Advancing pediatric perioperative care in India: A contemporary overview.

BACKGROUND: In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care. AIM: With this background, we aim to provide an overview of the present and future of healthcare in India. METHODOLOGY: With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable. RESULTS: With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships. CONCLUSION: India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

The role of collaboration in educating the global pediatric anesthesia workforce.

An estimated 1.7 billion children and adolescents do not have access to safe and affordable surgical care, and the vast majority of these are located in low-middle-income countries (LMICs). Pediatric anesthesia, a specialized field that requires a diverse set of knowledge and skills, has seen various advancements over the years and has become well-established in upper-middle and high-income countries. However, in LMICs, due to a multitude of factors including severe workforce shortages, this has not been the case. Collaborations play a vital role in increasing the capacity of pediatric anesthesiology educators and training the pediatric anesthesia workforce. These efforts directly increase access for children who require surgical intervention. Collaboration models can be operationalized through bidirectional knowledge sharing, training, resource allocation, research and innovation, quality improvement, networking, and advocacy. This article aims to highlight a few of these collaborative efforts. Specifically, the role that the World Federation of Societies of Anaesthesiologists, the Safer Anesthesia from Education program, the Asian Society of Pediatric Anaesthesiologists, Pediatric Anesthesia Training in Africa, the Paediatric Anaesthesia Network New Zealand, the Safe Pediatric Anesthesia Network and two WhatsApp™ groups (global ped anesthesia and the Pediatric Difficult Intubation Collaborative) have played in improving anesthesiology care for children.

Use of ultrasound to estimate the prevalence of occult spinal dysraphism in children undergoing urogenital and anorectal surgeries: A cross-sectional study.

Background and Aim: The use of ultrasound has immensely increased the safety toward regional blocks and central venous access and has been considered as the standard of care for securing central access. The aim of this study is to estimate the prevalence of occult spinal dysraphism using ultrasound in children less than 2 years of age undergoing elective urogenital or anorectal surgery. Material and Methods: The lumbosacral region of 159 American Society of Anesthesiologists (ASA) category I/II patients, posted for elective urogenital and anorectal surgery was scanned with ultrasound, prior to giving caudal block. Results: The prevalence of occult spina bifida was 3% in our study. There was no statistically significant association of cutaneous marker with abnormal scan. Conclusion: Prevalence of occult spina bifida was ten-times higher in our study than in the general population. Perioperative ultrasound screening of the lower spinal anatomy by anesthesiologist done prior to performing neuraxial block is worthwhile in ruling out occult spinal anomalies in high-risk children of occult spinal dysraphism.

Delivery of Safe Pediatric Anesthesia Care in the First 8000 days: Realities, Challenges, and Solutions in Low- and Middle-Income Countries.

BACKGROUND: Worldwide, perioperative mortality has declined over the past 50 years, but the reduction is skewed toward high-income countries (HICs). Currently, pediatric perioperative mortality is much higher in low- and middle-income countries (LMICs) compared to HICs, despite studied cohorts being predominantly low-risk. These disparities must be studied and addressed. METHODS: A narrative review of the literature was undertaken to identify contributing factors and potential knowledge gaps. Interventions aimed at alleviating the outcomes disparities are discussed, and recommendations are made for future directions. RESULTS AND CONCLUSIONS: There is a lack of adequately trained pediatric anesthesia providers in LMICs, and the number must be bolstered by making such training available. Essential anesthesia medications and equipment, in pediatric-appropriate sizes, are often not available; neither are essential infrastructure items. Perioperative staff are underprepared for emergent situations that may arise and simulation training may help to ameliorate this. The global anesthesia community has implemented several solutions to address these issues. The World Federation of Societies of Anaesthesiologists (WFSA) and Global Initiative for Children's Surgery have published standards that outline essential items for the provision of safe perioperative pediatric care. Several short educational courses have been developed and introduced in LMICs that either specifically address pediatric patients, or contain a pediatric component. The WFSA also maintains a collection of discrete tutorials for educational purposes. Finally, in Africa, large-scale, prospective data collection is underway to examine pediatric perioperative outcomes. More work needs to be done, though, to improve perioperative outcomes for pediatric patients in LMICs.

