Journal of Family Medicine and Primary Care

: 2018  |  Volume : 7  |  Issue : 7  |  Page : 1--68

Abstract submission FMPC 2015


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 A picture is worth 1000 words: Telling the story of family medicine to the citizens

Sahadev Swain1

1General Practitioner, Luton, United Kingdom

E-mail: [email protected]

Family medicine is the holistic medical care of the individual and their family from “cradle to grave.” This is as much as an art as it is science. The effective family physicians endeavor to get the balance right and put the disease in the context of family and the society. It is difficult to explain this to the citizens when they have not experienced what the “good family physician” feel like. Telling story of family medicine through visual art will be a unique approach. In this session of a double act, the doctor-artist will describe some of his paintings highlighting different aspects of family medicine such as family, fear, curiosity, superstition, and death. The experienced general practice will link this to the facts, figures, and anecdotes from personal experience. The ultimate aim is to convince the citizen why they should demand for holistic healthcare and establishment of family physicians in their locality and exercise their right “every family deserves a family physician.”

Keywords: Citizen forum, family doctor, healthcare

 Family physicians Registry of chronic diseases in Indians study: A prospective observational study in urban family practice

Atiya Faruqui1, Denis Xavier1, Mangala Rao1, B.C. Rao1

1Department of Pharmacology, St. John's Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Family physicians RegIstry of chronic disEases in iNDianS study was a prospective observational study of treatments and outcomes in hypertension and diabetes in an urban family practice in Bengaluru. Methods: Consenting patients from 19 clinics were recruited and followed over 1 year with two interim visits. Patient characteristics, investigations, and treatments were recorded at baseline, during interim visits and at 1 year and compared with standard guidelines (JNC VII and ADA 2012). Findings: We recruited 1297 patients, and 675 (52%) completed the 1-year visit. Mean age (standard deviation) was 55.0 (±13.1), 20.49% were <45 years and body mass index was 27.10 (±5.2). 969 (80.2%) had hypertension, 693 (56.2%) had diabetes, 394 (34.8%) had dyslipidemia, hnd 159/916 (17%) had all three. Cardiovascular complications at enrolment were present in 106 (IHD 78, TIA 17, and Stroke 11). Calcium channel blockers (441, 45%) was the most common antihypertensive and 579 (59.7%) used 2 or more drugs. Among patients who had both hypertension and diabetes, use of aspirin, lipid-lowering agent, and angiotensin converting enzyme inhibitors was low, at 27%, 38%, and 40%, respectively. During follow-up, physicians reported that 60% patients' visit to their physicians was as per advice. In between visits, 63% patients with hypertension got their blood pressure recorded, and 79% with diabetes got blood sugars checked. Among hypertensive patients, lipid profile, serum creatinine, and electrocardiogram were done in 61%, 57%, and 56%, respectively, over 1 year. Among diabetics, fasting blood sugars, hemoglobin A1c, and urine albuminuria were done in 98%, 71%, and 67%, respectively. Conclusion: Only about 50% of patients came for the final 1-year visit, and their management was reasonable. Educational interventions among patients would improve regular follow-up, which in turn will result in better outcomes.

Keywords: Diabetes, hypertension, management, primary care

 Comparison of prevalence of bacteria in the hands of urban and rural children and their perception on hand washing practices

Shankar Radhakrishnan, E. Manivannan

Vinayaka Missions Kirupananda Variyar Medical College, Salem, Tamil Nadu, India

E-mail: [email protected]

Introduction: Public health importance of hand washing as well as its importance in the reduction of communicable diseases such as diarrhea and acute respiratory infections have been highlighted in many studies worldwide, but still in practice it has not been implemented. Aim: To compare the prevalence of bacteria in the hands of urban and rural children and to assess their perception on hand washing practices. Methodology: A cross-sectional study was conducted on 300 students (150 urban and 150 rural) of middle school to find out the extent of germs present in hand and also the students' perception on hand washing. This was assessed by a questionnaire as well as by the collection of swab from hands and performing bacteriological culture in the laboratory. Results: In regard to students' perception about the dirty areas of the hands, it was observed that majority (86% urban vs. 62% rural) felt palm was likely to be dirtier. Almost 86% of the urban and 70% of the rural students reported that they washed hands before eating lunch, but only 8% of the urban and 0% of the rural students used soap to wash their hands. The swabs of 72% in the urban and 78% in the rural children showed potential pathogens. The most common of these was Staphylococcus aureus. In regard to the perception, there was a statistically significant difference between the urban and rural school children (P < 0.005), whereas when it comes to practice, there was no significant difference (P > 0.05). Conclusion: The hands of both the rural and urban school children were contaminated before taking food, though they washed hands before meals, they hardly used soap due to nonavailability of soap.

Keywords: Bacteria, hand washing, rural, students, urban

 Health camp profile and costing in hilly terrains, Uttarakhand, North India

B. Venkatashiva Reddy1, Arti Gupta1, Amit Kumar Singh1

1Department of Community, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar, Uttarakhand, India

E-mail: [email protected]

Background: Uttarakhand is largely a hilly state, having a diversity of disease. Due to low income, lack of knowledge, difficult terrains, and lack of proper transport, the sick population cannot visit health institutions. These ground the search for more effective ways of delivering public primary healthcare and achieve universal health coverage. Objective: The main objective of the study is to demonstrate a model to identify and manage health problems of the poor people living in hard to reach areas of Uttarakhand, through specialized health camps as an approach for Universal Health Coverage and to demonstrate a cost-effective model. Materials and Methods: The community-based health camp was organized in 2015 to address medical problems of the people of Ragdi Village, Uttarakhand. Information such as age, gender, residence, and principal diagnosis were extracted from the camp registers coded as per International Classification of Diseases 10. An estimated model specialist end cost of the health camp and a patient end cost for seeking treatment at the health facility. The cost-effectiveness analysis was done. Results: The health camp saw the attendance of 233 patients. The average distance traveled by the patients to seek treatment care was 1.3 km, standard deviation (SD) 2.1. The mean time to reach the health camp by walking was 17.2 min, SD 27.3. Overall, the musculoskeletal disorders were the most common (26.6%) followed by the respiratory (17.2%), eye (14.2%), and others. Estimated per- patient specialist end cost was 2.2 US$. Each patient end cost varied from 4 to 5 US$ for the primary and secondary care and 6–9 US$ for tertiary care. Conclusion: The health camp with specialist services is a cost-effective way to bridge the major gap in achieving universal health coverage in difficult to reach hilly areas.

Keywords: Camp, cost, health, universal

 Challenges faced in providing primordial care, Central India

B. Venkatashivareddy1, Arti Gupta2, Surya Bali1, Arun M. Kokane1

Departments of 1Family Medicine and 2Community Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

E-mail: [email protected]

Introduction: The All India Institute of Medical Sciences, Bhopal, is one of the pioneer institutes of health care in India. As we aim to shift from medical care to health care, it was important to start various community-based activities. It was important to be a care manager rather than physician only to achieve health in all aspects. Objective: We organized various public health events in our intensive field practice area. We aim to understand various obstacles in communicating with the people from the local community to recognize their health care perspective along with the generation of awareness about various common health problems. Methods: This was a community-based activity conducted in CUHA and CRHA, AIIMS, Bhopal, India. The team comprises doctors, medical social service officers, and attendants. The detailed proposal was prepared, and the necessary permission was obtained from the concerned authorities. The medical social service officers informed people of the community prior to the activities both verbally and written by house-to-house visits. All the activities were principally health education-based. Result: We faced various challenges and learned from them for the future activities in the community. Financial constraints are particularly most critical in innovative activities. In community- based activities, arranging infrastructure is a mega exercise. In addition, in the poor community, people are always busy and occupied in agriculture or daily wages activities. Most of the community activities are affected by shortage of workforce. No structured pathway of establishing community contact to deliver a message was present. There was a lack of necessities in remote area. Conclusions: We are living in an era of accelerating change. This certainly needs the transformation of the physician to the care managers. We are still searching for an appropriate method of interventions and health activities in the community.

Keywords: Barrier, community, health, local

 Nutritional status of people living with HIV/AIDS: Need for active interventions

Ravishekar Hiremath1, Shailaja Patil1

1Department of Community Medicine, BLDEA's University, Bijapur, Karnataka, India

E-mail: [email protected]

Background: Knowledge of nutrition aspects and dietary practices among the affected households significantly contributes to the worsening of HIV status. Addressing gaps in nutrition among people living with HIV and AIDS (PLWHA) is essential because nutrition plays a vital role in the care and management of HIV and AIDS as it is intrinsically linked to immune function. Objectives: (1) To assess the nutritional status of HIV patients on antiretroviral therapy (ART). (2) To assess the knowledge regarding nutrition aspects and care to be taken to stay healthy. (3) To assess their nutritional status association with various factors. Methods: One-time cross-sectional survey among PLWHA was carried out with a sample of 97 patients by means of predesigned and pretested questionnaire and the sample was collected by means of systematic random sampling technique. Results: Mean age of the study population was 38.5 ± 9.6 years and mean duration since HIV positivity was 40.19 months. Among the study population, 48% were males, 52% were females, and 70% were employed out of which 23.6% were drivers. 16.3% were illiterate, 33.7% belonged to rural areas, and 28.8% were undernourished, while 20% were overweight and 46.2% were anemic. Seventy-four percent had satisfactory knowledge regarding the general ways to stay healthy, while only 29.8% were having satisfactory knowledge regarding nutrition aspects. CD4 count and hemoglobin levels increased significantly with ART. A significantly higher body mass index was seen in individuals who were employed and those with longer duration of ART. The better-nourished respondents showed a significant increase in CD4 count compared to under-nourished after starting ART (P < 0.05). Conclusion: There is still a huge scope for increasing the PLWHAs knowledge regarding nutritional aspects. This study also shows that good nutrition has a good influence on CD4 count. This study was just a cross-sectional one, and various factors contribute to the nutritional status which change during the course of disease and therefore there is a need to carry out prospective studies involving larger studies to show the influence of various factors on nutritional status prior to and post-ART, so that effective interventions can be conducted.

Key Words: Diet, HIV/AIDS, nutrition, people living with HIV and AIDS

 Are people living with HIV/AIDS practices toward prevention of adequate spread of HIV: A vital scope

Ravishekar Ningayya Hiremath1, Renuka Kunte1, Sandhya Ghodke1, Apoorva Sindhu1

1Central Government (Health), Central Government Health Services

E-mail: [email protected]

Background: A substantial proportion of HIV-positive individuals engage in unsafe sexual behavior and/or unsafe drug use. Therefore, the practices of HIV-positive individuals in preventing the spread of the disease to others are very much important to design strategies that encourage HIV-positive people to live active without putting others at risk for infection. Objectives: To study the practices of people living with HIV/ AIDS (PLHAs) toward prevention of the spread of HIV and to make suitable recommendations, if any. Methodology: A cross-sectional study was carried out among the PHLAs attending OPD and data were collected by means of predesigned, pretested questionnaire. A total of 110 PLHAs consented to be part of the study and, therefore, were included. Results: 62.7% respondents said that they avoided sex with multiple partners, while 37.3% gave a history of having sex with multiple partners. Majority (85.3%) of them gave a history of condom usage during every sex regularly. Only 50% were found to be practicing safe sex which includes both avoiding sex with multiple sex workers and using condom during sex. All the respondents (100%) were insisting for change of blade at barbers shop and new syringe and needle during injection. Only 61.8% of the respondents have screened their wives and children. Majority, that is, 90.2% and 93.1% respondents said that they will disclose their HIV status during dental and wound treatment, respectively. All the respondents (100%) said that they will disclose their HIV status during blood donation, lab investigations, medical/surgical interventions, during tattooing, and during ear piercing. Conclusion: There is a vital scope for the improvement in practices involving safe sex. Measures for health promotional activities, that is, activities for behavioral change and communication are required to be taken to educate HIV-positive individuals on a regular periodic basis to adopt safer sexual practices which include avoiding sex with multiple partners and always using condom during sex. These points should be highlighted and emphasized during each follow-up and during planning health education programs and creating mass awareness about HIV/AIDS-directed toward HIV-positive persons.

Keywords: People living with HIV/AIDS, practices, prevention

 Association between overweight/obesity and prevalence of noncommunicable disease multimorbidity in six low- and middle-income countries

Sutapa Agrawal1, Soumyadeep Bhaumik2

1Public Health Foundation of India, New Delhi NCR, 2Journal of Family Medicine and Primary Care, New Delhi, India

Background: Chronic diseases are increasingly becoming a health burden in terms of both morbidity and mortality in low- and middle-income countries (LMICs). The role of obesity in the prevalence and clustering of multimorbidity, the occurrence of two or more chronic conditions, is understudied in LMICs where two-thirds of the world's obese individuals reside. We estimated the prevalence of noncommunicable disease (NCD) multimorbidity by obesity status, the interaction of obesity with other predictors of multimorbidity in six LMICs. Methods: Cross-sectional data of total of 40,166 participants from China (n = 13,970), India (10,915), Mexico (2426), Russia (3892), South Africa (4000), and Ghana (4971), aged 18 years and above included in the WHO Study on Global Ageing and adult health, 2007–2010 were analyzed. Data were analyzed country-wise, as well as pooled together to give overall LMICs estimates. Multivariable logistic regression models were fitted to test for associations between overweight/obesity and clustering of NCD multimorbidity after adjusting for age, sex, rural/urban residence, education, marital status, occupation, household wealth, current tobacco smoking, alcohol drinking, daily fruits or vegetable intake, and health insurance status. Results: The mean body mass index was 24.4 (± 7.3) in the pooled countries, being as low as 20.8 (± 8.0 standard deviation [SD]) in India to 23.4 (± 6.3 SD) in Ghana, 23.9 (± 4.9 SD) in China, 28.4 (± 5.4 SD) in Mexico, and 28.6 (± 6.3 SD) in Russia, to as high as 30.5 (± 12.0 SD) in South Africa. The prevalence of overweight was 13%, and obesity was 24% in the six LMICs. The prevalence of multimorbidity was 18% in the overall LMICS, highest being in Russia (46%), followed by Mexico (23%), South Africa (20%), China (18%), India (11%), and Ghana (7%). The mean number of multimorbidity reported was 2.50 (95% confidence interval [CI] 2.49–2.52) in the pooled countries, highest in Russia 2.75 (95% CI 2.71–2.80) and lowest in Ghana 2.27 (95% CI 2.21–2.32). The prevalence of multimorbidity was 34% among obese population and 23% among overweight population in the pooled countries, highest prevalence in Russia (61% among obese; 43% among overweight) and lowest in Ghana (14% among obese; 9% among overweight). Being overweight (odds ratio [OR]: 2.05; 95% CI: 1.52–2.75) or obese (OR: 4.65; 95% CI: 3.35–6.46) was associated with significantly higher likelihood of having multimorbidity in the overall six LMICs as compared to nonobese. The likelihood of reporting multimorbidity among obese were 9 times higher in Russia, 5 times higher in China, and almost 2 times higher in India. Nonsignificant but positive association between obesity and clustering of multimorbidity was also found in Mexico, South Africa, and Ghana. Conclusions: The prevalence of multimorbidity in the LMICs is high, almost double in obese than in general population. Obesity was an important independent predictor of the occurrence of multimorbidity in the six LMICs. These findings have important implications for monitoring overweight and obesity levels and may be vital for public health surveillance, prevention, and management strategies for multimorbidity in the LMICs.

Keywords: Chronic conditions, low- and middle-income countries, multimorbidity, overweight/obesity, World Health Organization-Study on Global Ageing

 A study of menstrual hygiene management and absenteeism among female medical and dental students in a university of East India

Adrija Roy1, Ipsa Mohapatra1

1Department of Community Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Menstrual hygiene management has not received adequate attention in reproductive health sectors in developing countries. In India, the practices being still poor, due to which the girls are exposed to reproductive tract infections, sickness absenteeism. Doctors being the main health care providers, their knowledge help in transforming practices of the society and community. Objectives: To assess the practice of menstrual hygiene and associated factors among female Medical and Dental students in Kalinga Institute of Medical Sciences. To find associations with parents' education, socioeconomic status, religion, and practices. Methods: Institution based cross-sectional study conducted from June 15 to July 15. Four hundred and forty-one study participants were selected, and a pretested self-administered, anonymous questionnaire was used after consent. Data analyzed using EpiInfo. Chi-square test used to identify the association with P < 0.05 as significant. Results: Most of the girls (67%) were in the age group of 20–24 years; surprisingly, 57% girls were ignorant about menstruation before menarche. The mean age of attaining menarche was 12.6 years; ranges were 9–17 years. In 80% of students, menstrual habits were inculcated by their mothers. Three hundred and sixty-four girls used sanitary napkins as absorbent material during their menstrual cycle; 95% of them practiced vaginal washing daily. As high as 90% of girls reported to experience premenstrual symptoms; 64% of whom said it upset their daily routine. Three hundred and fifty- six were forced to practice restrictions during menses. Majority of the participants (86%) practiced good menstrual hygiene and had a high level of menstrual hygiene knowledge. Using bivariate analysis significant association was found between good menstrual hygiene and those participants who had a high level of knowledge about menstrual hygiene, mothers' level of education, and place of residence. Conclusion: Majority of the participants had a high level of menstrual hygiene knowledge and practiced good menstrual hygiene. Different factors affect the practice of menstrual hygiene such as the source of information, religion, and prior knowledge about menstrual hygiene. Even due to religious and cultural taboos there are a lot of restrictions in their daily routine.

Keywords: Cross-sectional, menstrual hygiene, practice

 Pattern and factors associated with obesity in adults attending a private practice in Lagos, Nigeria

Macrina Olusolape Ige

EKO Hospital Research

E-mail: [email protected]

Introduction: The global burden of obesity is increasing rapidly. Until recently, it was considered almost exclusively a problem of developed nations; however, developing nations are now experiencing a rise in obesity and obesity-related disorders. The growing body of evidence linking obesity to dietary and lifestyle changes has little representation from low-and middle-income settings. Aims and Objectives: This study aimed at filling this knowledge gap. Materials and Methods: A cross-sectional descriptive design was used. The sample size was estimated. Ethical approval was obtained from the EKO Hospital Research and Ethical Committee and informed written consent was obtained from each participant. The sociodemographic characteristics, eating habits, physical activity, and anthropometric measurements of 200 participants were assessed. Results: There were 90 (45.0%) male and 110 (55.0%) female respondents. Their ages ranged from 19 to 63 years (mean: 35.1 ± 9.4 years). The prevalence of general obesity by body mass index was 19.5% with 12.2% of males and 25.5% of females obese (P < 0.05). The overall prevalence of abdominal obesity using waist:hip ratio was 33.5% (11.1% of males and 51.8% of females) and 20.5% (8.9% of males and 30.0% of females) using waist circumference. Obesity was found to be significantly associated with marital status (P < 0.05), eating two or more fruits or ≥1 cup of fruit juice per day (P < 0.05), and adding butter or oil to food (P < 0.05). Abdominal obesity was associated with eating last meal after 7 pm (P < 0.05). Conclusion: The population in this study had a high prevalence of obesity. These identified areas would benefit from targeted intervention by family physicians to reduce the burden of obesity and its associated co-morbidities.

Keywords: Community care, obesity, private practice

 Morbidity profile of geriatric population in an urban community of Gangtok, Sikkim

Anish Prabhakar1

1Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

E-mail: [email protected]

Introduction: In most countries of the world, including India, population ageing is likely to become a serious policy and programmatic issue in the coming decade. The number of “elder” people in India (60+ years) has increased by 54.77% in the last 15 years. Objectives: To study the morbidity pattern among geriatric population and their health-seeking behavior in an urban area of Gangtok, Sikkim. Materials and Methods: A cross-sectional study was done in the field practice area of Department of Community Medicine, SMIMS. The sample size was calculated to be 289 taking a prevalence of 7% geriatric population, assuming a nonresponse of 10%. Door to door visit was done from March to May 2015 to include all the houses in the area. All the elderly giving consent for interview were included. Visitors were excluded from the study. The demographic characteristics of the geriatric were analyzed in relation with the morbidity profile and health-seeking behavior using a partially open-ended pretested data collection tool that was prepared in the Department of Community Medicine at the institute with the help of faculty and experts. Results: Of the 289 elderly, 48.9% were males and 51.1% were females; mostly were between 71 and 80 years (41.90%); most common morbidity reported was visual (70.7%), followed by locomotor (50.4%), and auditory (15.2%) problem. Psycho-social problem was reported by 20.3%. To seek aid for health related issues, 34% sought help from private practitioners followed by government health facility (19.1%). Conclusions: In conclusion, there is an emergence of a host of problems faced by the elderly in India. However, with nuclear families springing up and the focus more on the individual than the family, elder care has taken a beating. One practical approach could be to integrate geriatric care at the primary care level effectively.

Keywords: Gangtok, geriatric, health-seeking behavior, morbidity

 Prevalence of low birth weight in a village: Panchayath in Northern Kerala

Kailas Parayankizhi1, Usha Karunakaran2

1Department of Family Medicine, Lourdes Hospital, Kochi, 2Department of Community Medicine, Academy of Medical Sciences, Kannur, Kerala, India

E-mail: [email protected]

As defined by the World Health Organization, an infant is considered to be of low birth weight (LBW) if his/her weight at birth is <2500 g irrespective of the gestational age of the infant. The studies from across the world show that at least 15% of newborn babies are of LBW The prevalence is highest in Asia (18.6%).[1] In India, it is 23%.[2] It is a paradox that the reported percentage of LBW in Kerala is close to the average of developing countries (16%),[3] when other health indicators of Kerala are comparable to that of developed countries. Previous studies on birth weight in Kerala depended on hospital data mainly, and most of the studies took place in Southern Kerala. Hence, I am conducting this study among all those who delivered in Madikkai Panchayat (kasargode) in the year 2007 with the help of a pretested questionnaire after getting their consent. The objective of this study is to assess the prevalence of LBW in the study population in Northern Kerala and to determine risk factors associated with LBW. In our study among 175 mothers, the prevalence of LBW was 12%, out of which one-third was preterm and rest two-third was due to intrauterine growth restriction. Almost 91% of the mothers started antenatal care in the 1st month itself. 92% of the birth was registered. 89.7% were term pregnancies. 18.9% were anemic, and 14.1% were hypertensive. 97% of the population is fully immunized, and 84% had taken the full course of iron folic acid tablets. The significant features contributing to LBW babies were found to be complications during pregnancy, history of communicable diseases during pregnancy, a hemoglobin percentage <10 g%, and the height of the mother.

Keywords: Intrauterine growth restriction, low birth weight, Northern Kerala, prevalence


Available from: publications/lowbirthweight/lowbirthweight_estimates.pdf.International Institute for Population Sciences, Measure DIIS and ORC Macro, India, National Family Health Survey (NFHS) – I (1992-93), II (1998-99).Why Low Birth Weight (LBW) is Still a Problem in Kerala: A Preliminary Exploration. Raman Kutty Discussion Paper No. 57. Kerala Research Programmed on Local Level Development Centre for Development Studies Thiruvananthapuram.

 Prevalence and correlates of nicotine dependence among construction site workers: A cross-sectional study in Delhi

Mamta1, Rashmi Agarwalla1, Praveen Mallik2, S. Dwivedi3, Bilkish1, Rambha Pathak1

Departments of 1Community Medicine, 2Medicine and 3Community Medicine, Hamdard Institute of Medical Sciences and Research, New Delhi, India

E-mail: [email protected]

Introduction: Recent epidemic of tobacco use has been recognized as one of the major problems facing the human race, both in the developing and the developed countries. Workers represent half the world's population and are major contributors to economic and social development. Tobacco consumption in construction site workers has been considered a big challenge. Objectives: (1) To assess the prevalence of nicotine dependence among tobacco users. (2) To study the correlates of nicotine dependence among the construction site workers. Methodology: A cross-sectional study was conducted using a predesigned and pretested structured proforma. The study was conducted among all construction site workers aged 18 years and above in campus of Hamdard Institute of Medical Sciences and Research and Associated Hakeem Abdul Hameed Centenary Hospital, New Delhi. The study included 172 workers for 6 months (May 2014–October 2014). Karl Fagerstrom Nicotine Dependence Questionnaire was used to assess dependence on nicotine. Results: The mean age of construction site workers was 32.04 ± 11.6 years. Among the workers, the majority (91%) were tobacco user. Among the users, 60% found it difficult to refrain from smoking/chewing in places where the use of tobacco is not allowed (e.g., hospitals, government offices, cinemas, libraries, etc.,). Fifty-five percent of the users smoked or chewed tobacco more during the 1st h after waking than during the rest of the day. On multivariate analysis, the factors that were found to be significantly associated with nicotine dependence were lower income group (odds ratio [OR] 2.57, confidence interval [CI]: 1.66–3.99), smokeless tobacco use (OR 2.36, CI: 1.30–4.27), lower education (OR = 2.86 [95% CI 1.97–4.16] for illiterate). Discussion: The prevalence of tobacco use (91%) among construction workers is very high as compared to that in the general population. Recognition of construction sites as work places and proper implementation of the law are needed. Immediate intervention programs are warranted to reduce the future burden of tobacco among these workers.

Keywords: Nicotine dependence, tobacco use

 Epidemiologic correlates of chronic respiratory infections in an urban slum of Bhubaneswar

Sonali Kar1, Amrita Kumari1, Ipsa Mohapatra1

1Department of Community Medicine, Kalinga Institute of Medical Science, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Urbanization is marked by the emergence of slum areas wherein migrants from the nearby villages stay in temporary establishments for seeking avenues of employment. These dwellings lack most of the essential living conditions such as safe water, healthy living conditions, and access to health services. This population is also vulnerable to social evils such as alcohol and tobacco addiction. Kalinga Institute of Medical Science, Urban Health Training Centre caters to a slum population of nearly 15,000 populations catering to their primary health needs. Of the monthly average of 200 patients/ day, it is observed that incidence of respiratory infections was the highest both among the young and adults. For the study, chronic respiratory infections was defined as three or more episodes of any respiratory symptom in the last 6 months or a diagnosed case of asthma/chronic obstructive pulmonary disease warranting the medical treatment. Aims and Objectives: (1) To assess the cumulative/mean prevalence of chronic respiratory infections in the adult population in slum and also symptoms-wise prevalence. (2) To assess the influence of social, demographic, and attributable risk factors on the prevalence of the disease. Methodology: A house to house survey was done wherein all the population aged 20–60 years were interviewed using a pretested, predesigned questionnaire adapted from questionnaire used in the International Union Against Tuberculosis (TB) and Lung Diseases study. Given the prevalence of nearly 4%, with 95% CI and a relative error of 20%, the optimum sample is considered to be nearly 400. The person who was noted to have chronic respiratory disease was the one who showed any respiratory symptom as per operational definition given above. The data was analyzed using SPSS version 21. Results: The cumulative prevalence was seen as 7.1% males being affected in 5.2%. Smoking (both men and women), overcrowding, and history of TB were seen as positive predictors of the disease. The use of wood or kerosene in case of women gave an OR of 2.4 times for manifestation of the disease. Conclusions: Chronic respiratory illness is a major burden for slum dwellers and they should be educated against the risk factors and take appropriate precautions to safeguard against the illness. This simple study suggests the epidemiological patterns of infections in June and July months in a rain prone state of Odisha and helps the hospital administration to take steps to initiate target interventions for the same.

Keywords: Chronic respiratory infections, overcrowding, slums, tobacco use

 Growth and development among infants in a rural community: A longitudinal study

Vijayashree Shivprasad1, Vijaya Naik1, N. S. Mahantshetty1

1Department of Public Health, District Surveillance Unit, J.N. Medical College, KLE University, Belgaum, Karnataka, India

E-mail: [email protected]

Introduction: About 2.92% of Indian population is constituted by infants.[1] Infants form a vulnerable group. Growth and development is very crucial component among infants as it depicts the physical and mental development of the child. Growth indicates the increase in size and development depicts increase in skills, intellect, and emotional aspect.[3] Aims and Objectives: (1) To assess the prevalence of nutritional status among infants. (2) To study the developmental delay using Trivandrum developmental scale (TDS) among infants. Materials and Methods: The present study was carried out among 3 Primary Health Centers of Kinaye, Handignur and Vantamuri the population constituting around 1, 17, and 111. A longitudinal study was carried out among infants residing in a rural community. Sample size was calculated using the formula N = (Z1-α)2x pq/d2. Where prevalence of stunting (p): 28.8, Z1-α: 1.96, tolerable error (d): 3. Adding 10% attrition rate. Sample size = 962. Around 962 babies born (approximately, 150 neonates/month) were enrolled using random number table and followed up from birth until 1 year at an interval of 1 month. Data collection period was from March 2013 to Jan 2015. AnthroPlus manual was used to assess the nutritional status of infants and developmental delay among infants was assessed using TDS. Result and Discussion: In the present study, among 982 infants, majority of mothers (72%) belonged to age group of 19–25 years. 54.6% were males and 45.4% were females. Prevalence of low birth weight among infants was 21.6%. Prevalence of malnutrition among neonate, 6 months and 1 year were 17%, 16%, and 18%, respectively. 13% of underweight infants showed developmental delay were as a 15% and 42% developmental delay were seen with respect to stunting and wasting. Conclusion: Malnutrition in terms of underweight was more common among first 6 months. Whereas stunting and wasting were more prevalent during last 3 months of infancy. Developmental delay was significantly associated with chronic malnutrition and poor socioeconomic status.

Keywords: Development, growth, infants, malnutrition

 Barriers to cardiovascular risk reduction in a rural setting: What do patients and physicians say?

Dhanya Ramadas1, Gift Norman1, Carolin Elizabeth George1

1Bangalore Baptist Hospital, Hebbal, Bengaluru, Karnataka, India

E-mail: [email protected]

Background: Cardiovascular disease (CVD) has emerged as a major public health problem both in urban and rural populations. This study is an attempt to understand the barriers and challenges faced by patients and physicians in CVD risk reduction in a rural setting. Materials and Methods: In a community-based observational study conducted in 12 villages of two taluks of Bengaluru rural district, 290 patients with diabetes, hypertension, coronary artery or cerebrovascular diseases, were interviewed using a semi-structured questionnaire to assess their lifestyle for CVD risk reduction and the barriers they faced. To gain understanding of the provider's perspective, in-depth interviews were conducted among 34 doctors practicing in Devanahalli taluk. Rigorous procedures for both quantitative and qualitative methods were used independently to provide an enhanced understanding of the barriers. Results: Among the patients interviewed, almost one-fifth reported that they were confused about the information provided by their doctors, 91% said that they do not do any exercise, 20.6% have not modified their diet, 22% had missed their medications at least once the past week, 15.8% modified their drug dosage themselves, and 6.5% confessed that they had skipped their physician visit due to lack of money. From a patient's perspective, lack of clear knowledge about their disease, confusion about lifestyle modifications, financial constraints, and lack of family support were seen as the main barriers to CVD risk reduction. The leading barriers for CVD risk reduction among physicians were noncompliance to medications, lack of knowledge and understanding of the disease, myths and beliefs, indifferent attitude of the patients, nonadherence to life style changes, the chronic nature of the disease, financial constraints, and lack of national guidelines. Conclusion: Financial constraints, lack of knowledge, and indifferent attitude toward their disease seem to be the major barriers to risk reduction.

Keywords: Barriers, cardiovascular risk, physicians, rural

 Awareness regarding human papilloma virus and its vaccine among medical students

Sambedana Mohanty1, Manasee Panda1, Radhamadhaba Tripathy1

1Department of Community Medicine, M.K.C.G Medical College, Berhampur, Dist-Ganjam, Odisha, India

E-mail: [email protected]

Background: Cancer of uterine cervix is the most common malignancy among women in India caused by human papilloma virus (HPV). Early diagnosis is done by screening and prevention can be done by vaccine. As the medical students will be the future doctors, their awareness regarding HPV, cervical cancer, and vaccine is very much necessary. Aim of the Study: (1) To study the awareness about various aspects of HPV infection and vaccine among female medical students. (2) To assess their attitude toward vaccines. Materials and Methods: Type of study: Cross-sectional study. Study Area: M.K.C.G Medical College and Hospital, Berhampur, Odisha. Ethical Clearance: It was obtained from the Institute of Ethical Committee, M.K.C.G Medical College and Hospital. Study Population: 150 female medical students. Sampling: Convenient sampling. Study Instrument: Pretested, predesigned, semi-structured questionnaire regarding cervical cancer, HPV, and vaccine. Data Analysis: Results were analyzed using SPSS-20. Results: All the medical students interviewed had heard of cancer cervix (Cacx) caused by HPV that is transmitted sexually. Cacx and cancer breast were held to be the most common cancer among Indian women by 80% and 20% of students, respectively. Postcoital bleeding, intermenstrual bleeding, leucorrhoea, and blood stained offensive discharge were known to be present in Cacx by 95%, 86%, 62%, and 93% students, respectively. HPV 16, 18 as the most common strains causing Cacx was known to 93% of students. Carcinoma in situ as the earliest stage at which the disease if detected then survival is maximum was known to 63%. Pap smear as the screening test, to be done above 21 years and every 3 years were known to 95%, 58%, and 53% of students, respectively. All knew about Gardasil and Cervarix, but 65% and 32% said that they were given to only girls and both boys and girls, respectively. Various aspects of Cacx were known to 90% of students in class. Out of all students interviewed 51% said that there was no screening program for Cacx and inadequate information and high cost were reasons for inability to implement such program according to 50% and 48% of students, respectively. But in spite of adequate knowledge 93% were not vaccinated. Conclusion: There are gaps between knowledge and practice among medical students. A more integrated teaching regarding HPV carcinogenesis, vaccination, and cervical cancer needs to be introduced into the curriculum along with proper counseling.

Keywords: Cancer cervix, human papilloma virus, medical students, vaccine

 Prevalence of age- and gender-specific risk factors of “acute ischemic stroke” in North Indian population

Esha Arora1

1Resident, Guru Teg Bahadur Sahib (C) Hospital, Ludhiana, Punjab, India

E-mail: [email protected]

Introduction: Ischemic stroke is a complex disease in which genetic and environmental factors make equal contribution to the etiology. Many studies have identified various nonmodifiable and modifiable risk factors predisposing to stroke. Aims and Objectives: To study the frequency of association of various modifiable and nonmodifiable risk factors with ischemic stroke in different age groups and genders in North Indian population. Materials and Methods: This is an epidemiological study conducted with 100 patients. Informed consent was taken. Ethical committee approval was obtained. Number of patients with each risk factor and their respective percentage was calculated. Comparison of various risk factors between the age groups and genders was made using Chi-square test. Results: Hundred patients with ischemic stroke (both outpatient department and inpatient department patients) were studied at Guru Teg Bahadur Sahib (C) Hospital, Ludhiana. It was observed that 84% patients with ischemic stroke were more than 50 years of age. The male to female ratio was 1.94:1. Hypertension was the most common risk factor, associated with 69% patients. Diabetes mellitus, which is an established risk factor, was found in 34% patients. Smoking was seen in 2% patients. Alcohol intake was associated with 38% patients and drug addiction with 13% patients, more commonly seen in male population. Fifteen percent patients had coronary artery disease and 8% had atrial fibrillation. Fifty-nine percent patients had dyslipidemia, more commonly associated with patients more than 50 years of age. Twenty percent patients were obese, more frequently the female population. A total of 12% patients had family history of coronary artery disease (CAD)/cerebral vascular accident (CVA). Family history of CAD/CVA was more commonly associated with patients <50 years. Conclusion: Stroke being one of the most common cerebrovascular diseases has drawn attention of researchers all over the world. As our knowledge continues to evolve about pathogenesis and therapeutic options, epidemiological aspects and risk factors associated with stroke remain as important as ever. Targeting these risk factors for preventing stroke in the first place will help reduce the burden of this disabling disease.

Keywords: Ischemic stroke, risk factors

 Can rural medical assistants form part of the primary healthcare team? - Our experience in capacity-building these rural medical assistants

Immanuel Rajamani1, Jachin Velavan2, Rebekah Zechariah1

1Department of Distance Education, Faculty of Family Medicine, Christian Medical College, 2Department of Distance Education, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

The Rural Unit for Social and Health Activities Department of Christian Medical College (CMC), Vellore runs a 2 weeks long capacity building training program for the Rural Medical Assistants (RMAs) from Chhattisgarh for the past 2 years. They are around 1200 in numbers. Each month around 30–35 are being trained. So far around 600 of them have been trained. Another 600 of them need to be trained. The Department of Distance Education CMC is also part of this initiative. Who are these Rural Medical Assistants? These RMAs are the ones who have undergone a 31/2 year medical training after their 10+2 study (truncated MBBS!). They are posted in the remote, rural and tribal areas of Chhattisgarh along with MBBS doctors or alone. They can only be posted in a Primary Health Centre (PHC) or Community Health Centre and often serve as the first point of medical contact for most of the patients in these regions. In a study published by K.D. Rao et al. in Social Science and Medicine 84 (2013) 30–34, Table 2, it has been pointed out that their history taking, examination, investigation, diagnosis, appropriate prescription writing, home care are as good as medical officers. Advantages and disadvantages of Rural Medical Assistants: With the help of the RMAs, the government is able to run the PHCs 24—7. They are able to treat most of the common illnesses. They are a boon to MCH services in these rural areas. They handle malaria, snakebites sickle cell disease, etc., which are very common in Chhattisgarh. Though most of them do a very good job, some tend to be overconfident and may delay in referring the patient at the right time which can seriously affect the patient.

What is being done?

