Comparative Evaluation of Quality Management Practices in the Public and Private Hospitals in Visakhapatnam District: An Original Research.

Background: In the Visakhapatnam District, this study compares the quality management procedures used by public and private hospitals. Knowing how these practices are similar and different from one another can help inform policy decisions and improve the quality of health care. Materials and Methods: A cross-sectional study design was used, and 100 hospitals from both public (50 hospitals) and private (50 hospitals) were included in the sample size. A standardized questionnaire that evaluated different aspects of quality management practices was used to gather the data. Descriptive statistics and inferential tests were used in the quantitative analysis. Results: Significant variations in quality management procedures between public and private hospitals were found. In terms of patient happiness, service responsiveness, and technological use, private hospitals scored better. Regarding accessibility, cost, and equity of healthcare services, public hospitals fared better. Conclusion: The report emphasizes the necessity of focused initiatives to improve quality management procedures in both public and commercial institutions. Collaboration between the two sectors can make it easier to deploy evidence-based tactics and share best practices to raise overall healthcare quality in the Visakhapatnam area.

Multi-center prospective survey of hepatocellular carcinoma in Kerala: More than 1,200 cases.

BACKGROUND: Hepatocellular carcinoma (HCC) is considered uncommon in India. The aim of this study was to document the demographic characteristics and clinical aspects of HCC in Kerala, India. METHODS: A survey of HCC in Kerala was performed. All gastroenterologists in the region were invited. From May 2018 to April 2020, data was collected in a standardized questionnaire. RESULTS: Forty-three doctors from 15 centers contributed the data. Total 1217 patients were analyzed. This is the largest state-wide survey of HCC in India. HCC was more common in men (90%) than in women (p < 0.01). The etiology of liver disease was hepatitis B virus (7%), hepatitis C virus (4%) and alcohol (40%). Diabetes mellitus was present in 64%, hypercholesterolemia in 17% and hypertension in 38%. Obesity was present in 33% and 15% were overweight. Non-alcoholic fatty liver disease (NAFLD) with or without metabolic syndrome was present in 44%. Serum alpha-fetoprotein was > 400 ng/mL in 24%, total tumor diameter was > 5 cm in 59%, portal vein invasion was seen in 35% and distant metastasis was seen in 15%. Specific therapy was given to 52%. Treatments given included liver transplantation (n = 24), liver resection (n = 39) and transarterial chemoembolization (TACE, n = 184). Although the study was not designed to compare survival, patients who had liver transplantation had longer survival (median 69 months) compared to matched patients given only TACE (median 18 months) (p = 0.03). CONCLUSION: HCC is common in Kerala, India. NAFLD has a predominant association with HCC in Kerala. Most of the patients report late when curative treatment is not possible.

Molecular mechanism of Escherichia coli H10407 induced diarrhoea and its control through immunomodulatory action of bioactives from Simarouba amara (Aubl.).

Enterotoxigenic Escherichia coli (ETEC) infection is a major cause of death in children under the age of five in developing countries. ETEC (O78:H11:CFA/I:LT+:ST+) mechanism has been studied in detail with either heat labile (LT) or heat stable (ST) toxins using in vitro and in vivo models. However, there is no adequate information on ETEC pathogenesis producing both the toxins (LT, ST) in BALB/c mice model. In this study, female mice have been employed to understand ETEC H10407 infection induced changes in physiology, biochemical and immunological patterns up to seven days post-infection and the antidiarrhoeal effect of Simarouba amara (Aubl.) bark aqueous extract (SAAE) has also been looked into. The results indicate that BALB/c is sensitive to ETEC infection resulting in altered jejunum and ileum histomorphology. Withal, ETEC influenced cAMP, PGE2, and NO production resulting in fluid accumulation with varied Na+, K+, Cl-, and Ca2+ levels. Meanwhile, ETEC subverted expression of IL-1ß, intestine alkaline phosphatase (IAP), and myeloperoxidase (MPO) in jejunum and ileum. Our data also indicate the severity of pathogenesis reduction which might be due to attainment of equilibrium after reaching optimum rate of infection. Nevertheless, degree of pathogenesis was highly significant (p < 0.01) in all the studied parameters. Besides that, SAAE was successful in reducing the infectious diarrhoea by inhibiting ETEC H10407 in intestine (jejunum and ileum), and shedding in feces. SAAE decreased cAMP, PGE2, and fluid accumulation effectively and boosted the functional activity of immune system in jejunum and ileum IAP, MPO, IL-1ß, and nitric oxide.

