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   Table of Contents - Current issue
Coverpage
May 2019
Volume 8 | Issue 5
Page Nos. 1519-1815

Online since Friday, May 31, 2019

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EDITORIAL  

A primary care–based patient centric palliative care model Highly accessed article p. 1519
Sunil Kumar Raina, Raman Kumar, Rajiv Kumar Gupta
DOI:10.4103/jfmpc.jfmpc_391_19  
The World Health Organization defined palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. The patient centric primary care model (PCCM) promises to provide a solution to control these health-care challenges. The model is largely based on the chronic care model (CCM) and the model developed by the Organized Medicine Academic Guild (OMAG) for delivering health care in India.
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COMMENTARIES Top

Medical problem in Asia pacific and ways to solve it: The roles of primary care/family physician (Indonesia Xperience) Highly accessed article p. 1523
Retno Asti Werdhani
DOI:10.4103/jfmpc.jfmpc_154_19  
WHO reported that Environment contributed significantly as the causal of the disease in Asia Pacific. Indonesia is facing major health challenges, namely triple burden health problems, due to communicable diseases, non-communicable diseases and re-emerging disease. Primary care in Indonesia is conducted by Public Health Centers/Puskesmas and Primary Care Clinic covering around 86% of total health care facilities in Indonesia. Primary Care Physician plays important role as a gatekeeper and care coordinator. Primary care in Indonesia responsible for primary prevention and screening, should also be prepared to deal with various reasons for encounters of patient/community health problems, and conduct comprehensive management including referral management. It is therefore necessary to have teamwork with various health workers and patients/families at all levels of prevention.
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Need for a universal thalassemia screening programme in India? A public health perspective Highly accessed article p. 1528
Arulmani Thiyagarajan, Sudip Bhattacharya, Neha Sharma, Abhay Srivastava, Dipak Kumar Dhar
DOI:10.4103/jfmpc.jfmpc_90_19  
Thalassemia is one of the significant public health concerns as the carrier rate and disease numbers are increasing worldwide. The increase in number is because of consanguineous marriage which has a deep-rooted norm among many people globally. Besides various clinical and psychological problems associated with thalassemia, a lifelong treatment aspect makes it much more difficult for a person or family to sustain with thalassemia or thalassemia-affected children. Though the government has come up with a screening programme for thalassemia, given the fact that it is optional, people tend to ignore it. Examples from Pakistan and Iran remind us to have a mandatory prenatal screening programme which is very much cost-effective. With a highly recommended notion, we suggest that it should be universal to have an antenatal screening programme to avert thalassemia-related deaths.
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REVIEW ARTICLES Top

Cytochemical tests to investigate sperm DNA damage: Assessment and review Highly accessed article p. 1533
Soheila Pourmasumi, Alireza Nazari, Niloofar Fagheirelahee, Parvin Sabeti
DOI:10.4103/jfmpc.jfmpc_35_19  
Male factor infertility has been diagnosed as the cause of infertility in about 20% of infertile couples. Sperm analysis is the most common method for diagnosing infertility in a laboratory. However, approximately 15% of infertile men have a normal sperm analysis. Therefore, the result of a routine sperm analysis often cannot be a definitive diagnosis for male factor infertility. Also, approximately 8% of infertile men with normal sperm parameters have high levels of abnormal sperm DNA. This indicates the role of the integrity of sperm DNA in male infertility. Here, we review the current tests available to evaluate the sperm DNA integrity along with their benefits and limitations.
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Cosmetovigilance: A review of the current literature Highly accessed article p. 1540
Hale Z Toklu, Abigail Antigua, Vanessa Lewis, Mar'Tina Reynolds, Jennifer Jones
DOI:10.4103/jfmpc.jfmpc_447_18  
The term “pharmacovigilance” defines the activities related to the collection, detection, assessment, monitoring, and prevention of adverse reactions occurring with medications. Recently, the spectrum of “-vigilance” has broadened to include safety of herbal products and cosmetic products as well. “Cosmetovigilance” was introduced as a new term used for defining surveillance carried out by industry to address the safety of cosmetic products. It was first used in literature by Vigan (1997) to refer to the monitoring of cosmetic product safety. Today, it is recognized globally as a concept of public health. For this systematic review, a PubMed search was conducted in July 2018 for the term “cosmetovigilance.”
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Get lean and go green: Role for “Eat-ology” behavior modification p. 1546
Samra Abouchacra, Satish Chandrasekhar Nair, Oudi Abouchacra, Omar Yaman
DOI:10.4103/jfmpc.jfmpc_177_19  
Obesity rates are rising exponentially reaching global epidemic proportions and are associated with substantially increased morbidity and mortality. Less appreciated are the serious risks this poses on our environment from increased greenhouse gas emissions related to obesogenic behavior. In spite of a plethora of diets, the results are short term and nonsustainable, thereby leaving individuals battling with more weight than they lost. This is likely attributable to inherent flaws in the nature of weight loss diets or perhaps the approach of implementing them. These grim realities will be exposed to lead the way to uncover a novel “behavior modification for weight loss” strategy called Eat-ology. It exposes eating errors and imparts techniques to transform them into eating essentials, thereby enabling weight loss and its long-term maintenance. It is through such approaches that we can hope to win the fight against obesity and achieve not only a leaner global society but also a greener environment.
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ORIGINAL ARTICLES Top

Nursing efficiency in patient care: A comparative study in perception of staff nurse and hospital management in a trust hospital p. 1550
Homa Mosaffay Khomami, Nasreen Rustomfram
DOI:10.4103/jfmpc.jfmpc_37_19  
Background and Objective: While efficient use of resources and cost control is the responsibility of hospital managers, it is the duty of the nurses to carry out patient care and provide high-quality services. The aim of present research was to study the perception of staff nurses and nurse managers about nursing efficiency in patient care in a trust hospital. Materials and Methods: This quantitative and explanatory research has been done on staff nurses as well as nurse managers in a 550-bedded trust hospital in rural Gujarat of India. Data collection tool was a researcher made questionnaire and the data collection method was interview schedules for staff nurse and nurse managers. The total number of staff nurse in this hospital was 450 including 50 nurse managers. Results: Staff nurses had shown dissatisfaction regarding managers' practice and stated some aspects of managers practice which needed to improve such as keeping competitive salary for staff nurse, providing counseling system to supporting nursing practice, better recognition and acknowledgement system, better job security, providing supportive managerial style, better unit size and Applying vacation system. Conclusions: There was a difference between staff nurses' perception and nurse managers' perception regarding professional characteristics for nursing profession and factors, which affect nursing efficiency in patient care (with 95% confidence interval and P < 0.05).
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Evaluation of hypercalciuria in patients receiving intravenous Cefotaxime p. 1558
Zahra Kalantari, Parsa Yousefichaijan, Manijeh Kahbazi, Ali Arjmand Shabestari
DOI:10.4103/jfmpc.jfmpc_33_19  
Introduction: Cefotaxime is one of the third generation cephalosporins, which is used against many infections. This drug has a urinary excretion and potentially may have nephrotoxic effects. Hypercalciuria can cause important complications, including the formation of kidney stones. In the recent study, we decided to evaluate hypercalciuria in children receiving cefotaxime. Materials and Methods: This case-control study was conducted in Amirkabir hospital (Arak, Iran), where 30 children received intravenous cefotaxime were placed in the case group and 30 children without intravenous administration of cefotaxime were included in the control group. The ratio of calcium to creatinine was measured in both groups. Data were analyzed by SPSS software version 23. Results: This study showed that the ratios of male and female children in both the groups were 19 (63.3%) and 11 (36.7%) respectively, the mean age of children in the case group was 2.36 years with a standard deviation of 0.71 and the mean age of the children in the control group was 5.18 years with a standard deviation of 3.31. The ratios of urine calcium to creatinine in the case and control groups were 0.90 with a standard deviation of 1.79 and 0.37 with a standard deviation of 0.44 (P value = 0.003). Conclusion: According to the above results, it is concluded that receiving intravenous cefotaxime may increase calcium to creatinine ratio in children.
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Prevalence of smoking among dental students and gauging their knowledge about tobacco cessation methods: An original study p. 1562
Jubin Thomas, R B Vinod Kumar, S Akhil, Ajish M Saji, Amal K Iype, Diana Antony
DOI:10.4103/jfmpc.jfmpc_167_19  
Aims: The aims of this study are to determine the prevalence and type of tobacco use among dental students and to identify the factors that influence them to initiate tobacco use. Subjects and Methods: Dental students at two dental colleges affiliated to State Health University of Kerala answered a 20-item questionnaire during Jan–Feb 2015 that investigated their smoking habits and knowledge about the risk factors of smoking habits. The questions were based on the modified Global Health Professional Students Survey (GHPSS) by WHO. Some additional questions were also added from Global Youth Tobacco Survey (GYTS) by WHO to meet the objective of this study. Result: Current smoking was reported by 17% of the participants. None of the participants smoked more than half a packet of cigarette. More students from families with at least one tobacco user were using tobacco than those from families with no members using tobacco (51.2 versus 37.0%, respectively). The majority of dental students (92%) considered education on tobacco use cessation to be the responsibility of dentists/doctors. Conclusion: One of the main aims of this study was to shed light on the knowledge and attitudes of dental students on tobacco use cessation. Fairly high number of participants reported receiving inadequate information on tobacco cessation during their studies. Dental students should be taught and encouraged early on to routinely discuss with smokers the impacts of smoking on health.
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Toll like receptors (TLRs) in response to human gut microbiota of Indian obese and lean individuals p. 1567
Tej Bahadur, Rama Chaudhry, Vishwa Deepak Bamola, Sonu K Agrawal, Pawan Malhotra, Alka M Chutani, Bijay R Mirdha, Bimal K Das, Rahul K Sharma, Chandan K Thakur
DOI:10.4103/jfmpc.jfmpc_136_19  
Background: The rising incidence of obesity is one of the most serious public health issues in the developed as well as in developing countries like India. Obesity and overweight are most important risk factors for many chronic diseases, including cardiovascular diseases, diabetes and cancer. In this study the body mass index (BMI) cut off was taken as 18.5-22.9 kg/m2 for normal, 23.0-24.9 kg/m2 for Overweight and >25 kg/m2 for obese as per WHO recommendation for Asian Indians, which is different for developed and developing countries. Role of gut microbiota mediated immune response in the development of obesity has been studied but the literature on Indian population are lacking. Therefore, a study was conducted to determine Toll like receptors (TLRs) in response to human gut microbiota of Indian obese and lean individuals using viable colonocytes in a Non invasive technique and Flowcytometry. Methods: A total of 20 healthy volunteer (10 obese and 10 lean) were enrolled in the study as per inclusion and exclusion criteria. Viable colonocytes were isolated from fecal samples using a Non invasive technique (SCSR Method). Toll like receptors (TLRs) and immunoglobulin (IgA &IgG) receptor concentration were measured by standard Flowcytometry methods using specific fluorochrome conjugated antibodies. Results: Average TLR2 receptor concentration was significantly higher in obese (6.35 %) as compared to lean (2.9 %) (P = 0.01). TLR4 receptor concentration was 1.4 % in obese and 1.65 % in lean although the difference was not statistically significant (P = 0.59). IgA & IgG receptor concentration was 49.6 % & 11.2 % in the obese and 67.15 % & 8.05 % in the lean respectively but the differences among both the group were not statistically significant. Conclusion: The results of the present study will be helpful for physicians and researchers to find some biomarkers which can determine predisposition of the obesity in Indian population and helps to use alternative therapeutics such as probiotics to maintain gut homeostasis and immune modulation to prevent obesity.