The objectives of the training we impart are:

Help improve their history taking, examination and diagnostic skillsHelp them manage patients appropriately with rational use of drugs and investigationsTeach them to work with “Red Flag signs,” and to, stabilise and refer appropriatelyRun and implement national health programs.

We teach red flags for every condition, hone some clinical skills, and teach them the importance of prevention and health promotion. Expected results: These RMAs are already in the needy remote rural and tribal areas. By carefully teaching, training and encouraging them, we can achieve our goal of health care is primary not only to the affordable rich but to the poorest of poor Indians as well.

Keywords: Capacity building, Primary Health Centre, Rural Health, Rural Medical Assistants

 Gap analysis between provisional diagnosis on admission and final diagnosis during discharge: A retrospective, comparative study between government and private teaching hospitals

Sudeshna Chatterjee1, Syam Sundar Chakrabortti2, Anup Kumar Das3, Krishnangshu Ray4

1Netaji Subhas Open University, 2West Bengal University of Health Sciences, 3RG Kar Medical College, 4Institute of Health and Family Welfare, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: Achieving a high degree of diagnostic accuracy is important in the practice of medicine. Accurate provisional diagnosis (PD) invites less investigations and less cost burden to the health sector. PD is the first considered diagnosis which sets the first phase of treatment in motion, whereas final diagnosis (FD) is the chronological organization and critical evaluation of all information obtained from history, physical examination, and investigation. Aims and Objectives: Gap analysis aims to ascertain how accurately PD matches with FD. It also evaluates the competencies of the caregivers and quality of diagnostic procedures, the important indicators of hospital performances. Materials and Methods: A retrospective, record- based, comparative study was conducted upon the in-patients of major disciplines of two teaching hospitals representing both government and private sectors. Bed head tickets (n = 200) were collected from medical records section of respective hospitals and examined. The major outcome variables of the study were to observe the matching or un-matching of FD with PD. Results and Discussion: In government hospital, both PD and FD matched in 71% patients in general surgery which was followed by 56% in CTVS and 22% in medicine. Whereas in the private sector, both PD and FD matched in 54% in general surgery, 87% in gynecology and obstetrics, and 52% in medicine. Department-specific comparison of records could not performed due to nonavailability (documental gap). Conclusion: Our pilot observation concludes, gaps between PD and FD in both the institutions indicates poor hospital performances. Better matching lowers the clinical gap in terms of knowledge and skill of the caregivers. Accurate diagnosis curtails investigation cost, minimizes hospital stay, and improves patient's satisfaction. The reasons of such outcome need to be elucidated and warrants appropriate remedial measures.

Keywords: Final diagnosis, gap analysis, provisional diagnosis

 Prevalence of overweight and obesity and assessment of their risk factors and attitude of parents among school children

Hemavathi Dasappa1, Krithika Ganesh1, Rathna Prasanna1, Shankar Prasad1

St. Philomena's Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.[1],[2] Overweight and obesity are the results of “caloric imbalance” – too few calories expended for the amount of calories consumed – and are affected by various genetic, behavioral, and environmental factors.[3],[4] Indian data regarding current trends in childhood obesity are emerging. A recent study conducted among 24,000 school children in South India showed that the proportion of overweight children increased from 4.94% of the total students in 2003 to 6.57% in 2005 demonstrating the time trend of this rapidly growing epidemic.[5] Aim and Objective: The present study was conducted with objective of (1) estimating the prevalence of overweight and obesity among the school children between the age group of 6 and 12 years. (2) To assess the risk factors related to overweight and obesity. (3) To assess the attitude of the parents. Materials and Methods: The study is being conducted in the St. Joseph's Boy's School situated in the central part of Bangalore. This school has a strength of 1011 children between 6 and 12 years of age (1st to 7th standard). The study is carried out using a structured proformal, which includes details about the socioeconomic data, dietary habits, and physical activity of the child and questionnaire on the attitude of the parents. This proforma will be filled by the parents. The study also includes measurement of height and weight using standard methods by the nursing staff of St. Philomena's Hospital. Written consent is taken from the parents for participating in the study. The study is approved by the Ethic Committee of the St. Philomena's Hospital. Collected data will be alpha-numerically coded and entered into an excel sheet. Analysis will be done using SPSS 19.0 software and Chi-square test will be used for analyzing the association of risk factors. Results and Discussion: Data collection is happening presently. Results will be sent after the data collection.

Keywords: Obesity, overweight, prevalence, risk factors


Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.National Center for Health Statistics. Health, United States, 2011: With Special Features on Socioeconomic Status and Health. Hyattsville, MD: U.S. Department of Health and Human Services; 2012.Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, et al.Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation 2005;111:1999-2012.Office of the Surgeon General. The Surgeon General's Vision for a Healthy and Fit Nation. Rockville, MD, U.S. Department of Health and Human Services; 2010.Raj M, Sundaram KR, Paul M, Deepa AS, Kumar RK. Obesity in Indian children: time trends and relationship with hypertension. Natl Med J India 2007;20:288-93.

Information for the parents:

This is a study conducted to assess the child for overweight and obesity. The study needs informations like height and weight of the child, details about food habits and physical activity/exercise. The identity of the participating child will not be revealed to anybody. At the end of the study a feedback about your child's health relating to weight will be given to the parents.

I ______________________, hereby give consent for my child ___________ to participate in the survey.

Signature of the parent

Student Details

Name: _________________________________________

Age: __________

Gender: Male □ Female □

Address: __________________________________________


Phone number: ____________Class: ______ Section: ______

Height (in cm): __ Weight (in kg): __ Birth weight (in kg): __

Parent Details

1. Father's education:

NilPrimary to PUCDegreeProfessional

2. Mother's education:

NilPrimary to PUCDegreeProfessional

3. Father's occupation: ________________

4. Mother's occupation: _______________

5. Family income/month:

<25,000 rupees26,000–50,000 rupees>50,000 rupees

6. Child is taken care of by

Parents □ Grandparents □ Other □

relatives □ Guardian □

Name of person filling the form: ______________________

Relationship to child: _______________________


12. I feel my child is:

OverweightAppropriate weight for ageUnderweight

13. I control my child's diet to make it more healthy and

balanced yes □ no □

14. My child has at least one meal a day together with family

yes □ no □

15. I feel my child has adequate physical activity

yes □ no □

16. If no, what do you feel are the barriers for physical activity:

Too much academic workExcess TV watching/video games

17. How much time do you spend with your child (mother):

6 h or more2–4 h<2 h

18. Who feeds the child at home:

ParentsGrand parentsCare giver/Day careChild himself

 Nonalcoholic fatty liver disease in urban population: Incidence and associated risk factors

Anupama Nagaraja

Sakra World Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Nonalcoholic fatty liver disease (NAFLD) is a benign condition that is becoming extremely common among the urban India population. The disease has a wide spectrum ranging from simple NAFLD to nonalcoholic steatohepatitis that leads to cirrhosis and liver cancer. Aim: To understand the incidence and identify the major risk factors for NAFLD in this population. Methods: A cohort of about 100 adult subjects who attended for general health check-up at our hospital were screened for NAFLD using ultrasound of liver. The clinical data including age, gender, body mass index, blood pressure, fasting blood sugar, lipid profile, liver function test, and liver ultrasonic findings were analyzed. Results: Initial study revealed that the incidence of NAFLD in urban population is high, and its prevalence is highest in populations with preexisting metabolic conditions such as obesity and dyslipidemia. Conclusions: The results demonstrated the prevalence pattern of NAFLD and associated major risk factors as obesity and dyslipidemia. Early intervention with lifestyle changes can prevent the progression of NAFLD in this population.

Keywords: Dyslipidemia, nonalcoholic fatty liver disease, obesity

 Awareness of body mass index in diabetes/ hypertensive/hyperlipidemic patients in a tertiary care hospital in Eastern India

Ghazala Siddiqui1, Ashis Chakrabortty2

Departments of 1Family Medicine and 2Internal Medicine, Calcutta Medical Research Institute, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: The concept of body mass index (BMI), the most commonly used parameter to assess obesity, is very poorly understood by patients. Especially, high-risk patients with diseases like diabetes, hypertension, and hyperlipidemia should have clear concept about obesity and BMI. Aim of the Study: The purpose of this study was to assess high-risk patients' knowledge about BMI in a tertiary care hospital. Methods: Adult patients who are diagnosed to be suffering from any of the three (diabetes/ hypertension/hyperlipidemia) attending OPD in a tertiary care center in Eastern India were invited to participate in a voluntary survey. We assessed through a predefined set of questionnaire the patient's baseline knowledge of BMI including his own BMI, any knowledge about association of his BMI to his medical ailments and their willingness to know about BMI if informed. Results: Very few (19.9%) of high-risk patients were aware of the meaning of BMI and also that it is used as an index to measure obesity. BMI cut-off values, obesity class as per BMI value, and own BMI were not known to more than 90% of our patient population. Almost 95% of patients revealed it that it was their first interaction with any physician regarding BMI, they were never informed about this before, and 85% showed their interest to know about BMI and to incorporate into their knowledge to achieve the target BMI for better control of their disease. Conclusion: Our study revealed that very few proportion of high-risk patients has a basic knowledge about BMI. The basic knowledge about BMI may be delivered to these patients during consultation so that they can be aware of this and ultimately it will have a significant impact on the public health.

Keywords: Body mass index, diabetes, hyperlipidemia, hypertension

 A study of burden and quality of life assessment of the caregivers of stroke victims

Arabinda Mukherjee1, Sitanshu Sekhar Nandy2, Dipak Naskar3

1Department of Neurology, Vivekananda Institute of Medical Science, 2Department of Neurology, Calcutta Medical Research Institute, 3Institute of Neuroscience, Kolkata, West Bengal, India

E-mail: [email protected]

Background: In the era of modern medical science, care and rehabilitation of a chronically ill patient is becoming a more important aspect of management and it has two way benefits, both in economics and health. Among these, family care giving is more emphasized, but a family care giver has to face troubles and burden to put them in a state of poor wellbeing or quality of life (QOL) and depression. Hence, one has to recognize the situations of care givers and help them by means of suitable interventions as they can adapt easily for better QOL and psychological state of wellbeing. There are significant numbers of stroke victims with various state of physical and psychological disabilities and caring them is really a big challenge. Objectives: There are two main objectives of the study: (a) To evaluate the magnitude of the burden and QOL of a family care giver and the relation between them. (b) To find which care giving situations are more burdensome, so that a suitable intervention can be made. Methods: Subjects (n = 37) were taken from the neurology outpatients' department of the Calcutta Medical Research Institute, Kolkata. They were interviewed using self- rated questionnaires (a) World Health Organization Quality of Life-BREF (b) Zarit Burden Interview (short form 12) (c) Zung depression scale, and (d) for patient's activities of daily living, the modified Barthel Index. Results: Burden is positively related to care giving situations such as care givers' age, duration of care giving, male gender, and negatively to income and education of care giver. Similarly, QOL was negatively related with burden, particularly physical and psychological states. It is seen that socioeconomic condition is the most important factor of burden and so QOL. Conclusion: Beside treatments of stroke survivors, if we can modify the care giving situations in terms of: (a) Educating care giver at an early stage, during hospital stay of the patients. (b) providing proper rehabilitation and social support, and (c) economic empowerment of care giver are among those, can help both care giver and care recipient in a positive direction of QOL.

Keywords: Activities of daily living, burden, care giver, stroke, quality of life

 Beliefs and perceptions of low-income, low literacy women toward smokeless tobacco use and quitting: A primary care-based study from Odisha, India

Sandipana Pati1, Abhimanyu Singh Chauhan2, Sanghamitra Pati3

1Department of Health and Family Welfare, Government of Odisha, 3Indian Institute of Public Health, Public Health Foundation of India, Bhubaneswar, Odisha, 2Public Health Foundation of India, New Delhi, India

E-mail: [email protected]

Introduction: Smokeless tobacco consumption has been identified as a primary risk behavior contributing to the escalating burden of oral cancer in Odisha, India. The problem is more prominent in low-income, low literacy women population. Objectives: To explore the perceptions of socially and economically deprived women attending urban primary care. Methods: The study was conducted in six suburban primary care facilities at Bhubaneswar, Odisha, India. Thirty outpatient women of low socioeconomic status and regularly consuming smokeless tobacco were selected. In-depth interviews were conducted to explore these women's perceptions on tobacco consumption, reason for initiation and continuing, intention to quit, and risk perception. Data were transcribed, translated, and analyzed using thematic framework approach. Results: All were long habitual users of smokeless tobacco and had started during adolescence through friends, family, and neighbors. Principal reasons for continuing were the beliefs that tobacco is a benign addiction with no serious health consequences. It has beneficial health effects such as laxative, antacid, and mouth freshener, keeps them alert and energetic, and helps to ward off loneliness. Those aware of the health risks thought oral cancer to be a rare possibility. All interviewees demonstrated a low-risk perception and cited examples of individuals who remain healthy despite consuming tobacco lifelong. Most had never thought of quitting since they were apprehensive of getting other health problems such as indigestion and constipation. All were confident of their ability and self-efficacy to quit tobacco anytime if they had to in future. Conclusion: Smokeless tobacco consumption appears to be ingrained into the sociocultural milieu of these women. One of the reasons could be the failure of conventional tobacco control interventions to reach this vulnerable group. It is, therefore, important to mainstream these low–income, low- literacy women into national tobacco control program through designing and piloting appropriate strategies.

Keywords: Clinical prevention, health beliefs, primary care, smokeless tobacco

 Assessment of nutritional status of under-five children in urban field practice area of Sikkim Manipal Institute of Medical Sciences

Anand Ranjan1, V.K. Mehta2

1Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, 2Department of Community Medicine, Sikkim Manipal University, Gangtok, Sikkim, India

E-mail: [email protected]

Introduction: Childhood is a time of active growth and development and nutrition forms a core pillar of human development. In India, the prevalence of underweight among under-five children is estimated to be 48% (NFHS 3). Nearly half of all deaths among under-five children in India are attributed to malnutrition. Aims/Objectives: To assess the nutritional status of under-five children in urban field practice area of Sikkim Manipal Institute of Medical Sciences (SMIMS). To study the demographic, socioeconomic and environmental factors and their association, if any, with the prevalence of malnutrition. Materials and Methods: Study design - Community-based cross-sectional study. Study setting - Urban field practice area of SMIMS. Study duration - Three months (1st May–31st July). Study population - All under-five children in urban field practice area of SMIMS. Sample size - One hundred and twenty samples were included in the study purposively by enumeration technique. Study tool - Predesigned pretested schedule was used. Results/Discussion: The total number of 120 participants enrolled in the present study. Out of the total study population, 62 (51.7%) were boys and 58 (48.3%) were girls. The prevalence of underweight was 10% of which 4.2% were boys and girls accounts 5.8%. Overall prevalence of stunting was 25.8% and boys accounted for 11.7% and 4.2% of these boys were severely stunted also 14.1% of the girls were in the same category, and 3.3% of these were severely stunted. The magnitude of wasting was nearly equal in both sexes (boys 1.66% and girls 2.5%) of which only a single case (0.83%) was a girl. The prevalence of was found to be almost similar in both the sexes. Conclusion: Strengthening public health interventions for malnutrition cases among the under-five children needs to be focused on, and its etiological factors are the prerequisites required to tackle malnutrition among under-five children.

Keywords: Stunting, under-five children, undernutrition, wasting

 Domestic violence against married women in rural Delhi: A clinic-based, cross-sectional study on prevalence and related issues

Mamta Parashar1, Jugal Kishore2, Bilkish Nabilal Patavegar1, Farzana Islam1

1Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, 2Department of Community Medicine, Vardhman Mahavir Medical College, New Delhi, India

E-mail: [email protected]

Background: Domestic violence shows characteristic features and patterns depending on the local context and has been recognized as an important public health problem. It affects the health of the person; however, data on domestic violence among rural women are scarce. Objectives: (1) Find out the prevalence and related issues of domestic violence among rural married women and (2) assess the behavior of victims regarding domestic violence. Materials and Methods: A clinic–based, cross-sectional study carried out at rural health center attached to Maulana Azad Medical College, New Delhi for 4 months. Systematic random sampling technique was used for the selection of the subjects and pretested, semi-structured questionnaire adopted from National Family Health Survey III; the questionnaire was used to interview all ever-married women attending the health facility. Data were analyzed using SPSS 16 version and presented in simple averages and proportions. For detecting difference, Chi-square test was used and accepted statistically significant when P value was less than 0.05. Results: Of 171 married women surveyed, 43.9% reported some violence by their family members. Husbands were the main perpetrators of violence (62.73%). Slapping was the most common (93.6%) form of physical violence found among the rural women. It was found that husbands (64.3%) control their wives. One-fifth (22.2%) of the women were aware about domestic violence law. Conclusion: Domestic violence is widely prevalent in the rural community, and women suffered a lot despite various initiatives taken by the government to curb the problem of violence and empowerment of women.

Keywords: Domestic violence, emotional violence, physical violence, sexual violence

 Young mothers, women's health and empowerment and child malnutrition: Trends across empowered action group states from National Family Health Survey-3 data

Zarin Pilakkadavath1, T. N. Anand2

1Department of Family Medicine, Kerala Institute of Medical Sciences, 2Health Systems Research India Initiative, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Women's overall health and well-being is an indicator of progress and development. National Family Health Survey-3 (NFHS-3) looked into women's role in household decision making and spousal violence in addition to the health indicators. Aims/Objectives: To compare across and to correlate key indicators of women's health and empowerment and child malnutrition in empowered action group (EAG) states using NFHS-3 data. Materials and Methods: We used the state level NFHS-3 data on young mothers (defined as those who have become mothers between 15 and 19 years of age), women's health and proportion of stunting and wasting among children under five. Data of EAG states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa, and Rajasthan) were compared with that of the national average and the state of Kerala. Results/Discussion: In Bihar and Jharkhand more than a quarter were already mothers, compared to less than 6% in Kerala. Stunting ranged from 52.6% in Chhattisgarh to 39.6% in Uttarakhand while it was 26% in Kerala. 43% women were having low body mass index in Bihar compared to 12.5% in Kerala. There was clear correlation between age of marriage/ child bearing and child malnutrition indicators [Graph 1].[INLINE:2]

Almost double the proportion of women were anemic in EAG states compared to Kerala. While only a little above a quarter in Rajasthan reported to have a say in household decisions it was close to 50% in Kerala. 50% women reported to have experienced spousal violence in Bihar while the figure was only 16% for Kerala [for more data, [Table 1]]. Conclusion: Women's health, age of marriage/child bearing and decision making power have significant impact on nutrition status of children born to them. More emphasis should be given to health and empowerment of women, especially in EAG states which require very specific interventions.{Table 1}

Keywords: Child malnourishment, empowered action group states, National Family Health Survey-3, women's health

 Awareness about noncommunicable diseases and its associated risk factors in school going adolescents

Isha Goyal1, S. Nagesh1, Manish K. Goel1, S. K. Rasania1

1Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

E-mail: [email protected]

Introduction: Currently, India is going through the epidemiological transition from communicable diseases to noncommunicable diseases. Therefore, under the aegis of universal health coverage, noncommunicable diseases also have to be covered besides communicable ones. The best method to control noncommunicable diseases is primary prevention through health education. Since risk factors of noncommunicable diseases develop in younger age especially the adolescent age group, so their health education about healthy living is very necessary, that is, they should be aware about noncommunicable diseases and their risk factors. Objective: To assess the awareness about noncommunicable diseases and associated risk factors. Materials and Methods: A cross-sectional study was conducted in Mehrauli, New Delhi among 600 school going adolescents studying in class 8th–10th. Results: Out of total 600 study subjects, 435 (72.5%) were boys, and 165 (27.5%) were girls. The majority of study subjects (66.7%) students were in the age group of 13–15 years. Only 35.4% boys and 37.6% girls had heard about lifestyle diseases. Only 24.6% boys and 43.1% girls were aware about the risk factors associated with lifestyle disease/noncommunicable diseases. The majority (80%) students were aware about the association of smoking with cancers. Conclusion: Very less number of students were aware about noncommunicable diseases and their associated risk factors so health education of students who are future of our country, is very important and should be given importance under universal health coverage.

Keywords: Adolescents, awareness, noncommunicable

 Awareness regarding diabetes and its complications among adults in an urban resettlement colony of East Delhi

Anshu Singh1, Anita S. Acharya1, Balraj Dhiman1, S. K. Rasania1

1Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

E-mail: [email protected]

Introduction: India has the dubious distinction of being the diabetes capital just next to China having 62.4 million diabetics which is expected to rise to 100 million by 2030. Diabetes is a growing problem in India, yet little is known about the awareness levels and barriers to care among patients with diabetes. Objective: To assess the awareness regarding diabetes and its complications among adults in an urban resettlement colony of East Delhi. Materials and Methods: A cross-sectional survey was conducted on adults >30 years (n = 580) in an urban resettlement colony of Delhi in 2014. A semi-structured interview schedule consisting of questions regarding diabetes and its complications was used. Data were entered and analyzed in SPSS. Results: Out of 580 subjects, nearly 71% men and 61% women had heard about “diabetes.” Only 124 (46.4 %) men and 120 (38.3%) women knew that it is familial. Men 175 (65.5%) were more aware than women 159 (50.8%) about the fact that diabetes is treatable. Half of the study subjects did not know that diabetes is preventable. Most common symptoms known were increased thirst (39.6%), appetite (37.5%), and urination (37%). Majority of the study subjects 259 (67.9%) thought that diabetes occurs by eating sugar. Only few 89 (23%) knew that along with medicine, diet and exercise also had a role in the treatment. Only 50% had the correct knowledge that diabetes needs lifelong treatment. Majority 240 (63.1%) of the subjects had the knowledge of avoiding sugar in food of diabetics. Knowledge about the organs affected by diabetes was more in men (82%) as compared to women (71%). Only 30% of the study subjects had heard of hypoglycemia as a complication. Conclusion: As the awareness regarding diabetes, its cause, symptoms and complications was poor in the study area health education activities regarding diabetes should be increased.

Keywords: Adults, awareness, Delhi, diabetes

 Are Accredited Social Health Activist workers aware of their roles and responsibilities? A cross-sectional survey

Charu Kohli1, Jugal Kishore1, Shantanu Sharma1, Harsavardhan Nayak1

1Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

E-mail: [email protected]

Introduction: The role of community health workers in healthcare delivery system is widening as they are considered inevitable to meet the universal healthcare provision and the millennium development goals. The role of Accredited Social Health Activist (ASHA) workers is vital in the public health delivery system in India. Objectives: The study was planned to assess the sociodemographic profile of ASHA workers, awareness and practices of their roles and responsibilities, and difficulties faced while working in the North-East District of Delhi, India. Materials and Methods: A descriptive cross-sectional study was conducted in the North-East District of Delhi among 55 ASHA workers after taking written informed consent. Data were collected using a pretested semi-structured questionnaire consisted of items on the sociodemographic profile of ASHA workers, knowledge and practices about their roles and responsibilities, and difficulties faced in the community. The data were analyzed using SPSS software version 17. Qualitative data were expressed in percentages, and quantitative data were expressed in mean ± standard deviation (SD). Results: Mean age (±SD) of ASHAs was 31.84 ± 7.2 years. Most of them were married (96.4%), Hindu (85.5%), and catering to a population of 1000–2000 (87.3%). Most of the ASHAs workers were aware of their work of maternal and child health services. However, lesser numbers were aware of their role in the registration of births and deaths and to treat minor ailments. A total of 96.4% reported that they maintain family planning register, only 51 (92.7%) reported that they maintain antenatal register. Ten (18.2%) ASHAs reported that they face problems in coordination with auxiliary nurse midwife. Conclusion: ASHAs performance is impacted by their limited orientation toward their roles and responsibilities. Training should provide complete knowledge about the same.

Keywords: Accredited Social Health Activist, community health workers, Delhi, roles

 Nutritional status and common morbidities among children aged 1–5 years in rural community of Jammu

Shivali Suri1, Dinesh Kumar2

1Department of Community Medicine, Lady Hardinge Medical College and Associated Hospitals, New Delhi, 2Government Medical College and Associated Hospitals, Jammu, Jammu and Kashmir, India

E-mail: [email protected]

Introduction: Malnutrition has long been a major public health concern globally leading to high morbidity and mortality in under-five children. Mortality due to acute respiratory infections (ARIs) and diarrheas has declined in the recent years; still, they are the leading cause of death in these children. Objectives: (i) To study burden of under-nutrition, ARI, and diarrheal diseases among children aged 1–5 years (ii) to study the association with selected sociodemographic factors and dietary factors. Materials and Methods: Seven hundred and fifty children aged 1–5 years were studied with 50 subjects each from 15 villages using multi-stage, random sampling technique. Caregivers of the eligible participants were interviewed to determine the history of ARIs and diarrhea in the last 2 weeks preceding the date of interview. The nutritional status of children was assessed by measurement of mid-upper arm circumference. History of factors such as age, gender, socioeconomic status (SES, breastfeeding, complementary feeding practices, and number of doses of Vitamin A prophylaxis received was also ascertained. Results: More than one-fourth of the study children were suffering from of under-nutrition. The prevalence of ARI and diarrhea in the sample studied was 39.1% and 21.2%, respectively. Exclusive breastfeeding for 6 months and age at which the child started complementary feeding were found to have significant association with the nutritional status of children. Significant association was also observed between under-nutrition and morbidities such as ARI and diarrhea. Diarrhea was found to be significantly associated with age of the child, SES, age at which child started weaning. There was a negative association between prevalence of diarrhea with Vitamin A supplementation and nutritional status. Conclusion: Under-nutrition continues to be a significant public health problem in under-fives. Multi-pronged approaches aimed at improving maternal and child healthcare would be beneficial to combat the problem of malnutrition.

Keywords: Acute respiratory infections, diarrheal diseases, under-five children, under-nutrition

 Quality of care: Predictor for utilization of antenatal care services in slum women of Aligarh

Saira Mehnaz, Ali Jafar Abedi, Shazia Farooq Fazli, Zulfia Khan, Mohammad Athar Ansari

Department of Community Medicine, J.N. Medical College, A.M.U., Aligarh, Uttar Pradesh, India

E-mail: [email protected]

Objectives: (1) To assess the quality of antenatal care (ANC) received by women living in the newly formed urban slums of Aligarh (<10 years duration). (2) To evaluate the attitude of caregivers as perceived by the target population. Materials and Methods: This cross-sectional, community-based study was done in the newly formed slums of Aligarh city. A total of 347 women who had delivered within the last 1 year were identified for the study. One woman did not give consent, and 2 women were not available during the second visit. Three hundred and forty-four women from 63 slums who had delivered a live baby within the last 1 year formed the study population. The findings were entered on SPSS 17 and on ATLAS.ti and analyzed. Results/Discussion: Of the 344 women forming the study population, 86% were aged between 20 and 35 years, 60% were Muslims, 71.4% belonged to the other backward class category, and 10.6% were scheduled caste. A poor quality ANC was received by only 54.9% women. Only 23.3% slum women had three or more than three ANC visits while 19.6% had single visits. 77.2% women preferred being treated by a doctor, and only 50% women got the required information in a satisfactory manner. Only 18.5% women were always treated with dignity and only 28% were respected for privacy. Conclusion: The utilization of ANC care services was low, and the quality of services offered was poor. The attitudes and behavior of healthcare workers was a major barrier observed in this low utilization of services.

Keywords: Antenatal care, attitudes, barriers, utilization

 Sexual behavior of adolescent students in Chandigarh and their perceptions regarding family life education

Dinesh Kumar1, N. K. Goel1, Ravleen Kaur Bakshi1, M. K. Sharma1, Abhik K. Ghosh2

1Department of Community Medicine, GMCH, 2Department of Anthropology, Panjab University, Chandigarh, India

E-mail: [email protected]

Objectives: To investigate the sexual behavior of adolescent students and to study misconceptions prevailing among them. Methods: A cross-sectional survey of 1022 adolescent students aged 14–19 years as a part of an Indian Council of Medical Research sponsored survey. Sexual behavior explored by interview method. Logistic Regression Analysis for finding correlates. Results: Intimate friendship was reported by 19.2% respondents. Sexual behavior included 89% exposure to sex-related material, 74.7% were aware of sexual intercourse. Awareness regarding at least one contraceptive was found among 95.5% (94.5% of condoms and 67.2% of emergency contraception). About 6% respondents reported some sex- related problems and 2.5% of all respondents consulted some doctors for these problems. Awareness of HIV/AIDS was quite high (about 99%) and respondents, and 96.4% of them were of the opinion that it is spread through sexual intercourse. Knowledge regarding the transmission of sexually transmitted infections (STI's) through sexual contact was found among 89.2% respondents. Avoidance/abstinence from sex (84.7%), faithful to one partner (81.7), and use of barrier methods (90.3%) were main reported preventive measures for STI's. About 33% want that the discussion about sex should be open and frank, and 69.4% showed the need for sex education in the schools mostly by doctors. Conclusions and Suggestions: Sexual behavior of adolescent students is changing, and awareness about sex acts is also increasing. There is likelihood of indulging in risky behavior by adolescents. Family life education was felt necessary mainly by qualified medical staff.

Keywords: Adolescent, family life, sexual behavior

 A study to determine difference in risk factor distribution for cardiovascular diseases among high school boys and girls of urban Dibrugarh, Assam

Ekta Gupta1, Tulika Goswami Mahanta2

1Department of Community Medicine, Lady Hardinge Medical College, New Delhi, 2Department of Community Medicine, Assam Medical College and Hospital, Dibrugarh, Assam, India

E-mail: [email protected]

Introduction: Chronic noncommunicable diseases including cardiovascular diseases are the leading cause of death in the world, and their incidence is rising rapidly due to increasing rates of risk factors such as hypertension, dyslipidemia, diabetes, obesity, physical inactivity, and tobacco use. These risk factors track from childhood to adulthood, and their distribution varies among males and females; hence, there is a need to determine risk factor prevalence among adolescent age group so as to plan preventive strategies. Objective: To determine the difference in distribution of risk factors for cardiovascular diseases among high school boys and girls of urban Dibrugarh, Assam. Materials and Methods: A cross-sectional study was conducted from October 2012 to June 2013 in the schools of the urban Dibrugarh, Assam wherein data were collected from 1000 students in class 8 to 10 using multistage random sampling and risk factors were assessed using WHO steps methodology. Statistical analysis was done using SPSS version 16 software, and test of differences used were Chi- square test and t-test. Results: The prevalence of ever tobacco use was 32.3% among boys and 6.6% among girls (P = 0.000) while ever alcohol use was reported by 11.9% boys and 1% girls (P = 0.000). Prevalence of overweight and hypertension was found to be higher among girls (11.7% and 24.1%) as compared to boys (6.8% and 18.1%). Prevalence of hypercholesterolemia was higher among boys while high triglycerides levels were more prevalent among girls. Conclusion: The study revealed a high prevalence of various risk factors among boys and girls. There is a need to reduce the risk factor prevalence of cardiovascular diseases among this group of the population to address the future epidemic of noncommunicable disease. Different health promotional activities need to be implemented to target boys and girls as the risk factor distribution among these groups is different.

Keywords: Cardiovascular disease, high school students, hypertension, risk factor

 Impact of discount card on utilization of clinic services of an urban primary care clinic chain

Naveen Kumar Vashist1, Devashish Saini1

Ross Clinic, Gurgoan, Haryana

E-mail: [email protected]

Introduction: Family practice clinics offer multiple services often including an in-clinic pharmacy. The effective utilization of this service depends on the perceived quality of medicines dispensed as well as discounts offered on the printed maximum retail price. We found that some of our patients were opting out of buying medicines from the clinic, due to discounts being offered at nearby pharmacies. We introduced a discount card (smile card) in November 2014 in one of our clinics, offering 10% discount on medicines purchased from our in-house pharmacy, and discounts on other services as well. Objective: To study the impact of a new discount card on the proportion of patients opting out of buying medicines from the in-house pharmacy. Methods: We collated summary financial data from the clinic, over a period of 3 months prior to and 3 months after the launch of smile card in 2014–2015. No patient identifiers were collected. Using Google spreadsheets, we calculated the percentage of patients opting not to buy medicines from the in-house pharmacy, out of all patients who availed consultation at the clinic. Results: With the introduction of smile card, the proportion of patients who were opting not to buy medicines decreased from 16% to 11%. There was a marginal increase in the revenue from the in-house pharmacy. Conclusion: Urban Indians are looking for discounts, and it is an important factor in making choices, in addition to quality. Offering discounts does not seem to decrease the clinic revenue and may lead to better patient satisfaction.

Keywords: Discount card, in-house pharmacy revenue, primary care, retail discount

 General morbidity pattern among urban population of Kozhikode City, Kerala, India

Vineeth Rajagopal1, A. V. Gopalan2, Biju George3, M. Roshni1

Departments of 1Family Medicine, 2Paediatrics and 3Community Medicine, Government Medical College, Kozhikode, Kerala, India

E-mail: [email protected]

Introduction: Different morbidity studies revealed that Kerala accounted for highest morbidity among Indian states. However, the available literature is largely concentrated on rural areas and is based on self-perceived illness of the study subjects. The present study attempted to implore the morbidity status of an urban population of Kozhikode City focusing on family as a basic unit of community. Objectives: To study the morbidity pattern in an urban population of Kozhikode City, prevalence of specific morbidities and to determine the specific morbidities present in families. Materials and Methods: A community-based cross-sectional study was conducted in 4 randomly selected wards of Kozhikode Corporation from March 2013 to February 2014. A total of 812 subjects belonging to all age groups were studied using family interview record and clinical examination. Data on sociodemographic variables, overall morbidity, specific morbidities, and morbidities specific to families were collected and were statistically analyzed. Results: About 69% of the population was affected with any of the variables studied with females showing a higher rate of 72%. Major morbidities observed were systemic hypertension, obesity, type 2 diabetes mellitus, musculoskeletal ailments, refractive errors, cataract, and menstrual disorders. Apart from this asthma, fungal infections, and dyspeptic disorders showed relatively higher prevalence among families. Conclusion: Urban population of Kozhikode revealed higher prevalence for different morbidities studied. Noncommunicable diseases such as systemic hypertension, obesity, and type II diabetes mellitus showed higher prevalence than infectious diseases. The family specific design revealed higher rates of occurrence for different noncommunicable diseases which is a reflection of the lifestyle they practiced.

Keywords: General morbidity, prevalence

 Comparative evaluation of various anthropometric measures of insulin resistance in overweight and obese adults from North India

Sudhish Sehra1, Shalini Jaggi2, Mugdha Singh2

Departments of 1Medicine and 2Family Medicine, Sri Balaji Action Medical Institute, New Delhi, India

E-mail: [email protected]

Introduction: As the burden of diabesity is increasing, the search is on for developing simpler, inexpensive, and noninvasive methods as clinical markers of insulin resistance that need minimum expertise and resources and can be effectively used in identifying high-risk individuals from a mass population. Aims: (1) To comparatively evaluate neck and wrist circumferences and waist-height ratio (WHtR) as anthropometric measures of insulin resistance in overweight and obese nondiabetic, nonhypertensive adults (2) To compare these with the preestablished markers of insulin resistance namely, waist circumference (WC), waist-hip ratio (WHR), body mass index(BMI), and homeostasis model assessment of insulin resistance (HOMA-IR) to propose their order of correlation and cutoffs. Materials and Methods: A cross-sectional study with 100 adults with BMI ≥23 kg/m2. Anthropometric measures assessed using WHO specified methods - wrist, neck, waist, and hip circumferences; WHR and WHtR as well as BMI. Fasting blood sugar and fasting serum insulin levels were measured, and insulin resistance was evaluated by the HOMA-IR. Spearman correlation was used for comparison. For all statistical tests, a P < 0.05 was taken to indicate a significant difference. Results: Sixty-one percentage of the study subjects were found to be insulin resistant. Neck circumference (NC), WHtR, and wildlife resources commission (WrC) showed a statistically significant correlation with HOMA-IR. The receiver operating characteristic curve demonstrated a statistical significance for NC, BMI, WHtR, and WrC with best cut-off points for each being 37.25 cm, 27.95 kg/m2, 0.60 cm, and 15.75 cm, respectively. Conclusion: Among all the various anthropometric indicators evaluated for assessing insulin resistance, the most promising indicators that emerged from our data were NC, BMI, and WHtR apart from WC, which still remains to be the strongest measure in the group. WrC was significant only in the male population. Hence, we propose NC as an easy alternative to the cumbersome measurement of WC in a busy outpatient department setting.

