COVID-19 has exposed the fault lines of India's public health system. The pandemic can be a useful window of opportunity to undertake public healthcare reforms that are long due. Such reforms are, however, constrained by the path-dependent characteristics of private healthcare in India. Measures taken to expand healthcare during the pandemic appear unlikely to sow the seeds of successful path transformation, and may rather reinforce the private sector dominated trajectory. Policymakers must introduce a bold set of pro-public healthcare reforms during the pandemic, which can then be incrementally built upon through securing legitimacy and support.

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SARS CoV2 is an emerging infectious pandemic. The preemptive measures taken to curtail the spread has its effects far and wide across different sectors and all age groups. The most unspoken sufferers are adolescents. In this article, we have reflected on how adolescent issues addressed by the government's dynamism, have had collateral damage due to the COVID initiatives. Globally, around 89% are currently not in school because of COVID-19. They will pave a way to unforeseen collateral effects on the physical, social, psychological health, and future of the young minds. From an increase in school drop-outs, interrupted learning, worsening of the gender gap in education to technology dependence and addictions, this pandemic is going to unravel the uninvited social evils. The regular benefits of adolescents from the government have not been paid heed to. Supply of IFA tablets, sanitary napkins, provision of supplementary nutrition, health education, and implementation of immunization activities are a few of the services to mention which are being hampered. We have recommended a few strategies like establishing the peer educator system in disseminating COVID-related awareness, engaging them in a smooth public distribution system, and act as a potential linkage for the families in distress. We have proposed a few modus operandi like direct cash transfer or food supplements as take-home rations will be able to sustain the nutrition of the adolescents to keep the flow of uninterrupted amenities to adolescents in education, nutrition, mental health, personal hygiene, and other such sectors.

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SARS-CoV-2 is the third major coronavirus epidemic to affect humans. There had been multiple instances of patients turning positive after recovering from SARS-2-CoV infection. Though many different theories emerge, false positive RT-PCR is logically the foremost cause and there is a general consensus that during quarantine re-infection from outside seems unlikely when strictly adhered to. As many new strains emerge worldwide during the course of on-going pandemic, the chances of re-infection cannot be ignored as it may contribute to false negative RT-PCR test results. SARS-2-CoV though a novel virus, is phylogenetically similar to SARS-like CoV with around 79% similarity. Studies on immunological response to these infections suggest that antibodies formed after infection confers immunity only for a short period of time before it starts to wane. Also studies on SARS-CoV-2 suggest that antibody formation and longevity of immunity in an individual is dependent on the strain of coronavirus, its severity and age of the person infected. All these considerations demand reviewing the treatment duration, discharge criteria, appropriate use of imaging techniques and importance of risk communication and health education to those recovered.

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Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.

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People living with comorbidities especially chronic non-communicable disease (NCDs) like diabetes and hypertension are at greater risk of acquiring severe form of Corona Virus Disease (COVID-19) infection known to be caused by Severe Acute Respiratory Syndrome-CoV –2 (SARS-CoV-2) due to underlying immunodeficiency. The government has taken various public health measures to reduce the risk of infection, such as physical distancing, Information Education and Communication (IEC) messages regarding hand-washing, usage of masks, and avoidance of unnecessary travel including lockdown to combat the spread of disease. However, nationwide lockdown due to COVID-19 pandemic has also confronted the existing health care system (clinician centric approach) for the management of diabetes and hypertension in India. Using secondary source of data from specific website and search engine a review was done for existing guidelines and literature focusing on the various components of self-care management (patient-centered care) and highlights the importance of self-care management education to cope up with twin pandemic of COVID-19 and NCDs. An attempt was also made to highlight the use of eHealth to manage diabetes and hypertension which may act as a bridge to fill the gap between primary care physician and patient's amid lockdown and help physician to deliver comprehensive care for people suffering from comorbidities.

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Penile fracture is a well-recognized but uncommon urological emergency. It is a tear in the tunica albuginea with rupture of corpus cavernosum. It may be associated with injury to corpus spongiosum and urethra. Diagnosis is usually clinical and Urethral injury should be suspected in penile fracture, especially in those cases with urethral bleeding and bilateral cavernosal rupture. Penile fracture is most commonly caused by injury during sexual intercourse. It has also been described with masturbation, rolling over or falling onto the erect penis, and other scenarios. A cracking or popping sound followed by pain, rapid detumescence, discoloration and swelling of penile shaft and urethral bleeding are common presenting symptoms. Prompt surgical intervention with closure of tunica albuginea is the treatment of choice with satisfactory cosmetic and functional results. We report a case of fracture penis in a 25-year-old male who came to emergency department of our hospital.

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The outbreak Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a highly contagious and lethal beta coronavirus SARS-CoV-2, which has spread fast to encroach the entire globe and hence declare pandemic. Pregnancy alters body physiology and immune systems, can have worse effects of some respiratory infections and due to limited research and published data we still are in dilemma of appropriate management guidelines This article covers the updated guidelines for infection prevention and control (IPC), screening, sampling, antenatal visit schedules, risk scoring, triaging, supportive care, delivery, postpartum care and care of the newborn. This article aims to provide up-to-date information as per recent guidelines of various association which would serve as guidance in managing pregnant women and newborn with suspected or confirmed COVID-19. All the published papers till date, NCPRE, WHO Interim guidelines, RCOG, FOGS GCPRI, Medical Council of India^, ICMR, MOFHW, CDC^, ACOG guidelines are referred to compile this article to reach to a conclusion of evidence based management of pregnant ladies during COVID-19 pandemic. This article covers the not only infection prevention and control (IPC) guidelines, but also screening and sampling guidelines, antenatal visit schedules, risk scoring, triaging but also in-patient supportive care, delivery, postpartum care and care of the newborn. Data are very limited and hence very difficult to accurately define clinical management strategies and needs to be constantly updated.

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Background and Objectives: Social media offers a platform for its users to share information and spread awareness regarding various issues including mental health problems. In some previous studies it was found that people suffering from mental health issues benefited from social media. However, the use of social media is also significantly associated with increased depression, mood and anxiety disorders in adolescents. Furthermore, it was found that the prevalence of poor mental health was high in medical students. With this background, this study was taken up to contribute to the scarce literature about the impact social media has on the mental well-being of medical students. Methods: The setting was a medical college and research centre, situated in the metropolitan city of Bengaluru in Karnataka. A pretested and predesigned questionnaire was self-administered anonymously by 318 students. The data was analyzed using appropriate statistics. Results: A statistically significant relationship was found between the amount of time spent on social media and the mental well-being score, according to the Sell and Nagpal scale, of students. In participants with scores of < 90.8, (30.2%) of them used social media for 4 hrs or more, as opposed to those with scores ≥ to 90.8, (35.6%) of them spent between 1 and 2 hrs a day on social media, 90.8 being the mean well-being score in India. Conclusions: Students need to monitor their screen time. There is a need to go back to old times of establishing human connections and, families and friendships should be nurtured.

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Objectives: A three-member central Rapid Response Team (RRT) was deputed to Union Territory of Ladakh on 26^th March 2020, to assess the situation and support the preparedness measures including implementation of cluster containment plan and social distancing measures for coronavirus disease 2019 (COVID-19). Methods: Central RRT addressed the panchayat sarpanch and religious leaders, sensitized doctors and paramedical staff on COVID-19 situation; conducted situational analysis, review of records and logistics, key informant interviews of senior administrative and healthcare officials, focus group discussions with local community people and field visits to various hospitals, isolation centers, quarantine facilities, and containment zones. Results: A total of 14 COVID-19 cases with no deaths were reported and nine patients had recovered till 4 April 2020. The median (range) age of positive cases was found to be 32.5 (6 months–76 years) years and overall attack rate was 1.65 per 1000 population. Ladakh Government declared Chuchot Gongma, Yokma and Sankoo as the containment zones and deputed surveillance teams. A total of 2397 persons were quarantined and 496 samples were tested from Ladakh. COVID-19 sample testing, Srinagar-Leh highway opening and Iran pilgrimage returnees were the major challenges identified. Conclusions: The Ladakh government must continue the robust surveillance system and stringent strategies in key areas for management of COVID-19 namely – aggressive screening and testing, isolation, quarantine, hand hygiene, respiratory etiquettes and social distancing.

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In the present scenario of COVID-19, there has been a sudden surge in demand for tele- consultancy. Such measures require resources to support the system. Replacement of conventional equipment used in a clinic with digital equipment is not feasible due to their cost and scalability issues. The authors developed a simple low-cost (almost zero cost) method to convert a conventional stethoscope into a tele-stethoscope. Such a simple modification can be useful in periphery wherein doctors are still not available and the growing number of patients would require a diagnosis of the chest conditions.

