Tata Medical Center Research Articles

The cost of keeping a hospital clean: Insights from a cancer hospital in East India

CONTEXT: Assessment of cleaning cost of hospitals is important for hospital administrators, infection control experts and housekeeping managers. Such data are lacking in the medical literature. AIMS: The aim of this study was to determine the cleaning cost of a tertiary care not-for-profit private cancer hospital. SETTINGS: This study was conducted in Tata Medical Center, Kolkata, India, which has 183 inpatient beds. DESIGN: This was a retrospective observational study. MATERIALS AND METHODS: Cleaning cost assessment was done from financial records over one financial year (April 2015–March 2016). The methodology involved taking into account the cost of various types of wastes (general, biomedical and microbiological), human resource cost (housekeeping staff salary), laundry cost, costs of cleaning equipment, cost of consumables (personal protective equipment, soap solutions, disinfectants, cleaning mops etc.) and the cost of water consumption. STATISTICAL ANALYSIS: No special statistical tests were used. RESULTS: The cost of keeping the hospital clean was INR Rs. 49,206,015 ($745,546 USD/€668,854). This comprised 4% of the total operational expenditure of the hospital. The maximum proportion of cost for cleaning hospitals was due to housekeeping staff salaries (66%), followed by cost of laundry (17%) and cost of cleaning consumables (13%). The trend analysis of the multidrug-resistant organism (MDRO)-related bacteraemia rate during the study period (calendar year of 2015 and 2016) showed a slight reduction of Methicillin- resistant Staphylococcus aureus, Vancomycin- resistant Enterococci and extended-spectrum beta-lactamase and AmpC beta-lactamase bacteraemia rates. CONCLUSION: Keeping hospital clean is resource intensive. This is an essential strategy to keep MDRO infection rates under control.

Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study.

Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.

CA125 Value As an Indicator for Imaging for Detection of CA Ovary Recurrence After Primary Treatment

Background: GCIG states that CA125 value double of upper limit of normal during follow-up after primary treatment is a criteria for further intervention. However, in our institution we found that significant number of women with a CA 125 > 35 u/mL have recurrent disease on imaging. Aim: To compare values of CA125 rise as an indicator for imaging for detection of recurrence after primary treatment. Methods: It was retrospective observational study. 64 women with stage III and IV epithelial ovarian cancer who had normal CA125 on completion of primary therapy from January 2012 to December 2016 at Tata Medical Center, Kolkata, India were included in the study. These women were followed up with Ca125 three monthly for 2 years then six monthly. CA 125 doubling from posttreatment baseline or exceeding 35 u/mL were investigated with CT imaging. Data were collected from hospital management system electronic medical records. Results: Out of 146 patients who underwent IDS 64 (43.8%) had normal CA125 post treatment. 2 patients with doubling of Ca125 but < 35 u/mL had recurrence, all of whom had R0 during IDS. 1 patient with normal CA 125 had clinical recurrence and this patient had R2 disease during IDS. 2 patients with normal CA 125 had recurrence on radiology only and they had R0 during IDS. 18 (24%) had radiologic recurrence when CA125 was > 35 u/mL out of which14 patients had R0 and 4 patients R1 disease during IDS. 41 patients had recurrence detected on radiology when CA125 was > 70 u/mL. Out of these 27 had R0, 11 patients had R1 and 3 patients had R2 disease on IDS. 78% of R0 patients had disease recurrence when CA125 was > 35 u/mL. Conclusion: Imaging should be considered when CA125 rises > 35u/mL, rather than waiting for it to double the upper limit of normal, so that early detection of recurrence can initiate timely treatment. Rise of CA125 above 35 u/mL is a good criteria for imaging to detect recurrence even in women with R0 resection. CA125 can be used as a good tool for follow-up especially in low resource setting where people cannot afford routine imaging.

Role of Gynaecology Oncology Specialist Nurses in Improving Patient Follow-Up and Integration With the Health Care Team

