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Abstract Background The date of sowing is a non-monetary input factor that plays a crucial role in field crop management. Based on the sowing time, management practices of crop production affect crop growth, development, and yield. Under varied environmental conditions, this factor may be useful in addressing low yields and combating/escaping stresses either due to diseases or due to any unfavourable environment. Results A field experiment was conducted during the rabi season of 2017–18 and 2018–19 to study the accumulated growing degree days (GDD) and performance of six wheat cultivars (HS 562, HD 2967, HD 3086, HI 1544, MACS 6222 and WR 544) under four sowing dates (5th November, 25th November, 15th December and 5th January). The study revealed that 5th November is the best date for sowing resulting in higher pooled grain yield of 4.85 Mg ha−1 and 3.94 Mg ha−1 at Bajaura and Malan, respectively. Significant reductions in the grain yield and yield attributes were observed when the date of sowing was set beyond 5th November. Among the cultivars tested, HS 562 gave a significantly higher pooled grain yield of 4.46 and 3.75 Mg ha−1 at Bajaura and Malan, respectively. Pooled data on physiological maturity revealed that variety HS 562 took the highest calendar days (168 days) and GDD (1573.42 °C days) to attain physiological maturity at Bajaura while at Malan HI 1544 and HD 3086 took the highest calendar days (156 and 155 days, respectively) and GDD (2055.41 and 2051.81 °C days, respectively) to attain their physiological maturity. Conclusion From the study, it can be concluded that the early date of sowing provides the crop with ample duration to accumulate growing degree days resulting in a higher accumulation of photosynthates resulting in significantly higher yield attributes and grain yield. Therefore, 5th November is recommended as the best time for sowing of wheat crop whereas the sowing must not be delayed beyond 25th November. HS 562 was superior among the cultivars and is recommended for Malan and Bajaura regions for attaining higher yield.

Cowpea (Vigna unguiculata L. [Walp.]) cultivation encounters a plethora of challenges such as suboptimal productivity levels, declined income levels, and poor soil health under conventional fertilization systems. Therefore, the present field investigation was undertaken at the Research Farm, Department of Agronomy, CSKHPKV, Palampur in the rainy season of 2019 to evaluate eight combinations of organic farming and Zero Budget Natural Farming (NF) based inputs, i.e., Beejamrita (100 ml kg−1 of seed) + Jeewamrita (187.5 L ha−1); Beejamrita (100 ml kg−1 of seed) + GhanaJeewamrita (250 kg ha−1); Beejamrita (100 ml kg−1 of seed) + Jeewamrita (187.5 L ha−1) + GhanaJeewamrita (250 kg ha−1); farm yard manure (FYM) 10 Mg ha−1; FYM (10 Mg ha−1) + GhanaJeewamrita (250 kg ha−1); biofertilizers (PSBs and Rhizobium at 10 g kg−1 of seed) + FYM (10 Mg ha−1) + vermiwash (1:10); biofertilizers (PSBs and Rhizobium at 10 g kg−1 of seed) + vermicompost (7.5 Mg ha−1) + vermiwash (1:10); absolute (untreated) control; in a randomized complete block design with three replications for their influence over cowpea productivity, profitability, and energetics. The results of the investigation revealed that applying FYM (10 Mg ha−1) and GhanaJeewamrita (250 kg ha−1) in combination resulted in significantly higher grain yield(1,070.5 kg ha−1), economic net returns (766.61 USD ha−1), net energy gains (78,230 MJ ha−1), and considerably improved soil microbial biomass carbon (133.92 mg g−1 of soil), nitrogen (27.40 mg g−1 of soil), urease (52.20 (mg g−1 urea of soil h−1), and dehydrogenase activity (5.21mg g−1 TPF of soil h−1). Improved soil biological properties in the present study might have been responsible for considerable increment in cowpea yield and profitability. Therefore, in-combination application-based module of FYM (10 Mg ha−1) and GhanaJeewamrita (250 kg ha−1) can be recommended for enhancing productivity and profitability of cowpea cultivation under North-Western Himalayan agro-ecological conditions. This study contributes valuable insights for organic input strategies in regions facing similar challenges.

Introduction: Alloimmunisation to red blood cell antigens, resulting from genetic disparities between donors and recipients, is one of the risks associated with blood transfusions. Antibody screening cells are used to detect unexpected antibodies. The risk of alloimmunisation is higher in patients who have undergone multiple blood transfusions. Aim: To estimate the frequency of various Red Blood Cell (RBC) alloantibodies and to determine the types of antibodies present in repeatedly transfused patients. Materials and Methods: This cross-sectional study was conducted on 200 patients with a history of multiple blood transfusions from October 1, 2019, to April 30, 2021, at the blood centre of Sri Guru Ram Das Institute of Medical Sciences and Research (SGRDIMSR), Amritsar, Punjab, India. Antibody detection and identification were performed, and the results were recorded. The data was statistically analysed using the Statistical Package for Social Sciences (SPSS) version 26.0 to draw relevant conclusions. The observations were tabulated in the form of numbers and percentages. Categorical data was analysed using the Chi-square test. The level of significance was determined as p≤0.05. Results: The study included 200 patients who were on multiple transfusions. The most common blood group among the patients was B positive (39%), followed by O positive (26%). The majority of patients (73.50%) had solid malignancies, followed by 28 (14%) thalassemia patients and 25 (12.50%) patients with chronic kidney disease. Solid malignancies included patients with breast cancer, cervical cancer, ovarian cancer, prostate cancer, and liver cancer. Alloantibodies were found in 15 patients (7.50%), of which 11 had solid malignancies and 4 had thalassemia. The most frequent antibody detected was the anti-K antibody (40%). Alloantibody formation was observed in both males and females. However, no statistical significance was found between gender and alloimmunisation (p=0.940). Conclusion: The effect of alloimmunisation can be avoided by routine RBC antibody screening before blood transfusion, especially in patients with a history of multiple blood transfusions. These measures decrease the incidence of red blood cell alloimmunisation and delayed hemolytic transfusion reactions in multi-transfused patients.