Keywords: Neck circumference, waist circumference, waist to height ratio, wrist circumference

 Prevalence of prehypertension and undiagnosed hypertension among urban population of Kozhikode city, Kerala, India

Saleela Karuthedath1, N. K. Thulaseedharan2, Biju George3, M. Roshni1

Departments of 1Family Medicine, 2Internal Medicine and 3Community Medicine, Government Medical College, Kozhikode, Kerala, India

E-mail: [email protected]

Background: Prehypertension and hypertension are two important treatable causes of cardiovascular morbidity and mortality. There are no reported studies from North Kerala on prevalence of prehypertension and undiagnosed hypertension in urban areas. Aims and Objectives: (1) To study the prevalence of prehypertension and undiagnosed hypertension among urban population of Kozhikode city. (2) To study the comorbidities associated with prehypertension and hypertension. Methodology: This is a cross-sectional study. The study population was selected by cluster sampling. Information regarding biodata, sociodemographic variables, behavioral, and other risk factors were collected using proforma. Blood pressure (BP), weight, height, waist circumference, and hip circumference were measured. Results: Mean age of the study population was 46.23 years. Of 300 participants, 82 (27.3%) were males, and 218 (72.7%) were females. One hundred and seven (35.7%) participants were prehypertensives, 148 (49.3%) were hypertensives (60 [20%] known hypertensives, 88 [293%] newly detected/ undiagnosed hypertensives), and only 45 (15%) were normotensive. Of 148 hypertensives, 60 (40.54%) were previously diagnosed to have hypertension, of which 81.66% were on treatment, in which only 34.6% had controlled BP. Eighty-eight (59.45%) were newly diagnosed hypertensives. On univariate analysis, sedentary work (odds ratio (OR) 2.63, P value [P] =0.001), BMI >23 (OR 2.42, P = 0.004), increased waist circumference (OR 2.15, P = 0.049) in females were significantly associated with prehypertension. Increasing age (OR 5.69, P = 0.002), sedentary work (OR: 2.3.9, P = 0.02), low education status (OR 2.1, P =0.04), comorbidities such as diabetes mellitus (OR 13.8, P = 0.002), dyslipidemia (OR 17.4, P = 0.0004), stress within last 1 month (OR 8.9, P = 0.02), BMI >23 (OR 2.19, P = 0.03), and increased waist circumference (OR 2.29, P = 0.03) in females were significantly associated with hypertension. Conclusion: Prevalence of prehypertension and undiagnosed hypertension was significantly high in the study population. Increasing age, sedentary work, low education status, diabetes mellitus, dyslipidemia, stress, body mass index >23, and increased waist circumference were significantly associated with high BP.

Keywords: Prehypertension, prevalence

 An epidemiological study of locomotor problems among rural elderly population

Mohd Maroof1, Anees Ahmad1, Najam Khalique1, M. Athar Ansari1

1Department of Community Medicine, J N Medical College, AMU, Aligarh, Uttar Pradesh, India

E-mail: [email protected]

Introduction: Locomotor functions decline with the age along with other physiological changes. This results in deterioration of quality of life with decreased social and economic role in the society, as well as increased dependency, for the health care and other basic services. The demographic transition resulting in increased proportion of elderly may pose a burden to the health system. Objectives: To study the prevalence of locomotor problems among the population, and to find out various sociodemographic factors associated with locomotor problems. Methods: The study was a community-based cross-sectional study done at field practice area of Rural Health Training Centre, J N Medical College, AMU, Aligarh, Uttar Pradesh, India. A sample of 225 elderly was selected using systematic random sampling with probability and interviewed using pretested and predesigned questionnaire. Data were entered and analyzed using SPSS version 20. Test of proportion and Chi-square test was applied. P < 0.05 was considered significant. Results: About 25.8% of the elderly had locomotor problems. Age, gender, and working status significantly affected the locomotor problem. Conclusion: The sociodemographic factors significantly related with locomotor problems needs to be addressed properly to improve the quality of life and lessen dependency and economic burden to the society.

Keywords: Elderly, locomotor problems, rural

 Immunization-related knowledge of mothers of under five children attending immunization clinic of a Tertiary Care Hospital in Haryana

Nitika Sharma1, N. Kumar1, J. S. Malik1

1Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

E-mail: [email protected]

Introduction: The World Health Organization rates immunization as one of the interventions with a large potential impact on health outcomes. Parents', especially mothers' concern regarding immunization have a direct impact on adherence to the immunization schedule. The current study was carried out to assess the knowledge of mothers of under five children regarding immunization. Objectives: To assess immunization- related knowledge of mothers of under five children attending immunization clinic of a tertiary care hospital. Study Design: community-based, cross-sectional study. Study Period: June 2015 to September 2015. Study Participants: Two hundred mothers of under five children attending immunization clinic of a Tertiary Care Hospital in Haryana. Study Tool: Semi- structured pretested schedule was used to obtain information from respondents to assess the knowledge regarding diseases prevented by vaccine, the recommended schedule, and other key ancillary facts regarding childhood immunization. Results: Out of 200 mothers, majority were educated up to higher secondary (31%) and secondary (27%) level. Majority (82%) had knowledge about oral polio vaccine and 79% and 4% had knowledge about diphtheria, pertussis, and tetanus and measles, respectively. 42% had knowledge about Vitamin A administration. Educational status of women was significantly associated with knowledge about immunization. Conclusion: Most of the mothers' were well aware of the importance of immunization. Intensified pulse polio immunization campaign has a positive influence on awareness regarding their vaccination. Information, education, and communication activity regarding Vitamin A and newly introduced vaccines need to be stressed upon. There is a need of increased media involvement for increasing awareness regarding immunization.

Keywords: Immunization, tertiary care hospital

 A study of lower respiratory tract infection in Kolkata

Anita Banerjee1,2, Bibhas Saha Dalal3, Manab K Ghosh2, Sudeshna Mallik2, Kalpana Karak1, Bibhuti Saha2

Departments of 1Microbiology and 3Pathology, KPC Medical College and Hospital, 2Department of Tropical Medicine, School of Tropical Medicine, Kolkata, West Bengal, India

E-mail: [email protected]

Background: Lower respiratory tract infection (LRTI) is recognized as an important cause of mortality worldwide. In India, few data are available on the pattern and impact of bacterial LRTI on adults. Objective: We aimed to correlate risk factors, initial antibiotic treatment, severity of illness, duration of hospital stay, and in-hospital mortality among culture-negative (CN) and culture-positive (CP) hospitalized LRTI patients. Materials and Methods: A prospective, observational study in adult LRTI patients was carried out in Calcutta School of Tropical Medicine, a 150-bedded postgraduate teaching hospital and KPC Medical College and Hospital, a 750-bedded undergraduate teaching hospital in Kolkata. Result: There were 74 (26.8%) community-acquired pneumonia patients among 276 admitted LRTI patients. Admitted LRTI patients have substantial underlying pulmonary comorbidity including chronic obstructive pulmonary disease, interstitial lung disease, bronchiectasis, and history of pulmonary tuberculosis n = 155 (56%). One hundred and thirty (47.1%) LRTI patients were CP and 146 (52.9%) were CN. Significant alteration observed in the initial antibiotic given to CP patients in comparison to CN patients (n = 33 [25%], n = 11 [7.5%] P = 0.0002, respectively). No significant association of CP patients were observed with Intensive Care Unit admission; CP (n = 49 [37.6%] and CN n = 36 [24.6%], P = 0.06). However, need for mechanical ventilation, (CP n = 25 [19%]; CN n = 12 [8%] P = 0.02), in-hospital mortality (CP n = 22 [16.9%]; CN n = 5 [3.4%] P = 0.000), and duration of stay in hospital (CP [11.73 ± 6.4 days]; CN [8.92 ± 4.7 days] P < 0.001) were all significantly associated with CP patients in comparison to CN LRTI patients. Conclusions: We observed initial antibiotic change, duration of hospital stay, the requirement for mechanical ventilation, and in-hospital mortality were significantly more in CP LRTI patients in comparison to CN LRTI patients.

Keywords: Community-acquired pneumonia, comorbidity, culture-positive, lower respiratory tract infection

 Silicosis in stone workers: A correlation of clinical, radiological, and lung function changes in 47 patients

Priyank Sharma1, Anil Kumar Chawala1

1Department of Family Medicine, J W Global Hospital and Research Centre, Mount Abu, Rajasthan, India

E-mail: [email protected]

Introduction: Silicosis damages the lungs irreversibly. Rajasthan has mines and stone industries where a large number of workers are exposed to silica dust. Aims and Objectives: We planned to study people working in stone industries to find if their duration of exposure related to changes on chest X-ray and to forced expiratory volume in one second (FEV1) and Forced vital capacity (FVC) on spirometry. Materials and Methods: Forty-seven patients exposed to silica dust were included. Their demographic data, duration of exposure, respiratory symptoms, history of tuberculosis, and smoking were recorded. Chest X-ray and spirometry were done in each patient. Results: The age group of the all male 47 patients was 20–65 years. The duration of exposure varied from 1 to 30 years (average 9 years). Ninety- five percentage had a cough, 57% breathlessness, and 10% had chest pain. History of tuberculosis was elicited in 36%, and 36% were smokers. X-ray changes according to International Labor Organization were classified using profusion or density level, into 1–3 grades. Those with 1–2 years of exposure had mild (profusion level 1) changes in 70%, 2–8 years exposure had (profusion level 2) changes in 65%, and 8–10 years exposure had (profusion level 3) changes in 65%. Spirometry results were divided into a mild, moderate, and severe restriction on the basis of FVC and FEV1/FVC ratio. Those with 1–2 years' exposure had a mild restriction in 65%, 2-8 years exposure had a moderate restriction in 60%, and more than 8 years exposure had a severe restriction in 65% cases. Patients with tuberculosis and smoking history had worse changes on X-ray and spirometry. Conclusion: Exposure to silica dust leads to lung fibrosis. The resulting radiological changes and lung function abnormalities are proportional to the duration of silica exposure in over 60% of patients.

Keywords: International Labor Organization X-ray classification, silicosis, spiromerty

 Anemia profile at presentation in tuberculosis patients at a Secondary Care Hospital in Rural Chhattisgarh (January 2014 – September 2015)

Gajanan Phutke1, Sushil Patil1, Kishore Kumar1, Raman Kataria1, Timothy Laux1, Yogesh Jain1

1Jan Swasthya Sahyog, Bilaspur, Chhattisgarh, India

E-mail: [email protected]

Introduction: Anemia is associated with active tuberculosis. Individuals with severe anemia tend to have later sputum conversion and increased mortality rates. Tuberculosis-related anemia is generally considered to be anemia of chronic disease and is usually mild according to the WHO criteria. This contrasts with our institutional experience, where severe anemia is frequently seen among tuberculosis patients. Aims and Objectives: To describe anemia profile at the presentation in patients with tuberculosis at a rural Secondary Care Hospital in Central India. Materials and Methods: A cross-sectional, observational study to describe anemia profile (prevalence, severity, and type) in patients newly diagnosed with tuberculosis from January 1, 2014, to September 31, 2015. Data were collected via chart review. Analyses focused on describing the severity of anemia in the general tuberculosis population and by certain demographic characteristics. Results and Discussion: Among 786 patients diagnosed with tuberculosis, anemia prevalence according to the WHO criteria was very high (93%). The median hemoglobin was 9.2 g/dL (range 3.6–17.8). The majority of patients had microcytic anemia (73%). Of all the anemic patients, 16% has mild, 58% has moderate, and 26% has severe anemia. The proportions of severe anemia remain same across sites of diseases (pulmonary 24.7%, extrapulmonary 22.7%, and disseminated 23.8%) and among pulmonary in both sputum positive (67.2%) and negative patients (32.8%). Conclusions: Existing literature suggests that anemia of chronic diseases is usually mild form. This unusually higher severity (80% had moderate to severe grades of anemia) needs to be investigated for other possible factors contributing to anemia. With about a fourth of patients with tuberculosis having severe anemia (23.8%), blood transfusion becomes essential for optimal treatment. These need further evaluation for understanding exact cause and subsequent treatment recommendations.

Keywords: Anemia, rural health, tuberculosis

 Awareness of cervical cancer in women in the general population

Rama P. Joshirao1, Veena G. Rahatgaonkar1

1Department of Family Medicine

E-mail: [email protected]

Context: Cervical cancer ranks the fourth most common malignancy among women, worldwide and the second most common in India, causing significant mortality, and high disease burden. Cancer cervix is potentially a preventable disease, with a known cause viz., human papillomavirus (HPV). Herein lies the importance of screening tools which essentially facilitate early detection, leading to early treatment. The late presentation has more invasive treatment, and outcomes are minimal. The awareness of cervical cancer and its screening plays a role in early cancer detection. Aim: The aim of the study was to evaluate awareness regarding cervical cancer and its screening among females, above 15 years of age, in the general population. Settings and Design: Retrospective analytical study. Methodology: We reviewed 32 different studies done in the last 15 years in 13 countries and compared their results regarding knowledge of cervical cancer, its etiology (HPV) and screening. We grouped countries as economically developed and developing according to HDI and analyzed results in each group. Statistical Analysis Used: Mean. Results: In developed countries, screening done by Papanicolaou (Pap) test was ranging from 43% to 95% with mean of 65.4% in the total population of 5561 of all studies. In developing countries, screening done by Pap test was ranging from 2.4% to 11% with mean of 7.9% in the total population of 5033 of all studies, even though 20–95% (mean - 58.3%) had heard of cervical cancer. Whether women had heard of cervical cancer was a parameter scarcely included in the studies carried out in developed countries, most probably because most of the women had heard of it. In developed countries, 47.7% were aware of HPV as a cause of cervical cancer; while, in developing countries, it was only 20.9%. Conclusion: There was a wide gap in the proportion of women undergoing screening for cervical cancer in developing and developed countries, likely due to lack of knowledge and positive attitude among women in developing nations.

Keywords: Awareness, cervical cancer, human papillomavirus

 Prevalence of chronic insomnia in adult patients in a primary care outpatient department and to assess its correlation with medical comorbidities

Swapna Bhaskar1, Hemavathy1, Shankar Prasad1

1Department of Family Medicine, St. Philomena's Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Insomnia is a common yet under-recognized symptom given by many adult patients who visit the outpatient department (OPD) with varied morbid conditions. Many physicians tend to underestimate the importance of the symptom and do not look into the possible risk factors associated with it and sideline it as a subtle symptom. Hence, we look at the prevalence, risk factors, and medical comorbidities in chronic insomnia in the adult population. Aims and Objectives: To study the prevalence of chronic insomnia in adults visiting a primary care OPD in a hospital and to assess the risk factors and comorbidities associated with it. Materials and Methods: All adult patients attending the OPD from September 1st to October 30th will be enrolled in the study after obtaining written consent. Athens insomnia scale will be used to diagnose insomnia and information regarding medical, comorbidities, their duration, and treatment will be collected. Data collected using a structured protocol that includes age, sex, socioeconomic status, and effects of insomnia will be analyzed for different variables and presented.

Keywords: Chronic insomnia, comorbidities, primary care

 Development and validation of a protocol to assess multimorbidity in primary care settings: An Indian experience

Sanghamitra Pati1, Subhashisa Swain1, Mohammad Akhtar Hussain2, Marjan van den Akker3,4, Job Metsemakers3, J. Andre Knottnerus3, Chris Salisbury5

1Indian Institute of Public Health, Public Health Foundation of India, Bhubaneswar, Odisha, India, 2School of Population Health, Queensland University, Brisbane, Australia, 3Department Family Medicine, School Caphri, Maastricht University, Maastricht, The Netherlands, 4Department General Practice, KU Leuven, Leuven, Belgium, 5Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK

E-mail: [email protected]org

Introduction: Multimorbidity is becoming increasingly common in India. Few studies highlighting the magnitude of noncommunicable disease multimorbidity from secondary data sources have explored a limited number of chronic diseases. Aims/Objectives: We undertook a study to assess the prevalence, pattern, correlates, and outcomes of multimorbidity in public and private primary care settings in India. The present abstract describes the process of development and validation of our data collection tool “Multimorbidity Assessment Protocol (MAP).” Description: The MAP questionnaire comprised sociodemographic information (age, sex, residence, ethnicity, religion, education, marital status, and family income); multimorbidity assessment (information on whether the patient had ever been told by a physician or diagnosed with any of the chronic health problems). We adopted an iterative approach to arrive at the list of chronic diseases. First, a list of chronic diseases was prepared by a review of prevalence studies. It was further revised with chart review of both hospital records. It was then shared with a panel of primary care physicians and refined for each of the reported chronic disease, patients were asked on how much the particular health problem interfered in their daily activities (e.g., not at all, a little, or a great deal), number of outpatient consultations in last 1 year, past and current use of medication and inpatient admissions if any. Multimorbidity outcomes were assessed through burden score (treatment utilization and severity), self-rated physical and mental health and health-related quality of life (using SF 12). The instrument was cognitively tested with 17 adults of diverse age and socioeconomic strata for comprehensibility. Next, it was pretested with 88 nonstudy patients. These 88 patients were re-administered the questionnaire after 2 weeks, and the test-retest reliability, internal consistency, inter-rater reliability, and construct validity were calculated. The validated questionnaire was administered to 1649 patients in 20 public and private primary care facilities.

 Role of procalcitonin as a prognostic marker in recent (2015) outbreak of H1N1 influenza in India

Pratyush Kumar1, Atul Gogia2, Atul Kakar2

1Departments of Family Medicine and 2Medicine, Sir Ganga Ram Hospital, New Delhi, India

E-mail: [email protected]

Introduction: Re-emergence of H1N1 in 2015 has led to an increase in morbidity and mortality as compared to 2009 pandemic in India, though the viral strain remains the same. Several factors such as dense population, virulence, and rapid spread caused panic among the masses and posed a serious challenge for healthcare providers. Aims and Objectives: To investigate the role of procalcitonin as a prognostic marker in admitted patients with confirmed H1N1 infection. Methods: A prospective observational study at a tertiary care center in Northern India was done from 1 January 2015 to 31 March 2015. Clinico-laboratory data were analyzed of all H1N1 infected patients which were confirmed by reverse-transcription polymerase chain reaction testing on nasopharyngeal swabs. Procalcitonin was measured on day 1 following admission using an enzyme-linked fluorescent immunoassay. Results: Totally, 200 confirmed H1N1-infected patient's data were collected. Mean age was 41.5 years with patients who died had higher mean age of 53.4 years (P = 0.017). Age ranged from 3 months to 85 years with 46% females. Type 2 diabetes mellitus and hypertension were seen in 22.5% and 23% of patients, respectively. The time between the onset of symptoms and hospitalization ranged from 1 to 25 days. Documented clinical features were fever - 92%, dry cough - 86.5%, productive cough - 7.5%, and dyspnea - 84.5%. Management included oseltamivir and antibiotics, if indicated. Supplemental oxygen was given in 64% of patients, whereas 25.5% required Intensive Care Unit care with 16% - mechanically ventilated and 7.5% - maintained on noninvasive ventilation. Mortality was 10.5%. Mortality correlated significantly with serum procalcitonin measured on day 1 (P = 0.005) [Figure 1].{Figure 1}

Risk of secondary bacterial sepsis leading to mortality was higher among referred cases (P ≤ 0.001). High-risk factors such as pregnancy, diabetes, and hypertension did not correlate with mortality significantly. Conclusion: The mortality rate in our study was 10.5%. Procalcitonin was found to have a significant association with mortality. Procalcitonin on day 1 following admission is a useful marker in defining prognosis of the patient.

 Glycosylated hemoglobin values in nondiabetic pregnant women in third trimester and adverse fetal outcomes: An observational study

P. Shobha1, Sherly Mathen2, Joison Abraham3

1Department of Family Medicine, Lakeshore Hospital, Nettoor, 2Departments of Obstetrics and Gynaecology and 3General Medicine, Lourdes Hospital, Pachalam, Kochi, Kerala, India

E-mail: [email protected]

Introduction: Physiology of glucose metabolism in pregnancy is characterized by fasting hypoglycemia, postprandial hyperglycemia, and hyperinsulinemia, all of which help to meet the fetal needs of energy. Glycosylated hemoglobin (HbA1c) value is a measure of the blood glucose level of the preceding few weeks and gives an idea about the glycemic control. Fetal outcomes are affected by glycemic level. Aims and Objectives: To estimate the level of HbA1c for a safe fetal outcome and to estimate the relation between this level and various adverse fetal outcomes. Materials and Methods: Primigravida who are diagnosed as not having gestational diabetes mellitus as per the glucose challenge test done at 24 weeks with a cut-off value up to 140 mg/dl. Subjects are followed up at 30–34 weeks for the estimation of HbA1c in the blood and further until the time of delivery and postnatal period for the outcomes. Data were analyzed to obtain the mean value HbA1c in the third trimester. Fetal outcomes were analyzed with the HbA1c value. Results: The HbA1c values in the third trimester of pregnancy in this study ranged from 4.5% to 6%. Unfavorable outcomes were found the least in the 4.5–5%. The average plasma blood glucose corresponding to HbA1c value of 5% is 101 mg/dl. The majority were admitted for observation (49.5%) and hyperbilirubinemia (16.5%) requiring phototherapy, hypercalcemia requiring calcium supplements (12.6%), hypoglycemia requiring glucose (7.8%), and persistent tachypnea of newborn (5.8%), and all the outcomes correlated significantly with the HbA1c values. Conclusions: HbA1c can be utilized for the monitoring of glycemic level and as a screening test.

Keywords: Fetal outcomes, glycosylated hemoglobin, nonpregnant diabetic women, third trimester

 Polyarticular septic arthritis mimicking seronegative spondyloarthropathies

Pratyush Kumar1, Atul Gogia1, Atul Kakar1

1Department of Family Medicine, Sir Ganga Ram Hospital, New Delhi, India

E-mail: [email protected]

Septic arthritis is an infective joint pathology which presents with classical signs of inflammation rubor, tumor, calor and dolor, and functio laesa and carries poor prognosis if not detected early and managed aggressively. Here, we present a case of arthritis in the elderly male involving bilateral knees elbows, wrists, and shoulder joints with intraspinal abscesses.

Keywords: Abscess, arthritis, prognosis, septic

 Chronic disease management: An experience from a primary health care unit in Singapore

Santosh Lional Thomas1

1SingHealth Polyclinic, Queenstown, Singapore

E-mail: [email protected]

Introduction: With the advent of better hygiene, immunization, and variety of antimicrobials, death from communicable diseases worldwide have decreased, while the morbidity and mortality with noncommunicable diseases have increased. Family physicians by virtue of the prolonged relationship with patients are well equipped to provide comprehensive care for their clients with chronic medical conditions and collaborate in “shared care arrangements” with the help of specialists for patients with established complications who require closer monitoring. Aims: To describe the organization and functioning of public health care delivery system in the management of chronic diseases in Singapore. Objectives: (1) To describe the practice of principles of family medicine in caring for adult patients with chronic medical conditions. (2) To describe the organization of health care delivery system and financing of chronic disease management. Materials and Methods: Descriptive review of the organization of health care delivery systems, analyzed demographic data, and monthly/annual clinical indicators on chronic disease management at the SingHealth polyclinics. Discussion: Health care in Singapore is a model of private– public partnership among general practitioners, family physicians (private and public sector), and specialist physicians. Enriched with a diverse population of multi-racial origin and various ethnic groups, Singapore is an ideal representation of urban Asia and chronic diseases pose unique challenges to the country's health care system. SingHealth Polyclinics is a state-subsidized arm of family medicine practice in Singapore with a significant role in chronic disease management focused on patient empowerment by integration of health promotion, education, comprehensive, and continuing care for disease prevention and management. Conclusion: In Singapore, family medicine forms the core specialty involved in the management of chronic diseases with commendable outcomes in cost-effective care, increased longevity, improved quality of life, and “Patient-Centered Care.”

Keywords: Chronic disease management, Singapore

 A chart review of morbidity pattern among adult patients attending primary care setting in urban Odisha, India: An International Classification of Primary Care experience

Pati Sanghamitra1, Swain Subhashisa1

1Indian Institute of Public Health Bhubaneswar, Public Health Foundation of India, JSS Software Technology Park, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Disease burden estimations based on sound epidemiological research provide the foundation for designing health services. Patients visiting a primary care often present with symptoms and signs. The recording of the reasons for encounter (RFE) at primary care settings and linkage of encounters over time permits a classification of the episode and estimation of burden at the community. This is important for a public health point of view in developing countries such as India. Methodology: This cross-sectional study was undertaken at four urban health dispensaries of Bhubaneswar, Odisha, with the aim to explore the prevailing patterns of diseases among patients attending these facilities. Data collection spanned from May to October 2012. At each center, patients' information on age, sex, religion, and presenting illness was extracted from the out patient records over these time period. Data were entered and analyzed in SPSS version 20, and the International Classification of Primary Care-2 was used for coding the illnesses. Results: In total, 2248 patient's records were extracted over 12 weeks. Out of them, 1241 (55.20%) were male and the mean age of males was 41.76 (±15.76) years vis- -vis 38.25 (±14.12) years for females. Around 151 (6.7%) had two or more symptoms or conditions. Overall, the most common categories were general and unspecified followed by digestive related symptoms in both male and female. The most common symptoms among males were fever (11.4%), heart burn (8.1%), and vertigo or dizziness (3.6%). Among females, a similar pattern was seen. Respiratory (17%) and cardio vascular (10.2%) were the most common diagnosis among males and females. The most common RFE for acute care among males and females were fever, allergic rhinitis, upper respiratory tract infection, and acute bronchitis. Leading RFE for chronic care among males were hypertension uncomplicated, heart burn, low back ache among males whereas among females hypertension and heart burn were mostly seen. Over 3.4% patients reported for trauma and/or injury. Nearly 20% of the patients were referred to other physician/clinician/hospital/specialists. Conclusion: Both acute and chronic conditions are prevalent among urban primary care patients. This chart review indicates a need for improving patient record keeping. No coding system is being followed by the primary care physicians for recoding the presenting illness. There is need of appropriate coding system for patient record keeping.

Keywords: International Classification of Primary Care, medical records, primary care

 A double-blind, randomized, placebo-controlled trial of the effect of Vitamin D3 supplementation on long-term glycemic control

Shaheen Chowdhury1, Carolin Elizabeth George2, Gift Norman2, R. Spurgeon2

Departments of 1Family Medicine and 2General Medicine, Bangalore Baptist Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction and Justification: Diabetes is responsible for a major share of the burden of chronic disease worldwide. It has been postulated that the islet cell reactivity and inflammation in type 2 diabetes mellitus (T2DM) is responsible for the progressive nature of the disease. In this context, the role of Vitamin D is being explored in view of its modulation of inflammatory pathways which comprise key events in T2DM progression. In addition in the Indian context particularly, Vitamin D deficiency appears to be an endemic problem. Objectives: To study the effect of adding Vitamin D3 supplementation to the therapeutic regimen on the long-term glycemic control in type 2 diabetes patients. Methods: This randomized, double-blind, and placebo- controlled clinical trial were conducted with 85 type 2 diabetic participants. The Vitamin D-group (n = 44) and the placebo group (n = 41) were matched for gender, age, sunlight exposure, and HbA1c at the baseline. The Vitamin D group received 60,000 IU Vitamin D3 once a month for 3 months, whereas the placebo group (n = 42) received a matching placebo. Results: One hundred and sixteen participants were randomly assigned to two groups. Postattrition 85 subjects (with no difference in baseline characteristics) were analyzed. Mean Hb1Ac increased at the end of 3 months in the placebo group (P = 0.021), whereas the Vitamin D group did not show a statistically significant increase (P = 0.090). Conclusion: Three months of Vitamin D3 supplementation to T2DM patients appeared to arrest the progression of the natural course of disease. Limitations: Vitamin D3 level was not measured at baseline.

Key words: Diabetes mellitus, Vitamin D

 To study clinical and laboratory profile of scrub typhus infection in inpatient in a tertiary care center

Dhawal Modi, Zarin Pilakkadavath, A. Govindrajan

Department of Family Medicine, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Scrub typhus is a rickettsial infection caused by Orientia tsutsugamushi transmitted through the bite of mite. Scrub typhus is an acute febrile illness which causes nonspecific symptoms and signs. The clinical manifestations of this disease range from subclinical disease to organ failure and death. Deaths are attributable to late presentation, delayed diagnosis, and drug resistance. Therefore, we decided to study the clinical, laboratory profile, and organ dysfunction in scrub typhus infection. Aims and Objectives: (1) To study clinical and laboratory profile of scrub typhus infection in inpatient. (2) To assess the organ dysfunction in scrub typhus infection. Materials and Methods: A hospital-based observational prospective study from KIMS hospital, Trivandrum, Kerala during September 2013 to July 2015. All the cases of febrile illness diagnosed as scrub typhus were analyzed. Diagnosis was made by enzyme-linked immunosorbent assay based immunoglobulin M serology. Observations and Results: A total of 44 patients were studied. All of them presented with fever (100%); other major symptoms were headache (27.3%), cough (22.7%), dyspnea (11.4%), and myalgia (25%). On examination, patients had hepatosplenomegaly (6.8%), lymphadenopathy (4.5%), and eschar (11.4%). On investigation, deranged liver function tests (68.2%) were the most common finding. Other laboratory findings were thrombocytopenia and deranged renal function tests. Most common X-ray finding observed in these patients was bilateral lung infiltrates. Other complications were multiple organ dysfunction syndromes (18.2%), acute respiratory distress syndrome (9.1%), renal failure (4.5%), and hepatitis (31.8%). Majority responded to doxycycline. Conclusions: Scrub typhus though prevalent is underreported in our country. It should be considered as an important differential diagnosis in a febrile patient with thrombocytopenia, deranged liver or renal functions, and chest infiltrates. Early diagnosis and treatment will prevent morbidity and mortality.

Keywords: Immunoglobulin M enzyme-linked immunosorbent assay, scrub typhus

 Always better control-vital essential desirable matrix analysis of pharmacy inventory of an urban primary care clinic chain

Nitin Ahuja, Devashish Saini

Ross Clinics, Gurgaon, Haryana, India

E-mail: [email protected]

Introduction: Pharmacy is an integral facility in many primary healthcare facilities. Purchase and storage of medicines often require significant expense and administrative time. For efficient care and service, both understocking and overstocking of medicines must be minimized. Always better control-vital essential desirable (ABC-VED) matrix is a tool that allows a better understanding of stock flow, both in terms of sale contribution and clinical importance of stock items. Objective: To compare the pattern of the sale of drugs in a chain of urban primary care clinics using ABC-VED matrix in 2013 and 2014. Methods: We cleaned and collated medicine sale data from all our clinics for two calendar years: 2013 and 2014. Each inventory item was classified as A, B, or C based on its contribution to total sale, and as vital (V), essential (E), or desirable (D) based on criticality. ABC-VED matrix was formulated by cross-tabulating ABC and VED analyses and items sorted into three categories: Category I (AV, BV, CV, AE, and AD), Category II (BE, CE, and BD), and Category III (CD). Results: Our dispensing pharmacy had 162 items in 2013 and 205 in 2014. The total annual drug sold amount was Rs. 8 lakh in 2013 and Rs. 7.5 lakh in 2014. ABC analysis revealed that top 70% of the sale (Category A) was contributed by 12% of items in both years. The middle 20% of the sale (Category B) was contributed by 20% of items in 2013 and 15% in 2014. Vital items accounted for about 7% of our formulary. On ABC-VED matrix analysis, 20%, 30%, and 50% items in 2013 and 19%, 24%, and 57% in 2014, were found to be Categories I, II, and III, respectively. Conclusion: ABC-VED matrix helps to focus administrative efforts on the most important stock items in terms of sale and criticality (Category I).

Keywords: Always better control-vital essential desirable, inventory management, primary care, stockouts

 Diabetes ongoing sustainable care and treatment: An innovative strategy rooted in principle of near- peer mentoring

Ankur Joshi1, Dinesh Pal1, Sharad Tiwari1, Viswanath Arutagi1, Rakesh Biswas2

1Department of Community Medicine, Gandhi Medical College, 2LN Medical College, Bhopal, Madhya Pradesh, India

E-mail: [email protected]

Background: The informational continuity for a diabetic patient is of paramount importance. This study on a pilot basis explores the process utility of structured educational modular sessions grounded on the principle of near-peer mentoring. Methodology: Visual modules were prepared for diabetic patients. These modules were instituted to 25 diabetic patients in logical sequences. They were in depth interviewed for ascertaining effectiveness of module. These interviews were analyzed by thematic and framework analysis. In the next phase, four persons out of these 25 patients were designated as diabetic-diabetes ongoing sustainable care and treatment (DOST). Each Diabetic- DOST was clubbed with two patients for the modular session and informational deliverance at initial month and for the subsequent 6 months with facilitation of investigator. Process analysis was done with “proxy-indicators,” namely monthly glycemic status, knowledge assessment scores, and quality of life. Data were analyzed with both qualitative (thematic and framework analysis) and quantitative (interval estimates and nonparametric analysis). Results: Visual module was perceived by diabetic patients as an optically engaging tool for receiving, connecting, and synthesizing information about diabetes. Nonparametric analysis indicated a significant improvement in glycemic status in terms with fasting blood sugar (W= 78, z = 3.04, P = 0.002), 2 h-postprandial blood sugar (W = 54, z = 2.01, P = 0.035), and in knowledge score (H= 25.27, df = 3, P < 0.0001). Quality of life scored showed a significant improvement in two out of seven domains namely - satisfaction with the treatment (difference in mean score = 1.40 [1.94–0.85]) and symptom botherness (difference in mean score = 0.98 [1.3–0.65]). Self-reported hypoglycemia events showed a linear, constant trend during the process. Conclusion: Because of inherent methodological limitations and innate biases, at this juncture no conclusive statement can be drawn. Although primitive process evidence indicate the promising role of the Diabetic-DOST strategy.

Keywords: Care-continuum, diabetic care, mentorship

 Audit on management of heavy menstrual bleeding at Blenheim Medical Centre for primary care

Sara Al-Nahi1, Jawad Yahya1, Suprio Dhas1, Sahadev Swain1

1Blenheim Medical Centre, United Kingdom

E-mail: [email protected]

Introduction: Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss, which interferes with a woman's physical, social, or emotional quality of life (National Institute of Clinical Excellence [NICE] guideline CG44). It affects a large number of women of reproductive age in the UK who consequently consult their general practitioner with this problem. The NICE recommends all women to be offered medical treatment with a levonorgestrel-releasing intrauterine system (LNG-IUS) as first line option, provided there are no contra-indications. Aims: To assess the compliance with the HMB NICE guidelines at our primary care surgeries in Luton. Methods: Data were collected from patients who consulted their general practitioner at Blenheim Medical Centre and Link Surgery, using electronic medical records from system one. Results: A total of 298 patients were included in this study. Twenty-two (7.4%) patients were on first line treatment (LNG-IUS) for HMB, followed by 147 patients (49.3%) who were on second line therapy with tranexamic acid, mefenamic acid, or combined hormonal therapy. Thirty-two patients (10.7%) were found to be on third line therapy with norethisterone. Conversely, 152 out of 276 patients (55%) who were not on first line therapy showed to have a high burden of HMB, affecting their quality of life. Furthermore, a total of 38 (12.8%) patients were identified as needing a review of their menorrhagia with possible eligibility for IUS. Conclusion: Our data suggest that only a small fraction of women with HMB are treated with a LNG-IUS as first line management and, therefore, indicates that compliance to the national guideline is suboptimal. We will recall all patients with view to discuss their choice of treatment.

Keywords: Heavy menstrual bleeding, intrauterine system, menorrhagia, primary care

 Fluoroquinolones are associated with delayed diagnosis and treatment and resistance in tuberculosis

Modipalli Rajeswari1, Hemavathi1

1St. Philomena's Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: The Infectious Diseases Society of America and the American Thoracic Society have recommended the use of fluoroquinolones (FQs) for the treatment of adult community-acquired pneumonia (CAP) in the presence of co-morbidities or risk factors.[1] Empirical treatment of CAP with FQs raises great concerns about delayed diagnosis and treatment of pulmonary tuberculosis (TB) and the development of FQ-resistant TB.[2] Several studies and case reports have demonstrated the same and in endemic areas FQs increase the potential for masking active TB and the emergence of an epidemic of drug-resistant TB.[3] Case Reports: Evidence of three case reports in January 2015 in our hospital showing empirical use of antibiotics, especially FQs, for CAP, delaying the diagnosis and treatment of pulmonary TB by >1-month. Discussion: Several studies and case reports have demonstrated that the administration of FQs may delay the diagnosis of pulmonary TB and lead to the emergence of FQ-resistant Mycobacterium TB; in particular, use of FQs in endemic areas would increase the potential for masking active TB and the emergence of an epidemic of widespread drug-resistant M. TB. M. TB should be considered as a possible pathogen, and an appropriate diagnostic workup should be initiated for patients who have symptoms consistent with TB.[4] Conclusion: Empirical prescriptions of FQs for pneumonia are associated with delayed diagnosis and treatment of pulmonary TB and a higher risk of developing FQ-resistant TB; therefore, in patients with pneumonia, the possibility of pulmonary TB should be considered.

Keywords: Community-acquired pneumonia, fluoroquinolones, tuberculosis


Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S27-72.Hsueh PR. Should fluoroquinolones be first-line antibiotics in the treatment of community-acquired pneumonia in areas with high incidence of tuberculosis? J Microbiol Immunol Infect 2007;40:386-7.Grupper M, Potasman I. Fluoroquinolones in community- acquired pneumonia when tuberculosis is around: an instructive case. Am J Med Sci 2008;335:141-4.Chang KC, Leung CC, Yew WW, Lau TY, Leung WM, Tam CM, et al. Newer fluoroquinolones for treating respiratory infection: do they mask tuberculosis? Eur Respir J 2010;35:606-13.

 Prediabetes: Where are we now? Impact after early intervention

Srividhya Raghavendran1

1Consultant Family Physician, NationWide Primary Healthcare Services, Bengaluru, Karnataka, India

E-mail: [email protected]

Indian Council of Medical Research-India Diabetes study 2011.

