Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis.

BACKGROUND: Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS: Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION: Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

The elephant in the room: Exploring the influence and participation of patients in infection-related care across surgical pathways in South Africa and India.

OBJECTIVE: The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection-related care, including antibiotic decision-making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala). METHODS: Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face-to-face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection-related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software. RESULTS: Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision-making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection-related decision-making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection-related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities. CONCLUSION: For patients to have a valuable role in AS and make informed decisions regarding their infection-related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient-centred healthcare delivery. PATIENT OR PUBLIC CONTRIBUTION: Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings.

Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery, is the mainstay of managing locally advanced esophageal cancer. However, the optimal timing of surgery after neoadjuvant therapy is not defined clearly. METHODS: A systematic search of PubMed, Embase and Cochrane databases was conducted. 6-8 weeks were used as a cut-off to define early and delayed surgery groups. Overall Survival (OS) was the primary outcome, whereas pathological complete resolution (pCR), R0 resection, anastomotic leak, perioperative mortality, pulmonary complications, and major complication (> Clavien-Dindo grade 2) rates were secondary outcomes. Cohort studies and national registry bases studies were analysed separately. Survival data were pooled as Hazard Ratio (HR) and the rest as Odds Ratio (OR). According to heterogeneity, fixed-effect or random-effect models were used. RESULTS: Twelve retrospective studies, one RCT, and six registry-based studies (13,600 participants) were included. Pooled analysis of cohort studies showed no difference in OS (HR 1.03, CI 0.91-1.16), pCR (OR 0.98, CI 0.80-1.20), R0 resection (OR 0.90, CI 0.55-I.45), mortality (OR 1.03, CI 0.59-1.77), pulmonary complications (OR 1.26, CI 0.97-1.64) or major complication rates (OR 1.29, CI 0.96-1.73). Delayed surgery led to increased leak (OR 1.48, CI 1.11-1.97). Analysis of registry studies showed that the delayed group had a better pCR rate (OR 1.12, CI 1.01-1.24), with no improvement in survival (HR 1.01, CI 0.92-1.10). Delayed surgery was associated with increased mortality (OR 1.35, CI 1.07-1.69) and major complication rate (OR 1.55, CI 1.20-2.01). Available RCT reported surgical outcomes only. CONCLUSION: National registry-based studies' analysis shows that delay in surgery is riskier and leads to higher mortality and major complication rates. Further, well-designed RCTs are required.

Expression and clinicopathological correlation of Ki-67 in gallbladder carcinoma.

INTRODUCTION: Gallbladder cancer is an aggressive cancer with short median survival from the time of diagnosis. Improved understanding of the pathological molecular mechanisms of gallbladder carcinogenesis is important to refine the diagnosis, prognosis, and also to develop novel targeted therapies for patients with advanced Gallbladder cancer (GBC) malignancy. Ki-67 is a marker of cell proliferation and its detection by immunohistochemistry is considered to be an effective method for the detection of prognosis in several tumors. In the present study, we have analyzed expression of immunohistochemical marker Ki-67 in gallbladder carcinoma and its correlation with clinicopathological and radiological parameters. MATERIALS AND METHODS: This prospective observational study was conducted from December 2017 to July 2020. The patients of newly diagnosed gallbladder cancer were enrolled as per the inclusion and exclusion criteria defined in the study protocol. Contrast-enhanced computer tomography of the chest and abdomen and serum tumor markers such as carbohydrate antigen (CA)-19.9, carcinoembryonic antigen, and CA 125 were done. Immunohistochemical expression of Ki-67 was evaluated on biopsy tissue from the gallbladder mass. RESULTS: Fifty newly diagnosed patients of carcinoma gallbladder were included in the present study. The correlation was studied between clinicodemographic parameters and Ki-67, but no association was found with age, gender, and symptoms. There was a weak positive correlation between Ki-67 and direct bilirubin, serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase (P = 0.094; 0.126; 0.542; and 0.328, respectively). There was a weak positive correlation between body mass index (Kg/m2) and Ki-67, but this correlation was not statistically significant (P = 0.304). CONCLUSIONS: Ki-67 is a marker of proliferation and it correlated with histological differentiation, jaundice and liver function tests, presence of stones, and location of metastases but did not correlate with stage and extent of disease.

