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   Table of Contents - Current issue
Coverpage
November-December 2018
Volume 7 | Issue 6
Page Nos. 1153-1595

Online since Friday, November 30, 2018

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EDITORIAL  

War and peace: Is our world serious about achieving Sustainable Development Goals by 2030? Highly accessed article p. 1153
Raman Kumar, Pritam Roy
DOI:10.4103/jfmpc.jfmpc_231_18  
Only 12 years are left to achieve Sustainable Development Goals (SDGs) by 2030. However, the 2018 Global Peace Index revealed that global peacefulness declined for the fourth straight year, with the average level of country peacefulness deteriorating by 0.27% last year. There is an increased political instability worldwide. These three years are also the formative years of the SDG period (2015–2030). Peace, stability, human rights, and effective governance based on the rule of law are important conduits for sustainable development. From the perspective of war and peace, the periods of millennium development goals (2000–2015) and healthcare for all by 2000 were no different. We are residing in a world that is increasingly divided. Some regions enjoy sustained levels of peace, security, and prosperity, whereas others fall into seemingly endless cycles of conflict and violence. Globe is witnessed a steep rise in armed conflicts in recent years and with 62% of those in extreme poverty estimated to be living in countries at risk from high levels of violence by 2030. It is time to ask – Is the world really serious about achieving SDGs? Or will we set yet another ceremonial set of goals for 2050 and allow the global war to continue?
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AFPI POSITION PAPER Top

Rural Health Scenario – Role of family medicine: Academy of Family Physicians of India Position Paper Highly accessed article p. 1157
Pratyush Kumar, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_254_18  
Half the world's people currently live in rural and remote areas. About 70% of the world's 1.4 billion people who are extremely poor live in rural areas. The problem is that the majority of healthcare providers prefer to serve in urban areas. Only a comprehensive and systematic approach can address these inequities. India, the largest democratic republic in the world, possesses 2.4% of the world's land area and supports 16% of the world's population. According to census 2011, 68.84% of population resides in rural areas. Nearly 86% of all the medical visits in India are made by rural inhabitants with a majority still traveling more than 100 km to avail healthcare facility, of which 70%–80% is born out of pocket landing them in poverty. A country's approach must systematically and simultaneously address legal coverage and rights, health worker shortages, extension of healthcare protection, and quality of care. Only then can equitable access for all be fully achieved. Those living in rural areas have access to health protection and services that meet the criteria of availability, affordability, accessibility, acceptability, and quality. Family medicine as a broad specialty has its role from womb till tomb. Family medicine is defined as a specialty of medicine which is concerned with providing comprehensive care to individuals and families by integrating biomedical, behavioral, and social sciences. As an academic discipline, it includes comprehensive healthcare services, education, and research. A family doctor provides primary and continuing care to the entire family within the communities; addresses physical, psychological, and social problems; and coordinates comprehensive healthcare services with other specialists, as needed. The practitioners in family medicine can play an important role in providing healthcare services to the suffering humanity. The general practitioner's responsibility in Medicare includes management of emergencies, treatment of problems relating to various medical and surgical specialties, care of entire family in its environment, appropriate referrals, and follow-up. He or she is the first-level contact for the patients and his or her family. Family medicine is the ideal solution to growing rural healthcare challenges. This article is a formal position paper of the Academy of Family Physicians of India.
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COMMENTARIES Top

Historical perspectives on prevention paradox: When the population moves as a whole p. 1163
Syed Ahsan Raza, Jason Lee Salemi, Roger Jamil Zoorob
DOI:10.4103/jfmpc.jfmpc_275_18  
Rose's Strategy of Preventive Medicine is critical reading for students and teachers in public health as well as practitioners of family and preventive medicine. In his classic, Geoffrey Rose outlines the prevention paradox that led to a discussion of two main preventive approaches to a disease, the individual- and population-based. This commentary briefly provides historical perspectives and viewpoints on the message of fundamental importance that when the population moves as a whole, the relative differences are the characteristics not of individuals but of populations. The “population as a whole” has been adopted in the lexicon of public health, enriched by Hippocrates' treatise on air, water, and places; Durkheim's collective consciousness; Pickering's continuous unimodal distribution; and Keys' charts of contrasting distributions. These readings should provide the public health professionals with a critical understanding of prevention paradox when they tend to focus only on the expression of the root cause above ground but fail to at the roots beneath the ground.
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Measles is in the news yet again p. 1166
Mac-Paul Osei Kwadwo Odei
DOI:10.4103/jfmpc.jfmpc_234_18  
The purpose of this article is to communicate a sense of urgency to healthcare providers, particularly those in the United States, to not take recent news reports of new outbreaks of measles in some parts of the country lightly. Measles is a highly contagious killer disease with no racial or age discriminations. It can have disastrous effects on the quality of life of the patients, their families, and the country. Before implementation of the National Measles Vaccination program in 1963, approximately 500,000 persons in the United States were reported to have had measles every year, of whom 500 died, 48,000 were hospitalized, and another 1,000 had permanent brain damage (Seward, 2014). Through an effective two-dose measles vaccination program, measles was curtailed in the United States, and in the year 2000, measles was declared eliminated from the country. “Eliminated” means the absence of continuous transmission of measles for 12 months or more in a specific geographic area. While it is obvious that measles is no longer endemic in the United States, measles is imported into the country every year, mostly by US residents returning from travel abroad. This is probably responsible for the 107 newly confirmed cases in 21 states as of July 14, 2018 (Chodosh, 2018). If the figures from the Center for Disease Control and Prevention are to be believed (and they are), then chances are high that no matter where you are in the country, a case of measles might just show up in your consulting room.
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Gestational diabetes mellitus 2018 guidelines: An update Highly accessed article p. 1169
Surabhi Mishra, Ajeet Singh Bhadoria, Surekha Kishore, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_178_18  
Gestational diabetes mellitus (GDM) has emerged as a global public health problem, both globally and in India. Despite government of India (GoI) prior mandate to screen all Indian pregnant women for GDM, its real operationalization at primary health-care level is suboptimal. Adding new operational component, GoI revised its existing recommendations and released new technical operational guidelines on GDM diagnosis and management in February 2018. The revised guideline highlights integration of two vertical programs, ensuring effective GDM service delivery to all antenatal women at every pause point of existing service delivery platform within public health system. However, its real success depends on knowledge and commitment level of health-care providers. Despite maternal and child health holding high public health relevance since long, community-level delivery of services still persists to be at high risk of fragmentation and inefficiency.
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REVIEW ARTICLES Top

Socioeconomic and cultural impact of tobacco in India p. 1173
Sujay Shah, Bela Dave, Rutu Shah, Tejas R Mehta, Rutvik Dave
DOI:10.4103/jfmpc.jfmpc_36_18  
Tobacco consumed either in the form of smoke or smokeless is hazardous to the human body. Death toll due to tobacco globally, has risen to about 6.4 million annually, and is on a constant increase. Since long, tobacco consumption has been attributed to a variety of factors including geographical variation, cultural factors and other associated variables. Earlier tobacco was considered as a taboo, but with advent of 21st century and commercialization of tobacco it has been prevalent among males and females. Global adult tobacco survey (GATS) in India 2016-17 revealed that there has been drop of 34.1% tobacco consumers in India, mainly due to the increasing awareness and anti-tobacco campaigns and tobacco hazards warning on the packs. Analysing the changes in trends by healthcare professionals can prove to be a valuable tool in devising strategies to control and limit the morbidity and mortality caused due to tobacco consumption.
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Prevalence of disability and its association with sociodemographic factors and quality of life in India: A systematic review p. 1177
S Ramadass, Sanjay K Rai, Sanjeev Kumar Gupta, Shashi Kant, Sanjay Wadhwa, Mamta Sood, V Sreenivas
DOI:10.4103/jfmpc.jfmpc_10_18  
Disability is complex, dynamic in nature, multidimensional, and most contested. Quality of life is an abstract concept that is related to the level of disability in the population. Approaches to measuring disability vary across different regions, and purpose and application of the findings. We systematically reviewed the studies that have been undertaken to study the prevalence of disability and its association with sociodemographic factors and quality of life among the general population in India, between January 2000 and June 2018. The prevalence of impairment ranged from 1.6% to 43.3%. In major surveys, males had higher impairment than females. Studies that used the International Classification of Functioning, Disability and Health concept for measuring disability reported prevalence ranging from 70.0% to 93.2%. Most studies used semi-structured questionnaires for measurement of disability. Some studies have used Barthel Index for Activity of Daily Living, Instrumental Activities of Daily Living, Indian Disability Evaluation and Assessment Schedule, Rapid Assessment of Disability scale, and Standard Health Assessment Questionnaire. The quality of life was low among females. This review brings out the heterogeneity in the concepts for measuring disability and quality of life. Lack of standardization in the measurement of disability restrains any comparison between these studies.
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ORIGINAL ARTICLES Top

Development of a return to work tool for primary care providers for patients with low back pain: A pilot study p. 1185
Lisanne C Cruz, Hasanat A Alamgir, Parag Sheth, Ismail Nabeel
DOI:10.4103/jfmpc.jfmpc_262_18  
Context: Low back pain (LBP) is a common cause of disability in adults and primary care physicians (PCPs) are commonly the first medical practitioners to assess these patients. Despite this, PCPs often feel unprepared to make return to work (RTW) recommendations. Aims: The purpose of our project was to develop RTW guidelines for patients with LBP in the form of an accessible and adaptable electronic medical records (EMR) integrated tool. Settings and Design: All licensed physicians and physician extenders who see patients over the age of 18 years, presenting with acute LBP who are currently employed were eligible for participation. PCPs were randomized with and without the RTW guidelines and charts were reviewed to assess if PCPs made RTW recommendations. Subjects and Methods: RTW guidelines were developed using the Oswestry LBP Disability Questionnaire and the Official Disability Guidelines and integrated into the EMR. Statistical Analysis Used: A Chi-square analysis was used to compare physicians in the interventional and control groups. Results: Forty-four PCPs were randomized into the intervention group and 37 into the control group. In the intervention group, 301 patient encounters met the inclusion criteria for acute LBP. Of these, RTW recommendations were used in 7.3% encounters. Comparatively, there were 256 cases of LBP in the control group and RTW recommendations were offered in 1.6% of encounters (P < 0.001). Conclusion: This study showed that PCPs with access to the RTW guidelines in an EMR-integrated tool were significantly more likely to make such recommendations.
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Prevalence of primary headache among medical students at King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia p. 1193
Ibrahim S Almesned, Nayef G Alqahtani, Jammaz A Alarifi, Turki N Alsaawy, Sajida Agha, Mohammed A Alhumaid
DOI:10.4103/jfmpc.jfmpc_240_18  
Background: Headache is among the commonest complaints in medical students; it could be due to many physical or psychological stressors. It has two main types: primary (including tension-type, migraine, and cluster) and secondary. The aim of this study is to assess the prevalence of headache among male and female medical students. Materials and Methods: This study was conducted at KSAU-HS, COM, in January 2018. Third- and fourth-year medical students from both genders who have experienced headache throughout their life or are experiencing it for the past 3 months were included in this study. All medical students completed filling the questionnaire, which consisted of demographical data, headache characteristics and triggers, and associated symptoms. Results: A total of 264 [150 (56.81%) males and 114 (43.19%) females] students were evaluated. The prevalence of headache was 53.78%, and the prevalence of tension-type headache was 41.66%. The prevalence of migraine headache was 7.1%. Only one case of cluster headache was detected. Those who did not fit the criteria for the primary types were categorized as unspecified headache. The prevalence of unspecified headache was 3.78%. Conclusion: We can conclude from the study that tension-type headache is commonly reported in medical students. It is imperative to provide a stress-free study environment where students can perform more effectively, and sessions on how to reduce stress and alleviate fatigue are highly recommended.
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Knowledge, readiness, and myths about menstruation among students at the Princess Noura University p. 1197
Kholoud K Alharbi, Afnan A Alkharan, Doha A Abukhamseen, Maryam A Altassan, Wareef Alzahrani, Amel Fayed
DOI:10.4103/jfmpc.jfmpc_279_18  
Background: Menstruation is a natural part of the female reproductive cycle in which periodic discharge of blood from the uterus exits through the vagina, it is the spontaneous onset of puberty. Aim: The study is to assess the level of knowledge, readiness, and myths about menstruation among young Saudi girls in the Princess Noura University, Riyadh. Materials and Methods: This cross-sectional study of a convenient sample of 500 students from different colleges at the Princess Nora Bint Abdul Rahman University, Riyadh, Saudi Arabia was conducted between January 2016 and March 2016. A validated questionnaire assessing knowledge, readiness, and attitude of participants was used. Questions assessing beliefs and myths about menstruation were included. Results: About 500 students participated in the study, their average age was 21.1 ± 7.8 years and 25.8% of them were from the health colleges. The main source of information about menstruation was the mother in about 60%, whereas only 4% considered doctors and nurses as a source of information. The study shows that the knowledge, attitude, and readiness of participants about menstruation were really poor. The majority (73.4%) of the participants were not able to correctly recognize why girls get their period. Similarly, the percentage of students having a negative attitude about menstruation is 78.4% (370), and <23% were defined to be ready before their first menses. Conclusion: The results of the study depict that the respondents lack proper knowledge of information relevant to menstruation. This included the importance of increasing awareness and giving accurate information using scientific sources, such as schools, colleges, or health team members.
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The effect of training problem-based learning on the quality-of-life symptom scales in patients suffering from breast cancer p. 1203
Hossein Feizi, Rounak V Tajreh, Nasser R Manesh
DOI:10.4103/jfmpc.jfmpc_301_18  
Background and Aim: Breast cancer is one of the most common cancers and most deadly malignancies among the women all over the world. The diagnosis, treatment, and complications arising from this cancer bring about numerous physical, mental, and social complications as well reduced quality of life in these patients. The present study aims at investigating the effect of training problem-based learning on the quality-of-life symptom scales in patients suffering from breast cancer. Materials and Methods: In a randomized controlled clinical trial, 50 breast cancer patients hospitalized in the oncology ward of Tohid Hospital of Sanandaj, Iran. The patients were randomly divided into two groups: experimental and control. Experimental group patients were trained according to problem-based learning, but no specific measure was conducted on control group patients. Right after the training course, the patients' quality of life was measured once more by using the abovementioned questionnaires, and the data collected were analyzed by using statistical tests. Results: The mean age of the samples was 44.22 ± 10.32. The findings of the study indicate that there was a significant statistical difference between the two groups in the quality-of-life symptom scales before the intervention and after conducting it (P < 0.05). Moreover, as for the breast cancer-specific quality-of-life symptom scales, there was no significant statistical difference between the two groups both before and after the intervention (P < 0.05). Conclusion: The findings obtained in the present study indicate that training problem-based learning had a positive effect on the quality-of-life symptom scales in women suffering from breast cancer. This training method can be applied as a part of normal measures taken for the patients alongside other medical measures.
