Study to assess the acceptability and feasibility of cervical cancer screening using visual inspection with acetic acid and treatment of precancerous lesions using cryotherapy in low resource settings

Background: Objective of current study was to assess the acceptability and feasibility of cervical cancer screening using VIA, and treatment of precancerous lesions using cryotherapy in low resource settingsMethods: 526 women from three primary health centers of Shinor taluka (population based approach) and 250 women of Medical College, Vadodara (facility based approach) were sensitized and screened for cervical cancer. Visual Inspection with Acetic acid (VIA) was performed as the screening test. In the population based approach, VIA positive women were referred to a Community Health Centre (CHC) for colposcopy and biopsy. Ablative treatment in the form of cryotherapy was offered. Patients requiring higher forms of treatment were referred to medical college, Vadodara. In the facility based approach, VIA positive women underwent colposcopy. Guided biopsy was performed in those with positive lesions on colposcopy. Cryotherapy was offered in the same sitting. Those not suitable for cryotherapy were offered loop electrosurgical excision procedure. Women found to have invasive cancer were offered definitive management.Results: VIA positivity rate was 18.8% in the population based approach and 27.2% in the facility based approach.58.8% women in the population based approach and 77.77% women in the facility based approach were treated with cryotherapy on the same day as screening and none reported any severe side effects. Dropout rate in the community approach was 32.32% whereas in the facility it was 0.4%.Conclusions: VIA and cryotherapy procedures were well tolerated by all screened women. This project has shown that the “screen and treat” approach can be successfully implemented in the existing health setup.

Fetal heart rate patterns in patients with thick meconium staining of amniotic fluid and its association with perinatal outcome

Background: This study assesses the role of abnormal fetal heart rate tracing patterns in patients with thick meconium staining of the amniotic fluid and its association with perinatal outcomes.Methods: Prospective unmatched case-control study on 2 groups of 136 subjects each- cases had thick MSAF and controls had clear liquor with abnormal fetal heart rate tracings on cardiotocography.Results: Gestational age (GA) >40 weeks, was found to have a significant association with MSAF (p value 0.01556 CI 95%). Premature Rupture of membranes at term (PROM) showed a significant association with MSAF with an OR of 2.25 (95% CI 1.37, 3.7); Post datism had significantly higher odds for being a risk factor for MSAF with an OR (3.194) (CI 95% 1.003-10.165). MSAF was not found to be significantly associated with abnormal trace on CTG. Neonatal morbidity (MAS, birth asphyxia, sepsis, HIE) had statistically higher odds in cases 1.669 (0.884-3.150) as compared to controls.Conclusions: No particular cardio-tocograph pattern can be considered to have a poor prognostic value in the presence of thick MSAF and the decision to deliver and the mode of delivery should be based on the overall assessment and the stage and progress of labor. While management should be individualized, a higher Caesarean section rate in thick MSAF can be justified to ensure a better outcome for the neonate even in the presence of a normal CTG trace

Evaluating role of parity in progress of labour and its outcome using modified WHO partograph

Background: The progress of labour and its outcome differ based on the parity. These can be graphically proven by using an inexpensive tool -the modified WHO partograph. The plotting also helps to early recognition and prevention of the complications of labour. The objective of the study was to study and compare the course of labour and its outcome in primigravidae and mutigravidae using a graphical tool-Modified WHO partograph.Methods: The study was undertaken at SSG hospital, Baroda from August 2012 to July 2013. One hundred twenty four primigravidae and 124 multigravidae women were recruited according to defined inclusion and exclusion criteria. The progress of labour in active stage was assessed and plotted on Modified WHO partograph. The outcomes studied were: duration of active first stage and second stage, cervicometric progress, Incidence of labour augmentation, Incidence of operative delivery and neonatal outcome (Apgar score, NICU stay and birth weight).Results: The duration of active first stage (5.07 hrs) and second stage (33.57 min) was longer in primigravidae with a slower progress of labour as plotted on the Modified WHO partograph, than in multigravidae (3.78 hrs and 22.86 min respectively). The cervical dilatation rate in primigravidae was 1.22 ± 0.287 cm/hr which was slower than that of multigravidae (1.65 ± 0.408 cm/hr). There was also a higher rate of operative delivery in primigravidae (16.93% vs 3.22%).Conclusions: The results highlight that the modified WHO partograph worked as a useful tool in our population in comparing the progress of labour

Effectiveness and acceptability of progestogens in combined oral contraceptives – a systematic review

BACKGROUND: The progestogen component of oral contraceptives (OCs) has undergone changes since it was recognized that their chemical structure can influence the spectrum of minor adverse and beneficial effects. METHODS: The objective of this review was to evaluate currently available low-dose OCs containing ethinylestradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates. The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases were searched. Randomized trials reporting clinical outcomes were considered for inclusion and were assessed for methodological quality and validity. RESULTS: Twenty–two trials were included in the review. Eighteen were sponsored by pharmaceutical companies and in only 5 there was an attempt for blinding. Most comparisons between different interventions included one to three trials, involving usually less than 500 women. Discontinuation was less with second-generation progestogens compared to first–generation (RR 0.79; 95% CI 0.69–0.91). Cycle control appeared to be better with second-compared to first-generation progestogens for both, mono-and triphasic preparations (RR 0.69; 95% CI 0.52–0.91) and (RR 0.61; 95% CI 0.43–0.85), respectively. Intermenstrual bleeding was less with third- compared to second-generation pills (RR 0.71; 95% CI 0.55–0.91). Contraceptive effectiveness of gestodene (GSD) was comparable to that of levonorgestrel (LNG), and had similar pattern of spotting, breakthrough bleeding and absence of withdrawal bleeding). Drospirenone (DRSP) was similar compared to desogestrel (DSG) regarding contraceptive effectiveness, cycle control and side effects. CONCLUSION: The third- and second-generation progestogens are preferred over first generation in all indices of acceptability. Current evidence suggests that GSD is comparable to LNG in terms of contraceptive effectiveness and for most cycle control indices. GSD is also comparable to DSG. DRSP is comparable to DSG. Future research should focus on independently conducted well designed randomized trials comparing particularly the third- with second-generation progestogens

