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   2020| May  | Volume 9 | Issue 5  
    Online since May 31, 2020

 
 
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EDITORIALS
Preventive and treatment strategies of COVID-19: From community to clinical trials
Kamal Kant Sahu, Raman Kumar
May 2020, 9(5):2149-2157
DOI:10.4103/jfmpc.jfmpc_728_20  
The latest threat to global health is the form of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic. This new coronavirus (SARS-COV-2) started as a local outbreak in Wuhan, China but soon tightened its grip on human lives around the globe. So far, we do not have a particularly effective anti-SARS-COV-2 vaccine or antiviral agent against COVID-19. Across the globe, many research organizations such as the National Institutes of Health (NIH), United States are studying and testing various drugs and vaccines for their effectiveness against SARS-COV-2. Currently, the principle fighting tool being promoted by the World Health Organization (WHO) is the prevention of acquiring SARS-COV-2 infection by following basic health hygiene rules and social distancing. We hereby discuss major non-pharmacological and pharmacological interventions.
  5 2,443 414
INVITED ARTICLES
Are we prepared? Lessons from Covid-19 and OMAG position paper on epidemic preparedness
Sunil Kumar Raina, Raman Kumar, Sagar Galwankar, Suneela Garg, Ramesh Bhatt, Akshay C Dhariwal, DJ Christopher, Bakul J Parekh, S Vimal Krishnan, Praveen Aggarwal, Ishwar Gilada, Udhay Bodhankar
May 2020, 9(5):2161-2166
DOI:10.4103/jfmpc.jfmpc_384_20  
Covid-19 has once again brought into focus our limited preparedness to deal with epidemics. Most nations, across the globe, have responded with a resolve to come stronger out of this crisis and leaderships across the world have shown great commitment to protecting its people from Covid-19. Covid-19 has also taught us a few things for the future. One such learning has been that a strong shift in focus towards non-communicable diseases driving health infrastructure across the globe for the last few decades has come at neglect of communicable diseases. In that sense, therefore, the current pandemic has been a wake-up call. Organised Medicine Academic Guild (OMAG), an umbrella organization of professional associations gathered a group of health experts to develop a policy document on epidemic preparedness to limit the influence of epidemics like Covid-19.
  2 223 47
COMMENTARIES
Customized personal protective equipment (PPE): Solution to conservation and management of supplies during the coronavirus disease 2019 (COVID-19) pandemic
Binit Sureka, Arvind Sinha, Vibhor Tak, Mahendra Kumar Garg, Pradeep Kumar Bhatia, Pankaj Bhardwaj, Vijaya Lakshmi Nag, Naveen Dutt, Abhay Elhence, Suryanarayanan Bhaskar, Ashok Bishnoi, Nishant Chauhan, NR Bishnoi, Sanjeev Misra
May 2020, 9(5):2180-2182
DOI:10.4103/jfmpc.jfmpc_556_20  
In the COVID-19 pandemic, global health care systems have become overwhelmed with potentially infectious patients seeking testing and care. Preventing spread of infection to and from health care workers (HCWs) and patients relies on effective use of personal protective equipment(PPE). The most critical part in due course of managing this pandemic is adequate supply of PPEs. We have customized a PPE which is economical and reusable after proper disinfection. This customized PPE can be a solution to conservation of supply during this pandemic.
  1 587 317
INVITED ARTICLES
Disability ethics in the coronavirus crisis
Satendra Singh
May 2020, 9(5):2167-2171
DOI:10.4103/jfmpc.jfmpc_588_20  
The disability viewpoint is fundamental for understanding and advancing social justice for everyone in the population. Despite this fact, it is regularly dismissed by public health experts and policymakers. Understanding of disability rights is central in an all-inclusive COVID-19 preparedness. This paper attempts to explore disability ethics in understanding structural discrimination, equitable practices, respect for disability culture and ways to safeguard health care professionals with disabilities in the coronavirus pandemic. In crisis standards of care, resource allocations must not be solely based on a disabled person's subjective quality of life. Health professionals should avoid stereotypes about an individual's disability to ration care. Triage protocol committees and disaster risk reduction working groups should explicitly recruit people with disabilities and chronic illnesses in their response strategies. Disability ethics can reform medical rationing by removing prejudices and safeguarding fair protection of the interests of all patients, including those with a disability.
  1 2,075 292
ORIGINAL ARTICLES
Risk factors for severe acute malnutrition among children aged 6–59 months: A community-based case-control study from Vellore, Southern India
Sam M David, Ruby A Pricilla, Sherin S Paul, Kuryan George, Anuradha Bose, Jasmin H Prasad
May 2020, 9(5):2237-2243
DOI:10.4103/jfmpc.jfmpc_211_20  
Background: Malnutrition plays an important role in the economic burden of society as well as the country. This study aimed to identify the various risk factors and determinants of severe acute malnutrition (SAM) as defined by WHO growth reference standards in children aged 6 months to 59 months living in Vellore. Methods: A community-based case-control study matched for age (±2months), gender and location was done among the children of the age group 6- 59 months residing in both rural and urban Vellore. Children of age group 6-59 months with SAM according to WHO definition, i.e., weight for height of less than -3SD with or without nutritional oedema were classified as cases. Children with weight-for-height z-score more than -1 SD and MUAC ≥13.5cms were classified as controls. With 2 controls per case, the required sample size was 54 cases and 108 controls. A questionnaire used to identify the risk factors including dietary intake. Uni-variate and multivariate analysis was done to generate an odds ratio and 95% confidence interval for the risk factors. Results: Majority of the cases 64.8% and 50% of the controls belonged to low SES. After adjusting all confounders, Severe Acute Malnutrition was significantly associated with birth weight <2.499kg [AOR- 8.95 (95% CI: 2.98-26.85)], not exclusively breastfed for 6 months [AOR 4.67 (95% CI: 1.72-12.65)], inadequate calorie intake [AOR 8.09 (95% CI: 3.15-20.82)] and mother being underweight [AOR 6.87 (95% CI: 1.92-24.55)]. Conclusion: Programs should be implemented to reduce the poor nutritional status of young girls and women in the reproductive age group. The importance of exclusive breastfeeding for the first six months, the time of weaning and appropriate feeding practice for the child should be emphasized to postnatal mothers during their hospital visits.
  1 488 117
CASE REPORTS
Role of Kalpa Chikitsa in the management of Lynch syndrome- A case report
Pooja Sharma, Divya Kajaria
May 2020, 9(5):2487-2491
DOI:10.4103/jfmpc.jfmpc_161_20  
Lynch syndrome (hereditary non-polyposis colorectal cancer) is an autosomal dominant condition and it is caused by germline mutations in the DNA mismatch repair genes. The present case report was conducted to evaluate the efficacy of Madhuyasti (Glycyrrhiza glabra) Ksheerpaka kalpa in Lynch syndrome. A 28-year-old male was diagnosed with Lynch syndrome in 2016. The patient was operated three times followed by chemotherapy. In 2019, he was diagnosed with adenocarcinoma and advised for surgery. But despite getting surgery patient prefer to take Ayurvedic consultation considering his miserable condition after previous surgeries. It is decided to give the kalpa method of therapy prescribed in Ayurveda for rejuvenation and overall improvement of health. After the 15 days of treatment with Madhuyasti (Glycyrrhiza glabra) Ksheerpaka Kalpa chikitsa, the patient showed significant improvement in quality of life (P < 0.001 for SPF) and CT abdomen showed a reduction in circumferential thickening from 2.8 to 1.5 cm (~50% improvement) with no worsening complications. Although the pathogenesis cannot be revert back to the normalcy as the patient already had resection of the total colon, it can be concluded that with the help of Ayurveda, the appearance of complications can be delayed and the quality of life can be improved in such patients. It is further suggested that better result may obtained if the Ayurvedic therapy starts at earlier stage.
  - 275 58
Functional ambulation with bent knee prostheses for an adult with bilateral 90 degrees knee flexion contractures—A case report
Veerendra K Shandilya, Lata D Parmar, Ashwinikumar V Shandilya
May 2020, 9(5):2492-2495
DOI:10.4103/jfmpc.jfmpc_1043_19  
An adult male who never stood, ambulating on all four due to bilateral severe knee flexion contractures, since his childhood, was 21 years of age, and not deterred by his condition, was pursuing his higher education. He was coaxed by his friends to seek medical opinion and it was decided to give a trial and let the client have a feel of bipedal stance and ambulation. Although there is a paucity of recent evidence on the use of bent knee prosthesis, the trial successfully restored the dignity.
  - 282 35
Mixed phenotypic presentation of autoimmune polyendocrine syndrome type II in adolescent female
Sandip Kumar, Sunil Kumar Rao, Parul Khanna
May 2020, 9(5):2496-2499
DOI:10.4103/jfmpc.jfmpc_1237_19  
Autoimmune polyendocrine syndrome (APS) is a constellation of multiple endocrine and various autoimmune diseases. The hallmark features of APS are gradual onset, circulating autoantibodies, and tissue or organ infiltration by lymphocytes. There are genetic basis and failure of the immune system to maintain self-tolerance to a variety of molecules, which manifest as autoimmunity over a period of time. Age of onset of the syndrome may range from early infancy to adulthood, new onset of autoimmunity of the given syndrome can manifest thoughout life. We report a case of an adolescent female with endocrine and non-endocrine manifestation of APS, starting at a very young age of 7 years with nephritis and hypertension as an unusual association.
  - 204 37
A temporal skin lesion
Alexandra Targan, Morteza Khodaee
May 2020, 9(5):2500-2501
DOI:10.4103/jfmpc.jfmpc_359_20  
Epidermoid cysts are very common and therefore relevant to Family Medicine physicians in the primary care setting. Epidermoid cysts can undergo transformation if they become infected or ruptured, resulting in keratin granulomas. Importantly, these may be misdiagnosed or confused with malignancy and should be differentiated histologically after excision if a presumed epidermal cyst has an atypical presentation. In this article we are reporting a case of temporal keratin granuloma as a result of an epidermoid cyst rupture in a middle-aged man.
  - 178 36
Diagnostic dilemmas in Epstein-Barr virus hepatitis mimicking autoimmune hepatitis: A case report
Krithiga Ramachandran, Reshu Agarwal, Chhagan Bihari, Vikram Bhatia, Ekta Gupta
May 2020, 9(5):2502-2504
DOI:10.4103/jfmpc.jfmpc_98_20  
We report a case of 55-year-old female with chief complaints of fever and deranged liver function tests, diagnosed as autoimmune hepatitis (AIH) and under immunosuppressive therapy for two years. Following the failure in clinical improvement, she was started on anti-tubercular therapy (ATT). While investigating the underlying etiology, virological markers for Hepatitis A to E were found to be negative with plasma Epstein-Barr virus (EBV) viral load of 5 log10copies/ml. Additional investigation of the liver biopsy showed Hodgkin's lymphoma (HL). The patient was initiated on chemotherapy but eventually succumbed to the illness. This case report underlines the dilemma in the initial diagnosis of AIH and the importance of considering hepatic involvement of EBV as one of the differential diagnosis among clinically suspected AIH cases not responding to immunosuppressive medications.
  - 273 52
Ulcerated oral lichen planus of the lower lip, common disease with the uncommon presentation: A case series
Satya Ranjan Misra, Pavitra Baskaran, G Maragathavalli
May 2020, 9(5):2505-2508
DOI:10.4103/jfmpc.jfmpc_19_20  
Dermatologic diseases are often associated with oral manifestations and sometimes the oral lesions are the sole presenting features of the disease. Diagnosing a dermatologic disease based on its oral manifestations is a challenge, especially in the absence of associated cutaneous lesions. Lichen planus is a common dermatologic disease that affects the oral mucosa in the adult population. While some patients have concomitant oral and cutaneous lesions, the oral lesions are persistent and seen for years together even after the cutaneous lesions have healed. Herein, we present two cases of oral lichen planus seen as an ulcerated lesion on the lower lip which is an uncommon manifestation of this otherwise common disease.
  - 235 47
The 3 Ds of geriatric psychiatry: A case report
Kartik Singhai, Navratan Suthar, Pratibha Gehlawat
May 2020, 9(5):2509-2510
DOI:10.4103/jfmpc.jfmpc_221_20  
The three Ds of geriatric psychiatry—delirium, dementia, and depression are common and challenging diagnoses among elderly. Delirium is often difficult to diagnose and is an independent risk factor for morbidity and mortality in older adults. Dementia also affects a significant number of older adults and is associated with delirium, depression, frailty, and failure to thrive. It is well known that depression too increases with increasing age. These three syndromes can exist simultaneously in the same patient, and often confer increased risk for each other, especially in the geriatric population. Early identification, classification, and differential diagnosis are important at the primary care level for the timely management of these common problems of old age. We present a case of concurrent findings and complexity in the medical literature.
  - 269 59
Allopurinol: Sorrow to the marrow
UR Raaju, Siddharth Gosavi, K Sriharsha
May 2020, 9(5):2511-2513
DOI:10.4103/jfmpc.jfmpc_249_20  
Allopurinol is a xanthine oxidase inhibitor used in management of chronic gout. It acts by reducing the amount of uric acid by inhibiting purine metabolism. A middle-aged hypertensive female who was on allopurinol for 7 months presented with generalized weakness and exertional dyspnea. Investigations revealed pancytopenia: normocytic normochromic anemia (Hb-3.2g/dL, TLC-3400/mm3) and severe thrombocytopenia (Platelets-1000/mm3) with mild hepatosplenomegaly and grade 2 medico renal disease with normal cardiac status. Nutritional, hemolytic and infective causes were ruled out. She was transfused with fresh whole blood, platelets, administered empirical antibiotics and started on steroids. Initially, she responded to treatment but later developed an episode of convulsions with anuria and succumbed to leukopenic sepsis secondary to hypo/aplastic anemia probably due to allopurinol. Allopurinol is used extensively in the management of chronic gout and is well tolerated due to its safety profile. But we here report a case of allopurinol induced aplastic anemia leading to the demise of a patient. Allopurinol though safe needs careful monitoring.
  - 325 79
Kounis syndrome: A rare case
Ashok Sunder, Bijaya Mohanty, Abha Singh
May 2020, 9(5):2514-2516
DOI:10.4103/jfmpc.jfmpc_355_20  
Allergic angina and allergic myocardial infarction are ubiquitous diseases covering a wide spectrum of mast cell activation disorders, which are associated with acute coronary syndromes and are referred to as ''Kounis Syndrome''. Here, we report a case admitted with dyspnea and mild chest heaviness secondary to bee sting, later diagnosed as Kounis syndrome.
