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   Table of Contents - Current issue
Coverpage
October-December 2016
Volume 5 | Issue 4
Page Nos. 745-893

Online since Tuesday, February 28, 2017

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EDITORIAL  

Future of profession Highly accessed article p. 745
Raman Kumar
DOI:10.4103/jfmpc.jfmpc_23_17  
Being a doctor in today's time is a tough experience in many parts of the world. Many young people motivated by the traditional image of profession and desire for service opted for this vocation without anticipating today's challenging environment. Bad press, violence against doctors, tough employment conditions, unemployment, and lack of societal respect have become common phenomenon across the world. It is indeed time to introspect. The institution of medical profession is rapidly transforming not necessarily only under the influence of rapidly changing technology. The presented viewpoint is an analysis on impact of changing global political scenario on the future of medical profession.
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REVIEW ARTICLES Top

Dental public health in India: An insight p. 747
Ramandeep Singh Gambhir, Amanpreet Kaur, Arshdeep Singh, Anmol Rattan Singh Sandhu, Angad Prakash Singh Dhaliwal
DOI:10.4103/2249-4863.201155  
Oral diseases are a major public health problem, and their burden is on increase in many low- and middle-income countries. Dental public health (DPH) aims to improve the oral health of the population through preventive and curative services. However, its achievements in India are being questioned probably because of lack of proficiency and skill among DPH personnel. The literature search for the present study was conducted utilizing various search engines and electronic databases such as PubMed and MEDLINE. Documents related to the Central and State Governments of India were also considered. Finally, 26 articles were selected for the present study from which relevant information can be extracted. The present study focuses on some of the important aspects relating to DPH in India such as priority for oral health, DPH workforce and curriculum, utilization of DPH personnel in providing primary oral health care, role of mobile dental vans, and research in DPH. It was concluded that more attention should be given toward preventive oral health care by employing more number of public health dentists in public sector, strengthening DPH education and research, and combining oral health programs with general health-care programs.
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Current concepts in the management of acute pancreatitis p. 752
Gautham Srinivasan, L Venkatakrishnan, Swaminathan Sambandam, Gursharan Singh, Maninder Kaur, Krishnaveni Janarthan, B Joseph John
DOI:10.4103/2249-4863.201144  
Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The “step up” approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.
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ORIGINAL ARTICLES Top

A cross-sectional study of migrant women with reference to their antenatal care services utilization and delivery practices in an urban slum of Mumbai p. 759
Vijay Loknath Badge, Minal Pandey, Mridula J Solanki, Ratnendra Ramesh Shinde
DOI:10.4103/2249-4863.201157  
Introduction: Migrant is a vulnerable population. They face several barriers in accessing health services. The immigration status presents various challenges for maternity services utilization. So this study was conducted (1) to estimate proportion of women utilizing full ANC package and to find out reasons for its nonutilization (2) to estimate the proportion of institutional deliveries and reasons for home deliveries. Methods: A cross-sectional community based study was conducted among migrant women in reproductive age group in an urban slum. The sample size was 120. Multistage simple random sampling was done. Results: Maximum numbers of migrants (71.7%) were from Uttar Pradesh. Sixty two percent married before the age of 18 years. Full ANC package was received by only 18% migrants. Proportion of home deliveries was 12%, and all were conducted by Untrained Dai. Lack of transport facility and availability of Dai (local birth attendant) were the reasons mentioned for home delivery. For nonutilization of full ANC package, far location of health center (30%); it is not necessary (25.8%); and family did not allow them to visit health center (21.8%) were the reasons mentioned. Religion and type of family were significantly associated with nonutilization of full ANC package. Conclusion: The present study revealed low utilization of ANC services and high proportion of home deliveries among the migrant women even after availability of health facilities for providing ANC care and to conduct deliveries in urban area.
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Factors associated with internet addiction among school-going adolescents in Vadodara p. 765
MC Anusha Prabhakaran, V Rajvee Patel, D Jaishree Ganjiwale, M Somashekhar Nimbalkar
DOI:10.4103/2249-4863.201149  
Introduction: The internet is an important modern means of obtaining information and communicating with others which has converted the world into a global village. At the same time, increasing internet use among adolescents is also likely to pose a major public health concern that is internet addiction (IA). The aim was to assess the prevalence of IA among school-going adolescents and factors associated with IA. Methods: A cross-sectional study was designed to survey adolescents studying in 8th to 11th standard of five schools of Vadodara. Information regarding sociodemography and various patterns of internet use were obtained using survey forms. IA test (IAT) was used to screen for IA. Descriptive analysis, univariate analysis, and logistic regression were done to analyze the data. Results: Seven hundred and twenty-four participants that completed IAT were analyzed. Internet use prevalence was 98.9%. Prevalence of IA was 8.7%. Male gender, owning a personal device, hours of internet use/day, use of smartphones, permanent login status, use of internet for chatting, making online friends, shopping, watching movies, online gaming, searching information online and instant messaging were found to be associated significantly with IA in univariate analysis. Internet use for online friendships was found to be a significant predictor of IA (odds ratio [OR] =2.4), and internet use for searching information was found to be protective (OR = 0.20) against IA on logistic regression. Conclusions: IA is prevalent in the adolescent population and requires awareness and intervention. Characteristics of internet usage found to be associated with IA needs to be considered while developing strategies for interventions.
