An Indian surgeon's perspective on management of asymptomatic gallstones

INTRODUCTION

Cholelithiasis is widely prevalent in India, with a majority of patients being asymptomatic while a small proportion experiencing mild complications. In the laparoscopic era, the rate of cholecystectomies has increased owing to early recovery and fewer complications. In asymptomatic patients, the risk of complications must be balanced against the treatment benefit. Recent guidelines suggest no prophylactic cholecystectomy in asymptomatic patients. We aimed to find out the Indian surgeons' perspective on asymptomatic gallstone management.

METHODS

A cross-sectional e-survey was conducted of practicing surgeons, onco-surgeons and gastrointestinal-surgeons in India. The survey had questions regarding their perspective on laparoscopic cholecystectomy and treatment modalities in asymptomatic gallstones.

RESULTS

A total of 196 surgeons responded to the survey. Their mean age was 42.3 years. Overall, 111 (57%) respondents worked in the private sector. Most surgeons (164) agreed that the rate of cholecystectomy has increased since the advent of laparoscopy; 137 (70%) respondents agreed that they would not operate on patients without risk factors. Common bile duct stones, chronic hemolytic diseases, transplant recipients, and diabetes mellitus were the risk factors. Majority of the participants agreed on not performing a cholecystectomy in patients with asymptomatic gallstones.

CONCLUSION

There exists a lack of consensus among Indian surgeons on asymptomatic gallstone management in India. Where the majority of cases are asymptomatic and do not require surgery, certain comorbidities can influence the line of treatment in individual patients. Currently, the treatment guidelines for asymptomatic patients need to be established as cholecystectomies may be overperformed due to the fear of development of complications.

Innovative blood transfusion strategies to address global blood deserts: a consensus statement from the Blood Delivery via Emerging Strategies for Emergency Remote Transfusion (Blood DESERT) Coalition

In rural settings worldwide, many people live in effective blood deserts without access to any blood transfusion. The traditional system of blood banking is logistically complex and expensive for many resource-restricted settings and demands innovative and multidisciplinary solutions. 17 international experts in medicine, industry, and policy participated in an exploratory process with a 2-day hybrid seminar centred on three promising innovative strategies for blood transfusions in blood deserts: civilian walking blood banks, intraoperative autotransfusion, and drone-based blood delivery. Participant working groups conducted literature reviews and interviews to develop three white papers focused on the current state and knowledge gaps of each innovation. Seminar discussion focused on defining blood deserts and developing innovation-specific implementation agendas with key research and policy priorities for future work. Moving forward, advocates should prioritise the identification of blood deserts and address the context-specific challenges for these innovations to alleviate the ongoing crisis in blood deserts.

Does women empowerment associate with reduced risks of intimate partner violence in India? evidence from National Family Health Survey-5

BACKGROUND

Women empowerment is commonly believed to be an important factor affecting a woman's likelihood of facing violence from her intimate partner. Even as countries invest in policies that aim to strengthen women empowerment, studies show that increase in women empowerment does not necessarily decrease intimate partner violence (IPV) against them. Against this paradox, the present study seeks to understand the specific empowerment components that associate with IPV against women in India. It also studies the state-level distribution of the different types of IPV.

METHODS

The study analyses state-level data from the National Family Health Survey, India (2019-21). A total of 72,056 women responded to the domestic violence questionnaire. The Dimension Index (DI) was used to compute composite scores for Women Empowerment and for IPV to rank states and Union Territories. The correlation between Women Empowerment and IPV scores was determined using Spearman's rank correlation coefficient.

RESULTS

The state of Karnataka had the highest composite score of IPV and also showed the highest burdens of physical, sexual and emotional IPV, while Lakshadweep had the lowest burden. Physical IPV was the most common form of IPV for most states across the country. The states in the western part of India had reduced burdens for all three types of IPV. Three specific components of empowerment, viz. household decision-making and mobile phone ownership significantly associated with reduction of all three types of IPV. Hygienic menstrual practices strongly associated with reduction of sexual and emotional IPV. However, property ownership of women increased risks of all three types of IPV, while employment had no significant association with any type of IPV.

CONCLUSIONS

The study found no significant reduction in overall IPV with improvement in women empowerment. However, it identifies components of empowerment that associate with IPV. Household decision-making, ownership of mobile phones, and hygienic menstrual practices associated with a lowered risk. By contrast, owning property increased the risk. The findings of this study would inform future research and intervention that aim to strengthen specific components of women empowerment in India and other low-and-middle-income countries.

Recognising socio-cultural barriers while seeking early detection services for breast cancer: a study from a Universal Health Coverage setting in India

BACKGROUND

Breast cancer is the commonest cancer among women in India, yet the uptake of early detection programs is poor. This leads to late presentation, advanced stage at the time of diagnosis, and high mortality. Poor accessibility and affordability are the most commonly cited barriers to screening: we analyse socio-cultural factors influencing the uptake of early detection programmes in a Universal Health Coverage (UHC) setting in India, where geographical and financial barriers were mitigated.

