Family Medicine and Primary Care

EDITORIAL
	The tyranny of the Medical Council of India's new (2019) MBBS curriculum: Abolition of the academic discipline of family physicians and general practitioners from the medical education system of India	p. 323
	Raman Kumar DOI:10.4103/jfmpc.jfmpc_147_19   After 21 years, a new MBBS curriculum has been released by the Medical Council of India (MCI), titled "Competency-based UG Curriculum for the Indian Medical Graduates." This curriculum is to be rolled out from August 2019 across India. The curriculum document runs through 890 pages in three volumes. Overall, 2939 competencies have been proposed to be acquired by trainee MBBS doctors. The parliament of India in one of its reports (2016) noted that the medical education system is designed in a way that the concept of family physicians has been ignored. Not to mention a formal introduction as discipline, the new MCI MBBS curriculum does not even mention the words "General Practice" or "Family Medicine" or "Family Physicians" throughout the voluminous document. The curriculum committee has also ignored the recommendations of National Health Policies (NHPs) of 2002 and 2017 of the Government of India (GOI). In practicality, it leaves the MBBS students in the road of no return of specialist and tertiary level hospitalist care. It deliberately deprives thousands of medical graduates an invaluable autonomous career in community setting as practicing family doctors. Simultaneously, this new curriculum drafting exposes a treacherous hierarchical monopoly of hospital based specialists doctors over generalist community based primary care physicians within the healthcare delivery system of India. Keeping out family physicians and general practitioners from the health system means a free flow of patients from community to expensive tertiary care facilities in the absence of any structured referral system. Family medicine and general practice are independent medical disciplines/specialties across world. The curriculum neither meets the national public health aspirations nor the GOI policies on medical education. If implemented, it will be disastrous to the healthcare delivery system and public good in general. The new MBBS curriculum deserves to be outright rejected for the inherent fallacies.
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INVITED EDITORIAL
	Communicable or noncommunicable diseases? Building strong primary health care systems to address double burden of disease in India	p. 326
	Pavitra Mohan, Sanjana Brahmawar Mohan, Manisha Dutta DOI:10.4103/jfmpc.jfmpc_67_19   Between 1990 and 2016, India has seen an epidemiological transition in disease burden and deaths, with a steady rise in noncommunicable disease (NCD) burden. This has led to a tussle for policy attention and resources between proponents of communicable diseases such as tuberculosis, and of NCDs, such as cardiovascular diseases and diabetes. Review of evidence from global burden of diseases studies and from our own field data from rural south Rajasthan reveals that communicable-malnutrition- maternal-newborn diseases (CMNND), injuries, and NCDs are major causes of disease burden and deaths in childhood, youth and older age group, respectively. Risk factors related to diet, nutrition, and air pollution contribute significantly to communicable as well as NCDs. Many NCDs in adults have origins in malnutrition during pregnancy and early childhood; similarly, certain NCDs are caused by a communicable disease. We argue that the binary of communicable and NCD is incorrect, and that resources and policy attention be focused on strengthening primary health care systems that address CMMNDs as well as NCDs; and reduce the underlying risk factors.
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INVITED ARTICLE
	A health care delivery model focusing on development of a cadre of primary care physicians—Recommendations of Organized Medicine Academic Guild	p. 330
	Sunil Kumar Raina, Raman Kumar, Sagar Galwankar, Ishwar Gilada, Praveen Aggarwal, S Vimal Krishnan, Santosh Soans, Ramesh Bhatt, RP Srivastva DOI:10.4103/jfmpc.jfmpc_31_19   Organized medicine is the academic guild of professional medical organizations in India. It was founded at the annual conference of Indian Academy of Pediatrics (PEDICON) on January 7, 2018. Organized medicine is constituted by leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India. A group of experts on behalf of Organized Medicine Academic Guild (OMAG) of India was constituted to facilitate adequate theories and models on how to make primary care integral to participation of people and intersectoral collaboration in equitable delivery of health care. A subtle, flexible, and comprehensive approach instead of a "compartmentalized existing in silos" approach is likely to be needed. This paper is a formal recommendation on behalf of OMAG with an aspiration to deliver to the people of India, what they need, focusing on discrete objectives with long-term plans.
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REVIEW ARTICLES
	Using the concepts of positive deviance, diffusion of innovation and normal curve for planning family and community level health interventions	p. 336
	Sudip Bhattacharya, Amarjeet Singh DOI:10.4103/jfmpc.jfmpc_392_18   In medical schools across the globe, students are taught about the "THE NORMAL CURVE" as a part of statistics unit of Public Health, Community, and Family Medicine. However, its potentials for explaining the subject of health education and behavior change are grossly underutilized. Through this article, we attempt to demonstrate that this can be sorted out by integrating theories of Positive Deviance and Diffusion of Innovation through extrapolation of the concepts of "THE NORMAL CURVE" for explaining or planning things and events in Public Health, Community, and Family Medicine.
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	Unmanned aerial vehicle (drones) in public health: A SWOT analysis	p. 342
	Karthik Balajee Laksham DOI:10.4103/jfmpc.jfmpc_413_18   In developing countries, lack of access to roads is critical for medical supplies like vaccines and drugs. Air transport like a helicopter is expensive and not affordable. The success of drones in the fields of ecology and environment makes us believe that they can also be used in the field of Public Health as medical couriers. The important strength of using drones is its potential to decrease the travel time for diagnosis and treatment. They are a cost-effective alternative to road transport in difficult terrains. Drones can be used in the transport of blood from the blood bank to the place of surgery and that of specimens from hard-to-reach areas to the labs in nearby towns. They can deliver essential medicines like anti-venom for snake bite and dog bite and prevent deaths. Drones can be employed in disaster relief operations for rescuing victims and in the delivery of food, water, and medicines. Organs can be transported in a short time bypassing the busy traffic. However, operating drones require trained staff and the lack of infrastructure like runway is a potential problem. Drones cannot carry heavier payloads or deliver goods long distances. Drones in the hands of terrorist groups may be weaponized and used for terror attacks. Medical drones may be mistaken for military Drone and attacked by armed forces.
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	The application of palliative care in dementia	p. 347
	Masoumeh Pandpazir, Mozhdeh Tajari DOI:10.4103/jfmpc.jfmpc_105_18   Introduction and Objective: Palliative care can be of great help to people with dementia during their old ages. The aim of this study was to assess the use of palliative care in patients with dementia. Methods: Search was conducted in PubMed, ScienceDirect, Google Scholar, and Scopus databases. A step-by-step approach was used to identify relevant studies, and related studies of were demarcated and other studies were excluded. This study has used empirical studies, review studies, and guidelines for health organizations in different countries. Results: A total of 65 sources were used, of which 24 were completely related to the subject of the study. In related studies, the use of various ways and means of palliative care to improve quality of life, reduce pain, and prevent falling in people with dementia is discussed. Discussion and Conclusion: Palliative care can help people with dementia to improve their quality of life; however, more research is needed on the application and proper management of palliative care in patients with dementia.
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COMMENTARY
	Dual-degree MBBS-MPH programs in Saudi Arabia: A call for implementation	p. 352
	Ahmed Abu-Zaid, Abdulaziz M Eshaq, Khaled Alkattan DOI:10.4103/jfmpc.jfmpc_461_18   Nowadays, any healthcare problem should be dealt with in a multidisciplinary approach that employs not only treating the symptoms of the problem but also its source. This simply implies the necessity to produce well-rounded medical graduates (physicians) who can competently integrate clinical knowledge/skills (for disease treatment) and public health knowledge/skills (for disease prevention). Moreover, the medical training (MD/MBBS curriculum) largely gives emphasis to the clinical skills needed to treat individual patients, whereas public health training (MPH degree) emphasizes the methods needed to improve the overall community health. Bridging the gap between patients and community is best achieved through a combined multidisciplinary training in both medicine and public health, that is, dual-degree MBBS-MPH programs are the way forward. In United States, for example, there are >80 medical schools that offer such joint MD-MPH programs, whereas there is none in Saudi Arabia. Herein, I call on higher education bodies to implement dual-degree MBBS-MPH programs in Saudi Arabia. To the best of knowledge, this is the first ever report to call for such an innovative implementation. Also, this short communication briefly sheds light on background, rationale, benefits, curriculum design, and future directions of such programs. The implications of this perspective (i.e. dual-degree MBBS-MPH programs) should not be limited to Saudi Arabia only; rather, it should be contemplated by the other medical curricula in the different countries.
