Resource Constraint Settings Research Articles

Reusable Generic Clinical Decision Support System Module for Immunization Recommendations in Resource-Constraint Settings.

Clinical decision support systems (CDSS) are routinely employed in clinical settings to improve quality of care, ensure patient safety, and deliver consistent medical care. However, rule-based CDSS, currently available, do not feature reusable rules. In this study, we present CDSS with reusable rules. Our solution includes a common CDSS module, electronic medical record (EMR) specific adapters, CDSS rules written in the clinical quality language (CQL) (derived from CDC immunization recommendations), and patient records in fast healthcare interoperability resources (FHIR) format. The proposed CDSS is entirely browser-based and reachable within the user's EMR interface at the client-side. This helps to avoid the transmission of patient data and privacy breaches. Additionally, we propose to provide means of managing and maintaining CDSS rules to allow the end users to modify them independently. Successful implementation and deployment were achieved in OpenMRS and OpenEMR during initial testing.

Thoracoabdominal Flap Closure for Large Post Pectoralis Major Myocutaneous Flap Donor Site in Advanced Oral Cancer: An Innovative Approach in Resource Constraint Setting

Thoracoabdominal Flap Closure for Large Post Pectoralis Major Myocutaneous Flap Donor Site in Advanced Oral Cancer: An Innovative Approach in Resource Constraint Setting

A pragmatic randomized trial to examine the effect of combining healthy diet with mindfulness cognitive therapy to reduce depressive symptoms among university students in a low-resource setting: protocol for the NutriMind Project

BackgroundMental health disorders still rank as leading causes of morbidity worldwide despite increasing awareness and improvements in treatment. Notably, low- and middle-income countries like Uganda, are disproportionately affected by such disorders. The burden of depressive symptoms in these countries is particularly high among students, aggravated by poverty, malnutrition, and inadequate public health governance, yet it is clearly under-researched, making it hard to achieve several of UN Sustainability Development Goals. Current treatment options are insufficient to tackle the increased burden of depressive disease. This is more challenging for low-resource regions especially in Sub-Saharan Africa, suggesting the need for alternative treatments that can swiftly be applied if proven effective. The main aim of this randomized controlled trial (RCT) is therefore to examine if a low-cost healthy diet (based on local Ugandan foods) combined with easy-to access mindfulness cognitive therapy can reduce depressive symptoms among university students in Uganda.MethodsWe will recruit female and male students at Makerere University, the largest public university in Uganda, to an open, intention-to-treat, two-armed RCT. Those who score above a predefined threshold on a self-reported assessment of depressive symptoms, measured by the Center for Epidemiological Studies – Depression score (CES-D), are eligible for study inclusion and will be randomized to either an intervention (n = 125) or a control (n = 125) group. The intervention group will receive educational group-based sessions on how to prepare a Mediterranean-type of healthy diet and how to adhere to the principles of mindfulness-based cognitive therapy. Outcome measures include self-reported depression symptoms, quality of life, and dietary intakes. In addition we will perform a cost-effectiveness analysis. The RCT intervention will last 9 months, followed by additional 15 months with regular data collections.DiscussionWe here describe a novel approach to treat depressive symptoms among university students living in resource constraint settings, by combining a healthy diet with low threshold psychotherapy. If this intervention succeeds, our project can be viewed as a step towards evidence-based behavior practices for young adults with a common mental disorder (depression) that are beneficial to public mental health initiatives and management.Trial registrationThe RCT is registered in ClinicalTrials.gov (ID: NCT05848973). The date of registration was August 14, 2023.

P205 HYPERTENSION AWARENESS, TREATMENT, AND CONTROL RATE IN NEPAL: AN EFFECTIVENESS OF WHO-PEN PACKAGE INTEGRATION THROUGH PRIMARY CARE TO ADDRESS THE NCDs

