Analysis of the operational risk factors in public hospitals in an Indian state.

PURPOSE: Risk management in the healthcare sector is a highly relevant sub-domain and a crucial research area from the humanitarian perspective. The purpose of this paper is to focus on the managerial/supply chain risk factors experienced by the government hospitals in an Indian state. The present paper analyzes the inter-relationships among the significant risk factors and ranks those risk factors based on their criticality. DESIGN/METHODOLOGY/APPROACH: The current research focuses on 125 public hospitals in an Indian state. Questionnaire-based survey and personal interviews were conducted in the healthcare sector among the inpatients and hospital staff to identify the significant risk factors. An integrated DEMATEL-ISM-PROMETHEE method is adopted to analyze the impact potential and dependence behavior of the risk factors. FINDINGS: The analysis asserts the absence of critical risk factors that have a direct impact on patient safety in the present healthcare system under investigation. However, the results illustrate the remarkable impact potential attributed to the risk factor, namely, staff shortage in inducing other risk factors such as employee attitudinal issues, employee health issues and absenteeism altogether resulting in community mistrust/misbeliefs. Maintenance mismanagement, monsoon time epidemics, physical infrastructure limitations are also found to be significant risk factors that compromise patient satisfaction levels. PRACTICAL IMPLICATIONS: Multiple options are illustrated to mitigate significant risk factors and operational constraints experienced by public hospitals in the state. The study warrants urgent attention from government officials to fill staff vacancies and to improve the infrastructural facilities to match with the increasing demand from the society. Furthermore, this research recommends the hospital authorities to start conducting induction and training programs for the hospital employees to instill the fundamental code of conduct while working in hectic, challenging and even in conditions with limited resources. ORIGINALITY/VALUE: Only limited papers are visible that address the identification and mitigation of risk factors associated with hospitals. The present paper proposes a novel DEMATEL-ISM-PROMETHEE integrated approach to map the inter-relationships among the significant risk factors and to rank those risk factors based on their criticality. Furthermore, the present study discloses the unique setting of the public healthcare system in a developing nation.

Comparison on the use of semi-automated and automated core biopsy needle in ultrasound guided breast biopsy.

OBJECTIVE: The aim of this study was to compare the use of semi-automated (Medax Velox 2; Poggio Rusco, Italy) and automated (Bard Magnum Biopsy Instrument; Covington, GA, USA) core biopsy needles, for ultrasound guided breast biopsy. MATERIALS AND METHODS: A 14G semi-automatic spring loaded core biopsy needle with a 22-mm-throw (Medax Velox 2; Poggio Rusco, Italy) and 14-gauge automated needle device with a 22-mm-throw biopsy gun (Bard-Magnum Biopsy Instrument, Covington, GA, USA) were used for breast biopsies under ultrasound guidance on alternate months during the study period between July 2009 and May 2011. One hundred and sixty lesions were biopsied and specimens were sent for histological evaluation. RESULTS: The automated needle obtained a higher number of histology reports at 84% (67/80) as compared with the semiautomated needle at 60% (48/80) (Fisher exact test, p value=0.023). Inadequate samples with the automated needle were much less at 9% (7/60) than with the semiautomated needle at 23% (18/60) (Fisher exact test, p value=0.028). The semi-automated needle showed slightly less fragmented samples. However, the number of fragmented samples with definitive diagnosis was slightly higher with the automated compared with the semiautomated needle, at 16% (13/80) and 13% (10/80) respectively. Compared with histology of 29 lesions that were excised, the semi-automated needle had higher sensitivity (100%) but lower specificity (75%) and accuracy (90%) compared with the automated needle (88% sensitivity, 100% specificity, 95% accuracy). CONCLUSION: Definitive diagnosis from the study samples slightly favours the use of automated core biopsy needle as compared to semi-automated core biopsy needle.

Generation of human induced pluripotent stem cells from dermal fibroblasts.

