Healthcare Delivery

Neuroendocrine Tumours: Management and Treatment

Do you know what is common to Steve Jobs and Irfan Khan? Well apart from the fact that both were brilliant individuals and masters of their field, they also suffered from Neuroendocrine Tumours and died as a result of those.

Steve Jobs – Source CNBC

So what is a Neuroendocrine Tumour?

A Neuroendocrine Tumour or NET is a specific tumour affecting the endocrine glands. Specifically a variant known as the Carcinoid Tumour is very common and lethal. It affects the Gastrointestinal Track (Stomach), Intestine, Lungs, Pancreas, Testicles and Ovaries.

This is the distribution of the NET – Carcinoid Tumours

  • Intestines -39%
  • Rectum-15%
  • Lungs -10%
  • Appendix -7%
  • Colon-7%
  • Pancease-3%
  • Liver-1%

Both Steve Jobs and Irfan Khan has the variety that grows in the Pancreas. Interestingly NETs strike later in life mostly around the 50s and 60s. Also there is a misconception that NETs are benign, but in reality there is nothing like a benign NET, according to Dr P Jagannath at Lilavati Hospital, this misleading information was one of the reasons Steve Jobs did not aggressively treat his condition when he was diagnosed.

The Treatment

  1. Surgery- The number one line of treatment seems to be surgery. This is specially if the tumour is detected early and has not spread. Another minimal invasive surgery is Laparoscopic surgery.
  2. Radiation- If the NET has spread then radiation is the best line of treatment. Both external beam radiation and internal beam radiation called brachytherapy are options that are available.
  3. Medication- A new medication called Everolimus has emerged on the scene that controls the tumour for a long time.

Innovation in treatment and therapies

1) PPRT – Peptide receptor Radionuclide Therapy – A radio isotope based therapy is showing good result specially in Pancreatic NETs, acts like a magic bullet just eliminating the cancer leaving the other healthy cells intact.

2) DOTA NOC – Scanning method is specifically helpful in treating gastrointestinal NETs.

The diagnosis and successful cure of NETs depends on early detection. The symptoms depend on the site of the tumour. Example in cases with Pancreatic NET, patients might see dizziness and increased fainting as blood sugar levels are not in line with the expectations as the tumour releases Insulin.

In conclusion, India has made many advances in the detection, cure and management of NETs. There is a registry of NET cases with the India chapter of the Asia Pacific Neuroendocrine Tumour Society. Also hospitals like Lilavati, KEM, JJ Hospital are all leading the charge on the treatment of NETs.

Dental Practice

Dental Practice Management- Strategy

Dental Surgery is a key part of the healthcare ecosystem. If you look at it closely we see that most of the health and wellness starts from digestion and the entire process of digestion starts from the mouth. Dental Surgeons play a very critical part of the ecosystem.

I took some time last week to put out a series of videos to help dentists to relook at their practice and their clinic. Here is a brief highlight on the first in the series- Strategy.

Strategy is a key to a successful business, a dental clinic is no different. The first step is

  1. Think Local, Act Local – It is important for the dentist to look at his local ecosystem, and understand the people that live in 2-5 KM radius of the clinic. Attention needs to be paid to their demographics, Age , Gender and Lifestyle.
  2. What Dental Services Would they Need- The next step is to extrapolate what services these communities would need. For example if there are many senior citizens living in that area, they may need more of Prosthodontic services.
  3. Finally Are you in a position to provide those services?- This is a critical step. If the demand is there but you are unable to supply it then it is best to look at another area. The services should be close to your core competency and your ability to provide them will be the key to success.

Please do let me know your your thoughts and ideas and I will be happy to respond to them. I will be sharing a lot more of my thoughts on topic in subsequent posts.

Healthcare Delivery

Decoding Total Knee Replacement

Total knee replacement is a surgical process in which the joint of the knee is replaced using an artificial material. If any part of the body experiences intolerable pain, it is difficult for a person to use it and the same is true for knees as well. If a person’s knee is damaged due to an injury or due to arthritis, then he/she may find it difficult to person daily tasks and activities such as climbing stairs, walking and general moving around.

Diagnosis is a critical part of managing total knee replacements

The pain remains even while lying down or sitting. In such a situation, a doctor may first prescribe medications and physiotherapy but in extreme cases, one may have to undergo total knee replacement.

Total knee replacement is also termed as resurfacing of the knee mainly because in the process, only the surface of the bones is replaced. The process combines of 4 broad steps and they are given as follows:

  1. Preparing the bone- in this step, the cartilage surfaces present at the ends of femur and tibia are removed together with a small part of the underlying bone.
  2. Positioning of the metal implants-metal components are used in place of the removed cartilage and bone so that they can recreate the surface of the knee joint. These parts of metal are press-fit or cemented into the bone.
  3. Resurfacing the patella-patella is basically the kneecap and in this step, the under surface of the patella is cut and a plastic button is used for its resurfacing. This process or step may vary depending upon patient to patient.
  4. Inserting a spacer- in between the metal parts, a plastic spacer is placed so as to create a smooth gliding surface. This plastic spacer is of course of medical grade quality.