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Comparing the effects of face-to-face and telenursing education on the quality of family caregivers caring in patients with cancer p. 1209
Masoumeh Shohani, Mosayeb Mozafari, Ali Khorshidi, Shohreh Lotfi
DOI:10.4103/jfmpc.jfmpc_317_18  
Background: Taking care of patients with cancer is often done at home and by family caregivers. However, these groups do not receive the necessary education regarding care at home. Objectives: The present study aimed to compare the effects of face-to-face and telenursing training methods on the quality of services provided by the family caregiver for patients with cancer. Materials and Methods: A total of 103 family caregivers of patients with cancer were randomly divided into 3 groups: control (N = 35), face to face (N = 34), and telenursing (N = 34). The control group only received the routine training, and the face-to-face and telenursing groups were trained for 12 weeks. Quality of care was measured using a questionnaire before and after intervention. Chi-square, Fisher's exact, and analysis of variance tests were used for data analysis. Results: After intervention, the average total quality score for the care of patients in face-to-face (166.13 ± 13.91) and telenursing (157.76 ± 17.24) groups was significantly higher than the control group (82.51 ± 16.84) (P < 0.001). In addition, the average psychosocial care score for face-to-face group (49.06 ± 6.05) was significantly higher than telenursing group (43.83 ± 6.15) (P < 0.001). Conclusion: The results of the study showed that the two methods of training were effective on the quality of care among family caregivers of patients with cancer to a similar extent.
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Public knowledge and awareness about Parkinson's disease in Saudi Arabia p. 1216
Alwaleed M Alyamani, Jammaz Alarifi, Abdulmajeed Alfadhel, Fahad Alfarawi, Khalid Alshamardl, Faisal Alassaf, Mohammed Alyamani, Fahad Alshahrani
DOI:10.4103/jfmpc.jfmpc_335_18  
Background: Parkinson's disease (PD) is one of the most prevalent neurologic disorders, leading to progressive disability that can be slowed but not stopped by treatment. It is characterized by tremors, slow movements, stiffness in arms and legs, and balance impairment. Despite advancement in treatment, diagnosis, and care of PD patients, lack of adequate knowledge and associated beliefs among the community might have a key role in limiting access to proper treatment and care. Objectives: To identify the level of awareness of our population regarding PD in terms of causes, signs, symptoms, and treatment. Materials and Methods: A cross-sectional study was conducted on Saudis, who have active Twitter accounts. Data were collected through a previously validated questionnaire, which tests recognition of PD symptoms and general knowledge regarding PD. The questionnaire was translated into Arabic. Part 1 of the questionnaire is the demographic data collection sheet, Part 2 of the questionnaire tests recognition of PD symptoms, and Part 3 of the questionnaire tests general knowledge regarding PD. Results: The questionnaire was administered to 3,050 members of the public, of which 2,609 questionnaires (86.20%) were included in the analysis. The tremor was the most widely recognized symptom (86.10%), and weight loss was the most recognized non-motor symptom (24%). Most respondents (56%) were able to identify imbalance as a symptom of PD, whereas only 4.10% of them were able to identify the reduced sense of smell as a symptom of PD. Motor symptoms were significantly better recognized (range 31.30%–86.10%) than non-motor symptoms (range 4.10%–24%). Conclusion: Educational campaigns may be appropriate to improve public awareness of PD and individual knowledge about PD symptoms and treatment.
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A comparative study of dental fluorosis and non-skeletal manifestations of fluorosis in areas with different water fluoride concentrations in rural Kolar p. 1222
MN Shruthi, NS Anil
DOI:10.4103/jfmpc.jfmpc_72_18  
Background: Fluorosis is an endemic disease which results due to excess exposure to high fluoride from different sources. The climatic factors and dependency on ground water add to the risk of fluorosis in Kolar. In addition to it, the epidemiological studies conducted on fluorosis in Kolar are very few. Aims: (1) To estimate age-specific prevalence of dental fluorosis in the study population. (2) To determine the proportion of study subjects with non-skeletal manifestations of fluorosis (3) To assess and compare the influence of various socio-epidemiological factors in the occurrence of dental fluorosis among the study population in areas with high and normal fluoride. Methodology: A cross-sectional study was conducted among the residents of three randomly selected villages, Thimmasandra and Batwarahalli (high fluoride) and Maddinayakanahalli (normal fluoride) belonging to Bangarpet taluk, Kolar for 1 year. Dental fluorosis was assessed by the Dean's grading. Non-skeletal manifestations were elicited based on clinical features. Fluoride levels of drinking water sources were estimated by ion-electrode method. The Chi-square and Fisher's exact tests were used to see the difference in proportions and a P value of <0.05 was considered for statistical significance. Results: The prevalence of dental and non-skeletal fluorosis in the study groups with high and normal fluoride groups were 13.17%, 5.5%, 3.84%, 1.9%, respectively. The prevalence of dental fluorosis was significantly higher among the children and adolescents compared to adults (P < 0.05). Conclusion: Dental fluorosis is a public health problem mainly affecting children and adolescents in Bangarpet.
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Out-of-pocket expenditure and drug adherence of patients with diabetes in Odisha p. 1229
Swagatika Priyadarshini Swain, Sudipta Samal, Kirti Sundar Sahu, Sarit Kumar Rout
DOI:10.4103/jfmpc.jfmpc_24_18  
Introduction: The burden of diabetes mellitus (DM) is increasing in India and across states. Given the chronic and progressive nature of the disease, it implicates huge financial burden on patients. Given this, the objectives of this study are to estimate the out-of-pocket (OOP) expenditure on diabetes care and assess the magnitude of medication adherence among patients in a public hospital. Materials and Methods: A cross-sectional survey was conducted among 206 patients with age ≥25 years visiting the outpatient department of a tertiary care hospital in Odisha. Cost data were collected from April to June 2016 using a structured questionnaire, and drug adherence was assessed using the Morisky Medication Adherence Scale. Results: The average total expenditure per patient per month was INR 1265 (95% confidence interval 1178–1351), of which medical expenditure was INR 993 (95 confidence interval 912–1075) and that of nonmedical expenditure was INR 271 (95 confidence interval 251–292). Expenditure on medicine constituted around 65% of total medical expenditure. The other drivers of medical expenditure were diagnostics services constituting 13.2% and transportation (11.8%). Overall, only 15% of the patients reported high adherence to medication. Discussion: This study generated evidence on OOP expenditure on diabetics in Odisha which are comparable to many Indian studies. One of the critical findings of this study was that a majority of patients visiting public hospitals had to spend OOP on medicine and diagnostic services. These findings could be used to design appropriate financing strategies to protect the interest of the poor who largely use public health facility in Odisha.
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Screen-based media use and screen time assessment among adolescents residing in an Urban Resettlement Colony in New Delhi, India p. 1236
Mahasweta Dubey, Baridalyne Nongkynrih, Sanjeev Kumar Gupta, Mani Kalaivani, Anil Kumar Goswami, Harshal Ramesh Salve
DOI:10.4103/jfmpc.jfmpc_190_18  
Background: Media forms an important part of the lives of adolescents in as much as the shows they watch on television, playing video games, as well as visiting the various websites. There is a growing concern of the influence of media on every aspect of health of children and adolescents. About 95% of the population in India has availability of television. India has limited studies which have explored the use of screen-based media (SBM) and its effect on child health. This study was conducted to assess the pattern of SBM use. Methods: A community-based cross-sectional study was conducted in an Urban Resettlement Colony, New Delhi. The study included 550 adolescents of age group from 10 to 19 years of age selected through simple random sampling from a list of adolescents residing in the area. A semi-structured interview schedule was used. Results: About 98% of the adolescents used SBM. Television formed the maximum used media (96.5%). The mean (standard deviation) of the screen time was found to be 3.8 (2.77) h/day. Out of the total screen time, time contributed by television is 2.8 h/day followed by other SBM. About 68% of adolescents reported having screen time more than the recommended (>2 h). Significant association was observed between screen time and watching television while eating [odds ratio (95% confidence interval) = 0.35 (0.22, 0.55)]. Conclusion: High proportion of adolescents use SBM for more than the recommended screen time. We should have a recommendation for maximum screen time separately for developing countries.
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Clinico-radiological characteristics and not laboratory markers are useful in diagnosing diabetic myonecrosis in Asian Indian patients with type 2 diabetes mellitus: A 10-year experience from South India p. 1243
Riddhi Das Gupta, Surjit Singh Haobam, Anish Krishna, Roshna Ramchandran, Anil Satyaraddi, Shrinath Shetty, HS Asha, Thomas V Paul, Nihal Thomas
DOI:10.4103/jfmpc.jfmpc_4_18  
Introduction: Diabetic myonecrosis or muscle infarction is an unusual complication of Type 2 Diabetes, usually associated with longstanding disease. It commonly presents as an acute non-traumatic palpable swelling of the affected muscle with predilection for the quadriceps and thigh muscles, often accompanied by retinopathy and nephropathy. Methodology: A retrospective review of the medical records of patients admitted with diabetic myonecrosis under the Department of Endocrinology, Christian Medical College Vellore over a period of ten years(2006-2015) was done. Data pertaining to clinical, biochemical and radiological characteristics were obtained and treatment modalities and outcomes were recorded. Results and Analysis: A total of n = 4 patients with diabetic myonecrosis and completed clinical data were included in the study. In our present series, the mean age at presentation was 45.5 years (±7.3 years), the mean duration of the diabetes was 9.0 years (±2.5 years)with an equal distribution of male and female subjects. The mean HbA1c (9.5 ± 0.6%) was suggestive of poor glycemic control at presentation with all (100%) the patients in our series having concomitant one or more microvascular complications. While laboratory parameters of elevated CPK or LDH were mostly normal, the findings of T1 hyperintense and T2 hypointense heterogenous lower limb lesions were present in all the subjects (n = 4). Conservative management with bed rest, analgesics and good glycemic control were effective in good clinical improvement over a period of 1-2 months. Conclusions: Our series of diabetic myonecrosis in Indian patients with Type 2 diabetes mellitus, elucidates the varied clinical presentations, with MRI findings rather than laboratory markers being the mainstay of diagnosis.
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Causes of delayed arrival with acute ischemic stroke beyond the window period of thrombolysis p. 1248
Narenraj Arulprakash, Meenakshisundaram Umaiorubahan
DOI:10.4103/jfmpc.jfmpc_122_18  
Context: Early thrombolytic therapy in acute ischemic stroke has proven to reduce the associated morbidity. Many factors are in play, delaying the arrival of patients. Aim: To ascertain the factors causing delay in patients with acute ischemic stroke presenting beyond the window period of thrombolysis in and around Chennai, Tamil Nadu, India. Subjects and Methods: An observational cross-sectional study involving 200 patients with acute ischemic stroke at Sri Ramachandra Medical College, Chennai, India between June 2015 and July 2016 was conducted. The data was collected by direct interview using a questionnaire designed to study factors such as age, family structure, residence, distance from the hospital, education status, wake-up stroke, transport, symptoms, knowledge about symptoms, seriousness of symptoms, waiting on symptoms, insurance and point of admission. Data was analyzed for means, frequencies, percentages and multiple linear regression analysis was performed to identify factors independently influencing delayed arrival. Results: Mean age of the cohort was 58.08 years: 142 men and 58 women. Mean time of delayed arrival was 13.6 hours. Multiple linear regression analysis revealed that seriousness of symptoms (P = 0.001), residence (P = 0.001), point of admission (P = 0.033) and wake-up stroke (P = 0.005) were statistically significant predictors of delayed arrival. Conclusion: Patients not perceiving their symptoms to be serious, residing in a rural area, not arriving to the emergency, and having a stroke while awake were all the significant predictors of pre-hospital delay in our study. Awareness among the masses about symptom recognition and early arrival to a tertiary care center will reduce the delay and associated morbidity. Primary care physicians notably play a significant role in educating patients at risk, identifying the symptoms of stroke and referring them for thrombolysis.
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Banji's test: A new diagnostic test of ear wax impaction p. 1253
Oyebanji A Olajuyin
DOI:10.4103/jfmpc.jfmpc_152_18  
Background: Impaction is a major clinical criterion for the treatment of ear wax. In this paper, a new diagnostic test of ear wax impaction is described with a view to improve the diagnostic accuracy of ear wax impaction. Methods: Patients with or without impaction of their ear wax were examined with the Banji's test. The test consists of a pull on the pinna and a response to sound perception. A sudden, momentary increase in sound perception following the pull is considered positive and indicates impaction. A negative response is when there is no increase in sound perception and is non-specific. Results: In all, 165 patients aged 10 to 43 years were studied. Of this, 60 (36.4%) had bilateral while 105 (63.6%) had unilateral ear wax, giving a total of 225 ears with the condition. Of the 225 ears, 132 had impaction while 93 had no impaction. Banji's test was positive in 121 and negative in 11 ears with impaction, while it was positive in 12 and negative in 81 ears without impaction. This gives a sensitivity of 91.7% and specificity of 87.1%. There was a strong correlation between the Banji's test and clinical criteria for impaction. Conclusion: With a sensitivity of 91.7%, Banji's test can accurately diagnose ear wax impaction. A positive test is predictive that removal of the ear wax will significantly relieve the patient of auditory symptoms. The test is simple, harmless, and can discriminate between wax and other causes of otological symptoms.
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Availability of infrastructure and manpower for primary health centers in a district in Andhra Pradesh, India p. 1256
Shyamkumar Sriram
DOI:10.4103/jfmpc.jfmpc_194_18  
Background: India has a vast public health infrastructure with 23,391 primary health centers (PHCs) and 145,894 subcenters providing health services to 72.2% of the country's population living in rural areas. Although the numbers look impressive, their functional status needs to be studied in terms of physical infrastructure, manpower, equipment, drugs, and other logistical supplies that are greatly needed for ensuring quality services. This work aims to study the infrastructure facilities and manpower in a sample of PHCs in the district of Nellore in the state of Andhra Pradesh in India. Methods: Randomly selected samples of 15 PHCs have been studied using structured and pretested performance standard questionnaire. Data have been analyzed with reference to the Indian Public Health Standards (IPHS) of the Government of India. Results: Many deficiencies were identified in infrastructure and manpower in the PHCs studied. Some of the important findings were that the deficiency of AYUSH medical officers was 86.6% and the deficiency of health workers (female) was 13.33%. Some of the important drugs such as antihypertensives, anticonvulsants, emergency drugs, drops, ointments, and solutions were available in less than 50% of the PHCs. Only 47% of the PHCs had Typhidot tests and H2S test strips, and in the labor rooms only 20% of the PHCs have a Standard Surgical Set for episiotomies in accordance with IPHS. Conclusion: PHCs lack the manpower and vital infrastructure that are necessary for the effective day-to-day functioning and provision of primary healthcare to the population.
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Vitamin D status among women aged 40 years and above in a rural area of West Bengal: A community-based study p. 1263
Tania Pan, Rajarshi Banerjee, Aparajita Dasgupta, Bobby Paul
DOI:10.4103/jfmpc.jfmpc_130_18  
Introduction: Vitamin D deficiency is a recognized pandemic.Even in a tropical country like India, where there is plentiful sunshine, vitamin D deficiency is widely prevalent. Adult females, particularly those above the age of 40, are mostly affected because vitamin D determines the pattern of post-menopausal bone loss and age-related osteoporosis. Methods: A community-based cross-sectional study was conducted from April–December 2017 among 194 women aged 40 years and above residing in the village of Singur, West Bengal. For this study, multistage random sampling method was used. Each respondent was interviewed using a structured schedule to collect data on sociodemographic characteristics, dietary pattern, their daily sun exposure, tobacco use, and morbidity profile. Individuals with 25OH vitamin D <30ng/ml were said to have vitamin D insufficiency (VDI). Data entry and analysis was done using SPSS version 16.0. Results: Out of 194 participants, 70.6% had VDI (Vitamin D deficient-19.6%, Vitamin D insufficient-51.0%). Mean (SD) age of the participant was 56.9 (8.9) years. Mean (SD) duration of daily sun exposure was 138.5 (59.2) minutes. 74 (38.1%) had overweight/obesity. Only 73 (37.6%) had adequate diet. Test results revealed low SES, decreasing duration of daily sun exposure, diabetes, overweight/obesity, and inadequate diet as significant predictors of VDI, explaining 39.3% of the variance with model fit. Conclusion: The study has identified factors associated with VDI among the study participants. Emphasis on promoting consumption of vitamin D rich food and with vitamin D supplements, outdoor activities to increase sun exposure, maintaining optimum body weight, and strictly adhering to diabetes control will help alleviate the problem at large.