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Evaluating role of parity in progress of labour and its outcome using modified WHO partograph

Background: The progress of labour and its outcome differ based on the parity. These can be graphically proven by using an inexpensive tool -the modified WHO partograph. The plotting also helps to early recognition and prevention of the complications of labour. The objective of the study was to study and compare the course of labour and its outcome in primigravidae and mutigravidae using a graphical tool-Modified WHO partograph.Methods: The study was undertaken at SSG hospital, Baroda from August 2012 to July 2013. One hundred twenty four primigravidae and 124 multigravidae women were recruited according to defined inclusion and exclusion criteria. The progress of labour in active stage was assessed and plotted on Modified WHO partograph. The outcomes studied were: duration of active first stage and second stage, cervicometric progress, Incidence of labour augmentation, Incidence of operative delivery and neonatal outcome (Apgar score, NICU stay and birth weight).Results: The duration of active first stage (5.07 hrs) and second stage (33.57 min) was longer in primigravidae with a slower progress of labour as plotted on the Modified WHO partograph, than in multigravidae (3.78 hrs and 22.86 min respectively). The cervical dilatation rate in primigravidae was 1.22 ± 0.287 cm/hr which was slower than that of multigravidae (1.65 ± 0.408 cm/hr). There was also a higher rate of operative delivery in primigravidae (16.93% vs 3.22%).Conclusions: The results highlight that the modified WHO partograph worked as a useful tool in our population in comparing the progress of labour

Assessing the new ICD-MM classification for assigning the cause of maternal mortality at a tertiary centre in Western India: a retrospective study

Background: The World Health Organisation (WHO) in 2012 introduced the 10th revision of International Classification of Disease (ICD 10) to deaths in pregnancy, labour and puerperium (ICD-MM) for consistent collection, analysis and interpretation of information on maternal deaths. The proper use of this classification requires training to avoid heterogeneity and error in the classification of maternal deaths.Methods: We analysed the Maternal Death Review (MDR) forms of 295 deaths over a period of 5 years (January 2014 to December 2018 inclusive) occurring at a tertiary health centre in Western India. The ICD-MM classification was used to reassign the cause of death.Results: There were 295 deaths in women during pregnancy, childbirth and puerperium during the 5 year period. Of these there were 294 maternal deaths and one coincidental death. There were 173 deaths of the direct type (58.84%), 105 deaths of the indirect type (35.71%) and 16 deaths (5.44%) of the unspecified type. Obstetric haemorrhage was  the highest contributor to direct deaths (23.8%) and anaemia contributed to the maximum deaths from indirect causes (13.6%) followed by liver diseases in pregnancy (10.54%).Unanticipated complications of management accounted for 2% of the total deaths. There was considerable inaccuracy in assigning cause of death by consultants who were untrained in the use of the ICD-MM classification.Conclusions: ICD-MM classification promotes an accurate assignment of the cause of death. Training of healthcare providers performing maternal death reviews in the use of this classification is essential to identify accurate underlying cause of death and contributory conditions.

Non Melanoma Skin Cancer and Subsequent Cancer Risk

<div><p>Introduction</p><p>Several studies have shown an increased risk of cancer after non melanoma skin cancers (NMSC) but the individual risk factors underlying this risk have not been elucidated, especially in relation to sun exposure and skin sensitivity to sunlight.</p><p>Purpose</p><p>The aim of this study was to examine the individual risk factors associated with the development of subsequent cancers after non melanoma skin cancer.</p><p>Methods</p><p>Participants in the population-based New Hampshire Skin Cancer Study provided detailed risk factor data, and subsequent cancers were identified via linkage with the state cancer registry. Deaths were identified via state and national death records. A Cox proportional hazard model was used to estimate risk of subsequent malignancies in NMSC patients versus controls and to assess the potential confounding effects of multiple risk factors on this risk.</p><p>Results</p><p>Among 3584 participants, risk of a subsequent cancer (other than NMSC) was higher after basal cell carcinoma (BCC) (adjusted HR 1.40 [95% CI 1.15, 1.71]) than squamous cell carcinoma (SCC) (adjusted HR 1.18 [95% CI 0.95, 1.46]) compared to controls (adjusted for age, sex and current cigarette smoking). After SCC, risk was higher among those diagnosed before age 60 (HR 1.96 [95% CI 1.24, 3.12]). An over 3-fold risk of melanoma after SCC (HR 3.62; 95% CI 1.85, 7.11) and BCC (HR 3.28; 95% CI 1.66, 6.51) was observed, even after further adjustment for sun exposure-related factors and family history of skin cancer. In men, prostate cancer incidence was higher after BCC compared to controls (HR 1.64; 95% CI 1.10, 2.46).</p><p>Conclusions</p><p>Our population-based study indicates an increased cancer risk after NMSC that cannot be fully explained by known cancer risk factors.</p></div