Impact of Life Cycle Costing in Procurement of Robotic Track-Based Central Laboratory at Apex Medical Institute in India.

Introduction Life cycle costing is an important management tool that takes into account the implications of planning, acquiring, operating, maintaining, and disposing of an asset during its complete life cycle. A major hindrance to the procurement of expensive equipment in developing countries is the lack of a reliable framework combining and integrating all the equipment life cycle aspects into procurement process. Methods The study was conducted from the data collected from the bids that were received for procurement of two robotic track-based central laboratories which were installed at All India Institute of Medical Sciences (AIIMS), New Delhi. The procurement was done as per the guidelines laid down under General Finance Rules (GFR) 2017 following the two bid systems: technical bid and price/commercial bid. Results A complete financial analysis of the robotic laboratory was done that involved gathering of all the pertinent financial information into one place and then using that data to analyze the feasibility of the bid. The life cycle costs of both the labs were calculated by assuming the life of equipment as 10 years and by factoring in cost of equipment including 5-year warranty, comprehensive maintenance from years 6 to 10, indicative cost of all reagents for 10 years, and indicative cost of all other consumables for 10 years. Conclusion Results showed that the cost of equipment alone should not be the sole predictor of making purchase decisions of equipment. Further research may additionally explore differences between processes being followed in government versus private organizations, as well as national guidelines and subnational practices.

Study to assess the utility of discrete event simulation software in projection & optimization of resources in the out-patient department at an apex cancer institute in India.

Background and Aims: A study was done to create and run a discrete event simulation in the outpatient department (OPD) of a tertiary care cancer hospital in North India to project and optimize resource deployment. Methods: The OPD process & workflow as per the expected load at tertiary care cancer hospital were finalized with various stakeholders in a focused group discussion. The finalized OPD process & workflow along with the OPD Building plans were utilized to develop a discrete event simulation model for the OPD at a tertiary care cancer hospital using a discrete event simulator. The simulation model thus developed was tested with incremental patient loads in 5 different scenarios/"What if" situations (Scenario 1-5). The data regarding initial patient load and resources deployed was taken from on-ground observations at the tertiary care cancer hospital. Results: It was found that rooms and doctors were over-utilized and support staff utilization remained low. This was implemented with a lesser waiting time for patients. No additional support staff was provided thus improving utilization of existing staff and saving on resources. The simulations enabled us to deploy resources just when it was required, which ensured optimal utilization and better efficiency. The peak census helped us to determine the capacity of the waiting area in different scenarios with incremental patient load and resource deployment. Conclusion: The simulation software was very helpful, as "what if scenarios" could be created and the system tested, without disturbing the normal functioning of OPD. This enabled decision-making before making on-ground changes which saved a lot of time and money. Also, the processes of the old system were reengineered to fit the needs of changing times.

Short Term Clinico-Radiological Outcome of Extra Osseous Talo-Tarsal Stabilization (EOTTS) in Flat Foot: An Indian Perspective.

INTRODUCTION: Flexible flat foot is one of the most common foot conditions found amongst any age group across the world. One very important reason for this condition is the incongruency or partial dislocation of one or more joints within the talo-tarsal mechanism. This flexible talo-tarsal malalignment is termed as recurrent talo-tarsal joint dislocation (RTTJD). MATERIALS AND METHODS: Between 2016 and 2018, 32 patients were advised Extra osseous talo-tarsal stabilization (EOTTS) as a standalone procedure for RTTJD following detailed clinical examination including foot posture index (FPI) scoring and weight-bearing radiographic evaluation. Subjective assessment was done through Maryland Foot Score (MFS) questionnaire. Radiological parameters like talar declination angle, talar second metatarsal angle and tibio-calcaneal valgus angle were assessed for preoperative and postoperative comparison. 15 patients (20 feet) underwent surgery and rest 17 patients (25 feet) became our control group. A retrospective record analysis of longitudinal data was done over a period of 4 years. The purpose of this study is to depict the short-term results of EOTTS procedure in terms of functional and radiological improvement and compare it with the non-surgical group. RESULT: Significant improvement was seen in MFS from 67.31 ± 16.04 to 95.47 ± 4.36 over a mean follow-up period of 30.66 ± 7.09 months. Total FPI improved by 96.83 ± 4.80% at final follow-up of EOTTS group. Radiologically, maximum correction achieved was in coronal plane (93.07 ± 30.05%). CONCLUSION: EOTTS, as a standalone procedure improved the foot radiological angles and restored the normal foot biomechanics significantly in presence of competent spring ligament and posterior tibial tendon. This procedure resulted in excellent patient satisfaction score as assessed by MFS questionnaire. LEVEL OF EVIDENCE: III.

