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   Table of Contents - Current issue
Coverpage
September 2019
Volume 8 | Issue 9
Page Nos. 2751-3076

Online since Monday, September 30, 2019

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EDITORIAL  

Competency-based medical education: How far, how much Highly accessed article p. 2751
Amrita Ghosh, Ranabir Pal, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_680_19  
Competency-based medical education inscribed in the Graduate Medical Education Regulations from Medical Council of India is cogently grounded by the Curriculum Implementation Support Programme throughout the country under the aegis of Medical Education Units and Curriculum Committees of the medical institutes. Global researchers on academic curriculum visualize paradigm of system based teaching–learning in evidence based medicine. This intermingled with participatory contribution from the learners in a non-threatening environment can inculcate philosophy of life-long learning mindset. Creative teaching-learning environments free the mind to freely learn to meet the challenges of the health needs of the country.
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COMMENTARIES Top

Asthma exacerbation related to viral infections: An up to date summary Highly accessed article p. 2753
Mehdi Adeli, Tamara El-Shareif, Mohamed A Hendaus
DOI:10.4103/jfmpc.jfmpc_86_19  
Asthma exacerbation can be a major life threatening event. Viruses have been pinned as the cause behind the vast majority of these exacerbations. The purpose of this short review is to explore the mechanisms behind these exacerbations, focusing mostly on viral infections as triggers. We will also be discussing the phenotypes prone to asthma exacerbation, the pathophysiology of viral induced asthma and ventilation patterns of asthmatic lungs. This manuscript will assist primary care physicians in delineating the proper pathophysiology of the disease as well as the management.
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Momentousness of denture labeling using Aadhaar number in Indian population Highly accessed article p. 2760
Neha Sikka, Sameer Saxena, Kannu Priya, Vanita Suthar
DOI:10.4103/jfmpc.jfmpc_293_19  
Personal identification is of prime importance for forensic and medicolegal purposes especially in case of natural calamities, accidents, state of unconsciousness, or loss of memory. The denture labeling is an important method which has been acknowledged by the field of dentistry. Various denture labeling techniques have been advocated but none of them is universal. Aadhaar is the instantly verifiable national identification number assigned to residents of India, which is currently being used vastly by the Government of India. The article describes a simple, economical, and permanent method for inclusion of Unique Identification Number and bar code in dentures.
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REVIEW ARTICLES Top

Calciphylaxis and its diagnosis: A review Highly accessed article p. 2763
Deepak Baby, Meenakshi Upadhyay, M Derick Joseph, Swati Joshi Asopa, Basanta Kumar Choudhury, Jagadish Prasad Rajguru, Shivangi Gupta
DOI:10.4103/jfmpc.jfmpc_588_19  
Calciphylaxis also known as Calcific uremic arteriolopathy (CUA), is a rare fatal complication usually associated with end-stage renal disease (ESRD). It is characterized by skin ulceration and necrosis leading to significant pain. The disease calciphylaxis is pathological state resulting in accumulation of calcium content in medial wall of small blood vessels along with the fibrotic changes in intima. The aetiopathogenesis of this disease, small vessel vasculopathy, remains complicated, and unclear. It is believed that development of calciphylaxis depends on medial calcification, intimal fibrosis of arterioles and thrombotic occlusion. The disease is rare, life-threatening medical condition that occurs mostly in population with kidney disease or in patients on dialysis. Skin biopsy and radiographic features are helpful in the diagnosis of calciphylaxis, but negative results do not necessarily exclude the diagnosis. This article highlights steps undertaking in the diagnosis of calciphylaxis.
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A comparative review of the outcomes of using arterial versus venous conduits in coronary artery bypass graft (CABG) p. 2768
Mansour Jannati, Mohammad Rafati Navaei, Leila Ghaedian Ronizi
DOI:10.4103/jfmpc.jfmpc_367_19  
Nowadays one of the most frequent reasons of death in the world is coronary artery disease. CABG is a portion of a common revascularization mediation that is done to supervise CAD by applying vessels that are grafted to revascularize vessels distal from the blockage. Different sources of grafts are included veins (specifically saphenous) and arteries (include mammary and radial arteries). Multiple conduits are used to this end, but the most suitable is left internal mammary artery (LIMA) to the left anterior descending artery (LAD) as a golden standard. Saphenous vein grafts were the guiding approach applied by the vast majority of cardiac surgeons in the 1970s, even though all approaches were supported by doctors. Although the radial artery graft was introduced simultaneously, this approach due to its complications was not as prevalent. This article is aimed to define the pros and cons of applying each kind of grafts according to the results furnished by existent studies. It has also examined the benefits provided by total arterial coronary artery bypass graft against CABG including venous graft for patients with CAD from the perspective of surgeons.
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Pulmonary hydatid cyst: Review of literature p. 2774
Sanjib Rawat, Rupesh Kumar, Javid Raja, Rana Sandip Singh, Shyam Kumar Singh Thingnam
DOI:10.4103/jfmpc.jfmpc_624_19  
Echinococcosis is a rare infectious disease in human being that occurs by the larval stages of taeniid cestodes of the genus Echinococcus. Human cystic echinococcosis is the most common presentation. The liver is the most common site of echinococcal cyst, followed by the lungs. The symptoms of lung infestation lead to sudden onset of chest pain, cough, fever, and hemoptysis after a cyst rupture. The diagnosis is confirmed by radiology supplemented with serology. Chest X-ray and computer tomography of chest is the principal investigation for pulmonary hydatid cyst (PHC). The treatment of PHCs is either pharmacotherapy and/or surgery. Surgical intervention is the most preferred treatment of choice; pharmacotherapy is useful in selected patients. Pharmacotherapy includes oral administration of benzimidazoles group of drugs like mebendazole or albendazole.
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Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis Highly accessed article p. 2779
Suresh K Sharma, Shiv K Mudgal, Rakhi Gaur, Rakesh Sharma, Maneesh Sharma, Kalpana Thakur
DOI:10.4103/jfmpc.jfmpc_669_19  
Background: Around the globe, protocols for flushing the catheter to maintain the patency of central venous catheter (CVC) vary by institution to institution or by practitioner to practitioner. Therefore, this review was carried out with the aim of evaluating the efficacy of heparin flush vs. normal saline flush to maintain the patency of CVC among adult patients. Methods: We followed the guidelines of Cochrane handbook for interventions and searched in MEDLINE, Embase, Cochrane library, Clinical trials database, and reference list of related articles, which were published from Jan. 2012 to 31 Dec. 2018 in English language. We included only randomized controlled trials, and nine studies were included in this review. The pooled standard mean difference and relative risk were calculated by using Rev Man Review Manager 5. Results: We identified nine eligible studies with a total number of 3,113 participants. Consolidated results from eight studies conveyed little favorable effect to maintain patency of CVC with heparin when compared with normal saline as evident by risk ratio 0.83, 95% CI 0.50 – 1.40; P = 0.13. We also carried out analysis for secondary outcomes, and there was no evidence that heparin was better than normal saline in terms of safety except heparin-induced thrombocytopenia. Conclusions: Heparin has little favorable effects to maintain patency of catheter than normal saline but not in secondary outcomes. As the quality of evidence was very low, therefore, results should be comprehend with care.
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ORIGINAL ARTICLES Top

Incidence of hypoglycemia and its risk factors among diabetics during Ramadan in Abha city, Aseer Region, KSA p. 2793
Yahia Mater AlKhaldi, Ali Yahya AlKhaldi, Abdullah Salman AlQahtani, Bushra Saeed Al-Shahrani, Eman Abdullah Meshawi, Boshra Mohammed Albishri
DOI:10.4103/jfmpc.jfmpc_250_19  
Background and Aims: This study aims to explore the incidence of hypoglycemia and its risk factors among diabetic patients attending primary health care center during Ramadan Abha city, Aseer region, Saudi Arabia. Methods: This cross-sectional study was conducted among adult diabetic patients attending Primary health care centers (PHCCs) in Abha city, southwest of KSA. A questionnaire in Arabic language was used. It consisted of five parts that covered patients demographic and DM relevant profile, hypoglycemia attacks during Ramadan, compliance with drug, diet, exercise and glucose monitoring. Four PHCCs in Abha city were selected randomly to conduct this study. All diabetic patients who attended the selected PHCCs during the month of Shawwal 1439 (corresponding to June-July 2018) were interviewed by the investigators. Data were coded, entered and analyzed using SPSS version 22. Appropriate statistical tests were used accordingly and P value was considered as significant if it was less than 5%. Results: The total patients participated in this study was 378. The mean age was 45 years, males represents 51%, mean duration of DM was 12 years, type-1DM constitutes about one third. Most of type-1 DM patients used act rapid and long acting insulin (65%), while in type-2 DM, more than one third (38%) used OHA, 8% were on insulin alone. More than half of patients (52%) reported at least one attack of hypoglycemia during Ramadan, (29%) out of them had more than four attacks. About two third of attacks (67%) occurred in the morning and evening while less than one fourth have hypoglycemia at night (17%), (2%) visited ER or PHC and 1% were admitted to hospital for further management. Conclusion: This study revealed that the incidence of hypoglycemia among diabetics was high. Many Risk factors were identified; young age, type-1 DM, long duration of DM, insulin use. More attacks occurred during Ramadan day period and led to breaking the fasting among all affected patients. Most of patients were not given instructions regarding self-care immediately before or during Ramadan. Structured health education program for diabetics attending PHCC should be constructed and implemented before beginning of Ramadan in order to minimize the incidence of acute complications particularly hypoglycemia.
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Association between lifestyle and pathologic fractures in patients admitted to surgery departments of selected hospitals affiliated to Alborz University of Medical Sciences in 2014–2015 p. 2799
Mohammad Islami Vaghar
DOI:10.4103/jfmpc.jfmpc_531_19  
Background and Purpose: Health professions that previously focused on treatment of patients are now focusing on prevention and health provision by improving lifestyle and eliminating factors that somehow have a negative impact on human health. Some people have strong skeleton genetically, but others do not. So far, medical science has not been able to change the genetic characteristics of individuals; however, lifestyles can be changed to reach the maximum bone mass. The aim of this study was to investigate the association between lifestyle and pathologic fractures in patients admitted to surgery departments of selected Hospitals in 2014–2015. Materials and Methods: In this descriptive (correlational) study, using the Cochran sampling formula, 350 patients with fractures were selected by stratified sampling in surgery departments of selected hospitals affiliated to Alborz University of Medical Sciences. Data were collected using the standard lifestyle questionnaire, which was validated through the test–retest method. The qualitative data of this project were analyzed using SPSS 20 software at a significance level of 0.05. Results: Most of the subjects were in the age group of 72–85 years which included 103 (26.8%) people. In all, 187 (48.6%) subjects were male and 198 (51.4%) subjects were female. A total of 83 (21.6%) participants were in the healthy group, 123 (32.0%) subjects were in the osteoporosis group, 113 (29.3%) subjects were in the bone infection group, and 66 (17.1%) individuals were in the general bone disease group. Conclusion: All studied components including smoking, physical activity, and nutrition directly affect pathologic fractures.
