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   Table of Contents - Current issue
November 2019
Volume 8 | Issue 11
Page Nos. 3457-3770

Online since Friday, November 15, 2019

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Violent-acts against doctors and healthcare professionals in India: Call for action Highly accessed article p. 3457
Raman Kumar, Pritam Roy
Doctors in India are facing violent-acts against them, and there is an increasing trend in recent years, leading to a Public Health Riot-like scenario in India. There are reports of a doctor being murdered, thrashed, beaten, injured, handicapped, harassed, threatened, and socially maligned with news of demeaning messages spreading such as wild-fire through social media and news channels. More alarming is that common people are justifying the acts of killing, beating, and provoking others to do more such acts, thereby triggering a vicious cycle. Most of them get away without any legal proceedings being instituted against them. A recent incidence of grievous injury to the junior doctor at NRS Medical College, Kolkata, drew National and International attention. More recently, a retired senior doctor volunteering part-time at a tea estate of Assam was killed by a mob. The authors call for action and earliest resolution of this issue with active involvement of all stakeholders.
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Artificial intelligence enabled healthcare: A hype, hope or harm Highly accessed article p. 3461
Sudip Bhattacharya, Keerti Bhusan Pradhan, Md Abu Bashar, Shailesh Tripathi, Jayanti Semwal, Roy Rillera Marzo, Sandip Bhattacharya, Amarjeet Singh
In this paper, we have described the health care problem (maldistribution of doctors) in India. Later, we have introduced the concept of artificial intelligence and we have described this technology with various examples, how it is rapidly changing the health care scenario across the world. We have also described the various advantages of artificial intelligence technology. At the end of the paper, we have raised some serious concerns regarding complete replacement of human based health care technology with artificial intelligence technology. Lastly, we concluded that we have to use artificial intelligent technology to prevent human sufferings/health care problems with proper caution.
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The AFPI-CAR policy paper on identifying basic framework of possible roadmap for one health Highly accessed article p. 3465
Dinesh Kumar, Raman Kumar, Sunil Kumar Raina, Ashoo Grover, Ashok Panda, Rajiv Gupta, Amir Maroof Khan
Zoonotic diseases are an important public health problem. Keeping this in way, a panel reviewed the discussion around “one health” strategy of the WHO in combating zoonotic diseases during Seventh annual conference of Consortium Against Rabies (CAR) with the theme of “Zoonoses: Thinking beyond Rabies” held on 14th and 15th June 2019. The panel came out a manuscript discussing the need, background, and rationale for basic framework of possible roadmap for one health. Background —About CAR: CAR has been established with the aim to serve as a platform for the control of the rabies menace in India. It will evolve into a full fledged struggle against rabies in the country. The association comprises of medical professionals, veterinary doctors, and public health persons. The idea behind CAR is to bring the best minds in the country for research and information dissemination in the field of rabies. About Academy of Family Physicians of India (AFPI): AFPI is the official association of family physicians in India. Dedicated to provide professional leadership, conduct healthcare advocacy, policy development and a change in health system within the domain of family medicine, and larger public health system in the country, the academy is the recipient of the Healthcare Leadership Award 2012 in the category of Healthcare Governance and Public Administration. The white paper development Process: More than 100 medical experts, veterinary doctors, and public health persons from across the country and belonging to the fields of internal medicine, family medicine, public health, veterinary sciences, nursing science and environmental science and representing reputed medical institutions, government funded research institutions, and policy making bodies participated in discussions on topic of “one health” made during 7th Annual national conference of CAR with the theme of “Zoonoses: Thinking beyond Rabies” held on 14th and 15th June 2019. The panel steering the discussion included leading expert from ICMR, medical colleges, veterinary college, family medicine, private practitioners, and health program managers. The panel committee had prepared a draft document well in advance of the conference, which was communicated to all participants for feedback and comments. The panel was steered by ICMR expert. The discussion of the panellist was presented to the consensus group and unanimously adopted. A writing group worked on the manuscript, which was again circulated by email to all for any comments and suggestions before final publication.
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A holistic approach to remove the bottlenecks and to improve the quality of medical research in India Highly accessed article p. 3469
Sudip Bhattacharya, Raman Kumar, Shaili Vyas, Amarjeet Singh, Md Mahbub Hossain, Roy Rillera Marzo
The current trend of conducting research and publishing the same to fulfill the academic or professional requirements can jeopardise what research actually means in health sciences. Rather than highlighting how many publications one can have, or showcase the expertise as a researcher, research can inform knowledge gaps and address the same in a replicable and scientific manner. More importantly, for low- and middle- income countries like India, research can be a powerful tool to assess healthcare problems at the primary care and develop innovative solutions to strengthen health systems at the grass root level. It can be argued that, enriching research portfolio for an individual is a misleading approach whereas research has much more to offer to the society at large. In the context of in primary care, academic and implementation research is important for several distinct reasons. The practice-based research can inform better practice through communicating the concerns or findings from research with key stakeholders of primary care. If the primary care practitioners are equipped with fundamental research skills, it may help them to become better critics and evidence-based practitioners. Publishing research findings in a good scientific journal is not an easy job. A lot of time and resources are often required from the submission process to publication. There are many obstacles for publishing a research, some are inherent some are man-made. In this article we describe our experiences about the bottlenecks that we have faced while conducting medical research and we have also prescribed some possible solutions which can help to the researchers in future while conducting medical research.
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Impact factor: Mutation, manipulation, and distortion Highly accessed article p. 3475
Deepak Juyal, Vijay Thawani, Ashutosh Sayana, Shekhar Pal
Currently, there is an increased dependency on the impact factor in scientific research publications. Sometimes the overzealousness in implementing the impact factor value to a publication is detrimental to the growth of the scientific authors, especially the junior lot, for no fault of theirs. The inept and myopic application of the impact factor defeats the purpose of making the value judgment and hence has been criticized by many learned authors. The scientist Eugene Garfield, who formulated the impact factor, feels wrong that it is being not judiciously used. A corollary is the invention dynamite by Alfred Nobel which instead of helping, aiding, and reducing human effort and endeavor it was more misused for human annihilation and pained the scientist who gave it to the world. The authors reexamine the application of impact factor to scientific manuscripts for rightful application of the value judgment.
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Red complex: Polymicrobial conglomerate in oral flora: A review p. 3480
Rinkee Mohanty, Swati Joshi Asopa, M Derick Joseph, Bhupender Singh, Jagadish Prasad Rajguru, K Saidath, Uma Sharma
Oral diseases are the complex host responses composed of a broad array of inflammatory cells, and cytokines, chemokines, and mediators derived from the cells resident in the gingival tissues, as well as from the emigrating inflammatory cells. A chronic polymicrobial challenge to the local host tissues triggers this response, which under certain circumstances, and in a subset of the population, leads to the progressing soft and hard tissue destruction that characterizes periodontitis. The red complex has been proposed as a pathogenic consortium, consisting of P. gingivalis, T. denticola, and T. forsythia. This review has attempted to examine the virulence potential and determinants of these commensal opportunists.
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Supportive therapy for dysmenorrhea: Time to look beyond mefenamic acid in primary care p. 3487
Nachimuthu Gomathy, Karukkupalayam Ramasamy Dhanasekar, Dutta Trayambak, Rajasekar Amirtha
Dysmenorrhea is a recurrent and chronic primary health care issue. Mefenamic acid and NSAID based therapy regimens have unwanted side effects on its long-term usage. NSAIDs reduce pain, albeit they do not address the enhanced pain sensitivity and other neuronal symptoms of dysmenorrhea. Hence, there is a need for supportive therapy which can target both pelvic pain and the neuronal symptoms. Historically, European medicinal plants and their extracts such as, valeriana officinalis, humulus lupulus, and passiflora incarnata have been used in menstrual disorders for centuries. The current review is focused on the available evidence for its use as monotherapy or as supportive therapy in combination with other conventional medications.
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Metabolic syndrome and periodontal disease: An overview for physicians p. 3492
Mahesh C Srivastava, Ruchi Srivastava, Pushpendra Kumar Verma, Anju Gautam
The metabolic syndrome (MetS) (also known as insulin resistance syndrome, syndrome X) is a cluster of factors associated with increased risk of developing coronary heart disease or type 2 diabetes mellitus. Several studies in the past have reviewed an association between MetS and periodontitis. Periodontal disease is considered an infectious and chronic inflammatory disease, and it has been considered to be a potential risk in cardiovascular and respiratory diseases and diabetes, and has implications in adverse pregnancy outcomes, osteoporosis, and so on. These systemic disorders have been documented as capable of affecting the periodontium or treatment of periodontal disease. Oral inflammatory lesions have different basic mechanisms concerning the possible association with systemic diseases. They concern local spread, metastatic spread, or immunologic cross-reactivity. In many studies, sometimes contrasting, periodontal pathogens have been evaluated in atheromatous plaques isolated from patients with chronic periodontitis. Oral inflammatory lesions have been shown unequivocally to contribute to elevated systemic inflammatory responses. In some studies, intensive periodontal therapy showed a significant reduction in c-reactive protein levels, interleukin-6, and low-density lipoprotein cholesterol after 2 months. The aim of this article is to reflect the association between MetS and periodontitis and to suggest an understanding to promote interprofessional practice; with proper oral care and plaque control, we can reduce the severity of MetS.
