Hysteroscopic salpingosonography: a novel technique for infertile patients

Background: Infertility is akin to curse in our country. Patients of infertility run from pillar to post to get relief. Government Hospitals in India lie at the tail end of window-shopping of infertility centres by the patients having exhausted all their resources. Patients report without any detailed records, lost reports, coming after long hiatus of having stopped treatment in desperation, making one wonder how to proceed. At the other end are patients who have undergone laparotomy for various reasons like intestinal obstruction, tubercular abdomen, adnexal masses and their tubal status is not very clear on HSG. So, repeat laparoscopy in the former group and performing ab initio in the latter, involves putting the patients to the risk of general anesthesia, injury to internal organs due to anticipated adhesions. Although Hassan’s technique of open trocar entry is well accepted the first port entry, whatever be the mode, is an entry open to risks.Methods: In a selected group of infertile women, a baseline TVS was done on 2/3 day of menses and on the 7/8 day of menstrual cycle hysteroscopy was done which was immediately followed by another transvaginal ultrasound. The descriptive statistics is presented in the form of percentages and appropriate graphs.Results: Among the 54 patients who underwent this procedure, 65% had normal uterine cavity. 18% were referred for IVF. 9.2% conceived post procedure.Conclusions: Successive use of transvaginal ultrasound after hysteroscopy i.e Hysteroscopic sonosalpingography is a useful procedure in a select group of infertile patients.

Reciprocal obligations for prevention of occupationally acquired tuberculosis among healthcare workers.

As I began my work on occupationally acquired tuberculosis (TB), I was perturbed by a series of media reports on TB among healthcare workers (HCWs) in India. This included a report on the death of a resident doctor who was suffering from multidrug-resistant (MDR) TB. The risk of occupationally acquired TB is well documented. A few studies have reported an increased risk of TB among HCWs in developing countries, including India.

Identifying beneficiaries for user fee waivers: ethical challenges in public health.

Shortages in the public budget for government health services led to the adoption of a system of user fees for healthcare in many developing countries. The Government of India introduced user charges in public health services on a pilot basis as a part of its health sector reforms in the late 1990s and early 2000. A major criticism of user charges relates to 'equity'. Full waiver of the fees has been recommended for the poor to ensure equitable access to services. Waiver is a right conferred on an individual that entitles him/her to obtain health services in certain health facilities at no direct charge or at a reduced price.

Trends in Choosing Place of Delivery and Assistance during Delivery in Nanded District, Maharashtra, India.

Delivery in a medical institution promotes child survival and reduces the risk of maternal mortality. Many initiatives under the National Rural Health Mission (NRHM) focus on increasing the institutional deliveries. This study describes the trends in choosing place of delivery in Nanded district at the end of the first phase of the mission. Key informants were interviewed to document the initiatives under NRHM implemented in the district. A cross-sectional descriptive study was conducted in 30 villages selected using one stage cluster-sampling method. A house-to-house survey was conducted in June 2009. A set of structured open-ended questionnaire was used for interviewing all women who had delivered during January 2004–May 2009. The outcomes studied were place of delivery and assistance during delivery. Analysis was done by calculating chi-square test and odds ratio. Interventions to improve the quality of health services and healthcare-seeking behaviour were implemented successfully in the district. The proportion of institutional deliveries increased from 42% in 2004 to 69% in 2009. A significant increase was observed in the proportion of institutional deliveries [60% vs 45%; χ2=173.85, p<0.05, odds ratio (OR)=1.8 (95% confidence interval (CI) 1.65-1.97)] in the NRHM period compared to the pre-NRHM period. The deliveries in government institutions and in private institutions also showed a significant rise. The proportion of deliveries assisted by health personnel increased significantly during the NRHM period [62% vs 49%; χ2=149.39; p<0.05, OR=1.73, 95% CI 1.58-1.89] However, less than 10% of the deliveries in the home (range 2-9%) were assisted by health personnel throughout the study period. There was a wide geographic variation in place of delivery among the study villages. The results showed a significant increase in the proportion of institutional deliveries and deliveries assisted by health personnel in the NRHM period. Since a less proportion of deliveries in the home is conducted by health personnel, the focus should be on increasing the institutional deliveries. Special and innovative interventions should be implemented in the villages with a less proportion of institutional deliveries.

Survival analysis and risk factors for death in tuberculosis patients on directly observed treatment-short course.

Background : Tuberculosis is a disease with a high case fatality of 4.65%. Objectives : To describe the survival pattern of patients on Directly Observed Treatment-Short course (DOTS) according to categories, age and sex of patients. Settings : Tuberculosis unit (TU) at District Tuberculosis Centre (DTC), Yavatmal, India Design : Retrospective cohort study. Materials and Methods : Data of patients registered for DOTS in the year 2004 were collected from the tuberculosis register. Statistical Analysis : Kaplan Meier plots and log rank tests to assess the survival pattern. Cox proportional hazards model for multivariate analysis. Results : A total of 716 patients were registered at the TU. The survival rates by the end of the intensive phase were 96%, 93% and 99% in categories I, II and III of DOTS, respectively. The cumulative survival rates were 93%, 88% and 96% in the three DOTS categories, respectively. There was a significant difference in the survival curves amongst the three DOTS categories (log rank statistic= 7.26, d.f..= 2, P=0 0.02) and amongst the different age groups [log rank statistic= 8.78, d.f.= 3, P= 0.012). There was no difference in the survival curves of male and female patients (log rank statistic= 0.05, d.f.= 1, P= 0.80) and according to type of disease (log rank statistic= 5.63, d.f.= 2, P= 0.05). On Cox proportional hazard analysis, age groups of 40 to 60 years [adjusted hazard ratio= 7.81 (1.002-60.87)] and above 60 years [adjusted hazard ratio= 21.54 (2.57-180.32)] were identified as significant risk factors for death. Conclusions : Age above 40 years is a significant risk factor for death in patients of tuberculosis. There was a significant difference in survival curves of the three DOTS categories and age groups.

