DHFL Meltdown: The Corporate Governance Lapses

India’s non-banking financial institutions (NBFIs), broadly constituting the less-regulated shadow banking sector, have been plagued with scams, triggering a domino effect in the Indian money market. Major corporate governance issues were highlighted in NBFIs with the unfurling of the ILF&S fraud; it virtually created a sub-prime crisis. In such a scenario, where the shadow banking sector was subject to change in regulations to ensure vigilance, corporate governance lapses had again led to the meltdown of Kapil Wadhawan led Dewan Housing Finance Limited (DHFL). Registering a net profit growth of 25% in the third quarter of financial year 2017, DHFL was one of India’s leading housing finance companies with a value of whopping ₹1.01 trillion as its asset under management (AUM). The company had nose-dived from its coveted position, suffering a loss of ₹22.23 million for the last quarter of the financial year 2018–2019. The company’s credit ratings of commercial papers and non-convertible debentures were downgraded; non-payment of interests led to enforcement of resolution plan, with the board of directors acceding to nationalized banks. The company’s reputation had crashed with its share prices, amidst allegations of lookout notice issued for its promoters for siphoning funds through shell companies. The case describes the oversights and negligence of DHFL in terms of corporate governance practices in the context of the NBFC (non-banking financial company) sector. The jury is out to evaluate whether Wadhawan had followed the rules of corporate governance in letter and spirit, or the tightening noose of regulations and market sentiments around the ‘shadow banking’ sector of India spelt doom for DHFL.

IndiGo: Cruising in Market but Crashing Within

M. Damodaran,1 chairman IndiGo, has a lot on his plate, and the servings are not over yet. What happened on 26 April 2019, was just a precursor to what was eventually to follow. Aditya Ghosh,2 the longstanding director of InterGlobe3 for 10 years, resigned from his position, making way for Greg Taylor4 as president and chief executive officer (CEO). Rahul Bhatia5 became the interim CEO. This, ironically, happened when the airline had bagged in traffic rights to as many as 15 countries, including France, UK and Germany. The most ill-timed dispute between the two co-founders of IndiGo, Rakesh Gangwal6 and Rahul Bhatia, which had been brewing for about a year, came out in the open on 16 July 2019, at the most inopportune moment. Rakesh Gangwal alleged violations of corporate governance rule at IndiGo7 and requested the Securities and Exchange Board of India8 (SEBI) to intervene. The feud between the founders of InterGlobe Aviation Ltd. opened a can of worms, although Gangwal was not inclined to sell or raise his stakes. Analysts wondered about the timing of the complaints to SEBI: Why now? Will IndiGo be able to come out of this predicament or follow Kingfisher and Jet Airways’ footsteps?11 Will it be yet another episode of shallow vested interests? Will this lead to the downfall of IndiGo,12 or will it survive the turbulence and keep flying like a phoenix?

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

PURPOSE

To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma.

METHODS

Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively.

RESULTS

A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O⁶-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression.

CONCLUSION

This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.

Communication Themes of Patient Engagement for Multi-speciality Hospitals: Nurses’ Perspective

Introduction:

Patient engagement is engaging patients in their own medical care to heal them faster and take their valuable inputs to improve the health of population. Nurses contribute significantly in treatment, interact and spend most of their time with inpatients. Therefore, exploring the perspectives of nurses on patient engagement-communication is of vital importance.

Objective:

This article focuses on exploring the communication themes of patient engagement from the perspective of nurses in a multi-speciality hospital in Delhi.

Methodology:

The exploratory qualitative case study was carried out with semi-structured interviews of 12 nurses, observation at receptions of ICUs and emergency department and analysis of documents from the hospital’s official website. Grounded theory—three-level coding—was performed to identify the themes of patient engagement-communication.

Results:

A total of nine themes have been identified: ‘attendant’s role’, ‘communicating with patients of different categories’, ‘doctor’s support to nurses’, ‘nurse action’, ‘nurse behaviour’, ‘nurse challenges’, ‘patient actions’, ‘patient emotions’ and ‘wider role of nurses’.

Conclusion:

Nurses play a critical role in engaging patients through communication. They should change their approach of communication with different types of patients, understand, respect and give due weightage to patient’s emotions and actions and, play a wider role of teacher and guardian than just being the nurse.

P14.50 Clinicopathological spectrum of intracranial germ cell tumors: an Indian tertiary cancer center experience

BACKGROUND

Incidence of intracranial germ cell tumors (ICGCT) in Western literature is low (0.3–0.6 %) as compared to East Asia (3–4 %), & their clinicopathological features are well documented. However, there are scant studies on ICGCT from India.