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The role of gut microbiome in the pathogenesis of psoriasis and the therapeutic effects of probiotics p. 3496
Dalal I Alesa, Haidar M Alshamrani, Yahya A Alzahrani, Dania N Alamssi, Nada S Alzahrani, Marwan E Almohammadi
The adult intestine hosts a huge number of diverse bacterial species, collectively referred to as the microbiome, that reside mainly in the lower gut, where they maintain a symbiotic relationship with their host. Recent research points to a central role of the microbiome in many biological processes. These microbial communities are influenced by multiple environmental and dietary factors and can modulate immune responses. In addition to local effects on the gastrointestinal tract, the microbiota is associated with effects on other organs and tissues, such as the skin. Indeed, an altered microbiome has been associated with skin disorders in several instances. Thus, in this review, we describe the recent advances regarding the interplay between gut microbiota and the skin. We explore how this potential link affects skin homeostasis and its influence on modulating the cutaneous immune response, focusing on psoriasis disorder. Finally, we discuss how to take advantage of this interplay to manage this disorder, particularly through probiotics administration. In the gastrointestinal tract, the microbiome has been proven to be important in the maintenance of the balance between effector T cells and regulatory T cells, and the induction of immunoglobulin A. Moreover, gut bacterial dysbiosis is associated with chronic inflammatory disorders of the skin, such as psoriasis. Thus, the microbiome can be considered an effective therapeutical target for treating this disorder. Despite some limitations, interventions with probiotics seem promising for the development of a preventive therapy by restoring altered microbiome functionality or as an adjuvant in specific immunotherapy.
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Oral lichen planus and associated comorbidities: An approach to holistic health p. 3504
Shamimul Hasan, Sameer Ahmed, Ravi Kiran, Rajat Panigrahi, Joseph Mathew Thachil, Shazina Saeed
Lichen planus (LP) is a chronic inflammatory disorder with involvement of skin, oral and genital mucosa, scalp, and nail appendages. Oral lichen planus (OLP) lesions demonstrate a number of morphologic presentations, persist for a long time with rare self-resolution, and undergo malignant changes. OLP has been associated with numerous systemic connotations such as metabolic syndrome, diabetes mellitus, hypertension, thyroid diseases, psychosomatic ailments, chronic liver disease, gastrointestinal diseases, and genetic susceptibility to cancer. The oral health physician should be aware of these systemic associations and should work in close connect with the primary healthcare physicians to rule out the predisposing factors for the associated comorbidities. This article aims to highlight the various systemic associations of OLP and warrants the screening of these ailments in OLP for prevention and effective management.
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Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance p. 3518
Ramta Bansal, Aditya Jain, Mehak Goyal, Tejveer Singh, Himanshu Sood, Harjeet Singh Malviya
Antibiotic resistance is one of our most serious global health threats. The adverse effects of overusing and misusing antibiotics are highly publicized in the health professional literature. Antibiotic abuse occurs during routine endodontic treatment and there are deficiencies in knowledge regarding prescribing antibiotic and appropriate prophylactic antibiotic use. Multidisciplinary coordination and cooperation among dentists, pharmacists, and patients is needed to curb antibiotic abuse. As endodontists, we can become part of the solution to the antibiotic resistance crisis and deal with it conclusively. This review article discusses antibiotic resistance resulting from antibiotic abuse during endodontic treatment, various factors contributing to it, and measures required for stopping antibiotic abuse in endodontic treatment. A web-based research on MedLine was performed with terms Review Articles published in the last 10 year's dental journals in English for literature researching, extracting, and synthesizing data. Relevant articles were shortlisted. Important cross-reference articles were also reviewed.
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Assessment of knowledge and attitude about child abuse amongst parents visiting rural tertiary care hospital in central India p. 3525
Yashika Sharma, Kushagra Mathur
Introduction: Child abuse is one of the pressing human rights issues which still needs to be highlighted for general public, especially in traditional societies. This study depicts perspectives of parents and caregivers. Methods: The study was, conducted amongst parents visiting paediatric department (OPD and ward) at Rural Tertiary care Hospital in central India. A questionnaire was prepared and filled by parents and then was statistically analysed. Results: It was seen that: 1. Majority of parents lack knowledge regarding children's education and protection (POSCO and RTE) 2. Most parents were in favour of having better career prospects for Male child. 3. Parents were also asked regarding physical, emotional and mental health of a child. Majority of the parents were of the opinion that children should be distinguished based on academic performances. The study also recommended various measures to combat child abuse.
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A cross-sectional survey on medical education needs of general practitioners and family medicine: Delhi, Himachal Pradesh and Tamil Nadu, India p. 3531
Surjeet Bakshi, Linda Kaljee, Dana Parke
Background: In India, most physicians pursue a specialist's degree resulting in a dearth of general practitioners (GPs). To provide primary care across populations and support universal healthcare coverage (UHC), there is a need to develop a core educational foundation for generalists and family medicine in undergraduate and post-graduate training. Methodology: A cross-sectional survey was conducted as a part of a medical educational needs assessment (ENA) with a focus on family medicine. Respondents included practicing physicians, residents and medical students in Himachal Pradesh, Delhi and Tamil Nadu. Descriptive and bi-variate data analysis (Pearson's Chi square, independent t-tests and analysis of variance [ANOVA]) was performed to summarise data and determine significant differences between demographic groups of respondents. Results: Three hundred and sixty-one surveys were completed. From which, 80.7% (284) of respondents felt that family medicine would be beneficial/very beneficial to the Indian health system. Respondents were split over whether family medicine programmes should be integrated within the existing bachelor of medicine and bachelor of surgery (MBBS) programmes (149/42.5%) or created as a separate post-graduate level specialty (131/37.3%). Overall, 84.2% (292) and 85.4% (294) agreed/strongly agreed that family medicine would benefit specialists and decrease the health disparities. Challenges include lack of information about family medicine and patients' use of specialists for primary healthcare needs. Conclusions: There was a positive response to expanding education for generalists and development of family medicine as a specialty in India. Mechanisms to support policies and programmes need to be further explored to ensure successful implementation across the country. Interest in skills-based courses can be an opportunity to provide GP and family medicine training while broader system-level changes are considered.
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Exploring Iranian obese women's perceptions of barriers to and facilitators of self-management of obesity: A qualitative study p. 3538
Omolhoda Kaveh, Hamid Peyrovi
Background: Despite the clinical importance of self-management for obesity, poor compliance or noncompliance with the treatment regimen is a prevalent and persistent problem concerning people with obesity. Aims: The aim of this study was to explore Iranian obese women's perceptions regarding the barriers to and facilitators of self-management of obesity. Materials and Methods: In this qualitative study, the participants were selected through purposeful sampling and the data were collected using semistructured interviews and focus groups between July 2017 and September 2018. Nineteen participants between the age range of 28–50 years and mean age of 38.56 years were interviewed. A focus group with seven participants was conducted to reach data saturation. All the interviews and the focus group were transcribed verbatim and the data were analyzed using constant comparative method. Results: The perceived barriers to obese women's self-management for obesity were identified and classified into four main categories: (I) restrictions, (II) the pressures of being in the group, (III (temptation, (IV) resonators. In addition, seven main categories emerged as facilitators of obese women's self-management for obesity: (I) achieving self-awareness, (II) positive consequences for weight loss success, (III) positive outcomes of exercise and physical activity, (IV) peers experience, (V) correct and logical program, (VI) autonomy and empowerment, and (VII) having supporting umbrella. Conclusion: This qualitative research provided a range of facilitators and barriers to self-management of obesity perceived by an obese woman to improve our understanding of the complex nature of self-management of obesity. Healthcare providers may consider this issue while designing and implementing appropriate interventions to upgrades woman's ability for self-management of obesity.
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Osteoarthritis in women reporting to tertiary care hospital in Eastern India: Associated factors determining management p. 3544
Arup Mahapatra, Sonali Kar
Introduction: Osteoarthritis (OA) is a painful joint condition that is left heavily underdiagnosed, as it is also related to advancing age. Hence, those affected, tend to live with it, until the condition becomes excruciating or disabling. The women in our society are a section, who have very poor health seeking behavior. However, in today's era, tertiary care hospitals offer definitive management for OA in the form of Joint Replacement Surgery (JRS). This again is taken up often as a last resort and is heavily dependent on the socioeconomic condition of the family. The surgery offers proven better quality of life. Objectives: This study discusses a public health hypothesis regarding the disease presentations of OA in women visiting a tertiary care hospital and endeavors to develop a model based on some predictors that increase the predilection of recommendation of surgery among these women, These studies have been done for general populations, but here we chose to study women, as the society in eastern part of the country is male dominated and the decision to go for a surgery in case of the women is dependent on several issues. This model perhaps will bring to light the need of surgery in the women with OA and help take some policy decisions to offer some subsidized care to this section of the society. The results were derived from 350 women coming to an orthopedic tertiary care center during a 6-month study period with joint pain in any of the big joints and then finally given a definitive diagnosis of OA based on radiological KL score and clinical presentations. Results: Women above age 40 years were taken up; mean age in study being 55.94 SD 6.648 (maximum 83, minimum 43). A semi structured questionnaire was used to compare the sociodemographic parameters like type of residence, type of family, attained menopause, occupation, duration of OA, etc., In the sample, which gave multiple responses, right and left knee were maximally inflicted by OA i.e. 59.1% and 57.1% of cases, followed by hip (28.9%) and lower back (26.1%). 75% were offered conservative treatment, only 24.6% were on physiotherapy. Conclusion: Menopause, increased age, comorbidities, and preobese were seen to be significantly associated with recommendations of JRS. This can help develop a screening method for women and encourage them to undergo assessment for OA as a targeted intervention and address this growing burden of disease at the earliest.
