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   Table of Contents - Current issue
Coverpage
July 2021
Volume 10 | Issue 7
Page Nos. 2433-2727

Online since Friday, July 30, 2021

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EDITORIAL  

“Covishield and Covaxin” – India's contribution to global COVID-19 pandemic Highly accessed article p. 2433
Sunil Kumar Raina, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_174_21  
The coronavirus disease 2019 (COVID-19) pandemic continues to bring in its wake not only morbidity and mortality but also an unprecedented challenge to public health, food systems, human dignity, and work across the world. The availability and possible delivery of a safe and effective vaccine to populations across the world are not only being seen as a hope to surmount these challenges but also as a show of human resilience in the face of adversity. Nations need to galvanize their resources and make the availability of vaccines universal, without which the real benefits of its development cannot be realized. Despite its large domestic needs, our country is being looked upon with both hope and expectation to deliver at this crucial juncture in the evolution of human civilization, and India is more than willing to do its part.
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COMMENTARY Top

Repercussions of lockdown on primary health care in India during COVID 19 Highly accessed article p. 2436
Shaili Vyas, Neha Sharma, Archisman , Pritam Roy, Raman Kumar
DOI:10.4103/jfmpc.jfmpc_1991_20  
Primary health care is a comprehensive care with a wide range of essential services for people living in the rural and hard-to-reach areas. However, the primary healthcare delivery system in India is still in its initial stages and lacks human resources. With the COVID-19 pandemic around the corner, there has been a diversion of resources for controlling corona pandemic leading to undermining availability and accessibility of health services. This article highlights a few case scenarios and the multidimensional impact of lockdown on primary healthcare services. The article suggests certain appropriate measures that can be implemented as the lockdown simply cannot stop the transmission with no definite treatment and vaccine. There should be a multipronged strategy for breaking the chain of transmission and for future preparedness in case of such situations and to strengthen our primary healthcare system.
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REVIEW ARTICLES Top

Flashback and lessons learnt from history of pandemics before COVID-19 p. 2441
Shivay Parihar, Rimple Jeet Kaur, Surjit Singh
DOI:10.4103/jfmpc.jfmpc_2320_20  
With an increasing frequency of infectious disease outbreaks, the COVID-19 pandemic causing mortality around the world and the threat of similar future events looming large, mankind is faced with the herculean task of counteracting such threats with the best possible strategies and public health decisions. It is key that such decisions should be guided by previous examples of similar health emergencies. Here we review some of the significant infectious disease outbreaks, including epidemics and pandemics occurring worldwide in the past including their impact at population and global levels, unique challenges presented by each and the measures taken by authorities worldwide as well as the crucial lessons each epidemic or pandemic provided. This review highlights that throughout history measures such as contact tracing, quarantine and isolation have been incredibly effective in limiting an outbreak in its severity, thus ensuring accurate information flow to the public is as essential as limiting the spread of misinformation. With global populations rising, surveillance for emerging and re-emerging pathogens will play an immense role in preventing future epidemics or pandemics. And finally that even though for novel strains or pathogens, although vaccines are thought to be an irreplaceable defense, but their development and distribution in time to curb an epidemic has seldom been witnessed and remains an important challenge for the future. Hence, we conclude that looking at these past examples not only highlights the important knowledge gained for the strategies to devise, but also the mistakes that can be avoided in the way forward.
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Safe and appropriate use of diclofenac in chronic kidney disease: An Indian perspective p. 2450
Sharad Sheth, Sneha Thakur, Anup Thorat, Pankaj Gupta
DOI:10.4103/jfmpc.jfmpc_2358_20  
Pain is most common symptom associated with progressive disorder, chronic kidney disease (CKD), and is usually undertreated during the early stages of CKD. So, present review was conducted to evaluate the challenges for the management of pain in CKD patients and addresses the scope for considering Diclofenac as suitable alternative for pain management in CKD patient. The database PubMed and Google Scholar were searched from 1970 to Dec 2020 for literature published in English and all studies, review articles that examined the use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in pain management in CKD patients were included. Literatures revealed that there is a considerable challenge in appropriate management of pain in CKD patients include understanding the altered pharmacokinetics and pharmacodynamics of analgesics in CKD patients and the risk of acute interstitial nephritis. The shorter duration of analgesics is acceptable and considered to pose a low risk of acute interstitial nephritis in patients. Considering that Diclofenac has a shorter half-life and high efficacy, it may be well tolerated in patients with CKD. The acceptance of Diclofenac is partly attributed to being a potent COX-2 inhibitor with the lowest IC50 and its rapid onset of action at lowest effective dose. In conclusion, diclofenac may be well tolerated in patients of renal impairment when used at lowest effective dose for shortest dose duration. Diclofenac is worthy of consideration in mild to moderate cases of CKD. For effective pain management, it is vital to evaluate the tolerability and efficacy of the available analgesics critically.
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A comprehensive insight on the COVID-19 vaccine candidates p. 2457
Anu Sharma, Ravi Prakash Sharma, Rimplejeet Kaur, Ria Sharma, Surjit Singh
DOI:10.4103/jfmpc.jfmpc_1570_20  
The world is currently facing a pandemic triggered by the novel corona virus (SARS – CoV2), which causes a highly infectious infection that predominantly affects the lungs, resulting in a variety of clinical symptoms some cases may be asymptomatic while others may result in to severe respiratory disorder, if the infection is left unattended it may result in multi-organ failure and eventually death of the patient. The transmission of infection is by droplet and fomites of the infected person. The incubation period of virus is from 2 to 14 days. Most common symptoms resemble flu-like but later progress to pneumonia along with dyspnoea and worsening of oxygen saturation, thus requiring ventilator support. The diagnostic modalities include Reverse transcriptase real time PCR (Quantitative Reverse transcriptase polymerase chain reaction) which is recommended method used for diagnosis of the COVID-19 infection using oro-pharyngeal or nasopharyngeal swabs of the patients. Recently serological tests for antigen and antibody detection has been approved by ICMR. Till now, nine COVID-19 vaccines are granted emergency approval for prevention and for the management of infection symptomatic and supportive measures are being adopted. Globally major pharmaceutical firms are engrossed for development of a potent vaccine candidate. This review highlights on various vaccine candidates under clinical trials.
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Mapping the footprints of COVID-19 pandemic p. 2467
Aayushi Rastogi, Abhishek Padhi, Sabin Syed, Pranav Keshan, Ekta Gupta
DOI:10.4103/jfmpc.jfmpc_2361_20  
The new member of the coronavirus family created havoc in the world in few days of its discovery and was declared as a pandemic by March 2020. The enveloped, single-stranded RNA virus was first identified in a patient with dry cough, pain, and weakness for the past1 week with unknown etiology in Wuhan. The coronavirus soon spread across the globe in the next few weeks. To curb the spread of coronavirus, stringent measures such as lockdown and social distancing were enforced resulted in a declining of cases in various countries. However, unlocking, relaxation of preventive measures, and changing human behaviors led to a drastic increase in the number of COVID-19 cases resulting in the second wave of transmission. This resulted in reimposing of lockdown measures in countries such as Nepal, Italy, France, Netherland, and Germany. At present, the virus has affected over 110.7 million peoples and over 2.4 million deaths across the world, with India having the second-highest number of COVID-19 cases, following the United States of America. Furthermore, a cross-sectional view of the disease states several new strains being reported across the globe at one end and at another end there is rolling out of vaccine against COVID-19. There is still uncertainty related to curbing of the pandemic as effect of vaccine on new strains is undetermined. Thus, it is important to understand the transforming epidemiology of the virus as it helps in planning necessary steps for physicians and policymakers. The present review summarizes the updated information primarily about the epidemiology of COVID-19, from initiation to the present scenario.
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Prognostic importance of deranged sodium level in critically ill patients: A systemic literature to review p. 2477
Abubakar Tauseef, Maryam Zafar, Erum Syed, Joseph Thirumalareddy, Akshat Sood, Noman Lateef, Mohsin Mirza
DOI:10.4103/jfmpc.jfmpc_2291_20  
It is common upon admission or during stay at a hospital or intensive care unit (ICU) for patients to present with or acquire a serum sodium abnormality. Hyponatremia, serum sodium level less than 135 mmol/L, frequently associated with critical illnesses such as heart failure and liver cirrhosis, is an indicator of disease severity as well as a risk factor for poor prognosis. Hypernatremia, serum sodium level greater than 145 mmol/L, results due to any ailment disabling a patient's modality of thirst or the ability to relieve it once sensed. Hypernatremia has a more frequent iatrogenic component than hyponatremia. It can develop insidiously among patients through IV fluid administration of saline; both its presentation upon admission and development during stay is associated with mortality. Hyponatremia is associated with increased mortality and its treatment with morbidity as it carries a risk of overcorrection and consequently the development of central pontine myelinolysis. This review article covers the findings, and subsequent correlation between findings sought, of six articles catering to underscore the correlation between sodium disorders and prognosis of hospitalized or critically ill patients. PubMed search engine was utilized to select articles befitting the purpose of this review. Cumulatively, this review article substantiates the need to diligently evaluate and treat serum sodium disorders in hospitalized patients to achieve better prognosis.