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Aim: The study aimed to measure the level of the stigma of medical students at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh campus, towards mentally ill patients. Material and Methods: A cross-sectional survey was conducted in King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh. The data collection was started in July 2017 till March 2018. The students completed a self-administered questionnaire consisting of sociodemographic data and the Community Attitudes toward the Mentally Ill (CAMI) Scale. Results: The sample size was realized as 274 participants. There were no significant differences in all CAMI subscales for the different academic years except for Authoritarianism which showed a significant increase in the level of stigma (P-value = 0.04). Male gender, previous psychiatric treatment, and having a relative with psychiatric illness were associated with higher Authoritarianism and Social Restrictiveness scores and lower Benevolence and CMHI scores. Discussion: More stigma was observed among the 4^th year students and it might be due to insufficient academic preparation as well as more exposure to psychiatric rotations. Conclusion: The results support the importance of implementing anti-stigma programs throughout the medical program to improve the healthcare provided to mentally ill patients.

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Background: Chronic anal fissure is a common condition which is classically treated by surgery which may lead to incontinence. Recently medical treatment in form of calcium channel blockers (CCB) has gained interest. Aims: The aim of this study is to compare the effectiveness of local Nifedipine and Diltiazem with lignocaine as control. We also aimed to observe the clinical pattern of chronic anal fissure. Material and Method: Patients of chronic anal fissure were divided into three groups. First group received topical Nifedipine, second received topical Diltiazem, and the control group received only local lignocaine for 1 month. Their clinical data was recorded. The intensity of pain and bleeding was assessed from a visual analogue score (VAS). On the 4^th week patients were examined for healing. Statistical Analysis: Statistical analysis was done by Medcalc statistical software v14. Student's t-test and Chi-square test was used accordingly. Results: Mean age was 35.89 with a male female ratio of 1.7:1. Most common clinical feature was pain (100%), followed by constipation, bleeding, and pruritus. Most common location was posterior. VAS scores for pain of the Nifedipine group and Diltiazem group was significantly better than control group (P < 0.0001). VAS scores for bleeding in the Nifedipine group (P = 0.0091) and Diltiazem group (P = 0.0045) was significantly better than control group. The healing rate for NFD group was 93.33% (P < 0.0001), that of DTZ group was 86.67% (P = 0.0002), which was statistically better than control group (36.67%). There was no significant difference between the two CCBs. Conclusion: Adding topical Nifedipine or Diltiazem in the treatment of anal fissure is far superior to treatment with only topical Lignocaine.

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Background: It is imperative to acknowledge that COVID-19 poses significant burden on the psychological well-being of people. With implementation of lockdown and measures like quarantine, the mental health of people is affected, and the associated problems may range from depression to suicidal ideation. With this background, the aim of this study was to assess COVID-19 anxiety among general population of the state of Andhra Pradesh. Materials and Methods: This cross-sectional study assessed the COVID-19 anxiety among the population of Andhra Pradesh using COVID-19 Anxiety Scale (CAS-7), a seven-item validated psychometric instrument which assesses the cognitive, emotional, and physiological dimensions of COVID-19 anxiety, using a semantic differential scale. The final sample constituted 1,346 participants. Statistical analysis was done using SPSS version 20 software (IBM SPSS statistics for Windows version 20, Armonk, NY, USA). Results: The mean age of the study participants was 36.13 ± 10.2 years, and 55.8% were males. The mean CAS-7 score in this study was found to be 18.9 ± 6.4. The item with highest mean scores was: “How concerned are you when people cough or sneeze because of the fear that you may acquire COVID-19?” No significant differences in CAS-7 scores were found based on gender, educational qualification of the participants, while significant differences were observed based on place of residence, presence of COVID-19 affected individuals in close surroundings, tobacco, and alcohol consumption. Conclusion: The results of this study inform that it is imperative for authorities and health care professionals to focus on the mental health aspect of COVID-19 and arrange for necessary support mechanisms.

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There are pressing issues that are plaguing healthcare systems across the world (especially in the lower-middle-income countries), which comprise low-quality care, affordability, accessibility, poor infrastructure, violence against healthcare personnel, deficiency of physicians and healthcare staff. COVID-19 has put an immense physical and mental strain on the young physicians who are at the forefront in fighting this pandemic. This has lead to an increase in incidences of burnout among young doctors, which adversely impacts the quality of healthcare, patient well-being and satisfaction. The present-day medical training typically creates solo medical experts; but, modern-day management of patients and organisations require team-work and leadership. To profoundly alter the way the young physicians work and for creating physician leaders for the future, leadership training ought to commence during the medical school.

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Context: Primary healthcare in India is provided by both public and private providers. However, access to good quality primary healthcare is lacking in underserved populations such as communities in rural and remote areas and families in low income quartiles. While there are government programs on comprehensive primary healthcare, stagnant investments restrict their reach and quality. At the same time, there are several for-profit and not-for-profit primary healthcare providers that fill the gap, but are limited in scale and geographical reach. They also often find it challenging to provide affordable comprehensive primary healthcare. Aims: The Consultation on Financing Primary Healthcare was organized to draw lessons for financial sustenance of comprehensive and equitable primary healthcare initiatives. Eighteen academicians and practitioners, representing different institutions from across India, presented and engaged in discussions around the theme of financing primary healthcare. Methods and Material: The Consultation proceedings were recorded, transcribed, analyzed, and synthesized to bring out the key insights. Results: The Consultation drew insights from the experiences and evidence shared by the participants on the ways to finance primary healthcare services sustainably, especially for underserved populations. The financing models discussed include public-private partnership, user fees, community financing, subscription and cross-subsidy. Cost-reduction strategies such as task-shifting and use of appropriate technology were also identified as key to improving efficiency in service delivery.

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Corynebacterium diphtheriae is a gram-positive bacillus with characteristic polar metachromatic granules. It was a significant public health problem, infecting the throat and upper airways and producing a highly potent exotoxin but with the advent of diphtheria vaccine, cases have rapidly decreased. Now over the last decade, the reemergence of this infection has been noted and case reports from India have been documented. India represents 78% of globally reported cases with significant mortality despite national immunization programs in place. This case study indicates the severity of an improperly managed case, the importance of microbiological diagnosis with a special interest in molecular detection, and reinforces a resurgence of diphtheria infection.

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Through this manuscript, we would like to share our experience with building a COVID hospital, allocating duties, planning and managing supplies during COVID-19 pandemic. This manuscript is prepared by the Doctors of various specialties with vast experience involved in actual planning of the infrastructure and resources. This comprehensive manuscript will help teams to prepare and train, stockpile necessary equipment and prepare their staff to deal with current crisis if there is a surge in infected cases.

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Context: Anemia is a serious public health concern especially in women of reproductive age (WRA) as it causes a high burden of morbidity and mortality and persists through intergenerational cycle. As most of the risk factors are preventable, a thorough understanding of its risk factors is necessary to design better interventions. Aims: Current study aimed to estimate the burden of anemia as well as explore determinants of various grades of anemia among WRA in a rural area. Settings and Design: A community-based cross-sectional study was conducted among non-pregnant, non-lactating women of reproductive age in rural field practice area of All India Institute of Hygiene and Public Health. Methods and Materials: House to house visit was conducted for interviewing with pre-designed pre-tested questionnaire along with blood hemoglobin and anthropometric measurement. Statistical Analysis Used: Descriptive statistics and test of significance like multinomial logistic regression and Kruskal-Wallis test (with post-hoc) were used. Results: Majority (70.8%) of participants were anemic. Proportion of mild, moderate, and severe anemia were 24.16%, 37.5%, and 9.16%, respectively. Different levels of anemia were significantly associated with higher age, lower education, poor iron-rich food intake, lack of dietary diversity, and adiposity. Significantly low hemoglobin level in both underweight and obesity was noticed suggesting U shaped relationship between BMI and anemia. Conclusion: Periodic screening for anemia among WRA especially in both extremes of malnutrition, i.e., undernutrition and obesity should be considered at the policy level. Year-round behaviour change communication campaigns must be carried out for the promotion of necessary food groups in diet.

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Context: The prosthetic technology in recent years has grown by leap and bounds. The most advanced gadgets like microprocessors are available worldwide at exorbitant costs. Developing countries have issues with terrain, access to services, and cost. The new design of the prosthetic knee joint was planned to develop a cost-effective, sturdy, and easy to fit a universal system. Methods and Material: This exploratory design was undertaken to develop a prototype. The design was further developed and tested for its materialistic properties. Pilot study assessing functions using this joint is also underway. Results and Conclusion: The novelty of this knee joint is that locking and unlocking are made simple such that it can be done by the transfemoral amputee at will, with ease, on the spot, independent of the terrain he/she is traversing. The awareness of such a prosthetic joint is vital for family physicians.