One for Everyone: A Study of User Satisfaction Among Health-Care Providers Regarding Extended Use of N95 Masks During the COVID-19 Pandemic.

OBJECTIVE: This study was conducted to assess the feasibility of extended use of N95 masks in our hospital during the coronavirus disease 2019 (COVID-19) pandemic. We also studied the use pattern, user satisfaction, and issues faced during extended use of the mask. METHODS: This cross-sectional study was conducted among health-care providers in a large tertiary care teaching hospital in northern India from April 1 to May 31, 2020. A list was prepared from the institute's register, and participants were chosen by random sampling. The data collected from the physical forms were transferred to excel sheets. RESULTS: A total of 1121 responses were received. The most common problem stated with reuse of N95 masks was loss of fit followed by damage to the slings, highlighted by 44.6% and 44.4% of the participants, respectively. A total of 476 (42.5%) participants responded that they would prefer "cup-shaped N95 mask with respirator". The median scores regarding the satisfaction with the quality of masks and their fit was also 4 each. CONCLUSIONS: It was concluded that the extended use of N95 masks was acceptable, with more than 96% of the participants using these masks.

How informed is the informed consent?

BACKGROUND: Informed consent is a cornerstone of the ethics of modern medical care. In an ideal world, informed consent is a process of education - a conversation between a surgeon and a patient or family that allows the patient or family to make the best possible decision regarding care. OBJECTIVE: The study was conducted with objectives of assessing information given to the patient before taking consent for surgery and determining the compliance to various contents of the consent forms. MATERIAL AND METHODS: This was a prospective study over a period of 12 weeks in wards of various surgical departments of a 1000+ bedded tertiary care hospital. Patient interviews were conducted to assess their level of information and the consent forms were reviewed to assess the compliance. OBSERVATIONS: The overall level of information r4egarding various aspects among the participants was 75.14%. The level of information varied statistically with age, literacy level, annual income and the type of surgery. All the patients (100%) stated that they were informed about the current clinical condition/ problem, while only 34% were informed about risk and 26% about the alternative options. All the forms (100%) had a statement regarding the explanation of procedure to the patient/ guardian and none of the forms (0%) contained names of all practitioners performing the procedure. CONCLUSION: There is need to create awareness among doctors and also to educate patients regarding the importance of informed consent.

Leucocytosis and early organ involvement as risk factors of mortality in adults with dengue fever.

The clinical profile and risk factors for mortality in dengue fever have evolved over the years. The all-cause mortality in admitted dengue patients is around 6%. We aimed to evaluate the recent change in trends of the clinical characteristics and risk factors for in-hospital mortality in adults with dengue fever. This is a retrospective study on adults with confirmed dengue fever admitted in a medical unit of a tertiary care center in North India. Medical records of confirmed dengue fever patients admitted between January 2011, and December 2016 were reviewed. Chi-squared tests with Bonferroni correction for multiple testing were used to identify risk factors for mortality. 232 records were included, of which 66.8% were males. The mean age was 31.6 ± 14 years. There were 17 deaths with an all-cause mortality rate of 7.3% with 76.5% being classified as severe dengue at admission. Among the 17 mortality cases, dyspnea (47%), tachypnea (86.7%), leucocytosis (58.8%), raised urea (80%), and elevated serum creatinine (52.9%) at presentation were significantly associated with mortality (p < 0.001). Shock at any time during the hospital stay (58.8%) was also found to be significantly associated with mortality (p < 0.001). We found that dyspnea, tachypnea, acute kidney injury, and leucocytosis at presentation was significantly associated with in-hospital mortality. Based on our results, we recommend aggressive management of patients with severe dengue and those with mild/moderate disease with the above risk factors.

Psychometric analysis and construct validation of Health Professional Education in Patient Safety Survey in the Indian context.