Phase 1 Results: Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes. There has been a significant increase in the incidence of prediabetes over the last decade. Identifying individuals with prediabetes offers the opportunity to modify their risk prior to the development of significant sequelae. Preventing diabetes remains a challenge but one that is, both feasible and imperative. Close surveillance of rising prediabetes prevalence is critical to projecting the future burden of diabetes and the resources that will be required to combat diabetes going forward. Criteria for Inclusion in the Study: (Fasting blood glucose >100 mg/dl and <126 mg/dl). Age group: 25–35 years of age. Gender: Both Background family history of diabetes present in some individuals. January-April 2015, 50 patients in the outpatient department were randomly selected. As a part of the role of general practitioners as holistic doctors, management started with an active discussion of lifestyle Intervention by providing patient education material and empowering them in their management plan. These patients are followed up actively in the clinic every 4 weeks for a total of 12 weeks. Results: Preliminary results are very positive with nearly 45% of patients have shown improvement in the fasting sugar levels. A detailed description of the results will be displayed during the presentation. As a general practice, we have a huge social responsibility, if we identify patients at risk, we are in better position to address the problem early and help in controlling the long-term illness.

Keywords: Diabetes in India, patient education, prediabetes

 A study on clinical profile and outcome of leptospirosis in a tertiary care hospital, South Kerala: Retrospective observational study

Saurabh Rathore1, Jacob Neil1, Z. Pilakkadavath1

1Kerala Institute of Medical Science, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Leptospirosis is a worldwide zoonotic disease with much greater incidence in tropical regions and has now been identified as one of the emerging infectious disease. Aim: To study the clinical presentation, complications, and outcome of leptospirosis. Materials and Methods: A retrospective study was conducted over 2 years and 8 months, in Department of Infectious Disease and Microbiology, Kerala Institute of Medical Science (KIMS), Trivandrum, Kerala, India. A total of 85 leptospirosis cases admitted to KIMS Hospital from January 2013 to August 2015 were studied. All cases were lepto-IgM (enzyme- linked immunosorbent assay) positive. Descriptive statistics were used to analyze data. Results: Of 85 cases of leptospirosis, the common symptoms were fever (97.6%) of 6–10 days (45.8%) followed by myalgia (50.6%), headache (36.5%), vomiting (29.4%), and abdominal pain (29.4%). Most common age group was 41–60 years (39.4%) with a male:female ratio as 1.8:1, hepatic involvement (94.1%) being commonly involved followed by renal (56.4%) system. Patients with elevated C-reactive protein (91.8%), altered liver function test (85.9%), thrombocytopenia (83.5%), leukocytosis (78.8%), and raised bilirubin (51.8%). Hospital stays 6–10 days (48.2%), Intensive Care Unit admission (38.8%), dialysis (22.3%), and mortality (0%). Most of them responded to ceftriaxone and doxycycline (70.6%). The clinical spectrum showed mild flu-like illness (43.5%), Weil syndrome (41.2%), respiratory failure (12.9%), and meningitis (2.4%). Most common complications were acute kidney injury (AKI) (34%), multiple organ dysfunction syndrome (14%), acute respiratory distress syndrome (4.8%), and septic shock (4.8%). Conclusion: Study demonstrated flu-like symptoms as the most common presentation followed by gastrointestinal and renal symptoms. Leptospirosis mimics with viral fever, malaria, and enteric fever so high clinical suspicion is required for early diagnosis due to its varied clinical presentation. All suspected cases should be watched for AKI. However, the prevalence of Weil syndrome found to be more compared to other studies can be explained as ours was tertiary care center.

Keywords: Leptospirosis, outcome, South Kerala, symptoms

 Experiences with an APP to identify womb to tomb preventive care advice in minutes

Roshni Jhan Ganguly, Kamlesh Bhargava

Nationwide Primary Healthcare Services

E-mail: [email protected]

Introduction: Preventive healthcare has health and socioeconomic impact on countries, communities, and individuals. Family physicians are responsible preventive care from “womb to tomb.” There is a lack of structured recommendations for family physicians in India to advise our patients. Methods: A literature was done and “Electronic Preventive Services Selector (ePSS)” was identified. The ePSS APP “ePSS is an evidence-based app developed by the US Preventive Services Task Force, it can be used to search and browse recommendations on the web or on a mobile device for patient aged 1–99 years. The usefulness of this APP was evaluated in an urban health centre in Bengaluru, a metropolitan city in India. 500 patients, age between 1 and 82 years were randomly selected, over a period of 45 days. Recommendations were identified based on four details (i) age, (ii) sex, (iii) tobacco usage and, (iv) sexually active or not. They were graded as ABCD and I, A being - strongly advised, B, C, D - strongly against and I - insufficient evidence. Results: 70% of the patients ranged between 20 and 50 years. It took 10 s to identify the recommendations. Only “A” grade were advised. The range of recommendations included: Children <1 year - congenital disease screening; older children-obesity check; adult females - cervical cancer screening; adult males - HIV with other chronic disease checks depending on tobacco usage and sexual activeness; elderly patients - aspirin to prevent cardiovascular disease and colorectal cancer checks; depression and fall prevention were present in category B for most patients. Conclusion: There are certain things that we usually miss out in our regular consultations which this tool enables and reminds us to do. The effectiveness of ePSS in terms of ease of use, relevance, and acceptance was good and it can be recommended for our practice settings with some improvisation.

Keywords: APP, Electronic Preventive Services Selector, preventive healthcare, recommendations

 Common finding but an uncommon cause

S. Prasanth1

1Medical Trust Hospital, Kochi, Kerala, India

E-mail: [email protected]

This is a case report of a 46-year-old policeman, chronic alcoholic, who presented with complaints of loss of weight, loss of appetite, abdominal discomfort, and recurrent fever since 2 months. On evaluation, his blood reports were found to be normal, except for thrombocytopenia. Differential diagnosis of chronic liver disease, tuberculosis (TB), and malignancies were considered and investigated further. Finally, computed tomography (CT) thorax showed miliary nodules and bone marrow biopsy showed necrotizing granulomatous inflammatory lesion, and he was diagnosed to be having miliary TB with immune thrombocytopenia. The patient was started on anti-tubercular therapy and therefore, patient's condition improved.

Keywords: Bone marrow granuloma, immune thrombocytopenia, miliary tuberculosis, pyrexia of unknown origin

 Managing major psychiatric illnesses through teleconsultation in a rural secondary care setting

Neha Kale1, Innaciammal Jacob1, Timothy Laux1, Raman Kataria1, Yogesh Jain1, Prashant Gogia1

1Jan Swasthya Sahyog, Ganiyari, Bilaspur District, Chhattisgarh, India

E-mail: [email protected]

Introduction: Specialist care for mental illnesses in rural India is a neglected issue. We have developed a program based on teleconsultation with a psychiatrist to address this issue in a rural hospital. Aim and Objectives: (1) To provide diagnosis and appropriate treatment for psychiatric patients by a consultant psychiatrist. (2) To provide continued specialist care at affordable rates with adequate patient compliance. Materials and Methods: Patients screened on, and outpatient department (OPD) basis were called for weekly telepsychiatry clinic. With high-speed Internet, audio-visual consultations were provided by a remote consultant psychiatrist with simultaneous electronic medical record usage. A resident doctor or paramedic is present during clinic for logistic reasons and to facilitate the discussion. Diagnosis and treatment plans are made. Patients continue to get specialized care in the OPD or teleconsultation clinic. Occasional emergency consultations are also provided. Results and Discussions: In the last 3 years, 316 patients with 1200 consultations were provided in weekly clinic. The most common diagnoses made were depression (n = 169, 52%), anxiety disorders (37, 11.7%), schizophrenia (24, 7.5%), unspecified psychosis (19, 6%), and Somatoform disorders (14, 4.4%). Our pharmacy is equipped with medicines to support psychiatric illnesses in rural India. Conclusions: Teleconsultations is a feasible model of providing specialist psychiatric care. This allowed us to reduce referral rates to Medical Colleges for psychiatric illnesses and provide a learning environment for residents. Both the consultant psychiatrist and patients reported high rates of satisfaction. Treatment compliance rates have improved with internet consultations. We have been able to sensitize communities about mental health and form local, mental health support groups at the village level. We hope to develop methods to improve the outreach and compliance and reduce stigma of mental illness.

Keywords: Mental health, psychiatry, rural health, teleconsultation

 Magnitude of behavioral risk factors for cardiovascular diseases among college going young adults (18–25 years) in Mysore city

Laksmi Malavika Nair1, Madhu Basavegowda2, Renuka Manjunath2

Departments of 1Medicine and 2Community Medicine, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India

E-mail: [email protected]

Introduction: Sedentary lifestyle and unhealthy diet patterns increase the risk of cardiovascular disease. Estimating the magnitude of behavioral risk factors is vital for planners and policy makers to formulate appropriate and locally suitable interventions. Objectives: To estimate the magnitude and pattern of behavioral risk factors for cardiovascular diseases among college students (medical, dental, pharmacy, engineering, and commerce colleges) in Mysore. Materials and Methods: A cross-sectional study was carried out among 970 students of medical (210), dental (152), pharmacy (169), engineering (214), and commerce (225) colleges in Mysore. Based on CDC-BRFSS and New Zealand Behavioral Risk Factor Assessment Questionnaire, a locally relevant self-administered questionnaire was developed. Information on dietary pattern, exercise pattern, tobacco, alcohol consumption, body mass index, and blood pressure was collected for each participant. Statistical analysis was performed using SPSS software (version 22). Results: Of 970 students, 496 were males and 474 were females. Age distribution of the students was given that 42.5% (413) were 18–19 years old, 48.9% (474) were 20–22 years old. Percentage of students pursuing each course was given as 21% MBBS, 15.5% BDS, 17.4% B. Pharm, 22% Engineering, and 23% Commerce. About 45.8% of the students lead a sedentary lifestyle and 13.1% exercise in the gym regularly. Dietary pattern assessment revealed that 71% of the students consumed fried food frequently (highest among medical students - 82.4%). Medical and dental students also consume the maximum amount of sweets, that is, 60.9% and 67.1%, respectively. Nonvegetarian food was consumed daily by 30% of medical and dental students. Of the 9% regular smokers, 80.5% started during college. Only about 8% of the regular smokers smoked more than 20 cigarettes in a day. Of the 135 participants who consumed alcohol, 37% admitted to binge drinking. Nearly, 75% of the students started consuming alcohol after entering PUC and college. About 62% claimed an increase in tolerance to the effects of alcohol. Nearly, half of the medical students were either overweight or obese. Prevalence of prehypertension and hypertension among medical students was 19% and 8.9%, respectively. Conclusions: Unhealthy behavioral practices are higher among medical students, although they are taught about the detrimental effects of these practices. Developing strategies targeting at these behavioral risk factors to improve the health status of college students play a crucial role in protecting the youth from cardiovascular diseases in future.

Keywords: Behavioral risk factors, cardiovascular risk factors, Mysore, young adults

 Assessment of quality of care among diabetic patients in a rural area

Sai Tharuni Nandaluru1, K. M. Srinath2, B. Madhu3, K. A. Sudharshana Murthy2

1JSS Medical College, Departments of 2General Medicine and 3Community Medicine, JSS Medical College, Mysore, Karnataka, India

E-mail: [email protected]

Introduction: In rural area, the array of health services for the successful management of diabetes is limited. Hence, in this study, we propose to assess the proportion of diabetic patients advised according to the standard American Dental Association (ADA) regimen and the extent to which the patients have followed the advised regimen and also reasons for not following in the rural population. Objectives: To understand the socio-demographic and clinical characteristics of diabetic patients residing in rural area. To determine the proportion of diabetic patients advised according to standard ADA regimen and to assess the extent of compliance of the patients to doctors' advice, self-care, along with the reasons for not availing the advised treatment. Materials and Methods: A community-based house to house cross sectional study will be conducted on 400 diabetic patients from 2 Primary Health Centers (PHCs), Suttur and Hadinaru. Patients who are diabetic for more than a year will be included in the study and those who are diabetic for less than a year or who are severely ill will be excluded. The questionnaire has been developed to cover the socio-demographic profile of the study population, their diabetic history, compliance to medication, dietetic history, details of self-care (foot, eye, dental, and skin care), exercise, and reasons for noncompliance. Measurement of waist and hip circumference, blood pressure, examination of the nervous system, feet, and complications will be observed and records checked. The number of drugs prescribed and time spent by the doctor in PHC with each patient will be assessed. The fasting and postprandial blood glucose levels will be determined for each patient using a glucometer. Results: This study is an ongoing Indian Council of Medical Research short-term studentship project. The data collected by the survey will be compiled, analyzed and the report will be prepared by mid- September, and the results will be available for presentation during the conference.

Key words: Blood glucose levels, diabetes type-2, rural people (Mysore), self-care

 Retrospective study of mortality in diabetes mellitus

Anita Goyal Gupta1, Krishan Singh Kajal1

1Department of Family Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India

E-mail: [email protected]

Context: The prevalence of diabetes is rising rapidly and it will be the leading cause of morbidity and mortality worldwide in the foreseeable future. The chronic complications of diabetes affect many organ systems and are responsible for this. It causes decrease in the quality of life and affects all strata of community. Aim: To study the causes of mortality in diabetic patients. Materials and Methods: It was a retrospective, hospital-based study to estimate the mortality in the diabetic patients and its cause. Results: Out of total 1500 hospital deaths in 2 years (January 2013 to December 2014), 324 were diabetic patients. Out of these, 158 (48.8%) were males and 166 (51.2%) were females. The mean age at the time of death was 57.3 years. The leading causes to which deaths were attributed included infections (39.5%), chronic kidney disease (20.4%), coronary artery disease (14.2%), and cerebrovascular accident (10.5%). Conclusion: Infections play a dominant role in diabetes-related mortality followed by chronic renal failure; this is in contrast to the results from the developed world where coronary artery disease and cerebrovascular accidents predominate as the causes of death.

Keywords: Chronic kidney disease, diabetes, infections

 Sleep problems in Parkinson's disease: Role of gender and disease-related factors

Rohit Verma1, Kuljeet Singh Anan2

1All India Institute of Medical Sciences, 2Post Graduate Institute of Medical Education and Research,

Dr. Ram Manohar Lohia Hospital, New Delhi, India

E-mail: [email protected]

Background: Sleep disturbances among patients of Parkinson's disease (PD) are one of the most common nonmotor symptoms. Little work has been undertaken, especially from the Indian subcontinent to assess disease-related factors and gender differences in sleep disturbance in PD patients. The aim of current study was to investigate gender differences and factors associated with sleep in PD patients. Method(s): Sixty-five PD patients were included, consecutively, from movement disorder clinic of the Department of Neurology of a tertiary care center in New Delhi, India. The clinical profile, severity, and disability of PD were evaluated using unified PD rating scale, Hoehn and Yahr staging (H and Y), and Schwab and England activities of daily living (ADL), respectively. Subjective sleep arousal questionnaires included the PD sleep scale (PDSS) and Epworth sleepiness scale. Results: Sleep disturbance and excessive sleepiness were reported by 63.1% and 44.6% subjects, respectively. Motor symptom severity and dopaminergic medication were significantly related to measures of sleep quality (P < 0.01). There was a positive correlation of PDSS and ESS scores with H and Y staging (r = 0.32, P = 0.007; r = 0.54, P = 0.003) and ADL scores (r = 0.26, P = 0.03; r = 0.22, P = 0.04). Gender status was positively correlated to H and Y stages, PDSS, ESS, and ADL scores. Males had worse sleep quality than females (P < 0.05). Conclusion(s): Sleep disturbances in PD increase with increasing disease severity and the amount of dopaminergic medication use. Males suffer worse sleep quality and more excessive daytime sleepiness than females.

Keywords: Gender, nonmotor, Parkinson's, parkinsonism, sex, sleep

 Bridging gaps in primary health care delivery by training National Health Workforce using a “blended learning” approach

Rebekah Zechariah1, Jachin Velavan1, Immanuel1

1Department of Distance Education, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

The Christian Medical College (CMC), Vellore, introduced its first distance education course in family medicine in 2005. Thus far, the department has trained nearly 3000 general practitioners across the country who are now the first points of care for millions. Physicians in rural hospitals have equipped themselves by completing the Fellowship in Diabetes Management; the Fellowship in HIV Medicine; the Diploma in Allergy and Asthma, among others. The department also provides a 1-year program that teaches basic primary healthcare to grass-roots- level non-governmental organization workers, which is a nurse- led program and has proven to be very effective. CMC graduates working in remote hospitals are able to enroll in the distance course in family medicine, resulting in better-equipped, efficient and motivated physicians in areas of acute need and ensuring continuing medical education. Since 2009, the Government of India has contracted with CMC to provide its distance course in Family Medicine (through the National Rural Health Mission and Tamil Nadu State Health Project) in their Primary Health Centers and Community Health Centers. In March of 2015, CMC received the prestigious National SKOCH award in nine areas of excellence including E-learning and distance education. Collaboration with the University of Edinburgh, Scotland, UK, and the International Christian Medical and Dental Association, is a Masters' program in family medicine which imparts similar training to physicians in other developing countries in Africa and South-East Asia and is in its 2nd year of implementation. The concept of blended learning is very unique to these programs. Much of the learning happens in the student's own environment, using self-directed learning methods. This is augmented with intermittent face-to-face contact sessions at one of many centers in the country where the main focus is on skills training and hands-on learning experiences. This approach has allowed for many physicians to update their knowledge, skills, and attitudes without having to displace themselves from their practices and has resulted in much improved primary healthcare delivery.

Keywords: Blended learning, family medicine, family physician, National Rural Health Mission

 Need for change in medical education techniques used to teach undergraduate medical students of India

Mansi Mathur1, M. K. Goel2, Vibha2, R. Das2, S. K. Rasania2

1Lady Hardinge Medical College, New Delhi, India

E-mail: [email protected]

Introduction: The Government of India recognizes medical training to produce competent “Physicians of First Contact.” However, the medical education and health care in India are facing serious challenges in content and competencies. Aims/Objectives: The objective of this study is to sensitize medical fraternity about need for change in teaching techniques used in undergraduate medical education. Methods: We have searched the MeSH terms “integrated medical education,” “undergraduate medical education,” and “problem-based learning” in PubMed, Google, Google Scholar, and Medline. Both national and international publications in English language were reviewed. Results: At present in India we are having a semester based system in MBBS curriculum with 9 semesters and sequential pattern of university examinations. Different techniques of medical education are problem-based learning and integrated medical teaching. These techniques are practiced in some medical colleges and have reported better outcomes. Conclusions: To revamp the undergraduate medical curriculum meticulous planning needs to be done for conducting studies which prove that the introduction of problem-based learning and integrated medical teaching could be feasible in our set up.

Keywords: Integrated, medical education, problem-based learning, undergraduate

 Problem solving and learning from clinical cases in rural India using global network of physician experts

Priyank Jain1,2, Timothy Laux1,3, Yogesh Jain1

1Jan Swasthya Sahyog, Ganiyari, Chhattisgarh, India, 2Cambridge Health Alliance, Cambridge, MA, 3University of California, San Francisco, CA, USA

E-mail: [email protected]

Introduction: There is a severe shortage of physicians in rural India, especially specialists. Lack of expert opinion limits the scope of patient care and professional growth of physicians and trainees in rural areas. Jan Swasthya Sahyog is a Healthcare Organization in Chhattisgarh that provides comprehensive healthcare to rural and tribal population and trains family medicine residents in Diplomate of National Board Program. Aims and Objectives: Providing real-time assistance in the clinical management of complex cases in a limited resource rural hospital setting using email for teleconsultation. The participants in teleconsultation will benefit by meaningful use of their clinical expertise and learning from clinical cases. Materials and Methods: Treating physician sends a case summary along with the objective data and images via email to physicians in the USA and India who engage their professional network to answer the clinical question(s) and report back to the entire group. The referring physician eventually reports the case's outcome. All learn from this information exchange. Results: Since January 2013, this model of teleconsultation has connected experts in the USA and India for clinical problem solving of >150 consultations. The expert input has informed the interpretation of key investigations such as radiographs, electrocardiography, echo, and guided further investigations to arrive at an accurate diagnosis. It has also influenced therapeutic decisions taken for patient care. Expert physicians have continued to participate in this activity without financial remuneration. Conclusions: Using email consultation has proven (1) an effective means of obtaining expert input for patient care and (2) professional growth of trainees in remote healthcare settings with limited access to specialists. Next steps include a formal evaluation of participant feedback and impact on patient care. We believe this model of teleconsultation for learning and service can be replicated to other resource-limited settings worldwide.

Keywords: Case-based learning, global health, postgraduate training, telemedicine

 Introduction of BASIC DHS course for primary care physicians: An experience from Distance Education Department in Christian Medical College

Beulah Raji1

1Department of Distance Education, Distance Education Unit, PGDFM (Family Medicine) Faculty, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

Introduction: The first BASIC DHS course (Basic Assessment and Support of Seriously Ill Patients in Developing Healthcare Systems) was conducted at Christian Medical College (CMC), Vellore, by the Distance Education Department during July 4th–8th 2015. BASIC DHS course is designed to teach the acute medicine to doctors practicing in healthcare systems with limited resources and hence will be useful for doctors working in mission hospitals and low-resource areas across the country to teach how to manage critical care patients. Aims/Objectives: BASIC DHS course aims to teach management of critically ill patients in low-resource settings where there is: (1) no access to mechanical ventilation (except in the operating theater), (2) few investigations (Hb, urea, potassium, sodium, and glucose), (3) no blood products other than whole blood, and(4) only simple plain radiology and no electrocardiograms. The course is designed, like all our courses, to be disseminated on a train the trainers' basis. The course takes 3 days to deliver and requires 1 instructor for every 6 students. Trainers do not need to be intensive care specialists. Target audience for this course is healthcare professionals interested in working in or already working in mission hospitals and low-resource areas across the country. Materials and Methods: Course manuals distributed to course participants 1 month in advance. The participant who has reliable internet access does the precourse multiple choicequestion test online, and they will get immediate feedback. A faculty team from The Chinese University of Hong Kong came to Vellore to train the instructors, faculties of Distance Education Department in CMC on the first day during the instructor course. During the next 3 days of the provider course, the instructors trained the family medicine facilitators (PGDFM, M. Med.) during the course. Results/Discussion: Name of the skills covered during the course are airway management, chest drain insertion, intraosseous cannula insertion, how to assess and manage burns, trauma, acute pain, medical emergencies such as anaphylaxis, meningitis, severe malaria, tetanus, severe asthma, pneumonia, acute heart failure, severe hypertension, and metabolic and electrolyte disturbances. Management of snake bites, acute poisoning, obstetrics emergencies, shock, severe sepsis and infection control, postoperative care, management and prevention of organ failure – oliguria, and acute renal failure are also covered during the course followed by a posttest. Conclusion: This course is very much relevant for our doctors who are working in remote mission hospitals and low-resource areas. It builds more confidence in managing emergency situations; something that one may not be comfortable. In a government sector, very basic things are available so that this course can be well used in those settings.

Keywords: BASIC DHS course

 To study antibiotic use in acute diarrheal disease in noncritically ill adult patients admitted to Tertiary Health Care Hospital in Kerala

Pawan Wagle1, Rajalakshmi Arjun1, P. Zarin1

1Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Acute diarrhea in adults is one of the most common diagnoses, in general, practice and is responsible for considerable morbidity around the world. One of the dilemmas in assessing patients with acute diarrhea is deciding when to test for an etiological agent and when to initiate antimicrobial therapy. Aim and Objectives: To study antibiotic use in acute diarrheal disease in noncritically ill adult patients admitted to Tertiary Health Care Hospital in Kerala. Materials and Methods: A cross-sectional study was conducted in KIMS Hospital, Trivandrum, India, to investigate the use of antibiotics in acute diarrheal disease in inpatient admitted in the Department of Internal Medicine from January 2015 to June 2015. Results: Of 105 patients, 6 were excluded as they had another source of infection and diagnosis. Of 99 patients, 53% had a diagnosis of acute gastroenteritis, 18% acute diarrheal disease, 10% viral gastroenteritis, 10% infective diarrhea, 3% acute bacillary dysentery, 2% antibiotic-induced diarrhea, 1% clostridium difficile diarrhea, and 1% diagnosed with traveler's diarrhea. Of 99 patients, 82 received intravenous and oral antibiotics and 17 did not receive any antibiotics. Most commonly used antibiotics were in a combination of 2–3 of intravenous or oral antibiotics. Cephalosporins were used in 45 patients, rifaximin in 31 patients, metronidazole/tinidazole in 21 patients, fluoroquinolones in 16 patients, doxycycline in 7 patients, and azithromycin in 3 patients. Fifteen patients had stool routine positive for pus cells and red blood cells, and only 3 patients had positive cultures for Salmonella species [Figure 1]. Conclusion: Overuse of antibiotics in the treatment of acute diarrhea in adults is common. Antimicrobial is not required in most patients with acute gastroenteritis because the illness is usually self-limiting. Antimicrobial therapy can also lead to adverse events, and unnecessary treatment adds to resistance development. Hence, empiric antimicrobial therapy has to be given with caution.{Figure 2}

Keywords: Acute diarrheal disease, acute gastroenteritis, infective diarrhea, viral gastroenteritis

 Role of Family Nurse Practitioner in ambulatory care at a Family Medicine Centre

K. Angeline Jeya Rani1

1Department of Community Health Nursing, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

Introduction: The current trend in nursing is on evidence- based practice. The advanced practice in nursing needs a strong knowledge base, decision-making skills, and clinical competencies for expanded practice beyond that of a registered nurse, and this credential to practice is achieved by the trained Nurse Practitioner (NP). The role of a NP at ambulatory care is to assess patients with chronic diseases, generate management plan, set long-term goals, and follow up them regularly. NPs focus on prevention, promoting wellness, and patient education. Family Medicine Centre: I work in a Family Medicine Centre, which is a part of the Department of Family Medicine, at Christian Medical College, Vellore. It is located in and easily accessible part of the town of Vellore. It is run exclusively by trained Family Physician team. People of Vellore are seen both by appointments and as “walk-ins.” All the health needs of the people who access the services are dealt with there. When needed, they are referred to sub-specialists at specific departments but long-term follow-up is done here. The center is equipped with pharmacy services, dentists, sample collection center, and an area for minor day-care procedures. Role of a Family Nurse Practitioner: I, as a family NP, am a part of this secondary ambulatory care facility, assess people with chronic diseases such as diabetes mellitus, hypertension, obesity, and bronchial asthma. The comprehensive history taking, advanced health assessment along with physical examination to identify the health status of the individual who is then educated on their individual illness management plans. The illness management strategies are discussed with the individuals and their families, and decision making is always shared. The role also includes educating patients on health behaviors using available resources, self-care skills and treatment options in coordination with Family Physician. I counsel patients on coping with illness, dietary management, medication adherence and lifestyle modifications. I prepare the required materials for health teaching. I demonstrate exercise pertaining to various health conditions. The NPs input is recorded in the electronic medical record to ensure the quality of Health Information System. This is accessible to all who give care to that particular patient, across the whole institution. Outputs: Over the period of last 1 year, 250 patients with various health conditions were assessed. Preliminary informal feedback from patients about the input of NP revealed that they are satisfied with the counseling and management of patients and were able to practice as per the advice. The acceptance of NP is reflected in their behavior when most of them return back to NP for follow-up. There is preliminary evidence to show that patients with high glycosylated hemoglobin had reduced levels of glycated hemoglobin with their lifestyle modifications, obese clients have made efforts to modify their diet and exercise patterns, women with urinary incontinence were able to practice Kegel's exercise with improvement in symptoms among others. It is highly self-satisfying, though challenging to give in inputs as part of Family Medicine team. Systematic collection of evidence for the effect of the NPS input and satisfaction studies are underway. Conclusion: NPs make a significant contribution as a part of the primary health care providing a team for patients attending ambulatory care services, across their lifespan in resource-limited settings by providing comprehensive health care services. They play a vital role in an individual's life by providing team based holistic longitudinal care. The scope of an NPs role has increased in western countries, and it is yet to be explored in India.

Keywords: Advanced nursing practice, family nurse practitioner, nurse practitioner

 Antenatal Care: A Well-Omitted Chapter

Sonia Singh1, Pankaj Hans1, Nandita Bose1

1Ruban Emergency Hospital, S.P Verma Road, Patna, Bihar, India

E-mail: [email protected]

Introduction: Antenatal care (ANC) has its beginning way back in 1901 when J.W Ballantyne published his “plea for a pro-maternity hospital.” In its widest sense, ANC includes not only strictly medical activities but the education of girls and women to understand the potential benefit of ANC. Goal 5, among health-related Millennium Development Goals in India also targets on ANC coverage. However, there exist a huge vacuum between the programming of ANC at the apex and its implementation at grass root level, leaving girls and women in most deserted condition difficult to believe. Aim: To study the essentials and importance of ANC, to promote better health of women and reduce maternal mortality with filling the gap between planning and implementing various aspects of ANC. Materials and Methods: A prospective case study over 36 women of age group 19 to 37 years, was conducted at Ruban Emergency Hospital, S P Verma Road, Patna over a period of 2 years from December 2010 to December 2012.The inclusion criteria was all patients who were not suffering from any previous renal disease. This study though focused on acute kidney injury and significance of serum creatinine level in pregnant women, ultimately indicated the omission of ANC from the prevailing health care system. Results: Acute kidney injury in pregnant women indicated illiteracy, omission of essentials of ANC, lack of maternal and child health (MCH) services, poorly understood the concept of contraception, early marriage, and gender discourage leading to septic abortions. Conclusion: ANC forms the backbone of the health of mother and newborns. Serum creatinine level emerges an important indicator of health during pregnancy and should be included in regular ANC. Proper planning of MCH services and its implementation at grass root level will help in reducing maternal mortality rate and fulfilling the primary aim of ANC, that is, to achieve at the end of pregnancy a healthy mother and a healthy baby.

Keywords: Antenatal care, Millennium Development Goals, serum creatinine level during pregnancy

 Health-related quality of life among chronic obstructive pulmonary disease patients attending a tertiary care hospital

Sandipana Pati1, Sanghamitra Pati2

1Department of Health and Family Welfare, Zonal Dispensary, Khordha, 2Public Health Foundation of India, Indian Institute of Public Health, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Chronic obstructive pulmonary disease (COPD) is a major public health challenge in India with significant economic burden, health care utilization and contributes to patients' daily life limitations. Health-related quality of life (HRQoL) reflects the health - and disease related aspects of quality of life. Even though, measurement of HRQoL could indicate the impact of disease and treatments on daily life, limited studies have examined this dimension in health care settings. Objective: We explored the HRQoL among COPD patients attending a tertiary care facility and the factors (enablers and constraints) influencing it. Methods: Data were collected from 110 COPD patients attending the outpatients Department of the Tertiary care Hospital at Bhubaneswar, Odisha. The translated and pretested version of St. George Respiratory Questionnaire (SGRQ) was used. In addition, in-depth interviews (IDI) were held with 17 patients. Results: The overall HRQoL was significantly lower in females and patients from the rural area. It declined with increasing age and was worst in patients aged 70 years or above. Patients having two or more comorbid conditions had the poorest HRQoL. IDI revealed dyspnea and cough as the two key symptoms affecting the daily life of the patients. While most have been advised to use inhalers and all agreed that use of inhaler helped in alleviating symptoms the high cost of inhalers was the major reason for nonuse. Another reason for not using inhalers was mentioned to be the perceived harm due to prolonged use. Family support and better financial condition were enablers while easy accessibility of health care facilities helped in early interventions. Conclusions: COPD has considerable negative impact on the quality of life with advancing age and is worse among the geriatric age group population. Acute exacerbations impair HRQoL. The degree of severity of COPD could be determined by SGRQ, which reflects the impairment of their HRQoL.

Keywords: Chronic obstructive pulmonary disease, health- related quality of life, St. George Respiratory Questionnaire, tertiary care hospital

 Periconceptional supplementation of folic acid knowledge and practices of pregnant women and health providers

Vartika Saxena1, Richa Singh1, Manisha Naithani2, Ranjeeta Kumari1

Departments of 1Community and Family Medicine and 2Biochemistry, All India Institute of Medical Sciences, Rishikesh - Dehradun, India

E-mail: [email protected]

Introduction: Congenital malformations are one of the important causes of infant mortality. Among all the congenital malformations, neural tube defects (NTDs) are one of the most common congenital anomalies. NTDs are preventable if folic acid (FA) is supplemented before and during conception. Knowledge and supplementation of FA by pregnant women as well as its timely provision by health providers including frontline workers are crucial in reducing the burden of NTDs in the community. Objectives: (1) To study knowledge and supplementation of FA by pregnant women. (2) To assess knowledge and FA prescription/provision practices of health providers. Materials and Methods: The present study was conducted in the block Doiwala, Dehradun District, Uttrakhand. A total of 400 pregnant women and all the government health providers (5 medical officer, 25 auxiliary nurse midwifes [ANMs] and 91 accredited social health activist [ASHA] workers) were interviewed on predesigned, pretested questionnaire by study/field investigator. Results: Of 400, 94.25% were planned pregnancies. 73.50% women had heard of FA with 30.75% having knowledge that FA reduces anemia. Whereas only one woman knew FA reduces NTDs. On overall knowledge scoring, pregnant women scored intermediate to low level of knowledge. 4.75% women reported to be taking FA from sometime prior to the conception. 60% of medical officers knew FA deficiency as one of the causes of NTD while only 4% of ANMs and 3.3% of ASHAs were aware of this fact. FA was out of supply in the block. Even iron FA tablets were not available at any sub-center at the time of study. Conclusions: Knowledge and supplementation practices-related with FA are poor. Training of health providers and strong information, education, and communication strategies along with ensuring the availability of FA tablets is crucial for reducing NTDs incidence.

Keywords: Folic acid supplementation, health provider, periconceptional pregnant women

 Impact of Rheumatoid Arthritis Among Patients Seeking Care at Rheumatology Clinics in the District of Colombo, Sri Lanka

Anoma C. Mohotti Basnayake1, Udaya Basnayake2, Arunasalam Pathmeswaran3

1Ministry of Health, 2National Hospital of Sri Lanka, Colombo, 3Department of Public Health, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka

E-mail: [email protected]

Introduction: Evidence shows that rheumatoid arthritis (RA) has an immeasurable impact on patients in terms of their physical, mental, and social functioning. Objectives: To determine the physical, psychological, and social impact of RA on patients seeking care at the rheumatology clinics at Tertiary care Hospitals in the District of Colombo. Methods: A descriptive cross- sectional study included a sample of consecutive 850 RA patients from four clinics at three teaching hospitals in Colombo, using probability proportionate to the size of the average monthly clinic visits. Validated Sinhala version of Arthritis Measurement Scale 2 – Short Form (AIMS2-SF) was used to collect data. It consists of physical, symptom, affect, social, and role components in which scores can be ranged from 0 to 10 and 0 representing good health while 10 representing poor health. In this study, the poor impact was defined as the proportion of patients with component score values over 5. Disease activity at the time of the study was assessed using disease activity score - 28 in which scores <2.6 indicates remission, up to 3.2, up to 5.1, and more than 5.1, respectively indicating low, moderate, and high disease activity. Results: Approximately, 46% and 14% of the study participants were with moderate and high disease activity, respectively, at the time of the study and 20% were either with low disease activity or in remission. All component scores of AIMS2-SF among participants ranged from 0 to 10 while quality of life in relation to physical ability, symptoms, affect, social interaction, and role were affected among 6.6% (n = 56), 27.5% (n = 234), 29.1% (n = 247), 21.2% (n = 180), and 12.7% (n = 108) of patients, respectively. Conclusion: Physical ability was least affected but the poor quality of life due to pain, psychological and working disability and deprived social interaction were considerable.

Keywords: Impact, quality of life, rheumatoid arthritis

 Effect of insulin administration education in patients with diabetes mellitus

Smruti S. Nikumbh1, Prajakta Yeshwant Thakur2

1Department Family Medicine, USM KLE IMP, Belgaum, Karnataka, 2ECHS Polyclinic, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction and Objective: The use of insulin to maintain good glycemic control has been increasingly acknowledged as a treatment option for diabetes mellitus (DM). However, it remains underutilized due to several reasons which hinder treatment compliance resulting in several life-threatening complications. A considerable subset of insulin dependent diabetic population fails to take it as desired. Lack of knowledge about the site of injection, dose, timing, and technique is most important and prominent cause of underutilized insulin therapy in developing countries like India. This can be achieved through effective counseling. This prompted us to evaluate the effect of insulin administration education in patients with DM. We ask them to follow (while taking insulin over arm patient should keep 3 fingers over biceps and triceps, then remaining area is ideal for insulin administration. They can take it laterally when the arm is put in supine position. This helped us to overcome the misconception of injection site - “for any injection is deltoid.” Over abdomen, we asked the patient to leave 4 finger area from the umbilicus. This leads to sparing of rectus sheath and facilitates administration of insulin more subcutaneously. Hence, here patient can rotate sites easily. Over thigh, we used 5 finger rules so patient spared quadriceps and hamstrings. The patient can take insulin over tensor fascia lata or adductor compartment. However, here chances of absorption via intramuscular route are higher. Hence, it is not an ideal site. Finger rule of 3 fingers, 4 fingers, and 5 fingers while administration of insulin. This rule is “keep advised finger distance over chosen site of insulin administration to avoid intramuscular administration and facilitate subcutaneous absorption.” Materials and Methods: The present study is 1 year cross-sectional study and was carried out in the urban and rural private clinics (ECHS Polyclinic and Rukmini Hospital) situated in Mumbai, Maharashtra and Sankeshwar, Karnataka, respectively, from July 2014 to June 2015. A total of 160 known type 2 diabetic patients were included in the study. Patients were counseled about the insulin self-administration, and the effect was assessed by estimating fasting blood and postprandial sugar levels at enrollment and every month until four months duration.