Effect of Protein Corona on the Drug Delivery of Carbogenic Nanodots and Their Mapping by Fluorescence Lifetime Imaging Microscopy.

It is practically impossible to avoid the nonspecific binding of protein to a nanocarrier when it enters a biological fluid. This hinders the chemotherapeutic efficacy of the nanocarrier to a large extent. Surface functionalization, in the recent past, helped in reducing such nonspecific interactions. However, there is a lack of understanding as to how they help in the case of nanocarriers with size <6 nm. Here, we show that the glutathione and folic acid functionalization to a small carbogenic nanocarrier leads to substantial improvement in cell internalization and chemotherapeutic efficacy. The functionalization on smaller size of the nanocarrier helped in manipulating the binding affinity of the protein, which in turn helped in easy dynamic exchange with the surrounding environment. Using fluorescence lifetime imaging, we directly visualized and mapped the released drug at a very high resolution and provide a comprehensive mechanism of the drug distribution inside a cancer cell, as a consequence of the different affinity of protein corona on the carbon nanoparticle.

Genome sequences and SNP analyses of Corynespora cassiicola from cotton and soybean in the southeastern United States reveal limited diversity.

Corynespora cassiicola attackes diverse agriculturally important plants, including soybean and cotton, in the US. It is a reemerge pathogen on cotton in southeastern US. Whole genome sequences of four cotton and one soybean isolate from Tennessee were used to develop single nucleotide polymorphism markers for cotton isolates. Cotton isolates had little diversity at the genome level and very little differentiation from the soybean isolate. Analysis of 75 isolates from cotton and soybean, using targeted-sequencing of 22 polymorphic SNP sites, revealed eight multi-locus genotypes and it appears a single clonal lineage predominates across the southeastern region. The cotton and soybean genome sequences were significantly different from the public reference genome derived from a rubber isolate and the utility of these novel resources will be discussed.

Clinical correlates of leukoaraiosis: A study of 175 patients.

BACKGROUND: In India, the correlates of leukoaraiosis (LA) have not been widely reported. This study was designed to investigate the factors which correlate with LA. MATERIALS AND METHODS: We included patients with LA who consented for the study and graded their severity on the basis of Fazekas scale. We excluded patients with LA who did not consent/cooperate for the study as also patients with other white matter changes which mimic LA. RESULTS: LA is a common and under-rated cause of disability. Presentations include cognitive decline, gait disturbance, dysarthria, bladder/bowel sphincter disturbances, and increased risk of stroke. The comorbidities include hyperhomocysteinemia, hypertension, dyslipidemia, tobacco use, ischemic heart disease, previous stroke, atrial fibrillation, chronic renal failure, and bariatric surgery.

Acute esophageal necrosis: an uncommon cause of hematemesis.

Acute esophageal necrosis or black esophagus is an uncommon clinical entity, diagnosed at the upper gastrointestinal endoscopy with the presence of strikingly black necrotic esophagus. Very often no definite etiology will be identified even though a large list of potential associations has been postulated. Upper gastrointestinal bleeding is the most common clinical presentation, others being epigastric pain, retrosternal chest discomfort and dysphagia. Only about a hundred cases of acute esophageal necrosis have been described in medical literature till this date. We report a case of acute esophageal necrosis in an elderly female who had presented with hematemesis.

Protein-protein interaction and gene co-expression maps of ARFs and Aux/IAAs in Arabidopsis.

The phytohormone auxin regulates nearly all aspects of plant growth and development. Based on the current model in Arabidopsis thaliana, Auxin/indole-3-acetic acid (Aux/IAA) proteins repress auxin-inducible genes by inhibiting auxin response transcription factors (ARFs). Experimental evidence suggests that heterodimerization between Aux/IAA and ARF proteins are related to their unique biological functions. The objective of this study was to generate the Aux/IAA-ARF protein-protein interaction map using full length sequences and locate the interacting protein pairs to specific gene co-expression networks in order to define tissue-specific responses of the Aux/IAA-ARF interactome. Pairwise interactions between 19 ARFs and 29 Aux/IAAs resulted in the identification of 213 specific interactions of which 79 interactions were previously unknown. The incorporation of co-expression profiles with protein-protein interaction data revealed a strong correlation of gene co-expression for 70% of the ARF-Aux/IAA interacting pairs in at least one tissue/organ, indicative of the biological significance of these interactions. Importantly, ARF4-8 and 19, which were found to interact with almost all Aux-Aux/IAA showed broad co-expression relationships with Aux/IAA genes, thus, formed the central hubs of the co-expression network. Our analyses provide new insights into the biological significance of ARF-Aux/IAA associations in the morphogenesis and development of various plant tissues and organs.

