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.

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.

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.

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.

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.

Gastrointestinal stromal tumor of gastrohepatic omentum in a patient with von Recklinghausen's disease (neurofibromatosis type 1).

It is very rare to find large gastrointestinal stromal tumors arising from the gastrohepatic omentum in a patient with neurofibromatosis type 1. We here document a case of two large gastrointestinal stromal tumors arising from the gastrohepatic omentum in a patient with von Recklinghausen's disease. In the present case, two large tumors in the lesser sac were evident on preoperative computed tomography and magnetic resonance imaging and were surgically removed successfully. Biopsy was suggestive of gastrointestinal stromal tumors.

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.

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.

Listening to music decreases need for sedative medication during colonoscopy: a randomized, controlled trial.

BACKGROUND: Music played during endoscopic procedures may alleviate anxiety and improve patient acceptance of the procedure. A prospective randomized, controlled trial was undertaken to determine whether music decreases the requirement for midazolam during colonoscopy and makes the procedure more comfortable and acceptable. METHODS: Patients undergoing elective colonoscopy between October 2003 and February 2004 were randomized to either not listen to music (Group 1; n=40) or listen to music of their choice (Group 2; n=38) during the procedure. All patients received intravenous midazolam on demand in aliquots of 2 mg each. The dose of midazolam, duration of procedure, recovery time, pain and discomfort scores and willingness to undergo a repeat procedure using the same sedation protocol were compared. RESULTS: Patients in Group 2 received significantly less midazolam than those in Group 1 (p=0.007). The pain score was similar in the two groups, whereas discomfort score was lower in Group 2 (p=0.001). Patients in the two groups were equally likely to be willing for a repeat procedure. CONCLUSION: Listening to music during colonoscopy helps reduce the dose of sedative medications and decreases discomfort experienced during the procedure.

Prevalence of Hepatitis B and C in the normal population and high risk groups in north Kerala.

BACKGROUND: Our aim is to assess the prevalence of Hepatitis B and Hepatitis C infections among normal healthy persons and high risk groups in the northern part of Kerala state in South India as there is insufficient published literature related to this subject. METHODS: HBsAg and AntiHCV screening were done in normal persons and in high risk groups. Normal persons screened included voluntary blood donors, those attending mandatory medical check up for jobs in middle east Asia and pregnant women. High risk groups were health care workers, intravenous drug abusers, commercial sex workers and male homosexuals. RESULTS: HBsAg and anti HCV antibody test results in the various groups were as follows. Voluntary blood donors--HBsAg was positive in 0.71 % and anti HCV was positive in 0.33%; job seekers to middle east Asia had 0.89% and 0.12% prevalence of HBV and HCV respectively. Among the pregnant women, 0.21% were HBsAg positive. Among the high risk groups, none of the health care workers were HbsAg positive and 0.79% were antiHCV positive. Among the IV drug abusers 2.7% were HBsAg positive and 51.89% were positive for antiHCV. In commercial sex workers, 3.47 % were HBsAg positive and 2.6 % were antiHCV positive. In male homosexuals, 4.49% were HBsAg positive and 3.37% were antiHCV positive. CONCLUSIONS: The prevalence of Hepatitis B and C in the normal population of Calicut in the northern part of Kerela is 0.52% and 0.24%. Compared to other areas of India, the seroprevalence of Hepatitis B and C are low in the normal population of Calicut. Among the high-risk groups, IV drug users have a high prevalence of AntiHCV.

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.

Umbilical hemorrhage as first manifestation in a case of cirrhosis.

Portal hypertension is often associated with an extensive collateral circulation. The paraumbilical vein is a relatively common collateral pathway recognized in these patients but cutaneous bleeding from the umbilicus is rare; the same as first manifestation of cirrhosis is exceptional. We report a case of umbilical venous bleed causing hemodynamic compromise, which turned out to be a case of alcoholic cirrhosis with portal hypertension. The patient was managed with suture ligation of the vessels.