Background Improving patient safety (PS) is critical to optimizing healthcare delivery. There is a need to develop curricula or incorporate PS concepts in health professionals' (HPs) education, in both theoretical and practical training. Consequently, there is a need to measure the perception of HPs regarding various PS competencies imparted to them during their training. The Health Professional Education in Patient Safety Survey (H-PEPSS) is a tool that measures HPs' self-reported PS competence and was designed to reflect six sociocultural areas central to PS. The tool has been validated in Canada but not in India. We did a confirmatory factor analysis (CFA) and psychometric validation of the H-PEPSS in the Indian context. Methods The sample comprised 240 HPs. We used the maximum likelihood estimation method on AMOS V20 (SPSS Inc.) to carry out a CFA of the tool. We used the normed fit index, Tucker-Lewis index, comparative fit index, standard root mean square residual, root mean square residual and root mean square error of approximation to evaluate the model fit. Internal consistency and reliability of the six factors of the model were examined using Cronbach's alpha. Convergent validity of the model was examined using average variance extracted and composite reliability. Discriminant validity was examined using the Fornell and Larcker criterion and the heterotrait-monotrait method. Results The results indicate a good fit. The H-PEPSS was found to be reliable and valid for assessing PS competencies among HPs. Comparison of the results with the results of the Canadian setting confirmed external validity. Conclusion The 16-item H-PEPSS has good psychometric properties for use in the Indian context. The 23-item HPEPSS was found to be reliable and valid for assessing PS.

Inventory management practices in the blood bank of an institute of national importance in India.

Background: The demand and supply gap in blood and components has always existed in healthcare facilities. Blood inventory management is crucial to meet the demand and to minimize wastage. This study explores the blood inventory management practices at the blood bank of an institute of national importance in India. Methods: The technicians of the blood bank were interviewed on the practices they followed on blood inventory management and records were reviewed where required. Results: Simple rule of thumb practices, the experience of staff, training, clear policy on stock keeping and allocation, daily stock review, record-keeping, monthly performance review, automation, adoption of information system, regular communications, and leadership emerged as factors contributing to inventory management. Conclusion: The blood bank follows simple procedures and relies on the experience of its staff to manage its inventory. Rigorous training, strict oldest-unit-first-out (OUFO)/first-in-first-out (FIFO) principle for stock management, stringent allocation policy, diligent record-keeping, daily stock review, and monthly performance reports were identified as the key drivers for inventory management. Other measures like regular preventive maintenance of equipment, robust blood bank information system, communication with stakeholders, and effective leadership were found to contribute indirectly to inventory management practices.

Assessment of a deep-learning system for fracture detection in musculoskeletal radiographs.

Missed fractures are the most common diagnostic error in emergency departments and can lead to treatment delays and long-term disability. Here we show through a multi-site study that a deep-learning system can accurately identify fractures throughout the adult musculoskeletal system. This approach may have the potential to reduce future diagnostic errors in radiograph interpretation.

Evaluation of Patients Record and its Implications in the Management of Trauma Patients.

INTRODUCTION: A medical record audit is a type of quality assurance task which involves formal reviews and assessments of medical records to identify where a medical organization stands in relation to compliance and standards. A study was carried out with the objective to document the audit of the medical records in a tertiary care trauma center and suggest the corrective measures and preventive measures in case of lacunae. METHODOLOGY: A retrospective study was conducted in an apex trauma care facility of New Delhi. All the admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. A list of 106 admissions were made using the online software at the trauma center. The files were taken from the medical record departments and compared using a checklist prepared in accordance with the guidelines laid down by the Joint Commission International. RESULTS: A total of 106 admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. The average length of stay for the disaster beds was 11.7 days and the mortality rate was 9.5%. Signature of the patient and doctor and name of the witness were missing in more than 50% of the cases of consent. Discharge summary in which the investigation details, signature of the doctor, and contact number in case of an emergency were not documented. In the miscellaneous records, transfer (61%) and referral (42%) were not documented properly. CONCLUSION: The average length of stay for the disaster beds was 11.7 days. Maximum admissions were under the neurosurgery department. The filing and assembling of records were poor. Signature of the patient and doctor and name of the witness were missing in more than 50% of the consent forms. There was no anesthesia consent form used. The doctor daily records were poor, while the nursing records were well maintained. It is recommended to have a periodic weekly auditing to minimize chances of deficiency/misplacing of records. Periodic training sessions and workshops should be organized.

Serum calcium level among pregnant women and its association with pre-eclampsia and delivery outcomes: A cross-sectional study from North India.