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Evaluation of presence of proximal contacts on recently inserted posterior crowns in different health sectors in Riyadh City, Saudi Arabia p. 3549
Ahmad D Almalki, Mohammad A Al-Rafee
Background: For the successful outcome of the rehabilitation of the teeth with crown, the proximal contact points play a significant role hence the aim of the present study was to evaluate the presence of proximal contacts on recently inserted crowns in posterior teeth. Methods and Materials: The cross-sectional study was conducted on recently inserted posterior crowns. Clinical assessment of proximal contact points on crowns was made with dental floss, the floss was wrapped around the index fingers of both hands and was passed through the crowns mesial and distal contact points and was categorized as acceptable, open contact points, and tight contact points. Results: In the present study 401 crowns were examined to assess proximal contacts on 788 proximal surfaces. It was found that 522 (66.2%) crowns were in normal proximal contact, 144 (18.3%) showed open proximal contacts, 122 (15.5%) showed tight proximal contacts. Conclusion: Regarding the assessment of proximal contacts, the study showed that a significant number of crowns had open or tight proximal contacts. Specialists and residents were able to perform better in providing the optimum proximal contacts.
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A study to assess correlation between maternal weight gain and fetal outcome among primigravidae registered in antenatal clinics p. 3554
Swati T Dahake, Uzma A Shaikh
Context: Inadequate prenatal weight gain is a significant risk factor for adverse maternal and fetal outcomes. Nutrient intake and weight gain during pregnancy are the two main modifiable factors influencing maternal and infant outcomes. Aim: To assess the social and demographic factors affecting weight gain of pregnant women and to determine the correlation between maternal weight and fetal outcome. Setting and Design: Observational prospective study. Materials and Methods: Two different groups and settings of populations were studied, one enrolled in the antenatal clinic of a tertiary care hospital (sample size 197) and the other suburban antenatal clinic located in a slum community (sample size 97) of the same metro city. Statistical Analysis: Chi-square test, Fisher's exact test, and Pearson's correlation coefficient were used for analysis. Result: In the tertiary care hospital, 16.75%, 75.13%, and 8.12%, whereas in the suburban hospital 47.42%, 46.39%, and 6.19% primigravidae gained less than or equal to 8, 8.1–16 kg, and more than 16 kg weight, respectively. In the tertiary care hospital, the percentages of preterm birth, low birth weights, special attention needed, and no immediate cry after birth were 5.1%, 19.80%, 4.1%, and 4.1%, respectively, while in the urban health center they were 9.3%, 41.24%, 21.65%, and 11.3%, respectively. A significant association was found between maternal weight gain and birth weight of neonate and special attention needed by baby in both groups. Conclusion: Monitoring the maternal weight during the antenatal period epidemiologically determines the strength of association between maternal weight gain and birth weight of child.
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Pattern of antinuclear antibody and antiextractable nuclear antigen antibody test requisitions in Riyadh p. 3559
Najla Ali Alghabban, Zahid Shakoor
Background: International guidelines for screening of systemic autoimmune rheumatic diseases (SARD) recommend antinuclear antibody (ANA) test as the first level test and antiextractable antigen (anti-ENA) along with anti-double-stranded DNA (anti-dsDNA) as second line tests following a reactive ANA test. This study was performed to assess adherence to international guidelines for investigation of SARD and to compare the requesting pattern of ANA and second level tests between rheumatology and nonrheumatology physicians in Riyadh. Methodology: This retrospective cross-sectional study comprising of 300 first time requests for investigation of SARD was performed in the immunology unit at King Khalid University Hospital (KKUH). Data were collected between April and May 2018. Information regarding the requesting physicians' specialty and the first time requested tests (ANA, anti-dsDNA, and anti-ENA) were extracted from the electronic medical records. Reasons for requisition of tests were also recorded. Results: Of the total requests, 159 (53%) requests included ANA as a single first level test, whereas the rest of the requests (n = 141, 47%) included ANA test in conjunction with second level tests for the investigation of SARD. From the department of rheumatology, 14 (29.8%) initial requests were for ANA test as the only first line investigation that was significantly lower than 145 (57.3%) similar requests from the rest of the departments (P < 0.001). Conclusion: ANA and second level tests requests by physicians particularly among rheumatologists lacked compliance to international guidelines. The current study strongly suggests the need for strict compliance to international guidelines for screening of systemic autoimmune disorders among physicians.
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General outpatient department in tertiary care institute: A model to be adopted by medical colleges p. 3565
Yuvaraj B Chavan, Bhanupriya S Pande
Context: Teaching medical institutes and tertiary care hospitals in various cities are overcrowded and overburdened. The general outpatient department (GOPD) plays a vital role as screening OPD to triage patients who require secondary or tertiary care and refer them to appropriate OPD. Primary health care is initiated at the GOPD itself and the mechanism of referral is established. Aim: To study GOPD model and its services in the institute. To assess perception of patients towards it. Settings and Design: It was an observational study conducted in a medical college of Mumbai, Maharashtra for 1 month on persons attending the GOPD. Materials and Methods: Data and monthly reports were used for baseline comparisons and exit interviews of patients were taken using questionnaire. Statistical Analysis Used: Quantitative analysis was done using the proportions and means for the number of patients served daily by the GOPD and medicine OPD. Results: Around 44% of services were therapeutic in nature and it had contributed to a significant reduction in patient load into another specialist department. Nearly 30% cases needed referrals during the study period. Statistically, the significant value was obtained for patient satisfaction for consultation services from GOPD. Conclusions: A statistically significant value for patient satisfaction for consultation services from GOPD indicates that patients were in favor of such type of services.
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Performance of Indian diabetic risk score as a screening tool of diabetes among women of industrial urban area p. 3569
Sudha Bala, Harshal Pandve, K Kamala, A Dhanalakshmi, Haritha Sarikonda
Introduction: Hyderabad, the capital hub of Diabetes mellitus type 2 due to the epidemiological transition and varied lifestyle of urbanization. Indian Diabetes Risk Score (IDRS)is used to detect undiagnosed Type 2 diabetes. Aim: This study was taken up with an aim to assess the performance of IDRS as a screening tool to detect undiagnosed cases of type 2 Diabetes mellitus among women in Industrial urban area. Setting and Design: A Community based cross sectional study was undertaken at urban field practice area attached to our medical college, Hyderabad. Methods and Material: Women with already diagnosed type 2 Diabetes mellitus and those who were unwilling to give informed consent were excluded from the study. IDRS was used to to detect undiagnosed diabetes. Diabetes was confirmed using blood sugar levels on fasting venous sample. Statistical Analysis Used: Data was entered in Microsoft excel 2010 and was analysed as frequency, Mean+ Standard deviation along with sensitivity and specificity of the test. Results: As per the classification of IDRS 22% were at low risk, 40% medium risk and 38% at high risk. Components of IDRS noted majority about 45.4% with waist circumference > 90cms, no exercise among 66.6% and one parent having diabetes among 26%. Sensitivity was 59.4% and specificity was 37.3% of IDRS with the gold standard test (Fasting blood glucose) to assess the performance. Conclusion: IDRS is a cost effective tool which can be used for screening among undiagnosed cases.
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Evaluation of lifestyle and endometriosis in infertile women referring to the selected hospital of Tehran University Medical Sciences p. 3574
Mohammad I Vaghar
Background and Aim: Endometriosis is a chronic and common disease in the world in which living endometrium stroma and glands are found outside the uterus. The presence of this tissue in different parts of the body causes various symptoms that have an adverse effect on women's quality of life, fertility rate, and productivity. The aim of this study was to determine the relationship between lifestyle and endometriosis in infertile women referred to the selected hospital of Tehran University of Medical Sciences. Materials and Methods: The nature of this study is descriptive-comparative. The convenient sampling method is used among all infertile women undergoing laparoscopy, in group 1 (with endometriosis diagnosis) and group 2 (without endometriosis). The sample size is estimated to be 125 in each group according to the Cochran formula and with the alpha coefficient of 0.05. Data analysis was done using SPSS software version 20. Results: There was a direct and significant relationship between the probability of developing endometriosis and age, education level, and regularity of menstruation variables so that with the increase in each of the above variables, the probability of the disease increases. There was a significant and inverse association between the incidence of endometriosis and the body mass index (BMI) variable, which means that with the increase in this variable, the risk of endometriosis in individuals is reduced. Conclusion: This study suggests that high age, low BMI, menstrual cycle regularity, and education have a strong relationship with endometriosis in infertile women, and there was no relationship between lifestyle and the incidence of endometriosis among them.
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Reproductive tract infections in rural India – A population-based study p. 3578
Vanitha Durai, Suresh Varadharajan, Anitha R Muthuthandavan
Context: Reproductive tract infections (RTI) occupy the second position among public health problems. Aims: To find out the prevalence of RTI and its associated conditions among ever married women in the reproductive age group (15–49 years). Settings and Design: This cross-sectional study was conducted among 330 women in a rural area of Poonamallee block at Thiruvallur district in Tamil Nadu from August 2013 to January 2014. Materials and Methods: In this cross-sectional study, the selection of participants was done through cluster sampling and data on symptoms by questionnaires. Statistical Analysis Used: For descriptive prevalence, statistics was used. Using Chi-Square, categorical data were analyzed and using the odds ratio P value associations were assessed. Results: About 21% had anyone symptom of RTI. Occupation of women (OR2.0), occupation of spouse (OR1.9), anemia (OR 2.0), dysuria (OR51.5), burning micturition (OR15.9), frequency (OR3.3)/the urgency of urination (OR2.7), and incomplete urination (OR5.4)/defecation (OR3.6) were significantly associated with RTI. The prevalence rate of abnormal vaginal discharge was more (12%) than any other symptoms (each <4%) of RTIs. Conclusions: The prevalence of RTI was high. Moreover, women with dysuria, burning micturition, incomplete urination/defecation, frequency/the urgency of urination, and anemia are at a higher risk of developing RTI.