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Background: One of the factors that may influence patient adherence to a healthy lifestyle is the adherence of their treating physicians to a healthy lifestyle. This study aimed to measure the lifestyles of primary healthcare center (PHCs) physicians in the Jazan region and to identify the prevalence of diabetes, hypertension, hypercholesterolemia, and obesity among this sample of physicians. Methods: This cross-sectional study was conducted in the Jazan region which lies in the southwest of Saudi Arabia. Data were collected via a questionnaire completed during personal interviews. The questionnaire included several components related to physicians' demographics, lifestyles, and history of chronic non-communicable diseases. Descriptive statistics were performed to summarize the overall lifestyle of the physicians and disease prevalence. Results: A total of 234 physicians agreed to participate in this investigation. The age of the participants varied between 25 and 65 years, with a median age of 38. Almost 70% of the physicians reported BMI levels higher than 25, indicating a high prevalence of overweight and obesity. Twenty-seven physicians reported no engagement in any type of exercise while the majority reported engagement with low-intensity exercise. While 56% reported daily consumption of vegetables, only 41.8% of them reported daily consumption of fruits. The prevalence of hypertension, diabetes, and dyslipidemia was 10.3%, 8.5%, and 3.4%, respectively. Conclusion: Poor lifestyle choices of the physicians may indicate limited engagement of the physicians in providing effective lifestyle counseling to patients visiting their clinics in PHC settings of the studied community.

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Context: India has been witnessing a huge surge of COVID-19 cases, with increasing number of new cases and deaths daily. There is yet no effective vaccine, drug or strategy to combat this disease. Various models of COVID-19 trend and management have been put forward by different researchers, yet no prediction has yet turned out to be close to the reality. Aims: To find an effective public health strategy against COVID control. Settings and Design: Ahmedabad district in Gujarat. Methods and Material: Ahmedabad Model for control of COVID-19 based on Ct threshold has been put forth which stresses upon the fact that higher viral load (super-spreaders) could be an important determinant in spreading infections in the community. Results: The cycle threshold (Ct)-based segregation of laboratory-confirmed positive cases along with contact tracing of all of them of previous 5 days has been found to be effective strategy and needs to be adopted for further management. The Ahmedabad model of COVID-19 control was practiced during 3rd week of June 2020 onwards. Following implementation, cases started declining in Ahmedabad district whereas it showed an increasing trend in rest of Gujarat where it was not implemented. Conclusions: Cases with low viral load may be quarantined at home with standard precaution whereas cases with higher viral load need to be quarantined in institutions (hospital or separate premises away from family).

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Background: There is a paucity of literature on depression among adolescents in the north Indian community. Objectives: The aim of this study was to estimate the prevalence of depression among adolescents residing in a rural community of north India, and to determine associated factors, psychiatric comorbidities, and functional impairment. Methods: A simple random sample of 630 adolescents aged 10-19 years was drawn. Participants were enrolled in house-to-house visits, and screened for depression using the nine-item version of Patient Health Questionnaire (PHQ-9). Diagnostic confirmation and assessment of psychiatric comorbidities was done using Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) for 10-17-year-old adolescents, and MINI for 18 year olds. Prevalence was reported with 95% confidence interval. Multivariable logistic regression analysis was done to determine the association of depression with socio-demographic and other factors. Children's Global Assessment Scale (CGAS) was used to assess functional impairment. Results: The prevalence of depression was 3.7% (95% CI: 2.3–5.2) (n = 583), comparable in both sexes. Over half the participants with depression had psychiatric comorbidities; the most common were conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder; nearly two-fifth had suicidal ideas/attempt. About two-third of participants with depression had functional impairment. Depression was associated with perceived frequent conflicts at home [adjusted odds ratio (aOR) = 4.0 (95% CI: 1.0-16.0), P = 0.049], and perceived stressful event (s) in past six months [aOR = 7.0 (95% CI: 2.4-20.3), P < 0.01], which were predominantly related to academics. Conclusion: Study results indicate the need to strengthen diagnostic and therapeutic/rehabilitative mental health services in adolescent age group. Low-stress lifestyle could be a promising approach to sidestep depressive symptoms.

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This review was intended on major factors contributing to abutment screw loosening. A search of Pubmed and Google Scholar, as well as a manual search, was conducted. Publications and articles accepted for publication up to February 2020 were included. Out of 150 studies retrieved, a total of 57 were selected for this review. Dental implants are associated with a complexity of abutment screw loosening. Implantologists and prosthodontists should be aware of factors that contribute to this problem. In this review previously identified factors were collected, the consideration of which can help to reduce the frequency of abutment screw loosening.

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Context: Epilepsy is said to be intractable when two or more trials of anticonvulsants fail to control the seizures. Literature suggests that intractable epilepsy carries a higher morbidity than controlled epilepsy in children and their caregivers. Aims: The aim of this study is to assess the quality of life (QOL) in children with intractable epilepsy (IE) in KASCH, a tertiary care hospital in Riyadh, Saudi Arabia. Settings and Design: This is a cross-sectional study utilizing a self-administered questionnaire filled by caregivers of epileptic patients visiting the outpatient neurology clinics. Methods and Materials: The quality of life in childhood epilepsy (QOLCE-55) scale examined four domains of life: cognitive, emotional, social, and physical. The sample consisted of 59 parents whose children aged 4-14 of either sex. Statistical Analysis Used: The collected data were analyzed by Statistical Package for the Social Sciences (SPSS) version 22. Results: The mean age of children was 8.9 (SD = 2.9). The mean QOL was 52.8 (SD = 12.9), which reflected a poor QOL. Age was not related to the QOL. Gender was significantly associated with the total and social scores, (P = 0.04) (P = 0.001), respectively. Out of all comorbidities, global developmental delay (GDD) and encephalopathy were significantly associated with the QOL (P < 0.05).Conclusions: Intractable epilepsy impacted all functioning domains of life rendering a poor QOL. Males have reported better QOL and social functioning compared to females. Children with GDD and encephalopathy showed lower well-being.

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Objective: The objective of the study is to identify the etiology, risk factors, frequency of major and minor components of the Framingham criteria for heart failure, discharge medications, mortality, and quality of life after discharge from the hospital, for patients who were admitted to the in-patient unit of a tertiary care hospital in central India, with a diagnosis of congestive heart failure (CHF). Methods: This hospital-based cross-sectional study involved retrospective chart review of patients who were admitted to the in-patient unit with a diagnosis of CHF. These patients were then attempted to reach via their telephone numbers listed in the medical records and their current quality of life was assessed using Euro-QoL 5D questionnaire. Results: In the 69 patients who were admitted to the hospital with congestive cardiac failure during the pre-defined period, ischemic heart disease was the most common etiology and smoking was the most common risk factor for the development of CHF. The most common findings based on Framingham criteria were dyspnea on mild exertion, rales and bilateral ankle edema. It was determined that one-fourth of the individuals were non-compliant to the medical treatment and more than half of the patients had a poor health score. Conclusion: Smoking remains to be a major risk factor for patients to develop ischemic heart disease and subsequent CHF. Patients with congestive cardiac failure also had severe deterioration in their quality of life after discharge from the hospital, implying the need for improving efforts toward prevention and better management.

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The outbreak of the new coronavirus in Wuhan, Chinese Hubei City (COV-2) was also known as COVID-19 and has spread to more than 213 countries, zones or territories worldwide, and is an emergency of international public health with no antiviral drugs or vaccines; and, also, the presencouragement of the disease has become a global public health emergency. This novel coronavirus is now the seventh member of the coronaviridae family, known for infecting humans and showing evidence of causing gastric symptoms, and has the potential to be transmitted through the fecal-oral route according to a new report published online by physicians at Shanghai Jiao Tong University (Gastroenterology. 2020 March 3. doi: 10.1053/j.gastro. 2020.02.054). Here we identify the efforts to compile and disseminate the COVID-19 epidemiological information on Its potential G.I. Demonstration of news media and social networks, and few newspapers recently published. Physicians should know, how GI manifestation discussed in different publications to suspect CORONA virus infection in that patients who does not have any upper and lower respiratory tract symptom and intervein to discuss the disease severity and duration. It will increase the threshold of suspicion of physician toward Covid-19 disease.

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Background: As both orthodontist and patient should play a role hand in hand for the better outcomes of the treatment their knowledge and perceptions regarding problems are important. Hence, the present study was undertaken to evaluate the perception of patients and knowledge and attitude of the Orthodontist with regards to oral mucosal ulceration during the treatment. Material and Methods: For this cross-sectional questionnaire study was two questionnaires were distributed. The first questionnaire was given to orthodontic practitioners (n = 103) to obtain demographic details, measure their knowledge, attitude and practices toward oral mucosal ulcers encountered during orthodontic treatment and the second questionnaire was given to orthodontic patients (n = 190) to record demographics, and experience and perceptions regarding mucosal ulcerations caused by orthodontic treatment and pain severity. Data analysis was done by using SPSS version 22. Cross tabulation was achieved using Chi-square tests and Fisher's exact test. Results: Over half of the patient 63% had oral ulcers during orthodontic treatment. More than half of the orthodontic practitioners 55.3% in this study reported that orthodontic treatment is the cause of oral ulcerations. The majority of orthodontic practitioners 70% participating in this study educated their patients about oral ulcerations by using verbal means of education. Conclusion: Although patients rarely visit their orthodontic practitioner with the complaint of ulcers it may be due to the fact that they seek physcian or implement various home remedies rather than seek their orthodontic practitioner. Further studies are needed to elucidate the correlation between ulcers and orthodontic treatment clinically.