BACKGROUND: Calcium requirement increases during pregnancy, thereby increasing the chances of developing hypocalcaemia. Hypocalcaemia may be associated with pregnancy-related complications. Therefore, we planned this study to estimate the prevalence of hypocalcaemia among pregnant women attending secondary care hospital, and to study the association between hypocalcaemia and pregnancy outcomes. MATERIALS AND METHODS: This study was conducted in a secondary level hospital at Ballabgarh, district Faridabad, Haryana, India. Consecutive pregnant women with gestation period more than 28 weeks were enrolled. Dietary calcium intake was ascertained using 24-hour dietary recall method. Serum calcium estimation was done by Biolis 24i auto analyser. Outcome of pregnancy (preterm delivery, low birth weight (LBW) babies, and neonatal mortality) was assessed telephonically 3 months after the enrolment. RESULTS: A total of 696 pregnant women were enrolled in the study. Mean (SD) dietary calcium intake and serum calcium level was 796.4 (360.4) mg/day and 9.56 (0.94) mg/dl respectively. Prevalence (95% CI) of hypocalcaemia was 23.9% (20.8 - 27.2%). Serum total calcium level was not associated with dietary calcium intake (p-value = 0.36). Mean serum calcium level was significantly lower in mothers who had LBW babies. Pre-eclampsia, preterm delivery, and neonatal mortality were not associated with serum calcium level. CONCLUSION: Serum calcium level may not be related to dietary calcium level. Hence, the current recommendation of calcium supplementation during antenatal period appears to be inconclusive among our study population.

Noise Pollution and Impact on Children Health.

With rapid urbanization and life style changes, loud noise is omnipresent and has become a part of life. Indoor and outdoor environmental noise pollution have been documented as a serious health hazard with increasing adverse effects on fetus, infants, children, adolescents and adults. Noise induced hearing loss and non-auditory adverse effects due to noise pollution, are being increasingly diagnosed in all age groups including the fetus. Outdated motorized vehicles, machinery, increasing traffic, congested residential areas, crowded educational institutions and workplaces, unregulated commercial and industrial noise have become a source of noise pollution with long-term disability. Areas of noise pollution must be identified and corrective measures be taken. Toys, personal, domestic, commercial, industrial equipment should be within the safe sound intensity. Loudspeakers and vehicular horns should be banned except in emergencies. Nocturnal noise pollution must be avoided near residential areas as sleep disturbances have serious long-term health consequences. Pregnant women, fetus, newborns, infants and children are most susceptible to noise induced health hazards and should be given utmost protection. Educational institutions, workplaces, commercial and industrial areas should be regularly monitored for noise levels and protective ear muffs and plugs be used. Public be educated repeatedly regarding health hazards of noise. Traffic noise should be regulated to be within safe limits. Bus-stands, railway stations and airports should be moved away from residential areas. Houses should be sound proofed suitably. Long term studies should be conducted in pregnant women, newborn children and adults to have more data on hazards of noise pollution.

Serum FRAP Levels and Pre-eclampsia among Pregnant Women in a Rural Community of Northern India.

INTRODUCTION: There is a balance between the oxidative and the anti-oxidative forces in human body. Some studies document decreased level of anti-oxidant in pre-eclampsia while other studies showed normal level of anti-oxidant in pre-eclampsia and the evidence is equivocal. AIM: The aim of the present study was to assess enzymatic anti-oxidant activities in pre-eclamptic women and compare it with normotensive pregnant women with period of gestation between 28 to 36 weeks. MATERIALS AND METHODS: A community-based cross-sectional survey was conducted (from November 2012-December 2013) at the Ballabgarh Health and Demographic Surveillance System (HDSS) site which was managed by Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India. All registered pregnant women with period of gestation between 28 weeks - 36 weeks were eligible for inclusion in the study. All eligible pregnant women were contacted through home visit. A total of 217 pregnant women were enrolled out of which 209 blood samples were collected from pregnant women. About three ml of blood from antecubital vein was drawn without use of tourniquet, under aseptic conditions. It was later analysed for the serum anti-oxidative measures {Malanoaldehyde, Vitamin C, Ferric Reducing Ability of Plasma (FRAP) levels}. Data were entered on Epi-Info version 3.5.4. Data management and analysis was carried out in Stata 11. The means were compared using t-test and p-value stated. Categorical data was analysed using chi-square test. Logistic regression was used and adjusted p-value was stated. RESULTS: A total of 217 pregnant women were eligible for the study and all were enrolled. Out of the 217 blood samples collected, eight samples accidently got destroyed. A total of 28 out of remaining 209 pregnant women (13.4%) had pre-eclampsia. Mean age (SD) was 22.4 (2.3) years, mean height (SD) was 156.6 (6.9) cm, mean weight (SD) was 65.1 (9.7) kg in pre-eclampsia group. In pre-eclampsia group mean serum levels of malanoaldehyde, vitamin C and FRAP was 4.2 (0.26) ng/dl, 0.83 (0.11) mg/dl, 678.0 (35.6) µmol/L. It was 4.5 (0.09) ng/dl,0.88 (0.03) mg/dl, 599.3 (13.3) µmol/L in normotensive pregnant women group respectively. The difference was statistically significant for FRAP levels only. CONCLUSION: Serum anti-oxidant levels are not raised among women with pre-eclampsia.

