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   Table of Contents - Current issue
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October-December 2017
Volume 6 | Issue 4
Page Nos. 701-888

Online since Thursday, February 15, 2018

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EDITORIAL  

Addressing the escalating burden of chronic diseases in India: Need for strengthening primary care Highly accessed article p. 701
Rajeshwari Sinha, Sanghamitra Pati
DOI:10.4103/jfmpc.jfmpc_1_17  
The growing epidemic of noncommunicable diseases (NCDs) has impacted the national health systems, policies, and socioeconomic developments, thereby leading to increasing country level disparities. Despite substantial improvements in health indicators made in the past decade, the Indian health-care system continues to contribute disproportionately to the global disease burden, wherein NCDs holds significant prominence. Against this background, the present review analyzes the current NCD landscape from the perspective of India's health system preparedness toward meeting this growing challenge. Implementation and delivery of strategies and interventions are often impeded by existing grass root level challenges. Recognizing the importance of effective primary care, the review highlights the importance of implementing affordable, accessible, and comprehensive interventions, and delivering them at societal, a community and individual level. This simultaneously calls for strengthening of the primary care system through appropriate strategy and policy frameworks. Toward addressing India-specific needs in NCD prevention and management, concerted efforts on development of robust surveillance mechanisms, intersectoral and interdepartmental collaborations, integration of national programs, enhanced role of education and awareness should be made, to ensure effectivity, scale-up, and outreach of services in primary care.
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CME Top

Primary immunodeficiencies for general practitioners – making a difference in diagnosing severe illness Highly accessed article p. 709
Lotte Vosmar Denning
DOI:10.4103/jfmpc.jfmpc_414_16  
PIDs are heterogeneous disorders caused by hereditary genetic defects of the immune system. The immune system normally helps the body fight off infections by germs/'micro-organisms' such as bacteria, viruses, fungi and protozoa. Because the immune systems do not work properly, people with PIDs are more prone than other people to infections. When PIDs are left undiagnosed or misdiagnosed, the immune system remains defective, often leading to illness, disability, permanent organ damage or even death. Too often infections are treated while missing the underlying cause. Current estimates of the prevalence are 1:1200 patients. Knowledge gaps, delayed diagnosis and treatment are leading into increased morbidity and mortality.Unlike many (rare) diseases, effective treatment options for PID patients are available, which can enable them to carry out a next to normal life. PID patients must therefore be diagnosed early and informed about the most adequate treatment for their particular condition. Unfortunately, none of the available therapies can reverse the damage of late diagnosis.
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FAMILY MEDICINE EXCHANGE Top

Diversity in family medicine: The art of thinking independently together – Reflections on the RCGP exchange 2016 p. 712
Ana Beatriz Figueiredo, Gabriella Pesolillo, Sidra Kanwal, Amelia Tezen
DOI:10.4103/jfmpc.jfmpc_77_17  
This narrative summarizes the reflections of a UK conference exchange experience of four young general practitioners (GPs) from Peru, Portugal, Italy, and Pakistan. This article was written after participating in a RCGP exchange program in October 2016. This consisted of 2 days of observation in a GP practice in Liverpool followed by attendance at the RCGP preconference and annual conference. The exchange was organized by the RCGP Junior International Committee, which links to the Vasco da Gama Movement, a European network of new and future GPs.
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COMMENTARIES Top

Time for the two-spirits: Shaping the inclusive policy environment for hispanics and transgenders through global health diplomacy p. 716
Vijay Kumar Chattu, Mario O Laplume, Soosanna Kumary
DOI:10.4103/jfmpc.jfmpc_74_17  
Minority populations in the world are permanently challenged with unequal living and working conditions in their daily lives that compromise their access to needed clinical and preventive services. When we discuss the health-care conditions for minorities, we must address the social determinants of access that are ultimately determined by the policies and politics of the governments. Renowned experts of quality in healthcare have been critical of the current design and implementation of randomized clinical trials, the gold standard of clinical research because they believe that they often, but not always, presume a linear, mechanistic system when in fact improvement in health care takes place within complex adaptive systems that evolve. The combined action of ignorance and prejudice can impair the efficient recruitment and retaining of “different people” like hispanics and transgender that have long suffered discrimination in their access to health-care services in spite that they are more prone to have chronic conditions. Even though the incidence of AIDS has decreased in the general population during the past two decades, it is continuing in the gay population due to educational issues, discrimination in health-care access and lack of proper public and private funding for the life-saving retroviral medication. The declaration of the “International Conference on Health Promotion” sponsored by PAHO in Colombia in 1992 have emphasized the aim of reducing differences in health status as well as ensuring equal opportunities and resources to enable all people to achieve their full health potential. Through the entreaties of the Global Health Diplomacy, the resiliently hardcore issues of discrimination and marginalization must be addressed by encouraging public policies that guarantee equity and ensure access for the most socially castigated groups.
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Enabling the disabled: Call for intercepting disability surge in Pakistan p. 721
Nadia Naseem, Usman Jawad
DOI:10.4103/jfmpc.jfmpc_50_17  
Muscular dystrophies have always been marginalized culturally and socially, particularly in underdeveloped and developing countries. Pakistan is facing significant dearth of “appropriately” trained neurologists and neuromuscular pathologists. A careful and methodical link between clinical, pathological and molecular analysis must be established before making a diagnosis in such cases. Increased collaboration between local and international neurology societies may add value to collaborative neuromuscular research and education in Pakistan, both in community and health sectors. These goals are all achievable but require persistence, dedicated workforce, and positive efforts to meet them.
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REVIEW ARTICLE Top

Errors of insulin therapy: Real-life experiences from developing world p. 724
Subhankar Chowdhury, Partha Pratim Chakraborty
DOI:10.4103/jfmpc.jfmpc_418_16  
A significant bulk of people living with diabetes is on insulin therapy aiming for satisfactory glycemic control and resultant reduction in vascular complications of diabetes. Insulin undoubtedly is the most potent antihyperglycemic agent. However, a significant proportion of insulin-treated diabetics fails to achieve the desired glycemic goal. Errors of insulin therapy remain an important and correctable factor in many of them. Such errors of insulin therapy can potentially arise at each and every step starting from the office of the clinicians while prescribing it for the first time up to the point of administration. Here, we share some of our clinical experiences on potential errors of insulin therapy and discuss preventive measures to overcome these simple barriers to achieve long-term glycemic control. We believe, these unfortunate but interesting scenarios, though rampant in the developing world may not be uncommon in the other parts of the world if carefully looked for. It is important for the clinicians to learn from these experiences with insulin therapy because it represents, for a majority of patients, the last option in our therapeutic armamentarium.
