Road Traffic Accident Research in India: A Scientometric Study from 1977 to 2020

This study carried out the scientometric analysis of road traffic accident research in India from 1977 to 2020. It aimed to examine type of publications with their citations and usage, the year wise publication and citation growth, most preferred journals, authors’ preference of keywords used, collaboration of Indian authors, authorship pattern and most prolific authors, and top contributing organizations. During 44 years of study, 1,132 research items were published and indexed in Web of Science (WoS) bibliographic database. Analysis discovered that number of publications increased from one (0.08%) in 1977 to 182 (16.07%) in 2018 and observed good progress in scholarly literature.

Majority of scholarly publications were published in the form of article (740, 65.37%). From 2006 to 2018, number of publications increased rapidly from 11 (0.97%) to 182 (16.07%) publications, which was the most productive year for the researchers. On an average 25.73 documents were published per year and received 392.95 citations per year. Journal of Evaluation of Medical and Dental Sciences published majority of the publications (108, 30.50%). The word “Trauma” was the most frequently used keyword. Majority of publications (83.38%) on road traffic accidents (RTA) were written by the Indian authors individually or with local collaboration. Majority of the publications (1,081, 95.49%) were written by multiple authors while 51 publications (4.51%) were from single author. Most prolific authors were Tiwari, G. and Mohan, D. with 18 publications each. The Indian Institute of Technology was highly contributing organization, which published 120 documents (10.60%).

Continuing Education for Prehospital Healthcare Providers in India – A Novel Course and Concept

Background
Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public–private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India.

Methods
From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide).

Lessons Learned
During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials.

Conclusion
These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

Towards a framework approach to integrating pathways for infection prevention and antibiotic stewardship in surgery: a qualitative study from India and South Africa

Background The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC). We investigated the drivers for surgical AMS and IPC, across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams in two academic hospitals in South Africa (SA) and India. Materials and methods An ethnographic observational study of IPC and AMS was conducted (July 2018–August 2019), with data gathered from 190 hours of non-participant observations (138 India, 60 SA); face-to-face interviews with patients (6 India, 7 South Africa), and healthcare professionals (HCPs) (44 India, 61 SA); and, in-depth patient case studies (4 India, 2 SA). A grounded theory approach aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of moving between the coded data and the higher-level themes, ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of findings. Results Across surgical pathways, multiple barriers exist impeding effective IPC and AMS practices. The existing, implicit roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating care across the surgical team members. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Conclusions IPC and AMS are not integrated in surgery. Identifying the implicit existing HCPs roles in IPC and AMS is critical and will facilitate the development of effective and transparent processes across the surgical team for IPC and AMS. Developing a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care.

Palliative surgery in gastrointestinal malignancy: experience from a regional cancer centre

Background: With so much burden of advanced incurable disease, the role of palliative surgery is paramount for gastrointestinal malignancies improving quality of life. Aim of the study was to study the indications, risks and outcome of palliative surgeries in gastrointestinal malignancies, the burden of disease requiring palliative surgery, and to describe strategies to improve end of life care.

Methods: All the patients diagnosed with gastrointestinal malignancy and who underwent palliative surgery between January 2017 and December 2017 were analysed.

Results: A total of 186 cases underwent palliative surgery. The most common age group affected was between 50-60 years and the mean age was 54.55 years. Stomach was the most common primary consisting of 58.60% followed by colorectal (23.66%), small intestine (9.68%), hepato-pacreatico-billiary (4.30%), and oesophageal (3.76%) primary. Major complications were seen in 4.84% of cases. Average symptomatic relief was observed for 5.5 months in cases of stomach and 7 months in case of colorectal malignancies. 35.48% cases were alive at the end of one year.

Conclusions: Present study concludes that palliative surgery improves quality of life of the patient, provides them with time to accept death and live rest of the life in a dignified manner.

Evaluation of Portable Tablet-Based Audiometry in a South Indian Population

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear–Nose–Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5–18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80–94%) and 70% (95% CI 56–82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.

Estimation of the National Surgical Needs in India by Enumerating the Surgical Procedures in an Urban Community Under Universal Health Coverage

Background
11% of the global burden of disease requires surgical care or anaesthesia management or both. Some studies have estimated this burden to be as high as 30%. The Lancet Commission for Global Surgery (LCoGS) estimated that 5000 surgeries are required to meet the surgical burden of disease for 100,000 people in LMICs. Studies from LMICs, estimating surgical burden based on enumeration of surgeries, are sparse.

Method
We performed this study in an urban population availing employees’ heath scheme in Mumbai, India. Surgical procedures performed in 2017 and 2018, under this free and equitable health scheme, were enumerated. We estimated the surgical needs for national population, based on age and sex distribution of surgeries and age standardization from our cohort.

Result
A total of 4642 surgeries were performed per year for a population of 88,273. Cataract (22.8%), Caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries. We estimated 3646 surgeries would be required per 100,000 Indian population per year. One-third of these surgeries would be needed for the age group 30–49 years, in the Indian population.

Conclusion
A total of 3646 surgeries were estimated annually to meet the surgical needs of Indian population as compared to the global estimate of 5000 surgeries per 100,000 people. Caesarean section, cataract, surgeries for fractures and hernia are the major contributors to the surgical needs. More enumeration-based studies are needed for better estimates from rural as well as other urban areas.

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.