The generation of patient-specific pluripotent stem cells has the potential to accelerate the implementation of stem cells for clinical treatment of degenerative diseases. Technologies including somatic cell nuclear transfer and cell fusion might generate such cells but are hindered by issues that might prevent them from being used clinically. Here, we describe methods to use dermal fibroblasts easily obtained from an individual human to generate human induced pluripotent stem (iPS) cells by ectopic expression of the defined transcription factors KLF4, OCT4, SOX2, and C-MYC. The resultant cell lines are morphologically indistinguishable from human embryonic stem cells (HESC) generated from the inner cell mass of a human preimplantation embryo. Consistent with these observations, human iPS cells share a nearly identical gene-expression profile with two established HESC lines. Importantly, DNA fingerprinting indicates that the human iPS cells were derived from the donor material and are not a result of contamination. Karyotypic analyses demonstrate that reprogramming of human cells by defined factors does not induce, or require, chromosomal abnormalities. Finally, we provide evidence that human iPS cells can be induced to differentiate along lineages representative of the three embryonic germ layers indicating the pluripotency of these cells. Our findings are an important step toward manipulating somatic human cells to generate an unlimited supply of patient-specific pluripotent stem cells. In the future, the use of defined factors to change cell fate may be the key to routine nuclear reprogramming of human somatic cells.

Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study.

OBJECTIVE: Posterior circulation ischemic stroke (PCiS) constitutes 20-30% of ischemic stroke cases. Detailed information about differences between PCiS and anterior circulation ischemic stroke (ACiS) remains scarce. Such information might guide clinical decision making and prevention strategies. We studied risk factors and ischemic stroke subtypes in PCiS vs. ACiS and lesion location on magnetic resonance imaging (MRI) in PCiS. METHODS: Out of 3,301 MRIs from 12 sites in the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Genetics Network (SiGN), we included 2,381 cases with acute DWI lesions. The definition of ACiS or PCiS was based on lesion location. We compared the groups using Chi-squared and logistic regression. RESULTS: PCiS occurred in 718 (30%) patients and ACiS in 1663 (70%). Diabetes and male sex were more common in PCiS vs. ACiS (diabetes 27% vs. 23%, p < 0.05; male sex 68% vs. 58%, p < 0.001). Both were independently associated with PCiS (diabetes, OR = 1.29; 95% CI 1.04-1.61; male sex, OR = 1.46; 95% CI 1.21-1.78). ACiS more commonly had large artery atherosclerosis (25% vs. 20%, p < 0.01) and cardioembolic mechanisms (17% vs. 11%, p < 0.001) compared to PCiS. Small artery occlusion was more common in PCiS vs. ACiS (20% vs. 14%, p < 0.001). Small artery occlusion accounted for 47% of solitary brainstem infarctions. CONCLUSION: Ischemic stroke subtypes differ between the two phenotypes. Diabetes and male sex have a stronger association with PCiS than ACiS. Definitive MRI-based PCiS diagnosis aids etiological investigation and contributes additional insights into specific risk factors and mechanisms of injury in PCiS.

Antioxidant potential and indole alkaloid profile variations with water deficits along different parts of two varieties of Catharanthus roseus.

The variations in antioxidant potentials and indole alkaloid content were studied in the present investigation, in two varieties (rosea and alba) of Catharanthus roseus, an important herb used in traditional as well as modern medicine, exposed to water deficit stress. The antioxidant and alkaloid profiles were estimated from root, stem, leaf, flowers and pods. The antioxidant potentials were examined in terms of non-enzymatic antioxidant molecules and activities of antioxidant enzymes. The non-enzymatic antioxidant molecules studied were ascorbic acid (AA), alpha-tocopherol (alpha-toc) and reduced glutathione (GSH). The estimated antioxidant enzymes were superoxide dismutase (SOD), ascorbate peroxidase (APX), catalase (CAT), peroxidase (POX) and polyphenol oxidase (PPO). The antioxidant concentrations and activities of antioxidant enzymes were high under water deficit stress in all parts of the plants. Indole alkaloid content was high in the roots of rosea variety in response to stress when compared to alba variety.

Comparative effects of different triazole compounds on antioxidant metabolism of Solenostemon rotundifolius.