The scarcity of high-quality forage has a significant influence on the productivity and profitability of livestock. Addressing this concern, an investigation was undertaken to assess the effects of distinct Italian ryegrass genotypes, namely, Punjab ryegrass-1, Kashmir collection, and Makhan grass, in conjunction with varying seeding ratios of Italian ryegrass to Egyptian clover. The seeding ratios considered were 100:0 (Italian ryegrass to Egyptian clover), 75:25, 50:50, and 25:75. All possible combinations of Italian ryegrass and Egyptian clover with seeding ratios were set up in a randomized complete block design and replicated thrice. Co-cultivating Italian ryegrass and Egyptian clover at a 75:25 seeding ratio yields the best yield benefit, as determined by the land equivalent ratio. It is noteworthy that in this configuration, real yield loss is higher for Egyptian clover and for Italian ryegrass when the seeding ratio is 25:75. The higher competitiveness of Italian ryegrass in comparison to Egyptian clover is highlighted by the competitive ratio. Notably, the nutritive parameter, crude protein yield, was significantly higher in the Makhan grass-based 50:50 and 75:25 seeding ratio. Results of the study ascertained the compatibility of grass-legume co-cultivation with significantly higher quantity and quality forage harvested under mixed cropping systems whereas Makhan grass as the superior and dominant genotype in comparison to Kashmir collection. The outcomes of this study revealed that the 100:0 seeding ratio, coupled with the Makhan grass genotype, exhibited superior performance in terms of cumulative forage harvest, dry matter accumulation, net returns, and benefit–cost ratio.

Introduction Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world’s largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions.Methods A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes.Results Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives.Conclusion While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.

Background There has been a lot of debate on how to ‘generalise’ or ‘translate’ findings of economic evaluation (EE) or health technology assessment (HTA) to other country contexts. Researchers have used various adaptive HTA (aHTA) methods like model-adaptation, price-benchmarking, scorecard-approach, etc., for transferring evidence from one country to other. This study was undertaken to assess the degree of accuracy in results generated from aHTA approaches specifically for EE.Methods By applying selected aHTA approaches, we adapted findings of globally published EE to Indian context. The first-step required identifying two interventions for which Indian EE (referred to as the ‘Indian reference study’) has been conducted. The next-step involved identification of globally published EE. The third-step required undertaking quality and transferability check. In the fourth step, outcomes of EE meeting transferability standards, were adapted using selected aHTA approaches. Lastly, adapted results were compared with findings of the Indian reference study.Results The adapted cost estimates varied considerably, while adapted quality-adjusted life-years did not differ much, when matched with the Indian reference study. For intervention I (trastuzumab), adapted absolute costs were 11 and 6 times higher than the costs reported in the Indian reference study for control and intervention arms, respectively. Likewise, adapted incremental cost and incremental cost-effectiveness ratio (ICER) were around 3.5–8 times higher than the values reported in the Indian reference study. For intervention II (intensity-modulated radiation therapy), adapted absolute cost was 35% and 12% lower for the comparator and intervention arms, respectively, than the values reported in the Indian reference study. The mean incremental cost and ICER were 2.5 times and 1.5 times higher, respectively, than the Indian reference study values.Conclusion We conclude that findings from aHTA methods should be interpreted with caution. There is a need to develop more robust aHTA approaches for cost adjustment. aHTA may be used for ‘topic prioritisation’ within the overall HTA process, whereby interventions which are highly cost-ineffective, can be directly ruled out, thus saving time and resources for conducting full HTA for interventions that are not well studied or where evidence is inconclusive.

Background: The introduction of Xpert MTB/RIF® has revolutionised the diagnosis of tuberculosis (TB) by reducing time to the identification and detection of drug resistance. Methods: We prospectively studied clinical profile of admitted patients who underwent Xpert MTB/RIF® for the diagnosis of TB in the Department of Medicine and Allied Specialties at our tertiary care teaching hospital in Ludhiana. Results: During the period from January to December 2018, 140 patients (mean age 55.7 ± 16 years; male: female = 1.5:1) were included. Type 2 diabetes mellitus was the most common comorbid disease (n = 37; 26.4%). The most common presenting complaints were fever, breathlessness and cough with expectoration. Overall, 61 admitted patients were discharged with a diagnosis of TB; 26/61 (42.6%) tested Xpert MTB/RIF® positive (bacteriologically confirmed); the remaining 35 (57.4%) were clinically diagnosed along with the ancillary supportive investigations. The remaining 79 patients had a non-TB diagnosis. In extrapulmonary TB, Xpert MTB/RIF® had low detection and positivity rate as compared to other ancillary investigations for TB. Conclusions: Xpert MTB/RIF® was useful in the diagnosis in 42.6% of cases. When Xpert MTB/RIF® was negative, TB was diagnosed empirically on the basis of clinical, radiological and ancillary laboratory investigations. Xpert MTB/RIF® positivity with the clinical background suggesting that TB makes the diagnosis rapidly and with a high degree of confidence.

