The information imperative: to study the impact of informational discontinuity on clinical decision making among doctors.

BACKGROUND: Informational discontinuity can have far reaching consequences like medical errors, increased re-hospitalization rates and adverse events among others. Thus the holy grail of seamless informational continuity in healthcare has been an enigma with some nations going the digital way. Digitization in healthcare in India is fast catching up. The current study explores the components of informational continuity, its impact on clinical decision-making and captures the general perception among the doctors towards a digital solution. METHODS: Cross-sectional study with snowball sampling. A survey questionnaire was developed and validated through a pilot study, then circulated through online platforms. Responses from doctors were obtained through an online Google form for a period of 3 months and analyzed using SPSS 20. The categorical variables were analyzed using Chi-square test. RESULTS: 1413 responses were obtained through a national level survey. Respondents were from a wide range of work experiences, locations, sectors, specialties and patient load. Components of patient records like clinical notes, investigation reports, previous diagnosis and treatment details were rated to be very important. 41% reported about half and 20% reported about 3/4th of their patients do not bring relevant records. Patients from rural areas, visiting state government hospitals and visiting general practitioners were less likely to bring relevant records during consultations. The fallouts of not having timely relevant patient information of the patients include more time per patient, repeat investigations, difficulty to arrive at definitive diagnosis, difficulty to take further treatment decisions and impaired overall clinical decision making which were said to be significant by respondents across the spectrum. The benefits of having timely relevant patient information were also reported consistently across the spectrum. An overwhelming proportion (83%), from across the spectrum, unequivocally expressed their willingness to use digital platforms for accessing patients' relevant medical records. CONCLUSION: Prevalence of informational discontinuity and its impact on clinical decision making is significant with definite benefits of having timely relevant medical history. There is strong willingness among the doctors to use digital solution(s) without any extra investment or effort on their part making customized solutions pertinent.

Hsp70 nucleotide exchange factor Fes1 is essential for ubiquitin-dependent degradation of misfolded cytosolic proteins.

Protein quality control systems protect cells against the accumulation of toxic misfolded proteins by promoting their selective degradation. Malfunctions of quality control systems are linked to aging and neurodegenerative disease. Folding of polypeptides is facilitated by the association of 70 kDa Heat shock protein (Hsp70) molecular chaperones. If folding cannot be achieved, Hsp70 interacts with ubiquitylation enzymes that promote the proteasomal degradation of the misfolded protein. However, the factors that direct Hsp70 substrates toward the degradation machinery have remained unknown. Here, we identify Fes1, an Hsp70 nucleotide exchange factor of hitherto unclear physiological function, as a cytosolic triaging factor that promotes proteasomal degradation of misfolded proteins. Fes1 selectively interacts with misfolded proteins bound by Hsp70 and triggers their release from the chaperone. In the absence of Fes1, misfolded proteins fail to undergo polyubiquitylation, aggregate, and induce a strong heat shock response. Our findings reveal that Hsp70 direct proteins toward either folding or degradation by using distinct nucleotide exchange factors.

A versatile bacterial expression vector designed for single-step cloning of multiple DNA fragments using homologous recombination.

Production of recombinant proteins is the starting point for biochemical and biophysical analyses and requires methodology to efficiently proceed from gene sequence to purified protein. While optimized strategies for the efficient cloning of single-gene fragments for bacterial expression is available, efficient multiple DNA fragment cloning still presents a challenge. To facilitate this step, we have developed an efficient cloning strategy based on yeast homologous recombination cloning (YHRC) into the new pET-based bacterial expression vector pSUMO-YHRC. The vector supports cloning for untagged expression as well as fusions to His6-SUMO or His6 tags. We demonstrate that YHRC from single PCR products of 6 independent genes into the vector results in virtually no background. Importantly, in a quantitative assay for functional expression we find that single-step YHRC of 7 DNA fragments can be performed with very high cloning efficiencies. The method and reagents described in this paper significantly simplifies the construction of expression plasmids from multiple DNA fragments, including complex gene fusions, chimeric genes and polycistronic constructs.

Bottlenecks and reflections from turnkey installation of MRI in a tertiary care Greenfield project: a case study.