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ORIGINAL ARTICLES Top

Epidemiological study of adverse events following immunization in under 5 year children p. 2482
Vikrant S Pagar, Sushant S Chavan, Sarika P Patil, Anant Borde, Amol D Kinge, Naveen Khargekar
DOI:10.4103/jfmpc.jfmpc_2328_20  
Background: The present study was conducted to study the socioeconomic and the demographic profile of children reporting with adverse events following immunization (AEFI) along with the determinants associated with AEFIs, based on investigation of each case and to assess the proportion of programmatic errors linked with AEFI cases. Materials and Methods: Record-based cross–sectional study conducted among sample of 118 cases of AEFI were reported. The case reports of all AEFI cases were procured and analyzed to identify factors associated with reported AEFI. The questionnaires related with preliminary investigation reports (PIRs) including forensic evidence of death cases were analyzed. Percentage analysis of data was done by proportions, measures of central tendencies, and Chi-square test. Results: Most of the cases reported were between 0 and 3 months of age constituting 39%. AEFI was seen more in male child than female. more than half of cases of AEFI were recorded following immunization with OPV/DPT/HBV together (66.94%). Most common AEFI reported were convulsion (68.64 %) and fever (58.47%) followed by local swelling at site of injection (11.86%). More than half of the cases of AEFI occurred within 12 hours of immunization (61.88%). Birth weight of most cases of AEFI were in the range between 2 and 2.4 kg (44.06%), followed by range between 2.5 and 2.9 kg (32.20%), the mean of birth weight was 2.51 kg. Conclusion: Convulsion was the most commonly reported AEFI, majority of AEFI occur within 12 h of immunization. Most of the AEFI were recorded following immunization with OPV/DPT/HBV together.
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Parents attitudes toward the human papilloma virus (HPV) vaccine: A new concept in the State of Qatar p. 2488
Mohamed A Hendaus, Manasik Hassan, Moza Alsulaiti, Tasabeh Mohamed, Reem Mohamed, Dure Yasrab, Hadeel Mahjoob, Ahmed H Alhammadi
DOI:10.4103/jfmpc.jfmpc_1122_20  
Background: Human papillomavirus (HPV) is one of the leading causes of cervical and genital cancer in both genders. Purpose: To delineate parental attitude regarding HPV in Qatar. Methods: A cross-sectional study using a questionnaire was conducted at Sidra Medicine, Qatar. Results: A total of 334 questioners were completed. More than 60% of the parents were not aware that HPV can cause cervical and genital cancer. When asked about the level of comfort in giving their children a vaccine that would prevent them from getting genital cancer, 77% of the participants answered “very comfortable.” Interestingly, less than 4% of the parents stated that their children's primary care physicians ever mentioned that such a vaccine exists. When asked about the most preferable mode of receiving information regarding the HPV vaccine, 54% preferred the clinician's office, followed by 34% of whom preferred social media. In terms of the preferred age to receive the vaccine, 45% of the participants preferred to administer the vaccine to their children before they were mature enough to understand sexual relations, while 22% recommended vaccination right before marriage and 15% preferred to wait till they were grown up and decide for themselves. Furthermore, only 42% of the caregivers agreed that it is important to explain to their children that the vaccine can protect against some of the sexually transmitted infections. Finally, approximately 20% of the participants were not convinced about the HPV vaccine. Conclusion: A large proportion of parents residing in Qatar have a positive perception regarding the HPV vaccine. TheParents' attitudes and perceptions are considered indispensable targets for community health intervention. We will share the result of our study with the ministry of public health in Qatar with a goal to incorporate the HPV vaccine in the National Immunization Schedule.
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Acute Diarrhoeal Disease in Children Aged 6 Months to 24 Months: An In-Hospital Cross-Sectional Study p. 2494
Mathews Marian Mathew, Resmi S Kaimal, Jose Goodwill
DOI:10.4103/jfmpc.jfmpc_1443_20  
Introduction: Diarrheal disease comes second among the causes of death in children under 5 years of old. We are well aware that this common disease is preventable and treatable. But the practice of preventive strategies is not as efficient as it should be. Aims and Objectives: 1. To determine the frequency of acute diarrheal disease in children aged 6 months to 24 months attending the immunization clinic of Lourdes Hospital, Kochi, Kerala. 2. To assess the associated factors and practices involved with acute diarrheal disease in the study group. Material and Methods: A cross-sectional study was done in children above 6 months attending immunization clinic in Lourdes hospital during the period from 1st October 2017 to 31st March 2019. After receiving their informed consent, a pretested, semistructured, and validated questionnaire was given to the mothers/caregivers to gather data on socio-demographic characteristics and practices. In order to assess the prevalence of diarrhea, details of the diarrheal episode after the 6 months of age were included in the questionnaire. To eliminate repeats, caution was taken not to include previously recorded data on the diarrheal episode. Discussion and Conclusion: The proportion of children with diarrhea in the study population was 38.7% which was high compared with other studies in the same age group. Many of the practices associated were found faulty and needing rectification which is a Family Physician's area of expertise. The study concludes that there is a need for identifying novel risk factors for diarrhea and educating the caregivers regarding the prevention of diarrhea. Primary Care Physicians/Family Physicians can play an effective role in educating the caregivers.
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COVID-19 pandemic and death anxiety among intensive care nurses working at the Hospitals Affiliated to Tehran University of Medical Science p. 2499
Iran Belash, Fateme Barzagar, Gohar Mousavi, Kosar Janbazian, Zahra Aghasi, Arezoo Taheri Ladari, Maryam Taghizadeh, Fateme Jahanbakhsh, Elnaz Saripour, Fateme Gholami, Kosar Rahnamaei
DOI:10.4103/jfmpc.jfmpc_2105_20  
Introduction: The unpredictable challenges and conditions of COVID-19 can cause mental health problems. In such a situation, one of the most important psychological problems is the fear and anxiety of death. Death anxiety can affect the quality of patient care services and the job satisfaction and mental health of nurses. Methods: This is a descriptive cross-sectional study in which 110 nurses working in the intensive care units of hospitals affiliated to the Tehran University of Medical Sciences were selected by the convenience sampling method from April to September 2016. The data collection tools used in the study include a demographic questionnaire and a Templer death-anxiety questionnaire. Findings: The results showed that the level of death anxiety in nurses working at COVID-19 intensive care units is associated with age, working hours per week, childbearing, several patients needing end-of-life care, cases of direct participation in resuscitation operations, cases of patient death observations, and satisfaction with personal protective equipment (P < o.o5). Conclusion: Increasing the nurses' awareness of the critical situations of COVID-19, management measures, improving the working environment, social support, and increasing personal protective equipment seem to be the effective factors in protecting the intensive care unit nurses against COVID-19 and reducing death anxiety.
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Prevalence of contraceptive use and its association with depression among women in the Jazan province of Saudi Arabia p. 2503
Mashael Alfaifi, Ali H Najmi, Khadija H Swadi, Abdullah A Almushtawi, Sattam A Jaddoh
DOI:10.4103/jfmpc.jfmpc_1308_20  
Background: Hormonal contraceptives (HC) are used for birth control and the treatment of premenopausal syndrome. Mood changes represent the leading reported cause of discontinuation of HC. Changes in mood vary from mild disturbances to severe clinical depression. Objectives: This study aims to estimate the prevalence of depression among HC users who visit primary health care centers in the Jazan Province of Saudi Arabia and to identify psycho-social factors that may predispose HC users to depression. Methods: A self-administered questionnaire was distributed among women who visited five primary health care centers in the Jazan Province. The survey included questions about socio-demographic information and an Arabic adaptation of the Beck Depression Inventory. Results: Among the 904 women surveyed, the prevalence of HC use was 57.3%. Mood disturbances were observed in approximately one-third of these women. There is was a significant correlation between higher depression scores and a history of depression therapy (P-value < 0.001), as moderate, severe, and extreme depression was more common in those with a history of taking depression therapy. The type of contraception used was also found to be a significant factor (P-value = 0.01) in the degree of depression. Conclusion: Approximately one-third of women using HC were shown to exhibit symptoms of mood disturbance. Working, limited social support, asked whether or not they experienced living problems in the past 2 months, and having an uncomfortable or somewhat comfortable marital relationship increased the likelihood of mood disturbances. Primary health care physicians should be aware of the relatively high prevalence of mood disturbances in women using HC, to provide support and care to patients.
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Clinico-microbiological spectrum of anaerobic pyogenic infections in an Indian tertiary care teaching hospital: A two-year study p. 2512
S Nema, S Brahmachari, Teja N Vishnu, D Biswas
DOI:10.4103/jfmpc.jfmpc_2368_20  
Introduction: Anaerobes are important however the most neglected pathogens. Timely isolation of anaerobes can guide the clinician about the correct course of clinical treatment and thus reduce the mortality and also the problem of antimicrobial resistance. Materials and Methods: Tissue and/or pus aspirates were collected aseptically from infectious sites in the Robertson's cooked meat medium (RCM) and sent to anaerobic bacteriology laboratory for culture. Subcultures from RCM for each sample were done on neomycin blood agar and 5% sheep blood agar along with metronidazole disc (5μg). The plates were incubated in an anaerobic jar using GasPak for 72 hrs. The preliminary identification was performed by standard biochemical tests for both obligate and facultative anaerobic isolates. Speciations of obligate anaerobes were performed by Vitek 2 automated system. Results: Obligate anaerobes either single or polymicrobial were obtained in 38/216 (14.5 %) samples processed during the study period. Polymicrobial infections were reported in 21/216 (55.26%) samples and most commonly with obligate anaerobic gramnegative bacilli i.e. Prevotella-Porphyromonas and Bacteroides fragilis group. Most common monomicrobial anaerobic infections were observed with Veillonella spp. (n=4) and Porphyromonas spp. (n=4) followed by Bacteroides fragilis (n=3). Obligate anaerobes were predominantly isolated from skin and soft tissue infections (n=14) followed by surgical site infections (n=8). Conclusion: Although most of the infections are polymicrobial, a rise in the incidence of monomicrobial anaerobic infections has been noticed. Therefore, the performance of anaerobic cultures along with aerobic cultures is much needed for complete bacterial work-up of specimens from infectious sites and better patient management.