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Determinants of acute respiratory infections among under five children in a rural area of Tamil Nadu, India p. 1268
AK Savitha, S Gopalakrishnan
DOI:10.4103/jfmpc.jfmpc_131_18  
Introduction: Acute respiratory infection (ARI) is an infection of the respiratory tract. It may interfere with normal breathing of the individual and is communicable in nature. There are several modifiable risk factors that predispose younger age group of children to ARI. The aim of this study is to evaluate the risk factors that contribute to occurrence of ARI among the under 5 children. Methods: This community based cross sectional study was carried out among 380 rural under five children in Kancheepuram district, by systematic random sampling method. A pretested structured questionnaire was used for data collection that was analyzed using SPSS software version 16. The analytical statistics such as Chi – square test, Odds Ratio, and Confidence Interval were used to determine the association of ARI with its determinants. Results: In this study, the prevalence of ARI among under five children was 41.6%.The prevalence of ARI was predominant among boys (50.6%) and those residing in semi pucca and kutcha type of house (50.3%) with poor ventilation (61.3%), history of parental smoking (57%), respiratory infection among family members (51.1%) children who did not cry immediately after birth because of any complication (60.9%), and malnourished children (66.4%). These factors contributed to increased prevalence of ARI with a statistically significant association with a P value < 0.05. Conclusion: The high prevalence of ARI in this study was contributed by multiple factors. The primary care physician can play a vital role to create awareness on hazards because of exposure to the various contributing factors by lifestyle modifications, good nutrition, and healthy and safe environment.
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Do family physicians suffer an identity crisis? A perspective of family physicians in Bangalore city p. 1274
Srividhya Raghavendran, Leeberk Raja Inbaraj
DOI:10.4103/jfmpc.jfmpc_149_18  
Background: The need of the hour in Indian healthcare is well-qualified, competent family physicians, but there is an overwhelming importance given to specialized medical care. Family physicians feel that they do not get the recognition they deserve. This study was undertaken to explore the views and perceptions of family physicians and residents about their specialty. Materials and Methods: This cross-sectional study was conducted among 110 doctors who are undergoing family medicine (FM) residency and practicing family physicians in Bangalore. The questionnaire was developed with domains on patient or family relationship, balancing breadth and depth in practice, comprehensive nature of patient care, career flexibility, and patient advocacy. Data were analyzed using SPSS version 17.0, and P value less than 0.05 was considered as statistically significant. Results: The majority of the participants (55.5%) felt that there is poor acceptance among the people about FM doctor as a specialist. A significant proportion (39.1%) of them indicated that thought of “Jack of all trades and Master of none” bothers them much. More than 90% of respondents felt a sense of pride being family physicians. FM practitioners (28.4 ± 3.1) had a good perception score when compared with residents (27 ± 3.6) (P < 0.05). There was a significant difference among FM residents and practitioners on being pride of FM physician sense of belonging to larger community FM physicians. Conclusion: FM residents go through more identity crisis when compared with practitioners. This can be addressed well by incorporating FM curriculum in undergraduate medical training and strong FM department where students have role model as mentors and take FM as specialty as their preferred choice.
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Estimation of serum prolactin levels and determination of prevalence of hyperprolactinemia in newly diagnosed cases of subclinical hypothyroidism p. 1279
Tanvi Sirohi, Harkaran Singh
DOI:10.4103/jfmpc.jfmpc_155_18  
Background: Hyperprolactinemia is a common endocrine disorder involving hypothalamic–pituitary axis. Prolactin (PRL) secretion is stimulated by dopamine antagonism and thyroid-releasing hormone. Hyperprolactinemia has been reported in subclinical hypothyroidism (SCH) but results are markedly variable and studies on SCH are very few. The objective of this study was to find out prevalence of hyperprolactinema in newly diagnosed subclinical hypothyroid patients. Materials and Methods: In this cross-sectional study, serum PRL levels of 150 newly diagnosed subclinical hypothyroid patients were determined using electrochemiluminescence method. Results: Raised PRL levels were found in 18 (%) patients with SCH. There was positive correlation between serum thyroid-stimulating hormone and PRL levels. Prevalence of infertility was significantly higher with presence of hyperprolactinemia than normoprolactinemia in subclinical hypothyroid patients. Conclusion: Routine prolactin estimation and subsequent treatment is required in patients with subclinical hypothroidism.
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Awareness of breast cancer screening and risk factors among Saudi females at family medicine department in security forces hospital, Riyadh p. 1283
Bushra Fahad Binhussien, Medhat Ghoraba
DOI:10.4103/jfmpc.jfmpc_286_18  
Objectives: To describe the level of knowledge about breast cancer screening and breast cancer risk factors according to sociodemographic characteristics and to know the most common source of their knowledge among the females participating in this study. Patients and Methods: A cross-sectional descriptive study conducted through distributing validated pretested Arabic questionnaire. The sample are Saudi adult females age 18–55 years attending the Family Medicine Department at Security Forces Hospital for healthcare services or accompanying patients. Results: Of 384 participants, 57% were aware that lump or thickening in the breast could be a sign of breast cancer and 68% knew bleeding or discharge from nipple as a warning sign of breast cancer. Fortunately, 291 women (75.8%) have a good knowledge about breast cancer risk factors, and only 93 women (24.4%) have poor knowledge. Regarding knowledge about the screening of breast cancer, 60.9% knew breast self-examination and clinical breast examination (CBE) are the methods of early detection of breast cancer. About 53.1% of women have heard about CBE. Conclusion: All the participants showed sufficient knowledge about the risk factors and symptoms of breast cancer but insufficient knowledge about screening methods. These findings are encouraging for public awareness about how to screen themselves and guidance to health authorities for developing effective breast healthcare programs in the entire Kingdom for the all-female population.
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A study of the prevalence of anemia and associated sociodemographic factors in pregnant women in Port Blair, Andaman and Nicobar Islands p. 1288
Manju Mehrotra, Seema Yadav, Archana Deshpande, Harshita Mehrotra
DOI:10.4103/jfmpc.jfmpc_139_18  
Background: Anemia in pregnant women, a significant cause of maternal and infant mortality and morbidity, has not been adequately studied in the population of Andaman and Nicobar Islands. In this regard, the study was conducted to document the prevalence and severity of anemia and its associated sociodemographic factors in pregnant women in Andaman and Nicobar Islands. Methods: The cross-sectional study was carried out at the Department of Obstetrics and Gynecology at G. B. Pant hospital over a period of 6 months. WHO guidelines were used to define and classify anemia as mild, moderate, or severe. A total of 786 pregnant women of age 12–40 years were included in the study. Data were collected by means of interviewer-administered questionnaire and complete blood count of venous blood. IBM SPSS version 21 was used for statistical analysis. Frequency tables and cross-tables were constructed. Corr elations were determined using Kendall's Tau-b, Pearson's r, and Spearman's rho coefficients. Results: Hemoglobin levels of the participants ranged from 4.4 to 15.0 g/dl. Anemia was observed in 50.9% of the sample. Prevalence and severity of anemia decreased with increasing educational levels of both husband and wife and increasing gestational age, and increased with increasing gravidity and parity. Conclusions: Awareness and education helped reduce the prevalence of anemia. Education of husband was seen to have a greater effect than education of wife. Wide coverage, systematic intervention, and disbursement of folic acid and iron supplements to pregnant women by subcenters and primary health centers prior to their visit to G. B. Pant Hospital were also effective.
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A study on awareness and utilization of Mission Indradhanush in an urban slum of Bhubaneswar p. 1294
Ipsa Mohapatra, Amit Kumar, Krishna Mishra
DOI:10.4103/jfmpc.jfmpc_146_18  
Background: India records 5 lakh child-deaths annually due to vaccine preventable diseases. As a strategic endeavor, the Ministry of Health and Family Welfare, Government of India, launched Mission Indradhanush in December 2014 to achieve more than 90% full immunization coverage by the year 2020. Objectives: To assess the awareness of the respondents about Mission Indradhanush, to assess their attitude and practices regarding childhood immunization, and to determine the association between knowledge and practice with selected variables. Materials and Methods: A cross-sectional study was undertaken from June to September 2017 among mothers with children aged 12–23 months in urban slums under field practice area of Community Medicine Department, Kalinga Institute of Medical Sciences, Bhubaneswar. Results: Mean age of the children was 17.23 ± 3.43 months; 65% were males and 35% females. Mean age of the respondents was 24.48 ± 3.97 years; 68% were literate and 94% were Hindus. Majority (76%) belonged to upper-lower Kuppuswamy socio-economic status scale. Only 10% had heard about Mission Indradhanush; health worker (90%) being the most common source of information. A total of 91% believed that vaccination prevented disease. A total of 96% believed that immunization was important for their children. A total of 73% had the maternal and child protection card with them. A total of 72% of children were fully immunized. Of the 28% partially vaccinated children, only 12.5% had heard about Mission Indradhanush. Reasons stated for partial immunization were mother too busy, child illness, and lack of information. Conclusion: Very few participants had heard about Mission Indradhanush in this study although most of them were aware of immunization services. Strengthening of Information, Education, Communication (IEC) activities regarding the program—Mission Indradhanush—needs attention. The immunization coverage was satisfactory.
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Physical accessibility audit of primary health centers for people with disabilities: An on-site assessment from Dakshina Kannada district in Southern India p. 1300
KR Nischith, M Bhargava, KM Akshaya
DOI:10.4103/jfmpc.jfmpc_177_18  
Background: Access to health care is important for persons with disability (PwD). The Government of India has launched the “Accessible India Campaign” (AIC) as a nationwide campaign for achieving universal accessibility for PwDs. Objective: To conduct an on-site assessment for physical accessibility of all primary health care centers (PHCs) of Dakshina Kannada (DK) district in Karnataka using the AIC checklist. Materials and Methods: A cross-sectional facility-based assessment of all 67 PHCs under the administrative control of the District Health and Family Welfare Office of the district was done using Physical Accessibility Audit Checklist prepared by the AIC. Ethics approval was obtained from the Institutional Ethics Committee and written permission was obtained from the District Health and Family Welfare Officer. Data were analyzed for frequencies and percentages. Results: The Accessible India Physical Accessibility Audit Checklist consists of more than116 numbers of items. Out of 67 PHCs, 57 (85%) PHCs had an accessible pathway and 60 (90%) PHCs had a ramp for wheelchair. Only 25 (36%) PHCs had accessible doors. No PHCs had height-adjustable examination table, disable friendly toilets and only two PHCs had accessible weighing scales. Conclusion: This unique on-site assessment finds that our PHCs are not well equipped for catering to PwD. To realize AIC in terms of health care access for the PwD, there is much that remains desirable at primary health care level, a point of first contact in the public health system.
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Evaluation of cardiac rehabilitation on functional capacity in depressed and nondepressed patients after angioplasty p. 1304
Habib Haybar, Teimoor Shirani, Sirous Pakseresht
DOI:10.4103/jfmpc.jfmpc_306_18  
Background: About 50% of the annual deaths in the developed countries are as a result of coronary artery disease. Several studies have shown the role of cardiac rehabilitation (CR) in improving cardiovascular indices including functional capacity, reducing depression, and mortality rates in cardiovascular patients. One of the psychological problems observed in cardiovascular patients is depression. Depression is one of the most important barriers to the treatment of heart attack, because it leads to denial of the disease and reduces the patient's motivation to continue treatment. Objectives: There are controversy information about the relationship between the effects of CR on these cases after angioplasty. The aim of this study was to evaluate the effect of CR on functional capacity in depressed and nondepressed patients after angioplasty in patients referred to Imam Khomeini, Ahvaz. Methods: This descriptive epidemiological study was performed on 54 patients referred for angioplasty. Functional capacity and depression score before and after participation in the 2-month CR program were evaluated in two groups of depressed and nondepressed patients. Data were analyzed by SPSS software, and the significance level was considered as P < 0.05. Results: The results of this study showed that in both the groups, the functional capacity after CR was significantly increased compared with the previous period (P < 0.001). Also in depressed patients, there was a significant decrease in depression scores (P < 0.001). Conclusion: Our findings showed improvement of functional capacity index following angioplasty, suggesting that patients participating in CR can be recommended by therapists. In addition, the results of this study showed that the participation in the CR program greatly affects the improvement of functional capacity and reduction in depression in patients undergoing angioplasty.
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Provision of the minimum dataset of asthma for electronic health record p. 1309
Farahnaz Sadoughi, Azade Yazdanian, Farahnaz Hamedan
DOI:10.4103/jfmpc.jfmpc_46_18  
Background: Determining the standard data elements for developing an integrated information system is of crucial importance in order to better design electronic health records system at the national level. The aim of the present study was to determine the minimum data elements of asthma for the electronic health record in Iran. Materials and Methods: The present study was an applied research that was conducted in a descriptive method. Minimum dataset (MDS) of asthma in selected countries was assessed through print and electronic literature. Data on MDS of asthma in selected countries were analyzed using comparative tables and determining the common and differentiating features of the dataset. At the validation phase of the model, frequency distribution (number and percentage), median, and quark distortion index of the questions in the questionnaire were analyzed using SPSS and Minitab software. Results: MDS of asthma was categorized into management and clinical classes. Management class had 3 subclasses (demographic, clearance, and insurance-financial) and 12 data elements, whereas clinical class had 4 subclasses (risk factors, diagnosis, treatment, and asthma education to the patient) and 22 data elements. Conclusion: The present study showed that some of the essential data elements in the MDS of other countries are needed by organizations or care providers in the country that were not collected. Therefore, a complete list of the minimum data elements set for the health electronic record was created.
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Evaluation of HbA1C and serum levels of vitamin D in diabetic patients p. 1314
Samiramiss Ghavam, Mohammad Reza Hafezi Ahmadi, Ali Davar Panah, Behrang Kazeminezhad
DOI:10.4103/jfmpc.jfmpc_73_18  
Background: Diabetes mellitus is the most common metabolic disease around the world. The present study aims at studying hemoglobin A1C (HbA1C) and vitamin D serum levels in diabetic patients. Materials and Methods: A descriptive study was conducted on 102 diabetic patients presenting to the diabetic clinic of a tertiary care hospital in West of Iran in 2016 (Shahid Mostafa Khomeini Hospital of Ilam city). The data collected were inserted into the SPSS-20 software, and it was then analyzed by using the relevant statistical tests. For describing the quantitative variables, mean and standard deviation were used. Moreover, for describing the qualitative variables, number and percentage were applied. The mean serum levels of HbA1C and vitamin D were compared for different variables using the Chi-square and ANOVA. Results: There is a positive and statistically significant relationship between the HbA1C and fasting blood sugar (FBS). Moreover, there is a statistically significant relationship between the serum level of vitamin D with smoking and body mass index (BMI). There is also an inverse linear relationship between vitamin D with HbA1C, FBS, BMI, and disease duration. The relationship between HbA1C with FBS and disease duration is a linear direct one. Their relationship between HbA1C and BMI is an inverse linear one, yet not significant. Conclusion: Given the role of this vitamin in secretion and the effect of insulin, it seems useful to monitor the serum level of vitamin D in a diabetic patient and prescribe its supplements if necessary.