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Utilization of ICDS program by adolescent girls and implementation barriers in Urban Rishikesh, India p. 3584
Meenakshi P Khapre, Surekha Kishore, Anusha Sharma
Context: Adolescent girls are at higher risk of mortality and morbidity due to childbirth. Government of India therefore initiated Adolescent girls' scheme since year 2000. However, since its inception program received various setbacks. Aims: This study was carried out to assess the utilization of ICDS program for adolescent girls through Anganwadi centers (AWC) and implementation barrier from providers point of view. Also study assessed gaps in knowledge, attitude, and practice of anemia. Settings and Design: Mixed-method sequential explanatory approach was adopted. Quantitative data was collected by community-based cross-sectional survey in Urban Rishikesh, Uttarakhand. This was followed by in-depth interview of Anganwadi worker (AWW). Methods and Materials: Twenty adolescent girls from each of 20 clusters were selected by cluster sampling. Data was collected by structured validated questionnaire using Epicollect 5. AWWs were interviewed with help of interview guide. Statistical Analysis: Variables were described as proportion and mean. The interview transcript was analyzed using content analysis. Results: Out of 400 adolescent girls, 10% were school dropouts and 59% were undernourished. Seven percent had ever visited AWC in last year. The main reason for nonutilization was unawareness. 38% had knowledge regarding symptoms of anemia. AWW faces problems due to nonavailability of iron tablet, untrained for health education sessions, and service not meeting demand of beneficiaries. Conclusions: Poor utilization of ICDS services by adolescent girls due to unawareness. There is gap in knowledge regarding anemia among adolescent girls. Adolescent girls' scheme is not as per felt need of beneficiary and poorly implemented.
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A comparative study on the effectiveness of rectal advancement flap and seton placement surgeries in patients with anal fistula on the rate of recurrence, incontinence and infection p. 3591
Jafar Jafarzadeh, Neda Najibpoor, Amirahmad Salmasi
Introduction: Due to the high prevalence of anal fistulas and the recurrence of the disease following surgery, different methods have been suggested for appropriate treatment of this disease. In this study, the effects of rectal advancement flap surgery and seton placement on the recurrence rate, incontinence and wound infection were compared. Methods: In this interventional, prospective and quasi-experimental study, 45 patients with anal fistulas including 28 males and 17 females were studied for 2 years (2015-2017). Patients were divided into two groups and mucosal advancement flap and seton placement techniques were used for each of them. Descriptive analysis of data was performed by SPSS software. Results: 24 patients (54%) had seton placement surgery and 21 patients (46%) underwent rectal advancement flap surgery. Recurrence was significantly higher in patients who underwent seton placement surgery than the group that underwent rectal advancement flap surgery. Twelve patients (57%) who underwent rectal advancement flap surgery showed improvement in sphincter tone while 11 patients (45%) showed improvements with seton placement. Conclusion: The overall results of this study showed that rectal advancement flap surgery reduces recurrence and wound infection more significantly than seton placement in patients with anal fistula.
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Assessment of road traffic behavior using Youth Risk Behavior Survey questionnaire among school-going adolescents of Jaipur city, Rajasthan: An observational analysis p. 3595
Priyanka Dobhal, Aviral Dobhal, Amita Kashyap, Ajeet Singh Bhadoria
Background: Adolescents are a relatively healthy group, but their developmental stage makes them vulnerable to many risk-taking behaviors. One such major issue is road safety practices and their risk on roads. Objective: To determine road safety risk behavior among school-going adolescents of Jaipur city and factors associated with it. Materials and Methods: An observational, cross-sectional study was conducted from July 2015 to February 2016. A total of 900 school-going adolescents were enrolled from eight schools of Jaipur city and the Youth Risk Behavior Survey (YRBS) questionnaire was administered. Results: Most of the participants (67.56%) were in the age group of 13–16 years. A total of 682 (75%) adolescents were driving one or other type of vehicle to commute. Out of the 682 vehicle-using adolescents, 603 (88%) had risky behavior on roads. Driving under the influence was found more among those using four-wheelers (10%) than two-wheelers (5%). Almost half of drivers used mobile phones while driving a car or two-wheeler. There was statistically significant association between risk on roads with respect to rising education and occupation of parents. A majority (88.41%) of the school-going students were found to be at risk on roads while driving. Safety-belt was not used by 28% of the students while half did not use a helmet. More than 70% of the car drivers and two-wheeler drivers drove without license. Conclusion: Majority of the adolescent drivers are at risk on roads. Driving without license and/or helmet and using mobile phone are the main risk factors.
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Staphylococcus aureus: A predominant cause of surgical site infections in a rural healthcare setup of Uttarakhand p. 3600
Shekhar Pal, Ashutosh Sayana, Anil Joshi, Deepak Juyal
Introduction: Surgical site infections (SSIs) represent the second most common type of healthcare-associated infections and remain a relatively common postoperative complication and the most common reason for readmission after surgery. SSIs have dire implications for the surgeon, patient, and institution which often require prolonged treatment, impose an economic burden and double the risk of patient mortality. Staphylococcus aureus is currently the most common cause of SSIs causing as many as 37% of cases of SSIs in community hospitals with methicillin-resistant S. aureus (MRSA) of particular concern. Materials and Methods: This cross-sectional study was conducted from January 2014 to December 2014 in a rural tertiary care hospital of Pauri Garhwal district of Uttarakhand state, India. Samples were collected using sterile cotton swabs from 269 patients clinically diagnosed with SSIs and were processed as per standard microbiological techniques. Antimicrobial susceptibility testing was done using a modified Kirby-Bauer disc diffusion method. Results: Out of 1294 patients, 269 (20.8%) were found to have SSIs and samples were collected from them. Out of a total of 269 samples, 258 (95.9%) yielded bacterial growth and 267 bacterial isolates were obtained. S. aureus (45.3%) was the commonest organism followed by Escherichia coli (13.9%), Pseudomonas aeruginosa (6.7%), and Proteus species (4.9%). Antimicrobial profile of S. aureus revealed maximum sensitivity to rifampicin, linezolid, teicoplanin, vancomycin, and amikacin whereas ampicillin, cefazolin, and gentamicin were found to be least sensitive. Conclusion: S. aureus played a predominant role in the etiology of SSIs in this hospital with MRSA being a major concern as the treatment options for such resistant strains are limited. Reduction in SSI rates can lead to both better clinical outcomes for patients and cost savings for hospitals. Adherence to strict infection control measures, maintenance of proper hand hygiene and optimal preoperative, intraoperative, and postoperative patient care can surely reduce the incidence of SSIs. A multifaceted approach involving the surgical team, microbiologist, and the infection control team is required to provide quality surgical services.
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Reproductive health status of rural married women in Tamil Nadu: A descriptive cross-sectional study p. 3607
S Gopalakrishnan, VM Anantha Eashwar, P Mohan Kumar, R Umadevi
Introduction: Reproductive health of women is of special concern, especially during their reproductive years where the reproductive morbidity is very high, especially in countries like India. Aims: This study was carried out to find the reproductive health status of rural married women and identify those suffering from reproductive morbidity to provide appropriate guidance and treatment. Methodology: This community-based cross-sectional descriptive study was carried among rural married women above 18 years of age in the field practice areas of a medical college. By simple random sampling method, the required sample size of 650 was identified. Data collected by female investigators using a pretested structured questionnaire was analyzed using SPSS version 22. Results: Most of the study participants were in the age group of 21–40 years. About 32% of married women delivered by cesarean section and exclusive breastfeeding was followed by 88.9% of the mothers. Around 78% of the participants used contraceptive methods and the major reason given was for economic reasons (48%). About 67% of study participants suffered from one or more gynecological problems such as menorrhagia, lower abdominal pain, dysmenorrhea, and abnormal vaginal discharge. UTI (14%) and RTI (11.6%) were the most commonly diagnosed gynecological morbidity. Pallor was present in 45.5% of the study participants and 6.9% had clinical goiter. Conclusion: High prevalence of gynecological morbidity in this study shows that there is a dire need to plan and implement health education and awareness creation programs to complement the existing programs targeting women.