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Dynamic profile and clinical implications of hematological and immunological parameters in COVID-19 patients. A retrospective study p. 2518
Shekhar Yashwant Suryawanshi, Shrishtee Priya, Sandarbh Saumya Sinha, Srinath Soni, Naqoosh Haidry, Shilpi Verma, Supriya Singh
DOI:10.4103/jfmpc.jfmpc_2400_20  
Background: Ever since the World Health Organization (WHO) announced the SARS-CoV-2 or nCOVID-19 infection (a pandemic), continuous spread of the virus has been observed which has continuously seen to affect and kill multitudes of individuals all over the world. An understanding of the pathophysiology of this disease is necessary for an effective treatment. Laboratory investigations play an important role in the diagnosis as well as treatment of this infectious disease. Hematological parameters demonstrate alterations during the progression of nCOVID-19 infection. Of these, many are indicative of extremely poor clinical outcome. Hematological findings like leukopenia, lymphopenia, thrombocytopenia and coagulation-related abnormalities are the most common manifestations. The aim of this study was to assess the dynamic profile and clinical implications of hematological and immunological parameters among nCOVID-19 infections. Materials and Methods: This retrospective study was designed after categorizing patients suffering from COVID-19 into three groups: (a) Group I; (b) Group II and (c) Group III or severe critical patients. Hematological and immunological parameters of neutrophilic and white blood cell counts, d-dimer levels, hemoglobin levels, immunoglobulin G (IgG) and M (IgM) levels and interleukin-6 (IL-6) levels were assessed. Statistical analysis using Kruskal–Wallis test was used. Results: Normal white blood cell and neutrophil count among COVID-19 patients was seen. However, median values in Group II (P < 0.01) and Group III (P < 0.0001) were found to show significantly higher values when compared to Group I. A significant (P < 0.01) decrease in lymphocytic counts was found among severe and critical patients. Hemoglobin level was found to demonstrate higher decrease (P < 0.01) among severe and critical patients. Platelet count was found in normal range in all COVID-19 patients. Routine coagulation tests revealed increased fibrinogen (P < 0.01) and d-dimer levels (P < 0.0001) in severe and critical patients. Normal proportions of total CD3+ and CD4 + T lymphocytes were observed in COVID-19. However, CD8 + T lymphocytes proportion was found to be decreased (P-value < 0.05). Immunoglobulin G levels among Groups II and III patients were found to be lower when compared with Group I (P < 0.001). No statistical significance was observed between the groups in IgM levels. Plasma IL-6 levels were found to show progressive rise among Groups II and III patients (P < 0.05). Conclusion: Analysis of hematological and immunological parameters profiles in COVID-19 patients may help in deciphering the clinical progression of patients suffering from COVID-19 disease. Thus, regular monitoring of the hospitalized patients may help in planning the management of these cases.
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Assessment of Knowledge and Awareness of Public School Teachers Towards Learning Disabilities in Children - An Institutional Based Cross-Sectional Study in Dharmapuri District, Tamil Nadu p. 2524
Arunachalam Madhamani, Alex Joseph
DOI:10.4103/jfmpc.jfmpc_1869_20  
Introduction: Literature indicates that the incidence of specific learning disabilities among Indian children has been rising. Scholars have been paying much attention to teachers' knowledge which is largely associated with early identification and treatment of learning disabilities. Objectives: This study aimed to understand the knowledge and awareness of public-school teachers, about learning disabilities among children, in Dharmapuri district of Tamil Nadu, India. Material and Methods: A cross-sectional study was done among 200 school teachers in Dharmapuri district to achieve the desired objectives using structured and self- administered questionnaire. Results: The knowledge of teachers regarding learning disabilities among children was found to be moderate among the majority of the teachers (45%), where as substantially large number of participants showed an adequate level of knowledge (33.5%), and rest of the participants (21.5%) have shown an inadequate level of knowledge. A vast majority of participants (73.5%) were aware of the learning disability amongst children. The educational qualification (P value < 0.001) and experience (P value < 0.05) of the teachers had a significant association between knowledge level. Conclusion: In light of the findings, it is essential to spread the awareness and knowledge about the learning disabilities of children among teachers. The government should take necessary policy directions in raising awareness and knowledge of various learning disabilities among parents, teachers and peer groups so that these children will be handled in a better way in the social circle. This also should be included as a part of curriculum in teachers' training programs.
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Effect of COVID 19 Lockdown on glycemic parameters in people with type 2 diabetes p. 2529
Ajoy Tewari, Vineeta Tewari, Jay Tewari
DOI:10.4103/jfmpc.jfmpc_1896_20  
Coronavirus disease (COVID-19) is an infectious disease caused by the newly discovered SARS-COV-2. Older people and people with pre-existing medical conditions, such as diabetes and obesity, appear to have the worst outcomes with the COVID-19 virus. In response to the COVID-19 pandemic, many countries enforced stringent lockdowns to prevent the spread of the disease. India had a lockdown of 68 days between 21st March and 31st May 2020. In this background, we undertook this study to assess the effect of the lockdown on the glycemic status and weight of people with diabetes, which was indirectly an opportunity to assess the self-care practices of people with diabetes. Material and Methods: The subjects included in the study were people with type 2 diabetes identified from electronic medical records who had attended the Jai Clinic and Diabetes Care Centre in Lucknow and were tested for HbA1c between 20th Feb 2020 and 20th March 2020. A total of 313 people with diabetes were identified meeting the inclusion criteria, out of which 171 were females and 142 were males. They were again tested for HbA1c between 1st June 2020 and 1st July 2020 after lockdown. Their pre- and post-lockdown HbA1c and weight were analyzed statistically. Results: HbA1c was increased in 195 patients, which was statistically significant. A total of 151 patients had an increase in weight compared to their prelockdown weights, but it was not statistically significant. Furthermore, an increase in weight correlated with an increase in HbA1c and a decrease in weight correlated with a decrease in HbA1c. Both were statistically significant. Conclusion: Optimum diabetes control and adherence to good self-care practices is the need of hour, and contingency plans for medicines and diabetes care supplies are of utmost importance in these testing times.
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Utility of Panfungal PCR in the diagnosis of invasive fungal infections in febrile neutropenia p. 2533
Sujay Srinivas, Pushpa Kumari, Dipendra Kumar Gupta
DOI:10.4103/jfmpc.jfmpc_2325_20  
Background: The prevalence of invasive fungal infections (IFIs) is increasing due to the increasing population of immunocompromised patients. Fungal culture is the gold standard for diagnosis but not sensitive and the turnaround time is long. Samples for histopathology are difficult to obtain because of profound cytopenias. We conducted this study with the aim to evaluate panfungal PCR for the diagnosis of IFIs in patients of febrile neutropenia. Methods: This was a single-centre, cross-sectional observational study. Patients of febrile neutropenia suspected of having IFI were included in the study. Panfungal PCR was performed on the blood of included patients along with other investigations for diagnosis of IFI. The sensitivity, specificity, positive predictive value, and negative predictive value of panfungal PCR were calculated using EORTC/MSG 2008 criteria as the gold standard. Results: Fifty patients of febrile neutropenia were included in the study, of which 52% were diagnosed positive by panfungal PCR assay. The sensitivity, specificity, positive predictive value, and negative predictive value of panfungal PCR assay was found to be 82.76%, 90.48%, 92.31% and 79.17% respectively. Conclusion: Panfungal PCR is a promising and highly sensitive diagnostic test for screening at-risk patients suspected to have IFIs. The use of panfungal PCR assay in combination with other diagnostic modalities and clinical judgment can be very helpful in the early diagnosis of IFI.
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Preventability, predictability, severity and causality assessment of adverse drug reactions reported from a teaching hospital in chhattisgarh: A retrospective analysis p. 2541
Yogendra Keche, Nitin Gaikwad, Suryaprakash Dhaneria
DOI:10.4103/jfmpc.jfmpc_2374_20  
Background and Objectives: Adverse Drug Reactions (ADRs) can lead to significant morbidity, rarely mortality and financial burden over the patient. ADRs that can be prevented can be considered as form of medication error sometimes. This study assessed the preventability, predictability and severity of ADRs using different assessment scales. Methods: ADR Monitoring Centre under newly established teaching hospital in Chhattisgarh collected ADR reports from different healthcare professionals during the period from November 2016 to November 2018. Analysis of the reported ADRs was done for their causality assessment, demographic details of patients, most common drug class responsible for the ADR. Seriousness and preventability of ADRs were analysed by using WHO Causality Scale and Modified Schumock and Thornton Scale respectively. Severity of ADRs was assessed by Modified Hartwig and Siegel Scale. Results: Totally 288 ADRs were reported in a 2-year period. 92.01% ADRs were non serious. 44.8% were mild, 53.81% moderate and 1.39% were severe ADRs. Causality assessment showed: 5.21% certain, 54.86% probable, 39.24% possible and 0.69% unlikely ADRs. Around 26% ADRs were definitely and probably preventable and 27.78% ADRs were predictable. The highest number (32.29%) of ADRs were reported to antimicrobials. 11.15% ADRs were reported to NSAIDs, in that 37.5% ADRs were due to NSAIDs combination. Conclusion: Many ADRs in this study are non-serious, preventable and predictable. Management of such ADRs through therapeutic interventions would be beneficial in a better patient outcome. Multidisciplinary strategies involving physicians, pharmacists, other healthcare professionals and patient education and awareness about ADRs are needed for prevention of ADRs.