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ORIGINAL ARTICLES
	Vitamin D status in pregnant women visiting a tertiary care center of North Eastern India	p. 356
	Nalini Sharma, Chandan Nath, Jamil Mohammad DOI:10.4103/jfmpc.jfmpc_404_18   Background: Studies of vitamin D (VD) physiology suggest that effects of vitamin D deficiency (VDD) could be much broader than rickets including cardiovascular disease, cancers, diabetes, infection, and allergy and pregnancy complications. Data regarding the prevalence of hypovitaminosis in pregnancy are scanty especially in north eastern part of India. Therefore, this study has undertaken with the intention to find out prevalence and outcome of hypovitaminosis of VD in pregnancy. Materials and Method: In total, 177 pregnant women with singleton pregnancy, <16 weeks of gestational age, visited to antenatal clinic of our institute were consecutively enrolled for the study. The serum VD was estimated by Beckman coulter unicel DXI immunoassay system using the principle of Chemiluminescence. Incidence of vitamin deficiency and insufficiency calculated. VDD was defined as 25(OH)D levels in blood <20 ng/mL, and insufficiency of VD was defined as 25(OH)D levels <32 ng/mL. Antenatal complications, such as intrauterine growth restriction (IUGR), oligohydramnios, pre-eclampsia, preterm labor, gestational diabetes, if any, were noted. Labor and delivery information including induction of labor, mode of delivery, and newborn birth weight were noted. Result: In total, 177 women recruited for the study. Mean age and parity of the subjects were 26.71 ± 9.96 and 2.10 ± 1.8, respectively. For detailed statistical analysis, women were divided into three groups depending upon their VD levels: deficiency group [25(OH)D level <20 ng/mL], insufficiency group [25(OH)D level <32 ng/mL], and sufficient group [25(OH)D level >32 ng/mL]. VDD was present in 84.18% subjects. VD insufficiency was present in 12.44% of cases. There is association of preeclampsia, cesarean section, and low birth weight babies with lower level of VD. Conclusion: This study showed that the prevalence of VDD in pregnancy is astonishingly high till now there is no guideline to screen antenatal women for VDD. As the test is costly even, offering it to all at-risk women may not be cost effective compared with offering universal supplementation, particularly as treatment is regarded as being very safe.
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	Sickle cell disease prevents diabetes mellitus occurrence: A hospital based cross-sectional study	p. 361
	Biswaranjan Prusty, Thakura Soren, Anurag Choudhury, Reshma Biswal, Dillip K Pradhan, Pravat K Thatoi DOI:10.4103/jfmpc.jfmpc_466_18   Background: Sickle cell disease is the commonest inherited hemoglobinopathy. There are few reports point towards decrease incidence of diabetes mellitus in sickle cell disease patients. Materials and Methods: This cross-sectional study was conducted in VIMSAR, Burla, Odisha between Nov 2014 to Oct 2016. FBS and 2 hours OGTT reports of adult sickle cell disease patients were compared with the same reports from equal no of adult persons without sickle cell disease (controls) to found out any significant difference in prevalence of diabetes mellitus in sickle cell disease patients versus controls. Results: A total of 137 adult patients of sickle cell disease out of which males were 94 (68.61%) and females were 43 (31.38%) with an average age of (26.7 ± 10.9) years and an equal number of controls [males 87 (63.8%) and females 50 (36.5%)] with an average age of (47.6 ± 13.6) years were included in the study. We found diabetes mellitus in 2 (1.46%) out of 137 sickle cell disease patients with an average BMI 18.5 kg/m2 versus 12 (8.76%) in equal number of controls with an average BMI of 22.6 kg/m2. Conclusion: This study concludes that prevalence of diabetes mellitus in sickle cell disease patients is significantly lower than non-sickle cell disease persons. This may be due to less longevity and low BMI in sickle cell disease patients.
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	Knowledge, attitude, and practices regarding dietary supplements in Saudi Arabia	p. 365
	Mashael Abdullah Alowais, Manal Abd El-Hakim Selim DOI:10.4103/jfmpc.jfmpc_430_18   Objective: The study was aimed at determining the characteristics and lifestyle choices of dietary supplement users and to assess knowledge, attitude, and practice related to dietary supplements in the health sciences students versus other individuals in Saudi Arabia. Methods: A descriptive cross-sectional, online questionnaire-based study was conducted on 351 participants (138 were health sciences students and 203 were not). The results were documented and analyzed using SPSS- version 22. Results: More than half of the participants consumed dietary supplements, 53.6% of the health sciences students versus 56.3% of the other individuals. Multivitamins were the most commonly used supplement in all participants (49%). Both groups believed that people might need dietary supplements more during specific times as pregnancy or recovery from diseases, with higher percentage in health sciences students than other people (43% versus 38%). Most of the students were somewhat aware about the facts concerning dietary supplements compared to others. Significant difference (P ≤ 0.05) was found concerning opinion and beliefs related to dietary supplements between the two groups. However, the health sciences students were not highly knowledgeable about the facts regarding supplements. Conclusion: The users of dietary supplements tend to incorporate these products into their lifestyles as part of a broader focus on healthy living. Many of health sciences students do not have accurate information about dietary supplements. It is important to strengthen the health science curriculum concerning this topic, with the aim of producing better-informed future professionals.
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	Awareness, knowledge, and practices related to diabetic retinopathy among diabetic patients in primary healthcare centers at Riyadh, Saudi Arabia	p. 373
	Manal H AlHargan, Khalid M AlBaker, Abdulmajeed A AlFadhel, Mohammed A AlGhamdi, Salman M AlMuammar, Haifa A AlDawood DOI:10.4103/jfmpc.jfmpc_422_18   Context: Diabetic retinopathy (DR) is a microvascular complication for diabetes mellitus (DM), with around 35% of diabetic patients developing some form of DR. Aims: This study assessed the awareness toward DR, practice of regular eye examination, and DM control among diabetic patients. Settings and Design: This was a cross-sectional study among diabetics at two primary healthcare centers in Riyadh, Saudi Arabia, who were selected by convenience sampling. Methods and Materials: The questionnaire contained sections for demography, knowledge, attitude, and practice toward DR, and compliance to DM treatment. The association of awareness about retinopathy with demographics was compared. Statistical Analysis Used: The association of awareness about retinopathy and education level with demographics and compliance with treatment were compared using Chi-square test. Results: In total, 280 diabetic patients were included, 187 (67%) were males, mean age was 58.9 ± 10.1 years, and median duration of diabetes was 10 years. There was good awareness about DR, diabetes was well controlled in 170 (61%) patients, but less than half (45%) had their eyes checked within 1 year. Patients with education level of high school and above had higher awareness than those with no formal education (P < 0.001). Also, those with income level >10,000 SR had higher awareness than those with income ≤5,000 SR (P < 0.05). Conclusion: There was high awareness among the diabetic patients regarding DR but annual check-up was done in less than half of the patients. Improvement is required for scheduling annual eye examinations for the early detection of DR.
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	Effect of iron and folic acid tablet versus capsule formulation on treatment compliance and iron status among pregnant women: A randomized controlled trial	p. 378
	Rahul Srivastava, Shashi Kant, Arvind K Singh, Renu Saxena, Kapil Yadav, Chandrakant S Pandav DOI:10.4103/jfmpc.jfmpc_339_18   Background: Iron supplementation during pregnancy in programmatic settings has failed to produce desired results. Formulation of iron supplementation may have a role in compliance and hematological parameters. Objective: We did this study to compare the compliance to iron supplementation, change in mean hemoglobin and serum ferritin level after iron supplementation in capsule form and tablet form during pregnancy. Materials and Methods: In this single-blinded (investigator blinded), active comparator, randomized controlled trial we enrolled pregnant women (aged ≥18 years) from May to November 2014 during second trimester to receive iron supplementation either as capsule (ferrous fumarate) or tablet (ferrous sulphate) during entire pregnancy. The outcome was compliance (good compliance ≥ 90%) to iron supplementation assessed by pill count and change in mean hemoglobin and serum ferritin. Statistical significance was tested using Chi-square test and Student's ttest. Results: We enrolled and randomized 204 pregnant women for iron supplementation; capsule form (n = 100) and tablet form (n = 104). Out of which 52 (25.5%) women (23 in capsule arm and 29 in tablet arm) were lost to follow up. As compared to tablet arm, the capsule arm had higher good compliance (22% vs 16.8%), increase in mean hemoglobin (0.79 vs 0.44 gm/dL) and increase in mean serum ferritin (2.50 vs -2.14 ng/mL), but the difference was not statistically significant. Conclusion: Pregnant women who received either of the formulation reported a low compliance. Iron supplementation in capsule formulation resulted in more increase in blood hemoglobin level, though clinically insignificant.
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	Supportive supervision of routine immunization in Rajnandgaon district of Chhattisgarh	p. 385
	Harshal G Mendhe, Kiran G Makade, Nitin Kamble, Rohit David, Daneshwar Singh, Lalit Chandrawanshi DOI:10.4103/jfmpc.jfmpc_429_18   Background: Immunization coverage in Chhattisgarh has never been abysmal but the improvement is rather insignificant over the years. Some more interventions are essential to strengthen different aspects of immunization services such as micro-planning, cold-chain and logistics management, monitoring/supportive supervision, and community mobilization. The present study was considered as a part of ongoing UNICEF funded Project on Supportive Supervision of Routine Immunization in Rajnandgaon district undertaken by the Department of Community Medicine, Government Medical College, and Rajnandgaon CG with the objectives to observe key quality parameters at Ice Lined Refrigerator (ILR) points and to assess knowledge and practice of Vaccine Cold Chain Handler (VCCH). Methods: A facility-based, cross-sectional study (repeat survey) was conducted from May 2017 to June 2018 in the Rajnandgaon district of Chhattisgarh. First phase of the study was conducted from May 2017 to November 2017 and repeat survey was conducted from December 2017 to June 2018. Structured questionnaires as a part of standard tool prescribed by Government of India was used for the collection of required data. Results: The cumulative score status out of all the 50 centres in Rajnandgaon district showed improvement in 35 centres. The score of important components such as vaccine management, equipment maintenance, temperature monitoring, and monitoring and supervision information improved, but that of background information and human resource component decreased. Conclusion: Supportive supervision strategy can be more beneficial in improving the cold chain maintenance process provided that components such as logistic, infrastructure, and manpower are in place to enhance service delivery. Supportive supervision is a continuous process, so regular follow-up and monitoring visits are essential to achieve the targets.