Improving safety in anesthetized patients undergoing magnetic resonance imaging-Concept of time-out in the MRI suite and measures to improve adherence to time-out protocol.

BACKGROUND: The time-out protocol introduced by the Joint Commission is an important tool to prevent adverse events and improve safety in various health-care environments. However, its implementation and utilization involve human, social, behavioral as well as system issues. AIMS: The SMART aim of the current project was to increase the utilization of the time-out protocol to more than 80% from baseline of 13%, over 6-month period in all the magnetic resonance imaging (MRI) procedures performed at a tertiary care, teaching institute in South India. METHODS: The Plan, Do, Study, Act (PDSA) cycle and root cause analysis strategies were utilized in this quality improvement initiative. The time-out protocol was modified for MRI environment and put into practice to improve safety. Six months after the initiation of this safety protocol, our audit showed only a 13% compliance to the time-out protocol. A multimodal strategy was utilized by involving all the stakeholders, educational interventions, and placing reminders for following the time-out protocol, to affect change and achieve improvement in safety. RESULTS: The compliance to time-out protocol increased from 13% to 86% and the run chart showed that a special cause variation indicated by six points above the centerline at 86%. When analyzing individual components of the time-out, the greatest improvement was noted in the ferromagnetic check of the personnel involved, namely, the Anesthesiologist, radiographer, and anesthesia technician. There were no delays in the list because of adherence to the time-out protocol. CONCLUSION: Time-out protocol in an MRI suite provides a final check to the anesthesia team before the anesthetized patient is wheeled into MR gantry. Using quality improvement methodology, we increased the compliance of time-out protocol in the magnetic resonance imaging environment. Our study is an example how other institutions in India and elsewhere can adapt similar improvement strategies to enhance patient safety.

A cross-sectional observation study to evaluate the efficacy and complications of epidural analgesia in paediatric population.

Background and Aims: With advances in pediatric surgery, pediatric epidurals are increasingly being used for analgesia. As there is scarcity of data in India about the pediatric epidurals, we sought to determine the efficacy and complications of epidural analgesia. The aim of this study was to determine the efficacy of pediatric epidural analgesia and the incidence of complications aimed at improving the quality of care. Material and Methods: It was a prospective observational study in tertiary care hospital in the Southern part of India. Newborns to children aged 18 years in whom continuous epidural analgesia was planned were recruited. They were followed up postoperatively at specified intervals wherein pain scores were used to determine analgesic efficacy. Complications were noted in a specified format and the level of satisfaction of patient and surgeon was noted objectively. All the statistical analyses were performed using SPSS 25.0. Results: 100 children were recruited of which 63 received thoracic epidurals and 37 lumbar epidurals. Overall efficacy of epidural in pain management was 90.96% with the highest efficacy for lower abdominal epidurals (94.9%). Kinking of a catheter was the most common complication encountered (11%), followed by migration of catheter, occlusion of pump, and motor block. Conclusion: Continuous epidural analgesia has proven to be a safe and effective method to provide analgesia to the children in a protected environment and experienced hands.

Pediatric lower respiratory tract infection: Considerations for the anesthesiologist.

Neonatal and childhood infectious diseases continue to be a global health problem. Acute respiratory tract infections are typically classified as upper respiratory tract infection and lower respiratory tract infections. The most common lower respiratory infections in childhood are pneumonia and bronchiolitis. Vaccination against measles, diphtheria, pertussis, Haemophilus influenzae, pneumococcus, and influenza resulted in a significant reduction in the incidence of acute respiratory tract infection globally. Though the global burden of the disease has decreased, the mortality rates still are higher in developing countries. Patients with severe lower respiratory tract infections and their complications are often evaluated for elective or emergency procedures. In this review article, the authors aim to discuss the etiology, pathogenesis, preoperative evaluation of lower respiratory tract infections, and the anesthesia implications pertinent to the practice of anesthesia.

Surgical and anaesthetic outcomes of paediatric splenectomies at a tertiary care institution in South India: a retrospective cohort.