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Exclusive breastfeeding among Saudi mothers: Exposing the substantial gap between knowledge and practice p. 2803
Nada Ahmed Alsulaimani
DOI:10.4103/jfmpc.jfmpc_533_19  
Background: Rates of exclusive breastfeeding are exceedingly low in the Arabic world. This study aims to estimate the local prevalence of, and knowledge about, exclusive breastfeeding in Saudi Arabia. Method: This is a cross-sectional survey of mothers of infants aged 6–12 months who attended Taif-based “well-baby clinic.” A structured questionnaire was developed to explore predictors of, and participants' knowledge about, exclusive breastfeeding. Results: Participants in the study were 202 mothers. The rate for initiation of breastfeeding in the first hour after childbirth was 13.9%. The prevalence of exclusive breastfeeding was 16.3%. Knowledge level was great among participating mothers as 65.3% of mothers scored over 75% of the total knowledge score and 95% got more than half of the questions right. Only having 3–6 children (P = 0.023) and 1-year interpregnancy interval (P = 0.005) were associated with the positive likelihood of exclusive breastfeeding. Baby age (P = 0.0218), birth in a private facility (P = 0.00843), and university education (P = 0.0131) were associated with better knowledge. Discussion and Conclusion: Rates of exclusive breastfeeding practice are low in Saudi Arabia despite adequate knowledge about its benefits and necessity.
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Radiological difference between new sputum-positive and sputum-negative pulmonary tuberculosis p. 2810
Deependra K Rai, Ravi Kirti, Subhash Kumar, Saurabh Karmakar, Somesh Thakur
DOI:10.4103/jfmpc.jfmpc_652_19  
Introduction: The current guidelines for the diagnosis of pulmonary tuberculosis (PTB) are based primarily on the demonstration of acid-fast bacilli (AFB) on sputum microscopy and chest radiograph. Knowing various radiological manifestations and their association with sputum microscopy findings can allow for early diagnosis and early initiation of treatment. Aims: This study was performed to compare the chest radiograph features seen in sputum-positive and sputum-negative tuberculosis patients, respectively. Materials and Methods: It was a prospective observational study, which included 147 consecutive patients newly diagnosed and treated as PTB between Jan 2018 and July 2018. Chest X-ray was reviewed by 2 independent radiologists and the findings were compared between sputum-positive and sputum-negative PTB cases. The obtained data were analyzed by statistics using SPSS version 15 for Windows (SPSS Inc., Chicago, IL) and χ2 test and Student t test were used for statistical analysis. P values < 0.05 were considered statistically significant. Results: Out of a total of 147 patients, 38 (25 males and 13 females, mean age 35.23 ± 18.40) were sputum positive and 109 (77 males and 32 females, mean age 36.07 ± 18.15) were sputum negative. The frequency of patchy consolidation (78.94% vs 49.54%) and cavitation (36.84% vs 15.59%) was significantly higher in sputum-positive PTB (P < 0.05). Radiological lesions like nodular shadow (10.09% vs 2.63%), cystic lesion (13.76% vs 5.26%), fibrosis (12.84% vs 7.89%), miliary shadows (2.75% vs 2.63%), and pleural effusion (1.83% vs 0%) were seen more commonly with sputum-negative PTB but the difference was not statistically significant for any of these features. Sputum-positive PTB tends to occur more commonly on the left side (47.36%) compared with sputum-negative PTB (27.52%) (P < 0.05). 34.21% and 35.77% of the chest X-ray lesions were bilateral in sputum-positive and sputum-negative PTB, respectively. Conclusion: Patchy infiltration and cavitation on chest X-ray are seen more frequently in sputum-positive cases of PTB compared with sputum-negative cases.
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Study of maternal outcome in referral obstetric cases in a tertiary care centre p. 2814
Rekha Jakhar, Ankita Choudhary
DOI:10.4103/jfmpc.jfmpc_402_19  
Introduction: To identify the pattern of Obstetric referral to our hospital and the primary reasons for referral, so as to implement measures to reduce unnecessary referrals and to reduce maternal mortality and morbidity. Method: All the referred cases for obstetrics indications above 20 weeks were analysed for cause of referral, their condition and outcome for a period of 6 months from January 2016 to June 2016. Results: According to our study out of a total of 10172 delivered patients, 1014 (9.96%) cases were referred patients. Maximum cases i.e. 713 (70. 3%) were in the age group of 21-30. Most of the cases 678 (66.86%) did not receive any treatment at referral hospital before being referred. Only 27.52% patients were referred with referral slips/chit etc., having adequate information and 40.24% of cases were delayed referrals. 183 (18.04%) patients required intensive care unit admission. Conclusion: The present study showed that illiteracy and ignorance of female regarding healthcare requirements and poor infrastructure came out to be a major contributor of poor pregnancy outcome. Timely referral is crucial for a satisfactory maternal and fetal outcome. To reduce the number of unnecessary referrals and to reduce burden on tertiary care hospitals, health care workers should be trained in essential and emergency obstetric care which will help in reducing morbidity and mortality.
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Intervention on malaria awareness among 'Bedia' tribal community in West Bengal, India p. 2820
Uttam Kumar Paul, Ranabir Pal
DOI:10.4103/jfmpc.jfmpc_554_19  
Background: Tribals have a vulnerable health status because of malarial morbidities, yet they ignore their illnesses and do not go to physicians during sickness for several reasons including poverty. Objective: This qualitative research project attempted to create awareness among 'Bedia' tribal to initiate preventive and other personal protective measures against malaria. Methods: Initially, efforts were made to create malaria awareness by literate 'Bedia' volunteers who were trained to do so; however, their tribal fellows were reluctant to receive awareness efforts from them. After thorough analysis and interaction, a novel “interprofessional team” of composer, vocalist, and instrumentalists approach was made to impart malaria awareness by composing songs in the language of the aborigine. Then health education was imparted to the 'Bedia' participants by the trained 'Bedia' through theme songs with their rustic music instruments and group dance performances in the intermingled media from the team. An evaluation was done to assess usefulness of the health education intervention by the researchers. Results: Overall, 137 adult 'Bedias' in 42 families (M = 74; F = 63) participated in our study. In the informal feedback session, only 51 adult males and 46 adult females could furnish expected results. Out of the 42 families residing in the village, 11 houses consistently used mosquito bed nets before the awareness program; after the awareness program, it became 15 as was demonstrated by using social mapping. Conclusions: Our project activities on the Bedia tribes could unearth required interventions of awareness about malaria. However, it was possible to create awareness and confidence among them so that they could themselves take necessary preventive measures and positive approaches toward malaria.
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Study on incidence of phlebitis following the use of pherpheral intravenous catheter p. 2827
Abhijit Mandal, K Raghu
DOI:10.4103/jfmpc.jfmpc_559_19  
Context: Peripheral vein cannulation is commonly performed for rapid and accurate administration of medications. Phlebitis is one of the commonest complications that develop after intravenous catheter application. Aims: This study aims to investigate the incidence of phlebitis and to evaluate factors contributing to the development of phlebitis. Settings and Design: This was a prospective observational study conducted on patients admitted at 4 Air Force Hospital Kalaikunda. Methods: Study conducted on 150 patients who were admitted to the medical and surgical division of the hospital during the period from July 2018 to April 2019. The factors studied were age, gender, site of insertion, place of insertion, cannula size, IV medications, and blood products used. Phlebitis was graded using Visual Infusion Phlebitis Score. Statistical Analysis Used: The incidence of phlebitis was expressed in percentage and odds ratio was calculated to estimate the effects of suspected risk factors. Results: Incidence of phlebitis was found to be 31.4% from our study. The increased incidence rate of phlebitis was seen in the female gender, age less than 60 years, insertion in the lower limb, large catheter size, catheters inserted in emergency situations, and IV drugs administration. Conclusion: Phlebitis is an important on-going problem in present-day clinical practice. Avoiding of preventable risk factors, proper nursing care, and daily inspection of catheters needed for prevention of phlebitis.
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A qualitative analysis of the impact of Kudumbashree and MGNREGA on the lives of women belonging to a coastal community in Kerala p. 2832
Hyfa M Ali, Leyanna S George
DOI:10.4103/jfmpc.jfmpc_581_19  
Background: The rural coastal population of Njarakkal are dependent on fishing for their daily livelihood making them highly economically unstable. Both Kudumbashree and MGNREGA have been implemented in this area for the upliftment of this population especially women. Therefore, the objective of this study was to qualitatively analyze the impact of Kudumbashree and MGNREGA on the lives of women belonging to the rural coastal community of Njarakkal. Methods: A qualitative study consisting of Focused group discussions and key informant interviews were conducted on women belonging to the fishing community who were active members of both the Kudumbashree and MGNREGA program. Results: Participation in Kudumbashree and MGNREGA was found to have a positive impact on the lives of these coastal women. They experienced social, economic and political empowerment along with an improvement in their leadership skills and decision making capacity. Their participation in these groups not only led to empowerment in various domains of their lives but also had an impact on their health awareness, needs and utilization of healthcare services. Conclusion: Both Kudumbashree and MGNREGA were found to very useful platforms for the empowerment of women and thereby aiding in the eradication of poverty. Irrespective of a few lacunae's in these programs, it has resulted in the creation of a cohort of empowered women who can be effectively used as future ambassadors for spreading health awareness in the community.
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Community perspectives on primary health centers in rural Maharashtra: What can we learn for policy? p. 2837
Sudha Ramani, Muthusamy Sivakami
DOI:10.4103/jfmpc.jfmpc_650_19  
Introduction: Primary Health Centers (PHCs) are intended to be the “backbone” of the Indian public health system. Yet, these do not get utilized as frontline institutions for basic curative care. As we embark on comprehensive primary health care initiatives, it is important to understand people's perceptions on PHCs; and design services that cater to their felt needs. Aim: In this paper, we examine explanations that communities give for the use or bypass of PHCs. From these perspectives, we derive some policy directions for improving basic curative care services at PHCs. Methods: This qualitative study is based on data from 14 Focus Group Discussions in a rural area in Maharashtra in the catchment area of 8 PHCs (total 91 community participants). The discussions were coded and analyzed thematically with the aid of a qualitative software. Results: PHCs were not viewed as first-access points for health care, though these were valued for specific services. The limited use of PHCs was attributed to the lack of availability of drugs/services of perceived relevance to communities; prevalent healing norms that mismatched with PHC services; doctor-patient interactions that were colored with mistrust; and widespread poor opinions of public-sector services in health. Conclusions: Currently, there seems to be little in the design of PHC services- that appeals to the “felt” needs of communities. Thus, the proposed Health and Wellness Centers (HWC) initiative resonates with people's expectations. In addition, staff at the periphery must provide “attentive” care and be prepared to contend with pre-existing poor expectations of care.
