When to Discharge a Patient After Endoscopy: A Narrative Review.

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Primary eosinophilic gastroenteritis: A case series from western India.

Primary eosinophilic gastroenteritis is a rare inflammatory disorder of gastrointestinal tract characterized by symptoms like abdominal pain, diarrhea, vomiting, weight loss, and eosinophilic infiltration of the intestinal wall with or without peripheral eosinophilia. We found four cases with different causes of eosinophilic enteritis with varying manifestations ranging from chronic diarrhea with malabsorption, dysphagia, and gastric outlet obstruction due to mass-like lesions.

Lactate-free AARC ACLF Score (LaFAS) - A Simple Userfriendly Score is the Best Prognostic Marker for Patients with Alcohol Induced ACLF in Western Indian Population in a Nontransplant Resource-limited Setting.

INTRODUCTION: Acute-on-Chronic liver failure (ACLF) is a disease with a distinct spectrum of liver injury, with a rapid downhill course Here we describe three new scores - Albumin Bilirubin Index (ALBI), platelet albumin bilirubin index (PALBI) and Lactate-free AARC ACLF score(LaFAS), in predicting short-term mortality in patients with alcohol induced ACLF when compared to standard validated scores. METHODS: Consecutive patients diagnosed as alcohol induced ACLF as per the APASL 2014 definition were included in the study. Standard scores - MELD, MELD-Na, Maddreys' discriminant function, CLIF-OF and CLIF-C ACLF scores, APACHE II, ALBI, PALBI and LaFAS were calculated. The endpoints of the study were to predict short term mortality in alcohol induced ACLF patients using ALBI, PALBI and LaFAS and finding the cut-offs of these new scores and comparing it with standard validated scores. RESULTS: 67 patients were studied with 97% being male. Mean age was 45.78 + 8.15 years.44 patients died. The cut-offs, area under the ROC curve; sensitivity and specificity, positive and negative predictive values of the new prognostication scores were, respectively: ALBI (-0.57; 0.948; 90.9% and 82.6%; 77.69% and 93.15%),LaFAS(7; 0.968; 95.5% and 96.7%; 95.075 and 96.99%), PALBI(-0.28; 0.59; 61.4% and 52.2%; 46.13% and 66.98%). LaFAS and ALBI outnumbered the valid prognostic scores in predicting short-term mortality. PALBI underperformed when compared to all other scores. CONCLUSION: Thus incorporating albumin and bilirubin in a mathematical equation (for ALBI) or combining it with creatinine and grade of hepatic encephalopathy (for LaFAS) would help in prognosticate the patients with ACLF on admission in a resource limited setting thus enabling them to be transferred to a transplant center.

Restructuring the Modified Faine's Criteria for the Diagnosis of Leptospirosis in Monsoon: A Study from South Gujarat.

CONTEXT: Clinical and epidemiological variables in the modified Faine's criteria offered low validity in our study setting. AIMS: Restructuring and validating modified Faine's criteria for leptospirosis to better suit health scenario of south Gujarat. SUBJECTS AND METHODS: Clinical, epidemiological, and laboratory features of derivation cohort (1216 suspected leptospirosis cases) admitted at a tertiary care hospital of south Gujarat (2007-2015) that significantly correlated with confirmed leptospirosis were used in binary logistic regression to derive scoring models and receiver operating characteristic to determine cutoff values. Validity and net reclassification improvement (NRI) were estimated in validation cohort (82 cases, 2016-2017) and algorithm for diagnosis was prepared. RESULTS: Screening model consisted of the presence of conjunctival suffusion, calf tenderness, raised serum creatinine, headache with conjunctival suffusion and/or jaundice, and dyspnea/meningism. Area under curve (AUC) for screening model was 0.590 (standard error [SE] ±0.017) and cutoff score ≥9 gave sensitivity 79.16%, specificity 50%. The confirmatory model consisted of laboratory parameters, namely polymerase chain reaction, immunoglobulin M ELISA, and microscopic agglutination test and gave AUC 0.998 (SE ± 0.001), sensitivity 89.58%, specificity 85.29%, positive predictive value 89.58%, and negative predictive value 85.29% at cutoff score ≥100. Net sensitivity of algorithm was 98.27% at the point of screening (screening model and rapid test) and net specificity 87.89% at the point of confirmation (screening followed by confirmatory model) in validation cohort. CONCLUSIONS: Simultaneous use of screening model and rapid test gave NRI 81.25% and sequential use of confirmatory test gave NRI 47.18% compared to corresponding parts of the modified Faine's criteria.