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ORIGINAL ARTICLES Top

Assessment of menstrual hygiene among reproductive age women in South-west Delhi Highly accessed article p. 730
Gunjan Kumar, Josyula G Prasuna, Gaurav Seth
DOI:10.4103/jfmpc.jfmpc_24_17  
Background: The issue of menstrual hygiene is inadequately acknowledged in our nation. The use of sanitary pads and washing the genital area are essential practices for good menstrual hygiene. Poor menstrual hygiene may lead to itching or rashes in the perineal region, bad odor, and sometimes, major complications such as pelvic inflammatory disease and toxic shock syndrome. Therefore, the objective of this study was to assess the knowledge and practice of menstrual hygiene among reproductive age group women. Methods: A Community-based cross-sectional study design was employed. Study was conducted from January 2012 to April 2013. Data were collected using a pretested semi-structured structured questionnaire. The data were entered and analyzed into a computer using SPSS version 20. Results: In this study, 584 (81.7%) respondents had good practice of menstrual hygiene. The findings of the study showed a significant positive association between good practices of menstrual hygiene and years of education of the study subject (adjusted odds ratio [AOR] =9.3, 95% confidence interval [CI]: 4.4–19.5), having a higher socioeconomic status (AOR = 9.27, 95% CI: 4.7–18.03). Conclusions: Awareness of good menstrual practices is of utmost importance. Health education regarding menstrual hygiene should be a part of school curriculum and health institutes. Social marketing of good quality, low-cost sanitary napkins at accessible outlets, provision for adequate water supply, vending machines for low-cost sanitary napkins, privacy and wall-mounted incinerators for disposal in schools, workplaces, and public places would go a long way in improving the menstrual hygiene and help them in securing healthy lifestyle.
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Bacteriological profile of neonatal sepsis in a secondary care hospital in rural Tamil Nadu, Southern India p. 735
Doniparthi Venkata Pavan Kumar, Jesinth Mohan, PS Rakesh, Jasmine Prasad, Lenikumar Joseph
DOI:10.4103/jfmpc.jfmpc_66_17  
Introduction: Neonatal sepsis is a leading cause of neonatal mortality and morbidity in the world. The objective of the current study was to detect the common causative microorganisms of neonatal sepsis and their antimicrobial resistance patterns in a rural secondary hospital in Tamil Nadu, India. Materials and Methods: Neonates (0–28 days) admitted to this newborn care unit from October 2013 to September 2015, with a diagnosis of probable sepsis were studied. All the enrolled babies had blood cultures taken and were followed up till final outcome, which was discharge or death, irrespective of culture result. Univariate analysis was performed for factors associated with culture positivity, generating odds ratios, and confidence intervals. Results: Among the 107 babies with a diagnosis of probable sepsis, 28 (26.2%) had shown bacteria in culture. The majority (94.4%) were of early-onset sepsis. The predominant organisms were Staphylococcus aureus (10/28) and Klebsiella (6/28). 100% of Gram-negative bacilli and 90% of Staphylococcus were resistant to Ampicillin. Gentamicin resistance among Gram-negative bacilli and Staphylococcus was 52.9% and 20%, respectively, while third-generation cephalosporin resistance was 31.2% and 20%, respectively. Among the neonates diagnosed as probable sepsis, idiopathic prematurity (P = 0.007) was found to have a statistically significant association with culture-positive sepsis. Conclusion: The culture positivity rate among the neonates with probable sepsis in the current study was 26%. An alarmingly high degree of antibiotic resistance observed calls for robust infection control practices and an urgent evaluation and development of individual and national antibiotic policies for neonatal sepsis.
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Prospective study on prevalence of anemia of pregnant women and its outcome: A community based study p. 739
Ravishankar Suryanarayana, Muninarayana Chandrappa, Anil Navale Santhuram, S Prathima, SR Sheela
DOI:10.4103/jfmpc.jfmpc_33_17  
Background: Anemia is one of the most common nutritional deficiency disorders affecting the pregnant women in the developing countries. Anemia during pregnancy is commonly associated with poor pregnancy outcome and can result in complications that threaten the life of both mother and fetus. Objective: The objective of the study was to estimate the prevalence of anemia among pregnant women and to determine its association with maternal and fetal outcomes. Settings and Design: This study design was a prospective, observational, community-based study. Subjects and Methods: Four hundred and forty-six pregnant women were included in the study from three primary health centers in Kolar district by multistage sampling technique and were followed up till 1 week after delivery. Statistical Analysis: The data were analyzed using SPSS version 22; correlation coefficient, Chi-square test, and logistic regression were used. Results: There was a significant overall improvement in the hemoglobin levels of pregnant during the follow-up (10.3–10.72 gm%). About 35.6% of the women had maternal or fetal morbidity. Anemia was one of the main pregnancy-related complications (62.3%), other complications include difficult labor (3%), postpartum hemorrhage, and preeclampsia 1.6% each abortions/stillbirths (3.5%). The fetal complications include low birth weight (25.5%) followed by premature delivery (0.2%) and birth asphyxia (0.5%). Conclusions: A high prevalence of anemia in pregnant women apparently increases the maternal and fetal risks. To improve maternal and fetal outcome, it is recommended that the primary health care has to be strengthened, prevention, early diagnosis, and treatment of anemia in pregnancy to be given priority.
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A comparative study of epidemiological investigations of malaria outbreaks and related deaths in two districts of Jharkhand during the same prewinter season using shoe-leather epidemiology p. 744
Dewesh Kumar, Shashi Bhushan Singh, Abhishek Kumar, Anupam Kishore, Vivek Kashyap
DOI:10.4103/jfmpc.jfmpc_55_17  
Background: Following news of deaths in two districts of Jharkhand (West Singhbum and Garhwa) in November 2016, epidemiological investigations were contemplated to investigate any current outbreak of falciparum malaria and deaths attributed to it. Methodology: The epidemiological investigations, verbal autopsy of suspected deaths attributed to malaria and keys interviews were conducted in the 2nd and 4th week of November 2016 in Khuntpani and Dhurki block of West Singhbum and Garhwa districts, respectively, following a strict protocol. Results: The affected villages were Argundi and Korba-Pahariya and their adjacent tolas in Khuntpani and Dhurki block. Undoubtedly, there was the continuous transmission of falciparum malaria in both the regions in October and November 2016. The total cases (according to case definitions) were 1002, of them, 338 and 12 patients were positive for Plasmodium falciparum positive (Pf +ve) and Plasmodium vivax positive (Pv +ve), respectively, in the affected areas of Khuntpani block. In Dhurki block, out of the total of 631 patients fulfilling the case definition, 65 patients were PF +ve and 23 Pv +ve. Comparing to the last year, there is remarkably high number of falciparum cases. Verbal autopsy of deceased individuals showed that malaria might be one of the strongly probable diagnoses, but not conclusively. Conclusion: According to epidemiological investigation, verbal autopsy and key interviews conducted, it may be concluded that there is a definite outbreak of falciparum malaria in the area and environment is congenial for malaria and other tropical diseases.
