Quality improvement and patient safety in India-Present and future.

India is a vast, populous and diverse country, and this reflects in the state of health care as well. The spectrum of healthcare services ranges from world class at one end, to a dearth of resources at the other. In the rural areas especially, there is a shortage of trained medical personnel, equipment, and medications needed to carry out safe surgery. Several initiatives have and are being made by the government, medical societies, hospitals, and nongovernment organizations to bridge this gap and ensure equitable, safe, and timely access to health for all. Training medical personnel and healthcare workers, accreditation of healthcare facilities, guidelines, and checklists, along with documentation and audit of practices will all help in improving services. This narrative review discusses the measures that have been taken, systems that have been established and the challenges involved in ensuring quality and patient safety in India.

Challenges and Opportunities Facing Pediatric Anesthesia Providers in Low- and Middle-Income Countries (LMICs), India.

India is a vast, populous country with a huge variability in the standards of health care. While the cities have state of the art hospitals with trained doctors, rural areas where most of the population lives, have a severe shortage of resources. Children form nearly 40% of India's population, and there is a great demand for pediatric surgical and anesthesia services. Specialty training in pediatric anesthesia, however, is still in its infancy, with the majority of children being administered anesthesia by general anesthesiologists. This review discusses the reasons behind India's ailing healthcare system and the shortage of qualified pediatric anesthesiologists. Anesthesiologists face multiple challenges in their daily work including inadequate infrastructure, paucity of medications and working equipment, nonavailability of trained help, and poor remuneration. All these factors contribute to work-related stress. On the other hand, the dearth of anesthesiologists offers ample opportunities to serve the underserved, improve the safety and quality of perioperative care in the rural areas, and improve the self-image of the anesthesiologist. A paucity of data regarding anesthesia, surgery, and work-related issues makes writing an article like this very difficult. However, it highlights the need for professional bodies to take note of these facts and play an active role in encouraging documentation, data collection, and improving standards of teaching and practice.

Taking care of our future doctors: a service evaluation of a medical student mental health service.

BACKGROUND: Studies suggest medical students experience high levels of mental distress during training but are less likely, than other students, to access care due to stigma and concerns regarding career progression. In response, The School of Clinical Medicine, University of Cambridge supported the development of the 'Clinical Student Mental Health Service' to provide specialist input for this vulnerable group. This study evaluates the efficiency and effectiveness of this service. METHODS: Using mixed-methods, cross-sectional analysis of validated psychiatric rating scales and qualitative feedback, 89 responses were analysed from 143 clinical students referred, between 2015 and 2019. The care pathway included initial review by a psychiatrist, who triaged students to psychologists delivering therapies including: Cognitive Behavioural Therapy, Interpersonal Therapy, Eye Movement Desensitization Reprocessing Therapy or Cognitive Analytic Therapy. Efficiency was assessed by waiting times for psychiatry and psychology interventions, and number of sessions. Academic outcomes included school intermission and graduation. Clinical effectiveness was analysed by measuring global distress, depression, anxiety, functioning and suicidal risk. Pre/post intervention changes were captured using t-test and McNemar test with thematic analysis of qualitative feedback. RESULTS: Referral rates increased from 3.93% (22/560) in 2015 to 6.74% (45/668) in 2018. Median waiting times for initial psychiatric assessment and start of therapy was 26 and 33 days, respectively. All graduating students moved on to work as junior doctors. Levels of distress, (t = 7.73, p < 0.001, df = 31), depression (t = 7.26, p < 0.001, df = 34) anxiety (Z = - 4.63, p < 0.001) and suicide risk (Z = - 3.89, p < 0.001) were significantly reduced. Participant's functioning was significantly improved (p < 0.001, 99.5% CI 4.55 to 14.62). Feedback indicated high satisfaction with the rapid access and flexibility of the service and the team clinicians. CONCLUSIONS: A significant proportion of medical students attending the service scored highly on validated rating scales measuring emotional distress, suicidality and mental illness. Reassuringly they benefitted from timely specialist mental health input, showing improvements in mental well-being and improved functioning. The development and design of this service might serve as an exemplar for medical schools developing similar support for their students.

Preoperative assessment of gastric contents and volume using bedside ultrasound in adult patients: A prospective, observational, correlation study.

