Resuming elective surgeries in Corona pandemic from the perspective of a developing country

Since the COVID-19 pandemic, healthcare facilities have entered into a “crisis mode”. One of the measures used to allow hospitals to surge their capacity and serve the patient population with COVID-19 infection was the suspension of elective activity, most importantly elective surgery and other procedures. Now as the infection is fading, efforts are being made to resume elective surgical services keeping in mind the safety of the patient and health care workers. Resuming surgical services in developing countries is an uphill task.

Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients’ demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.

Evaluation of Gasless Laparoscopy as a Tool for Minimal Access Surgery in Low- to Middle-Income Countries: A Phase II Non-Inferiority Randomized Controlled Study

Background: Minimal access surgery [MAS] is not available to most people in the rural areas of Low Middle-Income Countries [LMIC]. This leads to an increase in the morbidity and the economic loss to the poor and the marginalized. The Gasless laparoscopic surgeries [GAL] are possible in rural areas as they could be carried out under spinal-anaesthesia. In most cases, it does not require the logistics of providing gases for pneumoperitoneum and general anaesthesia. The current study compares GAL with conventional Laparoscopic surgeries [COL] for general surgical procedures METHODS: A single-centre, non-blinded randomized control trial [RCT] was conducted to evaluate non – inferiority of GAL versus COL at a teaching hospital in New Delhi. Patients were allocated into two groups and underwent MAS (Cholecystectomies and appendectomies). The procedure was carried out by two surgeons by randomly choosing between GAL and COL. The data was collected by postgraduates and analyzed by a biostatistician.

Results: 100 patients who met the inclusion criteria were allocated into two groups. No significant difference was observed in the mean operating time between GAL group (52.9 min) vs COL group (55 minutes) [p=0.3]. The intraoperative vital signs were better in the GAL group [p < 0.05]. The postoperative pain score was slightly higher in the GAL group [p = 0.01]; however, it did not require additional analgesics. Conclusions: No significant differences were found between the two groups. GAL can be classed as non-inferior compared to COL and has the potential to be adopted in low resource settings.

Systematic review of barriers to, and facilitators of, the provision of high‐quality midwifery services in India

Background
The Indian government has committed to implementing high‐quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high‐quality midwifery care in India.

Methods
We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high‐quality midwifery care in India.

Results
Thirty‐two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands‐on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women’s experiences of maternity care, and improving health system infrastructure.

Conclusions
The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India’s plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Assessment of Eustachian Tube Functioning Following Surgical Intervention of Oral Submucus Fibrosis by Using Tympanometry & Audiometry

Oral Submucus fibrosis has been reported to cause variation in hearing sensitivity & changes in middle ear function. This study was conducted to validate the influence of OSMF and its surgical correction on middle ear function and hearing sensitivity. In this study, 20 patients (40 ears) suffering from biopsy proven OSMF (Group 2 & 3) were tested for Middle ear dysfunction and hearing sensitivity using Tympanometry & Audiometry. On Tympanometry, Type A curve was obtained in 29 ears, Type B curve in 11 ears preoperatively. Immediate postoperatively TYPE A curve was obtained in 27 ears, TYPE B curve in 13 ears. After 1 month and 3 month Type B curve was not obtained in any ear. On Audiometry,28 ears showed normal hearing and 12 ears showed minimal conductive hearing loss preoperatively and Immediate postoperatively. Tests after 1 month and 3 months showed all 40 ears having normal hearing. Results were found statistically significant with p value 0.000 and F value of 11.331 in Tympanometry and 11.143 in Audiometry. Pearson correlation test revealed that results from both the test are highly co related (0.902). OSMF causes fibrotic changes in paratubal muscles which in addition with restricted mouth opening hampers proper Eustachian tube functioning in turn causing changes in Middle ear function. This feature is seldom/infrequently found in Group 2 and 3 and if encountered can be dealt effectively with surgical intervention.

The Impact of Cleft Lip/Palate and Surgical Intervention on Adolescent Life Outcomes: Evidence from Operation Smile in India

Cleft Lip/Palate (CLP) is a congenital orofacial anomaly appearing in approximately one in 700 births worldwide. While in high-income countries CLP is normally addressed surgically during infancy, in developing countries CLP is often left unoperated, potentially impacting multiple dimensions of life quality. Previous research has frequently compared CLP outcomes to those of the general population. But because local environmental and genetic factors both contribute to the risk of CLP and also may influence life outcomes, such studies may present a downward bias in estimates of both CLP status and restorative surgery. Working with the non- profit organization Operation Smile, this research uses quasi-experimental causal methods on a novel data set of 1,118 Indian children to study the impact of CLP status and CLP correction on the physical, psychological, and social well-being of Indian teenagers. Our results indicate that adolescents with median-level CLP severity show statistically significant losses in indices of speech quality (-1.55), academic and cognitive ability (-0.43), physical well-being (-0.35), psychological well-being (-0.23), and social inclusion (-0.35). We find that CLP surgery improves speech if carried out at an early age, and that it significantly restores social inclusion.

Uro-oncology in Times of COVID-19: The Available Evidence and Recommendations in the Indian Scenario

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.

All India Ophthalmological Society – Oculoplastics Association of India Consensus Statement on Preferred Practices in Oculoplasty and Lacrimal Surgery During the COVID-19 Pandemic

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.

Resurgence of “Bow and Arrow” Related Ocular Trauma: Collateral Damage Arising From COVID-19 Lockdown in India?

Penetrating ocular trauma in children often presents late and may be associated with complications due to delayed presentation as children are not always able to verbalize their injuries. Previous studies have shown that children aged 5 and above were more frequently affected and it was also noted that boys were more frequently affected than girls. Children involved in unsupervised games often get injured and “bow and arrow” injuries were known to be a fairly common cause of penetrating trauma in children, in the past.

COVID 19 and Laparoscopic Surgeons, the Indian Scenario – Perspective

Coronavirus Disease 2019(COVID 19) had emerged as a global pandemic in recent times. The healthcare sector is at the epicentre of this unprecedented global pandemic challenge. Hospitals all over the world have reduced the number of non-emergency surgeries in order to utilize the staff and resources in a more efficient way. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is most transmitted via respiratory droplets, but risk of transmission is hugely increased while doing aerosol generating procedures (AGPs). Laparoscopy remains the preferred surgical approach for most surgical indications. There is theoretical possibility of generation of aerosols contaminated with COVID-19 from leaked CO2 and smoke generation after energy device use. The aim of this paper is to review available evidence evaluating the risk of spread of COVID-19 during necessary laparoscopic procedures and to compile guidelines from relevant professional organizations to minimize this risk.