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Variation in body mass index in patients with chronic obstructive pulmonary disease p. 1571
Mukesh S Paudel, Amrendra Mandal, Paritosh Kafle, Jasdeep S Sidhu, Pradeep Puri, Baikuntha Chaulagai, Azad Mojahedi, Vijay Gayam
DOI:10.4103/jfmpc.jfmpc_158_19  
Introduction: Chronic obstructive pulmonary disease (COPD) is associated with systemic inflammation. Weight loss seen in patients with COPD is a consequence of this inflammation. We hypothesized that higher grades of COPD are associated with greater degree of weight loss. Materials and Methods: In this cross-sectional study, we assessed the body mass index (BMI) of 34 patients with COPD proven by handheld spirometer. The difference in BMI among various grades of COPD was compared. Results: BMI was found to be inversely related to the grades of COPD in our study (P = 0.001). No significant difference was seen among the patients with regards to age and duration of symptoms before presentation. Conclusion: Advanced COPD is associated with greater degree of weight loss.
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Are pregnant women also vulnerable to domestic violence? A community based enquiry for prevalence and predictors of domestic violence among pregnant women p. 1575
Adity Priya, Sanjay Chaturvedi, Sanjiv K Bhasin, Manjeet S Bhatia, Gita Radhakrishnan
DOI:10.4103/jfmpc.jfmpc_115_19  
Aim: To generate local evidence to fill up the knowledge gap about the domestic violence faced by the antenatal females. Objectives: To screen for domestic violence in antenatal females. To explore association, if any, with socio-demographic and pregnancy related attributes among antenatal females of an urbanized village of Delhi. Materials and Methods: Socio demographic details and pregnancy related attributes and HITS (Hurt, Insult, Threaten, Scream) questionnaire for screening domestic violence was used on 165 pregnant females in a community based setting. Results: 23% of pregnant women were screened positive for domestic violence. Physical hurt was present among 60% of victims of domestic violence. The predictors for domestic violence among pregnant women as derived from logistic regression were – educational status of head of the family/husband, substance abuse by husband and history of previous abortions. Conclusion and Recommendations: More emphasis should be given on well being of the pregnant women who are victims of domestic violence. The policy makers and program managers should integrate social welfare schemes with the RCH program and all levels of health care functionaries should be sensitized about dealing with victims of domestic violence. Laws should be implemented effectively against perpetrators of domestic violence and more importantly females should be made aware of such laws and should be motivated to report it to the legal authorities and not to take up violence for granted.
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Evaluation of obstructive sleep apnea in metabolic syndrome p. 1580
Divya Soin, Praveen Ashok Kumar, Jasmeen Chahal, Sumit Pal Singh Chawla, Sarabjot Kaur, Ravinder Garg, Rupinderjeet Kaur
DOI:10.4103/jfmpc.jfmpc_175_19  
Background: Metabolic syndrome has become one of the most important public health problems with a growing prevalence in both developed and developing countries. Obesity is a major risk factor for obstructive sleep apnea (OSA), which is associated with significant cardiorespiratory morbidity. Aims: The aims of this study were to find out the prevalence of OSA in patients with metabolic syndrome and to highlight the importance of assessment of OSA in these patients. Methods: This cross-sectional analytical study was conducted on 100 subjects aged 30–60 years, comprising 50 cases of metabolic syndrome and 50 controls without metabolic syndrome. Overnight polysomnography was done in all the subjects. Prevalence and severity of OSA were assessed and compared between the two groups. Results: Prevalence of OSA was significantly higher (66%) in patients with metabolic syndrome than in subjects without metabolic syndrome (12%). Out of 33 (66%) OSA patients with metabolic syndrome, 8 (16%) had mild OSA, 11 (22%) had moderate OSA, and 14 (28%) had severe OSA. Increasing severity of OSA was associated with higher mean levels of all the metabolic syndrome parameters except serum high density lipoprotein (HDL). Conclusions: OSA is highly prevalent in patients with metabolic syndrome. Also, the increasing severity of OSA is associated with poorer control of diabetes, hypertension, and dyslipidemia, which are all components of metabolic syndrome. Therefore, effective treatment of metabolic syndrome can prevent and control OSA in these patients. Similarly, reducing the severity of OSA (by early diagnosis and treatment) in patients with metabolic syndrome might help to optimize control of blood sugar, blood pressure, and serum lipids, thereby reducing the risk of cardiovascular disease. Therefore, the need for screening metabolic syndrome patients for OSA has been reinforced by this study.
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Knowledge and practice of secondary school teachers about first aid p. 1587
Majed Al Gharsan, Ibrahim Alarfaj
DOI:10.4103/jfmpc.jfmpc_76_19  
Background: School students are vulnerable to the risks of accidents and injuries and hence require first aid more often than do adults. The first responsible person to reach an injured student at school is the teacher. Aim: To assess secondary school teachers' knowledge and practice regarding first aid. Methodology: Following a cross-sectional descriptive study design in Khamis Mushayt City, Saudi Arabia, 250 secondary school teachers (110 males and 140 females) were included in this study. A self-administered questionnaire designed by the researcher was used for data collection. Results: Main sources of knowledge for secondary school teachers were mass media, physicians, and educational school books. Most teachers are not trained on first aid. About half of the teachers face cases that need first aid, but only half of them provide the necessary first aid. Only 19.6% were knowledgeable regarding first aid, 48.8% faced cases that needed first aid, and only 54.9% of those who faced cases that needed first aid could provide the necessary first aid. Participants' knowledge grades differed significantly according to their age groups (P = 0.003), gender (P = 0.035), and experience in teaching (P = 0.001). Conclusion: Knowledge and practices of secondary school teachers on first aid need to be improved.
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A randomized controlled trial comparing the radiographic evaluation of crestal bone resorption in single implant versus two implant–retained overdentures p. 1594
Barun Kant, Madhu Ranjan, Arunoday Kumar, Bodhisatta Mukherjee, Souvir Mohan Pandey, Meetu Agarwal, Deepak Passi
DOI:10.4103/jfmpc.jfmpc_58_19  
Aim: The aim of this study was to evaluate and compare radiographically the amount of crestal bone resorption during healing and loading period in single implant versus two implant–retained mandibular overdentures in totally edentulous patients. Materials and Methods: A total of 20 edentulous patients (12 male and 8 female) with age range of 58.6 years were included in this clinical trial which was completed in four phases (clinical and radiographic diagnosis, surgical phase, implant loading phase, and bone level measurement phase). The eligible patients were randomly allocated in two equivalent groups of 10 participants each per group. The allocation was in 1:1 ratio via randomized chit method. Group I included the case group, that is, single implant, and Group II included the control group, that is, two implants located in mandible. A total of 30 implants were placed in Group I and 20 implants in Group II. Digital intraoral peri-apical radiographs (RVG 5100) were used for measuring the bone level immediately after implant surgery, 1 month, 3 months, 4 months, and 6 months. Result: This study showed that there was a mean crestal bone loss of 0.7 mm between the tip of the implant and alveolar crest at the end of 6 months after implant placement in single implant Group I while 0.67 mm in case of Group II two-implant-retained mandibular overdentures. The percentage of crestal bone loss after 6 months follow-up was 6.45% in Group I which was statistically insignificant compared with Group II where 6.25% of bone loss was recorded. Conclusion: Single implant–retained mandibular overdentures could be used as another alternative treatment option for completely edentulous elderly patients with severely resorbed ridges and financially and systemically compromised conditions.
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Can identification badges be vectors of infection: Experience from a tertiary care center in Riyadh, Saudi Arabia p. 1599
Fahad Alfarawi, Khalid Alshamardl, Muhammad Almutairi, Alwaleed Alyamani, Saif Aldhali, Faisal Alassaf, Abdulmajeed Alfadhel, Msab Aldakheel, Ali Almuhesseny, Sameera Aljohani, Ebrahim Mahmoud, Adel Alothman
DOI:10.4103/jfmpc.jfmpc_173_19  
Background: Wearing identification badges is mandatory in many hospitals. Identification badges worn by healthcare workers may be contaminated with pathogens. Objective: The objective of this study is to determine the levels and types of contamination on identification badges of healthcare workers at King Abdulaziz Medical City in Riyadh, Saudi Arabia. Materials and Methods: This is a cross-sectional study of 200 healthcare workers at King Abdulaziz Medical City in Riyadh, Saudi Arabia. A data collection form was handed to all the participants and swab cultures of their identification badges were taken. Results: A total of 200 identification badges were sampled in this study. 37% were contaminated with pathogens. Coagulase-negative Staphylococcus was isolated from 70 badges (35%), and methicillin-sensitive Staphylococcus aureus from four badges (2%). Contamination was highest in physicians (45% compared to 14–32% in other healthcare workers). Males and females had similar contamination rates (39 and 36%, respectively). Conclusion: Identification badges worn by healthcare workers may be vectors of significant infection. We suggest more compliance of infection control measures in regards to disinfecting badges or personal belongings of healthcare workers.
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Elevated levels of Interleukin (IL)-1β, IL-6, tumor necrosis factor-α, epidermal growth factor, and β2-microglobulin levels in gingival crevicular fluid during human Orthodontic tooth movement (OTM) p. 1602
Poonam K Jayaprakash, Jayaprakash Mugur Basavanna, Harpreet Grewal, Palash Modi, Pranav Sapawat, Parag D Bohara
DOI:10.4103/jfmpc.jfmpc_204_19  
Aim: The aim of this study was to identify and quantify the various cytokines in human gingival crevicular fluid (GCF), and to investigate the changes in their levels during orthodontic tooth movement (OTM). Materials and Methods: A statistically significant no. of subjects (n = 10 and mean age = 15.6 years) were included in the study. A maxillary cuspid of each subject having one treatment for distal orthodontic tooth movement served as the experimental tooth, whereas the contralateral cuspids were used as controls. Gingival crevicular fluid (GCF) around the experimental and the two control teeth was collected from each subject immediately before activation, and at 1, 24, and 168 hours after the initiation of tooth movement. Result: ELISAs were used to determine cytokine levels. The concentrations of interleukin (IL)-1lβ, IL-6, tumor necrosis factor-α, epidermal growth factor, and β2-microglobulin were significantly higher in the experimental group than in the controls at 24 hr after the experiment was initiated. All the cytokines remained at baseline levels throughout the experiment for the control groups. Conclusion: Since all cytokines in GCF play an important role in the bone remodelling processes in vivo, the present results indicate that the changes in cytokines in GCF are associated with OTM.