BACKGROUND AND AIMS: Pulmonary aspiration of gastric contents is a serious complication of anaesthesia. The aim of this study was to determine, with the help of ultrasound, the gastric volume and content in fasted patients presenting for elective surgeries and correlate the results with fasting times and co-morbidities of the patients. METHODS: The study was conducted in 100 adult patients presenting for elective surgery. A preoperative bedside gastric ultrasound scan was done in supine and right lateral position. Gastric contents were noted, and gastric volume was calculated at the level of the gastric antrum. Gastric volume was estimated by measuring antral cross-sectional area (CSA) and using a mathematical model. Gastric volume in the right lateral decubitus (RLD) position was taken as the final reading. Analysis of variance and Student's t-test were done for statistical significance and P < 0.05 was considered statistically significant. RESULTS: Six out of 100 patients had solid gastric contents and 16 had >1.5 ml/kg clear liquids, although they had been fasting between 10 and 15 hours. Patients suffering from diabetes and chronic kidney disease had statistically significant increase in CSA in both supine and RLD. We also found increase in estimated gastric volume as the BMI of the patients increased. CONCLUSION: Our study showed that fasting for more than 6-10 hours does not guarantee an empty stomach. Those with co-morbidities like diabetes mellitus, obesity and chronic kidney disease (CKD) appear more prone to have unsafe gastric contents.

Cognitive deficits including executive functioning in relation to clinical parameters in paediatric MS patients.

BACKGROUND: A number of studies have investigated cognitive impairment in paediatric patients with multiple sclerosis (MS) but deficits regarding executive functions have not been comprehensively assessed up to now. This study was meant to explore cognitive impairment in German paediatric MS patients with a focus on deficits in executive functions and relate these to clinical disease parameters. METHODS AND FINDINGS: Forty paediatric MS patients, which presented at the German centre for MS in childhood and adolescence, were assessed for cognitive deficits applying a very comprehensive battery of cognitive tests including the Wechsler Intelligence scale and subtests of the D-KEFS for executive functions. The performance of MS patients was compared with a group of age and sex matched healthy controls using between-subjects ANOVAs. Paediatric MS patients performed worse in tests assessing verbal comprehension and fluency, processing speed, memory, calculation skills and other executive functions. Arranged by the cognitive domain, group differences were most pronounced regarding verbal comprehension and fluency for the WISC subtests Comprehension (p = 0.000), Vocabulary (p = 0.003) and Information (p = 0.005); regarding processing speed for the written SDMT (p = 0.001) and the WISC subtest Coding (p = 0.005); regarding memory for the VLMT training (p = 0.007) and the BASIC MLT pattern learning training (p = 0.009); regarding executive functions including working memory for the WISC subtest Arithmetics (p = 0.002), the D-KEFS Design Fluency (p = 0.003) and the Corsi block tapping backward task (p = 0.003). Fluid reasoning was largely intact. Relations of cognitive performance and clinical parameters were assessed in MS patients. Disease duration was associated with a reduced performance in tests belonging to the domains verbal comprehension and fluency (WISC Vocabulary: p = 0.034, WISC Information: p = 0.015) and fluid reasoning (WISC Picture Completion: p = 0.003) as well as the WISC Working Memory Index (p = 0.047). Patients with a disease onset between 11 and 14 years performed better in fluid reasoning (WISC matrix reasoning: p = 0.024) than patients with a disease onset at an age above 14. The number of relapses negatively influenced the visual spatial memory performance (BASIC MLT pattern learning training: p = 0.009). CONCLUSIONS: The distribution of cognitive deficits in a representative group German of paediatric MS patients was similar to the pattern known from other European and North-American cohorts. Paediatric MS patients do have cognitive deficits in executive functions and key qualities necessary for successful school performance. Disease duration, age of onset and the number of relapses influence cognitive performance. Cognitive screenings should be implemented on a regular basis for paediatric MS patients, enabling early intervention.

Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design.

Frequent attendance to the emergency department (ED) is a growing public health concern. Designing services for frequent attenders poses challenges, given the heterogeneous nature of this group. This was a two-part observational study identifying frequent attenders from ED records. The first stage studied trends and developed personas with emphasis on differentiating moderate frequent attenders (attending between 5 and 20 times per year) and extreme frequent attenders (attending more than 20 times). Stage 2 included a case note review of 100 consecutive frequent attenders. Results showed an increase in frequent attendance from 2.59% to 4.12% over 8 years. Moderate frequent attenders accounted for 97%. Of the 100 frequent attenders studied, 45% had medically unexplained symptoms (MUS), associated with younger age (p<0.001) but not with gender (p>0.05). In conclusion, the ED is a useful hub for identifying frequent attenders with MUS, particularly among moderate frequent attenders; service design for this group should consider a 'whole-systems approach' with integration between primary and secondary care, including specialist liaison psychiatry services where appropriate.

Hydrogen-atom attack on phenol and toluene is ortho-directed.

