The World Neurosurgery Global Champions Program: First-Year Experience of a Model Initiative for Reducing Disparities in Global Neurosurgical Literature

OBJECTIVE

Most surgical journals are published in English, representing a challenge for researchers from non-Anglophone countries. We describe the implementation, workflow, outcomes, and lessons learned from the World Neurosurgery Global Champions Program (GCP), a novel journal-specific English language editing program for articles rejected because of poor English grammar or usage.

METHODS

The GCP was advertised via the journal website and social media. Applicants were selected to be a reviewer for the GCP if they demonstrated English proficiency on writing samples supplied in their application. The demographics of GCP members and characteristics and outcomes of articles edited by the GCP during its first year were reviewed. Surveys of GCP members and authors who used the service were conducted.

RESULTS

Twenty-one individuals became part of the GCP, representing 8 countries and 16 languages apart from English. A total of 380 manuscripts were peer-reviewed by the editor-in-chief, who determined these manuscripts to have potentially worthwhile content but needed to be rejected due to poor language. The authors of these manuscripts were informed of the existence of this language assistance program. Forty-nine articles (12.9%) were edited by the GCP in 41.6 ± 22.8 days. Of 40 articles resubmitted to World Neurosurgery, 24 (60.0%) were accepted. GCP members and authors understood the purpose and workflow of the program and recognized improvements in article quality and the probability of acceptance through their participation.

CONCLUSION

The World Neurosurgery Global Champions Program mitigated a critical barrier to publication in an English language journal for authors from non-Anglophone countries. This program promotes research equity by providing a free, largely medical student and trainee operated, English language editing service. This model or a similar service can be replicated by other journals.

Physician empathy during crisis: A survey of doctors in COVID-19 pandemic (COPE study)

Background

There is a lack of research studies on physician empathy levels towards patients, which is a critical component of providing high-quality patient-care and satisfaction. Our study aimed at assessing the physician-reported empathy levels towards patients during a crisis like the ongoing COVID-19 pandemic.

Methods

Cross-sectional online-based survey was conducted among 409 practicing doctors from varied healthcare levels during the pandemic. We used a validated Jefferson Physician's Empathy (JPE) - Health Professional (HP) version questionnaire. Empathy score was expressed as a median and interquartile range, and the analysis was done in STATA 12.1 (StataCorp LP, Texas, USA).

Results

Among the survey respondents, 55% were between 26-35 years, 56% were from the government health sector, and 57% were male doctors. Overall physicians' empathy score was 100 (89, 113). The empathy score among physicians engaged in OPD duty was significantly higher (p = 0.022). A total of 70.0% of physicians consulting more than 50 patients/day reported a score ≤105 (p = 0.035). Physicians aged more than 40 years (AOR = 2.545, 95% CI = 1.1133, 5.8184) and those working in government healthcare centers (AOR = 2.711, 95% CI = 1.1372, 6.4616) were about three times more likely to have a score >105 compared to younger physicians (p = 0.027) and private practitioners (p = 0.024).

Conclusion

Physician-reported empathy scores during the COVID pandemic were high. Middle-aged physicians involved in OPD consultation and those working in government healthcare recorded good scores. However, reporting lower empathy scores when the patient load increases highlights the need for administrative and medical education interventions.

Epidemiology, clinical presentation and management of COVID-19 associated mucormycosis: A single center experience from Pune, Western India

Background

The second COVID‐19 wave in India has been associated with an unprecedented increase in cases of COVID‐19 associated mucormycosis (CAM), mainly Rhino‐orbito‐cerebral mucormycosis (ROCM).

Methods

This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all‐cause mortality due to CAM.

Results

59 patients were diagnosed with CAM. Median duration from the first positive COVID‐19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID‐19. 56% patients were prescribed steroids for non‐hypoxemic, mild COVID‐19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID‐19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death.

Conclusions

CAM is a rapidly progressive, angio‐invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases.