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Prevalence of intestinal parasites among rural and urban population in Puducherry, South India - A community-based study p. 1607
Dashwa Langbang, Rahul Dhodapkar, Subhash C Parija, KC Premarajan, Nonika Rajkumari
DOI:10.4103/jfmpc.jfmpc_196_19  
Introduction: Developing country, like India intestinal parasitic infections are still remaining as the most important health problem in public of concern. The infection remains the most leading cause of morbidity and mortality especially among the childrens. It is presumed that the prevalence is high in developing countries probably due to poor sanitary conditions and improper personal hygiene practice. Aim: The main aim of this study was carried to find out the prevalence of intestinal parasitic infection among rural and urban population of Puducherry, India. Materials and Methods: This is a cross-sectional descriptive study carried out between the period September 2016 to December 2018. Random sampling was adopted to collect stool samples from urban and rural population in Puducherry. A door to door survey was done. Stool samples were collected from rural setting (n = 500) and urban setting (n = 506) and transport to the parasitology section, Dept. of Microbiology, JIPMER were subjected to routine stool investigations. The results were recorded, and data were presented in the form of frequency and distribution. Data entry was done in MS Excel and analysis was carried out in SPSS software version 22. Results: Among the rural and urban population, 500 stool samples from the rural population showed nearly 40.4% intestinal parasites Giardia intestinalis (21.2%), Blastocystis spp (8.8%), Entamoeba spp (6.6%), hookworm (2.8%), Ascaris lumbricoides (1%), Hymenolepis nana (0%) and 506 stool samples from urban population showed 20.3% of intestinal parasites (Giardia intestinalis (10.4%), Blastocystis spp (3.7%), Entamoeba spp (3.3%), hookworm (1.7%), Hymenolepis nana (0.9%), Ascaris lumbricoides (0%). There was a noticeable male predominance pattern (31.4%) compared to female showing 29.1% positivity. The increase in the prevalence of intestinal parasites among rural population than the urban population was statistically significant. Conclusion: The stool samples collected from rural population showed high prevalence of intestinal parasite infestation when compared to urban population, hence necessary interventions like health education, awareness creation and medical intervention should be undertaken particularly among the rural population. In our study population, age group between 1-10 years are predominantly infected with these parasites.
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Correlation of high-resolution ultrasonography findings of thyroid nodules with ultrasound-guided fine-needle aspiration cytology in detecting malignant nodules: A retrospective study in Malabar region of Kerala, South India p. 1613
P P Baby Manoj, A Innisai, D K Shahul Hameed, Aysha Khader, M Gopanraj, Nikhil H Ihare
DOI:10.4103/jfmpc.jfmpc_163_19  
Aims: The purpose of our study is to assess the role of high-resolution real-time gray-scale ultrasonography with ultrasound-guided fine-needle aspiration cytology (FNAC) in detecting malignant nodules in the thyroid gland. Settings and Design: It is a retrospective study of 25 patients (aged 16–63 years) who underwent high-resolution ultrasound (HRUSG) of the thyroid gland and ultrasound-guided FNAC from February 2017 till November 31, 2017. Materials and Methods: A total of 25 patients with thyroid nodules detected at ultrasound were included in this study. The characteristics of each nodule were determined. The results were then compared with FNAC (ultrasound-guided) findings. Statistical Analysis Used: Sensitivity, specificity, positive predictive value, negative predictive value and accuracy were used. Results: Of the 25 nodules examined, 5 (20%) were found to be malignant on cytology. Conclusions: Gray-scale ultrasound features of thyroid nodules are useful to distinguish malignant thyroid nodules from those with benign nodules. From our study, it is obvious that the HRUSG findings of hypoechogenicity, microcalcification, and poorly defined margins have high diagnostic accuracy for identifying malignant thyroid nodules.
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A comparative study of postoperative port-site pain after gallbladder retrieval from umbilical versus epigastric ports in laparoscopic cholecystectomy p. 1617
Ranendra Hajong, Malaya Ranjan Dhal, Tanie Natung, Donkupar Khongwar, Arup Baruah Jyoti, Kewithinwangbo Newme
DOI:10.4103/jfmpc.jfmpc_172_19  
Introduction: Gall bladder (GB) retrieval is an important cause for postoperative pain after laparoscopic cholecystectomy (LC). GB is usually extracted either from the epigastric or the umbilical port and there are limited data to decide the superiority of one over other in terms of postoperative pain. This study was designed to determine whether GB retrieval from the umbilical port was associated with less pain as compared to epigastric port in adult patients undergoing four ports elective LC. Material and Methods: A total of 100 patients took part in the study and were randomly allocated into 2 groups. Postoperatively, port-site pain score was assessed at 1, 6, 12, and 24 h by visual analog scale (VAS) score both for the epigastric and umbilical ports in all the patients and the collected data were analyzed by using SPSS version 22. Result: VAS score for postoperative pain at epigastric port at 1, 6, 12, and 24 h found to be higher as compared to umbilical port (6.640 ± 1.494 vs. 5.500 ± 1.176, 6.620 ± 1.549 vs. 5.320 ± 1.188, 6.100 ± 1.549 vs. 4.660 ± 1.232, 5.250 ± 1.459 vs. 3.970 ± 1.274, respectively) which was statistically significant (P value 0.001). But the time taken for retrieval of GB was significantly longer in the umbilical group (4.94 ± 1.56 vs. 3.24 ± 1.29). Conclusion: Umbilical port is better as compared to epigastric port for GB retrieval in patient undergoing elective four port LC in terms of postoperative port-site pain but it takes relatively longer time for the extraction.
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Are adolescents ready for future responsibilities? Experience from a cross-sectional study regarding Breastfeeding knowledge and attitude p. 1621
Simmi Oberoi, Kamal Kishore, Sunvir Kaur Rai, Siriesha Patnaik
DOI:10.4103/jfmpc.jfmpc_192_19  
Background: Breastfeeding plays an important role in the holistic development of a child. Current knowledge and attitude of future parents will significantly influence breastfeeding practices. Therefore, ascertaining current knowledge and attitude of both soon-to-be parents will help to formulate breastfeeding promotion strategies. Research Aim: To ascertain the knowledge and attitude of adolescents towards breastfeeding and its correlates with socioeconomic and demographic factors. Materials and Methods: A cross-sectional institutional based study in which participants were recruited from Punjab, state of India. A total of 392 adolescents from January to June 2017 were evaluated on the basis of a pretested, reliable, and valid instrument. The instrument consisted of questions on knowledge and attitude regarding breastfeeding. Results: One-hundred two (26%) participants had good knowledge and 290 (74%) had poor knowledge regarding breastfeeding. A bothersome fact is that only 25% of the participants knew about the age till which a child should be breastfed. There was a statistically significant (OR = 2.93; 95% CI: [1.45--5.93]) association between high knowledge and positive attitude. Conclusion: The level of knowledge amongst adolescents showed variation ranges from 15.82% to 93.11% on various aspects of breastfeeding. Despite this glaring variation, 75% of the participants had a positive attitude towards breastfeeding. Thus, there is a need for implementing modified and improved breastfeeding promotion strategies in India.
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Study of the effect of obesity on QT-interval among adults p. 1626
Tarun Kumar, Kamlesh Jha, Ashok Sharan, Pooja Sakshi, Shishir Kumar, Amita Kumari
DOI:10.4103/jfmpc.jfmpc_168_19  
Background: Obesity affects the different organ systems of human body and has been recognized as a risk factor for the development of many diseases. Most of the cardiovascular diseases develop due to obesity which reflects alterations in either cardiac morphology or conduction defects. These abnormalities are reflected in ECG as prolongation of various intervals. Prolongation of QT-interval has been found to be associated with ventricular arrhythmia and sudden cardiac death. Aims and Objectives: The aim of the study was to investigate the effect of obesity on QT-interval to assess the risk of development of cardiovascular diseases in early stage.Materials and Methods: A cross-sectional study was conducted on 80 cases and 80 controls, which included adults of 18–40 years age groups from both sexes. The cases were obese [body mass index (BMI) >30 kg/m2] and the controls were nonobese (BMI < 25 kg/m2). ECG of the cases and controls was recorded and their QT-intervals were calculated and analyzed with BMI by independent samples test. Results: We found significantly higher QT-intervals in obese group in comparison to that of nonobese group (P = 0.000). Conclusion: Obesity was found to be associated with prolongation of QT-interval among young obese adults. This prolongation of QT-interval duration increases the possibility of left ventricular enlargement and ventricular fibrillation. Hence the present study helps in creating awareness among obese people so that they can change their lifestyle in order to prevent the onset of the deleterious effects of obesity on their health.
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Implementation of “health systems approach” to improve vaccination at birth in institutional deliveries at public health facilities; experience from six states of India Highly accessed article p. 1630
Rajeev Gera, Neelesh Kapoor, Pradeep Haldar, Sachin Gupta, Rakesh Parashar, Shailendra Singh Tomar, DP Taneja, Saumyadripta Chaudhuri, Subodh Chandra, Gunjan Taneja
DOI:10.4103/jfmpc.jfmpc_70_19  
Introduction: Newborn vaccination is an integral part of routine immunization program in India, but program implementation gaps exist. The focus of this article is to identify and describe an implementation strategy which could improve the newborn vaccination at the facility level. Materials and Methods: A situation analysis was conducted through a mixed-methods approach to identify the lacunae in the health system and the same was used to develop an implementation strategy to improve newborn vaccination coverage across the six priority states. Results: Issues in stewardship and human resource, vaccine-related stock-outs, and poor service delivery were some of the reasons for low facility-level vaccination coverage. After implementation of a health system–based strategy, the new born vaccination improved from 55% to 88% across 10 quarters of program implementation. Factors such as sensitization of stakeholders, vaccination on holidays, rigorous documentation, and supportive supervision of health staff were primary reasons for improvement in service delivery. Conclusion: Importance of newborn immunization at birth is well established. The results from six states prove that “health systems approach” as an implementation strategy is a viable tool to improve newborn immunization at birth.
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Pattern of sexual behavior among people in a rural area of Bihar: A qualitative study on wives of migrant workers p. 1637
Alok Ranjan, Pragya Kumar, Shamshad Ahmad, Sanjay Pandey, Roger Detel
DOI:10.4103/jfmpc.jfmpc_180_19  
Background: Population mobility and migration are important processes of human life. It affects broad range of sociocultural parameters. Mobility increases personal interaction and exposure to sexual partners from high-risk group. Although traditional Indian value prohibits premarital or extramarital sexual activities, but this aspect has not been explored in migrant workers. Methods: It was a qualitative study based on indepth interview of participants. The participants were wives of migrant workers. Indepth interviews were conducted by two female field interviewers recruited for the study. A total of 24 study subjects were recruited for the study. An indepth interview guide was prepared which mainly focused on sexual behavior, including premarital, marital, and extramarital, quality of marital relationship, gender roles, peer networks, substance abuse, work-related activities, etc., The transcripts were analyzed in NVIVO and themes were generated. Results: The premarital sex was more common in boys than girls. It is more common in the same age group and has increased in the recent years. Various reasons were cited in relation to premarital sex in rural areas like love affair, delayed marriage, watching bad movies, bad company, allurement for gifts money, etc., Some women had opinion that males belonging to affluent and powerful families had tendency to enjoy sex with other women within and outside village. The major themes which emerged from the study were the sexual activity, type of sexual partners, reasons for multiple sexual partner, and risky and nonrisky sexual activity. Conclusion: The findings of the study provided insights to design and conduct a larger and more representative quantitative study among the wives of migrant workers to understand the dynamic combination of biomedical, behavioral, and sociocultural factors that may influence transmission of infection within marriage.
