Tension Band Wiring in Gap Non-union Patella - A Simple Technique with Profound Results: Case Report.

Introduction: Gap non-union patellas are challenging to treat for an orthopedic surgeon. We hereby report a case of a 22-year-old person with a 3 cm gap nonunion, its surgical management, functional outcome, and implications for clinical practice. Case Report: A 22-year-old active male presented to us with a background of comminuted fracture patella left side that he suffered 1 year ago, following which he was treated by open reduction and internal fixation (ORIF) with Tension Band Wiring (TBW). One year post-surgery, the patient had another fall, following which he had pain swelling in his left knee and difficulty in his knee extension. The patient presented 6 months later with painful ambulation and a swelling left knee. A 3 cm gap along with underlying implants could be palpated. The patient underwent surgery in the form of previous implant removal, freshening and apposition of fracture ends, and single-staged reconstruction of the extensor mechanism using TBW. The patient had full range of motion at the 1-year follow-up. Conclusion: The present case highlights the fact that small-gap non-union patella can be managed simply as a single-stage procedure with ORIF and TBW.

Spontaneous miscarriage/abortion in the first trimester and expectant management - a meta-analysis approach.

Introduction: To determine effectiveness and side effects of expectant care in first-trimester miscarriage. An increase in the spontaneous miscarriage rate and its associated complications exerts a burden on the overall health and quality of life of women. Expectant care in a first-trimester miscarriage has shown success ranging 75-80%. This study was designed to search the literature for information on the clinical safety and effectiveness of expectant management on spontaneous miscarriage during the first trimester. Material and methods: The review included studies that included women in expectant care for spontaneous miscarriage in the first trimester. Trial studies were recognized through a methodical and organized database search from PubMed, COCHRANE, MEDLINE, Embase, and bibliography from January 2000 until December 2022. The methodological assessment and risk of bias was assessed using the Joanna Briggs Institute criteria. Results: Eleven studies in systematic review and 7 studies in the meta-analysis were included. The included studies showed a low to moderate risk of bias. The odds of success in expectant intervention were low when compared with surgical intervention (odds ratio - OR: OR: 0.37 [0.28, 0.48]) and medical management (OR: 0.47 [0.36, 0.61]), and the need for surgical evacuation was high (OR: 2.59 [1.88, 3.59]). Conclusions: Future trials should consider women's opinions and the effect on quality of life along with clinical consequences, to provide improved suggestions on the efficiency and adverse effects.

Tuberous Sclerosis Complex-Varied Presentations in Family Clusters.

Tuberous sclerosis complex (TSC) is a disease of varying presentations characterised by the presence of multiple hamartomas in various organ systems in the body. This is an Autosomal dominant disease with damages in two suppressor genes namely TSC1 and TSC2 located on chromosome 9 (9q34-hamartin) and chromosome 16 (16p13.3-tuberin). It is a lifelong disease with neurological manifestations, for example, epilepsy, mental retardation and autism and major dermatological features like facial fibromas (adenoma sebaceum), periungual fibromas, shagreen patches and hypopigmented macules. Some conditions, for example, autosomal dominant polycystic kidney disease can co-exist with TSC as a result of concurrent deletion of both polycystic kidney disease 1 and TSC2 genes present on chromosome 16p13.3. We present a cluster of three families with TSC having varied presentations.

Bilateral Radial Head Fractures in a Young Patient: A Rare and Unique Presentation.

Introduction: Bilateral radial head fractures are a unique and rare presentation. Few studies are available in the literature documenting these type of injuries. We present a rare case of bilateral radial head fractures (Mason type 1) and managed conservatively with full functional recovery. Case Report: A 20-year-old male sustained bilateral radial head fractures (Mason type 1) following a roadside accident. The patient was managed conservatively with above elbow slab for 2 weeks followed by range of motion exercises. The patient had uneventful follow-up with full range of motion at elbow. Conclusion: Bilateral radial head fractures in a patient are a discreet clinical entity. A high index of suspicion, meticulous history, clinical examination, and appropriate imaging is essential in patients with history of fall on outstretched hands to avoid missing diagnosis. Early diagnosis, proper management, and appropriate physical rehabilitation lead to complete functional recovery.