BACKGROUND: Turnkey projects are often pegged to be the solution for coordination issues and are common in procurement and installation of high-end expensive equipment. Considering the scale, cost and complexity of high-end diagnostic services like MRI, challenges during installation and commissioning have been commonly seen ever since the early days. The current case study elaborates on the lessons learnt from on-ground issues pertaining to delays in MRI installation in a Greenfield project. METHODS: Root cause analysis with Ishikawa chart was done. RESULTS: On detailed root cause analysis of the 5 broad issues, 20 causes for project delay were identified. These fall into three broad themes that can potentially affect performance of leadership. CONCLUSION: There are three key lessons/takeaways from the current case study. First, establishing proactive feedback loops and communication between all stakeholders. Second, the leadership should have strong control on events and milestones of the project by leveraging project management techniques and technologies. Third, unity of command and unity of direction are of paramount importance to steer the project out of doldrums. These lessons can be useful for healthcare leaders in effective project management.

Povidone Iodine Sclerotherapy for the Treatment of Persistent Seromas after Breast Cancer Surgery.

Persistent seroma following breast cancer surgery causes morbidity and delays adjuvant treatment. Sclerotherapy helps in managing recalcitrant seromas. We evaluated efficacy of 10% povidone iodine sclerotherapy treatment for persistent seromas after breast cancer surgery. Persistent drainage of > 100 mL/day 15 days following surgery, and seromas that required aspiration > 100 mL/week 2 weeks after drain removal, was considered for 10% povidone sclerotherapy in a non-randomized observational study. Resolution (drain output < 20 mL/day), treatment days, recurrence, and complications were assessed as measures of efficacy. Descriptive measures of central tendency and dispersion were reported. The relationship of the seroma quantity with risk factors (age, body mass index, levels and number of axillary lymph nodes dissected, neoadjuvant chemotherapy) and efficacy was analysed. We examined the correlation using Pearson and Spearman' signed rank, Student's t, and Mann-Whitney U-tests, to compare the means. Of 14/312 (4.5%) patients with persistent seroma, 13 (92.8%) had complete resolution after sclerotherapy within 6.71 days (range: 6-8). AC (p = 0.04), neoadjuvant chemotherapy (NACT) (p = 0.005), and number of nodes harvested without NACT (p = 0.025) were significantly associated with the quantity of discharge, while age (p = 0.072), body mass index (p = 0.432), type of surgery (breast conservation surgery vs. modified radical mastectomy) (p = 0.28), and total number of axillary lymph nodes (p = 0.679) were not. When used in this unique innovative manner, 10% povidone iodine sclerotherapy was found to be very effective (93%), minimally invasive, and safe in our study, and therefore appears to be an ideal sclerosing agent. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01629-0.

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.

The Holy grail of healthcare analytics: what it takes to get there?

BACKGROUND: Indian healthcare is rapidly growing and needs efficiency more than ever, which can be achieved by leveraging healthcare analytics. National Digital Health Mission has set the stage for digital health and getting the right direction from the very beginning is important. The current study was, therefore, undertaken to find what it takes for an apex tertiary care teaching hospital to leverage healthcare analytics. AIM: To study the existing Hospital Information System (HIS) at AIIMS, New Delhi and assess the preparedness to leverage healthcare analytics. METHODOLOGY: A three-pronged approach was used. First, concurrent review and detailed mapping of all running applications was done based on nine parameters by a multidisciplinary team of experts. Second, capability of the current HIS to measure specific management related KPIs was evaluated. Third, user perspective was obtained from 750 participants from all cadres of healthcare workers, using a validated questionnaire based on Delone and McLean model. RESULTS: Interoperability issues between applications running within the same institute, impaired informational continuity with limited device interface and automation were found on concurrent review. HIS was capturing data to measure only 9 out of 33 management KPIs. User perspective on information quality was very poor which was found to be due to poor system quality of HIS, though some functions were reportedly well supported by the HIS. CONCLUSION: It is important for hospitals to first evaluate and strengthen their data generation systems/HIS. The three-pronged approach used in this study provides a template for other hospitals.

NMDAR mediated dynamic changes in m6A inversely correlates with neuronal translation.