MATERIAL AND METHODS

Retrospective observational study of all ICGCT histologically diagnosed in our hospital from 2007–2018. Metastasis were excluded. Clinicopathological features were retrieved from hospital’s electronic medical records.

RESULTS

We diagnosed 82 primary ICGCT, forming approx. 0.54 % of all primary brain tumors, & 3.5% of pediatric brain tumors. Age range: 2 months-32 yrs (Median age 14 yrs). M:F ratio: 1.82:1 (53M,29F). Nearly 80% patients were pediatric (<18 yrs), & 8 very young (<3 yrs, 7M1F). Majority were suprasellar & pineal (31/82, 37% each), with one bifocal presentation. Other rarer sites: posterior fossa (4), midbrain (1), corpus callosum (1) & 11 non midline (4 thalamic, 4 frontal, 2 cerebellar, 1 CP angle). Predominant histology was germinoma (G) (51/82, 62%), while non germinomatous (NGGCT) were 31/82 (38%), of which 9 were mixed. Pure teratoma were 11 (9 immature (IT), 2 mature), & 5 pure yolk sac tumor (YST). Interestingly, all very young age group patients (<3 yrs), showed only NGGCT histology (5/8 IT, 3/8 pure YST). In contrast, G histology formed nearly 70% of all patients >3 yrs. Females were associated mainly with G (21/29, 72%). NGGCT were predominantly seen in males (M:F=2.9:1). Also, pure IT (9) were seen only in males. Posterior fossa tumors were all IT (4/4). Spinal tumors were NGGCT (1 mature teratoma, 1 YST). Majority of suprasellar tumors (25/31, 80.6%), other midline locations like corpus callosal, midbrain, & all thalamic tumors were G. However, pineal tumors showed equal distribution of G (15/31) & NGGCT (16/31). Spine screening was positive in 8 patients (6 G, 2 IT)- 7 on MRI and 1 only on CSF cytology. Serum tumor markers were raised in 13/54 cases- 6/34G(17.6%), vs 7/20 NGGCT (35%). CSF tumor markers were raised in 14/34-10/23 G (43.4%), vs 4/11 NGGCT (36.3%). Follow up was available for 37 patients (Duration 3 months-10 yrs, median 2 yrs). On f/u 6/15 (40%) NGGCT showed progression/death, while only 2/32 G relapsed (6.5%). Four deaths in G group were not directly attributable to the tumor.

CONCLUSION

Frequency of ICGCT in our hospital similar to western data rather than Asian, albeit with less striking male preponderance. ICGCT were tumors of 2nd decade & majority occurred in pineal/suprasellar areas. About 2/3rd were pure G on histology, and showed good prognosis. NGGCT were common in infants, males and in posterior fossa. IT were seen exclusively in males and pure YST mainly in males. Although majority of ICGCT are in midline, rarely non midline involvement also occurs, and it’s essential to exclude metastasis before considering primary ICGCT. Expectedly, NGGCT showed poorer prognosis, compared to pure germinomas.

Thermodynamic geometry, phase transitions, and the Widom line

A microscopic characterization, based on the thermodynamic curvature R, is proposed for first-order liquid-gas phase transitions. Near the critical point, where R is proportional to the correlation volume ξ(3), we propose that R takes the same value in the coexisting phases. This proposal allows a determination of the liquid-gas coexistence curve with no use of the problematic Maxwell equal area construction. Furthermore, |R| ~ ξ(3) allows a direct determination of the Widom line in the supercritical regime. We illustrate with input from the van der Waals model and the National Institute of Standards and Technology Chemistry WebBook.

The Role of Knowledge Management in Innovation

Research on innovation practices reinforces the notion that majority of innovation projects fail systematically due to being managed as raw technology projects. Open forms of innovation where internal and external ideas are leveraged across the organisation are gaining importance over the internal and centralised approach to R&D. India, during the last 15 years, has been spiralling ahead towards ultimate economic success based on its 'knowledge-based talent pool'. Innovation has become a top strategic focus for most Indian companies. Seeing the growing importance of innovation and knowledge management, a need was felt to understand how organisations manage their knowledge capital so as to promote innovation.

This paper aims to provide insights into how an organisation manages knowledge through culture, structure, technology and leadership, so as to promote acquisition and application of knowledge which leads to innovation. The study brings out the importance of tacit knowledge embedded in the firm's culture, structure and leadership as a complement to the explicit knowledge embedded in the firm's technology and documents.

Methylphenidate for gait impairment in Parkinson disease: a randomized clinical trial

BACKGROUND

There is a paucity of therapies for gait impairment in Parkinson disease (PD). Open-label studies have suggested improved gait after treatment with methylphenidate (MPD).