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The effect of endometrial thickness and endometrial blood flow on pregnancy outcome in intrauterine insemination cycles p. 2845
Mojgan Javedani Masrour, Ladan Yoonesi, Hossein Aerabsheibani
DOI:10.4103/jfmpc.jfmpc_212_19  
Objective: To investigate whether endometrial thickness and endometrial blood flow on the day of hCG administration is a predictor of intrauterine insemination (IUI) success. Method: A cross-sectional prospective clinical study with simple randomized sampling; Patient: 100 women experiencing the IUI cycle; Interventions: a comparison was made between pregnant and non-pregnant patients in terms of the endometrial thickness and pattern as well as the color Doppler flow on the day of hCG administration and also cycle parameters. Main outcome measures: endometrial thickness and patterns as well as the blood flow in color Doppler. Results: With the overall pregnancy rate being 38%, it was demonstrated that the endometrial blood flow was significantly greater in the cycle pregnancy obtained on the day of hCG administration, yet it was realized that the endometrial thickness and pattern of sonography did not have any predictive values for endometrial receptivity . In a multivariate analysis, the pregnancy rate was affected by the following variables: the duration of infertility, the women's age, the type number of IUI cycles, the number of injections to stimulate dominant follicles, and the sperm count. In the current study, the variability was realized to be of no predictive values for the IUI outcome, yet the endometrial flow in color Doppler was found to be positively connected with the pregnancy outcome.
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Menace of Hepatitis C virus among multitransfused thalassemia patients in Balasore district of Odisha state in India p. 2850
Mithilesh K Sinha, Babita Raghuwanshi, Bijayanimala Mishra
DOI:10.4103/jfmpc.jfmpc_449_19  
Context: Hepatitis C virus (HCV) is a potential cause of morbidity and mortality worldwide. It is most commonly transmitted through injecting drug use; the reuse or inadequate sterilization of medical equipment and the transfusion of unscreened blood products. Management of thalassemia requires long-term blood transfusion. Though it improves the overall survival, it carries a definite risk of infection which is expected to be higher in resource limited settings. Aims: To find the percentage of transfusion-transmitted infections (TTIs) in multitransfused patients of thalassemia in Eastern India. Settings and Design: The study was conducted to assess blood safety in rural population in India by measuring the percentage of TTIs including HCV in multitransfused thalassemia patients. Methods and Materials: One hundred and twenty three patients with major beta-thalassemia were enrolled in this study. The blood samples were tested using ELISA technique for all TTIs. HIV fourth generation kits, HbsAg, HCV third generation kits, malaria and syphilis, parbovirus IgM and parbovirus IgG kits, HEV Antigen and IgM antibody were used. Statistical Analysis Used: Proportions and means were calculated for categorical and continuous variables, respectively. Chi-square test was applied and P value of <0.05 was taken as significant. Results: The mean age of patients was 9.5 years ± 5.2 years. Among various TTIs, Hepatitis C and HIV was prevalent among 59.3% and 4.1% of the study participants, respectively. Conclusions: The causes of high prevalence of HCV may be due to donors being usually asymptomatic in early stages, despite being screened for HCV possibly due to missing early window period infections. The screening methodology of TTIs particularly HCV at the district and village level and consequent increased prevalence of HCV in multitransfused rustic population of India shows the extent of blood safety.
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Menstrual patterns and problems in association with body mass index among adolescent school girls p. 2855
Monika Singh, Om Prakash Rajoura, Raghavendra Appasaheb Honnakamble
DOI:10.4103/jfmpc.jfmpc_474_19  
Background: Menstruation is a normal physiological phenomenon for females indicating her capability for procreation. Menstrual problems are common in adolescent girls, which may affect their life and outdoor activities. Adolescent girls with abnormal body mass index (BMI) suffer even more often. Objectives: To assess the relationship between menstrual patterns and problems with BMI among adolescent school girls of Delhi. Materials and Methods: This study was a cross-sectional study conducted among 210 adolescent school girls of Delhi. Permission was obtained from principal of the school and written informed consent was taken from the parents of the school girls before taking part in the study. All the data were collected, entered, and analyzed in SPSS 17.0. The data were analyzed using percentages and proportions through tables. Results: Out of 210 adolescent girls, 114 (54.3%) were having BMI <18.5, which implies that >50% of the girls were undernourished. Only 13 (6.2%) of adolescent girls were overweight. Adolescent girls who had BMI <18.5 experienced more symptoms and problems associated with menstrual cycles. This difference was statistically significant. Conclusion: Menstrual problems especially dysmenorrhea are frequent among adolescent girls. BMI play a very vital role for menstrual cycle regularity. Consequently, adolescent girls have to be given healthy and balance nutrition, which leads to maintenance of their normal BMI and regulate their menstrual cycle.
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Causes, comorbidities and current status of chronic kidney disease: A community perspective from North Kerala p. 2859
Sabitha Rose Jacob, Rini Raveendran, Suthanthira Kannan
DOI:10.4103/jfmpc.jfmpc_478_19  
Context: Chronic kidney disease is an upcoming public health problem characterized by premature mortality and expensive treatment in low resource settings where diabetes is highly prevalent. Aim: To find out the causes and comorbidities and to explore the community support systems for treatments availed. Settings and Design: Community based cross sectional design. Materials and Methods: Interview of known chronic kidney disease patients above 18 years registered under palliative clinics. Statistical Analysis Used: Mean, SD, proportions, and 95% Confidence interval, chi square test at significance level P = 0.05. Results: Majority of patients were males, below 60 years. Mean duration was 5.26 years and mean age at onset was 48.6 years and 62% were in advanced stages of disease. The commonest cause was diabetic nephropathy (44.6%) followed by hypertensive nephropathy (33.3%).The comorbidities included hypertension (61.4%), diabetes (47.3%), cardiovascular disease (30.6%), Chronic obstructive pulmonary disease (10%) malignancies (2.6%), and retinopathy (28%). Considering treatment status 60.6% were on dialysis 13.3% had undergone transplantation, mostly from private institutions with help of public donations and both at significant underutilization by women. Though 44.6% were protected by social security schemes, the median monthly cost of disease management amounted to Rs. 10,500 which was unaffordable for the majority who were below the poverty line. Conclusions: There is an impending need for strengthening management, high-risk screening among diabetic and hypertensive patients and provision for specialist care to delay the onset of end-stage renal disease. The social security support system should be improvised for our setting to facilitate dialysis and transplantation to minimize out of the pocket expenditure.
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Assessment of knowledge, attitudes, and practices about antibiotic resistance among medical students in India p. 2864
Manoj K Gupta, Chirag Vohra, Pankaja Raghav
DOI:10.4103/jfmpc.jfmpc_504_19  
Context: To reduce the magnitude of antimicrobial resistance, there is a need to strengthen the knowledge for future prescribers regarding use and prescription of antibiotics. Before that, it is required to have a conclusive evidence about knowledge, attitude, and practices of that group. Aim: To assess the knowledge, attitudes, and the practices of medical students in India with respect to antibiotic resistance and usage. Settings and Design: It was a cross-sectional study which was done online through Google forms for a period of 4 months from July to October 2018. Materials and Methods: A structured questionnaire containing a five-point Likert scale was sent to medical students across India by sharing link through contacts of Medical Students Association of India. Respondent-driven sampling technique was also adopted for the study. Statistical Analysis Used: Descriptive statistics, parametric (Chi-square), and nonparametric (Kruskal--Wallis and Mann--Whitney U) tests. Results: A total of 474 responses were received from 103 medical colleges across 22 states of India. The mean score of knowledge was 4.36 ± 0.39. As compared to first year students, knowledge was significantly higher among students of all the years. As much as 83.3% students have consumed antibiotics in previous year of the survey. Around 45% of medical students accepted that they buy antibiotics without a medical prescription. Conclusion: The knowledge level of medical students was quite satisfactory. As far as attitude and practices are concerned, there is a substantial need for improvements.
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Comparative assessment of psychosocial status of elderly in urban and rural areas, Karnataka, India p. 2870
Govindarajan Venguidesvarane Akila, Banavaram Anniappan Arvind, Arjunan Isaac
DOI:10.4103/jfmpc.jfmpc_536_19  
Background and Aims: Psychological and social factors form an integral part in the health and well being of an elderly. Understanding these factors and their differential distribution based on geographical location will help in providing quality care. The aim of this study is to provide a comparative assessment of the psychological and social status of the elderly living in urban and rural area of Karnataka and to identify factors associated with the occurrence of psychological problems among elderly. Methods: This comparative cross-sectional study was done by interviewing 510 elderly in house to house survey in urban and rural area. A pre-tested semi-structured questionnaire was used to collect information pertaining to social and demographic characteristics Cognitive assessment of the elderly was done using Hindi Mini Mental State Examination. Subsequently cognitively normal elderly was assessed for depression using Geriatric depression scale (GDS 15). The Barthel's Activities of Daily Living and Lawton's Instrumental Activities of Daily Living was used for functional assessment of elderly. Results: The proportion of elderly who were at risk of developing depression was higher in rural area (32.6%) when compared to urban area (30.4%). Logistic regression analysis showed that illiteracy, poor perceived mental health, having no one to confide to when they have a problem and feeling financially insecure were significantly associated with risk of depression. Conclusion: Study showed that there is a significant difference in the social and psychological status of elderly in urban and rural areas. Understanding these differences is essential to plan and implement services specifically for urban and rural population.
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Integrated primary palliative care model; facilitators and challenges of primary care/family physicians providing community-based palliative care p. 2877
Shrikant Atreya, Chaitanya Patil, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_653_19  
Introduction: Patients with advanced cancer often suffer from complex symptoms necessitating constant supervision and management. Primary care/family physicians act as an important bridge between the patients in the community and the specialists in the hospital ensuring continuity of care. Materials and Methods: The present paper explored the facilitators and challenges in providing home-based palliative care as perceived by the primary care/family physicians (PCP/FP). Results: 62 physicians reported that they were involved in palliative management of at least one cancer patient in the previous year. A significant number of GPs (34%) lacked confidence in providing this care because of patient complexity, inadequate training and insufficient resources. Other barriers included poor communication from specialists and treating teams. Factors facilitating provision of home-based palliative care included their willingness to help palliative care patients, their inclination to train in palliative care and enthusiasm to refer to guidelines while caring for patients. Conclusion: It is explicit in the paper that resources with respect to information sharing and communication, technical support and training are essential to empower the PCP/FP in providing community-based palliative care.
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The knowledge, attitude and practice of fixed prosthodontics: A survey among Qassim dental practitioners p. 2882
Aryaf Alhoumaidan, Minu P Mohan, Mazen Doumani
DOI:10.4103/jfmpc.jfmpc_683_19  
Aim: The aim of this study was to evaluate the knowledge, attitude and fixed prosthodontics practice guidelines amongst dental practitioners of Qassim in Saudi Arabia. Materials and Methods: A descriptive cross-sectional study was done amongst the Dental Practitioners of Qassim Province, Saudi Arabia in 2018. A total of 290 dentists were selected randomly (from public and private dental clinics and dental schools). A survey was conducted through printed and online questionnaire composed of 19 open and multiple-choice questions. Data from the completed questionnaires were analysed using the SPSS Statistical Software Package (version 25). All statistical analyses were carried out at a significance level of P < 0.05. Results were analysed and compared using the Chi-square test and frequency test. Results: This study showed that 227 (78.3%) of the participants assessed abutment tooth radiographically, also most of them fabricated study cast before starting crown and bridge procedures 37.2% (108). The vitality test for restored abutments was always done by 132 (45.5%) respondents, and 111 (38.3%) of them used poly vinyl siloxane for making final impression, which provides the level of quality of final impression. A total of 117 (40.3%) of them always used retraction cord before making final impression. Both written prescriptions and verbal instructions were used by 209 (72.1%) of the practitioners for communication with the lab. The study revealed that there were no significant differences between males and females in answering questions 11, 13 and 17. Conclusion: The dental practitioners (DPs) of Qassim displayed an acceptable level of knowledge and a level of awareness of fixed prosthodontics practicing. However, to further enhance the proficiency, efforts should be made to encourage the practitioners to be aware of the advances in fixed prosthodontics practice through state-of-the-art continuous education programmes. Clinical Significance: As fixed prosthodontic restorative procedures are widely practiced for dental rehabilitation in Saudi Arabia, it was very important to measure and evaluate the knowledge of DPs about the details of basic steps in the field of fixed prosthodontics and the way of practicing this important branch of dentistry.
