Oral Oncology

Patient access to voice prostheses and heat and moisture exchangers: Factors influencing physician's prescription and reimbursement in eight European countries Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): A.C.C. Beck, V.P. Retèl, M.W.M. van den Brekel, W.H. van Harten Abstract Objectives Patient access to the voice prosthesis and heat and moisture exchanger (HME) is not always guaranteed in Europe. Therefore, the aim of this qualitative study is to evaluate factors influencing physician's prescription and reimbursement of these devices in eight European countries, and to identify barriers of and facilitators to effective patient access. Materials and methods In this mixed methods study, we conducted a survey among stakeholders evaluating prescription (Part 1 of the survey), reimbursement (Part 2), and barriers of and facilitators to effective patient access (Part 3). Part 1 was completed by head and neck surgeons employed in France, Germany, the United Kingdom, Italy, Spain, Belgium, the Netherlands and Poland. Part 2 and 3 were completed by medical device company representatives in respective countries, followed by semi-structured interviews. Results Based on the survey, filled in by 36 surgeons, all prescribed the voice prosthesis. Four surgeons didn't prescribe the HME in Italy and Poland due to lack of both reimbursement and experience/training, and feeling uncomfortable with device use. Most restrictive factors (e.g. increased workload, insufficient staff) occurred in countries with decentralized healthcare systems including Spain and Italy. Conclusion Non-HME-usage was influenced by economical and physician-related factors. Restrictive factors were related to limited regional device reimbursement and provision. Nationwide reimbursement, guideline implementation, support for physicians by training/education and providing a rehabilitation team will increase device use.

Results of a combination treatment with intensity modulated radiotherapy and active raster-scanning carbon ion boost for adenoid cystic carcinoma of the minor salivary glands of the nasopharynx Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Sati Akbaba, Dina Ahmed, Kristin Lang, Thomas Held, Matthias Mattke, Juliane Hoerner-Rieber, Klaus Herfarth, Stefan Rieken, Peter Plinkert, Juergen Debus, Sebastian Adeberg Abstract Objectives We aimed to present the first clinical results for adenoid cystic carcinoma (ACC) of the nasopharynx after primary radiotherapy (RT) with the focus on local control (LC) and patterns of recurrence. Materials and methods We retrospectively analyzed 59 patients with ACC of the nasopharynx, who were treated with bimodal radiotherapy (RT) consisting of intensity modulated radiotherapy and carbon ion boost at the Heidelberg Ion-Beam Therapy Center between 2009 and 2018. The patients had predominantly inoperable (n = 42, 72%) or incompletely resected (n = 17, 29%) tumors. Kaplan-Meier estimates and the log-rank (Mantel-Cox) test were used for univariate and multivariate analyses. Results The median follow-up was 32 months. At last follow-up, 67% of the patients were still alive (n = 39/58), of whom 74% were free of progression (n = 29/39). The 2-year LC, distant progression-free survival (DPFS) and overall survival (OS) were 83%, 81%, 87% and the estimated 5-year LC, DPFS and OS were 49%, 54%, 69%, respectively. LC was significantly inferior in patients with large tumor volumes (gross tumor volume, GTV > 100 cc, p = 0.020) and T4 tumors (p = 0.021). The majority of the recurrences occurred at the margin, where critical structures were spared (n = 11/19, 58%). Overall, grade 3 toxicity was moderate with 12% acute and 8% late side effects. Conclusion Bimodal RT including active raster-scanning carbon ion boost for nasopharyngeal ACC resulted in adequate LC and OS rates with moderate toxicity. T4 stage, large tumor volume and the necessary dose sparing in critical structures, i.e. optic nerves, brain stem and orbit, negatively affected LC.

Quality insurance in head and neck cancer multidisciplinary team meetings: A watchful eye on real-life experience Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Jean-Baptiste Guy, Marouan Benna, Yaoxiong Xia, Elisabteh Daguenet, Majed Ben Mrad, Omar Jmour, Nicolas Vial, Yann Lelonge, Pierre Fournel, Jean-Michel Prades, Alexis Vallard, Nicolas Magné Abstract Introduction Although Multidisciplinary Team Management (MDT) is integrated in most international head and neck cancer treatment guidelines, its applications and proceedings were rarely described. The present study explores a 6-year real-life experience in a French Comprehensive Cancer Care Center. Methods Patients, tumor and meeting characteristics of all consecutive cases discussed in head and neck MDT meetings between 2010 and 2015 were retrospectively reviewed. Results From 2010 to 2015, 1849 cases (accounting for 1786 patients) were discussed in 138 MDT meetings. Median age was 62 (range: 15–96). When reported (n = 310, 16.8%), performance status was ≥2 in 36.1% of patients. Tumors were mainly squamous cell carcinomas (n = 1664, 91.5%) of the larynx/hypo-pharynx (n = 630, 34.4%), oropharynx (n = 518; 28.3%) and oral cavity (n = 339; 18.5%). Tumors were diagnosed at a locally (n = 358, 25%), locally advanced (n = 946, 66%) or metastatic setting (n = 53, 3.7%). Mean number of discussed patients per MDT meeting was 16 (range: 3–32). Most patients were discussed once (n = 1663, 97%). Most patients (n = 969, 52%) underwent treatment before MDT meetings: mainly surgery (n = 709, 73.2%). The mean time between MDT meeting and first radiation course was 21 days (range: 1–116). Discussion Optimal multimodal treatment management is based on MDT meetings and results from the interaction and coordination of surgeons, medical and radiation oncologists. In the present series, most patients were discussed once despite the number of expected recurrences, suggesting that the management of tumor progression was not discussed in head and neck MDT meetings. Furthermore, most patients had surgery before MDT meeting, pointing out that MDT role and place still needs to be improved. Finally, the present population significantly differed from patients included in phase III clinical trials, with more advanced age and poorer condition. It calls for the necessity of a high-quality head and neck MDT meeting since evidence-based recommendations should be adapted to patient's frailties.