The effect of different triazole compounds, viz., triadimefon (TDM) and hexaconazole (HEX) treatments on the antioxidant metabolism of Solenostemon rotundifolius Poir., Morton plants was investigated in the present study under pot culture. Plants were treated with TDM at 15 mg l(-1) and HEX at 10 mg l(-1) separately by soil drenching on 80, 110 and 140 days after planting (DAP). The plants were harvested randomly on 90, 120 and 150 DAP for determining the effect of both the triazoles on non-enzymatic antioxidant contents like ascorbic acid (AA), reduced glutathione (GSH) and alpha-tocopherol (alpha-toc), activities of antioxidant enzymes like superoxide dismutase (SOD) and ascorbate peroxidase (APX). All the analyses were made in leaf, stem and tubers of both control and treated plants. It was found that both these triazole compounds have profound effects on the antioxidant metabolism and caused an enhancement in both non-enzymatic and enzymatic antioxidant potentials under treatments. These results suggest that, the application of triazoles may be a useful tool to increase the antioxidant production in S. rotundifolius and thereby make it an economical food crop.

Carbohydrate metabolism in Dioscorea esculenta (Lour.) Burk. tubers and Curcuma longa L. rhizomes during two phases of dormancy.

We have examined the changes in carbohydrate metabolism in food yam (Dioscorea esculenta (Lour.) Burk.) tubers and in an economically important spice cum medicinal plant turmeric (Curcuma longa L.) rhizomes under storage. Both specimens showed varied levels of dormancy and sprouting appeared at the end of dormant period. Harvested, fully matured tubers of yam and rhizomes of turmeric were stored in wooden boxes under the conditions of 28+/-2 degrees C temperature and 65-75% relative humidity (RH) in dark. The starch, sugars, enzymes of starch degradation, respiration, glycolysis, tricarboxylic acid (TCA) cycle and oxidative pentose phosphate pathway (PPP) were studied during 1-70 days after harvest (DAH). This investigation revealed that, the starch degradation and the enzymes involved, viz. alpha-amylases and starch phosphorylase showed a lower level of activity during early period of dormancy, while sugar content and enzymes of carbohydrate metabolism increased rapidly during sprouting. The isoenzymic profiles of alpha-amylases showed marked variations in these two phases. The key enzymes of glycolysis, TCA cycle and PPP, viz. aldolase, succinic dehydrogenase, malic dehydrogenase, glucose-6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase were increased even before the visible appearance of sprouting and their activities were at their maximum during sprouting. Based of the observations the dormancy period may be distinctly divided into peak period of rest and presprouting period.

Comparative effects of different triazole compounds on growth, photosynthetic pigments and carbohydrate metabolism of Solenostemon rotundifolius.

The effects of two triazole compounds, triadimefon and hexaconazole, on the growth and carbohydrate metabolism were studied in Solenostemon rotundifolius Poir., Morton plants under pot culture. Plants were treated with triadimefon at 15mg l(-1) and hexaconazole at 10mg l(-1) separately by soil drenching on 80, 110 and 140 days after planting (DAP). The plants were harvested randomly and growth parameters were studied on 90, 120 and 150 DAP for determining the effect of both the triazole on growth and chlorophyll pigments. These triazole compounds increased the chlorophyll pigments. However, both the treatments decreased the fresh and dry weights of shoot and leaf area. Both these triazole resulted in a marginal increase in starch content and decreased the sugar contents. The carbohydrate metabolizing enzymes alpha- and beta-amylase activities were reduced and invertase activity increased in S. rotundifolius under triadimefon and hexaconazole treatments.

Changes in antioxidant metabolism of Vigna unguiculata (L.) Walp. by propiconazole under water deficit stress.

In the present study, a pot culture experiment was conducted to estimate the ameliorating effect of propiconazole (PCZ) on drought stress in cowpea (Vigna unguiculata (L.) Walp.) plants. From 30 days after sowing (DAS), the plants were subjected to 3, 6 and 9 days interval drought (DID) stress and drought stress with PCZ at 15 and 15 mg l(-1) PCZ alone and 1 day interval irrigation was kept as control. The plant samples were collected on 34 DAS (3 DID), 37 DAS (6 DID) and 40 DAS (9 DID). The plants were separated into root, stem and leaf for estimating the antioxidant contents and activities of antioxidant enzymes. Individual and combined drought stress and PCZ treatments increased ascorbic acid (AA), alpha-tocopherol (alpha-toc) contents, superoxide dismutase (SOD), ascorbate peroxidase (APX), catalase (CAT) and polyphenol oxidase (PPO) activities when compared to control. The PCZ treatment mitigated the adverse effects of drought stress by increasing the antioxidant potentials and thereby paved the way for overcoming drought stress in V. unguiculata plants.

