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   Table of Contents - Current issue
Coverpage
May-June 2018
Volume 7 | Issue 3
Page Nos. 487-648

Online since Tuesday, July 17, 2018

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EDITORIAL  

What is in the name? Understanding terminologies of patient-centered, person-centered, and patient-directed care! Highly accessed article p. 487
Raman Kumar, Vijay Kumar Chattu
DOI:10.4103/jfmpc.jfmpc_61_18  
The traditional “medical model” of health care has a paternalistic approach where patients are reassured and not decision makers, but some individuals and families prefer it. But there are some other confusing terminologies in health-care delivery and quality improvement namely patient-centered, person-centered, and patient-directed care. By changing the language, it is emphasizing that people are more than diseases and their socioeconomic determinants can affect their disease trajectories and care choices. Patient-centered denotes more holism and empowerment as it promotes and increases the access to personal health information through various modes using updated technology such as computers or mobile phones and keeping them informed through their active participation. Whereas person-centered care would focus on the whole person not just the medical conditions. In patient-directed care model, again the approach puts individuals in control of decisions about their care. One of the reasons why family medicine fraternity sprang up was to provide an antidote for high-tech specialty care that did not respect patients' values and concerns which is seen by their emphasis on the patient as a whole.
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COMMENTARIES Top

Game change in Indian Health Care System through reforms in medical education curriculum focusing on primary care- Recommendations of a joint working group Highly accessed article p. 489
Sunil Kumar Raina, Raman Kumar, Dinesh Kumar, Raman Chauhan, Sujeet Raina, Vishav Chander, Rajiv Gupta, Bhanu Awasthi, Rashmi Kaul, Rahul Gupta, Ajay Bhat, Mitasha Singh, Harshdeep Joshi
DOI:10.4103/jfmpc.jfmpc_92_18  
Despite the stated aim of Medical Council of India (body regulating medical education in India) to produce an Indian Medical Graduate with requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a doctor of first contact of the community while being globally relevant, it appears that we failed. The joint working group extensively consisting of medical teachers have come up with suggestions which may work as the game changer in Indian Health care system. The key is to dedicate medical education towards primary care.
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Health at the time of demonetization p. 495
Sanghamitra Pati, Pranab Mahapatra, Rajeshwari Sinha
DOI:10.4103/jfmpc.jfmpc_27_18  
Health care is one of the key essential services to be traditionally impacted by financial turbulences. The Government of India announced the demonetization of INR 500 and INR 1000 currency notes in November 2016 to curb corruption and introduce economic transparency. The present commentary analyzes the impact of this economic reform on the availability/delivery of health-care services and also its transient effect on the general population availing such services during the first 2 weeks post demonetization. While print and electronic media indicated initial setback and displeasure with reference to delivery and access of health-care services, personal interaction with caregivers or patients suggested that there was no lasting adverse effect on health-care delivery. In fact, the enthusiasm for a cleaner economy meant for the greater good of the country prevailed among the general public and allowed them to bear these hardships. Our assessment suggests that demonetization and its consequential transition were viewed favorably. Financial and economic reforms initiated in the national interest can therefore be managed well with public support.
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REVIEW ARTICLES Top

Biopsychosocial model of illnesses in primary care: A hermeneutic literature review Highly accessed article p. 497
Hari Kusnanto, Dwi Agustian, Dany Hilmanto
DOI:10.4103/jfmpc.jfmpc_145_17  
Biopsychosocial model is a useful worldview for primary care or family doctors. However, it is often considered as impractical or too complicated. The objective of this study is to review the implementation of the biopsychosocial model in clinical practice, and its contributions to clinical outcomes. Hermeneutic circle literature review was conducted to provide experiential learning in an attempt to understand biopscyhosocial model, first developed by George Engel. Literature search started with review articles in Medline and Scopus as search engines. Citations from previous articles, editorials, and research articles were identified and interpreted in the context of the knowledge derived from all identified relevant articles. The progress of biopsychosocial model has been slow, and primary care doctors do not implement biopsychosocial medicine in their practice, while biomedical thinking and approach are still the dominant model. Biopsychosocial research addressed chronic illnesses and functional disorders as conditions in need for biopsychosocial model implementation. As payment scheme, clinical guidelines and clinical performance indicators are biomedically oriented, there is no incentive for primary care doctors to adopt biopsychosocial model in their practice. Workload and lack of competence in primary care may hinder the implementation of biopsychosocial model. Biopsychosocial model helps primary care doctors to understand interactions among biological and psychosocial components of illnesses to improve the dyadic relationship between clinicians and their patients and multidisciplinary approaches in patient care. Biopsychosocial model potentially improves clinical outcomes for chronic diseases and functional illnesses seen in primary care.
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A review on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care Highly accessed article p. 501
Kok Wai Kee, Cheryl Wai Teng Char, Anthony Yew Fei Yip
DOI:10.4103/jfmpc.jfmpc_196_17  
Introduction: Transition of care from hospital to primary care has been associated with increased medication errors. This review article aims to examine the existing evidence on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care. Methods: We systematically reviewed the articles in primary or ambulatory care setting on patients with care transition that involved medication safety, discrepancy, or error as outcome assessment. Primary research articles were selected. Interventions in nursing homes or long-term care facilities were excluded from the review. Results: We found 6 articles that met the inclusion criteria and 4 are prospective cohort study. The key players were pharmacists, nurse, and primary care physician. The interventions included care communication, medication reconciliation or review, and clarifying medication-related problems. Conclusion: There is evidence that interventions in primary care setting reduce medication discrepancies on patients with the transition of care from hospital to primary care setting. Only one randomized trial involving pharmacist-led medication reconciliation was done in an outpatient setting. More good-quality randomized controlled trials should be carried out to confirm the evidence.