Effect of a quality improvement package on reducing newborn mortality from 26 to 14 in a Himalayan North Indian State.

Background: In India, newborn mortality remains high due to a number of factors, including poor quality of care at health facilities. The experience of executing complete neonatal care quality improvement (QI) package at selected hospitals in Himachal Pradesh and reduction in newborn mortality rate (NMR) is described in this study. Objective: The short-term objective was the participants' retention of knowledge and skills, and the achievement of uniform QI objectives following training and after a minimum of 6 months. Overall reduction in NMR was long-term objective. Methods: Newborn care QI package was implemented according to India Newborn Action Plan over a period of 48 months from 2013 to 2016, through infrastructure, trainings, and supportive supervision. Results: Total 13 health facilities were upgraded; 350 staff nurses and medical officers were trained. The mean posttraining knowledge score was 75% compared to 29% in the pretraining test, and 63% 1 year later. The competencies of health workers in the care of high-risk babies and 12 QI targets had improved, resulting in a 46% reduction in neonatal mortality in the state across all gestations and weights based on sample registration survey. Conclusion: Implementation of a bundle of evidence-based practices in low-resource setting for health system strengthening for intrapartum and neonatal care was linked to changed care behaviors among health-care providers, and reduction in NMR.

Emerging Evidence on Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection: a Systematic Review with Meta-analysis.

With the increased spread of severe acute respiratory syndrome coronavirus 2 infection, more patients with multisystem inflammatory syndrome in children (MIS-C) are being reported worldwide. This systematic review with meta-analysis aims to analyse the clinical features, proposed pathogenesis and current treatment options for effective management of children with this novel entity. Electronic databases (Medline, Google Scholar, WHO, CDC, UK National Health Service, LitCovid, and other databases with unpublished pre-prints) were extensively searched, and all articles on MIS-C published from January 1, 2020, to October 10, 2020, were retrieved. English language studies were included. This systematic review analysed 17 studies with 992 MIS-C patients from low-income and middle-income countries (LMICs) and developed countries (France, the UK, Italy, Spain, Chile and the US CDC data). Fever (95%) was the most common clinical manifestation followed by gastrointestinal (78%), cardiovascular (75.5%), and respiratory system (55.3%) involvement. Laboratory or epidemiologic evidence of inflammation and SARS-CoV-2 infection was present. Though the exact pathogenesis remains elusive, virus-induced post-infective immune dysregulation appears to play a predominant role. Features resembling Kawasaki disease, toxic shock syndrome or macrophage activation syndrome were present; 49% had shock; 32% had myocarditis; 18% had coronary vessel abnormalities and 9% had congestive cardiac failure. Sixty-three percent of the patients were admitted in paediatric intensive care unit (PICU); 63% received intravenous immunoglobulin, 58% received corticosteroids and 19% received alternate agents like tocilizumab; there were 22 (2.2%) deaths. Only 9/144 children in LMICs received tocilizumab that was significantly less than children in developed countries (p < 0.0001). This systematic review delineates and summarises recently published data on MIS-C from LMICs and developed countries. Although most needed PICU admission and received treatment with IVIG and steroids, most of the patients survived. Significantly fewer patients in developing countries received tocilizumab therapy than those in developed countries. It is crucial for clinician to recognise MIS-C, to differentiate it from other defined inflammatory conditions and initiate early treatment. Further studies are needed for long-term prognosis, especially relating to cardiac complications of MIS-C. Supplementary Information: The online version of this article (10.1007/s42399-020-00690-6) contains supplementary material, which is available to authorized users.

Acetabulum Reconstruction with TantalumCup and Augments in Dysplastic Hip Type 4 using 3D Printing Technology.