Visual evoked potentials in ataxia telangiectasia.

Pattern reversal visual evoked potentials (VEPs) elicited in four patients with ataxia telangiectasia revealed normal results in two and absent responses in two. The pathogenesis of the VEP abnormalities is discussed. It is surmised that the VEP changes reflect progressive degeneration of the nerve fibres in the anterior visual pathway, as in Friedreich's ataxia.

Prevalence and pattern of multiple sclerosis in Benghazi, north-eastern Libya.

A search for Libyan patients with multiple sclerosis (MS) was made in Benghazi, located on the southern Mediterranean coast at a latitude of 32 degrees N. Twenty-one clinically definite and probable cases were detected during the period July 1982-June 1984. On the basis of 2 probable incidental cases, the incidence for 1983 was 0.8 per 100 000 of the population at risk (10-50 years). On July 1st, 1984, the rough prevalence rate for the total population was 4 per 100 000 and the age-adjusted prevalence rate was 5.9 per 100 000. This study suggests that Benghazi falls within the medium frequency band for MS. High prevalence of brainstem involvement and cerebellar dysfunction and infrequent occurrence of the severe optic-spinal form and sphincter disturbance indicates that the present group of patients resembles Western pattern of MS as opposed to Asian MS.

Conformational analysis of A and B rings in 2-, 4-, and 6-bromosubstituted steroidal 4-en-3-ones by nuclear magnetic resonance.

The conformational preference of A and B rings in four differently functionalized bromosubstituted 4-en-3-one steroids is studied by concerted application of high-resolution one- and two-dimensional nuclear magnetic resonance (NMR) techniques, such as homonuclear and heteronuclear correlated spectroscopy, transient and steady-state nOe spectroscopy, temperature-dependent chemical chemical shift variation, and application of a modified Karplus equation. The steroids studied include 6 beta-bromocholest-4-en-3-one (3), 4,6 beta-dibromocholest-1,4-dien-3-one (2), 2 alpha,4,6 beta-tribromocholest-4-en-3-one (1), and (25R)-2 alpha,6 beta-dibromospirost-4-en-3-one (4). Steroids 1-4 were prepared by either acid-catalyzed or free-radical bromination from appropriate 4-en-3-one steroid. The study has yielded an insight into the factors responsible for conformational preferences of the A and B rings of these bromosubstituted steroids. Bromosubstitution at the 2 alpha position is responsible for the inversion of the A ring to inverted 1 beta,2 alpha-halfchair conformation. The electronic interaction between 4-bromine and carbonyl oxygen distorts the A-ring conformation further. Inversion of the A ring has a concomitant effect of distortion in the chair form of the B ring. Conformational preferences of A and B rings are not found to be influenced by transmission effect of a side chain or oxygenated ring system. Temperature-dependent NMR studies indicate the reduced conformational flexibility of the A ring for 2 alpha-bromosubstituted steroids. Complete assignment of the 13C and 1H resonances of two of the steroids studied (3 and 4) is presented.

Visual evoked potentials in spinocerebellar degenerations.

Pattern reversal visual evoked potentials were studied in 21 patients with spinocerebellar ataxias among whom 6 had Friedreich's ataxia, 10 had hereditary spastic ataxia and 5 had spinocerebellar degeneration with slow eye movements (olivopontocerebellar degeneration). The VEP abnormalities found in 4 cases of Friedreich's ataxia and one with spinocerebellar degeneration with slow eye movements, consisted of, bilaterally absent VEP in 3 patients and bilaterally abnormal responses with asymmetry in two. All the patients with spastic ataxia had normal VEP latencies. The N 70 - P 100 amplitudes, in patients with hereditary ataxias were significantly reduced compared to controls (P less than 0.001). The VEP abnormalities correlated best with neuroophthalmic findings, but had no relation to age, sex, inheritance or duration of illness. The VEP findings are probably suggestive of progressive nerve fibre loss in the visual pathways with associated slowing of conduction. The higher incidence of visual pathway involvement in Friedreich's ataxia compared to other hereditary ataxias as reported in recent studies is confirmed.

