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.

Dilated Cardiomyopathy and Nail-Patella Syndrome: A Case Report.

Nail-patella syndrome (NPS) is a rare genetic disorder with multiple skeletal deformities and a variety of extra-skeletal involvements. We present a 17-year-old male with a clinical tetrad of skeletal abnormalities, multiple bony deformities, advanced renal failure, hypothyroidism, and dilated cardiomyopathy. A clinical diagnosis of NPS was made, supported by radiographic findings, and corroborated by compatible renal biopsy results. There are very few published reports describing the association of dilated cardiomyopathy with this syndrome. A high index of suspicion is needed to make this diagnosis, given myriads of multi-systemic manifestations.

COVID-19 and Sepsis in an Atypical Case of Mixed Connective Tissue Disorder Presenting With a Myasthenic Crisis.

Myasthenia gravis (MG) is an autoimmune illness that causes neuromuscular junctions to be damaged by anti-acetylcholine receptor antibodies. It is a very rare condition that is more common among women. Fatigable fluctuating diplopia or ptosis is the characteristic early appearance of this condition. Dysphagia or dysphonia may be present in rare cases. This illness can affect any group of skeletal muscles, including those in the neck and upper limbs. It can also affect the muscles that help you breathe, which can lead to breathing failure. We present a case of a 20-year-old female diagnosed with mixed connective tissue disease presenting with acute respiratory failure as the initial presentation of MG. Clinicians have to have a high index of suspicion for myasthenia when patients arrive with fatigable muscle weakness. This will cut down on the amount of money spent on investigations and the risk of morbidity.

Endoscopic closure of fecal colo-cutaneous fistula by using metal clips.

Fecal colo-cutaneous fistula often requires surgical intervention for successful closure increasing the morbidity and mortality associated with this condition. Endoscopic fistula closure can be a less invasive modality. We report successful closure of fecal colo-cutaneous fistula by endoscopic application of metal hemo-clips after failure of prolonged treatment including diverting proximal ileostomy in 2 consecutive patients after emergency primary repair of cecal perforation caused by stab injury of abdomen and iatrogenic fecal fistula after left hemicolectomy and colo-colic anastomosis for adenocarcinoma of descending colon, respectively. The endoscopic closure of fecal colo-cutaneous fistula by using metal clips is an effective, safe, and less invasive treatment modality. It can add to therapeutic armamentarium of surgeons and may obviate the need for additional surgical intervention and associated morbidity in a proportion of such patients.

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.

Pitfalls of radiofrequency assisted liver resection.

BACKGROUND/AIMS: Radiofrequency has been used recently for bloodless liver resection. We studied the safety and feasibility of using RF energy for liver parenchymal transection in 8 patients. METHODOLOGY: We performed eight (n=8) open RF assisted liver resection for various malignancies. There were 5 men and 3 women, with mean age of 56.5 years (range 20-80 years). RESULTS: All patients had successful liver resection. The mean operating time for liver resection was 45 minutes (range 25-60 min). The average blood loss for wedge resections and segmentectomies was 30 mL (range 10-100 mL). None of the patients required postoperative transfusion. Three out of eight patients developed minor complications in the form of intra-abdominal abscesses which were managed by USG guided drainage of abscess in two patients and one patient had open surgical drainage of the subhepatic abscess. CONCLUSIONS: RF assisted liver resection is safe and effective with minimal blood loss for minor liver resections. Though the procedure is slightly more time consuming presently, with further improvement in technology and needles, the operative time may be reduced for this technique. RF assisted liver resection should be avoided in the presence of overt local sepsis.

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.

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.

Primary transitional cell carcinoma of spleen.

Transitional cell carcinoma arises from the lining of the urogenital tract and ovary. We report a 39-year-old lady with transitional cell carcinoma of the spleen that presented as a complex cystic lesion. Exhaustive search for another primary was negative. She is doing well 18 months after splenectomy was performed.

Prospective evaluation of oral gastrografin in postoperative small bowel obstruction.

BACKGROUND: Orally administered gastrografin has been used for early resolution of postoperative small bowel obstruction (POSBO) and to reduce the need for surgery in various studies. However the studies have reported conflicting results as patients with complete obstruction and equivocal diagnosis of bowel strangulation were also included. PATIENTS AND METHODS: We carried out a prospective study to evaluate the efficacy of gastrografin in patients with partial adhesive small bowel obstruction. Patients with suspected strangulation, complete obstruction, obstructed hernia, bowel malignancy, and radiation enteritis were excluded. Sixty-two patients with partial adhesive small bowel obstruction were given an initial trial of conservative management of 48 h. Thirty-eight patients improved within 48 h and the other 24 were given 100 ml of undiluted gastrografin through the nasogastric tube. In 22 patients the contrast reached the colon within 24 h. In the remaining two patients the contrast failed to reach the colon and these underwent surgery. RESULTS: The use of gastrografin avoided surgical intervention in 91.3% (22 of 24) patients who failed conservative management of POSBO. Gastrografin also decreased the overall requirement for surgical management of POSBO from the reported rate of 25 to 30% to 3.2% (2 of 62). CONCLUSION: Use of gastrografin in patients with partial POSBO helps in resolution of symptoms and avoids the need for surgical management in the majority of patients.

