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.

Protocol for the formative phase of a trial (SHE-CAN) to test co-designed implementation strategies for HPV-based cervical screening among vulnerable women in two diverse settings in India.

BACKGROUND: In view of the WHO's call for the elimination of cervical cancer as a public health problem, and current low screening coverage, Indian policy makers need evidence on how to effectively implement cervical screening programmes, ensuring equity in access. Our study will follow the INSPIRE implementation framework to co-design and test HPV-based screening approaches in two states of India with different health system organisation, based on understanding the status of screening as currently implemented, readiness and challenges to transition to HPV-based screening, and preferences of key stakeholders. Here, we describe our protocol for the formative phase of the study (SHE-CAN). METHODS: The study population includes women from vulnerable populations, defined as residents of tribal areas, rural villages, and urban slums, in the states of Mizoram and Tamil Nadu. The baseline assessment will use mixed methods research, with desktop reviews, qualitative studies, and surveys. A capacity assessment survey of screening and treatment facilities will be done, followed by interviews with healthcare providers, programme managers, and community health workers. Interviews will be conducted with previously screened women and focus group discussions with under and never-screened women and community members. Stakeholder workshops will be held in each state to co-design the approaches to delivering HPV-based screening among 30-49-year-old women. DISCUSSION: The quality and outcomes of existing screening services, readiness to transition to HPV-based screening, challenges in providing and participating in the cervical cancer care continuum, and acceptability of screening and treatment approaches will be examined. The knowledge gained about the current system, as well as recognition of actions to be taken, will inform a stakeholder workshop to co-design and evaluate implementation approaches for HPV-based screening through a cluster randomised implementation trial.

Lateral Anal Sphincterotomy for Chronic Anal Fissures- A Comparison of Outcomes and Complications under Local Anaesthesia Versus Spinal Anaesthesia.

INTRODUCTION: Fissure-in-Ano is one of the common and most painful anorectal conditions encountered in surgical practice. Inspite of several conservative treatment options, surgical treatment in the form of Lateral Anal Spincterotomy (LAS) remains the gold standard of treatment for Chronic Anal Fissures (CAF). However, LAS is often done under spinal or general anaesthesia incurring huge treatment costs and hospital stay. AIM: To study if LAS can be treated with Local Anaesthesia (LA) thereby, reducing the costs and the anaesthetic risk to patients with no significant change in the surgical ease or clinical outcome. MATERIALS AND METHODS: A total of 79 patients with chronic fissure underwent randomized allocation to two treatment arms - The first to undergo LAS under LA and the second under Spinal Anaesthesia (SA). The primary outcome variables studied were complications like post-operative pain, infections, healing rate of fissure and incontinence rates. Secondary outcome variables studied were cost, hospital stay and need for additional anaesthetic. RESULTS: A total of 79 patients underwent LAS procedure. A total of 42 patients had LA and 39 patients had SA. There was no statistically significant difference in the healing rate, pain, infection and incontinence rates between the two groups. Moreover, the LA group incurred lower cost, reduced hospital stay and reduced risk of anaesthesia. CONCLUSIONS: LAS can be satisfactorily performed under local anaesthesia with no increased risk of pain or complications, and is best suited for resource-poor surgical settings.

The Tribal Health Initiative model for healthcare delivery: a clinical and epidemiological approach.

BACKGROUND: Tribal populations generally have poor health outcomes, often because of a healthcare delivery system that does not cater to their needs. This study evaluates a current healthcare model for tribals, and explores it in combination with the health status of the target population, placing emphasis on the long term sustainability and cross-implementation of the model. METHODS: We examined the health system from the perspective of the base hospital, by concentrating on mortality patterns, inpatient incidence of selected infectious and non-infectious illnesses, and the preventive and curative health services administered by the hospital to the community. RESULTS: Gender susceptibility patterns revealed disparities in anaemia and tuberculosis besides fluctuations in gastrointestinal disorders, tuberculosis and typhoid. A combination of gender- and age-susceptibility patterns revealed specific age intervals for mental health-related disorders. Mortality patterns indicated an Increase in youth deaths and suicide, with an overall reduction in infant mortality. However, an increased tribal confidence in allopathic medicine was noted after implementation of the health system. CONCLUSION: The base tribal hospital is important in administering primary and secondary healthcare, health education, disease surveillance, community outreach and for continued confidence in allopathic medicine. Diet-based morbidities may be combated via organic farming and banning local alcohol production, while anaemia may be combated through continued iron, salt and folic acid supplementation to women. The formulation of mental health programmes and long term educational initiatives at the village level are critical to reducing suicide and infant mortality. Further epidemiological studies are required to gain a complete picture of health within the population, and successful implementation of the model elsewhere must factor in sociocultural disparities among tribes.

A low-cost banding device for oesophageal varices using Foley catheters.

Our institution has devised a low cost method of banding oesophageal varices by loading cut Foley catheters on to a banding apparatus.