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Acceptance rate, probability of follow-up, and expulsion of postpartum intrauterine contraceptive device offered at two primary health centers, North India p. 770
Shashi Kant, S Archana, Arvind Kumar Singh, Farhad Ahamed, Partha Haldar
DOI:10.4103/2249-4863.201173  
Introduction: Acceptance rate of postpartum intrauterine contraceptive device (PPIUCD) offered through a public health approach is unknown. Our aim was to describe the acceptance rate, expulsion, and follow-up and factors associated with it when PPIUCD was offered to women delivering at two primary health centers (PHCs). Methods: We analyzed routine health data of deliveries at two PHCs in district Faridabad, India between May and December 2014, having sociodemographic variables, obstetric history, and during the follow-up check-up at 6-weeks postpartum for in situ status of intrauterine contraceptive device, side effects, and complications. Results: The overall acceptance rate among those eligible for PPIUCD was 39% (95% confidence interval [CI]: 35.1–42.9). Independent predictor of acceptance was a monthly family income of <USD75$ (odds ratio [O.R.]: 2.29, 95% CI: 1.58–3.31). The expulsion rate, and removal rate at 6 weeks postpartum was 18.0% and 13.0%, respectively. Expulsion by 6 weeks was associated with, age >25 years (O.R.: 2.21, 95% CI: 1.03–4.73), gravida ≥4 (O.R.: 4.01, 95% CI: 1.28–12.56), and a living previous-child (O.R.: 1.51, 95% CI: 1.04–2.19). Conclusion: Acceptance rate of PPIUCD was higher than that reported in literature. Women from lower income family, having at least one living child, and having attended antenatal care clinic were more likely to accept PPIUCD.
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Reporting measles case fatality due to complications from a tertiary care hospital of Kolkata, West Bengal 2011-2013 p. 777
Pallavi Indwar, Falguni Debnath, Arijit Sinha
DOI:10.4103/2249-4863.201161  
Introduction: Measles is affecting millions of people in the developing countries particularly in India with significant morbidity and responsible for thousands of death in spite of having a safe, effective, and cheap vaccine. Pulmonary complications account for 90% measles-related death. The objectives of this study were to describe age distribution, clinical features, complications, and clinical outcomes of measles cases in a referral infectious disease hospital of West Bengal. Methods: We conducted a retrospective descriptive study including 584 patients and collected information from record section on demographics, clinical features, complications, and clinical outcomes using data abstraction form. Results: The mean age of 584 measles cases was 3.7 years (±1.2 years). The most common complication was pneumonia (149 cases) followed by diarrhea and encephalopathy. Very severe pneumonia occurred in 34 cases requiring intensive care out of which 13 patients died. The average duration of stay in the hospital was 5.7 days (±3.2 days). Surprisingly, 45 cases admitted to this hospital were <9 months of age with subsequent death in 5 cases. Conclusion: Substantial number of measles cases was seen in zero to <9 months of age group and fatality due to complication was more among them.
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Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities p. 780
Swapna Bhaskar, D Hemavathy, Shankar Prasad
DOI:10.4103/2249-4863.201153  
Introduction: Insomnia is one of the common but neglected conditions seen in family practice with long term and serious effects on health of a patient. Family physicians have the responsibility of diagnosing and adequately treating this. This study was done to find the prevalence of chronic insomnia in adult patients visiting a family medicine outpatient department (OPD) in a hospital and to assess the risk factors and co morbidities associated with it. Materials and Methods: A cross-sectional study was done in the family medicine OPD at St. Philomena's Hospital, Bengaluru. All adult patients attending the OPD from September 1 to October 30, 2015 were enrolled in the study after obtaining written consent. Athens Insomnia Scale was used to diagnose insomnia and information regarding medical co morbidities was collected. Data was analyzed for the prevalence of insomnia and its association with co morbidities. Results: Chronic insomnia was seen in 33% of the adult population sampled. Increasing age and diabetes were significantly associated with insomnia, while other socioeconomic factors and co morbidities were not significantly associated. Twenty-seven percent of patients who had insomnia did not perceive the condition, which was statistically significant. Conclusion: Insomnia is a common sleep disorder which is many times missed by a primary care physician until/unless asked for. Since there is a higher incidence with increasing age and co morbidities such as diabetes, all patients, especially middle-aged and diabetics, should be screened for insomnia by the primary care physician with a self assessed questionnaire and counseled.