Background: Antisynthetase syndrome (ASSD) is a multisystem autoimmune disease characterized by the presence of antibodies against aminoacyl-transfer RNA synthetases, most common being anti-Jo1 antibody. It is an under-recognized entity with a significant delay in diagnosis, both due to lack of awareness of this condition and presentation as “incomplete” form more often than the complete form, characterized by the presence of triad of interstitial lung disease (ILD), myositis, and arthritis. We aimed to study the clinical spectrum and outcomes of anti-Jo1 antibody-positive ASSD at a single tertiary care referral hospital in North India. Methods: Anti-Jo1 positive ASSD patients diagnosed according to the Connors et al. criteria were included in this observational study conducted over 3 years by the departments of Rheumatology and Pulmonary Medicine at a single tertiary care hospital in North India. Results: The clinical spectrum and treatment outcomes of 17 patients diagnosed with anti-Jo1 positive ASSD were studied. Only 2 of the 17 patients presented with the “complete” form at the onset. While 12 patients improved with treatment with steroids and immunosuppressives (mycophenolate, azathioprine, or methotrexate), five patients died, four due to sepsis and one due to progressive lung disease. Conclusion: ASSD is an under-recognized disease, often presenting as an incomplete form rather than the classic triad of arthritis, ILD, and myositis. Infections are the major cause of death contributing to high mortality in Indian patients with ASSD.

Abstract The 'Cost of Health Services in India (CHSI)' is the first large scale multi-site facility costing study to incorporate evidence from a national sample of both private and public sectors at different levels of the health system in India. This paper provides an overview of the extent of heterogeneity in costs caused by various supply-side factors. A total of 38 public (11 tertiary care and 27 secondary care) and 16 private hospitals were sampled from 11 states of India. From the sampled facilities, a total of 327 specialties were included, with 48, 79 and 200 specialties covered in tertiary, private and district hospitals respectively. A mixed methodology consisting of both bottom-up and top-down costing was used for data collection. Unit costs per service output were calculated at the cost centre level (outpatient, inpatient, operating theatre, and ICU) and compared across provider type and geographical location. The unadjusted cost per admission was highest for tertiary facilities (₹ 5690, 75 USD) followed by private facilities (₹ 4839, 64 USD) and district hospitals (₹ 3447, 45 USD). Differences in unit costs were found across types of providers, resulting from both variations in capacity utilisation, length of stay and the scale of activity. In addition, significant differences in costs were found associated with geographical location (city classification). The reliance on cost information from single sites or small samples ignores the issue of heterogeneity driven by both demand and supply-side factors. The CHSI cost data set provides a unique insight into cost variability across different types of providers in India. The present analysis shows that both geographical location and the scale of activity are important determinants for deriving the cost of a health service and should be accounted for in healthcare decision making from budgeting to economic evaluation and price-setting.

Summary: Background: Over the years, there has been introduction of newer drugs, like bendamustine and ibrutinib, for the management of chronic lymphocytic leukaemia (CLL). Though these drugs lead to better survival, they are also associated with higher cost. The existing evidence on cost effectiveness of these drugs is from high-income countries, which has limited generalisability for low-income and middle-income counties. Therefore, the present study was undertaken to assess the cost-effectiveness of three therapeutic regimens, chlorambucil plus prednisolone (CP), bendamustine plus rituximab (BR) and ibrutinib for CLL treatment in India. Methods: A Markov model was developed for estimating lifetime costs and consequences in a hypothetical cohort of 1000 CLL patients following treatment with different therapeutic regimens. The analysis was performed based on a limited societal perspective, 3% discount rate and lifetime horizon. The clinical effectiveness of each regime in the form of progression-free survival and occurrence of adverse events were assessed from various randomised controlled trials. A structured comprehensive review of literature was undertaken for the identification of relevant trials. The data on utility values and out of pocket expenditure was obtained from primary data collected from 242 CLL patients across six large cancer hospitals in India. Findings: As compared to the most affordable regimen comprising of CP as first-line followed by BR as second-line therapy, none of the other therapeutic regimens were cost-effective at one time per capita gross-domestic product of India. However, if the current price of either combination of BR and ibrutinib or even ibrutinib alone could be reduced by more than 80%, regimen comprising of BR as first-line therapy followed by second-line ibrutinib would become cost-effective. Interpretation: At the current market prices, regimen comprising of CP as first-line followed by BR as second-line therapy is the most cost-effective strategy for CLL treatment in India. Funding: Department of Health Research, Government of India.

In this work, we propose a machine learning (ML)-based technique that can learn interatomic potential parameters for various particle–particle interactions employing quantum mechanics (QM) calculations. This ML model can be used as an alternative for QM calculations for predicting non-bonded interactions in a computationally efficient manner. Using these parameters as input to molecular dynamics simulations, we can predict a diverse range of properties, enabling researchers to design new and novel materials suitable for various applications in the absence of experimental data. We employ our ML-based technique to learn the Buckingham potential, a non-bonded interatomic potential. Subsequently, we utilize these predicted values to compute the densities of four distinct molecules, achieving an accuracy exceeding 93%. This serves as a strong demonstration of the efficacy of our proposed approach.