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Microbiologic profile and clinical practices in urinary tract infections in a tertiary care center in Southern India p. 2888
Keithellakpam Kiranmala, Reuben Johnson, Jayanthi Savio, Jyothi Idiculla
DOI:10.4103/jfmpc.jfmpc_346_19  
Context: Studies reported differences in clinical profiles of urinary tract infections (UTIs) in patients with and without type 2 diabetes mellitus (T2DM). Studies on the impact of the pattern of antibiotic resistance of organisms causing UTI on actual clinical practice are lacking. Objectives: 1. To study the clinical and microbiologic profiles of UTIs. 2. To compare treatment given with the prevailing antimicrobial sensitivity. Settings and Design: This is a cross-sectional study conducted in a tertiary care hospital. Methods and Materials: Retrospective chart review of inpatients with UTI (N = 200, 100 each of patients with and without T2DM), aged >18 years with a positive urine culture. Statistical Analysis: We used the statistical package SPSS version 17. The categorical variables were analyzed by the Chi-square test. Data were considered significant if P value was less than 0.05. Results: Similar to previous Indian studies, T2DM patients with UTI had significantly more asymptomatic bacteriuria, asymptomatic bacteriuria (32% vs. 6%), previous history of UTI (25% vs. 2%), and prior catheterization (16% vs. 1%). Escherichia coli (E. coli) was the most common organism isolated and showed sensitivity pattern of meropenem > netilmicin > amikacin > nitrofurantoin. Ceftriaxone was the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. All ASB cases were treated unlike recommendations. Conclusions: Ceftriaxone is the most common empirical therapy given in spite the prevailing low sensitivity of E. coli to it. Cases of ASB were treated unlike recommendations.
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Investigation of correlation between religious attitude and mother-adolescent girls conflict p. 2893
Naeimeh Tayebi, Elham Khooshab, Fatemeh Ghodrati, Marzieh Akbarzadeh
DOI:10.4103/jfmpc.jfmpc_387_19  
Background: Religion is considered as one of the factors influencing one's behavior and cognition and plays an important role in shaping the individual's lifestyle. People with religious beliefs, due to less stress, may have less conflict with others. Objective: Comparison of adolescents with high and low religious attitudes in terms of conflict with mother. Methodology: This is a cross-sectional, analytic, epidemiological study on girls aged between 15 to 18 years in middle and high schools of Shiraz. The sample size, with a percentage of conflict in a sample of 86 pilots, was 509. Data collection tools included a demographic questionnaire, conflict tactics scale parents (CTSP), and religious attitude questionnaire. Results: There was no significant relationship between religious attitude and individuals' reasoning tactics (P = 0.072), and physical aggression tactics (P = 0.83) of the girls with mother conflict resolution. However, there was a significant relationship between religious attitude and verbal aggression tactics (P = 0.83) of adolescents and mothers (P = 0.04(. There was a significant difference between religious attitudes and total the girls with mother conflict resolution scale (P = 0.003). Relationship between religious attitude and individuals' reasoning tactics in conflict resolution (P = 0.072) and physical aggression tactics (P = 0.83) of self and mother was not seen significant relationship. Conclusion: The majority of girls (91.2%) had a moderate religious attitude (48.4%) at low levels of conflict. There was a significant relationship between religious attitude and the total score of There was no significant relationship between religious attitude and individuals' reasoning tactics (P = 0.072) and physical aggression tactics (P = 0.83) of the girls with mother conflict resolution conflict.
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Relationship between personality traits and burnout in oncology nurses p. 2898
Shahram Molavynejad, Mahbubeh Babazadeh, Fariba Bereihi, Bahman Cheraghian
DOI:10.4103/jfmpc.jfmpc_423_19  
Introduction: Nurses burnout is a serious problem which can affect their health, the quality of patient care, and health institutions. Personality traits affect level of nurse burnout, and burnout characteristics vary depending on nurses' personality traits. The present study assessed burnout levels in order to determine stages of burnout in oncology nurses and to analyze the relationship between burnout and demographic characteristics and personality traits. Methodology: This is a cross-sectional study performed on 106 oncology nurses working in Baghaei Hospital affiliated to Ahvaz Jundishapur University of Medical Sciences in Iran. The main personality traits were assessed using the NEO Five-Factor Inventory (NEO-FFI) and anxiety and depression employing a clinical educational questionnaire. The Maslach Burnout Inventory (MBI) was utilized to determine burnout levels, the t-test to compare the means, and Pearson correlation to evaluate correlations between personality traits and the different dimensions of the MBI. Findings: About 32.1% of the oncology nurses present in this study were in the most severe phase of burnout. Depersonalization and emotional exhaustion had a significant positive correlation with anxiety and depression, whereas personal accomplishment had a negative correlation with anxiety and depression. Conclusion: A significant number of the oncology nurses experienced the most severe stage of burnout. Given the effects of personality traits on burnout dimensions, they should be taken into account to prevent the burnout syndrome.
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Culture positivity of smear negative pulmonary and extrapulmonary tuberculosis- A study from North Kerala, India p. 2903
Shabana Orvankundil, Beena P Jose, Fahmiya L Yacoob, Sreelatha Sreenivasan
DOI:10.4103/jfmpc.jfmpc_424_19  
Introduction: The identification of smear negative pulmonary and extrapulmonary tuberculosis continues to remain a diagnostic challenge. This study was conducted in a tertiary care setup in north Kerala to isolate and identify mycobacteria by culture from radiologically and clinically suspected cases of smear negative pulmonary and extrapulmonary tuberculosis. Methods: A total of 200 samples (100 pulmonary and 100 extrapulmonary) were processed and cultured by automated (MB/BacT) and conventional methods. Heat stable catalase test, nitrate reduction test and detection of MPT 64 antigen were done to aid species identification. Results: Overall culture positivity was 7% (14 isolates - 8 pulmonary and 6 extrapulmonary) of which 92.9% (13) of the isolates were Mycobacterium tuberculosis and 7.1% (1) was Mycobacterium fortuitum (identified by molecular typing). Detection rate by automated method was 7% (14) and by conventional method was only 1.5% (3). Conclusion: Despite its shortcomings and low positivity, culture still remains the gold standard for the diagnosis of EPTB and SNPT. However, automated liquid cultures have better isolation rates than the conventional LJ culture. Subjecting these isolates to rapid diagnostic tests like antigen detection and LPA can aid in the early institution of appropriate treatment regimen.
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Parental knowledge and common practices regarding acute respiratory infections in children admitted in a hospital in rural setting p. 2908
Kapil Bhalla, Ashish Gupta, Sanjiv Nanda, Shuchi Mehra, Savita Verma
DOI:10.4103/jfmpc.jfmpc_510_19  
Context: In developing countries, there is paucity of data regarding knowledge and practices of parents regarding acute respiratory infections (ARIs). Aims: The present study was undertaken to study the knowledge and practices of parents for ARIs. Settings and Design: This was a prospective, cross-sectional study conducted over period of 3 months in pediatric ward of a tertiary care teaching hospital. Subjects and Methods: All the children admitted in pediatrics ward with complaints of ARI were included in the study. Statistical Analysis Used: Statistical analysis was carried out by using Statistical Package for Social Sciences software version 20. Results: A total of 1,752 children were enrolled in the study out of which 885 (50.51%) were males and 867 (49.49%) were females. Only 42.6% of parents answered correct answers about the proper use of antibiotics for children with ARI. Most of the caregivers (58.4%) had poor knowledge about incomplete immunization as a risk factor for developing diseases like diphtheria and pertussis. Majority of caregivers (66.3%) practice home remedies by themselves. Conclusion: The knowledge of caregivers/parents regarding symptoms, risk factors, and complications of ARI was adequate. Better awareness is needed for safe use of antibiotics, and caregivers shall be encouraged to minimize indoor air pollution. More awareness is required for discouraging the practice of visiting quacks as it can lead to serious complications in the child.
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Non-cultured melanocyte transfer in the management of stable vitiligo p. 2912
Birinder Singh Gill, Manmohan Singh Brar, Neha Chaudhary, Avneet Randhawa
DOI:10.4103/jfmpc.jfmpc_546_19  
Background and Aims: Present study aimed to determine the clinical outcome for non-cultured melanocyte transfer in the management of stable vitiligo. Methods: A hospital based prospective study was conducted including 50 stable unresponsive patients of vitiligo undergoing non-cultured melanocyte transplant. Re-pigmentation was analyzed on the basis of baseline photographs after 6 months post procedure. Degree of re-pigmentation was estimated to the nearest of one of the following percentages and the final outcome of re-pigmentation for statistical analysis was graded as: >70% re-pigmentation: Good; 30-69% re-pigmentation: Fair and; <30% re-pigmentation: Poor. Results: The mean age of study group was 29.79 ± 13.8 with 52% males and 48% females. Out of total 50 patients, 31 (62%) patients showed good re-pigmentation, 10 (20%) showed fair re-pigmentation while 9 (18%) patients showed poor re-pigmentation. Patches over face, lips, trunk and legs showed good re-pigmentation, however patches over acral areas and bony prominences had poor re-pigmentation. Conclusion: Autologous non-cultured melanocyte transfer have an edge over the other modalities, however, proper patient selection, proper technique and good laboratory set up is required. It has an advantage over conventional split skin thickness grafting as it requires very little donor site skin.
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Effect of stress on sleep hygiene among school going adolescents in Chennai p. 2917
Srihari Ramamoorthy, Dilara Kamaldeen, Latha Ravichandran, Manikandan Sundaramahalingam
DOI:10.4103/jfmpc.jfmpc_564_19  
Background: Stress is a psychophysiological phenomenon. Due to recent lifestyle modifications prevalence of stress is increasing among adults and adolescents. Adolescence is a period of storm and stress and any excess stress would have negative impact on their sleep and would ultimately affect their academic performance and health. Hence the current study proposes to evaluate the effect of stress on sleep hygiene among school going adolescents in Chennai. Materials and Methods: A cross-sectional study and participants were healthy male (84) and female (48) school going adolescents between the age group of 15-19 years (n = 132). Stress was assessed using Perceived Stress Scale (PSS) and sleep hygiene was assessed using Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD). Results: In all, 84.8% of the adolescents reported that they are academically overloaded. Both the genders were found to be moderately stressed (Males: 63.6%; females: 66.7%). Prevalence of sleep disturbances was found to be 23.5% and increase in stress was found to be associated with decrease in sleep quality. Discussion: The study shows that prevalence of stress is high among adolescents and it is negatively influencing their sleep hygiene. Hence, early identification and management of stress is required for school going late adolescents for better academic performance and wellbeing.