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The prevalence of stress, stressors and coping mechanisms and the socio-demographic factors associated among the auto-rickshaw drivers in Bengaluru city, India p. 2546
Amey Joshi, Raveendra H. R. Reddy, Anurag Agarwal
DOI:10.4103/jfmpc.jfmpc_2413_20  
Context: Socio-demographic and environmental factors attribute to stress for auto-rickshaw driver leading to compromise of driver and passenger safety. Aims: This study assesses the prevalence and socio-demographic factors associated with stress and identifies the stressors and coping mechanisms in auto-rickshaw drivers. Settings and Design: A cross-sectional study was conducted amongst 140 randomly selected auto-rickshaw drivers in Bengaluru city, India. Methods and Material: Data was collected at a place and time convenient to the study participants using semi-structured pre-tested tool. Stress was assessed using Cohen's Perceived Stress Scale. Statistical Analysis: Data was entered and analyzed using Epi Info™ software. Two sample t/ANOVA tests were used to compare the difference in means and standard deviations (SD) between the sub-groups. P <0.05 was considered statistically significant. Results: Mean age of the auto-rickshaw drivers was 32.8 ± 8.3 years, majority belonged to the 25-30 years age-group. About 55.7%, 40.7% and 28.7% were consuming tobacco products, alcohol and some both, respectively. While the prevalence of self-reported stress was 76.4% (n = 107), 78.6% (n = 110) had stress based on Perceived Stress Scale (PSS) assessment. Mean PSS for participants self-reporting stress was 20.51 ± 5.25 as against 12.36 ± 4.98 who did not (P < 0.001). The mean PSS was 17.55 ± 4.13, 20.65 ± 5.23 and 23 ± 5.12 among those who self-reported having mild-, moderate- and severe-degree stress, respectively (P < 0.001). There was no significant association of any socio-demographic factors with the PSS score. Financial problems (n = 51; 47.7%) was the leading stressor, followed by road traffic (n = 49; 45.8%). Conclusions: Appropriate strategies are needed to address the high level of stress among auto-rickshaw drivers.
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Seroprevalence trends of Scrub typhus among the febrile patients of Northern India: A prospective cross-sectional study p. 2552
Sweta Singh, Sangram Singh Patel, Chinmoy Sahu, Ujjala Ghoshal
DOI:10.4103/jfmpc.jfmpc_2392_20  
Background: Rickettsial infections remain one of the most neglected and underdiagnosed tropical diseases in the developing countries. Scrub typhus can prove to an important diagnosis in pyrexia of unknown origin (PUO) patients and is transmitted by a species of trombiculid mites (“chiggers”). The disease leads to a plethora of symptoms like fever, rash, headache, nausea, abdominal pain, thrombocytopenia, etc. The current study was aimed to assess the seroprevalence as well as other demographic parameters of scrub typhus among patients diagnosed with PUO in the northern part of India. Materials and Methods: This study was undertaken for a period of 3 years from September 2017 to September 2020. Serum samples of suspected cases were tested for IgM Scrub typhus along with other common febrile illnesses like Malaria, typhoid, dengue, leptospirosis, chikengunya, etc. Additional testing for COVID-19 was also planned for samples received after February 2020. Results: The overall seroprevalence of Scrub typhus during the 3 year study period was noted to be 18.6% in the PUO patients. Typhoid was noted in 39.5%, malaria in 9.2%, Dengue in 13.5%, leptospirosis in 4.8%, and chikungunya in 5.3% of the patients. No cause was identified in 9.1% of the PUO cases. 3.9% of the samples were positive by RT-PCR for COVID-19. No mortality was noted in the scrub typhus positive cases. Conclusion: Scrub typhus is an emerging tropical rickettsial disease in the Indian subcontinent. The present study highlights the importance of screening of PUO cases for this important infection as timely institution of simple empirical treatment can prove to be life saving in such positive cases.
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Prevalence and predictors of prehypertension and hypertension in adult population of rural Southern India—An epidemiological study p. 2558
Sharvanan Eshwar Udayar, Srinivas T Thatuku, Devika Pandurang Jevergiyal, Anand M Meundi
DOI:10.4103/jfmpc.jfmpc_2415_20  
Introduction: Hypertension is considered as one of the major health problem worldwide and the most important risk factor for non-communicable diseases. Aims: To estimate the prevalence and the risk factors of prehypertension and hypertension. Methods and Material: A community-based cross-sectional study was conducted among adult population of rural area of Chittoor District. WHO STEPS was applied for data collection from 1,742 study participants aged 18 years and above. Chi-square test, Fisher exact, and ANOVA test applied to find out the intragroup and intergroup variable association with raised blood pressure. Results: The overall prevalence of hypertension and prehypertension in our study was 21.5% [95% CI: (19.6–23.5)] and 42.8% [95% CI: (39.5–46.3)], respectively. Males had higher prevalence when compared to females. The mean systolic and diastolic blood pressure was 118.7 ± 17.6 mmHg and 77.1 ± 9.7 mmHg, respectively. The odds of being hypertensive was higher among older age group (OR: 3.83), male study participants (OR: 1.83), either widowed or separated (OR: 2.03), unemployed (OR: 1.51), and those who belonged to upper socioeconomic status (OR: 2.01). Those who were overweight (OR: 3.15), obese (OR: 2.55) and having central obesity (OR: 1.74), and also tobacco smokers (OR: 1.53) were having higher odds of hypertension. Significant association was found between hypertension and age, gender, marital status, body mass index, abdominal obesity, tobacco smoking, and physical inactivity. Conclusion: The prevalence of prehypertension and hypertension in this study was found to be high in rural area of Andhra Pradesh. There is a need to develop a community-based program, which would aim at minimizing the risk factors of hypertension.
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Prevalence and reasons behind use of injectable contraceptive among the women of reproductive age group: A cross-sectional survey in rural areas of Nadia District, West Bengal p. 2566
Anwesha Bairagya, Gandhari Basu, Reshmi Mondal, Suman Kumar Roy
DOI:10.4103/jfmpc.jfmpc_2465_20  
Context: Estimated 42 million reproductive age group women currently use injectable contraceptive, fourth most prevalent contraceptive worldwide. Aims: To find out the prevalence, reasons and the associated factors for using injectable contraceptive among the women of reproductive age group. Settings and Design: A sub-centre-based observational, cross sectional survey was conducted among 212 reproductive age group women living in the rural areas of a district, West Bengal. Methods and Material: A multi-stage cluster random sampling technique was done considering villages as the cluster to get the required sample. Totally, 212 reproductive age group women were chosen from a total of 16 villages, selected by simple random sampling. Information regarding study variables was collected by direct interview of the respondents by visiting individual houses with help of a pre-designed, semi-structured proforma. Strict confidentiality and anonimousity were maintained throughout the study. Statistical Analysis Used: Data were analysed with SPSS 22.0 (licensed). Mean, median, proportion were used for quantitative variables whereas qualitative attributes were presented by proportion. Associations between dependent and independent variables were tested by Chi-square test. Results: The proportion of teenage marriage was unexpectedly high. More than half mothers were unwilling to have babies in future. One-third of study population used injectable contraceptive, ASHA was the main suggestion provider in choosing the method. The major reasons of use were discomfort in previous method and suggestion of service provider. Irregular menstrual problem and easy maintenance was the commonest cause of dissatisfaction and satisfaction, respectively. Conclusions: Use of injectable contraceptive must be sincerely promoted through social marketing and the front line health workers should motivate the women to use it by providing correct information.
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Clinico-bacteriological and antibiotic drug resistance profile of chronic suppurative otitis media at a tertiary care hospital in Western Rajasthan p. 2572
Sarika Prabhakar Kombade, Navneet Kaur, Sourabha Kumar Patro, Vijaya Lakshmi Nag
DOI:10.4103/jfmpc.jfmpc_2480_20  
Background: Chronic suppurative otitis media (CSOM) is a major cause of hearing disability and morbidity in poor socioeconomic developing countries with prevalence of 4%. Indiscriminate use of antibiotics and poor follow up of patients has resulted in treatment failure, emergence of resistant strains, super infection, intra-cranial and extra-cranial complications in CSOM patients. Staphylococcus aureus, P. aeruginosa, Proteus spp. and Klebsiella spp. are most common organisms causing infection. Knowledge of microbial profile and susceptibility pattern is essential for efficacious treatment of this disorder. Objective: To determine the clinico-bacteriological profile of CSOM, to analyze the susceptibility pattern of various antibiotics and to evaluate the in vitro efficacy of aminoglycosides over fluoroquinolones against the aerobic bacterial isolates from CSOM. Methods: We studied 153 clinically suspected CSOM cases from March 2018 to October 2018 in Microbiology and Otorhinolaryngology department. The ear swabs were aerobically cultured and identification of the isolate was done by standard bacteriological methods. Results: Safe type CSOM was a major cause of disease. Moderate (35.3%) and mild degree (32.7%) of hearing loss was seen in most of the CSOM cases. The culture positivity rate was 82.4% and the most common isolate was P. aeruginosa (55.8%) followed by S. aureus (27.5%). P. aeruginosa, A. baumannii and Enterobacteriaceae spp. showed high sensitivity to colistin, piperacillin-tazobactam, ceftazidime-tazobactam and good sensitivity for cefepime and amikacin; 33.3% S. aureus isolates were Methicillin-resistant which was sensitive to gentamicin, vancomycin and linezolid. Conclusion: Knowledge of the spectrum of microorganisms causing ear discharge is important for effective treatment.