BackgroundDuchenne muscular dystrophy (DMD) is a rare progressive muscular disease that primarily affects boys. A lack of comprehensive care for patients living with DMD is directly associated with a compromised quality of life (QoL) for those affected and their caregivers. This disease also has a huge economic impact on families as its treatment requires substantial direct, indirect, and informal care costs. ObjectiveThis study presents a protocol developed to evaluate the feasibility and efficacy of a patient-centered care (PCC) model for children with DMD. The care model was designed with the aim to empower families, improve QoL, and reduce economic burden on their families. MethodsThis study is planned as a quasi-experimental study that will enroll 70 consecutive families with boys (aged 5-15 years) with DMD visiting a tertiary care center. The study is being conducted in 2 phases (preintervention and postintervention phases, referred to as phase 1 and phase 2, respectively). During phase 1, the patients received routine care. The study is now in phase 2, with the intervention currently being administered. The intervention is based on the PCC model individualized by the intervention team. The model has a comprehensive DMD telecare component that includes teleconsultation as one of its key components to reduce in-person physician visits at the health facility. Teleconsultation is especially beneficial for late-ambulatory and nonambulatory patients. Data on economic burden are being collected for out-of-pocket expenses for both phases during in-person visits via telephone or messaging apps on a monthly basis. QoL data for patients and their primary caregivers are being collected at 3 time points (ie, time of enrollment, end of phase 1, and end of phase 2). Outcome measures are being assessed as changes in economic burden on families and changes in QoL scores. ResultsParticipant recruitment began in July 2021. The study is ongoing and expected to be completed by March 2023. The findings based on baseline data are expected to be submitted for publication in 2023. ConclusionsThis paper outlines a research proposal developed to study the impact of a PCC model for patients with DMD in low- and middle-income countries (LMICs). This study is expected to provide evidence of whether a multicomponent, patient-centric intervention could reduce economic burdens on families and improve their QoL. The results of this study could guide policy makers and health professionals in India and other LMICs to facilitate a comprehensive care program for patients living with DMD. The economic impact of a rare disease is an important consideration to formulate or evaluate any health policy or intervention related to new treatments and financial support schemes. Trial RegistrationClinical Trials Registry India (ICMR-NIMS) CTRI/2021/06/034274; https://www.ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=56650 International Registered Report Identifier (IRRID)PRR1-10.2196/42491

Cowpea is kharif pulse grown mostly under rainfed conditions. It acts as a major protein source with 25 per cent content. Cowpea besides fixing atmospheric nitrogen continues to produce under harsh conditions such as low moisture and nutrient supply, which makes it a suitable candidate for dryland conditions. A field experiment was conducted during kharif 2019 at Research Farm, Department of Agronomy, CSK Himachal Pradesh Krishi Vishwavidyalaya, Palampur to study the effect of organic nutrient sources on yield levels, nodulation, nutrient content and uptake of cowpea. Organic nutrient sources include farmyard manure, vermicompost, vermiwash, Bijamrita, Jiwamrita and Ghanajiwamrita can be prepared using on-farm inputs at a reasonable cost. These nutrient sources supply nutrients at a steady rate and in fewer amounts than inorganic fertilizers. The prime role of such organic sources is to sustain the soil ecosystems for longer functioning. The results of the experiment revealed that T5 [Farm yard manure (10 t/ha) + Ghanajiwamrita at sowing (250 kg/ha)] was most effective and resulted in significantly higher yield level (grain yield -10.71 q/ha, straw yield - 53.14 q/ha and biological yield - 63.84 q/ha), nodulation (number of nodules - 31.7 per plant and weight of nodules - 0.47 g/plant), nutrient content (N- 3.54%, P - 0.41% and K - 1.36%) and uptake (N -141.08 kg/ha, P -19.86 kg/ha and K - 112.34 kg/ha) in cowpea

Background: Unilateral pleural effusion is a challenge for a physician as the differential diagnosis is varied; sparse epidemiological data are available from India on this subject. Methods: We prospectively studied consecutive adult patients (aged >18 years) presenting with unilateral pleural effusion who underwent thoracocentesis with or without radiological guidance for diagnostic workup. Results: Over a period of 1 year, 116 patients admitted with unilateral pleural effusion were included, majority (63.8%) were in the age group of 20–60 years. Most common presenting symptoms were shortness of breath (56%), fever (53.4%), cough (52.5%), chest pain (35.3%), anorexia (34.5%) and weight loss (18.9%). Ninety-nine patients (85.3%) had exudative and 17 patients (14.6%) had transudative pleural effusion. Amongst exudative, tuberculosis (TB) pleural effusion was the most common cause (45.7%) followed by para-pneumonic (12.9%), malignant (10.3%), among others. TB (44.8%) and malignancy (10.3%) were common aetiologies among the lymphocyte-predominant effusions, whereas para-pneumonic effusion (11.2%) and empyema (4.3%) were common aetiologies amongst the neutrophil-predominant effusions. Pleural fluid lymphocyte-to-neutrophil ratio >0.75 increased the sensitivity and specificity to diagnose TB pleural effusion. Conclusions: Patients with TB pleural effusion were comparatively younger as compared to patients with malignant and para-pneumonic pleural effusion. Most pleural effusions resolved with treatment of underlying cause.

Background: No universally accepted parameter exists for selecting/restoring the form of maxillary central incisors (MCIs). Aim: The purpose of this cross-sectional, observational clinical study was to digitally determine the prevalent form of MCIs among males and females of the Central Indian population with AutoCAD software. Materials and Methods: This is a clinical study comprising 200 dental and engineering students (female: 100; male: 100) aged between 18 and 35 years. The pictures of the right (MCI) of each participant were clicked. The images were calibrated in the vertical position to standardize according to the long axis of the tooth. The AutoCAD computer program was used to evaluate the geometric form of the tooth graphically. The results revealed that the tooth form was classified as oval, triangular, or quadrangular. The intergroup comparison using one-way analysis of variance was made, followed by the intragroup comparison using Tukey's test for quantitative data. For comparison between males and females based on tooth form, the data were assessed using Student's t-test as quantitative analysis, and for qualitative assessment, Chi-square test was used. The significance level was set at 0.05. Remeasuring 40 samples from each group tested intraexaminer consistency by applying Bland–Altman and scatter regression analysis. Results: Males had 57% oval, 29% tapered, and 14% quadrangular, while females had 60% oval, 23% tapered, and 14% quadrangular tooth form. Conclusions: The oval tooth form was the most common, both in males and females, followed by the tapered and the quadrangular form. No gender variation was seen in tooth forms.

