Burden & pattern of illnesses among the tribal communities in central India : A report from a community health programme.

Tribals are the most marginalised social category in the country and there is little and scattered information on the actual burden and pattern of illnesses they suffer from. This study provides information on burden and pattern of diseases among tribals, and whether these can be linked to their nutritional status, especially in particularly vulnerable tribal groups (PVTG) seen at a community health programme being run in the tribal areas of Chhattisgarh and Madhya Pradesh States of India. This community based programme, known as Jan Swasthya Sahyog (JSS) has been serving people in over 2500 villages in rural central India. It was found that the tribals had significantly higher proportion of all tuberculosis, sputum positive tuberculosis, severe hypertension, illnesses that require major surgery as a primary therapeutic intervention and cancers than non tribals. The proportions of people with rheumatic heart disease, sickle cell disease and epilepsy were not significantly different between different social groups. Nutritional levels of tribals were poor. Tribals in central India suffer a disproportionate burden of both communicable and non communicable diseases amidst worrisome levels of undernutrition. There is a need for universal health coverage with preferential care for the tribals, especially those belonging to the PVTG. Further, the high level of undernutrition demands a more augmented and universal Public Distribution System.

Synovial Chondromatosis in a Rural Healthcare Setting.

Synovial chondromatosis is a rare, benign, and metaplastic cause of joint swelling resulting in the formation of cartilaginous nodules in the joint space. It is usually an oligoarticular disorder of large joints that typically manifests in the third to fifth decade of life. Synovial chondromatosis can be primary or secondary depending on whether an underlying etiology can be identified. Diagnosis can be made using imaging studies of the affected joint and confirmed on histopathology. Management of synovial chondromatosis can be done arthroscopically or surgically. We present a case of a 23-year-old male who presented with a long history of right knee pain, swelling, and limitation in range of motion. An X-ray of the knee showed multiple intra-articular and soft tissue calcifications. Due to the limitations of our setting, we proceeded with an open biopsy. During arthrotomy, clear straw-colored fluid with multiple nodules of varied sizes was found. A google image search helped put us in the direction of the diagnosis of synovial chondromatosis. We did a complete evacuation of loose bodies and a biopsy of synovium, which confirmed the diagnosis. The rarity of synovial chondromatosis results in a delay in the diagnosis. With the thoughtful application of resources and surgical principles, synovial chondromatosis can be safely and effectively managed in resource-limited settings.

Exploring the perioperative infection control practices & incidence of surgical site infections in rural India.

BACKGROUND: Surgical site infections (SSIs) affect around a third of patients undergoing surgeries worldwide, annually. It is heterogeneously distributed with a higher burden in low and middle-income countries. Although rural and semi-urban hospitals cater to 60-70% of the Indian population, scarce data regarding SSI rates are available from such hospitals. The study aimed to determine the prevalent SSI prevention practices and existing SSI rates in the smaller rural and semi-urban hospitals in India. METHODS: This is a prospective study performed in two phases involving surgeons and their hospitals from Indian rural and semi-urban regions. In the first phase, a questionnaire was administered to surgeons enquiring into the perioperative SSI prevention practices and five interested hospitals were recruited for phase two which documented the rate of SSIs and factors affecting them. RESULTS: There was full compliance towards appropriate perioperative sterilisation practices and postoperative mop count practice at the represented hospitals. But prophylactic antimicrobials were continued in the postoperative period in more than 80% of the hospitals. The second phase of our study documented an overall SSI rate of 7.0%. The SSI rates were influenced by the surgical wound class with dirty wounds recording six times higher rate of infection than clean cases. CONCLUSIONS: SSI prevention practices and protocols were in place in all the less-resourced hospitals surveyed. The SSI rates are comparable or lower than other LMIC settings. However, this is accompanied by poor implementation of the antimicrobial stewardship guidelines.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis.

Introduction: The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals. Methods: Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children's Hospital's (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues. Results: Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios. Conclusion: An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Dentinogenic ghost cell tumor-a rare case report with review of literature.

Dentinogenic ghost cell tumors (DGCT) are very rare tumors considered as solid variants of calcifying epithelial odontogenic cysts (CEOC). They are locally invasive neoplasms and their main characteristic features are ameloblastoma like odontogenic epithelial proliferation, an aberrant keratinization in the form of ghost cells and dysplastic dentin. DGCT occur as two forms intraosseous (central) and extra osseous (peripheral), of which more aggressive intraosseous variety requires careful monitoring and aggressive local resection to prevent recurrence. This paper discusses a case of a 14-year-old male patient with a complaint of swelling in his right mandibular premolar molar region since 4 months and missing permanent right mandibular canine and first premolar was also observed. The lesion was diagnosed with radiological, cytological and histopathological investigations which revealed it to be rarest entity.