INTRODUCTION: Acetabular reconstruction in a patient with neglected DDH during complex primary total hip replacement is a challenging procedure to do. We are reporting assessment of acetabular defect in one such patient with pre-operative 3D printing, followed by reconstruction with trabecular metal shell and augments. CASE REPORT: A 32-year-old female with neglected DDH (Crowe's type 4) reported to us with pain, limp, and shortening of affected limb. Operated somewhere else with THR, she had a missing acetabular component and coral stem in situ at the time of presentation. Acetabular defect was assessed by 3D printing of pelvis following which acetabular reconstruction with tantalum cup and augments along with femoral stem revision was done. CONCLUSION: This study confirmed the role of 3D printing pelvis model in meticulous pre-operative planning in patients with complex hip deformities. Reconstruction of acetabular defects with tantalum cup, and augments is a reasonable solution to achieve better function.

Resection and Stump Stabilization in Giant Cell Tumor Distal Ulna: A Case Report.

INTRODUCTION: Giant cell tumors (GCTs) of distal ulna are extremely rare accounting for 0.45%-3.2% of all the cases of GCTs. These are locally aggressive and have a higher rate of recurrence of up to 40% with conservative modality of treatment. Proximity to carpus and diminished range of motion makes their treatment a challenge. CASE REPORT: A 27-year-old male presented to us with swelling right distal ulna. X-ray and MRI were suggestive of GCT. The diagnosis was confirmed by core needle biopsy. The patient was managed by wide resection ulna with extensor carpi ulnaris tenodesis. CONCLUSION: GCT ulna although very rare in presentation is a possible diagnosis. Wide resection of ulna is a viable treatment option to achieve disease free status. Extensor carpi ulnaris tenodesis helps stabilization of ulnar stump.

Comparison Between Use of Oral Misoprostol Versus Vaginal Misoprostol for Induction of Labour at Term.

BACKGROUND AND OBJECTIVE: In modern obstetrics, around 30% of cases require induction of labour for various reasons. Misoprostol is gaining popularity as pharmacological inducing agent, though the route and dosage of administration are not standardised. The objective of the study is to compare the safety and efficacy of the two routes of misoprostol administration-oral (100 µg 4th hourly) and vaginal (25 µg 4th hourly), for induction of labour at term. METHODS: In this randomised trial, 104 women having crossed the expected date of delivery without going into spontaneous labour and cases which had premature rupture of membranes <12 h were considered for labour induction and were divided into two equal groups. Group A received 100 µg misoprostol orally 4th hourly, and group B received 25 µg misoprostol vaginally 4th hourly. Labour characteristics and maternal and foetal outcome were compared. RESULTS: In terms of maternal outcome, mean number of doses for oral group is 2.73 and vaginal group is 3.04. In oral group, mean induction to vaginal delivery interval was 13 h 43 min and in vaginal group interval is 13 h 26 min which was statistically not significant. The need for oxytocin augmentation was also statistically not significant. Both groups had equal number of failed inductions. Emergency LSCS done for foetal distress was more in vaginal group 2.9% compared to oral group which is 1%, but difference was not statistically significant (p value -0.55). Number of thick MSL in oral group was 3.2% as compared to vaginal group which is 10.7% which was statistically significant (p value -0.04). APGAR score at 5 min 7/10 was seen in 7.7% in vaginal group as compared to 0% in oral group which was also statistically significant (0.004). Number of NICU admissions was also more in vaginal group compared to oral group. CONCLUSION: Misoprostol in either oral or vaginal route has proven to be equally effective for inducing labour in women at term pregnancy. However, occurrence of lesser incidence of meconium-stained liquor and NICU admissions and fewer caesareans with better neonatal outcome in women induced with oral misoprostol outweighs its advantages over the vaginal misoprostol.

Building Interdisciplinary Leadership Skills among Health Practitioners in the Twenty-First Century: An Innovative Training Model.