PURPOSEThe COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India.METHODSWe used a Markov-model–based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease.RESULTSWe estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years.CONCLUSIONDelays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.

Introduction: The fracture of shaft of the tibia is the most common long bone fracture. The treatment goal for shaft tibial fracture is to achieve union with correction of both axial and rotational alignment and, maintain initial fracture length. Higher malunion rates are seen in fractures of the proximal and distal 1/3rd of the shaft of the tibia. However, Intramedullary (IM) nailing is the preferred choice of operative management of diaphyseal fractures of the lower limb. Aim: To evaluate the functional and radiological outcomes of IM nail supplemented with Poller screws for proximal and distal 1/3rd shaft tibial fractures. Materials and Methods: A prospective, interventional study was conducted in the Government Medical College, Patiala, Punjab, India from May 2020 to November 2021. A total of 30 fracture patients in the age group of 18 to 60 years were included in the study. All the subjects were treated with IM nail supplemented with Poller screws for proximal and distal 1/3rd shaft tibial fractures. Twenty cases were closed fractures and 10 were open (grade I or II according to Gustilo Anderson’s classification of compound tibia fracture). Patients were followed-up at 3 weeks, then 6 weekly till union. Patients were evaluated by Karlström-Olerud’s functional evaluation criteria.The data was statistically analysed using IBM Statistical Package for the Social Sciences (SPSS) software version 23.0. Results: The mean time of fracture union was 17.33±2.59 weeks with a maximum (n=19) patients in ≤15 weeks, followed by 15-20 weeks (n=10) and only one patient had delayed union (>20 weeks). According to Karlström-Olerud’s functional evaluation scale 18 (60%) patients had excellent outcome followed by good outcome in 8 (26.7%) patients, while 2 (6.7%) patients had satisfactory and 2 (6.7%) patients moderate outcomes. The total mean varus/valgus deformity preoperatively was 10.17±4.15° while postoperatively it was 1.63±2.3°. The total mean antecurvatum/recurvatum deformity preoperatively was 6.47±5.906° while postoperatively it was 0.20±0.61°. Postoperative complications were observed such as shortening of the leg (n=2), movement loss in the ankle (n=4), movement loss in the knees (n=3), muscle wasting (n=6) and subtalar movement loss (n=6). One patient had a superficial skin infection (oozing of purulent discharge from distal locking skin suture site), which was treated with prolonged antibiotics. Conclusion: Poller screws were found to be effective in achieving fracture alignment and hence, serve as a effective fracture reduction tool. Also helps to maintain the fracture aligned until it healed, preventing the loss of the initial reduction.

Summary: Background: The role of post-mastectomy radiotherapy (PMRT) for breast cancer is controversial when 3-or-less lymph nodes are metastatic. Apart from local control, survival and toxicity, cost also plays an important role in decision-making. Methods: A Markov model was designed to assess cost, health outcomes and cost-effectiveness of different radiotherapy techniques for management of PMRT patients. Thirty-nine scenarios were modelled based on type of radiotherapy, laterality, pathologic nodal burden, and dose fractionation. We considered a societal perspective, lifetime horizon and a 3% discount rate. The data on quality of life (QoL) was derived using the cancer database on cost and QoL. Published data on cost of services delivered in India were used. Findings: Post-mastectomy radiotherapy results in incremental quality adjusted life years (QALYs) that ranged from −0.1 to 0.38 across different scenarios. The change in cost ranged from estimated median savings of USD 62 (95% confidence intervals: −168 to −47) to incurring an incremental cost of USD 728 (650–811) across different levels of nodal burden, breast laterality and dose fractionation. For women with node-negative disease, disease-specific systemic therapy remains to be the preferred strategy. For women with node-positive disease, two-dimensional radiotherapy (2DRT) with hypofractionation is the most cost-effective strategy. However, a CT based planning is preferred when maximum heart distance (MHD) >1cm, irregular chest wall contour and inter-field separation >18cm. Interpretation: PMRT is cost-effective for all node-positive patients. With similar toxicity and effectiveness profile compared with conventional fractionation, moderate hypofractionation significantly reduces the cost of treatment and should be the standard of care. Conventional techniques for PMRT are cost-effective over newer modalities which provide minimal additional benefit, at high cost. Funding: The funding to collect primary data for study was provided by Department of Health Research, Ministry of Health and Family Welfare, New Delhi, wide letter number F. No. T.11011/02/2017-HR/3100291.

PURPOSEPatients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India.METHODSUsing a disaggregated societal perspective and lifetime horizon, a Markov model was developed for estimating the costs and health outcomes in a hypothetical cohort of 1,000 patients with advanced and metastatic cervical cancer treated with either standard chemotherapy alone or in combination with bevacizumab. Effectiveness data for each of the treatment regimen were assessed using estimates from Gynecologic Oncology Group 240 trial. Data on disease-specific mortality in metastatic cervical cancer, health system cost, and out-of-pocket expenditure were derived from Indian literature. Multivariable probabilistic sensitivity analysis was undertaken to account for parameter uncertainty.RESULTSOver the lifetime of one patient with advanced and metastatic cervical cancer, bevacizumab along with standard chemotherapy results in a gain of 0.275 (0.052-0.469) life-years (LY) and 0.129 (0.032-0.218) quality-adjusted life-years (QALY), at an additional cost of $3,816 US dollars (USD; 2,513-5,571) compared with standard chemotherapy alone. This resulted in an incremental cost of $19,080 USD (7,230-52,434) per LY gained and $34,744 USD (15,782-94,914) per QALY gained with the use of bevacizumab plus standard chemotherapy.CONCLUSIONAddition of bevacizumab to the standard chemotherapy is not cost effective for the treatment of advanced and metastatic cervical cancer in India at a threshold of 1-time per-capita gross domestic product.

