Publications by authors named "Aparna Sharma"

95 Publications

A Cross-Sectional Analysis to Evaluate Knowledge, Attitude And Practices Among Pregnant Women During COVID-19 Pandemic.

J Obstet Gynaecol India 2021 Sep 4:1-10. Epub 2021 Sep 4.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To assess knowledge, attitude and practices (KAP) towards COVID-19 among pregnant women at a tertiary care hospital.

Methods: This was a questionnaire-based cross-sectional analysis pertaining to COVID-19 which was conducted at a tertiary care obstetric facility in India among 200 consecutive consenting pregnant women. They were assessed for demographic details and KAP score (knowledge-17 questions, attitude-9 questions and practice-8 questions). Analysis of data was done using Statistical Package for the Social Sciences (SPSS) version 25.0.

Results: The participants had adequate mean knowledge score (± SD) of 22.5 (± 3.5) were following good practices [mean score (± SD) = 15.5 (± 2.6)] and showed positive attitude for preventive measures against COVID-19 [ (%) = 194(96%)]. Low knowledge score (-value 0.030) was seen in non-health care workers.

Conclusion: This study demonstrated that majority of the pregnant women had satisfactory knowledge, positive attitude and were following practices in right manner regarding COVID-19 but continued efforts for generating awareness were warranted. As India is battling the second COVID-19 wave and in the absence of definitive cure, strengthening of health policies directed at pregnant women should be prioritized with special focus on significant gaps in KAP.
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http://dx.doi.org/10.1007/s13224-021-01558-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416569PMC
September 2021

Prevalence of Trismus and Its Impact on Oral Health-Related Quality of Life in Patients Treated for Oral Squamous Cell Carcinoma.

Asian Pac J Cancer Prev 2021 Aug 1;22(8):2437-2444. Epub 2021 Aug 1.

Department of Community Dentistry and Oral Epidemiology, College of Dentistry, Qassim University, Buraydah, Kingdom of Saudi Arabia.

Oral squamous cell carcinoma, one of the most common malignancies, has a poor prognosis due to impairment in oral functions secondary to treatment. Trismus one of the major causes of impairment of oral function. The present study investigated the prevalence of trismus and its impact on oral health-related quality of life (OHRQoL) in patients treated for oral squamous cell carcinoma (OSCC). The maximum inter-incisal mouth opening of hundred OSCC patients was recorded at post-treatment and 3 months post-treatment. OHRQoL questionnaire (OHIP-14) was intervened to assess the OHRQoL of patients post-treatment and 3 months follow-up, with emphasis on correlation with grades of trismus. The prevalence of trismus was 16% pre-treatment, 72% post-treatment, and 62% at 3 months after treatment. The overall OHIP-14 scores indicated that patients with trismus reported greater impairment of OHRQoL than those without trismus at the end of treatment and 3 months follow-up. At the end of treatment, patients with severe trismus demonstrated a higher mean OHIP-14 score (23.47 ±3.34) than those with moderate (17.72 ±2.83) and mild trismus (12.66 ±3.84) with statistically significant differences (p <0.001). Equivalent results were obtained at 3 months follow-up period. Patients with trismus suffer greater impairment of OHRQoL. The findings demand the need of identifying risk factors for developing trismus and early institution of newer/modified treatment approaches for better OHRQoL in OSCC survivors.
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http://dx.doi.org/10.31557/APJCP.2021.22.8.2437DOI Listing
August 2021

Establishing the practice of birth companion in labour ward of a tertiary care centre in India-a quality improvement initiative.

BMJ Open Qual 2021 07;10(Suppl 1)

Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi, India

Background: Birth companion is a key component for providing respectful maternity care and has been recommended by WHO and Government of India. It is a low-cost beneficial intervention that is vital in improving quality of care during labour and delivery.

Local Problem: Despite the available evidence on benefits of birth companion, there was no policy on allowing birth companion at our hospital in the past.

Methods And Interventions: We aimed to establish the practice of allowing birth companions in all eligible women in labour ward from existing 0% to 50% in 6 weeks' duration. This study was conducted in the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi. A quality improvement (QI) team was formed, and after obtaining the baseline data, problems were analysed using fish bone chart. A new policy of allowing birth companion was made and efforts made to sensitise and train the doctors and nurses posted in labour ward. Changed ideas were executed in multiple plan-do-study-act (PDSA) cycles. Simple interventions such as dress code for birth companions, curtains for ensuring privacy, display of posters and frequent reminders on WhatsApp groups were planned .

Results: The median value of women accompanied by birth companion marginally increased to 25% after the first PDSA cycle. Implementation of further changed ideas led to increase in median, which reached 66.6%. Thereafter, there was a decline, but by the end of 6 months, it was possible to attain the goal and sustain it.

Conclusions: Simple steps of QI methodology can be used to address the prevalent problems in our healthcare. Implementation of any new practice comes with major challenges, but we could achieve our goal because of a motivated team working together on multiple changed ideas applied sequentially in PDSA cycles.
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http://dx.doi.org/10.1136/bmjoq-2021-001409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336223PMC
July 2021

Checklist to aid young physicians managing obstetric emergencies in rural India: a quality improvement initiative.