Expression of Human epidermal growth factor receptor 2, Survivin, Enhancer of zeste homolog -2, Cyclooxygenase-2, p53 and p16 molecular markers in Gall bladder carcinoma.

INTRODUCTION: Gallbladder cancer exhibits striking variability in the global rates, reaching epidemic levels for some regions and ethnicities. The basis of its variability resides in differences in environmental exposure and intrinsic genetic predisposition to carcinogenesis. There is little information present regarding genetic and molecular alterations in gall bladder cancer (GBC). We, therefore, have evaluated the molecular marker expression in GBC and studied their correlation with clinicopathological staging. MATERIALS AND METHODS: This prospective observational study was conducted on newly diagnosed GBC patients from July 2017 to July 2020. After complete staging workup, the GBC biopsy samples paraffin block was tested for molecular markers estrogen receptor (ER), progesterone receptor (PR), p53, p16, Human epidermal growth factor receptor 2 (HER 2-neu), Survivin, Enhancer of zeste homolog-2 (EZH2), and Cyclooxygenase-2 (COX-2) expression by immunohistochemistry. RESULTS: Fifty newly diagnosed patients of carcinoma gall bladder were included in the present study. Age was ranged from 29 - 69 years (mean 53.42). p53 was the most common positive marker in 74% of patients, survivin in 58%, COX-2 in 44%, and p16 in 42% whereas Her 2 neu and EZH-2 were positive in 16% of patients each. None of the patients of GBC were ER or PR positive. There was a significant difference between the various groups in terms of the distribution of histological grade and Her 2 neu (χ2 = 9.886, P = 0.014) but not with other markers. Furthermore, there was a significant difference in terms of distribution of p16 and p53 with stage (χ2 = 7.017, P = 0.037 and χ2 = 5.861, P = 0.033) respectively. CONCLUSIONS: The present study shows the expression of molecular markers Her2 neu, p53, p16, survivin, COX-2, and EZH-2 in GBC. Now the time has come, and it is also the need of the day to establish early biomarkers of this highly lethal malignancy. It can be used in future for the detection of disease in the early phase and targeted therapy.

Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in Living Donor Liver Transplantation: A Randomized Trial.

Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine-tryptophan-ketoglutarate solution either via both the HA and portal vein (DP group, n = 62) or only through the portal vein (standard perfusion [SP] group, n = 62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09-0.95; P = 0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2 groups. The 3-year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P = 0.004 and P = 0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P = 0.04 and P < 0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

Randomized trial on extended versus modified right lobe grafts in living donor liver transplantation.

Despite advances in the practice of living donor liver transplantation (LDLT), the optimum surgical approach with respect to the middle hepatic vein (MHV) in right lobe LDLT remains undefined. We designed a randomized trial to compare the early postoperative outcomes in recipients and donors between extended right lobe grafts (ERGs; transection plane was maintained to the left of MHV and division of MHV performed beyond the segment VIII vein) and modified right lobe grafts (MRGs; transection plane was maintained to the right of MHV; the segment V and VIII drainage was reconstructed using a conduit of recipient portal vein). Eligible patients (n = 86) were prospectively randomized into the ERG arm (n = 43) and the MRG arm (n = 43) at the beginning of donor hepatectomy. The primary endpoint considered in this equivalence trial was patency of the MHV or the reconstructed "neo-MHV" in the recipient. The secondary endpoints included biochemical parameters, postoperative complications, mortality in recipients as well as donors and volume regeneration of remnant liver in donors, measured at 2 months. The patency of the MHV was comparable in the ERG and MRG arms (90.7% versus 81.4%; difference, 9.3%; 95% confidence interval [CI], -5.8 to 24.4; z score, 1.245; P = 0.21). Volume regeneration of the remnant liver in donors was significantly better in the MRG arm (111.3% versus 87.3%; mean difference, 24%; 95% CI, 14.6-33.3; P < 0.001). The remaining secondary endpoints in donors and recipients were similar between the 2 arms. To conclude, MRG with reconstructed neo-MHV has comparable patency to native MHV in ERG and confers equivalent graft outflow in the recipient. Furthermore, it allows better remnant liver regeneration in the donor at 2 months. Liver Transplantation 24 888-896 2018 AASLD.