Results: Of the 160 (80 urban and 80 rural) patients with type 2 DM, 145 complete the study. Among them 90 (40 rural and 50 urban) were males and 55 (24 rural and 31urban) were females. Most of the patients were aged between 36 and 69 years. Majority (70%) of the patients belonged to nuclear family. Out of 145 patients 130 patients showed improved glycemic control. Remaining 15 shown moderate controls. Female patients showed better results than male patients. Patients with good educational background understand technique easily but Finger rule helped in illiterate and less educated population. Conclusion: The present study showed improved comfort of self-insulin administration, adherence, decrease in fear regarding insulin as treatment option, and complications such as lipodystrophy, bruise marks, and dependency rate in diabetic patients. Relatives became more confident and technically correct. The study also showed role of primary care physician in giving patient adequate time for counseling and give adequate insight to the patient regarding disease.

Keyword: Administration, diabetes mellitus, insulin, technique


Tondon N, Sanjay K, et al. Forum for injection techniques, India: The first Indian recommendations for best practice in insulin injection technique. Indian J Endocrinol Metab 2012;16:876-85.Frid A, Hirsch L, Gaspar R, Hicks D, Kreugel G, Liersch J, et al. New injection recommendations for patients with diabetes. Diabetes Metab 2010;36 Suppl 2:S3-18.Thomas N, Jayaraman K, Asha HS. A Practical Guide to Diabetes Mellitus. 6th ed. Jaypee Brothers Medical Publishers Ltd.; 2012. Shah S, editor. Association of Physicians India (API) Textbook of Medicine. 7th ed. Association of Physicians India; 2004.Certificate Course in Gestational Diabetes Mallitus Cycle 3 Public Health Foundation India, Dr. Mohan's Diabetic Education Academy Module 3 Annexure 1.

 Role of psychological counseling skills in primary healthcare practice: A conceptual model

Nimisha Kumar1, Nimisha Kumar1

1Centre for Early Childhood Development and Research, Jamia Millia Islamia, New Delhi, India

E-mail: [email protected]in

Introduction: Primary care physicians are often the first point of contact for patients suffering from illness, whether physical or mental and emotional. With the tremendous increase in the daily living stress levels, there has also been a rise in the incidence of psychosomatic illnesses, lifestyle diseases as well as challenges of adherence to the medical regimen. It, therefore, becomes imperative that primary care physicians are confronted with issues of how to handle these patients and the need to equip themselves with skills to deal with such cases that frequently present before them. Aims/Objectives: The aim of this paper is to highlight the role of the primary care physicians as the first point of contact for mental health intervention and management of psychosomatic as well as lifestyle diseases and illness. In the absence of any formal training in emotional management and counseling skills, it becomes an added source of pressure, in an already challenging health care practice. At the patient's end, it also causes lack of satisfaction and may lead to the exacerbation of problems which remain unattended. The objective of this paper is to present a conceptual model highlighting the role and practical use of psychological counseling skills and techniques in primary health care practice. Materials and Methods: It is a conceptual and literature-based study. Results/Discussion: A conceptual model is presented which highlights the role of the primary care physician in the early identification, assessment, and management of mental and psychosomatic conditions which they are presented with as a first point of contact. In addition, the model will also cater to challenges related to patient adherence to medical regimen. Conclusion: Since the primary care physicians often become the initial points of contact for patients suffering with mental health conditions, psychological issues exacerbating physical health, psychosomatic conditions, lifestyle diseases, and adherence issues, a conceptual model which addresses the early identification and management of these patients using basic counseling skills and techniques should serve as an additional resource for effective primary care practice, in addition to proving beneficial for public health and the mental health burden in the community.

Keywords: Conceptual framework, mental health, primary care practice, psychological counseling

 Integrating technology in primary health care in India: A concept paper

Shabeerali Thattarumattil1, Fathima Abdul Khader1

1Hodo Medical Informatic Solutions Private Limited, Malappuram, Kerala, India

E-mail:[email protected]

Background: India is the second most populous country in the world, we also have the 3rd largest number of people using the internet and the rural population who have access to the internet is also increasing yearly. It is the right time to integrate technology to develop primary health care. Aim: To discuss how a big difference can be made in the primary health care of India existing today by centralizing healthcare data of individuals, integrating the different levels of health care available and moving toward a patient-centered healthcare. Methods: This is a concept paper discussing how the technology engine designed and developed by Hodo Medical Informatic Solutions Private Limited can empower primary health care providers to build their health care portal in quick, cost-effective, and secure way. To introduce a QR-based cloud health card for each patient that will enable healthcare providers access the patient's emergency health details and electronic health records. Result: This concept paper suggests that the idea proposed can be easily implemented at the primary health level, and it can help integrate technology into healthcare cost effectively and thereby improving the quality of primary health care.

Keywords: Electronic health record, healthcare informatics, healthcare portal, patient centered healthcare, primary healthcare, QR-based cloud health card

 Choice of empirical antibiotic in urinary tract infection

Sumanta Saha1, Ruchita Nitin Bhorkar1, Anand V. Kulkarni1

1Bhabha Atomic Research Centre and Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction: Urinary tract infection (UTI) is one of the most common health problem present globally, both in inpatient and outpatient settings. UTI is frequently treated empirically with antibiotics without performing a urine culture test, necessitating the need of having some knowledge about the most common uropathogens in a particular community and their antibiotic sensitivity pattern. To achieve this goal, this study was done on patients attending Bhabha Atomic Research Centre and Hospital (BARCH), Mumbai for healthcare services, during the last 3 years between January 2011 and January 2014. Objectives: To determine the most prevalent uropathogens causing UTI in patients visiting BARCH. To determine the antibiotics to which the above-mentioned uropathogens are most sensitive too. Materials and Methods: This study was done retrospectively on 140 patients, who visited the BARCH between January 2011 and January 2014 with urine culture reports showing bacterial growth of >105 CFU/ml. The data were collected and evaluated in Microsoft Office Excel program. Results: Most common uropathogens responsible for UTI in BARCH's patient population were Escherichia coli being positive for 47% cases followed by Klebsiella spp. (28%) and Pseudomonas spp. (28%). E. coli isolates were most susceptible to nitrofurantoin and chloramphenicol (93% each, respectively), followed by sparfloxacin (89%) and ofloxacin (87%). However, only 40% of the E. coli was susceptible to cephalexin. Conclusion: Nitrofurantoin and chloramphenicol may be considered as the first-line empirical antibiotic of choice for UTI in BARCH's patient population.

Keywords: Antibiotic, infection, urine, uropathogens

 Primary breast tuberculosis: Recent advances Puneet Agarwal1, Richa Goyal2

Departments of 1Surgery and 2Community Medicine, AIIMS, Bhopal, Madhya Pradesh, India

E-mail: [email protected]

Tuberculosis (TB) breast is a rare entity with incidence in the developed world to be <0.1% and in the developing worlds is 3–4%. It is unique in that it lacks accurate, rapid point-of- care diagnostic tests. Currently, recommended gold-standard diagnostic tests for TB are laboratory based, and multiple investigations may be necessary over a period of weeks or months before a diagnosis is made. As far as, the breast TB is concerned patient workup includes initial clinical evaluation and then imaging followed by tissue diagnosis and laboratory tests. From a long time, since the description of tubercular mastitis in 1829, the incidence, clinical presentation, diagnostic, and treatment methodology of breast TB has gradually changed. This article discusses the role of recent imaging modalities such as ultrasonography, mammography, magnetic resonance imaging, F-18 fluorodeoxyglucose, positron emission tomography (PET), and PET/computed tomography scan in breast TB. It also reviews the role of rapid diagnostic laboratory tests such as nucleic acid amplification tests, serological tests, urinary-based diagnostic tests, and tests for drug resistance screening. This article deals with the recent issues such as HIV and breast TB and periprosthetic TB breast infection. The prevention of TB among HIV-infected mothers should be a high priority for communities with significant HIV/TB burden as this is associated with increased mother to child transmission of HIV. All the above, the recent issues are of immense importance for a family physician, and this article also has a series of three case reports of different clinical presentations of TB breast depicting the clinical profile of breast TB, which add to it.

Keywords: Breast tuberculosis, clinical presentation - diagnosis - maternal tuberculosis, HIV

 A case of Miller Fisher variant with Guillain–Barré syndrome overlap in a child

Pratyush Kumar1, Praveen Kumar1

1Department of Family Medicine, Sir Ganga Ram Hospital, New Delhi, India

E-mail: [email protected]

Miller Fisher syndrome (MFS) is a rare variant of Guillain– Barré syndrome (GBS). GBS is a neuromuscular disorder affecting peripheral nerves whereas MFS presents as a triad of ophthalmoplegia, areflexia, and ataxia. Rarely do we encounter cases presenting with a triad of MFS overlapping with GBS. Here, we are reporting an interesting case of MFS with GBS overlap in a 9-year-old girl in which ataxia, areflexia, and ophthalmoplegia with limb weakness occurred within few days.

Keywords: Ataxia, Guillain–Barré syndrome, Miller Fisher variant, ophthalmoplegia

 Sweet's syndrome: A case report

O. K. Javid Risvan1, M. Roshni1, V. K. Jayadev2

Departments of 1Family Medicine and 2Community Medicine, Government Medical College, Kozhikode, Kerala, India

E-mail: [email protected]

Keywords: Sweet's syndrome

 Antibiotic sensitivity profile from urine cultures at an urban primary care clinic chain

Devashish Saini1

1Ross Clinics, Gurgaon, Haryana, India

E-mail: [email protected]

Introduction: Urinary tract infections are very common in primary care clinics. Although Escherichia coli is a common pathogen at all ages, its sensitivity to antibiotics varies greatly with location and time. Guidelines suggest that institutions use the antibiotic sensitivity profiles in their locality to guide empirical antibiotic therapy. Methods: A retrospective study was conducted by collating urine culture data from August 2011 to July 2015 in an urban primary care clinic chain in the North India. Results: A total of 140 urine samples were sent for urine culture during this period, out of which 51 (38%) were reported to have growth of E. coli. The patients were mostly female (63%), and their ages ranged from 2 years to 93 years. Among oral antibiotics, the only one found to have more than 80% samples sensitive to it was nitrofurantoin (88% sensitive), while 71% samples were found to be sensitive to levofloxacin. Resistance to other fluoroquinolones and cephalosporins and trimethoprim-sulfamethoxazole was found to be very high. Among intravenous antibiotics, gentamicin and amikacin had very high sensitivity rates, 100% and 82%, respectively. Resistance rates to most antibiotics are increased over the course of the 4 years of this study. Conclusion: This study supports the use of nitrofurantoin as an empirical antibiotic in urinary tract infections in primary care clinics. Levofloxacin may be considered a second-line antibiotic for those patients who cannot tolerate nitrofurantoin. Antibiotic sensitivity profiles are important to guide local empirical antibiotic policies.

Keywords: Antibiotic resistance, antibiotic sensitivity, cystitis, Escherichia coli, urinary tract infection

 Diagnostic challenge: A case of pain abdomen

Pranesh Jain1, Pramati Reddy1, K. Somasekhar Rao1, Swagat Sasane1

Department of Family Medicine, Apollo Hospitals Hyderabad, Andhra Prasesh, India

E-mail: [email protected]

A good family physician is one who has a high index of suspicion and is aware of the length of medicine. Pain abdomen is one of the important complains of presentations to out-patient clinics, of which pancreatitis is an important differential that needs urgent attention, as it is the leading gastrointestinal cause needing admission. Although alcohol and gallstones are the most common etiologies of acute pancreatitis, other causes include drugs, endoscopic retrograde cholangiopancreatography, trauma, infection, hypertriglyceridemia, and hypercalcemia. We present a case of a 46-year-old woman who presented with pain abdomen, vomiting, headache, body ache, and on evaluation found to have acute pancreatitis. Further investigations revealed elevated serum calcium levels, on evaluation found to be primary hyperparathyroidism - right inferior parathyroid adenoma on sestamibi scan; colonoscopy revealed mucosal erosions and ulcerations confirmed to be ulcerative colitis on histopathology.

Keywords: Pain abdomen, parathyroid adenoma, primary hyperparathyroidism, ulcerative colitis{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}

 Correlates of the tobacco use screening done by health care providers among smokers and smokeless tobacco users according to their sociodemographic characteristics: Global Adult Tobacco Survey India 2009–2010

Rohini Ruhil1

1Independent Public Health Professional

E-mail: [email protected]

Introduction: World Health Organization and Indian Public Health Standards recommend the provision of tobacco use screening and cessation help at primary care settings. Evidence shows that brief advice by health care provider helps tobacco user quit. It starts with asking the patient about his tobacco use status. The rate of tobacco use screening done by health care providers is very low and also depends on sociodemographic characteristics of patients along with several other factors. Aims and Objectives: This paper intends to study how sociodemographic characteristics (age, gender, residence [rural/urban], education, and occupation) of tobacco users influence the tobacco use screening done by health care providers. Materials and Methods: The study was a cross-sectional secondary data analysis of the Global Adult Tobacco Survey India 2009–2010. There were 4958 smokers and 7255 smokeless tobacco users included in the study who visited healthcare provider in the past 12 months prior to the survey. Results and Discussion: The results showed that male smokers were more likely to be screened for smoking by health care providers as compared to female smokers. Furthermore, tobacco users in younger age groups were less likely to be screened for tobacco use by healthcare providers as compared to tobacco users in older age groups. Urban smokeless tobacco users were more likely to be screened for tobacco use by healthcare provider as compared to rural smokeless tobacco users. Conclusion: It becomes the responsibility of healthcare provider to ask each patient about his/her tobacco use status irrespective of his/her sociodemographic characteristics.

Keywords: Global Adult Tobacco Survey India, healthcare providers, tobacco cessation, tobacco use screening

 The effect of kangaroo mother care on fuss and crying time in colicky infants

Zahra Akbarian Rad1, Mohsen Haghshenas Mojaveri1, Mostafa Javanian2, Zahra Farhadi Kotenaei3

1Department of Neonatology, Non-Communicable Pediatric Diseases Research Center, Babol University of Medical Sciences, 2Department of Infectious Diseases, Infectious Diseases Research Center, Babol University of Medical Sciences, 3???, Faculty of Medical, University of Babol, Babol University of Medical Sciences, Babol, Iran

E-mail: [email protected]

Introduction: Infantile colic is a common complaint in the 1st few weeks of life. On the other hand, because of its unknown etiology, there is not a specific therapy for this complaint, but various therapeutic options for reducing pain and restlessness of these infants are recommended. Skin to skin contact by kangaroo mother care (KMC) increases in pain threshold and it seems to be a suitable method for the care of these infants. Aims/Objectives: This study was designed to evaluate the effect of KMC on infantile colic. Materials and Methods: This clinical trial study was performed between March 2012 and March 2013. Subjects were 55 infants with exclusive breast fed infant, aged 15–0 days with excessive fuss and crying, referred to Infant and Child Clinic in Ayatollah Rouhani Hospital in Babol, North of Iran, and whose weights were <2500 g and with inheritance and clinical diseases excluded from the study. The researcher interviewed the parents and gave them a chart ruler of professor Barr (15) to fill out the time of sleep, nutrition, and awakening with comfort of their infants and parents answer can be hugging or holding in cradle or car. Within 3–5 days, the parents did the same care in the next checkup, charts were gathered, and the method of kangaroo care was taught by researcher. The researcher gives the mother a special vest to keep the baby in kangaroo care position and asked her to do this exercise at least 2 h a day. Data were analyzed by SPSS. Results/Discussion: In the end of this study, 55 infants of 58 completed the study. The mean crying time before the KMC for 55 infants was 2.21 ± 1.54 h per day and decreased to 1.16 ± 1.3 h per day after the implementation of KMC (P = 0.001). We also compared crying time before and after intervention in male versus female, vaginally versus cesarean delivery, high versus low education mother, and age groups [Table 1]. Intervention by KMC was more effective in vaginally delivered baby and with high education mother and age group 15–30 days. Study of Ellet and Saeidi showed that KMC reduces the time of crying and restlessness. In another study of Saeidi showed that vaccination pain in infants is reduced by KMC. Johnston's study showed that the preterm infants who receiving KMC, pain levels are considerably lower during the sampling process. Sajedi showed the intensity of pain during intramuscular injection of Vitamin k is lower in healthy and term newborns by KMC. Conclusions: KMC at home can be used as a simple and safe method for decreasing of crying and fussiness in colicky infants.{Table 2}

Keywords: Colic, colicky infants, fussiness, kangaroo mother care

 Subclinical hypothyroidism and the risk of hypercholesterolemia

Indhu Aynipullya Jayasingh1, Paul Puthuran1

1Lourdes Hospital, Ernakulam, Kochi, Kerala, India

E-mail: [email protected]

Introduction: Subclinical hypothyroidism is a term used for a condition wherein there are small elevations in thyroid stimulating hormone (TSH), yet there are normal circulating levels of free thyroid hormones (FT4). It is known that alterations in thyroid function result in changes in the composition and transportation of lipoproteins. Aim: To assess whether subclinical hypothyroidism is associated with abnormal lipid levels and compare it with euthyroid group. To evaluate the lipid parameters in patients of either group with respect to age, gender, and TSH values. Materials and Methods: This study was undertaken in the Outpatient Department of Lourdes Hospital, Ernakulam. 110 patients between 40 and 69 years of either sex were studied, of which 60 were identified to have subclinical hypothyroidism based on observational cross-sectional survey, while 50 patients were randomly selected to represent the euthyroid control group. Data were based on interview, clinical examination, thyroid function, and lipid profiles. Student's t-test and Chi-square test were used for the computation of P-values. Results: Subclinical hypothyroidism was predominantly seen in females (66.66%) and in the age group of 40–49 years (61.66%). The mean cholesterol values were elevated in the subclinical hypothyroid group in general and in relation to age (60–69) and gender. Statistical analysis showed significant difference in total cholesterol (P < 0.005) and triglyceride levels (P < 0.05) in relation to age (40–49 years.) between the two groups. Based on TSH values, Group A of 5–7.49 mU/L and Group B of 7.5–10 mU/L were compared to the euthyroid Group N < 5 mU/L. The mean cholesterol values were raised in both the subgroups. Statistically significant difference was seen (P < 0.0005) in serum cholesterol values between the subclinical hypothyroid Group B and the euthyroid Group N. Conclusions: Subclinical hypothyroidism appears to be associated with increased mean cholesterol levels in females and in the age group more than 60 years. The total cholesterol values were also elevated in both sub-group of patients with subclinical hypothyroidism (A and B) based on the TSH values.

Keywords: Hypercholesterolemia, lipid profile, subclinical hypothyroidism, thyroid function test

 Presumptive diagnosis and treatment of pulmonary tuberculosis

Ritesh Chaudhary1, Rabin Bhandari1

1Department of General Practice and Emergency Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

E-mail: [email protected]

Introduction: Tuberculosis (TB) is one of the major public health problems in the South-East countries such as Nepal with immense socioeconomic impacts. The 2010/2011 report of National Tuberculosis Programme shows 8% retreatment cases for pulmonary TB cases and one-fourth of treated cases are sputum-negative cases. The advantage/disadvantage of starting antitubercular therapy is debatable in a resource-constrained setting such as Nepal. However, presumptive diagnosis and treatment even in the face of high prevalence should rule out important pitfalls. Objectives: To illustrate a case of pleural effusion found later to be due to lymphoma. Materials and Methods: A case report. Case Report: A 28-year-old male was started on antitubercular therapy on a presumptive diagnosis of TB. The patient had past history of TB and presented with pleural effusion and consolidation at the index visit. The complaint for the presentation was pleuritic nature of chest pain and mild fever with no hemoptysis and no significant expectoration. The old documents related to past TB were not available. The pleural effusion workout showed exudates with sugar - 87 mg/dl and predominant lymphocytosis. Pleural adenosine deaminase was 28 U/L, and sputum was negative for acid-fast bacilli. First follow-up assessment showed generalized lymphadenopathy with minimal improvement in symptoms. A contrast-enhanced computed tomography scan was requisitioned which reported features suggestive of lymphoma with anterior mediastinal mass. Conclusion: Pitfalls can occur with a presumptive diagnosis of TB.

Keywords: Nepal, pitfalls, pulmonary tuberculosis

 Prevalence of antibiotic resistance in diabetic patients with urinary tract infection

Smita Minz1, Prasanth Sankar1, Sasi Kuppusamy1, Amit Kumar1

1MGM Muthoot Medical Centre, Pathanamthitta, Kerala, India

E-mail: [email protected]

Background of the Study: Urinary tract infections (UTIs), one of the most common infections in patients especially those with diabetes. Current knowledge on antimicrobial susceptibility pattern is essential for appropriate therapy. Objective of the Study: To describe the clinical and bacteriological profile of UTI in diabetic and nondiabetic individuals. Materials and Methods: Data from 105 patients with UTI, evaluated and treated for UTI at a semiurban multispecialty hospital in Pathanamthitta during the period December 2013 to December 2014 were analyzed. Prior ethics approval was taken. Using a well-structured questionnaire, clinical details were extracted from the hospital electronic medical records and microbiological results from the Microbiology Department. Missing clinical data were obtained by a telephonic interview of the patients. Data were analyzed using the IBM SPSS Statistics version 21 software. Results: Of 105, 60 (57%) were diabetic. HbA1c was >7 in 48. Organisms grown in diabetes mellitus (DM) and non-DM were Escherichia coli (33 vs. 21) followed by Klebsiella (14 vs. 14), Staphylococcus aureus (4 vs. 3), Psuedomonas (3 vs. 3), Enterococcus (2 vs. 1), and Proteus(2 vs. 1), one each of Enterobacter and fungi. Resistance pattern for E. coli seen in DM and non-DM patients: 3rd generation cephalosporin (40% vs. 26%), amoxicillin (26.6% vs. 13%), piperacillin–tazobactum (26.6% vs. 15%), quinolones (21.6% vs. 17.7%), cotrimoxazole (13.3% vs. 8.8%), and nitrofurantoin (11% vs. 6 %). 68.3% of DM patients and 53.33% of non-DM patients did not present with fever but had pus cells in urine (P = 0.01). 80% of diabetic patients and 66.67% of non-DM patients did not have dysuria as a urinary symptom. Conclusion: E. coliis still the major pathogen in UTI in DM, as well as non-DM patients, but the higher resistance pattern in DM is alarming. Poor glycemic control predisposes to UTI and resistance to drugs. Antibiotic policy for rational antibiotic use is required for diabetic patients at higher risk for UTI.

Keywords: Antimicrobial susceptibility, diabetes, resistant pattern, urinary tract infection

 Recommendation of empirical therapy in community- acquired urinary tract infection based on current pattern of susceptibility of uropathogens

Anupam Das1, T. A. Rajalakshmi1, Pawan Wagle1, Zarin Pilakkadavath1, Ketan Malvi1

1Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Urinary tract infection (UTI) is one of the most common infectious diseases in clinical practice. The pathogens and their susceptibility to antibiotics vary regionally and over time. Aim: To formulate an empiric therapy for community- acquired UTI. Materials and Methods: A descriptive study was conducted over 6 months in the Department of Infectious Disease and Microbiology, Kerala Institute of Medical Sciences, Trivandrum. A total of 4013 midstream urine samples were collected from the outpatient department with symptoms of UTI. The culture was done as per standard microbiological methods. Antibiotic susceptibility was carried out by Kirby– Bauer disc diffusion method. Descriptive statistics was used to analyze data. Results: Of 4013 urine sample, 1213 (30%) samples showed growth of organisms. Escherichia coli (46.4%) was the most common sensitive to colistin (100%), amikacin (98%), ertapenem (95.8%), and nitrofurantoin (77.86%) while highly resistant to ampicillin (78.6%), ceftriaxone (58%), and cotrimoxazole (55%). Followed by Klebsiella pneumoniae(16.45%) sensitive to colistin (100%), amikacin (95.5%), cefeperazone + sulbactum (80%), and resistant to ampicillin (99%) and nitrofurantoin (89.8%); Enterococcus faecalis(12.2%) is sensitive to daptomycin (100%), vancomycin (99.27%), linezolid (99.25%), and teicoplanin (99.26%). While Streptococcus agalactiae (7%) to ampicillin (98.97%) and ceftriaxone (98.59%), Accenatobactor baumanni (3%) sensitive to tigecyclin (94.6%), cefeperazone + sulbactum (92.3%), and resistant to ceftazidime (45.8%) and doripenem (40%). Moreover, Pseudomonas (2.7%) is sensitive to colistin (100%), ceftazidime (83.33%), and doripenem (80%) while resistant to ciprofloxacin (42%). Conclusion: Study demonstrated E. colias the most common pathogen followed by Klebsiella and E. faecalis. Drug resistance in Gram-negative organisms is more prevalent than Gram-positive organisms. This could be due to the higher prevalence and subsequently more antibiotic exposure of former. Ampicillin, ciprofloxacin, and cotrimoxazole are less efficacious as compared to nitrofurantoin. Similarly, among parenteral antibiotics amikacin, cefoperazone + sulbactam, and ertapenem are better options for empirical treatment. However, continuous surveillance is required to detect the changes in resistance pattern of these antibiotics as increasing resistance rates may change the choice of empirical antibiotic therapy for UTI in its future.

Keywords: Community-acquired, empirical, susceptibility, urinary

 To study the clinical and laboratory profile of dengue in adults presenting to a tertiary care center and to study their outcome

Ketan Malvi1, A. Rajalakshmi1, Anupam Das1

1Department of Family Medicine, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Dengue is one of the most important tropical infectious diseases in the world with a 30-fold increase in incidence in the last 50 years. At present, it remains hyperendemic in India and many other countries. Aims and Objectives: To study the clinical and laboratory profile of dengue in adults presenting to a tertiary care center and to study their outcome. Materials and Methods: All clinical and laboratory confirmed cases of dengue infection >18 years of age were included in this study. The diagnosis of dengue was made based on positive NS-1 antigen test and/or immunoglobulin M ELISA. Patients were classified according to new 2009 WHO dengue diagnostic criteria. The clinical and laboratory manifestations were recorded in the standard format, and patients were followed up until the outcome. Results: The most commonly affected group was 21–30 years with male:female ratio of 1.1:1. A maximum number of patients were resident of coastal areas. The peak number of cases presented during monsoon and postmonsoon season, which is the month of June to September. The most common manifestations were fever (100%), myalgia (91%), gastrointestinal symptoms (58.6%), and rash (26.9%). Laboratory profile showed thrombocytopenia (95.1%) and leukopenia (71%). The major complications observed were hemorrhagic manifestations (39.3%), plasma leakage (23.4%), and organ failure (4.1%).A total of 6.9% patients developed features of severe dengue. A total of 50% patients had secondary dengue infection. About 26.9% patients required ICU admission. All severe dengue patients were recovered. Conclusions: The new 2009 WHO classification helps in identifying severe dengue cases including organ failure. The seasonal occurrence of dengue during postmonsoon season and a high prevalence of secondary dengue require initiating preventive measures at household and community level before the monsoon starts. Early identification of warning signs and judicious fluid management resulted in good outcome even in patients with severe dengue.

Keywords: Dengue, secondary dengue, severe dengue

 Complicated vivax malaria: A case report

O. K. Ameena1, Abraham P. George1, Indhu Rajeev1

1Lourdes Hospital, Pachalam, Ernakulam, Calicut, Kerala, India

E-mail: [email protected]

Malaria is an endemic infection in India. Among different malaria species, even though Plasmodium vivax is the largest infecting species; it was considered to be benign. We would like to report a case of complicated vivax malaria, as recently complicated vivax malaria and mortality due to the same is increasing. A 57-year-old gentleman, who has recently returned from South Africa, presented with fever for 3 days, altered sensorium, yellowish discoloration of urine for 1 day, and with type 2 diabetes mellitus as comorbidity. Peripheral smear showed a low parasitemia of vivax malaria. He had one episode of seizure, anemia, rising bilirubin, and leukocytosis. He also developed acute respiratory distress syndrome and circulatory collapse. He was closely monitored, and the treatment was given according to WHO guideline and he recovered. This highlights the importance of prompt identification of complicated vivax malaria and treatment without delay for early recovery.

Keywords: Complicated, peripheral smear, vivax malaria

 A rare case of resistant hypertension

Pranesh Jain1, C. Venkat Ram1, V. Sreenivas2, Swagat Sasane1, Tushar Charkha1

Departments of 1Family Medicine and 2Medicine, Apollo Health City, Jubilee Hills, Hyderabad, Telangana, India

E-mail: [email protected]

The treatment of hypertension is the most common reason for the population across the world to visit family physicians. Broadly classified as primary (95%) and secondary (5%), around 30% of hypertensives are sub-classified as resistant hypertensives when blood pressure is not on target with 3 first-line anti-hypertensives (including a diuretic). One of the rare causes of secondary hypertension is Conn's syndrome or primary hyperaldosteronism which presents as resistant hypertension and chronic hypokalemia. Early suspicion, evaluation, diagnosis, and referral if required would have a definite benefit to a patient for a better outcome as specific investigations and the treatment are warranted. We present a case of primary hyperaldosteronism caused by adrenal adenoma confirmed with radiological and histopathological evidence as well.

Keywords: Conn's syndrome, primary hyperaldosteronism, resistant hypertension, secondary hypertension

 Vocal cord dysfunction: A case report

Vishal Mallusingh Baghele1, Dhiren Gupta2

Departments of 1Family Medicine and 2Paediatrics,

Sir Ganga Ram Hospital, New Delhi, India

Vocal cord dysfunction (VCD) is a condition characterized by paradoxical closure of vocal cord. This condition results in symptoms such as wheezing, stridor, shortness of breath, anxiety, hyperventilation, suprasternal, and neck muscle retraction. VCD is a condition that closely resembles asthma, making the two entities difficult to differentiate symptomatically. The family physician may misdiagnose VCD as exercise-induced asthma or asthma, which is refractory to treatment. Misdiagnosis of this condition leads to inappropriate treatment and often patients have been treated unsuccessfully with high dose corticosteroids and bronchodilators that have led to iatrogenic side effects. The present case report describes a 7-year-old male child presented to OPD with signs and symptoms resembling bronchial asthma since 8 months. The child was unresponsive to the treatment of bronchial asthma. This forced us to think about the different diagnosis. With the help of pediatric pulmonologist, bronchoscopy was done which revealed abnormal adduction of the vocal cord during respiration. This confirmed us to the diagnosis of VCD. We managed child with speech therapy, psychotherapy, painting exercise, and ipratropium bromide inhaler. The child improved symptomatically on this line. The child is now asymptomatic on successive follow-up in OPD. Hence, this concludes that family physician should think in a different direction when bronchial asthma patient does not respond to the treatment.{Figure 9}{Figure 10}{Figure 11}{Figure 12}{Figure 13}

Keywords: Airflow limitation, asthma, family physician, vocal cord dysfunction

 Predictors of anemia in diabetes: An Outpatient Department based cross-sectional study in Indira Gandhi Government General Hospital and Post Graduate Institute

Ishan J. Chavada

Indira Gandhi Government General Hospital and Post Graduate Institute, Puducherry, India

E-mail: [email protected]

Introduction: Anemia in diabetics is more common than general population. Anemia is also been associated with development and progression of macro- and micro-vascular complication. Finding its predictors will help in understanding diabetes and its management. Objectives: (1) To find out the percentage of type 2 diabetic patients having anemia from diabetic Outpatient Department (OPD) of Indira Gandhi Government General Hospital and Post Graduate Institute. (2) To determine independent predictors of anemia in the same population. Materials and Methods: In this cross-sectional study, 300 consecutive type 2 diabetes mellitus (T2DM) patients were selected from OPD and their hemoglobin (Hb) was checked along with relevant history, blood, and urine examination. Fundus examination was done by an ophthalmologist for retinopathy. Univariate and multivariate regression was done to determine the independent predictors. Results/Discussion: The percentage of anemia in diabetic patients (Hb <12 g/dl in women and <13 g/dl in men) was 61.3%. Serum iron (P < 0.001), serum ferritin (P = 0.006), and transferrin saturation (P = 0.005) were significantly associated with anemia in diabetes. Epidermal growth factor receptor and micro- or macro-albuminuria were not significantly associated with anemia. Nonproliferative diabetic retinopathy (P < 0.05) was significantly associated with anemia. Multiple logistic regression, found age group (>60 years) (P = 0.004), odds ratio (OR) = 5, 95% confidence interval (CI) = 1.659–15.089; female sex (P < 0.001), OR = 4.3, 95% CI = 2.342–8.164; number of years of diabetes mellitus (DM) (2–5 years) (P = 0.017), OR = 3, 95% CI = 1.2–7.9; history of hypertension (P = 0.002), OR = 3.5, 95% CI = 1.603–7.831; serum ferritin level (<15 μg/L) (P = 0.048), OR = 2.6, 95% CI = 0.969–7.381; and high-density lipoprotein category <35 mg/dl (P = 0.03), OR = 2.4, 95% CI = 1–5.3, as independent predictors of anemia in T2DM. Conclusion: Six out of 10 patients of T2DM may have anemia using World Health Organization definition. Anemia is not an isolated condition in T2DM patients, but it is strongly associated with comorbidities and complications of DM. Detecting anemia and treating it promptly may have beneficial effects on the complications of DM.

Keywords: Anemia, predictors, type 2 diabetes

 “RESPECT” model in healthcare services

Binit Sureka1, Aliza Mittal2

1Department of Radiology, Institute of Liver and Biliary Sciences, 2Department of Pediatrics, NDMC Medical College and Hindurao Hospital, New Delhi, India

E-mail: [email protected]

Purpose: The rising healthcare costs across the globe and ever increasing demand for quality by the patients pose a significant burden and stress among the healthcare providers and hospital administration. Healthcare costs are increasing more rapidly than costs of fast moving consumer goods and services in daily practice. Healthcare providers, particularly government- owned hospitals, are under continuous strain to reduce the costs while at the same time improve service, patient safety, reduce patient waiting times, minimize errors, and associated litigation. For continuous quality improvement, RESPECT model can be applied for healthcare service delivery. RESPECT is an acronym for responding to our patients with excellence, safety, professionalism, empathy, confidentiality, and timeliness. Patients who are treated with RESPECT reciprocate with respect. Caregivers who are treated with respect will respond by giving their best. This theme is more customer-focused. Methods: The values statement is to be introduced to all new employees joining the hospital during orientation. It can be reinforced to all employees by regular E-mail. Banners proclaiming “RESPECT” can be placed in hospitals. The employees are asked to make a commitment to these values by signing which are then displayed in the hospital wards, Doctor's duty room, nursing station, etc. Conclusion: RESPECT model can substantially improve the quality of services in all the departments of hospitals.

Keywords: Improvement, model, quality, RESPECT

 Review of management of animal bites: A peculiar case of failure of postexposure prophylaxis

J. S. Kshatri1, M. Panda1, R. M. Tripathy1

1Department of Community Medicine, MKCG Medical College, Berhampur, Odisha, India

E-mail: [email protected]

Introduction: Rabies is an acute viral encephalomyelitis, that is, caused by animal bites and is always fatal. However, it can be largely prevented by following the World Health Organization/ national guidelines at the primary care level itself. The knowledge about the use of vaccines and immunoglobulin in postexposure prophylaxis (PEP) of such cases is necessary in family practice. Review of Management of Animal Bites: This would be discussed under the following headings: (1) Decision to treat: Categories of animal bites, (2) wound management protocol, (3) PEP: The vaccines, (4) PEP: Immunoglobulin, (5) regimens and routes, (6) preexposure prophylaxis: Need and regimens, (7) counseling, pitfalls, and precautions, and (8) diagnosis of a case of the clinical rabies: Things not to do in the clinic. Case Report: A Peculiar Example of Postexposure Prophylaxis Failure: The patient, a 35-year-old male, presented to the medicine OPD of MKCG Medical College with the chief complaint of low backache, unable to urinate, unable to move lower limbs, and lower abdominal pain for the last 1 day. The patient gave a history of unprovoked stray dog bite 10 days back. He had the history of alcoholism. He received full treatment with 3 doses of antiretroviral (day-0, 3, and 7) and equine rabies immunoglobulin on day-0, initiated within 24 h of bite. He continued alcohol consumption even after repeated counseling. He was consequently diagnosed with clinical rabies and was declared dead after 2 days of admission, signaling failure of postexposure prophylaxis. Conclusion: Rabies has terrified man since antiquity. The fear is by no means unfounded since it is invariably fatal, and perhaps, the most painful and horrible of all communicable diseases. Fortunately, if managed appropriately and timely, the disease is preventable to a large extent. Hence, the proper management of animal bite cases is an important tool in the arsenal of a complete family practitioner.

Keywords: Animal bites, prophylaxis, rabies

 Symptomatic adult onset islet cell hyperplasia (nesidioblastosis) treated by distal pancreatectomy

Vivek Aggarwal1, Parul Gupta2, Monika Garg3, Prerna Bahety4

Departments of 1Surgery, 2Pathology, 3Radiology and 4Family Medicine, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India

E-mail: [email protected]

Endogenous hyperinsulinemic hypoglycemia (EHH) is characterized by low blood glucose level due to excessive endogenous insulin. Insulinoma is the most common cause. Nesidioblastosis, rare cause in adults, is a diffuse proliferation of pancreatic islet cells budding from ductal epithelium. A 45-year-old male was admitted with loss of consciousness with blood glucose 30 mg/dL. Testing revealed hyperinsulinemia and increased C-peptide levels during the hypoglycemia episodes, clinching the diagnosis of EHH. All other blood investigations and preoperative imaging studies were normal. A distal pancreatectomy was performed. Diagnosis of Islet cell hyperplasia or nesidioblastosis was made on histopathology. Even after 3 months postoperation, patient has had no hypoglycemic symptoms and plasma sugar levels are normal. We present this case due to its rarity and to highlight that symptomatic adult patient of EHH with negative imaging studies can be treated by distal pancreatectomy with histopathology giving the diagnosis of nesidioblastosis.