Survey of antidoping knowledge, attitudes and practices amongst elite Indian sportsmen and the way forward

BACKGROUND

Indian sportspersons have reported several antidoping rule violations with several cases suggesting inadvertent use of prohibited substances. This study was designed to evaluate the anti-doping knowledge, attitudes and practices amongst elite Indian sportsmen to suggest future interventions.

METHODS

This study conducted at a Sports institute used an anonymized questionnaire to survey 181 male (18-35 years old) elite young athletes' attitudes toward performance-enhancing substances and anti-doping rules.

RESULTS

Athlete awareness regarding antidoping agencies and antidoping rule violations was poor. 40% or less reported receiving antidoping updates. All reported improvement in antidoping knowledge and attitude changes after attending updates. Health is more important than sporting performance for 80% or more. Very low percentage reported consumption of banned substances amongst themselves and team mates. One-third of these athletes reported not having being tested for banned substances. Athletes who have attended antidoping sessions exhibit significantly higher knowledge levels and a significantly higher 80% reported consulting their Team doctor before any therapeutic drug use as compared with non-attendees.

CONCLUSION

Indian elite athletes report low awareness about anti-doping rules and prohibited substances with low proportion of athletes reporting doping and being tested for doping. Grass root level education, supplement regulation, trained athlete support personnel and accessible reference material seems to be the way forward.

Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India

Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.

Efficacy and safety of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg, lamivudine 300 mg and efavirenz 400 mg as a switch strategy in virologically suppressed HIV-1-infected subjects on nonnucleoside reverse transcriptase inhibitor-containing first-line antiretroviral therapy in Pune, India

OBJECTIVES

As per National AIDS Control Organization (NACO) estimates, there are 2.1 million people living with HIV (PWH) in India, of whom 1.2 million are on first-line antiretroviral therapy (ART). This study explored the use of a single-tablet regimen containing tenofovir disoproxil fumarate 300 mg + lamivudine 300 mg + efavirenz 400 mg (TLE400 STR) as a first-line switch strategy in PWH in Pune, India.

METHODS

This retrospective cohort study was conducted in private sector ART clinics in three tertiary-level hospitals in Pune, India. PWH > 12 years of age (n = 502) who initiated first-line ART (predominantly TLE600 STR), completed ≥ 6 months of follow-up and achieved virological suppression [plasma viral load (VL) < 1000 HIV-1 RNA copies/mL] were identified and switched to TLE400 STR. The virological and immunological efficacy of TLE400 STR at 6 and 12 months of follow-up were noted. Grade 3/4 adverse events (especially efavirenz-related neuropsychiatric adverse events) leading to regimen discontinuation were also noted.

RESULTS

Of 502 PWH who switched to TLE400 STR, complete virological suppression (VL < 20 copies/mL) was maintained in more than 97% of patients at follow-up. TLE400 STR was successful in maintaining CD4 counts within the range observed at the start of the regimen. Grade 3/4 adverse events leading to TLE400 STR discontinuation were seen in 11 (2.2%) patients. Virological failure (VL > 1000 copies/mL) and treatment regimen failure were seen in six (1.2%) and 49 (9.8%) subjects, respectively.

CONCLUSIONS

TLE400 STR exhibits excellent efficacy and safety as a switch strategy and should be introduced in the Indian National ART Program, especially for PWH who are virologically suppressed on TLE600 STR.

Incidence of tuberculosis among HIV infected individuals on long term antiretroviral therapy in private healthcare sector in Pune, Western India

Background

Despite rapid scale up of antiretroviral therapy (ART), Tuberculosis (TB) remains the commonest opportunistic infection and cause of death among HIV infected individuals in resource limited settings like India. Incidence of TB in individuals on ART in private healthcare sector in India is infrequently studied.

Methods

This retrospective cohort study conducted between 1st March 2009 and 1st March 2017 aimed to evaluate rate of incident TB in individuals initiated on ART at 3 private sector ART clinics in Pune, India. Individuals more than 12 years of age with ART duration of atleast 6 months were included. Patients were classified as having prevalent TB if they had a TB episode within the year prior to ART initiation or if they developed TB within 6 months of starting ART. Individuals who were diagnosed with TB after 6 months of starting ART were classified as incident TB cases. A recurrent episode of TB after treatment completion or cure of prevalent TB was also regarded as incident TB. Patients were classified as definitive TB if Mycobacterium tuberculosis was grown in culture from a biological sample or a positive rapid molecular test. Patients were classified as probable TB if there was radiologic evidence of TB in absence of confirmatory culture or PCR.

