Improving postpartum care in a large hospital in New Delhi, India.

Despite recent progress, the maternal mortality ratio (MMR) in India remains high at 174 per 100 000 live births. Bhagwan Mahavir Hospital (BMH) is a secondary level hospital in New Delhi. In 2013, five women died in BMH's postpartum ward. In January 2014, a United States Agency for International Development-funded team met with BMH staff to help improve their system for providing postpartum care to prevent maternal deaths. The hospital staff formed a quality improvement (QI) team and, between January and December 2014, collected data, conducted root cause analyses to understand why postpartum women were dying and tested and adapted small-scale changes using plan-do-study-act cycles to delivery safer postpartum care. Changes included reorganising the ward to reduce the time it took nurses to assess women and educating women and their relatives about common danger signs. The changes led to an increase in the number of women who were identified with complications from two out of 1667 deliveries (0.12%) between January and May 2014 to 74 out of 3336 deliveries (2.2%) between July and December 2014. There were no deaths on the postpartum ward in 2014 compared with five deaths in 2013 but the reduction was not sustained after the hospital started accepting sick patients from other hospitals in 2015. QI approaches can improve the efficiency of care and contribute to improved outcomes. Additional strategies are required to sustain improvements.

Improving Adolescent Health Services across High Priority Districts in 6 States of India: Learnings from an Integrated Reproductive Maternal Newborn Child and Adolescent Health Project.

BACKGROUND: India has been at the forefront of designing adolescent health (AH) policies. The National Adolescent Reproductive and Sexual Health policy (2006), the Reproductive, Maternal, Newborn Child, and AH strategy (2013), and the "Rashtriya Kishor Swasthya Karyakram (RKSK)" (2014) have been the critical milestones in this direction. However, despite policies being available, the AH outcomes need improvement through operationalization of focused and need-based AH interventions. OBJECTIVES: The objectives of this study were to improve services for RKSK interventions across select geographies of India. MATERIALS AND METHODS: USAID's VRIDDHI Project has been providing technical support at the national level and in six focus states to improve uptake of evidence-based high-impact reproductive, maternal, newborn, child, and AH interventions. To improve AH services and outcomes, two approaches were implemented, namely (a) strengthen the functioning of adolescent-friendly health clinics in 95 high caseload health facilities in 26 high priority districts across six states and (b) demonstrate other operational strategies outlined in RKSK program including strengthening of district committees on AH, undertaking formative research for developing adolescent-focused communication strategy, and operationalizing weekly iron and folic acid supplementation program. RESULTS: As a result of ongoing technical support over 2-year period (January 2016-December 2017), improvements were noted across multiple AH indicators. In addition, evidence-based learnings were also generated from the demonstration models for potential scale up to other geographies. CONCLUSION: The project was successful in improving AH services in the intervention facilities through an integrated approach which is replicable, sustainable, and scalable for driving the AH program in India.

MRI in the detection of hepatic metastases from high-risk uveal melanoma: a prospective study in 188 patients.

BACKGROUND/AIMS: To evaluate MRI in the detection of asymptomatic hepatic metastases from uveal melanoma. METHODS: A single-arm prospective cohort study. PARTICIPANTS: We enrolled 188 patients whose predicted 5-year mortality from uveal melanoma exceeded 50%. This prognostication was performed by multivariate analysis of clinical stage, histological grade and genetic type, using our online tool, based on Accelerated Failure Time modelling. These high-risk patients underwent a six-monthly assessment, which included history-taking, clinical examination, hepatic MRI (without contrast, unless suspicious lesions were identified) and biochemical liver function tests. RESULTS: Ninety (48%) of the 188 patients developed detectable metastases, a median of 18 months after ocular treatment. Six-monthly MRI-detected metastases before symptoms in 83 (92%) of 90 patients developing systemic disease, with 49% of these having less than five hepatic lesions all measuring less than 2 cm in diameter. Of these 90 patients, 12 (14%) underwent hepatic resection, all surviving for at least a year afterwards. CONCLUSIONS: Six-monthly MRI detects metastases from high-risk uveal melanoma before the onset of symptoms, enhancing any opportunities for early treatment of metastatic disease and clinical trial participation. Whether these actually result in prolongation of life, after taking lead-time bias into account, requires further investigation.

Proton beam radiotherapy of iris melanoma.

PURPOSE: To report on outcomes after proton beam radiotherapy of iris melanoma. METHODS AND MATERIALS: Between 1993 and 2004, 88 patients with iris melanoma received proton beam radiotherapy, with 53.1 Gy in 4 fractions. RESULTS: The patients had a mean age of 52 years and a median follow-up of 2.7 years. The tumors had a median diameter of 4.3 mm, involving more than 2 clock hours of iris in 32% of patients and more than 2 hours of angle in 27%. The ciliary body was involved in 20%. Cataract was present in 13 patients before treatment and subsequently developed in another 18. Cataract had a 4-year rate of 63% and by Cox analysis was related to age (p = 0.05), initial visual loss (p < 0.0001), iris involvement (p < 0.0001), and tumor thickness (p < 0.0001). Glaucoma was present before treatment in 13 patients and developed after treatment in another 3. Three eyes were enucleated, all because of recurrence, which had an actuarial 4-year rate of 3.3% (95% CI 0-8.0%). CONCLUSIONS: Proton beam radiotherapy of iris melanoma is well tolerated, the main problems being radiation-cataract, which was treatable, and preexisting glaucoma, which in several patients was difficult to control.

Proton beam radiotherapy of choroidal melanoma: the Liverpool-Clatterbridge experience.

PURPOSE: To report on outcomes after proton beam radiotherapy of choroidal melanoma using a 62-MeV cyclotron in patients considered unsuitable for other forms of conservative therapy. METHODS AND MATERIALS: A total of 349 patients with choroidal melanoma referred to the Liverpool Ocular Oncology Centre underwent proton beam radiotherapy at Clatterbridge Centre for Oncology (CCO) between January 1993 and December 2003. Four daily fractions of proton beam radiotherapy were delivered, with a total dose of 53.1 proton Gy, and with lateral and distal safety margins of 2.5 mm. Outcomes measured were local tumor recurrence; ocular conservation; vision; and metastatic death according to age, gender, eye, visual acuity, location of anterior and posterior tumor margins, quadrant, longest basal tumor dimension, tumor height, extraocular extension, and retinal invasion. RESULTS: The 5-year actuarial rates were 3.5% for local tumor recurrence, 9.4% for enucleation, 79.1% for conservation of vision of counting fingers or better, 61.1% for conservation of vision of 20/200 or better, 44.8% for conservation of vision of 20/40 or better, and 10.0% for death from metastasis. CONCLUSION: Proton beam radiotherapy with a 62 MeV cyclotron achieves high rates of local tumor control and ocular conservation, with visual outcome depending on tumor size and location.