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Relationship between serum ferritin level and transient elastography findings among patients with nonalcoholic fatty liver disease p. 750
Seyed Saeed Seyedian, Eskandar Hajiani, Seyed Jalal Hashemi, Abdolrahim Masjedizadeh, Ali Akbar Shayesteh, Pezhman Alavinejad, Ahmad Hormati, Ali Javaherforoushzadeh, Mehdi Khabazkhoob
DOI:10.4103/jfmpc.jfmpc_158_17  
Introduction: Nonalcoholic fatty liver disease (NAFLD) is raising prevalence among children, and adolescence population in developed and developing countries as a major public health concern. The present study aims to determine the relationship between serum ferritin level and transient elastography findings in patients suffering from NAFLD. Materials and Methods: The demographic and biochemical profile of included individuals such as body mass index, age, level of serum transaminases, fasting blood sugar, lipid profile, and serum ferritin level were determined and a transient elastography was performed for all of them. Results: The mean serum ferritin level among men with mild and advanced liver stiffness was 154 ± 97 and 244 ± 214, respectively (P < 0.001), which showed a meaningful relationship. These figures among female patients with mild and advanced liver stiffness included 79 ± 91 and 161 ± 103, respectively (P = 0.003) and again revealed a significant relationship. The cutoff values of ferritin with 90% accuracy for differentiation of mild from advanced liver stiffness among male and female patients were determined as 255 ng/ml and 135 ng/ml, respectively. These cutoff values for ruling out of advanced liver stiffness with 90% accuracy among both sexes were 72.5 ng/ml and 65.5 ng/ml, respectively. Conclusion: The finding of this study revealed a significant relationship between serum ferritin level and liver stiffness among NAFLD patients, and if these results repeated in further investigations, it could be advisable to measure serum ferritin level for predicting possibility of advanced liver fibrosis.
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The evaluation of the relationship between some related hormone levels and diet in obese or overweight patients with hirsutism: A randomized clinical trial p. 755
Atefeh Krouni, Sedighe Forouhari, Bahia Namavarjahromi, Mohammad Hossein Dabbaghmanesh, Arezoo Shayan, Sara Sepasi, Atefeh Zare
DOI:10.4103/jfmpc.jfmpc_179_17  
Introduction: Hirsutism is a common disorder that has remarkable physical and mental effects on individuals. No appropriate diet has yet specified for individuals with hirsutism. The present study was carried out to examine the effect of high-fibre, low-caloric balanced diet on some related hormone levels in obese or overweight women with hirsutism who had referred to clinics affiliated with Shiraz University of Medical Sciences. Materials and Methods: The present study was a clinical trial that was carried out on 47 obese or overweight women with hirsutism in 2014. The women were randomly assigned to an intervention group and a control group that, respectively, consumed a high-fiber, low-caloric balanced diet and a normal diet for 3 months. A demographic characteristics questionnaire and a researcher-designed diet questionnaire were filled out by the two groups before the intervention. Before and 12 weeks after the intervention, body mass index (BMI) was measured and blood samples (on the 3–5 days of menstruation) were collected. Factors of luteinizing hormone, follice stimulating hormone, sex hormone binding globulin, dehydroepiandrosterone sulfate, low-density lipoproteins, high-density lipoproteins (HDL), fasting blood sugar (FBS), CHOL, prolactin, triglycerides, insulin, 17-hydroxyprogesterone, and free androstenedione testosterone were measured. The collected data were analyzed through t-test, Chi-square, and intergroup analysis using SPSS 22.0. Results: The mean age of the participating women was 27.23 ± 5.42 years. After the study, the level of FBS and insulin in the intervention group dropped while they increased in the control group. Moreover, the postintervention level of BMI in the intervention group on average decreased 1.89 units while it rose by 0.3 units in the control group, and there was a significant difference between the two groups (P < 0.001). Conclusion: The results of the present study showed that consuming high-fiber diet by obese or overweight women with hirsutism and polycystic ovary can reduce some factors including the level of FBS, insulin, and cholesterol and enhance blood HDL. Therefore, consuming this type of diet is recommended to treat this disorder.
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Silent changes of tuberculosis in Iran (2005-2015): A joinpoint regression analysis p. 760
Abolfazl Marvi, Mehran Asadi-Aliabadi, Mehdi Darabi, Fereshteh Rostami-Maskopaee, Hasan Siamian, Ghasem Abedi
DOI:10.4103/jfmpc.jfmpc_190_17  
Introduction and Aim: Tuberculosis (TB) poses a severe risk to public health through the world but excessively distresses low-income nations. The aim of this study is to analyze silent changes of TB in Iran (2005–2015): A joinpoint regression analysis. Materials and Methods: This is a trend study conducted on all patients (n = 70) that register in control disease center of Joibar (one of coastal cities and tourism destination in Northern Iran which was recognized as an independent town since 1998) during 2005–2015. The characteristics of patients imported to the SPSS 19 and variation in incidence rate of different forms of pulmonary TB (PTB) (PTB+ or PTB–) and extra-PTB (EPTB)/year was analyzed. Variation in incidence rate of TB for male and female groups and different age groups (0–14, 15–24, 25–34, 35–44, 45–54, 55–64, and above 65 years) was analyzed, variation in trend of this diseases for different groups was compared in intended years, and also, variation in incidence rate of TB was analyzed by Joinpoint Regression Software. Results: The total number of TB was 70 cases during 2005–2015. The mean age of patients was 42.31 ± 21.26 years and median age was 40 years. About 71.4% of patients were PTB (55.7% for with PTB+ and 15.7% with PTB–) and rest of them (28.4%) were EPTB. In regard to classification of cases, 97.1% of them were new cases, 1.45% of them were relapsed cases, and 1.45% of them imported cases. In addition, history of hospitalization due to TB was observed in 44.3%. Conclusion: Despite recent developments of governmental health-care system in Iran and proper access to it and considering this fact that identification of TB cases with passive surveillance is possible. Hence, developing certain programs for sensitization of the covered population is essential.