Transformational learning is the focus of twenty-first century global educational reforms. In India, there is a need to amalgamate the skills and knowledge of medical, nursing, and public health practitioners and to develop robust leadership competencies among them. This initiative proposed to identify interdisciplinary leadership competencies among Indian health practitioners and to develop a training program for interdisciplinary leadership skills through an Innovation Collaborative. Medical, nursing, and public health institutions partnered in this endeavor. An exhaustive literature search was undertaken to identify leadership competencies in these three professions. Published evidence was utilized in searching for the need for interdisciplinary training of health practitioners, including current scenarios in interprofessional health education and the key competencies required. The interdisciplinary leadership competencies identified were self-awareness, vision, self-regulation, motivation, decisiveness, integrity, interpersonal communication skills, strategic planning, team building, innovation, and being an effective change agent. Subsequently, a training program was developed, and three training sessions were piloted with 66 participants. Each cohort comprised a mix of participants from different disciplines. The pilot training guided the development of a training model for building interdisciplinary leadership skills and organizing interdisciplinary leadership workshops. The need for interdisciplinary leadership competencies is recognized. The long-term objective of the training model is integration into the regular medical, nursing, and public health curricula, with the aim of developing interdisciplinary leadership skills among them. Although challenging, formal incorporation of leadership skills into health professional education is possible within the interdisciplinary classroom setting using principles of transformative learning.

Enhancing public health practice through a capacity-building educational programme: an evaluation.

BACKGROUND: The Post-Graduate Diploma in Public Health Management, launched by the Govt. of India under the aegis of the National Rural Health Mission in 2008, aims to enhance the managerial capabilities of public health professionals to improve the public health system. The Govt. of India invested enormous resources into this programme and requested an evaluation to understand the current processes, assess the graduates' work performance and identify areas for improvement. METHODS: Quantitative telephone surveys as well as qualitative in-depth interviews were used. Graduates from the first three batches, their supervisors, peers and subordinates and faculty members were interviewed. Quantitative data were analysed using proportions, means and interpretative descriptions. Qualitative analyses involved transcription, translation, sorting, coding and filing into domains. RESULTS: Of the 363 graduates whose contact details were available, 138 could not be contacted. Two hundred twenty-three (223) graduates (61.43% of eligible participants) were interviewed by telephone; 52 in-depth interviews were conducted. Of the graduates who joined, 63.8% graduates were motivated to join the programme for career advancement and gaining public health knowledge. The content was theoretically good, informative and well-designed. Graduates expressed need for more practical and group work. After graduating, they reported being equipped with some new skills to implement programmes effectively. They reported that attitudes and healthcare delivery practices had improved; they had better self-esteem, increased confidence, better communication skills and implementation capacity. While they were able to apply some skills, they encountered some barriers, such as governance, placements, lack of support from the system and community, inadequate implementation authority and lack of planning by the state government. Incentives (both monetary and non-monetary) played a major role in motivating them to deliver public health services. They suggested that states should nominate candidates expected to make a significant contribution to the health system, recognition from a relevant authoritative national body and need for a placement cell, especially for the self-sponsored candidates. CONCLUSIONS: A continuous mechanism for interaction and dialogue with the graduates during and after completion of the programme should be designed. This evaluation helped by providing inputs for refining the programme.

Assessment of essential newborn care services in secondary-level facilities from two districts of India.

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts-two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (> 75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (< 50%). The findings underpin the need for improving the existing ENC services by making newborn care comers functional and enhancing skills of service providers to reduce neonatal mortality rate in India.

Accreditation of public health education in India: Enhancing quality, competence and trust.

With an increase in the number of institutes offering public health education, there is a need for discussion on future directions and challenges. The World Health Report 2006 identified the need to improve the quality of public health education. There are various mechanisms and bodies that look after accreditation issues in several countries. The Council on Education for Public Health in the USA assists in the accreditation of schools of public health, as well as public health programmes. The Australian Network of Academic Public Health Institutions is actively engaged in discussions to improve the quality of its programme and institutions. In Europe, the European Agency for Accreditation in Public Health Education is responsible for accreditation. The South-East Asia Public Health Education Institutes Network facilitates accreditation of public health education in the region. In India, public health education varies across institutes. India needs an accreditation system to ensure that public health education is of the desired quality. Certain initiatives, such as conferences, consultation and the Calcutta Declaration, have been taken in the past two decades. However, the ideas mooted have yet to be translated into reality. The broad framework for accreditation may entail an institutional self-assessment against set standards, preparation of a database, cataloguing, and site visits by a peer team. There is a need for an apical body with all stakeholders participating in the process. Accreditation has specific benefits, but there are critical challenges as well. For example, the autonomy of the institutions needs to be protected, the accreditation bodies should exhibit professionalism and substantial financial resources are required. Before tackling specific criteria for accreditation, it is necessary to define a collective vision for schools of public health in India.