Keywords: Hypoglycemia, nesidioblastosis, pancreatectomy

 Molecule and breast cancer: Comprehensive review

Puneet Agarwal1, Richa Goyal2

Departments of 1Surgery and 2Community Medicine, AIIMS, Bhopal, Madhya Pradesh, India

E-mail: [email protected]

Over the past two decades, the molecular profiling of cancer has led to a revolution in the knowledge of breast cancer. Though the initial workup and management of breast cancer is still banking on histopathological and immunohistochemical means, but the scenario is now shifting from the classical clinicopathological attitude toward evolving genomic notion. As regards the classical clinicopathological approach is concerned it exploits physical characteristics such as tumor size, histological grade, number of metastatic axillary lymph nodes, and hormone receptor status (viz., estrogen receptor/progesterone receptor by immunohistochemistry (IHC) and HER2 by IHC/in situ hybridization) for prediction of recurrence and to plan the treatment. On the contrary, genomic concept comprises of the study of cluster of genes. These biomarkers can be recognized by using Oncotype Dx a 21 gene set; PAM50 intrinsic subtyping; or by distinguishing favorable versus unfavorable outcome using cDNA microarrays to identify genes that is., MammaPrint a 70 gene analysis. This information is of immense importance in estimating the risk of recurrence of breast cancer at an early stage and to identify patients who are benefited from chemotherapy. The genetic signature can forecast whether it will (a) respond to certain medicines or not, (b) metastasize to lymph nodes, and (c) respond to radiation or chemotherapy or newer drugs (d) also it can estimate the risk of recurrence. We can tailor our treatment in most cases using the detailed molecular knowledge. Some tumors look alike in histological slides; yet by molecular stain, we can identify each tumor in correct manner, allowing us to choose the proper treatment. Spread of tumor is also linked to molecular and genetic knowledge, as size of tumor or histology, that is, classical clinicopathological survey alone cannot predict the course of disease, in breast cancer. Aggressive type of tumor will need a more aggressive treatment, whereas indolent type of tumor will need a more conservative approach. This has led to availability of polymerase chain reaction and microarray tests that have profoundly changed the way that oncologists calculate the recurrence risk in early stage breast cancer patients. A family physician should be well aware of all these recent developments as primarily the patient is in his hands, and this is true even during the follow-up treatment by a specialist. In this article, we will review the strengths and limitations of presently available breast cancer-specific molecular tests.

Keywords: Mamma print, molecular profiling, oncotypedx, PAM50

 “Knowledge sharing session:” An effective way of training and self-motivated learning

Swapnil Lekhi1, Devashish Saini1

1Ross Clinics, Gurgaon, Haryana, India

E-mail: [email protected]

Introduction: At Ross Clinics, we identified that once into clinical practice, professionals get disconnected with academics and latest developments. To develop their academic interests and stimulate them intellectually, “Knowledge Sharing Sessions” were devised. The physicians, dentists, paramedical staff, and hospital administration take part in the weekly sessions. KSS has proved to be an effective tool in talent development, grooming, and networking. It has helped in better communication and confidence levels of staff. It is the best practice sharing and knowledge sharing tool. Aims and Objectives: To measure the impact of training on physicians, dentists, paramedical staff and administrative staff on knowledge, day to day practice, and motivation levels. Materials and Methods: We analyzed the impact of training by before and after surveys and primary survey in the form of session feedback/pre- and post-training assessment, of professionals who attended the sessions. We intend to use Likert scale for detailed analysis of primary survey data, and Chi-square test for impact analysis of the training on the assessment scores. Results and Discussion: Research is ongoing, we have done analysis on a small set of data which shows there is a strong impact. Conclusion: KSS is an effective tool for training and development of employees through sharing of knowledge, improving communication, increasing motivational learning, and networking.

Keywords: Human resource management, knowledge sharing, talent development, training

 Quality of life and psychosocial burden of parents of children suffering from thalassemia major

Nonita Dhirar1, Jyoti Khandekar1, Damodar Bachani1, Deonath Mehto2

1Department of Community Medicine, Lady Hardinge Medical College, 2Department of Pediatrics, Kalawati Saran Children's Hospital, New Delhi, India

E-mail: [email protected]

Introduction: Thalassemia major, a preventable genetic disorder characterized by repeated blood transfusions from early childhood, has profound impact on the quality of life of not only the suffering children but also of their parents as well. The chronic nature of disease leads to constant psychosocial stress on parents. Aims and objectives: To study the quality of life and psychosocial burden on the parents of children suffering from thalassemia major. Materials and Methods: A descriptive cross-sectional study was conducted at a tertiary level children's hospital in Delhi on parents of 241 children suffering from thalassemia major. Either the parent or the child was assessed using the pediatric quality of life inventory family impact module for analyzing the quality of life and psychosocial burden on the parents of the children. Results: A total of 230 parents were interviewed. The majority of the parents (93.5%) were living together. Almost 1/3 (28.3%) of the mothers of the study subjects were illiterate while 18.3% of the fathers were illiterate. The majority (88%) of the mothers were homemakers. One in 2 (49.7%) fathers was employed as unskilled and semi-skilled workers while only 5.9% had semiprofessional and professional jobs. The overall family impact module score was 69.2 ± 21.3. The parent health-related quality of life summary score was 69.9 ± 23.6. The total family functioning summary score was 79.2 ± 25.2. The least affected domain was that of family relationships with a mean score of 84.7 ± 27.1. Worry was the most affected domain (47.4 ± 29.1) in the parents of the study subjects. The family impact scores in all domains were lowest for families belonging to the lower socioeconomic status (48.6 ± 26.1) (P = 0.012). Conclusions: A preventable disease like thalassemia major in children severely affects the quality of life and imposes a huge social burden on their parents. A major solution is prevention of the disease.

Keywords: Parent quality of life, social burden on family, thalassemia

 Preventing mother to child transmission of HIV: Need for universal coverage through integrated health care

Damodar Bachani1,2, Neha Dahiya2

1Ministry of Health and Family Welfare, Government of India, Nirman Bhawan, 2Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

E-mail: [email protected]

Introduction: Birth of every HIV-exposed child is a sentinel health event signaling a missed opportunity of prevention. Suboptimal antenatal care and home deliveries, a large number of HIV-exposed children, may remain undetected and succumb to HIV. Aims and Objectives: To identify gaps and challenges in prevention of mother to child HIV transmission in India. Materials and Methods: Information available under National Programmes on Reproductive and Child Health and HIV/ AIDS for the year 2013 was collated and analyzed to identify gaps in prevention of mother to child transmission of HIV. Results: Every year, nearly 27 million children are born in India. In 2013, only 9.75 million pregnant women could be tested for HIV though 13 million pregnant women opted for institutional deliveries. Only 12,088 HIV-positive pregnant women were identified during the year and 10,085 mother-baby pairs were provided antiretroviral (ARV) prophylaxis for prevention of mother to child transmission of HIV. Due to gaps in antenatal care, HIV testing during pregnancy, home deliveries, and partial coverage of HIV-positive mother and newborns by administering prophylactic ARV drugs, an estimated 42,450 newborns were exposed to HIV through perinatal transmission in that year. Due to this situation, as many as 106,824 children living with HIV/AIDS were registered for seeking ARV treatment in that year, of which 42,015 were receiving free ARV therapy. Seven percentage of all deaths reported due to HIV/AIDS occur in children, though the actual number may be higher as many HIV-exposed children remain undiagnosed and untreated due to above-mentioned gaps. Conclusion: To achieve global target of zero incidence of HIV among the new born, universal access to antenatal care, institutional deliveries, coverage of HIV-positive mothers with multidrug ARV therapy would be required.

Keywords: Antenatal clinics, HIV

 Study on functioning of sub-centers in system of primary healthcare in District Jhansi, India

Geetu Singh1, Shobha Chaturvedi2, Bhakt Prakash Mathur3, Preeti Rai3

1Department of Community Medicine, SNMC, Agra, 2Department of Community Medicine, GMC, Jalaun, 3Department of Community Medicine, MLBMC, Jhansi,

Uttar Pradesh, India

E-mail: [email protected]

Introduction: The priority for achieving universal health coverage should be a determined effort to strengthen our public health systems. Primary healthcare (PHC) must be improved starting with sub-centers, the first health post for the community. As sub-centers are the first contact point with the community, the success of any nationwide program would depend largely on the well-functioning sub-centers. It is imperative to get insight into sub-centers that are established with the objectives of minimizing the hardships of the rural people. Material and Methods: A cross-sectional study was conducted in 20 sub-centers in District Jhansi from June 2012 to July 2013. The data were collected by facility survey and interview technique. Results: Average population covered by sub-center was 4282.About 75% of sub-centers were located at an easily accessible area. Functional toilet facility available was present in 45% of sub-centers. Only 25% of sub-centers had regular electric supply. None of the sub-centers had transport facility for movement of staff and facility for transport beneficiaries from sub-center. Availability of functional furniture at 20–60% sub-centers. Deliveries are being conducted at only 15% of sub-centers. Women who received 3 or more antenatal visits were only 29% in the study. Similarly, women with full antenatal check-up were only 3%. Supervision, at periodic intervals, by the supervisors from PHC and by the medical officer was done only at 50–60% of sub-centers. Citizen's charter was displayed at none of the sub-centers. Availability of various guidelines issued by the Government of India or State Government was absent in all sub-centers. Conclusion: Investing in sub-centers will go a long way not only in providing quality health services but also in achieving laid down health related goals as per National Health Policy, Millennium Developmental Goals, and National Rural Health Mission.

Keywords: National Rural Health Mission, primary health care, sub-center, universal health coverage

 Exposure to Tobacco Among Rural School Children

Mohammad Shibly Khan1, Ashib Parvez1

1Department of Community Medicine, F H Medical College, Firozabad, Uttar Pradesh, India

E-mail: [email protected]

Introduction: The exposure to the social environment has a tremendous effect in the habit formation of the future youth. The present study seeks to measure the exposure to tobacco use among the adolescent rural school children. Materials and Methods: This is a part of an ongoing study that is taken up in a rural area of western Uttar Pradesh, India. One private school under the field practice area of Rural Health Training Center (FH Medical College, Tundla) was selected purposely and all the students belonging to 9th and 10th standard are planned to be included into the study. The students were asked to fill a self-reported questionnaire. Permission was taken from the Principal of the school and health education provided to the students. The results of the data collected so far are being presented here. Results: Out of the total 45 students belonging to the class 9th, the majority (60%) were males, and mostly from the age 13–15 years (82%). Up to 62% (28/45) children reported to have at least one family member to be smoking, while the percentage for having at least one family member to be chewing tobacco was reported to be 80% (36/45). About 44% (20/45) students were admitted to be aware of the tobacco usage by their teachers whereas only 13% (6/45) were admitted to have at least one friend indulged in tobacco use. The percentage of students who were ever sent to purchase any tobacco product was found to be 78% (35/45). All of the study participants were able to name at least any one brand name for tobacco products. Conclusion: A very high level of exposure to tobacco was revealed in our study which is a matter of concern as there are high chances that these children would be at much ease of taking up this habit. By taking prompt action at this level, a great number of potential tobacco users could be prevented.

Keywords: Adolescents, exposure, school children, tobacco

 An update of the menstrual pattern and menstrual problems of the rural adolescent girls in Haryana

Garima Sangwan1, B. M. Vashisht1

1Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

E-mail: [email protected]

Introduction: Adolescents in India comprise around 19.3% of the total Indian population. Adolescent girls constitute a vulnerable group, particularly in India where female child is discriminated in the society. There has also been a high prevalence of reported cases of infections due to lack of hygiene during menstruation. Aims and Objectives: (1) To determine the prevalence of menstrual problems among adolescent girls (2) compare knowledge and beliefs regarding menstruation in different subgroups. Type of Study: A cross-sectional survey of 200 postmenarcheal adolescents attending Government Schools in Lakhan Majra Block of Rohtak District, which is the rural field practice area attached to Pt. B.D. Sharma PGIMS, Rohtak. Period of Study: July 01, 2015-September 01, 2015. Participants were asked to respond to a semi–structured questionnaire on menstrual health. Main Outcome Measures: Description of menstrual pattern, problems, knowledge and beliefs, premenstrual syndrome, and analgesia medications. Results: The mean age of the girls was 16.6 ± 0.96 years. Mean age at menarche was 14.20 ± 1.13 years. Respondents reported various menstrual disorders. Dysmenorrhea was the most prevalent (83%) menstrual disorder in our sample, followed by premenstrual syndrome(65%), and irregular menses (43%). Long periods (>6 days) were reported in 19%. Conclusion: Clinicians need to identify menstrual abnormalities as early as possible to minimize their possible consequences and sequelae like iron deficiency anemia. Adolescents should be encouraged to chart their menstrual frequency and regularity prospectively from the menarche onward.

Keywords: Adolescents, dysmenorrhea, menarche, premenstrual syndrome

 Health care seeking behavior and awareness of maternal and child health practices in a rural block of Haryana

Srishti Singh1, Nitika Sharma1, Meenakshi Kalhan1, J. S. Malik1

1Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India

E-mail: [email protected]

Introduction: The infant mortality rate and maternal mortality rate still continues to be high. To address these, the National Rural Health Mission promotes newborn care, immunization, antenatal care, institutional delivery, and postpartum care. Despite this, there is still a need to look into these aspects. Objective: To assess health seeking behavior; common ailments; practices of maternal and child health care; and awareness about existing schemes for the benefit of mother and child. Study Design: Community-based cross-sectional study. Study Subjects: Married males and females attending Out Patient Department at a Community Health Centre in a rural block of Haryana. Study Period: One month (September 2015). Study Technique: Interview schedule. Results: The proportion of pregnant women who received at least three antenatal check-ups was 51%. The coverage of women receiving tetanus toxoid 70% and iron and folic acid was 22%. Of which the coverage from government hospital was 65%, private hospital was 35%. The coverage of institutional delivery was 76%. The percentage of children immunized with the basic six vaccine preventable diseases was 67%. For contraception, 40% practiced tubectomy, 8% oral contraceptive pills, and 13% barrier method. Conclusion: It was found that about half of the total pregnant women had at least three antenatal check-ups, 85% children were immunized, more than 50% deliveries were institutional, 22% people did not respond regarding the practice of contraception.

Keywords: Health seeking behavior, maternal and child health practices

 High burden of undernutrition among children registered at Anganwadi centers in an urban slum of Delhi

Amir Maroof Khan1, Sameer Samar2, Anjur Tupil Kannan3

1Department of Community Medicine, University College of Medical Sciences, New Delhi, 3Department of Community Medicine, Kannur Medical College, Kannur, Kerala, India, 2Primary Care Practitioner

E-mail: [email protected]

Introduction: Nutrition has emerged as an important prerequisite for national development. There is a little consensus on the success of the Integrated Child Development Servicesprogram in tackling problems of health and nutrition in early childhood, despite being one of the most studied health and nutrition interventions. Studies among under-five children, using the World Health Organization (WHO) standard growth charts, attending the Anganwadi centers (AWCs) in Delhi are very rare. Aims and Objectives: To find out the prevalence and risk factors of underweight, stunting, and wasting among children under-five year of age registered at selected AWCs in an urbanized village of the East Delhi. Materials and Methods: A cross-sectional study was conducted in an urban slum of Delhi. A total of four AWCs were selected out of the 21 AWCs using a stratified sampling approach. A statistically appropriate sample size of 308 arrived at using finite population correction. Weight and height were measured using standard techniques. A pretested and structured questionnaire was used for data collection. The WHO ANTHRO software was used for calculating the z-scores of weight for age, height for age, and weight for height. The WHO 2006 criteria were used for categorizing the children as undernourished. SPSS 17.0 software was used for statistical analysis. Data are presented in proportions and means. Chi-square test was used to compare the proportions and t-test for means. Logistic regression was applied for finding out the independent predictors of underweight, stunting, and wasting. Results: Of the 324 children studied, 51.2% were males. 31.8% of the children were underweight, 42.0% were stunted, and 20.7% were wasted. A shorter previous birth interval, a child suffering from diarrhea in the past fortnight and not having a separate kitchen in the house were found to be significant independent predictors of underweight. Conclusion: A high prevalence of undernutrition was found among the Anganwadi registered children. This pointed toward increasing the effectiveness and utility of AWCs in curbing undernutrition.

Keywords: Child, slum, stunting, underweight, wasting

 Factors causing early discharge of women with uncomplicated pregnancies delivering at government facilities in a rural block of the North India

M. A. Bashar1, Manju Pilania1, A. K. Aggrawal1

1School of Public Health, PGIMER, Chandigarh, India

E-mail: [email protected]

Introduction: First 48 h postdelivery is a crucial period for the survival of newborn as most of (more than 50%) the neonatal deaths occur in this period. Similarly for the mother, this period is equally important because maternal mortality is high in this period. The recent recommendation requires all government institutions to discharge the mother and baby only after 48 h of delivery. Aim: The aim of the study was to find out the various factors causing early discharge of women having normal deliveries at government health facilities. Materials and Methods: The study was conducted in a rural block of Haryana. The total study duration was of 2 months. Postnatal women delivering normally within 6 months were included in the study after their written consent. A 30-item questionnaire was developed by the investigators to interview the women containing the demographic details and questions on various factors affecting postnatal stay at the health facility. Results: A total of 40 women consented and participated in the study. The mean age of participants was 24 ± 14.2 years. Most of the women (60%) were having their first child. Of them, 12 delivered at Primary Health Centre (PHC), 18 at Community Health Centre, and rest at district hospital. Forty- five percentage (18) of the women were discharged early (<48 h). Education of mother, lower socioeconomic status, delivering at PHC, and no counseling by doctor/nurse were significantly associated with early discharge. Among those who stayed until 48 hours, only 25% of women were told the reason by doctor/ nurse to stay. Conclusions: The proportion of cases discharged early is high. There is a need for essential counseling by health workers (Accredited Social Health Activists and Auxiliary Nurse Midwifes) during antenatal period to the pregnant women for staying at the health facility until 48 h after delivery. Doctors and nurses too need to explain to the mothers about reasons for staying at the facility until 48 h.

Keywords: Early discharge, neonatal mortality, uncomplicated pregnancy

 A cross-sectional study on biomedical waste management of a multi-specialty hospital

R.N. Hiremath1, Shailaja Patil1

1Department of Community Medicine, BLDEA's University, Bijapur, Karnataka, India

E-mail: [email protected]

Background: While on one hand, access to state of the art healthcare services are being provided to the community thereby resulting in the better health for all, on the other hand, improper management of biomedical waste (BMW) emanating from these healthcare establishments has also given rise to many environmental and health problems, thereby negating the benefits of the expanding health sector. Objectives: To assess the current level of BMW management operating system in multi-specialty hospital as well to assess the level of knowledge, attitude, practices (KAP) of BMW management among Health Care Workers (HCWs) with an endeavor to improve and suggest the BMW management standards. Methodology: A hospital-based, cross- sectional, descriptive study at one of the multi-specialty hospital was conducted with a view to carry out a survey of on ground operating system of BMW management and later on to assess the KAPs among HCWs. Results: The hospital is following Bio Medical Waste (Management and Handling) Rules in a satisfactory level with well-functioning hospital BMW management committee set up. Assessment of KAP with a predecided scoring system showed, 17.5% had excellent knowledge, 70% with good to average, and 12.5% had poor knowledge with respect to BMW management. 47 (58.7%) nursing assistants, 21 specially trained assistants with different diploma degree, and 12 (15%) nurses with graduate degree were taken part in the survey. Association of knowledge score was assessed with age category, education status, working experience, and job profile. However, knowledge status was not significantly associated with any of them. When asked about needle stick injuries, 88% felt that needle stick injury was a concern to them and 86% of them were well aware about the consequences of needle-stick injuries. Conclusion: The hospital is following BMW management system in a good way; however, it can be upgraded by newer techniques of BMW management. Although the awareness level was high with respect to BMW generation hazards, legislation and management among HCWs were compared to other studies, but there is still a scope for improvement.

Keywords: Biomedical waste, hospital, Health Care Workers

 Study of breastfeeding practices among children living in East District of Sikkim

Manisha Rai1, Dechenla Tsering Bhutia1

1Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, Tadong, Gangtok, Sikkim, India

E-mail: [email protected]

Introduction: Breastfeeding is an ideal way of providing food for growth and development of infants. According to NFHS- III, only 46.4% of children in India and 37.2% in the state are exclusively breastfed. The availability of data in the healthcare arena in Sikkim regarding breastfeeding practice is limited and thus this study was undertaken. Aim and objectives: To study the breastfeeding practices among children between 6 months and 2 years of age and to assess the factors affecting breastfeeding practices in East Sikkim. Methods: A cross-sectional study was conducted from 3 September 2013 to 3 September 2014 among a study population of children in the age group of 6 months to 2 years in East Sikkim. The sample size was calculated to be 675, considering the prevalence of exclusive breastfeeding as 37.2% (NFHS-III 2005–2006) and allowable error of 10%, using the formula 4PQ/L2. The sampling technique used is multistage simple random sampling, and semi-structured pretested interview schedules were used as sampling tools. Statistical analysis was done by SPSS version 16. Results: Among the study population, 46.5% children were exclusively breastfed for 6 months and 97.2% initiated breastfeeding within 1 h. Majority (95.8%) of the children was given colostrum and only 8.9% were given prelacteal feed. Various factors such as maternal age, area of residence, place of delivery, and occupational status of the mother had significant association with exclusive breastfeeding. It was found that rate of exclusive breastfeeding was lower among women with higher literacy status. Most of the mothers inferred insufficient milk secretion (50%) as the reason for not giving exclusive breastfeeding. Conclusion: Promotion of exclusive breastfeeding and targeting the identified key factors affecting exclusive breastfeeding practices are to be focused.

Keywords: Colostrum, exclusive breastfeeding, prevalence

 Is work associated stress converting into psychological distress among the staff nurse: A hospital-based study

Anuradha Davey1, Parul Sharma2, Sanjeev Davey3, Arvind Shukla1

1Department of Community Medicine, Subharti Medical College, Meerut, 3Department of Community Medicine, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, 2Department of Community Medicine, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

E-mail: [email protected]

Introduction: “Stress is the subjective feeling produced by events that are uncontrollable or threatening.” Constant stress brings about changes in the balance of hormones in the body which may lead to the situation or thought that makes us feel frustrated, angry, nervous, or anxious. Objective: (1) To find out the level of stress among staff nurses, (2) the association between sociodemographic determinants and working environment and stress, and (3) the impact of these sociodemographic determinants and working environment on their mental well-being in terms of somatic symptoms, anxiety/insomnia, social dysfunction, severe depression, and on work productivity. Methodology: The Institutional-based cross-sectional study was Subharti Medical College, Meerut. Study unit: GNM qualified nurse. Total sample size of the study comprised 100 staff nurses. Data collection technique by questionnaire which had two parts: Part I: Their sociodemographic variables and variables in their working environment, Part II: Goldberg and Hillier's 28-item scaled version of the General Health Questionnaire-28 was used to measure the psychological aspect of the quality of life of staff nurses. Results: Hospital nurses in this study reported mild (12%) to moderate/severe (77%) levels of job-related stress. The common stressors found in our study were the poor attitude of male patients, poor hygiene conditions at hostel, the absence of separate washroom for female nurses, posting in busy departments with increased workload, and inadequate salary. The single most important factor responsible for high levels of stress (70%) among the study subjects in the present study was inadequate salary. Conclusion: Assessing stress and job satisfaction are not a one-time action; it requires continuous monitoring and evaluation. Therefore, it is important to further explore, how work associated stress affects nurses, and what factors in their working environment cause the greatest burden.

Keywords: General stress score, staff nurses, working environment

 Caffeine habits among medical students in college of medicine, King Saud University, Riyadh

Yousef A. Al Turki1, Basel A. Alenazy1, Abdulrhman H. Algadheeb1, Mazi M. Alanazi1, Abdulsalam O. Almarzouqi1, Abdulrahman A. Alanazi1, Abdulelah A. Alanazi1

1King Saud University, Riyadh, Saudi Arabia

E-mail: [email protected]

Introduction: Caffeinated beverages have been one of the most consumed drinks. Since it is a psychoactive substance, medical students used to consume it more than other students to overcome the stress they face due to studying. Objectives: Estimation of the daily amount of caffeine consumption among medical students in college of medicine at King Saud University (KSU) in Riyadh in 2012 and comparison the amount of caffeine consumption among medical students based on the source of caffeine (coffee, soft drinks, and energy drinks). Materials and Methods: A cross-sectional study design using simple random sampling technique was used in this study. A self-administered questionnaire of 26 questions was distributed to 550 medical students (275 males and 275 females) at college of medicine, KSU, Riyadh, Saudi Arabia, from 26 January 2013 to 12 February 2013. Data were analyzed using SPSS. Results: (97.5%) of medical students are consuming caffeine while only (2.5%) of them have not used it. Low intake caffeine users represent the majority by (49.3%). However, moderate and high caffeine intake users are (28%) and (22.7%), respectively. Conclusion: We found a very high percentage of caffeine consumers among medical students. However, their use is still in the safe side. In other hand, high intake users which represent the smallest percentage should try to minimize the daily caffeine use.

Keywords: Caffeine, consumption, medical, students

 Cervical cancer and its awareness among students seeking medical-related professional courses in Bhubaneswar, Eastern India

Sonali Kar1, Seba Biswal2, Avinandan Sarkar1, Shalini Ray1

1Department of Community Medicine and 2Paediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Cervical cancer, in women, is the second most common cancer worldwide, next only to breast cancer. In India, cervical cancer is the most common woman-related cancer. In the west, early detection through regular screening has aided to significantly control the prevalence of this disease, thereby lowering its incidence. However in India, the number of deaths due to cervical cancer is estimated to rise to 79,000 by the year 2010. This is one of the few cancers which has a good prognosis if diagnosed early and has a vaccine to prevent human papillomavirus infection which is the key etiology of cervical cancer. Objectives: Identify the gaps in knowledge and practice of cervical cancer vaccination among students seeking medical courses. Assess the improvement in vaccine and knowledge (if any) from the time of admission (1st year) and the final year students of these courses and also between courses. Methodology: A cross-sectional questionnaire-based study was done among the 1st year and final year students of medical, dental, and nursing students (irrespective of their gender) of KIIT University after their due informed consent. The questionnaire was self-administered and anonymous, comprising questions on their sociodemographic profile, knowledge about cervical cancer, vaccination and screening programs, and also their acceptance of vaccination. The data were compiled in excel sheet and analyzed for statistical significance using percentages, Chi-square, and paired t-test. Results: Knowledge regarding cervical cancer was better among medical students as compared to their dental and nursing counterparts. Knowledge improved among medical students as their levels of education improved (P < 0.001), which was not so for dental and nursing. Female students had better knowledge as compared to the male, all courses taken together and incidence of cancer in the family improved the vaccine acceptance to 2–3 times. Details would be presented in the conference. Conclusion: This study strongly points out that advocacy regarding prevention strategies need a big boost as the knowledge and acceptance of vaccination for this important preventable cancer in women is less even in the health-related courses. It is also important to encourage male participation in this strategy as when the woman is suffering from cancer, the whole family suffers with her.

Key words: Cervical cancer, human papillomavirus vaccination, knowledge gap, medical courses

 Prediction of infections prevailing in a geographical region through microbial tests done in a Tertiary Care Centre, Bhubaneswar, Odisha

Sonali Kar1, Dipti Pattnaik2, Rahul Pal1

Departments of 1Community Medicine and 2Microbiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Kalinga Institute of Medical Sciences is a private medical college along with a super speciality hospital catering to the health care needs of Southern half of Bhubaneswar, the capital of Odisha state. It has a state of art microbiology laboratory that receives on an average 2000 samples on any given day to test for various infections. In spite of advanced diagnostics, the culture of various body exudates continues to be the gold standard to identify the exact etiological agent especially bacteriological. These tests are done routinely besides as a part of the treatment of admitted patients in order to prescribe apt antibiotics to an admitted patient. Aims and Objectives: This study hypothesizes that: (a) Exudates examined at the micro laboratory that hint at the common infections prevailing in the community and also probably the hospital acquired infections. (b) To decide on parameters like skill sets of the laboratory technicians and any other quality measures that should be undertaken to improve the laboratory reporting. Methodology: With this view, an integrated secondary data based study was attempted by the Department of Community Medicine and Microbiology wherein the culture results of all patients regardless of age, gender and form of exudates, and departments were taken from the record register for the months of June-July 2015; entered in excel sheet and analyzed for any trends of infections that are common to the people in this part of state. Data of 2 months which came out to be 410 culture reports were collated. Results: Showed that culture was done for 51.2% males. Forty percentage of the results were for routine OPD cases and among referral Departments Intensive Care Unit accounted for the highest, that is, 22%, followed by medicine (12.5%), and pediatrics (9.8%). Irrespective of the type of exudates, Escherichia coliaccounted for highest, that is, 18% followed by Enterococcus which was 9%. E. coli was also the most common infection reported from females. Enterococcus was the most common among infants. For laboratory records, 8.7% reports were contaminated mostly for women, that is, 69% which meant that special precautions should be undertaken to take the specimens in case of women. Conclusion: This simple study suggests the epidemiological patterns of infections in June-July months in a rain-prone state of Odisha and helps the hospital administration to take steps to initiate target interventions for the same.

Keywords: Culture reports, Escherichia coli, laboratory records, microbiological infections

 Gender preference and awareness regarding fetal sex determination among antenatal women attending a tertiary care hospital, Bhubaneswar

Shalini Ray1, Ipsa Mohapatra1, Sonali Kar1

1Department of Community Medicine, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, Odisha, India

E-mail: [email protected]

Introduction: Gender preferences are a well-known feature of the society. Huge differences in gender preference are seen in the developed and developing countries. People in India exhibit a strong gender preference for a male child and this discrimination continues in spite of socioeconomic development and higher growth rates. [1],[2] The preference for sons has been associated with the preferential abortion of female fetuses. The sex ratio has been declining in India through decades since 1901.[3] It has been estimated at 933 in India during the census of 2011. One of the most important preventable factors is the prevention of sex-selective female abortions. Aims and Objectives: To find out the awareness regarding fetal sex determination and to explore gender preference and factors associated among antenatal women attending a tertiary care hospital. Materials and Methods: Interviews were done among 113 married antenatal women using predesigned, pretested proforma. The data were analyzed by EpiInfo 7.0. Results and Discussion: In our study, most of the antenatal women 67.26% were primigravida and the mean age of the study population was 23.4 ± 2.7 years. The majority of the subjects were from the urban area (74.34%) no gender preference was observed among 56.6% of antenatal women and 43.36% preferred a male child. The main reasons cited for male preference were old age security and financial security. Lower socioeconomic status, unemployment, and multiparity were significant determinants of male preference among study participants (P < 0.05). However, 68.14% women were aware of PCPNDT Act and their sources of information were media (54.2%), hospital (24.1%), and relatives (21.6%). 95.5% opined to stop female feticide. Conclusion: Gender empowerment, women education and stringent implementation of PCPNDT Act can curb the social issue of female feticide.

Keywords: Female feticide, gender


Bharadwaj P, Nelson LK. Discrimination Begins in the Womb: Evidence of Sex-Selective Prenatal Investments; 24 February, 2013.Dasgupta SS. Preference and Gender Gaps in Child Nutrition: Does the Level of Female Autonomy Matter?Census of India. Sex composition of India.

 Evaluating patterns of self-medication practices among dental students in a teaching dental institution in Delhi

Pawan Kumar1, Deep Inder2

1Jamia Millia Islamia, 2Department of Pharmacology, Jamia Millia Islamia, New Delhi, India

Introduction: Self-medication is the practice of use of any medication for the self-diagnosed condition without medical advice. Correct practice of same proves economical and saves time, but the incorrect practice may prove harmful for health. Objective: This study was planned to compare the pattern of self- medication in first and final year dental students. Methods: The cross-sectional study was done using prevalidated questionnaire consisting of both open and close-ended items-related to various aspects of self-medication. The study population (164 respondents) comprised two groups (Group 1: First year and Group 2: Final year) dental students who filled the questionnaire. Comparison between the two groups was done using Chi-square test. Results: Sixty-seven percentage respondents in Group 1 and 95% respondents in Group 2 practiced self-medication. Indications for self-medication included pain (43% vs. 84%; P< 0.05) followed by fever (72% vs. 76%) and cough and cold (21% vs. 53%). Reasons for self-medication included lack of time (66% vs.80%) and illness perceived as minor (60% vs. 78%). The main guiding sources included previous prescriptions (44% vs. 52%) and pharmacists (29% vs. 21%). Analgesics and antipyretics were the most commonly used drugs. Awareness about over-the-counter drugs, dose, and adverse effects was statistically significantly higher in Group 2. Conclusion: Self-medication is widely practiced among dental students. Final year dental students have a better knowledge about certain aspects of self-medication, which reflects the influence of pharmacology subject, but even the 1st year dental students who are not exposed to the pharmacology are aware of most aspects of self-medication which may be due to easy availability of information through various media. Therefore, there is an urgent need to create awareness about risks and benefits of self-medication to ensure rational and safe use of drugs.

Keywords: Adverse effects, dental students, self-medication

 Prevalence and determinants of visual impairment among 10–15-year-old school children in Puducherry: A cross-sectional study

R. Vishnu Prasad1, Joy Bazroy1, K. Madhanraj1, Hannah Ranjee Prashanth2, Z. Sing1

Departments of 1Community Medicine and 2Ophthalmology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India

E-mail: [email protected]

Introduction: According to the 2010 estimates by the WHO, nearly 285 million (4.24% of total population) people of all ages worldwide are visually impaired. Almost 18.9 million children under 15 years of age are visually impaired globally. In developing countries, 7–31% of childhood blindness and visual impairment is avoidable. The study aims to measure the prevalence of visual impairment among 10–15-year-old school children in Puducherry and to identify possible determinants. Materials and Methods: The study was conducted as a cross- sectional study among 1884 school students in Puducherry in the age group of 10–15 years. A child with presenting maximum vision ≤6/12 Snellen equivalent in the better eye is considered visually impaired. Data was entered in Microsoft Excel 2013 and analyzed using the statistical software SPSS version 21.0. Chi- square test was applied for testing difference in proportion, and a P < 0.05 was considered statistically significant. Results: The overall prevalence of visual impairment (vision ≤6/12) among the study participants was 6.37% (95% confidence interval = 5.27–7.47). The prevalence of visual impairment increased with age, and it was found to be high among male students (6.6%) when compared to female students (6%). Presenting vision of 6/6 was observed in 79.8% of the children, while with pinhole correction, population was found to be 6.37% and the prevalence was even higher among children who belonged to schools, the proportion increased to 94.6%. Conclusion: The prevalence of visual impairment in our study of the urban region or private schools. Children with a positive family history of spectacle use were more likely to have a visual impairment.

Keywords: Myopia, school children, visual impairment

 Prevalence of selected risk factors for non communicable diseases among medical students in PGIMS Rohtak

V. Yashodha1, Meena Rajput1, Pradeep Khanna1

1Pt.B.D.Sharm, PGIMS, Rohtak, Haryana, India

E-mail: [email protected]

Introduction: Noncommunicable diseases (NCDs) are a major contributor to the total disease burden in developed countries and are increasing rapidly in developing countries such as India. There are several risk factors associated with NCDs that are modifiable. Therefore, this study was undertaken to assess the prevalence of selected NCDs risk factors among medical students of a teaching institution from north India. Aims and Objectives: To assess the prevalence of selected risk factors for NCDs among medical students. Materials and Methods: The present cross-sectional study was carried out among the 1st year medical (MBBS) students during the month of February and March 2015. Data collection were carried out using predesigned, pretested semi-structured interview schedule. Height and weight were measured using a standard protocol. Data management was done using Excel sheet. Results: Nearly, 187 (93.5%) 1st year students were covered in the present study. The mean age, weight, height, and body mass index of study participants were found to be 18.6 years, 60.1 kg, 166.2 cm and 21.02 kg/m2, respectively. Around 21.2% of study participants were overweight or obese. 38.0% had a family history of at least one-NCDs. Around 12% of students had consumed alcohol and also had consumed at least one-drink during last 30 days with 16.6 years as the age of starting alcohol. Tobacco product consumption was seen in 3.0% of students with 12.7 years as the age of starting. About two-third of students (62.0%) were involved with sports/rigorous physical activity of at least 30 min duration in last 30 days. Conclusion: There was the variable but substantial presence of NCD risk factors among medical students. Regular communication on healthy food habits and motivation to uptake sports/rigorous physical activity are required on urgent basis during the formative period of medical education.

Keywords: Non communicable diseases, risk factors

 National Accreditation Board for Hospitals and Healthcare Providers standards in healthcare

Binit Sureka1, Aliza Mittal2

1Department of Radiology, Institute of Liver and Biliary Sciences, 2Department of Pediatrics, NDMC Medical College and Hindurao Hospital, New Delhi, India

E-mail: [email protected]

Purpose: The rising healthcare costs across the globe and ever increasing demand for quality by the patients pose a significant burden and stress among the healthcare providers and hospital administration. Healthcare costs are increasing more rapidly than costs of fast moving consumer goods and services in daily practice. Healthcare providers, particularly government- owned hospitals, are under continuous strain to reduce the costs while at the same time improve service, patient safety, reduce patient waiting times, minimize errors, and associated litigation. Knowledge of basic National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards and its utility is essential for healthcare providers as it helps build trust among healthcare providers and patients. NABH standards have 10 key chapters, 102 standards, and 636 objective elements. Patient-centered chapters are - access, assessment and continuity of care, patients' rights and education, care of patients, management of medications, and hospital infection control. Management centered chapters are continuous quality improvement, responsibilities of management, facility management and safety, human resource management, and information management systems. Conclusion: Basic knowledge of NABH standards is essential for every healthcare provider. These standards if practiced carefully can substantially improve the quality of services, environment of working among healthcare providers, and built trust among stakeholders in the hospitals.