BMJ Open Qual 2021 07;10(Suppl 1)

Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Background: The decision to admit or refer a patient presenting with an obstetric emergency is extremely crucial. In rural India, such decisions are usually made by young physicians who are less experienced and often miss relevant data points required for appropriate decision making. In our setting, before the quality improvement (QI) initiative, this information was recorded on loose blank sheets (first information sheets (FIS)) where an initial clinical history, physical examination and investigations were recorded. The mean FIS completeness, at baseline, was 73.95% (1-5 January 2020) with none of the FIS being fully complete. Our objective was to increase the FIS completeness to >90% and to increase the number of FIS that were fully complete over a 9-month period.

Methods: With the help of a prioritisation matrix, the QI team decided to tackle the problem of incomplete FIS. The team then used fishbone analysis and identified that the main causes of incomplete FIS were that the interns did not know what to document and would often forget some data points. Change ideas to improve FIS completeness were implemented using Plan-Do-Study-Act (PDSA) cycles, and ultimately, a checklist (referred to as antenatal care (ANC) checklist) was implemented. The study was divided into six phases, and after every phase, a few FIS were conveniently sampled for completeness.

Results: FIS completeness improved to 86.34% (p<0.001) in the post implementation phase (1 Feb to 31 August 2020), and in this phase, 69.72% of the FIS were documented using the ANC checklist. The data points that saw the maximum improvement were relating to the physical examination.

Conclusion: The use of ANC checklist increased FIS completeness. Interns with no prior clinical and QI experience can effectively lead and participate in QI initiatives. The ANC checklist is a scalable concept across similar healthcare settings in rural India.
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http://dx.doi.org/10.1136/bmjoq-2021-001435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336185PMC
July 2021

Facility preparedness for an obstetric unit during the Covid-19 pandemic.

Natl Med J India 2020 Nov-Dec;33(6):349-357

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.

Covid-19 infection has placed health systems under unprecedented strain and foresight for preparedness is the key factor to avert disaster. Every facility that provides obstetric service needs a certain level of preparedness to be able to handle at least Covid-suspect pregnant women awaiting test reports, who need to be managed as Covid-positive patients till reports are available. Thus, these facilities need to have triage areas and Covid-suspect labour rooms. Healthcare facilities can have designated areas for Covid-positive patients or have referral linkages with designated Covid-positive hospitals. Preparation includes structural reorganization with setting up a Covid-suspect and Covid-positive facility in adequate space, as well as extensive training of staff about infection control practices and rational use of personal protective equipment (PPE). A systematic approach involving five essential steps of making standard operating procedures, infrastructural reorganization for a triage area and a Covid-suspect labour ward, procurement of PPE, managing the personnel and instituting appropriate infection control practices can ensure uninterrupted services to patients without compromising the safety of healthcare providers.
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http://dx.doi.org/10.4103/0970-258X.321135DOI Listing
August 2021

Pseudoamniotic band syndrome after bipolar cord coagulation in monochorionic twins complicated by twin-to-twin transfusion syndrome.

BMJ Case Rep 2021 Jul 13;14(7). Epub 2021 Jul 13.

Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, Delhi, India

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http://dx.doi.org/10.1136/bcr-2021-244471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278920PMC
July 2021

Perinatal outcome in monochorionic twin pregnancies after selective fetal reduction using radiofrequency ablation.

Int J Gynaecol Obstet 2021 Jun 12. Epub 2021 Jun 12.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To study the perinatal outcomes in women with complicated monochorionic twin pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA).

Methods: This retrospective study included 44 patients with monochorionic twin pregnancies, between 14 and 28 weeks of pregnancy, who underwent RFA for selective fetal reduction. Perinatal and maternal outcomes and procedure-related complications were analyzed.

Results: The procedure was technically successful in all 44 cases. Indications for selective fetal reduction included twin-to-twin transfusion syndrome (52.3%), twin reversed arterial perfusion (20.5%), twins discordant for anomaly (15.9%), and selective fetal growth restriction (11.4%). Median gestational age at procedure was 22  weeks (range 14-26 ). Live birth rate was 77.3% with three neonatal deaths; so overall survival was 70.5%. Median procedure-to-delivery interval was 12  weeks (range 2 -23). There were eight losses before 24 weeks of pregnancy, which included two co-twin deaths. Median gestational age at delivery was 35 weeks (interquartile range 32 -37 weeks). The preterm delivery rate was 66.7% (24/36) and preterm prelabor rupture of membranes (PPROM) occurred in 22.7% (10/44) of patients.

Conclusion: Selective fetal reduction using RFA is safe and effective in complicated monochorionic pregnancies. However, the rates of PPROM and preterm delivery remain high.
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http://dx.doi.org/10.1002/ijgo.13785DOI Listing
June 2021

Pazopanib based oral metronomic therapy for platinum resistant/refractory epithelial ovarian cancer: A phase II, open label, randomized, controlled trial.

Gynecol Oncol 2021 Aug 2;162(2):382-388. Epub 2021 Jun 2.

Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi 110029, India. Electronic address:

Background: Treatment of patients with platinum resistant/refractory epithelial ovarian cancer (EOC) is an unmet need. We evaluated the role of oral metronomic therapy in this setting.

