Technical expertise and behavior of the doctor- a major determinant of waiting time of OPD patients

Background: The study was conducted to understand various factors affecting waiting time spent by the patients in outpatient department (OPD) and to provide recommendations for reducing the waiting time in OPD of the selected hospital. Methods: It was a descriptive cross-sectional pretested questionnaire-based study involving all new 100 consenting patients at OPD recruited into the study using a systematic sampling technique after calculating the sampling interval. Results: The study indicates that 70% of patients were satisfied and only 30% were dissatisfied with the attention given by the OPD staff, cleanliness, attentiveness of doctor but shows great dissatisfaction regarding the waiting time spent by them in the outpatient department. Most of the subjects gave the reason for their satisfaction despite more time because of expertise of the doctor, behavior of the doctor, association of hospital with non-government organizations and insurance companies for free medicine and surgery. The dissatisfaction was not because of lack of administration but because of low level of awareness amongst patients attending the OPD about internet booking of appointment, COVID protocols, priorities given to recommendations given by other doctors/VIPs and walk in OPDs attended without prior appointment. Conclusions: A very important observation which evolved from the study was the version of patients that waiting time does not matter because they want to be treated from same doctor due to his/her expertise. Second important observation was that the addressing and greeting of patient by his/her name gave a great satisfaction and level of comfort to patients and affects the waiting time.

An echocardiographic study in patients with non haemorrhagic cerebral infarction to find cardiac abnormalities.

Background: Strokes are a major cause of morbidity and mortality worldwide. Majority are due to ischemic cerebral infarction. Ischemia may result from occlusion of blood vessels due to a disease process intrinsic to carotid and intracranial vessels or may relate to coexisting heart diseases, predisposing to embolic phenomenon. Objective: Echocardiographic study in patients with cerebrovascular accident, confirmed to be of non hemorrhagic nature on CT scan/MRI, for evidence of potential cardiac abnormalities as a predisposing cause for the vascular event. Material and Methods: An observational study was conducted in department of medicine, GNDH, Amritsar. 50 patients of ischemic stroke were taken and 2D transthoracic echocardiography was done to find potential cardioembolic abnormalities. Results: 76% of patients had echocardiographic abnormalities and 42% had potential cardioembolic abnormalities, out of which most common were ventricular wall hypokinesia, calcific aortic valve, rheumatic heart disease and dilated cardiomyopathy. The prevalence was almost similar in different age groups and both the sexes. Conclusion: Prevalence of potential cardioembolic abnormalities is high (42%) in ischemic stroke patients and 2D echocardiography is therefore recommended in the management and secondary prevention of cardioembolic stroke, which has a higher mortality and more chances of recurrence than atherothrombotic type of ischemic stroke.

Cutaneous T-cell lymphomas and their management strategies.

Cutaneous T-cell lymphomas (CTCLs) comprise a heterogeneous group of lymphoproliferative disorders characterized by the proliferation of skin-homing post-thymic T-cells. It is the second most common extranodal non-Hodgekin's lymphoma. Many variants of mycosis fungoides and CTCLs are known to date, differing in clinical, histological, and immunophenotypic characteristics. Oral involvement has also been reported rarely in CTCLs. Treatment depends on the disease stage or the type of variant. New insights into the disease and the number of emerging novel therapeutic options have made it an interesting area for dermatologists and medical oncologists.

Cerebroprotein hydrolysate: Innovation in Neurodegenerative disorders.

Stroke, traumatic brain injury and neurodegenerative disorders are one of the leading causes of death and disability in both developing and developed countries. A number of drugs including neurotrophic drugs are available for these disorders. Cerebroprotein hydrolysate is the latest one offering new hopes to patients suffering from these disorders. Its superiority is because of different actions which help in faster and more complete nerve repair and growth than other neurotrophic agents. It acts by multiple mechanisms viz.-regulation and improvement of the neuronal metabolism, modulation of the synaptic plasticity, promoting neuronal differentiation and protection against ischemic and neurotoxin lesion, reducing excitotoxic damage, blocking over activation of calcium dependent proteases, and scavenging free oxygen radicals. Till now no serious adversity has been reported.