If you are wondering whether total knee replacement is a process for you, then it is best to consult a good doctor. Most patients who undergo this process are between the age 50-80 however the treatment does not depend upon the age but rather the severity of the problem. One is likely to stay in the hospital for 3 days and has to recover at home for pain management and movement for a few weeks.

Public Health

On-time delivery: Ensuring reliable reproductive choice in India

Dr. Sudhir Maknikar

PATH has helped leverage the India Post—the world’s largest postal service—into a full-fledged distribution system delivering access to contraceptives for thousands of people in the state of Odisha.

In India, health systems face many obstacles when moving family planning commodities from state warehouses to towns and villages where health care providers and patients need them most. A lack of reliable transportation and other essentials triggers delays in delivery, severely impacting access to contraceptives. Lack of access—often triggered by failures in the supply chain—is a principal barrier to contraceptive use in the country.

PATH’s India office is working with state health systems, governments, and partners to address the gaps that prevent access to family planning commodities such as condoms, oral contraceptive pills, injectable contraceptives, and intrauterine devices (IUDs). With support from the Bill & Melinda Gates Foundation, the family planning supply chain strengthening project provides technical support to eight states in India to improve delivery of contraceptives.

Leveraging the India Post to meet supply chain challenges

A vehicle designated by India Post to transport contraceptives to towns and villages in Odisha, on India’s east coast. Photo: PATH

In Odisha, on India’s east coast, the state’s health system relied for many years on the services of a state-owned vehicle with a government driver to transport family planning commodities to district warehouses. With only one vehicle for a large state, it took at least three months to deliver shipments to all of Odisha. When a given district ran out of supplies—as was frequently the case—there was no chance for replenishment until the next quarter. Especially for women depending on the state-supplied contraceptives, this distribution system jeopardized their access to and choice in family planning.

In response, PATH analyzed several distribution systems that could supplement the existing one. The choice quickly become obvious: India Post, the world’s biggest postal network. With more than 155,000 offices across the country, it has been connecting the subcontinent for 242 years. In January, the state government used India Post to ship its first-ever consignment of family planning supplies from a warehouse in Odisha to depots in five districts.

An illustration of the flow of family planning commodities through India Post. Photo: PATH

The government of Odisha now uses India Post’s express parcel services to transport small quantities of commodities like IUDs, injectable contraceptives, and tubal rings. Larger shipments of condoms, emergency contraceptive pills, and pregnancy testing kits are still supplied through the state-owned transport.

This powerful intervention has strengthened the supply chain and distribution network for contraceptives throughout Odisha. Overall costs are lower, delivery times are faster, and there are no restrictions on the quantities that can be transported. Since the partnership between India Post and the state government began, the state’s health system has been more successful in meeting the urgent demand for contraceptives.

A boon during the COVID-19 crisis

In Odisha, the India Post and state government staff prepare a consignment of family planning commodities for delivery by India Post. Photo: PATH

Until the COVID-19 outbreak in India, the government of Odisha used both its own distribution system and India Post to supply contraceptives to the districts. But the nationwide lockdown closed borders and restricted the movement of vehicles. Soon, districts sounded the alarm: they were running out of contraceptives.

This is when the India Post proved invaluable. Classified as essential, postal services remained functional throughout the lockdown. Since March, the Odisha government has relied on India Post vehicles to dispatch more than 115 consignments of family planning commodities to about 28 districts, charting a 100 percent rate of on-time arrivals.

The project has also demonstrated the huge potential of India Post as a delivery method for other essential medical commodities. PATH is discussing with the governments of other Indian states how to leverage India Post for distribution of family planning commodities and expand it to strengthen the supply chain across the public health spectrum. The success of this intervention has proven, yet again, that innovative approaches can tackle critical health challenges and improve lives.

Dr. Sudhir Maknikar is Director, Family health at PATH’s India Country Program.

Healthcare Delivery

Management and care of Migraine

One of the common questions asked by people is the difference between headaches and migraine.

Headache, as the name suggests is a kind of pain which is experienced by a person in the head area. In medical terms, headaches is a pain located in head confined within certain boundaries which doctors describe from upper edges of eyes to backwards towards the ears to the nape of the neck. On the other hand, migraine is a neurological condition which can lead to several symptoms, one of which is a headache.