Patients And Methods: Between October 2017 and September 2019 seventy five patients with platinum resistant/refractory EOC were enrolled. Patients received oral etoposide (50 mg, day 1 to 14, cyclophosphamide 50 mg, day 1 to 28, every 4 weeks (Arm A, n = 38). Patients in Arm- B (n = 37) received Pazopanib (400 mg once daily) in addition to etoposide and cyclophosphamide. Quality of life (QoL) was evaluated using the EORTC questionnaire. Serum VEGF and PDGF were estimated at baseline, after 3rd and 6th cycle. The primary endpoint was progression free survival (PFS). Secondary endpoints were overall survival (OS), toxicity and QoL.

Results: Patients characteristics were well matched. Median PFS was higher in arm B, 5.1 months (95% CI 3.13 to10.33) compared to 3.4 months (95% CI 3.0 to 6.53) in arm A, p = 0.045. Median OS has 'not reached' in Arm B compared to 11.2 months (95% CI, 5.66 - not reached) in arm A, p = 0.032. Therapy was tolerated well; oral mucositis (p = 0.36) and fatigue (p = 0.08) being more in arm B. QoL assessment revealed modest improvement in 'symptom scales' in Arm B. Serum VEGF and PDGF levels decreased with therapy in both arms (Arm A-p < 0.0001, Arm B-p < 0.016).

Conclusion: Addition of pazopanib to etoposide and cyclophosphamide could be a novel oral combination for metronomic therapy for platinum resistant/refractory EOC.

Trial Registration: CTRI/2017/10/010219.
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http://dx.doi.org/10.1016/j.ygyno.2021.05.025DOI Listing
August 2021

A descriptive audit of healthcare workers exposed to COVID-19 at a tertiary care center in India.

Int J Gynaecol Obstet 2021 Jun 18;153(3):393-397. Epub 2021 Apr 18.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To provide a descriptive audit of healthcare workers (HCWs) exposed to COVID-19, and their contacts, to understand the dynamics of transmission among HCWs.

Methods: Retrospective analysis of contact tracing data of infected HCWs was done from March 1, 2020 to July 31, 2020 at a tertiary care center in New Delhi, India. Contacts were categorized according to the nature of contact and followed for 14 days.

Results: Qualitative RT-PCR testing was performed on 106 HCWs (from a total of 257) owing to exposure or development of symptoms. Positive results were found in 16 HCWs (6.2%) who were exposed to 120 other HCWs, generating 197 exposure incidents. Of these, 30 (15.2%) exposure incidents were high risk with multiple exposures in 48 (40.0%) HCWs. Exposure to infected HCWs was noted in 3 (18.8%) of 16 positive cases. Of the 197 exposure incidents, 54 (27.4%) were deemed avoidable exposures. Infection prevention and control policies were periodically reviewed, and the department implemented mitigating steps to minimize the risk to healthcare providers.

Conclusion: Instituting appropriate infection prevention and control policies and use of adequate precautions by HCWs is vital to minimize high-risk exposure to COVID-19.
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http://dx.doi.org/10.1002/ijgo.13691DOI Listing
June 2021

Oral metronomic chemotherapy is a cost effective alternative to pazopanib in advanced soft tissue sarcoma.

J Oncol Pharm Pract 2021 Mar 9:10781552211000113. Epub 2021 Mar 9.

Department of Medical Oncology, All India Medical Sciences, New Delhi, India.

Introduction: Soft tissue sarcoma(STS) is a rare and heterogeneous group of disorders with dismal outcomes in metastatic setting. Pazopanib and oral metronomic chemotherapy (OMT) have been evaluated as therapeutic options in this cohort.

Materials And Methods: We conducted a retrospective, single center study evaluating 45 patients with unresectable and/or metastatic STS, who received pazopanib or oral metronomic regimen as per instituitonal protocol between January 2013 and December 2019. An informal cost minimisation analysis was conducted for both OMT and pazopanib arms, considering equivalent outcomes for both (PFS and OS).

Results: Median PFS in OMT and Pazopanib groups was 4.13 months and 3.53 months,respectively (HR1.31, 95% CI:0.68-2.51, p = 0.41) Only one patient in the OMT group achieved an objective response (partial response) and no objective response was noted in the pazopanib group. The incidence of grade III/IVtoxicities was higher with pazopanib than with OMT (p = 0.08). There were no toxicity related deaths noted in either arm.

Conclusions: Our study demonstrates that OMT have a similar progression free survival (PFS) and overall survival (OS) in metastatic STS. This study raises the possibility that OMT might be an equally efficacious and less toxic alternative to pazopanib, without compromising survival outcome especially in LMIC.
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http://dx.doi.org/10.1177/10781552211000113DOI Listing
March 2021

Oral and general health-related quality of life in oral squamous cell carcinoma patients- comparative analysis of different treatment regims.

J Oral Biol Craniofac Res 2021 Apr-Jun;11(2):125-131. Epub 2021 Jan 6.

Department of Community Dentistry and Oral Epidemiology, College of Dentistry, Qassim University, Buraydah, Saudi Arabia.

Background: Modern aggressive oncological treatment options for oral squamous cell carcinoma (OSCC) are inevitably associated with impaired general health-related quality of life (HRQoL) and oral HRQoL (OHRQoL). However, there is dire need for prospective and concomitant assessment of HRQoL and OHRQoL after different treatment regims. Hence, present study was designed to investigate HRQoL and OHRQoL in patients treated for OSCC using various modalities.