Time trends of thyroglobulin antibody in ablated papillary thyroid carcinoma patients: Can we predict the rate of negative conversion? Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Eyun Song, Jonghwa Ahn, Hye-Seon Oh, Min Ji Jeon, Won Gu Kim, Won Bae Kim, Young Kee Shong, Jung Hwan Baek, Jeong Hyun Lee, Jin Sook Ryu, Ki Wook Chung, Suck Joon Hong, Tae Yong Kim Abstract Objectives Persistence of thyroglobulin antibody (TgAb) in patients with papillary thyroid carcinoma (PTC) years after total thyroidectomy (TT) followed by ablation occurs even without any evidence of structural disease. Few studies have studied the natural course of TgAb positivity and factors that may influence this course. The present study evaluated the time trends of TgAb in ablated PTC patients and aimed to identify the predictive factors for the rate of negative conversion of TgAb. Materials and methods Overall, 1279 patients who underwent TT and subsequent ablation for PTC, with available data on thyroid peroxidase Ab (TPOAb) and TgAb prior to surgery (preop-) and ablation (abl-) were enrolled. Patients with initial distant metastasis or recurrence during follow-up were excluded. Results and conclusion Preop-TgAb was positive in 24.9% of patients (n = 319), whereas abl-TgAb positivity decreased to 12.8% (n = 164). In 164 patients positive for abl-TgAb, TgAb in patients with higher abl-TgAb levels decreased more gradually than those observed in patients with lower abl-TgAb levels (p < 0.001). Furthermore, in patients within the same range of abl-TgAb levels, patients positive for abl-TPOAb had a higher rate of negative conversion of TgAb compared with negative patients for abl-TPOAb (log rank p < 0.001). TPOAb significantly increased the rate of negative conversion in multivariate analysis adjusted for abl-TgAb (odds ratio 1.59, 95% confidence interval 1.11–2.28, p = 0.011). This study clearly showed that abl-TgAb titers and abl-TPOAb status can predict the rate of negative conversion. These findings can guide the optimal timing for additional examination in patients positive for TgAb during follow-up.

Differences of tumor-recruiting myeloid cells in murine squamous cell carcinoma influence the efficacy of immunotherapy combined with a TLR7 agonist and PD-L1 blockade Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Hidetake Tachinami, Naoto Nishii, Yulong Xia, Yoshihisa Kashima, Tatsukuni Ohno, Shigenori Nagai, Lixin Li, Walter Lau, Kei Tomihara, Makoto Noguchi, Miyuki Azuma Abstract Objectives The immune status of the tumor microenvironment has a marked impact on clinical outcomes. Here we examined the immune environments of tumor-infiltrating leukocytes (TILes) in two murine models of squamous cell carcinoma and compared the effects of immunotherapeutic agents, including a TLR7 agonist and an immune checkpoint inhibitor, and a chemotherapeutic agent, gemcitabine, in these models. Materials and methods TILes from NR-S1- and SCCVII-grafted mice were analyzed by flow cytometry. NR-S1-inoculated mice received resiquimod (a synthetic TLR7 agonist), an anti-PD-L1 antibody, or both, and tumor growth and TILs were examined. Gemcitabine was administered to deplete CD11b+ cells. Results More than 50% of TILes from NR-S1- and SCCVII-inoculated mice were CD11b+Gr-1+ cells. A major fraction of NR-S1 CD11b+ cells was Ly6GhighLy6Clow-negaF4/80− tumor-associated neutrophils (TANs) and the majority of SCCVII CD11b+ cells were Ly6GlowLy6C−F4/80+ tumor-associated macrophages. NR-S1 TANs did not express MHC class II and CD86, but did express reactive oxygen species and PD-L1. Resiquimod, alone and in combination with an anti-PD-L1 antibody, did not regress NR-S1 tumors, but the combination increased the CD8/regulatory T cell-ratio, and IFN-γ and PD-1 expression in CD8+ TILes. Pre-administration of low-dose gemcitabine prior to the combination treatment suppressed the progression of NR-S1 tumors. Conclusions NR-S1 tumors with abundant recruitment of TANs were resistant to treatments with a TLR7 agonist, alone and in combination with PD-1 blockade, and required an additional gemcitabine treatment. The phenotype and status of tumor-infiltrating CD11b+ myeloid cells may influence the efficacy of immunotherapeutic agents.