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Seasonal variation in the prevalence of preeclampsia p. 766
Fatemeh Janani, Farahnaz Changaee
DOI:10.4103/jfmpc.jfmpc_132_17  
Introduction: Hypertension in pregnancy is one of the three factors of maternal mortality. Etiology of the disease is unknown, but the many factors contributing to the identification and control of it can be taken a step to prevent and reduce the symptoms of the disease. The purpose of this study was to determine the prevalence of preeclampsia (high-blood pressure) in different seasons of the year. Methods: The present retrospective cross-sectional study was conducted on more than 8,000 pregnant women visiting Assali specialized hospital from 2011 to 2013. Required data was collected through questionnaire checklist. The Chi-square test with multiple comparisons was used to compare the frequencies of pregnancy-induced hypertension (PIH) according to the month of year, and adjustment of multiplicity was conducted using Bonferroni's method. Student's t-test was used to compare the means of PIH prevalence rates. In all analyses, P < 0.05 was taken to indicate statistical significance. Results: In these 8000 woman admitted to labor, overall prevalence of PIH was 3.8 ± 0.6%. The prevalence rate of PIH was highest in the summer (4.5%) and lowest frequent in the winter (2.7%), respectively. In July, the prevalence rate was significantly higher than those for any other month (4.7%), and in March, it was lower prevalence than for any month (2.2%), respectively. Using the Chi-square test, a significant difference between the incidence of disease was observed in summer and winter (P < 0.001). Conclusion: The prevalence rate of PIH was higher for delivery in summer and early spring and lowest for winter delivery among Khorramabad women based on these results; it seems that changes in temperature and humidity in different seasons can affect preeclampsia, and preeclampsia increases with increasing frequency temperature.
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The evaluation of hepatoma-derived growth factor in determining of prognosis and estimating of invasive probability of tumoral cells, recurrent, and metastasis of lymphatic glands in breast carcinoma p. 770
Behrang Kazeminezhad, Behdad Baradaran, Mohammad Reza Hafezi Ahmadi
DOI:10.4103/jfmpc.jfmpc_177_17  
Introduction: Recently, hepatoma-derived growth factor (HDGF) has been considered as a significantly important factor in determining the prognosis and estimating the probability of tumor cell invasions, recurrence, and lymph node metastasis in different cancers, including breast malignancies. Materials and Methods: Immunohistochemistry (IHC) study for HDGF was performed on paraffin-embedded blocks of patients with breast carcinoma in Modarres hospital, Tehran, Iran, since 1387–1390 (74 cases); three separate pathologists read the slides after complete IHC staining. Thereafter, necessary information was recorded from patient files, and eventually, findings were analyzed by SPSS program. Results: Expression of nuclear HDGF has significant statistical correlation with tumor grade according to Nottingham grading scheme; this correlation is also seen with nuclear pleomorphism of tumor cells and mitotic count. No correlation between age and tumor size with expression of HDGF is found. Lymph node metastasis is in inverse ratio to nuclear HDGF staining. Conclusion: Nuclear expression of HDGF in tumor cells is increased concordantly to tumor grade, which implies us to the role of this marker in determining the prognosis and choosing the most suitable treatment plan.
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Comparing depressive symptoms in teenage boys and girls p. 775
Mahnaz Fallahi Khesht-Masjedi, Somayeh Shokrgozar, Elahe Abdollahi, Mahbuobe Golshahi, Zahra Sharif-Ghaziani
DOI:10.4103/jfmpc.jfmpc_129_17  
Introduction: Symptoms of depression vary between the males and females. Depressed men show behaviors such as irritability, restlessness, difficulty in concentrating, and instead of the usual behaviors. Sleep disturbance is a common symptom in depressed men. Men are less likely to go to doctors and unconsciously show other behaviors such as anger instead of the sadness. It seems that considering depression as “feminine” is a great injustice toward male patients whom their illness will not be diagnosed nor treated. Materials and Methods: The sample consisted of 191 depressed adolescents, 108 males and 83 females aged 13–19 years old. Data collected for 10 years from 2005 to 2015 and their depressive symptoms were evaluated by the Beck Depression Inventory-Second Edition. Results: Depressed girls felt sadness, guilt, punishment, worthlessness, low energy and fatigue, or more asthenia, whereas depressed boys have symptoms such as irritability, depression, suicidal thoughts, or desires to reduce their pleasure. The results of t-test showed that the difference between the total scores of boys and girls with depressive disorder (16.93) is significant at 0.001. F values for feeling sad (58.13), hatred of self (12.38), suicidal thoughts or desires (12.97), restlessness (17.35), and irritability (46. 41) were significant in the 0.001. Conclusion: Experiencing depression in boys and girls according to the role of gender was different. Gender can have an effective role in showing depression symptoms in adolescents.
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Antiadhesive and cytotoxic effect of Iranian Vipera lebetina snake venom on lung epithelial cancer cells p. 780
Akbar Oghalaie, Fatemeh Kazemi-Lomedasht, Mohammad Reza Zareinejad, Delavar Shahbazzadeh
DOI:10.4103/jfmpc.jfmpc_208_17  
Background: Cancer is one of the major health problems worldwide. Hence, finding potent therapeutics from natural sources seems necessary. Snake venom of Vipera lebetina contains potential component with anticancer activities such as antiproliferation, migration, invasion, adhesion, and angiogenesis effect. Evaluation of cytotoxic and antiadhesive effect of V. lebetina venom on lung epithelial cancer tumor cell (TC-1) was the main aim of this study. Materials and Methods: Here, we purified snake venom of V. lebetina by fast protein liquid chromatography (FPLC) using Sephacryl S-200 hr column. The fractions collected and evaluated by SDS-PAGE analysis. The cytotoxicity and antiadhesive effect of crude venom and fractions on TC-1 cells were demonstrated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and adhesion assay, respectively. Results: Our results showed six fractions in FPLC diagram. V. lebetina crude venom and fractions showed dose-dependent cytotoxic effect on TC-1 cells. Fractions 2 and 5 showed high cytotoxic effect with high IC50 value (IC50 = 6 μg/ml for fraction 2 and IC50 = 7.3 μg/ml for fraction 5). Fractions 2 and 5 selected for analysis antiadhesive effect on TC-1 cells. Furthermore, our results showed that both fractions 2 and 5 had antiadhesive effect on TC-1 cells. Conclusion: Because of potent cytotoxic and antiadhesive effect of V. lebetina fractions on lung epithelial cancer cell line, it could be promising tools for further analysis as anticancer therapeutic development.
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An investigation on the level of awareness, attitude, and interest among medicine, dentistry, and pharmacy students toward their majors on entering university: The case of Islamic Azad University, Tehran medical sciences branch p. 784
Farhad Adhami Moghadam, Sara Afshari Azad, Mohammad Sahebalzamani, Hojjatollah Farahani, Mojgantabatabaee Jamaran
DOI:10.4103/jfmpc.jfmpc_224_17  
Introduction: Having awareness, interest, and positive attitude toward one's fields of study leads to the development of a compatibility between demands and expectations on the one hand and future career on the other hand. This study was carried out to determine the level of awareness, attitude, and interest of medicine, dentistry, and pharmacy students of Islamic Azad University, Tehran Medical Sciences Branch toward their own field of study on entering university. Materials and Methods: This research is a basic descriptive study conducted on 273 students who had just entered university. This study was performed using census. Data collection instrument was a four-part questionnaire which included demographic information, and questions measuring students' awareness, attitude, and interest. Results: With regard to their field of study, there was no statistically significant difference in the average of students' awareness (P = 0.731). The attitude of medicine students was significantly more positive than pharmacy and dentistry students (P < 0.001), and the attitude of dentistry students was significantly more positive than that of pharmacy students (P = 0.460). Medical students' interest level was significantly higher than that of pharmacy and dentistry students (P < 0.05), and the interest level of dentistry students was significantly greater than the interest level of pharmacy students (P = 024/0). There was a statistically significant positive relationship between awareness and attitude and between awareness and interest in all of the study subjects (P < 0.001). Conclusion: The study results indicated that having a high level of awareness toward one's major led students studying in medicine, dentistry, and pharmacy to experience a more positive attitude and a higher level of interest. Thus, before entering the university, academic counseling will be beneficial for acquiring a better understanding of most majors, a goal which could be provided through school, social media, and family.
