setting, there is insufficient data on the side effects of dupilumab in adults with AD, and much less among children and adolescents. The aim of this study was to analyze the spectrum of side effects in all patients receiving dupilumab for the treatment of AD and related conditions in a real-world setting at a single tertiary referral center, and correlate any risk factors for the development of these side effects. A retrospective review of electronic medical records was conducted for all patients who had received dupilumab for a minimum of 2 months for the treatment of AD and related conditions in the department of dermatology at Rashid hospital, Dubai from February 2018 to November 2021. We analyzed the medical records of 128 patients who received dupilumab according to standard age-related dosing. This included 78 adults (age range 18-81 years) and 50 children and adolescents (aged 6-17 years). There were 73 males and 55 females. The mean duration of dupilumab treatment was 14.9 months. The most common side effects encountered during dupilumab therapy were head and neck dermatitis in 25 (19.5%), conjunctivitis in 20 (15.6%), erythema, pruritus and peeling of skin in 14 (10.9%) and dryness of eyes in 10 (7.8%) patients, respectively. Overall, dupilumab was well-tolerated in our patient population. Most of the side effects were mild and did not require discontinuation of dupilumab. These findings would enable dermatologists understand the side effects of dupilumab better, resulting in improved treatment plan decisions in clinical practice.

The goal of this review was to determine the current treatment and prevention recommendations for Clostridium difficile infections (CDI) and their efficacy. We elucidate new treatment and prevention strategies that are in development, and define populations that are at greatest risk of CDI. New practice guidelines recommend vancomycin or fidaxomicin as first-line treatment for CDI with oral metronidazole only being used in cases of non-severe CDI when vancomycin and fidaxomicin are not available. Metronidazole is recommended in an IV formulation in conjunction with oral vancomycin in fulminant CDI. Recurrent CDI (rCDI) may be treated with vancomycin, fidaxomicin, or fecal microbiota transplant (FMT). Recent studies show fidaxomicin and fecal microbiota transplantation to be the most effective in decreasing the risk of rCDI. Prevention of CDI is primarily through judicious use of antibiotics and strategies aimed at minimizing the spread of C. difficile spores in hospitals. New preventative options are being studied including an oral beta-lactamase that may decrease the risk of developing CDI after beta-lactam use and a potential vaccine against toxins A and B produced by C. difficile. rCDI continues to be a significant problem particularly in older populations. New treatment guidelines may provide increased protection of recurrence as new medications and treatment modalities are more often utilized. Adjunctive treatments currently being studied may provide additional protection against recurrence but prevention against initial (iCDI) is still of great importance.

Bengaluru is one of the most populated cities in India. The rise in urbanization has caused an increase in air pollutant concentrations and land surface temperature. The present study explored the four-year (2019-2022) seasonal relationship between PM2.5 and its precursor’s air pollutants SO2, NO2, NH3, and meteorological parameters (WS, WD, RH, SR). Another relationship was explored to find the combined impact of air pollutants (PM2.5 SO2, NO2, NH3) and meteorological parameters on LST. Results from correlation analysis show that PM2.5 is strongly and very strongly correlated with NH3 during 2022 and moderately correlated with SO2 in 2021 and NO2 in 2022, respectively, during both seasons. LST is positively associated with air pollutants except for PM2.5 in 2020 and NO2 in 2022. The multiple linear regression analysis shows that PM2.5 strongly correlates with its precursors and meteorological parameter in both summers (0.66 to 0.74) and winters (0.59 to 0.93). Similarly, LST is strongly associated with all four air pollutants and meteorological parameters in summer (0.66 to 0.81) and winter from 0.60 to 0.79 from 2019 to 2021. The result shows that multiple parameters are responsible for the formation of secondary PM2.5 and change in LST.

Purpose The aim of this study was to compare patient-reported quality of life (QOL) scores after accelerated partial breast irradiation (APBI) using interstitial brachytherapy vs. external beam whole breast radiotherapy (WBRT) for breast cancer. Material and methods Women with breast cancer treated with WBRT or APBI after breast conservation surgery were enrolled in this prospective study. Single cross-sectional QOL assessment was performed using EORTC QLQ-C30 and BR-23 questionnaires. Patients treated with APBI were propensity-score matched to similar cohort of patients treated with WBRT. QOL scores were analyzed for the entire unmatched cohort and compared between the two matched cohorts using Student's two-tailed t-test. P-value of < 0.05 was considered statistically significant, and a 10-point difference between mean scores was considered clinically meaningful. Results A total of 64 APBI patients were matched with 99 WBRT patients out of the entire study cohort of 320 cases. QOL scores for functional scales of QLQ-C30 were similar between the two groups for both matched and unmatched cohorts, while symptom scores of QLQ-C30 did not show any clinically significant difference. Functional scales of BR-23 did not show any clinical or statistically significant difference. Among symptom scales of BR-23, scores were similar for APBI and WBRT groups except for a worse score of "upset by hair loss" sub-scale in the brachytherapy group of the matched cohort (51.9 vs. 22.7, p = 0.006). Conclusions Patients undergoing APBI reported similar QOL compared to WBRT when matched for various factors.

Epithelioid Hemangioendothelioma (EHE) is a vascular tumour with intermediate malignant potential which rarely occurs in the breast. We report a unique case of EHE of breast that presented with nodal metastases along with the review of literature. This case was initially misdiagnosed on fine needle aspiration cytology (FNAC) as breast carcinoma; however, histopathology revealed the characteristic short strands and single cell infiltrating pattern by epithelioid cells embedded in a myxohyaline matrix. The typical intracytoplasmic vacuoles with red blood cells were seen in occasional cell hinting at the vascular nature of tumor. Patchy foci of nuclear atypia, pleomorphism and frequent mitoses were seen. Although focal reactivity for AE1/AE3 initially did lead to a differential diagnosis of carcinoma, diffuse positivity for vascular differentiation markers like CD31, CD34 and FLI-1 clenched the diagnosis of EHE. The patient underwent modified radical mastectomy with axillary dissection with post-operative locoregional adjuvant radiation therapy. Till date, with a follow-up of 36 months patient is fine with no event. To conclude EHE can occur in breast and show nodal metastasis like breast carcinomas. However awareness of histologic features with typical immunohistochemistry (IHC) will assist the diagnosis. Inspite of nodal metastasis patient has an uneventful follow up indicating a non-aggressive behavior of this tumor.