Biliary complications among live donors following live donor liver transplantation.

INTRODUCTION: In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse. METHODS: Prospective evaluation of 452 live donors over 10 years was performed to ascertain the incidence & risk factors of clinically significant biliary complications. RESULTS: Of the 452 donor hepatectomies (M: F = 114:338, median age = 38), 66.2% (299) were extended right lobe grafts, 24.1% (109) modified right lobe and 9.7% (44) were left lobe grafts. Portal vein anatomy was Type-I in 85% (386), Type-II in 7.5% (34) and Type-III in 7.1% (32). Following donor hepatectomy, a single bile duct opening occurred only in 46.5% (210) of the grafts. Of the remaining 53.5% grafts, 2 ductal openings were noted in 217 (48%) and three ductal openings in 25 (5.5%). Incidence of multiple openings in the duct were more commonly noted in Type II (70.6%) and III (75%) portal vein anatomy than in grafts with Type I (50.4%) portal anatomy (P = 0.001) Bile leak was noted in 15 (3.3%) donors which included one broncho-biliary fistula and bilio-pleural fistula. Analysis revealed no association between post-operative biliary complications and type of graft, portal vein anatomy or biliary anatomy. There was a single mortality in this series secondary to biliary sepsis. On long term follow, there were no biliary strictures in any of the patients. CONCLUSIONS: Biliary complications although rare (3.3%), present significant peri-operative morbidity to the donors.

Perioperative prostaglandin e1 infusion in living donor liver transplantation: A double-blind, placebo-controlled randomized trial.

The role of prostaglandin E1 (PGE1) infusion in improving early graft function has not been well defined, especially in the scenario of living donor liver transplantation (LDLT). We designed a randomized, double-blind, placebo-controlled trial to evaluate the role of perioperative PGE1 infusion in LDLT. Patients in the study arm received PGE1 (alprostadil) at the rate of 0.25 µg/kg/hour, starting at 1 hour after portal venous reperfusion, and continued for 96 hours. The primary endpoint was early allograft dysfunction (EAD). We analyzed multiple secondary endpoints including postoperative liver function and renal function parameters, acute kidney injury (AKI), hepatic artery thrombosis (HAT), postoperative bleeding, overall mortality, and posttransplant hospital stay. The incidence of EAD was lower in the PGE1 arm, although the difference did not reach statistical significance (22.4% versus 36%; P = 0.21). Among the secondary endpoints, the incidence of AKI was significantly lower in the PGE1 arm (8.2% versus 28%; P = 0.02), as were the peak and mean postoperative creatinine levels. The need for renal replacement therapy was similar between the 2 groups. Among the postoperative graft function parameters, postoperative alanine aminotransferase level was significantly lower in the PGE1 arm (P = 0.04), whereas the remaining parameters including serum bilirubin, aspartate aminotransferase, and international normalized ratio were similar between the 2 arms. There was no difference in the incidence of HAT and postoperative bleeding, in-hospital mortality, and posttransplant hospital stay between the 2 arms. Perioperative PGE1 infusion reduces the incidence of posttransplant renal dysfunction in patients undergoing LDLT. Liver Transplantation 22 1067-1074 2016 AASLD.

Reconstructive techniques following low anterior resection for carcinoma of the rectum.

INTRODUCTION: Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied. EVIDENCE ACQUISITION: PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023. EVIDENCE SYNTHESIS: Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown. CONCLUSIONS: In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.

The Practice of Pancreatoduodenectomy in India: A Nation-Wide Survey.

Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.

IgG4-Related Pancreato-Biliary Disease in the Disguise of Malignancy.