Patient-reported outcomes of symptom burden in patients receiving surgical or nonsurgical treatment for low-intermediate risk oropharyngeal squamous cell carcinoma: A comparative analysis of a prospective registry Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Moran Amit, Kate Hutcheson, Jhankruti Zaveri, Jan Lewin, Michael E Kupferman, Amy C Hessel, Ryan P Goepfert, G. Brandon Gunn, Adam S Garden, Renata Ferraratto, C. Dave Fuller, Samantha Tam, Neil D. Gross Abstract Purpose To explore treatment-related changes in symptom burden and quality of life (QOL) in oropharyngeal squamous cell cancer (OPSCC) patients treated surgically and non-surgically. Patients and Methods Eighty-six patients with human papillomavirus–associated OPSCC treated at the Head and Neck Center at The University of Texas MD Anderson Cancer Center were recruited to a prospective registry study between 2014 and 2016 and completed the core, head and neck-specific, and symptom interference sections of the MD Anderson symptom inventory (MDASI) multi-symptom questionnaire and the EQ-5D health status assessment as a measure of QOL at four time points. Results Longitudinal improvements from post-treatment nadir were observed across all groups. For patients treated with single modality, symptom interference, but not core and head and neck specific, MDASI scores were significantly better at 6 months in patients treated with surgery than radiation (P = 0.04). For patients treated with multiple modalities, scores for each of the three domains (i.e., core, head and neck -specific, and interference MDASI) were significantly better in the surgical group than the nonsurgical group at treatment completion (P = 0.0003, P = 0.0006 and P = 0.02) and 6 weeks (P = 0.001, P = 0.05 and P = 0.04), but not 6 months (P = 0.11, P = 0.16 and P = 0.040). No significant differences in EQ5D health status were observed between groups at any time point, reflecting similar overall QOL in all groups. Conclusion Symptom burden and QOL improves after treatment in OPSCC survivors over time regardless of whether primary surgical or nonsurgical treatment is used, although acute symptom profiles may differ.

Patterns of EBV-positive cervical lymph node involvement in head and neck cancer and implications for the management of nasopharyngeal carcinoma T0 classification Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Wei-Jie Luo, Yan-Fen Feng, Rui Guo, Ling-Long Tang, Lei Chen, Guan-Qun Zhou, Wen-Fei Li, Xu Liu, Ying Sun, Ai-Hua Lin, Jun Ma, Yan-Ping Mao Abstract Objectives Epstein-Barr virus (EBV)-positive cervical lymph node (CLN) metastasis of unknown primary origin is classified as nasopharyngeal carcinoma (NPC) T0 by the American Joint Committee on Cancer staging manual (8th edition). We aimed to investigate the possible primary sites and patterns of EBV-positive CLN metastases and to provide implications for the management of NPC T0 classification. Materials and methods We retrospectively reviewed 269 patients with newly diagnosed EBV-positive CLN metastatic disease who underwent EBV detection via EBV-encoded RNA in situ hybridization. Fifteen patients with unknown primary tumors underwent follow-up after initial treatment. Results In patients with EBV-positive CLNs, the most common primary sites after the nasopharynx (51.7%) were the salivary gland (24.5%), lung (7.8%), oropharynx (3.3%), nasal cavity/maxillary (3.3%), oral cavity (2.2%), orbit (1.1%), and liver (0.4%). No primary site was found in 15 patients (5.6%). For salivary gland malignancies, level II and I were the most frequently involved regions. Tumors arising from the lung or liver metastasized to the lower neck (level IV, V, and VI) rather than the upper neck. After initial treatment, 2/15 patients with EBV-positive CLNs of unknown primary exhibited primary NPC and oropharyngeal tumor, respectively. Further, even without prophylactic irradiation to the nasopharynx, only one of 13 unknown primary patients developed NPC. Conclusions The origins of EBV-positive CLNs may not be restricted to the nasopharynx alone, and are likely to involve the head and neck or non-head and neck regions. NPC T0 classification should be cautiously assigned to such tumors.

Human papillomavirus detection in matched oral rinses, oropharyngeal and oral brushings of cancer-free high-risk individuals Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Maria Gabriella Donà, Barbara Pichi, Francesca Rollo, Maria Benevolo, Alessandra Latini, Valentina Laquintana, Raul Pellini, Manuela Colafigli, Mirko Frasca, Massimo Giuliani, Antonio Cristaudo Abstract Objectives The detection of oral Human Papillomavirus (HPV) may be of clinical utility because of the major role HPV plays in the etiology of oropharyngeal cancer. However, oral HPV testing is not standardized and the best sampling method has yet to be identified. We aimed to compare HPV findings in matched oral rinse-and-gargles (rinses), oropharyngeal brushings and oral brushings. Materials and methods HPV-DNA was investigated using Linear Array in samples collected from cancer-free individuals at increased risk for oral HPV. Results 163 oral rinses already tested for HPV were selected. The matched oropharyngeal (n = 163) and oral brushings (n = 100) were analyzed. The detection rate for any HPV, high-risk (HR)-HPVs and HPV16 was significantly higher in rinses than brushings. The overall agreement for any HPV between rinses and oropharyngeal brushings was 51.2% (Cohen K: 0.14, 95% CI: 0.07–0.21). The proportion of positive agreement was 16.8%. The overall agreement for HR-HPVs was 74.1% (Cohen K: 0.20, 95% CI: 0.07–0.33). The genotype-specific profile of rinses and brushings which were concomitantly HPV-positive only partially overlapped in cases with multiple infections, with more genotypes detected in the rinse, which were not isolated in the corresponding brushings. Conclusion The agreement for HPV status between rinses and brushings is poor, particularly for the HPV-positive findings. Despite the fact that the origin of the HPV-infected cells present in the oral rinse is unclear, since they could not be traced back to the oropharynx or oral cavity, oral rinses provided the highest detection rate for HR-HPVs and HPV16.