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Impact of the COVID-19 pandemic on residents' clinical training and psychosocial well-being in Saudi Arabia's Western region p. 2580
Reem Alshareef, Abdullah Al Zahrani, Meshari Alzhrani, Abdulaziz Suwaidi, Bander Alamry
DOI:10.4103/jfmpc.jfmpc_2173_20  
Background: The novel COVID-19 pandemic has imposed a significant burden on healthcare systems. Similarly, it has also affected the performance and well-being of the medical staff working during the pandemic. This study aims to evaluate the negative effect of COVID-19 pandemic on medical training and psychological well-being of resident doctors practicing in the Western region of Saudi Arabia. Methods: This is a quantitative cross-sectional study that included a survey distributed to resident physicians working in the western region in Saudi Arabia. The survey included questions on demographic data and factors influencing the academic training, attitude, and daily habits of the residents during the pandemic. Psychological impact was assessed using the Kessler Psychological Distress Scale. Data analysis was executed using IBM SPSS version 26. Results: A total of 121 residents responded to this survey. Of all respondents, 71.1% were junior residents, 66.9% had a medical specialty; and 33% were family medicine physicians, followed by 17% from general surgery. In regard to work amid the pandemic, 36.1% were in contact with confirmed COVID-19 patients, and 35.5% had to work overtime during the pandemic. There was a non-significant difference detected between the residents regarding the factors negatively affecting their psychological well-being. Conclusion: Residents working during the pandemic in the Western area of Saudi Arabia were significantly affected by the pandemic from both professional and psychological perspectives. Further research on how the pandemic is affecting physicians in other areas in Saudi Arabia is needed.
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Knowledge, attitude, and practice of travel medicine among primary health care physicians in the Cluster-1, Riyadh City, Saudi Arabia: A cross-sectional study p. 2587
Abeer Ahmed Sharahili, Fayiz AL-Eanzi, Amal Ahmed Ghzwany, Alhanouf Mamluh Alazmi, Esra Ali Alhwsawi
DOI:10.4103/jfmpc.jfmpc_2354_20  
Introduction: Travel medicine deals with prevention and management of health problems of travelers to avoid or reduce the risk of avoidable illnesses. Primary healthcare physicians are the key individuals to provide the same. The objective of current study was to explore the level of knowledge, attitude, and current practical application of travel medicine among primary health care physicians serving in the Riyadh Health Cluster, Saudi Arabia. Methodology: A descriptive cross-sectional study among 210 primary healthcare physicians serving in Riyadh Health Cluster was conducted using a paper-based self-administered questionnaire collecting information on socio-demographic characteristics and knowledge, attitude as well as practice of travel medicine. Results: The majority of study participants were females (117, 55.7%) and 63% (n = 133) were non-Saudi physicians. More than 30% that is 66 participants had clinical experience of less than 5 years and around 67% (i.e., 141) participants were serving at the designation of registrar/senior registrar. One hundred sixty-seven participants (79.5%) had ever provided health advice to the travelers. Majority of the study participants had gained information on the travel medicine through Ministry of Health guidelines (66%). Nearly 11.4% participants were not sure about the cause of occurrence of typhoid infection. As reported by 30.5%, travelers never really sought advice on the travel insurance. Nearly 79.5% participants reported to have provided post-travel consultation for diarrhea, followed by respiratory infection (45.2%), fever (42%), and skin problems (21%). Conclusion: The knowledge, attitude, and practice of travel medicine among primary healthcare physicians was found to be sub-optimal in Riyadh.
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An observational study to estimate the level of essential trace elements and its implications in type 2 diabetes mellitus patients p. 2594
Satyendra Kumar Sonkar, Krishnapal Singh Parmar, Mohammad Kaleem Ahmad, Gyanendra Kumar Sonkar, Medhavi Gautam
DOI:10.4103/jfmpc.jfmpc_2395_20  
Background and Objectives: Insulin action of reducing blood glucose has been found to be enhanced by trace elements. Material and Methods: This was a cross sectional study including 150 patients with Type 2 Diabetes Mellitus (T2DM) and 50 controls. Serum concentrations of zinc, copper, chromium, selenium and magnesium was measured by colorimetric kit. Fasting Blood Glucose and Glycated Haemoglobin (HbA1c) were assayed using the standard kit. Results: Out of 150 patients, 85.4% (n = 128) of the cases had uncontrolled blood sugar with HbA1c ≥7 and only 14.6% (n = 22) had good control of blood sugar with HbA1c <7%. Hypertension (42%) and hypothyroidism (14%) were the most commonly associated comorbidities among patients with T2DM. Following percentage of diabetic patients had complications such as peripheral neuropathy (45.3%), diabetic retinopathy (36.7%), coronary artery disease (20.7%), diabetic nephropathy (17.3%), peripheral vascular disease (8.7%), and cerebrovascular accident (6%) respectively. The mean level of zinc, copper, selenium and magnesium was significantly lower in patients with T2DM than the control cases (62.89 vs. 74.95 μg/dL, P < 0.05; 116.30 vs. 150.39 μg/dL, P < 0.001; 8.57 vs. 16.16 μg/dL, P < 0.001; 1.92 vs. 2.31 mg/dL, P < 0.05, respectively). Multivariate analysis showed that there was a significant trend between levels of zinc, copper, selenium, and magnesium and the prevalence of T2DM. Conclusions: The levels of selenium, zinc, copper, and magnesium were significantly lower in patients with T2DM when compared to healthy counterparts.
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Risk of non-resumption of vaginal sex and dyspareunia among cesarean-delivered women Highly accessed article p. 2600
Prakash Prabhakarrao Doke, Varsha Mahesh Vaidya, Arvinder Pal Singh Narula, Archana Vasantrao Patil, Tushar Madhavrao Panchanadikar, Girija Narendra Wagh
DOI:10.4103/jfmpc.jfmpc_2482_20  
Context: Many women have postpartum sexual dysfunction. The mode of delivery is an important determinant. Aims: To calculate the risk ratio of non-resumption of vaginal sex and dyspareunia during the postpartum period among cesarean-delivered women. Settings and Design: This large multisite study was conducted in 13 selected hospitals in Pune District during 2017–19. Methods and Material: A total of 3,112 women (half cesarean delivered and half vaginally) were interviewed by trained health workers using a structured questionnaire. Women were interviewed at 4 weeks, 6 weeks, and 6 months. Statistical analysis used: Chi-square test was applied. A risk ratio with a 95% confidence interval was calculated. Results: At 6 weeks, the risk ratio of non-resumption of vaginal sex was significantly high among cesarean-delivered participants (1.14). Cesarean-delivered women had a lesser risk ratio of dyspareunia at both follow-ups (0.59, 0.49). Even at 6 months, about one-third vaginally delivered women had dyspareunia. The proportion of women non-resuming vaginal sex gradually decreased from 6 weeks to 6 months. The proportion of women having dyspareunia also decreased from 6 weeks to 6 months following childbirth. Residence in the rural area and cesarean delivery were the significant determinants of an early resumption of vaginal sex. Dyspareunia was significantly high among vaginal delivered than cesarean. About 25% of women continued to have dyspareunia up to 6 months. Conclusions: A large number of women suffer from dyspareunia; hence antenatal and postnatal care should include some counseling and management about the resumption of sex and dyspareunia.
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Maternal and neonatal outcomes in extra hepatic portal vein obstruction: Our experience p. 2608
Smitha Elizabeth Jacob, Ravi Shankar, Anoop John, CE Eapen, Bijesh Yadav, Swati Rathore
DOI:10.4103/jfmpc.jfmpc_1486_20  
Background: Women with Extra hepatic portal vein obstruction (EHPVO) are mostly young and belong to Asian countries. In the Indian subcontinent, 20–30% variceal bleeds are caused by EHPVO. Hence pregnancy is a concern in such patients. The objective of this study is to observe the maternal and neonatal outcomes in women with EHPVO. Materials and Method: Extra hepatic portal vein obstruction was studied retrospectively in 28 pregnancies in 20 women from Jan 2011 to July 2018 at a tertiary hospital in South India and the pregnancy outcomes were observed during this period. Institutional Review Board approval obtained. Results: The mean age of the women was 24.3 years and the mean age of diagnosis was 18.5 years. Splenomegaly, thrombocytopenia and anaemia were seen in 22 (78.5%), 17 (60.7%) and 8 (28.5%) of pregnancies, respectively. Rate of abortions and preterm deliveries were 2 (7.1%,n=28) and 10 (35.7%,n=28). There was one stillbirth (3.6%) in the study group. EHPVO was diagnosed in 25 (89.3%) women prenatally in our series. During pregnancy only one woman had variceal bleed, which was managed conservatively. Blood and blood product transfusion was required in 7(25%) of women and there was no maternal mortality. Conclusion: Pregnancies in EHPVO have good maternal and neonatal outcomes, provided they are taken care of by a multidisciplinary approach in a tertiary care centre.