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E-cigarette use among medical students at Qassim University: Knowledge, perception, and prevalence p. 2921
Abdullah Almutham, Mohammed Altami, Fawzy Sharaf, Ali AlAraj
DOI:10.4103/jfmpc.jfmpc_567_19  
Background: The popularity of e-cigarettes is increasing rapidly worldwide and advertisements for such products are becoming ubiquitous in the media. Health concerns and smoking cessation are the most commonly reported reasons for traditional tobacco smokers to shift to e-cigarettes. As a result, the global market for e-cigarettes is on the rise. However, they are still a potential cause for many diseases. Methods: This is a cross-sectional study carried out at Qassim University in Buraydah, Saudi Arabia. A prevalidated questionnaire was distributed to medical students in April 2018 to evaluate the experience, knowledge, and awareness of e-cigarettes among the participants. Results: About one in ten students confirmed having smoked an e-cigarette. There was no significant relationship between e-cigarette users and demographic factors, such as gender, academic level, or age. However, the study showed a significant association between e-cigarette smoking and having an e-cigarette smoker among family members or friends. Most students 71.9% were not sure whether e-cigarettes were approved by the Food and Drug Administration (FDA) for smoking cessation. Only 23.3% of those surveyed believed that e-cigarettes can help in smoking cessation, whereas only 11% said that they would recommend it for a patient. On the contrary, 49.6% agreed that e-cigarettes are addictive. In response to another question, 92% reported receiving no education in medical school about e-cigarettes. Conclusion: Our study showed that medical students lacked knowledge about e-cigarettes. Therefore, more studies are needed to raise awareness about e-cigarettes, especially since the habit of using e-cigarettes is invading our society.
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Is it necessary to screen patient with adhesive capsulitis of shoulder for diabetes mellitus? Highly accessed article p. 2927
SK Rai, Manoj Kashid, Barun Chakrabarty, Vimal Upreti, Omna Shaki
DOI:10.4103/jfmpc.jfmpc_244_19  
Background: Idiopathic adhesive capsulitis of shoulder is common cause of pain and restriction of shoulder motion between the ages of 30 and 65. The prevalence of adhesive capsulitis is as high as 10% to 22% in diabetes mellitus as compared normal population which is 02% and 04%. Therefore, the doubt arises whether patients developed adhesive capsulitis are at greater risk to develop diabetes mellitus and should be screen for diabetes so that it can be detected early. Purpose: To compare the prevalence of prediabeties and diabetes mellitus among patients with features of idiopathic adhesive capsulitis of shoulder who are otherwise healthy. Methods: Patients between 30-65 years of age who attended Orthopaedics OPD with features of idiopathic adhesive capsulitis of shoulder were included. Participated underwent a 2 hour long oral glucose tolerance test and based on fasting and 2-hour plasma glucose levels, patients were diagnosed as normal glucose tolerance, prediabetic, or diabetic and the results were matched with previous published data. Results: 135 patients as participated and completed the test. 21 (15.5%) patients with idiopathic adhesive capsulitis of shoulder were found to be prediabetic, and 37 (27.4%) patients were found to be diabetic. However, 31 patients had family history of diabetes. Conclusion: Based on our study, we can recommend that patients with features of idiopathic adhesive capsulitis of shoulder should be screened at least for fasting and post prandial blood sugar so that diabetes can be detected early.
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Profile of newly diagnosed adult patients with rheumatic heart disease in sub-Himalayan region – A 5-year analysis p. 2933
Minakshi Dhar, Nidhi Kaeley, Nowneet Bhatt, Sohaib Ahmad
DOI:10.4103/jfmpc.jfmpc_363_19  
Introduction: Rheumatic heart disease (RHD) is one of the leading acquired causes of cardiac diseases affecting the young population, worldwide. Aims and Objectives: The primary objective was to study the prevalence, profile, and complications of patients with RHD in a tertiary care hospital of Uttarakhand. The secondary objective was to assess the demographic and clinical parameters of patients with RHDs. Materials and Methods: All adult patients above the age of 18 years, diagnosed with RHD, over a period of 5 years from July 2008 to June 2013 were enrolled in the study. Detailed clinical data of the patients were obtained retrospectively from the hospital record section. Information regarding prevalence of RHD, profile, and complications of patients with RHD was collected from patient's case sheet and tabulated. Results: In all, 1001 patients age more than 18 years with RHD presented to either medical or cardiology outpatient departments over a period of 5 years from July 11 to June 2018. Mitral regurgitation (n = 610, 61.9%) was the most common RHD. Females (n = 538, 53%) outnumbered males (n = 464, 46.2%). Heart failure (n = 353, 35.1%), severe pulmonary arterial hypertension (n = 118, 11.7%), and atrial fibrillation (n = 212, 21.1%) were common complications. A total of 75 (7.4%) patients presented with bacterial endocarditis, whereas 32 (3.2%) patients succumbed to death due to RHD.
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Association of 4-basepair G-to-A transition in the 5′-untranslated region of ANKH gene with selected patients of primary knee osteoarthritis: A cross sectional study p. 2937
Puneet Kumar, Aarti Sharma, Siddharth Das, Ragini Srivastava, Nikhil Gupta
DOI:10.4103/jfmpc.jfmpc_471_19  
Method: A cohort study was carried out for a year to evaluate the presence of G-to-A transition in 5′-untranslated region of ankylosis human (ANKH) gene in Indian Khatri patients (closely resembling Europeans of primary knee osteoarthritis (OA), residing in Lucknow, India. Results: In the total participants, 25 were Khatri primary knee OA patients (cases) residing in Lucknow and 101 were random blood donors' samples (controls) collected from a blood bank. All were studied for the abovementioned mutation using real-time polymerase chain reaction (RT-PCR). GG genotype was present in 72.3% of controls and 76% of Khatri knee OA patients. The studied G-to-A mutation was found to be positive in 24.8% of controls and 16% of cases, odds ratio (95% confidence interval) being 0.6 (0.19–1.98, P = 0.42). The frequency of AA (D) genotype found around 3% (cases) and 8% (controls) with P value of 0.70. The combined frequency of both homozygous and heterozygous mutation (GA and AA) in the studied population was 28 (27.7%) in controls and 6 (24%) in cases with the odds ratio (OD) ratio of 0.82 (0.29–2.27, P = 0.70). No significant differences were observed at both genotype and allelic level in the distribution of ANKH-4 G-to-A gene polymorphism in studied subjects. Conclusion: This study did not show any significant G to A mutation in the studied subjects.
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Cost and effectiveness analysis of the diagnostic and therapeutic approaches of group A Streptococcus pharyngitis management in Iran p. 2942
Zahra Behnamfar, Vahid Shahkarami, Sara Sohrabi, Amin Shafiee Aghdam, Hasan Afzali
DOI:10.4103/jfmpc.jfmpc_487_19  
Background: A sore throat is one of the common causes behind visits to the physician and antibiotic overtreatment in the world, especially in Iran. There are six ways of approaching pharyngitis patients. It is necessary to perform a cost-effectiveness analysis and find the best approach in all situations on group A streptococcus (GAS) pharyngitis management to propose a pharyngitis guideline. Method: The decision tree of managing pharyngitis and its complications was drawn. The probability of every status and the branches of the tree were derived from the literature, and the cost of related diseases and complications were calculated based on the dossiers of the patients in two main pediatric central hospitals in Tehran, Iran. Further, cost-effectiveness, sensitivity, and threshold analyses were conducted to find out the best management strategy. Moreover, for a situation analysis of pharyngitis management in Iran, a questionnaire was designed and given to general practitioners and pediatricians; 130 subjects responded to it. The results were then analyzed. Results: The rapid test antigen (RTA) and culture strategy were proved to have the highest effect on the quality-adjusted life year. In addition, a less expensive strategy was solely observed to be the RTA. The worst effect gained (most quality-adjusted lost days) was, however, from the “treat none” strategy. Conclusion: According to our cost-effectiveness analysis, the best management of pharyngitis occurs in RTA alone, followed slightly by culture strategies; the “RTA then culture if needed” and “RTA and culture” approaches become possible options after them. The “treat all” and “treat none” approaches, however, were not proper strategies in any case.
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The evaluation of ocular refractive error and axial length changes after scleral buckle removal p. 2950
Ahoor M Hosein, Sorkhabi Rana, Eftekhari M Amir, Ojaghi Habib, Najafi Amin
DOI:10.4103/jfmpc.jfmpc_557_19  
Purpose: The present study aimed to evaluate refractive error and axial length changes after buckle removal due to buckle complications. Methods: A total of 15 patients involved in this study. The enrolled patients who had history of scleral buckling (SB) for rhegmatogenous retinal detachment referred to clinic for buckle removal due to buckle-related complications. Complete ophthalmic examinations and IOLMaster (Carl Zeiss) device performed prior and 3 months after buckle removal. Also best corrected visual acuity (BCVA), refractive error and axial length changes evaluated after buckle removal. Results: BCVA, refractive error, and axial length changes were not statistically significant (P value: 0.24, 0.23, 0.33, respectively). No redetachment or any other complication was observed after buckle removal. Conclusion: The study displayed induced globe shape changes due to SB are irreversible after buckle removal. In addition, it is a safe procedure and does not raise any risk of retinal redetachment.
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Evaluating the relationship between smartphone addiction/overuse and musculoskeletal pain among medical students at Qassim University p. 2953
Abdullah M Alsalameh, Mohammad J Harisi, Muath A Alduayji, Abdullah A Almutham, Farid M Mahmood
DOI:10.4103/jfmpc.jfmpc_665_19  
Background: Smartphone use has greatly increased in recent days, and most of the daily tasks are done through these devices. As a result, long time use may involve bad posture that may result in musculoskeletal pain. Therefore, it is important to evaluate the association between addiction/overuse of smartphones and musculoskeletal pain. Aim: To determine the prevalence of addictive/overuse of smartphones among medical students and to investigate if there is an association between smartphone addiction and musculoskeletal pain. Method: A cross-sectional study conducted at Qassim University, medical college. The Smartphone Addiction Scale Short Version (SAS-SV) was used to measure the level of smartphone addiction while the Nordic musculoskeletal questionnaire (NMQ) was utilized to evaluate the musculoskeletal pain. Results: The prevalence of smartphone addiction among medical students was relatively high (60.3%). The most frequent pain related to smartphone addiction was in the neck (60.8%), followed by lower back (46.8%), shoulder (40.0%). The academic year level was statistically associated with the level of smartphone addiction. Moreover, we found a significant relationship between musculoskeletal pain and smartphone addiction at certain body regions, neck, wrist/hand and knees, Other musculoskeletal parameters included in the test were found to have no statistically significant association. Conclusion: More than half of the medical students identified as addicted to smartphones. The most common musculoskeletal pain was the neck, lower back, and shoulder. The academic year level found to have a significant association with the level of smartphone addiction while musculoskeletal pain such as neck, wrist, and knee were the independent significant factors of smartphone addiction; therefore, it is important to educate the community about the effect of being addicted to smartphone use in order to prevent the consequences of this behavior.