WHO-PEN, the essential NCD services even in resource constraint settings through PHC approach has been implemented in Nepal since 2017. PEN approach consists of set of protocols for the management of listed major diseases and behavioral interventions to address the associated major modifiable risk factors. The major focused diseases in PEN includes cardiovascular diseases, diabetes, cancer and chronic respiratory diseases. By 2021 it has been expanded across all 77 districts of Nepal. The aim of this analysis is to assess the before and after PEN package changes in hypertension prevalence, awareness, treatment and control rate in Nepal. This analysis used the 2016 Nepal demographic and health survey (NDHS) data as a baseline(N=14,823) and 2022 NDHS data as an Edline(N=10,022). Awareness, treatment and control rate was calculated from the population aged 15 years and above along with the concentration Index (CI) to assess the changes in magnitude and inequalities before and after the intervention. Cluster sampling design was considered for all the inferential statistics and sample weight was used to obtain the population estimates. P<0.05 were considered statistically significant. The study revealed a non-significant change in the hypertension prevalence before and after the intervention (19.6% vs 20.1%;p>0.05). However, a significant change was observed in the awareness rate (40% vs 50.2%,p<0.05) and treatment rate (20.2% vs 31.7%,p<0.05). A significant wealth inequality was observed in awareness ((CI:0.12,p<0.001 in 2016) and (CI:0.13,p<0.001 in 2022)) and treatment rate ((CI:0.24,p<0.001 in 2016) and (CI:0.21,p<0.001 in 2022)) over the period of time. We did not find a significant change (51.7% vs 56.7%, p>0.05) and wealth inequalities in control rate (figure 1). The improvement in awareness and treatment rate over the period entails the integration of WHO-PEN package through primary care is effective, however, the persistent wealth inequalities indicate next level community-based intervention should be instrumental to address the NCDs burden targeted to ultra-poor/poor and marginalized population of Nepal.

A rare case of trigeminal trophic syndrome with periorbital cellulitis and full-thickness upper eyelid defect in an undiagnosed patient with human immunodeficiency virus: a case report

BackgroundTrigeminal trophic syndrome is a rare cranial and facial condition caused by damage to the central or peripheral branches of the trigeminal nerve. This syndrome consists of a triad of anesthesia, paresthesia, and crescent-shaped facial ulcer involving the ala nasi and sometimes extending to the upper lip. Although previous screening for human immunodeficiency virus in some patients with trigeminal trophic syndrome was negative, we present a unique case of trigeminal trophic syndrome who tested positive for human immunodeficiency virus with eye complications.Case presentationWe present a rare case of trigeminal trophic syndrome in a 44-year-old Black African woman who tested positive for human immunodeficiency virus. She presented with a 6-week history of progressive, persistent, and painless left sided facial and scalp ulcerations that started as small skin erosion. Diagnosis of trigeminal trophic syndrome was made on clinical grounds based on the triad of anesthesia, paresthesia, and unilateral crescent-shaped ulcer in the trigeminal dermatome and her past medical history. The ulcer healed completely after counseling and pharmacological therapy, but she later developed left periorbital cellulitis and left upper eyelid full-thickness defect.ConclusionThis is by far the first documented case of trigeminal trophic syndrome with a positive human immunodeficiency virus test. Testing for human immunodeficiency virus in patients with trigeminal trophic syndrome is necessary as this can help improve clinical management and treatment outcomes. Seeking the services of specialists remotely in resource constraint settings is beneficial for managing complications associated with trigeminal trophic syndrome.

Comparison of indirect cyanmethaemoglobin method and TrueHb haemometer point of care test with direct cyanmethaemoglobin (gold standard) method for strengthening anaemia detection at primary health care level

ABSTRACT Introduction: The most reliable indicator for anaemia diagnosis at the population level is haemoglobin (Hb) estimation. The direct cyanmethaemoglobin method is considered the gold standard method for haemoglobin estimation. However, for resource constraint areas like primary health care (PHC) level, either blood samples are transported on filter paper for Hb testing (indirect cyanmethaemoglobin method) in laboratory or point of care testing is commonly used. Therefore, a comparative analysis of haemoglobin estimation of direct with indirect cyanmethaemoglobin method and also with TrueHb (Wrig Nanosystems Pvt. Ltd.) haemometer was done to strengthen anaemia diagnosis at the PHC level. Materials and Methods: This was a cross-sectional study. A total of 90 participants above 9 years of age, who visited the outpatient department (OPD) of health centre, Kheri and gave consent were included. Comparative analysis was done between Hb concentration assessed by indirect cyanmethaemoglobin method and TrueHb haemometer device against the gold standard method. Results: The mean Hb value estimated by direct method, TrueHb haemometer and indirect methods (filter paper A, B and C) was 11.42 ± 1.59 g/dl, 11.52 ± 1.54 g/dl, 10.66 ± 1.52 g/dl, 9.84 ± 1.50 g/dl and 10.19 ± 1.62 g/dl, respectively. There was no significant difference found between the mean Hb concentration estimated by the direct method and the TrueHb haemometer device. However, there was a significant difference in mean Hb values between the direct method and the indirect method. Therefore, regression analysis was done to estimate the correction factor for the indirect method. Conclusion: TrueHb metre device gave promising results in comparison to the gold standard method and can be used if resource permits in PHC centres. Indirect methods of haemoglobin estimation can be an alternative in resource-constraint settings, specifically for surveys. However, further studies are required for the validation of the indirect method.