"My Life is Spoiled Because of Him " A Qualitative Study of Human Immunodeficiency Virus Disclosure and Male Involvement in Prevention of Mother-to-Child Transmission Program.

BACKGROUND: India has the third largest human immunodeficiency virus (HIV) epidemic in the world, with 15,000 newborns infected every year. Prevention of mother-to-child transmission (PMTCT) services can eliminate new HIV infections. Nondisclosure of positive HIV status and nonoptimal uptake of PMTCT are related. Therefore, understanding different aspects of HIV disclosure are necessary for program managers and careproviders for prevention and support. OBJECTIVE: The present research explores HIV disclosure narratives, the family's perspective, and theoretical framework in the context of PMTCT. METHODS: A qualitative study was conducted among 31 (16 mothers and 15 fathers) utilizers of PMTCT at an urban antiretroviral therapy center. A semi-structured in-depth interview guide based on disclosure process model (DPM) was used to explore HIV disclosure goals and outcomes by both members of parental dyad. The recorded interviews were transcribed verbatim, translated into English, and analyzed with Atlas.ti software. Directed content analysis was used to code data according to "a priori" and emerging themes. Demographic data were analyzed using descriptive statistics. RESULTS: Limited disclosure is a necessity for pregnant women and their male partners for approach coping with HIV diagnosis and pursuing positive support for PMTCT adherence. Interpersonal, society, and community contextual outcomes affect the care uptake and future likelihood of disclosure. CONCLUSIONS: DPM suggestions from the present study can be used to facilitate a goal-directed process that allows parents/PLWHA to selectively disclose their HIV status to family members and acquaintances for obtaining maximum support to eliminate newborn HIV infections while minimizing distress, stigma, and discrimination.

"HIV is not an easily acceptable disease": the role of HIV-related stigma in obtaining cervical cancer screening in India.

Women living with HIV (WLWH) are at high risk for cervical cancer (CC); however, many WLWH in India do not obtain regular CC screening. Little is known about facilitators and barriers of CC screening in this population. This qualitative study examined the relation of HIV-related stigma to obtaining CC screening among women in Surat, India. Semi-structured individual in-depth interviews were conducted between April 2015 and July 2015 with 25 WLWH at the New Civil Hospital Anti-Retroviral Centre and 15 stakeholders providing health care to WLWH. HIV-related stigma emerged as a considerable barrier to gynecologic care and CC screening among WLWH. Two major subthemes were identified: (1) perceptions of HIV-related normative stigma and enacted discrimination; and (2) HIV status disclosure in the context of health care and CC screening. Stakeholders described a general awareness of HIV-related stigma as a barrier to care for WLWH, while WLWH focused on experiences of enacted discrimination. Both patients and stakeholders described that concerns about disclosure and fear of stigma hinder WLWH in India from obtaining health care and CC screening. Findings suggest that interventions to increase cancer screening among WLWH in India should address the role of HIV-related stigma to be maximally effective.

"My husband says this: If you are alive, you can be someone ": Facilitators and barriers to cervical cancer screening among women living with HIV in India.

PURPOSE: Women living with human immunodeficiency virus (WLWH) have a higher risk of cervical cancer than women without HIV. In addition, women in India experience a high burden of death from cervical cancer. This qualitative study evaluated individual and interpersonal factors influencing cervical cancer screening among WLWH in Surat, India. METHODS: In-depth interviews were conducted with 25 WLWH and 15 stakeholders in Surat, India. Data were analyzed using directed content analysis to identify individual and intrapersonal barriers and facilitators. RESULTS: WLWH lacked knowledge and reported being afraid of cervical cancer and cervical cancer screening but were interested in learning more about it. Interpersonal factors influencing cervical cancer screening included receipt or lack of instrumental and emotional family support, interactions with healthcare providers, and receipt or lack of information about cervical cancer and the Pap test from healthcare providers. CONCLUSION: Widespread public education is necessary to increase awareness of cervical cancer and cervical cancer screening and to encourage family members to support women who wish to obtain screening. Patient- and provider-focused interventions may facilitate the process of providing cervical cancer care to WLWH who are obtaining care in busy public healthcare systems in India.

Development of the Sexually Transmitted Infection Service Evaluation Tool: Use of Delphi Approach.