Modulatory effects of Azadirachta indica leaf extract on cutaneous and hepatic biochemical status during promotion phase of DMBA/TPA-induced skin tumorigenesis in mice.

The modulation in biochemical status of skin and hepatic tissue at the time point of commencement of promotion stage of skin carcinogenesis in mice and its intervention with aqueous Azadirachta indica leaf extract (AAILE) were investigated. 7,12-Dimethylbenz(a)anthracene (DMBA, 500 nmol/100 ul of acetone) was applied topically for 2 weeks (twice weekly), followed by phorbol-12-myristate-13-acetate (TPA, 1.7 nmol/100 ul) twice weekly for 6 weeks on the depilated skin of mice and AAILE was administered orally at a dose level of 300 mg/kg body wt thrice a week for 10 weeks. DMBA/TPA treatment upregulated the phase I enzymes in skin and hepatic tissue, as revealed by the increased cytochrome P450 (CYP) and cytochrome b5 (cyt b5) levels and aryl hydrocarbon hydroxylase (AHH) activity when compared to the control group and differentially modulated the activities of phase II enzymes like glutathione-s-transferase (GST), DT-diaphorase (DTD) and uridine diphosphate glucuronosyltransferase (UDP-GT). AAILE treatment decreased the DMBA/TPA-induced increase in cutaneous CYP level and enhanced the DTD and UDP-GT activities when compared with DMBA/TPA group. In the hepatic tissue of AAILE + DMBA/TPA group, an increase in UDP-GT activity was observed when compared to DMBA/TPA group. DMBA/TPA treatment did not alter the skin lipid peroxidation (LPO) level when compared to control group, however, in the animals that received AAILE treatment along with DMBA/TPA, a significant increase in LPO was observed when compared to control group. This was associated with a decrease in cutaneous reduced glutathione (GSH) level of AAILE + DMBA/TPA group. Enhanced LPO level was observed in the hepatic tissue of DMBA/TPA and AAILE + DMBA/TPA groups when compared to control group. However, no alteration was observed in their hepatic GSH levels. The micronuclei score in hepatic tissue did not exhibit significant inter-group differences. The results of the present study suggest that apart from skin, liver may be affected during DMBA/TPA-induced skin tumorigenesis. AAILE treatment has the ability to modulate these changes potentially influencing the process of tumor formation. These findings seem to be important to carcinogenesis and its intervention with anti-cancer agents.

Persistence of goitre in the post-iodization phase: micronutrient deficiency or thyroid autoimmunity.

Background & objectives: Despite years of salt iodization, goitre continues to be a major public health problem worldwide. We examined the prevalence of goitre in the post-iodization phase and the relationship of goitre with micronutrient status and thyroid autoimmunity in school children of Chandigarh, north India. Methods: Two phase study; in the first phase, 2148 children of 6 to 16 yr were screened for goitre by two independent observers as per the WHO grading system. In the second phase, a case-control study, 191 children with goitre and 165 children without goitre were compared with respect to urinary iodine, iodine content of salt, serum levels of T3, T4, TSH, anti-TPO (thyroid peroxidase) antibody, haemoglobin, ferritin and selenium. Results: Prevalence of goitre in the studied subjects was 15.1 per cent (13.9% in 6 to 12 yr and 17.7% in 13 to 16 yr age group, P= 0.03). Median urinary iodine excretion in both the groups was sufficient and comparable (137 and 130 µg/l). 3.2 per cent children with goitre and 2.4 per cent without goitre had hypothyroidism (subclinical and clinical) and only one child with goitre had subclinical hyperthyroidism. Nine (4.9%) children in the goitre group and 3 (1.9%) in control group had anti-TPO antibody positivity. The median serum selenium levels were not different in both the groups (181.9 and 193.5 µg/l). Seventy one (37.4%) of the goitrous children had anaemia (haemoglobin <12 g/dl) as compared to 41 (24.8%) of the control group (P <0.01). More number of goitrous children (39, 20.6%) were depleted of tissue iron stores (serum ferritin <12 µg/l) as compared to controls (11, 6.4%; P<0.001). Serum ferritin level negatively correlated with the presence of goitre (r = - 0.22, P =0.008) and had an OR of 2.8 (CI 1.20 - 6.37, P =0.017). Interpretation & conclusions: There was a high prevalence of goitre in young children despite iodine repletion and low thyroid autoimmunity. The concurrent iron deficiency correlated with the presence of goiter. However, the cause and effect relationship between iron deficiency state and goitre requires further elucidation.