Comparing deep learning models for tuberculosis detection: A retrospective study of digital vs. analog chest radiographs

PurposeChest X-ray (CXR) is an essential tool and one of the most prescribed imaging to detect pulmonary abnormalities, with a yearly estimate of over 2 billion imaging performed worldwide. However, the accurate and timely diagnosis of TB remains an unmet goal. The prevalence of TB is highest in low-middle-income countries, and the requirement of a portable, automated, and reliable solution is required. In this study, we compared the performance of DL-based devices on digital and analog CXR. The evaluated DL-based device can be used in resource-constraint settings. MethodsA total of 10,000 CXR DICOMs (.dcm) and printed photos of the films acquired with three different cellular phones - Samsung S8, iPhone 8, and iPhone XS along with their radiological report were retrospectively collected from various sites across India from April 2020 to March 2021. Results10,000 chest X-rays were utilized to evaluate the DL-based device in identifying radiological signs of TB. The AUC of qXR for detecting signs of tuberculosis on the original DICOMs dataset was 0.928 with a sensitivity of 0.841 at a specificity of 0.806. At an optimal threshold, the difference in the AUC of three cellular smartphones with the original DICOMs is 0.024 (2.55%), 0.048 (5.10%), and 0.038 (1.91%). The minimum difference demonstrates the robustness of the DL-based device in identifying radiological signs of TB in both digital and analog CXR. ConclusionThe DL-based device underwent evaluation using 10,000 chest X-rays to identify radiological signs of tuberculosis. When tested on the original DICOMs dataset, the device achieved an Area Under the Curve (AUC) of 0.928, with a sensitivity of 0.841 and a specificity of 0.806. Comparing the device's performance with three cellular smartphones on the same original DICOMs dataset, the AUC differences were found to be 0.024 (2.55%), 0.048 (5.10%), and 0.038 (1.91%) at optimal thresholds. These results highlight the device's robustness in detecting radiological signs of TB, showcasing consistent performance across both digital and analog chest X-rays. The smallest difference in AUC further underscores the device's reliability in accurately identifying TB indicators, reaffirming its potential clinical utility.

IJCM_134A: Community Engagement Strategies for Prevention and Control of Non-communicable Diseases in Primary Healthcare Settings: A review of evidences from Low- and Middle-income countries

Background: Community engagement is considered as one of the pillars in successful implementation program for prevention and control of Non- Communicable Diseases (NCDs). Objective: To gather evidence from the available literature concerning effective strategies for enhancing community engagement in primary healthcare for NCD prevention, which are appropriate for resource constraint settings in low- and middle-income countries. Methodology: This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis for Scoping Reviews (PRISMA- ScR) guidelines. Original articles and reports published from January 2000 to September 2023, in English language; with the following designs- Randomized controlled trials with single or multiple arms, quasi- experimental studies, public health practices and qualitative studies, available online were included in this review. Digital databases like PubMed and Google scholar were searched to find out articles, using a pre-designed peer- reviewed search strategy by combining established search terms and free text terms. Further, hand search was made by going through the references of the retrieved articles. All publications were independently evaluated by two reviewers. Information extracted from the published articles were recorded using a pre-designed data extraction sheet in Microsoft excel. Results: Key interventions emerged from the review included group-based peer support program; family level intervention; setting based approach (Health Promoting school /institution /market /hospital); advocacy, network and counselling among People Living with NCDs etc. Evidence also suggested use of appropriate technology such as CPHC-NCD Software, generation of Ayushman Bharat-Health Account IDs (ABHA IDs) through National NCD Portal, maintenance of NCD data record and register in digital formats on National NCD Portal and spreading community dialog using mass media, digital media and social media. Conclusion: The findings of this study will guide the development and implementation of evidence-based interventions for prevention of NCDs using primary healthcare platform suitable for resource limited settings.