Results

1904 patients with a median duration of follow up on ART of 57 (IQR = 32.0, 84.0) months were included. Of these, 182 developed incident TB (22% definitive TB, 38% recurrent cases). TB incidence at 6–12 months, 13–24 months, 25–60 months and > 60 months of ART was 24.32, 5.46, 2.54 and 0.75 cases per 100 person years respectively. Current time updated CD4 count < 500 cells/mm³ (p < 0.0001), virologic failure on ART (adjusted Hazard Ratio (aHR): 3.05 (95% CI: 2.094, 4.454), p < 0.0001) and receipt of ART without IPT (aHR: 8.24 (95% CI, 3.358, 20.204), p < 0.0001) were associated with higher risk of incident TB.

Conclusion

Starting ART early in treatment naïve individuals, prompt detection of virologic failure on ART and providing IPT along with ART will be useful in reducing incident TB. Efforts from private sector are crucial in achieving Sustainable Development Goals set by Government of India and attaining the vision of a TB free India.

Cost-effectiveness of a repeat HIV test in pregnancy in India

OBJECTIVE

To evaluate cost-effectiveness of second HIV test in pregnancy.

BACKGROUND

Current strategy of single HIV test during pregnancy in India can miss new HIV infections acquired after the first test or those HIV infections that were missed in the first test due to a false-negative HIV test.

METHODS

Between August 2011 and April 2013, 9097 pregnant HIV uninfected women were offered a second HIV test near term (34 weeks or beyond) or within 4 weeks of postpartum period. A decision analysis model was used to evaluate cost-effectiveness of a second HIV test in pregnant women near term.

PRIMARY AND SECONDARY OUTCOME

Our key outcome measures include programme cost with addition of second HIV test in pregnant women and quality-adjusted life years (QALYs) gained.

RESULTS

We detected 4 new HIV infections in the second test. Thus HIV incidence among pregnant women was 0.12 (95% 0.032 to 0.297) per 100 person women years (PWY). Current strategy of a single HIV test is 8.2 times costlier for less QALYs gained as compared to proposed repeat HIV testing of pregnant women who test negative during the first test.

CONCLUSIONS

Our results warrant consideration at the national level for including a second HIV test of all pregnant women in the national programme. However prior to allocation of resources for a second HIV test in pregnancy, appropriate strategies will have to be planned for improving compliance for prevention of mother-to-child transmission of HIV and reducing loss-to-follow-up of those women detected with HIV.

TRIAL REGISTRATION NUMBER

CTRI/2013/12/004183.

Cervical cancer screening and treatment of cervical intraepithelial neoplasia in female sex workers using "screen and treat" approach

Objective

Female sex workers (FSWs) are at an increased risk of human immunodeficiency virus (HIV) as well as human papillomavirus (HPV) infections and thus have an increased risk of cervical intraepithelial neoplasia (CIN) and cervical cancer. We evaluated the feasibility of “screen and treat approach” for cervical cancer prevention and the performance of different screening tests among FSWs.

Methods

Women were screened using cytology, VIA (visual inspection with acetic acid), and VILI (visual inspection with Lugol’s iodine) and underwent colposcopy, biopsy, and immediate treatment using cold coagulation, if indicated, at the same visit.

Results

We screened 300 FSWs of whom 200 (66.67%) were HIV uninfected and 100 (33.34%) were HIV infected. The overall prevalence of CIN 2–3 lesions was 4.7%. But all women with CIN 2–3 lesions were HIV infected, and thus the prevalence of CIN 2–3 lesions in HIV-infected FSWs was 14/100 (14%, 95% confidence interval: 7.2–20.8). All of them screened positive by all three screening tests. Cold coagulation was well tolerated, with no appreciable side effects.