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Jet lag: Heuristics and therapeutics p. 507
Paurush Ambesh, Vijay Shetty, Sahitya Ambesh, Sushilkumar Satish Gupta, Stephan Kamholz, Lawrence Wolf
DOI:10.4103/jfmpc.jfmpc_220_17  
Jet lag is one of those common medical problems, to which most people don't give a serious thought. However, it is intricately intertwined with our normal circadian rhythm. It is classified as a sleep disorder. There is also a dearth of good scientific literature, not to mention clinical trials on the subject. Slowly but steadily, the scientific community is realizing the various deleterious health effects of jet lag and is devising innovative methods to counter them. This narrative review touches upon the etiopathogenesis, clinical manifestations and therapeutic strategies effective against the nagging problem of jet lag.
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Ultraviolet radiation and its effects on pregnancy: A review study p. 511
Malihe Botyar, Rozita Khoramroudi
DOI:10.4103/jfmpc.jfmpc_311_17  
Seasons and Vitamin D are factors that are directly and indirectly related to ultraviolet (UV) radiations and can affect pregnancy. Therefore, the present study aims at investigating the effects of being exposed to direct UV radiation during pregnancy period and its effects on fetal growth, premature birth, and high blood pressure. This study was conducted by searching different websites such as Medline, Embase, ProQuest, Global Health, Google Scholar, and Scopus. Of the 430 papers found, between 1985 and 2017, seventeen related articles were used. The results showed that being exposed to UV radiation during the first 3 months of pregnancy is associated with improved fetal growth and causes high blood pressure during pregnancy. The literature shows that being women exposure to UV radiation had beneficial effects on fetal growth and blood pressure during pregnancy period. However, since this issue has not been extensively studied in the past, the results from previous studies should be generalized with extreme care and caution. Therefore, it is suggested that further studies be carried out in this area.
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ORIGINAL ARTICLES Top

Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study p. 515
Arvind Kumar Singh, Shashi Kant, Rizwan Suliankatchi Abdulkader, Ayush Lohiya, Vijay Silan, Baridalyne Nongkynrih, Puneet Misra, Sanjay Kumar Rai
DOI:10.4103/jfmpc.jfmpc_348_17  
Background and Objectives: Sexual health disorders are an important but less researched public health issue in India. We aimed to estimate the prevalence of sexual health disorders and their associated factors among adult men in a rural community of Haryana, India. Materials and Methods: A community-based cross-sectional study was conducted among adult men aged 18–60 years using a multistage stratified random sampling. Information pertaining to sociodemographic characteristics, lifestyle and sexual practices, and self-reported sexual problems were collected. Sexual health disorders were defined based on International Statistical Classification of Diseases-10 classification of mental and behavioral disorders. Step-wise logistic regression was carried out to identify factors independently associated with sexual disorders. Results: At least one sexual health disorder was reported by 81% of the men. The most commonly reported disorder was self-perceived defect in semen (64.4%), followed by loss of libido (21%), masturbation guilt (20.8%), erectile dysfunction (5%), and premature ejaculation (4.6%). Factors significantly associated with sexual health disorders among all men were being never married (odds ratio = 2.04; 95% confidence interval: 1.51, 2.77), smoking (1.57; 1.16, 2.14), cannabis use (4.20; 1.68, 10.48), diabetes (2.40; 1.22, 4.73), and hypertension (3.17; 1.12, 8.92). Interpretation and Conclusions: A high burden of sexual health disorders was identified among the rural men. Wider recognition of this issue is needed among the health-care providers and policymakers.
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Monitoring of birth registry coverage and data quality utilizing lot quality assurance sampling methodology: A pilot study p. 522
Shiyam Sunder Tikmani, Sarah Saleem, Elizabeth McClure, Farnaz Zehra Naqvi, Farina Abrejo, Zahid Soomro, Dennis Wallace, Robert L Goldenberg
DOI:10.4103/jfmpc.jfmpc_59_17  
Background: Effectively monitoring the coverage and quality of data in low-resource settings is challenging. Lot quality assurance sampling (LQAS) is a method to classify coverage as adequate or inadequate. The aim of this pilot study is sought to determine the coverage and quality of a birth registry in a rural district in Pakistan. Methods: This survey was conducted in 14 clusters of Thatta, Pakistan. LQAS methodology was used to monitor the birth registry from December 2015 to February 2016. We randomly selected 19 villages from each cluster. We used a short questionnaire to review the quality of data collection for select variables. Frequency and percentages were reported for categorical variables. For data validation, Kappa statistics (κ) were applied to assess the agreement between categorical observations, and the Bland–Altman test was used to assess agreement for continuous data. Results: Of the 14 clusters sampled, 12 clusters had adequate coverage. Agreement of hemoglobin performance between the women's response and information in birth registry data was good (κ = 0.718) (95% confidence interval [CI]: 0.58–0.82); agreement on birth outcome recorded by the workers in the registry and as mentioned by women was very good (κ = 1.0); and agreement whether birth weight was assessed within 48 h of delivery was good (κ = 0.648) (0.37–0.92). Conclusion: LQAS is a powerful tool to monitor coverage and data quality of the birth registry maintained by the global network for women's and children's health in Pakistan and potentially for data from other surveillance systems.