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Introduction: The frequency, as well as the severity of the PMS (Pre-Menstrual Syndrome), varies from female to female based on various socio-demographic, dietary, and lifestyle factors. Nevertheless, the PMS is known to affect day-to-day functioning including interference with school/work productivity, relationships with friends, family, and colleagues. This is especially important for medical students where academic performance is much skillful and demanding. Methodology: The inclusion criteria for this cross-sectional survey were female medical students studying in one of the medical colleges of the city, having regular menstrual cycle (in the last three consecutive months) and willing to participate in the research. Students were assigned from each of the four professional years (First, Second, Third, and Final) through random sampling so that the desires sample size was achieved. The study used a pre-designed questionnaire, the “Premenstrual Symptoms Screening Tool (PSST)” (through Google form), that included 14 items assessing premenstrual symptoms of appetite, mood, sleep, anxiety and physical symptoms. It includes functional impairment items in five different domains as well. Results: The common symptoms seen in the respondents were anger/irritability (Mild n = 76, 46.3%; Moderate to severe n = 68, 41.4%) followed by physical symptoms which included headaches, joint or muscle pain, breast tenderness, gain in weight and bloating. The commonest functional impairment was college/work efficiency or productivity (n = 79, 48.2%). Alcohol and tobacco consumption had a significant association with PMDD. The type of diet did not have significant statistical association with PMS or PMDD. Conclusion: The most common symptoms seen were anger/irritability as well as physical symptoms like headache, breast tenderness etc., Factors like sleep, diet, exercise, yoga, alcohol and smoking were assessed.

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Our aim during prolonged COVID-19 pandemic, is to keep the training of undergraduate surgery students rolling as they may be future GPs (general practitioners) or primary care physicians of tomorrow. World Health Organization (WHO) in its public advisory for COVID-19 pandemic has stressed on physical distancing and this has resulted in discontinuation of in-person undergraduate surgery lectures and demonstrations. Also WHO has laid out directions to deliver only essential health-care services, which has resulted in reduced patient load in didactic surgical clinics and fall in number of planned surgeries and adversely effected the teaching of undergraduate surgery students. So there is an urgent need to reschedule and revise the teaching activities for undergraduate surgery students. Therefore, with this background, we plan to propose certain web-based, distant learning novel strategies to keep the training of undergraduate surgery students rolling. These novel strategies include adopting social media platforms and flip classroom concept to replace in-person lectures, involvement of undergraduate surgery students in telemedicine consultation to substitute didactic clinics, use of multimodal computer-based programs, and use of high-end surgical videos for learning of basic surgical skills. These web-based, distance training modalities can be collaged to form training modules for undergraduate surgery students, and as they are GPs or primary care physician of tomorrow, they can use these e-technologies for patient care and patient education also. It was concluded that proposed web-based strategies may be of use to role training of undergraduate surgery students. As some of them may be future GPs/primary care physicians of tomorrow, they can use this concept of e-technology in patient care and patient education in difficult time. Although these virtual technologies can compensate for gap in learning in times of crisis, these cannot replace real-time experience of learning.

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Context: Diabetes mellitus (DM) is one of the most common diseases worldwide. Patients with DM are prone to develop multiple musculoskeletal (MSK) manifestations, which may lead to disability and an impact on patients' quality of life. These manifestations include but not limited to, adhesive capsulitis, shoulder hand syndrome, diabetic hand syndrome, diffuse idiopathic skeletal hyperostosis, Dupuytren's contracture. Aims: The aim of this study is to assess the prevalence of MSK manifestations in diabetic patients in Saudi Arabia. Settings and Design: The study was carried out in NGHA hospital and PHC in Saudi Arabia. Methods and Materials: This is a retrospective study carried out between 2015 and 2019 where all patients with DM type II between the age of 18 and 65 and were diagnosed with MSK manifestations included in the study. Statistical Analysis Used: Statistical Package for the Social Sciences (IBM-SPSS) software (Version 23). Results: A total of 208 patients were found to have MSK manifestations. The average age of patients was 53 years old ranging from (31-63). The mean reading of A1C was 8%. A total of 34.1% were controlled and 65.9% were uncontrolled. Carpal tunnel syndrome (CTS) was found in 10%. Adhesive capsulitis in 2.4%. Septic arthritis in 1%. Trigger finger was found in 7.2%. Osteomyelitis was found in 0.5%. Plantar fasciitis was found in 4.8%. Osteoarthritis (OA) was found in 149 subjects (71.3%). Two subjects had ankle OA, one hand OA, nine shoulder OA, one hip arthritis. The rest had knee OA. Rotator cuff tendonitis was found in 1%. No significant correlation between age, A1c and all the MSK manifestations that were mentioned above (P value >0.05). Conclusions: MSK manifestations are common among diabetic patients. OA was the most frequently seen disorder. Physicians should be aware of the high prevalence and the huge impact on patients when treating patients with type II DM.

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Objectives: To assess the water, sanitation, and hygiene (WASH) practice among the tribal population of Tamil Nadu, India and to determine the physiochemical and bacteriological quality of drinking water at the principal source and at the households along with the household-level determinants of WASH practices. Methods: A door-to-door survey was conducted in 150 households, distributed across six villages of Jawadhi hills, a tribal area in the state of Tamil Nadu, India. Water samples were collected from the principal sources and a subset of households for assessing water quality. A composite scoring was formulated to determine the overall WASH practices. Results: Overall, a poor WASH score (≤4) was found in 103 (68.7%; 95% CI: 60.7, 75.6) households. The majority (96.7%) of the household water samples showed the presence of fecal coliforms. Poor WASH score was uniformly distributed across the villages. Low per capita income (≤1000 INR) was strongly associated with the poor WASH score (Adjusted OR 2.4; 95% CI: 1.04, 5.7). The per capita income had a strong negative association with the high fecal coliform count (Adjusted OR 5.07; 95% CI: 1.08, 23.74). Conclusions: We conclude that WASH-related practices among the tribal population of Tamil Nadu is not acceptable. The lack of administrative function and poor economic conditions are the likely causes attributed to the poor WASH conditions and drinking water quality. Urgent action from the stakeholders is the need of the hour to improve the water quality and living standards of such marginalized populations.

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Background: Poor nutritional status in primary school children can lead to several health problems such as easy susceptibility to common childhood diseases. Personal hygiene status is an important predictor of nutritional status and morbidity in children as water- and sanitation-related diseases are the leading causes of early morbidity and mortality in children. The present study was conducted to assess the nutritional status as well as personal hygiene practices of primary school going children. Method: The present study was a cross-sectional study conducted in selected urban and rural areas of Shillong in children 6–12 years of age. Two schools each from the rural and urban area were selected using simple random sampling. The total sample size calculated was 510. Height, weight, and BMI were taken for all the children following the standard procedures. WHO growth standards were used for grading of nutritional status. A questionnaire with scores was used for grading of personal hygiene status. Results: The overall prevalence of underweight in the children of 6–9 years was 74 (18.7%) and that of stunting was 68 (17.2%). The overall prevalence of thinness and stunting in children aged 10–12 was 38 (19.1%) and 46 (23.2%). The prevalence of nutritional deficiency syndromes was 192 (32.4%). Regarding the personal hygiene status, it was observed that 65 (11%) had very good personal hygiene, 292 (49.3%) were labeled as good, 200 (33.8%) were average, and 35 (5.9%) had poor personal hygiene. Conclusion: The primary school going children in Shillong had poor nutritional status but the majority of them had good personal hygiene practices. Mother's educational status played an important role in determining the nutritional and personal hygiene status of the children.

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Background: Lack of a cure or vaccine of COVID-19 forced us to rely on public health interventions (PHIs) for combating the pandemic. The main objective of the study to assess the PHI in selected countries and relate the various factors related to the intervention with the case load of the country. Methods: An ecological analysis was conducted using secondary data on PHIs and disease burden extracted from official documents and press releases of the respective countries. Disease transmission was described based on calculated doubling time. PHIs were classified into 14 categories within three domains. An intervention score was calculated to reflect the number and stringency of the PHIs. Correlations between intervention scores, daily new cases and doubling time were presented. Results: Brazil and the USA had the lowest intervention scores while South Korea had the highest scores. The median doubling time was negatively correlated with the rapidity of the escalation of the PHIs.Conclusion: Dynamic government policies and timely PHIs, which are locally relevant and ably supported by the public are key to successful containment of the COVID-19 pandemic.

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Aim: To know the prevalence of sexual activity, their sexual behaviour and attitude towards sex among unmarried adolescent females. Materials and Methods: It was a hospital-based prospective observational study. The study duration was 1 year. The study participants were unmarried girls between the age group of 10–19 years who gave written informed consent. In the case of a minor, consent was obtained from parents also. Pre-designed, pre-structured and pre-tested questionnaire was used to evaluate the sexual behaviour. Results: Out of the 320 adolescents presented to the OPD, only 165 consented to participate in the study. Prevalence of sexual activity was 16.9% (28/165) in the study. Eight (8/165) adolescent girls have not attained menarche and all were not having any knowledge of sex. Three girls were the victims of sexual exploitation. Around 64% of these girls were sexually active with their classmates. All the sexually active females were having intercourse through the vaginal route, however non-vaginal route was also practiced by 6 girls. Home (11, 39%) was the preferred place followed by the hotel (10, 35.7%) for sexual activity. Conclusion: Prevalence of sexual activity is low among Indians as compared to the western world but it may be a tip of iceberg as it is a hospital-based study. This is the first study that assessed the route of intercourse, frequency of sexual activity, and place preferred by these adolescents to evaluate the sexual health behaviour.