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Fatal carbon monoxide poisoning: A lesson from a retrospective study at All India Institute of Medical Sciences, New Delhi p. 791
Asit Kumar Sikary, Sumit Dixit, Om P Murty
DOI:10.4103/jfmpc.jfmpc_408_16  
Background: Carbon monoxide (CO) is a colorless, odorless, tasteless, and nonirritating gas which makes it difficult for those who are exposed, to detect it, leading to unexpected death. This study was undertaken to see the pattern of fatal CO poisoning and to discuss preventive aspect. Materials and Methods: It was a retrospective descriptive study of fatal CO cases which were autopsied at All India Institute of Medical Sciences, New Delhi, from the year 2010 to the year 2015. The cases were analyzed as per age groups, circumstances of death, season of death, and sources of CO formation. Results and Discussion: The study involved 40 cases of fatal CO poisoning. About 80% of cases were reported in winter months. The maximum cases were reported in the month of January followed by November and December. All the cases except one, died with a source of CO nearby and the person was inside a room or some closed space without ventilation. Source of CO was firepot and electric room heater in most of the cases. Some cases were of CO build inside the car with a running engine. Most of the cases occurred accidentally. Conclusion: Clustering of cases is seen in winters. Poisoning can occur in different ways. The study documents the various possibilities of CO poisoning and advocates community education targeting the high-risk groups and masses, especially during the winter season.
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Walking ability in stroke patients using knee gaiter and suspended walker for gait training p. 795
Bhavin Mahendrabhai Patel, Nirav Vaghela, Deepak Ganjiwale
DOI:10.4103/jfmpc.jfmpc_133_17  
Background and Objective: The objective of this study is to assess the walking ability of a stroke patient using knee gaiter and suspended walker. Methodology: Thirty participants with first acute stroke within first 3 months with the mean age of 55.73 years participated and were allocated randomly into two groups. Participants were taken from Inpatient Department of Medicine of Shree Krishna Hospital, Karamsad and Physiotherapy Department of Shree Krishna Hospital, Karamsad. Both the groups received conventional physiotherapy for 3 weeks. Group A was administered knee gaiter, and Group B was allocated suspended walker. Outcomes/scales were measured in terms of 10-meter walk test (10MWT), 3-min walk test (3MWT), and dynamic gait index (DGI). Results: After the treatment, both the groups showed significant improvement (P < 0.001) in 3MWT, 10MWT, and DGI scores, but Group A shows additional beneficial effect on 3MWT (P = 0.023) and 10MWT (P = 0.754) with using t-test and no significant improvement in all the components of the DGI except step component with using the Mann–Whitney test. Conclusions: The findings support the hypothesis that knee gaiter has better gait outcome as compared to suspended walker in stroke patients.
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Care management process of breast cancer in primary health-care system, Golestan Province, Iran, 2013–2014 p. 798
Zahra Hajiebrahimi, Ghahraman Mahmoodi, Ghasem Abedi
DOI:10.4103/jfmpc.jfmpc_220_16  
Introduction: Health-care service processes need to be assessed over time. We aimed to assess the breast cancer care process in primary health system of Golestan Province, North Iran. Materials and Methods: To perform a descriptive cross-sectional study, information on breast cancer care processes in primary health-care system was collected using a “collecting form” from 234 health houses, 29 health posts, 44 urban health centers, and 80 rural health centers in Golestan Province. Registered data in the centers and patients' journal were used in data collection. Moreover, we collected data on all women who were diagnosed with breast cancer in 2014 to know the characteristics of the patients. Results: Around 50% of health workers at rural or urban area were trained on breast cancer. Moreover, 2% of women from general population in rural area and around 6% of them in urban area have been trained on breast cancer. Mean age of women diagnosed with breast cancer was 48 ± 10 years and 40.2% of them were affected at age between 43 and 52 years. The results showed that 18.9% of women have received their information through self-study before the diagnosis of breast cancer while 53.8% of them received their information from the private clinics after diagnosis of breast cancer. Conclusion: The process of breast cancer care in Golestan Province needs to be improved in the primary health-care level. Both inter- and multi-disciplinary activities are needed.
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Magnitude of depression and its correlates among elderly population in a rural area of Maharashtra: A cross-sectional study p. 803
Sourav Goswami, Pradeep R Deshmukh, Ramesh Pawar, Abhishek V Raut, Mansi Bhagat, Ashok M Mehendale
DOI:10.4103/jfmpc.jfmpc_97_17  
Background: Depression is the most common psychiatric disorder among elderly population in India, yet, it is commonly misdiagnosed and undertreated. The exact burden of depression among the elderly population in rural India was not known. Objectives: To study the magnitude of depression among the elderly masses in rural Maharashtra and to find its correlates. Material and Methods: This is a cross sectional study, carried out among the elderly (≥60 years) population of both sexes residing in the field practice area of the department of community medicine. Geriatric depression scale was used for screening depression among the study population. Data collection was completed within 2 months using convenience sampling. Ethical approval was taken before beginning the study. Magnitude was expressed in percentage along with its 95% confidence interval (CI). Univariate and multivariate logistic regression was carried out to study associated correlates. Odds ratio and 95% CI was used to express association. Results: The magnitude of depression among the elderly population was found to be 41.7% (95% CI 36.1–47.4). We got the significant positive association of female sex, living without spouse, lacking in decision making capability, a victim of abuse or neglect, or suffering from chronic illnesses with depression among elderly population in univariate analysis that did not hold good in the multivariate logistic regression. Our study showed the prevalence of mild depression among elderly to be 26.72% and that of severe depression to be 15.17%. Conclusion: To deal with this huge social problem of depression among the elderly population, more enthusiastic steps should be undertaken.