COVID-19 surveillance in fragile health systems, armed conflict and humanitarian crisis, the case of Yemen

ABSTRACT Background Yemen is a poor country facing armed conflict which significantly disrupted the Health System. Yemen reported fewer COVID-19 cases than neighbouring countries, yet the case fatality rate (19.6%) remained five times the global average. Conflict typically hinders surveillance, however obtaining representative mortality and morbidity indicators remains essential to efficacious epidemic planning. We aimed to explore challenges hindering COVID-19 surveillance in Yemen and opportunities for addressing them, to increase surveillance effectiveness in such conflict and resource-constraint settings. Methods Qualitative study question guide was used for in-depth interviewswith 30 healthcare workers who worked in Yemen’s surveillance system during the pandemic. Participants were recruited through in-country gatekeepers using a ‘snowball’ sampling technique. Thematic framework analysiswas used. Findings A basic level of preparedness existed following responses to previous epidemics, including activating Rapid Response Teams (RRTs), and electronic disease surveillance. Key challenges included the ongoing conflict, an unstable health system, minimal infrastructure restorations, misinformation, community incompliance, and inadequate laboratory diagnostics or transportation capabilities. Participants recommended addressing these barriers through strengthening RRTs, transportation and laboratory testing capacities, implementing community awareness campaigns, alongside improving primary health care services and inter-governorate governance. Conclusion Active community surveillance by RRTs supplemented with community volunteers is imperative and necessary nationwide. National community awareness campaigns on case detection, reporting, and addressing misinformation are essential to implementing such community surveillance. Increased utilization of mobile laboratories could enhance laboratory testing capacity in underserved areas. For each recommendation to be effectively implemented, the international community must provide sufficient resources and financial aid.

A 2-year review of stroke admissions and short term out-come predictors in a teaching hospital, Southeast, Nigeria.

Stroke is a common neurological disorder with a huge global burden in terms of mortality and morbidity. Epidemiological evidence has shown that modifiable risk factors are responsible for more than 90% of all strokes. Stroke outcome in hospitalized patients is influenced by several variables, such as socio-demographic factors, stroke subtype, and admission severity. The interaction between stroke outcomes and these parameters is often complex. The study is aimed to profile hospitalized stroke patients and determine outcome predictors. A descriptive retrospective study of 100 patients hospitalized for acute stroke. Their medical records were reviewed for demographic and clinical variables and relevant data were retrieved and analysed using appropriate statistical methods. Of the 100 acute stroke patients studied, 36% were men and 64% were women. The mean age was 65.16±15.72. About 78%had ischemic stroke while 21% had haemorrhagic strokes. The commonest risk factor was hypertension (71.2%). On multivariate analysis, stroke subtype and admission duration were significantly linked to stroke outcome. Ischemic stroke comprises more than two-thirds of stroke admissions, with hypertension being the most common risk factor and stroke case fatality of 23%. Stroke subtype and admission duration significantly predicted stroke outcomes. The need to step up measures aimed at improving acute stroke care in hospitalized patients is imperative as this will hopefully improve overall outcomes in resource constraint settings such as Nigeria.

Comparing commercial versus low-cost gelatinous phantoms for ultrasound-guided needle tracking: A randomized crossover trial, among emergency medicine residents.

The objective of this study was to devise a low-cost indigenous gelatin-based vascular phantom and to compare this newly constructed phantom with a commercially available phantom. This was a randomized crossover study conducted at a tertiary care hospital of India. The aim of the study was to develop a prototype low-cost gelatin-based vascular phantom and compare it with a commercially available phantom. Gelatin, psyllium husk, corn starch, antiseptic liquid, food-coloring agent, latex balloons, and metallic containers were used to prepare the gelatin phantom. The newly prepared gelatin model was labeled "Model A" and the commercially available gelatin model was labeled "Model B." Emergency medicine residents (n = 34) who routinely perform ultrasound (USG)-guided invasive procedures were asked to demonstrate USG-guided in-plane and out-of-plane approach of needle-tracking in both the models and fill out a questionnaire on a Likert scale (1-5). An independent supervisor assessed the image quality. The cost of our phantom was USD 6-8 (vs. USD 1000-1200 for commercial phantom). The participants rated the ease of performance and tissue resemblance as 4 (interquartile range [IQR]: 4-5) for both the models "A" and "B." The supervisor rated the overall performance as 4 (IQR: 3-4) for both the models. In all the parameters assessed, model A was noninferior to model B. The indigenously developed vascular phantom was noninferior to the commercially available phantom in terms of tissue resemblance and overall performance. The cost involved was a fraction of that incurred with the currently available commercial model. The authors feel that gelatin-based models can be easily prepared in resource-constraint settings which may be used for USG-guided training and medical education in low- and middle-income countries.