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The barriers and facilitators in providing spiritual care for parents who have children suffering from cancer p. 1319
Foroozan Atashzadeh-Shoorideh, Neda Sheikh Zakaryaee, Mahdi Fani
DOI:10.4103/jfmpc.jfmpc_76_18  
Background: Given the importance of spirituality in crisis situations including life-threatening diseases such as cancer, paying due attention to this aspect of care is of great importance. This study aims to investigate the barriers and facilitators in providing spiritual care for parents who have children suffering from cancer. Methods: This study was conducted using a qualitative approach and the common content analysis method. Fifteen people who participated in the study included 11 mothers and 4 fathers. A purposive sampling method was used. The environment for the research included the oncology and hematology departments of state children's hospitals around the country. Semi-structured interviews were conducted individually. Results: Analyzing the data yielded “crossing the rocky route” as the main category in barriers to spiritual care, which included the subcategories “spiritual escape,” “lack of supporting resources,” and “family influenceability.” In addition, “multiple support” was obtained as the main category in facilitators of spiritual care, which included the subcategories “emotional support,” “healthcare support,” “social support,” “spiritual support,” and “supporting the child.” Conclusion: The results of the study showed that spirituality plays an important role in helping parents deal with and adjust to their children's disease. Therefore, it is of great importance to pay due attention to the different aspects of spiritual care and enforce factors that can act as facilitators in this area and remove the barriers to spiritual care. This aim is attainable through educating the parents and medical staff.
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Community-based rehabilitation for physically impaired earthquake victims: An evidence-based practice protocol and its pre–post experimental study p. 1327
Shambhu P Adhikari, Inosha Bimali, Sumana Baidya, Nishchal R Shakya
DOI:10.4103/jfmpc.jfmpc_112_18  
Background: A natural disaster like earthquake is a sudden event that causes not only the loss of life but also mental, emotional, and physical disabilities. An earthquake of 7.8 magnitudes hit Nepal and injured more than 18,500 people in 2015. There was a critical need to develop rehabilitation protocols. Therefore, we aimed to structure community-based rehabilitation protocols for physically impaired earthquake victims and to investigate immediate effect of the intervention to address disability and reduce public health burden. Materials and Methods: Evidence-based rehabilitation protocols for various injuries were structured to address the victims' impairments and activity limitations. The protocols were administered to 13 victims of one of the most affected community sites, for 60 min/day, 12 days in 2 weeks at their own doors. Local resources were used to make the protocols sustainable. An immediate effect of the protocols was evaluated within the group. The World Health Organization Disability Assessment Schedule, numerical pain rating scale, and time up and go (TUG) test were used to measure disability level, pain, and mobility status, respectively. Wilcoxon's signed rank test was used to analyze pre–post data. Results: All participants completed the rehabilitation without adverse effects. The treatment demonstrated significant reduction in disability level (P < 0.001, effect size = 0.63) and pain level (P = 0.007). However, change with TUG was not significant. Conclusion: The evidence-based, structured community rehabilitation protocols demonstrated benefits in improving the victim's quality of life. Follow-ups will be continued to explore sustainability and long-term effects of the interventions.
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Prevalence of goiter and associated factors among pregnant mothers residing in a district with poor socioeconomic status in Rajasthan state, India p. 1334
Jyoti Vijay, Sheel Sharma, Umesh Kapil, Ajeet Singh Bhadoria
DOI:10.4103/jfmpc.jfmpc_150_18  
Background: National survey documented that none of the Indian state is free from iodine deficiency (ID). Hence, the study was conducted with the objective to assess prevalence of goiter and associated factors among pregnant mothers (PMs) in a backward district of Indian state, Rajasthan. Methods: A cross-sectional survey was conducted during January to March 2015. Multistage random sampling was utilized to select PMs. A total of 1,183 villages were enlisted with their respective population, and 30 villages were selected using population proportionate to size sampling. Subjects were included from a cluster till the numbers reached to 17. PMs were clinically examined for goiter by palpation method. Casual urine (n = 226) and salt samples (n = 220), were collected from a subgroup of subjects, and iodine concentrations were analyzed by using wet digestion and iodometric titration methods, respectively. Results: The prevalence of goiter was found to be 14.2% (95% CI; 11.2–17.2). Goiter prevalence did not significantly differ with respect to trimesters of pregnancy (P = 0.09), iodine content in salt (P = 0.8), and urinary iodine concentrations (UIC, P = 0.69). The median UIC was 174 μg/L (IQR; 116–300 μg/L), which indicated adequate iodine intake. There was higher prevalence of goiter in PMs consuming salt with inadequate iodine than those with adequate, which was not significant (P = 0.8). Goiter prevalence was also insignificantly higher among PMs with UIC <150 μg/L than those with UIC ≥150 μg/L (P = 0.69). Conclusion: The study population is in transition phase from mild ID (goiter prevalence 14.1%) to sufficiency (median UIC 174 μg/L).
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A prospective observational study to evaluate the efficacy of facility-based management in malnourished children at NRC, district Meerut p. 1341
Swarna Rastogi, Chaitanya Maheshwari, Santosh K Raghav, Khursheed Muzammil
DOI:10.4103/jfmpc.jfmpc_157_18  
Background: Scarcity of suitable food, lack of purchasing power of the family as well as traditional beliefs and taboos about what the baby should eat, often lead to a sufficient balanced diet, resulting in malnutrition. In children, malnutrition is synonymous with growth failure. Malnourished children are shorter and weigh less than they should be for their age and height. Materials and Methods: The present study was conducted from September 2017 to November 2017.112 malnourish children, aged 6-60 months who were admitted to NRC during the study period at district hospital Meerut were assessed. Checklist based on operational guidelines on facility based management was used. Data was analyzed in Microsoft Excel and Epi info. Result: In the studied population, there were 45 males and 67 females, out of which highest representation was from the age group of 13 to 24 months.67% of studied population belonged to schedule caste. The average weight gain during the stay at the center was 9.92±5.43g/kg/day. The average duration of stay at NRC was 12.01±1.61 days. Only 30% of mothers had appropriate knowledge regarding therapeutic diet and only 50% of the mothers know about the preparation of nutritious food from locally available foods. Conclusion: Targeted supplementary nutrition and therapeutic nutrition with specific micronutrients when provided to malnourish children for 14 days by Nutrition Rehabilitation Center can be helpful to improve their nutritional status. There is need to scale up community awareness and community participation for NRCs.
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Association of non-allopathic drugs and dietary factors with chronic kidney disease: A matched case–control study in South India p. 1346
Sujiv Akkilagunta, KC Premarajan, Sreejith Parameswaran, Sitanshu Sekhar Kar
DOI:10.4103/jfmpc.jfmpc_166_18  
Background: The multifactorial etiology of chronic kidney disease (CKD) is known to vary with geographical region. Although diabetes and hypertension are the major known contributors for CKD, the role of other risk factors relevant to India needs to be explored. This study was done to find out the role of dietary factors and nonallopathic drugs in CKD. Materials and Methods: A hospital-based individual pair-matched case–control study was conducted in a tertiary care center in South India. The sample included 80 incident cases of CKD matched with 80 controls. Factors assessed in the study include sociodemographic factors, medical history, dietary factors, nonallopathic drugs, substance use, and other possible confounders. Univariate analysis was performed using McNemar's test and multivariate analysis was done using conditional logistic regression. Results: On multivariate analysis, lifetime exposure to nonallopathic drugs increased risk of CKD by approximately five times [odds ratio (OR): 5.15, confidence interval (CI): 1.27–20.87] and chicken intake (two to three times a month to once a week) had an increased risk by approximately four times (OR = 4.23, CI: 1.13–15.80). Fish intake at a frequency of two to three times or more reduced the risk of CKD by 94% (OR = 0.06, CI: 0.01–0.43). Conclusion: Chicken intake and lifetime exposure to nonallopathic drugs could increase risk for CKD in South India. Increased fish intake was found to be protective for CKD.
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Willingness to quit tobacco smoking and its correlates among Indian smokers – Findings from Global Adult Tobacco Survey India, 2009–2010 p. 1353
Mahendra M Reddy, Srikanta Kanungo, Bijaya Nanda Naik, Sitanshu Sekhar Kar
DOI:10.4103/jfmpc.jfmpc_169_18  
Background: In the stages of change model for smoking cessation, “willingness to quit” forms the starting point. Objective: To determine the prevalence and correlates of willingness to quit among smokers in India from Global Adult Tobacco Survey (GATS), 2009–2010. Methods: Secondary data analysis of GATS, 2009–10, was done to find the correlates of willingness to quit among smokers. All the sociodemographic variables, smoking-related factors such as frequency, previous attempt to quit, and also effect of antitobacco messages delivered to various media were tested for association using multivariable analysis. Results: Of 9627 current smokers analyzed, 50.9% [95% confidence interval (CI): 49.9–51.9] were willing to quit smoking. Multivariable analysis showed that younger age groups [prevalence ratio (PR): 1.31, 95% CI: 1.05–1.65], individuals who have their first smoke after 60 min of wakeup (PR: 1.19, 95% CI: 1.05–1.36), those living in a house with smoking restriction (PR: 1.29, 95% CI: 1.17–1.42), those who received advice to quit from doctor, those who attempted to quit in the past 12 months (PR: 1.28, 95% CI: 1.03–1.60), having knowledge about illness caused due to smoking, and those who have noticed antismoking messages in billboards/hoardings were willing to quit smoking compared to their counterparts (PR: 1.13, 95% CI: 1.04–1.23). Conclusion: Enforcing social restrictions like smoking restriction at house and also brief advice by doctors to quit smoking during any contact with the tobacco user could improve quit rate especially in young tobacco users and those who have attempted to quit before.
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Diagonal ear lobe crease: A premonitory diagnostic sign of impeding ischemic heart disease p. 1361
Himmatrao Saluba Bawaskar, Parag Himmatrao Bawaskar, Pramodini Himmatrao Bawaskar
DOI:10.4103/jfmpc.jfmpc_181_18  
Introduction: In India, significant number of individuals suffers from ischemic heart disease (IHD). Majority of chest pain victim initially report to his family physician. At times, sudden death is the first and last manifestation of IHD. Doctors are aware of various risk factors for IHD. The diagonal ear lobe crease (DELC) has been characterized in medical literature as a surrogate marker which can be easily identified as high-risk case for impending IHD. We report here the incidence of IHD accompanied with DELC in rural population. Patients and Methods: Eight hindered and eighty eight patients attended to general physician Mahad during January 2012 to December 2015 with complaints of chest pain were investigated for presence of DELC. Presence of DELC was correlated to varies risk factors including hypertension, hyperlipidemia, diabetes mellitus (DM), body mass index (BMI), occipital baldness, and tobacco consumption. Results: Out of patients studied, 645 (72.6%) had hypertension, 508 (57.2%) had DELC, of these 486 (95%) suffered from IHD, 246 (48%) had DM, 246 (48%) had occipital baldness, and 325 (64%) had hyperlipidemia. Significant association between BMI > 25+ in male >50 years old with odd ratio 2.08 (95% CI: 1.27–3.39; P = 0.003). Interpretation: Presence of DELC with or without risk factors is a simple clinical observation easily noted during examination by family physician to investigate and to rule out IHD.
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Malaria and dengue: Knowledge, attitude, practice, and effect of sensitization workshop among school teachers as health educators p. 1368
Vikas Kumar, Akanksha Rathi, Panna Lal, Shelesh Kumar Goel
DOI:10.4103/jfmpc.jfmpc_184_18  
Background and Objectives: Outbreaks of vector-borne diseases (VBDs) such as dengue and malaria can overwhelm health systems in resource-poor countries. Teachers can act as excellent educators by playing a key role of delivering important health education messages to school children and targeting an important health determinant – the health behavior. This study was done to assess the knowledge, attitude, and practice (KAP) of school teachers regarding VBDs and the effect of a sensitization workshop on the same. Materials and Methods: This is a cross-sectional study done on 212 school teachers to know their KAP regarding dengue and malaria. They were also exposed to an intervention workshop after the pretest, and the gain in knowledge scores was compared. Results: The mean age of respondents was 38.5 years and 57.5% of them were females. Participants had fairly good knowledge about dengue and malaria. More than 90% participants knew that mosquito bite is responsible for dengue and malaria. Around 75% of respondents were also aware of the symptoms of these diseases. The number of participants having a low, medium, and high pretest knowledge score (<50%, 50%–74%, and ≥75%, respectively) was 6.6%, 42.5%, and 50.9%, respectively. A significant improvement was seen in the knowledge score after the intervention workshop (χ2 = 23.6, P < 0.001). Conclusion: Key success for mosquito-borne diseases control depends not only on services provided by Health Authority but also on knowledge, awareness, preventive practices, and early care-seeking behavior of the community. There is a need to know and improve existing knowledge and practice regarding mosquito-borne diseases and its control in community, especially with the collaboration of school teachers as health educators.
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Incidence of nonalcoholic fatty liver disease in patients undergoing laparoscopic cholecystectomy p. 1375
Ranendra Hajong, Malaya Ranjan Dhal, Narang Naku, Buru Kapa
DOI:10.4103/jfmpc.jfmpc_193_18  
Introduction: Nonalcoholic fatty liver disease (NAFLD) includes a host of disease spectrum ranging from simple steatosis to steatohepatitis, cirrhosis liver, and even hepatocellular carcinoma. NAFLD can occur at all ages, and the highest prevalence is found in the age group of 35–55 years. NAFLD is becoming the commonest cause leading to hepatic cirrhosis, but there is no prescribed therapy for this common condition. Reduction in body weight may reverse the condition. Aim: To find the prevalence of NAFLD in a cohort of patients undergoing laparoscopic cholecystectomy in this part of the country and also to evaluate the usefulness of routine liver biopsy for the diagnosis of NAFLD. Materials and Methods: Interventional type of cross-sectional study. In all, 200 consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy, and detailed histopathological examination was done. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively. NAFLD Activity Score (NAS) was obtained for each patient. Statistical analysis was done using SPSS version 22. Results: A total of 200 patients (140 females and 60 males) were included in the study. In all, 138 patients were categorized as non-nonalcoholic steatohepatitis (NASH), 39 patients as borderline/suspicious NASH, and 23 patients had definitive NASH. A higher body mass index, weight, total cholesterol, low-density lipoprotein, alkaline phosphatise, and weight circumference were found in patients with NASH. Conclusion: The high prevalence of NAFLD in patients with gallstone disease may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possibly direct therapy.
