Prem Nair

Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: a prospective study.

Aim:  To evaluate predictors of neostigmine response in patients with acute colonic pseudo‐obstruction.

Colorectal cancer distribution in 220 Indian patients undergoing colonoscopy

AimColorectal cancer is one of the major cancers in the developed world. The incidence of colorectal cancer is low in India. The aim of the present study was to describe the anatomical distribution and age at diagnosis of colorectal cancer in India.MethodsRetrospective descriptive analysis of anatomical distribution, age at diagnosis and demography of 220 cases (149 [67.7%] men) of adenocarcinoma of the colon or rectum diagnosed at colonoscopy over a period of five years.ResultsThe mean age at diagnosis was 58.4 years (SD 13.3; range 23–85 years). Twenty-eight (12.7%) cases were below the age of 40 years. The majority (31.8%) cases were aged between 61–70 years. Most of the tumors (n=163, 74%) were located distal to the splenic flexure. Multivariate logistic regression analysis showed that bleeding per rectum (OR 2.8; 95% CI 1.2–6.2) was associated with distal cancer, and palpable mass (OR 3.9; 95% CI 1.7–8.6) was associated with proximal cancer.ConclusionsAlmost one-third of the colorectal cancers in this series occurred in the seventh decade and were located distal to the splenic flexure.

Improving outcomes and reducing costs by modular training in infection control in a resource-limited setting

OBJECTIVE To study the impact of modular training and implementation of infection control practices on all health-care-associated infections (HAIs) in a cardiac surgery (CVTS) program of a tertiary care hospital. DESIGN Baseline data were compared with post-intervention (with modular training) data. SETTING This study was conducted in a cardiovascular surgical unit. PARTICIPANTS In total, 2838 patients were admitted in cardiovascular surgical service. INTERVENTIONS Two training modules and online continuous education were delivered to all health-care workers in CVTS unit. MAIN OUTCOME MEASURES All four HAIs, such as surgical site infections (SSI), central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CA-UTI), were studied. Additional outcome measures included average length of stay cost of avoidance mortality and readmission rates. RESULTS The SSI rate had decreased in the post-intervention phase from 46 to 3.27% per 100 surgeries (P < 0.0001), CLABSI had decreased from 44 to 3.10% per 1000 catheter days (P < 0.009), VAP was reduced from 65 to 4.8% per 1000 ventilator days (P < 0.0001) and CA-UTI had reduced from 37 to 3.48% per 1000 urinary catheter days (P < 1.0). For every

Detection of occult hepatitis B and window period infection among blood donors by individual donation nucleic acid testing in a tertiary care center in South India

1 spent on training, the return on investment was

Gastrointestinal: Abdominal wall metastasis after percutaneous endoscopic gastrostomy

236 as cost of avoidance of healthcare associated infections (HAIs). CONCLUSIONS Standardization of infection control training and practices is the most cost-effective way to reduce HCAIs and related adverse outcomes.

Lean six sigma application in reducing nonproductive time in operation theaters

With the introduction of highly sensitive hepatitis B surface antigen immunoassay, transfusion associated HBV infection have reduced drastically but they still tend to occur due to blood donors with occult hepatitis B infection (OBI) and window period (WP) infection. Sera from, 24338 healthy voluntary blood donors were screened for HBsAg, HIV and HCV antibody using Vitros Enhanced Chemiluminescent Immunoassay. The median age of the donor population was 30 (range 18–54) with male preponderance (98%). All serologically negative samples were screened by nucleic acid testing (NAT) for viral DNA and RNA. NAT-positive samples were subjected to discriminatory NAT for HBV, HCV, and HIV and all samples positive for HBV DNA were tested for anti-HBc, anti-HBs, HBeAg. Viral load was determined using artus HBV RG PCR Kit. Of the 24,338 donors screened, 99.81% (24292/24338) were HBsAg negative of which NAT was positive for HBV DNA in 0.0205% (5/24292) donors. Four NAT positive donors had viral load of <200 IU/ml making them true cases of OBI. One NAT positive donor was negative for all antibodies making it a case of WP infection. Among OBI donors, 75% (3/4) were immune and all were negative for HBeAg. Precise HBV viral load could not be determined in all (5/5) NAT positive donors due to viral loads below the detection limit of the artus HBV RG PCR Kit. The overall incidence of OBI and WP infections was found to be low at 1 in 6503 and 1 in 24214 donations, respectively. More studies are needed to determine the actual burden of WP infections in Indian blood donors.