Methods: 135 OSCC patients were grouped according to treatment rendered into Group A: surgery only; Group B: post-surgical radiotherapy (PRT); and Group C: post-surgical chemo-radiation (PCRT). The 12-item Short Form Health Survey (SF-12) and Oral Health Impact Profile-14 (OHIP-14) were intervened to assess HRQoL and OHRQoL respectively at 1-month and 6-months post-treatment.

Results: At 1-month post-treatment, patients who received PCRT showed significantly lower mean values for physical and mental domains of SF-12 and higher mean subscales and overall OHIP-14 (24.57 ​± ​2.62) score than those treated by surgery alone (10.55 ​± ​2.26) and PRT (20.20 ​± ​3.80), with largest differences between PCRT and surgery alone groups (p ​< ​0.001). Social functioning, general health and bodily pain of SF-12 and functional limitations, physical pain and physical disability amongst OHIP-14 domains were greatly affected. Although few physical domains of SF-12 showed significant improvement, mental domains remained a greater problem after 6 months. However, OHRQoL was significantly poor in all the three study groups (p ​< ​0.001).

Conclusion: Irrespective of the post-treatment duration, patients who received PCRT had worse HRQoL and OHRQoL. There is a need to identify factors associated with impaired HRQoL and OHRQoL to customize better therapeutic decisions.
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http://dx.doi.org/10.1016/j.jobcr.2021.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829265PMC
January 2021

Indirect implications of COVID-19 towards sustainable environment: An investigation in Indian context.

Bioresour Technol Rep 2020 Sep 30;11:100491. Epub 2020 Jun 30.

Department of Civil Engineering, Indian Institute of Technology Delhi, New Delhi, India.

Efficacious transmittal of COVID-19 has compelled numerous countries worldwide to embrace temporary yet dramatic measures such as locking down entire cities, restricting all forms of transportation, imposing lockdowns, maintaining social distancing etc. These actions have considerably enhanced the quality of ambient air and water. India, being a densely populated country, imposed a strict nationwide lockdown mandate since the last week of March 2020. This paper discusses the effects of COVID-19 restrictions on several aspects of environment broadly in Indian scenario. The forward course of action in the present and probable scenarios has also been addressed. As the disease spread is still underway, lockdown restrictions yet to be lifted and the availability of metadata hitherto being restrictive, firm deductions and explications could not be made. This case study i.e. observing the effects of lockdown, is a unique opportunity to understand how the environment reacts to sharp reductions in anthropogenic activity.
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http://dx.doi.org/10.1016/j.biteb.2020.100491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834532PMC
September 2020

Neutrophilic leukoaggregates--A rare hematological phenomenon.

Indian J Pathol Microbiol 2021 Jan-Mar;64(1):223-224

Department of Medical Oncology, Care Hospitals, Hyderabad, Telangana, India.

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http://dx.doi.org/10.4103/IJPM.IJPM_957_19DOI Listing
July 2021

Neurological manifestation in severe hypothyroidism in pregnancy.

BMJ Case Rep 2020 Dec 28;13(12). Epub 2020 Dec 28.

Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi, India.

Neurological manifestations of hypothyroidism include peripheral neuropathy and pituitary hyperplasia. However, these associations are rarely encountered during pregnancy. We report a case of a known hypothyroid with very high thyroid stimulating hormone (TSH) values (512 μIU/mL) in the second trimester. At 24 weeks she developed facial palsy and pituitary hyperplasia which responded to a combination of steroids and thyroxine. She had caesarean delivery at 35 weeks and 3 days gestation in view of pre-eclampsia with severe features and was discharged on oral antihypertensives and thyroxine. On follow-up at 5 months, TSH normalised and pituitary hyperplasia showed a greater than 50% reduction in size. To our knowledge, this is the first reported case of facial palsy and pituitary hyperplasia associated with hypothyroidism during pregnancy.
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http://dx.doi.org/10.1136/bcr-2020-238069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771221PMC
December 2020

Impact of COVID-19 on psychosocial functioning of peripartum women: A qualitative study comprising focus group discussions and in-depth interviews.

Int J Gynaecol Obstet 2021 Mar 31;152(3):321-327. Epub 2020 Dec 31.

Department of Obstetrics & Gynaecology, AIIMS, New Delhi, India.

Objective: Peripartum is a period of profound hormonal changes in the body and COVID-19 seems to have an additional impact on these women's psychosocial functioning. This calls for a need to address the psychosocial and behavioural impact of COVID-19 on peripartum women's lives.

Methods: Three focus group discussions and ten in-depth interviews were conducted. A format to guide discussions and interviews was made to bring uniformity across groups and participants. Participants were recruited through purposive sampling. In verbatim transcription was done, followed by thematic analysis to extract key conceptual themes.

Results: Fourteen pregnant and eleven postpartum women were included. The mean age was 28.5 years. Two major domains were identified: 1) the psychological domain including the categories of thoughts, emotions, and behaviour, and 2) the social domain comprising categories of relationships with family members and friends, perceived loss of social support, doctor-patient relationship, and social determinants of health.