Background: The position of the dental midline is significant to enhance dentofacial esthetics. This study aimed to assess the closest anatomical landmark to the facial and mouth's midline applicable to dentate male and female Indian youths. Materials and Methods: A full-face photo of 100 males and 100 females with a broad smile showing visible anterior dentition was taken. An esthetic facial frame was developed digitally on the photographs taking the reference of facial anatomical landmarks. Relative facial midline values for nasion, the nose tip, the philtrum tip, and dental midline were obtained. The relative commissural midline value was obtained by dividing the variables by the constant. Statistical analysis: Data were statistically analyzed using the t-test. Results and Conclusions: Anatomic landmarks correlated with facial midline and with the inter-commissural midline (P < 0.01). The nasion is nearest to the facial midline, followed by dental midline, commissure, tip of the philtrum, and nose tip in that order. The anatomic landmarks nearest to the inter-commissural midline are the tip of the philtrum, followed by the dental midline, nasion, and nose tip. The nose tip was the farthest landmark from the face's midline and the inter-commissural midline. In gender-wise comparison, landmarks did not differ significantly (P > 0.05). All the measurements were almost equal in males and females.

Introduction: Many cases of pleural effusions remain undiagnosed even after investigations including Computed tomography (CT) chest, pleural fluid analysis. Role of Video Assisted Thoracoscopic Surgery (VATS) in undiagnosed pleural effusion is still controversial. VATS has the advantage of taking biopsy under direct vision and therapeutic procedures can be done in the same sitting. Aim: To evaluate the role of VATS in the diagnosis and management of pleural effusions. Materials and Methods: The study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India for a period of one and half year from January 2017 to May 2018. Efficacy of VATS as a diagnostic and therapeutic procedure was evaluated in patients with undiagnosed pleural effusion. Results: A total of 54 patients were included in the study. Diagnostic yield of VATS in present study was 100%. The most common diagnosis was parapneumonic effusion in 31.5% of the patients followed by chronic non-specific inflammation and tuberculosis in 25.9% patients each. Malignancy was final diagnosis in four patients. Some sort of therapeutic procedure was done in all patients and effective therapeutic yield of VATS in present study was 96.3%. Conclusion: This study adds to substantial data about the high diagnostic yield and high therapeutic efficacy of VATS in pleural effusions. The diagnostic yield of VATS for undiagnosed effusion is better than repeat thoracocentesis with the added advantage of therapeutic intervention if needed with a high success rate.

Introduction: Despite availability of adequate treatment, premature termination of treatment or lost to follow-up is great concern in patients with psychoactive substance use. This creates a hindrance in getting the favorable outcomes, indirectly adding up to the increased burden of the disease. This study focuses in assessing the socio-demographic and clinical variables associated with drop-outs in these patients which can guide the clinicians and health care delivery system to make required efforts in preventing these drop-outs. Aims and Objectives: To study the pattern including socio-demographic and clinical profile of drop-out patients with mental and behavioral disorder due to psychoactive substance use. Materials and Methods: Patients attending the Psychiatry Walk-In-Clinic of tertiary care teaching hospital of North India from June 2018 to July 2018 and diagnosed with ‘Mental and behavior Disorder due to psychoactive substance use’ (F10-19) as per ICD-10 were enrolled in the study. Socio-demographic and clinical variables of these patient were recorded using the Departmental walk-in Performa. Patient who didn’t come for follow-up visit till 4 weeks after first contact were considered drop-out. Data was analyzed for factors related to dropouts. Results: A total of 1553 patients registered in walk-in-clinic during a period of 2 months (June- July 2018), in which 175 patients were diagnosed with Mental and behavior disorder due to psychoactive substance use. Out of 175, 106 were drop-outs (60%). Socio-demographic and Clinical profile of drop-out patients revealed that 57% were of age group 20-40 years, 98% were Male, 75% were married, 70% had income more than 7000 rupees per month, 54% belonged to joint family, 49% were of opioid dependence, followed by alcohol dependence (31%) and 54% had no h/o of previous treatment. Conclusion: It can be concluded from the current study that patients with opioid use, employed and without any medical or surgical co-morbidity are more likely to drop-out after the first contact.

Introduction: Despite recent evolution in the operating techniques and surgical implants, debate continues around the choice of implant for the management of intertrochanteric fractures of femur bone. There is a paucity of clinical data on the results with Proximal Femoral Nail Antirotation (PFNA). Aim: To evaluate the functional and radiological outcome of reduction and fixation of these fractures with PFNA. Materials and Methods: This prospective interventional study was conducted from december 2015 to november 2018. A total of 62 patients of more than 50 years of age with intertrochanteric fracture were managed with internal fixation using PFNA. All the pateints were evaluated with respect to the mean operative time, blood loss. Fluoroscopy exposure, time to union and development of any complication. The statistical analysis involved calculation of the mean and Standard Deviations (SD) of above parameters which was done using the Microsoft excel chart sheet. Functional evaluation was done using the Harris Hip Score (HHS). Results: A total of 62 patients with age ranging from 54 to 94 years (mean 78.2, SD 09.11) were evaluated. The mean duration of follow-up was 14.3 months. The average operative time, the mean blood loss and the average fluoroscopy time were 61.4 (range 45-90 minutes, SD 11.6) minutes, 103.9 (range 60-200 mL, SD 36.4) mL and 74.0 (range 41 to 98, SD 13.5) seconds respectively. About 100% union rate with the average time to union being 16.1 (SD 3.3) weeks and ranging from 12 weeks to 24 weeks was reported. Varus collapse and limb shortening >1 cm were observed in 3 patients. The average HHS at the end of study showed a mean value of 82.8 (SD 8.6) and ranged from 65 to 94 with 46 (74.2%) patients having excellent to good outcome. Conclusion: Owing to easy insertion, reduced operative time and blood loss, stable fixation, less complications and good functional and radiological outcome, PFNA can prove to be an implant of choice for the management of intertrochantric fractures of the femur.