Low framingham risk score despite high prevalence of metabolic syndrome in asymptomatic north-Indian population.

Background : Conflicting data exists regarding relationship between the Framingham risk score (FRS) and presence of metabolic syndrome (MS). Strong influence of age on FRS may further modify this relationship as prevalence of MS at younger age increases in South-Asian countries including India. However, only limited information is available about the prevalence of MS and its relationship with FRS in such populations at present. Methods : Clinical examination and biochemical investigations were performed in 1905 asymptomatic office executives who underwent routine health check-up at a tertiary care centre in India during the year 2005. Diagnosis of MS and FRS were based on the modified National Cholesterol Education Program- Adult Treatment Panel III guidelines. Results : Mean age of the subjects was 45.2 ± 10.3 years and 71.8% were males. MS was present in 47.5% (905 of 1905) subjects. Overall, 76.8% patients with MS had 10-year cardiovascular (CV) risk <10%, 20.6% had 10-20% risk and only 2.7% had >20% risk according to FRS. In the lowest age-quartile, 95.9% patients had 10-year risk <10%, 4.1% patients had 10-20% risk and none had >20% risk. In contrast, in the highest age-quartile, less than half of the patients had 10-year risk <10% and nearly half had 10-20% risk of CV events. Conclusions : Although the prevalence of MS is markedly high in young asymptomatic Indians, majority have low 10-year risk of CV events as estimated by FRS. These findings necessitate continued emphasis on detection of MS in these populations as reliance on FRS alone may result in underestimation of CV risk in them. ©

Effect of vitamin E on alcohol-induced changes in oxidative stress and expression of transcription factors NFkappaB and AP-1 in mice brain cerebral hemispheres.

Redox sensitive transcription factors nuclear factor kappaB (NF-kappaB) and activator protein-1 are involved in the pathogenesis of alcohol-induced disorders. Because of its antioxidative properties, vitamin E may help prevent oxidative stress-induced disorders. The aim of the present study was to delineate the molecular mechanisms associated with alcohol-induced oxidative stress and to see whether vitamin E supplementation counters the alcohol-induced adverse effects. The results showed that vitamin E supplementation restored the redox status and thus prevented the alcohol-induced oxidative stress. Further measurements of the mRNA expressions of cjun, cfos, p65 (NFkappaB) indicated an increase in their expression during oxidative stress. Although Vit E inhibited NFkappaB activation, it stimulated AP1 expression. The results support the findings that alcohol induces oxidative stress in nervous tissue. The data further show that vitamin E can mitigate the toxic effects of alcohol and thus can be suitable as a potential therapeutic agent for alcohol-induced oxidative damage in brain.

Clinical Spectrum and Prognosis of Multiple Myeloma in Patients Younger than 30 Years : Is it Different from the Elderly

Multiple Myeloma (MM) is a disease of the elderly. The occurrence of MM in patients younger than thirty years is rare. Over the last ten years five patients with MM of less than thirty years of age were evaluated at our centre and which constituted 3.3% of all the MM cases. Three patients had initial extramedullary involvement. All patients responded to the initial planned therapy and were clinically disease free at the time of last follow-up. In the background of clinical and laboratory features, a brief review of literature was carried out and the prognosis of this subgroup has been discussed.