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Nicotine dependence and its correlates among the adult tobacco users in a slum of Burdwan district, West Bengal, India p. 813
Indranil Saha, Kamirul Islam, Bobby Paul, Tapas Kumar Som
DOI:10.4103/jfmpc.jfmpc_42_17  
Background: Tobacco kills half of its users, with smoking and smokeless tobacco killing nearly 6 million people worldwide – one death every 6 s in each year. Use of tobacco over time causes a physical and psychological addiction due to the presence of nicotine. To find out the level of nicotine dependence among adult (18 years and above) tobacco users and the factors responsible for it. Materials and Methods: A cross-sectional community-based study was conducted among 128 current tobacco users in an urban slum of Burdwan District, West Bengal, India. Study tools comprised of predesigned, pretested, semi-structured schedule, containing Fagerström test for nicotine dependence (FTND) questionnaire. Data were collected by interview after getting consent from the participants. Chi-square test, unpaired student t-test, ANOVA, correlation coefficient, and linear regression was calculated. SPSS software (Statistical Package for the Social Sciences Inc, Chicago, IL, USA). was used for analysis. Results: High level of nicotine dependence was maximally seen among increased in age group, prolonged duration of use and daily users. Age, duration of tobacco use and habit of tobacco use had a significant positive correlation with FTND score while starting age of tobacco had a significant negative correlation. Then in multivariable linear regression, starting age of tobacco use, habit of tobacco use and duration of tobacco use emerged as a significant predictor of FTND score and could explain 27.3% of total variation in FTND score. Conclusions: Suitable plan for quitting may be developed based on the FTND score of an individual, the most important determinant of quitting.
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Patients' satisfaction regarding family physician's consultation in primary healthcare centers of Ministry of Health, Jeddah p. 819
Khalid Bawakid, Ola Abdul Rashid, Najlaa Mandoura, Hassan Bin Usman Shah, Waqar Asrar Ahmed, Adel Ibrahim
DOI:10.4103/jfmpc.jfmpc_170_17  
Introduction: The current study aims to assess the level of patients' satisfaction and the factors contributing to patients' satisfaction toward family physicians (FPs) consultation, visiting primary healthcare centers (PHCCs) working under Ministry of Health, Jeddah. Materials and Methods: In this cross-sectional study conducted in Jeddah from November 1, 2016 to March 1, 2017, we used consultation satisfaction questionnaire and its four subscales with standard cutoffs. These subscales include general satisfaction, professional care, depth of relationship, and length of consultation. Mean scores along with standard deviation of these subscales were measured. Independent sample t-test, ANOVA, and multivariate regression analysis were performed to test the association between satisfaction level and predictors. Results: Overall, patients' satisfaction was 60%. Around 74% of patients were satisfied with the professional care and 58% with the depth of the relationship. Around 60% of patients need more consultation time with the physicians. Knowledge about the presence of FP in the nearest PHCCs was around 70%. Multivariate regression analysis for the overall high satisfaction showed that the most important predictors of this high satisfaction level are regular visits to a particular FP (P < 0.001), distance from the PHCC (P = 0.044) and gender of the patient (P = 0.027). Conclusion: This study concluded that satisfaction with the FP's consultation is acceptable but needs improvement. Lower satisfaction was reported among males, patients living at a distance from PHCC and who had less knowledge about the presence of FP in their nearest PHCC. Such study data are vital for any corrective measures to boost satisfaction in patients attending PHCCs.
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An assessment of reliability and validity of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 among breast cancer patients in Qatar p. 824
Abdulbari Bener, Reem Alsulaiman, Lisa Doodson, Hanadi R El Ayoubi
DOI:10.4103/jfmpc.jfmpc_17_17  
Introduction: Breast cancer has been the most common cancer type that affects women worldwide and subsequent treatment is often associated with considerable psychological and quality of life (QoL). Aim: This study aimed to assess psychometric properties of the Arabic version of the European Organization for Research and Treatment of Cancer (EORTC) general QoL questionnaire (QLQ-C30) for breast cancer patients in Qatar. Materials and Methods: This is a cross-sectional hospital-based study conducted on 678 breast cancer patients using Arabic version of the EORTC QLQ-C30 tool. Results: The mean age of women was 47.7 ± 10.2 years and 33.4% of women had consanguineous parents. Six subscales out of the nine met the standards of reliability with coefficients ranging from 0.55 to 0.89. The mean score of all functioning scales was high >55. Advanced breast cancer stages of III–IV had higher symptomatic scores significantly than those in early stages for the physical function, cognitive, fatigue, insomnia, appetite loss, constipation, and financial difficulties. Correlation coefficients between each item ranged from –0.113 to 0.960, and item 21 (tense) and item 23 (irritable) had strongest negative correlations with their corresponding emotional functioning subscale, whereas items 29 (physical condition) and 30 (overall QoL) had the strongest positive correlation with Global Health/QoL subscale. Item 6 (limited work) showed a higher correlation with fatigue (r = 0.749). Likewise, item 19 (pain interfered with daily activities) of the pain subscale had higher correlations with physical functioning, role functioning, and fatigue subscales. Conclusion: Qatari Arabic version of the EORTC QLQ-C30 showed acceptable psychometric properties, which is a reliable and valid instrument, that can be used by oncologists.
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Evaluation of skill-based training program on rational drug treatment for medical interns p. 832
Murugan Venkatesan, Amol R Dongre, Kalaiselvan Ganapathy
DOI:10.4103/jfmpc.jfmpc_172_17  
Context: A module-based training program for medical interns using World Health Organization guide for good prescription along with the individual feedback on their prescription was developed and implemented. Objective: The objective of the study was to obtain the medical interns' reactions to newly developed skill-based training program on rational treatment. Study Setting: This study was conducted at the Department of Community Medicine. Participants: A total of 96 medical interns were included in the study. Study Design: A cross-sectional study consisting of retro-prefeedback and open-ended questions about self-assessment of perceived skill on rational treatment. Analysis: Collected data were entered in Epi Info (3.5.4) and analyzed. Results: After training, there was a significant increase in self-perceived posttest scores of setting up the therapeutic objective for the treatment (2.9–4.9), ability to select the correct drug (2.8–5.1), ability to select right dose, schedule, and duration of drugs (2.5–4.9). and overall prescription skill (2.9–4.9). There is a significant decrease in self-perceived scores in the skill of practicing polypharmacy (4.1–2.5). Conclusions: Overall, the training program was taken well and interns perceived their skill on rational treatment was improved as shown by the feedback.
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Clinical presentation, etiology, management, and outcomes of iliopsoas abscess from a tertiary care center in South India p. 836
Joanne Rodrigues, Ramya Iyyadurai, Sowmya Sathyendra, Manjeera Jagannati, Kundavaram Paul Prabhakar Abhilash, Sudha Jasmine Rajan
DOI:10.4103/jfmpc.jfmpc_19_17  
Introduction: Iliopsoas abscess (IPA) is the collection of pus in the iliopsoas compartment. The etiology of IPA is variable and depends on the geographical area and the antibiotic usage prevalence in that area. This study attempts to evaluate the etiology, clinical features, risk factors, management modalities, and outcomes in patients with IPA from a tertiary care center in South India. Materials and Methods: This was a retrospective study done in a tertiary care center in South India. Patient details were obtained from electronic medical records. Results: A total of 43 patients were enrolled in the study, the causative organism could be identified in 20 (46.5%) patients. The most common etiology was tuberculosis (TB). Most (23 [56.5%]) patients were treated conservatively, 20 (46.5%) patients were treated with percutaneous drainage (PCD), and 2 (4%) patients required surgery. Conclusion: The most common cause of IPA is TB. PCD was successful in 95% of the patients with complete resolution of symptoms.