The prognosis of head and neck squamous cell carcinoma related to immunosuppressive tumor microenvironment regulated by IL-6 signaling Publication date: April 2019 Source: Oral Oncology, Volume 91 Author(s): Ming-Shao Tsai, Wen-Cheng Chen, Chang-Hsien Lu, Miao-Fen Chen Abstract Evasion of immune surveillance is a significant factor in head and neck squamous cell carcinoma (HNSCC) carcinogenesis. IL-6 signaling is a critical mechanism for the induction of dysfunctional immune responses. In the present study, we examined the role of IL-6 in the prognosis of HNSCC regarding the immunosuppressive tumor microenvironment. We retrospectively analyzed the clinical outcomes of HNSCC patients and examined its correlation with the levels of IL-6 in tumors and circulating myeloid-derived suppressor cells (MDSCs) in peripheral blood. Furthermore, the relationships between IL and 6, programmed death ligand (PD-L1) expression, and immune response were examined in vitro and in vivo. Our data revealed that IL-6 overexpression was associated with the increased risk of developing disease failure and poor prognosis for HNSCC. The immunoreactivity of IL-6 in HNSCC specimens was positively linked to the staining of PD-L1 and the level of circulating MDSCs. By cellular and animal experiments, there were augmented radiation-induced increases in the expression of PD-L1 and the activation of MDSCs noted in IL-6-positive tumors. When IL-6 signaling was inhibited, the levels of PD-L1 and MDSC recruitment were significantly down-regulated. Furthermore, the neutrophil-to-lymphocyte ratio (NLR) was positively correlated with the levels of IL-6 and PD-L1 in tumor, and circulating MDSCs. In conclusion, IL-6 is a significant predictor of treatment outcome in HNSCC patients, and plays an important role in the induction of immunosuppressive tumor microenvironment mediated by increased MDSCs and PD-L1 expression. Furthermore, IL-6 combined with NLR can assist the clinician to make an informed decision regarding treatment options.

Organ preservation in laryngeal and hypopharyngeal cancer Publication date: March 2019 Source: Oral Oncology, Volume 90 Author(s): Stephen Kang

Patient Safety and Infection Control

ORIGINAL ARTICLES
	Objective assessment of hand hygiene: When we see it, we believe it!	p. 67
	Shikha Ranjan, Dhivya Venkatesan, Ramya Devi DOI:10.4103/jpsic.jpsic_10_18   Background: Hand hygiene is the fundamental and leading measure to prevent the spread of antimicrobial resistance and to reduce hospital-acquired infections. Several strategies are recommended to increase the compliance for hand hygiene practice; however, health-care worker (HCW) compliance with optimal practices remains low in most settings. Aim: This study aims to assess the efficacy of hand hygiene practice in HCWs at our hospital, and to demonstrate objective result of their practices, followed by a questionnaire-based study to assess their attitude towards hand hygiene, and effect of workshop on their hand hygiene practice pattern.Materials and Methods: Participants were asked to disinfect their hands using a hand rub solution mixed with the fluorescent dye. Photos were taken under an ultraviolet lamp. A self-designed questionnaire was given to all the participants. Results: A total of 94 HCWs participated in the hand hygiene workshop. Only 11.11% nurses (6/54) and 17.5% doctors (7/40) were able to use disinfectant solution with complete coverage of hand areas. Incomplete coverage of dorsum of hand was more common than that of palms. About 84.21% doctors (32/38) and 80% nurses (36/45) wanted to participate in such hand hygiene workshop in future with majority of them opting for frequent workshop. All the participants admitted that such workshop changed their attitude towards their practice pattern. Conclusion: It is important to carry out hand hygiene training programmes regularly to achieve increased compliance with hand hygiene practices. This study also emphasises that an objective technique of demonstration has a greater effect in changing professional's attitude towards hand hygiene.
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	An analysis of health economics related to hospital-associated infections: A prospective case–control analysis of 7-year data from a tertiary referral corporate hospital in India	p. 73
	Murali Chakravarthy, Raj Gore, Navin Yellappa, Antony George, Sukanya Rangaswamy, Rajathadri Hosur, Sumant Pargaonkar, Chidananda Harivelam, Priyadarshini Senthilkumar, Tejaswini Saravanan, Suganya Arul Rose DOI:10.4103/jpsic.jpsic_20_18   Objective: Healthcare associated infections cause significant morbidity, mortality and escalation of cost of care. It is the responsibility of all concerned to work towards reducing this potentially preventable increase in morbidity, mortality and cost caused by healthcare associated infections. Such data in Indian subcontinent has been studied sparingly. The objective of this study was to understand the degree of the cost escalation, morbidity and mortality associated with healthcare associated infections. Design: This prospective case controlled observational study was carried out from the year 2007 onwards. All the infections that occurred unto 2014 were included. Cost, morbidity and mortality of two similar matched controls for each infected case were chosen.Setting: Tertiary referral hospital. Participants: All patients with healthcare associated infections and twice that number as control. Interventions: None. Main outcome measure: Escalation of cost, morbidity and mortality due to healthcare. Results: There were five hundred fifteen infections during the study period. The escalation of cost due to infection was $ 4611. The mean mortality in the infected group was 8.75% in contrast to 2.5 in the non infected group. The mortality due to central line associated blood stream infection and ventilator associated pneumonia was more than 30% each. The length of stay in the intensive care unit was 8 days in the infected group in contrast to 2.27 days in the non infected group. Length of stay in the hospital was 33.5 days in the infected patients in contrast to 10.3 days in the non infected group. Conclusions: Healthcare associated infections caused escalation of cost, length of stay in the intensive care unit and hospital. Mortality in the infected cohort was more in contrast to the controls.