Dietary Calcium Intake, Serum Calcium Level, and their Association with Preeclampsia in Rural North India.

BACKGROUND: Preeclampsia in pregnancy has been shown to be associated with low serum calcium level. Though the evidence is abundant, it is equivocal. OBJECTIVES: The study aimed to estimate the dietary calcium intake and serum calcium status among pregnant women, and to document the association of the dietary calcium intake and serum calcium status with incidence of preeclampsia in the 3rd trimester of pregnancy. MATERIALS AND METHODS: A community-based cross-sectional study was conducted in the Health and Demographic Surveillance System (HDSS) site, Ballabgarh, Haryana, India. All pregnant women between 28 weeks and 36 weeks of gestation were interviewed. A semi-structured interview schedule and a 24-h dietary recall questionnaire were administered to assess the dietary calcium intake. AutoAnalyser (Biolis 24i) was used for measuring serum calcium. RESULTS: We enrolled 217 pregnant women. The mean [standard deviation (SD)] dietary calcium intake was 858 (377) mg/day. The mean (SD) serum calcium level was 9.6 mg/dL (0.56). Incidence of preeclampsia was 13.4%. Preeclampsia was not associated with hypocalcemia [odds ratio (OR) = 1.2 95% confidence interval (CI); 0.27-3.98]. CONCLUSION: The majority of pregnant women had inadequate dietary calcium intake. The prevalence of hypocalcemia was low. Low serum calcium level was not associated with preeclampsia. Calcium supplementation may not reduce preeclampsia in this population.

Ureteric vasculitis, an unusual presentation of polyarteritis nodosa: a case report.

A 22 year old female presented with vasculitic skin rash. She was incidentally found to be hypertensive and had proteinuria. Skin biopsy showed leuco-cytoclastic vasculitis. On Imaging, there was left hydronephrosis, hydroureter with bilateral multiple foci of ureteric stenosis and micro-aneurysms in relation to interlobar arteries of kidney. A diagnosis of classical Polyarteritis Nodosa (cPAN) with multi-level ureteric stenosis was made. She was treated with Glucocorticoids, Cyclophosphamide, following which Azathioprine was given.

Comparison of the efficacy of inhaled budesonide and oral choline in patients with allergic rhinitis.

OBJECTIVE: A single blind parallel group study was conducted to evaluate the effects of oral choline [given as tricholine citrate (TRI)] in patients with allergic rhinitis, and compare its efficacy with intranasal budesonide (BUD). METHOD: The study was conducted at the Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, Delhi, India from February 2001 to April 2002. Sixty patients were randomized into 2 groups after a run-in period of 2 weeks. Group A received intranasal BUD 200 microg twice daily and group B received TRI 500 mg thrice daily. The patients were reviewed every 2 weeks up to 8 weeks. The mean individual symptom score, total symptom score and drug score were significantly reduced in both groups (p<0.05) compared to baseline values, with maximum effect occurring within 4 weeks of therapy. RESULTS: Budesonide showed statistically significant reduction (p<0.05) in all the outcome parameters, when compared to TRI. Crossover study between the 2 treatment groups also showed similar results. Seventy-six percent of patients with BUD and 43% of patients with TRI found the drug to be effective. CONCLUSION: Both intranasal BUD and oral TRI are effective in relieving symptoms of allergic rhinitis. Budesonide was found to be the statistically superior drug.