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Knowledge attitude, and practice regarding dietary salt intake among urban slum population of North India p. 526
Sudip Bhattacharya, JS Thakur, Amarjeet Singh
DOI:10.4103/jfmpc.jfmpc_60_17  
Introduction: Hypertension is an important modifiable risk factor for cardiovascular disease. High salt intake is an etiological factor for hypertension. Any effective salt reduction strategy will be based on people's mind-set about salt use. Our objective for this study was to assess the knowledge, attitude, and practice for dietary salt intake by urban slum populations in Indira Colony, Chandigarh. Methodology: In 2015, we conducted a cross-sectional survey among a representative sample of 300 adults aged 18–69 years using a standardized questionnaire. Variations in the knowledge attitude and practice by gender and residence location were compared using the Chi-square tests. Results: Most of them (96%) took processed foods and 99% did not bother about the salt levels in the food. They also added salt on table. They did not buy low-sodium salts. Majority of them (75%) perceived that they are taking right amount of salt. They were clueless about the daily recommended allowance. Many participants (43%) did not know about the harmful effects of dietary salt. One-fifth (18%) of them had wrong information about dietary salt. Majority of the participants (64%) considered that lowering salt in diet is not important. Conclusion: Overall awareness level about optimal salt intake in diet was very poor among the slum residents. Recommendation: Development of effective public education initiative is the need of the hour for combatting hypertension.
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Relationship between diet quality and carotid intima-media thickness in people with and without carotid atherosclerosis p. 531
Eman Mokbel Alissa, Sara R Helmi, Maisa'a M Al-salmi
DOI:10.4103/jfmpc.jfmpc_66_18  
Background: Dietary assessment and management appear to be essential to limit the impact of cardiovascular risk. Aim: This study aims to assess the association between diet quality as measured by Alternate Healthy Eating Index (AHEI) and coronary risk as determined by carotid artery intima-media thickness (CIMT) among Saudi adults. Methods: A case–control study was conducted in 210 participants who were matched for age and sex and recruited sequentially from King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Demographic and anthropometric variables were measured in all study participants. Dietary intake was measured by food frequency questionnaire. Results: Obesity was highly prevalent among the study population. The mean AHEI score for the total sample was found to be 58.3 ± 1.67. There were no differences according to the presence and absence of atherosclerotic disease; 45% had a poor diet, and 39% had a diet that needs improvement. Participants with higher CIMT values tended to be of lower AHEI category. Negative correlations were observed between CIMT and AHEI scores and components after adjustment for age and energy intake. Conclusions: Adherence to a healthier diet, as reflected by a higher AHEI score, is associated with lower coronary risk, as estimated by CIMT value, independently from obesity and personal behavior factors.
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Musculoskeletal manifestations of tuberculosis: An observational study p. 538
Nikhil Gupta, Anuj K Bhatnagar
DOI:10.4103/jfmpc.jfmpc_7_17  
Background: Data of musculoskeletal manifestations of tuberculosis (TB) are limited to case reports, series, or retrospective studies. Therefore, we conducted this study to create awareness among doctors about musculoskeletal manifestations of TB. Materials and Methods: This was a prospective observational study conducted at a referral TB Hospital in North India in September and October 2016. The aim of our study was to study musculoskeletal manifestations of TB. We included patients who had active TB as per the World Health Organization 2010 criteria. Patients with other chronic illnesses were excluded. A detailed history, examination, and appropriate investigations (blood, urine, serological, and radiological) of the 100 consecutive patients fulfilling the inclusion criteria were recorded. Results: The mean age of patients was 32.16 ± 12.93 years. Male-to-female ratio was 43:57. The mean duration of disease was 6.85 ± 8.83 months. Of the 100 patients, 60 (60%) had pulmonary TB. The mean duration of antitubercular therapy was 1.79 ± 1.34 months. Fibromyalgia was classified in 21 (21%) patients, polyarthralgia was seen in 9 (9%), Pott's spine in 7 (7%), osteomyelitis in 4 (4%), and scleritis in 2 (2%) patients. Uveitis, tenosynovitis, erythema induratum, subcutaneous abscess, and dactylitis were seen in 1 (1%) patient each. In 21 patients who had fibromyalgia, 11 developed fibromyalgia with the second episode of TB amounting to 60.75% patients. Conclusion: This is the first prospective study to look at the musculoskeletal manifestations of TB. Patients with active TB were found to have various rheumatological manifestations.
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A cross-sectional study on domestic violence in emergency department of Eastern Nepal p. 542
Pramendra Prasad Gupta, Rabin Bhandari, Vijay Khanal, Shital Gupta
DOI:10.4103/jfmpc.jfmpc_7_18  
Introduction: Domestic violence is certainly an important condition, and certainly carries significant health consequences. Screening is probably acceptable to most patients attending an emergency department. The objective of this study is to find out the frequency of domestic violence victims attending emergency department, to find out the factors related to domestic violence, type, and severity of injury and to identify the impact of domestic violence in the victims. Materials and Methods: This was a cross-sectional observational study done in the Department of General Practice and Emergency Medicine of BP Koirala Institute of Health Sciences from January 2014 to December 2014. Anyone presented with a physical injury intentionally caused by a relative, partner, or other household member (spouse, partner, sibling, ex-partner, child, and other wives/partner of spouse). Results: The total number of patient enrolled in this study was 423. Among which 71.9% were female and 28.1% were male. About 27% of female and 31.9% of male were in the age group of 20–30 years. Majority (42.4% females and 48% males) of the victim's family had agriculture for primary occupation. Among the study groups, 40.9% of cases were beaten by direct hit and 24.3 with weapon, 5% of cases were only reported as rape, and 23.6% as homicidal case. Conclusion: Domestic violence is particularly insidious form of gender-based violence. In the place where they should feel the greatest safety and security- the family-women often face terror form of physical, psychological, sexual, and economic abuse.