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Comparison of the effect of Elaeagnus angustifolia flower capsule and sildenafil citrate tablet female sexual interest/arousal disorder in clinical trial study p. 3614
Sanaz Zeinalzadeh, Abdol Ali Mohagheghzadeh, Fatemeh Ahmadinezhad, Marzieh Akbarzadeh
Background and Aims: Sexual desire is one of the main issues affecting people's individual and social life. The present study aimed to compare the effects of Elaeagnus angustifolia extract and sildenafil citrate tablet on female sexual interest/arousal disorder (FSIAD) among the women referring to health centers in 2013. Methods: In this randomized clinical trial, 125 women between 18 and 40 years old who suffered from FSIAD were divided into Elaeagnus angustifolia, sildenafil citrate, and control groups. The study data were gathered using Female Sexual Function Index (FSFI) and through measurement of TSH and prolactin. The first intervention group had to consume 4.5 g Elaeagnus angustifolia in two divided doses for 35 days and the second one had to use 50 mg sildenafil citrate tablets for 4 weeks one hour before their sexual relationships. On the other hand, the control group was required to consume the placebo. The data were analyzed using the SPSS statistical software (v. 18) and P < 0.05 was considered as statistically significant. Results: The frequency of sexual interest/arousal before the intervention was 53.7%, 50. %, and 66.7% in the Elaeagnus angustifolia, sildenafil citrate, and control groups, respectively (P = 0.269). However, these measures were respectively obtained as 19.5%, 33.3%, and 52.4% after the intervention (P = 0.007). Conclusion: Both interventions were effective in improvement of sexual interest/arousal. Yet, further studies are required to be conducted on the issue. Therefore, direct examination of health care providers, identifying and diagnosing sexual problems are the most important primary care. Influences the process of couples' sexual problems.
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Intimate partner violence against Palestinian women in Gaza strip: Prevalence and correlates p. 3621
Suha Baloushah, Raziyeh Maasoumi, Farideh Khalajabadi Farahani, Khalid Jamal Khadoura, Aymen Elsous
Context: Intimate partner violence (IPV) affects gravely the victims and is resulting in negative physical and psychological consequences. Aims: This paper aimed to determine the prevalence of IPV against women in Gaza strip and associated factors. Moreover, to explore women's seeking behaviors to help. Settings and Design: Cross-sectional study. Methods and Materials: Community internet-based survey was conducted using the Heart Insult Threat Scout questionnaire and the reporting behavior of respondent to violence act. Statistical Analysis Used: A number of 517 ever married women responded and data were entered and analyzed using SPSS software version 23. Results: About 517 women participated. Of which, 23% (119/517) reported exposure to any types of IPV. Multivariate logistic regression showed factors associated with IPV were as follows: husbands who are drug user (OR = 27.577, CI95%: 5.153–147.591; P < 0.001), husband exposure to violence in childhood (OR = 9.174, CI95%: 4.753–7.727; P > 0.001), and family with a special needs child (OR = 2.956, CI95%: 1.131–8.607; P < 0.05). Approximately, two-thirds of the victims tended to keep silent toward violence and dealt with it as a private and family issue; hence, they hesitated to communicate with others or seek any help to protect themselves. Conclusions: About 23% from the study participants experience violence in their life time. Factors associated with IPV are husband's drug abuse, having a child with special needs, and husband's childhood experience of violence. Qualitative researches are needed to understand the women experience to violence and sociocultural barrier for disclosure.
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Knowledge, attitude and uptake of human papillomavirus vaccination among female undergraduates in Lagos State, Nigeria p. 3627
Esther O Oluwole, Oluwaseun M Idowu, Adebola A Adejimi, Mobolanle R Balogun, Gbemisola E Osanyin
Background and Aims: Human papillomavirus (HPV) is a known cause of cervical cancer which is the second-most common cancer among women worldwide. HPV vaccination is a primary prevention to reduce the occurrence of cervical cancer. This study assessed knowledge, attitude and uptake of HPV vaccine among female undergraduates in Lagos State Polytechnic (LASPOTECH). Methods: A descriptive cross-sectional survey was conducted among 400 female undergraduates of LASPOTECH in August 2018. Participants were selected using a multi-stage sampling technique and data was collected with a pretested, self-administered, semi-structured questionnaire. Univariate and bivariate analyses were conducted using IBM SPSS version 20. Statistically significant level was set at P ≤ 0.05. Results: Mean age of respondents was 21.3 ± 2 years. Only 11 (3%) of the respondents had good knowledge of HPV and the vaccine. However, majority of the respondents 356 (92.7%) had positive attitude towards uptake of HPV vaccine. Only 10 (2.6%) of the respondents had received a single dose of HPV vaccine. Age, level of study and number of sexual partners of the respondents were statistically significantly associated with knowledge and attitude towards the HPV vaccine (P ≤ 0.05). The most common reason stated by the respondents for none uptake of HPV vaccine was lack of information. Conclusion: Knowledge and uptake of HPV vaccination among the respondents were poor. However, majority had positive attitude towards uptake of the vaccine. It is recommended that information on HPV and the vaccine should be made available to increase the knowledge and the uptake among female undergraduates in Lagos State.
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Magnitude of domestic violence and its socio-demographic correlates among pregnant women in Delhi p. 3634
Suneela Garg, MM Singh, Ruchir Rustagi, Kajok Engtipi, Indu Bala
Context: Domestic violence is violation of basic human rights, and poses a threat to the physical, mental, and social health aspects of women and her children. The causation of domestic violence is precipitated by many risk factors. Aims: Aim was to estimate the magnitude of domestic violence overall, and its sub-types, among pregnant women. The study also aimed to find the associated socio-demographic determinants of domestic violence among the subjects. Settings and Design: The study was designed as a cross-sectional study to estimate the prevalence of domestic violence and to find socio-demographic correlates in its causation. A total of 1500 apparently healthy pregnant women, with gestation up to 20 weeks were interviewed. Methods and Materials: A pre-tested semi-structured interview schedule was used to collect data on socio-demographic variables and details of domestic violence, after explaining the purpose of study to the subjects and obtaining informed consent. Statistical Analysis Used: Data was entered in Ms-Excel and IBM SPSS Version 25 was used for statistical analysis. Results: The findings revealed overall prevalence of domestic violence to be 29.7%, with emotional and verbal type of violence being most common type. Caste, religion, literacy status of study subjects, and occupational status of spouses of study subjects were reported as significant correlates affecting the causation of domestic violence among the subjects. Conclusions: The findings highlight the burden and thus, stress for the need for effective involvement of all sectors in the elimination of domestic violence against women as a public health issue and develop zero-tolerance towards it.
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Public health information systems for primary health care in India: A situational analysis study p. 3640
Dharamjeet Singh Faujdar, Sundeep Sahay, Tarundeep Singh, Harashish Jindal, Rajesh Kumar
Introduction: Information communication technology (ICT) based health information systems (HISs) are expected to transform health system functionality. The present study was aimed to evaluate HISs in India with a focus on primary health care (PHC). Methodology: The study used a qualitative method to evaluate and understand various ICT-based HIS implemented at the state/union territory (UT) level in India. After initial scoping research on HIS through literature search and observation, in-depth interviews of key informants at various levels (programme managers, analysts, co-ordinators, data entry operator and health care providers) was carried out to have an insight on the user experience of these systems. An inductive applied thematic coding of qualitative data was done for analysing the data. Results: Multiple applications have been developed under national health programmes to meet the health information needs, but at present, there is a limited role of these HISs in enhancing the effectiveness of comprehensive PHC. Many of these systems are proprietary-based, and the long-term sustainability and integration of these systems remain a challenge. Conclusion: A change is required in the approach to design a HIS that will cater to the needs of PHC. Moreover, HIS should be people-centred rather than technology-centric with focus on integration and sustainability.
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Towards improving primary care: Considerations on a Sicilian population-based survey p. 3647
Alfredo Manuli, Maria Grazia Maggio, Mariacristina De Cola, Daniele Tripoli, Rosaria De Luca, Rocco Salvatore Calabrò
Background: The healthcare reforms have led to the development of new primary care systems. These models allowed responding to people's needs but with problems in maintaining the relational continuity between the patient and therapist. Materials and Methods: We performed a survey on 12 May 2018, in Messina (Sicily, Italy), during an informational event. Participants were invited to fill in a self-reported Italian questionnaire composed of 12 multiple-choice questions, specifically created by the authors. The tool included the assessment of the social status, the presence of chronic diseases, preference in health care, and evaluation of the services offered in the territory. Results: As for the territorial services, we observed that the general practitioner (GP) was the most appreciated healthcare provider, followed by the nurse. Conclusions: We believe that nurses can represent the most appropriate healthcare figure to potentiate GP's patient management in primary territorial care.
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Are the medical interns ready to deal with the treatment, prevention and control of Nipah virus infection at the tertiary care hospital? p. 3653
H Pavithra, Abhay Subhashrao Nirgude, AG Balakrishna, Nihala Bijali, TM Revathi, Santosh K Yatnatti
Context: Nipah virus infection is an emerging life threatening zoonotic disease. Health care workers are at the highest risk of getting the infection. Objectives: To assess the level of knowledge and attitude regarding Nipah virus infection among medical interns of a tertiary care hospital, Mangaluru and also to assess the readiness of medical interns dealing with cases of Nipah virus infection. Setting and Design: A cross-sectional study was conducted among 94 medical interns of a teaching hospital in Mangaluru. Methods and Material: Questionnaire comprising of 33 questions was used to assess the knowledge, attitude and practice behaviors of the medical interns. Statistical Analysis Used: Descriptive statistics as mean and standard deviation and Pearson correlation coefficient. Results: The mean knowledge, attitude and practice scores were 10.28 (± 2.31), 8 (± 2.9) and 15.85 (± 3.7). Three (3.2%) of the medical interns correctly knew the best modality of diagnosis of Nipah. All the interns correctly answered the samples to be collected for diagnosis and 72 (76.6%) correctly answered the lab where samples have to be sent. Majority i.e. 64 (68.1%) of the medical interns correctly enumerated the preventive measures to be employed. Eighty four (89.4%) of them were aware about the availability of vaccine. The correlation between the adequate facilities available with practice domain and training provided with practice domain were found to be statistically significant. Conclusion: In this study, the knowledge, attitude and practice regarding Nipah virus infection were found to be inadequate. There is an urgent need to address these gaps.