  - 221 55
Plausible impact of forward head posture on upper cervical spine stability
Eric C P. Chu, Fa Sain Lo, Amiya Bhaumik
May 2020, 9(5):2517-2520
DOI:10.4103/jfmpc.jfmpc_95_20  
The cervical spine is responsible for allowing mobility and stability to the head and neck. Any deviation to the center of gravity of the head results in an increase in cantilever loads, which can be particularly damaging to the upper cervical joints. Excessive neck bending also exaggerates stretching through the cervical spine and all of the spinal structures below. It has been reported that forward head posture (FHP) can cause a multitude of disorders including cervical radiculopathy, cervicogenic headaches and cervicogenic dizziness. Most of these conditions manifest with clusters of painful symptoms and spine dysfunctions. The purpose of this case study is to describe the radiographic imaging considerations and to illustrate the potential impacts in symptomatic adults with FHP. We randomly selected radiographs of three individuals with FHP who had undergone cervical adjustment for cervical pain. The occipito-axial (C0-C2) and atlanto-axial (C1-C2) joints were assessed via the C0-2 distance from the C2 base to the McGregor line (Redlund-Johnell criterion) and the Ranawat C1-2 index, in addition to subjective radiographic parameters. By comparing the radiographs of before-and-after intervention of each patient, a regressive joint spacing was observed from both indices. Such a long-lasting stretching concordant with FHP was assumed to be hazardous to joint stability. A definite conclusion, however, cannot be drawn due to the small sample size and a lack of convincing measurements.
  - 325 75
Intramuscular pyrethroid with organophosphorus (cypermethrine 3% + quinolphos 20%) mixed poisoning, its clinical presentation and management
Mohammad Firoz Nizami, Chandra B Sharma, Bhoopendra Singh, Rishi T Guria
May 2020, 9(5):2521-2523
DOI:10.4103/jfmpc.jfmpc_16_20  
Organophosphorus compounds are absorbed by any route including intramuscular injection. Pyrethroid compounds are less toxic for human but in combination with organophosphates, its toxic effect potentiates due to inhibition of its metabolism. In this case report, a 40-year-old female patient presented with acute onset of pain abdomen, recurrent vomiting, and excessive salivation followed by altered mental status, on evaluation her clinical findings were suggestive of organophosphorus poisoning. Her treatment was started with injection atropine, anti-emetics, and adequate parenteral rehydration. After regaining consciousness, the patient confessed that she had taken herself intramuscular injection of pesticide which contained 3% cypermethrine plus 20% quinolphos. It was further confirmed by a very low level of plasma cholinesterase level. Intramuscular injection acted as a depot that leads to prolong intoxication and in the due course of illness, she also developed delayed onset intermediate syndrome that was managed appropriately.
  - 208 39
Mural Unicystic Ameloblastoma mimicking Odontogenic Cyst
Karthika Panneerselvam, B Kavitha, Elavenil Panneerselvam, Anantanarayanan Parameswaran
May 2020, 9(5):2524-2527
DOI:10.4103/jfmpc.jfmpc_178_20  
Unicystic ameloblastoma is considered a less aggressive variant of ameloblastoma with clinical and radiographic features mimicking a cyst. Herein, we present a case of unicystic ameloblastoma in a 20-year-old female who was clinically and radiographically diagnosed as an odontogenic cyst. Unicystic ameloblastoma and its subtypes are reviewed with special emphasis on the mural variant. The main aim of this case report is to highlight (1) the need of including an odontogenic tumor in the differential diagnosis of the unilocular, well-circumscribed radiolucent lesion by the clinicians (2) importance of serial sectioning of the specimen to identify the mural component if any present, and (3) following resection as the mode of treatment.
  - 271 53
Pregnancy-associated myocardial infarction following elective caesarean section for two previous caesarean sections and myomectomy
Adaeze Chidinma Oreh, Etin-osa U Imagbenikaro, Aderemi M Adelaja, Lawrence Ezeogu
May 2020, 9(5):2528-2530
DOI:10.4103/jfmpc.jfmpc_225_20  
A 39-year-old woman, gravida 4, para 2 + 1 (2 alive) for elective second repeat caesarean delivery on account of two previous caesarean sections and one open myomectomy. Following the caesarean section, she developed sudden cardiac failure and was transferred to the intensive care unit for mechanical ventilation support. Congestive cardiac failure secondary to non ST segment elevation myocardial infarction (NSTEMI) was subsequently diagnosed following an electrocardiogram (ECG), echocardiography, and cardiac enzyme assay. The presented case demonstrates the importance of skilled delivery and efficient referral services in developing countries to minimize poor maternal and fetal outcomes in pregnancy-related heart disease.
  - 207 38
Triple A syndrome (Allgrove syndrome) – A journey from clinical symptoms to a syndrome
Prakarti Yadav, Deepak Kumar, Gopal K Bohra, Mahendra K Garg
May 2020, 9(5):2531-2534
DOI:10.4103/jfmpc.jfmpc_237_20  
Triple A syndrome (Allgrove syndrome) is characterized by a triad of specific features, namely, alacrimia, adrenal insufficiency, and achalasia cardia. It is a rare autosomal recessive disorder. In the present study, an 18-year-old boy was presented with complaints of decreased tears, darkening of the skin, difficulty in walking and standing up from sitting position, and difficulty in swallowing liquids. Adrenal insufficiency, alacrimia, achalasia, and neurological manifestations were confirmed with relevant laboratory investigations. His condition improved with steroids and artificial teardrops. However, a vigilant eye of the clinician for clinical clues of syndromic manifestation will help in early diagnosis and proper management.
  - 245 40
Scrub typhus manifesting with intracerebral hemorrhage: Case report and review of literature
Mudit Kotwal, Esha Vaish, KK Gupta, Ahmad Ozair
May 2020, 9(5):2535-2537
DOI:10.4103/jfmpc.jfmpc_284_20  
Scrub typhus (ST), hitherto absent from many parts of India, is now recently being recognized as a significant cause of morbidity and mortality throughout the country. Its diverse clinical presentations, low of the index of suspicion by the treating physician, and lack of diagnostic testing in many parts of the country result in delayed treatment, leading to a host of complications. We here report such a complication, where ST manifested with a large intracerebral hemorrhage, of which, to the best of our knowledge, only nine cases have been reported in the English language worldwide. Family physicians, who are the often first point of contact for treatment of febrile illness, as ST typically manifests, need to be aware of this entity to prevent such catastrophic consequences.
  - 236 51
A rare etiology behind isolated lateral rectus palsy: Scrub typhus
Ahmad Ozair, Vivek Kumar, D Himanshu, Vivek Bhat
May 2020, 9(5):2538-2540
DOI:10.4103/jfmpc.jfmpc_287_20  
Scrub typhus (ST), a zoonotic disease, is currently being recognized as a significant contributor to the changing landscape of infectious diseases in India. As one of the important causes of febrile illness, in many parts of the country, general practitioners need to include it as part of the workup for cases of fever of unknown origin. While very amenable to early treatment with a simple regime of doxycycline, delayed diagnosis can result in a spectrum of complications. We report here one such complication of a case of ST manifesting with isolated lateral rectus palsy, which, to the best of our knowledge, has been reported only thrice in the world previously. Family physicians also need to be aware of the availability in India of affordable serological testing for ST that is useful for rapid and inexpensive diagnosis, leading to timely treatment.
  - 238 50
Hypomagnesaemia induced hypocalcemia mimicking as acute exacerbation of COPD—Rare cause of a common presentation: A case report
Shankar Roy, Mahendra Meena, Nisha B Dhoot, Ravi Kant
May 2020, 9(5):2541-2543
DOI:10.4103/jfmpc.jfmpc_314_20  
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterized by limitation in airflow. Most of the exacerbations are due to respiratory infections, some are due to environmental pollution. Hypocalcaemia( of any etiology ) is one of the rare causes of acute exacerbation. Here we are reporting a case of severe hypocalcaemia induced bronchospasm, presenting as acute exacerbation in a diagnosed case of COPD. 61 years old female patient, home maker by occupation and from a rural background and low socio-economic status with past history of chronic exposure to household wood smoke has presented to us with acute exacerbation of COPD. Her reports showed significant hypocalcaemia, hypomagnesaemia and low parathyroid hormone Her symptoms were controlled adequately only after correcting the hypocalcemia in addition to the standard COPD management.
  - 286 43
Desmoplastic ameloblastoma: A case report
Shruthi K Patil, Neethu Telagi, Mukund R Nair, B R Ahmed Mujib
May 2020, 9(5):2544-2547
DOI:10.4103/jfmpc.jfmpc_322_20  
Desmoplastic ameloblastoma (DA) is a rare variant of ameloblastoma, accounting for approximately 4 to 13% of ameloblastomas. It is uncommon, aggressive in nature, and there are high chances of misdiagnosis. Clinical and radiographical features are similar to fibro-osseous lesions of jaw. We reported a case of 35-year-old male patient of DA.
  - 194 45
Persistent cough: An unexpected diagnosis
Suman K Panda, Bhagyalakshmi Satyanarayan, Satish K Prasad, Binu Koshy
May 2020, 9(5):2548-2551
DOI:10.4103/jfmpc.jfmpc_41_20  
Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer death globally. Esophageal squamous cell carcinoma (ESCC) accounts for 70%–90% of esophageal cancers worldwide, 5% are adenocarcinoma, and 5% represent rare malignancies and metastases from other organs. We present a case where a 54-year-old lady, with multiple readmissions for persistent dry cough and respiratory symptoms, turns out to be an esophageal malignancy. CECT thorax revealed an enhancing wall thickening of the esophagus with paraoesophageal fat stranding, mediastinal lymphadenopathy, and subsegmental right lobe atelectasis, suggestive of a probable esophageal malignancy. An upper gastrointestinal endoscopy showed a circumferential esophageal growth which on biopsy and histopathological examination turned out to be a moderately differentiated squamous cell carcinoma of esophagus.
  - 222 58
Teneligliptin-induced hair loss: A case report
Prabhat K Agrawal, Ashish K Gautam, Nikhil Pursnani, Akankshi Agarwal
May 2020, 9(5):2552-2554
DOI:10.4103/jfmpc.jfmpc_65_20  
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the common phenotype of hyperglycemia secondary to various pathophysiologic mechanisms that include reduced insulin secretion, decreased glucose utilization, and increased glucose production. Individuals suffering from Type 2 DM (T2DM) tend to be at a higher risk for the development of both micro as well as macrovascular complications. Management strategy includes an armamentarium of drugs and lifestyle modifications. 35 years old male diagnosed with T2DM was started on a fixed-dose combination of 20 mg Teneligliptin and 1 g metformin once daily. After consuming this dose for a month, he observed no reduction in his blood sugar levels and consequently escalated the dose to twice daily without any consultation or supervision. Subsequently, on next visit OPD his blood sugar was controlled, however, he complained of hair loss from the scalp. This complaint was resolved with the discontinuation of Teneligliptin.
  - 261 49
Post-traumatic diaphragmatic hernia: Diagnostic dilemma in primary care
Nagasubramanyam Vempalli, Sireesha Reddy Konda, Nidhi Kaeley, Bharat B Bhardwaj, Subodh Kumar
May 2020, 9(5):2555-2557
DOI:10.4103/jfmpc.jfmpc_160_20  
Diaphragmatic hernia (DH) is a common condition following blunt trauma to upper abdomen and is also a commonly missed diagnosis. Its early anticipation in post-traumatic setting is very important to avoid any further life-threatening sequelae. X-ray chest with a nasogastric tube is a simpler way to diagnose this condition. CT scan is a gold standard tool to confirm diagnosis. Due to wide availability of ultrasound (US) in emergency room (ER), this tool will decide the correct way of further evaluation avoiding unnecessary delays in management. We present a case of a diaphragmatic hernia followed by blunt injury abdomen with multiple herniated abdominal contents successfully managed by early intervention.
  - 208 40
Massive gastric distension due to signet-ring cell gastric adenocarcinoma
Ali Zakaria, Fizan Khan, Shehbaz Ahmad, Issam Turk, Jay Levinson
May 2020, 9(5):2558-2561
DOI:10.4103/jfmpc.jfmpc_170_20  
Chronic massive gastric distention is a rare condition that can occur due to an underlying obstruction or dysmotility. Gastric outlet obstruction (GOO) is often the culprit that can manifest as the result of the luminal, mural, or extrinsic compression. Gastric adenocarcinoma can rarely manifest as massive gastric distention due to partially obstructing mass or peptic stricture. Severe and fatal sequelae may develop, if early detection and appropriate intervention are delayed, such as gastric decompression, endoscopic evaluation and/or surgical resection. Herein, we present a case of a 60-year-old male who presented with progressive worsening of nonspecific symptoms over the 8-month period. He was found to have remarkable massive gastric distention on imaging which was chronic in etiology secondary to GOO due to metastatic signet-ring cell gastric adenocarcinoma.
  - 188 35
Uncommon presentation of scorpion sting at teaching hospital
Y K L. Pradeep, Vijay K Bhogaraju, Monika Pathania, Vyas K Rathaur, Ravi Kant
May 2020, 9(5):2562-2565
DOI:10.4103/jfmpc.jfmpc_310_20  
Scorpion envenomation is a major public health problem in tropical and sub-tropical countries, especially in Africa, Middle East, Latin America, and India. Even though most of the scorpion envenomation are harmless, it is generally seen with a set of clinical features, such as pain, edema, numbness, and tenderness in the area of the sting but rarely have serious clinical sequelae with involvement of vital organ systems like cardiovascular system and respiratory system leading to fatal manifestations like acute pulmonary edema, acute heart failure, and acute respiratory distress syndrome (ARDS). Here we present a case of a 19-year-old village boy who developed myocarditis and cardiogenic shock following scorpion envenomation, which was successfully treated with vasopressors, non invasive ventilation, and other supportive care.
  - 286 52
Trichobezoar without a clear manifestation of trichotillomania
Akhilesh Jain, Aditi Agrawal, Anil K Tripathi, Roovendra K Bansod, Garima Jain, Kuldeep S Yadav
May 2020, 9(5):2566-2568
DOI:10.4103/jfmpc.jfmpc_11_20  
Trichophagia is a compulsive condition characterized by eating hair, mostly seen in adolescent females. Persistence of ingestion of hair over many years results in the formation of trichobezoar. Surgical intervention is often needed in the management of large trichobezoars. We present a case of a 23 year old female with trichophagia which led to the formation of gastric trichobezoar. The patient reported with complaints of pain in abdomen for past 1–2 years, and loss of appetite and vomiting post meals for 6 months. On detailed examination, a diagnosis of trichobezoar was formed which was removed by laparotomy with gastrotomy under general anaesthesia. Psychiatric evaluation revealed a history of fluctuating mood symptoms during her childhood and depressive symptomatology presently without any associated urge of plucking hair and subsequent gratification. Hence, the management of the disease requires proper liaison between the surgeon, psychiatrist, and caregivers of the patient; and regular psychiatric follow-up and treatment of the underlying psychopathology to prevent the recurrent formation of bezoar.
  - 218 38
Down syndrome presenting with different hematological manifestations: A case series of four cases
Darilin Shangpliang, Biswajit Dey, Jonali Das, Pakesh Baishya, Vandana Raphael, Yookarin Khonglah
May 2020, 9(5):2569-2572
DOI:10.4103/jfmpc.jfmpc_326_20  
Children with Down syndrome (DS) are found to have an increased risk of developing various hematological disorders. Particularly, they have an increased predisposition to acute leukemia, predominantly the myeloid type known as myeloid leukemia of Down syndrome (ML-DS). The major morphological subtype is acute megakaryoblastic leukemia. Approximately 10% of the neonates with DS show a unique disorder known as transient leukemia or transient abnormal myelopoiesis (TAM). Their clinical and morphological features are indistinguishable from acute myeloid leukemia (AML); however, they regress spontaneously within the first few months of life. Here we present a series of four cases with different hematological conditions in children with DS. Of the four cases, two presented with AML-M7, one with TAM, and one case was diagnosed as AML-M2 subtype. This case series highlights the spectrum of hematological disorders in children with DS. Although the majority of the case studies show that TAM and AML-M7 are strongly associated with DS, this case series brings to focus that other AML subtypes may occur as well.