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A study of serum Vitamin D level and its association with hypertension p. 546
Arnab Kar, Sumana Datta
DOI:10.4103/jfmpc.jfmpc_82_18  
Background: Evidence suggests that low levels of Vitamin D may adversely affect the cardiovascular (CV) system. Several studies have been done regarding the relation and possible causative role of Vitamin D in CV disorders and its well-known risk factors; however, there are limited studies in this part of the world. The aims were as follows: (1) To study the relation between serum Vitamin D level between nonhypertensive and hypertensive patients. (2) To study the relation of serum Vitamin D levels in patients with isolated systolic hypertension (ISH), isolated diastolic hypertension, systolo-diastolic hypertension, and their comparison vis-à-vis nonhypertensives. Materials and Methods: A cross-sectional study was conducted with 154 patients attending medicine outpatient department of a tertiary care hospital of North Bengal from June 2012 to May 2013. The Vitamin D was measured by direct ELISA method. Blood pressure (BP) measurements were done. Statistical analysis was done by using SPSS 16.0 for Windows. Results: The Vitamin D level in the hypertensive group was 22.36 ± 12.64; ISH Group was 22.04 ± 14.26; the isolated diastolic hypertension (IDH) Group was 18.82 ± 0.00; and the systolo-diastolic hypertensives (SDH) Group was 22.67 ± 12.51. Then, the mean value of Vitamin D in nonhypertensive Group (27.47 ± 13.43) was significantly (P < 0.05) higher than IDH, SDH, and the hypertensive as a whole groups. The relation with ISH Group also reached near significance (P = 0.074). There was a negative correlation with BP and serum Vitamin D. This remained statistically significant (P = 0.044) for systolic BP (SBP) and near significant (P = 0.075) for mean arterial pressure. In population having serum Vitamin D <30 ng/ml (deficient or insufficient), the negative correlation relationship between SBP and serum Vitamin D remains statistically significant (P = 0.010). Conclusion: Among the hypertensives, SDH shows significantly lower levels of serum Vitamin D. The patients with ISH show a trend, though not statistically significant, toward a lower level of Vitamin D compared to the nonhypertensive population.
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A randomized, controlled trial comparing the metformin, oral contraceptive pills and their combination in patients with polycystic ovarian syndrome p. 551
Yogesh Kumar, Narendra Kotwal, Yashpal Singh, Vimal Upreti, Shrikant Somani, K V. S Hari Kumar
DOI:10.4103/jfmpc.jfmpc_83_17  
Background: Polycystic ovarian syndrome (PCOS) is a condition characterized by insulin resistance (IR) and hormonal dysfunction. We conducted a randomized, controlled trial comparing the effects of metformin, oral contraceptive pills (OCP) and their combination in PCOS. Materials and Methods: We randomized 90 newly diagnosed PCOS (age 18–40 year, symptom duration >6 months) patients into three groups (Group 1–Metformin, Group 2–OCP, and Group 3– Metformin + OCP) in this prospective study. We excluded patients with past use of insulin sensitizers and hormone therapy. We evaluated for the hyperandrogenism (acne, acanthosis, hirsutism, and hormone panel), IR by homeostasis model assessment (HOMA-IR), inflammation (high-sensitivity C-reactive protein, fibrinogen, and ferritin), and body composition (% fat, android/gynoid ratio) markers at baseline and 6 months after therapy. The data were analyzed using appropriate statistical methods and P < 0.05 was considered statistically significant. Results: The study population had a mean age 23.2 ± 4.4 years and body mass index of 28.4 ± 6.1 kg/m2. The improvement in the clinical parameters was similar in all the groups. The combination therapy showed a better response in reducing inflammatory markers, IR, and body composition than either of the groups using a single drug. Metformin alone has resulted in a minor reduction of the androgens. None of the patients developed significant adverse effect to the given therapy. Conclusion: PCOS is managed with either metformin or OCP in many patients. The combination improves the hyperandrogenism, body composition, and reduces the inflammatory markers.
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Factors influencing utilization of reproductive health services among mothers in Meghalaya, India p. 557
Jurysha Nongdhar, Navya Vyas, P Arathi Rao, Prakash Narayanan, Star Pala
DOI:10.4103/jfmpc.jfmpc_242_17  
Background: Antenatal care (ANC) is one of the basic components where it can provide pregnant women with an expansive scope of well-being, health promotion, and preventive health services. However, still 830 women die every day from preventable pregnancy-related causes, and 99% of these deaths occur in developing countries, out of which 20% of these deaths were from India. Objectives: The objective of this study is to explore the factors influencing the utilization of reproductive health services among mothers and to find the association between various factors and utilization of reproductive health services. Methods: A community-based cross-sectional study was conducted during January–June 2017 among 160 mothers who had an infant aged <6 months in Mawkyrwat Block, South West Khasi Hills District in Meghalaya. Respondents were selected through simple random sampling, and semi-structured questionnaire was used for data collection. Data were analyzed using SPSS 16. Results: Mothers attending four or more antenatal checkups were 10.6%, where 53.5% of the mothers registered their first ANC checkups only by the second trimester and 57.5% preferred home delivery. Nearly 52.9% of the mothers were staying more than 5 km away from the health-care facilities. The usage of family planning methods was very low, i. e., 96.9% of the mothers are not using any of the family planning methods. Conclusion: Study finding reveals that the utilization of health-care services was low. Area-specific approaches such as health camps and mobile clinics might result in improved utilization of reproductive health services.