Treatment Pattern and Outcome of Newly Diagnosed Multiple Myeloma Patients in a Resource-Limited Setting.

Multiple myeloma is the third most common hematologic malignancy in Malaysia. The introduction of novel agents over the past decades has improved patient outcome and survival substantially. However, these agents incur significant economic burden, thus leading to limited use in less developed countries. This study aims to report on the real-world treatment pattern and outcome of newly diagnosed multiple myeloma (NDMM) patients from a resource-constraint setting. This is a retrospective study on NDMM patients diagnosed between 1 January 2008 and 31 December 2022 in a single academic center. Patients' demographic and treatment details were included for analysis of progression free survival (PFS) and overall survival (OS). One hundred and thirty-six NDMM patients with a median age of 64.0 years (ranged from 38 to 87 years old) were included. Bortezomib-containing regimens were the most commonly used induction agent, followed by thalidomide. Almost half of the patients (47.1%) achieved very good partial response (VGPR) or complete remission (CR), while 31.6% achieved partial response (PR). Bortezomib containing regimen was associated with significantly deeper and more rapid response, (p=0.001 and p=0.017, respectively) when compared to other agents. Only 22.8% of these patients proceeded to upfront autologous haematopoietic stem cell transplantation. The median OS and PFS were 60.0 months and 25.0 months, respectively. Best initial response and upfront autologous stem cell transplantation (ASCT) were significantly associated with better PFS. Achieving at least a VGPR significantly associated with better outcome in NDMM patients. In a resource constrain country, we recommend incorporating bortezomib in the induction therapy followed with an upfront ASCT.

The role of clinical breast examination and fine needle aspiration cytology in early detection of breast cancer: A cross-sectional study nested in a cohort in a low-resource setting.

Breast cancer is prevalent worldwide, with disparities in screening, diagnosis, treatment outcomes, and survival. In Africa, the majority of women are diagnosed at advanced stages, affecting treatment outcomes. Screening is one of the best strategies to reduce mortality rates caused by this cancer. Yet in a resource-constrained setting, there is limited access to screening and early detection services, which are available only at a few referral hospitals. We aimed to evaluate the prevalence and screening results of breast cancer using clinical breast examination coupled with fine needle aspiration cytology in a resource-constraint setting. A combined cross-sectional and cohort study. Women at risk of developing breast cancer in the Kilimanjaro region of Tanzania were invited, through public announcements, to their primary healthcare facilities. A questionnaire was used to assess the participants' characteristics. The women received a clinical breast examination, and detectable lesions were subjected to a confirmatory fine needle aspiration cytology or an excisional biopsy. Preliminary data from this ongoing breast cancer control program were extracted and analyzed for this study. A total of 3577 women were screened for breast cancer; their mean age was 47 ± 7.53 years. About a third of them (1145, 32%) were practicing self-breast examination at least once a month. Of 200 (5.6%) with abnormal clinical breast examination, 18 (9%) were confirmed to be breast cancer, making the prevalence to be 0.5%. The vast majority of participants with breast cancer (13, 72.2%) had early disease stages, and infiltrating ductal carcinoma, no special type, was the most common (15, 83.3%) histopathology subtype. Hormonal receptor status determination results indicated that 11 (61.1%), 7 (38.9%), and 5 (27.8%) of the tumors overexpressed estrogen receptor, progesterone receptor, and human epidermal receptor-2, respectively. Our study demonstrates 5.6% of Tanzanian women have abnormal clinical breast examination findings, with 9% having breast cancer. Nearly three-quarters (72.2%) of breast cancer screened for early disease were detected in the early disease stages. This finding suggests that organized screening with clinical breast examination coupled with fine needle aspiration cytology, which is a simple and cost-effective screening method, has the potential to improve early detection and outcomes for breast cancer patients in a resource-constraint setting.