Epilepsy is one of the most common childhood-onset neurological conditions with a genetic etiology. Genetic diagnosis provides potential for etiologically-based management and treatment. Existing research has focused on early-onset (

The establishment of link between high-risk human papillomavirus (HPV) infection and occurrence of cervical cancer has resulted in development of various HPV related control strategies for the prevention of cervical cancer. The objective of the present study was to assess the cost effectiveness of various screening strategies for cervical cancer and human papilloma virus (HPV) vaccination in India. A Markov model based on societal perspective was designed to estimate the lifetime costs and consequences of screening (with either visual inspect with acetic acid (VIA), Papanicolaou test or HPV DNA test at various time intervals) in a hypothetical cohort of 30-65 years age women or vaccination among adolescent girls. Diagnostic accuracy of the screening strategies, efficacy of HPV vaccination and data on transition probabilities was based on the results of the existing meta-analyses. Primary data was collected for assessing per person cost of screening, cost of treating cervical cancer and quality of life. We found that introduction of different screening strategies leads to reduction in lifetime occurrence of cervical cancer cases caused by HPV 16/18 from 20% to 61%, and cervical cancer deaths from 28% to 70%, as compared to no screening. Among various screening strategies, screening with both VIA 5 yearly and VIA 10 yearly came out to be cost effective at 1-time per capita GDP, with VIA every 5 years providing greater health benefits as compared to VIA 10 years. Hence, screening with VIA 5 years at an incremental cost of US$ 829 (INR 54,881) per QALY gained is the recommended strategy for India. Further, with regards to HPV vaccination, it leads to 60% reduction in cancer cases and mortality caused by HPV 16/18 as compared to no vaccination. Moreover, when this vaccinated cohort of adolescent girls is also screened later in their life (with VIA every 10 years and VIA 5 years), it leads to 69%-76% reduction in cancer cases and 71%-81% reduction in cancer deaths. As compared to no vaccination and no screening, both HPV vaccination alone and vaccination plus screening (with VIA every 5 yearly and VIA 10 yearly) appears to be cost effective with ICERs in the range of US$ 86 (INR 5,693) to US$ 476 (INR 31,511) per QALY gained. In the long run, when the cohort of adolescent girls, who were immunized for HPV, reach the age of 30 years, the screening frequency using VIA should be determined based on the coverage of HPV vaccination in that cohort.

Background: The treatment of chronic diseases like coronary heart disease (CHD) is expensive and can consume a significant portion of household′s income, leading to catastrophic effects on families, particularly those of low socioeconomic status. Methodology: This was a cross-sectional study carried out in a private super specialty hospital and a government tertiary care hospital. Nonprobability purposive sampling method was used to collect primary data from a sample of 102 households; having a member suffering from CHD. Economic burden was assessed regarding average out of pocket (OOP) expenditure and prevalence of distress financing (DF) (borrowings or selling of assets) among the households. Results: Average OOP expenditure among those having an episode of hospitalization and those who got treated in outpatient department sessions only was INR 243,606 and INR 48,578, respectively. This expenditure was statistically higher (P < 0.5) for richest than the poorest households. However this expenditure as a proportion of annual household consumption expenditure was highest for the poorer than the richest (P < 0.5). Expenses were reported higher for those who got treatment in private hospital as compared to government hospital by 26%. The prevalence of DF came out to be 38.2% with poorest reporting higher percentage of 67% as compared to 4% in richest households. Conclusion: There is a need to consider the rising OOP expenditure for the treatment of chronic conditions like CHD. There is a need to develop health financing systems that improve the financial risk protection for those requiring treatment.

Background: Pulmonary nocardiosis is a rare but a life-threatening infection caused by Nocardia spp. The diagnosis is often missed and delayed resulting in delay in appropriate treatment and thus higher mortality. Aim: In this study, we aim to evaluate the clinical spectrum and outcome of patients with pulmonary nocardiosis. Methods: A retrospective, 5-year (2009-2014) review of demographic profile, risk factors, clinical manifestations, imaging findings, treatment, and outcome of patients with pulmonary nocardiosis admitted to a tertiary care hospital. Results: The median age of the study subjects was 54 years (range, 16-76) and majority of them (75%) were males. The risk factors for pulmonary nocardiosis identified in our study were long-term steroid use (55.6%), chronic lung disease (52.8%), diabetes (27.8%), and solid-organ transplantation (22.2%). All the patients were symptomatic, and the most common symptoms were cough (91.7%), fever (78%), and expectoration (72%). Almost two-third of the patients were initially misdiagnosed and the alternative diagnosis included pulmonary tuberculosis (n = 7), community-acquired pneumonia (n = 5), lung abscess (n = 4), invasive fungal infection (n = 3), lung cancer (n = 2), and Wegener′s granulomatosis (n = 2). The most common radiographic features were consolidation (77.8%) and nodules (56%). The mortality rate for indoor patients was 33% despite treatment. Higher mortality rate was observed among those who had brain abscess (100.0%), HIV positivity (100%), need for mechanical ventilation (87.5%), solid-organ transplantation (50%), and elderly (age > 60 years) patients (43%). Conclusion: The diagnosis of pulmonary nocardiosis is often missed and delayed resulting in delay in appropriate treatment and thus high mortality. A lower threshold for diagnosing pulmonary nocardiosis needs to be exercised, in chest symptomatic patients with underlying chronic lung diseases or systemic immunosuppression, for the early diagnosis, and treatment of this uncommon but potentially lethal disease. Despite treatment mortality remains high, especially in those with brain abscess, HIV positivity, need for mechanical ventilation, solid-organ transplantation, and elderly.