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	Effect of academic stressors on eating habits among medical students in Riyadh, Saudi Arabia	p. 390
	Mohammed I AlJaber, Abdullah I Alwehaib, Hamad A Algaeed, Abdulrahman M Arafah, Omar A Binsebayel DOI:10.4103/jfmpc.jfmpc_455_18   Context: Stress can be defined as an integral response of the organism to pressures from the internal or external environment with the aim to maintain homeostasis. Usually, it has a negative impact on human health. Medical students can feel stress during their preclinical studies due to overload of work such as assignments, lectures, and seminars. As a result, their appetite can be affected by skipping meals eating fast food. Aims: The aim of this study was to assess the pattern of eating habits and to define its association with stress among medical students. Settings and Design: This cross-sectional study was conducted among the medical students of Al-Imam Muhammed Ibn Saud Islamic University. Subjects and Methods: The sample consist of 105 Arabian males (100%) with 21-year old being the average. We use questionnaires divided into three sections. Statistical Analysis Used: SPSS. Results: We have confirmed three hypotheses: freshman would have Higher Stress Levels than sophomores and junior, the spread of fast food restaurants increases the chance for students to eat Unhealthy Foods, and the students Who Have High Stress Levels Would Eat More Unhealthy Foods Than Students Who Have Low Stress Levels. Conclusions: Our findings have revealed the importance to develop a specific intervention program with the aim to decrease the stress in medical students. We suggest also the development of accurate university programs with resources well programmed and well established, development of the educational program with the aim to promote healthy eating habits in medical students, the longitudinal courses should be converted to Blocks to decrease the Academic stress on students.
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	An investigation into the clinical accuracy of twinkling artifacts in patients with urolithiasis smaller than 5 mm in comparison with computed tomography scanning	p. 401
	Mohammad Qasem Hanafi, Ahmad Fakhrizadeh, Esmat Jaafaezadeh DOI:10.4103/jfmpc.jfmpc_300_18   Background: Ultrasound (US) is a non-invasive method used for the diagnosis of urolithiasis. If the size of the stone is <5 mm, it may be difficult to diagnose. This study aimed to compare the accuracy of twinkling artifact (TA) of color Doppler US imaging with unenhanced computed tomography (CT) for detecting urolithiasis <5 mm. Materials and Methods: This prospective study was conducted on 100 patients with suspected renal calculus presented to the emergency room at the Imam Khomeini Hospital of Ahwaz in 2018. The US findings such as posterior acoustic shadowing and TA were examined for their ability to detect urinary stones (greatest diameter ≤5 mm) using CT findings as the gold standard. Results: The mean size of renal stone was 3.43 ± 0.80 mm in CT and 3.49 ± 0.82 mm in color Doppler US. There was no significant difference between CT and color Doppler US report in quantification of urolithiasis sizes (P = 0.603). TA on color Doppler US was detected in 94 (94%) patients while posterior acoustic shadow was detected in 83 (83%) patients (P = 0.004). A significant difference was found between the TA and size of stones (P = 0.036). The sensitivity, accuracy, and positive predictive values of TA for the detection of calculus were 94%, 94%, and 100%, respectively. Conclusion: The results demonstrated that TA on color Doppler US could be a good and safe alternative imaging modality with comparable results with non-contrast-enhanced computed tomography for the sensitive detection of urolithiasis <5 mm.
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	Assessment of need for limiting family after two children: A cross-sectional study from a Northern State of India	p. 407
	Rajesh Kumar Singh, Amandeep Kaur DOI:10.4103/jfmpc.jfmpc_448_18   Background: Success of a programme of free-choice participation, like Family Planning Programme, can be envisaged only when focus is on the needs of the people. Although India was the first country to introduce Family Planning Programme, total fertility rate of 2.1 has not yet been achieved, highlighting that the need of limiting family after two children is not yet felt by the people of India. Therefore, the study was undertaken to assess need for limiting family and permanent methods, and factors influencing it among couples with two or more living children. Materials and Methods: A community-based cross-sectional study was conducted in rural and urban areas of Haldwani Tehsil, Uttarakhand. Multistage sampling technique was used for selection of study sample. Data were collected using a pretested questionnaire. Statistical analysis was done using Epi Info version 7.2.2.6. Results: Out of 221 women interviewed, only one-third had adopted permanent methods of contraception for limiting family, one-third were using temporary methods, and remaining were not using any contraception. Merely one-third participants were willing to adopt permanent contraception in future. Unmet need for permanent methods was higher among women of younger age, literate woman, and/or husband and joint families. It was lower in women with three or more living children in comparison with women with two children. Unfelt need for limiting the family was 8.6%. Conclusion: Acceptance of permanent methods of contraception was low with temporary methods being equally preferred for limiting family. Unfelt need for limiting still remains in the community despite promotion of small family norm.
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	Evaluation of knowledge and attitude of parents about the importance of maintaining primary dentition - A cross-sectional study	p. 414
	Mahesh Ramakrishnan, Sarah Banu, Sharna Ningthoujam, Victor A Samuel DOI:10.4103/jfmpc.jfmpc_371_18   Introduction: Dental caries is very common in primary dentition because of improper oral hygiene and increased intake of sucrose. Grossly decayed primary teeth require extraction. The space created by extracted teeth should be replaced by primary dentition to avoid migration of adjacent teeth into the space and to prevent the eruption of permanent tooth. Different appliances are used to maintain the space post extraction of the primary tooth to preserve the space for the eruption of the permanent tooth in a sequential manner. Aim: Evaluate the attitude and knowledge of parents toward the importance of maintaining primary dentition in their children. Methods: A survey was conducted among randomly selected 100 parents having children between the ages of 2 and 16 years from the general population of Chennai, India. A questionnaire was created was distributed. The data were later collected and statistical analysis was performed. Results: Hundred percent awareness was seen among parents regarding maintenance of oral hygiene in children. Only 65% parents reported visiting dentists only when the child complains of pain. Eighty-nine percent of the parents were aware of the harmful effects of thumb sucking habits. However, only a minimum percent parents thought that treating primary teeth was not very important as it would shed off. Conclusion: Even though parents were aware that primary teeth have to be managed properly, they were not aware of the various treatment modalities available for treating spaces after extraction of primary teeth and caries management. An increase in the knowledge will encourage parents to provide better oral health to their children.
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	Psychosocial consequences of false-positive results in screening mammography	p. 419
	Zeina El Hachem, Marouan Zoghbi, Souheil Hallit DOI:10.4103/jfmpc.jfmpc_4_17   Introduction: To evaluate the psychosocial impact of benign breast biopsies on Lebanese women after a screening mammography and the effect of these biopsies on patients' attitudes toward subsequent screening. Methods: In this retrospective study (January 2005 till April 2011), 109 consecutive patients with a history of breast biopsy without cancer were asked to answer a phone questionnaire. The response rate was 91.7% (100 women accepted to participate). A questionnaire about sociodemographic characteristics, biopsy characteristics, and patients' attitudes as measured by the negative Psychosocial Consequences Questionnaire (PCQ) and other independent questions was filled by phone call by one interviewer. Results: The negative PCQ score was low for most women (only 9% have a negative PCQ score ≥18/36) and is statistically dependent on the result of the last mammography (P = 0.01) and the number of previous benign breast biopsies (P = 0.01). A total of 10% of women increased their medical visits after this biopsy, 8% were treated for psychiatric problems after this biopsy, and 19% self-examine their breasts more than once per week. The benign breast biopsy experience increases the willingness to adhere to the screening mammography in 71% of the patients, this reported adherence depends positively on the score of the negative PCQ (P = 0.043). Conclusions: The negative psychosocial effect of the biopsy is minimal in general and is positively correlated to the adherence to future mammographies. Interventions are necessary to decrease the anxiety in most susceptible women and to raise the awareness of women at risk of nonadherence to the screening mammography.