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Speech and language delay in children: Prevalence and risk factors p. 1642
Trisha Sunderajan, Sujata V Kanhere
DOI:10.4103/jfmpc.jfmpc_162_19  
Context: Intelligible speech and language is a useful marker for the child's overall development and intellect. Timely identification of delay by primary care physicians can allow early intervention and reduce disability. Data from India on this subject is limited. Aims: To study the prevalence and risk factors of speech-language delay among children aged 1-12 years. Settings and Design: A cross sectional study was conducted at the Pediatric outpatient department of a teaching hospital. Materials and Methods: Eighty four children (42 children with delayed speech and 42 controls) aged 1-12 years were included. The guardians of these children were requested to answer a questionnaire. History of the child's morbidity pattern and the risk factors for speech delay were recorded. The child's developmental milestones were assessed. Statistical Analysis Used: Data entry was analyzed using SPSS software, version 16. Standard statistical tests were used. A p value of less than 0.05 was taken as statistically significant. Results: Speech and Language delay was found in 42 out of 1658 children who attended the OPD. The risk factors found to be significant were seizure disorder (P=<0.001)), birth asphyxia (P=0.019), oro-pharyngeal deformity (P=0.012), multilingual family environment (P=<0.001), family history (P=0.013), low paternal education (P=0.008), low maternal education (P=<0.001), consanguinity (P=<0.001) and inadequate stimulation (P=<0.001). Conclusions: The prevalence of speech and language delay was 2.53%. and the medical risk factors were birth asphyxia, seizure disorder and oro-pharyngeal deformity. The familial causes were low parental education, consanguinity, positive family history, multilingual environment and inadequate stimulation.
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Rotator cuff tendon calcific tendinitis treatment algorithm for primary care musculoskeletal physicians p. 1647
Avais Raja, Edward V Craig, Jonathan P Braman
DOI:10.4103/jfmpc.jfmpc_110_19  
Purpose: Calcific tendinitis of the shoulder is a common pathology encountered by primary care sports medicine physicians and orthopedic surgeons. Understanding the patient demographics responsible for calcific tendinitis outcomes from various treatment modalities may lead to greater understanding of appropriate management. Methods: This was a retrospective study on patients who were diagnosed with calcific tendinitis by imaging (radiographs, MRIs) at our institution from 2014 to 2016. The data collection included patient demographics, clinical signs and symptoms management. Treatment outcomes were assessed by whether symptoms resolved and the number and type of treatment. Results: A total of 250 medical records were reviewed out of which 237 were involved in the data analysis. There were 95 male and 141 female patients with a mean age of 54.9 ± 11.5 years. In all, 120 patients complained of right shoulder pain and 117 of left shoulder pain. Smokers had a higher VAS Pain at Rest and Activity of 6.1 ± 3.5 and 8.2 ± 2.4, respectively, with non-smokers scoring a lower VAS Pain Rest score of 4.2 ± 3.1 and 7.9 ± 2.0 (P = 0.18). The VAS Pain Rest score after follow-up from corticosteroid injection, ultrasound-guided injection with needling, and surgery were 3.9 ± 3.0, 3.5 ± 3.0, and 0.7 ± 1.4, respectively. Conclusion: An algorithm constructed from our results recommends initial management with a subacromial corticosteroid injection with physical therapy followed by ultrasound-guided injection with needling and PT if the initial treatment fails. Surgical management is considered when the patient is recalcitrant to the first two forms of non-operative treatment.
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Comparing serum lead level in drug abuse pregnant women with non-addicted pregnant mothers referring to Shiraz university hospitals in 2017-2018 p. 1653
Mehrdad Rezaie, Seyedeh Zarrin Abolhassanzadeh, Hourvash Haghighinejad
DOI:10.4103/jfmpc.jfmpc_36_19  
Introduction: In recent decades, there are multiple reports of lead poisoning in drug abusers in Iran and other Middle East countries. The lead in the mother's blood can cause many dangerous, harmful effects on the mother and the fetus. Therefore, in this study, we evaluated the blood lead level (BLL) in pregnant women who were an illegal drug user and compared it with pregnant women who did not use these agents. Method: A cross-sectional study was conducted among 60 pregnant women referred to Shiraz Hazrat Zinab and Hafez Hospitals. All pregnant women with a history of any drug abuse were sampled. Two pregnant women without any history of drug abuse were sampled for each pregnant mother with a history of drug abuse on the same day. To check BLL, 5 cc blood sample of all participants sent to a reference laboratory. BLLs have been assessed by atomic absorption spectrophotometry with GBC Avanta, and all reports were confirmed by a specific pathologist. The data were completed with maternal demographic information and infants' anthropometric indices. Data analysis was performed using SPSS software version 24, and the significance was 0.05. Results: There was a significant difference in BLL among pregnant women with and without drug abuse history (9.91 ± 26.2 and 2.95 ± 0.7, respectively) (P-value: 0.001). The prevalence of lead levels of more than 5 μg/dl in mothers with and without substance abuse was 20% and 7.5%, respectively. Anthropometric indices, Apgar score, and gestational age in the mothers with a history of drug abuse were significantly lower than the control group (a significant level less than 0.05). Conclusion: The level of lead in pregnant women taking illegal drugs is higher than that of the control group who do not have a history of illegal drug abuse. On the other hand, it is likely that increased serum levels of lead with fetal complications and maternal health threats childbirth and clinical outcomes during childbirth.
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Muslim female gender preference in delaying the medical care at emergency department in Qassim Region, Saudi Arabia p. 1658
Amal Ebrahem Alqufly, Basil Mohammed Alharbi, Khawlah Khaled Alhatlany, Fahad Saleh Alhajjaj
DOI:10.4103/jfmpc.jfmpc_141_19  
Background: Hospitals are responsible for considering patients religious beliefs and spiritual ideas as part of their rights in emergency department (ED), where the urgent seek of medical intervention usually needed, these rights can be sometimes violated. This study is designed to take female Muslim patients view and their consideration when it comes to receiving health care from the same physician's gender or sex. Materials and Methods: This research is a cross-sectional study, which was conducted at three hospitals in Saudi Arabia, Qassim region. The collection of the data by using a questionnaire distributed to 393 patients and visitor in ED, mostly female which represent 87.5% of the entire sample in this study. Results: Indicated that more than half of female patient prefer to be seen by female physicians. The same preference with a male when the case involves one of their first-degree female relatives with exceptions in life-threatening cases, where more than half of the patients have not choose gender preference and want to rely on the available physician in ED either male or female physician. Conclusion: The study result shows an obvious considerable preference of the presence of a female physician in the ED to handle gastrointestinal disease, clinical assessment, non-life-threatening cases, and physical examination. However, in few situations such as life-threatening, psychiatric illnesses, and history taking, there was no preference for female over male physician. The religion was the main factor that affects in participants decisions. The intervention from the religious leader is mandatory to correct patient's beliefs, therefore, improve the outcome.
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Explaining the inhibitory characteristics of clinical instructors in the process of developing clinical competence of nursing students: a qualitative study p. 1664
Amir Sadeghi, Khodayar Oshvandi, Yaser Moradi
DOI:10.4103/jfmpc.jfmpc_34_19  
Background: Different inhibitory factors may play a role in the process of developing the students' clinical competence; among them, some of the characteristics of clinical instructors can be considered as the most important factors. Purpose: The aim of this study was to determine the inhibitory characteristics of instructors in the process of developing clinical competence in nursing students. Methods: This qualitative study was conducted using the conventional content analysis. Seventeen senior nursing students were selected by purposive sampling method. Individual semistructured interviews were used to collect data. After recording and implementing the interviews, the content analysis was used to extract the concepts. Results: According to participants' experiences, the three themes, i.e. “autocracy,” “low clinical competence,” and “self-confidence weakness” were extracted as inhibitory features of clinical instructor in the process of developing the clinical competence of nursing students. Conclusion: The findings of this study illustrate the characteristics of a clinical instructor, which play an important role in reducing the clinical development and lack of clinical competence development among students.
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Association of serum magnesium with type 2 diabetes mellitus and diabetic retinopathy p. 1671
Pratyush Kumar, Seema Bhargava, Pankaj Kumar Agarwal, Ambuj Garg, Amit Khosla
DOI:10.4103/jfmpc.jfmpc_83_19  
Introduction and Objective: The rising burden of type 2 diabetes mellitus (T2DM) globally has led to huge morbidity and socioeconomic impact in developing countries. In India, too, it has become a silent epidemic and it is estimated that there are over 60 million diabetics. Although in recent years, a lot of research papers have come up on the management of diabetes, latest treatment modalities may not be affordable to all. So, it becomes imperative to prioritize research on prevention and primary care. Magnesium is an intracellular cation and coenzyme for various reactions of the glycolytic pathway. Hypomagnesemia has been shown to precipitate hyperglycemia and has, therefore, been implicated in insulin resistance and its microvascular complications. Poor glycemic control has been associated with retinopathy. Hence, we evaluated association of serum magnesium with T2DM and diabetic retinopathy. Materials and Methods: In a cross-sectional study in North India, 250 consenting adult patients from outpatient department of family medicine of our hospital were recruited. Critically ill patients and those on magnesium supplements were excluded. Clinicolaboratory profile was evaluated. Patients were divided based on serum magnesium level ≤ 1.7 mg/dL (group 1) and > 1.7 mg/dL (group 2). Glycemic control and proportion of diabetic retinopathy were compared between these two groups by using univariate regression analysis. Results: Out of 250 patients, 110 patients (44%) were found to have hypomagnesemia. Glycemia by fasting blood sugar (P = 0.02), post-Prandial blood sugar (P = 0.04), and HbA1C(P = 0.01) was poorly controlled in hypomagnesemia group. In group 1, 62.7% had non proliferative diabetic retinopathy and 21.8% had proliferative diabetic retinopathy, whereas in group 2, 14.3% had nonproliferative diabetic retinopathy and 8.6% had proliferative diabetic retinopathy (P < 0.001). Conclusions: Magnesium deficiency is associated with increased risk of diabetic retinopathy and poor glycemic control. Dietary supplementation may be advised to prevent such complications and improve glycemic control.