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Myths and misconceptions in general public toward ocular complications followed by the removal of upper teeth p. 785
Ujwala Rohan Newadkar, Lalit Chaudhari, Yogita Khalekar
DOI:10.4103/2249-4863.201147  
Introduction: The upper jaw forms the floor of the maxillary sinus and the upper teeth are continuous with the whole midface and cranium, therefore while treating these teeth, it is important for the practitioner to consider the possibility of ocular complications. Ocular disturbances such as blurring of vision, mydriasis, ptosis, diplopia, enophthalmos, miosis, and blindness are rare complications due to intraoral local anesthesia. So far at present, the general population is having myths and misconceptions regarding the extraction of teeth and vision loss; hence, we evaluated the same. Methods: A cross-sectional prospective survey targeting the general public was conducted using a self-administered questionnaire. A total of 300 standardized self-administered questionnaires were given and the data were analyzed. Results: Out of 300 patients, 148 were educated and 152 were uneducated. The study population was analyzed based on their age, sex, and literacy, i.e. the level of education. Seventy-six percent of uneducated and 48% of educated groups had false belief of ocular complications followed by the removal of upper teeth and among them uneducated females of older age group showed higher prevalence. Conclusion: The general public's knowledge about ocular complications due to tooth extraction in our study group is not adequate and needs improvement. Although the practice of informing by dentists is satisfactory, there is a need for creating awareness in the general public against such complications.
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Community level evaluation of adenoid hypertrophy on the basis of symptom scoring and its X-ray correlation p. 789
Yogita Dixit, Prem Siddharth Tripathi
DOI:10.4103/2249-4863.201156  
Introduction: One of the major causes of pediatric morbidity today at the community level is infection involving the ear, nose, and throat. Maximum of these patients respond well initially on general regular medications, but then recurrent complaints are not very uncommon. One of the major causes for such recurrence is hypertrophy of adenoids, the evaluation of which requires a battery of sophisticated investigative tools and expertise which are lacking at the community level. The aim of the study is to evaluate various symptoms related to adenoid hypertrophy and its correlation to the size of the adenoid seen in the lateral view nasopharyngeal X-ray. The aim of the study was to assess various symptoms related to adenoid hypertrophy and its correlation with the size of adenoid radiologically. Methods: A total of fifty cases of pediatric age with strong clinical suspicion of adenoid hypertrophy were included in the study. Through ENT examination was done. X-ray lateral view nasopharynx was obtained. Results: Adenoid hypertrophy was graded according to symptoms score and lateral cephalometric/radiographs. Snoring was the most frequent symptom which had a linear relation with the size of the adenoid. Conclusion: There was good agreement between symptom and the X-ray findings.
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Profile of elderly attending a general practice clinic in a poor urban area: A cross-sectional study from South India p. 792
Dimple Madhukar Jamkhandi, Sara Bhattacharji
DOI:10.4103/2249-4863.201172  
Introduction: In India, the number of elderly is steadily increasing and is likely to reach 301 million by 2051. The increasing number and proportion of elderly will have a direct impact on the demand for health and pension services. As per the Demography of Indian Aging (Rajan et al.), information on morbidity profile of this population is essential to plan health-care facilities. Methods: A descriptive cross-sectional study was designed to study the morbidity profile of 100 elderly persons reporting to the outpatient clinic of a family practice unit of a tertiary care center in South India between June 2008 and May 2010. This was done with a view to plan better services for the elderly in that area. Results: In this study, 88% of the participants were on a follow-up while new ailment(s) were diagnosed in 11 participants. A majority of participants were illiterate (62%), unemployed (83%), and financially dependent (54%). Forty-four participants screened had depression that required intervention such as counseling and follow-up; in ten participants, the screening score was sufficient to warrant therapy. In nearly half of the participants, the musculoskeletal system was involved, and a significant number had the involvement of cardiorespiratory system and urinary incontinence. Conclusion: A large number of elderly are affected by a constellation of conditions including mental as well social issues. A family practice unit may be a good setup to provide the first-contact care for the diagnosis and management of common problems in the elderly and help to improve their quality of life.