Conclusion: The pandemic has indeed affected the psychosocial functioning of peripartum women. The study results might prove to be helpful for clinicians and mental health specialists who can suggest and develop different coping strategies for peripartum women during this pandemic.
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http://dx.doi.org/10.1002/ijgo.13524DOI Listing
March 2021

Reducing the waiting time to initiation of infertility treatment at a tertiary care centre in India.

BMJ Open Qual 2020 11;9(4)

Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Background: In a low-resource and high-volume setting, it is often felt that patient care cannot be improved within the limitations of existing infrastructure and resources. However, the use of a systematic problem-solving method can bring about significant improvement even in these settings.

Aim: To decrease the mean waiting time from first visit to initiation of infertility treatment by 70% within 4 weeks (1-30 June 2019) for patients coming to the gynaecological outpatient department (OPD).

Methods: We constructed a multidisciplinary quality improvement team consisting of an academic consultant, a senior resident physician, a junior resident physician and a nurse to address the problem of long waiting times to initiation of fertility treatment. We collected baseline data from 10 consecutive women presenting to gynaecological OPD with complaints of infertility by calculating the time between their first visit to the facility and the day of performance of hysterosalpingography (HSG). The average waiting time was found to be 6 months and 25 days (mean=6.85 months; 3.5-10 months). The team used process flow diagrams and fishbone analysis to identify various causes of these long waiting times. The main reason for the delay in starting infertility treatment was that the date for HSG was given only after seeing the endometrial aspiration report (ie, after ruling out endometrial tuberculosis as there is a risk of dissemination of tuberculosis during HSG). Also, HSG was done only once a week during a short 2-hour slot in the fluoroscopy room.

Results: After the implementation of change ideas, there was significant reduction in the waiting period to starting treatment in patients with infertility. After the first change idea, the average waiting period seen in 10 consecutive patients with infertility reduced to 3.25 months, that is, by 51.8% from baseline within a 2-week interval, and there is shift in the run chart diagram. After the second change idea, the waiting time reduced to 2 months, that is, by 70%, seen in the next 10 consecutive patients with infertility within the next 2 weeks' time. The results were sustained to the average waiting time of 2 months for 6 months without any additional resources.

Conclusion: With a well-organised and conducted quality improvement project and team efforts, the required changes can be brought about in an established conventional healthcare delivery system and improvements can be sustained over a long period of time.
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http://dx.doi.org/10.1136/bmjoq-2020-000975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684834PMC
November 2020

Aortic isthmus Doppler in normal and small-for-gestational-age fetuses and its association with prediction of adverse perinatal outcome.

Int J Gynaecol Obstet 2021 Jun 5;153(3):542-548. Epub 2021 Jan 5.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Objective: To establish reference ranges for aortic isthmus Doppler indices in appropriate-for-gestational-age (AGA) fetusesand to evaluate its association with perinatal outcome in small-for-gestational-age (SGA) fetuses.

Methods: Prospective cohort observational study in which 30 pregnant women with SGA fetuses and 60 women with AGA fetuses were recruited from the prenatal clinic of the hospital. The AGA group was eventually followed from 24 weeks by 4-weekly Doppler assessment, and the SGA group was examined as per institutional protocol. We analyzed the data using STATA version 14.0 statistical software. Continuous variables were examined for normality assumption using the Kolmogorov-Smirnov test. To develop a nomogram for appropriate gestational age, we adopted a mixed linear model analysis. For each of the variables Ao pulsatility index (PI), Ao peak systolic velocity (PSV), Ao systolic nadir (Ns), and Ao isthmic systolic index (ISI) mean predicted values, 3rd centile and 97th centile were calculated based on the parameter estimation of mixed model. Observed data for each of the variables in the SGA group were plotted in the nomogram developed for the AGA group to show the trend of SGA data in comparison to AGA data.

Results: The total number of observations made on 60 AGA and 30 SGA fetuses were 240 and 67, respectively. Nomograms for the 3rd and 97th centiles were derived for Ao PI, Ao PSV, Ao Ns, and Ao ISI. Mean Ao PI values were significantly higher in SGA group (2.37 vs 2.22; P < .05); mean Ao PSV was significantly lower in the SGA group (67.1 vs 76.3; P < .05), but mean Ao Ns and mean Ao ISI values were significantly higher in the SGA group (-5.24 vs 2.0 and -0.04 vs -0.01; P < .05).

Conclusions: Aortic Doppler assessment seems to provide beneficial information for monitoring small fetuses. Ao PI and Ao ISI, which were raised in fetuses with SGA, can be used in prognosis.
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http://dx.doi.org/10.1002/ijgo.13489DOI Listing
June 2021

Family planning and abortion services in COVID 19 pandemic.

Taiwan J Obstet Gynecol 2020 Nov 10;59(6):808-811. Epub 2020 Sep 10.