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Comparison of the sonographic findings in laparoscopic cholecystostomy with and without hemostatic agent on 45-day follow-up of patients attending hospital p. 1678
Mahyar Mohammadifard, Ghodratollah Naseh, Rozita Khatamian Oskooi, Gholamreza Sharifzadeh, Samira Eshraghi
DOI:10.4103/jfmpc.jfmpc_92_19  
Introduction: Cholelithiasis is one of the most prevalent pathological conditions, and elective laparoscopic cholecystostomy with and without hemostatic agent (HA) is the therapeutic approach to its treatment. This research study aimed to compare the sonographic findings of patients who underwent cholecystostomy with and without HA use. Materials and Methods: This cross-sectional, descriptive-analysis study was conducted by available nonprobability sampling technique, and according to Cochran Formula, 144 patients, who underwent laparoscopic cholecystostomy, were recruited and divided into two groups including a group of 85 patients with HA use and a group of 59 patients without HA use. Patients in each group had sonography on discharge date and 15, 30, and 45 days after the surgery. Data were collected and entered in SPSS-24 software; meanwhile, descriptive statistics was used to analyze Chi-square test, Fisher's exact test, and Friedman and Wilcoxon nonparametric test. Findings: The results of the study showed that the presence of echogenic mass with reverberation artifact (abscess mucosa) on 15- and 30-day follow-up sonography of patients, who underwent laparoscopic cholecystostomy, were significantly higher in patients with HA than in the group without HA (P < 0.05), and on 45-day follow-up sonography, there was no significant correlation regarding the presence of echogenic mass with reverberation artifact (abscess mucosa) and fluid in the two groups (P > 0.05). Besides, HA density significantly decreases in individuals over time (P < 0.05); however, there was no significant differences between HA reduction rate and gender (P > 0.05). Conclusion: These findings might be the indication of HA agents' effect on surgical operations and their resemblance to abscess. Due to the possibility of temporary immune responses to HA, as an external object, it is necessary, in vital pathologies, to pay close attention to what differentiates the normal imaging appearance in follow-up sonography.
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Attitudes and acceptance of the Saudi population toward cosmetic surgeries in Riyadh, Saudi Arabia p. 1685
Sarah A R Morait, Maha A Abuhaimed, Malak S Alharbi, Bayan E Almohsen, Atheer T Alturki, Alaa A Alarbash
DOI:10.4103/jfmpc.jfmpc_249_19  
Context: Public awareness regarding cosmetic surgery. Aims: To assess the attitudes and acceptance of cosmetic surgery among patients in a tertiary care hospital in Riyadh, Saudi Arabia. Settings and Design: Single-center, cross-sectional study in the family medicine department at our institution. Methods and Material: Data were collected from 389 patients (age 15-50, 29.37 ± 9.25 years, male: female = 139:250) using the Acceptance of Cosmetic Surgery Scale (ACSS) modified for Arabic speakers. Statistical Analysis Used: SPSS 22 statistical package. Results: One hundred eighty-five (47.6%) patients were willing to undergo minor cosmetic surgery, whereas 144 (37.1%) were not. Additionally, 237 (60.9%) patients agreed that cosmetic surgery is good because it can help people feel better about themselves, whereas104 (26.8%) patients disagreed. Robust Cronbach α values were observed among all ACSS scales. Mean significant (P = 0.002) differences were observed between gender and the intrapersonal scale scores. The average intrapersonal scale score was greater among female patients (22.48 vs. 19.29). Similarly, the mean consider scale scores among female patients (20.92 vs. 17.45; P = 0.001). Mean significant (P = 0.001) differences were also observed between education and the intrapersonal scale. Conclusions: The results reveal important information regarding the acceptance of and attitudes toward cosmetic surgery in Saudi Arabia. There is an urgent need for regulatory intervention to ensure patient safety and satisfaction.
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Comparison between gluten-free regime and regime with gluten in symptoms of patients with irritable bowel syndrome (IBS) p. 1691
Eskandar Hajiani, Abdolrahim Masjedizadeh, Ali Akbar Shayesteh, Sina Babazadeh, Seyed Saeid Seyedian
DOI:10.4103/jfmpc.jfmpc_464_18  
Background and Objective: Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder and accounts for most of the referrals of patients to gastroenterologists. Given the high prevalence of this syndrome and its significant effect on the reduced quality of life of patients, the present study aimed to investigate the effect of using gluten-containing or gluten-free diet on symptoms of patients with irritable bowel syndrome. Materials and Methods: In this trial, 140 patients with irritable bowel syndrome who referred to Imam Khomeini Hospital (2006) were randomly divided into two groups based on Rome III criteria. Seventy patients received a gluten-free diet and rest patent received a regular diet as control group for 12 weeks. In order to compare the quantitative characteristics, independent samples T-test was used, while Mann-Whitney and Z-tests were used to compare the qualitative characteristics. Findings: There was no significant difference between the control group (9.8 ± 37 years) and the group with gluten-free diet (0.2 ± 37 years) in terms of mean age. The effect of gluten-free diet on intestinal gas, fecal consistency, urgent need for expulsion, and insufficient defecation were higher than in control group. Although abdominal pain and reduced frequency of bowel movements were higher in the control group than gluten-free diet group (P < 0.05). The positive response to general improvement in the gluten-free group and in the control group was 67% and 52%, respectively. Conclusion: According to present results, providing gluten-free diet could be improved patient treatment's symptoms. Also, it seemed that the duration of treatment can lead to better therapeutic outcomes.
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Awareness and perception of preconception care among women in Usmanu Danfodiyo University Teaching Hospital Sokoto, North-Western Nigeria p. 1696
Amina G Umar, Sadiya Nasir, Karima Tunau, Swati Singh, Umar A Ibrahim, Mairo Hassan
DOI:10.4103/jfmpc.jfmpc_50_19  
Background: Preconception care is an interventions aim to identify and modify biomedical, behavioral and social risks to pregnancy through prevention and management, emphasizing factors that must be acted upon before conception or in early pregnancy to have maximal impact. Objective: The aim of the study is to assess awareness and perception of preconception care among women. Method: A cross-sectional study conducted at UDUTH Sokoto, Nigeria, from 5 February to 1 March, 2018. A total of 131 women were recruited by simple random sampling technique via the ante-natal care clinic, using semi-structured interviewer questionnaires. Data were analyzed using SPSS version 24 and the results were presented in tables and charts. A P value of <0.05 was considered statistically significant. Results: There ages ranged between 16 years to 46 years and 32.8% (43/131) were within 26-30 years with a mean of 28.10 ± 6.064. Only 20.61% of them were aware of preconception care. There was significant association between awareness and the patient's tribe as well as employment status at P value 0.004 and 0.017 respectively. Among those who were unaware, 88.46% will accept if offered while, about 45.75% of those who declined believed it was not necessary. Conclusion: There was poor awareness but good perception and acceptability of preconception care. Therefore, there is a need to create awareness and incorporate it into routine maternal healthcare services to achieve better feto-maternal outcome.
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The relationship between spiritual well-being, mental health, and quality of life in cancer patients receiving chemotherapy p. 1701
Atefeh Zare, Namavar Jahromi Bahia, Fereshteh Eidy, Neda Adib, Forouhari Sedighe
DOI:10.4103/jfmpc.jfmpc_131_19  
Background and Aim: Cancer is the second cause of death after cardiovascular diseases in the world. Each year, more than 70,000 new cases of cancer and 30,000 deaths from cancer have been recorded in Iran. Cancer also reduces quality of life (QoL) by creating negative physical and mental symptoms. The purpose of this study was to investigate the relationship between mental health, spiritual well-being and QoL among cancer patients receiving chemotherapy. Method: About 208 adults suffering from cancer and receiving chemotherapy in Shiraz hospitals were entered in the study and they were asked to complete the Paloutzian and Ellison Spiritual Well-being Questionnaire, and Goranowski Mental Health, Quality of Life and Excitement Questionnaire. For data analysis, descriptive statistics including mean (standard deviation) and frequency (percentages) were used in table and chart format, moreover Spearman correlation tests were also used. Results: The results of the study revealed that there was a positive and significant correlation between mental health and QoL (P = 0.001) in cancer patients receiving chemotherapy. The results of the study revealed that there was a positive and significant correlation between spiritual well-being and mental health (P = 0.001) and QoL (P = 0.01) in cancer patients receiving chemotherapy, but there was a negative and significant Correlation between spiritual well-being and negative emotions (P = 0.47). On the other hand, there was a negative and significant correlation between mental health (P = 0.026) and QoL (P = 0.019) and negative emotions respectively. Conclusion: The results of this study showed that there was a positive and significant relationship between spiritual well-being, mental health, and QoL in cancer patients.
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Serum vitamin D level, sun-exposed area, dietary factors, and physical activity as predictors of invasive breast cancer risk among Sudanese women: A case–control study Highly accessed article p. 1706
Nazik Elmalaika Husain, Ahmed A Suliman, Ismail Abdelrahman, Shahinaz A Bedri, Rasha M Musa, Hind E Osman, Ayda H Mustafa, Nahla Gafer, Ehab Farah, Ali Abdel Satir, Mohamed H Ahmed, Mugtaba Osman, Abbas Agaimy
DOI:10.4103/jfmpc.jfmpc_197_19  
Background: The role of vitamin D in the development, progression, and prognosis of breast cancer, though widely studied worldwide, has been inconclusive. This study intended to assess the role of some factors (including serum vitamin D level, sun-exposed area, dietary factors, and physical activity) as predictors of the development of invasive breast cancer (IBC) among Sudanese women. Methods: A case–control study was conducted on 200 Sudanese women (100 with newly diagnosed IBC and 100 matched healthy females). Serum 25-hydroxyvitamin D was measured through a competitive electrochemiluminescence immunoassay. Matching analysis was adopted by R version 3.4.1 making use of the “MatchIt” package for calculating propensity scores to build a confounder-adjusted, multiple generalized, linear logistic regression model. Results: Participants' age ranged from 28 to 85 years with a mean [±standard deviation (SD)] of 48.10 (±12.11) years. The mean (±SD) serum vitamin D level was 12.97 (±8.60) and 13.79 (±6.79) ng/mL in breast cancer and noncancer Sudanese women, respectively [P = 0.013; odds ratio (OR) 0.862; 95% confidence interval (CI) 0.766–0.969; β = 0.149)]. Sun-exposed area (P = 0.038; OR 0.013; 95% CI 0.000–0.782; β = 4.339) is significantly and negatively associated with breast cancer development. While moderate physical activity (P = 0.0008; OR 2625.430; 95% CI 26.647–258673.001; β = 7.873) is significantly and positively associated with IBC risk. Occasional consumption of milk, dairy products, eggs, and fish reduces the risk of developing IBC by 78.1%, 75.0%, 78.4%, and 76.4%, respectively. Conclusion: The higher the plasma vitamin D level by one unit, the lower the risk of breast cancer by 13.84%. Sedentary lifestyle, reduced sun-exposed skin area, and low serum vitamin D levels can be considered as predictors of IBC. Encouraging moderate physical activity and consumption of certain foods may, in part, decrease the precipitating risks of breast cancer. More studies and research are needed to confirm these findings.
