Total laparoscopic hysterectomy versus vaginal hysterectomy: a retrospective study

Background: Total laparoscopic hysterectomy (TLH) is now emerging as a safe procedure even in patients suitable for vaginal hysterectomy (VH) due to its advantages like better visualisation, less post-operative pain and shorter hospital stay. This study was done to compare the duration of surgery, intra-operative and postoperative complications, hospital stay and post-operative analgesia requirement in TLH and VH.Methods: A retrospective study of women undergoing TLH and VH between June 2013 and September 2014 in JSS Hospital, Mysore was done. Patients with suspected genital malignancy and uterine prolapse were excluded. Baseline characteristics like age, BMI, parity, indication for hysterectomy, uterine size and previous pelvic surgeries were noted. Intra-operative and post-operative parameters like duration of surgery, complications, post-operative analgesic dosage and hospital stay were compared between the two surgeries and the results were analysed using Chi square test and independent t test.Results: The mean time taken to perform TLH was significantly longer, i.e. 113.46 minutes compared with VH, i.e. 61.18 minutes ( p <0.0001). But the duration of stay in the hospital was shorter for the women undergoing TLH, mean duration being 3.74 days as opposed to 5.85 days in women undergoing VH  (p<0.0001). Also, women undergoing VH required more analgesic doses (mean 1.79) than those undergoing TLH (mean 1.36). When we studied the rate of complications in both the groups, we found no statistically significant difference.Conclusions: TLH was as safe as VH and had advantages like shorter hospital stay and reduced analgesia dose.

Blood loss assessment in abdominal hysterectomy: how accurate?

Background: Precise estimation of blood loss is the key to optimal transfusion practice in surgery. Many studies done in various fields of surgery infer that clinical assessment of blood loss by the surgeon or anesthesiologist is inaccurate. The purpose of this study is to see if there is any difference in visual estimation of blood loss and actual blood loss calculated using modification of gross formula in abdominal hysterectomy.Methods: Fifty four patients undergoing total abdominal hysterectomy for various indications at JSS Hospital, Mysore were included in the study. Baseline characteristics, pre-operative haematocrit, clinically estimated blood loss (EBL) and post-operative haematocrit were noted. Actual blood loss (ABL) was calculated from a modification of the Gross formula. The number of cases where the blood loss was clinically underestimated and overestimated; and the relationship between the difference in actual and estimated blood loss and accuracy of clinical assessment of blood loss was determined. The data obtained was analysed using descriptive statistics and Crammer’s V test.Results: In the 54 cases of abdominal hysterectomy which we studied, there was overestimation of blood loss in 28 (51.9%) cases and underestimation of blood loss in 26 (48.1%) cases. The more the inaccuracy in clinical assessment of blood loss, more was the possibility of clinicians underestimating the blood loss.Conclusions: Clinical estimation of blood loss is an inaccurate method of assessing blood loss in abdominal hysterectomy

CRITICAL ANALYSIS OF PURVA KARMA PRIOR TO NASYA W.S.R. SNEHA NASYA

Ayurveda Panchakarmas are an all-time big name for both Ayurveda doctors and patients. Their efficacy of targeting the body holistically and evacuating toxins, thereby, addressing most of the problems of an individual makes it a hit. This paper aims at estimating the contribution of Purva Karma (procedures prior to instillation of medicine) in the outcome, especially in the context of Sneha Nasya (instillation of unctuous medicine). Nasal route of administration may help address the hitches accompanying to poor bioavailability, slow absorption, drug degradation, and possible adverse events in the gastro intestinal tract and avoids the first-pass metabolism in the liver. However, when considering nasal delivery, appropriate measures need to be taken to address the limitations of drug delivery in this region. Purva Karma starts with drug preparation and ends with stage of instillation of medicine (8 check points). The role of each of them on overcoming the limitations and delivering the results is reviewed