Prevalence of cardiovascular risk factors in Indian patients undergoing coronary artery bypass surgery.

BACKGROUND: Conventional cardiovascular risk factors (CVRFs) are known to influence short-term and long-term outcome following coronary artery bypass graft surgery (CABG). There has been recent increase in prevalence of CVRFs in general population in India. However no information is available regarding the prevalence of same in patients undergoing CABG. METHODS AND RESULTS: In this cross-sectional study, one thousand consecutive patients undergoing elective CABG were included and data on major CVRFs was obtained in them. Mean age of the patients was 59.73 +/- 9.5 years and 884/1000 (88.4%) patients were males. 505/994 (50.8%) patients had BMI > or = 25.0 kg/m2 and 747/994 (75.2%) had BMI > or = 23.0 kg/m2. Diabetes mellitus was present in 475/1000 (47.5%) patients (46.5% men and 55.2% women), hypertension in 709/1000 (70.9% overall; 70.8% men and 71.6% women) and dyslipidemia in 781/913 patients (85.6% overall; 84.5% men and 93.9% women). 213/913 (23.3%) patients had LDL > or = 100mg/dl, 662/913 (72.5%) patients had low HDL and 338/913 (37.0%) patients had elevated triglycerides. 199/1000 (19.9%) patients (18.7% men and 29.3% women) had family history of premature CAD and 545/1000 (54.5%) patients (53.4% men and 62.9% women) had at least one family member having CAD (irrespective of the age of onset). 94/1000 (9.4%) patients (10.4% men and 1.7% women) were current smokers and another 302/1000 (30.2% overall; 33.7% men and 3.4% women) had history of smoking in the preceding one year. 876/913 (95.9%) of all the patients had at least one of the five major CVRFs and only 37/ 913 (4.1%) patients (4.1% men and 4.3% women) were free of all these risk factors. Sixty-one of the 1000 patients (6.1%) were younger than 45.0 years of age. As compared to older patients, dyslipidemia, family history of premature CAD and smoking were commoner in patients less than 45 years of age. In contrast, diabetes and hypertension were more prevalent in the older individuals. CONCLUSIONS: The present study showed high prevalence of most of the conventional CVRFs, esp. diabetes, hypertension and dyslipidemia in Indian population undergoing CABG.

Coexistence of Takayasu's arteritis with ulcerative colitis.

The association of ulcerative colitis with Takayasu's arteritis is rarely reported. The occurrence of the two together is possibly related to a common pathophysiology involving alteration in immune mechanisms. Takayasu's arteritis is more prevalent in Japan and South East Asia whereas Ulcerative Colitis is more in Western countries. The coexistence of these two diseases is uncommon and hence this report.

Selenium, a versatile trace element: current research implications.

Selenium (Se), a trace element, has evolved from its toxic properties to an essential element. Se was known a potent antioxidant through glutathione peroxidase (selenium being part of this molecule). Later, many other selenium-binding proteins were discovered and their functions were tried to be known with unsuccessful results in many cases. Se is known to be involved in carcinogenesis, immune function, male reproduction, cardiovascular diseases etc. The specific mechanism of the involvement of the element is still not known. Recent research with application of modern research tools viz. bioinformatics, cDNA microarray and transgenesis have revealed the mechanism of selenium involvement in various processes. This review highlights mysterious and useful roles of selenium in biological processes.

Paterson Kelly syndrome in celiac disease.

The association of Paterson Brown Kelly Syndrome and celiac disease is not widely reported. Both the entities have iron deficiency anemia. This case report emphasizes the need of screening for celiac disease in patients with Paterson Kelly Syndrome.

Effect of cholesterol and 7-beta hydroxycholesterol on glutathione status and nitric oxide production in murine peritoneal macrophages.