METHODS

Two hundred seventy-two women engaging in an awareness-based early detection program were recruited by randomization as the participant (P) group. A further 272 women who did not participate in the early detection programme were recruited as non-participants (NP). None of the groups were previously screened for breast cancer. Interviews were conducted using a 19-point questionnaire, consisting of closed-ended questions regarding demographics and social, cultural, spiritual and trust-related barriers.

RESULTS

The overall awareness about breast cancer was high among both groups. None of the groups reported accessibility-related barriers. Participants were more educated (58.09% vs 47.43%, p = 0.02) and belonged to nuclear families (83.59% vs 76.75%, p = 0.05). Although they reported more fear of isolation due to stigma (25% vs 14%, p = 0.001), they had greater knowledge about breast cancer and trust in the health system compared to non-participants.

CONCLUSIONS

The major socio-cultural barriers identified were joint family setups, lower education and awareness, and lack of trust in healthcare professionals. As more countries progress towards UHC, recognising socio-cultural barriers to seeking breast health services is essential in order to formulate context-specific solutions to increase the uptake of early detection and screening services.

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

Geometric analysis of the humeral head and glenoid in the Indian population and its clinical significance

BACKGROUND

Total anatomic and reverse shoulder prostheses are designed to match the dimensions of the native bony anatomy. Chinese and Japanese bony dimensions of the shoulder have been found to be different from that of the Caucasian population. We hypothesized that the geometric dimensions of the humeral head and glenoid in the Indian population would also be different from that of the Caucasian population.

METHOD

Fifty patients underwent computerized tomographic scans of their normal shoulders. We calculated the superoinferior (SI) diameter of the humeral head, anteroposterior diameter of the humeral head, radius of curvature of the humeral head, humeral head retroversion, humeral head thickness, inclination angle, critical shoulder angle, greater tuberosity angle, glenoid width, glenoid length, radius of curvature of the glenoid, glenoid inclination angle, and glenoid version.

RESULTS

The radius of curvature of the humeral head averaged 22.9 ± 1.7 mm, the articular surface thickness 17.1 ± 1.6 mm, and the SI diameter 42.3 ± 3 mm. The SI diameter strongly correlated with the thickness (r = 0.617, P = .001). The anteroposterior/SI articular surface diameter ratio averaged 0.9 ± 0.9, the articular surface thickness/radius of curvature ratio 0.7 ± 0.9, the inclination angle 133.8 ± 6.4, and the retroversion angle 33.5° ± 8.5°. The radius of curvature of the glenoid averaged 23.3 ± 3.4 mm, the glenoid width 24.0 ± 2 mm, the SI length 31.3 ± 2.2 mm, the glenoid inclination angle 78.7° ± 4.8°, and the glenoid retroversion 1.8° ± 3.8°.

DISCUSSION

Compared with the Western population, our cohort had a smaller humeral radius of curvature (P = .04), smaller articular surface diameter (P = .001), smaller inclination angle (P = .003), larger retroversion angle of the humeral head (P < .001), and smaller glenoid length and width (P < .0001). Most of the implant companies did not have smaller sized combinations of humeral heads with thickness to match our population. The glenoid width of females in our cohort was found to be smaller for the smallest size of the glenoid base plate.

CONCLUSION

Smaller sized options in humeral head diameter and thickness of the anatomic prosthesis and glenoid baseplate of the reverse shoulder prosthesis need to be made available to suit our population and avoid a mismatch.

Ventricular tachycardia in structurally normal hearts: recognition and management

Idiopathic ventricular tachycardia is a defined set of tachycardias when structural or pathological cause has been ruled out for the same. This paper tries to define and classify these arrhythmias to organize a logical therapeutic approach to deal with them. 60-80% of the idiopathic tachycardias originate from the right ventricular outflow tract (RVOT) and in 10% from the left ventricular outflow tract (LVOT). Outflow tract tachycardias have either LBBB or RBBB morphology with early R wave transition in chest leads. Adenosine, beta blockers and calcium channel blockers is the common medical treatment. Radiofrequency ablation is however the treatment of choice. Verapamil sensitive left ventricular tachycardia (ILVT) and propranolol sensitive left ventricular tachycardia (IPVT) are the other two forms recognized. RF ablation seems ideal for long-term management of ILVT and implantable cardioverter defibrillator (ICD) for IPVT. Inherited channelopathies include catecholaminergic polymorphic ventricular tachycardia (CPVT), Brugada syndrome and long QT syndrome where there is an inherited disorder in the ion-exchange channels of the cell-membrane leading to tachycardia. Prognosis in these is variable; CPVT, in particular, has a malignant course when untreated. RF ablation and placement of an ICD are important in the overall management of specific arrhythmia.