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	A cross-sectional pilot survey of sharp injuries among dental students in a tertiary care dental hospital in Lucknow, India	p. 78
	Rhythm Bains, Vivek K Bains, Reema Kumari DOI:10.4103/jpsic.jpsic_22_18   Aim: This study aims to estimate the frequency of sharp injuries among the post-graduate and undergraduate dental students and evaluate their knowledge regarding the needle-stick/sharp injuries, proper handling and disposal of sharp waste. Methodology: A written questionnaire containing questions regarding frequency of sharps injury, source of injury, status of immunisation and knowledge regarding handling and disposal of sharps waste was personally distributed to the participants and collected on the same day. Informed consent was obtained from the participants, and the purpose of the study was explained to them. The data obtained was statistically analysed. Percentage distribution of responses for Bachelor of Dental Surgery (BDS) and Master of Dental Surgery (MDS) students was recorded. Furthermore, the comparison of responses for BDS and MDS was analysed using the t-test. Chi-square test was used to find the significance difference between responses by BDS and MDS students. Results: The results of the present questionnaire study revealed that 38.5% (10/26) post-graduate students and 37.2% (16/42) undergraduate respondents had a history of sharps injury (P = 0.917). Most common reason for the injury among post-graduates was recapping of needles 84.6% (22/26) followed by endodontic instruments 11.5% (3/26) and use of probes/explorer 3% (1/26). Among the undergraduates, the most common source of injury was again recapping of needles 97.7% (42/43), followed by endodontic instruments 2.3% (1/43). Conclusion: Both undergraduates and post-graduates reported with history of sharps injury, though the difference among them was not significant. Needle-stick or sharps injury can prove to be fatal, and as dental students have an early clinical exposure, they should be trained early in their curriculum regarding correct disposal and handling of sharps.
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	A study of microbial flora of mobile phones used by health-care professionals in a tertiary care hospital in North India	p. 83
	Gurjeet Singh, Raksha Singh DOI:10.4103/jpsic.jpsic_19_18   Context: Mobile phones give all the advantages to its users but it also acted as a house for harbour the bacteria and causing health hazard that should not be over looked. Aim of study was study the prevalence of bacterial and fungal pathogens on mobile phones and their identification. Aims: 1. To study the prevalence of bacterial and fungal pathogens on mobile phones. 2. Identification of bacterial and fungal pathogens to species level.Settings and Design: The study was conducted in the Department of Microbiology, N. C. Medical College and Hospital, Israna, Panipat. Methods and Material: A total of 100 mobile phones were randomly sampled with sterile moistened swabs from doctors, nurses, laboratory technicians and attendants working in the hospital on the days of sampling. Statistical Analysis Used: Statistical analysis was done using SPSS 20.0 v. Descriptive analysis was done to estimate the percentage of microorganisms and Chi Square test was done to assess the difference in proportions. Level of significance was taken at p<0.05 Results: Total 100 mobile phones of health care professional were swabbed to check microbial flora harboured on mobile phones. Out of 100 mobile phones 79 (79%) were found with contaminated with microbial flora. Conclusions: Mobile phones may act as carrier for cross contamination among patients and dental personnel. Simple cleaning with isopropyl alcohol reduced the microbial load of the cellular phones. Hence it is recommended that dental colleges should develop strict guidelines concerning cell phone use and hygiene.
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PERSPECTIVE
	Needle-stick injury: A perspective	p. 90
	Padma Srikanth, Yazhini Ravi, Shyamala Mani DOI:10.4103/jpsic.jpsic_16_18
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LETTER TO EDITOR
	ABC's of hand hygiene: An aid to improve adherence	p. 93
	Chepsy C Philip, Shilpa Abraham, Amrith Mathew, M Joseph John DOI:10.4103/jpsic.jpsic_21_18
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Cancer Immunology and Immunotherapy Symposium 2019 Shanghai China

Psychological Medicine

PRESIDENTIAL ADDRESS
	Spirituality in psychiatry practice	p. 103
	Padma Sudhakar Thatikonda DOI:10.4103/IJPSYM.IJPSYM_532_18
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GUEST EDITORIALS
	Legal and ethical aspects of mental health care	p. 108
	Rajshekhar Bipeta DOI:10.4103/IJPSYM.IJPSYM_59_19
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	Mental Healthcare Act 2017 – The way ahead: Opportunities and Challenges	p. 113
	A Jagadish, Furkhan Ali, Mahesh R Gowda DOI:10.4103/IJPSYM.IJPSYM_38_19
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REVIEW ARTICLES
	The rights of persons with disabilities Act 2016: Mental health implications	p. 119
	Abhilash Balakrishnan, Karishma Kulkarni, Sydney Moirangthem, Channaveerachari Naveen Kumar, Suresh Bada Math, Pratima Murthy DOI:10.4103/IJPSYM.IJPSYM_364_18   India's ratification of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) necessitated the need for a rights-based, biopsychosocial model of disability, which was endorsed in the Rights of Persons with Disabilities (RPwD) Act, 2016. This article examines the Act, its rules, and guidelines provided by the Government of India, from a mental health perspective, and compares it to its predecessor, the Persons with Disabilities (PwD) Act, 1995. The RPwD Act provides clearer definitions of various constructs, a greater focus on rights of PwD, and guidelines for assessment and certification of disabilities. There is, however, an underemphasis on mental illnesses in the reservation and legal decision making, and a move toward centralizing the process of disability certification. Also, there is a lack of clarity about screening instruments to be used, resource allocation to implement the provisions, and the guidelines for inclusive education. This article suggests recommendations that could strengthen some of these provisions.
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	Psychiatrist in court: Indian scenario	p. 126
	Vinay Basavaraju, Arun Enara, Guru S Gowda, Shashidhara Nagabhushana Harihara, Narayana Manjunatha, Channaveerachari Naveen Kumar, Suresh Bada Math DOI:10.4103/IJPSYM.IJPSYM_53_19   The impetus for practical exposure to legalities that arise in the context of psychiatry and law is minimal in postgraduate training in psychiatry and curriculum. Those who choose to get trained often do not get first-hand exposure to court proceedings. Law and psychiatry often come into each other's interface, and psychiatry is regulated by the legal system more often than the other specialties in medicine. This article is an attempt to equip the psychiatrist in dealing with instances where they will present themselves in court.