Access to safe blood in low-income and middle-income countries: lessons from India.

Timely, affordable access to screened blood is essential to the provision of safe surgical care and depends on three key aspects: adequate volume of blood supply, safe protocols for blood donation and transfusion, and appropriate regulation to ensure safe, equitable and sustainable distribution. Many low-income and middle-income countries experience a deficit in these categories, particularly in rural areas. We draw on the experience of rural surgical practitioners in India and summarise the existing literature to evaluate India's blood banking system and discuss its major barriers to the safe and equitable provision of blood. Many low-income and middle-income countries struggle with accruing a sufficient voluntary, unpaid blood donation base to meet the need. Efforts to increase blood supply through mandatory family replacement donations can lead to dangerous delays in care provision. Additionally, prohibition of unbanked, directed blood transfusion restricts the options of health practitioners, particularly in rural areas. Blood safety is also a significant concern, and efforts must be taken to decrease the risk of transfusion-transmitted infections and inform and treat donors who test positive. Lastly, blood banking systems need a centralised governing body to ensure fair prices for blood, promote comprehensive transfusion reporting and increase system-wide transparency and accountability.

Rural blood availability: regulations must meet ethics.

Rural physicians have been practising the technique of emergency bleeding and transfusion called Unbanked Directed (to a specific recipient) Blood Transfusion (UDBT), which has been declared illegal, to meet the need for blood in rural and inaccessible areas. As a result, a crisis has emerged in the availability of blood. Is UDBT a second rate technology for the poor and the disadvantaged? And should we not rather advocate for rapid scaling up of the establishment of blood banks in all areas? We examine the ethical issues related to blood availability in the rural areas. We argue that a regulated and licensed UDBT passes muster on the ethical principles of beneficence, lack of maleficence, justice and Swaraj. Using this issue as a case in point, we further examine the idea of what constitutes appropriate or acceptable technology. While affirming that any technology has to pass muster on a litmus test of acceptability, we discuss the difference between "ideal" and "acceptable" (but less than ideal) technology. We argue there is a dynamic push and pull between the urge to regulate and restrict the use of skills by all versus the need to communitise technology. Regulated use of UDBT will allow blood to be available where it is needed most in the foreseeable future in India.

Persistent Müllerian Duct Syndrome (PMDS): a Rare Anomaly the General Surgeon Must Know About.

Persistent Müllerian duct syndrome is a rare condition occasionally encountered in men with normal phenotype but with presence of Müllerian duct structures. In India, owing to neglect and lack of facilities, we encounter this condition in adult males. We encountered on the same day in the operation theatre two phenotypic males aged 40 years and 10 months who had inguinal hernia on one side along with contralateral undescended testis. Both patients intraoperatively had uterus with fallopian tubes and underwent subtotal hysterectomy with preservation of vas. Repair of inguinal hernia with fixation of the testis in the scrotum was done. Though rare, every surgeon operating upon inguinal hernia or undescended testes or cryptorchidism needs to know about the presence of the uterus in a phenotypic male patient at any age. High degree of suspicion and awareness is needed to diagnose this condition. Early treatment is needed to maintain fertility and to prevent the occurrence of malignancy in remnant müllerian structures.

Nutritional status of adult patients with pulmonary tuberculosis in rural central India and its association with mortality.

Under-nutrition is a known risk factor for TB and can adversely affect treatment outcomes. However, data from India are sparse, despite the high burden of TB as well as malnutrition in India. We assessed the nutritional status at the time of diagnosis and completion of therapy, and its association with deaths during TB treatment, in a consecutive cohort of 1695 adult patients with pulmonary tuberculosis in rural India during 2004 - 2009.Multivariable logistic regression was used to obtain adjusted estimates of the association of nutritional status with deaths during treatment. At the time of diagnosis, median BMI and body weights were 16.0 kg/m(2)and 42.1 kg in men, and 15.0 kg/m(2)and 34.1 kg in women, indicating that 80% of women and 67% of men had moderate to severe under-nutrition (BMI<17.0 kg/m(2)). Fifty two percent of the patients (57% of men and 48% of women) had stunting indicating chronic under-nutrition. Half of women and one third of men remained moderately to severely underweight at the end of treatment. 60 deaths occurred in 1179 patients (5%) in whom treatment was initiated. Severe under-nutrition at diagnosis was associated with a 2 fold higher risk of death. Overall, a majority of patients had evidence of chronic severe under-nutrition at diagnosis, which persisted even after successful treatment in a significant proportion of them. These findings suggest the need for nutritional support during treatment of pulmonary TB in this rural population.