PURPOSE: Splenectomies though well-established in the successful management of several resistant haemoglobinopathies, have not been studied in detail in the paediatric population to assess the outcomes. We conducted this review to primarily assess the surgical and anaesthetic outcomes of paediatric splenectomies and secondarily highlight factors predictive for a high-risk splenectomy. METHODS: A 5 year retrospective chart review was made, and patient follow-up was done jointly using the hospital electronic medical records and telephonic calls. A p value of < 0.05 was considered significant. RESULTS: Among the 69 splenectomised children, 61% were male and the overall mean age was 10.2 years. The cohort consisted of patients with thalassemia (46%), ITP (30%), haemolytic anemia (19%) and 1 child each with lymphoma, splenic cyst and Kassabach Meritt syndrome. Most (96%) were electively operated and 23% were performed laparoscopically. 61% received intravenous analgesia and the mean volume of fluid administered intra-operatively was 21 ml/kg. There was no documented OPSI, and there was one mortality. The mean follow-up period was 43 months and the overall survival rate was 98.5%. CONCLUSIONS: Splenectomy was associated with a promising overall outcome. A greater pre-operative transfusion requirement, a larger sized spleen and increased fluid administration intra-operatively, were associated with a worse outcome.

Aerosol-generating procedures, how best did anesthesiologists use available personal protective equipment during early COVID-19 pandemic in a tertiary care center of southern India? A prospective cross-sectional study.

Background and Aims: Anesthesiologists are involved in high-risk procedures for transmission of SARS-CoV-2 like aerosol-generating procedures (AGPs). The present study was conducted to assess the compliance toward the use of personal protective equipment (PPE) and proposed modifications in anesthesia techniques to prevent dissemination of the virus among healthcare workers. Material and Methods: This prospective cross-sectional study was conducted during the first wave of the COVID-19 pandemic and included all elective surgeries involving AGPs inside operation theatres and remote areas. Participants were anesthesia consultants and trainees. Trained anesthesia technicians observed and documented all the AGPs and data entry with analysis was done using EPI Data 3.1, SPSS 21.0. Descriptive statistics were reported using mean ± SD for continuous variables. Results: Preoperative COVID-19 test was done in 96.3% of patients. Most (74.8%) of the AGPs were performed by consultants. In our study, compliance for N95 masks usage and hand hygiene was found to be 99.2% and 55.9%, respectively. Avoidance of crowding was followed in only 38.9% during intubation. To contain the aerosol-based spread of virus, modification of anesthesia practices like acrylic boxes (6.4%), plastic sheets (5.5%), video laryngoscopy (39%), rapid sequence intubation (RSI) (42.7%), and 59.3% of deep extubation were incorporated. Conclusion: In our study, we found satisfactory compliance toward usage of N95 masks alone, whereas compliance toward other available PPE and modification in anesthesia practice was found to be unsatisfactory.

Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting.

BACKGROUND: Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia. METHODS: A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated. RESULTS: During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients. CONCLUSION: Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

Evaluation of anesthesia informed consent in pediatric practice - An observation cohort study.

BACKGROUND AND AIMS: An informed consent requires active participation by both physicians and patients. It is the responsibility of the physician to give the complete disclosure of information in easy language for the parent to understand. An informed consent process can be a challenge especially for the anesthetists when time is a limiting factor for patient-anesthetist interaction especially in same day admission and day surgery. The aim of this study was to subjectively evaluate the understanding and recall of the informed consent by the parents. MATERIAL AND METHODS: The validated survey was conducted over 10 weeks and was limited to one parent per child and to the parent who was directly involved in the consent process. RESULTS: Majority of parents rated positively for adequate disclosure of all items of information. Consent process done on day of surgery was found to be associated with lower parental rating in adequacy of disclosure of pain relief options. Seniority of anesthetists was associated with higher parental rating of adequacy of information regarding post operative plan, specific risk of child and overall consent process. Consent for minor surgeries, on day of surgery, did not significantly affect the parental performance in their recall of disclosed information but was associated with significant lower rating of adequacy of postoperative plan. Postoperative pain is among the areas for improvement especially in day surgery cases. CONCLUSION: Consent taken on day of surgery was found to be associated with lower parental rating. Postoperative plan for pain required improvement especially in day surgery cases.

Genetic predisposition to autoimmunity--what have we learned?