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Comparative evaluation of serum alpha-1antitrypsin levels in patients with oral squamous cell carcinoma and in subjects with tobacco habit without carcinoma p. 3657
Upasana S Ahuja, Nidhi Puri, Anjana Bagewadi, Vaishali Keluskar, Anshuman Ahuja, Harkanwal P Singh
Aim/Objectives: To evaluate serum levels of Alpha-1 antitrypsin in patients with oral squamous cell carcinoma and compare them with that of healthy subjects with and without tobacco habits. Materials and Method: The sample of 83 subjects was divided into three groups: 30 subjects with oral squamous cell carcinoma formed Group A. The age, sex, habit matched 23 healthy subjects with tobacco habit formed Group B and 30 healthy without history of consumption of tobacco formed Group C. Analysis of the samples was done using Alpha 1 antitrypsin kit and spectrophotometer. Results: There was a 2.33-fold rise in serum levels of Alpha 1 antitrypsin in Group A compared to Group B, 3.71-fold rise in Group A compared to Group C and 1.59-fold rise in Group B compared to Group C (P < 0.001). A definite rise in serum Alpha 1 antitrypsin levels in patients with oral squamous cell carcinoma as compared with healthy subjects with and without tobacco habits was observed. Conclusion: Alpha1-antitrypsin can be used as an adjunct to various diagnostic procedures implied for the evaluation of oral squamous cell carcinoma.
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Frenal attachment and its association with oral hygiene status among adolescents in Dakshina Kannada population: A cross-sectional study p. 3664
Vijayalakshmi Divater, Praveen Bali, Aftab Nawab, Neel Hiremath, Jayesh Jain, Dhanraj Kalaivanan
Background and objective: Frenum is a mucous membrane fold that attaches the lip and the cheek to the alveolar mucosa, gingiva, and the underlying periosteum. The frena may jeopardize the gingival health when they are attached too closely to the gingival margin, either due to interference in the plaque control or due to muscle pull. Identifying labial frenum attachment and its association with oral hygiene helps in primary prevention of gingival health. The purpose of this study was to examine the prevalence of the various types of maxillary labial frenum attachment and its association with oral hygiene status in adolescent population. Methodology: A total of 300 adolescents between 13 and 18 years were selected randomly. They were clinically examined for maxillary frenum attachment. Placek's classification of the labial frenum attachments was used to check the origin of frenum. Oral hygiene index (simplified) was recorded and results were subjected to statistical analysis. Results: Among 300 examined children 53% were males and 47% were females. The prevalence of the maxillary labial frenum was gingival type (39%) followed by mucosal (28.3%), papillary (23.7%), and papillary penetrating type (9.0%). The gingival type of frenal attachment was statistically significant among different age of children and also between different types of frenal attachment and oral hygiene status (p value < 0.001). There was no significance between frenum attachment and gender. Conclusion: The type of frenal attachment is strongly associated with oral hygiene status. as the age progresses the frenum tends to migrate apically. However, our study did not reveal any relationship between the gender and type of frenal attachment.
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Adherence to the recommended physical activity duration among Saudis with type 2 diabetes mellitus p. 3668
Basmah Jassim AL Ramadhan, Mohammed J Alramadan, Rabab E Alhassan, Hanan A Almajed, Montaser A Bu Khamseen, Baki Billah
Background: Physical activity is important in managing type 2 diabetes, since it leads to better glycemic control, decreases macrovascular complications, and controls diabetes-related comorbidities. Objective: This study aimed to assess the levels of adherence to physical activity in Saudi adults with type 2 diabetes. Method: Participants with type 2 diabetes mellitus who visited diabetes centers in Riyadh, Jeddah, and Hofuf and completed interviewer-administered electronic questionnaires between May 15 and November 31 in 2017 were included in this study. Data related to sociodemographic information, medical history, level of physical activity, and depression and anxiety were collected. In addition, blood pressure, anthropometric measurements, and the most recent HbA1c, and fasting lipid profiles were obtained. Results: In total, 1,111 participants (65.2% women, mean age of 57.5 ± 11 years) were included in the analysis; 62.1% were obese (Body Mass Index [BMI] >30 kg/m2). Mean duration of DM was 13.8 ± 8.3 years. Approximately 75% of participants had uncontrolled diabetes (i.e. HbA1c ≥7%). Furthermore, only 30% adhered to the recommended physical activity duration of 150 min/week. Non-adherence to physical activity was associated with female sex, older age, low education, low economic status, longer disease duration, absence of family support, poor education from the physician or DM educator, and follow-up in health institutions other than the diabetes center. Conclusions: The majority of patients with T2DM in Saudi do not adhere to the recommended duration of physical activity. Sex, age, level of education, monthly income, disease duration, follow-up institution, among others, influenced adherence to physical activity.
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Awareness and knowledge of the obstetric and gynecological impact of bariatric surgery among women in the Eastern Province of Saudi Arabia p. 3678
Nourah Alqahtani, Salsabeel S Alkhudairi, Marwah S Aljahli, Isra B Alshammari, Badoor T Almansour, Sakinah N Alshayeb
Background and Aims: Obesity is still a major health issue worldwide and bariatric surgeries are now considered one of the most effective ways to manage morbid obesity. Women who are obese in their reproductive age appear to be representing the majority of the patients seeking bariatric surgeries, accounting for (80%). The aim of this study is to assess women's awareness level of obstetric and gynecological impact of bariatric surgery on their health. Settings and Design: A cross-sectional study was conducted using an online survey. Methods: Online survey was used to collect data which was distributed through social media. Questions regarding the level of knowledge were included along with sociodemographic characteristics of the population. Statistical Analysis Used: The Statistical Package for Social Sciences (SPSS) software was used to conduct the statistics analysis. Results: The survey elicited a total of (457) valid responses that were analyzed. The majority of responses were from married women (66.3%). Most common age group where those from (15 to 24) years. However, nearly about three-quarters of participants were found to have poor knowledge (73.1%) and only small percentage had a good level of knowledge (3.3%) and the rest of the participants were in the moderate group. Further analysis showed that good knowledge was among those who have consulted a physician, underwent bariatric surgery, whom source of information was the internet, and whom had more than one source. Conclusion: The level of knowledge regarding the obstetric and gynecological impact among females was found to be poor in the eastern region of Saudi Arabia.
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Assessment of knowledge and attitude regarding management of patients with substance usage in dental clinics in Modinagar- A cross-sectional study p. 3683
Divyangi Goel, Basavaraj Patthi, Ashish Singla, Ravneet Malhi, Pankaj Kumar Chaudhary, Ambar Khan
Introduction: The consequences of oral issues among drug users necessitate the implementation of a comprehensive dental care program. Integrated oral health-care services should be programmed for the management of drug addiction as a multi-organ disease needs a multi-disciplinary approach. Aim: The aim of the present study was to assess the knowledge and attitude regarding the management of patients with substance usage at a dental clinic. Methodology: A cross-sectional study was conducted among 208 dentists working as clinicians. A self-structured 27-item questionnaire consisting of questions related to the management of patients with substance usage at a dental clinic was distributed to them. Data were analyzed using Statistical Package for Social Sciences (SPSS) 20.0 (SPSS Inc., Chicago, IL, USA) and descriptive and analytical tests, including mean, standard deviation, and Chi-square test were used. P < 0.05 was considered statistically significant. Results: Majority of the dentist irrespective of qualification were unaware of the modalities regarding the management of the patients with substance usage at the dental clinic. Most dental clinicians were having a positive attitude regarding such patients and agreed that abuser should be identified and managed in dental settings. Conclusion: Educating dental graduates and postgraduates about the oral implications of substance usage and making it a part of the dental curriculum may help us deal with the global issues of substance usage. The dental setting is recognized increasingly as an untapped venue for the delivery of medical screenings, given the long-term nature and frequent contacts associated with the patient-dentist relationship.
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Oral manifestation in leprosy: A cross-sectional study of 100 cases with literature review p. 3689
Puneeta Vohra, Md Siraj UR Rahman, B Subhada, Rahul Vinay Chandra Tiwari, MS Nabeel Althaf, Monika Gahlawat
Background: Leprosy is a chronic granulomatous disease of the peripheral nerve and muscle of upper respiratory tract. Consequence to the neighboring primary site, oral lesions have been seen in 20--60% of patient with leprosy mainly lepromatous leprosy. The lepromatous nodules may be infective and may lead to the spread of disease and hence require proper diagnosis. Aim: To assess oral lesion in leprosy patients. To assess the disease and the occurrence of oral lesion according to age and gender. To detect any primary lesion in oral cavity and compare these lesions in duration to study. Materials and Methods: A total of 100 patients with leprosy were examined and there oral manifestations were recorded. Results: It was found that 70 (70%) leprosy patients showed oral manifestations. And 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, and 4 (5.71%) smokers palate, oral submucous fibrosis, and fissured tongue. Conclusion: Our clinical findings are in conjugation with previous studies; however, as per the review of literature this is the first study worldwide where we have examined 100 cases of leprosy which has not been documented till date. We suggest that the lesser incidence of oral lesions observed recently compared to older reports because of more effective present treatment which is initiated earlier.