Keywords: Improvement, National Accreditation Board for Hospitals and Healthcare Providers, quality, standards

 Current status of knowledge and attitude about human immunodeficiency virus/acquired immune deficiency syndrome among undergraduate medical and paramedical students of a university in New Delhi

Farzana Islam1, Sushovan Roy1, Arup Deb Roy2

1Department of Community Medicine, HIMSR, Jamia Hamdard, 2Immunization Technical Support Unit-Public Health Foundation of India, New Delhi, India

E-mail: [email protected]

Background: The current pandemic of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is in its fourth decade. A considerable amount of research on pathogenesis, epidemiology, and most importantly, treatment have been executed the world over. Currently, a patient of HIV/ AIDS can look forward to life of reasonable quality and length due to the advent of antiretroviral therapeutic agents. The maxim “Prevention is better than cure” is most apt for the morbidity of HIV/AIDS. However, stigma and discrimination at health care setting, workplaces, and at educational institutions are still a matter of concern and challenge. Objectives: To determine the extent of knowledge about HIV/AIDS among the 1st year MBBS, BUMS, and BSc Nursing students and to ascertain their beliefs and perceptions about HIV/AIDS and attitudes toward people living with HIV. Methodology: The present cross-sectional study explored knowledge and attitudes of 1st year MBBS, BUMS, and BSc Nursing students, of Jamia Hamdard University, New Delhi, on HIV/AIDS using a self-administered questionnaire. Data thus collected were entered into MS Excel spreadsheet and further analysis was done by using relevant statistical tests. Results: The study revealed that students are more comfortable to discuss anything regarding HIV/AIDS with the friends of the same sex (95.53%), rather than with husband/wife (65.92%) or any family member (58.56%). The general knowledge of the students regarding HIV/AIDS is good. The majority of the students were aware of the major routes of transmission of the disease, but only 53.07% students knew that HIV can transmit through mother's milk. Only 49.72% of the students have ever heard of antiretroviral therapy for HIV/AIDS. The study pointed out that attitude of the students toward people living with HIV (PLHIV) is variable. Most of the students (93.50%) have respect toward PLHIV while almost half of the students think that HIV+ couple should not have children. More than 25% of the students think that serving an HIV+ patient might put oneself at risk of contracting disease. Conclusion: Knowledge about HIV/AIDS is crucial for health care professionals. The study reveals that though HIV/AIDS is three decades old disease, and lots of work has been done, still the knowledge and the attitude of the people, in general, have not increased to the desired level. Therefore, there is a need and scope to provide correct and detailed information on HIV/AIDS for new entrants in medical and paramedical courses to help them acquire adequate knowledge and develop appropriate attitudes toward HIV/AIDS.

Keywords: Attitude, human immunodeficiency virus/acquired immune deficiency syndrome, knowledge, medical/paramedical students

 Primary care for adults with developmental disabilities: Knowledge to action

Ian Casson1, Janet Durbin2, Meg Gemmill1, Laurie Green3, Elizabeth Grier1, Andrea Perry2, Avra Selick2, Yona Lunsky2

1Department of Family Medicine, Queen's University, Kingston, 2Centre for Addiction and Mental Health, 3Department of Family and Community Medicine, University of Toronto, Toronto, Canada

E-mail: [email protected]

Introduction: In 2011, Canadian consensus guidelines for the primary care of adults with intellectual and developmental disabilities (IDD) were published and distributed to all family physicians in Canada along with a book of clinical tools to assist with guideline implementation. One of the key recommendations in the guidelines was that an annual comprehensive preventive care assessment, including physical exam, be offered to undertaken. This recommendation was informed by the international evidence regarding the benefits of the “Health Check,” along with recent Ontario, Canada data highlighting gaps in primary health care in this population. Population health information and clinical practice guidelines provide a knowledge base on which action may be taken. However, moving guidelines into practice is a complex endeavor that requires in-depth study. The implementation projects in three Family Health Teams in Ontario have evaluated how to put health checks into action. Aims: This poster will describe the lessons learned, which may be helpful to other family physicians in enhancing the care of adults with IDD in their practices. Methods: Data reflecting the implementation experience of health checks in the three pilot projects were collected through staff surveys, patient medical record audits, and individual and group interviews. Qualitative and quantitative analyses were done. Results: Barriers and enablers to implement health checks for adults with IDD were identified. Conclusions: A local champion and a link to a current project in a family practice (e.g., quality improvement programming, outreach to other groups with problems in access to health care services) are helpful. Systematic efforts are required to identify adults with IDD in family practices and to facilitate appointments, especially for those patients without advocates. The content of health checks may take several patient encounters to accomplish, but, that is, consistent with the comprehensive, continuing care model of family practice.

Keywords: Adults, developmental disabilities, primary care

 Behavior regarding tobacco consumption, its hazards and willingness to quit the habit among construction site workers of a tertiary care hospital

Mamta Parashar1, Praveen Malik2, Bilkish Patavegar1, Shridhar Dwivedi2

Departments of 1Community Medicine and 2Medicine, Hamdard Institute of Medical Sciences and Research,

New Delhi, India

E-mail: [email protected]

Background: Despite various initiatives, menace of tobacco problem remains a cause of concern globally. Jobs of construction site workers are making them prone to dependence. Their views are of great importance to be determined before implementing any antitobacco measures at workplace, so the study was conducted with the objective of assessing behavior regarding tobacco consumption, its hazards and willingness to quit the habit among construction site workers of Delhi. Methods: A cross-sectional study was conducted among all construction site workers aged 18 years and above in campus of Hamdard Institute of Medical Sciences and Research and associated HAH centenary hospital, New Delhi. The study included 172 workers for 6 months (May 2014 to October 2014). Data were analyzed using SPSS 16.0 version. Results: The majority (91%) of them were tobacco users, of these 49% were using smokeless tobacco (SLT), 29% were consuming bidi/cigarette, and 22% were consuming both. It was found that 55.8% of the population had knowledge about harmful effects of smoking while it was 46.5% for SLT. Only 23.3% were aware that second-hand smoke can also be harmful. Most of the workers (90.7%) had received tobacco- related information through media. Tobacco as cause of cancer was named by 55.8% while others named tuberculosis (17.4%), cough (39.5%), and other diseases (25.6%). Warning labels lead to thought of quitting tobacco in 62.8%. They had 52.4% and 42.2% in initiated smoking and SLT use during their adolescence, respectively. Most of them (97.4%) had a habit of tobacco consumption at their workplace. A significant association was found between good knowledge and marriage, good education, high income, and joint family. Conclusion: Although awareness of the health hazards of tobacco has improved, the prevalence of tobacco use (91%) was very high among construction workers. Effective behavior change communication package is required. Besides this effective workplace, law is necessary particularly at construction site.

Keywords: behavior, construction site worker, tobacco use

 Dietary calcium intake and physical activity levels among urban South Indian postmenopausal women

Jeffrey Pradeep Raj1,2, Anu Mary Oommen1,2, Thomas V. Paul1,2

1St. John's Medical College, Bengaluru, Karnataka, 2Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

Introduction: Calcium is the most abundant mineral in our body with varied functions, and its dietary deficiency leads to osteoporosis besides playing a significant role in pathogenesis of other diseases. The data regarding dietary calcium intake (DCI) among postmenopausal women in the urban areas of South India is limited. Objectives: This study was aimed to assess DCI and physical activity among postmenopausal women. The risk factors for a low intake of dietary calcium were also assessed. Materials and Methods: A cross-sectional study was done among 106 postmenopausal women selected by systematic random sampling from Erode City, Tamil Nadu. DCI and physical activity were measured using validated questionnaires. Results: The mean DCI was 632.72 ± 28.23 mg/day. The proportion of women consuming <800 mg/day of dietary calcium was 74.5%. Only 10.4% of the women (11 out of 106) were on calcium supplements while 55% of women had low physical activity. Low knowledge score (adjusted odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.31–20.42) and a low socioeconomic status score for the family (adjusted OR: 4.00, 95% CI: 1.32–12.11) were significantly associated with low DCI after adjusting for age, dietary preferences, and educational and occupational statuses. Conclusions: DCI was below the recommended daily allowance, and the majority of the postmenopausal women were physically inactive, indicating the need for better education regarding DCI, the need for calcium supplements and physical activity, all of which can contribute to prevention of consequences of osteoporosis.

Keywords: Calcium supplements, dietary calcium intake, physical activity, postmenopausal

 Comparison of transcutaneous bilirubin with total serum bilirubin in newborns

Sarang Ravindra Kokate1

1Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India

E-mail: [email protected]

Introduction: Neonatal jaundice is common in the 1st week of life. Mostly it is benign in nature. Severe jaundice may lead to kernicterus and death. It is prevented by regular assessment of jaundice in the 1st week of life. Traditionally, clinical observation and laboratory estimation of serum bilirubin was the assessment tools. Serum bilirubin is the gold standard but is invasive, painful and requires frequent sampling. Transcutaneous bilirubinometer (TcB) is new technique; it is painless and non-invasive. Objectives: (1) To find out the reliability and accuracy of TcB. (2) To ascertain whether transcutaneous bilirubin decreases frequent blood sampling for the assessment of jaundice. (3) To assess whether it is helpful in early intervention. Methods: We conducted a cross-sectional study over a period of 1 year on 353 healthy neonates within the 8th day of life. We took TcB measurements daily with the help of bilirubinometer. This TcB was plotted on Bhutani's nomogram chart. Total serum bilirubin (TSB) was sent for TcB level more than 75 percentile of nomogram chart or if pediatrician suggests. We obtained a maximum number of 562 TcB and corresponding TSB values were statistically analyzed on day of life 3, 4, 5, and 6. Results: (1) Pearson's coefficient of correlation (r) between TcB and TSB was r = 0.873 (P < 0.001), according to day of life r value ranges from 0.834 to 0.886. r in a group of babies classified according to gestational age and birth weight had good correlation coefficients ranging from 0.724 to 0.895. (2) We obtained a range of sensitivity 75–100%, specificity 71.92–100%, positive predictive value 48.39–100%, negative predictive values 86.84–100% for a different day of life. Sensitivity decreases and specificity increases with a day of life. (3) Receiver operating characteristic curve analysis gives a sensitivity of 82–93.3% and specificity of 82–89.5% for a different day of life. Areas under the curve were more than 0.89 suggestive of high accuracy of TcB. Conclusion: TcB and TSB values were comparable and significantly correlated and accurate. TcB value had good sensitivity and specificity, and it can be used as a screening tool for the assessment of jaundice and early diagnosis. It can reduce the need for frequent blood sampling done for the assessment of jaundice.

Keywords: Hyperbilirubinemia, icterus, neonatal jaundice, transcutaneous bilirubin

 Basics of epidemiology

Ranabir Pal1, Neeti Rustagi1

1Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

E-mail: [email protected]; [email protected]

Epidemiology is the grammar of medicine that elaborates distribution and determinants of risk factors and outcomes in question that the healthcare providers apply in the context of their particular interests or needs. Epidemiological concepts and procedures are not only useful in the surveillance and investigation of health-related states or events but also in the patient-centered care of the daily life of all levels of healthcare. A basic understanding of these practices of the arena, public health, and biostatistics is urgently needed for all the health professionals to internalize the natural history of disease for optimum intervention and reach the expectations of the stakeholders to the last man on road. We wish to share our knowledge in (a) key features and applications of descriptive and analytic epidemiology; (b) calculate and interpret ratios, proportions, incidence rates, mortality rates, prevalence, and years of potential life lost; (c) calculate and interpret central tendencies and dispersions of data viz., mean, median, mode, ranges, variance, standard deviation, and confidence interval; (d) how to collect data and organize in tables, and diagrams to learn how to read between the lines; (e) overall concepts of abstraction and generalization of processes, uses, and evaluation of public health surveillance; (f) elementary steps of an outbreak investigation.

Keywords: Epidemiology, health, outcomes, risk factors

 Prevalence of hypothermia among normal term neonates in a South-Indian city and assessment of practices and knowledge risk factors among mothers: Hospital-based cross-sectional study

Jeffrey Pradeep Raj1, T. Sathish Kumar, K. Suganthi2

1CSI Hospital, Om Shakthi Hospital, Erode, 2Department of Child Health-Unit-II, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

Introduction: Body temperature of a newborn below 36.5°C in axilla is neonatal hypothermia. Hypothermia has serious health concerns in a developing child and may lead to short stature, delayed growth, and even death. Objective: To estimate the prevalence of neonatal hypothermia among normal term neonates and to determine practice and knowledge risk factors among postnatal mothers. Design: A cross-sectional study. Setting: Secondary Care Hospital in Erode city. Participants: Consecutive sample of all healthy-term newborn infants born during the winter months of December 2014 and January 2015. Main Outcome Measures: Two axillary temperatures of neonates measured during their hospital stay and their respective mothers were assessed for their knowledge on neonatal thermoregulation. The practices followed were observed directly by the principal investigator (PI). Methodology: Two temperatures were measured; consecutively, once in the morning (between 07:00 and 08:00 am) and once in the evening (between 07:00 and 08:00 pm) and followed-up until discharge and any one temperature below 36.5°C was taken as hypothermia. Data were collected by the PI using a pilot tested semi-structured standardized questionnaire. Results: Total number of mothers and babies studied were 102. The prevalence of hypothermia was 44.1% (95% confidence interval [CI] 34.46–53.74%). A number of hypothermic episodes were 67 (out of 204; 32.84%). Babies that were by the mothers' side (adjusted odds ratio [AOR] 3.891, 95% CI 1.091–13.881), head covered (AOR 22.044, 95% CI 2.004–242.518), and breast fed within 1 h of birth (AOR 4.297, 95% CI 1.443–12.794) were significantly protected from hypothermia. The knowledge regarding neonatal thermoregulation was poor with misconceptions such as babies shiver (P = 0.014; AOR 14.055, 95% CI 1.702–116.08). Conclusions: The prevalence of neonatal hypothermia was considerably high despite good neonatal warm chain practices observed. The knowledge on neonatal thermoregulation among the mothers was poor, and hence regular health education is warranted.

Keywords: Hypothermia, neonate, newborn, prevalence, temperature

 Prevalence of anemia and menstrual problems among household women of Ranchi, Jharkhand, India: A cross-sectional study

Ravishekar Hiremath1, Sandhya Ghodke1, Radika Kumar1, Apoorva Sindhu1, Shailaja Patil1

1Central Government Health Services

E-mail: [email protected]

Background: Anemia in pregnancy accounts for one-fifth of maternal deaths and is a major factor responsible for low birth weight. In India, 16% of maternal deaths are attributed to anemia. The association between anemia and adverse pregnancy outcome, higher incidence of preterm, and low birth weight deliveries has been demonstrated. In most cases, anemia is associated with pregnancy and menstrual disorders. Objectives: (i) To assess the prevalence of anemia and to correlate the risk factors associated, if any, among household women of Ranchi, Jharkhand. (ii) To assess the menstrual problems associated with the household women and (iii) to carry out lecture cum discussion to increase their knowledge and teach them simple preventive measures for anemia. Materials and Methods: A cross-sectional study was carried out among all the household women staying in a particular community of Ranchi city. Data were collected among 1373 women who consented for the study using a pretested, self-administered, structured questionnaire, and relevant investigations were carried out. Results: The mean age of the participants was 29.01 with a standard deviation of 5.71. Majority (63.4%) of them basically belonged to urban areas. Sixty-five percent of them had a family monthly income of <20,000, while 2.5% had above 40,000/-. Sixty-five percent were having mild anemia, while 9% and 1% had moderate and severe anemia, respectively. 1.4% were pregnant, 3% had menstrual problems, and 2% were having clinically evident anemic signs such as giddiness, low backache, and headache, while 93% did not had any symptoms. Sixteen percent were obese and 38% were overweight. 8.5% of thin women, 39.5% of normal women, and 52% of obese/ overweight women were anemic. Anemia was not significantly associated with socioeconomic status, age, and place of residence (rural/urban). Conclusion: This study finding indicates that anemia prevalence is increasing even in higher socioeconomic status, increasing age, and normal/overweight/ obese women irrespective of whether they are from rural or urban background, indicating that knowledge awareness about measures for prevention and early identification of anemic signs is the need of the hour among all household women. Hence, an intensive lecture cum discussion and video display was carried out with regards to anemia risk factors, preventive measures, and early identification which were appreciated by all.

Keywords: Anemia, household, menstrual problems

 Qualitative Health Research: Must know area for family care physicians

Neeti Rustagi1, Ranabir Pal1

1Department of Community Medicine and Family Medicine, AIIMS, Jodhpur, Rajasthan, India

E-mail: [email protected]

Interpretation of people perception and behavior is one of the key determinants while addressing health concern of masses. Qualitative Health Research (QHR) is an essential tool in the hands of family physicians to explore specific issues of masses to achieve better compliance and patient satisfaction along with enabling upgradation of existing medical and scientific knowledge. Thus, understanding and adapting themselves to utilize the skills of QHR is definitely a must have skill set for all family care physicians to fulfill their role of general practitioner's with special consideration toward understanding and addressing patient and family role in modifying health-related behavior, attitudes, and practices of people.

 Workshop on women's health

Sahadev Swain1

1Blenheim Medical Centre, Luton, Bedfordshire, UK

E-mail: [email protected]

Aim: The aim of the workshop is to update on various aspects of women's health. The topics will include management of subfertility, abnormal uterine bleeding, and genital human papillomavirus infection. This will be an interactive session predominantly keeping in view Family Medicine Residents as the audience. Speakers will include Family Physicians from the UK and India and an Associate Specialist in Family Planning from the UK. Objectives: At the end of the session you will be able to know: (a) How to approach to conduct initial interview with a couple presenting with subfertility (b) when and how to investigate a couple with subfertility (c) when to refer to the specialist (d) how to manage a woman presenting with abnormal uterine bleeding (e) what are implications and preventive aspects of genital human papillomavirus. Methodology: The speakers will be free to use the audiovisual aids available. The session will be trainee oriented and will try to address their learning needs as explored in the beginning within the time constraints. The discussion will be based on case scenario whenever possible. The trainers will be encouraged to come up with the answers to make the workshop really interactive. PowerPoint may be used only to emphasize and illustrate with a view to signposting to further learning. The speakers will be more than happy if the participants bring their relevant cases for discussion.

Key words: Contraception, Women's Health

 Diagnostic tests

Ranabir Pal1, Neeti Rustagi1

1Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

E-mail: [email protected]

Diagnostic tests are performed to aid in diagnosis/prognosis of disease or disorder or (even risk factor) to diagnose diseases, to measure progress or recovery from disease, and even to confirm that a person is free from disease. Diagnostic tests check a sample of tissue for analysis leading to normal/abnormal results. Tests may be of different broad types ranging from invasive, minimally invasive to noninvasive (c.f. psychometry). Yet, the “Gold standards” for different diseases are yet to be available. Further, different accuracy parameters like prior probability (pretest probability), posterior probability (posttest probability)/predictive value: Positive predictive value, negative predictive value, sensitivity and specificity, and likelihood ratio (LR): LR (+)and LR (-) have to be internalized for the optimization of the battery of tests for given outcome. Test reports to diagnose, plan, evaluate, monitor depend on sociodemography, meal and drink, concurrent drug use, pretest instruction, comparison of diagnostic test/s with previous results, location (anatomical diagnoses), and multiple lesions, interplay between diagnostic test data and epidemiological relations, tests with a therapeutic potential. For serious health care providers learning through the lines of the systematic reviews, meta-analyses, and ethical issues involving care-seekers leads to patient-centered care.

Keywords: Diagnostic tests

 Women's health issues workshop: Case-based discussions and interactive quiz

Sahadev Swain

Blenheim Medical Centre, Luton, Bedfordshire, UK

E-mail: [email protected]

Outline: This will be a 2 h workshop for family physician postgraduate trainees. Aim: The aim of the session is to highlight the primary care management of women's health cases. Using cases and a quiz, work through areas where there might be a gap in knowledge. Objectives: (1) By the end of the seminar students will be able to discuss the primary care management of: (i) Contraceptive choices, (ii) Urinary problem, (iii) Menstrual problems, (iv) Domestic violence, and (v) Screening. (2) Be able to give examples of possible screening programs in general practice and discuss factors that influence uptake of these programs. (3) Be able to describe how the primary health care team is organized to provide high-quality women's health care. Concluding Remark: If you are coming to the session come prepared: Who knows there may be surprise prize!

Key words: Medical education, screening, women's health

 A cross-sectional study on psychological problems among call handlers employed in International Call Centers in the National Capital Region of Delhi, India

Bharat Paul1, J. S. Malik1

1Department of Community Medicine, Pt. B. D. Sharma, PGIMS, Rohtak, Haryana, India

E-mail: [email protected]

Introduction: There has been a boom in the call center industry in India. The National Capital Region (NCR) of Delhi is the hub of call centers in India. There is a lot of stress involved in these jobs due to night shifts, long hours of continuous work, and high work targets. The staff also suffers from musculoskeletal disorders, gastric upset, metabolic disorders, psychiatric disturbances, and disturbed relationships. This ultimately results in physical, psychological, and behavioral deviations among them which affect not only the employees and the organization but also the country on the whole. Objective: To measure the level of perceived stress, anxiety, and depression among call handlers working in call centers in Delhi NCR, India. Materials and Methods: A cross-sectional survey is being conducted among 200 call handlers aged 18–39 years in the months of June and July 2015. The study is being conducted at two reputed call centers located in the NCR of Delhi. Depression Anxiety Stress Scale-42 is being used to measure stress, anxiety, and depression along with a pretested questionnaire containing sociodemographic profile of the participants. The data obtained at the end of the study will be analyzed for the presence of stress, anxiety, and depression in the call center handlers.

Keywords: Anxiety, call centers, call handlers, psychological problems

 Awareness of breast cancer among women in an urban area of District Gurgaon, Haryana, India

Patel Puja Bharat1, B. S. Deswal1

1Department of Community Medicine, SGT Medical College, Gurgaon, Haryana, India

E-mail: [email protected]

Introduction: Breast cancer is the most common cancer of women in both developed and developing country. As per global health estimates WHO-2013, about 508,000 females died of breast cancer in 2011. Though breast cancer is considered a disease of developed countries in recent years, a rising incidence of cases is also being seen in developing countries. India is no exception to this. Breast cancer is on the rise, particularly in urban areas. Objective: To find the awareness regarding breast cancer in women in an urban area of Gurgaon, Haryana. Materials and Methods: The study was conducted in the urban area of District Gurgaon, Haryana, India. The study was conducted in 300 households located in the urban field practice area of Department of Community Medicine, SGT Medical College, Gurgaon. Married females in the age group of 18–60 in the selected houses were interviewed using a pretested schedule to get an insight about their awareness of breast cancer. Only one female per household was selected. Results: The majority of the participants were aware of breast cancer but lacked proper knowledge about the risk factors of the disease. Most of the participants were unaware of correct technique of breast self-examination. About 70 women admitted of having some disorder in breast (lump, cracks, discharges, pain, and tenderness). Only 25 of these sought medical check-up from a registered medical practitioner. Others sought help from other females of their locality or quacks. A considerable number of participants admitted; they were not comfortable discussing this subject within their homes. Conclusion: In recent years, there has been a rapid spurt of cases of breast cancer in India. The mortality associated with the cases is considerably higher in India as compared to the developed countries. This can be attributed to lack of proper knowledge and the taboo associated with the subject. Increasing the knowledge of women in self-examination techniques and the screening procedures for early detection and management of breast cancers can reduce the morbidity and mortality of females to a great extent.

Keywords: Awareness, breast cancer, breast self-examination

 The dire need for primary care specialization in India: Concerns and challenges

Nafis Faizi1, Najam Khalique1, Anees Ahmad1, M. Salman Shah1

1Department of Community Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

E-mail: [email protected]

Primary healthcare should be an evidence-based priority because of the many evidences in its favor, but the truth is that it is still inadequately supported in many countries. The affordability of high quality of healthcare makes India a popular destination for medical tourism on one hand, and, on the other hand, ill health and healthcare are the main reasons for becoming poor through medical poverty traps. All this, despite the fact that India has a primary care system and was committed to health for all by 2000 in the past and is also committed to Universal health coverage by 2022. Clearly, something is terribly wrong and commitments-like these are destined to fail unless something is done to improve the present state of affairs. This study argues for the need to develop primary care as a specialization in India as one of the most important remedial measures to reform its healthcare and really commit to the commitments. Three critical issues for this specialization are discussed in this review, emphasizing the need, and importance of primary care specialization: (1) The dynamic and distinct nature of primary care as opposed to other medical specializations, (2) the intersection of primary care and public health which can be facilitated by such a specialization, and (3) research in primary care including researchers to develop screening and referral tools for early diagnosis of cancers, researchers to supplement healthcare interventions via health programs and the wide scope of primary care epidemiology. Despite the potential challenges and difficulties, India is a country in dire need for primary care specialization. The double burden of diseases with the threat of emerging diseases coupled with the scale of diversity in sociocultural factors, environmental conditions, climate, and other health determinants further increase the value of this specialization. India's experience in providing low-cost quality healthcare for medical tourism presages a more cost-effective primary care if it becomes a specialization.

Keywords: India, primary, research, specialization

 Domestic violence: Beliefs, attitudes, and practices in a secondary hospital in South India

Baren Minz1, John Jacob1, K. Emmanuel2

Departments of 1Community Medicine and 2Family Medicine, Christian Fellowship Hospital, Oddanchatram, Dindigul, Tamil Nadu, India

E-mail: [email protected]

Introduction: Disturbing statistics released by the National Crime Records Bureau show that domestic violence (DV) is much more prevalent in Tamil Nadu than any other state in the country. The data show the state-registered 3838 cases of DV in 2012 or 84% of all complaints (4567) of DV recorded across the country and also most cases of DV in the country 3983, last year too. The protection of women from DV act was enacted by the union government in 2005 to protect women from violence at home. A trauma framework fosters awareness among health care providers to effectively help the victims through administrative, consultative, and peer support. Aims and Objectives of the Study: (1) To administer a questionnaire based interview among health providers regarding their knowledge and management of DV. (2) To identify lacunae in the present level of beliefs, attitudes, and practice. Materials and Methods: This is a cross-sectional study, questionnaire-based interview conducted in Christian Fellowship Hospital, Oddanchatram, a rural secondary hospital in Tamil Nadu with 300 inpatient and 1500 outpatient each day, done on 100 doctors, 150 nurses between 9th January and 15th January. The questionnaire responses were coded, and the frequencies were tabulated. SPSS software was used to analyze the data. Results and Discussion: 71% of the respondents realized that DV is common or very common. 73% reported they ask about DV. 71% had ever identified a victim of abuse. 78% would ask for DV in patients presenting with injury or depression or anxiety. However almost half (46%) declared that they were not comfortable in enquiring about DV. 65% felt they were not very confident in asking. More than 90% felt they were not able to manage a patient with DV appropriately. This implies that the respondents realize it is a significant health issue not to be missed. This is in contrast to other studies in Malaysia and Seattle where the respondents felt that DV was either very rare or rare. These issues identify specific areas where health care personnel need further exposure, training, equipping, and support systems. In the US, in 1989, they developed a protocol to detect abuse victims among injured women reporting to the emergency department. This improved their identification from 5% to 30%. In a busy outpatient clinic, identification of abuse victims may be missed due to the speed and the crowd. Training nursing staff to screen for DV among the attendees is another suggestion made by Sugg et al., in 1999. Even the emotional and sexual violence history may be sometimes disclosed by the victim. These victims need help, discussion, and counseling as a family who can support them through this time of emotional trauma. In repeated or the first episode of significant episodes of DV, in a region where the majority of the population is daily wage workers, having limited education and affordability are to be supported by legal services. The respondents pointed out that the institution needed to develop a protocol on how to approach an abuse victim and need for a social worker and the lack of training in this matter. Conclusion: There is an urgent need to train the health care personnel on the identification and management of victims of DV. A written protocol and defined support system in place would make things easier for the victim and the health care personnel.

Keywords: Domestic violence

 Awareness, knowledge, and control of hypertension among subjects attending specialty hypertension clinic

Santosh Salagre1, Shobha Itolikar1, Sneha Nandy1

1Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India

Introduction: Effective steps toward prevention and management of hypertension are the need of the hour because of the potential impact on the mortality and morbidity associated with cardiovascular disease and stroke. Patient knowledge and awareness regarding hypertension and its complications is an important contributor toward achieving this goal. Objective: We aim to describe among hypertensive subjects (1) the awareness, understanding, and control of blood pressure (BP) and (2) the factors influencing the same. Methodology: After ethical considerations, this 6 month long prospective questionnaire- based study was performed on 314 essential hypertensive subjects who were randomly selected from our specialty hypertension clinic. Hypertension was defined as per guidelines of JNC 7. Data were analyzed using the Chi-square test, Fisher exact test and multivariate analysis. Results: Out of 314 subjects consisting of almost equal number of males and females, 271 subjects (86.31%) had been informed of their hypertensive status by their healthcare provider. One-third of the study population (111, 35.35%) was not aware of Ideal BP levels and one-fifth (66, 21.02%) were not aware of their own current BP levels. Goal BP was found to have been achieved in around 85% of patients. It was achieved more easily in the middle aged (P = 0.05) and the literate (P = 0.03). Nearly two-fifth of the patients (132; 42.04 %) denied having knowledge of the long-term nature of their disease and its therapy. Similar number of subjects (139, 44.27%) was unaware that uncontrolled hypertension leads to end-organ damage. 50 (16%) subjects were not compliant with the routine 3 monthly check up. Compliance with check-up was found to be significantly higher in females (143, 89.94%) than in males (121, 78.06 %) (P = 0.004). 276 subjects (87.8%) were compliant with treatment. 78% of the subjects were not aware of the non-drug treatment of hypertension such as Dietary Approaches to Stop Hypertension diet and relaxation therapy. Conclusion: It is important to understand the patient factors to develop effective strategies and intervention to meet the ultimate goal of improving health by controlling hypertension.

Keywords: Awareness, hypertension, knowledge

 How can Rainbow programme contribute to the development of family medicine in India?

Sahadev Swain1

1Blenheim Medical Centre, Luton, LU3 1HA, UK

E-mail: [email protected]

Outline: This seminar will be at least an hour long program for the conference delegates. Aim: (1) The aim of the session is to bring together family physicians of Indian origin to this forum. (2) Using the experience of various speakers and the interactive audience to formulate strategies about how can the program contribute to the development of family medicine in India. Objectives: (1) By the end of the seminar they will be able to understand. (a) What is Rainbow program? (b) What are its main objectives? (c) How is the program going to deliver what is promises to? (2) Be able to give examples of possible collaborative programs in the family and discuss factors that influence uptake of these programs. (3) Be able to describe how the Rainbow program can be developed further care team is organized to provide high-quality education and training in family medicine. Concluding Remark: The session aims to provide a platform for a lively and interactive discussion with contribution from national and international faculties.

Keywords: Family physician

 Correlation study among platelet count, leukocyte count, complications, and duration of hospital stay in dengue fever with thrombocytopenia

Hari Kishan Jayanthi1, Sai Krishna Tulasi1

1Department of Family Medicine, Kamineni Hospitals, Hyderabad, Telangana, India

E-mail: [email protected]

Dengue is one of the common diseases presenting as fever with thrombocytopenia, also causing significant morbidity and complications. Though the correlation among platelet count, bleeding manifestations, and hemorrhagic complications has been extensively studied, less is known about the correlation between platelet count and nonhemorrhagic complications. This study was done to see the correlation between platelet count and nonhemorrhagic complications, and duration of hospital stay and additive effect of leukopenia with thrombocytopenia on complications. Our study is a prospective observational study done on 99 patients who had dengue fever with thrombocytopenia. Transaminitis (12.12%) was the most common complication followed by acute renal injury (2%). In this study, we found that as the platelet count decreased, the complication rate increased (P = 0.0006), and the duration of hospital stay increased (P = 0.00597). There was no correlation between thrombocytopenia with leukopenia and complications (P = 0.292). Platelet count can be used to predict the complication and duration of hospital stay and hence better use of resources.

Keywords: Complication, correlation, dengue, leukopenia, platelet count

 General practitioners role in the management of subfertility - A friend in need

Adrija Rahman1

1Department of Family Medicine, Apollo Clinic, Salt Lake, Kolkata, West Bengal, India

E-mail: [email protected]

Background: About 10–15% couples of reproductive age group experience difficulties in conceiving. The role of the general practitioners (GPs) to deal with this problem is immense. They should have not only the knowledge to deal with the initial presentation but also equip themselves to address the emotional aspect of the condition. In addition to timely referral to appropriate fertility specialist, GPs must provide adequate information and support also guide them through the different management facilities. Aim: The aim of the presentation is to empower the GPs to understand the process of subfertility and undertake a more comprehensive workup prior to referral, such as history taking, physical examination, and initial investigation, provide information for ongoing support throughout the treatment and manage psychological aspect of the condition. Methodology: Interactive lecture through case discussions and quizzes. Conclusion: After the session, GPs will be able to understand and handle the problem of infertility in a holistic manner, including consulting both partners, initiating appropriate investigations, providing ongoing care, and support throughout the management, along with timely referral to specialized fertility centers.

Keywords: Assisted reproduction, infertility, semen analysis

 Transforming family medicine through physician leadership

Vishal Marwah

VISHWAS, Mumbai, Maharashtra, India

E-mail: [email protected]

VISHWAS is a social enterprise founded in 2012 that seeks to transform the role of family physicians in communities through its Physician Leadership Program. Over the past 3 years, VISHWAS has designed and tested several innovative practices in family medicine namely an android app for doctors, chronic care programs, proactive community outreach strategies, and interactive health education materials. These tools, resources, and technological know-how are now being shared with established family physicians in Mumbai so as to enable them to transform their practice. The pilot project that was launched in July 2015 has a participation of 20 doctors. The key objectives of the program are to: (1) Train physicians in skills/topics such as counseling, health promotion, health policy, behavioral medicine, health psychology, eco-sustainability, and leadership. (2) Incorporate a novel health care delivery model based on health promotion and disease prevention, in addition to disease management. (3) Provide a platform for family physicians to roll-out community-based participatory projects, and create effective and sustainable collaborations with the civil society to provide the quality healthcare services to the population. (4) Design an innovative health IT platform which will allow for epidemiological monitoring, context specific and culture-sensitive program formulation, geographic information system mapping, and public health advocacy. (5) Ensure that the services provided are constantly upgraded through evidence-based practice driven by research; the physicians are trained in appropriate research tools. (6) Realign the aspirations of young medical graduates toward family medicine (which is becoming increasingly less popular) by enhancing the value creation of a family physician adding the glamor component to this field. The outcomes of the Physician Leadership Program and success stories of participating family physicians will be shared through this talk.

Keywords: Innovations in primary care, physician leadership, practice management

 The art of being a different doctor

Roshni Jhan Ganguly1, Srividhya Raghavendran1

Nationwide Primary Health Care Services

E-mail: [email protected]

The consultation is the basic tool of general practice. It has evolved over the years with essentially two components being of utmost importance – good knowledge and effective communication skills. Over the years, consultations have been studied by different people and different models have been defined. The aims of the consultation were outlined, and the reason for attendance emerged to be one of the very important factors. In our day to day practice, we notice that there are three parts in which the final diagnosis can be divided – physical, psychological, and social. Looking beyond the physical diagnosis by deciphering the ideas, concerns and expectations makes the consultation a complete and successful one. This, is turn, increases patient and doctor satisfaction and decreases medicine prescription and referrals. In our presentation, we would like to portray different case scenarios with the expression of ICE elements and its positive outcome in the management.

Keywords: Concerns, expectations, ideas

 Diplopia a possible adverse effect of beta-blockers

Anupama Nagaraja1

1Sakra World Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Beta-blockers are the class of oral drugs used for management of many cardiovascular conditions, mainly hypertension, postmyocardial infarction, and arrhythmias. They act by blocking the action of endogenous catecholamines namely epinephrine and norepinephrine. There are various adverse effects caused by this class of drugs, of which a possible rare side effect reported has been diplopia. Here is a study of one such case where beta- blocker withdrawal was associated with correction of diplopia.