Radiofrequency ablation of unresectable pancreatic carcinoma: feasibility, efficacy and safety.

CONTEXT: Unresectable pancreatic cancer has a dismal prognosis. Palliative surgery and chemo-radiotherapy have not produced significant improvement in survival. We evaluated the safety and the efficacy of radiofrequency ablation for cytoreduction of unresectable tumors of the pancreas. CASE REPORT: Radiofrequency ablation was performed in three patients with histologically proven unresectable cancer of the pancreas: two females and one male; 48, 60, and 66 years of age (mean 58 years). The sizes of the pancreatic tumors were 5.0, 6.5, and 8.0 cm (mean 6.5 cm), respectively. Two patients underwent radiofrequency ablation during an open operation while one patient had percutaneous CT guided radiofrequency ablation. All had endobiliary stenting for obstructive jaundice. Partial necrosis (up to 3 cm) of the tumor was achieved in all cases. There was no major morbidity or mortality. Self-limiting minor complications occurred in two patients. CONCLUSION: Radiofrequency ablation is a local ablative method used with increasing frequency and may be used safely for cytoreduction in locally advanced inoperable pancreatic malignancies. Further studies are required to ascertain whether this can improve survival/quality of life alone or in combination with other therapies.

IgG4 negative sclerosing cholangitis associated with autoimmune pancreatitis.

BACKGROUND: Sclerosing pancreatitis is an autoimmune condition characterized by periductal lymphocytic infiltration on histology, and elevated serum auto-antibodies and IgG4. Bile duct involvement is often associated with sclerosing pancreatitis but it is rarely the dominant feature. CASE REPORT: We report a patient with dominant biliary stricture and obstructive jaundice associated with IgG4 negative autoimmune pancreatitis. Due to uncertainties regarding the preoperative diagnosis, the patient underwent bilio-enteric bypass with an intraoperative pancreatic and bile duct biopsy. Post operatively, due to disease recurrence, the patient was started on steroids with consequent remission of the disease. CONCLUSION: Sclerosing pancreatitis may sometimes present with biliary stricture due to bile duct involvement due to the inflammatory process. The condition is often recognized after surgical exploration for a suspected malignancy. Preoperative diagnosis permits treatment with steroids and endoscopic biliary decompression, and avoids unnecessary surgery.

Squamous cell carcinoma of the distal common bile duct.

CONTEXT: Squamous cell carcinoma of the biliary tree is rare. Although few cases of squamous cell carcinoma of the intrahepatic bile-duct and gallbladder have been reported, until today, only four cases of squamous cell carcinoma of the extrahepatic bile duct have been reported in the literature. CASE REPORT: We present a case of squamous cell carcinoma of the distal common bile duct presenting with obstructive jaundice in a 60-year-old male which was successfully managed by a Whipple's pancreaticoduodenectomy. CONCLUSION: Squamous cell carcinoma of the distal bile duct without lymph node metastasis can be managed by pancreaticoduodenectomy alone.

Radiofrequency tissue ablation: an early Indian experience.

INTRODUCTION: Radiofrequency (RF) tissue ablation has been tried safely and effectively in the West as percutaneous local tissue ablation therapy. We present our experience with this technique in malignant lesions. METHODS: RF tumor ablation was done using an RF generator (Berchtold; Germany) generating 35-50 RF watts of power output. The RF needle was placed in the tumor under image guidance (n = 22) or at open surgery (n = 1). Around 1500 watts/cm3 RF energy was delivered to the tumor. Over 21 months, 23 patients underwent the procedure for 73 lesions, including metastatic liver lesions (n = 21) and locally advanced inoperable carcinoma of pancreas (n = 2). RESULTS: All lesions less than 3 cm in size (n = 15) and 39% of lesions 3-4 cm in size (17/44) had complete necrosis. Residual tumor was seen in 27/44 lesions (61%) 3-4 cm in size and in all 14 lesions more than 4 cm in size. There was no mortality or major morbidity. There were two minor complications (ascites 1, pleural effusion 1). Of 21 patients treated for liver metastases, 10 are still alive (6-month survival 19/21 [90%] and 12-month survival 11/17 [64.7%]). Only 2 of 32 (6.2%) lesions with complete necrosis had local recurrence. CONCLUSION: RF tumor ablation is a safe and effective local tissue ablative method in Indian patients.