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Demographic transitions accompanied with epidemiological shifts are affecting many countries around the globe. These apprehensions have raised the concern for constructing and sustaining healthcare systems especially among resource-constrained low- and middle-income-countries (LMICs) such as India. Introducing Health-Technology-Assessment (HTA) in the educational initiatives could support planners and policy-makers in formulating evidence-based-decision-making along with tackling inequalities/inefficiencies and promoting cost-effectiveness in resource allocation. A mapping exercise has been undertaken for examining the feasibility and implementation of HTA curriculum in the existing courses in India. To gain best possible insight on HTA curriculum, a situational analysis was conducted using systematic search strategy through search engines such as Google, Google Scholar, ProQuest and PubMed. Currently, seventy-one institutes in India are offering one or more courses through regular mode at undergraduate/postgraduate/diploma-certificate/doctorate-level pertaining to Medical-technology (MT), Biostatistics (BS), and Health-economics (HE). MT was offered in 37 institutes (52.12%), followed by BS in 23 (32.39%), and HE in nine (12.67%). Only two institutes (2.81%) are offering certificate-courses on HTA, mainly confined in virtual modules. This review reveals noticeable gaps in the existing curriculum in India and necessitates a novel academic initiative by introducing HTA in a full-fledged manner. Reforms in the research and educational initiatives need to be brought for promoting awareness regarding HTA. The application of domain needs to be widened from the field of health-policy formulators to research and teaching. This should be further strengthened with the strong academic collaborations to generate replicable findings, address challenges, and offer solutions for existing threats to HTA.

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Background and Aims: Dengue is a vector-borne viral disease which is one of the major causes of public health problem in India, and its control is often the major challenges of municipal bodies in the country, especially in West Bengal. The previous outbreaks of the disease can be used to forecast the future occurrence and burden, so that authorities may optimize the available resources in order to contain and minimize the impact. Materials and Methods: Weekly disease outbreak data were extracted from Integrated Disease Surveillance Programme website and arranged as monthly data. Mann-Kendall test was used to determine the significance of the disease trends in various districts of Gangetic West Bengal. Time series analysis was done by using Seasonal ARIMA method to predict the number of Dengue outbreak cases for the year 2020. Results: Murshidabad was the only district of Gangetic West Bengal that had a significant upward Dengue cases outbreak trend. Nadia had a downward trend but it was not statistically significant. Model SARIMA (1,0,0) (1,0,0)₁₂ was chosen to forecast the Dengue outbreak cases which showed that the cases might start from the month of June, peak in August and wane off in October 2020. However, this prediction was not significant. Conclusion: Gangetic West Bengal might experience similar dengue cases as the previous year, but their numbers would be low. Only the district of Murshidabad would have upward trend. Knowledge in advance about periods of disease occurrence may enable health authorities to initiate control measures during the start of the outbreak season.

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Objective: Coronary artery disease (CAD) is one of the leading causes of death and disability worldwide. Amongst the Middle East countries, Saudi Arabia is facing rapid progressive urbanization by the adoption of a westernized lifestyle and food habits, which contribute to the rising burden of CAD. We aim to evaluate the awareness and prevalence of CAD risk factors among Saudi adults. Methods: This was a cross-sectional study conducted between January and March 2020. Data were collected through an online survey using a self-administered questionnaire. Data assessed on socio-demographic variables, family history of CAD, knowledge of risk factors, symptoms, and complications of CAD. Results data were entered and analyzed using IBM SPSS statistics, version 25. All comparisons were considered significant at P < 0.05. Results: A total of 311 subjects (48.6% men and 51.4% women) included, and most of the participants were between 18 and 25 years. A majority of the participants did not hear about CAD (82%) and unaware of any risk factors (26.4%), symptoms (25.1%), and complications (72.7%) of CAD. The prevalence of a family history of CAD (9.3%), overweight/obesity (58.6%), physical inactivity (79.1%), and smoking (24.1%) observed considerably high among the participants. Conclusion: The present study reveals that a significantly low level of awareness and a high prevalence of CAD risk factors found among Saudi adults. Therefore, the awareness program is needed at the public level to increase the knowledge of CAD risk factors so that persons with high risk for future CAD can be prevented.

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Background: Generic drugs are low-cost alternatives to branded drugs. The government of India is encouraging physicians to prescribe the generics to decrease out-of-pocket expenditure of health care. Looking at India's low-prescription on generic drugs, it is crucial to analyze the factors responsible for it. A patient's unawareness may be an important factor; hence, it should be evaluated systematically. Objectives: This study was designed with the aim of assessing knowledge and perception of generics among patients visiting the outpatient department of primary care physicians at the Patan city of Gujarat. Material and Methods: A trained research associate visited the OPDs of various general practitioners to collect the data. A prevalidated questionnaire was administered to these patients. The data was analyzed with the help of statistical software. Descriptive statistics were used to analyze the data. Results: Among 345 patients, only 33.6% reportedly heard about generics. Of these only a few patients (<13%) had used the generic drugs in past. The majority (>60%) believed that generics are safe. Those who were not willing to take generics reported efficacy as the major concern. Out of various factors that may affect knowledge of generic drugs, young age (OR = 5.3) and education (Primary (OR = 8.01), Secondary (OR = 6.19), and Higher secondary (OR = 3.07) were statistically significant. Conclusion: Awareness about the generic drugs was low among the patients visiting the primary care physician. The young age and primary and secondary education levels were significantly associated with the awareness regarding generics.

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Background and Aims: Chronic obstructive pulmonary disease (COPD) is characterized by slow progressive deterioration of respiratory function with systemic effects which have a great impact on health-related quality of life (HRQoL). The severity of airflow limitation in COPD, as reflected by forced expiratory volume in one second (FEV1) does not represent the systemic consequences of COPD. Hence, a multidimensional grading system, BODE index (Body mass index, Airflow obstruction, Dyspnea and Exercise capacity) that assessed both the pulmonary and systemic manifestations has recently been proposed to provide useful prognostic information and predict the outcome in COPD patients. The objective of this study was to evaluate the relationship between BODE index and health-related quality of life (HRQOL) in stable COPD patients and its usefulness in predicting the disease exacerbations. Materials and Methods: Sixty stable COPD patients who presented in the out-patient departments of Medicine and Pulmonology were recruited over one year period. We evaluated them by body-mass index, forced expiratory volume in one second (FEV1), Modified Medical Research Council dyspnea scale and six minute walk test (6MWT). BODE index was calculated using these variables. Disease duration, number of exacerbations and hospitalization in the previous year were recorded. We also administered the St. George's Respiratory Questionnaire (SGRQ) to assess the health related quality of life (HRQoL) in these patients. BODE scores were categorized into four quartiles, quartile one to four with scores of 0-2, 3-4, 5-6 and 7-10, respectively. Results: According to BODE score, (16) 26.7% of patients were BODE 1, (27) 45% BODE 2, (15) 25% BODE 3 and (2) 3.3% were BODE 4. Higher BODE quartiles were associated with higher total SGRQ scores and SGRQ subscale scores (symptom, activity and impact). Very strong correlations were found between BODE quartiles and total SGRQ scores (P < 0.01). Among the components of BODE index, the decrease in the FEV1 (%predicted) and 6MWD, and the increase of MMRC dyspnea grade were associated with worsening of health status (increase in total SGRQ and SGRQ subscales). BODE index also correlated with the acute exacerbations (P < 0.0012) during one year follow-up. Conclusion: BODE index strongly correlated with the HRQoL and also reliably predicted acute exacerbations in stable COPD patients.

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Background and Objectives: Widespread use of the internet is a serious concern among university students worldwide. Internet addiction affects the students' physically and psychologically and poses social and environmental challenges to their well-being. This study was used to assess the levels of internet addiction among medical students at a major university in Saudi Arabia and to measure the quality of life among these students. Methodology: A cross-sectional study was used to gain responses from 437 students using questionnaire surveys. These questionnaires were based on the World Health Organization's standard quality of life survey questionnaire (WHOQOL-BREF). Results: Analysis of the results displayed that the students were only moderately addicted to the internet. Moreover, with respect to the quality of life, these students scored high in physical, social, psychological, and environmental sub-domains of the quality of life questionnaire survey. Conclusions: These results provide evidence that, in contrast to findings in some other countries, medical students in Saudi Arabia enjoy a better quality of life with moderate internet addiction levels. Future studies can broaden the scope of the survey methodology used in this paper to cover medical students in other universities in Saudi Arabia. Moreover, correlations with exam scores can be established using case-control studies for a more thorough analysis. Therefore, this study provides a significant positive step in the direction of further research in this field.