Keywords: Beta-blockers, bisoprolol, diplopia

 Health-care utilization among postnatal women in an urban slum in Bhubaneswar

Amrita Kumari1, Ipsa Mohapatra1, O.P. Panigrahi1

1Kalinga Institute of Medical Science, Bhubaneswar,

Odisha, India

E-mail: [email protected]

Background: Neonatal mortality is higher in developing countries as compared to developed countries. India contributes to 16% of global maternal death and 21% of under-5 deaths. When it comes to newborn mortality, the proportion increases to 29/1000 live birth. In addition to the number of deaths each year, over 0.76 million newborns suffer from preventable causes. Odisha is one of the states in India accounting for high maternal and newborn mortality. Despite the maternal and child health national health programs, maternal mortality and morbidity continue to be high, which could be related to several factors; an important one being nonutilization or underutilization of maternal health-care services, especially among the rural poor and urban slum population due to either lack of awareness or access to healthcare services. Objectives: (a) To study the health-seeking patterns of women for antenatal care during pregnancy and (b) to study the utilization of delivery services by women and the utilization of child healthcare during the 1st month of life of newborn. Materials and Methods: Study design – a cross-sectional study. Study area - urban slums covered under field practice areas of UHTC, Department of Community Medicine, KIMS, Bhubaneswar. A total of 5 slums having a population of 13,674 were covered from July 2014 to September 2014. Study participants - all postnatal women delivered within last 1 year and giving consent. Methodology: A house to house visit was carried out in these slums to find out the women. These postpartum women were interviewed by the investigating team using a predesigned and pretested questionnaire. Statistical Analysis: Data entered in Microsoft Excel and analyzed using EpiInfo. Result: A total of 259 mothers with infants were identified; however, 37 (14.28%) refused to participate and 29 (11.20%) who provided partial answers were excluded and 193 taken for final analysis. The majority 75.13% were in the age group of 20–29 years; only 2.07% of them were <19 years. About 84.97% belonged to upper-middle and middle (lower-middle) socioeconomic class. Almost 96.89% were Hindus. Of 193, 187 (97%) were those who received ANC check-up, and 6 (3%) were those who did not receive any ANC check-up. Sixty percent preferred private hospital for delivery. Only a few 15 (7%) went for home delivery. Around two-third of women had their postnatal check-up (PNC) done. In PNC, 94.83% newborns are immunized for age, 86.52% are on exclusive breast feeding; and out of 193, 182 (94.30%) have knowledge about contraceptives. Conclusion: The present study hereby concludes that there is a need for further. The majority of the mothers ignored postnatal care due to lack of awareness and knowledge about contraceptive.

Keywords: Antenatal coverage, health seeking behavior, health services, postnatal care, utilization of health services

 Management of abnormal uterine bleeding

Sahadev Swain1

1Blenheim Medical Centre, Luton, UK

E-mail: [email protected]

Abnormal uterine bleeding is a common women's health problem. It is estimated that one in 20 women in the UK aged between 30 and 49 years consults her GP each year with menorrhagia.[1] Menstrual disorders account for about 20% of all referrals to specialist gynecology services.[2] Guidelines exist for the appropriate management of menorrhagia.[3] Effective medical treatments exist and have a rational basis for their use. Increased use of effective treatments will improve patient choice and provide an alternative to surgery such as endometrial ablation and hysterectomy. The medical treatment options include tranexamic acid, nonsteroidal, anti-inflammatory drugs, combined oral contraceptives, and cyclical (21 days) progestogens. This presentation will draw reference to the author's audit of personal experience at an inner-city practice. He aims to present a case based interactive session at the workshop mainly aimed at Family Physician Residents. The discussion will be in the style of 15 min consultation style in the family physicians office exploring history, examination, investigations, and management from primary care view point. The author believes appropriate management in right time, in right environment by right health care professionals enhances patient choice, cost-effectiveness, and may increase patient satisfaction.

 Ethics in medical curriculum - junior doctors' and medical students' outlook and exposure: A cross- sectional study from Kerala

Muhammed Shaffi1,2, Kasi Visweswaran1,3

1State Research Cell, Indian Medical Association, 2Global Institute of Public Health, 3Ananthapuri Hospitals and Research Institute, Trivandrum, Kerala, India

E-mail: [email protected]

Introduction: Ethics in medical practice is increasingly being debated with very high levels of corporatization of health care as well as privatization of medical education in the country. Proper sensitization and training during undergraduate days is essential to inculcate better ethical practices among doctors. Aims/Objectives: To assess the extent of the exposure of undergraduate students and junior doctors to medical ethics during training and their attitude toward ethical medical practice. Materials and Methods: A cross-sectional study was conducted by the Research Cell of Indian Medical Association, Kerala state branch during January to June 2015 between junior doctors and medical students. Self-administered questionnaires were returned from 587 participants out of 650 (90%). The mean age was 24.05 ± 2.15 years with 58% of them females. 64% were graduates from Government Medical Colleges within Kerala, 31% from private colleges within Kerala while rest graduated from other states or other countries. Results/Discussion: Almost 70% respondents were exposed to <5 h of their entire medical education to medical ethics. Only 22% have gone through the “Professional Conduct, Etiquette and Ethics Regulations, 2002” prescribed by Medical Council of India. Only 40% told that they have being taught how to give evidence in a court of law while 46% recollect having exposed to handle ethical issues related to withdrawing and withholding of medical care. 88.4% did not find it wrong to accept pharmaceutical firms' support in attending conferences while 52% said they would accept commissions from labs and scan centers. Males were found to be more inclined to accept lab/scan commissions/gratifications in any form compared to females (odds ratio 1.2, P < 0.05). There were no other significant differences observed between sex groups or among college locations in any behavior/exposure factors related to ethics training. All the findings were similar across the three groups: Final MBBS students, house surgeons, and junior doctors. Conclusion: It is alarming to note that junior doctors and medical students are very less exposed to ethical dimensions of medical practice and that a large proportion of them do not find any problem in accepting gratification. There should be a revamp of medical curriculum urgently incorporating lectures, case studies/interactive sessions/debates, and introduction of rules and regulations of the governments and agencies in the syllabus.

Keywords: Curriculum, Medical Council of India, medical education, medical ethics

 Motion se hi emotion

Adrija Rahman1, Sumana Goswami1, Subha Chakraborty1, Sumana Datta1

1AFPI, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: Diarrhea is one of the most common presentations in family practice and primary care. A presenting complaint of diarrhea opens doors for a wide variety of diagnoses. Family physicians are expected to provide comprehensive and continuous care for patients over their entire lifetime. Aims and Objectives: At the end of the session, it is expected that participants will: (1) Understand diarrhea as a presenting complaint with multiple possible etiologies and not just a symptom. (2) Be able to conduce a clear, comprehensive, and complete clinical history and examination to be able to reach a diagnosis. Materials and Methods: We aim to present learning for the condition in a nondidactic fashion interactive and audio-visual manner to enable participants to understand the disease with the entire milieu it presents with. The session starts with multiple role-plays of doctor-patient interaction followed by the additional presentation of case scenarios and discussion.

Keywords: Diarrhea, family medicine

 Human papillomavirus infection in clinical practice

Anjali Agrawal1

1Family Planning and Sexual Health Clinic,

Hertfordshire, UK

E-mail: [email protected]

Being trained as a gynecologist in India and the UK and now working as an Associate Specialist in a Community Sexual Health Clinic in the UK, I have managed many cases of cervical cancer and genital warts. Low risk human papillomavirus (HPV) is responsible for genital warts, whereas high risk HPV is responsible for most of the genital cancers in men and women. I worked for 7 years in O and G Department in Banaras and Puducherry. While working in South and North India, I realized that cervical cancer is one of the most common female genital cancers, irony is its preventable as infectious in origin.

With the advent of quadrivalent vaccines and the availability of HPV testing in clinical practice, could it be possible to eradicate genital warts and HPV-related genital cancer 1 day? I would encourage postgrad doctors to realize their role in preventing this cancer in an interactive session.

Keywords: Human papillomavirus infection

 Second National Conference in Family Medicine and Primary Care 2015

David Weller1, L. Grant1, R. Ramsay1, J. Velavin1, V. Shah1, S. Balajis1, R. Dass1

1Centre for Population Health Sciences, University of Edinburgh, Doorway 1, Medical Quad, Teviot Place, Edinburgh, EH8 9AG, UK

E-mail: [email protected]

Aim: An international distance learning Masters Programme for Family Medicine – lessons learned and future directions. Introduction: It is widely accepted that family medicine development and training for low resource countries has the potential to significantly improve health outcomes. Family medicine is gaining in recognition as a discipline in its own right in developing countries and the breadth of training opportunities is increasing. We report on a unique partnership between Christian Medical College, Vellore, ICMDA and the University of Edinburgh which has led to a Masters of Family Medicine Programme, available to medical graduates around the world. It is based on distance learning supplemented by contact skill-building sessions based in various regions of the world. Aims and Objectives: Our program aims to equip students with a broad range of skills necessary to become family doctors. It covers essential principles of family medicine including continuity of care, holistic approaches and evidence-based practice – with a particular focus on management of chronic diseases. Materials and Methods: In developing the program we conducted an extensive information gathering exercise identifying learning needs for family medicine in India, and preferred modes of teaching delivery. The program has now been running for over 12 months and we have had our second intake of applicants. Results and Discussion: A profile of the course and its' developmental process will be presented along with characteristics of current students and their feedback. The program has been successful to date and is examining strategies for growth and extending its influence. Conclusion: Masters- based family medicine training is one approach to the critical need for more family medicine training in developing countries. Challenges include addressing financial and other barriers and making access as widely available as possible. We are examining how our masters program might best fit in to the current broad and complex training environment of family medicine in India and other countries.

Keywords: Family medicine, masters degree, training

 Evidence-based tools for clinical decision support in primary care

Oommen John1,2

1The George Institute for Global Health, 2Shalom Healthcare, New Delhi, India

E-mail: [email protected]

Introduction: India faces a huge healthcare crisis, the recently published “Rural Health Statistics Report 2015,” highlights an alarming overall decline in the number of trained medical staff and specialists; vacancies of up to 80% in village services indicate that India is still far from achieving its rural health goals. Currently, the primary healthcare delivery system in India is predominantly designed to address maternal and child health services, with the growing burden of non-communicable diseases, the primary care physician, particularly in the public healthcare delivery system needs to be supported with upskilling and provision of clinical decision support tools that will enable to delivered high quality evidence- based interventions in India's quest to achieve universal health coverage. Objectives: We aim to provide a conceptual model for healthcare delivery that creates shared value for all stakeholders, one which is built on a strong primary care centric approach and enabled through the appropriate use of information systems and clinical decision support tools at the point of care. Discussion: Healthcare delivery in India has relied on the use high-tech, specialist-delivered, hospital- based medical care, with little regard for primary healthcare or evidence-based practices and this has worsened the huge health inequities and increased the costs of healthcare.[1] With the compelling disparities in the availability of trained healthcare professionals to deliver high quality evidence based care and the growing dual epidemics of infectious diseases and noncommunicable diseases, the is an urgent need to look at innovative models centered around primary care that can be scaled to achieve maximal impact.


Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L; Lancet India Group for Universal Healthcare. Towards achievement of universal health care in India by 2020: a call to action. Lancet 2011;377:760-8.

 Study on the short-term effects of using continuous subcutaneous insulin infusion using insulin pump in Type 2 diabetes mellitus admitted with uncontrolled hyperglycemia

Raj Mohan1, Fathima Abdul Khader2

Departments of 1Endocrinology and 2Family Medicine, Kerala Institute of Medical Sciences Hospital, Thiruvananthapuram, Kerala, India

E-mail: [email protected]

Background: A series of studies has shown that poor glycemic control is associated with poor hospital outcomes while tight control is associated with decreased infection rates and improved survival. Objective: We have investigated the short-term effects of continuous subcutaneous insulin infusion (CSII) using insulin pump in hospitalized patients with Type 2 diabetes mellitus. Methods: Fourteen patients admitted to the Kerala Institute of Medical Sciences Hospital for various surgical conditions and whose blood sugar levels were difficult to control with standard multiple daily injections were included. The recommended initial total daily insulin dose was 0.5 U/kg of body weight, with 50% distributed throughout the day as one hourly basal rate and the remaining 50% distributed among daily meals. Seven point sugar readings were done, and correction dose insulin was given if random blood sugar was >180 mg%. The primary outcome was glycemic control. The secondary outcome was the incidence of hypoglycemia during the pump therapy. Result: The main findings of this pilot study were that a short-term use of CSII can markedly improve the glycemic control. It was observed that mean blood glucose decreased from 314 to 157.5, a drop of 50% from the baseline sugar readings. No patient suffered from any hypoglycemic episode during insulin pump therapy. Many patients noted improvement in the peripheral neuropathic pain associated with diabetes. Total daily insulin dose requirements were also reduced with the CSII therapy initiation. Conclusion: This study of insulin pump use in the inpatient setting showed that insulin pump therapy provides a sustained improvement in glycemic control, reductions of severe hypoglycemia, and improved quality of life for Type 2 diabetic patients.

Keywords: Continuous subcutaneous insulin infusion

 Tale of 3 ventricular septal defects

John Jacob1

1Christian Fellowship Hospital, Dindigul, Tamil Nadu, India

E-mail: [email protected]

Background: Ventricular septal defect (VSD) with Eisenmenger's syndrome is not a common entity. Here, 3 cases are discussed wherein the diagnosis was not initially apparent. In this era of investigations, I would like to reiterate the importance of a thorough clinical examination. Case 1: 32-year-old Mr. S had shortness of breath on exertion. He was thin built, had grade III clubbing and cyanosis. There was no cardiac murmur.

Echocardiogram did not report any structural anomalies. The patient was taken again to the consultant doing the echocardiogram. The suspicion was reiterated. This time, the VSD with bidirectional shunt was confirmed. Case 2: Ms. P had been diagnosed to have primary pulmonary artery hypertension at about 5–10 years. Now, at 30, she had dyspnea on exertion, central cyanosis and grade III clubbing. One echo done recently also confirmed the same diagnosis. On requesting a repeat evaluation to look for the right to left shunt, VSD with bidirectional shunt was diagnosed. Discussion: As family physicians, we get to see patients in early, undifferentiated stages of a disease. In this present era of advanced investigations, litigation, diminishing clinical skills, it is pertinent to evaluate patients clinically and have a clinical diagnosis. Investigations can be wrong at times. It will be prudent to look at results and the patient as a whole not to treat the results alone.

Keywords: Clinical diagnosis, echocardiogram, ventricular septal defect

 Evaluation of new onset seizures with special reference to their type, etiology, and imaging study

Vimlesh Mishra, G. C. Singhal, Sunil P. Massand, Prerna Bahety

Department of Medicine and Family Medicine, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India

E-mail: [email protected]

Context: To evaluate the etiology of new onset seizure so as to determine the use of prophylactic anti-seizure medication and thereby prevent the side effects. Aims: (1) To identify the etiology of new onset seizures in adults. (2) To study the clinical profile and neuroimaging results in patients with new onset seizure. Settings and Design: An observation census study was conducted in Maharaja Agrasen Hospital, New Delhi. Materials and Methods: Eighty-eight patients >18 years of age with new onset seizure occurring within 24 h of admission were included in the study according to the criteria, and the results were obtained over a period of 1 year. History, clinical examination, and lab and neuroimaging studies were undertaken. Statistical Analysis Used: Data were tabulated using MS Excel and were analyzed using SPSS version 16 software. Results: Etiology remained cryptogenic in 25%, followed by metabolic in 25%, CVA in 22.7%, neuroinfection in 18.2%, gliosis in 3.4%, tumor in 2.3%, and HIE, drug-induced and alcohol withdrawal in 1.1% patients, respectively. Neuroinfection and cryptogeny were leading cause of seizures in younger age group while metabolic disorders and CVA leading cause of seizures in older population. In addition, metabolic disorder and CVA were predominating in males while cryptogeny and metabolic disorder predominating in females. Electroencephalogram was abnormal in 50% of patients. Computed tomography head detected potential epileptogenic lesion in 42.8% of patients while magnetic resonance imaging brain detected in 46.6% of patients. Conclusions: Etiology of seizure varied with age and sex, and various imaging studies and investigations play a significant role in identifying the cause.

Keywords: Anti-seizure medication, neuroimaging, seizure

 Noninvasive cardiac testing for CAD in primary care: When to perform and which one to pick?

Ramakrishna Prasad, Vijayaraghavan Ramaiah, Jaya Bajaj

1Department of Family Medicine, University of Pittsburgh, Pittsburgh, PA, USA, Departments of 2Nuclear Medicine and 3Family Medicine, Narayana Hrudayalaya, Bengaluru, Karnataka, India

E-mail: [email protected]

Coronary artery disease (CAD) presents a major burden for the healthcare system in India. Family physicians (FPs) are uniquely positioned to detect, risk stratify, and treat patients with CAD at an early stage thereby alleviating symptoms, improving the quality of life and preventing irreversible heart damage. Noninvasive cardiac testing including modalities such as exercise and pharmacological stress testing, myocardial perfusion imaging, computerized tomography (CT) coronary angiography, and coronary artery calcification scoring using CT represent useful tools to risk stratify patients suspected to have CAD. However, a recent study examining a large cohort of Indian patients with stable angina revealed that despite indications, diagnostic testing was underutilized. In addition, invasive testing is overutilized in low-risk situations. Limited understanding of the indications, accuracy, appropriate utilization criteria, and cost to benefit ratios of noninvasive cardiac testing modalities could explain these findings. We propose an interactive, case-based workshop on the evaluation, and management of CAD by FPs. The workshop objectives are: (1) To outline the role of noninvasive cardiac testing in the evaluation of CAD; (2) To discuss comparative effectiveness of competing modalities (both invasive and noninvasive); and (3) To enable evidence-based selection of appropriate evaluation modality in different clinical scenarios. The planned length of the session 60 min. This workshop was developed as a result of collaboration between two FPs (RP and JB) and a nuclear medicine physician (VR). The collaborative process included clarifying objectives, framing key clinical questions of relevance to FPs, reviewing the literature, and determining the optimal format for delivering the workshop. The workshop will be evaluated by using Likert-scale questions to measure participants' assessment of relevance, effectiveness, knowledge content gained, and the likelihood of changing practice. In addition, open-ended requests for feedback on how the session could have been improved will be included.

Keywords: Coronary artery disease in primary care, educational workshop, noninvasive cardiac testing, risk stratification of coronary artery disease

 Design Thinking Workshop: A Creative Approach to Solving Common Problems in Family Medicine

Vishal Marwah1, Devashish Saini2

1Viswas Clinic, 2Ross Clinic, Mumbai, Maharashtra, India

E-mail: [email protected]

Design thinking is a well-established and widely acclaimed method to solve complex and systemic problems. It uses left and right- brained thinking, and an approach rooted in anthropology, human- centric design, and systems thinking to solve difficult problems. It has been employed by several healthcare organizations such as Mayo Clinic, Cleveland clinic, and Kaiser Permanente to transform the doctor and patient experience in their establishments. In this 90 min interactive workshop, participants will get hands-on experience with design thinking and will employ creative methods to solve some common yet complex problems encountered in family medicine. The format of workshop - 30 to 50 participants divided into smaller teams of 5 to 8 each. First 15 min - problem identification and problem validation (examples of problems - how to ensure patient compliance for chronic care programs, how to acquire and retain your patients, reducing healthcare expenditure, etc.) 15 to 30 min - creative brainstorming for solutions 30 to 45 min - solution validation and filtering of ideas 45 to 60 min - conceptualization solutions and rapid prototyping 60 to 90 min - presentation of solutions by the respective teams. The objective of the workshop is to provide the participants with hands-on experience with problem identification, and creative approach toward solving those problems. This is a valuable skill that they could apply in their daily practice.

Keywords: Brainstorming, creativity, design thinking, idea generation, problem-solving

 Docpreneurs: Leaders from off the Beaten Track

Devashish Saini1, Vishal Marwah2

1Ross Clinic, Gorgoan, 2Viswas Clinic, Mumbai, Maharashtra, India

E-mail: [email protected]

Indian healthcare startup arena is getting hotter every day. Indian healthcare startups have so far raised venture capital to the tune of $108 million. These startups are innovating to change each and every aspect of the Indian health system helping in the long- overdue systemic overhaul. Despite the independence, innovation and creativity that is the hallmark of startups, doctors traditionally opt for what they consider financially safer options. This panel discussion will have doctors as speakers who have chosen to tread the road less traveled. They have established businesses that have set standards for innovation, won awards, and changed the Indian healthcare scenario in a tangible way. After an introduction to the panel by the moderator for 5 min, the 4 invited speakers will share their stories for 15 min each. After that, the floor will be opened for questions from the audience. This question and answer session will last for 30 min. The panel discussion aims at fostering innovation among doctors and inspiring them to consider entrepreneurship as a career option.

This session is being supported by

Keywords: Electronic medical records, entrepreneurship, innovation, medical equipment, startup

 From Setup to Sustainability to Profitability: How to Accelerate the growth of a Family Practice Clinic

Devashish Saini1, Vishal Marwah2

1Ross Clinic Gorgoan, 2Viswas Clinic, Mumbai, Maharashtra, India

E-mail: [email protected]

Financial viability and risk of opening one's practice is a major concern for a new family medicine graduates as well as trainees. A large majority of family medicine trained doctors choose to practice in hospitals assuming that to be the financially safer option. This panel discussion will have speakers from established family practices who have a very short time, established their practice, and taken it from setup to financial sustainability and from financial sustainability to profitability without compromising on ethical or quality standards. The four invited speakers have widely taken different routes during their journeys. They range from diabetic treatment plans, home visits, travel vaccinations, and even academic. All speakers provide multiple services in their clinics, have built a team that as a whole delivers quality care, and provide preventive health services as well. After an introduction to the panel by the moderator for 5 min, the 4 invited speakers will share their stories for 15 min each. After that, the floor will be opened for questions from the audience. This question and answer session will last for 30 min.

This session is being supported by

Keywords: Family practice, growth, sustainability

 Patient Centred Innovation: A Collaborative Workshop Drawing on the Primary Care Innovator's Handbook

Devashish Saini1

1Ross Clinic, Gurgoan, Haryana, India

E-mail: [email protected]

Primary care clinics need to innovate constantly to be responsive to the changing needs of the communities, we serve. Five primary care organizations from India to East Africa worked together for 1 year learning about each other's innovations with support from the center for health market innovations. Our learnings were distilled in the form of the primary care innovator's handbook. This workshop will begin with an introduction to the year-long primary care learning collaborative, and touch on the learnings of the handbook which is organized into 10 chapters. The audience will then participate in speed-dating. Each member of the audience will spend 10 min talking to others in the audience about one of the 10 topics of the handbook, sharing their challenges in that area and sharing tools, and learnings and best practices relevant to that area. At the end of 10 min, they will be asked to pair up with other members of the audience to discuss a different topic out of the 10 topics. There will be 5 such pair-ups of 10 min each. The audience members will then be asked to note down on sticky notes, the new idea(s) which they would like to go back and try out in their clinic or organization. They will be asked to put up the sticky notes on the wall, under the relevant section(s) out of the ten topics. The combined learnings from the sticky notes will be shared with the group as a whole after the session. This speed-dating format has been tested earlier at the Unite for Sight conference at Yale earlier in 2015 and generated interest among participants and a number of successful connections. This session is being supported by the Center for Health Market Innovations, Washington D.C., USA.

Keywords: Collaboration, innovation, patient centered care, peer learning, speed-dating

 Rhinocerebral mucormycosis

Bajrang Gupta1

1Practicing Physician, Delhi, India

E-mail: [email protected]

Rhinocerebral mucormycosis (RCM) is a rapidly progressing infection seen frequently in patients with malnutrition, uncontrolled diabetes, or in patients with immunocompromised status like hematological malignancies or who are on immunosuppressive or cytotoxic therapy.[1] The disease manifests initially as sinusitis and is therefore diagnosed in an advanced stage.[2] We hereby report a rare case of RCM with candidiasis in a 40-year-old female from an urban background who presented with the complaints of unilateral facial pain, orbital swelling, headache, and right-sided nasal blockage with deviation of mouth toward left side [Figure 1]. The biopsy report of the affected lesion revealed mucormycosis with fungal hyphae. This report is to emphasize that in patients who present with unilateral headache, rhinorrhea, rigors, and symptoms suggestive of sinusitis, RCM should be foremost in the differential diagnosis, especially if diabetes exists as a comorbid condition.

Keywords: Mucorales, mucormycosis, rhinocerebral mucormycosis

 Using technology to tackle thyroid

Shiv Kumar1, Joel Ehrenkranz1

1Swasti Health Resource Centre, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Although thyroid disease is not fatal, disorders of the thyroid are common and are responsible for a large burden of disease. For example, a newborn with untreated congenital hypothyroidism loses 0.5 intelligence quotient points a day. Thyroid disease is reported to affect more than 10% of adults in Indian cities. Thyroid disease can present as a cardiac arrhythmia, high cholesterol, short stature, depression, hair loss, or dementia.

It is essential that primary care providers are familiar with the diagnostic, treatment, and monitoring of thyroid disease in a primary care practice. Aims and Objectives: Swasti Health Resource Centre recognizes the importance of thyroid disease in public health and has an active program in the primary care of thyroid disease. The aims and objectives of this program are: (1) increasing thyroid disease awareness, (2) providing next generation newborn thyroid screening, (3) offering disease management decision support, and (4) developing a continuing medical education curriculum for primary care providers. Materials and Methods: Swasti has developed a number of tools to aid in the diagnosis and treatment of thyroid disease: (1) smartphone/tablet point-of-care thyroid-stimulating hormone(TSH) assay, (2) thyroid disease decision support app, (3) graphic information system database for thyroid disease, and (4) thyroid disease management app. Results and Discussion: The point-of care TSH assay's performance characteristics are equivalent to an instrument-based TSH assay performed in a reference laboratory. The point-of-care TSH assay has a turn-around time of minutes and not days and <240 indoor residual spraying including decision support and disease management. Conclusions: Swasti Health Resource Centre has developed a set of tools for the diagnosis and management of thyroid disease in primary care. The technology has been field-tested and is now ready for roll-out and general implementation.

Keywords: Development, newborn, technology, thyroid

 Early detection of skeletal fluorosis in patients with dental fluorosis: A study of 40 cases

Anil Kumar Chawla1, Prakash Rabadiya1

1J. Watumull Global Hospital and Research Centre, Sirohi, Rajasthan, India

E-mail: [email protected]

Introduction: Skeletal fluorosis is a crippling disease both orthopedically, as well as neurologically. Fluorosis is widely prevalent in all districts of Rajasthan where the ground water level of fluoride is often well above the recommended levels. It takes years of high fluoride water ingestion to lead to dental and skeletal fluorosis, of which the dental fluorosis comes earlier. Aims and Objectives: We premised that we can detect skeletal fluorosis early in otherwise asymptomatic patients of dental fluorosis, with the objective of preventing its progression to advanced disease by instituting appropriate preventive measures. Materials and Methods: We selected 40 patients of 20–50 years age group with moderate to severe dental fluorosis according to Dean's classification, presenting at the Global Hospital and Research Center, Mount Abu, Rajasthan, between August 2014 and August 2015. With their due informed consent X-rays of a forearm and lumbosacral spine (anterior-posterior/lateral) taken to detect skeletal fluorotic changes. Results: Out of 40 patients, 75% had moderate dental fluorosis, 25% had severe dental fluorosis, among them 13 patients (32.5%) had skeletal fluorosis with male preponderance (92.3%). X-ray of the forearm showed interosseous membrane ossification and of the lumbosacral spine showed sclerosed vertebrae in all of them. The prevalence was maximum in the 30–50 years age group. The drinking water source was hand pump in 60%, deep-well in 30%, and mixed in 10% cases. The prevalence of 41.6% was found in those drinking hand pump water. Black tea consumption was found in 32.5% of patients. Conclusion: Skeletal fluorosis was detected in 32.5% patients (otherwise asymptomatic) of moderate to severe dental fluorosis. Hand pump and deep-well were their drinking water sources. They were advised to change their drinking water source to municipal supplies or other defluoridated water source and to stop drinking black tea, which increases the absorption of fluoride from the gut.

Keywords: Dental fluorosis, fluoride, prevention, skeletal fluorosis{Figure 14}

 Workshop for primary care professionals on medico-legal care for survivors/victims of sexual violence

Pratyush Kumar1

1Department of Family Medicine, Sir Ganga Ram Hospital, New Delhi, India

E-mail: [email protected]

Description: This workshop is aimed at providing an appropriate understanding of sexual violence and the needs and rights of survivors/victims of sexual violence, and to highlight the medical and forensic responsibilities of health professionals. The World Health Organization (WHO) defines sexual violence as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments/advances and acts to traffic, or otherwise directed against a person's sexuality, using coercion, threats of harm, or physical force, by any person regardless of relationship to the victim in any setting, including but not limited to home and work” (WHO, 2003). Sexual violence is a significant cause of physical and psychological harm and suffering for women and children. Although sexual violence mostly affects women and girls, boys are also subject to child sexual abuse. To realize the rights to health care of survivors/victims, health professionals must be trained to respond appropriately to their needs in a sensitive and nondiscriminatory manner respectful of the privacy, dignity, and autonomy of each survivor. Health workers cannot refuse treatment or discriminate on the basis of gender, sexual orientation, disability, caste, religion, tribe, language, marital status, occupation, political belief, or other status. Refusal of medical care to survivors/victims of sexual violence and acid attack amounts to an offense under Section 166B of the Indian Penal Code read with Section 357C of the code of criminal procedure. Learning Objectives: Operationalize informed consent and respect autonomy of survivors in making decisions about the examination, treatment, and police intimation. Specific guidance on dealing with persons from marginalized groups such persons with disabilities; sex workers; lesbian, gay, bisexual, and transgender persons; children; and persons facing caste, class, or religion-based discrimination. Ensure the gender sensitivity and proper history taking. Evidence collection based on science and history. Standard treatment protocols for managing health consequences of sexual violence. Guidelines for provision of first-line psychological support. Format: The workshop will have four parts, starting with a survey to know about current knowledge regarding sexual violence then there will be a lecture-based on recent guidelines followed by an instructional presentation and finally an interactive discussion and feedback session.

Keywords: Medico-legal, primary care, sexual violence

 Etic and emic perspectives on home deliveries in Chandigarh, Northern India: An in-depth view

Soundappan Kathirvel1, Kathiresan Jeyashree1, Amarjeet Singh1

1Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India

E-mail: [email protected]

Introduction: Chandigarh, a union territory in Northern India, has all the facilities and incentives for institutional deliveries. However, apparently, the practice of home deliveries is still widely prevalent in the city. Beyond the narrow confines of the etic perspective, it is essential that we understand the emic perspective of the issue also for us to be able to deliver culturally appropriate health care services. Objectives: To explore the factors, which determine health care seeking behavior of general public for childbirth. Design: This is an in-depth study of a case of home delivery in Chandigarh. Settings: The study was conducted in village Burail, Chandigarh (UT) in India. It is also the field practice area under the school of public health, Department of Community Medicine, Post Graduate Institute of Medical Education and Research. Results: There are many factors which determine the choice of place of childbirth. These may be economic, sociocultural (traditions or norms), perceived need, environmental, and demographic reasons. The etic perspective sees no reason why people should opt for home deliveries when institutions are available, and the government incentivizes the people to deliver there. The emic views are influenced by more than financial issues that urge them to choose home delivery. Conclusion: The mismatch between the emic and etic views has to be analyzed in-depth. This will help us design policies and deliver services that are more culturally appropriate and accessible. It is time, we revisit our strategies to promote maternal and child health and question their rationale in an unbiased manner.

Keywords: Emic, etic, home delivery, in-depth interview

 An innovative splint for postoperative swan neck deformity

Deepak Anil Ganjiwale1, Jaishree Ganjiwale2

1K.M.P.I.P., Shree Krishna Hospital, HMPCMC and E, 2Department of Community Medicine, PSMC, Karamsad, Gujarat, India

E-mail: [email protected]

Introduction: Swan neck deformity would be the common problem of the finger. After a stroke, the deformity creates in the finger is rare. The current study is based on making an innovative splint for insuring the different angle of the postoperative swan neck finger. Objective: Aim and objective of the study is to increase the range of motion gradually with standard criteria of Kleinert's approach. Methodology: A 5-year-old child operated for swan neck deformity. Author made splint by using the aluminum plate and rubber band. Results: Significant correction in range of motion is in the finger by using such an innovative splint. Conclusion: The following splint is low cost, and it would be afforded by the poor patients. This splint may correct the finger deformity and also follow the Kleinert's approach.

Keywords: Deformity, splint, stroke

 Melioidosis: A case report

S. Arunima Dev1, Bindu Vijayakumar1, P. Muraleedharan Nampoothiri2

Departments of 1Family Medicine and 2ENT, Government Medical College, Kozhikode, Kerala, India

E-mail: [email protected]

Melioidosis is an infection caused by the facultative intracellular Gram-negative bacterium; Burkholderia pseudomallei. Clinical features of melioidosis are highly variable. They range from asymptomatic disease, localized skin ulcers or abscesses, pneumonia, and acute fulminant septicemia to chronic infection. Immunocompromised states such as diabetes, chronic renal failure.[1] Act as predisposing factors but immunocompetent hosts are also seen. The infection spreads by percutaneous inoculation, inhalation, or ingestion. Melioidosis is endemic in tropical regions of South-East Asia (Thailand, Malaysia, and Vietnam)[2] and Northern Australia.[3] In India, increasing cases have been reported in recent years, with most cases reported from Tamil Nadu and Kerala[4],[5],[6] including fatalities.[7] Timely diagnosis and prompt institution of correct antibiotics will prevent high morbidity and mortality. Here, we report a case of melioidosis, in an 8-year-old immunocompetent girl who presented with a bilateral parotid abscess to our hospital. On review of literature, only very few cases of bilateral parotid involvement have been reported so far.

Keywords: Burkholderia pseudomallei, melioidosis, parotid abscess


Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis: 540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 2010;4:e900.Raja NS, Ahmed MZ, Singh NN. Melioidosis: an emerging infectious disease. J Postgrad Med 2005;51:140-5.Currie BJ, Fisher DA, Howard DM, Burrow JN, Lo D, Selva- Nayagam S, et al. Endemic melioidosis in tropical northern Australia: a 10-year prospective study and review of the literature. Clin Infect Dis 2000;31:981-6.Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei from a case of septicaemia – a case report. Indian J Med Microbiol 2003;21:129-32.Jesudason MV, Anbarasu A, John TJ. Septicaemic melioidosis in a tertiary care hospital in south India. Indian J Med Res 2003;117:119-21.Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei: An emerging pathogen in India. Indian J Med Microbiol 1997;15:1-2.4.Chrispal A, Rajan SJ, Sathyendra S. The clinical profile and predictors of mortality in patients with melioidosis in South India. Trop Doct 2010;40:36-8.

 Family medicine and primary care in India

John Jacob1

1Christian Fellowship Hospital, Dindigul, Tamil Nadu, India

E-mail: [email protected]

Family medicine (FM) has become an established specialty in India. Acceptance among public and medical fraternity is improving. In this fluid scenario, it is time to define for ourselves, our areas of expertise, and specialization as relevant in India. European General Practice (GP)/FM began in 1974. They have defined and modified over time the definition and scope of FM as relevant to its practice in the different countries of the European Union. GP in Britain has established itself with the NHS. It began and continued to deliver ambulatory healthcare taking healthcare delivery to enviable levels. Its note on the state of GP in London has listed the lacunae in delivery of care and advocated the focus on primary care delivery through GP. Canadian family physicians are trained separately for urban and rural practice. The latter gets additional training in the management of operative obstetric care. Australian College of GP has documented the need to integrate primary health care in its practice of GP. The American Family Physicians have now given importance to primary care renaming their practices as primary care medical homes. Discussion: As in Europe, it is essential that we define FM in India. The way GP in Britain was established to cater to ambulatory care, how can FM address the healthcare needs in India? Canadian training in FM quantifies special skills for rural areas. We need to define FM training similarly. Countries with established FM and GP such as the USA and Australia have realized the need to integrate primary care into the practice of FM/GP Conclusion: FM is evolving in India. As we begin the journey, let us dream and define for India, how FM can deliver primary care.

Keywords: Family medicine, general practice, primary care

 Clinical, radiological, and laboratory profile of patients presenting with polyarthritis at a Tertiary Care Center in Kolkata

Smriti Modi1, S. K. Das1

1Department of Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: Polyarthritis is a common health complaint in India and a reason for frequent visits to the family physician, despite numerous over the counter treatment for joint pain and other musculoskeletal problems. Aims and Objectives: Our aim was to study the relationship between clinical, laboratory, and radiological profile of polyarthritis patients. Materials and Methods: 100 randomly selected patients in the age group 20–65 years, who visited the outpatient department of Apollo Gleneagles Hospital, Kolkata, with symptoms and signs of polyarthritis, were included in this cross-sectional study. A detailed history was taken and physical examination performed as per a fixed proforma. Relevant investigations were carried out to establish a clinical diagnosis. Categorical and continuous variables were expressed as number and percentage of patients and compared across the groups using Pearson's Chi-square test for independence of attributes. Results: Majority of patients were in 41–60 years age group. Female:male ratio was 1.8:1. 33% patients had leukocytosis while only 17% had thrombocytosis. The mean erythrocyte sedimentation rate was 47 mm/h. 83% patients had raised C-reactive protein levels but normal X-ray findings. 50% patients with rheumatoid arthritis (RA) had positive RAF whereas anti-cyclic citrullinated peptide was positive in 54%. Anti-nuclear antibodies (ANA) were positive in 94.4% and anti-dsDNA in 83.3% patients with systemic lupus erythematosus (SLE). Conclusions: Polyarthritis affects more commonly the economically productive age group with a female predominance. An x-ray is not a sensitive investigation for the diagnosis of polyarthritis. It may have prognostic value and may be helpful for monitoring treatment response. RAF and ANA are sensitive markers of RA and SLE, respectively; hence they are used as first-line investigations for polyarthritis and also for prognostication. Their specificity increases in conjunction with anti-CCP and anti-dsDNA respectively.

Keywords: Anti-cyclic citrullinated peptide, polyarthritis, rheumatoid arthritis, systemic lupus erythematosus