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	Mortality pattern of elderly patients at a tertiary care hospital: A study from Sub-Himalayan region, Uttarakhand, India	p. 426
	Debajyoti Banerjee, Minakshi Dhar, Monika Pathania, Ravikant , Vyas Kumar Rathaur DOI:10.4103/jfmpc.jfmpc_416_18   Background: Currently, in developing countries like India, there is a paradigm shift in the mortality patterns of elderly from communicable to noncommunicable diseases. Objective: This study is aimed at providing an insight on mortality patterns of elderly patients within a 2-year period in a tertiary hospital, All India Institute of Medical Sciences (AIIMS), Rishikesh, India. Materials and Methods: This study is a retrospective review of mortality patterns of elderly patients from March 2016 to March 2018 occurring in the Department of General Medicine, in AIIMS, Rishikesh, India. Information derived from the Medical Records Department of AIIMS Rishikesh include age, sex, clinical history, diagnosis, duration, and cause of death. Results: During this period, a total of 1101 elderly (≥60 years) admissions were done in the Department of General Medicine, AIIMS Rishikesh. A total of 66 patients had expired during their hospital stay. Among this, 35 and 31 cases were elderly male and female patients, respectively, and therefore the ratio of male to female was 1.1:1.0. The peak age group was 60–64 years accounting for 23 patients (34.8%). The age range of patients was 60–94 years, while the modal and mean ages were 65 and 69 years, respectively, with 8.1 standard deviation. The most commonly encountered cause of mortality was cerebrovascular accident constituting 19 (28.8%) cases. The second majority of mortality cases were hypertensive disorders constituting 13 (19.7%) cases, and the third majority were septicemia and pneumonia accounting for 12 (18.2%) and 12 (18.2%) cases, respectively. Others include diabetes mellitus [metabolic disorder; 10 (15.2%) cases], acute renal failure [10 (15.2%) cases], ischemic heart disease or coronary artery disease [6 (9.1%) cases], while malignancies, tuberculosis, hepatitis, chronic liver disease, and chronic obstructive pulmonary disease consisted of five cases (7.6%) each. Conclusion: Noncommunicable diseases particularly cerebrovascular diseases and hypertensive disorders were the most commonly encountered cause of elderly mortality in this region of North India, that is, the state of Uttarakhand. Notwithstanding a large percentage of mortality patterns also results from communicable diseases with septicemia and pneumonia as the third leading cause of mortality.
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	Impact of different stages of chronic kidney disease on the severity of Willis–Ekbom disease	p. 432
	Jahnabi Bhagawati, Sunil Kumar, Abhijeet Kumar Agrawal, Sourya Acharya, Anil K Wanjari, Tarachand K Kamble DOI:10.4103/jfmpc.jfmpc_418_18   Introduction: Willis–Ekbom disease (WED)/restless legs syndrome (RLS) is a disorder in which the patient has neurologic features such as urge of rhythmic limb movement that may decrease or stop when the limb is moved. In this study, we had tried to compare the severity of WED in different stages of chronic kidney disease (CKD). Materials and Methods: In this study, a total of 300 patients with CKD who were >18 years of age were included. All the participants were subjected to questionnaire for the diagnosis of RLS (essential clinical criteria for the diagnosis of RLS) and a questionnaire on International Restless Legs Syndrome Study Group Rating Scale for its severity. Observation and Results: Our study showed a prevalence of 20% of WED in patients with CKD. Patients with CKD on hemodialysis had significantly more WED than the conservative group (P = 0.0001). Patients with a history of diabetes mellitus showed significant correlation with WED (P = 0.026), while patients who had a history of hypertension showed both diabetes mellitus and hypertension and smoking had no significant relation with WED (P = 0.27, P = 0.23, and P = 0.22, respectively). The different stages of CKD showed significant correlation with WED (P = 0.002), with more WED among patients with stage V CKD. WED was more in patients on hemodialysis (P = 0.0001). The correlation of different stages of CKD with the severity of WED was statistically significant (P = 0.029), with WED being more severe among stage V CKD. Conclusion:WED was more prevalent among patients with CKD who are on maintenance hemodialysis and diabetes mellitus. However, no such relation could be established for hypertension alone. Patients with higher grades of CKD were more prone to have WED symptoms, and the severity of these symptoms increases with the stages of CKD.
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	Quality of life among migrant construction workers in Bangalore city: A cross-sectional study	p. 437
	Shaik Zabeer, Leeberk R Inbaraj, Carolin E George, Gift Norman DOI:10.4103/jfmpc.jfmpc_424_18   Context: The construction industry is one of the oldest industries in India, which employs a large number of workers of poor socioeconomic status. Bangalore has seen significant rise in the number of migrants from various parts of the country to work in construction industry. These workers suffer from lack of good accommodation, basic sanitation, health facilities, stressful working conditions, and poor social life. Quality of life (QoL) among a population is an essential step to understand and improve health status, well-being, and mental health of the population. Materials and Methods: A cross-sectional study was done to assess QoL among migrant construction workers in Bangalore. We interviewed 400 workers using questionnaire containing sociodemographic profile and WHOQOLBREF scale. Factors associated with QoL were tested using independent "t" test and Chi-square test and P < 0.05 was considered as statistically significant. Results: The mean age of the workers was 26.38 + /4.3 years and majority of them were men (95.2%). The smokers had higher mean score in psychological domain with a significant P value. Those who lived in huts had higher mean score (60.4+/9.71) in the social domain as compared with those who lived in pucca houses (59.7 + /12.5). Those who were married, worked as nonlaborers, lived in pucca houses, earned higher income had higher mean scores in the environmental domain compared with those who were unmarried, laborers, lived in huts, and earned lower income. Conclusion: Migrant construction workers had poor physical, social, and psychological QoL, whereas QoL in environmental domain is better compared with studies done across the country and it was significantly associated with higher income, education, better accommodation, and type of work. We recommend strategies to improve their physical, social and psychological well-being of this vulnerable population through strict legislations.
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	Clinical and demographic characteristics of geriatric patients with acute poisoning in the state of Uttarakhand	p. 443
	Nidhi Kaeley, Bharat Bhushan, Vempalli Subramanyam, Subodh Kumar, Ankita Kabi DOI:10.4103/jfmpc.jfmpc_420_18   Background: Acute poisoning in geriatric age group is a clinical challenge due to multiple comorbidities and complications in this age group. There are very few studies done in the past, which have addressed this issue. Materials and Methods: This retrospective observational study was a carried out in the Department of Emergency Medicine of a tertiary care hospital of Uttarakhand over a period of 1 year from November 2017 to October 2018. Detailed demographic data and clinical history of patients with alleged history of acute poisoning was obtained from the hospital record section. Results: During the period of 1 year, 156 patients of acute poisoning attended the medical emergency department, of which 53 (33.9%) patients belonged to geriatric age group (>60 years). Maximum number of patients belonged to the age group of 71–80 years (n = 26, 16.6%). Males outnumbered female patients. The most common toxidrome in geriatric age group was alcohol intoxication followed by pesticide (organophosphorus) poisoning. Unintentional exposure of toxin in the form of drug over dosage encompassed more than one-third of poisonings in geriatric population. Nine (16.9%) geriatric patients succumbed to poisoning. Complications such as acute renal failure, shock, respiratory distress, acute liver injury, and need for ventilator support were more common in nonsurvivors as compared with survivors. Conclusion:The study demonstrated mortality of 16.9% (n = 9) among geriatric patients with alleged history of acute poisoning. The risk factors attributing to mortality were shock, aspiration pneumonia, and acute liver injury. Although cases of suicidal exposure outnumbered cases of unintentional exposure, the latter group comprised of a considerable number. Clearly, more attention is needed while managing a case of acute poisoning of geriatric age group as their pattern of presentation and complications differ from that of younger age group.
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	ART Registries–Characteristics and experiences: A comparative study	p. 449
	Maryam Zahmatkeshan, Majid Naghdi, Mojtaba Farjam, Mehrshad Mokhtaran, Azita Yazdani, Zahra Mahmoudvand, Reza Safdari DOI:10.4103/jfmpc.jfmpc_453_18   Background: The incident of infertility is continuously increasing. As a result, the demand for medical care such as assisted reproductive technology (ART) technology is equally increasing. In order to manage the growing data and information collected on ART, there is a need for a registry system can provide accurate statistics about activities and outcomes and ensure the quality control. Therefore, the aim of this study was to examine and compare In vitro fertilization (IVF) and ART registries. Methods: This is a descriptive-comparative study in which data from the national ART registries of 14 selected countries in 2018 were collected. In this study, databases such as PubMed, Web of Sciences, and Scopus, as well as Google Scholar websites were searched. Results:Important aspects of the registry were studied. One of the most important goals of these systems is to collect information about ART, as well as to monitor and report the results and implications, and also implement new care plans. Conclusion: A national registry helps to better understand the scope and the effect of assisted reproduction on the health of infertile couples. By this registry system, different countries can compare the data with other countries, allowing the improvement of techniques and the best possible care for patients.