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Knowledge, attitude, and practice about cervical cancer and its screening among community healthcare workers of Varanasi district, Uttar Pradesh, India p. 1715
Divya Khanna, Naveen Khargekar, Atul Budukh
DOI:10.4103/jfmpc.jfmpc_143_19  
Context: Cervical cancer is most common type of cancer in women of rural India. More than 60-70% of cancers are diagnosed in later stages with poor survival rate. Screening helps in early detection of cervical cancer and better survival. Awareness and attitude of women towards cervical cancer screening may determine health-seeking behavior. As per operational framework of cancer screening in India, community health workers will be key mobilizers for encouraging women to undergo cervical cancer screening. Aim: This study aims to assess the knowledge, attitude and practice (KAP) of cervical cancer and its screening amongst community health workers of Varanasi district, Uttar Pradesh. Settings and Design: Descriptive, cross-sectional study was done to assess the socio demographic profile and KAP for cervical cancer and its screening of community health workers. Scoring for awareness and attitude for cervical cancer screening was done. Statistical Analysis Used: Descriptive statistics such as mean±SD, frequency and proportion were used for socio-demographic data and KAP of study population. Determinants of knowledge and practice for screening was determined using Chi-square test. P value < 0.05 was considered statistically significant. Results: We observed that despite of good knowledge and perception less than 10 percent of workers have undergone screening. Significant association was seen between level of knowledge and practice of screening. Conclusion: It is of utmost importance that narrowing of existing gap between the perception and practice of cervical cancer screening should be initiated through introducing more educational programs for workers and encouraging them to participate in screening campaigns.
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Determinants contributing for poor adherence to antiretroviral therapy: A hospital record-based study in Balasore, Odisha p. 1720
Mallicka Gupta, Sai Chandan Das
DOI:10.4103/jfmpc.jfmpc_40_19  
Context: Over the years, because of the increase in the awareness among the population and strong political will, people have better access to services for diagnosis and treatment of the HIV and it is ensured that their confidentiality is maintained. To attain good results from Antiretoviral therapy (ART), high level of sustained adherence to ART is essential. High level of adherence to ART (at least 95%) is needed to ensure optimal benefits. Objective: The objective of the study is to find out the proportion of patients who did not adhere to ART and its associated factors among people living with HIV/AIDS attending ART center of a tertiary care government hospital in Balasore, Odisha. Settings and Design: This was a hospital record-based study. Subjects and Methods: Overall, 131 HIV-positive individuals were selected from hospital records using simple random sampling technique. Statistical Analysis Used: Data analysis used SPSS version 20.0. Chi-square test and logistic regression were used to identify determinants affecting nonadherence to ART. Results: The mean age of the study participants was 33 years ± 7 SD. The study data revealed that 47.3% of the study subjects were on ART for less than 24 months. There was a statistically significant association between duration of ART and adherence rate (P = 0.036), and using logistic regression, we found that patients who were on ART for less than 24 months are 2.1 times more at risk of becoming nonadherent. Of the total, 48% of patients are suffering from the concurrent infection. There was also a statistically significant association found between opportunistic infection and nonadherence to ART. Conclusion: This study has shown that the duration of treatment and opportunistic infections were factors associated with nonadherence to medication.
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Diagnostic efficacy of broncho-alveolar lavage carcino-embronic antigen in carcinoma of lung p. 1725
Sudarsan Pothal, Kamlesh P Patil, Rekha Manjhi, Pravati Dutta
DOI:10.4103/jfmpc.jfmpc_119_19  
Context: Biomarkers can be used for screening lung cancer and the clinician can decide for further invasive workup for diagnosis. Aims: To know the diagnostic sensitivity and specificity of Carcinoembryonic antigen (CEA) in Broncho Alveolar Lavage Fluid (BALF) and serum of bronchogenic carcinoma. Settings and Design: Case-Control study was conducted in the Medical College Hospital during a period of 2 years. Methods and Material: We randomly selected 50 cases and 50 controls subjects. Cases were the patients with proven malignancy by biopsy or cytology, and controls were other non-malignant pulmonary diseases. All patients' CEA of Broncho Alveolar Lavage Fluid and serum was done. Statistical Analysis: The mean and receiver operating curve were done for CEA of serum and BAL fluid, and based on the cut-off values, sensitivity and specificity were calculated. Results: Mean value of CEA in both BALF and serum in non-smoker patients of the malignant lesion was significantly higher than the non-malignant lesion. Mean value of CEA in both BALF and serum in smoker patients of the malignant lesion was higher than the benign lesion, but statistically not significant. The cut-off value for Serum CEA is 1μg/l, whereas for BALF CEA is 2μg/l. Sensitivity, specificity of CEA of Serum and BALF combined were 92% and 62% respectively. Conclusions: Determination of CEA in the BALF and serum may be helpful as a screening tool for further workup for malignancy.
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Comparison of pre-operative and post-operative (varicocelectomy) sperm parameters in patients suffering varicocle with and without reflux in Doppler ultrasonography p. 1730
Mostafa Babai, Mohammad Momen Gharibvand, Mohammad Momeni, Dinyar Khazaeli
DOI:10.4103/jfmpc.jfmpc_170_19  
Background: Varicocele can cause progressive testicular damage and infertility. Severe retrograde blood flow to the internal spermatic vein has been suggested as a risk factor for infertility or progressive/stable varicocele. We have aimed to Compared th pre-operative and post-operative (varicocelectomy) sperm parameters in patients suffering varicocle with and without reflux in Doppler ultrasonography. Methods: This descriptive-analytic study was carried out at the Imaging Center of Ahwaz University of Medical Sciences in Imam and Golestan Hospitals. The parameters assessed included the presence or absence of internal spermatic vein reflux in both sided. Patients were divided into three groups based on the presence of testicular reflux: no reflux, left-sided reflux, and both sides reflux. The reflux longer than 1 second was considered pathologic. All patients were also referred to the laboratory for semen analysis, including semen volume, sperm morphology, sperm counts, and motility. Semen analysis was repeated 2 months after varicocelectomy. Results: In this study, a total of 70 patients were evaluated. Forty-three patients (61.4%) did not have any reflux, 23 patients (32.9%) had left testicular reflux, and 4 (5.7%) had reflux in both testicles. Semen volume, number of sperms, number of motile sperm, and sperm morphology increased significantly after Varicocelectomy. We did not find any significant correlation between testicular reflux and improvement index of semen analysis factor was found. Conclusion: The findings of this study indicate that the presence of testicular reflux has no effect on semen analysis parameters, but also does not predict the consequences of varicocelectomy and therefore is not a suitable prognosis factor in varicocele patients.
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Knowledge about tuberculosis among pulmonary tuberculosis patients: A cross-sectional study from Uttarakhand p. 1735
Ram G Nautiyal, Sneha Mittal, Sadhana Awasthi, Rajesh K Singh
DOI:10.4103/jfmpc.jfmpc_51_19  
Background: Tuberculosis (TB) is a major health problem in India. The Revised National TB Control Programme (RNTCP) is working towards elimination of TB in the country by 2025. As the RNTCP relies on passive case finding, it is crucial for the success of the RNTCP that TB patients have knowledge about their disease. The present study aimed to assess the knowledge of TB among pulmonary TB (PTB) patients. Materials and Methods: A cross-sectional questionnaire based study using a pretested semi-structured questionnaire among new and previously treated PTB patients at Haldwani Block of Nainital District of Uttarakhand State of North India. Data was analyzed using the software Epi Info version 7.2.0.1. Results: A total of 111 PTB patients with mean age of 36.3 years were included for final analysis. Only 43.2% PTB patients were aware that TB is caused by germs, 48.6% knew that it is not a hereditary disease. Only 13.5% PTB patients knew that vaccine is available and majority (68.5%) were aware of covering mouth and nose while coughing and sneezing for prevention of the disease. Overall, only two-third (65%) patients had good knowledge about TB. Conclusions: About one-third of PTB patients had poor knowledge about TB. This highlights that to achieve elimination of TB, RNTCP needs to change the present information, education, and communication (IEC) system which is based on a bio-medical framework, and to design a culturally sensitive health education system. Alternatively, the Programme needs to shift from passive case finding to active case finding strategy.
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Using caffeine on the patients as therapeutic option against treatment-resistant obsessive-compulsive disorder p. 1741
Jamal Shams, Elahe Samadi Soufi, Alireza Zahiroddin, Reza Shekarriz-Foumani
DOI:10.4103/jfmpc.jfmpc_93_19  
Introduction: Obsessive-compulsive disorder (OCD) is one of the most common and debilitating diseases. Approximately 40-30% of these patients are resistant to treatment, which auxiliary drugs are used to treat these patients. One of these drugs is caffeine, which is capable of affecting adenosine receptors and interfering with its release and serotonin reuptake. Considering the limitations of previous studies in this area, including lack of control group, this double-blind study compared the effectiveness of caffeine in the management of patients with treatment-resistant OCD in comparison with placebo group. Materials and Methods: 62 patients who referred to the psychiatric clinic of Imam Hossein Hospital in Tehran from 2017 to 2018 were enrolled in the study. According to the psychiatrist's interview, patients with OCD were selected randomly in two groups including caffeine and placebo, after having met the criteria for inclusion and obtaining informed consent. Patients were followed for 8 weeks and compared in terms of the severity of OCD before and after intervention using YBOCS questionnaire. Results: The two groups of treatment and control were similar in terms of study variables (gender, age, education, age, comorbidity). The mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in the treatment and control groups before intervention were determined to be 27.16 and 25.4, respectively, which changed to 24 and 27.23 after medication intervention, which exhibited a decrease of about 3 points (12%) in the treatment group, and was statistically significant based on linear regression analysis (P = 0.009). Considering other variables, the effect of caffeine was still statistically significant in the two groups. Conclusion: Based on the findings of our study, caffeine can reduce the severity of the symptoms of OCD and serve as an auxiliary treatment for OCD.