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Severe or not so severe? The gravity of geriatric trauma p. 2614
Kundavaram Paul Prabhakar Abhilash, Sharon Pradeeptha, Andrea Cris, Darpanarayan Hazra, Anmol Jindal, Jagadesha Selvan
DOI:10.4103/jfmpc.jfmpc_2257_20  
Background: Due to associated comorbidities, the elderly population is more vulnerable to injuries with complications. This study was done to assess the severity of trauma and outcome of injuries among these patients presenting to the Emergency Department (ED). Materials and Methods: This was a retrospective cohort study. We included all patients aged more than 60 years, who presented to the ED with trauma in the year 2018. Details of the mode of trauma, severity of injuries and outcome were analysed. Results: During the study period a total of 7666 trauma patients presented to ED, among which 879 (879/7666: 11.4%) were in the geriatric age group. The mean age was 68.9 (SD: 7) years with 90.8% being young-old (60–79 years) and 9.2% being old-old (>80 years). Common modes of injuries were road traffic accidents (RTA) (64%) fall on level ground (FLG) (20%) and fall from height (FFH) (8%). Most of them had Injury Severity Score (ISS) and New Injury Severity Score (NISS) score of 0–7, i.e.: 62% and 51%, respectively. On multivariate logistic regression analysis RTA, FFH FLG and triage priority 1 patients were associated with trauma in the old-old as compared to the young–old age groups significantly. Independent risk factors associated with severe trauma were seen RTA, FLG and priority 1 patients. Forty-four per cent patients were managed by the ED team alone. Trauma speciality departments referred to included orthopaedics (47%), neurosurgery (22%), trauma surgery (14%), plastic surgery (8%) and hand reconstruction surgery (6%). About half of the population under study was discharged stable (44%), of which the majority belonged to the young-old category (44.1%). The in-hospital mortality rate was 0.5% (4/879). Conclusion: This study shows the gravity of multiple injuries sustained by the geriatric age group with RTA, FLG and FFH being the predominant causes of trauma. The NISS highlights the severity of injuries in the old and the frail.
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Assessment of pandemic (COVID-19) preparedness in a teaching hospital in northern India using available (CDC-Atlanta) checklist p. 2619
Sukhbir Singh, Manjunath B Govindagoudar, Dhruva Chaudhry, Pawan Kumar Singh, Aarushi Vashist, Madan Gopal Vashist
DOI:10.4103/jfmpc.jfmpc_2455_20  
Background: Hospitals are at the forefront of dealing infectious public health emergencies. Recently, COVID-19 has been declared as pandemic by the World Health Organization. Dealing with COVID-19 pandemic requires high intensity of administrative activity. Objective: We conducted this study to assess and compare, objectively, hospital preparedness with available Centre of Disease Control and Prevention (CDC) standards. Methods: CDC has issued checklist for the assessment of hospital preparedness for COVID-19 pandemic, globally. This list contains 10 elements with sub-sections. We objectified the same and scored the hospital preparations accordingly. Various financial efforts made by the hospital to procure COVID19-specified items was also recorded.Results: As per the CDC checklist, the hospital scored 197 points (72.06%) out of 270 points with highest points in element two and eight. Element two is for the development for written COVID-19 plan. Element eight consists of addressing the occupational health of healthcare workers. Lowest scoring was in the element seven represented visitor access and movement within facility. During the study period, the hospital procured items of approximately 55 lakhs. In the study period, doctors, nursing staff, housekeeping staff, and security staff were channelized for doing COVID-19 duties. Conclusions: We obtained a score above 70% (good) which is quite encouraging, and we concluded that pandemic preparations in hospitals are necessary and it can be assessed objectively against prevailing standards. It is important in poor countries like India where spending on healthcare is minimal compared to other countries. Additionally, this assessment can be used to guide us further changes in policies and identifying the gaps in pandemic preparedness in hospitals which require special attention.
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Diagnostic value of intravenous oxygen saturation compared with arterial and venous base excess to predict hemorrhagic shock in multiple trauma patients p. 2625
Ali Taherinia, Ghazal Saba, Mohsen Ebrahimi, Koorosh Ahmadi, Zabihollah Taleshi, Peyman Khademhosseini, Ali Soltanian, Atie Safaee, Mehran Bahramian, Shahin Gharakhani, Mohammad Ali Jafari Nodoshan
DOI:10.4103/jfmpc.jfmpc_2047_20  
Introduction: In this study, with the help of peripheral vein sampling, Spvo2, and peripheral artery and vein sampling, we examined base excess (BE) in trauma patients and determined its diagnostic value for hemorrhagic shock. Methods: In this cross-sectional study, from 64 patients with abdominal, pelvic and chest Blunt trauma who have a score of 2 or higher trauma during treatment, blood samples were taken from peripheral vein to measure oxygen saturation and peripheral vein and artery for BE measurements and were compared in order to assess their diagnostic value in predicting the occurrence of hemorrhagic shock. Results: Out of 60 examined patients, 43 (71.67%) patients were diagnosed with hemorrhagic shock. The correlation for the percentage of oxygen saturation of the peripheral blood and the rate of arterial and venous BE for these r2 patients were 17.0 and 09.0, respectively, with a P value greater than 0.005. In the case of the percentage of oxygen saturation of the peripheral blood, the sensitivity and specificity were 93.03 and 11.76%, respectively. The positive and negative likelihood ratios were 1.05 and 0.59, respectively. The positive and negative predictive values were 72.73 and 40%, respectively. Conclusion: In general, the results of this study showed that arterial and venous excess base levels had a proper correlation, specificity and sensitivity for diagnosing and predicting hemorrhagic shock, while the percentage of oxygen saturation of peripheral blood and BE arterial and venous levels had not proper correlation to detect and predict hemorrhagic shock.
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Metabolic syndrome awareness and attitudes among family medicine residents in Riyadh 2019–2020 p. 2630
Abeer S Alshuniefi, Nasser K Aljuhani, Abrar H Allafi, Mashael S Alruwayshid, Enas F Alaraik, Fatmah Alreshidi, Ebtehaj S Almughais
DOI:10.4103/jfmpc.jfmpc_1744_20  
Context: Metabolic syndrome (MS) is a group of metabolism diseases which includes over increase of the body weight, high insulin levels, elevated blood pressure, and abnormal level of cholesterol; these disorders may increase the risk of evolving coronary heart diseases. Primary health care physicians are responsible for caring for general patients and thus must have sufficient knowledge about MS, positive attitudes, and good medical practices. Aims: To evaluate the knowledge, attitudes, and practices of family medicine residents in Riyadh regarding the diagnosis, management, and preventive measures of MS. Methods and Material: This study is a cross-sectional; it was conducted on family medicine residents in Riyadh using a survey to investigate the demographics, knowledge, attitudes, and practices of the residents regarding MS. Results: This study included 224 physicians, of whom 35.3% had a high level of knowledge, 63.8% had positive attitudes, and 50% had good practices. No factors were associated with knowledge level; conversely, male gender and training at the KFMC were significantly associated with attitude (P = 0.009 and 0.004, respectively), and training level R1 and R2 were significantly related to the level of practice (P = 0.013 and 0.015, respectively). Conclusions: The family medicine residents reported a low knowledge level; however, more than half of them had positive attitudes and half had good practices.
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Drug utilization pattern and factors associated with polypharmacy and excessive polypharmacy in geriatric medical out-patients at a rural health training centre in India p. 2636
S Nitya, G Ramya, Sivagourounadin Kiruthika, R Meenakshi, Jayabalan Nalini Devi, Ganesan Suganya, S Pravin
DOI:10.4103/jfmpc.jfmpc_2417_20  
Context: Multiple chronic illnesses associated with ageing population demands the role of polypharmacy. Drug utilization study in terms of description of drug use pattern in the geriatric patients aids in monitoring polypharmacy as well as to determine the factors contributing to it. Objectives: To analyse the drug utilization pattern in geriatric patients at a rural health training centre. Subjects and Methods: A cross-sectional study was conducted in a rural health centre to assess the drug utilization pattern using the WHO core drug prescribing indicators. Polypharmacy was defined as usage of 5-8 drugs and excessive polypharmacy as intake of 10 or more drugs. The drugs were coded using Anatomical Therapeutical Chemical classification. Univariate and bivariate analysis were done using SPSS to present the data. Results: Among 207 patients, 29.5% were on polypharmacy and 1.5% patients on excessive polypharmacy. About 75% of patients had one or more comorbid medical condition. A total number of 829 drugs were prescribed and the average number of drugs per prescription was 4.02. Conclusion: The drug utilization pattern analysis in the geriatric patients reveals deviation of the average number of drugs per prescription from the WHO standard recommendation. The most common comorbid condition among the geriatric patients was diabetes mellitus. This drug utilization study imparts knowledge about the use of polypharmacy, comorbidities and the pattern of commonly used drugs among the geriatric patients in rural area. Periodic assessment of the pattern of drug utilization in the elderly aids to improve the prescribing pattern and minimize patient harm.
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Comparative role of tenofovir versus entecavir for treating patients with hepatitis B virus-related acute on chronic liver failure p. 2642
Sharker M. S. Hossain, Mamun A Mahtab, Dulal C Das, Sheikh M Noor-E-Alam, Ayub A Mamun, Md. Sakirul I Khan, Sheikh M. F. Akbar, Md Zakiur Rahman, Salimur Rahman
DOI:10.4103/jfmpc.jfmpc_2299_20  
Introduction: The aim of the study was to compare the safety and efficacy of tenofovir versus entecavir for treatment of naive acute on chronic liver failure (ACLF) due to hepatitis B virus (HBV) (ACLF-B). Methods: Thirty-two patients aged 14-65 years were enrolled in the study. Diagnosis of ACLF was confirmed by clinical condition, biochemical analysis, and virological data. The causes of both chronic liver damages and acute insult in all patients were HBV. They were expressing HBV DNA in the sera, positive for IgM anti-HBc, had increased levels of serum bilirubin, compromised prothrombin time; and more than 50% patients had encephalopathy. The standard dose of tenofovir and entecavir was given. Results: The antiviral effects of tenofovir and entecavir were evident as most patients became negative for HBV DNA in the sera after 90 days of therapy. Also, the levels of serum bilirubin, CTP (Child-Turcotte-Pugh) and MELD (model for end-stage liver disease) score exhibited significant improvement due to antiviral therapy. Although the improvement of liver functions, and liver damages were detected in patients receiving both tenofovir and entecavir, the survival of the patients was significantly higher in those receiving tenofovir compared to entecavir-treated patients. Conclusion: This prospective study with limited number patients provides a challenge to assess the real potential of tenofovir over entecavir as therapeutic option for ACLF-B by conducting a multicenter clinical trial enrolling patient of different races and background.