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The role of ultrasound in diagnosis and evaluation of bladder tumors p. 840
Mohammad Momen Gharibvand, Mehrzad Kazemi, Azim Motamedfar, Mojgan Sametzadeh, Aliakbar Sahraeizadeh
DOI:10.4103/jfmpc.jfmpc_186_17  
Introduction: Bladder tumors are common and the only way to prove it is cystoscopy which is invasive and expensive. Finding noninvasive, well-accepted, and cost-effective method for early detection of bladder cancer is necessary. The aim of this study was to evaluate the role of ultrasonography in the diagnosis and evaluation of bladder tumors. Methods: This study was conducted on 75 patients with indications for cystoscopy. After recording demographic data, ultrasound, and cystoscopy was performed for all patients. Sensitivity and specificity of sonography in the diagnosis of bladder tumors were measured. Results: The most common form of bladder in ultrasound was papillary tumors (86%) and the lowest was related to cystic mass (4%). The sensitivity, specificity, positive predictive value, and negative predictive value of sonography for the diagnosis of bladder tumors were 93.24%, 100%, 100%, and 16.66%, respectively. Conclusion: The results of our study showed that ultrasonography has high sensitivity and specificity in the diagnosis of bladder cancer and since that ultrasound is a noninvasive, well-accepted, and cost-effective diagnostic technique, ultrasound can be performed in suspected patients in the first stage.
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An epidemiological study of drowning survivors among school children Highly accessed article p. 844
Jaseena Nadu Veetil, Vijayan Ampaya Parambath, Bijayraj Rajanbabu, Sangeetha Suresh
DOI:10.4103/jfmpc.jfmpc_349_16  
Context: Drowning is a major, but often neglected, public health problem. Drowning is the second leading cause of death from unintentional injuries, after road traffic injuries. According to the World Health Organization, 0.7% of all deaths worldwide (>500,000 deaths) each year are due to unintentional drowning. In India, very little is known about the epidemiology of drowning. There is almost no awareness or protocols to prevent drowning. Objectives: The objective is to study the prevalence, risk factors, and types of drowning among school children in the Malabar region. Materials and Methods: A cross-sectional, population-based study by semistructured interview method was performed among 8433 school children of 5–15 years. Statistical Methods: The prevalence of drowning was calculated. Odds ratio was calculated and represented under 95% confidence interval. Risk factors were analyzed as frequency with percentage. Results and Discussion: The total study population was 8433 students, comprising 4795 boys (56.86%) and 3638 (43.13%) girls. A total of 342 (4.06%) students had a history of drowning. These survivors were further interviewed. The prevalence of drowning was much higher compared to figures reported in literature. Conclusions: Contrary to the general perception, drowning is a common occurrence among children. Swimming skills have no role in the prevention of drowning. Public awareness regarding supervision of children and restricting unsupervised access of children to water bodies need to be emphasized.
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A study of emotional intelligence and perceived parenting styles among adolescents in a rural area in Karnataka p. 848
Neethu George, Deepthi N Shanbhag, Meera George, Ann Christy Shaju, Reuben C Johnson, P Thomas Mathew, Chaitanya Prasad Golapalli, Ramakrishna Goud
DOI:10.4103/jfmpc.jfmpc_100_17  
Context: Adolescence is the time which is crucial for the overall development of a person both mentally and physically. In this period, along with academic intelligence, emotional intelligence (EI) also plays an equal or strong role in student life. Aims: This study was to assess EI, parental bonding, and their association among adolescents in high schools under Sarjapur PHC area. Subjects and Methods: This was a cross-sectional study conducted among high school students under Sarjapur PHC area. The EI was assessed using EI scale which measured self-awareness, self-regulation, motivation, empathy, and social skills. The parental bonding instrument was utilized to determine the parental styles of both the parents and was interpreted in terms of care and protection as neglectful parenting, affectionless control, optimal parenting, and affectionate control. Results: A total of 300 adolescents were interviewed. It was seen that most of them had low EI in self-awareness, i.e., 92 (30.7%), motivation 99 (33%), and social skills 101 (33.7%). It was also observed that most of them had high EI in self-regulation, i.e., 98 (32.7%) and moderately high EI in empathy 117 (39%). The study group perceived that 147 (49%) of the fathers and 109 (36.3%) of the mothers had affectionless control. Conclusion: Along with poor parenting, most of the respondents also have low EI in self-awareness, motivation, and social skills which has to be addressed for the future of the country.
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The effect of positional changes on oxygenation in patients with head injury in the intensive care unit p. 853
Jigar Nayankumar Mehta, Lata D Parmar
DOI:10.4103/jfmpc.jfmpc_27_17  
Background: Following head injury, cardiopulmonary functions are impaired and this disturbs the oxygenation transport pathway. Expanding cardiopulmonary physical therapy to encompass the oxygen transport system as a whole has implication for treatment as well as assessment and treatment outcome. Therefore, the aim of the study is to assess the oxygenation level in head injury patients with relation to body positioning in the intensive care unit (ICU). Methodology: Thirty consecutive patients with head injury with hemodynamically stable were included from the surgical ICU, ages ranging from 15 to 50 years. Noninvasive vital parameters (oxygen saturation [SpO2], pulse rate [PR], respiratory rate [RR], and blood pressure [BP]) were observed and recorded in different body positions at regular intervals of 5 min for 15 min in each position. Results: There was increment in SpO2 value in all positions from 0 min to end of 15 min in supine (98.63 ± 0.36–98.73 ± 0.30), right-side lying (98.77 ± 0.30–98.93 ± 0.20), left-side lying (98.73 ± 0.29–99.03 ± 0.24), and recline sitting (30°–70°) (99.03 ± 0.24–99.50 ± 0.22). However, there was statistically significant increment in recline sitting (30°–70°) compared to other positions (P = 0.036) while other parameters (PR, RR, and BP) were getting stabilized at lower values at end of 15 min in every positions tested. Conclusion: We conclude that upright position bring about significant increase in arterial SpO2 compared to any other positions. Other vital parameters were seen to stabilize at lower values at the end of 15 min in every position tested.