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Many routine and elective services have already been postponed or suspended by both Government and private setups in most parts of the world because of the unprecedented pandemic of COVID-19. Healthcare systems everywhere in the world are under pressure. Being a component of essential health services, family planning and abortion services should continue to cater the population in order to prevent the complications arising from unintended pregnancies and sudden rise in STIs. Due to airborne nature of transmission of the virus, it is advisable for all consultations relating to family planning services to be done remotely unless and until visit is absolutely necessary. Contraception initiation and continuation can be done by telemedicine in most individuals. Post partum contraception can be advised before discharge from hospital. In an individual planning for pregnancy, currently it is not advisable to discontinue contraceptive and plan for pregnancy as not much is known about the effect of the virus on foetal development. Also, pregnancy requires routine antenatal and peripartum care and complications arising from pregnancy may necessitate frequent hospital visits, exposing the individual to the risk of infection. Abortion services are time sensitive therefore should not be denied or delayed beyond legal limit. We need to change from real to virtual consultation to prevent the rise in unplanned pregnancies, sexually transmitted infections and unsafe abortions.
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http://dx.doi.org/10.1016/j.tjog.2020.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833030PMC
November 2020

Redesigning routine antenatal care in low resource setting during COVID-19 pandemic.

J Family Med Prim Care 2020 Sep 30;9(9):4547-4551. Epub 2020 Sep 30.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

Obstetric population because of its unique and varying needs specific for different gestations justifies for distinctive considerations in times of pandemic like COVID-19. Healthcare facilities providing obstetric care need to develop contingency plans for minimizing antenatal visits to limit exposure of both healthy pregnant women and care providers from ill people. However, to mitigate any potential adverse effects of reduced antenatal visits, intelligent and smart use of evolving telemedicine capabilities can provide the continuum of care despite overwhelming burden due to pandemic. A collaborative work-model involving health workers in the community and the regional levels of health centres also has the potential to prevent the catastrophic collapse of obstetric care services during any pandemic like COVID-19.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_831_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652110PMC
September 2020

The impact of a segregated team roster on obstetric and gynecology services in response to the COVID-19 pandemic in a tertiary care center in India.

Int J Gynaecol Obstet 2020 Dec 22;151(3):341-346. Epub 2020 Oct 22.

Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India.

Objective: To determine the impact of roster reorganization on ensuring uninterrupted services while providing necessary relief to healthcare workers (HCW) in the obstetrics department of a tertiary care center amid the COVID-19 outbreak.

Methods: The COVID-19 rostering response began in April 2020 and evolved in two phases: (1) development of new areas for screening and managing suspected/positive cases of COVID-19; and (2) team segregation according to area of work. The impact of these changes on HCWs and patients was assessed 3 months later.

Results: Developing separate areas helped to minimize the risk of exposure of patients and HCWs to those with COVID-19. Residents and consultants worked intensively in clinical areas for 1 week followed by 1-2 weeks of non-clinical or standby assignments, providing adequate opportunity for isolation. Frequent re-evaluation of the roster was nevertheless required as the pandemic progressed. Segregating teams vertically significantly reduced the number of contacts identified on contact tracing and quarantine leaves, while maintaining patient satisfaction with no increase in adverse events. Residents found the roster to be "smart" and "pandemic-appropriate."

Conclusion: The "COVID emergency roster" helped ensure quality care with minimum risk of exposure and sufficient breaks for physical and psychological recovery of HCWs.
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http://dx.doi.org/10.1002/ijgo.13408DOI Listing
December 2020

Restructuring fetal medicine services in a low-resource setting during the COVID-19 pandemic: Experience from a tertiary care fetal medicine center.

Int J Gynaecol Obstet 2020 11 1;151(2):291-293. Epub 2020 Sep 1.

Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India.

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http://dx.doi.org/10.1002/ijgo.13337DOI Listing
November 2020

Management of the first patient with confirmed COVID-19 in pregnancy in India: From guidelines to frontlines.

Int J Gynaecol Obstet 2020 07 17;150(1):116-118. Epub 2020 May 17.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1002/ijgo.13179DOI Listing
July 2020

Oral metronomic chemotherapy for recurrent & refractory epithelial ovarian cancer: A retrospective analysis.

Indian J Med Res 2019 12;150(6):575-583

Department of Medical Oncology, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: Advanced epithelial ovarian cancer (EOC) is associated with dismal outcome and progression-free survival (PFS) shortens with each subsequent relapse. For patients with recurrent and platinum refractory disease, therapeutic options are limited. Oral metronomic therapy (OMT) is associated with symptomatic relief and stable response in a significant proportion of patients. We retrospectively evaluated the outcome of patients with EOC treated with OMT at a tertiary care hospital in north India.

Methods: Between January 2011 to December 2017, 36 EOC patients received OMT. Patients' median age was 50 yr (range, 38-81 yr) and they had received a median of two lines of prior chemotherapy. OMT regimen included a combination of cyclophosphamide, etoposide (VP-16) and celecoxib with or without pazopanib along with supportive care. Response rates and outcomes were ascertained using the Gynecological Cancer Intergroup Guidelines. The toxicity was graded according to the Common Terminology Criteria for Adverse Events v.4.03.

Results: The median CA-125 before initiating OMT was 160 U/ml (range, 42.23-5330 U/ml). The median interval between last chemotherapy and starting OMT regimen was 159 days (range, 1-1211 days). The overall response rate was 50 per cent. The median progression-free survival (PFS) was 8.2 months [95% confidence interval (CI): 5.03-10.33], and the median overall survival was 38 months (95% CI: 25.6-NR). Patients who received two lines of chemotherapy before OMT (P=0.052) and those who received pazopanib-based OMT (P=0.0513) had better PFS.