  - 212 48
An injection abscess due to M. fortuitum: A rare case report
Shambhavi Singh, Sarika P Kombade, Salman Khan, Arghadip Samaddar, Jitu Mani Kalita, Vijay Lakshmi Nag
May 2020, 9(5):2573-2576
DOI:10.4103/jfmpc.jfmpc_71_20  
An iatrogenic injection abscess is usually easy to treat if caused by aerobic bacteria but some rapidly growing mycobacteria (RGM), namely, Mycobacterium fortuitum, M. chelonae, and M. abscessus are associated with postinjection abscess and may cause delayed wound healing. RGM can cause mild localized cellulitis or abscess to osteomyelitis following penetration injuries or unsafe injection practices. A 7-year-old girl was presented to pediatric surgery OPD with abscess formation over the right buttock. Incision and drainage from abscess were performed in OPD and pus sample was sent for aerobic bacterial culture and sensitivity. On gram stain plenty of pus cells with no microorganism were seen and growth on blood agar after 48 h of aerobic incubation at 37°C showed small off-white pinpoint, smooth butyrous waxy colonies. Smear prepared from blood agar showed uniformly stained short, slender, faintly stained gram-positive bacilli, for which acid-fast staining (1% and 20% H2SO4) was performed that showed acid-fast bacilli. The isolate was further identified by the molecular method and was confirmed to be Mycobacterium fortuitum by genotype Mycobacterium CM VER 1.0 (HAIN LIFESCIENCE, BioMerieux India Pvt. Ltd.).
  - 259 69
Rare case of gemination of mandibular third molar—A case report
S Sandeep, G Jeevan Kumar, Suraj Potdar, Rishabh Bhanot, Amit S Vathare, Rahul V C Tiwari, B Harshitha
May 2020, 9(5):2577-2579
DOI:10.4103/jfmpc.jfmpc_117_20  
Fusion and germination are the anomalies that occur due to some developmental eccentricity during the time of morpho-differentiation of the tooth bud and have a close resemblance to each other. The gemination is an attempt of the division of a single tooth into two and, hence, appears as an enlarged single tooth while the tooth count is normal when the affected tooth is counted as one. Its exact pathogenesis is ambiguous. This anomaly has been observed mostly in deciduous dentition as compared to that in permanent dentition. Gemination is rarely associated with the third molar and, hence, the terminology is arguable when this condition is seen in relation to the third molar. In the present article, a case of germination of mandibular third molar has been reported.
  - 217 35
“Dancing belly” in an old diabetic lady
Souvik Dubey, Subhankar Chatterjee, Debaleena Mukherjee, Ritwik Ghosh, Samya Sengupta, Durjoy Lahiri, Alak Pandit
May 2020, 9(5):2580-2582
DOI:10.4103/jfmpc.jfmpc_1223_19  
Movement disorder, although rare, is increasingly being recognized as the initial presenting sign of the hyperglycemic state. Although chorea-ballism has frequently been reported among diabetics, monoballism is a very rare phenomenon. While myoclonus is common, diaphragmatic myoclonus is extremely rare. Moreover, diaphragmatic myoclonus as the initial presenting manifestation has never been reported before. Herein, we report an index case of a 62-year-old previously undiagnosed diabetic lady presented with acute onset constellation of multiple abnormal movements viz. monoballism, focal myoclonus, action myoclonus, and diaphragmatic myoclonus. All of them disappeared with achieving normoglycemia. This case underscores the importance of rapid capillary blood glucose testing in any patient presenting with acute onset abnormal movements. This approach can especially be rewarding as it helps in the rapid diagnosis of a reversible catastrophe and avoiding unnecessary costly investigations.
  - 215 42
COMMENTARIES
Non-communicable diseases viewed as “collateral damage” of our decisions: Fixing accountabilities and finding sloutions in primary care settings
Sudip Bhattacharya, Ruchi Juyal, Md Mahbub Hossain, Amarjeet Singh
May 2020, 9(5):2176-2179
DOI:10.4103/jfmpc.jfmpc_202_20  
In the changing global socio-economic and epidemiological landscapes, non communicable diseases (NCDs) are affecting the health and wellbeing of populations. The burden is worse among people in low- and middle-income countries with more than 32 million deaths attributable to NCDs each year. This scenario can be explained through the concept of collateral damage, where intentional actions often lead to adverse consequences alongside the primary outcomes. Thus, NCDs can be viewed as collateral damage of unplanned urbanization, rapid globalization, fast pace of life etc., In addition, a lack of appropriate public health approaches has aggravated the situation. It is essential to build a collaborative approach engaging public health agencies to ensure that the developmental initiatives are without the threat of collateral damages and are people-friendly. This will help in reducing the burden of NCDs in primary care settings.
  - 315 51
NSAIDs and self-medication: A serious concern
Reena Doomra, Anjana Goyal
May 2020, 9(5):2183-2185
DOI:10.4103/jfmpc.jfmpc_201_20  
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used by the patients frequently for pain which may be acute, acute-on-chronic, and chronic. For the relief of pain and inflammation, some patients may take the analgesics without consulting the family physician as they can procure the same easily, not realizing that there may be adverse effects associated with regular self-medication of NSAIDs. The NSAIDs have a risk of upper gastrointestinal bleeding or perforation, which may vary between individual NSAIDs at the doses commonly used by the patients. Thus, there is a need to create awareness in the society regarding the same to prevent self-medication associated complications.
  - 340 70
COVID-19 pandemic: Clinical management protocols for cardiac disease patients at teaching institute in Western Rajasthan
Surender Deora, Pankaj Bhardwaj, Mahendra Kumar Garg
May 2020, 9(5):2186-2187
DOI:10.4103/jfmpc.jfmpc_558_20  
The world is facing the new pandemic COVID-19 caused by a novel coronavirus SARS-CoV-2. The demography and socio-economic condition are highly varied in different parts of the world. India also has braced itself to fight with this novel threat. Patients with COVID-19 may have primary cardiac involvement or may have associated cardiac disease. Therefore, the institution needs a protocol in managing cardiac patients during this pandemic.
  - 327 93
Misplaced outrage on India's new citizenship laws: Opinions of healthcare professionals
Satish Bhat, Purvish M Parikh, Suresh Bada Math
May 2020, 9(5):2188-2191
DOI:10.4103/jfmpc.jfmpc_245_20  
Historically India, that is Bharat, has shown its acceptance for refugees and the prosecuted minorities. As a civilization, India has given shelter, unbiased protection and habitation to the Christians from Syria, Zoroastrians (Parsis) from Iran, and Jews since ancient times from the Kingdom of Judah. More recently, Jews also arrived in India from Poland during the holocaust. The constitution of India provides means for meeting the aspirations of the citizen of India of diverse faiths and spiritualism. Since inception it has undergone several amendments from time to time, through a democratic process and by the elected represented in the Indian Parliament This Citizenship Amendment Act, 2019 (CAA 2019) is in continuation of the same ethos of pluralism and civilizational trait of protection for the prosecuted. Authors present their perspective on the misplace outrage on this issue specially propagated through international medical and medical journals.
  - 372 54
EDITORIALS
Banning unhealthy foods in school premises in India: Its implications and future recommendations
Sudip Bhattacharya, Raman Kumar
May 2020, 9(5):2158-2160
DOI:10.4103/jfmpc.jfmpc_431_20  
Globally, the consumer food environment is often shaped by market interests rather than emphasizing nutritional quantity and quality. In low- income countries like India, such unhealthy food products are becoming increasingly available, accessible, and affordable to the common people, especially the school going children, which is a major concern to us. Despite huge amount of evidence, public health institutions are not addressing this pressing issue adequately. It could be due to the contradictory nature of the policies. Now it will be interesting to observe the implementation of “Eat Right” campaign, new FSSAI guidelines and good food tax policy, which should take care of India's’ overall growth in terms of health and economy, both.
  - 622 112
ERRATUM
Erratum: Knowledge, attitude, and practice regarding prosthodontic rehabilitation and factors affecting the patients visiting private clinics in Riyadh, Saudi Arabia: A crosssectional study

May 2020, 9(5):2591-2592
DOI:10.4103/2249-4863.285147  
  - 151 34
INVITED ARTICLES
COVID-19: Older drugs for a novel disease—Chloroquine, hydroxychloroquine, and possible Pentoxifylline—set to start the second innings?
Pugazhenthan Thangaraju, Meenalotchini P Gurunthalingam, Shobanbabu Varthya, Sajitha Venkatesan, Eswaran Thangaraju
May 2020, 9(5):2172-2175
DOI:10.4103/jfmpc.jfmpc_422_20  
Currently no drug is approved for the prophylaxis and management of COVID 19. Lots of activities on vaccine and trials with drugs are underway. Some evidence have shown positive results using older established drug in the management of severe cases. We are also of same view and opinion to adopt some emergency measure by pharmacological intervention till a newer drug available in the market.
  - 837 182
LETTERS TO EDITOR
Medical residents: Research and publication priorities/confusions
Pugazhenthan Thangaraju, Sajitha Venkatesan
May 2020, 9(5):2583-2584
DOI:10.4103/jfmpc.jfmpc_103_20  
  - 189 60
Strengthening primary care to address workplace violence against doctors in India
Rachit Sharma, Md Mahbub Hossain, Priyanka Pawar
May 2020, 9(5):2585-2586
DOI:10.4103/jfmpc.jfmpc_149_20  
  - 274 40
Innovative mental health initiatives in India: Training and hand-holding of primary care doctors
Pinki Tak, Jitendra Rohilla, Shazia Hasan
May 2020, 9(5):2587-2588
DOI:10.4103/jfmpc.jfmpc_464_20  
  - 169 34
Is there antibody-dependent enhancement in SARS Coronavirus 2?
Rohit Kumar, Nitin Gupta, Parul Kodan, Ankit Mittal, Manish Soneja, Naveet Wig
May 2020, 9(5):2589-2590
DOI:10.4103/jfmpc.jfmpc_540_20  
  - 286 82
ORIGINAL ARTICLES
Awareness and knowledge of tobacco associated risk of development of oral cancer and oral potentially malignant disorders among patients visiting a dental college
Vidya Kadashetti, KM Shivakumar, Minal Choudhary, Swati Patil, Madhuri Gawnde
May 2020, 9(5):2244-2247
DOI:10.4103/jfmpc.jfmpc_181_20  
Introduction: Cancer is considered as a serious health problem in public with an increasing number of cancer patients reported every year hence public health awareness/knowledge on oral cancers oral potentially malignant disorders (OPMDs) and their risk factors is crucial for prevention and early detection of OPMD and it is important to prevent transformation of oral cancer. Materials and Methods: A cross-sectional survey with an interviewer-administered questionnaire was conducted. The questionnaire consists of relevant questions to ascertain sociodemographic information, awareness, and knowledge of Oral cancer and OPMDs, and their associated risk factors, and participants exposure to risk factors. Subjects above the age of 20 years (n = 200) were randomly selected, and the questionnaires were administered by the interviewer while they were waiting for treatment. Results: Results showed lack of awareness for OPMDs based on the evaluation of the questionnaires for sociodemographic data. Conclusion: Awareness about oral cancer is relatively significant; however, for OPMDs, awareness is low in our study and the subjects were unaware of the risk factors. So a high level of public awareness and knowledge of OPMDs should be brought to people via mass media as it is a very effective source of information. Early detection of oral cancer is the most effective means to improve survival and to reduce morbidity.
  - 260 71
Small group discussions as an effective teaching-learning methodology for learning the principles of family medicine among 2nd-year MBBS students
M Roshni, A Rahim
May 2020, 9(5):2248-2252
DOI:10.4103/jfmpc.jfmpc_1228_19  
Teaching methodology has a great impact on the learning outcomes in an undergraduate's education. Objectives: 1. To assess the effectiveness of small group discussions (SGD) over lecture in learning the principles of family medicine among 2nd-year MBBS students. 2. To assess the perception of students on SGD over lecture in learning principles of family medicine among 2nd-year MBBS students. Materials and Methods: This medical education, quasi-experimental study was conducted at a medical college in north Kerala. Study subjects were the 2nd-year MBBS students of this college. They participated after giving informed consent and were divided into two groups using serial roll number. The study was conducted for 2 months after getting ethical clearance. Study tools included PowerPoint presentation slides, literature regarding principles of family medicine, structured questionnaire, and question paper for posttest. Statistical analysis was done with an independent sample Z-test and Mann-Whitney test, using SPSS 20 software. Results: SGD show a definite advantage over lecture-based learning in improving the attention span of students, understanding the principles of family medicine, and recall. The scores for the overall learning experience was found to be significantly higher for SGD. Evaluating the effectiveness of training on the Kirkpatrick model showed that learners show better satisfaction and learning in small groups. Conclusion: Students strongly preferred SGD over lectures as the teaching-learning methodology for principles of family medicine. SGD is a more effective instructional tool in improving the attention span of students, understanding the principles of family medicine, and recall. The overall learning satisfaction was found to be significantly higher with SGD for learning the principles of family medicine.
  - 337 78
Seroprevalence of Toxoplasma, Rubella, CMV and HSV infection at a teaching hospital: A 7 year study from North India
Anju Dinkar, Jitendra Singh
May 2020, 9(5):2253-2257
DOI:10.4103/jfmpc.jfmpc_176_20  
Objectives: The present study was aimed to find seroprevalence in different age group population to explore the burden of TORCH (toxoplasma, rubella virus, cytomegalovirus [(CMV] and herpes simplex virus [HSV]) infection in the North Indian Population. Materials and Methods: It is a retrospective study carried out in the Microbiology Department, Institute of Medical Science, Banaras Hindu University (IMS, BHU), a tertiary care centre of North India. The blood samples of the suspected population of either sex or age group from different departments were analysed over a period of 7 years. The samples were tested for TORCH infections by the IgM ELISA kit following the manufactures instruction. Results: Out of total 4044 samples, 1353 (33.46%) cases were seropositive with maximum cases from the obstetrics and gynaecology department 39.46%. The highest seropositivity of TORCH (43.15%) was in the age group 15–25 years followed by 36.33% in the age group 25–35 years. This study revealed an overall male and female ratio of the total positive cases as 0.12 while it was 2.2 for pediatric cases (0–15 years). The overall seroprevalence was contributed as toxoplasma 1.38%, rubella 1.14%, CMV 13.63% and herpes 17.43%. The overall seropositivity (IgM) contributed as toxoplasma gondii with 4%, rubella with 3%, cytomegalovirus with 41% and herpes simplex virus with 52%. The coinfection of HSV with CMV was most abundant with 246 cases. Conclusions: The seropositivity of toxoplasma and rubella were comparatively more in infants while CMV and herpes were more prevalent in adults. Though, the incidence of TORCH has reduced over the past few years. Furthermore, knowing the epidemiology is an important aspect to develop strategies and appropriate implementation for the prevention of infection.