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Aim: To find out if there is any correlation between COVID-19 antibody serological testing and symptom severity. Methods: This study is a case series of 44 consecutive patients confirmed with COVID-19 who are divided into a group of 23 patients with mild disease and a group of 21 patients with severe disease. All 44 samples were confirmed positive SARS-CoV-2. Subsequent recombinant SARS-CoV-2 S1/S2 IgG test was performed for all patients and all patients developed neutralizing antibodies with altered range. Main outcomes: IgG level and its correlation with disease severity, demographic data, underlying comorbidities, clinical presentation, and treatment comparison between mild and severe disease groups. Results: Quantitative SARS COV-2 IgG was significantly higher in moderate and severe disease groups compared with those in the mild disease group. COVID-19 infection was more prevalent in male, Saudi nationals and smokers with comorbidities and higher inflammatory markers are more in the severe group than in the mild group which necessitates more management options to be taken for severe group patients. Conclusion: IgG antibody level was higher in the severe disease group. Also, the study showed significant differences between the mild and severe disease groups in terms of demographic, clinical, and management variables.

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Background: There remains equivocal evidence in terms of glucose-6-phosphate dehydrogenase (G6PD) and malaria occurrence. A case-control study was performed to assess protective relationship of G6PD and other lifestyle factors with malaria. Methods: One-hundred twenty six medical professionals were randomly selected from a tertiary care clinical institute. Along with demographic and lifestyle details, subjects were interviewed about their history of occurrence of malaria at all in previous 10 years. Their hematological, biochemical, and metabolic profile was assessed clinically as well as by investigations. The analysis was carried out with two groups: (1) those who were subjected with malaria at least once in past 10 years (Malaria Ever Group); (2) those who never encountered malaria (Malaria Never Group). Results: Out of 126, 65 subjects were in Malaria Ever Group and 61were in Malaria Never Group. There was no difference in lifestyle measures, hematological, and biochemical parameters. Mean G6PD levels were found similar in both the groups. Of 61 subjects in “malaria-never” group, 1 had deficient (1.1 unit/gm of Hb), 9 had low normal (between 2.5 and 10 units/gm of Hb), 48 had normal (10.1–20.5 units/gm of Hb), and 3 had higher than normal (>20.5 units/gm of Hb) G6PD levels. In comparison, 65 participants from “malaria ever” group, none was deficient, 6 had low normal, 58 had normal, and none had higher than normal G6PD levels. HPLC-based hemoglobin analysis showed significant higher number of participants in “malaria-never” group having altered hemoglobin. 12 participants had increased hemoglobin A2 levels, of which 10 were in “Malaria Occurrence Never” group; of them 6 could be diagnosed having hemoglobinopathy of specified variety. 3 of these 10 participants of “malaria-never” group had low G6PD levels also. Conclusion: Malaria Protection Hypothesis was not found to be true as per our findings, but there were subtle hints that G6PD protection with or without change in hemoglobin alteration maybe operable.

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Myocarditis in patients with diphtheria is a toxin-mediated complication that sets in after one week of onset of respiratory illness. Early administration of antidiphtheritic serum in patients with clinical diphtheria before the onset of myocarditis is of utmost importance to prevent this fatal complication. We report three patients who presented late in illness after the myocarditis had set in, to stress on the need of prompt administration of antitoxins by primary care physicians and highlight the importance of immunization.

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Context: The spread of COVID-19 pandemic poses a great challenge to health care organizations and unprecedented need for information. This study aims to identify possible factors causing delay and losing precious time during diagnosis and treatment of COVID-19 at home and health facility level. It also aims to highlight perceptions and experiences of family members of deceased regarding diagnosis and treatment of COVID-19 infection in hospital. Methods: A retrospective study was done to review COVID-19 deaths from 18^th March to 5^th June 2020 in Punjab, India. A total of 48 laboratory confirmed (RT-PCR) COVID-19 deaths were reported during this period. Socio demographic profile, sequence of events including clinical symptoms, medical aid taken, time of confirmation of diagnosis and treatment before death were noted from the records on a predesigned proforma. Family members of deceased were also interviewed and asked open-ended questions regarding their experiences at various health facilities. Descriptive statistics was presented in percentages, mean, and median. Results: Mean age of subjects was 56.3 ± 18.3 years. Majority (82.2%) had three or more than three comorbidities. Median time from appearance of first symptom to first medical contact and confirmation of diagnosis was 1 and 5 days, respectively. On the basis of interview with deceased's relative, various themes like delay in diagnosis and treatment, dissatisfied with hospital system and lack of communication between relative and patient were generated. Conclusion: Presence of comorbidities was the most important risk factor. Health seeking behavior of patients immediately after appearance of symptoms was found to be satisfactory.

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COVID-19 is an infectious disease caused by a newly discovered coronavirus. Most patients infected with the COVID-19 virus experience mild to moderate respiratory symptoms and heal without any special treatment. This survey aimed to assess the knowledge of Syrian and Saudi populations about the general information, symptoms, and methods of prevention of coronavirus (COVID-19). Materials and Methods: A standardized questionnaire composed of four sections (demography, general information about COVID-19, symptoms of COVID-19 infection, and methods of prevention) including 34 questions divided between the four mentioned sections were sent online to different social media in the Syrian Arab Republic and Kingdom of Saudi Arabia as a Google drive form. The collected data were coded, computerized, and analyzed using methods of descriptive statistics by SPSS 25. A Chi-square test was done. Results: The total number of participants was 790; most of them were in the age group of 18–30 years (60.3%) wherein females formed about 59.2% of the whole sample. About 94.6% of the respondents from Syria agreed that several coronaviruses are known to cause respiratory infections while 45.6% of Saudi people knew that diarrhea is one of the symptoms of coronavirus (COVID-19). The good results of this current study were clear in the section of coronavirus (COVID-19) prevention as most of the information was correct in more than 60% of answers. Conclusion: The knowledge of Syrian and Saudi populations about the general information, symptoms, and methods of prevention of coronavirus COVID-19 was very good to excellent except in very limited points.

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Background: Elderly population is rising due to advancement of health care, medical services, and increasing life expectancy. World Health Organization (WHO) has initiated a global project to define “age-friendly city for improving the elderly's quality of life”. Objectives: The purpose of the study was to determine the age-friendly cities characteristics from the elderly's point of view in Gorgan, Iran. Methods: This cross-sectional study was conducted in 2019 on elderly people who referred to the health centers of Gorgan, Iran. 160 eligible elderly people were recruited through multi-stage random sampling. The viewpoint of participants about the characteristics of Gorgan in the four age-friendly city indicators; urban and outdoor buildings, transport and transportation systems, information and communication services, and social support and health services was compared with the standard of WHO. Data were collected using the age-friendly city questionnaire and analyzed in SPSS-18 using Chi-square and one-sample t-tests. Results: From the elderly viewpoint, the mean score of 4 indicators; urban buildings and outdoor (58.50 ± 31.2), Transport and transportation system (43.3 ± 82.00), access to Information communication services (46.75 ± 15.1) and the level of access to social support and health services (81.43 ± 21.10). Considering age-friendly city indicators, the characteristics of Gorgan City were significantly lower than the WHO recommended standard (P < 0.001). The “Information and Communication” and “buildings and outdoor space” indicators had the highest and lowest differences from the standard, respectively. Conclusion: According to the present results it is recommended that managers and policymakers of urban planning and healthcare providers in their programs consider the elderly viewpoint to improve the urban characteristics as an age-friendly city.

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The recreational use of nitrous oxide (N₂O) is a growing public health concern. Increasing numbers of young individuals are presenting to accident emergency departments complaining of adverse neurological symptoms as a result of N₂O induced vitamin B12 deficiency. Despite its increasing popularity, many are still not aware of its devastating potential to cause a myriad of severe longstanding neurological impairment. Herein we present a case that highlights the effects of N₂O abuse and the best way to investigate and manage such patients.

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Background: The parental awareness and perceptions help in early recognition of problems in deciduous dentition, which will help us plan better preventive measures. Hence, the present study was conducted to evaluate the perceptions of Saudi parents residing in Riyadh towards the problems related to primary dentition of their children. Materials and Methods: A cross-sectional study was conducted on the patients attending private dental institution in Riyadh city. Information about demographic details, questions related to maintenance of primary teeth, and future implications of poor primary dentition health were collected. Descriptive statistics and Chi-square test were used for the analysis. The level of significance was set at P < 0.05. Results: A total of 1773 male and females filled up the survey form, which comprised of 28% males and 72% females, and maximum parents (68%) were university graduates. Overall better responses were in females and parents having more children. Conclusion: Over all mothers had a higher level of knowledge and positive attitude towards their children's oral health as compared to fathers. Developing and strengthening optimistic outlook among parents towards oral health especially primary dentition is utmost important.

