Increasing postpartum IUCD coverage through a QI initiative: a step towards reducing the unmet need of postpartum contraception

Background

Unintended pregnancies have a negative impact on the health and economy of a nation, which can be prevented by effective family planning (FP) services. Postpartum intrauterine device (PPIUCD) is a safe and effective FP method which allows women to obtain long-acting contraception before discharge from the point of delivery. We observed poor coverage of deliveries with PPIUCD at our facility. This was the trigger to initiate a quality improvement (QI) initiative to increase the PPIUCD coverage from current rate of 4.5%–10% in 3-month period.

Method

A fishbone analysis of the problem was done and the following causes were identified: lack of focused counselling for FP, lack of sensitisation and training of resident doctors and inconsistent supply of intrauterine contraceptive devices (IUCDs). A QI team was constituted with representatives from faculty members, residents, interns, nursing officers and FP counsellors. The point of care quality improvement methodology was used.

Interventions

Daily counselling of antenatal women was started by the counsellors and interns in antenatal wards. A WhatsApp group of residents was made initially to sensitise them; and later for parking of problems and trouble shooting. The residents were provided hands-on training at skills lab. Uninterrupted supply of IUCDs was ensured by provision of buffer stock of IUCDs with respective store keepers.

Result

The PPIUCD insertion rates improved from 4.5% to 19.2% at 3 months and have been sustained to a current 30%–35% after 1 ½ years of initiation of the project tiding through the turbulence during the COVID-19 pandemic using QI techniques.

Conclusion

Sensitisation and training of residents as well as creation of awareness among antenatal women through targeted counselling helped improve PPIUCD coverage at the facility. QI initiatives have the potential to facilitate effective implementation of the FP programmes by strategic utilisation of the resources.

A multi‐institutional randomized controlled trial comparing first‐generation transrectal high‐resolution micro‐ultrasound with conventional frequency transrectal ultrasound for prostate biopsy

Objectives

To study high‐frequency 29 MHz transrectal side‐fire micro‐ultrasound (micro‐US) for the detection of clinically significant prostate cancer (csPCa) on prostate biopsy, and validate an image interpretation protocol for micro‐US imaging of the prostate.

Materials and methods

A prospective randomized clinical trial was performed where 1676 men with indications for prostate biopsy and without known prostate cancer were randomized 1:1 to micro‐US vs conventional end‐fire ultrasound (conv‐US) transrectal‐guided prostate biopsy across five sites in North America. The trial was split into two phases, before and after training on a micro‐US image interpretation protocol that was developed during the trial using data from the pre‐training micro‐US arm. Investigators received a standardized training program mid‐trial, and the post‐training micro‐US data were used to examine the training effect.

Results

Detection of csPCa (the primary outcome) was no better with the first‐generation micro‐US system than with conv‐US in the overall population (34.6% vs 36.6%, respectively, P = .21). Data from the first portion of the trial were, however, used to develop an image interpretation protocol termed PRI‐MUS in order to address the lack of understanding of the appearance of cancer under micro‐US. Micro‐US sensitivity in the post‐training group improved to 60.8% from 24.6% (P < .01), while specificity decreased (from 84.2% to 63.2%). Detection of csPCa in the micro‐US arm increased by 7% after training (32% to 39%, P < .03), but training instituted mid‐trial did not affect the overall results of the comparison between arms.

Conclusion

Micro‐US provided no clear benefit over conv‐US for the detection of csPCa at biopsy. However, it became evident during the trial that training and increasing experience with this novel technology improved the performance of this first‐generation system.

In this work high‐frequency 29 MHz transrectal side‐fire micro‐ultrasound (US) for the detection of clinically significant prostate cancer on prostate biopsy is studied, and an image interpretation protocol for micro‐US imaging of the prostate is validated.

The YouTube link is here: https://youtu.be/U2Svj-4Ae_k

Task shifting of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in India. CVDs are to a large extent preventable with the availability of wide range of interventions focusing on primary and secondary prevention. However human resource deficit is the biggest challenge for implementing these prevention programs. Task shifting of the cardiovascular risk assessment and communication to nurses can be one of the most viable and sustainable option to run prevention programs.

METHODS

The study was quasi experimental in nature with 1 year follow up to determine the effect of CVD risk assessment and communication by nurses with the help of risk communication package on primary and secondary prevention of CVDs. The study was done in the outpatient departments of a tertiary health care center of Northern India. All the nurses (n = 16) working in selected OPDs were trained in CVD risk assessment and communication of risk to the patients. A total of 402 patients aged 40 years and above with hypertension (HTN) were recruited for primary prevention of CVDs from medicine and allied OPDs, whereas 500 patients who had undergone CABG/PTCA were recruited from cardiology OPDs for secondary prevention of CVDs and were randomized to intervention (n = 250) and comparison group (n = 250) by using block randomization. CVD risk modification and medication adherence were the outcomes of interest for primary and secondary prevention of CVDs respectively.