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Consumption of fruits, vegetables and salt in the context of control of type 2 diabetes and hypertension in Kerala, India Highly accessed article p. 2646
Jissa V Thulaseedharan, P Sankara Sarma, Kavumpurath R Thankappan, Biju Soman, Ravi P Varma, Kannan Srinivasan, Manju R Nair, Panniyammakkal Jeemon, V Raman Kutty
DOI:10.4103/jfmpc.jfmpc_2469_20  
Background: Proper diet is necessary to control hypertension and diabetes. This paper describes the combined fruit and vegetable, and salt intake of adults (>=18 years) who were detected to have hypertension or diabetes. Methods: We analysed the data from a state-wide survey of 12012 adults using the World Health Organization STEPs for NCD risk factor surveillance. We evaluated the recommended intake of fruit and vegetable (>=5 servings/day) and salt (<5 gm/day) across participants divided into four strata, and the probabilities were also estimated using the fitted multiple binary logistic regression models. Results: Overall, 13.9% (95%CI: 12.2%-15.9%) and 29.4% (95%CI: 28%-30.8%) of participants consumed the recommended level of fruit and vegetable, and salt, respectively. Adjusted odds ratios were not significantly different across the four strata based on the status of treatment and control of diabetes or hypertension. The likelihood of following the recommended fruit and vegetable intake was highest for 50-69-year-old females with above high school education, obese, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.28). The likelihood for recommended salt intake was highest for 50-69-year-old males with above high school education and had normal BMI, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.69). Conclusion: The status of diabetes or hypertension did not show considerable influence in the fruit, vegetable, and salt intake of adults in general. A detailed exploration of the accessibility and acceptability of such recommended intakes in the Kerala context is warranted.
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Relative risk factors for seropositive hepatitis E virus among blood donors and haemodialysis patients: The pivotal role of primary health care education p. 2655
Nassir A Babiker, Adam D Abakar, Nawal T Mohamed, Nadir Abuzeid, GadAllah Modawe, Mohamed A Iesa, Sami Assil, Hisham Osman, Mohamed Hamed, Mohamed H Ahmed
DOI:10.4103/jfmpc.jfmpc_2441_20  
Background: Hepatitis E virus is a zoonotic virus with a worldwide epidemic outbreak. The aim of the study was to identify relative risk factors and co-infections concerning the seropositive HEV IgG among blood donors and haemodialysis (HD) patients in the central blood bank and renal dialysis centre in Wad Medani city, Gezira State, Sudan. Materials and Methods: This was a cross-sectional study that included 600 participants, among them 180 showed strong seropositive HEV IgG. The structured questionnaire was used to collect data of the participants' demographics, disease risk factors and HEV IgG co-infections with HBV, HCV, HIV and syphilis. Results: Among the 180 strong seropositive HEV IgG respondents, 84 were blood donors and 96 were haemodialysis patients. The gender and age (18–30 years) had a significant association with the virus exposure (P = 0.000, P = 0.000). Importantly, a significant association of HEV prevalence due to the localities effect exhibited with the highest rate among South Gezira (OR = 38, CI = 14.1–107; P = 0.000). This also observed in Wad Medani, Umm Algura, East Gezira and Managil localities (P = 0.000). The effect of the animal contact on HEV distribution exerted the significant association among the respondents for blood donors and haemodialysis patients in univariate (OR = 4.09, 95% CI 1.5–10.9; P = 0.005) and multivariate (OR = 3.2, CI = 1.1–9.4; P = 0.027) analysis. Conclusion: The relative risk factors of the HEV seroprevalence were gender, age, locality and animal contact. Besides the need of a regular survey for the virus seroprevalence, primary health care physicians can play pivotal role in health education, especially in rural areas of Sudan. In addition, primary health care physicians in Sudan are expected to establish strategies and plans to eradicate and minimise the health impact of HEV.
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Lifestyle and behavioral changes during nationwide lockdown in India—A cross-sectional analysis p. 2661
Vishwambhar Singh, Pankaja Raghav, Garima Singh, TB Pritish Baskaran, Anil Bishnoi, Vedangi Gautam, Ashvanee Kumar Chaudhary, Ashutosh Kumar, Sagar Kumar, Suraj Sahu
DOI:10.4103/jfmpc.jfmpc_2464_20  
Introduction: After almost two months of reporting the first case of the novel coronavirus disease (COVID-19) in the country, the nationwide lockdown in India was initiated on 24th of March 2020, to curtail the spread of the SARS-CoV-2 infection in the country. While this lockdown had been in place for almost 3 months, the people of the nation have experienced changes in their routine lives in a wide range of activities, including personal behaviours. This study was conducted to identify the impacts that the lockdown had on the lifestyle and behavioural aspects of Indians during the lockdown. Methods: It was a cross sectional study, conducted by online survey. Data collection was done for the period of 3 months. Results: The study found that a huge number of participants had significant changes in their diet, sleep, bowel habits and also their personal traits. Also, the lockdown had improved interpersonal relationships and helped people explore their hobbies or even acquire a new skill (about 25% of the participants). More than 90% of the participants perceived decrease in air pollution and a majority reported increase in personal hygiene (74.2%), perceived decrease in crime rates (67.3%) as benefits of lockdown. Conclusions: It would be recommended to include variables to screen for mental health issues among the general population.
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Schoolteacher's knowledge, attitudes, and practice toward student with epilepsy in Taif, Saudi Arabia: Cross-sectional study p. 2668
Sarah Hasan Alzhrani, Maram Hassan AlSufyani, Rehab Ismail Abdullah, Sultan Almalki
DOI:10.4103/jfmpc.jfmpc_2087_20  
Background: Globally, teachers have misconceptions about epilepsy and its management. Little is known about Saudi Teachers' knowledge about epilepsy in Taif City. Method: Descriptive questionnaire-based cross-sectional survey of a sample of schoolteachers in Taif Governate. Results: The study included (n = 420) schoolteachers. All heard about epilepsy and (n = 116, 27.6%) knew about epilepsy from an afflicted individual, and (n = 102, 24.3%) from social media outlets. Most teachers believed that an epileptic fit constitutes seizures (n = 370, 88.1%). Some (n = 330, 78.6%) were not satisfied with their knowledge level. Attitudes were positively associated with years of experience, but, generally, were only modest with 50.2% fearful of having an epileptic child in class. The mean practice score was 6.9 (out of 15). Practice was improved by having a pupil with epilepsy in class. Discussion and Conclusion: Schoolteachers in Taif showed excellent crude knowledge about epilepsy. However, knowledge of crucial details of the disorder were poor. This could be due to reliance on social media for information. There was high level of insight among schoolteachers regarding their sub-optimum knowledge levels. Knowledge was much better among experienced schoolteachers. Witnessing an epileptic fit improved knowledge. Teachers' attitudes toward epilepsy were negative, likely because of significant epilepsy-related stigma. Years of experience were significantly associated with increased attitude score. Schoolteachers' actual practice in handling epilepsy cases was below-expectation. There is pressing need for high-quality workshops to address knowledge and practice deficits.
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Sociodemographic features associated with Hepatitis C Virus (HCV) in pregnant females: A tertiary care centre study from Malwa region of Punjab (North India) p. 2679
Neerja Jindal, Lajya D Goyal, Charu Singh
DOI:10.4103/jfmpc.jfmpc_2372_20  
Background: Hepatitis C virus (HCV) infection is high in state of Punjab, however very few studies have been done till date. We all know that pregnant females are a most important section of our community and are usually screened for HCV, HIV, and Hepatitis B at time of presentation. HCV is capable of causing chronic infections and having long-term implications on a person's health. Vertical transmission of HCV can be one of the major route of transmission of this virus to the neonate and there have been various sociodemographic factors like age, literacy, socioeconomic status, occupational status, associated with the disease causation and transmission. Methods: All pregnant females attending Obstetrics and gynecology department of our institute were included in study. All the sociodemographic characters and socioeconomic records were retrieved and analyzed. Results: In our study also a lower socioeconomic status, illiteracy have been significantly associated with the HCV-positive group, thus emphasizing the role of education so as to impart education to the masses as regard to mode of transmission and its effects on the disease. Higher age of conceiving is also significant associated with the increased maternal risk. Conclusions: The more involvement of health care officials and even persons not related to health care set up is required who can educate masses so as to protect the community.
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Awareness and attitude about basic life support among medical school students in Jeddah University, 2019: A cross-sectional study p. 2684
Yousef Abdulwahab Alghamdi, Tariq Ahmad Alghamdi, Fahad Saleh Alghamdi, Amal Hassan Alghamdi
DOI:10.4103/jfmpc.jfmpc_2557_20  
Objectives: To measure the level of knowledge and awareness towards basic life support (BLS) among students in preclinical years at Jeddah University (JU), and to determine their willingness to participate in BLS training in the near future. Subjects and Methods: A cross-sectional study was conducted among first-, second-, and third-year medical students of JU. A 27-item questionnaire measured the level of awareness and knowledge about BLS, including: 1) basic Information (seven items); 2) rescue reflex (eight items); and 3) CPR technique and process (12 items). Demographic and academic data, experience and exposure to BLS, and attitude regarding BLS (six items) were analysed as factors of adequate knowledge. Results: One hundred and four male students participated and 65 (62.5%) of them were in the second academic year. The correct answers varied from 10.6% to 67.3%, with eight items having <30% correct answers; and seven items showed >50% correct answers. Mean (SD) and median (P75) overall knowledge scores were 37.86 (13.92) and 37.04 (44.44) out of 100, respectively. Twenty-four (23.11%) participants attended a training course in BLS and 13 (12.5%) have ever performed BLS, either voluntarily or not voluntarily, and 18 (17.3%) felt that their current knowledge was sufficient. Knowledge level showed no statistically significant association with any of the investigated factors. Conclusion: There is an urgent need to integrate BLS courses to medical students to enrich their knowledge and improve resuscitation skills and ensure implementation of correct resuscitation techniques.