  - 271 66
mRNA expression analysis of interleukins 17A and 17F in bronchial asthmatic patients from Northern Indian population
Rashmi Pandey, Ved Prakash
May 2020, 9(5):2258-2263
DOI:10.4103/jfmpc.jfmpc_35_20  
Introduction: Asthma being a chronic inflammatory disease concerning to the airways involves genetic and environmental factors. It is known to develop a clinical condition of airway hyper-responsiveness, which induces frequent symptoms in patients such as breathlessness, chest congestion, coughing, and wheezing, particularly during night hours or during early morning hours. The cytokine, Interleukin 17F (IL17F), is important in mediating allergic reactions in the body and regulating the pathophysiology and pathogenesis of asthmatic attacks, as well as airway inflammation, respectively. The Interleukin 17A (IL17A) is involved in increasing the biosynthesis of interleukins IL-6 and IL11. In contrast, IL17F enhances the expression of interleukin IL11 and tumor growth factor, TGF-β. Methodology: Standard procedures were followed for collection and processing of blood samples from the subjects (controls and patients, 104 each), isolation of mRNA and to determine the quantities of IgE, and the interlukins (IL17A and IL17F) in the serum. The Real-time PCR and ELISA techniques were employed for synthesis of cDNA and determination of interleukins, respectively, using standard protocols. Early diagnosis of asthma is still a challenge to meet. Results: The statistical analysis of the data reflected a positive correlation between each of the interleukins (IL-17A and IL17F) and IgE (p = 0.001 and r = 0.41), (p = 0.004 and r = 0.077). The results indicated the upregulation of expression of IL17A and IL17F genes in the patients suffering from asthma. Conclusions: This study has indicated that the blood levels of IL-17A and IL17F could be utilized as viable clinical markers for early diagnosis, timely treatment, and proper management of asthma.
  - 251 54
Assessment of oral health status and inflammatory markers in end stage chronic kidney disease patients: A cross-sectional study
Lokesh Sharma, Devina Pradhan, Rahul Srivastava, Manas Shukla, Omveer Singh, Pratik
May 2020, 9(5):2264-2268
DOI:10.4103/jfmpc.jfmpc_101_20  
Aim: To assess the oral health status and inflammatory markers in end stage chronic kidney disease (CKD) patients. Objectives: To study and compare oral health status of end stage CKD patients with the control group (matched health individuals) and to study and compare inflammatory biomarkers in study and control groups. Materials and Methods: A cross-sectional study was conducted among 50 patients of end stage CKD and 50 matched healthy individual, who were taken as control in the study. Convenience sampling technique was used. Oral health status was recorded by using WHO proforma (2013). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP ) were also measured in the both groups. These are inflammatory markers which show systemic inflammation. Statistical analysis was done by using IBM SPSS Statistics-version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Results: The study revealed that patients on dialysis going for transplantation have evidence of increased inflammation as indicated by raised CRP values. Conclusion: The present study concludes that the oral hygiene of the patients is deteriorated who are having chronic kidney disease. Good oral and dental care in CKD patients can improve the transplant outcomes.
  - 284 66
Clinico-biochemical profile of sick children with severe acute malnutrition
Dhilip Kumar, Sunil Kumar Rao, Tej Bali Singh
May 2020, 9(5):2269-2272
DOI:10.4103/jfmpc.jfmpc_1236_19  
Objective: Severe acute malnutrition (SAM) classified as edematous and marasmus, however, Kwashiorker represents the most severe phenotype of edematous malnutrition. The aim of this study was to describe the clinico-biochemical profile in sick children with severe acute malnutrition. Materials and Methods: This is a descriptive cross-sectional study, which included children aged 6 to 60 months, fulfilling the World Health Organization (WHO) criteria of severe acute malnutrition. We collected data on demography, anthropometry, history, and clinical examination. Investigations included arterial blood gas analysis, serum electrolytes, calcium, serum albumin, and blood sugar.P value < 0.05 was considered significant. Results: One hundred twenty-two children with SAM were recruited, out of which 65 (53.27%) had edematous malnutrition and 57 (46.7%) had nonedematous malnutrition. Out of total children, 90 (73.77%) were discharged from hospital, 18 (14.7%) died, and 14 (11.4%) were left against medical advice. Out of 122 children with SAM, edematous children were younger (25.7 vs. 34.5 months,P= 0.002). Children with edematous malnutrition were more likely to have pneumonia (P = 0.04), acute gastroenteritis (P < 0.001), hyponatremia (P = 0.04), metabolic acidosis (P = 0.005), and hypocalcemia (P = 0.006) when compared with nonedematous children. Edematous malnutrition has 1.3 and 1.4 times more risk of death and leave against medical advice (LAMA) respectively as compared to nonedematous malnutrition. Mortality was higher in edematous malnutrition (12, 66.6%) than nonedematous malnutrition (6, 33.3%). Conclusion: Edematous malnutrition was commonly prevalent in 1 to 3 years of children and clinical and biochemical abnormalities frequently co-exist with edematous malnutrition.
  - 254 53
Knowledge, attitude and practice towards early screening of colorectal cancer in Riyadh
Sulaiman A Alshammari, Hanan A Alenazi, Hotoon S Alshammari
May 2020, 9(5):2273-2280
DOI:10.4103/jfmpc.jfmpc_290_20  
Background and Aims: Colorectal cancer (CRC) is a common cause of mortality worldwide. It is preventable, treatable when detected early. The aim of this study is to assess knowledge, attitude and practice (KAP) of the participants toward CRC and its early screening, and identify the sources of information on the subjects. Methods: We conducted a cross-sectional study on the people 40y old and above at the primary care clinics at King Saud university medical city (KSUMC) in Riyadh. The estimated sample size was 245 subjects whom we requested to complete a self-administered Arabic questionnaire, which consisted of three parts. These were: 1. Demographic data, 2. KAP toward CRC, its early detection. 3 sources of information of the public about colorectal cancer. Results: A total of 231 subjects participated; (54.5%) were male (mean age = 50.7 ± 9.8). About 47% of the participants heard about cancer screening, and 45% knew that colonoscopy is used for such purposes. Another 24.2% were aware that occult blood in the stool test is a method of early detection of colon cancer. About 40% to 50% of the subjects were knowledgeable about hazardous factors and cautioning symptoms for CRC. Only 6.5% of the subjects did an early screening for CRC, but 82.9% would do it if their doctor advised them to do so. Conclusion: The participant's knowledge and early checkups of CRC are inadequate. They would undergo early screening if their doctors advised them to do so. It is time to develop a national policy for CRC screening involving primary care doctors and utilizing social media to improve people's information.
  - 441 63
Knowledge and attitude of basic life support skills among female school teacher in Al-Madinah, Saudi Arabia
Amal S Alhejaili, Riyadh A Alghamdi, Sami A R Al-Dubai
May 2020, 9(5):2281-2285
DOI:10.4103/jfmpc.jfmpc_320_20  
Background and Objectives: Basic life support (BLS) is the care provided by first responders in case of cardiac or respiratory arrest in order to save someone's life. This study aimed to assess the knowledge and attitude of BLS skills among female school teachers in Al-Madinah. Materials and Methods: This cross-sectional study was conducted among 302 female teachers in 24 governmental school Al-Madinah city in 2019 by using a self-administrated questionnaire. T-test and ANOVA test were used to compare mean knowledge scale across variables. Results: The majority aged 41–50 years (46%). Only 30.5% had completed cardiopulmonary resuscitation (CPR) training and 73.9% had trained more than 2 years ago. Most of them (94.7%) wanted more training in CPR. The main reason to attend CPR training was to avoid unnecessary death (48.7%). The mean knowledge scale was (5.63 ± 1.49). There was a significant difference in the knowledge score between those who had observed CPR and those who had not observed CPR (P = 0.045). Conclusion: The knowledge and skills of BLS were low among female school teachers. Teachers' attitude toward CPR training was positive.
  - 246 51
Study of the role of regular physical activity on promoting hedonism and eudaimonia in breast cancer survivors
Arezou Kiani, Behzad Behzadnia, Hossein Jafarizadeh
May 2020, 9(5):2286-2290
DOI:10.4103/jfmpc.jfmpc_331_20  
Background: Individuals who have completed cancer treatment may have psychological and physical challenges. Participating in regular physical activity is considered as one of the most important factors for improving postcancer experience. Aims: The aim of this study was to examine the effect of participating in physical activities on hedonism and eudaimonia among breast cancer survivors. Methods: The research method was a semi-experimental design in the form of time-series using two experimental and control groups. 42 breast cancer survivors participated in this study in Urmia. Data using motives for activation of hedonism and eudiamonia (HEMA) were gathered before the intervention program (pre-test), at the end of intervention (the first post-test), and two weeks after the first post-test (the second post-test). For data analysis, descriptive and inferential statistics (T-test, Chi-square, and repeated measures ANOVA) were used. Result: Repeated measures ANOVA analysis in the three different periods of pre-test, post-test, and a month later post-test showed that changes in the mean score of hedonism and eudaimonia motivation were not similar in the two groups and indicated the improvement of dialysis adequacy in the intervention group compared with the control group. Conclusion: Generally, the results showed that participating in regular physical activity is an effective intervention on enhancing the motives for hedonism and eduaimonia in breast cancer survivors.
  - 236 48
Clinical profile of poisoning due to various poisons in children of age 0–12 years
Diganta Saikia, RK Sharma, Kole V Janardhan
May 2020, 9(5):2291-2296
DOI:10.4103/jfmpc.jfmpc_365_20  
Background: Majority of childhood poisonings are unintentional. The incidence of poisoning in children has been shown to be reduced by a significant amount. But to develop effective prevention strategies, the state health care planners need better information on the number and types of poisonings, circumstances in which they occur, and how serious the problem is. Objective: To study the clinical profile of poisoning in children. Methods: A hospital-based cross-sectional study was carried out among children aged 0–12 years with the history of poisoning. Detailed history, clinical examination, and details of poisoning was obtained. Data was analyzed using proportions. Results: Majority (77.8%) belonged to the age group of 1–5 years and were males (65.4%). Household chemicals were ingested in 83 cases out of 153, (54.25%) and in 147 cases (96.1%), poisonous substance was easily accessible to victim. In 144 out of 153 cases (94.1%), poisonous substance was accidentally ingested by the child itself, 131 out of 153 cases (85.6%) occurred at home, while 18 (11.8%) cases occurred in home surroundings. Of the 153 cases, 2 patients (1.3%) presented with the history of diarrhoea, 12 patients (7.8%) in altered sensorium, 6 patients (3.9%) had fever, 16 patients (10.5%) presented with cough, 37 patients (24.2%) presented with excessive secretions from mouth. 31 patients (20.3%) presented with vomiting without blood staining and 12 patients (7.8%) had blood stained vomiting as their chief complaint. Mucosal injury was noted in 41 cases (26.8%). Conclusion: Poisoning was common in males. Household chemical was most commonly ingested. Majority children had domestic poisoning and self-unintentional.
  - 269 61
Acceptability and outcomes of foreskin preservation for phimosis: An Indian perspective
BS Balaji, Tarun John K. Jacob, MS Gowri
May 2020, 9(5):2297-2302
DOI:10.4103/jfmpc.jfmpc_49_20  
Aim: Understanding the Indian perspective, effectiveness, and acceptability of prepuce conservation in children with phimosis. Circumcision is performed and recommended far too often for nonphysiological phimosis. Will a less radical approach be acceptable in the subcontinent? Method: A two-arm study with the first arm as KAP (knowledge, attitude, and practice) study (n = 502). The second arm recruited deserving boys (n = 47) with symptomatic phimosis (see inclusion criteria). Betamethasone ointment was applied twice daily over the foreskin and gently massaged to stretch the phimotic band. Those who failed were offered lateral preputioplasty or circumcision. Religious beliefs influence attitude and practice and these were looked at with subgroup analysis. Results: Most (85%) knew that circumcision was not the only treatment for phimosis. Though many parents (93%) knew the importance of foreskin cleanliness, few practiced it. The success of the steroid application was 81% (n = 38/47). Eight underwent preputioplasty. Minor discomfort as morbidity was noted. All parents were able to completely retract the foreskin of their children by the end of one month and were happy about the cosmetic result. Conclusions: KAP data on foreskin health is not available in the subcontinent, and this is a landmark study. Religious belief and community identity play a strong role in decisions related to foreskin preservation. Prepuce hygiene and knowledge about the usefulness of the foreskin is poor. The combination of medical and surgical methods of conserving the prepuce was effective. A high rate of success and the non-mutilating cosmetic result of prepuce preservation were acceptable to these parents.
  - 318 45
An institution-based study to assess the prevalence of Nomophobia and its related impact among medical students in Southern Haryana, India
Arvind Mengi, Abhishek Singh, Vikas Gupta
May 2020, 9(5):2303-2308
DOI:10.4103/jfmpc.jfmpc_58_20  
Background: Inappropriate usage of mobile phones is very hazardous for school and college students as it results in poor academic performance due to the poor concentration during classes or lectures over use of mobile phones, accidents due to reduced concentration while driving, and poor social relations due to preference for mobile usage and avoiding nearby people. Aim: Considering the above facts, the present study was conducted with an aim to estimate the prevalence of nomophobia among students and interns of medical college and its negative impacts on their sleep quality, and academic performance. Methods: The present study was conducted at SHKM GMC, Nalhar, Nuh from November to December 2018 among 600 MBBS students and interns who were using mobile phones using a pretested, predesigned, and standardized questionnaire. Test results with P value less than 0.05 only were considered statistically significant. Results: Nearly two fifth of the study subjects (40.1%) were found to have nomophobic, with scores more than twenty-four. The Pearson's chi square analysis reflected that most of the academic performance variables such as decline in study habits and grades, reduced concentration, and coming late for classes have a statistically significant (P = 0.000) association with nomophobe score. Conclusion: In conclusion, a significant burden of mobile phone addiction and a tendency for impaired control that compromises the health and wellness were prevalent in medical students. Measures need to be taken to address this challenge in view of the current era of growing information technology.
  - 294 64
Hematological malignancies in relation with ABO blood group at a teaching hospital, Varanasi, India
Sandip Kumar, Nivedita Mahto, Anju Bharti, Lalit P Meena
May 2020, 9(5):2309-2312
DOI:10.4103/jfmpc.jfmpc_1245_19  
Background: There has been enormous progress in the diagnosis and treatment modalities of leukemia, but its pattern and prevalence vary throughout India. This inter-regional variation may be due to geographic, cultural or racial variation or maybe due deficiency in case of notification, especially in rural areas. Objective: The aim of our study is to determine the prevalence of different types of hematological malignancies with the ABO blood group at a teaching hospital in Varanasi, India. This cross-sectional study of 77 cases was conducted during 2016–2017 at a tertiary care center. We analyzed the age, sex, subtype of leukemia, blood group, clinical features, and laboratory parameters of patients. Age ranged between 1 year and 81 years with a male to female ratio of 1.9:1. A total of 66.3% of patients were suffering from acute leukemia and 33.7% from chronic leukemia. The most common blood group was B positive (44.8%) but no significant association was found (P= 0.822). Fever (76.6%) and generalized weakness/easy fatigability (46.75%) were common complaints, whereas pallor (68.8%) and splenomegaly (51.9%) were common signs. Cases were from 23 districts of eastern Uttar Pradesh and western Bihar. The majority of the cases (70.12%) were from 8 districts (Jaunpur, Varanasi, Azamgarh, Ballia, Bhadhoi, Gazipur, Kaimur, Rohtas) of Uttar Pradesh, India and Aurangabad district of Bihar. Acute leukemia is more prevalent than chronic leukemia with more male preponderance. Acute lymphoblastic leukemia (ALL) were commonly found in children, acute myeloid leukemia (AML) was found in both children and adults. Chronic Myeloid Leukemia (CML) and chronic lymphocytic leukemia (CLL) mainly noted in adults. Unclassified acute leukemia was seen mainly in children and young adults. Anemia was more severe in acute conditions and thrombocytopenia was also more in acute leukemia. The most common blood group was B positive.