Non - DOTS Regimens Under RNTCP : Reasons for Initiation and Treatment Outcome.

Nearly 1% of the patients registered under RNTCP are put on non-DOTS regimens. Understanding the reasons for initiation of non- DOTS and its treatment outcome is one of the priority areas on the research agenda of RNTCP. In phase I the data of patients put on non DOTS at two TUs under Yavatmal DTC from April 2005 to March 2007 was collected from TB registers and treatment cards. In Phase II the reasons for initiating non DOTS was assessed in a sub sample by conducting two Focus group discussions with the staff at one of the TUs. In Phase III a comparison of the treatment outcome was done between patients on DOTS and Non DOTS by matched pair analysis using McNemar's chi square test. A total of 40(1.28 %) patients were put on non-DOTS .Nearly 27% of the patients on non DOTS belonged to the paediatric age group. Only one new smear positive patient and 11% of patients on retreatment after default were initiated on non-DOTS. The reasons for initiation of non DOTS was discussed for 27 patients registered at one TU in the FGDs. The main reasons for initiation of non-DOTS in new patients were drug intolerance, drug toxicity, liver disease. immunocompromised patient on ART and migration. The reasons in retreatment cases were persistent default and chronic smear positivity. The risk of un favourable outcome was significantly more in patients on non- DOTS. Many of the reasons for initiation of non-DOTS in new cases i.e. drug toxicity, intolerance; liver disease will continue to be indications for non DOTS in RNTCP areas. In some special circumstances interventions like DOTS plus and availability of ART compatible with Rifampicin will be better options for management of Tuberculosis. Default is a problem at all levels of treatment and concerted and coordinated efforts from various levels are needed to prevent it. Community DOTS providers can be involved in the programme in case of migration, some cases of persistent default and paediatric cases. The availability of Paediatric patient wise boxes will make it easier for dispensing DOTs in Paediatric Tuberculosis.

Child rearing practices amongst brothel based commercial sex workers.

BACKGROUND: The experiences of the commercial sex workers as they fulfill the role of being a parent, have rarely been reported. Considering their socioeconomic background, profession and work pattern, the women are bound to face major challenges. AIMS: To describe child bearing, family support, dietary practices and various placement options for raising children. STUDY DESIGN: A cross-sectional descriptive study of brothel-based commercial sex workers. STATISTICAL ANALYSIS: X2 test, Fisher's Exact test. RESULTS: Some commercial sex workers continued pregnancy with the hope of security and support, while others were compelled to do so, as they report late for medical termination of pregnancy. A group of sex workers (Devdasis) received support during pregnancy, delivery, puerperium and child-rearing. The role and responsibilities of raising the child, depended upon the kind of family support available to the mothers. Being a single parent, stigma of the profession, odd working hours and variable family support were major challenges, while the fact that the women were earning, availability of rehabilitation centers, the homogeneous groups within the brothels, supportive peers and local non governmental organizations were factors which helped them in the process of raising their children. CONCLUSIONS: Day care centers and night shelters should be opened up in the red light area where the children can be looked after, during the working hours. The sex workers should be educated about weaning and nutrition. The role of peer workers and NGOs was very important in helping the women raise their children.

Medical equipment in government health facilities: missed opportunities.

BACKGROUND: The availability and optimal utilization of medical equipment is important for improving the quality of health services. Significant investments are made for the purchase, maintenance and repair of medical equipment. Inadequate management of these equipment will result in financial losses and deprive the public of the intended benefits. This analysis is based on the conceptual framework drawn from the WHO recommended- lifecycle of medical equipment. AIMS: (1) To identify the problems in different stages of the life cycle. (2) To assess its financial implications and effect on service delivery. SETTINGS AND DESIGN: Analysis of secondary data from the latest Comptroller and Auditor General (CAG) Reports for the states in India. The study variables were category of equipment, financial implications and problems in the stages of life cycle. STATISTICAL ANALYSIS: Calculation of proportions. RESULTS AND CONCLUSIONS: A total of forty instances mentioning problems in the first phase of the life cycle of medical equipment were noted in 12 state reports. The equipment from the radiology department (15), equipment in the wards (5), laboratory (3) and operation theatres (4) were the ones most frequently implicated. In a majority of cases the financial implications amounted to twenty-five lakhs. The financial implications were in the form of extra expenditure, unfruitful expenditure or locking of funds. In 25 cases the equipment could not be put to use because of non-availability of trained staff and inadequate infrastructural support. Careful procurement, incoming inspection, successful installation and synchronization of qualified trained staff and infrastructural support will ensure timely onset of use of the equipment.