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Salivary antioxidant enzymes and lipid peroxidation product malondialdehyde and sialic acid levels among smokers and non-smokers with chronic periodontitis—A clinico-biochemical study p. 2960
C Naresh Kumar, Subramaniam M Rao, Prashanth R Shetty, V Ranganath, Abhilasha S Patil, Anu Anna John
DOI:10.4103/jfmpc.jfmpc_438_19  
Background: Pathogenesis of most of the inflammatory process are associated with reactive oxygen species (ROS), derived from various metabolic sources and which may lead to direct or indirect tissue damage due to oxidative stress, resulting in periodontal diseases. Usually antioxidant systems are capable of removing free radicals, thereby preventing tissue damage from free radical. ROS can result in tissue damage, involving lipid peroxidation. The aim of this study was to evaluate and compare the levels of superoxide dismutase (SOD), glutathione peroxidase (GPx), malondialdehyde (MDA), and sialic acid (SA) in periodontally healthy and chronic periodontitis among nonsmokers and smokers and to determine their value as diagnostic markers for chronic periodontitis. Materials and Methods: A total of 90 male patients aged 20--60 years were recruited and grouped as Group 1: 30 Healthy nonsmokers, who had never smoked. Group 2: 30 nonsmokers with chronic periodontitis. Group 3: 30 smokers with chronic periodontitis. Unstimulated saliva was collected for at least 5 min and clinical measurements; SOD, GPx, MDA and SA were assessed using a spectrophotometric method. Results: Data showed a significant correlation between salivary SOD, GPx, MDA, and SA in group 1, group 2, and group 3. SOD and GPx were found to be lower and MDA and SA levels were found to be higher among smokers with chronic periodontitis. Conclusion: Reduced levels of antioxidant enzymes SOD and GPx and elevated levels of lipid peroxidation product MDA as well as increased levels of SA could be used as diagnostic markers to measure oxidative stress in periodontal disease associated with risk factor such as smoking.
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Association of brachial and central hemodynamic parameters to eGFR and proteinuria in Gujarati diabetics with mild-to-moderate nephropathy p. 2965
Jayesh D Solanki, Rajkumar B Patel, Ila N Hadiyel, Hemant B Mehta, Hirava B Munshi, Param J Kakadiya
DOI:10.4103/jfmpc.jfmpc_493_19  
Introduction: Diabetes mellitus (DM) is a significant risk factor for nephropathy and cardiovascular morbidity. Pulse wave analysis (PWA) gives direct inference of brachial hemodynamics (BH) and central hemodynamics (CH). We studied relation of them with diabetic nephropathy (DN) among type-2 diabetics (T2D). Methods: We studied oscillometric PWA by a cross-sectional study in 160 T2Ds. Using Mobil-o-Graph (IEM, Germany), we derived BH (blood pressure, pulse pressure index, rate pressure product) and CH (aortic pressure, cardiac index, stroke volume index, stroke work). They were further compared and associated with DN in terms of creatinine, proteinuria, and estimated glomerular filtration rate (eGFR). Results: There were 89 males, mean age 56 years, mean duration 4.8 years, 80% hypertensive predominantly using ACE inhibitors, poor glycemic blood pressure (BP) control, mainly mild-to-moderate DN, mean eGFR 88.2, 34% prevalence of proteinuria. Arterial stiffness was high with female disadvantage. BH and CH parameters were not different with or without DN using proteinuria or eGFR (60 cutoff) criteria. BH, CH correlated insignificantly with creatinine and eGFR. Female disadvantage, correlation with bSBP and aSBP were only significant results. Conclusions: BH and CH are not related to eGFR and proteinuria in predominantly hypertensive, Gujarati diabetics with mild-to-moderate nephropathy suggesting need of other cardiovascular parameters.
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Association between knowledge of influenza vaccine and vaccination status among general population attending primary health care centers in Al-Madinah, Saudi Arabia p. 2971
Ayman Mobarak Almotairy, Wafa Allauddin Sheikh, Ali Ahmed Ali Joraid, Abdulaziz Ali Bajwi, Mohammed Salem F. Alharbi, Sami Abdo Radman Al-Dubai
DOI:10.4103/jfmpc.jfmpc_547_19  
Background: Influenza vaccination is essential for population health. However, despite its strong recommendation, studies indicated a low rate of vaccine uptake. This study aimed to explore knowledge and attitudes towards influenza vaccinations among the general population attending primary health care centers in Al-Madinah, Saudi Arabia. Materials and Methods: This cross-sectional study was conducted among 381 participants from four health care centers in Al-Madinah city. A validated self-administered questionnaire was used. It includes questions on sociodemographic variables, knowledge, attitude, and vaccine uptake. Chi square test and simple logistic regression test were used to assess association between vaccination status and study variables. Results: Mean (SD) age of participant was 37 (12.5) and age ranged from 18 to 65 years. The majority were male (64.6%). Three out of seven items were answered correctly by most of the participants. The majority were classified as not knowledgeable (53.5%). More than half have been vaccinated with influenza vaccine (58.3%). Factors associated with vaccination uptake were Age group (P < 0.05), Marital status (P < 0.05), education level (P < 0.05) and Knowledge (P < 0.05). Conclusion: The study showed poor knowledge and attitude toward influenza vaccination among general population but a relatively accepted rate of vaccine uptake. Vaccination uptake was associated with knowledge, marital status, education, and age. This study recommends implementation of educational programs to increase the awareness among the general population.
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Saudi teachers' confidence and attitude about their role in anaphylaxis management p. 2975
Mohammed A Alsuhaibani, Salman Alharbi, Salman Alonazy, Marwa Almozeri, Malak Almutairi, Aqeel Alaqeel
DOI:10.4103/jfmpc.jfmpc_562_19  
Background and Aims: Anaphylaxis is a common emergency and life-threatening hypersensitivity reaction defined as a rapid generalized allergic reaction. Prior international studies have shown that school personnel is often not familiar with the signs of hypersensitivity or with appropriate management strategies that should be initiated at school for children with an anaphylactic reaction. Moreover, no studies have evaluated the awareness of anaphylaxis by school teachers in Saudi Arabia. The aim of this study was to determine teachers' knowledge, attitudes, and practices toward anaphylaxis in Al-Qassim, Saudi Arabia. Methods: This was a cross-sectional study conducted at a public school in Al-Qassim, Saudi Arabia via a validated fourteen items questionnaire aimed to survey teacher knowledge, attitudes, and practices toward anaphylaxis. The questionnaires were disseminated using a multistage random sampling technique to Saudi national's teachers from different regions in Al-Qassim. Results: Most teachers had a low level of knowledge (85.3%) of anaphylaxis and positive attitudes (72.9%), and the level of practice was reported as low (48.9%) to moderate (47.5%). The most common sources of information regarding anaphylaxis were the internet and social media. When considering significant factors associated with knowledge, attitudes, and practices (KAP), we found that sex, years of experience in teaching and witnessing students suffering from anaphylaxis were all positively associated with KAP. Conclusion: The overall knowledge and practices of teachers regarding anaphylactic reactions were poor, although teachers' attitudes toward learning this information were positive. Thus, teachers need further education regarding the management of allergic reaction.
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Prevalence of malocclusion and orthodontic treatment needs among 12-15 years old school children in Patna, Eastern India p. 2983
Rana N P Singh, Ajoy K Shahi, Veeranna Ramesh, Swati Sharma, Sandeep Kumar, Subhash Chandra
DOI:10.4103/jfmpc.jfmpc_681_19  
Context: The people around the world are concerned about the aesthetic oral-facial structures as it is more important in interpersonal interactions and dictates vocal, physical, and emotional communication. Aims: The present study was conducted to assess the severity of malocclusion and orthodontic treatment need among 12-15-year-old school children of Patna, Eastern India. Settings and Design: A cross-sectional study design was used to assess the severity of malocclusion using Dental Aesthetic Index (DAI) index among 12-15-year-old school-going children. Methods and Material: A specially prepared and pretested format, exclusively designed for recording all the required and relevant general information and other clinical findings was used in the study. The sample size consisted of 902 children from middle schools (Government and Private) in Patna. Statistical Analysis Used: Chi-square test was done for the categorical data to compare differences between two independent groups. Data were presented as Mean ± SD and “P” value of less than 0.05 was accepted as indicating significance. Results: Around 5.3% had a DAI score of ≤25 which signifies that there is “no abnormality or may have minor malocclusion”; 15.3% had a DAI score of 26-30 which signifies that there is “definite malocclusion”; 6% had a DAI score of 31-35 which signifies that there is “severe malocclusion” and 4% had a DAI score of ≥36 which signifies that there is “very severe or handicapping malocclusion”. The finding was more commonly seen among 14 years age group. Conclusions: It can be concluded from the present study that the prevalence of malocclusion is reasonable high in this part of the region, and it is very important to bring in more awareness at the school level as primary prevention can be the most effective tool in control this menace.
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The effect of aromatherapy on mental, physical symptoms, and social functions of females with premenstrual syndrome: A randomized clinical trial p. 2990
Naval Heydari, Mliheh Abootalebi, Naeimeh Tayebi, Fahimeh Hassanzadeh, Maryam Kasraeian, M Emamghoreishi, Marzieh Akbarzadeh
DOI:10.4103/jfmpc.jfmpc_452_19  
Objective: This study was designed to compare the effect of aromatherapy with Rosa Damascena and Citrus Aurantium blossom on psychological and physical symptoms and social functions of females with premenstrual syndrome. Materials and Methods: This double-blind clinical trial was conducted on 95 students. They were randomly divided into three aromatherapy groups (aromatherapy with 4% concentration of Rosa Damascena and 0.5% concentration of Citrus Aurantium blossom essential oil) and aromatherapy with sweet almond oil (as control group). Premenstrual Symptoms Screening Tool questionnaire (PSST) was completed before and during the first and second month of the intervention. Data were analyzed by SPSS software version 22. Results: After intervention, the scores of mental symptoms decreased in all three groups and this decrease was significant in both Citrus Aurantium (P = 0.004) and Rosa Damascena groups (P = 0.007). The score of physical symptoms was decreased in all three groups but it was significant only in the Rosa Demecensa group (P = 0.042). The reduction of effect of symptoms on social function was observed in two intervention groups which were significant only in Rosa Damascena group (P < 0.001). Conclusion: Essential oils of Rosa Damascena and Citrus Aurantium were both effective in improving the symptoms of premenstrual syndrome but the effect of Rosa Damascena, with regard to improvement of symptoms of premenstrual syndrome was more than that of Citrus Aurantium in all psychological, physical, and social aspects.