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	Suicide risk in comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review	p. 133
	Andrea Amerio DOI:10.4103/IJPSYM.IJPSYM_367_18   Introduction: The co-occurrence of bipolar disorder (BD) and obsessive-compulsive disorder (OCD) seemed to be a poor prognostic factor associated with greater disability, lower social and occupational functioning, poorer treatment response, and higher suicidal ideas and attempts compared to BD patients. Materials and Methods: A systematic review was conducted on the risk of suicide in BD-OCD patients compared to BD patients. Relevant papers published through August 2018 were identified searching the electronic databases MEDLINE, EMBASE, PsycINFO, and the Cochrane Library. Results: In all cases, diagnoses were according to the standard Diagnostic and Statistical Manual criteria and were established using validated assessment scales. More than 80% of the selected studies presented higher rates of history of suicide attempts and lifetime depressive episodes in BD-OCD patients compared to non-comorbid patients. Conclusions: Osler's view that medicine should be a treatment of diseases, not of symptoms, is consistent with the approach of mood stabilization as the first objective in apparent BD-OCD patients, as opposed to immediate treatment with antidepressants. In line with that, especially in comorbid patients, lithium may be preferred because of its proven anti-suicidal effect.
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ORIGINAL ARTICLES
	Sociodemographic, legal, and clinical profiles of female forensic inpatients in Karnataka: A retrospective study	p. 138
	Guru S Gowda, Sai Komal, Tarasingh N Sanjay, Saumya Mishra, Channaveerachari N Kumar, Suresh B Math DOI:10.4103/IJPSYM.IJPSYM_152_18   Background: Forensic patients are often admitted to psychiatric hospitals without any details of illness or treatment. They pose a unique challenge for clinical services in the context of diagnosis, management, and particularly legal issues. Materials and Methods: We conducted a retrospective chart review using a structured data-extraction tool. A total of 23 female forensic inpatients were admitted under the Department of Psychiatry from January 2006 to June 2016. Data were analyzed by descriptive statistics. Results: The mean age of the patients was 31.3 ± 7.9 years. In total, 82.6% of them were married, 87% were from a nuclear family, and 78.3% were from an urban background. Totally, 73.9% were referred from prison and 26.1% from the court. However, 73.9% were referred for the purpose of diagnosis and treatment and 21.7% for assessment of fitness to stand trial. Moreover, 47.8% had an alleged charge of murder (of killing close family members). A total of 30.4% had schizophrenia and other psychotic disorders, and 47.8% had a mood disorder. The mean duration of inpatient care was 6.2 ± 7.4 weeks, and 87% had shown considerable clinical improvement at the time of discharge. Conclusions: The majority of female forensic patients were young adults from nuclear families. They had mood disorders, schizophrenia, and other psychotic disorders. They were referred primarily for treatment purposes. Prospective studies are required for a better characterization of the relationship between crime and psychiatric disorders.
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	Prevalence and clinical and coercion characteristics of patients who abscond during inpatient care from psychiatric hospital	p. 144
	Guru S Gowda, Abel Thamby, Vinay Basavaraju, R Nataraja, Channaveerachari Naveen Kumar, Suresh Bada Math DOI:10.4103/IJPSYM.IJPSYM_188_18   Background: Patients absconding from psychiatric hospitals pose a serious concern for the safety of patients and public alike. Absconding is associated with an increased risk of suicide, self-harm, homicide, and becoming "missing" from society. There are only scarce data on profile and outcome of the absconding patients in India. Aims: To study the prevalence and describe the clinical and coercion characteristics of patients who abscond during inpatient care from an open ward. Methodology: "Absconding" was defined as patients being absent from the hospital for a period of more than 24 h. This is an analysis of absconding patients out of the 200 admitted patients at a tertiary psychiatric hospital. Descriptive statistic was used to analyze the demographic, clinical, and perceived coercion profile and outcome. Results: The absconding rate was 4.5 incidents per 100 admissions. Most of these patients were males, from a nuclear family, admitted involuntarily, belonging to lower socio-economic status, diagnosed with schizophrenia or mood disorder with comorbid substance use disorder and had absent insight. The MacArthur Perceived Coercion Scale score was 4.58 (±1.44), and 80% of the absconded patients felt subjective coercive experiences in most domains at admission. Out of the 9 absconded patients, 2 patients had completed suicides and one continued to remain untraceable. Conclusion: The absconded patients were males; admitted involuntarily; diagnosed with schizophrenia, mood disorder, and comorbid substance use disorder; and had absent insight and high perceived coercion. Absconding patients had the tendency to harm themselves and wander away from home.
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	How does india decide insanity pleas? A review of high court judgments in the past decade	p. 150
	Parthasarathy Ramamurthy, Vijay Chathoth, Pradeep Thilakan DOI:10.4103/IJPSYM.IJPSYM_373_18   Background: The Section 84 of the Indian Penal Code (IPC) describes how Indian courts have to deal with 'the act of an unsound person'. This study was undertaken with the objectives of estimating the success rate of insanity pleas in Indian High Courts and determining the factors associated with the outcome of such insanity pleas. Materials and Methods: The data was collected from the websites of 23 High Courts of India using the keywords 'insanity' and 'mental illness', and the judgments delivered between 1.1.2007 and 31.08.17 were retrieved. Information regarding the nature of the crime, diagnosis provided by the psychiatrist as an expert witness, documents used to prove mental illness, and the judgment pronounced by the High Court were retrieved. Results: A total of 102 cases were retrieved from 13 High Courts for which data was available. Out of the 102 cases examined, the High Court convicted the accused in 76 cases (74.50%), thereby rejecting the insanity defense. The High Court acquitted the accused under section 84 IPC in 18 cases (17.65%), thereby accepting the insanity plea raised by the accused. Chi-square tests of independence revealed that the verdict of the lower court, documentary evidence of mental illness prior to the crime, and the psychiatrist's opinion were associated with the success of insanity pleas. Conclusion: Insanity pleas had a success rate of about 17% in Indian High Courts in the past decade. The factors associated with success of insanity pleas provide valuable guidance to several stakeholders who are dealing with mentally ill offenders.