CLOZAPINE INDUCED PARALYTIC ILEUS

Clozapine is an atypical antipsychotic drug used for the treatment of schizophrenia in patient not responding to other antipsychotics. Dry mouth, constipation, loss of accommodation and urinary retention are the common side effects encountered with this drug. Here we are reporting a case of paralytic ileus secondary to clozapin

Efficacy of metformin and insulin in the management of gestational diabetes mellitus: A comparative study

Background: In Gestational Diabetes Mellitus (GDM), the insulin secretion is not adequate enough to compensate for the severity of hyperglycaemia and pregnancy is also a state of high insulin resistance which leads to ineffective glycaemic control. Aim and Objectives: To compare the efficacy of metformin and insulin in management of GDM; and to assess neonatal and maternal outcomes in the study group. Material and Methods: One hundred pregnant women visiting the Outpatient Department of Obstetrics and Gynecology, JSS Hospital, Mysuru were screened for GDM at first antenatal visit. If the first test results were negative, then second test was done at 24 - 28 weeks of gestation. One hundred pregnant women diagnosed as GDM after 20 weeks of gestation by Diabetes in Pregnancy Study Group of India (DIPSI) method were included for the study. They were randomly assigned into two groups with 50 patients each and were subjected to pharmacological treatment with either insulin or metformin. Optimum glycemic control between the two groups was studied along with the maternal and fetal outcome. Results: Our study showed no significant difference in GDM with the use of metformin or insulin. All patients (100%) from the insulin group achieved good glycemic control whereas in the metformin group, 98% achieved good glycemic control. Maternal and fetal outcomes were also not significant between the two groups. Conclusion: Our study showed no significant difference in the use of metformin or insulin and suggests that metformin is effective in controlling GDM without associated higher risk of maternal or neonatal complications compared with insulin

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Nepali migrant workers and the need for pre-departure training on mental health: a qualitative study

Every year around 1,000 Nepali migrant workers die abroad. Every one in three females and one in ten males commit suicide, reflecting a high mental health risk among Nepali migrant workers. This study aims to identify triggers of mental ill-health among Nepali migrant workers and their perception on need of mental health components in the pre-departure orientation programme. We conducted five focus group discussions (FGD) and seven in-depth interviews with Nepali migrant workers and eight semi-structured interviews with stakeholders working for migrants. Participants were invited at Kathmandu’s international airport on return from abroad, at hotels or bus stations near the airport, through organisations working for migrants, and participants’ network. All FGD and interviews were conducted in Kathmandu and audio recorded, transcribed and translated into English. Data were analyzed thematically. High expectations from families back home, an unfair treatment at work, poor arrangements of accommodation, loneliness and poor social life abroad were frequently reported factors for poor mental health. Access to mental health services abroad by Nepali migrant was also poor. We found little on mental health in the pre-departure orientation. We need to improve our knowledge of mental health risks to provide better, more focused and more up-to-date pre-departure training to new migrant workers leaving Nepal

Unspoken inequality: How COVID-19 has exacerbated existing vulnerabilities of asylum-seekers, refugees, and undocumented migrants in South Africa

An estimated 2 million foreign-born migrants of working age (15-64) were living in South Africa (SA) in 2017. Structural and practical xenophobia has driven asylum-seekers, refugees, and undocumented migrants in SA to abject poverty and misery. The Coronavirus Disease 2019 (COVID-19) containment measures adopted by the SA government through the lockdown of the nation have tremendously deepened the unequal treatment of asylum-seekers and refugees in SA. This can be seen through the South African government's lack of consideration of this marginalized population in economic, poverty, and hunger alleviation schemes. Leaving this category of our society out of the national response safety nets may lead to negative coping strategies causing mental health issues and secondary health concerns. An effective response to the socioeconomic challenges imposed by the COVID-19 pandemic should consider the economic and health impact of the pandemic on asylum-seekers, refugees, and undocumented migrants

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care