Epitranscriptome modifications are crucial in translation regulation and essential for maintaining cellular homeostasis. N6 methyladenosine (m6A) is one of the most abundant and well-conserved epitranscriptome modifications, which is known to play a pivotal role in diverse aspects of neuronal functions. However, the role of m6A modifications with respect to activity-mediated translation regulation and synaptic plasticity has not been studied. Here, we investigated the role of m6A modification in response to NMDAR stimulation. We have consistently observed that 5 min NMDAR stimulation causes an increase in eEF2 phosphorylation. Correspondingly, NMDAR stimulation caused a significant increase in the m6A signal at 5 min time point, correlating with the global translation inhibition. The NMDAR induced increase in the m6A signal is accompanied by the redistribution of the m6A marked RNAs from translating to the non-translating pool of ribosomes. The increased m6A levels are well correlated with the reduced FTO levels observed on NMDAR stimulation. Additionally, we show that inhibition of FTO prevents NMDAR mediated changes in m6A levels. Overall, our results establish RNA-based molecular readout which corelates with the NMDAR-dependent translation regulation which helps in understanding changes in protein synthesis.

"Constrained Medical Oxygen Supply Chain in India During COVID-19: Red-tapism, the Elephant in the Room?"

BACKGROUND: Recent disruption of medical oxygen during the second wave of coronavirus disease 2019 (COVID-19) has caused nationwide panic. This study attempts to objectively analyze the medical oxygen supply chain in India along the principles of value stream mapping (VSM), identify bottlenecks, and recommend systemic improvements. METHODS: Process mapping of the medical oxygen supply chain in India was done. Different licenses and approvals, their conditions, compliances, renewals, among others were factored in. All relevant circulars (Government Notices), official orders, amendments, and gazette notifications pertaining to medical oxygen from April 2020 to April 2021 were studied and corroborated with information from Petroleum and Explosives Safety Organization (PESO) official website. RESULTS: Steps of medical oxygen supply chain right from oxygen manufacture to filling, storage, and transport up to the end users; have regulatory bottlenecks. Consequently, flow of materials is sluggish and very poor information flow has aggravated the inherent inefficiencies of the system. Government of India has been loosening regulatory norms at every stage to alleviate the crisis. CONCLUSIONS: Regulatory bottlenecks have indirectly fueled the informal sector over the years, which is not under Government's control with difficulty in controlling black-marketing and hoarding. Technology enabled, data-driven regulatory processes with minimum discretionary human interface can make the system more resilient.

It's the data, stupid: Inflection point for Artificial Intelligence in Indian healthcare.

Indian healthcare is fast growing and with significant chunk of it being in small, fragmented, informal sector; Artificial Intelligence (AI) is pegged as a magical tool for a better healthcare system. There is an inclination to merely mimic the US approach in the on-going policy making and legislative exercises, which can have serious fallouts for Indian healthcare. India needs a different approach to suite her unique requirements. In this regard, each of the five stages in AI development lifecycle has been analyzed in the light of current on-ground realities. These boil down to three fold challenges of how to increase adoption of digital health, prevent data silos and create maximum value from data. Availability of quality data for value addition without barriers and restrictions is the common denominator for leveraging the full potential of AI. This requires liberal policies enabling secondary use of data in developing countries with rapidly growing healthcare sector akin to India. This has to be carefully balanced with data privacy and security. Restrictive healthcare data policies and laws can slow down adoption of digitization, perpetuate status-quo, be biased towards the incumbent players, cause Industry stagnation and thus will do more harm than good. It is therefore the data policies that will make or break AI in Indian healthcare.

Impact of Low-dose Chest CT Screening on the Association Between Rurality and Lung Cancer Outcomes.