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	Does sociodemographic background determine the responses to ethical dilemma vignettes among patients?	p. 155
	Snehil Gupta, Siddharth Sarkar, Vaibhav Patil, Bichitrananda Patra DOI:10.4103/IJPSYM.IJPSYM_110_18   Background and Aims: Patients are important stakeholders in the care process and may have different viewpoints on clinical disclosure, which may be influenced by their sociodemographic and cultural background. Hence, the aim of this study was to assess whether age, gender, employment status, educational status, and other sociodemographic variables of persons with mental illness influence their views about ethical issues in clinical care. Materials and Methods: The study was conducted at the Outpatient Department of a tertiary care mental health/de-addiction center in North India. Patients aged ≥18 years and currently in remission of their primary psychiatric illness were included. Using case vignettes, their responses to ethical issues related to clinical situations were assessed. Results: The study included a total of 160 participants. The younger age group less frequently agreed on disclosure of a man's Human Immunodeficiency Virus-positive status to other family members against his wishes. Women less frequently agreed on disclosure of marital strife to husbands' parents. Higher educational status was associated with a less frequent agreement to disclosure of a man's suicidal ideas to other family members, and those currently employed less frequently agreed to disclosure of marital strife of a female patient to her parents. Conclusion: Age, gender, education, and employment status might influence some of the responses to ethical dilemmas in the clinical setting. These factors may be considered while clinical decision-making faces ethical challenges.
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	Geographical and temporal variation of suicide in India, 2006–2015: An investigation of factors associated with suicide risk difference across states/union territories	p. 160
	Parthasarathy Ramamurthy, Pradeep Thilakan DOI:10.4103/IJPSYM.IJPSYM_569_17   Background: In India, about 130,000 people died by suicide in the year 2015. It is important to understand the variation of suicide across different parts of India and the trend of suicide rates over the years. The objectives of this study were to determine whether suicide rates in India showed temporal variation in the last decade and to determine whether suicide rates in India showed geographical variation across different states and union territories (UTs). Methods: Data on suicide rates for the years 2006–2015 were collected from the official publication of the National Crime Records Bureau. This study looked for time trend in suicide rates over the years. Further, the variation in suicide rates across different states/UTs in India and the factors associated with the variation were also analyzed. Results: The average suicide rate in India for the years 2006–2015 was 10.9/100,000 population. Overall, there was no significant variation in the suicide rate over time in the years studied. The average suicide rate varied widely across the states and UTs, between 0.91 and 43.92 per 100,000 population. The analysis revealed a positive association between suicide rates and accident rates for the above years. In addition, for the year 2011, a positive association between suicide rate and per capita state domestic product was noted. Conclusion: There was no variation in the suicide rate in India over time. However, there were significant regional differences. Reporting differences and economic factors could partially explain the differences.
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	Utilization of emergency psychiatry service in a tertiary care centre in north eastern India: A retrospective study	p. 167
	Subrata Naskar, Kamal Nath, Robin Victor, Kaveri Saxena DOI:10.4103/IJPSYM.IJPSYM_55_18   Background: In a developing country like India, with a lot of psychosocial stressors and ample stigma toward psychiatry, we studied the sociodemographic pattern of the patients coming to a tertiary care center for emergency psychiatry services and also evaluated the types and pattern of emergency services provided to them. We also assessed the predominant presenting complaints with which patients presented at the emergency department, "reasons for referral" in an emergency by other departments, and types of psychiatric diagnoses in the patients. Subjects and Methods: Data were extracted retrospectively from the general emergency and psychiatry emergency register of Silchar Medical College and Hospital for 1 year and analyzed. Results: Out of 41,040 patients attending the hospital seeking emergency care, referral rate to the psychiatric emergency was only 2.8%. The commonest presenting complaint of subjects who were referred was "medically unexplained somatic complaints" (47.70%). The main reason for a referral from other departments was "no physical illness was detected" in the patient (38.59%). About 78.8% of the subjects were diagnosed as having a proper psychiatric illness, with the majority presenting with stress-related and somatoform disorders (F40–49) (43.45%). Conclusion: This study highlights various important parameters regarding emergency services being provided and their utilization by the patients attending a psychiatric emergency, which could be helpful for future policies and resource allocation for providing superior quality and cost-effective mental health care to the patients.