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Post-crash emergency care: Availability and utilization pattern of existing facilities in Aligarh, Uttar Pradesh
Urfi , Najam Khalique, Anees Ahmad, Syed Taheer Ahmad
May 2020, 9(5):2313-2318
DOI:10.4103/jfmpc.jfmpc_1251_19  
Context: Road traffic injuries is estimated to be the ninth leading cause of death across all age groups globally. People in need of trauma care, after a road crash, are most likely to survive if they receive definitive care within the first hour (Golden hour) after the crash. Essential prehospital care includes prompt communication, treatment, and transport of injured people to formal healthcare facilities. Aims: To assess the availability and utilization pattern of existing facilities for post-crash emergency care in Aligarh. Settings and Design: The present study was undertaken on two National highways- NH-91 and NH-93 and the connecting bypass roads of Aligarh district of Uttar Pradesh. Subjects and Methods: All the individuals who met road traffic accident (RTA) between the earmarked areas from 1st October, 2018 to 30th September, 2019 and reported for treatment (either on their own or brought by relatives, passersby, ambulance or police) to the selected hospitals were included in the study. Statistical Analysis Used: Data presented in the form of frequency tables and percentages. Results: Out of 665 patients interviewed during the study period, 556 (83.61%) patients were males and 109 (16.39%) were females with M: F ratio been 5.10:1. Among the first responders, 448 (67.36%) were lay persons and 42 (6.31%) were police personnel. 261 (39.25%) of patients received help within 10–30 min of RTA. Use of toll-free no. was limited to 265 (39.84%) patients. Ambulance was the mode of transport in 155 (23.30%) of RTA cases. 589 (88.58%) of patients reported to Government hospitals. Conclusions: Post-crash emergency care is in nascent stage in Aligarh district of Uttar Pradesh. Toll free numbers and ambulances are available but proper utilization and quality of care is lacking. Lay person is the most important personnel in improving the post-crash care.
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Evaluation and comparison between smartphone and photomicrography based whole slide imaging
Shruthi K Patil, Mukund R Nair, AB Manjunath, B R Ahmed Mujib
May 2020, 9(5):2319-2323
DOI:10.4103/jfmpc.jfmpc_18_20  
Context: In recent years, a new concept has emerged at the forefront of slide-based diagnosis and telepathology. This is the concept of whole slide imaging. This has very recently also been tried with smartphones using complex software for photo analysis and stitching. This study is aimed to evaluate and compare the use of Jenoptik photomicrograph camera and smartphone camera-based whole slide imaging (WSI) for various microscopic preparations and slides. The study also uses a commonly available IOS smartphone device, a commonly available phone to microscope attachment, and the most commonly used Adobe Photoshop software for all stitching purposes. Aim: To evaluate and compare smartphone and photomicrography-based whole slide imaging. Subjects and Methods: The study was conducted at the Department of Oral Pathology and Microbiology in Bapuji Dental College and Hospital, Davangere. The samples included in this study are 10 slides of routine hematoxylin and eosin stain slides and 10 ground section slides of teeth and bone samples. Continuous photographs of the entire slide were captured using an IOS device and a Jenoptik camera attached research microscope at 10× magnification. The photographs were stitched using Adobe Photoshop 2017 software to obtain a whole slide image. Then, two observers analyzed the whole slide image for a possible diagnosis and thus compared the efficiency of both the methods. Statistical Analysis Used: The statistical Chi-square test and analysis of variance (ANOVA) H test were done using Statistical Package for the Social Sciences (SPSS) 2010 Software. Results: Percentage of measure of agreement was 79.5%, 83.7% and 86.3%, 89.1% for the whole slide images taken in the smartphone and photomicrograph and analyzed by Observer 1 and Observer 2, respectively. Conclusions: In this study, it can be seen that the WSI by research microscopes is better than that with a smartphone and a compound microscope but still both the methods are equally good and can be followed with accurate results.
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Levels and determinants of knowledge about chronic migraine diagnosis and management among primary health-care physicians in ministry of health, Jeddah 2019
Mohammed Ahmed Aljunaid, Hussain Hassan Jamal, Anas Ahmed Mubarak, Wedad Bardisi
May 2020, 9(5):2324-2331
DOI:10.4103/jfmpc.jfmpc_266_20  
Background: Chronic migraine (CM) poses a significant burden for patients, and it has multiple diagnostic and managemental challenges, particularly among primary health-care physicians (PCPs). Objectives: The objective of this study is to assess the levels of knowledge regarding CM diagnosis and management among PCPs and to explore the factors associated with poor knowledge. Methods: A cross-sectional study was conducted among PCPs working at primary health-care centers in Jeddah, Saudi Arabia. A semi-structured questionnaire comprising 20 items related to CM diagnosis and treatment was used. Results: A total of 136 PCPs responded (aged 36.4 ± 8.1, 68.4% were females). The overall median (P75) knowledge score was 13.0 (15.0), and 45.6% of the participants had adequate knowledge (score > median). The majority of respondents (>50%) could not identify the lower limits of CM duration, the necessity of identifying at least eight migraine attacks in a month, the importance of managing medication overuse, and the indication of topiramate as the most efficacious agent in CM. Young physicians (23–35 years), bachelor graduates, general practitioners (GPs), and those having ≤5 years of experience scored lower than their peers. Physicians with 6–10 years of clinical experience were independently more knowledgeable than less-experienced PCPs (odds ratio = 5.09, P = 0.006). Conclusion: Knowledge regarding CM diagnosis and treatment was inadequate among PCPs, which could detrimentally influence the patterns of referral to secondary health-care facilities. Given these observations, it is recommended to amend the academic curricula for medical students/GPs and adopt continuing medical education programs for PHPs to support their levels of knowledge.
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Prevalence and determinants of geriatric depression in North India: A cross-sectional study
Bhavna Sahni, Kiran Bala, Tejinder Kumar, Akash Narangyal
May 2020, 9(5):2332-2336
DOI:10.4103/jfmpc.jfmpc_357_20  
Context: “Aging India” has become a phenomenon of public health importance. Old age is beset with physical, mental, and social challenges. Among these, mental health concerns are least prioritized in most of the developing countries with depression being the most common and easy to screen. Aims: To assess the burden of geriatric depression and determine its association with sociodemographic factors such as religion, age, gender, education, marital status, and family type. Settings and Design: A cross-sectional study was conducted in July-August 2018 in village Kirpind in north India. Methodology: 162 subjects aged 60 years or more, both males and females participated in the study. Depression was assessed using the 15-item Geriatric Depression Scale and those with a GDS score >=5 were categorized as depressed. Statistical Analysis Used: Pearson's Chi-square test and binary logistic regression were used for analysis. Results: Nearly 59.3% of subjects had no depression, 33.9% were suffering from mild to moderate depression whereas 6.8% were severely depressed. The mean age of subjects was 69 (±7.4) years. Chi-square test was used to study the association of various factors with depression and only female gender showed a positive statistical association. On using binary logistic regression analysis, being female again emerged to be a significant predictor of depression while no other factor was significantly associated with the outcome. Conclusions: There is a need to sensitize primary care workers and physicians to identify and manage geriatric depression early. It also points towards the need for multicentric, longitudinal studies evaluating various aspects of geriatric depression.
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Effects of Ramadan fasting on serum lipid profile
Perveen Akhtar, Amir Kazmi, Tarun Sharma, Aradhna Sharma
May 2020, 9(5):2337-2341
DOI:10.4103/jfmpc.jfmpc_550_19  
Introduction: Ramadan is the ninth month in the lunar Islamic calendar and lasts for about 29–30 days. It is mandatory for all adult individuals of the Islamic faith to fast during the holy month of Ramadan. During this period, healthy Muslims do not eat or drink (i.e., total abstinence from food and fluids) and refrain from tobacco, daily from pre-dawn until dusk (21) . Very few studies in the recent years have been conducted on this subject and for primary care physicians, it is of great help in understanding the physiological changes that occur in various populations with different rituals in Muslims. Materials and Methods: The present study included healthy adult male Muslim volunteers from different mosques in and around Jammu city. The number of subjects in the study was 100. Blood samples from all 100 subjects were collected twice during the study—once in the week prior to the beginning of Ramadan and then again in the last week of Ramadan (from 98 subjects as 2 subjects opted out). Following biochemical parameters were taken into consideration: (a) Serum total cholesterol (b) Serum triglycerides (c) Serum HDL cholesterol. Results: It was observed that compared to pre-fasting levels, total cholesterol (TC) and triglycerides (TG) were significantly decreased (P = 0.000) and high-density lipoprotein cholesterol (HDL-C) level had significantly increased (P = 0.000). Conclusion: This study showed a reduction in total cholesterol and triglycerides along with a rise in levels of HDL-C, which had beneficial effects on lipid profile post Ramadan fasting period.
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Awareness, medication adherence, and diet pattern among hypertensive patients attending teaching institution in western Rajasthan, India
Deepti Mathur, Surender Deora, Atul Kaushik, Pankaj Bhardwaj, Kuldeep Singh
May 2020, 9(5):2342-2349
DOI:10.4103/jfmpc.jfmpc_193_20  
Background and Objectives: Hypertension is an important disease of public health concern. Awareness and medication adherence with diet modification have an important effect on the control of blood pressure and its associated morbidity and mortality. Therefore, this study was conducted to assess the awareness of hypertension, medication adherence, and dietary pattern in hypertensive population of western Rajasthan. Materials and Methods: The study was hospital based cross-sectional. Blood pressure measurements were taken in a sitting position in right arm after a 5-min rest using nonmercury sphygmomanometer and required cuff size. A prevalidated and pretested questionnaire for the assessment of awareness of hypertension was used. Results: Out of the total 384 patients, the majority of the patients were males (62.5%). There was a statistically significant difference found in awareness of hypertension among rural and urban patients. Nonadherence to antihypertensive medications was seen more in males (60.0%) as compared to females (40.0%). The most common reason for nonadherence was found to be forgetfulness (27.6%) followed by poor knowledge about the hypertension and ignorance of long-term treatment (22.9%). Out of the total hypertensive patient studied, 54.9% were taking normal salt intake and 45.1% of the subjects were found to be taking excess intake of salt. Interpretation and Conclusions: In the present study, good awareness about hypertension was found with urban patients. Among all the variables, education and employment status showed a positive and significant association with awareness. The most common reason of poor adherence was found to be forgetfulness behavior followed by poor knowledge and lack of awareness about hypertension.
  - 299 64
Awareness and perceptions regarding taxation and health warnings related to sugar-sweetened beverages and the factors associated with these among visitors of a general out-patient clinic in Bhopal, India
Soumya K Mandal, Arun Mitra, Yash Alok, Shubhanshu Gupta, Anindo Majumdar
May 2020, 9(5):2350-2358
DOI:10.4103/jfmpc.jfmpc_226_20  
Introduction: Although increased taxation on sugar-sweetened beverages (SSBs) and warning labels on their packaging have been successful in other countries, India has not implemented these. It is imperative to understand the user perspectives before implementation, regarding which almost no information exists. Objectives: To assess the awareness and perceptions of people regarding taxation and health warnings on SSB packaging, and to determine the factors associated with these. Methodology: This cross-sectional study was conducted in the general out-patient clinic of a public tertiary care hospital in Bhopal, India, between April and November 2018. Patients and accompanying persons ≥15 years of age and attending the clinic were included. Severely ill patients were excluded. Exit interviews were conducted after the clinical consultation using a pre-tested semi-structured interview schedule. Data were analyzed using IBM SPSS version 21. Results: Out of the 503 participants interviewed, three-fourths had never heard of taxes on SSBs and had never seen any health warning on SSB packaging. Most participants (96.6%) wanted some health warning to be present on the packaging. Majority of them (69.3%) wanted both textual and pictorial warnings. Close to half of those who wanted a pictorial warning to be present opined that it should occupy <25% of the surface area of the packaging. Multivariable analysis showed that participants aged <25 years and females were not in favor of tax increment. Conclusion: Government policies should also focus on user perspectives and preferences before deciding to increase tax on SSBs or introducing mandatory health warnings on SSBs.
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Fabrication of a low-cost strap for holding precordial electrodes on the hirsute chest
Himel Mondal, Tanmoy Chattopadhyay, Shaikat Mondal, Debasish Das, Sairavi Kiran Biri
May 2020, 9(5):2359-2363
DOI:10.4103/jfmpc.jfmpc_292_20  
Background: Reusable suction-cup electrodes are used for recording a 12-lead electrocardiogram (ECG) in resource-limited settings. These electrodes may easily detach if those are attached on a hirsute chest. Additionally, the suction pressure may cause erythema and pain. Aim: The aim of this study was to develop a low-cost strap for holding the suction-cup-based precordial electrodes and to test its applicability to the recording of ECG. Materials and Methods: A scrap rubber tube was cut in size so that it can cover all the precordial electrode positions. Slit openings (electrodes can be inserted through these opening) were made on this rubber strap. A cloth and a hook-and-loop fastener were used to make an adjustable fastener. ECG was recorded first on 16 non-hairy males with electrodes placed on the chest with the strap and then with electrodes attached by suction. After that, ECG was recorded on 16 males with hirsute chest first with the electrodes placed with the help of the strap and then with suction (without strap) on the shaved chest. Results: The outcome of this study is a low-cost ECG chest strap for a hirsute chest. Both the negative and positive QRS voltages in six precordial leads recorded with electrodes placed with the strap were similar to that of suction-attached electrodes in both non-hairy and hirsute chest. Conclusion: Developed rubber chest strap can be made with minimal cost and expertise in any resource-limited settings. This would help in recording the ECG of a patient with a hirsute chest. This prototype strap has scope for further improvement.
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Proximal fibular osteotomy: Alternative approach with medial compartment osteoarthritis knee – Indian context
Jayanta K Laik, Ravi Kaushal, Ritesh Kumar, Somit Sarkar, Manish Garg
May 2020, 9(5):2364-2369
DOI:10.4103/jfmpc.jfmpc_324_20  
Context: Osteoarthritis knee is a common degenerative disorder for which various treatment modalities are available. Our aim was to evaluate the functional outcome and effectiveness of proximal fibular osteotomy (PFO) in patients who are unwilling to undergo total knee arthroplasty or high tibial osteotomy (HTO). Aims: To evaluate functional outcome of medial compartment osteoarthritis managed with PFO, clinically as well as radiologically in Indian study settings. Settings and Design: Study was done at the Department of Joint Replacement and Orthopedics, Tata Main Hospital, Interventional prospective cohort study. Subjects and Methods: Consecutive samples fulfilling study criteria were evaluated preoperatively with visual analogue scale (VAS) and preoperative functional status was assessed. The functional outcome was measured by pre- and postoperative VAS, Tegner Lysholm Knee score; X rays were used to measure pre- and postoperative “Medial joint space” and “Femoro-tibial angle (FTA).” Statistical Analysis: All the data were tabulated, and then analyzed with appropriate statistical tools “MedCalc. Chi-square test, test of significance and student paired and unpaired T-test were used. Results: There was a significant improvement in VAS score, Tegner Lysholm score postoperatively as compared to the pre-perative scores. FTA and medial joint space were also increased postoperatively. Conclusions: PFO is a good surgical alternative for medial compartmental osteoarthritis of the knee with an excellent functional outcome. A simple surgical procedure, non-requirement of specialized instruments, and low cost of surgery are some of the advantages for patients who do not want to undergo HTO or total knee replacement (TKR).