Oomycetes baited from streams in Tennessee 2010-2012.

Sixteen streams in middle and eastern Tennessee were surveyed for the sudden oak-death pathogen Phytophthora ramorum 2010-2012. Surveys were conducted in the spring and fall using healthy Rhododendron leaves, and a total of 354 oomycete isolates were recovered. Sequence analysis of the ITS region provisionally identified 151 Phytophthora, 200 Pythium, two Halophytophthora and one Phytopythium. These include six Phytophthora species (P. cryptogea, P. hydropathica, P. irrigata, P. gonapodyides, P. lacustris, P. polonica), members of the P. citricola species complex, five unknown Phytophthora species, 11 Pythium species (P. helicoides, P. diclinum, P. litorale, P. senticosum, P. undulatum, P. vexans, P. citrinum, P. apleroticum, P. chamaihyphon, P. montanum, P. pyrilobum), three unknown Pythium species, Halophytophthora batemanensis, and one Phytopythium isolate. The biology and implications are discussed.

Overcoming x-ray tube small focal spot output limitations for high-resolution region of interest imaging.

We investigate methods to increase x-ray tube output to enable improved quantum image quality with a higher generalized-NEQ (GNEQ) while maintaining a small focal-spot size for the new high-resolution Micro-angiographic Fluoroscope (MAF) Region of Interest (ROI) imaging system. Rather than using a larger focal spot to increase tube-loading capacity with degraded resolution, we evaluated separately or in combination three methods to increase tube output: 1) reducing the anode angle and lengthening the filament to maintain a constant effective small focal-spot size, 2) using the standard medium focal spot viewed from a direction on the anode side of the field and 3) increasing the frame rate (frames/second) in combination with temporal filter. The GNEQ was compared for the MAF for the small focal-spot at the central axis, and for the medium focal-spot with a higher output on the anode side as well as for the small focal spot with different temporal recursive filtering weights. A net output increase of about 4.0 times could be achieved with a 2-degree anode angle (without the added filtration) and a 4 times longer filament compared to that of the standard 8-degree target. The GNEQ was also increased for the medium focal-spot due to its higher output capacity and for the temporally filtered higher frame rate. Thus higher tube output, while maintaining a small effective focal-spot, should be achievable using one or more of the three methods described with only small modifications of standard x-ray tube geometry.

Evaluation and Comparison of High-Resolution (HR) and High-Light (HL) Phosphors in the Micro-Angiographic Fluoroscope (MAF) using Generalized Linear Systems Analyses (GMTF, GDQE) that include the Effect of Scatter, Magnification and Detector Characteristics.

In this study, we evaluated the imaging characteristics of the high-resolution, high-sensitivity micro-angiographic fluoroscope (MAF) with 35-micron pixel-pitch when used with different commercially-available 300 micron thick phosphors: the high resolution (HR) and high light (HL) from Hamamatsu. The purpose of this evaluation was to see if the HL phosphor with its higher screen efficiency could be replaced with the HR phosphor to achieve improved resolution without an increase in noise resulting from the HR's decreased light-photon yield. We designated the detectors MAF-HR and MAF-HL and compared them with a standard flat panel detector (FPD) (194 micron pixel pitch and 600 micron thick CsI(Tl)). For this comparison, we used the generalized linear-system metrics of GMTF, GNNPS and GDQE which are more realistic measures of total system performance since they include the effect of scattered radiation, focal spot distribution, and geometric un-sharpness. Magnifications (1.05-1.15) and scatter fractions (0.28 and 0.33) characteristic of a standard head phantom were used. The MAF-HR performed significantly better than the MAF-HL at high spatial frequencies. The ratio of GMTF and GDQE of the MAF-HR compared to the MAF-HL at 3(6) cycles/mm was 1.45(2.42) and 1.23(2.89), respectively. Despite significant degradation by inclusion of scatter and object magnification, both MAF-HR and MAF-HL provide superior performance over the FPD at higher spatial frequencies with similar performance up to the FPD's Nyquist frequency of 2.5 cycles/mm. Both substantially higher resolution and improved GDQE can be achieved with the MAF using the HR phosphor instead of the HL phosphor.