The Immunoglobulin G4-related disease (IgG4-RD) is a multisystem inflammatory condition. Pancreaticobiliary manifestations often present as mass lesions that mimic malignancies. The diagnosis is confirmed by histopathological examination, that shows lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and positive immunohistochemistry for IgG4. We encountered 3 such patients in a tertiary care hospital in India. Two patients presented with obstructive jaundice and the third with pain abdomen. They had resectable lesions involving the pancreatic head, the right hepatic duct, and gallbladder fundus, respectively, on imaging. Tumor markers were not significantly elevated in any of them. All 3 patients underwent radical surgeries, suspecting malignancy. Surgical specimens showed typical features of IgG4-RD on histomorphology. Serum IgG4 level was elevated in first 2 patients but was normal in sclerosing cholecystitis patient. To conclude, IgG4-RD is a malignant mimicker; hence, on clinical suspicion, liberal attempts for tissue diagnosis may avoid radical surgeries.

Expression of ER, PR, and HER-2 Neu and correlation with tumor markers in gall bladder carcinoma.

Background: Females having a large proportion of gallbladder carcinoma (GBC) and a higher incidence of gallstones pointed toward the role of sex hormones in GBC development. In this study, we evaluated the expression of Estrogen receptor (ER), Progesterone receptor (PR), and Her2/neu and their correlation with tumor markers and clinicopathological parameters in the GBC. Methods: A total of 50 patients of GBC and 42 patients in control group undergoing surgery for other conditions were taken. The patient's biopsy sample's paraffin block was tested for ER, PR, and Her2/neu expression by immunohistochemistry. Results: ER and PR had no significant expression in GBC and control group, but Her2/neu had 16% expression in GBC, significantly associated with the degree of differentiation with 62.5% (n-5) being well-differentiated; 75% of Her2/neu positive were in stages III and IV. Her2/neu did not correlate with tumor markers despite expression. Conclusions: Her2/neu amplification is a small step in validating that option so it could be included in the treatment and prognostication of GBC.

Staple Line Dehiscence in Gastric Conduit Following Esophagectomy: A Complication Conspicuously Missing a Mention It Deserves.

Following esophagectomy, anatomical reconstruction with a gastric tube is the most common practice. The construction of the gastric tube is done with staplers nowadays, be it a minimally invasive esophagectomy or a conventional open surgery. Even though anastomotic leak and conduit necrosis are reported widely in the literature, the number of studies on staple line dehiscence is meager in comparison. Management of conduit failure usually sacrifices conduit combined with a diverting cervical esophagostomy. We report a case of successful surgical management of a big staple line dehiscence and 'salvaging of the conduit'.

Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled.

Squamous cell carcinoma (SCC) involving the gastrointestinal tract is exceptionally rare, except in the esophagus and the anal canal. In the hindgut, a common site of involvement is the colo-rectum, commonly seen in the fifth decade of life. The presentation is usually in the advanced stages and carries a poor prognosis. Due to the rarity of the disease, before labeling it as a primary lesion, the possibility of metastasis from a distant primary should be entertained. Consensus guidelines regarding the management of such a rare condition are lacking. Here, we present the case of an elderly gentleman with a history of surgery for urinary bladder cancer 20 years back (the nature of which is not known). The patient presented with left lower abdominal pain and altered bowel habits. His pain had persisted for approximately two months along with a recent onset of overflow incontinence but no other associated constitutional symptoms. Examination revealed pallor and a vague abdominal mass in the left iliac fossa. On further evaluation with a colonoscopy, a growth was seen in the sigmoid colon. Computed tomography of the abdomen revealed a locally invasive growth arising from the sigmoid colon along with a space-occupying lesion in the left lobe of the liver enhancing on the portal phase. Biopsy from the sigmoid and the liver lesion was reported as SCC which was confirmed by immunohistochemistry. Given the metastatic nature of the lesion, treatment options were discussed in a multidisciplinary team setting, and the decision was made to proceed with diversion colostomy and palliative chemotherapy. SCC of the colon is a rare disease and is usually diagnosed at an advanced stage. Even in operable cases, the prognosis is dismal, and various treatment modalities have been attempted. Due to the rarity of the disease and paucity of data regarding definitive management, treatment varies from one patient to another.

Rapid Workforce Development to Combat the COVID-19 Pandemic: Experience From a Tertiary Health Care Centre in North India.