Background: All advanced gynecologic cancers treated initially with a curative intent should also be referred to palliative care at the outset for symptom management. Specialist nurses can play an integral role in this process as patients feel more comfortable to relay their symptoms to nurses rather than busy clinicians. The concept of specialist nurses has been introduced in June 2016 in the Gynecologic Oncology Department in Tata Medical Center. We aim evaluate our services through this prospective audit. Aim: i: To assess whether pre and posttreatment counseling and follow-up by gynecologic oncology specialist nurses lead to better patient care in the following areas. Increased patient participation in self-reporting of PROM (patient reported outcome monitoring) and uptake of follow-up methods via e-mail, telephone etc. ii: Coordinate administration of intraperitoneal chemotherapy and follow-up. iii: Detection of posttreatment complications and symptoms by telephonic follow up and coordination with the treating team including quality of life data collection. iv: Communicating MDT decisions to patients and arrange appropriate follow-up. v: Reduction of patient follow-up appointments and distress by coordinating with other departments i.e., palliative care team and gynae/medical oncology at same visit. vi: Develop patient information leaflets and providing preoperative education Methods: Prospective audit for service evaluation. Patients follow-up was done by face to face, telephone, e-mail in the pre and postoperative period, during chemotherapy and follow-up visits by 4 specialist nurses. Results: Between June 2016 and December 2017, specialist nurses conducted follow-up of 225 patients both in preoperative and postoperative period and collected 30 day morbidity data. Preoperative health education was given to all. 36 patients were coordinated with palliative care team on same day with gynecologic visit to reduce harassment/repeat appointments. Postchemotherapy follow-up was done for 80 patients after each cycle of chemotherapy. Coordination for 19 intraperitoneal chemotherapy was done by nurses during a 9 month period. As a result of regular follow-up visits, women were more comfortable in self-reporting of symptoms to the nurse including sensitive issues like body image and sexuality even by nonface to face methods including telephone calls/e-mails and postal mails. This has led to early detection of recurrences in 4 women, participation in multicentric national/international quality of life studies (SOCQER2/ SOCQER IND) and successful organization of survivorship programs in gynecologic oncology. Conclusion: Counseling, education and building up of interpersonal relationship with specialist nurses can improve patient participation. The role of CNS is vital to the advancement of nursing practice.

Dedicated social support services reduce abandonment and treatment-refusal in pediatric oncology: seven years’ experience from a not-for-profit, referral oncology hospital (Tata Medical Center) in Eastern India

Dedicated social support services reduce abandonment and treatment-refusal in pediatric oncology: seven years’ experience from a not-for-profit, referral oncology hospital (Tata Medical Center) in Eastern India

Developing a collaborative retinoblastoma service in eastern india: early experience from a referral oncology center (tata medical center) and two regional ophthalmic centers.

Developing a collaborative retinoblastoma service in eastern india: early experience from a referral oncology center (tata medical center) and two regional ophthalmic centers.

Detection of cytogenetic aberrations using FISH, and TP53 mutation using Sanger sequencing in pediatric medulloblastoma: experience from an exploratory cohort at Tata Medical Center Kolkata

Detection of cytogenetic aberrations using FISH, and TP53 mutation using Sanger sequencing in pediatric medulloblastoma: experience from an exploratory cohort at Tata Medical Center Kolkata

Demographics and Outcomes of Breast Cancer Patients Treated at Tata Medical Center, Kolkata

Demographics and Outcomes of Breast Cancer Patients Treated at Tata Medical Center, Kolkata

A prospective, pilot study on the use of olanzapine for optimum control of chemotherapy induced nausea and vomiting (CINV) in children with solid tumours receiving moderate/highly emetogenic chemotherapy at Tata Medical Center, Kolkata

A prospective, pilot study on the use of olanzapine for optimum control of chemotherapy induced nausea and vomiting (CINV) in children with solid tumours receiving moderate/highly emetogenic chemotherapy at Tata Medical Center, Kolkata

Establishment of a biorepository of paediatric cancers: The Tata Medical Center experience

Establishment of a biorepository of paediatric cancers: The Tata Medical Center experience

Pediatric medulloblastoma: Experience at Tata Medical Center, Kolkata

Pediatric medulloblastoma: Experience at Tata Medical Center, Kolkata

Feasibility of a mitoxantrone-based induction protocol in childhood acute myeloid leukemia: Follow up experience of 2 year cohort from Tata Medical Center, Kolkata

Feasibility of a mitoxantrone-based induction protocol in childhood acute myeloid leukemia: Follow up experience of 2 year cohort from Tata Medical Center, Kolkata

Pediatric Ewing Sarcoma: Experience from Tata Medical Center, Kolkata

Pediatric Ewing Sarcoma: Experience from Tata Medical Center, Kolkata

P0103 Results of breast conserving surgery in locally advanced breast cancer following neoadjuvant chemotherapy

Background Locally advanced breast cancer (LABC) includes patients with large tumours, extensive regional lymph node involvement, and direct involvement of the skin or underlying chest wall. Neoadjuvant chemotherapy followed by surgery, with adjuvant radiotherapy and hormonal therapy, has become the standard of care and a valuable strategy in the multimodal management of LABC. Methods This single institution, retrospective cohort study was done at Tata Medical Center for patients operated after neoadjuvant chemotherapy for LABC between November 2012 and August 2013. Eighty-nine women (30% of total breast surgeries) had undergone surgery after neoadjuvant chemotherapy during this period. Anthracycline-based chemotherapy regimens (FECx6 or FEC-Tx6) were always completed before surgery. All patients had adjuvant radiotherapy, with endocrine therapy if appropriate. Median follow up is 9 months. Findings Twenty-seven women requested breast conservation but at presentation had tumours too large. Conservation was possible in 24 women (three with volume replacement). Three others had mastectomy (two with immediate reconstruction). One had a second excision for close margins. Sixty-two women had fungating, inoperable or multi-quadrant tumours, necessitating mastectomy. Overall 26% of patients had a complete pathological response (23% in mastectomy and 37.5% in breast conserving surgery groups, chi-square 1.85, p = 0.17). Of the mastectomy patients, 18% had early lymphoedema. No lymphoedema was seen after breast conserving surgery (chi-square 4.1, p = 0.04). Local recurrence occurred in 6% of women following mastectomy, all in patients presenting with T4 disease. No local recurrence was seen after breast conserving surgery. Interpretation Neoadjuvant chemotherapy converts patients initially ineligible for breast conserving surgery into candidates for such surgery. We believe that the key to the successful breast conserving surgery after neoadjuvant chemotherapy is careful patient selection and coordination among specialties.