INTRODUCTION: Lung cancer mortality is higher among rural United States populations compared with nonrural ones. Little is known about screening low-dose chest computed tomography (LDCT) outcomes in rural settings. MATERIALS AND METHODS: This retrospective cohort study examined all patients (n=1805) who underwent screening LDCT in a prospective registry from March 1, 2015, through December 31, 2019, in a majority-rural health care system. We assessed the proportion of early-stage lung cancers (American Joint Committee on Cancer stage I-II) diagnosed among LDCT-screened patients, and analyzed overall survival after early-stage lung cancer diagnosis according to residency location. RESULTS: The screening cohort had a median age of 63 and median 40-pack-year smoking history; 62.4% had a rural residence, 51.2% were female, and 62.7% completed only 1 LDCT scan. Thirty-eight patients were diagnosed with lung cancer (2.1% of the cohort), of which 65.8% were early-stage. On multivariable analysis, rural (vs nonrural) residency was not associated with a lung cancer diagnosis (adjusted hazard ratio 1.59; 95% CI, 0.74-3.40; P =0.24). At a median follow-up of 37.1 months (range, 3.3 to 67.2 months), 88.2% of rural versus 87.5% of nonrural patients with screen-diagnosed early-stage lung cancer were alive ( P =0.93). CONCLUSIONS: In a majority-rural United States population undergoing LDCT, most screen-detected lung cancers were early-stage. There were no significant differences observed between rural and nonrural patients in lung cancer diagnosis rate or early-stage lung cancer survival. Increased implementation of LDCT might blunt the historical association between rural United States populations and worse lung cancer outcomes.

Effectiveness of an inactivated virus-based SARS-CoV-2 vaccine, BBV152, in India: a test-negative, case-control study.

BACKGROUND: BBV152 is a whole-virion inactivated SARS-CoV-2 vaccine that has been deployed in India. The results of the phase 3 trial have shown clinical efficacy of BBV152. We aimed to evaluate the effectiveness of BBV152 against symptomatic RT-PCR-confirmed SARS-CoV-2 infection. METHODS: We conducted a test-negative, case-control study among employees of the All India Institute of Medical Sciences (a tertiary care hospital in New Delhi, India), who had symptoms suggestive of COVID-19 and had an RT-PCR test for SARS-CoV-2 during the peak of the second wave of the COVID-19 pandemic in India between April 15 and May 15, 2021. Cases (test-positives) and controls (test-negatives) were matched (1:1) on the basis of age and gender. The odds of vaccination with BBV152 were compared between cases and controls and adjusted for level of occupational exposure (to COVID-19), previous SARS-CoV-2 infection, and calendar time, using conditional logistic regression. The primary outcome was effectiveness of two doses of BBV152 (with the second dose received at least 14 days before testing) in reducing the odds of symptomatic RT-PCR-confirmed SARS-CoV-2 infection, expressed as (1 - odds ratio) × 100%. FINDINGS: Between April 15 and May 15, 2021, 3732 individuals had an RT-PCR test. Of these, 2714 symptomatic employees had data on vaccination status, and 1068 matched case-control pairs were available for analysis. The adjusted effectiveness of BBV152 against symptomatic COVID-19 after two doses administered at least 14 days before testing was 50% (95% CI 33-62; p<0·0001). The adjusted effectiveness of two doses administered at least 28 days before testing was 46% (95% CI 22-62) and administered at least 42 days before testing was 57% (21-76). After excluding participants with previous SARS-CoV-2 infections, the adjusted effectiveness of two doses administered at least 14 days before testing was 47% (95% CI 29-61). INTERPRETATION: This study shows the effectiveness of two doses of BBV152 against symptomatic COVID-19 in the context of a huge surge in cases, presumably dominated by the potentially immune-evasive delta (B.1.617.2) variant of SARS-CoV-2. Our findings support the ongoing roll-out of this vaccine to help control the spread of SARS-CoV-2, while continuing the emphasis on adherence to non-pharmacological measures. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

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.

War on waste: Challenges and experiences in COVID-19 waste management.

COVID-19 has posed formidable challenges including overwhelming bio-medical waste. Guidelines have been rapidly changing along with mounting pressure of waste generation. These challenges were managed by smart re-engineering of structure and processes for desired outcomes. Dedicated staff in PPE with appropriate training were deployed to collect waste using dedicated trolleys. A dedicated route plan was drawn with a dedicated lift meant for COVID-19. A new temporary holding area was created. Dedicated trucks with requisite labels were deployed to transport COVID-19 waste to CBWTF. Communication challenge was addressed through timely circulars, which were further reinforced and reiterated during various on-going training programs.Before the onset of COVID-19 pandemic Bio-Medical Waste generated was 1.93kg/Bed/Day and currently the quantum of COVID-19 biomedical waste generated is 7.76Kg/COVID Bed/Day. Daily COVID-19 waste generation data is maintained and uploaded in an android Application. Till date none of the worker handling COVID-19 waste has acquired Healthcare associated COVID-19 infection which reflects on the soundness of the new system and the infection control practices in the Institute. A responsive leadership harmonizing with a robust communication and training system has augmented timely re-engineering of structure and processes for better outcomes in the war on waste.