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CASE REPORTS Top

Thrombocytopenia in HIV patients coinfected with tuberculosis p. 859
AS Sandhya, Brijesh Prajapat
DOI:10.4103/jfmpc.jfmpc_250_17  
Thrombocytopenia is one of the most common hematological manifestations seen in HIV patients with approximately 40% of the patients developing thrombocytopenia during their course of illness. Opportunistic infection like tuberculosis is a rare but curative cause of thrombocytopenia in these patients. Clinically, it is a challenge to determine the exact cause and decide the treatment of thrombocytopenia in these patients as both infections can lead to significant thrombocytopenia by varied mechanisms. The treatment options are limited by drug antitubercular treatment highly active antiretroviral therapy (ATT and HAART)-induced thrombocytopenia. A 25-year-old male patient presented with low grade, intermittent fever with left-sided pleuritic chest pain for 2 months along with dry cough, weight loss, malaise, and lethargy. Hematological examination showed anemia, leukopenia, and thrombocytopenia. The patient was found to be HIV reactive. Chest X-ray revealed nonhomogenous opacity with cavitation in the left upper and middle zone suggestive of tuberculosis. He received multiple units of blood and platelets and was started on isoniazid, rifampicin, pyrazinamide, and ethambutol. HAART was initiated 2 weeks after starting ATT. Patient's hematological parameters improved and he was discharged on ATT and HAART with recovery of the platelet counts. Thrombocytopenia is a complication associated with both HIV and tuberculosis and hence determining the cause and deciding the appropriate treatment is challenging. Decision about whom and when to treat has to be taken cautiously considering all possible contributors and treatment has to be individualized.
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Sporadic hypothyroidism-related hypokalemic paralysis: Diagnosis in a resource-poor setting p. 862
Nadasha Kadeeja, Nivetha Senthilnathan, Stalin Viswanathan, Rajeswari Aghoram
DOI:10.4103/jfmpc.jfmpc_215_17  
Hypothyroidism and distal renal tubular acidosis causing hypokalemic paralysis (HP) have been described only in four female patients. HP as the initial manifestation of uncomplicated diabetes has been reported only in three young males. We report two middle-aged patients presenting with gradual-onset areflexic quadriparesis and neck flop, associated with urinary potassium losses, and recovering over 3 days. The male patient with alcohol abuse had urine pH >5.5 and hyperchloremic metabolic acidosis due to renal tubular acidosis and hypothyroidism. The second, a hypertensive female, had metabolic alkalosis, hypomagnesemia, and diabetes mellitus diagnosed at admission. Both these patients improved with intravenous and oral potassium supplementation.
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Wrist swelling – Is it tuberculosis? p. 865
Miti Aatish Shah, Ira Shah
DOI:10.4103/jfmpc.jfmpc_200_17  
The hand and wrist are rare sites for tuberculosis (TB) and account for < 1% of all skeletal TB. Though rare, TB of the wrist is a cause of major morbidity. A common feature in the available reports on wrist TB is a delay in diagnosis causing residual stiffness and pain after treatment. Although TB of the wrist has a varied presentation, the majority of lesions respond to conservative treatment. We report a 12-year–old girl who presented with wrist swelling, having intercarpal, carpometacarpal, and radiocarpal joint involvement which turned out to be tuberculous and it healed with residual deformity.
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A case report of over-the-counter codeine dependence as consequence of self-medication for premature ejaculation p. 867
Sethulakshmi Sreevalsam Anil, Badr Ratnakaran, Nisha Suresh
DOI:10.4103/jfmpc.jfmpc_206_17  
Over-the-counter (OTC) opioid abuse, including codeine, has been a growing problem around the world. Although the majority of the abusers use it for recreational purposes, many become dependent on it after having used it a medication for pain or cough. We present a case of codeine dependence where the initial prescribed use had been as a cough medication, but the subsequent abuse of it occurred the following self-medication for premature ejaculation. There is growing need for awareness among doctors and pharmacists of OTC abuse of opioids and for preventive interventions such as restricting supply, audit of pharmacies, training pharmacists, and counter staff and dispensing knowledge about proper use of opioid-containing medications to patients.
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Complete eventration of right hemidiaphragm: A rare presentation p. 870
Krushna Makwana, Manish Pendse
DOI:10.4103/jfmpc.jfmpc_283_17  
Eventration of the diaphragm is a term used to describe an abnormal elevation of part or whole of the hemidiaphragm, where the whole or part of the diaphragm is made up of a thin fibro membranous sheet replacing normal diaphragmatic musculature. Complete and partial eventration both can occur, however, complete eventration of the right hemidiaphragm in an adult female, as presented in this patient, is rarely seen.
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Bilateral renal aspergillosis in an immunocompetent host p. 873
Sohini Das, Atul Ramchandra More, Ramya Iyadurai
DOI:10.4103/jfmpc.jfmpc_209_17  
Bilateral primary renal aspergillosis is rare in immunocompetent hosts. The clinical presentation of Aspergillus pyelonephritis is similar to that of bacterial pyelonephritis. Here, we present an immunocompetent patient with primary bilateral renal abscesses due to Aspergillus fumigatus.
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Self-limiting diarrhea in an infant exposed to sertraline in breast milk p. 876
NA Uvais
DOI:10.4103/jfmpc.jfmpc_217_17  
Sertraline is widely used to treat postpartum depression. Though studies found detectable levels of sertraline in infant blood, very few adverse effects are reported. Reporting hereby is a case of an infant who developed self-limiting diarrhea, probably due to exposure to sertraline in breast milk.
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A case report of rapid-onset hyponatremia induced by low-dose olanzapine p. 878
Sethulakshmi Sreevalsam Anil, Badr Ratnakaran, Nisha Suresh
DOI:10.4103/jfmpc.jfmpc_205_17  
Hyponatremia has been reported with the use of psychotropic drugs. Olanzapine does not find much mention as a cause of hyponatremia in literature; however, it has been found to be the second most frequently reported atypical antipsychotic to cause it. We report a case of hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion which occurred at a rapid onset following the administration of low-dose olanzapine during inpatient treatment of a patient with bipolar disorder. We would like to highlight our case for the need to be vigil about such fatal side complications apart from metabolic side effects of atypical antipsychotics.
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LETTERS TO EDITOR Top

Lack of special courts under protection of children from sexual offences act: A structural deficit p. 881
Deepak Juyal, Ajay Setia, Ashutosh Sayana, Adarsh Kumar, Vyas Kumar Rathaur, Benu Dhawan
DOI:10.4103/jfmpc.jfmpc_241_17  
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A roadmap to clinical assessment and evaluation of autism spectrum disorder p. 883
Ahmed Naguy
DOI:10.4103/jfmpc.jfmpc_426_16  
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Heart transplantation after the circulatory death; The ethical dilemma p. 885
Abdul Mannan Khan Minhas, Salman Assad
DOI:10.4103/jfmpc.jfmpc_108_17  
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Drug-resistant tuberculosis: Response to More et al. (2017) p. 887
Saurav Basu
DOI:10.4103/jfmpc.jfmpc_309_17  
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