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Analysis of tuberculosis case report in Hyderabad district of Telangana state p. 561
Snigdha Pattnaik
DOI:10.4103/jfmpc.jfmpc_110_18  
Background: The estimated incidence of TB in India was approximately 28,00,000 as per the Global TB report 2017. This accounts for a quarter of the world's TB (Tb) cases. National strategic plan, is a programme which aims at the elimination of Tb by 2018. The programme is crafted in line with other health sector strategies and global efforts, such as the draft National Health Policy 2015, World Health Organization's (WHO) End TB Strategy and the Sustainable Development Goals (SDGs) of the United Nations (UN). Key strategies under National Strategic plan: Private sector engagement, active case finding, drug resistant Tb case management, addressing social determinants including nutrition, robust surveillance system, community engagement and multisectoral approach. Methods: In March 2018, India Tb report was released by RNTCP. An analysis of the report is done in the research article, an attempt to take forward end Tb strategy. Result: According to The India Tb report, 85% of new TB cases were detected, nationwide, where as 90% of new cases were detected in Hyderabad, during the same time period. Tuberculosis (Tb) notification rate (per 100 000 population), in India is 138, where as in Hyderabad district of Telengana it is 100. Both Public and private sector Tb case notification rate, of Hyderabad district was less than that of India (90,10). 6% of Tb cases were paediatric cases both Hyderabad and Nationwide. HIV status was known in 66% cases, in India and 67% in Hyderabad district of Telengana.
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Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India p. 565
Rajmohan Panda, Sandeep Mahapatra, Divya Persai
DOI:10.4103/jfmpc.jfmpc_111_17  
Introduction: “Non-communicable diseases (NCDs) are the raging reality of today's world and have moved up the priority list of most countries worldwide including India. The government of India has launched programs such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke, but little is known about preparedness of health system to address NCDs. Methods: A qualitative study was conducted in the states of Odisha and Kerala to document the government stakeholder perspectives of health system preparedness for NCDs. Results: The study revealed that both the states have a NCD preparedness structure but need strengthening at various levels. The present human resource is inadequate, over-burdened, and requires specific skills. The lack of workforce adversely affects the service delivery mechanism. The study highlighted that there is a gap in the timely release of funds and also lack of evidence-based application if the information that is made available. Conclusion: There is a clear need to fill the gaps and strengthen the identified areas at various levels to address the increasing NCD burden. There is also a need to more in-depth and large-scale studies on such issues which act as external monitoring mechanisms thereby assisting the policy makers and program managers in with relevant and scientific evidence to bring reforms in the health system.
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Evaluation of accredited social health activists in Anand District of Gujarat p. 571
Dinesh J Bhanderi, Arunkumar R Varun, Deepak B Sharma
DOI:10.4103/jfmpc.jfmpc_207_17  
Background: Accredited social health activist (ASHA) has the pivotal role to play in the whole design and strategy of national rural health mission (NRHM). The performance of ASHA is, therefore, critical for the success of NRHM and hence of the health improvement strategy of the government of India. Objectives: (1) To evaluate the knowledge and performance of ASHA. (2) To assess the factors affecting these two attributes of ASHA. Methods: Ten ASHAs were randomly selected from each of the eight administrative blocks of Anand District. Thus, a total of 80 ASHAs participated in the study. Knowledge of ASHAs was assessed by computing knowledge score which included 15 questions, while the performance was assessed through performance score which included 17 indicators. Each ASHA was ranked “Poor,” “Average,” and “Good” based on the performance score. Results: Out of 80 ASHAs, 49 (61%) were in the age group of 30–40 years. Majority of ASHAs(68%) belonged to other backward class (OBC). 73 (91%) ASHAs had education up to at least secondary level. 65 (81%) ASHAs were working for more than 4 years. About 84% of ASHAs had knowledge score between 12 and 15. Nearly 51% of ASHAs ranked average in performance, while 49% ranked poor. None of the ASHAs ranked good. Knowledge score and performance ranks were not associated with age, caste, education, and duration of service of ASHAs. Performance ranks were found to be significantly associated only with time lapse since the last training received. Conclusion: To strengthen the grass root cader of ASHAs, their evaluation should be conducted regularly. Additional refresher training should be provided to ASHAs with low knowledge and performance scores so that the engagement of rural community with the health system can be improved.
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Prevalence of Helicobacter pylori infection in upper gastrointestinal tract disorders (dyspepsia) patients visiting outpatient department of a hospital of North India p. 577
Puneet Kumar Agarwal, Mayank Badkur, Richa Agarwal, Seema Patel
DOI:10.4103/jfmpc.jfmpc_213_17  
Background: Helicobacter pylori infection is a major health ailment in developing countries. The infection is related with high morbidity and mortality ranging from chronic gastritis to gastric malignancies. The prevalence of H. pylori infection greatly varies from country to country and region to region. The aim is to study the prevalence of H. pylori infection in upper gastrointestinal (GI) tract disorders (dyspepsia) patients. Methods: The study was carried out in an outpatient department, India. Patients presenting with dyspeptic symptoms were subjected to serological investigation and upper GI endoscopy, histopathological examination, and rapid urease test of specimen. Diagnosis of H. pylori infection was made if one or both diagnostic test results were positive. Results: H. pylori infection was diagnosed in 85% of patients. There was no significant difference in sex- and age-related distribution (<50 years' age group and >50 years' age group) of H. pylori infection. However, association of H. pylori infection was positive in 83.3% (45) of patients with endoscopic abnormalities (54). Conclusion: The prevalence of H. pylori infection is high in the study population. Early detection and prompt treatment are essential for prevention of serious complications.