Introduction During a large-scale disease outbreak, one needs to respond to the situation quickly towards capacity building, by identifying areas that require training and planning a workable strategy and implementing it. There are limited studies focused on fast-track workforce creation under challenging circumstances that demand mandatory social distancing and discouragement of gatherings. This study was conducted to analyze the planning process and implementation of fast-track training during the Coronavirus disease (COVID-19) pandemic, and evaluate its effectiveness in building a rapid, skilled, and massive workforce. Methods A cross-sectional study was conducted to evaluate rapid preparedness training delivered from March to June 2020, based on documents and data regarding the process, planning, and implementation for large-scale capacity building. Pre-test and post-test scores were compared to assess the effectiveness of training. The number of personnel trained was evaluated to determine the efficiency of the training program. Data on COVID-19 among health care workers (HCWs) were analyzed. Results The Advanced Center of Continuous Professional Development acted as the central facility, quickly responding to the situation. A total of 327 training sessions were conducted, including 76 online sessions with 153 instructors. The capacity-building of 2,706 individuals (913 clinicians and 1,793 nurses, paramedics, and non-medical staff) was achieved through multiple parallel sessions on general precautionary measures and specialized skills within four months. The rate of hospital staff infected with COVID-19 was found to be 0.01% over five months. Conclusions A fast-track, efficient, large-scale workforce can be created through a central facility even under challenging circumstances which restrict gatherings and require physical distancing. A training action plan for disease outbreaks would be a useful resource to tackle such medical emergencies affecting substantial populations in future.

Investigating infection management and antimicrobial stewardship in surgery: a qualitative study from India and South Africa.

OBJECTIVES: To investigate the drivers for infection management and antimicrobial stewardship (AMS) across high-infection-risk surgical pathways. METHODS: A qualitative study-ethnographic observation of clinical practices, patient case studies, and face-to-face interviews with healthcare professionals (HCPs) and patients-was conducted across cardiovascular and thoracic and gastrointestinal surgical pathways in South Africa (SA) and India. Aided by Nvivo 11 software, data were coded and analysed until saturation was reached. The multiple modes of enquiry enabled cross-validation and triangulation of findings. RESULTS: Between July 2018 and August 2019, data were gathered from 190 hours of non-participant observations (138 India, 72 SA), interviews with HCPs (44 India, 61 SA), patients (six India, eight SA), and case studies (four India, two SA). Across the surgical pathway, multiple barriers impede effective infection management and AMS. The existing implicit roles of HCPs (including nurses and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating infection-related care across the surgical team. Critically, the ownership of decisions remains with the operating surgeons, and entrenched hierarchies restrict the inclusion of other HCPs in decision-making. The structural foundations to enable staff to change their behaviours and participate in infection-related surgical care are lacking. CONCLUSIONS: Identifying the implicit existing HCP roles in infection management is critical and will facilitate the development of effective and transparent processes across the surgical team for optimized care. Applying a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads, is essential for integrated AMS and infection-related care.

Patient understanding of and participation in infection-related care across surgical pathways: a scoping review.

OBJECTIVE: To explore the existing evidence on patient understanding of and/or participation in infection-related care in surgical specialties. METHOD: A scoping review of the literature was conducted. PubMed, Web of Science, Scopus, and grey literature sources were searched using predefined search criteria for policies, guidelines, and studies in the English language. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. RESULTS: The initial search identified 604 studies, of which 41 (36 from high-income and five from low- and middle-income countries) were included in the final review. Most of the included studies focused on measures to engage patients in infection prevention and control (IPC) activities, with few examples of antimicrobial stewardship (AMS) engagement strategies. While patient engagement interventions in infection-related care varied depending on study goals, surgical wound management was the most common intervention. AMS engagement was primarily limited to needs assessment, without follow-up to address such needs. CONCLUSION: Existing evidence highlights a gap in patient participation in infection-related care in the surgical pathway. Standardization of patient engagement strategies is challenging, particularly in the context of surgery, where several factors influence how the patient can engage and retain information. Infection-related patient engagement and participation strategies in surgery need to be inclusive and contextually fit.

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario.

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.