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Evaluation of patient and doctor perception toward the use of telemedicine in Apollo Tele Health Services, India p. 798
Rajesh V Acharya, Jasuma J Rai
DOI:10.4103/2249-4863.201174  
Introduction: Telemedicine incorporates electronic information and medical technology. It connects healthcare through vast distances which would benefit both patients and doctors. The aim of this questionnaire study was to evaluate the effects of telemedicine on patients and medical specialists. Methods: A cross-sectional study was conducted among 122 participants (71 patients and 51 doctors) on satisfaction in quality of service, cost-effectiveness, and problems encountered in healthcare provided by the telemedicine in Apollo Tele Health Services, Hyderabad, Telangana, India. The data for each group were calculated and compared. Results: About 80% patients and all the doctors reported their satisfaction on the quality of treatment given through telemedicine. Approximately, 90% of the participants found telemedicine cost-effective and 61% of the doctors found an increase in patient's inflow apart for their regular practice. Problems encountered in telemedicine were 47% in technical issues and 39% in time scheduling by doctors and 31% of patients were uncomfortable to face the camera, and 24% had technical issues. Conclusions: The results of the present study showed that telemedicine in healthcare could prove to be useful to patients in distant regions and to rural doctors in India. In the near future, telemedicine can be considered as an alternate to face to face patient care.
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A study on alcohol use and its related health and social problems in rural Puducherry, India p. 804
V Vijay Ramanan, Suresh Kumar Singh
DOI:10.4103/2249-4863.201175  
Introduction: Harmful use of alcohol was the cause for 5.9% of all deaths and 5.1% of the global burden of disease and injury. India is the third largest market for alcoholic beverages in the world with estimated 62.5 million alcohol user in 2005. The objective of this study was to know the prevalence of alcohol consumption, pattern of drinking, and its effect on people's health and social consequences. Methods: This cross-sectional study was conducted in 850 households selected from 19 villages of two Primary Health Centers. A total of 30 clusters were selected, and from each cluster, 28 houses were surveyed by random walk method. Information was collected on predesigned and pretested questionnaire forms and analyzed using Epi Info 3.4.3. Chi-square test was used for statistical significance. Results: The overall prevalence of alcohol use among ≥18 years of age was 9.7% and exclusively among males was 17.1%. The highest prevalence (17.1%) was among 46–55 years age groups and the residents of joint families (37.0%). One-third of the users began drinking before 20 years of age and half of them consumed for getting relief from pain/strain/tiredness. About half of the users had strained relations with their family members and neighbors both. The majority had alcohol dependence problems and about one-fifth had chronic health problems, diabetes mellitus, and hypertension. Conclusion: The prevalence of alcohol use in Puducherry was low and restricted to males only. The prevalence was high among low uneducated farmers and labors. About one-third of users had alcohol dependence problems and one-fifth had chronic health problems.
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Subclinical hypothyroidism and the risk of hypercholesterolemia p. 809
Indhu Aynipully Jayasingh, Paul Puthuran
DOI:10.4103/2249-4863.201177  
Introduction: Subclinical hypothyroidism (SCH) is a condition wherein there are small elevations in thyroid stimulating hormone (TSH), yet normal circulating levels of free thyroid hormones (FT4). Alterations in thyroid function result in changes in composition and transport of lipoproteins. Methods: The study was undertaken in the outpatient department of Lourdes hospital, Ernakulam. 110 patients between 40-69 years were studied, of which 60 were identified to have SCH based on cross-sectional survey, 50 patients were randomly selected to represent the EU group. Data based on interview, clinical examination, thyroid function, lipid profiles. Student's t, chi-square tests used for computation of p values. Results: SCH were seen in females (66.66%) and in the age group of 40-49 years (61.66%). Mean cholesterol values were elevated in the subclinical hypothyroid group and in relation to age (60-69) and gender. Statistical analysis showed significant difference in total cholesterol(TC) (P<0.005) and triglycerides (P<0.05) in relation to age (40–49 yrs.) between two groups. Based on TSH, group A 5-7.49Mu/L and group B 7.5-10Mu/L were compared to the euthyroid group N<5Mu/L. Mean cholesterol values were raised in both subgroups. Statistically significant difference seen (P<0.0005) in cholesterol values between the subclinical hypothyroid group B and the euthyroid group N. Conclusions: SCH appears to be associated with increased mean cholesterol levels in females and of age > 60 years. The TC values were elevated in both subgroups of patients with SCH (A and B) based on TSH values.