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Prevalence and associated factors of stress among primary health care nurses in Saudi Arabia, a multi-center study p. 2692
Duoaa Seddiq Abdoh, Mohammed Adeeb Shahin, Ahmed Khalid Ali, Shumukh Mohammed Alhejaili, Osama Madani Kiram, Sami Abdo Radman Al-Dubai
DOI:10.4103/jfmpc.jfmpc_222_21  
Background: Nursing practice has been identified as one of the most stressful professions within the healthcare systems. The current study aimed to determine the prevalence of stress and its associated factors among primary healthcare nurses. Materials and Methods: This analytical cross-sectional study was conducted among 200 Saudi nurses in the government primary health care centers in Medina city, Saudi Arabia. Stress was measured by the stress subscale of the 21-Item Depression, Anxiety and Stress Scale. Sources of stress were assessed by 15 items. Results: The majority were females (68.0%) and aged less than 40 years (72.5%). Thirty percent had severe or very severe stress. Stress was associated significantly with the presence of chronic diseases (P = 0.037) and with working in night shifts (P = 0.042). All sources of stress in the workplace were associated significantly and positively with stress (P < 0.01). Conclusion: About one-third of the participants had stress. Improving work conditions and minimizing stress in the workplace should be a priority in the primary health care setting.
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Medication take-back programs in Qatar: Parental perceptions p. 2697
Mohamed A Hendaus, Shereen Darwish, Manar Saleh, Omar Mostafa, Ahmed Eltayeb, Mohammed Al-Amri, Faisal J Siddiqui, Ahmed Alhammadi
DOI:10.4103/jfmpc.jfmpc_1141_20  
Purpose: To identify parental perception of a take-back program for medications. Materials and Methods: A cross-sectional study using a questionnaire was conducted at Hamad Medical Corporation, the only tertiary pediatric hospital in the State of Qatar at the time of the study. Qatar is a rapidly developing country with limited national data on the awareness of medication misuse among adults living with children at home and on the safety practices regarding medication disposal. Results: 305 questionnaires were completed (response rate = 90%). More than 80% of parents were in between 20 and 39 years of age, 70% of them were females, and 80% were college graduates. Approximately 90% of participants have immediate relatives who were taking medications for chronic diseases. Almost 60% of parents stated that they keep unused medications at home, whereas 10% were not aware of the fate of the left over medications. Approximately 95% of the parents dispose the expired medications. In terms of the mode of disposing the medications, 66% of caregivers dispose the medication bottle or package in the trash can, whereas 14% remove the medications from the bottles or packages and throw them in the trash, and 15% put them through the drain. When asked if participants read disposal measures in the medication pamphlet, only 10% answered “always,” whereas 26% answered “sometimes.” Participants were asked if they have heard of any medications take-back programs, 75% answered no, whereas 14% were not sure. However, almost 60% of them will use the take-back program if available and 18% were not sure. Conclusion: Parents residing in the State of Qatar have deficiencies in knowledge about medication disposal. Parent's attitudes and perceptions are considered indispensable targets for community health intervention. Our next step is to share our data with the ministry of health to spread awareness about the proper disposal of medicines and take-back programs in Qatar.
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CASE REPORTS Top

Fifty Shades of COVID-19 – Immune Thrombocytopenic Purpura in HIV-TB-COVID Co-Infection p. 2703
Rohit Kumar, Saurav Sekhar Paul, Ved Prakash Meena, Pavan Tiwari, Sushma Bhatnagar, Anant Mohan
DOI:10.4103/jfmpc.jfmpc_1939_20  
SARS CoV-2 infection is associated with various hematological manifestations, including leucopenia, thrombocytopenia, thrombocytopenia. Severe thrombocytopenia is, however, rare and is associated with severe COVID-19. ITP remains an important differential among other causes. We report a case of HIV-TB-COVID-19 co-infection, without any feature of severe COVID, presenting with severe thrombocytopenia which resolved on its own; cause was attributed to immune-mediated effect of SARS CoV-2 virus.
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Getting paralysed after COVID: Guillain–Barre syndrome p. 2706
Sameer K Mehta, Ashok Sunder
DOI:10.4103/jfmpc.jfmpc_2454_20  
Neurological involvement after coronavirus disease (COVID-19) pneumonias is common and occurs in almost one-third of the patients. The commonest neurological symptoms are ageusia, anosmia, headache, nausea, vomiting, dizziness, and myalgia. Guillain–Barre syndrome (GBS) is a rare manifestation of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection; whereas the common neurological manifestations of the SARS-CoV-2 infection occur with the onset of the respiratory symptoms and may be due to the direct invasion of the nervous system by the virus, GBS in COVID-19 follows a time lag of 1–4 weeks and may be attributable to the immune mechanism of molecular mimicry. Here we report a case of GBS in a patient of COVID-19 which occurred on the 22nd day after the onset of the disease. The patient recovered completely and went home walking.
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Outcome of scrub typhus in pregnancy during COVID-19 pandemic: A case report p. 2709
Amrit Gupta, Kalika Dubey, Mansi Gupta
DOI:10.4103/jfmpc.jfmpc_2404_20  
Coronavirus disease 2019 (COVID-19) pandemic has emerged as the major public health threat in recent times. Although associated with high morbidity and mortality affecting all age groups across populations, “pregnant women” represent a subgroup that needs extra surveillance. We present the case of a primigravida in her advanced pregnancy presenting with acute febrile illness with flu-like symptoms. The clinico-radiological picture was suspicious for COVID-19; however, she tested negative for COVID-19 on two occasions. On further investigations, she tested positive for Scrub typhus (IgM-ELISA) and responded to treatment with doxycycline. However, due to the ongoing COVID-19 pandemic, much time was lost before suspecting and reaching the final diagnosis. Therefore, the patient had to suffer due to delayed medical intervention and intrauterine fetal death. Despite the unprecedented rise of COVID-19 in pregnant women in recent times, we should not forget about other tropical illnesses, which can mimic COVID-19 in clinical presentation and affect feto-maternal outcomes adversely.
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Seizure after recovery from Covid-19 p. 2713
Sidhartha Chattopadhyay, Sagar Basu, Kamalesh Majumdar
DOI:10.4103/jfmpc.jfmpc_2478_20  
There are various neurological presentations of covid-19 but here we report a 27-year-old female developed first episode of seizure, 14 days after documented SARS-CoV-2 infection. She had generalized tonic-clonic seizure with multiple injuries. She had no previous or family history of seizure but she had generalized anxiety disorder and was doing well on selective serotonin reuptake inhibitor (SSRI). Electroencephalogram (EEG) showed theta waves background (likely post-ictal discharges). Magnetic resonance Imagining (MRI) Brain showed features of focal cerebritis on both the frontal lobes. She was started with anti-epileptic drug. After 6 weeks, repeat MRI Brain and EEG were completely normal.
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A case report on umbilical endometriosis p. 2716
Kewithinwangbo Newme, Ranendra Hajong, Raguangjienlungle Newme, Keyikawangbo Newme
DOI:10.4103/jfmpc.jfmpc_2375_20  
Endometriosis is generally common benign disease manifested by the presence of uterine tissue outside the uterus. Umbilical endometriosis as such is rare entity but many a time it may go unnoticed to general physician if no symptoms arises from it. The documented case of umbilical endometriosis case is below 100 as per the case reports research. Here, in the case report we present an umbilical endometriosis arises after a laparoscopic and umbilical hernia repair procedure.
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Neonatal dermatitis neglecta---Neglect by health system: A case report p. 2718
Manish Taywade, Prem Sagar Panda, Chandra Sekhar Sirka, Binod Kumar Patro
DOI:10.4103/jfmpc.jfmpc_2442_20  
A 29 days old female child presented to the general outpatient department of Community Health Center with greenish black crusting over left ear for 7-8days duration without any other signs and symptoms. We report the diagnosis and management of the condition through ad-hoc store and forward tele-dermatology. This is the first reported case of dermatitis neglecta in neo-natal period.
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LETTERS TO EDITOR Top

Trends in pattern of communicable diseases during COVID-19 lockdown in Kerala p. 2720
SM Azhar, Anoop S Nair, Shyama Devi, Jaison Jacob, Sam Jose
DOI:10.4103/jfmpc.jfmpc_2390_20  
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Role of materiovigilance in COVID era: An update p. 2722
Ahmad Najmi, Shilpa Kaore, Balakrishnan Sadasivam, Avik Ray
DOI:10.4103/jfmpc.jfmpc_2499_20  
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Impact of social factors on medical illnesses and their management p. 2724
Harish Gupta, Nitu Nigam, Medhavi Gautam, Sudhir K Verma
DOI:10.4103/jfmpc.jfmpc_590_21  
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COVID-19 vaccination drive in India – Beginning of the end p. 2726
Rohit Bansal, Priya Bansal
DOI:10.4103/jfmpc.jfmpc_294_21  
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