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	Knowledge and practices of primary health care physicians regarding updated guidelines of MERS-CoV infection in Abha city	p. 455
	Saad Al-Amri, Rishi Bharti, Safar A Alsaleem, Hassan M Al-Musa, Shweta Chaudhary, Ayub A Al-Shaikh DOI:10.4103/jfmpc.jfmpc_336_18   Background: Human coronaviruses (hCoV) usually cause mild to moderate upper respiratory tract illnesses. The novel coronavirus (nCoV), or Middle East respiratory syndrome coronavirus (MERS-CoV), is a particular strain different from any other known hCoV with the possibility of human and also zoonotic transmissions. The aim of the study to assess primary health care (PHC) physicians' knowledge and adherence regarding Saudi Ministry of Health guidelines regarding MERS-CoV. Materials and Methods: A cross-sectional study design was followed to include 85 PHC physicians in Abha city. An interview questionnaire has been designed by the researcher that was used to assess knowledge and practices of PHC physicians regarding diagnosis and management of MERS-CoV. It includes personal characteristics, the MERS-CoV knowledge assessment questionnaire, and practices related to adherence toward guidelines regarding MERS-CoV. Results: PHC physicians' knowledge gaps regarding MERS-CoV included protected exposure (32.9%), highest seasonal incidence of MERS-CoV in Saudi Arabia (60%), relation between incidence of MERS-CoV and overcrowding (62.4%), case fatality of MERS-CoV cases (63.5%), and collecting specimens from MERS-CoV patients (64.7%). The knowledge of PHC physicians about MERS-CoV was poor among 5.9%, good among 63.5%, and excellent among 30.6%. Personal protective equipment to be used when seeing suspected cases of MERS-CoV infection were mainly the mask (94.1%), gloves (78.8%), the gown (60%), goggles (31.8%), and the cap (22.4%). All participants stated that the most important standard precaution that should be applied when seeing a case of MERS-CoV infection is hand washing, whereas 97.6% stated that the most important respiratory precaution to prevent transmission of respiratory infections in PHC setting when seeing a case of MERS-CoV infection is masking and separation of suspected MERS-CoV patients, and 81.2% stated that upon exit from the room of a MERS-CoV patient, the physician should remove and discard personal protective equipment. PHC physicians' knowledge about MERS-CoV differed significantly according to their nationality (P = 0.038), with non-Saudi physicians expressing higher percent of excellent knowledge than Saudi physicians (40% and 20%, respectively). Those who attended continuing medical education (CME) activities had significantly higher percent of excellent knowledge than those who did not attend a CME activity (55.6% and 23.9%, respectively, P = 0.011). PHC physicians' knowledge did not differ significantly according to their age, gender, qualification, experience in PHC, and practice-related adherence to guidelines. PHC physicians' practice-related adherence to guidelines about MERS-CoV differed significantly according to their position (P = 0.035), with specialists having the highest percent of excellent practice (13%). Conclusions: There are knowledge gaps among PHC physicians in Abha city, and their practice is suboptimal regarding MERS-CoV infection. Less than one-fourth of PHC physicians attend CME activities about MERS-CoV infection. However, significantly less practice-related adherence to guidelines are associated with Saudi PHC physicians, those who did not attend a related CME activity, and MBBS qualified physicians' general practitioners. To increase awareness, more CME activities related to MERS-CoV infection management needs to be organized.
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	Prevalence and risk factors of gastroesophageal reflux disease among Shaqra University students, Saudi Arabia	p. 462
	Abdulaziz A Alrashed, Khalid I Aljammaz, Aslam Pathan, Aeshah A Mandili, Samah A Almatrafi, Mashaeel H Almotire, Salha M Bahkali DOI:10.4103/jfmpc.jfmpc_443_18   Introduction: Gastroesophageal reflux disease (GERD) is one of the most common chronic gastrointestinal disorders in adults, it develops when the stomach contents reflux and rise up into the esophagus as a result from lower esophageal sphincter dysfunction. Stomach acid that touches the lining of the esophagus causes symptoms and complications. The classical symptoms of GERD include heartburn, usually after eating, chest pain, and regurgitation. Aim: To measure the prevalence of gastroesophageal reflux disease and determine its risk factors among the students of Shaqra University. Methods: A cross-sectional study was conducted using a structured questionnaire distributed among Shaqra University students after multistage stratification and random sampling technique to stratify students according to gender and the three main colleges in Shaqra city, Saudi Arabia. The sample size was determined to be 435 with the precision of ± 5% and a 95% confidence interval (CI). The questionnaire included demographic data like age, gender, height and weight, lifestyle, and dietary habits. Statistical data were analyzed using the Statistical Package for Social Sciences (SPSS) version 16. Results with a P value of <0.05 were considered statistically significant. Results: A total of 400 [227 (56%) male and 173 (43%) female] participants were evaluated. And 95 participants got a gastroesophageal reflux disease questionnaire score of ≥8 thus determining the prevalence of GERD to be 23.8%. Univariate analysis revealed that gender, smoking, familial history of GERD, high body mass index (>25 kg/m2), fast food, tea, carbonated beverages consumption, quick eating, and sleeping within 1 hour of dinner are associated with symptomatic GERD (P < 0.05). Conclusion: The results show a high prevalence of GERD in Shaqra university students and the presence of many modifiable risk factors which merits the conduction of public health campaigns to raise awareness about the disease and its risk factors.
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	The impact of sickle cell anemia on the quality of life of sicklers at school age	p. 468
	Karimeldin M. A. Salih DOI:10.4103/jfmpc.jfmpc_444_18   Background: Sickle cell anemia (SCA) is prevalent in Sudan in general, and in particular in the western part of the country among Misseria tribe. School absence, depressive symptoms, embarrassment, social disturbances, and emotional disturbance present negative impact for sicklers. Therefore, an urgent call for improving the quality of life of sicklers is needed. Objectives: To examine the impact of SCA on the quality of life of school-age children affected by the disease from the perspective of three dimensions: psychological, social, and schooling. Materials and Methods: This is a prospective, cross-sectional, observational study carried out over 2 weeks' period in April 2011 in Western Sudan, Gineana District. This study included 107 patients within the age group of 7–15 years with confirmed diagnosis of SCA in a steady state. A sickler with SCA who had hemoglobin genotype "SS" on hemoglobin electrophoresis without crises over the past 4 weeks was considered to be in steady state. Questionnaires designed by expert covering social and psychological aspects of the disease were filled by the authors. Results: Of 107 patients with confirmed diagnosis of SCA in steady state, 54.2% of them were male. About 17.8%, 29.6%, 23.4%, 48.6%, 16.8%, and 45.8% of the patients suffered from school absence, teasing, embarrassment due to bedwetting, embarrassment due to jaundice, failure to contribute to school activities such as sport, and depressive symptoms, respectively. Around 8.4% of the patients repeated classes. Divorce and anxiety among sicklers' families were found in 6.5% and 8.4%, respectively. Twenty-one (19.6%) families had less interest in social activities in the community. Conclusion: Sickle cell disease has many social and psychological problems which need to be addressed. Enuresis, depressive symptoms, school absentees, and deterioration in school performance were the common problems encountered.
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	A comparative study of satisfaction and family conflicts among married nurses with different working hours	p. 472
	Mohammad Islami Vaghar, Mojgan Javedani Masrour DOI:10.4103/jfmpc.jfmpc_395_18   Objective: Compared with other employees, Iranian nurses can lead a very difficult and exhausting life, especially when they are married and have different working hours. In this regard, the present study was carried out in order to compare satisfaction and family conflict among married nurses with different working hours in Tehran. Materials and Method: Multistage cluster sampling was employed to select 230 individuals from among 3,000 married female nurses working in teaching hospitals in Tehran. Among the selected participants, 115 were working morning shift and 115 on evening shift on a rotating shift basis. Enrich marital satisfaction scale and Carlson's work--family conflict questionnaire were employed in order to measure the study's variables. Results:Results showed that there was no significant difference between the two groups in terms of marital satisfaction (P > 0.05). However, they were significantly different with regard to work--family conflict (P < 0.05). Conclusion:It can be concluded that being a nurse implies this notion to other people that nurses are not dissatisfied with their marriage; however, family members may not have such a mutual understanding about them.
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	Interrelationship between dental health status and nutritional status among elderly subjects in India	p. 477
	Aakriti Gupta, Ritika Khandelwal, Umesh Kapil DOI:10.4103/jfmpc.jfmpc_353_18   Background: Poor dental health status has been suggested to negatively impact the food selection, ultimately leading to malnutrition. Objective: This study was undertaken to assess the association of dental health and nutritional status among elderly subjects in India. Methodology: A community-based cross-sectional study was conducted during 2015–2016 in district Nainital, Uttarakhand state, India. A total of 1003 elderly population were enrolled from 30 clusters (villages) identified using population proportionate to size sampling methodology. Information on sociodemographic profile and anthropometric measurements was collected. Body mass index (BMI) and Mini Nutritional Assessment scale (MNA) were calculated for assessment of nutritional status. A trained professional assessed the dental health status through physical examination. Dietary intake data was collected using 24-h dietary recall methodology. Results: We found that the prevalence of complete edentulism was 11%. Use of dentures was reported among only 9.6% subjects who were completely edentulous. Prevalence of underweight as defined by BMI and malnutrition as defined by MNA was higher among subjects with complete loss of teeth complete loss of teeth and chewing problems chewing problems and who did not wear dentures when compared with others. Subjects who wore dentures had significantly lower prevalence of malnutrition when compared with subjects who did not wear dentures. Conclusion: Dental health status was significantly associated with poor nutritional status among elderly subjects in India. There is a need for providing restorative dental healthcare services to elderly population to improve their nutritional status.
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	Status and determinants of birth preparedness and complication readiness in a rural block of Haryana	p. 482
	Nitika Sharma, Neelam Kumar, Srishti Singh, Jagbir Singh Malik, Anuj Jangra DOI:10.4103/jfmpc.jfmpc_372_18   Introduction: Pregnancy and motherhood is a physiological phenomenon. However, approximately 830 women die from preventable causes related to pregnancy and childbirth every day. Birth preparedness and complication readiness (BPACR) improves preventive behavior and improves knowledge of mothers about danger signs. Objective: The objective of the study is to assess the status and sociodemographic determinants of BPACR among the women who have experienced motherhood recently. Materials and Methods: The study was carried out among 200 women in a rural block of Haryana over a period of 6 months. The tool used to collect data was adapted from survey tools of Johns Hopkins Program for International Education in Gynaecology and Obstetrics/Maternal and Neonatal Health Program. Results: BPACR index came out to be 66.93 and 58.5% women were well prepared for BPACR. Education and occupation of participants, education of participant's husband, socioeconomic status, and caste were found to be significantly associated with BPACR. Conclusion:BPACR is a comprehensive strategy to ensure safer pregnancy and motherhood. Providing educational and skill acquisition opportunities for rural women for their empowerment and increasing their role in decision-making are imperative in order to improve BPACR and promote utilization of skilled attendants at every delivery.