IntroductionPublic health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India.MethodologyWe used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013-14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $.ResultsIn 2013-14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state.ConclusionThe healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state's GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level.

There are no published data on the cost of cancer treatment for guiding reimbursement decisions in India. The present study was designed to estimate the cost of treating head and neck cancer (HNC) with the aim of determining package rates. The present study was undertaken in the Departments of Radiotherapy and Otolaryngology of a large tertiary care hospital in North India. Economic health system costs incurred were assessed using a bottom-up methodology. Data on all resources-capital or recurrent, incurred on the delivery of HNC treatment were collected from April 2014 to March 2015. Following the cost-of-illness approach, patients were interviewed to elicit out-of-pocket (OOP) expenditure. A total of INR 40,993,017 (USD 0.67 million) was spent on radiotherapy care for treating HNC during 1 year. Salaries constituted the major component (42.6%) of this cost, followed by equipment/furniture (29%), space rent (20.7%), overheads and consumables (7.7%). In addition, INR 47,191 (USD 773) per HNC patient was spent on the surgery. Furthermore, patients spent an average amount ranging from INR 12,575 (USD 206) to INR 65,257 (USD 1069) on the different treatment therapies. In terms of package rates, cobalt radiotherapy alone was the cheapest (INR 38,714, USD 634), while intensity modulated radiotherapy (IMRT) was most expensive (INR 192,914, USD 3161). The estimates from the present study could be used for developing package rates under various publicly financed health insurance schemes as well as for the planning for creation of new cancer centres.

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

Introduction: Community Acquired Pneumonia (CAP) is one of the commonest causes of patient’s visit to the Emergency Room (ER). Hospitalisation of patient depends on severity of pneumonia. Various pneumonia severity assessment scores are available to predict mortality in community acquired pneumonia but these scores are not commonly used. Procalcitonin is a biomarker which is raised in bacterial infection and is easy and quick to measure. The aim of our study was to assess the ability of baseline serum procalcitonin level to predict mortality of community acquired bacterial pneumonia compared to PSI, CURB-65 and CRB-65 and its add-on value to the simple CRB-65 score. Materials and Methods: Fifty five patients admitted with Community Acquired Bacterial Pneumonia were enrolled after taking informed consent and satisfying all inclusion and exclusion criteria. PSI, CURB -65, CRB-65 and PCT scores were determined on admission. PCT was measured by semi- quantitative assay; PCT Q. Primary outcome was 30 day mortality. Sensitivity, specificity, positive and negative predictive value of PCT for assessing mortality was calculated and compared to validated pneumonia severity scores; PSI, CURB-65 and CRB-65. We also assessed the ability of the combination of PCT to each of the scores to predict 30 day pneumonia specific mortality. Results: In receiver operating characteristic analysis for mortality prediction, area under curve (95% CI) for PCT, PSI, CURB-65 and CRB-65 was 0.92 (0.85, 1.0), 0.88 (0.78, 0.98), 0.88 (0.76, 0.99), 0.9 (0.78, 1.0) respectively. Combination of PCT to each of the scores improved the prognostic ability to predict 30 day pneumonia specific mortality. Conclusion: Semi-quantitative PCT level at admission is an excellent test to predict the outcome of pneumonia. It predicts patients at low risk of mortality from community acquired bacterial pneumonia.

The diagnosis of pneumonia is clinical, based on the history of lower respiratory tract symptoms, physical, and/or radiographic signs of consolidation. Several diseases such as congestive heart failure, pulmonary embolism, and chemical pneumonitis may present with similar symptoms, signs, and chest radiographs, thus delaying the definitive diagnosis and initiation of appropriate treatment. Unilateral pulmonary edema (UPE) is a rare clinical entity that is often misdiagnosed at first as a focal lung disease. We have presented an unusual case of left-sided UPE in a 76-year-old man who developed acute heart failure resulting from dietary and pharmacological noncompliance. The patient was successfully managed with decongestive therapy and non-invasive mechanical ventilation.

We describe the case summary of a 70-year-old man diagnosed with interstitial lung disease due to prolonged nitrofurantoin therapy. Despite honeycombing confirmed by computed tomography of the thorax, symptoms and radiographic findings disappeared within 1 month after withdrawal of nitrofurantoin. The case highlights the fact that nitrofurantoin-induced lung disease may run a benign course and respond favorably despite radiographic evidence of established lung fibrosis (honey combing).

Acute lupus pneumonitis is an uncommon but life threatening condition associated with systemic lupus erythematosus. We report the case of a young female who presented to us with acute hypoxemic respiratory failure secondary to acute lupus pneumonitis as initial presenting manifestation of lupus. She was managed with non-invasive ventilation and pulse steroids, with which she had dramatic improvement.