Prospective evaluation of abnormal liver function tests in pregnancy.

Abnormalities in liver function tests (LFT) during pregnancy are a commonly encountered problem often associated with serious consequences especially when it occurs in the third trimester. The spectrum of abnormal liver functions in pregnancy can be fairly wide and diagnostic work up often challenging. There is insufficient prospective data on the spectrum and outcome of liver disease in pregnant population from south India. This study was performed to assess the causes of deranged liver function in the pregnant population and also to prospectively determine the outcome of liver dysfunction in pregnancy. All abnormal LFT results observed in serum samples from pregnant patients attending the obstetric unit of our hospital from January 2003 to January 2005 were evaluated and prospectively followed throughout pregnancy. Laboratory investigations included coagulation profile, renal function tests, serology for viral markers (HBsAg, anti-HCV, IgM anti-HEV and IgM anti-HAV) and other relevant biochemical tests. In those with liver dysfunction in the third trimester the maternal and perinatal outcome was evaluated. A total of 125 patients were identified with abnormalities in LFT results during this period. The majority of causes were related to pregnancy specific conditions (57.6%). Most episodes of abnormal LFT occurred in the third trimester (59.2%). Hyperemesis gravidarum (55.8%) and viral hepatitis (47%) were the most common causes of abnormal LFT in the first and second trimesters respectively. HELLP (28.3%) and AFLP (14.8%) were the most common causes of abnormal LFT in the third trimester. There were no mAternal deaths due to liver dysfunction in the first or second trimester. Liver dysfunction in the third trimester (74 patients) was associated with serious consequences. DIC was the most common complication (20.2%). The overall and perinatal mortality was 20.2% and 24.6% respectively. AFLP and HELLP syndromes were associated with poor maternal and fetal outcome. We conclude that liver dysfunctions were directly related to pregnancy in the majority of patients especially in the third namely trimester. Incidence of the most serious conditions AFLP and HELLP syndromes is much greater than what has been reported and is often associated with a high maternal mortality and poor perinatal outcome.

Carbamazepine-induced eosinophilic enteritis.

We describe a 15-year-old boy who was on carbamazepine for the past 8 years for seizure disorder, who developed recurrent episodes of small bowel obstruction. Full-thickness small bowel biopsy obtained at laparotomy was consistent with eosinophilic enteritis. He improved clinically after tapering the drug.

Pelvic ultrasonography in pubertal girls.

OBJECTIVE: To derive norms for the size of uterus, uterine shape (fundal-cervical ratio) and ovarian volume in girls in various Tanners stages of puberty. METHODS: Pelvic ultrasound was performed in ninety-two healthy girls in the age group of 8-15 years. These included twenty girls each in Tanner stages 1-4 and twelve in stage 5. All the subjects enrolled in the study had a weight and height within 5th-95th percentile of NCHS standards and their bone ages corresponded to the chronological age. Uterine height, fundal-cervical ratio (FCR) and ovarian volume were measured in all the subjects. The data was stratified according to various pubertal stages as well as for different ages. Statistical analysis was carried out to derive the percentiles for the three parameters in different pubertal stages and to study the correlation between these parameters and age, weight and height of the subjects. RESULTS: A statistically significant increase in uterine height, FCR and ovarian volume was observed with progressive pubertal stages. Maximum increase in uterine height was observed during the transition from stage 2 to stage 3. All girls beyond the age of 10 years or beyond Tanner stage 2 had a FCR>1. The ovarian volume, after showing an initial increase, tended to plateau and there was no significant increase from stage 4-stage 5. A significant correlation was found between the three parameters and the subject's age, weight and height, the maximum correlation was with age (correlation coefficients being 0.748, 0.648, 0.568 for uterine height, FCR and ovarian volume respectively). Centiles for these parameters were obtained for different pubertal stages. CONCLUSION: This work has provided some guidelines for normative data for various pubertal stages as well as for ages between 8-15 years. These may be used as a reference in evaluation of patients with suspected disorders of puberty.