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Proportion of beneficiaries and factors affecting Janani Suraksha Yojana direct cash transfer scheme in Puducherry, India p. 817
K Rajarajan, S Ganesh Kumar, Sitanshu Sekhar Kar
DOI:10.4103/2249-4863.201146  
Introduction: Janani Suraksha Yojana (JSY) direct benefit transfer scheme was launched in the year 2013 in India and there is a paucity of information affecting it. The study aimed to assess the proportion of eligible beneficiaries utilizing JSY direct cash benefit transfer in Puducherry and to identify its barriers and facilitating factors. Methods: This cross sectional study was conducted from January to March 2015 among 152 eligible JSY beneficiaries residing in rural and urban field practice areas of a tertiary care institution in Puducherry, India. Data were collected using a pretested semi structured questionnaire and presented as proportion or percentages. Results: About 144 beneficiaries participated in the study with a response rate of 94.7%. About 46% (66) of them availed cash transfer benefit. The mean time of receiving the benefit is 95.8 days (interquartile range 60–120 days). Among those who have not received (78), about 49 (62.8%) had not applied and 29 (37.18%) filled applications were rejected due to various reasons. About 77.1% (111) of beneficiaries were informed about JSY scheme through health workers. About 52.1% (75/144) still preferred direct bank transfer through the bank. The reasons for not availing benefits includes not having a bank account (24.3%), followed by not having Aadhaar number (9.7%), 11.8% had no ration card, and 13.8% stayed in their mother house. Conclusion: Majority of the beneficiaries did not receive direct cash transfer benefits in urban area than rural area and there is a need to simplify the procedures to improve the uptake of services to this group.
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Effect of female sex hormones on cardiorespiratory parameters p. 822
Gayatri Godbole, AR Joshi, Savita M Vaidya
DOI:10.4103/2249-4863.201148  
Introduction: Female sex hormones, estrogen and progesterone regulate various phases of the menstrual cycle. Hormonal changes tend to affect various parameters of physical fitness. Maximum oxygen uptake (VO2 max) is a measure of aerobic power. This study was planned to assess effect of different phases of menstrual cycle on cardiorespiratory parameters like pulse rate, respiratory rate and VO2 max. Methods: 100 female medical students in the age group of 17-22 years were studied for three consecutive menstrual cycles. Weight, resting pulse rate, respiratory rate and VO2 max were measured during premenstrual phase (20th-25th day) and postmenstrual phase (5th to 10th day). Results: It was observed that there was a significant increase in body weight, pulse rate, and respiratory rate during premenstrual phase. There was a decrease in VO2 max during the premenstrual phase. Conclusion: This study indicates that there is decreased cardio-respiratory efficiency during premenstrual phase.
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Goiter prevalence in school-going children: A cross-sectional study in two border districts of sub-Himalayan Jammu and Kashmir p. 825
Rajiv Kumar Gupta, Bhavna Langer, Sunil Kumar Raina, Rashmi Kumari, Reyaz Jan, Renu Rani
DOI:10.4103/2249-4863.201150  
Introduction: Iodine deficiency disorder remains one of the major public health problems, despite it being easily preventable. Initially thought as the disorder of Himalayan goiter belt, the disorder has been found to have a pan-India presence. The study was planned with the aim to assess the prevalence of goiter among 6–12 years school-going children and to identify levels of iodine in salt consumed at the household level in the study area. Materials and Methods: The study was conducted among 3955 school-going (2162 children from Rajouri and 1793 children from Poonch) children age 6–12 years in Rajouri and Poonch districts of Jammu Province. The children were examined clinically to detect and grade the goiter. Salt samples were collected from subsample (n = 400) to estimate iodine content in the salt. Results: The prevalence of goiter in the study population was found to be 18.87% and 9.70% in Rajouri and Poonch districts, respectively. Goiter prevalence was higher in 9–12 years age group as compared to 6–9 years age group and the difference in goiter prevalence in males of these two age groups was statistically significant (P = 0.02). Estimation of iodine content of the salt samples revealed that all of them (100%) had adequate iodine content. Conclusion: Despite the implementation of Universal Iodization Program and adequate content of iodine in salt consumed by the families, the goiter prevalence in both the districts is high. The future research should focus on identifying the reasons for this high prevalence.
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Oral health of preschool children in Dhanbad District, Jharkhand: A gander into the maternal behavior and practices p. 829
Gunjan Kumar, CL Dileep, Ravish Ahuja
DOI:10.4103/2249-4863.201151  
Introduction: Mothers have an important role in taking decisions about their children's oral health. The study assessed the echelon of oral health behavior and practices of the mothers in relation to their preschool-aged children, which could possibly influence their oral health. Methods: A cross-sectional study was carried out among 312 mothers, selected randomly from eight blocks of Dhanbad District, Jharkhand State, by administering a structured questionnaire on oral health behavior and practices regarding oral health. Results: The overall data indicated that the practices of mothers about oral health of their preschool children increased as their age increased, which was however, not statistically significant (P > 0.47). The mothers who had less than higher secondary school education and belonging to lower socioeconomic groups had poorer oral health practices and was found to be statistically significant (P < 0.002 ). Conclusion: The mothers ought to inculcate positive practices and perceptions about preventive oral health for themselves first, to be good role models for their children.