Meige's syndrome: clinical, pharmacological and radiological observations.

The clinical pharmacological, and neuroradiological observations in six patients with spontaneous blepharospasm-oromandibular dystonia (Meige's) syndrome are recorded. This group consisted of five males and one female, mean age at onset being 50.3 years. The duration of symptoms ranged from three months to 12 years, three patients having had symptoms for over four years. The dyskinesia was arrhythmic and asymmetrical in the orbicularis oculi and masseter muscles electrophysiologically. Pharmacological studies evinced no consistent response to parenteral physostigmine, no response to oral levodopa and no significant improvement in the dyskinesia following oral haloperidol. Lumbar air encephalogram was done in five patients, and showed frontal cortical atrophy without ventricular dilation in three. It is concluded that Meige's syndrome is a distinct nosological entity, and that physostigmine test is unlikely to be helpful in the differential diagnosis from neuroleptic-induced tardive dyskinesia. Neurotransmitter imbalance in the basal ganglia in this disorder remains to be established, and at present there is no satisfactory drug treatment for this progressively disabling movement disorder.

Migraine with interparoxysmal sharp complexes in the EEG: clinical features and response to anticonvulsant drugs.

The clinical profile and therapeutic response of 25 patients with migrainous headaches with interparoxysmal electroencephalographic (EEG) abnormalities in the form of sharp complexes are discussed. The clinical features of these patients consisted of male preponderance, early age of onset in males, long history of illness in females, very low incidence of aura and family history of migraine, frequent severe paroxysms, poor response to routine anti-migraine drugs and good response to anti-convulsant drugs. It is speculated that the EEG abnormalities in migraine may have a congenital basis which finds expression in vasomotor instability through hypothalamus and autonomic nervous system.

Epidemiology of Parkinson's disease in Benghazi, North-East Libya.

An epidemiological study of Parkinsonism was carried out in Benghazi situated in North-Eastern Libya. On the prevalence day, January 1, 1985, a total of 163 patients with Parkinson's disease were found living in the investigated area, which had a population of 518,745. The crude prevalence rate was 31.4 per 100,000 population and the incidence rate was 4.5 per 100,000 population per year. The average age at death was 71.2 years and the mean duration of the illness was 6.7 years. Our findings suggest that the risk of Parkinson's disease observed in the present study is intermediate to that reported among the white and black races and comparable with the yellow race and the Sardinians.

Syphilitic spinal neuroarthropathy with paraplegia.

The case of a 46-year-old male with syphilitic spinal neuroarthropathy complicated by paraplegia is reported. Marked sclerosis and osteophytes restricted to lumbo-dorsal spine, absence of ligamentous calcification and lack of long standing spinal symptoms in spite of the florid radiologic changes should raise the suspicion of neurogenic spinal arthropathy.

Adult aqueductal stenosis with Recklinghausen's neurofibromatosis.

A 28-year-old man with von Recklinghausen's neurofibromatosis was first seen with a spastic-ataxic gait and epileptic seizures of recent onset. computerized tomographic scan established the diagnosis of aqueductal stenosis, rarely reported in patients with von Recklinghausen's disease. The value of computerized tomography in the etiological diagnosis of hydrocephalus in von Recklinghausen's disease is emphasized and the pathogenesis of aqueductal narrowing in neurofibromatosis is discussed.

Clinical and epidemiological study of Bell's palsy in Benghazi, Libya.

An intensive search for 2 years for patients with Bell's palsy, conducted through the polyclinics, university hospitals and physiotherapy centres in Benghazi, revealed a total of 242 cases. The average annual incidence per 100,000 population was 23.35 and the age-adjusted incidence 35.72. The incidence increased with age up to the sixth decade. Seasonal clustering was noted in the months of December and January. Hypertension and diabetes mellitus were associated in 4.1% and 7% of patients, respectively. Only four patients presented during pregnancy. Recurrent facial paralysis was encountered in 5.4% of patients and was characterized by male preponderance and a tendency to recur more frequently on the same side as the initial paralysis. Familial incidence and bilateral involvement were rare features. Twelve per cent of patients who were followed up had moderate to severe residual weakness.