Present study was conducted to observe the effect of cholesterol and oxidized cholesterol (7beta-hydroxycholesterol,7beta-OH) on the nitric oxide (NO) production and the redox ratio by lipopolysaccharide-stimulated macrophages. Dose-dependent decrease in NO levels was seen with both cholesterol and 7beta-OH at different incubation intervals (6,12,18,24 hr) and concentrations (2.5,5,7.5microg/ml). On comparison, a significant decrease in the NO was observed at 24 hr interval in 7beta-OH exposed cells with all respective concentrations of cholesterol. Incubation with 7beta-OH also resulted in significant increase in levels of oxidized glutathione (GSSG) and decrease in reduced glutathione (GSH), while cholesterol showed no effect on GSSG levels. Moreover, GSH levels were lowered only at highest concentration (7.5microg/ml), and at longer incubation intervals (18,24 hr) with cholesterol exposure. This altered the redox status in both cholesterol/7beta-OH treated macrophages. Increased redox ratio and decreased NO levels indicated increased oxidative stress and decreased vasodilation by 7beta-OH compared to cholesterol.

Perventricular device closure of muscular ventricular septal defects on the beating heart.

This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects under echocardiographic guidance without cardiopulmonary bypass in two patients.

Endothelium-dependent brachial artery flow mediated vasodilatation in patients with diabetes mellitus with and without coronary artery disease.

AIM OF THE STUDY: Endothelial function as assessed by brachial artery flow mediated vasodilatation (FMD) has been shown to be impaired in patients with coronary artery disease (CAD). Since diabetes mellitus (DM) has been considered to be CAD risk-equivalent, we sought to determine whether endothelial dysfunction is present in patients with DM independent of presence of CAD. METHODOLOGY: One hundred and ninety eight individuals were included in the study and divided into four groups: Group 1--patients with risk factors for CAD, but no DM or CAD; Group 2--patients with DM but no CAD; Group 3--patients with CAD but no DM and Group 4--patients with both DM and CAD. Brachial artery FMD assessment was performed once in all subjects and FMD was calculated as percentage increase in brachial artery diameter in response to increase in brachial artery flow. RESULTS : Mean FMD was significantly higher in Group 1 (7.03 +/- 2.87%) compared to the other three groups. Mean FMD in Group 2 (5.51 +/- 2.12%) was similar to that in Group 3 (4.56 +/- 2.70%; p value 0.195) but significantly higher than that in Group 4 (4.26 +/- 1.93%; p value 0.038). There was no statistically significant difference in mean FMD in Group 3 and Group 4 (p value 0.65). CONCLUSION : Endothelial function as assessed by FMD is significantly impaired in diabetics compared to non-diabetics in absence of CAD. In addition, similar degree of impairment in endothelial function is seen in diabetics without CAD and non-diabetic patients having CAD, implying CAD risk-equivalence of diabetes.

Modelling studies on neurodegenerative disease-causing triplet repeat sequences d(GGC/GCC)n and d(CAG/CTG)n.

Model building and molecular mechanics studies have been carried out to examine the potential structures for d(GGC/GCC)5 and d(CAG/CTG)5 that might relate to their biological function and association with triplet repeat expansion diseases. Model building studies suggested that hairpin and quadruplex structures could be formed with these repeat sequences. Molecular mechanics studies have demonstrated that the hairpin and hairpin dimer structures of triplet repeat sequences formed by looping out of the two strands are as favourable as the corresponding B-DNA type hetero duplex structures. Further, at high salt condition, Greek key type quadruplex structures are energetically comparable with hairpin dimer and B-DNA type duplex structures. All tetrads in the quadruplex structures are well stacked and provide favourable stacking energy values. Interestingly, in the energy minimized hairpin dimer and Greek key type quadruplex structures, all the bases even in the non-G tetrads are cyclically hydrogen bonded, even though the A, C and T-tetrads were not hydrogen bonded in the starting structures.