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Environmental correlates of undernutrition among children of 3–6 years of age, Rajkot, Gujarat, India p. 834
Zalak Rameshbhai Matariya, Kaushik Kishorbhai Lodhiya, Rajkumar G Mahajan
DOI:10.4103/2249-4863.201152  
Introduction: There are lots of studies focusing on the role of reproductive and child health factors and dietary factors on the nutrition status of the child. The present study is an attempt to highlight the role of macro- and micro-environmental factors in predicting the occurrence of undernutrition in children. Methods: This was a cross-sectional study conducted in field practice area of Community Medicine Department, PDU Medical College, Rajkot. The nutrition status of children was assessed using the weight for age WHO reference standards, 2006. Children below two standard deviation of the reference median (weight for age) were considered as malnourished. Data were collected for sociodemographic factors, sanitation, hygiene, and attitude of mother toward her child, etc., Data were entered in MS excel, and logistic regression was used. Results: Analysis of 495 selected children showed 24% prevalence of undernutrition. Employment status of mothers (adjusted odds ratio [AOR] 1.65), drinking water quality (AOR 1.53), and cleanliness of mother's hands and clothes (AOR 1.91) significantly affected the nutrition status of the child. Children classified in fair or poor category for Briscoe's sanitation scale had 1.34 and1.92 times higher odds of being undernourished (P > 0.05), respectively. Children classified in fair or poor category for Elizabeth's microenvironment scale had 2.05 and 2.41 times higher odds of being undernourished (P < 0.05), respectively. Conclusions: Water, sanitation, and hygiene-related factors, as well as microenvironmental factors, significantly affected the nutrition status of the children.
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Family physicians' attitude and interest toward participation in urban family physician program and related factors p. 840
Masoumeh Sadeghi, Mohsen Dehghani, Monavar Afzal Aghaee
DOI:10.4103/2249-4863.201171  
Introduction: Every family physician has a key role in achieving the goals of the family physician program (FPP). Low satisfaction of physicians in certain areas of Iran and their low maintenance level in the program is quite challenging. The aims of the present study were; (1) to assess the attitude of rural/rural-urban family physicians about FPP and (2) to investigate their interest toward participation in urban FPP and (3) to explore the influencing factors. Methods: This cross-sectional study was performed on 137 family physicians who were working in rural/rural-urban FPP in Mashhad University of Medical Sciences (Iran). A self-designed valid and reliable questionnaire including demographic data and thirty questions on the participants' attitudes toward the FPP in Likert scale were used. Data were analyzed by multiple logistic regression models using SPSS software. Results: 49.3% of physicians were interested in continuing their cooperation in the urban-FPP. The mean total attitude score was 62.18 out of 100. The highest agreement and positive attitude of physicians were related to achievements of the program goals dimension. Multiple analyses showed that gender (odds ratio [OR] =5.5; male vs. female) and employment status (OR = 16.7 and 10.9 for permanent employment and by contract compared to legal obligation, respectively) were significantly associated with physicians' willingness toward participation in the urban-FPP. Conclusion: About half of the studied physicians were interested toward participation in the urban-FPP; Male physicians more than females and permanent employees more than others were willing and interested to participate in the urban-FPP.
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Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A community-based, cross-sectional study p. 847
Peraje Vasu Dinesh, Annarao Gunderao Kulkarni, Namratha Kurunji Gangadhar
DOI:10.4103/2249-4863.201176  
Introduction: Diabetes is a lifestyle disease which requires a multipronged approach for its management, wherein patient has an important role to play in terms of self-care practices, which can be taught to them by educational programs. To develop such an educational program, a baseline assessment of knowledge and self-care practices of patients, needs to be made. The two objectives of the study were to estimate the knowledge of diabetic patients regarding the disease and its complications, and to estimate the knowledge and adherence to self-care practices concerned with Type 2 diabetes mellitus. Methods: The study was conducted in rural Sullia, Karnataka, from January 2014 to May 2015. The sample size was calculated to be 400, and the sampling method was probability proportionate to sampling size. Result: Majority of them were married males of Hindu religion and belonged to upper middle class. Only 24.25% of them had good knowledge. Among the self-care practices, foot care was the most neglected area. Conclusion: Only one-fourth of the study population had a good knowledge toward diabetes. Adherence to some of the self-care practices was also poor. Government policies may help in creating guidelines on diabetes management, funding community programs for public awareness, availability of medicines, and diagnostic services to all sections of the community. Continuing education programs for health-care providers and utilization of mass media to the fullest potential may also help in creating awareness.