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The clinical usefulness of three depression screens for adolescents in India: A need in primary-care settings p. 1748
Sushila Russell, Shonima A Viswanathan, SatyaRaj Shankar, Priya M Mammen, Paul S S. Russell
DOI:10.4103/jfmpc.jfmpc_152_19  
Introduction: Adolescent Depression (AD) although is widely prevalent and is a prioritized disorder, it is under-diagnosed and under reported in primary-care. We document the post-test probability of three measures and select the best measure for identifying AD in primary-care settings in India based on the clinical utility. Materials and Methods: Three measures have been validated in India for AD and thus can be further evaluated for primary-care use; we calculated the positive (+PTP) and negative (-PTP) post-test probability from the prevalence of AD in India for Beck Depression Inventory-21 item version (BDI-21), Patient Health Questionnaire-9 item version (PHQ-9), and Children's Depression Rating Scale-Revised version (CDRS-R) using the Bayes theorem. The usefulness of the measure was defined a priori based on the odds ratio (OR) of +PTP (OR > 3) and −PTP (OR < 0.1). Results: The +PTP and −PTP for BDI-21 was 43% (95%CI = 40, 45%; OR = 0.7) and 25% (95%CI = 13, 43%; OR = 0.3) respectively. Similarly, the +PTP and − PTP for PHQ-9 was 74% (95%CI = 66, 81%; OR = 2.9) and 10% (95%CI = 6, 17%; OR = 0.1). Finally, +PTP and − PTP for CDRS-R was 78% (95%CI = 69, 84%; OR = 3.5) and 12% (95%CI = 7, 18%; OR = 0.1). Only CDRS-R achieved the useful decided a priori as can be seen in the Fagan's Nomograms. Conclusion: This research provides the evidence base for selecting CDRS-R as the screening measure, for Adolescent Depression, for clinical use in Primary-care settings in India.
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Practices and knowledge regarding dengue infection among the rural community of Haryana p. 1752
Ramesh Verma, Kapil Bhalla, Mukesh Dhankar, Raj Kumar, Rohit Dhaka, Ginni Agrawal
DOI:10.4103/jfmpc.jfmpc_6_19  
Background: The dengue infection has become a major global public health problem and 40% of the world's population living in an area at risk for dengue and causing nearly 400 million infections every year. There is no specific treatment for dengue, but if there is proper case management then case fatality rates can be below 1%. Aim and Objectives: To study the knowledge and practice about dengue fever in a rural community of Haryana. Methodology: The study recruited 400 adults (15-60 years) and all subjects were selected randomly from survey registers of eight anganwadi centres and data was collected by visiting house to house. Results: The association between demographic variables and knowledge about dengue fever and found out that only caste wise and socio-economic wise were found to be statistically significant rest associations were found to be statistically non-significant. Conclusion and Recommendations: There is a need of hour to make rural people aware of symptoms of DF and different preventive methods through mass media like television, newspapers, internet, social media etc or audio visual aids or through primary care physician
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A descriptive study of disability in patients presenting with medically unexplained physical symptoms in a medical OPD setting p. 1755
Goginani Ratnakara Rao, Piyush Ranjan, Rakesh K Chadda, GS Kaloiya, Sada N Dwivedi, Upendra Baitha, Manish Soneja, Ranveer S Jadon
DOI:10.4103/jfmpc.jfmpc_223_19  
Introduction: Medically unexplained physical symptoms (MUPS) are quite common in the primary care setting. These unexplained symptoms lead to physical, psychological, and functional disability increasing patient and caregiver distress. Methodology: Cross-sectional study was conducted on a sample of 100 patients attending medicine outpatient department. The data on sociodemographic profile and detailed clinical history were collected. Disability was assessed using the World Health Organization Disability Assessment Schedule 2.0 instrument. Association between qualitative measures was measured by Chi-square test or Fisher's exact test and for qualitative measure t-test or Wilcoxon test was used. Results: Most of the patients were young, from urban settings and belonging to lower socioeconomic strata. A mean of 6.54 symptoms per patient was presented with headache as the most common symptom. Average gross disability score in each domain was 1.6 with a major impact on the social and lifestyle-related domain. Conclusion: Patients with MUPS have significant disability especially in the domain of mobility and lifestyle-related activities. The disability is more in females, population dwelling in urban settlements, and population belonging to lower socioeconomic status.
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Association between health related quality of life (HRQOL) and activity of daily living (ADL) among elderly in an urban setting of Assam, India p. 1760
Gajendra Kumar Medhi, Jogesh Sarma, Star Pala, Himashree Bhattacharya, Parash Jyoti Bora, Vizovonuo Visi
DOI:10.4103/jfmpc.jfmpc_270_19  
Background: Ensuring better quality of life to an increasing number of elderly people is emerging as a stiff public health challenge in India. There is paucity of data on impact of functional health on health-related quality of life (HRQOL) in India. Objectives: The aim of this study is to explore the functional status and its association with different dimensions of HRQOL among elderly individuals in an urban setting of Assam, India. Materials and Methods: A total of 300 elderly were recruited in a cross-sectional study from the city of Dibrugarh, Assam, India. Eight domains of HRQOL of participants were assessed using short form 36 (SF-36). Functional status was assessed by using Barthel activity of daily living (ADL) tool. ANOVA test and binary logistic regression analysis was performed to examine the relationship between ADL status and HRQOL. Results: In all, 34.7% (n = 104) of participants had limitations in one or more ADL items. We also observed a strong graded relationship between ADL and HRQOL scores. Those who scored perfect 100 ADL score also scored highest in all eight HRQOL scales, whereas those with least ADL score scored lowest in all the HRQOL scales. In age- and sex-adjusted logistic regression analysis, the probability of poor health increased with decreasing level of ADL scores. Conclusion: Findings of the study suggest that decline in ADL can negatively impact different dimensions of HRQOL among elderly individuals. The findings indicate that there is need to pay proper attention for restoring functional health at later life in order to improve quality of life among elderly in India.
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CASE REPORTS Top

Pitting oedema in a polio survivor with lumbar radiculopathy complicated disc herniation p. 1765
Eric Chun Pu Chu, Aaron Ka Chun Chan, Andy Fu Chieh Lin
DOI:10.4103/jfmpc.jfmpc_254_19  
We report a 58-year-old male with sequelae of polio who presented with low back and left buttock pain, and pitting oedema of both legs for four months. The patient had a history of poliomyelitis at the age of 1 year which resulted in bilateral lower leg weakness, particularly on the left side. Magnetic resonance imaging showed cervical spinal stenosis secondary to posterior osteophyte formation, left paracentral disc extrusion at L2/L3 and L3/L4 levels with compression of the traversing L4 nerve root. The findings confirmed a diagnosis of lumbar radiculopathy caused by a herniated disc. The patient subsequently underwent a chiropractic treatment. The painful symptoms and pitting oedema in this case resolved with spinal adjustment in addition to scraping therapy to strengthen bilateral low back and the gluteal muscles. This case provides circumstantial evidence of a scarcely mentioned association between pitting oedema and lumbar radiculopathy caused by disc herniation. The pathophysiological mechanism is elusive, but might involve a complexity of cytokine-mediated inflammation and interconnection between somatic and autonomic nervous systems.
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Double-outlet left ventricle: A rare case p. 1769
Ashok Sunder, Bijaya Mohanty, Manoj Kumar Sahoo
DOI:10.4103/jfmpc.jfmpc_279_19  
Double-outlet left ventricle (DOLV) is a rare cardiac malformation in which both great arteries originate from the morphological left ventricle. DOLV is associated with high mortality, generally due to heart failure, myocardial infarction, or aortic thrombosis. With surgery, the 5-year survival rate is estimated at 70%–75%. Most patients will continue to present with residual cardiac anomalies, such as aortic or mitral valve regurgitation, arrhythmias, or hypertension. Here, we report a 25-year-old male with DOLV with pulmonary stenosis and patent ductus arteriosus who presented to us with hemoptysis, which was due to respiratory tract infection. He improved with standard therapy.
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Early onset gestational diabetes mellitus: A case report and importance of early screening p. 1772
Ahmad Najmi, Shubham Atal, Balakrishnan Sadasivam, Pooja Singh, Avik Ray
DOI:10.4103/jfmpc.jfmpc_290_19  
Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Screening for GDM is usually done at 24–28 weeks of gestation. In this case, we report a 31–year-old woman who developed gestational diabetes at 6 weeks in two successive pregnancies. She was in the perceived high-risk group to develop gestational diabetes. The first pregnancy terminated in spontaneous abortion at 10 weeks. In the second pregnancy, institution of insulin therapy at diagnosis was associated with a successful outcome. This case highlights the need of screening for gestational diabetes at the first antenatal visit in the high-risk group.
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Rare cause of stroke in young: Iron deficiency anemia and diabetic ketoacidosis p. 1775
Manna Sukdev, Kumari Sweety, Minakshi Dhar, Prasan Kumar Panda
DOI:10.4103/jfmpc.jfmpc_187_19  
Iron deficiency anemia (IDA) is a well-known cause of stroke in children, but its association is relatively rare in adults. We describe a case of 36-year-old woman, a known diabetes mellitus, who presented with recurrent vomiting, headache, and altered sensorium. Investigations revealed severe iron deficiency anemia, thrombocytosis, and ketoacidosis. Magnetic resonance imaging suggested acute infarct of B/L parieto-occipito-temporo-cerebellar region. Patient was worked up for possible causes of stroke in young. She underwent computed tomography angiography of the brain, echocardiogram, and screening for thrombophilia disorders. This, however, did not demonstrate a clear etiology and there were no other evidences of diabetic angiopathy. Some previously published case reports have suggested IDA as a potential cause of ischemic stroke; it is possible that the stroke in this young woman was attributable to severe IDA. Whether cerebrovascular accident has led to diabetic ketoacidosis or vice versa is a topic of discussion which needs further studies. Moreover, such catastrophes could be prevented by early diagnosis and timely management through involvement of primary care physicians.
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Complex regional pain syndrome—A forgotten entity p. 1778
Pulin Kumar Gupta, Pankaj Kumar Gupta, Subodh Kumar Mahto, Ankita Sheoran, Uttambir Singh, Akhila Bhandarkar, Udita Gupta, Nitin Hayaran
DOI:10.4103/jfmpc.jfmpc_193_19  
Complex Regional Pain Syndrome (CRPS) is a painful condition characterized by regional pain that is disproportionate temporality and severity to the usual course of any known cause. The pain is regional which is not in a specific nerve territory or dermatomal distribution. Judicious clinical suspicion and targeted investigations are necessary for correct diagnosis and appropriate treatment. We hereby report a case of a young lady with CRPS who presented to us with unilateral upper limb pain, swelling, discoloration and muscle atrophy without any history of inciting injury.
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Psychosis consequent to antimalarial drug use in a young child p. 1781
Jitender Aneja, Dheeraj Goya, Bharat Choudhary
DOI:10.4103/jfmpc.jfmpc_225_19  
The empirical use of anti-malarial agents in patients of unexplained pyrexia is a common practice in developing countries especially where the prevalence of malaria is high. The use of artemisinin-based combined therapies has gained prominence since some time, but chloroquine is still commonly utilized as monotherapy or in combination. Neuropsychiatric adverse effects of artemisinin are rarely reported, while chloroquine is associated with a range of such events. Further, the reporting of such side effects was more so in the 1980s and 1990s, and with the turn of this century, very few cases of chloroquine-induced psychosis especially in child and adolescent population have been reported. Herein, we report the development of psychosis in a young child who was exposed to chloroquine.