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Perception, awareness, and practice among patients seeking orthodontic treatment toward maintenance of periodontal health and factors affecting the same among patients visiting dental clinics in Patna p. 3695
Devashish Singh Sawai, Puja Singh, Tushar , Mehak Dogra, Rafat Sultana, Shabab Ahmed Khan
Background: During the orthodontic treatment, maintenance of periodontal health is of utmost importance; hence, this study was conducted to explore the perception and awareness of patients seeking orthodontic treatment toward maintenance of periodontal health and factors affecting the same. Materials and Methods: It was a cross-sectional descriptive questionnaire study conducted among134 patients seeking orthodontic treatment from 16 private clinics in Patna. The study was conducted in the month of June 2019. The city was divided into four directions east, west, north, and south and four clinics were selected from each directions randomly. A close-ended questionnaire was prepared consists of demographic details and questions regarding their perception, awareness, and practice to maintain periodontal health from the start of orthodontic treatment. Results: Majority of study participants {74 (55.22%)} were between the age group of 11 and 15 years. Among all study participants, females {81 (60.45%)} were more than males. It was determined that 112 (83.58%) of patients were using tooth brush and tooth paste/powder for cleaning teeth. There was moderate awareness, negative perception, and fair practice of majority of study participants seeking orthodontic treatment toward maintenance of periodontal health. Awareness of study participants was significantly (P-value ≤ 0.05*) associated with practice. Conclusion: There was moderate awareness, negative perception, and fair practice of majority of study participants seeking orthodontic treatment toward maintenance of periodontal health. Education of study participants was significantly associated with awareness and practice regarding maintenance of periodontal health. There is further need to educate the orthodontic patients toward maintenance of periodontal health.
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Survey of efficacy of pediatric appendicitis score in Iranian patients less than 18 years old referred to the emergency department p. 3700
Hojjat Derakhshanfar, Elham Pourbakhtyaran, Samane Rahimi, Samira Sayyah, Fereshteh Karbasian, Zahra Soltantooyeh, Shahrzad Fallah
Introduction: Abdominal pain, in particular appendicitis, is a common cause of emergency department visits in children. Therefore, early diagnosis is very important. There are different scoring systems for the diagnosis of appendicitis. This study is the first study to evaluate the performance and accuracy of pediatric appendicitis score (PAS) in Iranian children with abdominal pain in emergency departments. Methods: This is a cross-sectional study of children under 18 years with suspected appendicitis who were referred to the emergency medicine department of hospitals affiliated to SBMU during 2015. Acute appendicitis was determined according to pathological findings, and final PAS scores were calculated for all children. With statistical analysis, comparison between two groups was calculated and the diagnostic accuracy of PAS score was estimated. Results: 88 children with mean age of 10.5 ± 3 were studied. According to clinical examination 58 of the children were suspected to have acute appendicitis and 30 others were healthy. In current study, the diagnostic accuracy and precision of PAS at cutoff of 5.5 in patients younger than 18 years admitted to the emergency department with suspected acute appendicitis was 91% and 92%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value were 93.88%, 86.21% and 92%, 89.29%, respectively. Conclusions: The results of current study showed that PAS has high diagnostic predictive value for the diagnosis of acute appendicitis in children under 18 years and due to the advantages listed for this score, its use is recommended for children in emergencies.
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Knowledge regarding avulsion, reimplantation and mouthguards in high school children: Organised sports-related orodental injuries p. 3706
Abhishek Dhindsa, Gundeep Singh, Shalini Garg, Gurpreet Kour, Ambreen Kaur, Ashish Loomba, Manu Sharma
Purpose: To assess knowledge, awareness and attitude of high school children involved in various sports activities regarding avulsion, reimplantation and mouthguard use. Materials and Methods: An interview-based study was conducted among high school children in the age group of 8–16 years (n = 1105). A questionnaire was given to children and parents which included questions based on knowledge of children regarding avulsion, reimplantation, consequences of losing teeth, mouthgards and their usage and preferred media for tooth transportation. The research proposal was submitted to the ethics committee and the study design was approved. Data analysis included descriptive statistics and Statistical Package for the Social Sciences (SPSS) software. Results: Only 37.6% of the children knew that their teeth can be completely knocked out with injury and 20.1% knew that a knocked-out tooth can be replanted. The preferred media for tooth transportation were gauze/cotton (27.2%), handkerchief (17.5%), paper (14%), water (13.8%) and cellophane (1.3%), i.e. 81.3% of the children preferred dry transport media. Among the children playing contact sport, 53.8% did not know about mouthguards and the rest 46.2% knew about it, but most of them never used it. Conclusion: Considering the lack of awareness among children, as well as the people around them, there appears to be a crucial need for education of public and to determine dental manpower and dentists to increase awareness.
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Metabolic response to maxillofacial trauma revisited: A retrospective study p. 3713
V K. Sasank Kuntamukkula, Ramen Sinha, Prabhat K Tiwari, Bharadwaj Bhogavaram, Himaja Subramanium, Bheema Vinod Kumar, Rahul V. C. Tiwari
Purpose: Management of a trauma patient aims at stabilization or resuscitation and revival from critical condition resulting from various sequences of systemic pathophysiological responses in the body. Hematological changes are the first signs reflecting the homeostasis mechanisms starting in the body after injury. The aim of the current study is to evaluate the physiological changes following maxillofacial trauma and extrapolate the findings to understand the posttrauma responses. Patients and Method: This is a retrospective study involving 192 subjects divided into two groups, trauma group and control group. In both the groups, baseline vitals and complete blood picture were recorded for comparison. In trauma group, the recordings were made within 24 h after maxillofacial injury. Results: All the parameters were analyzed using SPSS version 18. Independent sample t-test was used to assess the nature of data distribution and statistical significance was considered only at P value < 0.05. On comparison of complete blood picture mean values of hemoglobin (13.63 vs 12.18), RBC count (4.51 vs 4.10), WBC count (8835.48 vs 8336.56) were seen to be higher in trauma patients compared to control subjects. The mean bleeding times are almost equal (2.35 vs 2.47) but the clotting times (5.42 vs 5.26), random blood glucose (94.78 vs 90.13), and blood urea (27.14 vs 26.30) were marginally higher in trauma group but were statistically insignificant. The mean value of serum creatinine (0.84 vs 0.80) was comparatively higher in trauma patients and was statistically significant. Study of vitals revealed that mean systolic blood pressures were almost equal (120.65 vs 121.08) in both the groups. The mean diastolic blood pressures (79.46 vs 88.49) and oxygen saturation (93.73 vs 98.86) in trauma patients are comparatively reduced. The mean values of temperature (99.30 vs 98.50) and pulse rate (102.38 vs 97.14) were on relatively higher side in trauma group compared with control group. Summary and Conclusion: Using basic blood parameters and vitals in the present study, the compensatory mechanisms happening in the body after maxillofacial trauma can be seen. These changes although significant on side by side comparison can still fall within the normal physiological range provided by various diagnostic setups. Hence, the need for maxillofacial surgeon to be sensitive to minor variations in these aspects to ensure safety of the patient cannot be overemphasized.
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Quality of spirometry testing in a community setting: A study among elderly persons in a rural area of Haryana p. 3718
Ravneet Kaur, Alok Kumar, Vijay Hadda, M Kalaivani, Baridalyne Nongkynrih, Shashi Kant, Sanjeev K Gupta, Dwarakanathan Vignesh
Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Early diagnosis and management of COPD require good quality spirometry testing, which is currently not available at primary care level in India. This study reports the quality of spirometry testing at the community level among elderly persons in a rural area. Materials and Methods: A community-based cross-sectional study was conducted among 449 elderly persons in a rural area of Ballabgarh block of Haryana state by a trained investigator. A portable spirometer (MIR Spirolab®) was used. House-to-house visits were undertaken. A self-developed pretested semistructured interview schedule was administrated and spirometry was done according to the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines. Results: Acceptable quality of spirometry tests was found among 87.3% (95% CI: 84.2%–90.4%) participants. Poor quality of spirometry was associated with low Body Mass Index (BMI) (aOR = 0.49, 95% CI = 0.26–0.93) and age ≥ 70 years (aOR = 0.45, 95% CI = 0.21–0.94) in multivariable analysis. Conclusion: Acceptable quality of spirometry can be performed in community settings by using a portable spirometer.
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The spectrum of malignancies presenting with neurological manifestations: A prospective observational study p. 3726
Dhruv Batra, Hardeep S Malhotra, Ravindra K Garg, Kiran P Malhotra, Neeraj Kumar, Madan L Brahma Bhatt, Rajesh Verma, Praveen K Sharma, Imran Rizvi
Introduction: A neurological consultation is needed in nearly 45% of patients suffering from cancer. The present study was planned to evaluate the clinical, radiological and histopathological spectrum of patients with an underlying malignancy and presenting with a neurological complaint. Materials and Methods: We prospectively evaluated all patients provisionally diagnosed either with a primary or secondary malignancy of the brain on the basis of clinical, radiological and/or histopathological features. Results: A total of 155 patients were enrolled from a total of 4893 admissions done from January 2015 to July 2016. The common presenting symptoms were headache, back pain and paraparesis. Around 26% of patients presented with an altered sensorium, 19.4% with seizures and 21% had at least one cranial nerve involvement. The most common site of involvement was the brain noted in 49.7% of patients. Primary malignancies constituted 78 cases (50.7%) while secondary malignancies included 77 cases (49.3%). Magnetic resonance imaging (MRI) revealed 92 (59.4%) intra-axial lesions and 59 (38.1%) extra-axial lesions, with five cases having both. The most common diagnoses were intra-cerebral metastases and glioblastoma (intra-axial), and vertebral metastases and meningioma (extra-axial). Histopathological confirmation was obtained in 59 patients (38.1%) with 12 primary and 47 secondary lesions. Ten (6.45%) patients had an unknown primary with secondary metastases. The three most common histopathologically confirmed diagnoses were adenocarcinoma lung, plasma cell dyscrasia and adenocarcinoma prostate. Conclusion: Primary neurological consultations with an unknown primary are common hence a high index of suspicion can prevent an inadvertent delay in the diagnosis and appropriate treatment of a malignant lesion. Developing a neuro-oncology register may help us in gaining more insight into such situations.