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Assessment of physical disability using Barthel index among elderly of rural areas of district Jhansi (U.P), India p. 853
Shubhanshu Gupta, Rashmi Yadav, Anil Kumar Malhotra
DOI:10.4103/2249-4863.201178  
Introduction: The health of the elderly will be an important issue defining the health status of a population. With the rise in aged population, there is a greater need to look into their physical disability aspects, which is otherwise neglected. The rationale behind the study is to assess the physical disability of the elderly living in rural area of Jhansi. The aims of the study were to study the prevalence of physical disability among the elderly of rural area, and to find out the factors and association affecting the physical disability. Methods: A community-based cross-sectional study was carried out in a Baragaon block of rural area of Jhansi, Uttar Pradesh, India, from July 2015 to October 2015. Multistage random sampling was performed. A total of 265 participants of age 60 years and above were selected. Physical disability was assessed using Barthel index. Appropriate data entry and statistical analysis were done in EpiInfo. Frequency tables were used to calculate the prevalence, and Chi-square test was used to find out the association. Results: The overall prevalence of physical disability was 23.4%. 70% belongs to the age group from 60 to 69 years. Physical disability was significantly higher among age group >80 years. Similarly, women were more affected with physical disability than men. Conclusions: High prevalence of physical disability is the major area of concern. More extensive postdischarge health facilities to be provided to elderly.
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CASE REPORTS Top

Multidrug-resistant Acinetobacter meningitis in children p. 858
Ira Shah, Muznah Kapdi
DOI:10.4103/2249-4863.201169  
Acinetobacter species have emerged as one of the most troublesome pathogens for healthcare institutions globally. In more recent times, nosocomial infections involving the central nervous system, skin and soft tissue, and bone have emerged as highly problematic. Acinetobacter species infection is common in intensive care units; however, Acinetobacter baumannii meningitis is rarely reported. Here, we report two cases of Acinetobacter baumannii meningitis which was multidrug resistance and ultimately required the carbapenem group of drugs for the treatment.
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Immediate access to antiretroviral therapy is important in children living with HIV p. 860
Sangeeta Das Bhattacharya, Bikas K Arya
DOI:10.4103/2249-4863.201142  
This article reviews a case of a child with perinatal HIV followed for 30 months during a prospective cohort study on pneumonia prevention in HIV-infected children. The point of this case report is to illustrate how delayed access to antiretroviral therapy (ART) in HIV-infected children impacts immunization response and growth. Given the WHO's early release guideline changes on ART recommendations and the expected full revised guidelines coming out this year, this article is a timely discussion on the need for access to ART for HIV infected Indian children regardless of CD4 count.
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Neonatal cholestasis due to primary sclerosing cholangitis p. 863
Naman Sadanand Shetty, Ira Shah
DOI:10.4103/2249-4863.201154  
Neonatal cholestasis is rarely caused due to primary sclerosing cholangitis, which is an inflammatory disease of the bile ducts, which results in obstructive fibrosis of the ducts. A 7-month-old male child presented with jaundice along with high-colored urine and clay-colored stools since birth. Liver biopsy showed mild bile duct proliferation with cholangioles showing bile and thrombi suggestive of primary sclerosing cholangitis.
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A case of hard palate perforation p. 865
Atul Saroch, Ashok Kumar Pannu
DOI:10.4103/2249-4863.201162  
Tuberculosis (TB) is a major public health problem in developing countries. Lung is most common affected organ, however extra pulmonary tuberculosis (EPTB) is also not uncommon. The clinical manifestations of EPTB may be non-specific that mimics other diseases and is usually misdiagnosed. Therefore, high clinical suspicion of EPTB infection is important, especially in endemic areas. Here, we present a case of hard palate perforation that proved to be tuberculous in origin. The diagnosis was made by histo-pathological examination and positive TB Polymerase chain reaction (PCR).
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An atypical presentation of infiltrating ductal carcinoma p. 868
Kunal Kishor Jha, Suresh Kumar Gupta
DOI:10.4103/2249-4863.201164  
A 64-year-old African-American female presented with nonbloody nipple discharge. Clinical and cytological examination of the discharge was normal. The mammography suggested pleomorphic calcification in the left breast. A stereotactic biopsy showed ductal carcinoma in situ and her estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2-neu receptor were negative. We removed the tumor tissue through lumpectomy and found that the mass was invasive ductal carcinoma. This case report highlights invasive ductal carcinoma, presenting with unilateral nipple discharge.