BACKGROUND: With the wide variation in sexually transmitted infection (STI) services, it is a challenge to devise strategies for ensuring effective service delivery. The objectives of this study were to develop a standard tool for STI services evaluation and use the Delphi method to derive a weighted factor for each parameter of the tool. METHODS: A review of existing guidelines for quality care STI services were conducted, and parameters were selected to form the content of the measurement tool. Delphi technique was used to derive weighted factor for each STI service delivery parameter by using the Likert scale of 0-7. A heterogeneous group of 18 anonymous experts was invited to rate the parameters. All the responses were collected online. Cronbach's alpha level ≥0.8 was selected to define consensus the experts. RESULTS: The STI service evaluation tool (SSET) was created including ten parameters to evaluate the performance of clinic with the help of standard National guidelines. The SSET was standardized by deriving weighted factor for each evaluation parameter. Three rounds of Delphi were required to achieve consistency. Response rates for each Delphi round were 77.78%, 100%, and 78.57%, respectively. Each parameter, such as workforce, materials, consumables, consultation, counseling, coverage, referral, records, information education and communication, and supervision, was assigned weighted factor derived by converting the final score into the total standard score of 100. CONCLUSION: The Delphi method represents a novel approach to develop standardized tools to evaluate the performance of service delivery.

Developing Domains to Assess Understanding Regarding Sexually Transmitted Infections among Sexually Transmitted Infection Clinic Attendees: A Qualitative Study.

OBJECTIVE: To develop and validate domains to assess attendee's gain at sexually transmitted infection (STI) clinic and their understanding after utilizing services at STI Clinic. METHODS: Study was done in two phases. In-depth interviews were conducted to explore attendee's perception. Domains generated through the first phase were validated by conducting another 50 structured interviews. RESULTS: Major domains developed were perceptions on STI, the source of information, treatment seeking behavior, understanding of treatment, laboratory test, and follow-up. Friends and counselor played an important role as the source of right information, while elder family female played a role in delayed seeking care. CONCLUSION: Developed domains can be used to assess STI clinic attendee's perspective on STI. Poor understanding of STI care component especially prevention, partner treatment, and referral was noted after the clinic visit.

Outcomes of Short Segment Posterior Instrumentation in Unstable Thoracolumbar Fractures.

INTRODUCTION: The spinal traumas are common and leading problem in orthopaedics practice. The individuals are at a risk of high energy trauma in modern era. Unstable thoracolumbar burst fractures are serious injuries of concern, if left untreated may result in marked morbidity and disability to the patient. Thoracolumbar is the second most common segment involved in the spinal cord following spinal injuries followed by cervical segment. The goal of treatment of any spinal injury is restoration of the patient to maximum possible function with disability free life. AIM: To analyse the outcomes of unstable thoracolumbar burst fractures stabilized with short segment posterior instrumentation with transpedicular screws. MATERIALS AND METHODS: This prospective interventional study consisted of 32 patients with unstable thoracolumbar burst fractures carried out at Department of Orthopaedics, New Civil Hospital, Surat during Jan 2014 to Dec 2015. We stabilized the patients with unstable thoracolumbar spinal fractures with short segment posterior instrumentation by using the intermediate screw option in the fractured vertebra level as a method of augmentation. Patients were evaluated for maintenance of spinal correction and neurological improvement after short segment posterior instrumentation in unstable thoracolumbar burst fractures. RESULTS: The mean age for males was 35.57 ± 11.62 years and for females was 33.56 ± 11.2 years. The most common vertebra involved in the study group was T12 (31.25%). In the study, about 66% patients had a fall from height as the mode of injury, whereas 34% injuries were due to road traffic accident. In the study group, the mean regional angle observed during pre-operative stages was 16.0°±5.1°. There was a statistically significant (p<0.05) difference between pre-op and post-operative regional angles as well as anterior wedge angles. There was a statistically significant difference (p<0.05) in the vertebral height between pre-operative and post-operative stages. CONCLUSION: Short segment posterior instrumentation is a very stable implant construct in maintenance of deformity correction and fracture reduction along with the added advantage of sparing of the motion segments.

Domestic environment and morbidity of under five children.

Healthy environment for children initiating an alliance for action (WHO) has reported that over 40% of the global burden of disease attributed to environmental risk factors fall on children below 5 years of age, who account for about 10% of the world's population. That is why to look into the new area of concern, this cross sectional study was carried out to explore the influence of domestic environment over the illness of under five children.