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	Risk of developing Diabetes Mellitus among urban poor South Indian population using Indian Diabetes Risk Score	p. 487
	Aditya Oruganti, Avinash Kavi, Padmaja R Walvekar DOI:10.4103/jfmpc.jfmpc_388_18   Background: Diabetes mellitus is increasing its share of burden to the health-related problems in developing countries such as India. Urban slum residents constitute the "vulnerable population" who lack the basic health amenities. Lack of effective screening for primary prevention has been one of the reasons for the rising burden. Materials and Methods: The cross-sectional study was conducted among 400 adults aged between 30 and 60 years residing in a settled slum of Rukmini Nagar area of Belagavi city, Karnataka. Data were collected after taking written informed consent from each participant using a pretested questionnaire that included demographic information and details of the risk factors. Risk of developing diabetes was assessed by using Indian Diabetes Risk Score. Results are expressed as proportions, and analysis was done using Chi-square test and multiple logistic regression analysis. Results: The mean age of participants was 44.3 ± 8.7 years. The proportion of low, moderate, and high risk of developing diabetes mellitus was 7%, 63%, and 30%, respectively. The prevalence of newly diagnosed cases was 10.25%. Moreover, 57.1% of them with positive family history were in the high risk category; 76.9% of the sedentary workers were at higher risk; overweight and obese individuals had higher proportion of the high and moderate risk (P < 0.0001). Correlation coefficient (R) was 0.782, and coefficient of determination (R2) was 0.61. Conclusions: Our study demonstrated that advancing age, low physical activity, family history, overweight, and obesity were the prominent factors that predicted the risk of diabetes in the near future. Hence, focused interventions for urban slum dwellers are imperative and draw special attention.
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	Greater concern about hypoglycemia in Type 2 diabetics is the need of the hour—findings from a prospective, single-center, observational study	p. 493
	Prafull Mohan, Shubham Saini, Jayant Kumar Kairi DOI:10.4103/jfmpc.jfmpc_417_18   Context: Hypoglycemia is a well-recognized adverse effect in the treatment of type 1 diabetes mellitus. For patients of type 2 diabetes mellitus (T2DM) on stabilized treatment with the current oral antidiabetic drugs, occurrence of hypoglycemia is considerably less well studied. The current study was undertaken to understand the extent of this problem in elderly Indian patients. Objectives: Primary Objective: Assessment of incidence of hypoglycemia in patients of T2DM on stable treatment. Secondary Objectives: 1. Estimation of incidence of episodes of severe hypoglycemia in patients. 2. Correlation of presence of hypoglycemia with treatment modality. Settings and Design: This study was conducted as an open label, single-center observational study at a multispecialty tertiary care hospital. Materials and Methods: The study participants consisted of 50 elderly confirmed patients of either gender suffering from T2DM undergoing treatment and follow-up in the hospital for at least 12 weeks. After a brief training session and enrolment, the patients were asked to report to study site every month for next 2 months. Parameters recorded were plasma glucose levels, HbA1c levels, treatment regimen, body mass index, possible hypoglycemic episode based on symptoms and self-monitoring of blood glucose, and quality of life based on questionnaire score. Statistical Analysis: Descriptive and other statistics were used to analyze the hypoglycemic episodes experienced by the patients for correlation with medicines and the effect of hypoglycemia on their quality of life. Results: Total of nine hypoglycemic episodes were recorded. Severe hypoglycemia did not occur in any patient. Patient on insulin reported significantly more hypoglycemia. Quality of life is not much different in patients using insulin in T2DM.
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	A study on the health seeking behavior among caregivers of under-five children in an urban slum of Bhubaneswar, Odisha	p. 498
	Krishna Mishra, Ipsa Mohapatra, Amit Kumar DOI:10.4103/jfmpc.jfmpc_437_18   Background: The under-five children are a vulnerable age group; their mortality reflecting a country's overall development. Timely and appropriate healthcare seeking behavior, if practiced by caregivers, can have a significant impact on survival. The slum dwellers have poor health-seeking behavior due to their lower socioeconomic status, prevailing malnutrition, poor immunization status, overcrowding, poor sanitation, personal and cultural practices, beliefs, and attitude toward healthcare providers. Objectives: (1) To assess the health-seeking behavior among caregivers of under-five children during acute childhood illness (2) To find out the factors associated with their treatment-seeking behavior. Materials and Methods: A community-based cross-sectional study, among 260 caregivers, in the field practice area of Urban Health and Training Centre of a medical college was undertaken from September 1, 2016 to February 28, 2017, using a pretested semistructured questionnaire after obtaining a list of under-fives from the female health worker. Results: In total, 260 caregivers with mean of 26.61 ± 4.31 years participated in the study, 77.69% reported of some health morbidity. Around 21.92% of the caregivers gave primary care at home, 33.46% visited a chemist, and 33.08% attended health facility nearby. About 79.23% sought healthcare immediately following illness. Of the remaining 20.77% who did not seek medical advice, 75.93% used home remedies. Significant association was found between the age of the mother, educational status of the mother, religion, birth order of the child and socioeconomic status of the caregivers, and appropriate treatment seeking behavior during an episode of acute illness. Conclusion: This study attempted to identify health-seeking behavior of caregivers for children under-five and the determinants of appropriate treatment-seeking behavior. The knowledge of signs and symptoms of ill-health can reduce morbidity and mortality; however, continuous education of caregivers for recognition of symptoms and the need to seek appropriate medical care is needed. Government facility was the preferred choice for the population in the sampled slum. Treatment-seeking behavior was good among the respondents with majority having appropriate behavior. Measures can be taken to help promote awareness among those who did not have appropriate treatment seeking behavior.
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	Depression and anxiety among high school student at Qassim Region	p. 504
	Reem Alharbi, Khalid Alsuhaibani, Abdullah Almarshad, Abdulhameed Alyahya DOI:10.4103/jfmpc.jfmpc_383_18   Background: Adolescence is a stage of changes in body and behaviour that may affect mental health. We found that no study measures the depression and anxiety in adolescence in our region, so we want to measure it and then try to improve our community. Aim: We aim to estimate the prevalence of depression and anxiety among high school students at Qassim region. Methods: A cross-sectional study done in al-Qassim region. A targeted population was secondary school students. The sample size was 1245 students. We used the questionnaire tool the Patient Health Questionnaire (PHQ-9) to assess depression in the students and the GAD7 for anxiety. The data had been gathered through MS Excel then exported to the Statistical Packages for Social Sciences (SPSS) for analyses. A P value cut-off point of 0.05 at 95% confidence interval (CI) was used to determine statistical significance. The analyses measure the association between socio-demographic and other related variables in the survey by using a Chi-square test. Result: Our study shows that depression by using (PHQ-9) among the 1245 students, 325 (26.0%) were not depressed, 423 (34%) were mildly depressed, 306 (24.6%) were moderately depressed, whereas 129 (10.4%) were moderately severe depressed and 62 (5.0%) were severely depressed. Anxiety by using the GAD-7 questionnaire, it was revealed that out of 1245 students, 455 (36.5%) of them were without anxiety, 425 (34.1%) of them were having mild anxiety, 243 (19.5%) of them were having moderate anxiety and 122 (9.8%) were having severe anxiety. Depression and anxiety, according to gender (Pvalue <0.001), show a significant relationship. Conclusion: We have to raise the awareness of the mental health in our community as the prevalence of mental disorder has significantly increased over time. Health services should make health education for students on how they deal with stress and depression through exercise and good sleep.
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	Is work-associated stress converted into psychological distress among the staff nurses: A hospital-based study	p. 511
	Anuradha Davey, Parul Sharma, Sanjeev Davey, Arvind Shukla DOI:10.4103/jfmpc.jfmpc_419_16   Introduction: "Stress is the subjective feeling produced by events that are uncontrollable." Constant stress brings about changes in the balance of hormones in the body which may lead to thoughts that make us feel frustrated, angry, nervous, anxious, etc., The aims of the study are (1) to find out the level of stress among staff nurses; (2) the association between sociodemographic determinants and working environment and stress; and (3) impact on their mental well-being in terms of somatic symptoms, anxiety/insomnia, social dysfunction, severe depression, and on work productivity. Materials and Methods: Institutional-based cross-sectional study; total sample size comprised 100 staff nurses. Data were collected using a two-part questionnaire: Part I: socio demographic variables and working envioronment, Part II: Goldberg and Hillier's 28-item scaled version of the General Health Questionnaire (GHQ-28) used to measure the psychological aspect of quality of life of staff nurses. Results: Hospital nurses reported mild (12%) to moderate/severe (77%) levels of job-related stress. The common stressors were poor attitude of male patients, absence of separate washroom for female nurses, posting in busy departments with increased workload, and inadequate salary. The single most important factor responsible for high levels of stress (70%) among the study subjects was inadequate salary. Conclusion:Assessing stress and job satisfaction is not a onetime action; it requires continuous monitoring and evaluation. Therefore, it is important to further explore how work-associated stress affects nurses, and what factors in their working environment cause the greatest burden.