RESULTS

The results revealed high level of agreement (k = 0.84) between the risk scores generated by nurses with that of investigator. In the primary prevention group, there were significantly higher proportion of participants in the low risk category (70%) as compared to baseline assessment (60.6%) at 1 year follow up. Whereas in secondary prevention group the mean medication adherence score among intervention group participants (7.60) was significantly higher than that of the comparison group (5.96) with a large effect size of 1.1.(p < 0.01).

CONCLUSION

Nurse led intervention was effective in risk modification and improving medication adherence among subjects for primary and secondary prevention of CVDs respectively.

TRIAL REGISTRATION

Trial registration no CTRI/2018/01/011372 [Registered on: 16/01/2018] Trial Registered Retrospectively.

Evaluating human rabies control in Asia: using 'One Health' principles to assess control programmes for rabies

Rabies is a global issue, and kills tens of thousands of people every year, despite being a preventable disease. The goal of the World Health Organization (WHO) and the World Organisation for Animal Health (OIE) to eliminate dog-mediated rabies by 2030 requires serious collaborative efforts across Ministries and countries. This cross-sector cooperation includes, but is not limited to, physicians, veterinarians, local authorities, local communities and the media; in other words, a 'One Health' approach. Countries where human rabies has been successfully eliminated still require constant vigilance, in terms of regulations on companion animal ownership and vaccination, the movement of animals from countries where the disease still exists, and the continued raising of public awareness. Rabies-endemic countries need to refocus their efforts towards eliminating the disease once and for all, by working together and sharing their knowledge, experiences and efforts. Rabies control programmes require the efficient management of resources, and surveillance programmes do not need to be specific to one disease. Governments must play a more proactive role by enforcing legislation and allocating funds and resources to help to eliminate human rabies by 2030 throughout the world.

Focal laser ablation as clinical treatment of prostate cancer: report from a Delphi consensus project

PURPOSE

To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method.

METHODS

A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings.

RESULTS

Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation.

CONCLUSION

Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.

Patient selection for prostate focal therapy in the era of active surveillance: an International Delphi Consensus Project

BACKGROUND

Whole-gland extirpation or irradiation is considered the gold standard for curative oncological treatment for localized prostate cancer, but is often associated with sexual and urinary impairment that adversely affects quality of life. This has led to increased interest in developing therapies with effective cancer control but less morbidity. We aimed to provide details of physician consensus on patient selection for prostate focal therapy (FT) in the era of contemporary prostate cancer management.

METHODS

We undertook a four-stage Delphi consensus project among a panel of 47 international experts in prostate FT. Data on three main domains (role of biopsy/imaging, disease and patient factors) were collected in three iterative rounds of online questionnaires and feedback. Consensus was defined as agreement in ⩾80% of physicians. Finally, an in-person meeting was attended by a core group of 16 experts to review the data and formulate the consensus statement.

RESULTS

Consensus was obtained in 16 of 18 subdomains. Multiparametric magnetic resonance imaging (mpMRI) is a standard imaging tool for patient selection for FT. In the presence of an mpMRI-suspicious lesion, histological confirmation is necessary prior to FT. In addition, systematic biopsy remains necessary to assess mpMRI-negative areas. However, adequate criteria for systematic biopsy remains indeterminate. FT can be recommended in D'Amico low-/intermediate-risk cancer including Gleason 4+3. Gleason 3+4 cancer, where localized, discrete and of favorable size represents the ideal case for FT. Tumor foci <1.5 ml on mpMRI or <20% of the prostate are suitable for FT, or up to 3 ml or 25% if localized to one hemi-gland. Gleason 3+3 at one core 1mm is acceptable in the untreated area. Preservation of sexual function is an important goal, but lack of erectile function should not exclude a patient from FT.

CONCLUSIONS

This consensus provides a contemporary insight into expert opinion of patient selection for FT of clinically localized prostate cancer.

Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project

PURPOSE

To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa).

METHODS

A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated.

RESULTS

Consensus was attained on 23 of 27 topics; Targeted FT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text.

CONCLUSION

Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice.