Microbiology, infection control and infection related outcome in pediatric patients in an oncology center in Eastern India: Experience from Tata Medical Center, Kolkata.

Infection is a major determinant in the outcome of patients with cancer. The aim was to know the epidemiology and outcome of patients with cancer in a cancer care center in Eastern India. Retrospective study of pediatric patients in Tata Medical Center, Kolkata, India. Patients (n = 262) between the age group of 0 and 18 years were reviewed for infections and infection-related outcome (January to December 2013). Modified Wald method was used to determine confidence interval of proportions. Gram-negative bacteria were found to be the most common cause of bloodstream infections (BSIs) (56.4%), followed by Gram-positive cocci (34.5%), and Candida species (9.1%). Carbapenem-resistance was noted among 24% of Gram-negative bacilli (GNB), and extended-spectrum beta-lactamase among 64% of GNBs. A single case of Vibrio cholerae septicemia was also noted. No case of vancomycin-resistant Enterococcus was observed, whereas only two cases of methicillin-resistant Staphylococcus aureus bacteremia (1/3 of all Staphylococcus aureus bacteremia) were detected. Escherichia coli, followed by Klebsiella, Pseudomonas, and Acinetobacter were the predominant organisms detected in BSIs. Among Candida spp. BSIs no resistance to caspofungin, amphotericin B, Voriconazole was noted. Candida tropicalis was the most common isolate, and 1 isolate of Candida glabrata showed dose-dependent sensitivity to fluconazole. Three out of 25 patients died of multi-drug resistant Gram-negative bacteria (12%) in 2013. Seventeen patients had radiological evidence of invasive fungal infections (no mortality was noted). Periodic review of infection-related data, as well as infection control practices, is essential to optimize clinical outcome in patients with pediatric malignancies.

In Response

Insertion of the endoscopic guidewire-assisted esophageal dilators, with or without fluoroscopic guidance, is as commented on by Chon et al., occasionally associated with severe complications (0.1% to 0.22%) including esophageal perforation and pneumomediastinum.1–4 Causes of severe complications include patient factors such as tight esophageal strictures and malignant esophageal diseases, operator inexperience, or might be related to the Savary-Gilliard wire guide, the endoscope, and the Savary-Gilliard esophageal dilators.2 Our study excluded patients with esophageal strictures as screened by clinical history and surgical workup.5 Also, our study was related to the procedure of nasogastric tube (NGT) insertion in patients with an anatomically normal esophagus.5 Manual forward displacement of the larynx probably safeguards against laryngeal entry of the wire guide–NGT assembly, while it passes from the hypopharynx into the cervical esophagus. The Savary-Gilliard wire guide also has a progressively flexible tip, which is again sheathed inside an NGT and follows the path of least resistance in the hypopharynx to the esophagus, since the laryngeal inlet is already blocked by the cuffed tracheal tube and displaced anteriorly by gentle manual traction.5 For any blindly performed wire guide–assisted clinical procedure, the most important principle is to “stop and retreat whenever any undue resistance is encountered.” Live fluoroscopy is perhaps the “gold standard” to guide the safe placement of any esophageal device. However, it is cumbersome, costly, and involves exposing the patient and the operator to ionizing radiation. Transcutaneous cervical esophageal ultrasound is a standard technique used by radiologists and gastroenterologists to measure esophageal wall thickness and luminal diameter as an adjunct to diagnosis of gastroesophageal reflux disorders.6 This might be helpful in guiding NGT placements in patients who are not tracheally intubated.7 We performed in-plane approach high-resolution B-mode ultrasound (using a high-frequency linear probe of the LOGIQ e USG console, GE Healthcare, Wauwatosa, WI) to visualize the passage of the NGT with and without laryngeal traction in 3 anesthetized and tracheally intubated patients. Although the trachea with the tracheal tube was clearly visible entirely along the long axis, the esophagus with the NGT was barely visible and that too from the right side only. With manual laryngeal displacement, visualization was even more difficult due to artefact from the operator’s fingers in the laryngoesophageal groove. Of course, an ill-defined motion artefact induced by the NGT movement was visualized. We suggest that real-time ultrasound imaging of the cervical esophagus in tracheally intubated patients requires refinement and standardization before being useful to the clinician as a tool to monitor the safe passage of the NGT. Jyotirmay Kirtania, MD Department of Anesthesiology Tata Medical Center, Kolkata [email protected] Shreyasi Ray, MD Department of Anesthesiology Medical College Hospital Kolkata Kolkata, India