Conclusion

Cervical cancer prevention by “screen and treat” approach using VIA, followed by ablative treatment, in this high-risk group of women is feasible and can be implemented through various targeted intervention programs.

The third phase of HIV pandemic: social consequences of HIV/AIDS stigma & discrimination & future needs

An overview of social responses to AIDS, characterized by high levels of stigma, discrimination central to the global AIDS challenge, as related to human dignity is described. Stigma is conceptualized as a problem of 'they' and 'us', or interactions perspective. Causes and consequences to enable the varied perspectives in understanding this third epidemic of social impact of HIV/AIDS are described. In the absence of an effective medical intervention, the social factors like stigma and discrimination attached to HIV/AIDS are a major obstacle in the curtailment of the disease requiring urgent action. The different forms of stigma associated with other diseases are compared. Ignorance about the disease, fear of discrimination and consequent denial for testing and treatment, contribute to spread of the disease. The disease status adds to vulnerability especially in women. The disease is often identified with groups like intravenous drug users (IDUs), and homosexuals who face a double stigma as a result of HIV. Research scenario on stigma associated with HIV/AIDS is reviewed to understand the future needs. Initiatives of ongoing intervention to reduce stigma exist globally. Emerging issues in research priorities have been highlighted to counter consequences of pandemic from social perspective of human dignity and rights.

Copper levels & reactive oxygen species in uterine flushings in copper intrauterine contraceptive device users

Copper levels were estimated in the uterine flushings in 15 copper 'T' 200 device acceptors. There was a statistically significant difference in the preinsertion and one week post insertion values (P < 0.001). This also corresponded to a high level of generation of reactive oxygen species. The levels of reactive oxygen species were similar to preinsertion values at 4 and 12 wk. The copper values declined over the 3 months but were still higher at 12 wk as compared to preinsertion levels and this difference was statistically significant. Hence addition of copper to the intrauterine device besides enhancing the contraceptive efficacy, perhaps also plays an important role in microbicidal activity and helps in overcoming the infection introduced at the time of insertion.

Asymptomatic axial torsion of the pregnant uterus: a cause of the failure of induction of mid-trimester abortion

Torsion of gravid uterus is a rare obstetric condition in which diagnosis is usually made only on laparotomy. A case of asymptomatic axial torsion of uterus during mid-trimester, because of an ovarian cyst is reported. This presented as a failure of induction of abortion by extra-amniotic isotonic saline instillation and oxytocin infusion.

A continuum model of elephant trunks

A continuum model is presented that relates the trunk parameters of loading, geometry, and muscle structure to the necessary conditions of static equilibrium. Linear theory for stress-strain behavior is used to describe an elephant trunk for an incremental displacement as the animal slowly lifts a weight at the trunk tip. With this analysis and experimental values for the trunk parameters, the apparent trunk stiffness Ea is estimated for the living animal. For an Asian elephant with a maximum compression strain of 33 percent, Ea is of the order of 10(6) N/m2. The continuum model is quite general and may be applied to similar nonskeletal appendages and bodies of other animals.

Macroscopic tuboplasty: reversal of female sterilization

Data is presented regarding 57 women who underwent reversal of sterilization procedure. In the majority (90%), the reason for request for reversal of procedure was loss of male child or more than one child. Thirteen subjects never came back for follow-up. Out of 39 subjects in whom follow-up is available for more than 3 months, in 35 (90%) the tubes are patent. There were 25 pregnancies in 21 subjects and incidence of viable pregnancy was 88% with only ectopic pregnancy (4%). In these 35 cases whose tubes were found to be patent post tuboplasty, 18 had laparoscopic ring application, 16 had abdominal tubal ligation and one had undergone vaginal tubal ligation. Thirteen subjects (62%) conceived within 6 months after reversal. In this series, no loupe or operating microscope was used.