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Profile of aluminum phosphide poisoning in a tertiary care institute in the sub-Himalayan region p. 581
Tarun Sharma, Aradhna Sharma, Dheeraj Kapoor
DOI:10.4103/jfmpc.jfmpc_231_17  
Context: Aluminum phosphide (ALP) is a highly toxic agricultural fumigant pesticide commonly implicated in poisoning. Aim: The aim of the study was to study the profile of patients presenting with ALP poisoning in Dr. RPGMC Kangra, Tanda, Himachal Pradesh. Settings and Design: This was a retrospective study conducted in the Department of Medicine at Dr. RPGMC Kangra, Tanda, Himachal Pradesh, from August 2011 to January 2014. Material and Methods: Case record forms of 117 patients were reviewed and analyzed. Data were collected for sociodemographic and clinical parameters. Outcome of patients was recorded as expired and improved. All the patients were managed symptomatically. Statistical Analysis: Statistical analysis was performed using SPSS version 15. P < 0.05 was considered statistically significant. Results: Out of the total 117 patients included in the study, 61 (52.1%) were males and 56 (47.1%) were females. Mean age ± standard deviation of presentation was 30.9 ± 12.2 years. About 70% of the patients were from rural background. Out of the total 117 patients, 68 (58.1%) patients had expired and 49 (41.9%) had improved. Most of the patients in the expired group consumed ALP in tablet form (54.7% of the total). Nearly 57% of the patients had leukocytosis at presentation and <5% had leukopenia. The mean pulse rate and mean systolic blood pressure in the expired group were 116.24 ± 14.3 per minute and 89.9 ± 16.83 mmHg which was statistically significant. The mean change in creatinine value (ΔCr) in the expired group was 1.03 ± 0.36 which was statistically significant. Conclusions: The prognosis of the patients can be anticipated on assessing the cardiac status and mean change in creatinine value (ΔCr) at the time of admission.
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Prevalence of thyroid dysfunction in chronic obstructive pulmonary disease patients in a tertiary care center in North India p. 584
Shyam Chand Chaudhary, Tauhid Ahmad, Kauser Usman, Kamal Kumar Sawlani, Kamlesh Kumar Gupta, Ajay Kumar Verma, D Himanshu Reddy
DOI:10.4103/jfmpc.jfmpc_84_17  
Introduction: Thyroid dysfunction can cause inspiratory and expiratory muscle weakness in patients with or without chronic obstructive pulmonary disease (COPD) Thyroid dysfunction in COPD results in increased frequency of exacerbation thus lead to poor quality of life. It may further increase cardiovascular disease risk thereby increasing mortality. Aims and Objectives: This study was conducted to evaluate the prevalence of thyroid dysfunction and hence that the quality of life of COPD can be improved Materials and Methods: This is a cross-sectional – prevalence study. The study was conducted over a period of 1 year from August 2015 to July 2016. The study group was consists of male and female COPD patients diagnosed with spirometry and severity was determined according to the global initiative for chronic obstructive lung disease classification criteria. The patients were enrolled in this study from medicine outpatient department (OPD), respiratory OPD and those admitted to indoor wards of Medicine Department. Patients were screened for thyroid dysfunction. Results: Out of 171 patients, thyroid dysfunction was present in 43 patients. All of them were hypothyroid. The prevalence of thyroid dysfunction was 25%. In Stage A it was 20.5%, Stage B 25.7%, Stage C 23.4%, and in Stage D 30.4%. Thyroid dysfunction was associated with more frequent exacerbation. Conclusion: Thyroid dysfunction is a common extrapulmonary manifestation in COPD patients. It is associated with frequent exacerbations which affect the quality of life in these patients. Early detection and proper management can improve the quality of life in these patients.
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Epidemiological profile of multidrug-resistant tuberculosis patients in Gorakhpur Division, Uttar Pradesh, India p. 589
U Venkatesh, DK Srivastava, AK Srivastava, HC Tiwari
DOI:10.4103/jfmpc.jfmpc_99_17  
Introduction: Multidrug-resistant tuberculosis (MDR-TB) poses a major threat to control of TB worldwide. Adequate information on socioepidemiological factors and their interaction is required for its control. The aim was to study the social and epidemiological profile of MDR-TB patient in Gorakhpur division. Methodology: A cross-sectional study of 157 MDR-TB patients from Gorakhpur division admitted at DR-TB Center of a tertiary care center were interviewed during initiation of MDR-TB treatment using structured questionnaire and collected data were described using descriptive statistics. Results: More than 2/3rd of patients were male and the mean age was 32.15 ± 13.19 years. Overcrowding was present in 82.8% of households and ventilation of living room was inadequate in 72.7% of households. About 21.7% had history of contact with TB cases. Two-third of the patients practice unhygienic sputum disposal practices at home and at public places it was more than 90%. More than 60% of patients have the history of irregular treatment in intensive phase and 80% in continuation phase. Nearly 68.8% of patients were resistance to isoniazid (H) and rifampicin (R) and 18.5% were resistance to H, R, and S (streptomycin) followed by H, R and E (Ethambutol). Nearly 3.8% of patients were HIV positive and 7% had history of diabetes. 64.3% were under severe thinness category according to the WHO classification. Conclusion: Study point out need of nutritional counseling and support throughout the treatment. Use of incentives, enhancing contact tracing and increasing awareness regarding sputum disposal practices are recommended for effective control.
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Mothers' preferences toward breaking bad news about their children cancer p. 596
Zahra Mostafavian, Zahra Abbasi Shaye, Arezou Farajpour
DOI:10.4103/jfmpc.jfmpc_342_17  
Background: The responsibility of breaking bad news (BBN) to patients is one of the most difficult tasks of a medical profession. Aim: The current study aimed to investigate the preferences of mothers of children with cancer about BBN. Materials and Methods: In this cross-sectional study was conducted in Mashhad during years of 2016, 62 mothers of children with cancer at Dr-Sheikh hospital were recruited by convenience sampling and completed a questionnaire including demographic data and 20 questions about the mothers' preferences to BBN. Data displayed as percent by SPSS V20 software. Results: Mothers preferred that BBN conducted by their child's doctor (93.5%), with an emotional and compassionate way (83.9%), and in a private setting (90.3%). Be told completely about the process of diagnosis (98.4%), meet people with similar conditions (83.9%), receive psychological (85.5%), and religious (79%) support after getting bad news, being in touch with a close relative (82.3%) and applying another term-like malignancy instead of cancer (95.5%). Conclusion: We tried providing helpful information for developing national guidelines about how to breaking news in Iran, by doing this study.