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	Perceived stigma regarding mental illnesses among rural adults in Vellore, Tamil Nadu, South India	p. 173
	Apoorva Guttikonda, Aleena M Shajan, Adeline Hephzibah, Akhila S Jones, Jerlyn Susanna, Sunil Neethu, Sharon Poornima, Sarah M Jala, D Arputharaj, David John, Nehemiah Natta, Dolorosa Fernandes, Shalini Jeyapaul, Dimple Jamkhandi, H Ramamurthy Prashanth, Anu M Oommen DOI:10.4103/IJPSYM.IJPSYM_297_18   Background: Stigma is an important factor that determines whether individuals seek treatment for mental illnesses. Studies assessing public perceptions regarding mental illnesses are scarce in India. This study documents the stigma perceived by a rural population toward patients with mental illness and their families. Materials and Methods: A cross-sectional pilot study was done in five villages, selected by simple random sampling, from a rural block in Vellore, Tamil Nadu. Households in each village were selected by systematic random sampling. From the selected households, 150 subjects aged 18–65 years, without known mental disorders, were chosen by convenience sampling, based on availability. Stigma was assessed using the Devaluation of Consumers Scale (DCS) and Devaluation of Consumer's Families Scale (DCFS). Results: The proportion with high perceptions of stigma associated with mentally ill persons was 63.8%, among the 150 interviewed rural respondents (women: 112, median age: 37 years). The proportion which perceived that there was public stigma toward families of those with mental illnesses was 43.4%. Older respondents (>37 years) had higher perceptions of stigma (odds ratio: 2.07; 95% confidence interval: 1.02–4.20) than others. Conclusion: The high perception of stigma associated with persons who are mentally ill as well as their families needs to be kept in mind while planning interventions to decrease the treatment gap for psychiatric morbidity, especially in rural areas.
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BRIEF RESEARCH COMMUNICATION
	Hypochondriasis: Clinical profile in a tertiary care psychiatry and neurosciences hospital in Southern India – A retrospective chart review	p. 178
	N Pavithra, Ajit Bhalchandra Dahale, Geetha Desai, Santosh Kumar Chaturvedi DOI:10.4103/IJPSYM.IJPSYM_177_18   Background: Hypochondriasis is a complex disorder in the realm of psychosomatic medicine, yet understudied in India. The aim of this study was to assess the clinical profile of patients diagnosed with hypochondriasis. Materials and Methods: Retrospective chart review was done in a tertiary care psychiatry and neurosciences hospital in southern India. Medical records of adults diagnosed with hypochondriasis between 2000 and 2010 were analyzed. These patients were also rediagnosed retrospectively using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for illness anxiety disorder (IAD) and Diagnostic Criteria for Psychosomatic Research (DCPR) criteria for health anxiety and illness phobia. Data were organized and analyzed using PSPP for descriptive statistics of different variables. Results: There were 114 patients with hypochondriasis, with the most common belief being about dysmorphic appearance. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed medications. The median follow-up duration was only 2 months. Five percent of the cases fulfilled the criteria for DCPR health anxiety and 20.4% for DCPR illness phobia. DSM-5 criteria for IAD were fulfilled by 45.6% of the cases. Conclusion: Dysmorphic appearance was the most common concern in patients with hypochondriasis and SSRIs the most common medications. The follow-up rate and the diagnostic concurrence with DSM-5 IAD and DCPR were low. Studies assessing the influence of psychopathology and culture on the presentation, course, and prognosis of hypochondriasis would be beneficial.
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LETTERS TO EDITOR
	Binge-watching: A matter of concern?	p. 182
	S Umesh, Swarnali Bose DOI:10.4103/IJPSYM.IJPSYM_279_18
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	Creutzfeldt–Jacob disease with psychiatric presentation: Hen's teeth in Indian subcontinent: A case report	p. 184
	Gurmukh Singh, Shivangi Mehta, Mitesh Kumar, Alisha Salhotra DOI:10.4103/IJPSYM.IJPSYM_102_18
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	Atypical limbic encephalitis and its complex psychiatric presentations: Implications for diagnosis and management	p. 187
	Ashvini Vengadavaradan, Karthick Subramanian, Ravi Philip Rajkumar DOI:10.4103/IJPSYM.IJPSYM_233_18
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	Mirtazapine induced tremors: A case report	p. 190
	NA Uvais, VS Sreeraj, P Shihabudheen, TP Mohammed DOI:10.4103/IJPSYM.IJPSYM_436_18
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	Lurasidone-induced parkinsonism and hyperprolactinemia	p. 192
	Navratan Suthar, Jitender Aneja DOI:10.4103/IJPSYM.IJPSYM_274_18
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	Use of stimulants in patients with psychosis having past history of or co-occurring attention deficit hyperactivity disorder: Is it safe?	p. 195
	Sumedha Purkayastha, Vaibhav Patil, Anamika Sahu DOI:10.4103/IJPSYM.IJPSYM_262_18
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COMMENTS ON PUBLISHED ARTICLES
	Multiple testing and protection against Type I error using P value correction: Application in cross-sectional study designs	p. 197
	Vikas Menon DOI:10.4103/IJPSYM.IJPSYM_12_19
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	Author's response to 'Multiple Testing and Protection against Type I Error Using P Value Correction: Application in Cross-Sectional Study Designs'	p. 198
	Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_61_19
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	Comments on "Stressful Life Events and Relapse in Bipolar Affective Disorder"	p. 199
	Satish Suhas, Gurvinder Pal Singh, Naga V. S. S. Gorthi, Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_42_19
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LEARNING CURVE
	Describing research design	p. 201
	Chittaranjan Andrade DOI:10.4103/IJPSYM.IJPSYM_66_19   This article explains how the research design of a study can simultaneously be described in many different ways as nonempirical or empirical, case-based or sample-based, observational or interventional, retrospective or prospective, cross-sectional or longitudinal, uncontrolled or controlled, single arm or multiple arm, nonrandomized or randomized, crossover or parallel group, nonblind, single-blind, or double-blind, superiority or noninferiority, exploratory (hypothesis generating) or confirmatory (hypothesis driven), and many others. Some of these categories can be associated with special types of research design as well, such as cohort studies, case-control studies, nested case-control studies, wedge design studies, and so on. Readers should understand which descriptors are mutually exclusive and which are not.
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