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Utilization of health services in Tenali Mandal, Andhra Pradesh- A cross-sectional study p. 2997
Suresh Chand Yaddanapalli, Ravuri Srinivas, B Vikram Simha, Talluri Devaki, V Viswanath, Srinivas Pachava, Viswa Chaitanya Chandu
DOI:10.4103/jfmpc.jfmpc_462_19  
Introduction: India has a plurality of health care with different systems of medicine delivered by government and local bodies in hospitals and clinics. Public hospitals provide 60% of all hospitalizations, while the private sector provides 75% of all routine care. Utilization is the actual attendance by the members of the public at health care facilities, which measures the number of visits per year or the number of people with at least one visit during the previous year, serves as an important tool and acts as a guiding path in understanding disease profile and also helps resource allocation. Materials and Methods: A cross-sectional study was done using the National Pathfinder survey (stratified cluster random sampling) to know the health care utilization, profile, and pattern in Tenali Mandal, Guntur, Andhra Pradesh. Results: The study sample comprised of 1,500 subjects who were equally divided among 5 age groups. Out of 1,500 participants, 52.8% were females and 47.2% were males. In total, 71.7% of the study participants have utilized health services, with majority of them (44.5%) had availed services within the last 6 months with prime reason of fevers (15.8%), while the main barrier for not seeking care was distance (17.03%), almost an equal proportion of the population sought care for their problems through home remedies and over-the-counter. Conclusion: There is an utmost need to minimize barriers of utilizing by making them aware of the health problems, so that they develop a positive attitude toward health care utilization. Therefore, knowledge of utilization of health services and associated factors is important in planning and delivery of interventions by the primary care physicians to improve health services coverage.
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Does anemia affects cognitive functions in neurologically intact adult patients: Two year cross sectional study at rural tertiary care hospital p. 3005
Sachin Agrawal, Sunil Kumar, Vaibhav Ingole, Sourya Acharya, Anil Wanjari, Shilpa Bawankule, Nitin Raisinghani
DOI:10.4103/jfmpc.jfmpc_599_19  
Background: The anemia not only negatively affects physical function but also the cognition, mood, and quality of life in adult patients due to hypoxic condition as per its severity. This study has been planned to investigate the cross-section association of anemia with cognitive function in neurologically intact patients. Methods: In this study, a total 200 subjects were enrolled out of which 100 were cases and 100 age and sex matched controls. Mini-mental status examination (MMSE) and short portable mental status questionnaire (SPMSQ) scales were used to assess cognition in all the subjects. Results: This study showed that there was a significant correlation between the anemia and the cognitive skills in the neurologically intact patients. Conclusion: The cognitive functions were strongly related to hemoglobin levels as seen by low MMSE score and higher SPMSQ error in those with low hemoglobin levels compared with those with higher hemoglobin levels.
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Coverage of mass drug administration for elimination of lymphatic filariasis in urban Nagpur, Central India: A mixed method study p. 3009
Sitikantha Banerjee, Kajari Bandyopadhyay, Mubashshera F Khan, Sujiv Akkilagunta, Kalaiselvi Selvaraj, Jaya P Tripathy, Ranjan Solanki, Arvind S Kushwaha, Pradeep Deshmukh
DOI:10.4103/jfmpc.jfmpc_503_19  
Background and Aims: Mass Drug Administration (MDA) coverage remains an important indicator in elimination of Lymphatic Filariasis (LF), especially in context of recent changes in programme strategies in India, such as incorporation of Ivermectin and involvement of urban Accredited Social Health Activists (ASHAs). This study aimed at assessing the coverage and compliance with MDA of Filariasis as well as exploring perspective of beneficiaries for non-consumption in selected slum area of Nagpur city. Methods: Mixed-method study design comprising of quantitative assessment of MDA coverage, followed by qualitative method to explore the reasons of non-compliance was used in selected slum areas of Nagpur city. Using cluster sampling, 240 households were selected and house-to-house visits were made to interview the eligible participants. In-depth interviews were conducted among selected non-compliant participants. Statistical Analysis: Multivariable logistic regression analysis to identify the factors associated with non-consumption. Thematic analysis was done to obtain the reasons of non-consumption as perceived by the beneficiaries. Results: Among the 1096 individuals studied, distribution and consumption coverage were 55.2% and 48.5%, respectively. Effective supervised consumption was further low (28.9%). Coverage compliance gap (CCG) was 12.1%. Male sex and younger age (2-5 years) were significant socio-demographic determinants of non-consumption. No repeat visit to houses left in first round, fear of side effects, pill burden, poor understanding about the need were important reasons as revealed by qualitative inquiry. Conclusion: Effective pre-campaign awareness, incorporation of context specific drug delivery strategies and strengthening monitoring system are essential for successful MDA implementation.
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Randomized controlled trial of cefazolin monotherapy versus cefazolin plus azithromycin single dose prophylaxis for cesarean deliveries: A developing country's perspective p. 3015
Manjeera S Jyothi, Jasvinder K Kalra, Aashima Arora, Amol Patil, Vanita Suri, Vanita Jain, Nusrat Shafiq, Shiv S Saini, Vikas Gautam
DOI:10.4103/jfmpc.jfmpc_593_19  
Aim: To compare the efficacy of pre-incision intravenous single doses of cefazolin versus cefazolin plus azithromycin as an antibiotic prophylaxis in cesarean delivery (CD). Methods: This was a single-center, double blind, randomized controlled trial conducted in the PGIMER, Chandigarh. 200 women undergoing elective/emergency cesarean section were randomized. Group A received single dose of cefazolin plus placebo while Group B received single dose of cefazolin plus azithromycin. Primary outcome evaluated was occurrence of surgical site infections (SSI); secondary outcomes included incidence of febrile morbidity, UTI, endometritis, neonatal outcome, total cost of antibiotics, and duration of hospital stay in both the study arms. Descriptive statistics and χ2 tests were used for analysis of the data. Result: There was an overall significant reduction in the incidence of SSI (15% vs 3%; P = 0.03), endometritis (8% vs 2%; P = 0.048), and post-operative febrile morbidity (17% vs 3%; P = 0.001) with the addition of azithromycin to cefazolin. Duration of hospital stay was almost two days lesser for the cefazolin plus azithromycin group. Subgroup analysis of patients with SSI showed the age, duration of ruptured membranes, and type of anesthesia as important predictors of infection rate. Study observed statistically significant reduction in requirement of additional post operative antibiotics, phototherapy for neonates, hospital stay and cost of therapy in cefazolin plus azithromycin group (P < 0.05). Conclusion: Tertiary care hospitals in developing countries such as India can opt for the cefazolin plus azithromycin as antimicrobial prophylaxis during CD to maximize the efficacy as well as for decreasing the cost burden of postoperative infections.
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CASE REPORTS Top

Abdelazim technique for repair of dehiscent previous cesarean section scars encountered during elective cesarean sections p. 3022
Ibrahim A Abdelazim
DOI:10.4103/jfmpc.jfmpc_556_19  
The cesarean sections (CSs) rates increased worldwide (32.9% in the United States 2009). CS scar dehiscence (CSSD) is one of the complications encountered after cesarean delivery due to disruption of the scar tissue of the previous CS. CSSD is a risk factor of uterine rupture during trial of labor after previous CS. A 32-year-old woman, previous 3 CSs, admitted to the Obstetrics and Gynecology department of Ahmadi hospital, Kuwait, for elective CS. During the elective CS, the scars of previous CSs were complete dehiscent through its whole length with missing anterior uterine wall leaving visible fetal membranes underneath. This report represents a case of complete CSSD encountered during elective CS and the suggested I. Abdelazim technique for repair of dehiscent previous cesarean section scars encountered during elective CSs.
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Potential therapeutic effect of ninjinyoeito for the treatment of pulmonary nontuberculous mycobacterial infections: A case report p. 3025
Tatsuya Nogami
DOI:10.4103/jfmpc.jfmpc_606_19  
A 40-year-old man presented with refractory pulmonary Mycobacterium avium complex infection, despite administration of antituberculous drugs for 2 years. We administered ninjinyoeito (NYT) to the patient, who experienced weight gain and demonstrated marked reduction in the lung cavity lesions. Thus, the traditional Japanese medicine, NYT could serve as an adjunct to the conventional pharmacotherapy for pulmonary Mycobacterium avium complex infection.
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Mepolizumab as an effective treatment for Kimura's disease associated with ulcerative colitis: A case report p. 3028
Faisal Al Shammari, Abdulrahman Nasiri, Mohammed Alkhathami, Fahad Alawfi, Mohammed Alfifi, Eqab Al Otaibi
DOI:10.4103/jfmpc.jfmpc_373_19  
Kimura's disease was first described by Kimura and Sceto in China in 1937. Kimura disease is a chronic inflammatory disorder of idiopathic etiology. The clinical presentation of Kimura's disease is painless solitary or multiple subcutaneous nodules, asymmetric, mostly in the head and neck region with often association with lymphadenopathy. Typically, the nodules are found on preauricular, submandibular, and popliteal regions as well as oral cavity, larynx, and parotid glands. In the present report, we describe a case of a 27-year-old male presented to our hospital with history of right neck and lip swelling for 10 days. In the history, the patient mentioned that he had bloody diarrhea four to six times day and he lost 10 kg in 1 month. The specimen was sent for histopathological examination which showed the lymph node architecture is preserved with significant increase number of eosinophils which is consistent with Kimura's disease. There is no agreement on the management aspects in Kimura's disease so far. The primary treatment for Kimura's disease includes surgical resection. Additional medical therapy including regional or systemic steroid therapy, cytotoxic therapy, and radiation has also been utilized. Considered as an inflammatory process, the disease has an excellent prognosis, although it may recur locally and wax and wane over time.
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Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy: Case reports p. 3032
Ibrahim A Abdelazim, Mohannad AbuFaza
DOI:10.4103/jfmpc.jfmpc_505_19  
The standard treatment of symptomatic fibroids is hysterectomy for women completed their childbearing and myomectomy for women desire future fertility. Myomectomy associated with life-threatening bleeding and emergency blood transfusion. The two studied cases were unmarried presented with multiple fibroid uterus of 28 and 24 weeks' gestation. Both the studied women refused hysterectomy because of their fertility potential. Myomectomy was done with removal of two big myomas (10x12 cm and 7x8 cm), three moderate size myomas (5x5 cm, 4x4 cm and 3x4 cm) and four small size myomas for the first case and removal of one big myoma (8x6 cm), four small size myomas for the second case. The hemoglobin difference was 0.6 and 0.4 gms% for the first and the second case; respectively and no blood transfusion was required for them. This report represents the outcome of Abdelazim and AbuFaza technique for temporary bilateral uterine occlusion to decrease the blood loss during myomectomy.
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Primary pulmonary nocardiosis by Nocardia brasiliensis: A case report and review of Indian literature p. 3035
Sanju Pannu, Ashok K Pannu
DOI:10.4103/jfmpc.jfmpc_576_19  
Infection by Nocardia brasiliensis is usually localized to the skin but can rarely spread to the lung, brain, or multiple sites particularly in the immunocompromised hosts. Moreover, primary systemic involvement without cutaneous disease is an extremely rare case. In the current study, we present a case of primary pulmonary nocardiosis caused by a multi-drug resistant N brasiliensis along with a review of the cases reported from India.