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Evaluation of physicians' skills in breaking bad news to cancer patients p. 601
Zahra Mostafavian, Zahra Abbasi Shaye
DOI:10.4103/jfmpc.jfmpc_25_18  
Background: Delivering bad news to patients is one of the most difficult tasks of physicians that play a big role in the process of treatment and cooperation of patients. The objective of this study is to evaluate the ability and skills of physicians in delivery bad news to cancer patients. Methods: This study is a cross-sectional study performed on 70 specialist physicians in two hospitals of Mashhad in 2016. Data were collected by Persian questionnaire of SPIKES included 16 questions and were analyzed by SPSS software. Results: In this study, among the questionnaire items, the most prevalent item was not giving the bad news by phone (100%) and the least prevalent item was putting the hand on the shoulder (24.3%). This study showed that 81.4% of doctors agreed on giving the bad news in private, 72.9% agreed on giving relative hope to patients and 67.1% agreed on evaluating patients knowledge of his/her disease when giving bad news. Conclusion: The results of this study show that the ability of physicians in giving bad news is not enough in some aspects. Therefore, holding educational courses during physicians' education and after graduation are recommended to increase patients' trust and decreasing worries and inconvenience of physicians in difficult situations of delivering bad news.
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Determining the effect of implementing an educational package on quality of life among patients with chronic obstructive pulmonary disease referring to teaching hospitals affiliated with Ilam University of Medical Sciences in 2016 p. 606
Mosaieb Mozaffari, Sanaz Azami, Madine Naderi
DOI:10.4103/jfmpc.jfmpc_304_17  
Introduction: Nowadays, pulmonary diseases have become one of the most important causes of mortality in the world. In this regard, the present study was aimed at examining the effect of implementing an educational package on quality of life (QoL) among patients with chronic obstructive pulmonary disease (COPD) referring to teaching hospitals affiliated with Ilam University of Medical Sciences. Materials and Methods: The present study was an interventional clinical trial in which the participants were randomly assigned into an intervention group and a control group. The statistical population included all COPD patients who had referred to the teaching hospitals affiliated with Ilam University of Medical Sciences. Sixty patients were selected by a convenience sampling method out of the whole patients who had referred to Shahid Mostafa Khomeini Hospital in Ilam. Afterward, they were randomly assigned into an intervention group and a control group (each including 30 patients). The collected data were analyzed using descriptive statistics; Chi-square test, independent and paired samples t-test, and correlational tests at a significance level of 0.05. Results: The results of the present study showed that as a result of the educational package, the intervention patients had a significantly higher QoL than the control patients (P = 0.001). The results also showed that implementing the educational package had a significant effect on QoL among the intervention patients in dimensions of physical function, mental health, social status, playing physical role, playing emotional role, physical pains, general health, and energy and vitality (P = 0.001). Conclusion: Based on the results of the present study, it can be concluded that collaborative education is a significant issue in health and treatment, and different dimensions of QoL can be enhanced by an appropriate educational program.
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Investigating the effect of education on health-promoting lifestyle among the elderly of Ramsar in 2017 p. 612
Razieh Torabi Chafjiri, Fatemeh Shirinkam, Hengameh Karimi
DOI:10.4103/jfmpc.jfmpc_306_17  
Introduction and Objective: Providing and enhancing the level of health are one of the essential needs of all people, and implementation of health promotion lifestyle is the most important and effective factor in maintaining and improving the health of the elderly. The present study aimed at defining the effect of aging on health-promoting lifestyle. Methodology: This randomized clinical trial was conducted on 72 individuals from the retirees clubs of Education department, Social Security, and Health centers in Ramsar, in 2017. Sampling was done randomly with blocking and random allocation in two groups: Experimental and control. Data were collected in two steps by Demographic profile questionnaire, AMT, ADL, OHI and HPlP II which validity and reliability of them were confirmed. Participants attended eight training sessions (twice each week). Data analysis was performed with the use of SPSS 18 and descriptive (Frequency) and analytic tests (Chi-square, Fisher's exact test, Independent Sample t test and Paired Sample t test) with a significance level of 0.05. Results: The results showed that the mean age of the elderly was 64.4 ± 4.1 years. The mean score of lifestyle enhancement was 148.59 and 173.25 before and after training in the experimental group, respectively. Based on the results of paired t-test (P < 0. 323), there was no significant difference between the mean life expectancy of elderly health promotion in control group before and after educational intervention; however, there was a significant difference between the two groups before and after training (P = 0.001). Conclusion: Educational programs play an important role in integrating health-promoting lifestyle to encourage the elderly to accept more accountability regarding health, sustained physical fitness, proper nutrition, healthy interpersonal relationships, expected spiritual growth, and the proper management of stress and anxiety in life.