A simple and low-cost paper-based device for simultaneous determination of hematocrit and hemoglobin levels in point-of-care settings

Hematocrit and hemoglobin levels are common blood tests used to assess the overall health status of patients as well as the oxygen-carrying capacity of the blood. The gold-standard technologies to determine the hematocrit and hemoglobin levels are precise and fast, but they are not pragmatic in extreme point-of-care settings due to the prohibitive cost, process complexity, and sophisticated facilities. Therefore, here, we report the development of a microfluidic paper-based analytical device to determine hematocrit and hemoglobin levels simultaneously. This device exploits the area of the stain formed by a spreading drop of 20 μl of whole blood on Whatman filter paper immobilized with sodium chloride and ethylenediaminetetraacetic acid for hematocrit level, whereas for hemoglobin concentration, it utilizes the gray color intensity of a 20 μl droplet of a mixture of blood and de-ionized water. The performance of the device is verified by comparing with gold-standard results of the automated hematology analyzer, showing a high degree of correlation (R2) of 0.9651 and 0.9701 for hematocrit and hemoglobin levels, respectively. The bias and standard deviation of the differences between the two measurements for hematocrit determination are 0.002 and 1.005, respectively, while the bias and standard deviation of differences between the two methods for hemoglobin determination are 0.065 and 0.398, respectively. This device is likely to provide a simple, fast, disposable, and inexpensive tool to determine the hematocrit and hemoglobin levels in resource-constraint settings.

Bridging the Access Gap for Comprehensive Sickle Cell Disease Management Across Sub-Saharan Africa: Learnings for Other Global Health Interventions?

Sickle cell disease (SCD) is a major unresolved global health issue, with the highest disease burden in sub-Saharan African countries; yet, SCD care has not proportionally reached patients in these regions, and the disease has received limited attention in the past. Addressing the burden of SCD in sub-Saharan Africa requires a holistic, collaborative approach to ensure solutions are both comprehensive - i.e., cover the entire continuum of care from early diagnosis to treatment - and sustainable - i.e., are co-created and co-owned with local partners and integrated into existing local systems to enable long-term independence without the need for continuous external support. We outline a set of recommendations for enhancing the provision of comprehensive healthcare for prevalent diseases in resource-constraint settings, gathered from the Novartis Africa SCD Program, that could serve as 'blueprint' for public-private partnerships to tackle global health priorities. The Novartis Africa SCD program was initiated with the aim to bridge access gaps to SCD care and provide comprehensive and innovative treatment solutions for SCD, especially in SSA where the disease burden is highest. The Program was first inaugurated in 2019 in Ghana through a public-private partnership with the Ministry of Health of the Government of Ghana, the Ghana Health Service, and the Sickle Cell Foundation of Ghana. Through engagement with these partners, as well as with support from other organizations with complementary competencies and resources, several targeted solutions were implemented to help strengthen the healthcare ecosystem to allow for comprehensive SCD management. Learnings from these interventions are highlighted as best practice consideration as a catalyst and to activate more public-private actors for this neglected global health issue. A solid understanding of the access barriers to comprehensive care has to be acquired by listening to and learning from patients, civil society, and local experts. Access barriers need to be addressed at multiple levels, i.e., by not only making medicines available and affordable, but also by strengthening healthcare systems, building capacity, and fostering local research and development. Partnerships across governmental, public, academic, non-profit, and private organizations are needed to secure political will, pool resources, gather expertise with understanding of the local context, and allow integration into all levels of existing local healthcare structures and the wider society.

The Post-COVID Deadly Trio of Mucormycosis, Invasive Aspergillosis, and Acute Kidney Injury: Physician’s Nightmare and Management Dilemma in Resource Constraint Setting

Abstract Invasive fungal infections are common in clinical settings of diabetes mellitus, immunosuppression, malignancy, and organ and tissue transplantation. Fungal infections were reported increasingly during the COVID-19 waves, with many cases ending in fatality. The reason for such increased incidence is deemed to be a mix of factors, with high steroid use being a major contributor. We present a patient with mixed mucormycosis and invasive aspergillus infection of paranasal sinuses, postrecovery from moderate COVID-19 disease. The patient developed acute kidney injury after starting liposomal amphotericin B, and it had to be stopped. The dilemma was “What next?” since the drug of choice could not be continued. The patient was managed with surgical debridement, intense surveillance, and alternate antifungals. The outcome was encouraging. We discuss the dynamics of polyene-induced renal function impairment, the possibility of the use of alternate antifungals and their basis, and the importance of a combination approach as a recipe for success.