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Prevalence of periodontitis and caries on the distal aspect of mandibular second molar adjacent to impacted mandibular third molar: A guide for oral health promotion
Prashant Gupta, Shantala R Naik, L Ashok, Tanya Khaitan, Anjani Kumar Shukla
May 2020, 9(5):2370-2374
DOI:10.4103/jfmpc.jfmpc_37_20  
Objectives: Pericoronitis of mandibular third molars is commonly encountered in our day to day practice. Most of the case extraction becomes mandatory. This study was carried out to find the incidence of periodontitis on the distal aspect of the second molar adjacent to impacted third molar. Materials and Methods: A total of 400 patients were included in the study. Patient selection was randomly done. Whoever came with a chief complaint of pain in the third molar area were included in the study. They were evaluated both clinically and radiographically with an orthopantomogram. Patients' age, gender, type of impaction, presence or absence of bone loss, type of bone loss, and presence or absence of caries was evaluated radiographically and noted. Results: Periodontitis was observed in 39% of the cases and caries in 26% of the cases. Conclusions: These percentages are alarming and could be used to prophylactically extract the impacted third molars and thereby promoting the oral health of the individual.
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Diagnosis and risk stratification of coronary artery disease in Yemeni patients using treadmill test
Nouradden N Aljaber, Shanei A Shanei, Sultan Abdulwadoud Alshoabi, Kamal D Alsultan, Moawia B Gameraddin, Khaled M Al-Sayaghi
May 2020, 9(5):2375-2378
DOI:10.4103/jfmpc.jfmpc_1231_19  
Background: Coronary artery disease (CAD) is a common medical problem that remains a great cause of morbidity and mortality. Based on clinical manifestation, CAD span from chronic stable angina to acute coronary syndrome (ACS), which encompasses (1) unstable angina (UA), (2) non-ST-elevation myocardial infarction (NSTEMI), and (3) ST-elevation myocardial infarction (STEMI). Objective: This study was conducted to describe the risk stratification and prognosis of CAD in Yemeni patients undergoing an exercise stress test. Method: A retrospective descriptive study involved the records of 302 patients who undergoing exercise stress testing by the Bruce protocol of Treadmill (TMT). Results: Out of 302 patients, the mean age was 43.29 years, (range, 22–70 years), and 79.80% were males. The majority of patients (86.75%) were normal. Most of the affected patients (82.50%) were males. All of the affected peoples were more than 30 years old with predominance in more than 50 years old. Results showed that 45% of the positive (+ve) patients were in high-risk group, and 55% were in intermediate and low-risk groups. Conclusions: CAD affects males more than females. It affects patients older than 30 years and predominates in elderly patients. Most of the affected patients were in the high, intermediate, and low-risk groups and rarely were in the very high-risk group.
  - 235 44
Heart rate recovery in normal and obese males with and without parental history of cardiovascular disease
Rahul , Narsingh Verma, Mayank Agarwal, Pravesh Vishwakarma, Arvind Kanchan, Pravesh Kumar
May 2020, 9(5):2379-2383
DOI:10.4103/jfmpc.jfmpc_132_20  
Background: Parental history of cardiovascular disease (CVD) and obesity is associated with delayed parasympathetic nervous system reactivation after exercise. Heart rate recovery (HRRe) after a minute of exercise is inversely related to cardiovascular events. Aim: To determine the effect of body mass index (BMI) and parental CVD history on HRRe in apparently healthy young Indian males. Method: The present cross-sectional experimental study involved 100 males, aged18–25 years. Subjects were divided into two equal groups based on the parental CVD history—(i) Parental CVD history present, and (ii) Parental CVD history absent. Each of these groups were further divided into two equal sub groups based on BMI—(a) BMI <23kg/m2, and (b) BMI ≥25 kg/m2. Participants exercised on the treadmill at variable speeds and grades to achieve their target HR (THR). THR was calculated by adding 60–90% HR-reserve (HRR) in their basal HR (BHR). HRR was calculated by subtracting maximal HR (MHR) from BHR. MHR was estimated by the formula: 208–0.7 × age. The HRRe was calculated by subtracting the immediate postexercise HR with the HR after a minute of rest postexercise. ANOVA with post-hoc Tukey was applied and a P value ≤0.05 was considered as statistically significant. Results: HRRe value was significantly lesser in subjects having a positive parental history of CVD than the subjects with no parental history of CVD, irrespective of BMI. Also, HRRe was inversely related to BMI. Conclusion: Not only obesity but also a family history of CVD impacts the recovery of HR after vigorous-intensity exercise.
  - 427 92
Preparedness of dental under-graduate students towards practicing endodontics in rural and remote areas of India
Vijay Parashar, Nitin Jhunjhunwala, Aiyana Parthi, Vaibhav K Singh, Kishan Agarwal, Tejas M Kulkarni
May 2020, 9(5):2384-2387
DOI:10.4103/jfmpc.jfmpc_220_20  
Background: Undergraduate students can provide valuable opinions and suggestions for modifying the educational program for the enhancement of learning. Therefore, the aim of this study was to explore the preparedness of undergraduate dental students with regard to practice endodontics in the rural and remote areas of India. Materials and Methods: The present cross-sectional questionnaire-based study was conducted among dental undergraduates (interns). The survey was conducted among the students of 3 private dental colleges. For the data collection, a close-ended questionnaire was designed to test the knowledge for performing endodontic therapy, root canal therapy (RCT), attitude, and behavior of performing these procedures in the rural set-ups. Unpaired t test and one way analysis of variance (ANOVA) was used to compare the significant difference based on demographics and Pearson's correlation was applied to find the associations among knowledge, attitude, and behavior of study participants. The level of significance was set at below 0.05. Results: A total of 79 students participated, out of which 22 respondents were males (27.8%), and 57 were females (72.15%). Overall mean knowledge scores for endodontics was 9.72 ± 2.19, and the scores of female students were slightly higher than males, whereas the attitude and behavior were better in males but there was no statistical significant difference between both the genders (P > 0.05). A statistically significant positive correlation was observed between attitude and behavior on practicing endodontics in rural settings among study subjects (P < 0.05). Conclusion: These findings highlights the necessity for taking initiatives to enhance the community-based dental education programs by various dental colleges for improving oral health care access for rural and isolated populations.
  - 224 42
Blood lead levels among the occupationally exposed workers and its effect on calcium and vitamin D metabolism: A case-control study
Jyoti Batra, Ajit Thakur, Shrawan Kumar Meena, Lakbir Singh, Jainendra Kumar, Deepak Juyal
May 2020, 9(5):2388-2393
DOI:10.4103/jfmpc.jfmpc_271_20  
Introduction: Lead (Pb) is one of the major occupational pollutants present in the developed and developing countries including India. In humans, Pb can cause a wide range of biological effects depending upon the level and duration of exposure. The goal of this study was to evaluate the blood lead levels (BLLs) and its associated effects on vitamin D and calcium metabolism, among the workers occupationally exposed to Pb. Materials and Methods: This cross-sectional, case-control study was conducted for a period of 18 months (January 2017 to July 2018). A total of 160 subjects were included in the study (80 in each, Pb-exposed group and control group). The blood Pb levels were quantified by using an inductively coupled plasma mass spectrometry with triple quadrupole technology (iCAP™ TQ ICP-MS). Other biochemical parameters were estimated using fully automatic analyzer by RANDOX, RX-imola, Crumlin, UK and Johnson and Johnson, VITROS® ECi Q, Immunodiagnostic system, Ortho Clinical Diagnostics, New Jersey, USA. Results: Upon analysis it was observed that serum calcium, phosphorous, and vitamin D levels were significantly decreased (8.35 ± 0.42 mg/dl, 3.07 ± 0.34 mg/dl, and 28.82 ± 10.81 ng/ml respectively;P < 0.001), whereas the BLL and serum iPTH levels were significantly increased (38.02 ± 19.92 μg/dl and 116.78 ± 19.93 pg/ml respectively;P < 0.001) in Pb exposed subjects as compared to control subjects. Conclusion: Our study results demonstrated that high BLL significantly alter vitamin D and calcium metabolism. The data extrapolated from our study emphasizes the necessity of surveillance in exposed workers. As the associated deleterious effects of Pb-exposure can be serious, we propose that a routine-periodical screening of the workers exposed to lead should be conducted.
  - 334 56
Knowledge, perceptions, and attitudes of students of health-related science colleges towards epilepsy in Taif, Saudi Arabia
Ahmed Mohamed Kabel, Shumukh Abdullah Algethami, Bayan Saaed Algethami, Abeer Saleh Alzahrani, Samiah Khalif Almutairi, Ashwaq Shaman Almutairi
May 2020, 9(5):2394-2399
DOI:10.4103/jfmpc.jfmpc_299_20  
Background: Epilepsy is one of the most common disorders that may be associated with negative attitudes among general populations. This may be due to poor public awareness and knowledge toward epilepsy. Aim: To assess knowledge, perceptions and attitudes of students of health-related science colleges toward epilepsy in Taif. Methods: This study was conducted in three health-related science colleges in Taif University. A questionnaire was distributed to students of these colleges. Results: More than 80% of the participants have heard or read about epilepsy. About half of them had witnessed a seizure attack. More than three quarters of the participants thought that epilepsy is a neurological disease. In total 97% of the participants stated that convulsions are the main manifestations of epilepsy. In total 77.7% of the participants selected the medical treatment and follow-up as the most effective treatment of epilepsy. More than three quarters of the participants agreed with that epileptic woman can get married and have children. About 90% agreed to work with epileptic persons and become a close friend of them. About half of the participants believed that the equal job opportunity for epileptic and normal persons should be practiced. Conclusion: The knowledge, perceptions, and attitudes of students of health-related science colleges toward epilepsy in Taif were acceptable regarding to this study. However, the negative attitudes and misconceptions still exist. Further studies are needed to determine methods of overcoming these negative attitudes and misconceptions.
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Insights of primary health care providers regarding opportunistic screening of oral cancer/precancers in Patna, Bihar
Pallawee Choudhary, Irfanul Huda, Anuradha Pandey, Naveen Kumar, Aaysha Tabinda Nabi, Rachna Raj
May 2020, 9(5):2400-2404
DOI:10.4103/jfmpc.jfmpc_301_20  
Background: Clinical opportunistic screening can be valuable for diagnosis of oral cancer/precancer prior to development of symptoms. Thus, the aim of the present study is to assess the knowledge, perceptions, and present practices of primary health care providers regarding oral cancer screening. Material and Methods: This cross-sectional questionnaire study was carried out on doctors working in primary health centres of Patna district, Bihar. A total of 10 questions in true/false or multiple choice format assessed the knowledge on oral cancer screening. Attitude and practices were evaluated by seven questions each on a 5-point Likert scale. Unpaired t-test and one-way ANOVA followed by post hoc test was applied to determine the significance difference between the mean scores of knowledge and demographic variables. The significance level was set at below 0.05. Results: The total mean knowledge scores were 6.5 ± 2.17. Response analysis showed that regarding opinion on only 28% health care providers agreed or strongly agreed that they have adequate knowledge regarding detection of oral cancer. It was found that 44.7% never/rarely examined the oral cavity of the patient. Only 14% and 16% doctors aid with the cessation of habits and advised dietary changes in patients with precancerous lesions/conditions, respectively. Conclusion: Capacity building of primary care physicians is very crucial for a successful screening program. The present study reveals that the training activities of healthcare providers in oral screening need to be reinforced.
  - 229 42
Assessment of monitoring and online payment system (Asha Soft) in Rajasthan using benefit evaluation (BE) framework
Nitin Kumar Joshi, Pankaj Bhardwaj, Praveen Suthar, Yogesh Kumar Jain, Vibha Joshi, Balwant Manda
May 2020, 9(5):2405-2410
DOI:10.4103/jfmpc.jfmpc_48_20  
Context: e-Health programs are implemented assuming that e-health/digital health can prove beneficial but pieces of evidence for assessing the actual benefits of e-health programs are lacking. Aims: To utilize the benefit evaluation (BE) framework to assess Asha Soft, which is an online payment and performance monitoring system initiative taken by Rajasthan. Settings and Design: BE of Asha Soft in Rajasthan. Methods and Materials: BE of ASHA Soft was done using scoping review with consultation exercise. The rationale behind using this methodological framework is to contextualize knowledge of the current state of understanding within BE framework practice contexts. The themes used for data compilation and analysis were based on three broad dimensions of BE framework namely, health information technology quality, use, and net benefits. Results: The state of Rajasthan has been the first in the country to start an online system of payment and monitoring of ASHA workers, through Asha Soft. It has administrative and supportive functions. Its simple and easy to use graphical user interference helps users to make accurate data entries and obtain desired monitoring and analytical reports. It has attributed to the availability of data on various parameters which help decision-maker to decide about the performance of ASHA worker and has brought a positive impact on the work performance of ASHAs. This online payment and monitoring mechanism has argumented motivational level and intention of use. The program has optimally utilized available human resources and no apparent monetary cost was involved in developing this software. Conclusions: This scoping study using the BE framework has provided evidence on the potential benefits of Asha Soft adoption in Rajasthan. It is recommended that future in-depth assessment of other e-health initiatives could be undertaken to guide the decision making.
  - 330 68
Sonographic assessment of kidneys in patients with hypertension co-existed with diabetes mellitus and ischemic heart disease
Moawia Gameraddin, Walaa Ismail Musa, Suzan Abdelmaboud, Sultan Alshoabi, Kamal Dahan Alsultan, Bushra A Abdelmalik
May 2020, 9(5):2411-2415
DOI:10.4103/jfmpc.jfmpc_50_20  
Background: Hypertension is one of the major world health problems. Ultrasonography plays a useful role in the assessment of morphologicalchanges at the kidneys in hypertensive patients. Aim: To assess sonographic findings of the kidneys in hypertensive patients’ co-morbidities with type 2 diabetes mellitus and ischemic heart disease (IDH). Materials and Methods: This was a prospective cross-sectional study involved 100 participants with primary hypertension selected by a method of simple convenient sampling. The patients were examined using ultrasonography to assess the sonographic findings of the kidneys. The renal length, corticomedullary differentiation (CMD), and renal artery diameters were assessed. Statistical Package for the Social Sciences (SPSS version 23.0) was used in data analysis. Results: The length of the right kidney was 8.9850 ± 1.01 cm and 9.48 ± 0.98 cm for the left kidney. Among the hypertensive patients, the incidence of hypertension was highest in housewives (27%) and students (23%) as compared with the other groups. The sonographic findings were 18% affected with simple renal cysts, 7% poor CMD, and the majority had normal kidneys. Significant correlation was found between age and sonographic findings of kidneys (r = 0.21, P value = 0.033). Conclusion: Simple renal cysts, poor CMD, and stenosis of renal arteries were most common sonographic findings in hypertension. Simple renal cystshad a significant association with hypertension.