Rapid advances in genetic technologies have led to the identification of more than 85 loci that contribute to susceptibility to autoimmune diseases. These susceptibility genes are distributed throughout the innate and adaptive immune systems, indicating that dysregulations in both immune systems participate in the development of autoimmunity. A significant subset of these susceptibility genes are shared between multiple autoimmune diseases. However, the dysregulation of specific pathways, such as the pathogen recognition receptors of the innate immune system and the TNF supergene family, are significantly involved in some autoimmune diseases. Although these findings dramatically increase the details available concerning the nature of genetic predisposition to autoimmunity, a mechanistic understanding of the processes involved has not been achieved. Future studies must focus on correlating phenotypes with specific genotypes to improve our understanding of the immune processes that are dysregulated during the development of autoimmunity.

SOX9 gene shows association with adolescent idiopathic scoliosis predisposition in Northwest Indians.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a common structural deformity of the spine affecting adolescent individuals globally. The disorder is polygenic and is accompanied by the association of various genetic loci. Genetic studies in Chinese and Japanese populations have shown the association of genetic variants of SOX9 with AIS curve severity. However, no genetic study evaluating the association of SRY-Box Transcription Factor 9 (SOX9) variants with AIS predisposition has been conducted in any Indian population. Thus, we aimed to investigate the association of the genetic variants of the SOX9 along with 0.88 Mb upstream region with AIS susceptibility in the population of Northwest India. METHODS: In total, 113 AIS cases and 500 non-AIS controls were recruited from the population of Northwest India in the study and screened for 155 genetic variants across the SOX9 gene and 0.88 Mb upstream region of the gene using Global Screening Array-24 v3.0 chip (Illumina). The statistical significance of the Bonferroni threshold was set at 0.000322. RESULT: The results showed the association of 11 newly identified variants; rs9302936, rs7210997, rs77736349, rs12940821, rs9302937, rs77447012, rs8071904, rs74898711, rs9900249, rs2430514, and rs1042667 with the AIS susceptibility in the studied population. Only one variant, rs2430514, was inversely associated with AIS in the population, while the ten variants were associated with the AIS risk. Moreover, 47 variants clustered in the gene desert region of the SOX9 gene were associated at a p-value ≤ 0.05. CONCLUSION: The present study is the first to demonstrate the association of SOX9 enhancer locus variants with AIS in any South Asian Indian population. The results are interesting as rs1042667, a 3' untranslated region (UTR) variant in the exon 3 and upstream variants of the SOX9 gene, were associated with AIS susceptibility in the Northwest Indian population. This provides evidence that the variants in the enhancer region of SOX9 might regulate its gene expression, thus leading to AIS pathology and might act as an important gene for AIS susceptibility.

Bergenin inhibits growth of human cervical cancer cells by decreasing Galectin-3 and MMP-9 expression.

Cervical cancer is still the leading cause of cancer mortality worldwide even after introduction of vaccine against Human papillomavirus (HPV), due to low vaccine coverage, especially in the developing world. Cervical cancer is primarily treated by Chemo/Radiotherapy, depending on the disease stage, with Carboplatin/Cisplatin-based drug regime. These drugs being non-specific, target rapidly dividing cells, including normal cells, so safer options are needed for lower off-target toxicity. Natural products offer an attractive option compared to synthetic drugs due to their well-established safety profile and capacity to target multiple oncogenic hallmarks of cancer like inflammation, angiogenesis, etc. In the current study, we investigated the effect of Bergenin (C-glycoside of 4-O-methylgallic acid), a natural polyphenol compound that is isolated from medicinal plants such as Bergenia crassifolia, Caesalpinia digyna, and Flueggea leucopyrus. Bergenin has been shown to have anti-inflammatory, anti-ulcerogenic, and wound healing properties but its anticancer potential has been realized only recently. We performed a proteomic analysis of cervical carcinoma cells treated with bergenin and found it to influence multiple hallmarks of cancers, including apoptosis, angiogenesis, and tumor suppressor proteins. It was also involved in many different cellular processes unrelated to cancer, as shown by our proteomic analysis. Further analysis showed bergenin to be a potent-angiogenic agent by reducing key angiogenic proteins like Galectin 3 and MMP-9 (Matrix Metalloprotease 9) in cervical carcinoma cells. Further understanding of this interaction was carried out using molecular docking analysis, which indicated MMP-9 has more affinity for bergenin as compared to Galectin-3. Cumulatively, our data provide novel insight into the anti-angiogenic mechanism of bergenin in cervical carcinoma cells by modulation of multiple angiogenic proteins like Galectin-3 and MMP-9 which warrant its further development as an anticancer agent in cervical cancer.