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A young female patient with recurrent paroxysms of inappropriate sinus tachycardia p. 3736
Hussein S Amin
Tachycardia is one of the most common presentations in medical practice. In most cases, it could be attributed to emotional problems, anemia, or thyroid disorders. A 16-year-old female visited primary care clinics with the complaints of palpitation for years and initially diagnosed as a case of anxiety or stress. Her condition worsened and became more symptomatic over the last few months for which investigations were done. A provisional diagnosis of pre-excitation syndrome, Lown-Ganong-Syndrome, was made. This was based on short PR interval in ECG and an attack of supraventricular tachycardia and another attack of brief atrial fibrillation in addition to the family history of her mother of having pre-excitation abnormality. She was sent to electrophysiological study where no concealed accessory pathway was confirmed, and the diagnosis of inappropriate sinus tachycardia was the final diagnosis and medical treatment was initiated.
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Spontaneous coronary artery dissection involving all major arteries LAD, LCX and RCA -A case report p. 3739
Tapan Kumar, Aparna Prajapati, Mandar M Shah
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and sudden cardiac death. Amongst various etiologies thought to be responsible for this condition, atherosclerosis seems to be the most common. There are various case reports on (SCAD) of single coronary artery but the presence of SCAD of all three arteries is not known. We describe a case of a 45-year-old gentleman without any conventional coronary risk factors, who was referred to us at Tata Main hospital, Jamshedpur, for cardiac evaluation prior to his urethral surgery. Although asymptomatic cardiac-wise, his ECG incidentally revealed healed inferior wall myocardial infarction. Echocardiogram confirmed hypokinetic inferior wall with left ventricular ejection fraction of 50%. His coronary angiography showed spontaneous dissection of LAD, LCX and RCA which was managed conservatively.
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Remission of recalcitrant dermatomyositis following a chiropractic adjustment p. 3742
Eric C P Chu, Fa-Sain Lo, Amiya Bhaumik
Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by progressive muscle weakness and pathognomonic skin eruptions. Systemic corticosteroid with or without an immunosuppressive agent is the current treatment of choice in most cases. Cutaneous disease in DM is often refractory and can become the most challenging component to manage effectively. Here, we report a case of recalcitrant DM in a 66-year-old female who sought chiropractic attention for recent episodes of pain and paresthesia in the neck and exacerbation of joint pain. As expected, the musculoskeletal complaints including neck pain, peripheral arthralgia, and muscle weakness that resolved within 1 month after starting treatment. Unexpectedly, dramatic remission of the characteristic skin rashes occurred concurrently. The underlying therapeutic mechanisms of chiropractic remain elusive. This case highlights the importance of family physicians becoming familiar with diagnosing the condition and using a multidisciplinary team approach to treat recalcitrant DM.
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Primary pyogenic ventriculitis caused by Streptococcal pneumoniae in adults p. 3745
Chavada I Jayendrakumar, Dinesh B Ganesan, Siddhant J Thampi, Vasanthi Natarajan
Primary pyogenic ventriculitis is more commonly manifested in children. Its presentation in adults due to Streptococcus pneumonia is rarely reported. It is mainly due to adequate vaccination cover and initiation of appropriate antibiotics. Ventriculitis is one of the complications of bacterial meningitis, requires long-term antibiotics and surgical intervention. Here, we are reporting a 67-year-old diabetic lady presented with a decrease in sensorium, seizure, and fever, diagnosed as bacterial ventriculitis. Her cerebro spinal fluid (CSF) picture suggestive of pyogenic meningitis, CSF, blood culture grew Streptoccous pneumoniae; MRI revealed –ventriculitis. She was treated with Injection Ceftriaxazone for 6 week duration. Serial MRI showed clearing of ventricular debris and she improved.This highlights the atypical presentation of pyogenic meningitis without nuchal rigidity, status epilepticus, and clinical improvement without the need of surgical intervention.
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Atypical presentation of intrahepatic cholangiocarcinoma---Fever and ascites in a postpartum lady p. 3748
Sohini Das, Manoj Job, Thomas Kodiatte, Ramya Iyadurai
Intrahepatic cholangiocarcinoma is an uncommon malignancy which usually occurs in the 7th decade. Here we present a postpartum patient with fever, hepatomegaly, and ascites, who was diagnosed to have metastatic intrahepatic cholangiocarcinoma.
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Acute pancreatitis as an initial presentation of Crohn's disease: A case report p. 3752
Norah Mohammed Almarri, Alaa Jamal Alobaidli, Ahmed Abdullah Almarhabi, Mohammed Ahmed Alshammari
Acute pancreatitis (AP) is not commonly known to be an extra-intestinal manifestations of Crohn's disease (CD). Several cases have been reported discussing the relation of AP with CD. However, no specific etiological factors for pancreatitis were found, which appears to support the possibility of a relationship between AP and CD. We report a 30-year-old male present with generalized abdominal pain associated with watery diarrhea. Diagnosis of AP was made. A CT abdomen showed pancreatic inflammation with a terminal ileum thickening. Colonoscopy with multiple biopsy was done for the patient, which confirmed the diagnosis of CD. The patient started on adalimumab for 6 months, showed good response, and became symptomatically free. No recurrent attacks after 2 years of follow-up. The association between AP and CD is not yet clear. Therefore, patients presenting with idiopathic pancreatitis should be investigated to rule out the coexistence of IBD for better outcome.
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Staphylococcus lugdunensis infection of ventriculoperitoneal shunt in adult: Case report and literature review p. 3755
Aroop Mohanty, Mithilesh Kumar Jha, Ankita Kabi, Nisha Jha, Pratima Gupta
Ventriculoperitoneal Shunt (VPS) placement is one of the most commonly performed treatment modality in patient with hydrocephalus and infection is usually seen in such patients with shunt complication. Multiple shunt revision and its complications are related to various causes including mainly Coagulase negative Staphylococcus (CONS) infection. VPS obstruction occurring in proximal catheter is he most common cause of VPS malfunction. Here we present a case of Venticuloperitoneal shunt infection caused by CONS in a adult patient.
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Apocrine carcinoma of the scalp with neck lymph node metastasis: A case report and review of the literature p. 3758
Hadi Al-Hakami, Baraa I Awad, Mohammed Al-Garni, Haneen A Al-Maghrabi, Noura Al-Shareef
Primary cutaneous apocrine carcinoma (PCAC) is an extremely rare malignancy. Distinguishing apocrine carcinoma from breast carcinoma metastasis is difficult. Only a few cases reported as PCAC of the scalp and primarily treated by wide local excision. The usual presentation is a skin lesion that rapidly progresses over the duration of a few weeks to few months. We reported a 56-year-old man with a right scalp ulcerative lesion diagnosed as a CAC. The patient underwent wide local excision. 1.5 years later, the patient developed neck lymph node metastasis that treated with neck dissection and adjuvant radiotherapy. No chemotherapy was given due to limited literature, suggesting substantial benefits of adjuvant chemotherapy for such cases. Review literature was performed to assess the clinical presentation, treatment, and prognosis of such malignancies. PCAC of the scalp is a challenging malignancy in the diagnosis and management.
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Root canal treatment of mandibular canine with two root canals: A case report series p. 3763
Mazen Doumani, Adnan Habib, Maram A Alhenaky, Khaled S. H. Alotaibi, Maali S Alanazi, Anas Alsalhani
Canine is the cornerstone of the mouth due to its position, which reflects its significance of mastication with incisors and premolars. Anomalous root canal morphology can be found in any tooth with different degrees. The unusual configuration of root canal system may lead to a lot of procedural errors during cleaning and shaping, and this, in turn, may increase the probability of root canal treatment failure. In most cases, mandibular canines have one root of a centrally located root canal and 15% of this type of tooth has two root canals.
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Common presentation of an uncommon anaemia in a resource-limited setting: A diagnostic challenge p. 3766
Shankar Roy, Monika Pathania, Ravi Kant, Minakshi Dhar, Amisha , Paras Malik, Vyas Kumar Rathaur
A 38-year-old female in the reproductive age group presented with anaemia in a resource-poor setting. The patient was given multiple transfusions during the course of her treatment. After a proper work-up she was diagnosed with Coomb's negative autoimmune haemolytic anaemia (AIHA). She was later treated with steroid and she showed significant improvement. Early diagnosis in her case at the primary care level with other causes of anaemia in mind could have prevented unnecessary transfusions and morbidity. Proper history and approach to anaemia is the key in a resource-poor setting.
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Healing touch of doctors – Today, tomorrow and always p. 3769
Reena Doomra
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Erratum: The effect of aromatherapy on mental, physical symptoms, and social functions of females with premenstrual syndrome: A randomized clinical trial. p. 3770

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