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Effectiveness of mental health community training on depression and anxiety to the health care profession working in rural centers of eastern Nepal
Pramendra P Gupta, Pallawi Jyotsana, Chris Larrison, Shelly Rodrigues, Cindy Lam, Chris Dowrick
May 2020, 9(5):2416-2419
DOI:10.4103/jfmpc.jfmpc_6_20  
Background: Depression and anxiety is the leading cause of disease burden in low- and middle-income countries. It is associated with a worse clinical course over the lifespan. This study aims the post-effect on the approach of managing depression and anxiety after the training on diagnosis and management of depression and anxiety. Methods: This is a prospective observational study done in the health care professionals who had done training on diagnosis and management of depression and anxiety from me. The participants were evaluated with the questionnaire. Results: The training was given in three parts in three different places of eastern Nepal with the health care professionals working near to those centers. There were total of 49 participants from 17 different primary health care centers. The referral rate of patients with depression and anxiety was decreased by 27% as stated by the participants as they can give psychoeducation and counseling in a very well manner after training which was lacking before training. Conclusions: Overall, the findings from the current data suggest that there is merit in continuing to evaluate and deliver community health training programs for depression and anxiety. While prevention type and personnel delivering the intervention account for aspects of the heterogeneity observed, more research is needed to identify how program completion and fidelity impact outcomes.
  - 308 41
A comparative study on knowledge and practice against malaria among Accredited Social Health Activists (ASHAs) of low and high endemic regions of Tripura, Northeast India
Purvita Chowdhury, Subrata Baidya, Debosmita Paul, Biraj Kalita, Gunendra Saikia, Sanjoy Karmakar, Sanghita Paul
May 2020, 9(5):2420-2425
DOI:10.4103/jfmpc.jfmpc_1169_19  
Introduction: This study was conducted to compare and evaluate the knowledge as well as the practice of community health volunteers, Accredited social health activists (ASHAs) in low and high malaria-endemic regions of Tripura, Northeast India. Materials and Methods: In this descriptive cross-sectional study, all ASHAs working in the randomly selected two blocks of each low and high malaria-endemic areas were included in the study. While ASHAs with less than 1-year experience were excluded from the study. The ASHAs were interviewed and information was gathered on knowledge and practice against malaria management. Chi-square test was used to identify differences in responses among the ASHAs. Results: Significant differences in knowledge of mixed malarial infection (P < 0.001) and early symptoms of malaria (P = 0.005) were observed when responses of high malaria-endemic ASHAs (HMEA) were compared to low endemic ASHAs (LMEA). With respect to malaria testing skills, 83.16% HMEA affirmed that they could perform Rapid diagnostic (RD) kit tests as opposed to 57.24% LMEA, (P < 0.001). Disturbingly only two HMEA could correctly describe the duration for Pf and Pv treatment. Conclusion: The study identifies major lacunae in the balance of knowledge and practices of ASHAs in both study areas of Tripura. Therefore,for a successful projected malaria elimination program, community-level ASHA volunteers need to have accurate malaria knowledge and management approaches irrespective of the endemicity. This study will help to understand the operational constraints and plan educational training for ASHA volunteers in malaria-endemic regions.
  - 264 60
Perceived effectiveness about endodontic practice among private general dental practitioners in Riyadh city, Saudi Arabia
Afra Hassan Elrashid, Khalid Jamal Alderaa, Hamad Abdulaziz Alissa, Waad Hamad Almadhi, Hadeel Salem Bawazir, Sarah Saleh Alsougi, Sulaiman Ali Alraffa
May 2020, 9(5):2426-2430
DOI:10.4103/jfmpc.jfmpc_129_20  
Background: Application of newer techniques in endodontics improves the prognosis and reduces the time to operate patients; hence, the present study was conducted to determine the characteristics of endodontic practice and to compare these characteristics between General Dental Practitioners (GDPs) and endodontists with regards to their years of experience in Riyadh city, Saudi Arabia. Materials and Method: A cross-sectional study was conducted among GDPs and endodontists working in private sector in Riyadh. Study subjects were chosen from 5 areas of Riyadh by stratified random sampling. A structured, pretested, closed-ended, and self-administered questionnaire consisting of 36 items was employed. Questionnaire identified different aspects of endodontic practice among participants. Information related to their behavior and perceived effectiveness, and demographic data were also collected. Results and Discussion: A total of 259 practitioners participated in the present study. The mean behavior and perceived effectiveness scores were 5.73 (71.63%) and 1.16 (58%), respectively. A total of 64 respondents (24.7%) used magnification, while 167 (64.5%) employed digital radiography/cone-beam computed tomography. Rotary instruments were employed by 170 participants (65.64%) and adjunctive activator during irrigation was utilized by 50 (19.30%) of respondents. A majority of 217 respondents (83.80%) reported that they need further training. Correlation analysis revealed that gender was significantly associated with perceived effectiveness (r = 0.136,P= 0.029). Conclusions: Behavior and perceived effectiveness of practitioners is far from satisfactory and a majority of practitioners identified the need for further training. There was a statistically significant correlation between gender and perceived effectiveness.
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CD4 cells count as a prognostic marker in HIV patients with comparative analysis of various studies in Asia Pacific region
Puneeta Vohra, Sharayu Nimonkar, Vikram Belkhode, Suraj Potdar, Rishabh Bhanot, Izna , Rahul V C. Tiwari
May 2020, 9(5):2431-2436
DOI:10.4103/jfmpc.jfmpc_137_20  
Purpose: To evaluate the correlation between CD4+ cells count with orofacial and systemic manifestations in newly diagnosed HIV seropositive patients and comparison of results with the previous studies. Materials and Methods: Hundred (100; 57 males and 43 females) newly diagnosed HIV seropositive patients, before starting antiretroviral therapy (ART) were included in the study. These patients were clustered according to CD4+ cells count into three groups: 0–200 cells/mm3, 201–499 cells/mm3, and more than 500 cells/mm3. Orofacial and systemic manifestations of these patients were recorded and correlated with CD4 cells count values. Results: There was no significant correlation found between CD4+ cells count values of males and females using independent t-test. Chi-square test showed significant correlation between the systemic manifestations and CD4+ cells count categories. Tuberculosis was found to be the most common systemic manifestation in both the genders. In addition, a significant correlation was between the CD4+ cells count and orofacial manifestations, where oral candidiasis was found to be the most common manifestation in both the genders. Conclusion: The prevalence of systemic and orofacial manifestations increases with decrease in the CD4+ cells count of HIV seropositive patients. Hence, it can be used as diagnostic and prognostic marker for immune suppression in HIV positive patients.
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Evaluation and diagnostic usefulness of saliva for detection of HIV antibodies: A cross-sectional study
Puneeta Vohra, Vikram Belkhode, Sharayu Nimonkar, Suraj Potdar, Rishabh Bhanot, Izna , Rahul Vinay Chandra Tiwari
May 2020, 9(5):2437-2441
DOI:10.4103/jfmpc.jfmpc_138_20  
Background: Use of saliva as a specimen for detection of antibodies to infectious agents has generated particular interest in AIDS research community since 1980s. HIV specific antibodies of immunoglobulin isotypes IgA, IgG, and IgM are readily found in salivary secretions. Aim and Objectives: In the present study, HIV specific antibodies were detected in saliva and serum samples of HIV patients by ELISA in confirmed HIV seropositive patients and efficacy of saliva was established in diagnosis of HIV. Methods: The 100 saliva and serum samples were collected from age and sex matched confirmed HIV seropositive subjects and 100 Healthy Controls without any infections. HIV antibodies were determined by enzyme-linked immunosorbent assay (ELISA) using Genscreen HIV 1/2 Kit. Results: The results were found to be 99% sensitive and 100% specific for saliva samples, while it was 100% sensitive and specific for serum samples. Conclusion: Saliva can be used as alternative to blood for detection of HIV antibodies as saliva collection is painless, non-invasive, inexpensive, simple, and rapid. Salivary antibody testing may provide better access to epidemic outbreaks, children, large populations, hard-to-reach risk groups and may thus play a major role in the surveillance and control of highly infectious diseases.
  - 337 54
Burnout syndrome among southern region orthopedic surgeons, Saudi Arabia
Mohammed Lafi Shaher Al-Otaibi, Sultan Abdulrahman Alyali, Turki Khalid Alshehri, Abdullah Khalid Alshehri, Abdulrahman Abdulelah Alshahrani, Abdualaziz Ghazi Banah, Rishi K Bharti
May 2020, 9(5):2442-2447
DOI:10.4103/jfmpc.jfmpc_142_20  
Background: Burnout is known as result of long term exposing to stress. There are some factors that may cause stress in physicians: nature of work, their training, their public image, their families and themselves. The person who has burnout syndrome (BOS) seems like to have tiredness, low energy, nervousness, and mentally unstable. The aim of the study is to assess the pattern and magnitude of burnout among orthopedic surgeons in southern region, Saudi Arabia. Methodology: A descriptive cross-sectional survey was applied targeting all orthopedic surgeons in 12 hospitals all southern region, Saudi Arabia during the period from December 2018 to April 2019. Data were collected using self-administered questionnaire that was developed by the researchers. The questionnaire included personal data. Burnout was assessed using Maslach Burnout Inventory Scale. Results: A total sample of 107 orthopedic surgeons were included with their ages ranged from 25 to 65 years old with mean age of 38.1 ± 8.9 years. About 94% of the surgeons were males and 43.9% were Saudi. Generally, the surgeons recorded mean score for emotional exhaustion of 18.9 points out of 54 with mean score% of 35.1%. Regarding depersonalization, the surgeons had mean score % of 30.7% and had a score of 39.6% for personal accomplishment. Conclusions: The study revealed that all included physicians had moderate levels of burnout. Personal accomplishment was the highest level of burnout recorded. Health education sessions and periodic training is required to improve surgeons coping strategies to overcome burnout.
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Role of fractal analysis in detection of dysplasia in potentially malignant disorders
Javed Iqbal, Ranjitkumar Patil, Vikram Khanna, Anurag Tripathi, Vandana Singh, M A I Munshi, Rahul Tiwari
May 2020, 9(5):2448-2453
DOI:10.4103/jfmpc.jfmpc_159_20  
Background: Fractal analysis is, a noninvasive method, used to determine the intricate characteristics of the matter. Oral leukoplakia (OL), a potential malignant disorder, has definite propensity to turn in to malignancy. In such lesions, fractal dimension analysis (FDA) could be helpful in the early detection of malignant transformation. Objectives: To determine the efficacy of fractal dimension analysis in detecting malignancy potential of oral leukoplakia. Materials and Methods: After ethical clearance, we enrolled 121 patients in our study. Lesions were photographed before and after toluidine staining. Image J software was used to analyze fractal dimensions (FDs) of digital image and results were compared with biopsy. Results: Fractal dimension value is significantly higher in leukoplakia with dysplastic changes. FD values increase as age of patients increases. FD value in leukoplakia with different tobacco products showed more positive correlation with surti/khaini abusers. Conclusion: Fractal dimension analysis is a useful method in determination of complication in OL cases and can be used as an effective, noninvasive screening tool at primary healthcare centers for early intervention.
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Postoperative pain, edema and trismus following third molar surgery – A comparitive study between submucosal and intravenous dexamethasone
S Sreesha, M Ummar, S Sooraj, Sachin Aslam, A Roshni, K Jabir
May 2020, 9(5):2454-2459
DOI:10.4103/jfmpc.jfmpc_188_20  
Background: Third molar surgey always needs primary intervention as it can lead to various complications and pathologies. Considering other ways for postoperative anesthesia it was infered that submucosal group which showed simple injection technique and direct surgical site administration is more beneficial. It was noticed as a patient comfort method which can be the preferred as the drug of choice over intravenous route of dexamethasone injection. Introduction: Impaction of third molar is a common affliction and surgical removal is the only treatment option. The post-operative sequelae following the third molar surgery are pain, edema and trismus. The use of corticosteroids is to counteract it via various routes. Still, controversy exists in the literature regarding the administration of corticosteroids over the routes and time of administration. The purpose of this study was to compare the postoperative pain, edema and trismus following third molar surgery while using preoperative intravenous and submucosal routes of dexamethasone, in terms of pain, facial swelling, and trismus. Materials and Methods: This study consisted of 64 patients presented with mesioangular impacted mandibular third molar for surgical removal. Preoperative measurements of edema, trismus were analyzed. Postoperative pain was estimated using visual analogue scale. Edema was assessed by the extra oral facial measurements. Trismus was measured by recording the interincisal opening in millimeters. Dexamethasone was administered intravenously or submucosally according to the choice of operating surgeon and were divided into 2 groups. Results: Mean and standard deviation calculated for continuous variables. Changes in parameters was analysed using t test and Mann–Whitney U test. Here, submucosal group were reported with increased pain on the second postoperative day. On seventh postoperative day mean value turns to 0.7 ± 1 for submucosal and 0.6 ± 1.2 for intravenous group. On overall observation, intravenous group expressed statistically significant (P < 0.01) reduction in pain compared to the submucosal group during immediate and second postoperative days. Conclusion: Analyzing the previous studies, and from the experience of the present one, it could be reasonably found out that administration of submucosal dexamethasone is beneficial for overall patient compliance.
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Baseline assessment of hand hygiene knowledge perception: An observational study at a newly set up teaching hospital
Aroop Mohanty, Puneet K Gupta, Priyanka Gupta, Neelam Kaistha, Pratima Gupta, Ravi Shankar, Pradeep Kumar
May 2020, 9(5):2460-2464
DOI:10.4103/jfmpc.jfmpc_20_20  
Background: Hand hygiene plays a crucial role in preventing health-care-associated infections (HCAIs) by reducing the spread of antimicrobial resistance. But, its compliance with optimal practices usually remains low at most of our health-care settings. Aim: This study focused on one of the primordial, basic and low-cost practice of infection control. Materials and Methods: A cross-sectional observational study was conducted among medical faculty, senior residents, postgraduates, nursing faculty, ward sisters/matron, and staff nurses at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand. Data were collected on a pretested structured questionnaire distributed among the participants, which consisted of questions to assess the knowledge and perception toward hand hygiene. Results: A total of 171 health-care workers (HCWs) were assessed in this study. Overall response rate observed was 87.8% ± 11.6%. Majority of the participants were staff nurses. Approximately 55% of them had received formal hand hygiene training in the last 3 years. Overall correct knowledge seen among participants was 66.4% ± 27.5%. It was observed that in situations requiring hand hygiene, it was performed in approximately 70%–80% of the times. Alcohol-based hand rub was not available at every point of care, whereas single-use towel was not present at every sink. When monitored whether the HCW started hand hygiene activity or not, compliance was seen in only 32% of the total. Conclusion: It is now essential for developing countries to formulate the policies for implementation of basic infection control practices. As we are facing an era of multidrug-resistant pathogens that are rapidly increasing globally, and paucity of availability of new antimicrobials, it is been essential to look at the role of basic infection control practices at health-care settings and implement them at priority level.
  - 304 65
Does laparoscopic hernia repair affect the vascularity of testis?