COMPARISON OF POINT-OF-CARE HEMOGLOBIN A1C TESTING WITH CENTRAL LABORATORY METHOD FOR ITS USE IN SCREENING AND MONITORING OF DIABETES MELLITUS IN A RESOURCE-CONSTRAINED SETTING

Objective: The aim of this study is to evaluate the analytical performance of the Point-Of-Care Testing HbA1c analyzer for its use as an alternate to the central/core laboratory method. Material and Methods: This was a cross-sectional study in which 176 samples of HbA1c were analyzed by POCT HbA1c analyzer (A1C EZ 2.0) and central laboratory analyzer (Cobas 6000) as comparative instrument. Results: Based on the Bland-Altman plot, the HbA1c level for 164 out of 176 (93.18%) subjects analyzed by the POCT-HbA1c was within the range of the 95% limit of agreement. The area under the receiver operating characteristic (ROC) curve for clinical diagnosis of diabetes was 0.91. The sensitivity and specificity for HbA1c POCT were 94.5% and 88.0%. Using regression analysis, the slope of the A1C EZ 2.0 vs the Cobas 6000 Analyzer was 0.934, with an intercept of 0.20 and a correlation coefficient of 0.97. Conclusion: This study concludes that the POCT-HbA1c analyzer is a suitable replacement for central/core laboratory HbA1c measurement. It is useful for screening and monitoring of diabetes mellitus in certain situations especially in a resource constraint setting. Keywords: Diabetes mellitus, Screening, Monitoring, HbA1c, Point-of-care testing

Cost-Effective Evaluation of Homemade Recipes in Cancer Patients on Liquid Diet from Low-Middle-Income Group Countries

Cancer patients, on liquid diet are at a high-risk of malnutrition. 10-20% of patients are estimated to die due to malnutrition rather than malignancy itself. In low-middle-income group countries (LMICs), patients are mostly undernourished. They need cost-effective, easily available and acceptable nutritional support. The study has been undertaken to evaluate the cost-effectivity of homemade recipes vs commercially available nutritional formulations for patients on liquid diet. Recipes for both vegetarian and nonvegetarian were designed using low-cost and locally available ingredients to fulfil the daily calorie requirement of ≈2,000 kcal (30 kcal/kg for a 65 kg adult) with ≥90 gm of protein (1.5 gm/kg). Alongside, five commercial nutritional formulations were evaluated to meet the above requirements. The caloric (380 ± 80.1 kcal/100 gm, 260–474 kcal) and protein contents (32.6 ± 10.9/100 gm, 15–49 gm) in commercial supplements were variable. For providing 2,000 kcal with minimum of 90 gm protein, the cost of commercial formulations ranged from INR 745 -3,461/day (1,700 ± 946). Comparatively, the vegetarian and non-vegetarian homemade recipes were estimated to cost just INR 135/day and INR 182/day respectively. For the 2000 kcal diet, the difference in nutrient contents of commercial vs homemade preparations were non-significant, while the cost was significantly lower with homemade recipes (p=0.03). Homemade recipes designed and suited to individual needs could meet the dietary requirements for patients on liquid diet, be highly cost-effective and thereby especially suit patients from resource constraint settings, like LMICs. Keywords: Nutrition, Cancer, Liquid diet, Malnutrition, Low middle­income countries, Nutrition supplement

Experience with Central Venous Access Devices in Hematology Practice from Resource Constraint Settings.

Experience with Central Venous Access Devices in Hematology Practice from Resource Constraint Settings.

Masked Language Modeling for Resource Constrained Biological Natural Language Processing.

Recent advances in Natural Language Processing (NLP) have produced state of the art results on several sequence to sequence (seq2seq) tasks. Enhancements in embedders and their training methodologies have shown significant improvement on downstream tasks. Word vector models like Word2Vec, FastText & Glove were widely used over one-hot encoded vectors for years until the advent of deep contextualized embedders. Protein sequences consist of 20 naturally occurring amino acids that can be treated as the language of nature. These amino acids in combinations with each other makeup the biological functions. The choice of vector representation and architecture design for a biological task is highly dependent upon the nature of the task. We utilize unlabelled protein sequences to train a Convolution and Gated Recurrent Network (CGRN) embedder using Masked Language Modeling (MLM) technique that shows significant performance boost under resource constraint setting on two downstream tasks i.e., F1-score(Q8) of 73.1% on Secondary Structure Prediction (SSP) & F1-score of 84% on Intrinsically Disordered Region Prediction (IDRP). We also compare different architectures on downstream tasks to show the impact of the nature of biological task on the performance of the model.