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Tuberculosis in a case of hyper immunoglobulin E syndrome p. 871
Renuka Ashtekar, Ira Shah
DOI:10.4103/2249-4863.201167  
Hyper immunoglobulin E syndrome (HIES) is a rare primary immunodeficiency disorder characterized by elevated serum IgE, dermatitis, and immunodeficiency that predisposes to multiple skin and lung infections. The most frequent pathogen responsible for infections in these patients is Staphylococcus aureus. Tuberculosis (TB) in patients with HIES is an uncommon finding, and there are only a few reports of mycobacterial infections in known cases of HIES. We present a case of abdominal TB that developed in a 15-year-old boy who also had HIES.
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Late onset hydrocephalus in children with tuberculous meningitis p. 873
Disha Sharma, Ira Shah, Sharad Patel
DOI:10.4103/2249-4863.201145  
Hydrocephalus is a known complication of tuberculous meningitis (TBM). It is almost always present in patients who have had the disease for four to six weeks. However, hydrocephalus can also develop later in the disease course as seen in our 3 patients. All 3 patients had multi-drug resistant (MDR) tuberculosis (TB) and developed hydrocephalus after variable time after starting second line anti-tuberculous therapy (ATT). A 7 years old girl had hydrocephalus at onset of TBM and was shunted but the hydrocephalus increased in size after 6 months of being on second line ATT in spite of a patent ventricular peritoneal (VP) shunt. Hydrocephalus responded to oral acetazolamide. Other 2 patients, a 2 years old girl and 3½ years old boy developed hydrocephalus after being on treatment for 14 months. Both required insertion of VP shunt. Thus, in patients with MDR-TB, hydrocephalus may develop as late onset phenomenon and a neurological examination would be essential in each visit to the hospital.
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Low-dose methotrexate-induced acute interstitial pneumonitis: Report of two cases from South India and review of literature p. 875
Ramya Iyyadurai, Ronald Albert Benton Carey, Sowmya Satyendra
DOI:10.4103/2249-4863.201163  
Methotrexate (MTX) is an antimetabolite used as a disease-modifying agent for various rheumatological conditions. We report two patients who were treated with daily low-dose MTX and developed acute interstitial pneumonitis requiring hospital admission. MTX-induced pneumonitis is a rare life-threatening side effect, high index of clinical suspicion is required, treatment is mainly withdrawal of MTX, supportive therapy, and adjunctive steroids, outcome is good if condition is recognized early, and appropriate treatment is given.
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An unusual case of sustained ventricular tachycardia following a wasp bite p. 879
Tarun Sharma, Aradhna Sharma, Mukul Bhatnagar
DOI:10.4103/2249-4863.201165  
Sustained ventricular tachycardia (VT) is a life-threatening condition which requires immediate intervention. We report a case of unusual etiology of sustained VT in a 42-year-old male after a wasp bite in the absence of anaphylaxis. The patient was treated with amiodarone and improved within 48 h. Thus, wasp stings can lead to serious tachyarrhythmias which can be life-threatening. Emergency care physicians should be aware of such arrhythmias in the setting of wasp bites which can be fatal.
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Sertraline induced mandibular dystonia and bruxism p. 882
NA Uvais, VS Sreeraj, SV Sathish Kumar
DOI:10.4103/2249-4863.201168  
Specific serotonin reuptake inhibitors have been associated with the occurrence of drug-induced parkinsonism, dystonia, dyskinesia, and akathisia. Here, we describe a young female patient with a diagnosis of the moderate depressive episode who developed mandibular dystonia and bruxism with sertraline in the absence of concurrent prescription of medications, which have potential action on the dopaminergic system.
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LETTERS TO EDITOR Top

Smoke on a white coat p. 885
Immad Arif, Salman Assad, Touqeer Sulehria
DOI:10.4103/2249-4863.201160  
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Screening of tuberculosis patients for diabetes mellitus is feasible with the existing health system in India p. 886
Janmejaya Samal
DOI:10.4103/2249-4863.201159  
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Psychological symptoms predicted chest pain intensity and discomfort in cardiac rehabilitation patients p. 888
Saeid Komasi, Ali Soroush, Mozhgan Saeidi
DOI:10.4103/2249-4863.201166  
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Bodybuilders pneumonia p. 890
Abhinav Bhanot, Arjun Khanna, Dev Rahul, Deepak Talwar
DOI:10.4103/2249-4863.201143  
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Acute disseminated encephalomyelitis after mumps infection p. 892
Kunal Kishor Jha, Durgesh Prasad Chaudhary, Semanta Dahal, Sabina Desar
DOI:10.4103/2249-4863.201170  
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