Mahendra Lodha, Mayank Badkur, Pavan Garg, Ashok Puranik, Ramkaran Chaudhary, Mahaveer S Rodha, Satya Prakash
May 2020, 9(5):2465-2468
DOI:10.4103/jfmpc.jfmpc_203_20  
Context: Laparoscopic hernia repair, despite its safety and effectivity is related to some drawbacks. Testicular complications are uncommon but serious among them. Testicular atrophy occurs in 0% to 2% of patients after hernioplasty. Aim: In this study, we tried to evaluate the effects of laparoscopic total extraperitoneal (TEP) repair on testicular blood flow in Indian population by comparing the testicular perfusion in preoperative and postoperative status. Settings and Design: A prospective study. Subjects and Methods: A prospective study was conducted among adult male patients having an uncomplicated inguinal hernia. Preoperative and postoperative CDUS evaluation of testicular blood flow was done for each patient. Statistical Analysis Used: Data were analyzed using the SPSS (SPSS, Chicago, IL, USA) software program. Results: The resistive indexes of testicular, capsular, and intratesticular arteries of the operated and nonoperated side were similar preoperatively and did not differ ominously postoperatively. Conclusion: Laparoscopic hernia surgery does not have any significant effect on testicular blood supply and can be advocated safely without any added risk of testicular atrophy.
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The study of placentrex and hydrocortisone as an adjunct treatment in oral submucous fibrosis
Parag Kisave, Vijay Shekhar, Prasoon S Babu, Syed W U. Hussaini, Rishabh Bhanot, Abhinav Kumar, Rahul V C. Tiwari
May 2020, 9(5):2469-2474
DOI:10.4103/jfmpc.jfmpc_268_20  
Background: Submucous fibrosis with a high incidence rate in the Indian subcontinent is a devastating disease affecting the oral cavity and oropharynx. Aims and Objective: To evaluate the efficacy of injection placentrex and injection hydrocortisone in oral submucous fibrosis patients in increasing mouth opening, burning sensation, and improve the mucosal lining. Materials and Methods: We recruited 60 patients with Stage II and Stage III of the ailment, who were randomly divided into Group A and Group B. They were administered submucosal injections of hydrocortisone and placentrex along with physiotherapy and oral iron, nutrients, and B-carotene supplements over a period of 2 months. Interpretations and Results: The pinnacle rate of the incidence was found in the age group of 30 to 40 years among both the genders. Statistically significant difference (P = 0.0001), that is, 5.19 ± 1.33 in Group A and 11.69 ± 1.26 mm in Group B was noted in the mean mouth opening values. Statistically significant difference in burning sensation was noted to be better in Group A than in Group B. Discussion and Conclusion: Overall hydrocortisone seems to be a better regimen for improving the mucosal health and increasing the mouth opening as compared to placentrix regimen. Although Placentrex is better than hydrocortisone in reducing burning sensation.
  - 310 69
Human immunodeficiency virus infection amongst newly diagnosed tuberculosis patients and their clinico-radiological profile: A prospective study from Western India
Sunita Grover, Gopal Chawla, HL Parihar, Ram Niwas, Anil Saxena, Suman Khangarot, Naresh Kumar, Rajani Kumawat
May 2020, 9(5):2475-2479
DOI:10.4103/jfmpc.jfmpc_121_20  
Background: Since time immemorial tuberculosis (TB) has been and continues to be one of the most significant infections causing human disease. In tropical countries, TB remains a leading cause of death. Human immunodeficiency virus (HIV) epidemic continues to fuel this global TB epidemic. The rapid growth of the HIV epidemic in many countries has resulted in an equally dramatic rise in the estimated number of new TB cases, which present therefore the integration of HIV and TB testing at the primary level is need of the hour. Methods: A prospective study was conducted on newly diagnosed, untreated TB patients aged 15-45 year and patients were screened for HIV infection. Clinico-radiological spectrum of TB among HIV seropositive and seronegative patients was evaluated. Results: Out of a total of 307 patients screened, 17 (5.54%) were found to be HIV seropositive. Seroprevalence was found significantly (P < 0.01, χ2 9.301) more common in 26-35 year age group and higher in Extrapulmonary TB (EPTB) patients than that in pulmonary TB (PTB) patients (9.90% vs 3.4%). Fever was the most common presenting symptom for TB in HIV seropositive patients. On examination pallor (58.82% vs. 15.86%), oral ulcer (35.3% vs. 0.35%) was found more common and on chest X-ray mid-lower zone involvement and mediastinal lymphadenopathy were more common in HIV seropositive patients. Conclusion: HIV seropositivity rates among newly diagnosed TB patients aged 15-45 year was 5.54 percent. The presentation of TB was more often atypical among these patients. Thus, an integrated model of TB and HIV at primary healthcare service delivery is an efficient use of resources that would address the two very important co-epidemics and thereby result in better management.
  - 247 54
“Patient centered care in medical disinformation era” among patients attending tertiary care hospital: A cross sectional study
Ravi Kant, Poonam Yadav, Surekha Kishore, Rajesh Kumar, Neetu Kataria
May 2020, 9(5):2480-2486
DOI:10.4103/jfmpc.jfmpc_362_20  
Background and Objectives: Patient-centered care refers to the provision of care for patients' comprehensive needs, perspectives, and preferences. In health security, communication between patient and physician is the main key through which we plan and implement to threats that can affect huge population. Aim: The aim of this study was to assess the patient-centered care in medical disinformation era among patients attending tertiary care teaching hospital, Rishikesh. Materials and Methods: A descriptive cross-sectional study was planned by enrolling 240 patients attending tertiary care teaching hospital. Total consecutive sampling technique was chosen to recruit the patients for the study. Tools: Tools used were case reporting form and components of primary care index (CPCI). Results: The results show statistically significant association between chronic history of illness of patient (P = 0.02), education of patient (P = 0.008), and habitat of patient (P = 0.05) with interpersonal communication between patient and physician, and the results also show statistically significant association between accumulated knowledge (P = 0.000), coordination of care (P = 0.001), continuity belief (P = 0.000), comprehensiveness of care (P = 0.001), and first contact (P = 0.001) with interpersonal communication between patient and physician. The lowest mean percentage of patient-centered care score was observed for accumulated knowledge (65.70%) and the highest mean percentage (85.15%) score of patient-centered care was observed for interpersonal communication. Conclusions: This study concluded that patient-centered care improves interpersonal communication between patient and physician. Threats arising due to present medical disinformation era can be combat by patient-centered care.
  - 310 56
Evaluation of a faculty development workshop aimed at development and implementation of a competency-based curriculum for medical undergraduates
Amir Maroof Khan, Piyush Gupta, Navjeevan Singh, Upreet Dhaliwal, Satendra Singh
May 2020, 9(5):2226-2231
DOI:10.4103/jfmpc.jfmpc_17_20  
Introduction: Faculty development to implement competency-based medical education (CBME) is urgently needed as the Medical Council of India has implemented the competency-based curriculum this year onwards. Objectives: To evaluate a 2-day faculty development workshop in terms of: (a) increase in knowledge about CBME terminology and concepts, (b) self-reported capacity to develop and implement a competency-based module in their respective disciplines, and (c) satisfaction of the participants. Methodology: A single arm interventional study using mixed methods was carried out in which faculty members were purposively identified and requested to volunteer for a two-day faculty development workshop on the development and implementation of CBME. The workshop was evaluated (open-ended and Likert scored items) by the participants for self-reported gain in knowledge, gain in their confidence to develop and implement CBME, and level of satisfaction with respect to the components of the workshop. Quantitative data was analyzed by Wilcoxon signed rank test and Kruskal–Wallis test. Qualitative data was analyzed by doing content analysis and emerging themes have been presented. Results: Eleven faculty members attended a capacity building workshop for developing and implementing a competency-based curriculum for medical undergraduates. There was a significant improvement in their self-reported knowledge and attitude regarding the competency-based curriculum. New concepts learned fell into four domains: modification of the existing curriculum toward competency-based curriculum, knowledge of CBME, teaching-learning and assessment methods, and beneficial to the students. The participants were highly satisfied with the workshop in its current form. Conclusion: A two-day faculty development workshop can increase the knowledge and understanding of competency-based medical education and can be an important first step in the journey to more specialized training.
  - 296 94
Acute undifferentiated febrile illness: Protocol in emergency department
Vempalli N Subramanyam, Nidhi Kaeley, Manish Kumar, Subodh K Pandey, Bharat B Bhardwaj, Konda S Reddy
May 2020, 9(5):2232-2236
DOI:10.4103/jfmpc.jfmpc_214_19  
Fever accounts for around 15% of emergency visits in elderly age group and around 5% in adults. The spectrum of etiologies ranges from non-infectious to infectious etiologies. There are very few studies done in the past highlighting the approach of patients with acute febrile illness without any localizing signs and symptoms. Objectives: The aim of the study was to formulate a targeted approach for evaluation and treatment of patients with acute undifferentiated febrile illness without evidence of localizing symptoms and signs. The secondary objective was to study the etiology and final outcome of patients with acute undifferentiated febrile illness. Materials and Methods: A protocol was devised for patients aged more than 18 years, who presented in emergency department with complaints of fever without localizing symptoms or signs of sepsis over a period of 6 months from April 2018 to September 2018. Patient's data were collected retrospectively from the hospital record section. Results: A total of 212 patients of undifferentiated acute febrile illness were enrolled in the study. Maximum number of patients [n = 69 (32.5%)], presented on second day of illness. All the patients presenting within 1 or 2 days of fever experienced defervescence. Out of these 69 patients, 35 (36.4%) were investigated of which in 29 (82.2%) investigations were not found to be useful; 75 (78.1%) patients with 1 or 2 days history of fever improved without investigations. Surprisingly, 54 patients (72%) with 1 or 2 days' history of acute febrile illness experienced defervescence without the need of antibiotics. Conclusion: There is an urgent need to devise a standardized protocol for diagnosis and treatment of patients with acute undifferentiated febrile illness in order to avoid unnecessary investigations and antimicrobial use.
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REVIEW ARTICLES
Antimicrobial resistance: Call for rational antibiotics practice in India
Shivani Chandra, P P R Prithvi, K Srija, Shalini Jauhari, Alka Grover
May 2020, 9(5):2192-2199
DOI:10.4103/jfmpc.jfmpc_1077_19  
It is a well-known fact that microorganisms are developing resistance to antimicrobial drugs present in the market that is known as antimicrobial resistance (AMR). This resistance in microbes is a great matter of concern among the scientific fraternity. This review article focuses on antibiotics and their respective resistant microbes, factors that cause resistance among microbes, and consequences of AMR at global as well as Indian scenario. This article would be a helpful resource in nutshell for making the ground for discovery of new antibiotics that will be more effective toward microbes.
  - 381 95
Glaucoma blindness–A rapidly emerging non-communicable ocular disease in India: Addressing the issue with advocacy
Suraj Singh Senjam
May 2020, 9(5):2200-2206
DOI:10.4103/jfmpc.jfmpc_111_20  
Glaucoma, a leading cause of irreversible blindness, can be prevented or stabilized the progression if identified early and managed it appropriately. In India, around 12 million people suffer from glaucoma, and 1.5 million are blind due to it, so making the third most common cause of blindness. More than 75% of glaucoma are undiagnosed, which perhaps represent the submerged portion of the iceberg phenomenon of the traditional disease explanations. Though glaucoma per se does not lead to mortality, glaucoma blindness is categorized as a severe form of disability (category VI) out of seven World Health Organization (WHO) classification on the global burden of diseases. Indeed, there is a large gap between the prevailing burden of glaucoma and service being delivered about its prevention compared to other leading causes of blindness in India. Considering the magnitude of the problem as well as the severity of disability, a strong and effective advocacy is an urgent call to deal glaucoma problem in the country. For a resource-limited country, where mass population based-screening programs are not feasible, alternative methods like facility-based opportunistic screening and referring the high-risk groups for early detection and treatment should be aimed. However, glaucoma should not be screened in isolation from other eye problems. In fact, screening of any potential blinding ocular problems, including glaucoma, should be a clear mandate under comprehensive eye program of the WHO to achieve Universal Eye Health Coverages. This paper highlights the strategy inclusive of advocacy to curtail the increasing burden of glaucoma blindness in India.
  - 274 49
Role of digital therapeutics and the changing future of healthcare
Amit Dang, Dimple Arora, Pawan Rane
May 2020, 9(5):2207-2213
DOI:10.4103/jfmpc.jfmpc_105_20  
With healthcare becoming digital, patients today are more empowered than ever before. As a result, digital health solutions have become the need of the hour to keep up with an increasing number of empowered patients participating in their own treatment decisions. Digital health encompasses various platforms and systems that apply technological solutions to enhance healthcare delivery. Digital therapeutics (DTx) is one such category of digital health solutions that provides evidence-based software-driven therapeutic interventions for the prevention and management of a medical disorder or disease. This review aims to provide a comprehensive overview of DTx, its functions and applications in healthcare, and associated regulatory aspects, among others.
  - 975 178
Cancer awareness and attitude towards cancer screening in India: A narrative review
Dinesh Prasad Sahu, Sonu H Subba, Prajna Paramita Giri
May 2020, 9(5):2214-2218
DOI:10.4103/jfmpc.jfmpc_145_20  
Cancer awareness is the key to early detection and better health-seeking behaviour. Cancer is quite common in both developing as well as developed countries, but awareness is yet poor among the general population. Poor awareness may lead to poor uptake of screening modalities and delay in diagnosis. One factor that has been consistently shown to be associated with late diagnosis and treatment is a delay in seeking help for cancer-like symptoms. This paper reviews the literature on cancer awareness among the general population and attitude towards screening modalities. The poor awareness level among the Indian population shows the need for health education and sensitisation regarding cancer and its different aspects. This will be helpful in the successful implementation of health programmes related to cancer.
  - 350 72
Cognitive dysfunction in patients of rheumatoid arthritis
Neha Chaurasia, Anup Singh, Indramani L Singh, Tara Singh, Trayambak Tiwari
May 2020, 9(5):2219-2225
DOI:10.4103/jfmpc.jfmpc_307_20  
Rheumatoid Arthritis (RA) is a form of arthritis characterized by joint pain, stiffness, swelling and deformity. There has been plethora of researches in the area of rheumatoid arthritis which focused on immune system, genetic predisposition and newer treatment modalities. Researchers have also examined the cognitive decline, physical deficits and their interrelationship in patients with RA. Among several psychological aspects depression, anxiety and stress emerge as significant psychological co morbidity. RA is a multifactorial, chronic, inflammatory disease primarily affects physical functioning as well as psychological aspects. Pain, fatigue, duration of disease, disease activity and functional disability are very common in rheumatoid arthritis which is leading cause of psychological distress and functional disability. Various types of neuropsychological battery were used to assess the decline in specific areas like attention, executive functioning, visuo-spatial learning, verbal learning/memory etc. These functions were compared with other type of arthritis disease. Also, various other factors like depression, cardiovascular diseases, other systemic and chronic disease and concomitant drugs intake etc. also affected cognitive functioning in Rheumatoid Arthritis patients. The objective of this review was to identify and explore the rates and types of cognitive impairment in RA.This present review paper systematically examines and summarizes the cognition related decrement in arthritis patients. Multiple research articles between 1990 to 2018 were searched. These reviews were evaluated and synthesized using a narrative and descriptive approach.
  - 410 88
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