Graphical User Interface for a Dual-Module EMCCD X-ray Detector Array.

A new Graphical User Interface (GUI) was developed using Laboratory Virtual Instrumentation Engineering Workbench (LabVIEW) for a high-resolution, high-sensitivity Solid State X-ray Image Intensifier (SSXII), which is a new x-ray detector for radiographic and fluoroscopic imaging, consisting of an array of Electron-Multiplying CCDs (EMCCDs) each having a variable on-chip electron-multiplication gain of up to 2000× to reduce the effect of readout noise. To enlarge the field-of-view (FOV), each EMCCD sensor is coupled to an x-ray phosphor through a fiberoptic taper. Two EMCCD camera modules are used in our prototype to form a computer-controlled array; however, larger arrays are under development. The new GUI provides patient registration, EMCCD module control, image acquisition, and patient image review. Images from the array are stitched into a 2k×1k pixel image that can be acquired and saved at a rate of 17 Hz (faster with pixel binning). When reviewing the patient's data, the operator can select images from the patient's directory tree listed by the GUI and cycle through the images using a slider bar. Commonly used camera parameters including exposure time, trigger mode, and individual EMCCD gain can be easily adjusted using the GUI. The GUI is designed to accommodate expansion of the EMCCD array to even larger FOVs with more modules. The high-resolution, high-sensitivity EMCCD modular-array SSXII imager with the new user-friendly GUI should enable angiographers and interventionalists to visualize smaller vessels and endovascular devices, helping them to make more accurate diagnoses and to perform more precise image-guided interventions.

Generalized two-dimensional (2D) linear system analysis metrics (GMTF, GDQE) for digital radiography systems including the effect of focal spot, magnification, scatter, and detector characteristics.

The MTF, NNPS, and DQE are standard linear system metrics used to characterize intrinsic detector performance. To evaluate total system performance for actual clinical conditions, generalized linear system metrics (GMTF, GNNPS and GDQE) that include the effect of the focal spot distribution, scattered radiation, and geometric unsharpness are more meaningful and appropriate. In this study, a two-dimensional (2D) generalized linear system analysis was carried out for a standard flat panel detector (FPD) (194-micron pixel pitch and 600-micron thick CsI) and a newly-developed, high-resolution, micro-angiographic fluoroscope (MAF) (35-micron pixel pitch and 300-micron thick CsI). Realistic clinical parameters and x-ray spectra were used. The 2D detector MTFs were calculated using the new Noise Response method and slanted edge method and 2D focal spot distribution measurements were done using a pin-hole assembly. The scatter fraction, generated for a uniform head equivalent phantom, was measured and the scatter MTF was simulated with a theoretical model. Different magnifications and scatter fractions were used to estimate the 2D GMTF, GNNPS and GDQE for both detectors. Results show spatial non-isotropy for the 2D generalized metrics which provide a quantitative description of the performance of the complete imaging system for both detectors. This generalized analysis demonstrated that the MAF and FPD have similar capabilities at lower spatial frequencies, but that the MAF has superior performance over the FPD at higher frequencies even when considering focal spot blurring and scatter. This 2D generalized performance analysis is a valuable tool to evaluate total system capabilities and to enable optimized design for specific imaging tasks.

Near-infrared phosphorescent polymeric nanomicelles: efficient optical probes for tumor imaging and detection.

We report a formulation of near-infrared (near-IR) phosphorescent polymeric nanomicelles and their use for in vivo high-contrast optical imaging, targeting, and detection of tumors in small animals. Near-IR phosphorescent molecules of Pt(II)-tetraphenyltetranaphthoporphyrin (Pt(TPNP)) were found to maintain their near-IR phosphorescence properties when encapsulated into phospholipid nanomicelles. The prepared phosphorescent micelles are of approximately 100 nm size and are highly stable in aqueous suspensions. A large spectral separation between the Pt(TPNP) absorption, with a peak at approximately 700 nm, and its phosphorescence emission, with a peak at approximately 900 nm, allows a dramatic decrease in the level of background autofluorescence and scattered excitation light in the near-IR spectral range, where the signal from the phosphorescent probe is observed. In vivo animal imaging with subcutaneously xenografted tumor-bearing mice has resulted in high contrast optical images, indicating highly specific accumulation of the phosphorescent micelles into tumors. Using optical imaging with near-IR phosphorescent nanomicelles, detection of smaller, visually undetectable tumors has also been demonstrated.