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Objective: We aimed to study the extent of liver fibrosis in chronic hepatitis C patients with indeterminate APRI score of ≥ 0.5 - ≤2 (between higher and lower cut off value) and correlate it to transient elastography (TE) and FIB 4 index. Method: A cross-sectional study, 80 patients with CHC mono infection, APRI score ≥ 0.5 - ≤2 were interviewed from the cohort visiting the CHC program clinic at a tertiary care hospital in Karachi, Pakistan. Data were analyzed using STATA 14.0 and R 3.5.2 and SPSS 24.0 software according to their capabilities. Result: Of 80 patients, 50 (62.5%) were females and 30 (37.5%) were males with mean (±SD) ages of 41.73 (±11.5) years and 41.16 (±9.24) years respectively. The FIB 4 value among indeterminate APRI was reported as 1.47 (IQR 1.05-2.43). TE categories was reported: F0-F1 (n = 29; 36%), F1-F2 (n = 10; 12.5%), F2 (n = 9; 11.2%) F3 (n = 13; 16.2%), F3-F4 (n = 1; 1.2%) F4 (n = 18; 22.5%). FIB4 had a moderate positive correlation with TE while a weak positive correlation was found between APRI and TE (0.488, P < 0.0001 and 0.289, P < 0.001, respectively). TE was taken as a gold standard and compared with FIB4. The model constructed reported FIB4 as a good prediction for liver fibrosis with diagnostic accuracy 72%. Conclusion: The combination of two serum markers proves to be a low-cost noninvasive testing strategy for CHC patients having an indeterminate APRI score. By being readily accessible both biochemical scores can simplify liver assessment in lower middle-income countries (LMIC) and help family physicians to take appropriate decisions about treatment initiation with minimum delays.

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Context: Effective clinical decision-making skills enhance the quality of patient care. Clinical reasoning and decision-making are fundamental aspects of best physiotherapy clinical practice. Aims: To evaluate the effectiveness of an evidence-based structured educational workshop in enhancing physiotherapists' clinical decision-making skills. Settings and Designs: A pre-post design conducted in a medical college Methods and Materials: A workshop protocol was developed based on the existing evidence and clinical practice guidelines. The workshop was advertised on the social media page of Nepal Physiotherapy association. On the first come first serve method; physiotherapists were selected. Those who met eligibility criteria were recruited for one of two workshops. Discussion was made on clinical scenarios aimed at enhancing clinical decision-making skills. Data were collected before and after the workshop using a self-administered clinical decision-making skills assessment tool to evaluate effectiveness of the workshop. Paired and unpaired t-tests were used to analyze within and between groups respectively. Results: Significant improvement in clinical decision-making skills was found for all individual items (P < 0.001 in all items, effect size: 0.6 – 0.9), total EP score (P < 0.001, effect size: 0.8) and total clinical decision-making score (P < 0.001, effect size: 0.9). A significant difference was found between Bachelor and Master level education (P < 0.05). Conclusions: An evidence-based structured educational workshop enhanced physiotherapists' clinical decision-making skills. The findings of this study could be relevant to all health care professionals working in clinical practice. Larger studies with a control group are recommended to strengthen the findings of this study.

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Introduction: Spontaneous bacterial peritonitis (SBP) is a frequent and severe complication in cirrhotic patients with ascites. SBP is generally diagnosed based on an increased number of polymorphonuclear neutrophils in the ascitic fluid (>250/mm³) and positive culture. Usually fluid analysis and culture take time and precious hours are lost in starting therapy. Leukocyte Esterase Reagent Strips (LERS) have consistently given a high negative predictive value (>95% in the majority of the studies). Aims and Objectives: Aim was to evaluate the diagnostic utility of leukocyte esterase reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. Methodology: The study was carried out on 64 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm³ was considered positive). Results: Of the 64 patients SBP was diagnosed in 17 patients, 47 patients were negative for SBP by manual cell count. At cut off of 2+; sensitivity to diagnose SBP was 100%; specificity of 94%; PPV being 57% and NPV of 94%. at the cut off level of 3+; sensitivity decreased down to 76%; specificity increased to 100%; PPV of 100% and NPV of 93.75%. Overall accuracy at 2 + and 3 + was respectively 94.5% and 93.75%. Conclusion: In this study we have found good sensitivity and specificity for the prompt detection of elevated polymorphonuclear neutrophil count. A negative test result excludes SBP with a high degree of certainty. Thus, it represents a convenient, inexpensive, simple bedside screening tool for SBP diagnosis.

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As per latest Global TB Report (2018), an estimated 2.2 lakh children get tuberculosis (TB) each year in India and illness constitutes a very high global burden. Here we report an unusual case of a child aged 14 years (female), who presented to Emergency with complaints of cough and restlessness for the past 1 day. Working diagnosis of septic shock was kept and child was started on intravenous ionotropes, vasopressors, and an antibiotic. There was no significant history suggestive of TB. Patient was shifted to PICU and managed for shock accordingly. X-ray lung showed single right-sided cavitatory lesion. Bronchoalveolar lavage was positive for acid fast bacilli, confirming the diagnosis of pulmonary TB. The patient was started on antitubercular drug regimen (ATT) for 6 months and showed significant improvement with complete resolution. Literature was searched for association of septic shock in tubercular patients as a presenting complaint, which is a rare entity.

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Background: As we know that close contact is the main reason of the contagious diseases, caregivers are at higher risk for diseases that we can prevent by vaccines. In present study, we aim at revealing an example of clinical inertia in geriatrics, which shows us the status of vaccination both in a group of older patients and their caregivers. Materials and Methods: Both the caregivers and their dependent geriatric patients were included, and the selection of the participants was designed on a random and volunteer basis. We performed the study with a phenomenological design and asked the participants their vaccination status. For the participants that were not vaccinated, the reasons were questioned with a demographic form. Correlations between parameters were analyzed with an independent t-test and analysis of variance. SPSS (IBM SPSS for Windows, ver.24) was used to analyze the data, which were saved in excel files. Results: A total of 144 caregivers with 21 men (14.6%) and 123 female (85.4%) were included in the study. A total of 111(77.1%) caregivers had never been vaccinated before, while 21 (14.6%) caregivers were vaccinated occasionally, and finally, 12 (8.3%) caregivers were vaccinated on a regular base. The vaccination status of the older adults was as follows: 42 patients (29.2%) had never been vaccinated before, 60 (41.7%) had been vaccinated occasionally, and 42 (29.2%) patients had been vaccinated regularly. Conclusion: The vaccination rates of caregivers and older patients were lower than we expected, so primary-care providers need to plan more vaccination awareness studies in social media and communities. Clinical inertia might be an essential reason in the lower vaccination rates of the caregivers and older adults' population.

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The most devastating late adverse effect of childhood cancer treatment is development of second malignancies. Retinoblastoma is the most common ocular malignancy of childhood and has a very good cure rate. Children with hereditary retinoblastoma have an increased risk of developing second malignancies due to the genetic cancer predisposition status and the additional risk factors are exposure to chemotherapy (alkylating agents and topoisomerase II inhibitors) and external beam radiotherapy during treatment. The common chemotherapy regimen of retinoblastoma consisting of etoposide, an epipodophyllotoxin is associated with risk of secondary AML (s-AML). We report a case of child with bilateral retinoblastoma who developed secondary AML after being treated for retinoblastoma.

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Introduction: HIV/AIDS-related stigma and discrimination together have long been recognized as one of the main obstacles in the prevention, care, and treatment of HIV and AIDS. Yet, little has been done on a large scale to combat them. Stigma still precludes many in need of treatment and care for people living with HIV/AIDS (PLHIV). The purpose of this study was to assess the social stigma among PLHIV and the factors influencing it. Material and Methods: This hospital-based cross-sectional study was conducted among four hundred PLHIV attending the antiretroviral therapy (ART) center of a tertiary care institute of Haryana, India, using a semi-structured questionnaire and Berger Stigma Scale. Data analysis was performed using SPSS version 20.0 software to explore the relationship between a dependent (social stigma score) and other independent variables. Results: The overall mean stigma score in our study was found to be 110.96 ± 17.05. The stigma score in the male PLHIV was higher than in females. Male gender, younger age group (18–25 years), nuclear family, and rural residents PLHIV experienced more stigma as showed by the logistic regression analysis. Conclusion: Stigma and discrimination are a continuous deterrent for program implementation or successful outcomes. Education, behavior change strategies, and building supportive environments to the targeted population (young, single, and rural residents) can provide a roadmap in ending stigma and discrimination.

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Hepatic hemangioma is a commonly encountered benign vascular tumour of liver during infancy. Acquired hypothyroidism is one of the rare manifestation of this entity. We report a 4-month-old infant born to a diabetic mother who developed acquired hypothyroidism not responding to treatment due to multiple hepatic hemangiomas. The mechanism behind is increased type 3 deiodinase activity due to hemangiomas of liver, which catalyses conversion of T4 to rT3 and T3 to T2. Hemangiomas were successfully treated with propranolol which lead to its regression and ultimately resulted in euthyroidism. Hence, screening for hepatic hemangioma should be done in all cases of congenital hypothyroidism not responding to thyroxine treatment. We also propose early initiation of treatment of hemangiomas with propranolol as the first line therapy to prevent growth retardation and intellectual loss.