More from less: Study on increasing throughput of COVID-19 screening and testing facility at an apex tertiary care hospital in New Delhi using discrete-event simulation software.

BACKGROUND: One of the challenges has been coping with an increasing need for COVID-19 testing. A COVID-19 screening and testing facility was created. There was a need for increasing throughput of the facility within the existing space and limited resources. Discrete event simulation was used to address this challenge. METHODOLOGY: A cross-sectional interventional study was done from September 2020 to October 2020. Detailed process mapping with all micro-processes was done. Patient arrival patterns and time taken at each step were measured by two independent observers at random intervals over two weeks. The existing system was simulated and a bottleneck was identified. Two possible alternatives to the problem were simulated and evaluated. RESULTS: Scenario 1 showed a maximum throughput of 316. The average milestone times of all the processes after the step of "Preparation of sampling kits" jumped 62%; from 82 to 133 min. Staff state times also showed that staff at this step was stretched and medical lab technicians were underutilized. Scenario 2 simulated the alternative with lesser time spent on sampling kit preparation with a 22.4% increase in throughput, but could have led to impaired quality check. Scenario 3 simulated with increased manpower at the stage of bottleneck with 26.5% increase in throughput and was implemented on-ground. CONCLUSION: Discrete event simulation helped to identify the bottleneck, simulate possible alternative solutions without disturbing the ongoing work, and finally choose the most suitable intervention to increase throughput, without the need for additional space allocation. It therefore helped to optimally utilize resources and get "more from less."

Tc-99m ethylcysteinate dimer SPECT in the differential diagnosis of dementias.

BACKGROUND: Dementias produce deficits in perfusion, in part, reflecting decreased metabolic needs. Single photon emission computed tomography (SPECT) studies have reported characteristic anterior-to-posterior perfusion gradients that permit distinction between the various forms of dementia. AIM: We undertook this study to evaluate the role of visual analysis of SPECT perfusion patterns for the differential diagnosis of types of degenerative dementia. MATERIALS AND METHODS: Tc-99m ethylcysteinate dimer (ECD) was used with a dual-head scanner to generate perfusion images of the brain in 136 patients referred from the dementia clinic. Diagnosis was made by the nuclear physician unaware of clinical diagnosis. RESULTS: Sensitivity, specificity, positive predictive value and negative predictive value of perfusion studies for Alzheimer's dementia were 93.42%, 95.12%, 97.26%, and 88.63%, respectively, and for frontotemporal dementia were 96.29%, 98%, 96.29%, and 98.88%, respectively. CONCLUSIONS: Tc-99m ECD brain perfusion SPECT is useful in the differential diagnosis of dementia with particular reference to AD as well as FTD.

Nicolau Syndrome, Masquerader of Postinjection Sciatic Nerve Injury: Case Report and Review of Literature.

BACKGROUND: Sciatic nerve injury after inadvertent intramuscular gluteal injection is a well-described entity. We have presented a case of a rare and probably underdiagnosed pathological entity, Nicolau syndrome, which can be confused with injection palsy. CASE DESCRIPTION: We report the case of a 13-year-old boy who had presented with foot drop and urinary and fecal incontinence after an intramuscular injection of benzathine penicillin in the left gluteal region. On examination, the patient had multiple ecchymoses over the left gluteal region and back of the thigh, mild swelling of the left lower limb, and left foot drop. Meticulous examination also revealed a subtle weakness of the opposite limb. Nerve conduction studies revealed axonopathy involving multiple bilateral lower limb nerves. These unusual neurological-dermatological signs and electrophysiological findings raised the concern for an alternative pathology, which was later diagnosed as Nicolau syndrome. The patient experienced clinical and electrophysiological recovery after a course of oral steroids and physiotherapy during the next few months. CONCLUSIONS: Before diagnosing injection sciatic nerve injury, the possibility of medically treatable Nicolau syndrome should be considered. Neurosurgeons' familiarity with this pathology and a timely diagnosis is essential to plan appropriate treatment strategies.