Interpretation & Conclusions: For patients with relapse and refractory EOC, OMT could be a reasonable option. A combination of oral etoposide (VP-16) and pazopanib needs further evaluation in a large number of patients in a randomized trial.
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http://dx.doi.org/10.4103/ijmr.IJMR_2030_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7038810PMC
December 2019

Weight Management Module for Perimenopausal Women: A Practical Guide for Gynecologists.

J Midlife Health 2019 Oct-Dec;10(4):165-172

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.

Menopause has been identified as a high-risk stage for weight gain in a woman's lifecycle. Menopause-related weight gain is a consequence of low circulating estrogen levels due to progressive loss of ovarian function. Moreover, the changes in the hormonal milieu, chronological aging, decline in physical activity coupled with westernized dietary pattern, and recurrent emotional eating episodes associated with psychological distress also contribute to the increase in total body fat and waist circumference. Higher waist circumference is an independent risk factor for cardiovascular and metabolic disease in menopausal women. These obesity-related cardiometabolic risk factors and menopausal symptoms can be effectively managed by achieving clinically significant weight loss through lifestyle modification. Behavioral lifestyle intervention uses behavioral techniques for counseling corrective dietary and physical activity practices in achieving sustainable weight loss outcomes. Majority of menopausal women seek this counseling from gynecologist, especially in primary care settings due to nonavailability of multidisciplinary teams. Thus, the aim of the review is to understand the menopause-obesity link, associated risk factors, and its health-related burden in perimenopausal women to devise a practical women-centric weight management module based on lifestyle modification techniques to address the burden of menopausal obesity in regular gynecological practice.
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http://dx.doi.org/10.4103/jmh.JMH_155_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947726PMC
January 2020

Emerging biomarkers in Multiple Myeloma: A review.

Clin Chim Acta 2020 Apr 31;503:45-53. Epub 2019 Dec 31.

Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Multiple Myeloma (MM) is the second most common hematological malignancy after non-Hodgkin lymphoma and is manifested by uncontrolled proliferation and accumulation of abnormal plasma cells in the bone marrow (BM). The incidence along with deaths associated with MM is on rise due to lack of an effective diagnosis at an early stage. The identification of MM decades ago marks the adoption of certain conventional markers such as plasma cell percentage in BM, serum protein electrophoresis for M-band and urinary Bence-Jones protein. This was then followed by utilization of β2 microglobulin and serum albumin for determining the staging of MM. The need for a better diagnostic or prognostic marker prompts researchers and hence, certain novel markers have been tested which includes extracellular matrix proteins, angiogenic factors, telomeres and telomerase along with the immune markers. Nowadays, proteomic and genomic studies are being performed to identify novel diagnostic and/or prognostic markers for MM. Followed by this, comes the emerging concept of liquid biopsy which allows easy and non-invasive detection of the disease. The liquid biopsy comprises of circulatory tumor cells along with the nucleic acids (microRNAs and cell-free DNA) released from the tumor cells in peripheral circulation which could be a true representation of BM. This review, hence, summarizes the emerging biomarkers involved in the diagnosis and prognosis of MM.
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http://dx.doi.org/10.1016/j.cca.2019.12.026DOI Listing
April 2020

Experience Of Resident Presentations In Consultation-Liaison Psychiatry Grand Rounds: Increase Value For Clinical Education.

Adv Med Educ Pract 2019 24;10:885-890. Epub 2019 Oct 24.

Department of Psychiatry, Loyola University Medical Center, Maywood, IL 60 153, USA.

Background: Grand rounds is a formal meeting at which physicians and trainees discuss excellence in medical care. Residents should participate in scholarly activity per Accreditation Council for Graduate Medical Education (ACGME). Consultation-Liaison (CL) psychiatry focuses on caring for patients presenting with psychiatric complications in general hospital. Post-residency subspecialty CL fellowship training plays a big role in creating future leaders in CL. Our program decided to conduct annual CL grand rounds fully allotted to discuss complex CL psychiatry cases in medical setting.

Methods: We conducted a retrospective review of resident's interest in pursuing CL fellowship. We compared the number of residents pursuing CL fellowship after the CL grand rounds to the previous years starting 2005 when CL was recognized as an ACGME approved subspecialty. We also compared our program residents pursuing CL psychiatry fellowship to national trend obtained from National Residency Matching Program (NRMP).

Results: From 2013 to 2018, CL grand rounds n=8, Number of residents graduated from 2013 to 2018 n=26. Number of residents pursued CL fellowship from 2013 to 2018 n=3 (11.5%) compared to no residents pursuing CL fellowship before 2013. Fisher's exact test to compare and examine the data from the residents pursuing CL fellowship after implementation of the CL grand rounds is 0.0668 (p value < 0.10). When combining all the available NRMP match results for CL from 2015 to 2019, a total of 531 positions were offered and 359 positions were filled (fill rate of 67.6%). In our program, after we implemented the annual CL grand rounds, 11.5% of the residents from 2013 to 2018 pursued CL fellowship, which is higher than the likely national average of 5.7%.

Conclusion: Our residency program grand rounds educational module appears to nurture and sustain interest in CL subspecialty compared to previous years. Prospective studies are required.
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http://dx.doi.org/10.2147/AMEP.S221026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817711PMC
October 2019

Mifepristone Followed by Misoprostol or Ethacridine Lactate and Oxytocin for Second Trimester Abortion: A Randomized Trial.