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Aims and Objectives: Asthma is a chronic inflammatory condition, which is associated with increase in airway hyper responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing. Asthma is a very common respiratory illness, in which some of the disease related factors may increases the vulnerability to psychiatric disorders. This study was done to determine the prevalence of psychiatric co-morbidity in patients of bronchial asthma. Methodology: It is an observational study conducted in 110 follow-up patients of bronchial asthma attending respiratory medicine OPD at tertiary care centre in central India. Psychiatric co-morbidities are assessed by pre-designed short-structured questionnaire using Mini international neuropsychiatric interview. Result: Among 110 patients of bronchial asthma 28% had psychiatric co-morbidity mainly depressive episode (59%). A significant association is found between lower socioeconomic status (P = 0.01), duration of of active illness (more than 1 year) (P = 0.001), and age of patient above 60 years (P = 0.001) with psychiatric co-morbidity of asthma patient. Conclusion: Our study shows there is increased prevalence of psychiatric co-morbidities in patients of bronchial asthma, higher than the national average. The predominant psychiatric disorder seen is depressive disorder, so treatment of asthma should be a multidisciplinary approach including medical treatment of asthma and psychiatric evaluation to prevent psychiatric co-morbidity or its early management. This will greatly reduce the morbidity, visits to hospital, expenditure on treatment and thereby having better outcomes in our patients of asthma.

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Granulomatous polyangiitis (GPA) is a small vessel vasculitis commonly affecting the upper and lower respiratory tracts and kidneys. About 90% of the cases are associated with ANCA, namely, PR3-ANCA and MPO-ANCA. Herein, we describe a patient of GPA who presented with anasarca, sensory neuropathy, recurrent upper airway congestion, epistaxis, and rapidly progressive glomerulonephritis. Granulomatous interstitial nephritis and necrotizing granulomatous inflammation of the nasal septum were found on biopsy of the kidney and nasal septum, respectively both of which are rare findings. PR3-ANCA and MPO–ANCA were negative. Fulfilling the ACR criteria, this case of GPA proves that biopsy is still the gold standard of diagnosis.

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Introduction: Janani Sishu Suraksha Karyakram (JSSK) is a flagship program of India to reduce out of pocket expenditure (OOPE) of the families during childbirth and neonatal sicknesses. Objectives: To assess the utilization of JSSK while availing services for childbirth and newborn care in a secondary care hospital in Southern India; estimate the OOPE in services covered by JSSK and identify the associated factors with OOPE. Methods: 228 mothers who delivered in the previous 2 days, were recruited from a secondary-level government hospital in Chittoor. Expenditure incurred under various components of JSSK was asked during the recruitment and subsequently through telephonic interviews. Results: All components of JJSK, except transport, were fully utilized by the families. 138 mothers (60.5%, 95% CI: 54.0, 67.0), and all sick children (n = 138, 100%) who visited government hospital, incurred OOPE in the form of transport cost. The median expenditure of transport (from home to hospital and hospital to home) of the mothers was 250 INR (IQR: 100-513 INR). Transport expenditure was greater for the rural families (300 INR) than the urban families (100 INR) (p < 0.05). In multiple logistic regression, nuclear families were associated with high OOPE (AOR- 2.0, 95% CI: 1.1- 3.7). Though education of the mother showed high association (AOR- 2.7, 95% CI: 1.0- 7.8), it was not statistically significant (p = 0.05). Conclusion: The families utilize most of the components of JSSK, except transport. Family-centric counselling of the beneficiaries during antenatal check-ups and home visits by the healthcare workers can reduce transport-related OOPE.

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This case is being reported to draw the attention of non-cardiac practicing physicians including pulmonologists, intensivists, and, as a matter of fact all primary care and emergency clinicians, towards a relatively uncommon ECG finding that could be the potential lead in suspecting the diagnosis of a commonly encountered, often fatal medical condition. Together with a high clinical index of suspicion, this alone could guide the decision-making process for further work-up and specific therapy.

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Aim of Study: To assess mental health literacy among Saudi adults attending the Ahad Rufaidah extension of Armed Forces Hospitals, Southern Region, 2017. Methodology: Following a cross-sectional descriptive study design, 400 adult Saudi attendants of the Armed Forces Hospitals, Southern Region – Ahad Rufaidah extension were included in this study. An anonymous interview validated questionnaire was utilized for data collection. It included variables related to participants' personal characteristics, knowledge assessment, and attitude regarding mental illness. Results: More than half of participants (55.3%) had poor knowledge regarding mental health, while 44.8% had satisfactory knowledge. Only 3.6% of participants had a positive attitude toward mentally ill persons, 43% were indifferent toward them, while 53.4% had a negative attitude toward them. Participants' attitudes toward mental health differed significantly according to their knowledge grades (P < 0.001), with the majority of those with positive attitudes having satisfactory knowledge (93.5%) and most of those who had negative attitudes had poor knowledge (66.8%). Participants' knowledge grades differed significantly according to their gender, with more satisfactory knowledge grades among males than females (50.8% and 22.4%, respectively, P < 0.001) and educational level, with more satisfactory knowledge grades among more educated participants (P = 0.002). Participants' attitudes toward mentally ill persons differed significantly according to their gender (P = 0.013) and their educational level, with the highest percentage of positive attitude among university-educated participants (35.3%, P < 0.001). Conclusions: There is widespread mental health illiteracy among attendants in the Ahad Rufaidah extension of Armed Forces Hospitals, Southern Region. Their attitude toward mentally ill persons is rarely positive but largely negative or indifferent.

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Background: India is an industrialised country and most work is labour intensive. There is very scarce data on occupation related injuries Aim: To evaluate the prevalence, profile, severity and risk factors for occupational injuries presenting to the emergency medicine department of a tertiary care hospital. Materials and Methods: A cross-sectional study was done in the emergency department of Christian Medical College, Vellore among the patients who presented with occupational injuries. The risk factors for occupational injuries like age, gender, shift work, work experience and type of work and their severity and outcome were evaluated. Results: Older age group, working in shift duty, working longer hours were significant risk factors for occupational injuries. Conclusion: Training and use of safety protective measures will decrease occupational injuries.

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The aim of this study is to report a 7-year-old girl with psychogenic visual disturbance that improved upon staying at home after the declaration of a state of emergency in relation to Coronavirus disease. Her uncorrected visual acuity (UCVA) in the right eye was 0.4 and in the left eye was 0.3. Slit-lamp examination and fundoscopy showed no abnormalities. She had a tight schedule on six days a week due to various lessons. To prevent the spread of infection, her school was closed, and she was not able to attend any lessons. She enjoyed spending time at home. Six months after her initial visit during school closure, her UCVA had improved to 1.2. The situation of staying at home may have had a positive psychological effect after removing factors contributing to her stress.

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Background: Basic life support (BLS) is an important component of emergency medical management. Ambulance personnel play a key role in resuscitation to save a life before reaching the hospital. We do not have any published data about the level of knowledge on BLS among the ambulance personnel. Objective: This study was done with the objective to assess the level of knowledge on BLS among the ambulance personnel. Materials and Methods: A cross-sectional study was done in the emergency department (ED) of a tertiary care hospital. Universal sampling was done taking all the personnel of ambulances over the period of one month. Data were collected about the type of vehicle used for ambulance, the number of personnel in an ambulance, educational qualifications, and equipment present in their ambulances. The questionnaire to capture the level of knowledge were based on American Heart Association 2015 guidelines. Result: The total number of ambulance arrivals was 729 times. But data analysis was done from 104 ambulances excluding the repeat arrivals and those who did not give consent. There were 62 type-C and D ambulances, and 42 were type-B ambulances. Total of 210 personnel were there in 104 ambulances. Seventy-nine team leaders did not have any paramedical degrees. Fifty-eight team leaders were trained in BLS before working in an ambulance. In spite of this, 66 (63%) team leaders had poor performance (score of 0 to 4). Conclusion: The level of knowledge on BLS was poor in more than half of the ambulance personnel. They should be trained regularly on providing BLS.

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Giant submandibular sialolithiasis is uncommon and sialoliths causing sialo-oral fistula are rare. We report a case of giant Wharton's duct sialolithiasis causing sialo-oral fistula in a 40 years male who presented with pain and swelling over right side of floor of mouth for more than two years and visualisation of yellow coloured stone like structure at floor of mouth in the last two days. With diagnosis of Submandibular gland sialolithiasis with sialo-oral fistula, sialolithotomy and marsupialization of Wharton's duct was done under local anaesthesia.

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Adenoid squamous cell carcinoma (ASCC) is a variant of squamous cell carcinoma. As this variant is rare it is difficult to distinguish it from other variants of squamous cell carcinoma. It commonly originates in the head and neck region as these parts are highly exposed to the sunlight. There are very few cases reported in the literature. Here we report a case in a 30-year-old male who reported with a nodular lesion over the upper lip with no unusual signs, which was confirmed as adenoid squamous cell carcinoma after various histopathological tests.

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