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	Effect of 1,25 dihydroxy vitamin D3 supplementation on pain relief in early rheumatoid arthritis	p. 517
	Dibyendu Mukherjee, Sandeep Lahiry, Sayanta Thakur, Dwaipayan Sarathi Chakraborty DOI:10.4103/jfmpc.jfmpc_446_18   Background: To assess effect of 1,25 dihydroxy vitamin D3 supplementation on pain relief in early rheumatoid arthritis (RA). Materials and Methods: An open-labeled randomized trial was conducted comparing 60,000 IU 1,25 dihydroxy vitamin D3 + calcium (1000 mg/day) combination [Group A] versus calcium (1000 mg/day) only [Group B], as supplement to existing treatment regimen in early RA. Primary outcome included (i) minimum time required for onset of pain relief (Tm) assessed through patients' visual analog scale (VAS); (ii) % change in VAS score from onset of pain relief to end of 8 weeks. Secondary outcome included change in disease activity score (DAS-28). Results: At the end of 8-weeks, Group A reported 50% higher median pain relief scores (80% vs. 30%; P < 0.001) and DAS-28 scores (2.9 ± 0.6 vs. 3.1 ± 0.4; P = 0.012) compared to Group B; however, Tm remained comparable (19 ± 2 vs. 20 ± 2 days; P = 0.419). Occurrence of hypovitaminosis-D was lower (23.3%) compared to Indian prevalence rates and was a risk factor for developing active disease (Odds Ratio (OR) = 7.52 [95% Confidence Interval (CI) 2.67–21.16], P < 0.0001). Vitamin D deficiency was significantly (P < 0.001) more common in female gender, active disease, and shorter mean disease duration. Vitamin D levels were inversely correlated to disease activity as assessed by DAS-28 (r = –0.604; P < 0.001). Conclusions: Vitamin-D deficiency is a risk factor for developing active disease in RA. Weekly supplementation of 60,000 IU of 1,25 dihydroxy vitamin D3 in early RA results in greater pain relief. The number needed to treat for this additional pain relief was 2. Identifier: CTRI/2018/01/011532 (www.ctri.nic.in).
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	Evaluation of the tibial cortical thickness accuracy in osteoporosis diagnosis in comparison with dual energy X-ray absorptiometry	p. 523
	Ahmad Fakhri Zadeh, Mohammad Ghasem Hanafi, Ali Kiasat, Marjan Mousavi DOI:10.4103/jfmpc.jfmpc_456_18   Background: Unlike public awareness around the world, osteoporosis is still underdiagnosed in most cases till bone fractures. Currently, the dual-energy X-ray absorptiometry (DEXA) is the gold standard diagnostic method of osteoporosis, but unfortunately this method is not available in all diagnostic centers, especially in developing countries. Aims: To evaluate the accuracy of tibial cortical thickness in the diagnosis of osteoporosis compared with DEXA. Materials and Methods: In this descriptive--analytic study, patients suspicious of osteoporosis who referred to Imam Khomeini Hospital, Ahvaz from 2016 --2017 were recruited. Data was collected for each patient including age, sex, radiography, and DEXA. The total thickness of the tibia cortex (sum of the two sides) was measured using knee anteroposterior radiography at 10 cm from the proximal tibial joint. The bone mineral density (BMD) was measured by DEXA method and reported as T-score. Results: In this study, 62 patients (90% female) were evaluated. The mean age of the patients was 57 years (range 45--80 years). T-score had a direct significant correlation with TCT level (r = 0.51, P < 0.0001). Also, T-score had a reverse and significant correlation with age of patients (r = −0.280, P = 0.028). The area under the curve (AUC) was 77%. Also, the sensitivity and specificity for the TCT level less than 4.37 mm (as cutoff point) was 100% and 39.1%, respectively. Conclusion: The findings of this study indicate that TCT has a direct significant correlation with the T-score obtained by the DEXA method. It has also been shown that TCT can be a relatively accurate diagnostic tool for predicting osteoporosis.
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	Comparative study of risk indicators associated with tooth loss among adult population in urban and rural areas of Muradnagar, Ghaziabad, Uttar Pradesh, India	p. 528
	Deepa Tomar, Ipseeta Menon, Avnish Singh, Upasana Tyagi, Deepak Passi, Jyoti Goyal DOI:10.4103/jfmpc.jfmpc_409_18   Background: Oral health objectives prescribed by World Health Organization for the year 2020 have expressed that there ought to be an expansion in the quantity of people with functional dentitions (at least 21 common teeth) at ages of 35–44 and 65–74 years. Aim: The aim of this study is to examine the prevalence of tooth loss and to evaluate and compare the risk indicators associated with tooth loss among adult population in urban and rural areas of Muradnagar, Ghaziabad. Materials and Methods: A cross-sectional study was led among 1200 adults aged 35–74 years in urban and rural areas of Muradnagar, India. Information was assembled by an interview followed by clinical examination (number of missing teeth). Demographic and socioeconomic factors and self-perceived oral health were the independent variables assessed. One-way analysis of variance, post-hoc test (Bonferroni), Chi-square test, Student's t-test, and logistic regression analysis were used for statistical analysis. Results: Low educational status, no dental check-ups, low frequency of brushing, older age, and smoking habit were independent risk factors for tooth loss. The odds of tooth loss in older adults and illiterates were higher; the odds for tooth loss among those who expressed their desire for replacement of missing teeth were 1.3 times lower than their counterparts. Conclusion: The experiences gained up showed that tooth loss was very pervasive in Muradnagar populace and the critical hazard indicators identified were age, education, socioeconomic status, and cigarette smoking.
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	Association between maternal dental anxiety and its effect on the oral health status of their child: An institutional cross sectional study	p. 535
	Jyoti Goyal, Ipseeta Menon, Ricky Pal Singh, Anubhav Sharma, Deepak Passi, Preeti Bhagia DOI:10.4103/jfmpc.jfmpc_415_18   Aim: To assess the association between maternal dental anxiety and its effect on the oral health status of their child, in Murad nagar –An institutional cross-sectional study. Materials and Methods: Among the randomly selected 200 mother-child pairs, a cross-sectional study was done. The children of 2–5 years were selected for the study. A five-level Modified Dental Anxiety Scale (MDAS), Hindi edition, was used to assess dental anxiety among the mothers. Clinical examination of the wards was finished by using a modified gingival record and WHO dentition status (2013). The SPSS software version 20 was used for statistical analysis. Results: Approximately, 61% of the children were males, and 39% were females. The modified gingival index (MGI) score was high, if there should arise an occurrence of high MDAS values. The mean MGI score was most astounding in phobic class of MDAS and least in the not anxious classification. The MGI score expanded on increment in maternal anxiety. Dental caries expanded in kids, if there should be an occurrence of high maternal dental uneasiness. The MDAS demonstrated a critical association with clinical oral health results of the child. The children whose mothers were "extremely anxious" (phobic) had the highest mean decayed, missing, or filled teeth. Conclusion:Maternal dental anxiety significantly affects the oral health status of their ward.
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	Asymptomatic bacteriuria among the patients of type 2 diabetes mellitus	p. 539
	Aman Bharti, Sumit Pal Singh Chawla, Sandeep Kumar, Sarabjot Kaur, Divya Soin, Neerja Jindal, Ravinder Garg DOI:10.4103/jfmpc.jfmpc_403_18   Background: Asymptomatic bacteriuria (ASB) is common in neonates, preschool children, pregnant women, elderly, diabetics, catheterized patients, and patients with abnormal urinary tracts or renal diseases. Though there is currently no consensus on treatment of ASB in various population groups, it is advisable to treat the same in patients with diabetes mellitus (DM). Aims: To determine the prevalence of ASB in patients with type 2 DM and to study the spectrum of uro-pathogens causing ASB along with their antibiotic susceptibility profile. Settings and Design: This prospective, observational study was conducted in the department of Medicine of a tertiary care teaching hospital. Methods: The study was conducted on 100 patients with type 2 DM. Urine wet mount and gram stain examination was done for all to detect the presence of pus cells and bacteria in urine. Antibiotic sensitivity testing was performed in patients with significant bacteriuria to determine the sensitivity profile of isolated uro-pathogens. The data were analyzed to determine the association between diabetes and ASB. Results: ASB was common among diabetics, as evident by a prevalence of 21%. Presence of ASB showed positive correlation with poor glycemic control. Escherichia coli (E. coli) was the most common organism causing ASB followed by Candida, Pseudomonas, Klebsiella, and Citrobacter. E. coli isolated from study patients was most sensitive to imipenem and nitrofurantoin (NFT). Conclusions: ASB is common among diabetics, with poor glycemic control being a significant risk factor. E. coli is the most common organism causing ASB in diabetics, and it is most sensitive to imipenem and NFT.