Recent advances in paediatric anaesthesia.

Recent development in science has led to a significant improvement in safety for the anaesthetic management of children. Enhanced recovery after surgery is one of the novel approaches aiming to enhance paediatric surgical outcomes and their quick recovery. Preoperative counselling, minimal fasting, and no routine pharmacological premedication are critical components of enhanced recovery after surgery. As anaesthetists, management of airway is our priority and introduction of paraoxygenation in addition to preoxygenation has resulted in reduction in desaturation episodes during periods of apnoea. Safe care has been made possible by improvements in monitoring, equipment, medications, techniques, and resuscitation protocols. We are motivated to collect more evidence regarding ongoing disputes and issues, such as the effect of anaesthesia on neurodevelopment.

Effect of Cr3+ doping on structural and optical properties of Eu3+ doped LaVO4 phosphor.

In this work, the Eu3+, Cr3+ doped and co-doped LaVO4 phosphors have been prepared through a high temperature solid-state reaction method. The powder XRD patterns of phosphors are very sharp and intense, which reflects a highly crystalline nature of phosphors. The XRD data were also refined by a Rietveld refinement method. The particle size of the phosphor samples lies in the sub-micron to micron range. The existence of La, Eu, Cr, V and O elements was verified by EDS spectra. The FTIR spectra show various absorption bands due to different vibrating groups. The optical band gap of the phosphor decreases on increasing concentration of Cr3+ ion. The photoluminescence excitation spectra of Eu3+, Cr3+ co-doped LaVO4 phosphor exhibit bands due to Eu3+ and Cr3+ ions. The Eu3+ doped LaVO4 phosphor exciting at 393 and 316 nm wavelengths gives intense red color at 614 nm due to the 5D0 → 7F2 transition of the Eu3+ ion. When the Cr3+ ion is co-doped in the Eu3+ doped LaVO4 phosphor the emission spectra contain emission bands due to Eu3+ and Cr3+ ions. The emission intensity of Eu3+ doped phosphor reduces due to energy transfer from Eu3+ to Cr3+ ions in presence of Cr3+ ions upon 393 and 386 nm excitations. The lifetime of the 5D0 level of Eu3+ ions decreases in the Eu3+, Cr3+ co-doped LaVO4 phosphor, which also reflects the energy transfer. The Eu3+, Cr3+ co-doped LaVO4 phosphor also produces a large amount of heat upon 980 nm excitation. Thus, the Eu3+, Cr3+ co-doped LaVO4 phosphors may be used for LEDs, solid state lighting and heat generating devices.

Morphometric analysis of Corpus Callosum in autistic and typically developing Indian children.

Corpus callosum (CC) is the largest commissural white matter bundle in the brain, responsible for the integration of information between hemispheres. Reduction in the size of the CC structure has been predominantly reported in children with autism spectrum disorder (ASD) compared to typically developing children (TD). However, most of these studies are based on high-functioning individuals with ASD but not on an inclusive sample of individuals with ASD with varying abilities. Our current study aimed to examine the CC morphometry between children with ASD and TD in the Indian population. We also compared CC morphometry in autistic children with autism severity, verbal IQ (VIQ) and full-scale IQ (FSIQ). T1-weighted structural images were acquired using a 3T MRI scanner to examine the CC measures in 62 ASD and 17 TD children. The length and height of the CC and the width of genu were decreased in children with ASD compared to TD. There was no significant difference in CC measures based on autism severity, VIQ or FSIQ among children with ASD. To our knowledge, this is the first neuroimaging study to include a significant number (n = 56) of low-functioning ASD children. Our findings suggest the atypical interhemispheric connectivity of CC in ASD.