Ultrasound guided intrauterine transfusion

Intrauterine transfusion was performed on 12 occasions in 9 Rh-sensitizedwomen. Under constant real-time ultrasound guidance, a 17G Touhy needle was negotiated through a placenta-free area and advanced into the foetal abdomen to reach the peritoneal cavity. After confirming the position of the needle, either by aspiration of foetal ascitic fluid or by injecting air into the peritoneal cavity, an epidural catheter was passed through the needle and the transfusion was accomplished. This procedure was successful in 11 (91%) of the 12 instances. In one patient the needle could not be placed in the foetal peritoneal cavity despite repeated. attempts; she developed pyrexia and went into spontaneous labour. The neonatal survival rate was 22% (2/9). The ultrasound guided technique not only eliminates the risk of radiation hazards, but also helps in precise placement of the needle in the uterus and foetal peritoneal cavity, which makes intrauterine transfusion safe.

A comparison of extra-amniotic physiological saline and ethacridine dye instillation for induction of mid-trimester abortion

In a prospective, randomized study of 209 patients, we induced mid-trimester abortion by instilling either normal saline (105cases) or ethacridine dye (Emcredil^®) (104cases) extra-amniotically. The mean induction-abortion interval for saline was 18 hours 25 minutes and for emcredil20 hours 12minutes. For a 'cut-off' time of30 hours there were 9 failures with normal saline and 7 failures with ethacridine but all women eventually aborted without surgical intervention. In the saline group the induction-abortion interval was longer in the more advanced than in the less advanced pregnancies. No difference was observed in bacteriological studies from samples collected before and 24 hours after instillation of the solution. We conclude that normal saline is a cheap, easily available and safe abortifacient.

Spectrophotometric analysis of amniotic fluid in Rh immunised pregnancies

A total of 307 amniotic fluid analysis done in 344 Rh negative immunised mothers showed that 46, 83 and 178 delta OD values at 450 millimicrons fell in the upper, middle and lower zones of Liley's charts respectively. The correlation of spectrophotometric analysis with the condition of the baby at birth was about 95 per cent in the upper and lower zones. In the middle zone, however, it was about 75 per cent only. Also, in 7 women in whom the OD at 450 millimicrons fell in the middle zone, the babies were found to be Rh negative; in another baby, the OD difference fell in upper zone. In spite of these limitations amniotic fluid examination seems to be an important single guide to severity, being superior to other parameters like previous obstetric history, antibody titre alone and Liley's charts, which are still widely used.

Laparoscopic removal of translocated intrauterine contraceptive devices

Data is presented regarding 20 translocated intrauterine contraceptive devices (IUCD). Successful laparoscopic removal was made in 13 (65%) cases though all these devices were Copper 'T' 200 model which tend to produce dense adhesions. Only when the IUCD was suspected to be partially or fully in the gut lumen or thick adhesions were present, or the device was not visualised, was laparotomy performed. Hence it is advocated that laparoscopy should be performed as a routine in patients with suspected translocated IUCD, as it obviates the need for laparotomy and thus decreases the duration of the hospital stay as well as preventing morbidity associated with laparotomy.

The Mechanics and Positioning of Highly Flexible Manipulator Limbs

This paper deals with the analysis of lightweight, flexible robotic limbs. A typical limb is a series of polymeric tube elements. One end is fixed and the payload at the other end is manipulated by varying the internal pressure in each element. The theoretical derivations relating limb position and its payload incorporate the nonlinear elastic properties of the element material and large deflections. A computer program stores information about limb position and after each successive limb manipulation the program adaptively upgrades itself to improve positioning accuracy. Results are illustrated with a numerical example.

Management of translocated and incarcerated intrauterine contraceptive devices

Thirty-seven consecutive patients who reported with absent or snapped strings and failed attempts at removal of intrauterine contraceptive devices (IUCD) by hooks or curette were posted for hysteroscopy/laparotomy following a plain X-ray of the pelvis to exclude unrecognized spontaneous expulsion. Direct visualization of the endometrial cavity was invaluable in locating and removing IUCDs, particularly the embedded and fragmented ones. Translocated medicated devices were associated with dense adhesions, suggesting the need for their prompt removal. There appears to be an increased risk of translocation in lactating women.