Tropical pancreatitis - a distinct entity, or merely a type of chronic pancreatitis?

A 53-year-old woman was referred for evaluation with recurrent carcinoma of the right piriform fossa. She had been previously treated by radiotherapy. Radical surgery was undertaken that included a total laryngopharyngectomy with reconstruction of the pharynx using a flap from the antero-lateral aspect of the left thigh. During the operation, percutaneous endoscopic gastrostomy was performed for post-operative feeding. The resected specimen revealed squamous cell carcinoma of moderate differentiation with infiltration of the tumor into the thyroid gland and into the esophageal wall. All surgical margins were free of tumor. After 5 months, she was noted to have a friable and bleeding mass at the gastrostomy site. The mass had raised margins and was approximately 5 cm in diameter (Fig. 1). Biopsies revealed squamous cell carcinoma of moderate differentiation (Fig. 2). Biopsies of a recurrent neck swelling also showed squamous cell carcinoma. She declined further therapy and is currently being treated symptomatically. Carcinomas of the head and neck are common neoplasms in many countries. Typical sites for metastases include lung, liver and bone. Surgical treatment for these neoplasms often involves prolonged avoidance of oral food and fluids and, because of this, feeding through a gastrostomy tube is widely used during the post-operative period. A metastasis in the abdominal wall at the site of the gastrostomy tube was first reported by Drs Preyer and Thul in 1989. Since that time, an additional 50 cases have been reported with an estimated frequency ranging from 0.5% to 1%. Clinically, metastases may present as non-healing peristomal ulceration, recurrent stomal bleeding, an exophytic peristomal mass or a deep abdominal wall mass. While direct spread of the neoplasm during the endoscopic procedure appears to be the most likely cause for abdominal wall metastases, other hypotheses have been suggested including hematogenous and lymphatic spread to the abdominal wall. The development of a gastrostomy metastasis with carcinoma of the head and neck is a poor prognostic feature. Such patients have a mean survival of 7 months and 1 year survival of <5%.

Groove Pancreatitis: A Case Report and Review of Literature

Background: Non Productive Time OT causes potential loss or deferment of revenue for the hospital and internal customer dissatisfaction. The quality tool Lean Six Sigma may help to reduce the non-productive time. Aim: To use elements of a six sigma model to reduce non-productive time in Gastro Intestine Surgery OT. It focuses on the reduction of NPT between Patient In time and Induction Begin time, Induction End time and Incision In time, Patient Out time and OT Readiness Time. Method: In a five phase study using DMAIC (Define. Measure, Analyze, Implement & Control) model, business case, value analysis, brain storming, FMEA (Failure Mode & Effect Analysis), RPN (Risk Priority Number) calculation identified causes and solutions. In six sigma analysis process sigma, target sigma and achieved sigma was calculated. Results: The null hypothesis of no difference in old and new Non Productive Time between Patient In time and Induction Begin time, between Induction End time and Incision and between Patient Out Time and OT Readiness Time was rejected using 2test since the p-value was below 0.05 at 95% confidence level. The process sigma was at 0.91, 0.96 and 0.67 which got improved to 2.55, 2.22 and 3.28 which was better than target Six sigma. Overall bottom line improvement was 4.8CR for the study period by bringing efficiency in the system. Conclusion: The six sigma project in OT resulted in reducing NPTs, helping to take more cases, patient discharge becoming more systematic, and reducing chaos regarding scheduling OT cases.