Headaches are of two types-primary headaches and secondary headaches. Primary headaches are common and take up to 90% of cases of headaches and migraine is one of them.  This kind of a headache starts from one side of the head and usually progresses to cause pain in the entire head. The patient may also complain of vomiting sensation and intolerance to light and sound in case of migraines.  One episode of migraine may last up to an interval of 4 hours but in severe cases, it may go on for 3 days.  Some other symptoms of migraine apart from pulsating headaches include nausea, fatigue, irritability, neck stiffness and numbness.

There are two types of migraines-one is the common type which is migraines without aura and the other is classic migraines or migraines with aura. An aura is basically a phase before onset of migraine wherein patient may experience improper vision, seeing flashes of light or bright spots and even difficulty in speaking. Some common triggers of migraine include fasting for long periods of time, sensitivity to sunlight or other lights, dehydration, loud sounds, changes in sleep pattern and stress.

Some red flags of migraines include sudden onset of headaches, high intensity headaches, headaches accompanied with other symptoms or signs such as double vision and headaches in elderly population. In such cases, the headaches must not be taken casually and neurological help must be taken. If headaches are increasing in intensity progressively, even in that case, consultation must be taken without any delay.

The treatment approach for migraines includes proper evaluation by a neurologist. The doctor may suggest a 3 point strategy.

First point is preventive. One must be able to analyse the triggers that may be causing them pulsating headaches or migraines and should avoid them to avoid chances of headaches altogether. Avoiding common triggers like high sunlight, certain foods and drinks and loud music etc is recommended.

The second point is to go for over the counter medicines prescribed by the doctor to control the episodes of migraines. The doctor may suggest medicines depending upon the intensity of the condition.

The third therapy is suggested for those who have frequent episodes of headaches or migraines and as many as 3 to 4 episodes per month. In this case, the doctor may give medicines especially suited for those who have high frequency and high intensity migraines.

Public Health

A healthy start for newborns in India

Every baby deserves access to lifesaving human milk and essential newborn care services.

By Isha Jain

A health worker pooling the donor human milk at Jay Prakash Hospital in Bhopal, India. Photo: Jay Prakash Hospital.

Nandini Kumari’s son arrived early. Because of his low birth weight, he was quickly shifted to the neonatal intensive care unit (NICU). The stay in the NICU and the feeding challenges that followed were hard on Nandini and her son. In an all too common story, what could have been a time of joy became a time of great distress.

India is home to roughly 18 percent of the world’s population, but about 33 percent of the world’s preterm births. The high prevalence of preterm births contributes to another alarming statistic—in India, newborns account for more than half all deaths of children under age five.

Though these statistics are grave, WHO estimates that nearly 71 percent of all prematurity-related deaths could be avoided with cost-effective interventions—breastfeeding and human milk banking, kangaroo care with skin to skin contact, and infection detection and treatment. With support from Philips India CSR, PATH is working with government partners in India to expand access to these critical interventions by scaling them across facilities and states.

Lifesaving human milk

With technical support from PATH, the states of Uttar Pradesh and Madhya Pradesh established their first comprehensive lactation management centers, and the states of Maharashtra and Rajasthan each upgraded their lactation centers into regional reference centers that now provide training and accreditation to others.

These achievements ultimately mean better access to lifesaving human milk for newborns in each state—especially preterm deliveries like Nandini’s son.

A mother expressing milk for her own baby at King George Medical University in Lucknow, India. Photo: King George Medical University.

To address the feeding challenges they faced, doctors prescribed donated, pasteurized human milk for Nandini’s son and provided counseling regarding its use. The donated milk helped him gain weight and prevented additional complications, while Nandini received lactation counselling and learned to express her own milk.

“Every hospital should offer this support for mothers and babies,” Nandini says. “I am really thankful to the mothers who have donated milk so other babies can benefit.”

Counselling support given to mothers by health workers at King George Medical University in Lucknow, India. Photo: King George Medical University

Pushing past the pandemic
The COVID-19 pandemic has disrupted the delivery of essential newborn nutrition and care services in India. Outpatient hospital services have been suspended. Hospital stays shortened. Staff headcounts reduced and more.

All these changes have made it difficult for mothers and families to get the feeding support they need. PATH is working with health facilities across India to help bridge these new gaps and provide lactation support to mothers and newborns. We’re supporting the government as they develop guidance for health workers, sharing best practices for newborn nutrition and care, and providing technical support as lactation management centers adapt to the new normal.

“From March to June of this year, PATH helped the health facilities to provide counselling and breastfeeding support to more than 10,000 mothers and their families,” says Ruchika Sachdeva, Deputy Director of PATH’s MNCHN portfolio in India. “Despite the pandemic’s challenges, we are working to ensure a healthy start for newborns.”

Isha Jain is Communications Officer with PATH’s India Country Program.