The reaction of H + phenol and H/D + toluene has been studied in a supersonic expansion after electric discharge. The (1 + 1') resonance-enhanced multiphoton ionization (REMPI) spectra of the reaction products, at m/z = parent + 1, or parent + 2 amu, were measured by scanning the first (resonance) laser. The resulting spectra are highly structured. Ionization energies were measured by scanning the second (ionization) laser, while the first laser was tuned to a specific transition. Theoretical calculations, benchmarked to the well-studied H + benzene → cyclohexadienyl radical reaction, were performed. The spectrum arising from the reaction of H + phenol is attributed solely to the ortho-hydroxy-cyclohexadienyl radical, which was found in two conformers (syn and anti). Similarly, the reaction of H/D + toluene formed solely the ortho isomer. The preference for the ortho isomer at 100-200 K in the molecular beam is attributed to kinetic, not thermodynamic effects, caused by an entrance channel barrier that is ∼5 kJ mol(-1) lower for ortho than for other isomers. Based on these results, we predict that the reaction of H + phenol and H + toluene should still favour the ortho isomer under elevated temperature conditions in the early stages of combustion (200-400 °C).

H and D attachment to naphthalene: spectra and thermochemistry of cold gas-phase 1-C10H9 and 1-C10H8D radicals and cations.

Excitation spectra of the 1H-naphthalene (1-C10H9) and 1D-naphthalene (1-C10H8D) radicals, and their cations, are obtained by laser spectroscopy and mass spectrometry of a skimmed free-jet expansion following an electrical discharge. The spectra are assigned on the basis of density functional theory calculations. Isotopic shifts in origin transitions, vibrational frequencies and ionization energies were found to be well reproduced by (time-dependent) density functional theory. Absolute bond dissociation energies, ionization energies and proton affinities were calculated using high-level quantum chemical methods.

Separation of thoraco-omphalopagus twins in a rural secondary hospital: Perioperative management.

Providing anaesthesia for the separation surgery of conjoined twins presents unique challenges to the managing anaesthesiologists. The low incidence of such surgeries and anatomical variations in each type of conjoined twins makes each separation surgery a unique experience. This report features the anaesthetic plan and challenges faced in performing the separation surgery of a set of thoraco-omphalopagus twins in a rural secondary hospital in a remote location in India.

Anaesthesia for biliary atresia and hepatectomy in paediatrics.

The scope of this article precludes an 'in depth' description of all liver problems and I will limit this review to anaesthesia for biliary atresia - a common hepatic problem in the very young - and partial hepatectomy in older children. I will not be discussing the problems of anaesthetising children with hepatitis, cirrhosis, congenital storage diseases or liver failure. Extrahepatic biliary obstruction is an obliterative cholangiopathy of infancy which is fatal if untreated. Diagnosis involves exclusion of other causes of neonatal jaundice and treatment involves a hepatico portoenterostomy carried out at the earliest. This is a review of current concepts in anaesthesia and postoperative management of neonates with extrahepatic biliary atresia. Anaesthesia for hepatic resection has seen great changes in recent times with the improvement in surgical techniques, technology and a better understanding of the underlying physiology. These are reviewed along with the problems of postoperative pain management.

Anesthesia for thoracic surgery in children in developing countries.

Anesthesia for surgery on the lung and intra-thoracic structures requires a high level of expertise. In the developing world, patients are often poor, anemic and malnourished. They present late with a variety of diseases. Surgery is often mandated in spite of inadequate resources. Maintaining the safety of the patient while treating them within the limits of our resources is a continuing challenge.

Pro: anesthesia for children in the developing world should be delivered by medical anesthetists.

Outcomes from pediatric surgery when carried out by trained pediatric anesthetists are excellent. This is not the case when the anesthesia provider is poorly trained. The presence of pediatric anesthetists is not only the norm but considered mandatory for children below the age of 2-3 years in developed countries. There are many reasons why trained anesthetists are not readily available in developing countries - migration to greener pastures, inadequate training facilities, poor remuneration and support services being some of them. These problems should be addressed but safety of the children should not be compromised. One should not condone poor standards to deprive children of safe anesthesia and the caregiver of much needed self-respect.

Clonidine in paediatrics - a review.

SUMMARY: Clonidine, an alpha-2 agonist is a known antihypertensive agent. Because of its sedative and analgesic effects, it is gaining popularity in anaesthesiology. It can be used to premedicate children, as an adjuvant to regional and general anaesthesia and it has several other applications in paediatric anaesthesia. It has also found use in the paediatric intensive care as a sedative, analgesic and to ensure haemodynamic stability. As in the case of any other anaesthetic drug, its use has to be vigilantly monitored.

Paediatric Auto Renal transplantation-Anaesthetic Challenge.

SUMMARY: Takayasu's arteritis is described to be the single most important cause of renovascular hypertension. Anaesthetising a child with Takayasu's arteritis for auto renal transplantation is a challenge as it is complicated by severe uncontrolled hypertension, end-organ dysfunction resulting from hypertension, stenosis of major blood vessels affecting regional circulation, and difficulties encountered in monitoring arterial blood pressure. A balanced anaesthetic technique, maintenance of stable haemodynamics with monitoring is required for a successful outcome. We describe the anaesthetic management of a child with Takayasu's arteritis and severe hypertension refractory to medical treatment requiring auto renal transplantation.