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Smartphone-induced tendinitis: A case report p. 1784
Kentaro Iwata
DOI:10.4103/jfmpc.jfmpc_230_19  
Repetitive manipulation of thumbs and fingers too much can cause de Quervain tenosynovitis. Some smartphones are becoming larger than their predecessors, with larger display, which might lead to more occurrence of tenosynovitis. A Japanese man in his 40s developed de Quervain tenosynovitis after buying a smartphone while using his thumb to handle it. Ceasing to use the thumb and using his right index finger while holding the phone eased his symptoms and he recovered without specific treatment. Health care providers should be aware of this phenomenon, particularly related to newly purchased smartphones.
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Carbamazepine-induced hyponatremia – A wakeup call p. 1786
Nidhi Kaeley, Ankita Kabi, Rohan Bhatia, Aroop Mohanty
DOI:10.4103/jfmpc.jfmpc_185_19  
Carbamazepine-induced hyponatremia is a rare condition. The patients may or may not be symptomatic. Epilepsy is considered a social taboo. Hence, patients do not reveal history of being on antiepileptic agents. Carbamazepine is a known antiepileptic and psychotropic agent. It is commonly used for the treatment of seizures and psychiatric disorders. We present a case of a 60-year-old female patient presenting in emergency department with history of carbamazepine-induced hyponatremia. It raises antidiuretic hormone (ADH) levels. This leads to increased sensitivity of renal tubules to ADH levels. She was diagnosed as a case of syndrome of inappropriate ADH and was treated accordingly. She was asymptomatic and was ambulatory. She recovered significantly. Hence, it is essential to monitor sodium levels in patients on carbamazepine therapy and also on drugs with similar mechanism of action.
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Cocktail treatment of antibiotic, steroid, and analgesic in a tubercular case; the urgency to set up antimicrobial stewardship practices in the community p. 1789
Archana J Pattupara, Augustine Jose, Prasan K Panda, Vibhu Goel
DOI:10.4103/jfmpc.jfmpc_4_19  
Tuberculosis is a well-known entity in India with many implemented policies to ensure the cost-effective early management. Missed, delayed, and complicated presentations do occur, requiring expensive tertiary level of health care. Among many contributing factors, lack of antibiotic stewardship is at the top. We report a case of 65-year-old man who presented with on and off fever for six months, receiving cocktail treatments of antibiotics, analgesics, and steroids from a local dispensary. Our initial investigations revealed microcytic anemia with high erythrocyte sedimentation rate, leukocytosis, and bilateral pleural effusion on chest X-ray. Contrast enhanced computer tomography of chest and abdomen suggested disseminated tuberculosis including bilateral empyema. Frank pus was drained on thoracocentesis, which was negative for Gram stain, Ziehl–Neelsen stain, and bacterial culture, but positive CB-NAAT for tubercular bacilli with no resistance to rifampicin. Mantoux test and stool occult blood were positive. This case highlights an unusual presentation of tuberculosis and the ongoing lacunae in the society with importance to the primary care providers in the effective management of tuberculosis focusing on antimicrobial stewardship.
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Peritoneal dialysis for the rescue in critical refractory metabolic acidosis in diabetic ketoacidosis p. 1792
Harpreet Singh, Relangi H S Krishna, Arihant Jain, Navneet Sharma
DOI:10.4103/jfmpc.jfmpc_138_19  
Diabetic ketoacidosis is one of the most serious complications of diabetes mellitus. Role of bicarbonate therapy in severe diabetic ketoacidosis is controversial. There are only few case reports of management of refractory diabetic ketoacidosis with renal replacement therapy. Here, we present a case of young male with severe diabetic ketoacidosis, which was refractory to fluid resuscitation, insulin and was managed successfully managed with peritoneal dialysis.
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Guillain Barre syndrome with pulmonary tuberculosis: A case series from a tertiary care hospital p. 1794
Sayan Malakar, Tarun D Sharma, Sujeet Raina, Kailash N Sharma, Dhiraj Kapoor
DOI:10.4103/jfmpc.jfmpc_161_19  
Introduction: Guillain-Barre syndrome (GBS) is post-infectious autoimmune polyradiculopathy which characteristically presents with a monophasic illness with CSF albumino-cytological dissociation with partial or complete recovery. The incidence of GBS is about 1 to 2/100,000 per year.[1] Subtypes are described based on electrophysiological patterns, the most common being acute inflammatory demyelinating polyneuropathy (AIDP) and rarer ones being acute motor axonal neuropathy (AMAN), and acute motor and sensory axonal neuropathy (AMSAN). Tuberculosis is prevalent in India with various neurological manifestation including tuberculoma, brain abcess, pott's spine, and radiculomyelopathy.[2] Five cases have been published of tuberculosis and GBS.[3],[4],[5],[6],[7] The main underlying pathophysiological mechanism is aberrant immune activation due to molecular mimicry against ganglioside in myelin. Although tuberculosis is mainly T-cell-mediated chronic disease, still there are cases reported with tuberculosis with GBS. Here we are going to present four cases of pulmonary tuberculosis presented with GBS. Materials and Methods: This study describes clinical profile of four patients who presented with concomitant pulmonary tuberculosis and GBS over a period of 4 years in a tertiary hospital. Diagnosis was made according to Brighton criteria and alternative diagnosis were ruled out by clinical examination, serological markers, and MRI imaging of the spine. All patient underwent thorough investigation including HIV 1, 2, anti-CMV, anti-EBV to rule out other possible triggers of GBS, NCV, CSF study along with sputum AFB culture. ZN staining and CECT thorax were also done to support the diagnosis. Results: Of total four cases, 3 were male and 1 was female who presented with weight loss, anorexia, cough with or without hemoptysis, and acute progressive LMN quadriparesis in which there was typical albumin-cytological dissociation in CSF. Nerve conduction studies were suggestive of AIDP in two patients, AMAN in one patient, and AMSAN in the fourth one. An exhaustive investigation for triggers of GBS were performed for all patients who were treated with IVIG and two of them completely recovered and rest of two did not recover completely after 6 weeks of follow-up. Conclusion: In pulmonary tuberculosis, patients with polyneuropathy demands urgent search for GBS as there has been case reports in literature though the association between tuberculosis and GBS is not clear.
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A rare cause of familial exogenous Cushing syndrome p. 1798
Remya Rajan, Cijoy Kuriakose, Jinson Paul, Nitin Kapoor, Kripa Elizabeth Cherian, Thomas Vizhalil Paul
DOI:10.4103/jfmpc.jfmpc_294_19  
Exogenous steroid use is the most common cause of Cushing syndrome. With the use of glucocorticoids(GC) for a variety of diseases, the indiscriminate use of this group of drugs has increased. We present a family from which both children were brought with features suggestive of Cushing syndrome. On evaluation, they were found to have suppressed hypothalamic pituitary adrenal (HPA) axis, signifying steroid use from exogenous sources. On further evaluation by a psychiatrist, the mother who was on treatment for chronic depression confessed that she had bought dexamethasone tablets over the counter, and administered the same, mixed with fruit juices to her sons. The family was counselled regarding the consequences of chronic steroid abuse and the children were started on replacement doses of prednisolone. Certain features like posterior subcapsular cataract, glaucoma, avascular necrosis of femur and psychosis are specific to exogenous Cushing syndrome. Despite efforts to understand the effects of long-term steroid treatment on the HPA axis, it is not yet clear as to which patients will have prolonged HPA axis suppression. The time taken for the recovery of HPA axis remains variable. Also, HPA axis suppression due to exogenous steroids may present as acute adrenal crisis. Hence, it is important to start these patients on replacement dose of steroids and also educate them regarding the increased requirement of steroids during stress.
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An uncommon cause of polyarthralgia p. 1801
Sudarsanababu Lalitha Soumya, Kripa Elizabeth Cherian, Riddhi Das Gupta, Pradeep M Poonnoose, Julie Hephzibah, Anne Jennifer Prabhu, Thomas Vizhalil Paul, Nitin Kapoor
DOI:10.4103/jfmpc.jfmpc_299_19  
Tumour induced osteomalacia (TIO) is a paraneoplastic syndrome characterized by renal phosphate wasting and hypophosphatemic osteomalacia, caused by FGF-23 (Fibroblast growth factor-23) producing mesenchymal tumours. Here, we report the case of a 40 year old lady referred by her family physician for multiple joint pains of 2 years duration. There was no evidence of inflammatory arthritis. Biochemical investigations revealed low phosphorus, with raised alkaline phosphatase and high levels of FGF-23. As a TIO was considered likely, functional imaging with a DOTATATE PET scan was done, which revealed a DOTA avid lesion in the right foot. Following surgical excision of the tumour, there was significant relief in symptoms and gradual recovery of phosphate to normal levels. It is relevant and important for family physicians as in subjects with symptom like polyarthralgia, a simple measurement of analytes like phosphate, calcium and alkaline phosphatase in primary care setting will help to arrive at a cause and referral for further evaluation as this condition is potentially treatable.
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Short-term monotherapy with Liraglutide for weight management: A case study p. 1804
Feras Almarshad
DOI:10.4103/jfmpc.jfmpc_213_19  
Background: Liraglutide 3 mg was approved by the FDA as an antiobesity drug. A recent study reported that short-term treatment with Liraglutide (20.0 ± 6.4 days) reduces body weight. Case Presentation: A 35-year-old male not having any medical illness was presented for medical weight-loss management. He was taking Liraglutide (Saxenda) by SC solution multidose pen 0.6 mg in the first week, 1.2 mg in the second week, 1.8 mg in the third week, 2.4 mg in the fourth week, and 3.0 mg in the fifth week, i.e. 0.6-mg dose increase per week. During the treatment period, he was maintained on low-calorie diet, which was not exceeded 1,500 calories/day. During the treatment period, he was on the mild exercise of walking 45 min three times per week. His initial anthropometric measurements include a weight of 118 kg, height 171 cm, and body mass index 40.4. Conclusion: Short-term (05 weeks) monotherapy with Liraglutide with restricted-calorie diet and mild exercise significantly reduces the weight by 13.55%.
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Cold agglutinin-induced hemolytic anemia as the primary presentation in SLE - A case report p. 1807
Bijaya Mohanty, Mohammad Zeya Ansari, Pranita Kumari, Ashok Sunder
DOI:10.4103/jfmpc.jfmpc_298_19  
Cold agglutinin-induced hemolytic anemia as the primary presentation in systemic lupus erythematosus (SLE) is extremely rare. Only few cases have been reported in literature so far. Here, we report a 17-year-old girl who presented with features of hemolytic anemia and later diagnosed as a case of SLE.
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LETTERS TO EDITOR Top

Sexual boundaries in the doctor–patient relationship p. 1809
NA Uvais
DOI:10.4103/jfmpc.jfmpc_312_19  
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Lessons on ethical healthcare communication from #MeToo movement p. 1810
Ganesh Singh Dharmshaktu, Tanuja Pangtey
DOI:10.4103/jfmpc.jfmpc_258_19  
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Save family medicine to protect health of the third world p. 1812
Amrita Ghosh, Ranabir Pal
DOI:10.4103/jfmpc.jfmpc_211_19  
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Need for a framework document on building competency in injury prevention p. 1814
Sunil K Raina
DOI:10.4103/jfmpc.jfmpc_282_19  
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