Microwave ablation in locally advanced pancreatic carcinoma--a new look.

BACKGROUND/AIMS: Pancreatic carcinoma is by far the most common malignancy and is the 5th most lethal cancer in the world and 40% of these carcinomas are locally advanced and unresectable at the time of presentation. Palliative surgery and chemoradiotherapy have not produced significant improvement in survival. The overall prognosis of these pancreatic cancers is poor, if left untreated without any form of palliation. Out of many palliative methods adopted for such locally advanced pancreatic carcinoma, none has shown much survival benefit. Microwave ablation is a well established and safe local ablative method for liver tumors and microwave ablation for locally advanced pancreatic tumors has been extensively used around the world. This is our largest series of microwave ablation in 15 patients with locally advanced pancreatic head carcinoma. The aim of this study was to evaluate the safety, efficacy, feasibility and complications of microwave ablation in unresectable locally advanced pancreatic carcinoma. METHODOLOGY: In total, 15 patients, from January 2004 to December 2006, were included in this study all having locally advanced pancreatic tumors which were found to be unresectable on radiological evaluation. The 15 patients (10 male and 5 female) with a mean age of 67 years were subjected to open microwave ablation after laparotomy and additional palliative procedure like biliary bypass (end-to-side hepaticojejunostomy) and gastric obstruction bypass by antecolic gastrojejunostomy was performed in 6 patients. The location of tumor was predominantly in the head and/or uncinate portion of the pancreas (n=12) and head and body (n=3). The average size of tumor was 6cm (range 4-8cm) and almost all had major regional vascular invasion on CT or MR angiogram. All tumors were histologically proven before the procedure by core needle and frozen section biopsy. Patients with distant metastasis were not included in this study. RESULTS: In all 15 patients, partial necrosis was achieved. There was no major procedure-related morbidity or mortality. Minor complications were seen in 6 out of 15 patients, mild pancreatitis (2), asymptomatic hyperamylasia (2), pancreatic ascites (1), and minor bleeding (1). All patients had close follow-up and the longest surviving patient had a follow-up of 22 months. CONCLUSIONS: Microwave ablation is a beneficial therapy as a local effective procedure which is feasible and safe with acceptable minor complications in a locally advanced pancreatic tumor which can be used as part of a palliative or multimodality treatment, however, further long-term and properly designed studies are required to prove its usefulness in achieving survival benefit.

Leiomyosarcoma of the inferior vena cava--an unusual case.

Primary tumors arising from great vessels like the aorta, pulmonary artery or inferior vena cava (IVC) are rare. The latter is the commonest site of its occurrence. It arises from the smooth muscle cells of the vessel wall. Aggressive surgical management should be attempted to excise it whenever possible. We describe a case of primary inferior vena cava tumor involving all three segments of the abdominal inferior vena cava infrarenal, suprarenal and retrohepatic vena cava, along with right kidney, right adrenal as well as right hepatic vein and left renal vein. We resected it completely without reconstruction of the IVC. The patient is doing well seven months after surgery without having any renal insufficiency, hepatic insufficiency or leg edema and having optimum quality of life. To our knowledge, this is the first case of such a long segment IVC leiomyosarcoma treated without IVC reconstruction, and despite its extent and concomitant involvement of the right kidney, right adrenal, right hepatic vein and left renal vein, it had a favorable response combining prolongation of survival and satisfactory quality of life.

External resection of a giant sigmoid lipoma causing colonic intussusception and prolapse through the anal canal.

We depict the case of an 80-year-old female patient who presented to us with a history of protruding mass per anum. Sigmoidoscopy revealed a large globular pedunculated polyp at 22 cm from the anal verge resulting in a sigmoidorectal intussusception. Endoscopic polypectomy was not technically possible due to the large size of the polyp. At the time of prolapse the polyp was tied at its pedicle with thread and resected surgically. The patient is asymptomatic on follow-up.

Non-familial juvenile polyposis in prolapsed rectum.

Juvenile polyposis located solely on prolapsed rectal mucosa is very unusual. We report the case of a 17-year old boy who presented to us with a history of passage of blood and mucus per rectum of a mass protruding through the anus during defecation. Per rectal and colonoscopic examinations revealed numerous polyps located solely on the prolapsed rectal mucosa. Histopathology was consistent with juvenile polyposis. He was managed with repeated sessions of endoscopic polypectomy. Family screening was negative for colonic polyps.