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CASE REPORTS Top

Spontaneous intracranial hemorrhage associated with dengue fever: An emerging concern for general physicians p. 618
Abhijeet Singh, Viswesvaran Balasubramanian, Nitesh Gupta
DOI:10.4103/jfmpc.jfmpc_56_18  
Dengue fever (DF) is an arboviral disease caused by a positive-sense RNA virus of the genus Flavivirus. The overall incidence of DF has increased exponentially worldwide over the last three decades. The atypical clinical manifestations of DF grouped under expanded dengue syndrome (EDS), have also been reported more frequently for the last decade. These unusual manifestations are usually associated with coinfections, comorbidities, or complications of prolonged shock. Intracranial hemorrhage (ICH) is one of the rare manifestations of the central nervous system involvement by dengue as a part of EDS. The pathogenesis and treatment of this manifestation also remain controversial. Therefore, we report a case of a previously healthy 65-year-old female who developed ICH as a part of EDS along with a brief review of literature.
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Long-term relief from tension-type headache and major depression following chiropractic treatment p. 629
Eric Chun Pu Chu, Michelle Ng
DOI:10.4103/jfmpc.jfmpc_68_18  
We report the case of a 44-year-old school teacher who experienced long-term relief from tension-type headache (TTH) and major depression following chiropractic treatment. It is well recognized that psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain. Recent studies indicated that autonomic dysfunction plays a role in the pathogenesis of TTHs and depressive disorders. The autonomic nervous system is mainly controlled by reflex centers located in the spinal cord, brain stem, and hypothalamus. This report highlights the rewarding outcomes from spinal adjustment in certain neuropsychiatric disorders. Long-term results of chiropractic adjustment in this particular case were very favorable. Further studies with larger groups are warranted to better clarify the role of chiropractic.
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First reported case of naturally acquired fatal anthrax from Northeast India Highly accessed article p. 632
Nitish Garg, Kakhangchung Panmei
DOI:10.4103/jfmpc.jfmpc_111_18  
Anthrax is a zoonotic disease and is caused by Bacillus anthracis which is a Gram-positive, nonmotile, spore-forming rod, found in soil. The spores can remain viable for decades. Transmission occurs naturally in humans by direct contact with infected animals or the contaminated animal products. Anthrax is a major health problem in eastern and southern India, with a significant human incidence because the disease is poorly controlled. Here, we discuss such a case of naturally occurring fatal anthrax in North-East India. A 48-year-old man from Assam presented with seizures, hematemesis, and fever. Apart from altered mental status and nonreactive pupils, his cutaneous and systemic examination was unremarkable. Noncontrast computed tomography head showed multiple hemorrhages. Blood and cerebrospinal fluid showed heavy growth of anthrax Bacilli. He was started on specific antibiotics after the reports, but unfortunately, the patient succumbed to infection. Due to high prevalence of anthrax in the endemic regions, a high degree of suspicion is required to clinch the diagnosis. Early initiation of therapy before developing the intracranial hemorrhagic complications might result in a better outcome. Careful history for a possible exposure to animal carcass or a suspected animal death due to anthrax will also help in early diagnosis of the disease and effective therapy.
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Hyperechoic amniotic fluid in a term pregnancy p. 635
Athula Kaluarachchi, Gardie Role Malwattage Udara Ganthika Peiris Jayawardena, Augustus Keshala Probhodana Ranaweera, Mohamed Riyal Mohamed Rishard
DOI:10.4103/jfmpc.jfmpc_83_18  
The presence of highly echogenic amniotic fluid (AF) is uncommon, and presence creates a dilemma in the mind of the clinician. Echogenic AF has been attributed to meconium, blood, and vernix caseosa. Many studies have shown that the presence of meconium is unlikely in most cases. We report a case of highly echogenic AF detected at 37 weeks which was managed conservatively with careful fetal monitoring for further 2 weeks expecting spontaneous onset of labor. Labor was induced due to reduced fetal movements at 39 weeks. Healthy baby weighing 3130 g was delivered by cesarean section after a failed induction with prostaglandin.
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Management of foreign body ingestion in children with cerebral palsy: Need for proper trauma management protocol p. 638
Vishnu Prasad, Victor Samuel, Mahesh Ramakrishnan, Dhanalakshmi Ravikumar, N Sharna
DOI:10.4103/jfmpc.jfmpc_91_18  
Cerebral palsy (CP) is described as a group of permanent, nonprogressive movement disorders that cause physical disability in development and further affecting body movement and muscle coordination. The condition develops when certain abnormalities persist inside the developing brain that ultimately disrupts the brain's ability to control movement and maintain posture and balance. Patients with CP are more susceptible to dental trauma due to the lack of muscle coordination and unexpected involuntary movements. The present case series highlights the need for emergency protocol management when these patients report with dental trauma and complications which can happen in dental office. The first case report is about ingestion of permanent incisor following trauma which was diagnosed incidentally in the abdominal radiograph, and the second case is reported to be accidental ingestion of head of dental mouth mirror during the routine oral examination. These two case reports emphasize the need for more comprehensive trauma management protocol in these children.
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Vitamin B12 deficiency presenting with hyperpigmentation and pancytopenia p. 642
Valluri Rama Rao
DOI:10.4103/jfmpc.jfmpc_347_16  
Hyperpigmentation with generalized weakness may be the initial presentation of several systemic conditions. Vitamin B12 deficiency can present very rarely as hyperpigmentation. Association of pancytopenia at this stage is even rare. Early identification and management can prevent various neurological complications. Here, we report a rare case of Vitamin B12 deficiency presenting as hyperpigmentation and pancytopenia.
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LETTERS TO EDITOR Top

Appropriately reporting results using the medication subscale of the summary of diabetes self-care activities measure: A comment on Dasappa et al. (2017) p. 645
Saurav Basu
DOI:10.4103/jfmpc.jfmpc_345_17  
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Cautious use of absolute and relative precision while calculating sample size p. 647
Preeti Usha, Ajeet Singh Bhadoria, Surekha Kishore
DOI:10.4103/jfmpc.jfmpc_39_18  
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