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A cross-sectional study of practices regarding HIV/AIDS among attendees of integrated counseling and testing center at the SMS Medical College, Jaipur p. 1379
Priyanka Kapoor, Rajeev Yadav, Ravindra Kumar Manohar, Mohit Shamra
DOI:10.4103/jfmpc.jfmpc_28_18  
Introduction: This proposed study was carried out among attendees of integrated counseling and testing center (ICTC) associated with the SMS Medical College, Jaipur which included general population as well as multiple types of high-risk behavior people to determine practices about the human immunodeficiency virus (HIV) and to correlate the socio-demographic profile of attendees with their practice about HIV/AIDS. Materials and Methods: This cross-sectional study was conducted among 177 attendees at ICTC at the SMS Medical College, Jaipur from May 2015 to October 2015. Data were collected through an anonymous pre-designed semi-structured questionnaire. Continuous variables were summarized as mean and standard deviation while categorical variables as proportion (%). Chi-square test was used for the analysis of categorical variable. Stepwise multiple logistic regression analysis was done to find out predictors of practice. All statistical calculations were done by using the Med Calc. 12.2.1.0 software. Results: Most participants were male (80.79%), age group 20–29 year (44.07%), married (57.63%), Hindu (92.09%), from OBC caste (36.72%), graduate (22.6%), from urban setting (53.11%), joint family (66.67%), from socio-economic Class 1 (31.07%), and referred by doctor (61.02%). About 22% agreed that they had sexual intercourse with a person other than spouse; 8.47% agreed on having more than one sexual partner; 8.39% male respondents agreed that they had sex with men. Poor practice was prevalent in 16.38%. Gender, age, literacy, mode of referral, socio-economic class, and area of residence were found significantly associated (P < 0.05) with high-risk behavior. Literacy of respondents was found only significant predictor of practice scores in stepwise multivariate regression analysis with following regression equation – Practice score = 2.9821 + 0.3421 (Education). Conclusion: Literacy of respondents was found only significant predictor of practice scores. Government should strengthen IEC activities and ongoing HIV/AIDS education and prevention programs.
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Knowledge of knee osteoarthritis among general population in Aseer region p. 1385
Mohammed S Mukharrib, Mohammad N Al-Sharif, Turki K Alshehri, Alshehri Shaker
DOI:10.4103/jfmpc.jfmpc_290_18  
Background: Osteoarthritis (OA) is the most common articular disease of the developed country and cause of chronic disability, and may cause joint failure. OA is one of the most prevalent situation that gives rise to disability, especially in elderly population. Aim: To assess the knowledge of knee OA among general population in Aseer region. Materials and Methods: A cross-sectional survey was conducted in Aseer region including 1052 participants. The participants were included by visiting the public areas in different cities in Aseer region where many people of different social and economic level were available, and because of the the nature of Saudi community regarding home-to-home interviews. Results: The research included 1052 participants from different areas in Aseer region. The ages of participants ranged from 17 to 80 years old, with a mean age of 38 ± 12 years old. Approximately 89.0% of the sampled population had good awareness regarding preventive measures of knee OA. The second highest awareness level was recorded for relieving the measures of knee OA as 84.1% of the sampled population recorded good level of knowledge. In general, 82.6% of the population had good awareness level regarding OA in total. Conclusions and Recommendations: The current research revealed that the awareness of the general population in Aseer region regarding knee OA was more than satisfactory, especially for preventive measures, relieving measures, and its risk factors.
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Psychometric properties of the Farsi version of the women's perceptions of vaginal examination during labor questionnaire p. 1390
Samaneh Dabagh-Fekri, Leila Amiri Farahani, Fatemeh Bazarganipour, Seyedeh Batool Hasanpoor-Azghady
DOI:10.4103/jfmpc.jfmpc_75_18  
Background: Vaginal examination is the essential part of obstetric care in women's life. Although the assessment of women's perceptions of vaginal examination is important, no appropriate instrument in Farsi is available. Therefore, the present study was conducted to evaluate validity and reliability of the Farsi version of the women's perceptions of vaginal examination during labor questionnaire. Materials and Methods: This cross-sectional study was carried out with 350 women who had vaginal childbirth between December 2016 and May 2017. The women were asked to fill out the demographic characteristics' form and the women's perceptions of vaginal examination during labor questionnaire. Construct validity, internal consistency, and stability of the questionnaires were evaluated using confirmatory factor analysis, calculation of the Cronbach's alpha coefficient, and Spearman–Brown correlation coefficient, respectively. The SPSS (Statistical Package for the Social Sciences) v. 21 and LISREL (linear structural relations) 8.80 were used for the data analysis. Results: Confirmatory factor analysis indicated that the Farsi version of the women's perceptions of vaginal examination during labor questionnaire had appropriate structure. The Cronbach's alpha coefficient of the questionnaire was reported as 0.76. The Spearman–Brown correlation coefficient also showed an appropriate test–retest reliability. Conclusion: Validity and reliability of this questionnaire can appropriately measure the women's perceptions of vaginal examination during labor among Iranian women.
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Intestinal parasitic infestations and anemia among urban female school children in Kancheepuram district, Tamil Nadu p. 1395
S Gopalakrishnan, V M. Anantha Eashwar, M Muthulakshmi, A Geetha
DOI:10.4103/jfmpc.jfmpc_89_18  
Introduction: In India, intestinal parasitic infection and anemia remain the most important cause of morbidity especially among the adolescent school children due to lack of awareness of personal hygiene practices, leading to intestinal parasite infections which could in turn lead to anemia. Aim: This study was conducted with the aim to find out the prevalence of intestinal parasitic infection and anemia among adolescent female school children in an urban area of Tamil Nadu. Materials and Method: This descriptive cross-sectional study was done among adolescent female school children in Anakaputhur area of Kancheepuram district. Three schools were selected randomly from a total of eight schools in the study area. Universal sampling was applied in each school, and a total of 250 willing children participated in the study. Early morning stool specimen was collected for microscopic examination and hemoglobin estimation was done. A pretested structured questionnaire was used to collect relevant data which were analyzed using SPSS version 22. Results: The prevalence of intestinal parasitic infection was found to be 36% with Entamoeba histolytica being the commonly isolated organism (23.2%) followed by Giardia intestinalis (5.2%), Hookworm (4.4%), and Ascaris lumbricoides (3.2%). The prevalence of anemia among them was found to be 84.8% with mild, moderate, and severe anemia being 12.8%, 46.8%, and 25.2%, respectively. Statistically significant association was found between intestinal parasitic infection and open field defecation, inadequate hand washing practices, and anemia. Conclusion: The study reveals high prevalence of anemia and intestinal parasitic infection among female school children. Preventive measures such as periodic deworming and health education about nutritional balanced diet, iron supplements, and personal hygiene practices have to be given to both the parents and their children to prevent and reduce disease burden.
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Screening for diabetes among tuberculosis patients registered under revised national tuberculosis control program, Bhopal, India p. 1401
Vivek Nagar, Pankaj Prasad, Devendra Gour, Akash R Singh, DK Pal
DOI:10.4103/jfmpc.jfmpc_14_18  
Context: Tuberculosis (TB) and diabetes mellitus (DM) remain a global public health problem. India has the largest number of TB cases; in 2015, out of total global annual incidence of 9.6 million TB cases, 2.2 million were estimated from India. There are 62.4 million people with type 2 diabetes and 77 million people with prediabetes in India, and these numbers are projected to increase to 101 million by the year 2030. Diabetes and TB affect each other at many levels. Screening for diabetes in patients with TB will not only help in early case detection but also better management of both comorbidities. Aims: (i) To determine the prevalence of diabetes and prediabetes among diagnosed cases of TB registered under RNTCP in Bhopal district. (ii) To determine additional yield of previously unknown DM and the number needed to screen (NNS) to find out a new case of DM. (iii) To find out the factors associated with diabetes among patients diagnosed with TB registered under RNTCP in Bhopal district. Settings and Design: This study was a cross-sectional study conducted on registered patients with TB under RNTCP in two TB units of Bhopal district. Materials and Methods: Participants were contacted and interview was conducted after obtaining consent using predesigned and pretested performa during the period of 1st October 2014 to 30th March 2015 for a period of 6 months. Statistical Analysis Used: Continuous variable were summarized as frequency, mean, and standard deviation. All variables were analyzed using Chi-square test of significance; P < 0.05 was taken as statically significant. Result: Of the total 528 patients with TB, 296 was male and 232 were female. Of the total, 63 (11.9%) patients were diagnosed as diabetic. NNS to diagnose a new case of DM was 22.1. Significant association was found with six variables which are age, sex, body mass index, type of TB, category of TB, and smoking. Conclusion: This study shows feasibility and importance of screening of patients with TB in existing program settings.
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Tobacco: Consumption pattern and risk factors in selected areas of Shillong, Meghalaya p. 1406
Himashree Bhattacharyya, Star Pala, GK Medhi, A Sarkar, Debjit Roy
DOI:10.4103/jfmpc.jfmpc_140_18  
Background: The percentage of adults above 15 years who consume tobacco in Meghalaya as per the Global Adult Tobacco survey is 55.2%. Aim: In the context of the high burden of tobacco use in Meghalaya, this study aims to study the consumption pattern and the sociodemographic correlates of tobacco use in the urban slums of Shillong, Meghalaya. Materials and Methods: This study is a cross-sectional study conducted in adults over 15 years of age. Data collection was done by personal interview using a pretested questionnaire during house-to-house visit after taking informed verbal consent. Results: A total of 400 people were included in this study. Most of the study population belonged to the age group 15–24 years (120, 30%). The majority of the study population (322, 80.5%) were aware of the health hazards of tobacco consumption. Most of the population (287, 71.75%) were tobacco consumers with 265 (76.4%) of them having co-addictions. In the study, 35% consumed smokeless forms, 30% were into smoking, and 35% consumed both forms. A significant association was observed between the status of tobacco consumption and knowledge of second-hand smoke harm (P = 0.019) as well as knowledge of any law regulating tobacco consumption (P = 0.026). Conclusion: It was observed that despite having a basic knowledge of the ill effects of tobacco, its consumption is still widely prevalent in the region. There is a need for stringent laws regarding tobacco consumption and proper measures should be taken to enforce these laws.
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Dietary calcium intake and physical activity levels among people living in Karnataka, India – An observational hospital-based study p. 1411
Jeffrey Pradeep Raj, Shreeraam Venkatachalam, Mahesh Shekoba, Joshua Jonathan Norris, Rajkumar S Amaravati
DOI:10.4103/jfmpc.jfmpc_153_18  
Background: Calcium is the most abundant mineral in our body with varied functions, and its dietary deficiency leads to osteoporosis. Various studies have shown that adequate dietary calcium intake (DCI) and moderately increased physical activity if maintained for long term prevent osteoporosis. The data regarding DCI of people living in Karnataka, south India, are limited. Thus, we aimed to assess DCI, physical activity, and their predictors among people living in Karnataka. Methodology: A cross-sectional study was done among 250 inpatients and normal relatives of orthopedics department of a tertiary care teaching hospital. Multistage random sampling was performed. DCI and physical activity were measured using validated questionnaires. Results: The mean (standard deviation) DCI was 499.94 (251.5). The prevalence [95 confidence interval (CI)] of poor intakers of DCI [DCI < Recommended Dietary Allowance (RDA)] was 76.6% (70.9, 81.7). However, only 43.52% of all participants with poor DCI were on supplements. Male gender [2.189 (1.125, 4.257)], elderly [1.988 (1.067, 3.705)], and low knowledge score [1.240 (1.093, 1.407)] were significant predictors of low DCI. The proportion (95 CI) of patients who were categorized as having low physical activity (LPA) was 44.0% (37.8, 50.4). The predictors for LPA [adjusted odds ratio (95 CI)] were marital status, being single [1.853 (1.047, 3.282)], and low socioeconomic status class [1.209 (1.002, 1.458)]. Conclusion: DCI was below the RDA for three-fourths of our patients with nearly half of them being physically inactive, indicating the need for better education regarding DCI and improving physical activity, all of which can prevent osteoporosis.
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Double burden of malnutrition among school-going adolescent girls in North India: A cross-sectional study p. 1417
Siraj Ahmad, Nirpal Kaur Shukla, Jai Vir Singh, Ram Shukla, Mukesh Shukla
DOI:10.4103/jfmpc.jfmpc_185_18  
Context: Double burden of malnutrition comprising both undernutrition and overnutrition is nowadays emerging as a major public health concern among adolescent girls in India. Aim: The present study was conducted to determine the prevalence of underweight, overweight, and obesity among school-going adolescent girls along with dietary and physical activity-related factors associated with them. Settings and Design: The present cross-sectional survey was conducted among 2400 school-going adolescent girls (10–19 years) in Barabanki district of Uttar Pradesh. Subjects and Methods: Multistage sampling technique was used for enrolment of the study subjects. Data were collected on sociodemographic profile, physical activity, dietary intake, and anthropometry. WHO body mass index (BMI)-for-age cutoff classification of girls was used for assessment of underweight, overweight, and obesity. Statistical Analysis Used: Statistical analysis was done with the Epi Info software. Multinomial logistic regression analysis was used to ascertain various predictors of underweight, overweight, and obesity among adolescent females (P < 0.05 was considered as significant). Results: The proportion of underweight, overweight, and obese students were 47.0%, 5.9%, and 2.7%, respectively. The girls in mid and late adolescent age group were significantly less susceptible for being underweight for age (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.22–0.36; P = 0.00). The girls belonging to middle and upper socioeconomic strata were about 35 times more susceptible toward obesity (OR 35.12; 95% CI 13.33–92.49; P = 0.00) and 12 times more susceptible toward being overweight (OR 12.46; 95% CI 13.33–92.49; P = 0.00) as compared to those in lower income groups. The probability of overweight and obesity were about 3 times (OR 3.13; 95% CI 1.76–5.55; P = 0.00) and 10 times (OR 9.66; 95% CI 4.00–23.35; P = 0.00) higher among adolescent girls who reside in urban areas as compared to rural one. Apart from these, non-Hindu religion, nuclear type of family, parent's education profile of middle school and above, and engagement in physical activities more than 2 h a day were other factors found to be directly associated with increased chances of overweight/obesity (OR > 1; P < 0.05). Conclusions: The high prevalence of the double burden of malnutrition revealed the need of the hour to modify and strengthen the existing adolescent health programs of India so as to deal with both the facets of nutrition spectrum substantially.
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Decreasing trend of seroprevalence of leptospirosis at All India Institute of Medical Sciences New Delhi: 2014–2018 p. 1425
Sonu Kumari Agrawal, Rama Chaudhry, Nitin Gupta, Nazneen Arif, Tej Bhadur
DOI:10.4103/jfmpc.jfmpc_198_18  
Background: Leptospirosis is an important emerging public health problem in India. There is limited information regarding the seroprevalence of leptospirosis in population from northern states of India. This study reports result of a 4-year-retrospective sero-epidemiological survey of leptospirosis conducted in a teaching tertiary care hospital in New Delhi, India. The aim of our study was to explore seroprevalence and clinical pattern of disease occurrence in suspected cases of leptospirosis and to search for any co-existing infections in northern areas such as New Delhi, India. Methods: The patients with clinically suspected leptospirosis who attended outpatient or admitted to the Departments of Medicine, Gastroenterology, Pediatrics and Neurology, etc. of our hospital were retrospectively analyzed. The qualitative determination of anti-leptospira-specific immunoglobulin (IgM) antibodies was carried out using commercially available enzyme-linked immunosorbent assay (ELISA) kit (Panbio Diagnostics, Brisbane, Australia). Results: Of these 1545 patients, 6.47% (100/1545) were seropositive for anti-leptospira-specific immunoglobulin (IgM) antibodies. Using modified Faine's criteria, a diagnosis of presumptive and possible leptospirosis was made in 79/100 (79%) and 21/100 (21%) patients. Significant declining trend of seroprevalence rate of leptospirosis from 26.90% in 2000–2010 and 20% in 2011–2014 to 6.47% in 2014–2018 (P value <0.05) in our referral tertiary care center. Seventeen patients showed co-infection with other common pathogen prevailing locally. Conclusion: There is a need to increase awareness among public and clinicians, however, more region/province-wise studies on seroprevalence of leptospirosis are required to improve our understanding of the actual burden.