Veterinary public health capacity-building in India: a grim reflection of the developing world's underpreparedness to address zoonotic risks.

Veterinary public health (VPH) is ideally suited to promote convergence between human, animal and environmental sectors. Recent zoonotic and emerging infectious disease events have given rise to increasing calls for efforts to build global VPH capacities. However, even with their greater vulnerability to such events, including their economic and livelihood impacts, the response from low-and middle-income countries such as India has been suboptimal, thereby elevating global health risks. Addressing risks effectively at the human-animal interface in these countries will require a clear vision, consistent policies, strategic approach and sustained political commitment to reform and refine the current VPH capacity-building efforts. Only then can the discipline serve its goal of disease prevention, poverty alleviation and support for sustainable livelihoods through improvements in human and animal health.

Situational analysis of nursing education and work force in India.

Nursing care has been mentioned in the Indian culture from the times of the Vedas. However, according to World Health Organization, the nursing workforce in India is still insufficient to meet the needs of the country. The purpose of this article is to examine the status of nursing education and the nursing workforce in India and the challenges faced by the profession. Data supporting the statements made in the article were obtained from the Nursing Council of India, the Ministry of Health and Family Welfare, the Government of India Web sites, printed journals and communication with experts in the field. In India, there is a need to train approximately a million nurses to meet the current shortfall of health workers in the country. The nursing "brain drain" suggests that it may be one of the factors responsible for this shortfall. Further, nursing education faces challenges, such as streamlining nursing education, enriching the curriculum, strengthening faculty development and increasing the use of innovative teaching and learning techniques.

Designing the framework for competency-based master of public health programs in India.

Competency in the practice of public health is the implicit goal of education institutions that offer master of public health (MPH) programs. With the expanding number of institutions offering courses in public health in India, it is timely to develop a common framework to ensure that graduates are proficient in critical public health. Steps such as situation assessment, survey of public health care professionals in India, and national consultation were undertaken to develop a proposed competency-based framework for MPH programs in India. The existing curricula of all 23 Indian MPH courses vary significantly in content with regard to core, concentration, and crosscutting discipline areas and course durations. The competency or learning outcome is not well defined. The findings of the survey suggest that MPH graduates in India should have competencies ranging from monitoring of health problems and epidemics in the community, applying biostatistics in public health, conducting action research, understanding social and community influence on public health developing indicators and instruments to monitor and evaluate community health programs, developing proposals, and involving community in planning, delivery, and monitoring of health programs. Competency statements were framed and mapped with domains including epidemiology, biostatistics, social and behavioral sciences, health care system, policy, planning, and financing, and environmental health sciences and a crosscutting domain that include health communication and informatics, health management and leadership, professionalism, systems thinking, and public health biology. The proposed competency-based framework for Indian MPH programs can be adapted to meet the needs of diverse, unique programs. The framework ensures the uniqueness and diversity of individual MPH programs in India while contributing to measures of overall program success.

Need and supply gap in occupational health manpower in India.

Industrial growth in India has resulted in increased employment opportunities, thereby inflating the size of the workforce engaged in both organized and unorganized sectors. This workforce is exposed to various occupational factors at workplace and hence is susceptible to occupational diseases, which requires trained occupational health manpower. The present study is undertaken to estimate the need and supply gap of occupational health manpower, based on present regulations. The total workforce in the organized sector in India is 26.92 million. There are 254,951 working registered industrial factories in India, with about 11.16 million workers. These factories have employed 6953 factory medical officers (FMOs) and 2308 safety officers (SOs). Hence, for 26.92 million of total workforce engaged in organized sector, we would require a total of 16,728 FMOs and 5619 SOs, thereby estimating the deficit of 58% for FMOs and 59% for SOs based on current ratio of employment.