Antagonistic and antimicrobial activities of some bacterial isolates collected from soil samples

Thirty seven bacterial cultures isolated from soil samples obtained from different locations were tested for their antagonistic activity against some fungal pathogens, viz., Sclerotium rolfsii, Fusarium oxysporum and Rhizoctonia solani, causal agents of collar rot of sunflower, wilts and root rots, respectively. Among them, 5 bacterial strains, viz., A1 6 (Bacillus sphaericus), K1 24 (Pseudomonas fluorescens), M1 42 (Bacillus circulans), M1 66 (Bacillus brevis) and T1 22 (Bacillus brevis) showed positive antagonistic activity. M1 66 was the most effective in inhibiting mycelial growth of S. rolfsii in vitro followed by M1 42, T1 22, K1 24 and A1 6. Only one bacterial strain i.e. M1 42 exhibited antagonistic activity against F. oxysporum, and none of the bacterial strains gave positive activity against R. solani. Furthermore, antimicrobial activities of all the 5 strains were checked against different test organisms. These strains showed their extensive inhibition effect particularly against gram-positive test bacteria (Staphylococcus aureus and Bacillus subtilis) and the test fungal strain (Candida albicans). On the other hand, B. brevis M1 66 and B. brevis T1 22 strains had an inhibitory effect against gram positive and gram-negative test bacteria (Escherichia coli and Proteus vulgaris) as well as the test fungal strain.

Prenatal ultrasound findings of lissencephaly associated with Miller-Dieker syndrome and comparison with pre- and postnatal magnetic resonance imaging

OBJECTIVE

To report on the prenatal ultrasound findings in fetuses with lissencephaly associated with Miller-Dieker syndrome (MDS) and to compare these findings with those of magnetic resonance imaging (MRI).

METHODS

Cases of MDS confirmed by postnatal chromosome microdeletion analysis were identified through review of patient records. Prenatal ultrasound scans were reviewed retrospectively by two radiologists. For cerebral cortical development, the Sylvian, parieto-occipital and calcarine fissures, and the cingulate sulcus and sulci over the cerebral convexity were evaluated. If one or more of these fissures or sulci were not visualized at the expected gestational age or their appearance was abnormal for gestational age, cortical development was considered delayed. Prenatal and postnatal MRI examinations were reviewed by a pediatric neuroradiologist.

RESULTS

There were seven cases of MDS. In three cases, the prenatal diagnosis of agyria/lissencephaly was prospectively suspected by ultrasound at 23, 26 and 30 weeks, and subsequently confirmed by prenatal MRI. When we retrospectively reviewed the prenatal ultrasound scans of all fetuses, all had delayed cortical development identified on ultrasound performed after 23 weeks' gestation. In all cases the Sylvian fissure was abnormal on both ultrasound and MRI. In one fetus, a normal cortical appearance for gestational age was seen at the initial 20-week ultrasound examination, but delayed cortical development was identified at a 24-week scan. Mild ventriculomegaly was seen in six fetuses and dysgenesis of the corpus callosum in one. Extracranial abnormalities were detected in five fetuses. Delayed cortical development was seen in two fetuses with mild ventriculomegaly, but no other fetal anomalies.

CONCLUSIONS

In fetuses with MDS, delayed cortical development can be suspected on ultrasound as early as 23 weeks' gestation. This finding warrants further investigations including MRI and FISH analysis for chromosome 17p13.3 deletion.

Haemophilic pseudotumour of the paranasal sinuses: management with radiotherapy and factor replacement therapy

A case of pseudotumour of the paranasal sinuses occurring in a patient with haemophilia A is reported. There was a favourable response to combined treatment with radiation therapy and factor VIII replacement.

Pelvic lipomatosis presenting as uraemic encephalopathy

Pelvic lipomatosis is a benign disorder of unknown aetiology, characterised by deposition of mature fat in the pelvis. It has a variable natural history, manifesting either with symptoms attributable to the lower urinary tract or varying degrees of renal failure. Owing to the mild, non-specific initial symptoms and slow progression, presentation is delayed and patients are often lost to follow-up, only to present with advanced renal failure later on. We report a case of a young patient with pelvic lipomatosis who, after an initial diagnosis, was lost to follow-up for several years and then presented with uraemic encephalopathy. The case highlights the importance of regular follow-up and an early intervention before irreversible changes occur.

Rapidly filling pleural effusion due to a subarachnoid-pleural fistula

Only five cases of subarachnoid-pleural fistula in children have been reported previously. All had a history of trauma and associated neurologic deficit which gave clue to the diagnosis. The authors present a child who presented with a massive, rapidly filling, clear pleural effusion in whom there was no neurologic deficit. The history of an automobile accident in the past had almost been forgotten. A subarachnoid-pleural fistula was discovered on exploratory thoracotomy. The entity should be thought of, and actively investigated, in a child with a history of trauma and a pleural effusion of obscure etiology, even if there is no associated neurologic deficit.