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Prevalence of malnutrition and its associated factors among elderly population in rural Puducherry using mini-nutritional assessment questionnaire p. 1429
Yuvaraj Krishnamoorthy, M Vijayageetha, S Ganesh Kumar, Sathish Rajaa, Tanveer Rehman
DOI:10.4103/jfmpc.jfmpc_22_18  
Background: Nutritional status of the elderly population has become an important issue but often gets neglected. Both undernutrition and over nutrition are important public health priorities in this vulnerable group. Objectives: To determine the prevalence of malnutrition and factors associated with it among elderly population in rural Puducherry using mini-nutritional assessment (MNA) questionnaire. Materials and Methods: A community-based cross-sectional study was conducted among 279 elderly population between November and December 2016 in four villages of rural Puducherry, India. Information on sociodemographic characteristics and nutritional status of the elderlies were collected using validated MNA questionnaire. Body mass index was used to report obesity based on Asia-Pacific guidelines. Results: Among 279 participants, 178 (63.8%) were in the age group of 60–70 years, 190 (68.1%) were females, and 208 (74.6%) had no formal-education. Prevalence of malnutrition among elderly was found to be 17.9% (95% CI: 13.7–22.7) and about 58.8% (95% CI: 52.9–64.4) were at risk of malnutrition which was assessed using MNA questionnaire. Prevalence of obesity was found to be 32.5% (95% CI: 27.3–38.3) and 38.4% had inadequate fruits and vegetables intake. About 250 (89.6%) are living independently according to ADL score. Conclusion: Both undernutrition and over nutrition are important health issues to be considered among elderly population in this area. Primary healthcare strengthening to address and prevent this health issue by balanced dietary practices may improve their nutritional status, thereby enhancing their quality of life.
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Heme-bound iron in treatment of pregnancy-associated iron deficiency anemia p. 1434
Ibrahim A Abdelazim, Mohannad Abu-Faza, Svetlana Shikanova, Gulmira Zhurabekova, Manal M Maghrabi
DOI:10.4103/jfmpc.jfmpc_271_18  
Background: The iron requirements increase during the second and third trimesters of pregnancy. Maternal anemia is a leading cause of adverse perinatal outcome. Objectives: This study was designed to evaluate the efficacy of the heme-bound iron in treatment of pregnancy-associated iron deficiency anemia (IDA). Materials and Methods: In all, 122 women with IDA during pregnancy and hemoglobin ≤10 g/dL were studied. The studied women were treated with heme-bound iron tablets for ≥3 months. Pretreatment hemoglobin, ferritin, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) were compared with the posttreatment values to detect the efficacy of heme-bound iron (Optifer®) in treatment of IDA during pregnancy. Results: The mean pretreatment hemoglobin significantly increased from 8.4 ± 2.7 to 11.2 ± 2.1 g/dL and the mean pretreatment ferritin level significantly increased from 22.6 ± 5.6 to 112.8 ± 4.8 μg/L (P < 0.003 and 0.04; respectively) 3 months after heme-bound iron treatment. In addition, the mean pretreatment red blood cells' MCV and MCH significantly increased from 74.2 ± 4.8 fL and 24.2 ± 7.8 pg, respectively, to 92.0 ± 4.1 fL and 32.6 ± 6.2 pg) (P = 0.04 and 0.007, respectively) 3 months after heme-bound iron treatment. Conclusion: Heme-bound iron (Optifer®) is an effective oral iron preparation to treat IDA during pregnancy and to replace the depleted iron store.
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Menstrual hygiene among adolescent girls – A study from urban slum area p. 1439
Tanvi Nitin Deshpande, Supriya Satish Patil, Supriti Balaram Gharai, SR Patil, PM Durgawale
DOI:10.4103/jfmpc.jfmpc_80_18  
Background: Adolescence has been recognized as a special period that requires specific attention as it marks the onset of menarche, an important milestone, and hence good hygienic practices during menstruation are crucial to maintain a healthy life. Aims and Objectives: This study was planned to assess knowledge, beliefs, and source of information regarding menstruation, and also to assess hygiene among them. Materials and Method: A cross-sectional study was carried out in urban slum area. Data were collected using pre-tested proforma during the period of 1st June to 31th August 2017. Among the 100 adolescent girls, 72% were between 15 and 19 years. A maximum of 47% were having high school education. About 47% mothers were illiterate; 27% girls had menarche at 14 years and 82% had regular cycles. About 76% had no knowledge of menses before menarche. The source of information was mother in 84%. Only 16% girls commented that bleeding initiated in uterus. About 60% girls used sanitary pad and the rest used cloth pieces. About 22% used water and no soap for hand washing. Multiple restrictions were practiced. Conclusion: This study reported that menstrual hygiene was unsatisfactory among adolescent girls. Therefore, girls should be educated about the facts of menstruation and proper hygienic practices.
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Exercise prescriptions given by GPs to sedentary patients attending chronic disease clinics in health centres – The effect of a very brief intervention to change exercise behavior p. 1446
Terence Babwah, Vishalla Roopchan, Binta Baptiste, Azzim Ali, Krystle Dwarika
DOI:10.4103/jfmpc.jfmpc_84_18  
Aim: To determine the effect of a very brief structured exercise prescription given by general practitioners (GPs) to sedentary patients attending chronic disease clinics in a primary care setting lead them to begin exercising. Materials and Methods: One hundred and six patients of the intervention (INV) group were counselled for 1–2 minutes individually about a benefit of regular exercise after which a written exercise prescription was provided by the GP. The 110 patients in the control (CON) group received usual care given to patients attending health centres. The patients in both groups were called at both one month (T1), and three months (T3) post intervention, respectively where they were interviewed about their current exercise habits. Results: At T1, 84/106 (79.2%) of INV vs. 34 (30.9%) of CON were exercising and at T3, 79/106 (74.5%) of INV vs 19/110 (17.4%) of CON were exercising at least one time weekly (P < 0.0005). Greater than 90% of patients who began exercising “agreed/strongly agreed” that the doctors' advice was “important to start exercising.” Conclusion: The brief intervention seemed to be more effective than regular care in getting patients to begin exercising at 1 month and 3 months post intervention than regular care. The intervention was well received by most of the patients receiving the intervention.
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Prevalence of bronchial asthma and its associated risk factors in school-going adolescents in Tier-III North Indian City p. 1452
Kapil Bhalla, Deepak Nehra, Sanjeev Nanda, Ramesh Verma, Ashish Gupta, Shuchi Mehra
DOI:10.4103/jfmpc.jfmpc_117_18  
Background: Asthma is one of the most common chronic diseases of childhood and a major health problem not only in India but globally. Despite multifold increase in prevalence, there is paucity of data on bronchial asthma from non-metro cities. The objectives were to find prevalence of bronchial asthma and various risk factors that are associated in this age group and determine the extent of under diagnosis. Materials and Methods: A cross-sectional study involving 927 students from four government and three private schools was conducted using International Study of Asthma and Allergies in Childhood questionnaire. Results: Prevalence of bronchial asthma in adolescents was 13.1% (n = 121) of which 10.3% had episodes in the past 1 year. Prevalence was higher among males (8.77%) compared to females (4.33%). About 77.7% of total asthmatics were newly diagnosed cases. Prevalence was significantly higher among those having pets at home (P < 0.001), belonging to higher socioeconomic status (P = 0.021), using smoke-producing fuel at home (firewood/cow dung/kerosene; P = 0.032), and with history of smoking among family members (P = 0.035). Among current asthmatics, 72.3% reported cold/rhinitis (54.6% in March–May duration), 63.6% nocturnal dry cough, 50.5% sleep disturbances, and 38.9% speech disturbances in the past 1 year. Conclusion: The study shows higher prevalence of bronchial asthma in school-going population (11–16 years) compared to other parts of Northern India possibly attributable to rapid industrialization and post harvesting season when the study was carried out. Preventive interventions need to be taken to reduce disease burden at community level.
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Workplace-based assessment of family medicine competencies using “field note tool” – A pilot study p. 1458
Asha E Mathew, Yeshvanth Kumar, Ruby P Angeline, Prince Christopher, Sajitha P Rehman, S Venkatesan
DOI:10.4103/jfmpc.jfmpc_141_18  
Background: Department of Family Medicine in a medical college in South India introduced “field note” (FN) as a tool for Work-Place Based Assessment in postgraduate training. FN collects “open-ended” feedback from both resident and faculty and helps them to arrive at an action plan. This study describes our experience of implementing FN and perceptions of learners and faculty. Methods: While precepting the residents in Family Medicine service areas, faculty documented their observations of the resident's clinical work using FN and provided an action plan. Faculty and residents described their experience and provided feedback. Focus group discussions were conducted for faculty and residents. Data were coded and grouped into themes. Results: Four residents and seven faculties participated in the study during 12 weeks period using 17 consultations. Clinical expert (13/17) and communicator (6/17) are the most commonly assessed competencies followed by professionalism (2/17) and collaborator (2/17). Faculty and residents agreed that “FN” was a useful tool and it helped the faculty to give feedback and guide the learner. Residents and faculty arrived at an action plan in 70% of the consultations. Three of four residents perceived the change in their behaviour positively after the use of FN. Both resident and faculty found the rating of the learner using Dreyfus scale as a barrier. Conclusion: FN could be one of the important tools in our “Toolbox of Assessment Methods” for family medicine specialty. There is a need for sensitizing the learners to feedback process and training the faculty in assessment and feedback.
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Dietary habits amongst medical students: An institution-based study p. 1464
Nupura A Vibhute, Rajendra Baad, Uzma Belgaumi, Vidya Kadashetti, Sushma Bommanavar, Wasim Kamate
DOI:10.4103/jfmpc.jfmpc_154_18  
Introduction: In recent times, with the increasing burden caused by the lifestyle diseases on the health sector, there has been a renewed interest in the relationship between food and health. Research regarding nutritional status in college students in western Maharashtra, India, has been found lacking. Therefore, this study was undertaken to ascertain the dietary habits in the undergraduate students of a health institute. Materials and Methods: This questionnaire-based study was conducted amongst 130 students from a health university regarding their dietary attitudes and lifestyle practices. The students had the option of choosing more than one answer based on the nature of the question. All the data were tabulated and relevant inferences were drawn. Results: A total of 130 students comprising 74 girls and 56 boys from a health university participated in the study. Daily consumption of fruits and vegetables was only 1–2 portions for 98 (75%) of the participating students. Twenty-four (18%) participants were noted to be underweight and 11 (8%) students were either overweight or obese. Conclusion: Thus, the findings of the study indicate that the diet and nutritional aspects of our future medical health professionals should be researched in further details and timely interventions initiated for ensuring the knowledge and practice of the WHO principles regarding the same to be incorporated.
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Attitudes and barriers toward the presence of husbands with their wives in the delivery room during childbirth in Riyadh, Saudi Arabia p. 1467
Ashwaq Awadh Alharbi, Abdulaziz Alhomaidi Alodhayani, Moudi Stam Aldegether, Mohammed Ali Batais, Turky Hamad Almigbal, Nada Abdulaziz Alyousefi
DOI:10.4103/jfmpc.jfmpc_170_18  
Objectives: The objective of the study is to assess the husbands' attitudes toward their presence with their wives during childbirth in the delivery room and to determine the barriers that prevent their presence. Methods: A cross-sectional study was conducted at two tertiary hospitals in Riyadh. Data were collected from a total of 250 husbands whom were selected randomly in the waiting areas of the delivery rooms and asked to participate in this study by filling a questionnaire after giving informed consent; data were collected during the period between December 2016 and April 2017. Results: The majority (95.6%) were Saudi and had only one wife. The positive mean score for the attitude increased significantly with increasing educational level (P < 0.01). The highest positive attitude was mainly for the item “It is calming for the mother.” Conversely, the highest negatively scored item was “my presence with my wife in the delivery room is insulting to my manhood” and “our culture is against a husband attending his wife's childbirth” (1.91 ± 1.12). The hospital system and not having a private room for their wives were the most identified barriers to the husband's presence in the delivery room. Conclusions: Increased level of education has better outcomes on husbands' attitudes toward supporting their wives in the delivery room. Authors recommend flexible hospital policies to support husbands' presences with their wives in the delivery room and provide privacy for them during childbirth, such will provide psychosocial support to the wife, and it is an important part in transition to a mother-friendly hospitals.
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Geriatric club attached to a primary care hospital as an effort to physically, socially, and mentally engage elderly: A case study from Kerala, India p. 1476
Lakshmi Premnazir, Arun S Nair, Sujith Suji, Amrita M Das, S Divyamol, PS Rakesh
DOI:10.4103/jfmpc.jfmpc_172_18  
Introduction: Ageing leads to physiological, social and mental changes. The case study shares experiences about the development and evolution of a 'geriatric club' attached to a primary health centre in Kerala, India and the early outcomes noticed among the members of the geriatric club. Process: This club, established three years before, has become an ongoing self-sustainable organisation helping senior citizens to socialise with their peers. Meeting on a regular day every week at the health centre, with programs varying from discussions on health issues to entertainments like music, dance, festival celebration and film shows, the club has become part of all elderly patients in and around the health centre. Outcome: Outcome of the club was looked qualitatively and quantitatively through Focus Group Discussions and before and after comparison of Mini Mental Status Examination Scores and Geriatric Depression Scale scores of elderly club members. FGDs concluded that members were benefitted through participation in the club and the club activities helped them to get engaged physically, mentally and socially. Mean GDS scores of the participants decreased from baseline [5.43, SE 0.76] to after six months [5.20, SE 0.74] (P 0.006). Mean MMSE scores showed improvement from baseline [22.26, SE 0.69] to after six months [24.80, SE 0.81] (P 0.001). Conclusion: Geriatric social clubs attached to primary health care hospitals with suitable contextual adaptations can engage elderly patients physically, mentally and socially. It is hypothesised that such activities can have positive impact on depression and cognitive improvement.
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Male medical students' perception of plastic surgery and its relationship with their cultural factors p. 1482
Khalid Ali Fayi, Mohammad Nassir Al-Sharif, Abdulsalam Ali Alobaidi, Mohammed Abdullah Alqarni, Mohammed Hasen Alghamdi, Bassel Ali Alqahatani
DOI:10.4103/jfmpc.jfmpc_180_18  
Objectives: This study is an attempt to establish the knowledge of the medical students on the specialty of plastic surgery, in addition, to know their opinions about its relationship with their cultural factors. Patients and Methods: This is a cross-sectional study; participants invited randomly from the college of medicine at King Khaled University to fill a questionnaire consisted of 20 questions regarding the basic knowledge, attitude, perception, and understanding of plastic surgery and its subspecialties. Results: Medical student participated in our study; their perception towards plastic surgery specialty was positive as they believed that this is a specialty as any other medical specialties; Out of 201 (45.6%), 81 (18.4%) assured plastic surgery is a good specialty. The biggest concerns about joining to cosmetic surgery were a difficulty of accepting in this specialty (34.9%). There is a significant relationship between the plastic surgery and cultural factors (P < 0.05). On other hand, there is no significant relation between choosing plastic surgery specialist among medical students and community overview about plastic surgery specialty (P = 0.15). Conclusion: Despite the confession of the importance of plastic surgery between Saudi medical students, a large portion of them refuses plastic surgeons due to cultural factors. Increasing knowledge of plastic surgery subspecialties deserves attention.