Eurasian J Med 2019 Oct 19;51(3):262-266. Epub 2019 Aug 19.

All India Institute of Medical Sciences, New Delhi, India.

Objective: To compare two medical methods for second-trimester abortion, mifepristone followed by misoprostol versus mifepristone followed by ethacridine lactate and oxytocin for success rate, induction to abortion time and acceptability.

Materials And Methods: This is a randomized trial conducted from July 2014 to May 2016 and enrolled 120 women undergoing second trimester abortion (13-20 weeks). All patients received 200mg mifepristone orally and were randomized to receive further treatment after 36 hrs. Patients in Group M (n=60) received 400 microgram of misoprostol vaginally every 3 hours (maximum - 5 doses) and Group E (n=60) had extra-amniotic ethacridine lactate instillation followed by oxytocin infusion (max-100miu).

Results: Baseline demographic characteristics were comparable in both the groups. Success rate was 100% in group M and 98.3% in group E (p=0.31). Mean induction to abortion time was significantly shorter in group M than group E (8.2+2.3hours & 10.9+2.6 hours respectively; p=0.001). Majority of women reported side effects, 96.7% women in group M and 75% women in group E (p=0.001). Fall in hemoglobin after procedure was significantly higher in group M (0.70+0.33gram %) than group E (0.52+0.23 gram %) (p=0.001). Perception of intensity of pain was significantly more in group M but patient satisfaction in both groups was similar.

Conclusion: Both methods are comparable for success rate, induction interval was more for ethacridine lactate compared to misoprostol.
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http://dx.doi.org/10.5152/eurasianjmed.2019.18341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6812907PMC
October 2019

NT-proBNP: A Useful Biochemical Marker for Prognosis in Rh-Isoimmunized Pregnancies.

J Obstet Gynaecol India 2019 Oct 1;69(Suppl 2):128-132. Epub 2018 Oct 1.

Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, 110029 India.

Background: Rh incompatibility sometimes results in life-threatening conditions in fetus like severe anemia and jaundice, leading to kernicterus and even death. Even after an uneventful intrauterine transfusion (IUT), fetus may not survive despite correction of the fetal anemia. Finding appropriate markers may help in determining the prognosis of such cases. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) suggests some degree of heart failure.

Objective: Present study was planned to evaluate its role in predicting the outcome of fetus in Rh-isoimmunized pregnant woman.

Methods: This prospective study consisted of total 40 pregnant patients: 10 pregnant Rh-isoimmunized women with hydropic fetuses, 10 with non-hydropic fetuses and 20 control group. If the MCA-PSV was > 1.5 MOM, cord blood sampling and IUT was done and sent for fetal hematocrit and NT-proBNP.

Results: The levels of NT-proBNP at various periods of gestation in hydropic, non-hydropic and control group fetuses showed positive correlation with the degree of fetal anemia.

Conclusion: Correlation of high levels of NT-proBNP to fetal anemia proves that hydrops fetalis is probably due to progressive high cardiac output myocardial failure, increased capillary permeability and perhaps reduced coronary flow.
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http://dx.doi.org/10.1007/s13224-018-1180-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6801230PMC
October 2019

Pazopanib efficacy and toxicity in a metastatic sarcoma cohort: Are Indian patients different?

Indian J Cancer 2019 Jul-Sep;56(3):207-210

Department of Medical Oncology, Dr. B.R Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.

Purpose: There is no study till date determining the spectrum of adverse events of pazopanib in Indian patients with advanced sarcoma.

Materials And Methods: We conducted a retrospective study by analyzing the case records of metastatic sarcoma patients treated with pazopanib from January 2016 to July 2017 in sarcoma medical oncology clinic. Toxicity was assessed according to CTCAE v.4.03 criteria. SPSS version 23 was used for statistical evaluation.

Results: A total of 33 patients received pazopanib. The median age was 41 years (range, 19-75 years), with a male predominance (54.5%). Twenty-six patients (78.8%) had ECOG performance status 1 at the time of pazopanib initiation. The most common type of sarcoma was synovial sarcoma, and the mean duration of pazopanib intake in patients was 4.12 months. The median follow-up was 13 months. Median progression-free survival was 5 months, and median overall survival was 18 months. Overall response rate was 6.0%. Out of the 33 patients, 42.4% (n = 14) received it after first line of therapy. Six patients (18.2%) required dose reductions due to toxicity. Thirteen (39.4%) patients experienced CTCAE grade 3 or 4 toxicities. Most common grade 3 and 4 toxicities experienced among patients were hand-foot skin reaction (18.2%) and proteinuria (9.1%). No significant difference was seen when analyzed for variables such as age, sex, ECOG performance status, comorbidities, and number of previous lines received in patients experiencing grade 3 and 4 toxicities.

Conclusions: The spectrum of adverse events in Indian patients at doses lower than the recommended dose is distinctly different from the western population. However, this unique toxicity profile needs to be validated in prospective studies.
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http://dx.doi.org/10.4103/ijc.IJC_105_18DOI Listing
January 2020

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy.

J Clin Exp Hepatol 2019 May-Jun;9(3):383-406. Epub 2019 Mar 6.

Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India.

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.
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http://dx.doi.org/10.1016/j.jceh.2019.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637074PMC
March 2019
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