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Abdelazim and Sakiyeva endocrinopathy associated with polycystic ovary syndrome: Case reports p. 3039
Ibrahim A Abdelazim, Sakiyeva Kanshaiym
DOI:10.4103/jfmpc.jfmpc_646_19  
Polycystic ovary syndrome (PCOS) is a multiple endocrine disorder associated with significant reproductive and metabolic manifestations. A genetic variation at the level of aromatase enzyme gene (CYP19 gene) and/or androgen receptors with subsequent increased ovarian androgen was suggested in PCOS. Recently, researchers noted that 56% of the PCOS women had evidence of hypothyroidism and this report represents three case of PCOS with hypothyroidism and hyperprolactinemia (Abdelazim and Sakiyeva endocrinopathy associated with PCOS) to highlight the hypothyroidism and hyperprolactinemia as a common endocrinopathy associated with PCOS. PCOS women should be screened for the endocrinopathy associated with PCOS especially the hypothyroidism and hyperprolactinemia because the undiagnosed endocrinopathy aggravates the PCOS symptoms.
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Light-assisted removal of ear canal live insect–A noninvasive approach for first level responders p. 3042
Amal Jaber Alfaifi, Liaqat Ali Khan, Hadi Mohammed Mokarbesh
DOI:10.4103/jfmpc.jfmpc_443_19  
Physicians, working in the primary care setting and/or emergency departments, encounter more often patients of any age group with foreign bodies in the external auditory canal (EAC) and urgent removal is crucial to avoid complications. The condition is more commonly managed on an urgent basis if the foreign body is a live insect that is more agonizing for the patient. Foreign body removal is quite challenging but an essential skill for first-level responders and different approaches, each with its own pros and cons, are used for EAC foreign bodies removal. Herein, we report two cases that were managed safely by a noninvasive approach by using light illumination of EAC in complete darkness. The approach, not reported in the available literature, can be used as first-level management before opting another alternative, in settings where otolaryngologist services are not readily available.
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Warfarin: A double-edged sword p. 3045
Prabhakar Yadav, Sonal Yadav, Saurabh Pathak
DOI:10.4103/jfmpc.jfmpc_671_19  
Warfarin is the commonest anticoagulant used in today's practice; it has a very narrow therapeutics window. Under and overdosing results in various life-threatening complications. Warfarin-related nephropathy (WRN) is a rare cause of acute kidney injury (AKI) in patients on long-term anticoagulation, as a result of supratherapeutic anticoagulation. Warfarin causes AKI by inducing glomerular hemorrhage with subsequent tubular obstruction by red blood cell (RBC) casts. WRN has been associated with irreversible kidney injury and increased risk of mortality. Despite a better understanding of pathophysiology and histopathology of WRN, its preventive measures and clinical outcome are not well known. We report here the case of a 62-year-old male, who was on a long-term warfarin therapy due to chronic atrial fibrillation with a history of old ischemic stroke and dilated cardiomyopathy. He was presented with AKI and his renal biopsy was suggestive of WRN. He was managed by withholding warfarin for a few days until the therapeutic range of international normalized ratio was achieved and steroids and N-acetylcysteine (NAC) recovered. WRN is a diagnosis of exclusion; other causes of AKI must be ruled out. Renal biopsy is the gold standard for diagnosis. Patients on chronic anticoagulant therapy should be monitored periodically for the therapeutic range of anticoagulants, deterioration of renal function, and hematuria.
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A rare case of Rhupus syndrome with Hashimoto's thyroiditis, associated adverse effect of drugs and incidental findings p. 3048
Mohammad Firoz Nizami, Chandra B Sharma, Rishi T Guria, Sanjay K Singh
DOI:10.4103/jfmpc.jfmpc_568_19  
The term Rhupus is coded for the individuals who have rheumatoid like arthritis with erosions and fulfil the criteria for both rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Abnormal Th2 cell plays a central role in SLE while Th1 participate in RA. Thus the overlap of SLE and RA has a very low incidence (0.01%-0.2%) in patient with arthritis. This 40-year-old male patient presented with complains of severe multiple joint pain with progressive deformities, diminished vision from last 2 months, redness on back, headache and swelling over scalp. As this patient had history of severe trauma that was considered as a precipitating factor for ongoing chronic inflammatory disorder. Posterior subcapsular cataract was explained by prolong use of systemic steroid and rashes on the lower back due to sulfasalazine. Radioimaging study revealed arachnoid cyst and calcified projection arising from outer table of skull, which was kept under observation.
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Attenuation of phenotypical expression of severe hemophilia A in presence of simultaneous prothrombotic Factor V mutation: The debate continues p. 3051
Saugata Acharyya, Kakoli Acharyya, Archana Parasar, Shanto Pramanik
DOI:10.4103/jfmpc.jfmpc_603_19  
The effect of coexistence of the prothrombotic Factor V Leiden mutation on the phenotypical expression in hemophilia is still debatable. Six-year-old boy with severe hemophilia A had presented with large soft tissue hematoma, treated with Factor VIII concentrate. Simultaneous Factor V Leiden mutation had resulted in attenuation of clinical features.
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Ectodermal dysplasia - A rare case report p. 3054
Poulomi Bhakta, Bhavna Barthunia, Haritma Nigam, Pallavi Pawar
DOI:10.4103/jfmpc.jfmpc_625_19  
Ectodermal dysplasia (ED) is a rare genetic disease caused by developmental disturbances of embryonic ectoderm derived tissues, organs, and other accessory appendages. The congenital missing of teeth is usually bilateral. Anodontia or hypodontia may be associated with other ectodermal disturbances, such as anhidrosis, asteatosis, hypotrichosis, and salivary glands defects. One such case report of ED is demonstrated here.
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Ranitidine-induced galactorrhea in a postmenopausal female p. 3057
Prabhat Agrawal, Nikhil Pursnani, Awantika Parihar, Boentika Singh
DOI:10.4103/jfmpc.jfmpc_633_19  
We report a case of drug-induced hyperprolactinemia in a 46 year postmenopausal female presenting as galactorrhea and painful breast engorgement as result of ranitidine exposure. The occurrence of galactorrhea as an adverse effect of ranitidine therapy is scarcely reported in literature and to the best of our knowledge this is first such reported case.
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Traditional Chinese therapy initiates oral feeding in a stroked woman after three years of nasogastric tube feeding Highly accessed article p. 3059
Koh Iwasaki, Motonari Kurachi, Tatsuya Nogami, Shin Takayama
DOI:10.4103/jfmpc.jfmpc_670_19  
Banxia Houpu Tang, a traditional Chinese medicine, helped in initiating oral feeding in a stroke patient, after three years of nasogastric tube feeding. This Chinese medicine has potential in eliminating the need for nasogastric feeding and for physical restraints in geriatric individuals after a stroke.
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Case of Ludwig's angina due to Corynebacterium diphtheriae from western Rajasthan, India-A case report of an uncommon presentation p. 3061
Yashik Bansal, Sarika P Kombade, Vijaya Lakshmi Nag, Sourabha Kumar Patro
DOI:10.4103/jfmpc.jfmpc_684_19  
Corynebacterium diphtheriae is a toxin producing, classically noninvasive bacteria that causes diphtheria a vaccine-preventable disease mainly in children. With increasing vaccine cover, new spectrum of infections is increasingly seen involving invasive infections and nontoxigenic strains of C. diphtheriae. Here, we present a case of Ludwig's angina caused by C. diphtheriae in a 45-year-old female. Only Corynebacterium spp. have been previously reported in Ludwig's angina patients.
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Klippel Trenaunay syndrome in the context of work-related injury: Case report and review of the literature p. 3064
Khalid Medani, Nasrin Kazemi, Cesar Reis, Juan Carlos Quispe-Espíritu, Haitham Juma
DOI:10.4103/jfmpc.jfmpc_182_19  
Background: Uncommon diseases are usually not suspected at initial presentation, and the diagnosis might be challenging. Here we present a rare disease diagnosed in a work-related injury setting, highlighting the importance of further investigation by means of a more detail physical exam, imaging studies and involvement of other specialties. Case Presentation: A 21-year-old Hispanic male, who is a food service worker, presented following a work-related right elbow contusion with severe pain to his right elbow associated with swelling and purplish-red bruising/discoloration on its medial side and forearm. Physical exam demonstrated swelling, tenderness, and conspicuous dilated blood vessels across the right arm and forearm; additionally, multiple red-purplish scattered patches were found on the right arm, anterior and posterior right upper chest. His past medical history was significant for Capillary Hemangioma. He was initially treated conservatively and with work restriction; however, the pain in the forearm persisted. CT angiogram showed multiple interweaving vascular structures on the forearm, and further imaging by MR angiography depicted multiple vascular malformations in the right upper extremity and chest. Vascular surgery was consulted, and the diagnosis of Klippel-Trenaunay syndrome was made. Conclusions: Klippel-Trenaunay syndrome is a rare congenital disorder that could present in a wide-range of signs and symptoms. Thorough history taking and clinical examination is warranted in any work-related injuries. Further work up and referral to specialist should always be considered when diagnosis is unclear, or when initial symptoms do not resolve with treatment.
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An unusual cause of foot ulcer in a patient with diabetes mellitus p. 3068
Kelita George, Kripa Elizabeth Cherian, Nitin Kapoor, Felix Jebasingh, Riddhi Dasgupta, Thomas Vizhalil Paul
DOI:10.4103/jfmpc.jfmpc_569_19  
A diabetic foot ulcer is the leading cause of nontraumatic amputation worldwide. The most important predisposing factor for diabetic foot ulcer is peripheral neuropathy. Rat bites are an uncommon but important cause of ulcer in patients with diabetes, especially in lower socioeconomic strata. A 56-year-old male from southern India, a known patient with type 2 diabetes for the past 15 years with severe peripheral neuropathy, presented to our center with multiple bite marks on bilateral feet and destroyed nails. He was initially managed with local measures and injection tetanus toxoid; however, he rapidly worsened over the next 5 days to develop bilateral cellulitis of the feet and right great toe osteomyelitis. His biochemistry showed uncontrolled diabetes (HbA1c: 9.9) and radiology confirmed right great toe osteomyelitis. He underwent transmetatarsal amputation of the right first toe along with intravenous antibiotics followed by oral antibiotics (amoxicillin with clavulanic acid) for a total duration of 6 weeks and optimization of glycemic control. He improved completely over the next 1 month. Rat bites are a rare but readily preventable cause of foot ulcer in diabetic patients. Primary care and family physician play a vital role in educating patients about preventive aspects such as avoidance of using vegetable oil as a moisturizer that may attract rodents and insects.
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LETTERS TO EDITOR Top

Warfarin overdose with a side of munchausen p. 3071
Denelle Mohammed
DOI:10.4103/jfmpc.jfmpc_509_19  
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Government of India initiative against leprosy—We should be aware p. 3072
Sajitha Venkatesan, Pugazhenthan Thangaraju
DOI:10.4103/jfmpc.jfmpc_500_19  
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Integrating palliative care with primary care: A synergistic mix p. 3074
Avik Ray, Ahmad Najmi, Balakrishnan Sadasivam
DOI:10.4103/jfmpc.jfmpc_519_19  
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ERRATUM Top

Erratum: An Investigation into the efficacy of nursing curriculum on elderly health problems via Delphi's method p. 3076

DOI:10.4103/2249-4863.268089  
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