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Prevalence and associated risk factors of female sexual dysfunction among Jordanian women p. 1488
Maher Elias Maaita, Basel M Khreisat, Omar A Tasso, Nareman Naser Otom, Bayan M Aljaafreh, Gharam M Abuassaf
DOI:10.4103/jfmpc.jfmpc_200_18  
Background: Female sexual dysfunction (FSD) and the associated risk factors are less studied in the Middle East. This study is designed to determine the prevalence of FSD and its associated risk factors in Jordan. Materials and Methods: A group of women were interviewed using detailed questionnaire on several aspects of FSD including desire, arousal, lubrication, orgasm, satisfaction, and pain disorders. They underwent sociodemographic investigation. Prevalence and risk factors of FSD are calculated in different age groups. Results: A total of 470 women aged 32.6 ± 9.6 years are included in this study. Desire problems were detected in 49.4% (232/470) of the studied women, while an arousal problem in 31.9% (150/470) and lubrication problem in 39.2% (184/470). An orgasm problem was detected in 39.57% (186/470) of the studied women, while satisfaction problem was detected in 43.82% (206/470) and pain problem during sexual relation in 19.2% (90/470). There was positive significant correlation between each domain of the FSD and the studied women's age except pain. FSD was found to be significant in women with more than four children (83.3%, P < 0.02), those who had been married for more than 10 years (76.7%, P < 0.02), in women with chronic medical diseases (76.7%, P < 0.02), in unemployed women (76.7%, P < 0.02), and in women not using contraception (75.2%, P < 0.005). There was no significant correlation with the level of education (P < 0.34) and monthly income (P < 0.24). Conclusion: The prevalence of FSD in Jordan is about 64.7%, the desire disorders are the most prevalent domain of FSD, and age is the most significant risk factor for FSD. Further research is needed with larger and more comprehensive sample to estimate the magnitude of FSD and to confirm its relationship with different risk factors.
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Awareness of basic life support and cardiopulmonary resuscitation among female secondary school students in government schools in Riyadh city, KSA p. 1493
Nouf Al Harbi, Ayman Afifi, Mohammed Alateeq, Ayla Tourkmani, Turki Alharbi, Saad Albattal
DOI:10.4103/jfmpc.jfmpc_21_18  
Background and Objective: Basic life support (BLS) and cardiopulmonary resuscitation (CPR) are urgently required and must be performed when cardiac arrest occurs. These lifesaving procedures must be learned by healthcare professionals. In developed countries, members of the public, academics, and students learn how to carry out these emergency procedures. Knowledge of these simple procedures determines successful outcome. This study was conducted to determine the level of awareness of BLS and CPR among female secondary students at governmental schools in Riyadh city, Saudi Arabia (SA). Methods: This cross-sectional study was conducted in five governmental secondary schools in Riyadh city, SA, between June 2015 and June 2016. Total of 1224 female students were selected randomly, and data were collected using a self-reported structured questionnaire. Results: A total of 1170 participants completed the questionnaire. Most of the participants (81.5%) were Saudis. More than 50% of the students (54.8%) did not have information about BLS, and 82.6% felt their knowledge about BLS was insufficient. Only 10.8% of the participants had taken a BLS course, and only 38.5% believe BLS courses should be mandatory. Conclusion: The level of awareness regarding BLS among female secondary school students in governmental schools in Riyadh was found to be insufficient. The introduction of BLS and CPR courses in the curriculum of governmental secondary schools in Riyadh city is highly recommended.
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The clinical value of the apparent diffusion coefficient of liver magnetic resonance images in patients with liver fibrosis compared to healthy subjects p. 1501
Mehdi Shayesteh, Ali Akbar Shayesteh, Azim Motamedfar, Morteza Tahmasebi, Shahram Bagheri, Mohammad Momen Gharibvand
DOI:10.4103/jfmpc.jfmpc_299_18  
Background: Fibrotic tissue forms following chronic inflammation in the liver, which may progress over time to cirrhosis. Liver biopsy is the gold standard for the diagnosis of liver fibrosis, and there has been a considerable interest in developing noninvasive methods. Objectives: In the present study, we evaluated the efficacy of the apparent diffusion coefficient (ADC) of the liver in the diagnosis and staging of liver fibrosis. Patients and Methods: This case–control study was conducted on 40 patients with chronic liver disease and 31 healthy controls who were subjected to diffusion-weighted magnetic resonance imaging (MRI). Diagnostic values for different stages of fibrosis were determined using receiver-operating characteristic (ROC) curves based on the sensitivity and specificity. Results: Of 37 patients in the case group, 12 were males (32.4%) and 25 (67.5%) were females, whereas in the control group of 31 patients, 11 were males (35.5%) and 20 (64.5%) were females. In the ROC analysis, area under the curve separating stage one or lower fibrosis from stage two or greater fibrosis groups with a b-value of 600 s/mm2 was 0.893 (98% confidence interval (CI): 0.795–0.955), and that with a b-value of 1000 s/mm2 was 0.946 (98% CI: 0.813–0.946). Conclusion: Our results are in line with the previous studies, which showed that liver ADC values could be considered as a method for the diagnosis and staging of liver fibrosis.
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Lessons learnt from the Indian H1N1 (swine flu) epidemic: Predictors of outcome based on epidemiological and clinical profile p. 1506
RM Kshatriya, NV Khara, Jaishree Ganjiwale, SD Lote, SN Patel, RP Paliwal
DOI:10.4103/jfmpc.jfmpc_38_18  
Introduction: Influenza A (H1N1) virus has caused serious respiratory illness (swine flu) and death over the years. The first confirmed case of swine flu H1N1 in India was documented in May 2009, but huge numbers of cases were reported thereafter. In 2015, swine flu outbreak in India had led to significant morbidity and mortality. Objective: to study details of swine flu patients admitted in a rural tertiary care center in western India in 2015 and to identify predictors of mortality. Methodology: Retrospective data of swine flu cases admitted at a tertiary care teaching hospital in 2015 and their outcome as either cured or expired was recorded. Result: Out of 65 confirmed cases of severe swine flu that required hospitalization, 40(61%) were male. 55 of 65 (84.61%) patients [mean (SD) age: 50(15)] were cured while 10 patients [mean (SD) age 51(15)] expired. Overall mean (SD) age was 50.23(15) years with average (SD) days of hospitalization were 6.32(3.3) days. The commonest symptoms were cough (100%) followed by throat pain (96.9%), common-cold, fever (93.8%), and breathlessness (83.1%). 40% of patients needed non invasive ventilator support while 16.9% patient required invasive ventilator. Mean temperature on presentation was (99.96'F), RR (25.89/min), SpO2 on room air was 82.06%. Average White Blood Cells were 8274/mm3 with neutrophils were 79.58%. Mean procalcitonin was 0.83 ng/ml. It was found through univariate analysis that sputum production (P = 0.013), chest pain (P = 0.04), Respiratory Rate (P = 0.013), SpO2 on presentation at room air (P = 0.001), Days of non invasive ventilator (P = 0.001), intubation and invasive ventilator (P = 0.001) were statistically significantly associated with outcome but through multivariate analysis it was revealed that only requirement of intubation (invasive ventilator) was significantly predicting mortality(Odds ratio=234) (P = 0.0001). Conclusion: Requirement of intubation was associated with poor outcome.
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Cold chain maintenance in Rajnandgaon and Bilaspur districts of Chhattisgarh: A process evaluation p. 1510
Harshal Mendhe, Kiran Makade, Dhiraj Bhawanani, Rohit David, Nitin Kamble, Daneshwar Singh, Monika Dengani
DOI:10.4103/jfmpc.jfmpc_128_18  
Background: Cold chain and vaccine logistic is a key driver of immunization program. It has been observed that besides intensification of routine immunization, more strategic interventions are essential to strengthen the different aspects of immunization services like cold–chain management and monitoring/supportive supervision. The present study was considered as a part of ongoing UNICEF funded Project on Supportive Supervision of Routine Immunization in Rajnandgaon and Bilaspur districts undertaken by the Department of Community Medicine, Government Medical College, and Rajnandgaon with the objectives to assess the background information about cold chain points (CCPs), to observe the vaccine storage and handling practices, and to study the knowledge and practices of VCCH. Materials and Methods: A cross-sectional facility based study was conducted from August 2017 to February 2018. Among60 CCPs, 48 from Rajnandgaon and 12 from Bilaspur district were considered for analysis. Structured questionnaires as a part of standard tool prescribed by Government of India was used for the collection of required data. Result: In 92% CCPs, the temperature of cold chain equipment (CCE) was recorded twice a day. In 93% CCPs, vaccines were correctly stored in ILR. In 75% CCPs, icepacks were correctly stored in DF, 90% vaccine cold chain handler (VCCH) could correctly demonstrate temperature reading from thermometer, 91% could tell about stages of VVM correctly. Conclusion: Most CCPs in both districts are doing good enough, and there is a scope of improvement in all the parameters by means of ongoing project of Strengthening of Supportive Supervision of Routine Immunization in both districts. It was evident that Rajnandgaon district scored more than Bilaspur in some parameters related to vaccine storage and handling practices.
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Community perception about swine flu in an urban slum of Haryana: A cross-sectional study p. 1515
Ramesh Verma, Vinod Chayal, Raj Kumar, Kapil Bhalla, Mukesh Dhankar, Rohit Dhaka, Ginni Agrawal
DOI:10.4103/jfmpc.jfmpc_151_18  
Background: Swine flu caused by influenza virus and it's a respiratory disease of pigs. The people like farmers and pork processors working in close proximity with pigs are at higher risk of getting swine flu. In India, a total of 117 deaths and 1,154 cases have been reported in the first two months of year 2018. Objectives: To assess the community perception about Swine flu among adults in an urban slum of District Rohtak. Methodology: The study was a community based epidemiological study with cross-sectional design and carried out by visiting house to house. The study recruited 500 adults of age 18-60 years. Results: The study found that there was no significant difference between gender and age with heard of swine flu while education wise (p= 0.002) and caste wise (p=0.011) awareness of swine flu was found to be statistically significant. Conclusion and Recommendation: The study concluded that the majority of subjects heard about swine flu and majority of subjects said that swine flu spread after coughing or sneezing. The study recommends that health care functionaries should spread awareness about signs and symptoms of swine flu.
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Service provider perceptions of the trend in severity of symptoms and complications in women admitted following an incomplete abortion p. 1521
Athula Kaluarachchi, Sumithra Tissera, Achini C Jayatilleke, Suchira Suranga, Philip Guest, Karthik Srinivasan, Bela Ganatra
DOI:10.4103/jfmpc.jfmpc_188_18  
Background: Sri Lankan abortion law which dates back to the year 1883, and still unchanged, only allows a legal termination when the mother's life is in danger. Many studies undertaken in the country estimates that even in the light of such a backdrop, and with a high contraceptive prevalence rate, many women attempt an abortion when faced with an unwanted pregnancy. This study aims to describe the changes in abortion-related complications in the country over a period of time and explore the reasons for any changes in severity of symptoms among women hospitalized following an abortion based on the perceptions of healthcare service providers. Method: Using an interviewer guide, in-depth interviews were carried out among 30 service providers of post abortion care with more than 5 years of experience in obstetrics and gynecology in Sri Lanka. Results: Service providers perceived that the number of women presenting to hospitals after an induced abortion caused by a mechanical method is minimal or not at all at present. Over time, a significant reduction is seen in the number of women presenting with any abortion-related complications and the severity of complications has also reduced significantly. The common method of termination at present identified by the providers was the use of “drugs” or “the drug – Misoprostol.” Conclusion: Over the years, women appear to have switched from surgical and mechanical methods to medical means (drugs) to induce an abortion and this change has contributed to reduce the severity of complications.
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Prevalence of hypertension, diabetes, and associated risk factors among geriatric population living in a high-altitude region of rural Uttarakhand, India p. 1527
Umesh Kapil, Ritika Khandelwal, Lakshmy Ramakrishnan, Preetika Khenduja, Aakriti Gupta, Ravindra Mohan Pandey, Ashish Datt Upadhyay, Ravi Shankar Belwal
DOI:10.4103/jfmpc.jfmpc_108_18  
Background: Hypertension (HTN) and diabetes mellitus (DM) both are rapidly emerging as public health problems among geriatric population in developing countries. HTN can lead to stroke, myocardial infarction, congestive heart failure, and chronic kidney diseases among geriatric population. DM increases the risk of coronary heart disease, cerebrovascular disease, peripheral vascular disease, retinopathy, nephropathy, and neuropathy among geriatric population. Methodology: A community-based, cross-sectional study was conducted during 2015–2016 in District Nainital, Uttarakhand. A list of all villages with their population in the district was developed. From this list, 30 villages were identified using population proportionate to size sampling method. From each village, 30 geriatric subjects were selected. A total of 1003 geriatric subjects age 60 years and above were included in the study. Data were collected on sociodemographic profile, blood pressure, fasting blood glucose, anthropometry, and lipid profile from all the enrolled subjects. The prevalence of HTN and DM was assessed. Univariate and multivariate analyses were done to identify risk factors associated with HTN and DM. Results: The prevalence of HTN and DM was found to be 54.5% and 14.6%, respectively. For HTN, advancing age, high educational level and body mass index (BMI) (≥25 kg/m2) and for DM higher education level and BMI (≥25 kg/m2) were found to be significant risk factors. Conclusion: A high prevalence of HTN and DM was found in geriatric population residing in rural area of Uttarakhand.
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Investigating a community wide outbreak of hepatitis A in Kerala, India p. 1537
PS Rakesh, T T. Carmel Regeela Mainu, Arun Raj, Devika Babu, Midhun Rajiv, K Sreelakshmi Mohandas, Amrita Das, Arjun Balasubramanian
DOI:10.4103/jfmpc.jfmpc_127_18  
Background: There was an outbreak of acute hepatitis in Nellikuzhy panchayat of Kothamangalam taluk, Ernakulam district, Kerala, during November and early December 2016. Objective of this study is to describe the epidemiological features of the outbreak and to identify the probable source. Materials and Methods: The outbreak was defined in terms of time, place, and person. A hypothesis was generated and tested using a case–control study. Cases were selected by simple random sampling from the line list and controls were age-matched neighborhood individuals without any history of jaundice. Chi-square test, univariate analysis, and multi-variate logistic regression analyses were done to identify the probable risk factors. Results: Around 223 hepatitis A cases were identified. Attack rate was found to be highest among the age group of 16-30 years at 1.44% and was eight times higher among males. Epidemic curve suggested a point source outbreak possibly from exposure to food or water from a newly opened hotel in the area. The case–control study confirmed the hypothesis with a statistically significant association between cases and history of exposure to food from the hotel [OR 120; 95% CI 14.6–996.2; P value < 0.001]. Conclusion: Observations and results of the case–control study revealed that the probable source of the Hepatitis A outbreak at Nellikuzhy panchayat was a hotel. The study findings also add evidences to the changing epidemiological pattern of hepatitis A in Kerala, and warrant the necessity to enforce food safety rules in the State.