OBJECTIVE

To evaluate the efficacy of MPD for the treatment of gait impairment in PD.

METHODS

Twenty-seven subjects with PD and moderate gait impairment were screened for this 6-month placebo-controlled, double-blind study. Subjects were randomly assigned to MPD (maximum, up to 80 mg/day) or placebo for 12 weeks and crossed over after a 3-week washout. The primary outcome measure was change in a gait composite score (stride length + velocity) between groups at 4 and 12 weeks. Secondary outcome measures included changes in motor function, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS), Freezing of Gait Questionnaire (FOGQ), number of gait-diary freezing episodes, and measures of depression, sleepiness, and quality of life. Three-factor repeated-measures analysis of variance was used to measure changes between groups.

RESULTS

Twenty-three eligible subjects with PD were randomized and 17 completed the trial. There was no change in the gait composite score or treatment or time effect for any of the variables. Treatment effect was not modified by state or study visit. Although there was a trend for reduced frequency of freezing and shuffling per diary, the FOGQ and UPDRS scores worsened in the MPD group compared to placebo. There was a marginal improvement in some measures of depression.

CONCLUSIONS

MPD did not improve gait and tended to worsen measures of motor function, sleepiness, and quality of life.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence for the lack of benefit of MPD on PD-associated gait impairment.

CLINICAL TRIAL REGISTRATION

NCT00526630.

Effect ofAsparagus racemosus rhizome (Shatavari) on mammary gland and genital organs of pregnant rat

Asparagus racemosus (AR) Willd (family Liliaceae) is commonly known as Shatavari. The alcoholic extract of its rhizome was administered orally to adult pregnant female albino rats at a dose of 30 mg/100 g body weight, daily for 15 days (days 1-15 of gestation). The macroscopic findings revealed a prominence of the mammary glands, a dilated vaginal opening and a transversely situated uterine horn in the treated group of animals. The weight of the uterine horns of the treated group was found to be significantly higher (p < 0.001) but the length was shorter (p > 0.01). Microscopic examination of the treated group showed proliferation in the lumen of the duct of mammary gland. It was obliterated due to hypertrophy of ductal and glandular cells. Hyperplasia of the glandular and muscular tissue and hypertrophy of the glandular cells were observed in the genital organs. The parenchyma of the genital organs showed abundant glycogen granules with dilated blood vessels and thickening of the epithelial lining. The oviduct in the treated group showed hypertrophied muscular wall, whereas the ovary revealed no effect of the drug. The results suggest an oestrogenic effect of Shatavari on the female mammary gland and genital organs.

Neuropilin-2 is required in vivo for selective axon guidance responses to secreted semaphorins

Neuropilins are receptors for class 3 secreted semaphorins, most of which can function as potent repulsive axon guidance cues. We have generated mice with a targeted deletion in the neuropilin-2 (Npn-2) locus. Many Npn-2 mutant mice are viable into adulthood, allowing us to assess the role of Npn-2 in axon guidance events throughout neural development. Npn-2 is required for the organization and fasciculation of several cranial nerves and spinal nerves. In addition, several major fiber tracts in the brains of adult mutant mice are either severely disorganized or missing. Our results show that Npn-2 is a selective receptor for class 3 semaphorins in vivo and that Npn-1 and Npn-2 are required for development of an overlapping but distinct set of CNS and PNS projections.

Computer-integrated revision total hip replacement surgery: concept and preliminary results

This paper describes an ongoing project to develop a computer-integrated system to assist surgeons in revision total hip replacement (RTHR) surgery. In RTHR surgery, a failing orthopedic hip implant, typically cemented, is replaced with a new one by removing the old implant, removing the cement and fitting a new implant into an enlarged canal broached in the femur. RTHR surgery is a difficult procedure fraught with technical challenges and a high incidence of complications. The goals of the computer-based system are the significant reduction of cement removal labor and time, the elimination of cortical wall penetration and femur fracture, the improved positioning and fit of the new implant resulting from precise, high-quality canal milling and the reduction of bone sacrificed to fit the new implant. Our starting points are the ROBODOC system for primary hip replacement surgery and the manual RTHR surgical protocol. We first discuss the main difficulties of computer-integrated RTHR surgery and identify key issues and possible solutions. We then describe possible system architectures and protocols for preoperative planning and intraoperative execution. We present a summary of methods and preliminary results in CT image metal artifact removal, interactive cement cut-volume definition and cement machining, anatomy-based registration using fluoroscopic X-ray images and clinical trials using an extended RTHR version of ROBODOC. We conclude with a summary of lessons learned and a discussion of current and future work.