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Outcome of the vaginal birth after cesarean section during the second birth order in West Kazakhstan p. 1542
K Zh Sakiyeva, Ibrahim A Abdelazim, M Farghali, SS Zhumagulova, MB Dossimbetova, MS Sarsenbaev, G Zhurabekova, S Shikanova
DOI:10.4103/jfmpc.jfmpc_293_18  
Background: Vaginal birth after cesarean section (VBAC) increases the chance of subsequent vaginal deliveries and reduces the repeat cesarean section (CS) rate with subsequent postoperative morbidity. Objectives: To detect the outcome of VBAC during the second birth order in Aktobe region of West Kazakhstan. Patients and Methods: A total of 832 women eligible for trial of VBAC were included in this study. Women who signed the consent of VBAC were evaluated thoroughly and data such as maternal age, body mass index, height, gestational age at admission, indication of the previous CS, estimated fetal weight, engagement of the fetal head, condition of the membranes, and cervical dilatation were collected. Data collected after delivery include duration from active phase of labor, mode of delivery, fetal, and neonatal outcomes. The collected data analyzed to detect the outcome of trial of VBAC during the second birth order in Aktobe region of West Kazakhstan. Results: Logistic analysis and odds ratio (OR) showed that body mass index (BMI) ≤25 kg/m2 (OR 1.7; P = 0.0004), height ≥150 cm (OR 1.7; P = 0.002), gestational age ≤40 weeks (OR 2.3; P = 0.0001), and inter-delivery interval ≥2 years (OR 1.6; P = 0.008) were significantly associated with successful VBAC. In addition, <2/5 of the fetal head palpable abdominally, station <−2 (OR 1.7; P = 0.0009), cervical dilatation ≥4 cm (OR 1.7; P = 0.003), and duration of active phase of labor ≤7 h (OR 1.6; P = 0.01) were significantly associated with successful VBAC. Conclusion: VBAC is safe in properly selected cases. BMI ≤25 kg/m2, gestational age ≤40 weeks, inter-delivery interval ≥2 years, and fetal head <−2 station increase the success of VBAC. Prolonged active phase of labor >7 h and the need for labor augmentation decrease the chance of VBAC success.
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Associated head injuries and survival rate of patients with maxillofacial fractures in road traffic accident:A prospective study in Saudi Arabia p. 1548
Omar Mufi Aldwsari, Khalid Hadi Aldosari, Musab Khader Alzahrani, Zaid Ali Alzahrani, Abdulrahman Hamoud Alanazi, Khalid Mansour Alkhathlan, Mohammad Ghormallah Alzahrani, Ali Hazzaa Alzahrani, Sameer Al-Ghamdi
DOI:10.4103/jfmpc.jfmpc_101_18  
Background: Every minute, an accident occurs in Saudi Arabia, causing 39,000 injuries and 7,000 deaths annually. Facial trauma or maxillofacial trauma (MFT) is a frequent presentation of road traffic accidents (RTAs), ranging from simple nasal fractures to gross or severe maxillofacial injuries. Methods: A total number of 237 patients were included in this prospective study from May 2013 to January 2018. The following medical details were recorded for each case, gender, age, fracture location, the presence of scalp laceration, the presence of brain damage, type of brain damage, shock degree, Glasgow Coma Scale (GCS), number of units used for blood transfusions for documentation of patient survival rate. We followed up the patients in their first appointment after 21 days of patient discharge from the hospital. Results: Majority of the patients were young male adults. A total of 59.1% of patients had cerebral damage, 38% (n = 90) of patients had at least, one scalp laceration, 43.5% (n = 103) of patients had some degree of shock, whereas 27.8% of the recruited patients needed at least 1 unit of blood transfusion. A total of 14.3% of the patients died as a result of their injuries, and the survival rate was 85.7%. Conclusions: Kingdom of Saudi Arabia (KSA) is having a high incidence of RTAs leading to high mortality rate. Therefore, it requires a sound evaluation of the risk factors for RTAs and establishment of guidelines to decrease the incidence of road traffic injuries and reduce health-care burden. Road safety campaigns focused on young population can help reduce RTAs and subsequent mortalities. Prompt arrival at the hospital, early diagnosis, and timely management of maxillofacial fractures and brain damages by skilled physicians will lower mortality rate in KSA..
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Investigating the risk of Incident diabetes mellitus among primary care patients treated with simvastatin in North-Central Trinidad p. 1555
Raveed Khan, Arlene Williams, Devon Matthew Dass, Amelia Dan, Rhea-Marie Cunningham, Cherrise Choya, Yan Shao Chen, Atieannah Choucoutou, Cherisse Crawford, Yasmine Cooke
DOI:10.4103/jfmpc.jfmpc_55_18  
Aim: To determine the risk of new-onset diabetes mellitus in patients treated with simvastatin at primary healthcare clinics in North Central Trinidad. Materials and Methods: A retrospective descriptive case-series study design was applied to 384 conveniently sampled patient medical records from the cluster of primary healthcare centers during the period of February 2016–May 2016. Information from the patient files were then recorded using a systematic data extraction form. The major inclusion criteria were non-diabetic patients who were compliant with daily simvastatin for a minimum period of 1 year. The risk of incident diabetes mellitus was calculated, using SPSS version 20.0. Chi-squared (χ2) testing was performed to determine any association between new-onset diabetes mellitus and simvastatin use. Results: In all, 207 patients became diabetic during their treatment period translating into a 53.9% risk of incident diabetes mellitus (χ2 = 2.3438, P = 0.1258). A subgroup analysis of 133 subjects was performed to eliminate the confounders of family history of diabetes and age greater than 60 years. In this subgroup, 50 incident diabetics (37%) were identified and a statistically significant association was observed (χ2 = 8.118, P = 0.0042). Linear regression revealed that this association was dose-dependent with a corresponding 32% higher risk in patients taking 40 mg (P = 0.001) of simvastatin daily compared with 20 mg of simvastatin (P = 0.094). Linear regression also revealed that there was significant statistical association between onset of diabetes mellitus and duration of statin therapy (P = 0.006). Conclusion: In this population, simvastatin use is associated with a 53.9% increased risk of development of new-onset diabetes mellitus (χ2 = 2.3438, P = 0.1258). A statistically significant association was attained after subgroup analysis involving patients less than 60 years old and without a family history of diabetes with an incident risk of 37%. The increased risk of incident diabetes mellitus conferred by higher doses of simvastatin warrants consideration by physicians considering therapies for dyslipidemia in patients with multiple risk factors for diabetes mellitus.
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CASE REPORTS Top

Cesarean section scar dehiscence during pregnancy: Case reports p. 1561
Ibrahim A Abdelazim, Svetlana Shikanova, Sakiyeva Kanshaiym, Bakyt Karimova, Mukhit Sarsembayev, Tatyana Starchenko
DOI:10.4103/jfmpc.jfmpc_361_18  
Background: The incidence of cesarean section increased worldwide with subsequent increase in the risk of cesarean section scar dehiscence (CSSD). The clinical significance and the management of the CSSD are still unclear. Case Reports: Here, we report two cases of CSSD. A 35-year-old woman, gravida 2, previous CS, due to preterm premature rupture of membranes (PPROM) and breech presentation at 30 weeks, was admitted for elective CS at 38+3d weeks' gestation. During the second elective CS, it was seen that the site of the previous CS scar was very thin along its whole length and the anterior uterine wall was completely deficient, leaving visible bulging fetal membranes and moving baby underneath. A 32-year-old woman, previous three CSs, was admitted as unbooked case without any antenatal records at 29+4d weeks' gestation, triplet pregnancy with preterm labor. She received betamethasone and magnesium sulfate (MgSO4) for fetal lung and fetal brain protection, respectively, followed by emergency CS. During the CS, the previous CSs scars were dehiscent over more than half of its length and the anterior uterine wall was missing leaving visible fetal membranes. The uterine incision of the studied women was repaired in two layers using vicryl 0 interrupted simple stitches for the first layer, followed by interrupted mattress stitches for the second layer. The studied women had uneventful postoperative recovery and were discharged from the hospital after counseling regarding intraoperative findings, uterine incisions repair, and future pregnancies. Conclusion: It is useful to assess the lower uterine segment of women with previous CS using the available ultrasound facilities. If the CSSD is diagnosed before the elective CS, the surgeon should prepare himself with the safest uterine incision with least possible complications and the best way of repair of the defective or dehiscent uterine wall.
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Very early-onset psychosis/schizophrenia: Case studies of spectrum of presentation and management issues p. 1566
Jitender Aneja, Kartik Singhai, Karandeep Paul
DOI:10.4103/jfmpc.jfmpc_264_18  
Schizophrenia occurs very uncommonly in children younger than 13 years. The disease is preceded by premorbid difficulties, familial vulnerability, and a prodromal phase. The occurrence of positive psychotic symptoms such as delusions and hallucinations depends on the level of cognitive development of child. Furthermore, at times it is very difficult to differentiate the psychopathology and sustain a diagnosis of schizophrenia in view of similarities with disorders such as autism, mood disorders, and obsessive compulsive disorders. Here, we present three case studies with varying presentation of childhood-onset psychosis/schizophrenia and associated management issues.
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Diffuse erythematous rash after teneligliptin therapy: A case report p. 1571
Prabhat Agrawal, Apoorv Jain, Saurabh Bansal, Abhishek Raj
DOI:10.4103/jfmpc.jfmpc_283_18  
We report a yet unreported, adverse effect of teneligliptin [Dipeptidyl peptidase IV inhibitor (DPP IV)] presenting as diffuse pruritic erythematous rash, in a patient, 2 days after initiation of the drug. The rash waned off after the discontinuation of the drug without any residual lesion.
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Clofazimine-induced methemoglobinemia: A rare incidence p. 1573
Ahmed Asif, Chandrappa Preetham, Chakravorty Mahajyoti, Mishra Nibedita
DOI:10.4103/jfmpc.jfmpc_296_18  
Clofazimine is commonly used for the treatment of leprosy and chronic use of it can lead to methemoglobinemia, which is a rare but major concern. Iron of hemoglobin remains in the form of ferric (Fe3+) in methemoglobinemia as compared with ferrous form (Fe2+) in normal situation. This transformation prevents oxygen carriage and results in higher level of MetHb in blood which could be dangerous to life. In normal patients the level of MetHb is <1%. We report a case where acute ingestion of many tablets of clofazimine resulted in methemoglobinemia. Cyanosis was not apparent in this case leading to delayed diagnosis, and despite >30% MetHb levels, the clinical presentation was not very suggestive. Because of the nonavailability of intravenous methylene blue and parenteral ascorbic acid, tablet ascorbic acid was used for the management. Gradual decrease of MetHb levels was observed, with amelioration of symptoms and improvement in patient's condition. Review of the literature failed to reveal publication of acute methemoglobinemia with such presentation in the past. Awareness about possibility of methemoglobinemia and its possible contributors will help primary care physician and emergency physician suspect this condition early in patients presenting with history of unknown drug overdose and work in proper direction.
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Linezolid-induced dental hyperpigmentation in an adult male being treated for an ulcer caused by atypical mycobacteria p. 1576
Prabhat Agrawal, Prashant Prakash, Nikhil Pursnani, Maaz Farooqui
DOI:10.4103/jfmpc.jfmpc_284_18  
Mycobacteria are intrinsically resistant to most antibiotics as a result of multiple mechanisms. Linezolid, a member of the oxazolidinones, is a newer class of synthetic antimicrobials which is frequently used to treat mycobacteria. Here, we report a case of a patient with an ulcer on the right arm, caused by atypical mycobacteria, who presented with discoloration of both the upper and lower teeth after being treated with linezolid for a period of 2 months. On detailed evaluation, the patient was found to have linezolid-induced dental hyperpigmentation. This is the first case reported ever in an adult having linezolid-induced dental hyperpigmentation.
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Pulmonary arterial dilation with normal pulmonary artery pressure in sarcoidosis p. 1578
Anas Al-khateeb, William Meng, Muqueet Kadri, Sharath Bellary, Hari Sharma, Richard Miller
DOI:10.4103/jfmpc.jfmpc_263_18  
In this paper we present a clinical case that has improved on our knowledge and our curiosity about sarcoidosis. We report a case of a patient known to have pulmonary sarcoidosis, who presents with respiratory failure with severe hypercapnia. Following thorough investigations this patient was recognized to have three unique yet interrelated aspects of clinical manifestations. He was found to have severe bilateral diaphragmatic hypokinesis, dilated pulmonary vasculature with normal pulmonary pressure, and a state of high output right sided heart failure. We propose an explanation of such a presentation, while we attempted to discuss possible alternative mechanisms. In conclusion, we report this case as the first recognized case of sarcoidosis to be related to diffusely dilated pulmonary vasculature of normal vascular pressure.
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A rare case of childhood Hepatitis A infection with pleural effusion, acalculous cholecystitis, and ascites p. 1581
Richie Dalai, Sumit Malhotra, Aditya K Gupta, Manisha Mandal, Shashi Kant
DOI:10.4103/jfmpc.jfmpc_298_18  
Hepatitis A is common among children of developing nations. Young children with Hepatitis A infection usually have a mild form of the disease. Serious manifestations like pleural effusion and acalculous cholecystitis are very rare in Hepatitis A infection in young children. There have been some reports of these manifestations of childhood Hepatitis A occurring in isolation but for these to co-exist, is extremely rare. In this article a young child with Hepatitis A infection who had all these three manifestations of pleural effusion, acalculous cholecystitis and ascites together, is reported.
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Not so sweet; severe Sweet's syndrome presenting as SIRS and pleural effusion p. 1584
Kandy M. Niyas Vettakkara, Sayantan Banerjee, Ankit Mittal, Pawan Goel, Prabhat Kumar, Upendra Baitha, Pankaj Jorwal, Manish Soneja, Ashutosh Biswas
DOI:10.4103/jfmpc.jfmpc_289_18  
Acute febrile neutrophilic dermatosis (Sweet's syndrome) is a rare inflammatory condition which presents as abrupt onset of painful erythematous plaques or nodules, often associated with fever and leucocytosis. Many extracutaneous manifestations are described in literature, but pulmonary manifestations and systemic inflammatory response syndrome (SIRS) are rare. Here we report a case of a 35-year-old male who presented with SIRS and pleural effusion. The presence of vesiculobullous and pustular skin lesions raised the suspicion of Sweet's syndrome and it was confirmed by skin biopsy. Initiation of systemic glucocorticoids lead to complete resolution of symptoms.
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LETTERS TO EDITOR Top

Are we still living in NTP era? p. 1588
Jaykumar N Mehta
DOI:10.4103/jfmpc.jfmpc_364_18  
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Poncet's disease: Uncommon musculoskeletal manifestation of tuberculosis p. 1589
Harpreet Singh, Ashok K Pannu, Vikas Suri, Ashish Bhalla, Savita Kumari
DOI:10.4103/jfmpc.jfmpc_288_18  
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School teachers as communicator for oral health promotion among school children in Malappuram municipality in Kerala p. 1591
Thorakkal Shamim
DOI:10.4103/jfmpc.jfmpc_310_18  
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Grand Coeur, Grand Ecoeurement! Depression and the Heart! p. 1592
Ahmed Naguy, Fouziya Alrashidi
DOI:10.4103/jfmpc.jfmpc_267_18  
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Role of Treponema pallidum hemagglutination assay for diagnosis of syphilis in low titers of VDRL-reactive sera: A prospective study from a large tertiary care center of East Delhi p. 1594
Kavita Gupta, Abhilasha Bhardwaj, Saroj Dash, Iqbal R Kaur
DOI:10.4103/jfmpc.jfmpc_258_18  
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