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	Assessment of efficacy of ultrasonography in cervical lymphadenopathy in oral malignancies	p. 544
	Samruddhi Swapnil Metha, Amit Anil Mhapuskar, Swati P Marathe, Swapnil Suresh Metha, Santosh Jadhav, Shweta D Thakare, Deepak Passi DOI:10.4103/jfmpc.jfmpc_440_18   Aims and Objectives: To substantiate the use of ultrasonography in diagnosis of cervical lymphadenopathy in oral malignancies and to assess if ultrasonographic examination done prior to lymph node (LN) biopsy can yield important information regarding the diagnosis. Materials and Methods: Twenty subjects with histopathologically confirmed oral malignant lesions with clinically palpable and untreated cervical LNs included into study. These patients were subjected to clinical examination (number of LNs, shape, size, location, overlying temperature, overlying skin, tenderness, consistency, and fixity to the underlying structures), and ultrasonographic evaluation (number of LNs, shape, size (mm), location, borders, matting, peripheral halo, hilum, calcification, necrosis, reticulation, and echogenicity) of the LNs, and finally, histological assessment was done after surgical excision during the course of treatment. Results: Predominantly male (65%) patients were having with malignant LN involvement with age group of 60–69 years, i.e., 35%. Ultrasonogram is superior to clinical examination as it detected additional 49 nodes. Malignant nodes tend to have longest axial diameter (17 mm with standard deviation of 8.7 mm). Over all 52 malignant nodes were round, whereas 35 nodes were oval in shape. Most of the nodes were detected in submandibular region. Around 61 (70.9%) nodes had sharp borders and 26 (29.9%) had smooth borders. Loss of echogenic hilus is a common feature of malignancy showing 70% sensitivity and 67% specificity. Most of malignant nodes were hypoechoic. Around 51 (58.6%) of nodes showed intranodal necrosis, whereas it was absent in 36 (41.4%) nodes. Matting and edema were present 25 (28.7%) nodes. Intranodal calcification was present in 37 nodes. Sensitivity of USG was 90%, whereas specificity was 100%. Conclusion: Ultrasonographic examination of cervical LNs can yield important information regarding the diagnosis. Ultrasound examination should be done prior to FNAC and ideally an ultrasound-guided FNAC.
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	Effect of orthodontic treatment needs on oral health related quality of life among the young population in Delhi NCR-region of North India	p. 550
	Tarun Kumar Singh, Preeti Bhagia, Utkarsh Gupta, Deepak Passi, Jyoti Goyal, Garima Yadav, Bhawna Gautam, Swati Jain DOI:10.4103/jfmpc.jfmpc_431_18   Aim: To assess the effect of orthodontic treatment needs on oral health-related quality of life among the young people of Delhi NCR. Methods: The study was conducted on 12–15 years of individuals attending dental clinic/hospital in Delhi NCR region. Data were collected using Index of Orthodontic Treatment Need -Dental Component and oral health impact profile 14 questionnaire. The Chi-square test was used to analyze the qualitative data. SPSS software version 20 was used for statistical analysis. Results: Orthodontic treatment needs had an almost similar impact on the daily activities of both males and females. The sense of taste was not significantly affected by the need for orthodontic treatment in either males or females. The proportions of orthodontic patients found to have the painful arch, embarrassment, tension, and self-conscious both in males and females. Conclusion: There is a significant correlation of orthodontic treatment needs among oral health-related quality of life.
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	An outbreak of cutaneous leishmaniasis among a displaced population in North Sudan: Review of cases	p. 556
	Amel Abdalrhim Sulaiman, Wadie Mohammed Elmadhoun, Sufian Khalid Noor, Sarra Osman Bushara, Ahmed O Almobarak, Heitham Awadalla, Elmoubashar Farag, Mohamed H Ahmed DOI:10.4103/jfmpc.jfmpc_432_18   Background: Human cutaneous leishmaniasis (CL) is an endemic disease in many parts of Sudan. Objective:To document an outbreak of CL among internally displaced people (IDP) in north Sudan. Methods: A household survey was conducted in the rural region of New Manasir, at El Damer Locality in north Sudan during the year 2013. All villagers were screened for recent and old skin lesions in addition to other urgent medical problems. Written consent was obtained from each participant before data collection. A pretested, interviewer-administered questionnaire was used to collect the socio-demographic and clinical characteristics of participants. The diagnosis of CL was based on clinical findings and/or identification of the amastigotes on skin smears. Results:Out of the 1,236 individuals enrolled in this survey, 688 were diagnosed as cases of CL, giving an infection rate of 55.7%. Children constituted 244 (35.5%) of infected cases. Majority of skin lesions were found in the Extremities 524 (76.2%). The average duration of skin lesions was 3.6 months (±1.6). Conclusion: This outbreak among IDPs affected a large proportion of inhabitants of the newly established villages in north Sudan. Preventive measures might have help control such outbreaks.
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	Effect of gutkha chewing on periodontal health and oral hygiene of peoples in Delhi NCR region of North India: A cross-sectional multicentered study	p. 564
	Santosh Kumar Verma, Barun Dev Kumar, Swati Singh, Puja Kumari, Anurag Agarwal, Tarun Kumar Singh, Deepak Passi, Jyoti Goyal DOI:10.4103/jfmpc.jfmpc_439_18   Background: In India, gutkha is popular among all socioeconomic groups, since it is available easily and is of less cost. Various investigations have demonstrated the relationship of gutkha biting with periodontal status and oral hygiene. Aim: The aim of this study is to assess the effect of gutkha chewing on periodontal health and oral hygiene of patients attending the dental department in India. Materials and Methods: A cross-sectional investigation was directed among 200 patients going to dental camps. Among them, 100 were gutkha chewers and 100 were smokers. The oral hygiene status of selected patients was determined by using the Simplified Oral Hygiene Index. Various periodontal parameters like a gingival recession, clinical attachment loss, mobility, and furcation were used to evaluate the periodontal status. Data were collected and analyzed with the help of SPSS software version 20. Result: Among the 200 subjects, 102 were males and 78 were females. In 100 gutkha chewers, 67% were male and 33% were females. About 68% gutkha chewers showed poor oral hygiene as compared to nonchewers (41%). The values of all the periodontal parameters were significantly higher in gutkha smokers compared to nonchewers. Conclusion: Gutkha chewing has a strong effect on oral hygiene. The findings can contribute to the evidence of smokeless tobacco (gutkha) as a risk factor for periodontal disease.
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	Knowledge, attitude, and practice of breast self-examination amongst female IT professionals in Silicon Valley of India	p. 568
	Samarth Kalliguddi, Sahithi Sharma, Chaitali A Gore DOI:10.4103/jfmpc.jfmpc_315_18   Introduction: Breast cancer is one of the leading causes of cancer deaths among women in India today. Overall outcome of this disease is largely dependent on early detection and medical intervention. Breast self-examination (BSE) is an easy, cost effective, and safe method of screening for the same. Materials and Methods: A cross-sectional descriptive questionnaire-based study was conducted among female IT professionals and their scores in the fields of knowledge, attitude, and practice were calculated. The scores were categorized linearly as good, fair, and poor, then analyzed in detail. The correlation between knowledge and attitude, attitude and practice, and knowledge and practice were ascertained using the Spearman's rank correlation coefficient. Results: About 356 women spanning from 18 to 55 years of age were included in the study, out of which 44 women (12.35%) gave family history of breast cancer. The mean scores in knowledge, attitude, and practice fields were 18.17 ± 2.90, 27.07 ± 8.14, and 19.11 ± 5.08, respectively. Spearman's rank correlation coefficient revealed that knowledge and attitude were not correlated, attitude and practice were not correlated; but knowledge and practice were extremely correlated. Conclusion: Educational programs to create awareness regarding breast cancer and its occurrence, risk factors, screening including BSE, symptoms, need for early help-seeking practices, diagnosis, and treatment modalities are the need of the hour.
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	Retrospective study of etiology of non variceal acute gastrointestinal bleeding in Eastern Himalayan region of india in Sikkim	p. 573
	Karma D Bhutia, Sangey C Lamtha DOI:10.4103/jfmpc.jfmpc_330_18   Upper gastrointestinal bleeding is one of the most commonly encountered emergencies in day-to-day practice. In the present retrospective study, the various causes of acute nonvariceal upper gastrointestinal bleeding (NVUGIB), its management modalities, and the final outcome of patients were studied. Methods: A retrospective study of etiology of upper gastrointestinal (UGI) bleeding for a period of 13 months, January 2015 to February 2016 in Department of Gastroenterology, Central Referral Hospital, Gangtok, was conducted. There were a total of 127 upper gastrointestinal bleeding patients, out of which 70 patients were excluded due to endoscopically proven variceal bleeding. Of the 57 patients, the various causes were determined by investigations and were treated accordingly. Conclusion: Hematemesis was the most common presentation and duodenal ulcers the most common etiology among the acute nonvariceal upper gastrointestinal bleed. The cause of bleeding was not identified in one patient. Majority (34 patients, 59.64%) of the patients was treated conservatively, some needed endoscopic interventions (23 patients, 40.35%) and there was no any mortality.
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	Knowledge, attitude, and practice among Saudi primary health care attendees about family planning in Abha, Kingdom of Saudi Arabia	p. 576
	Hassan M Al-musa, Mohammed Abadi Alsaleem, Waleed Hassan Alfaifi, Zainah Alshumrani, Nouf Saleh Alzuheri, Abeer Saeed Aslouf, Jamaan Raffia Alshahrani, Abdullah Saeed Mastour, Abdulrahman Mohammad Alqahtani, Rishi Kr Bharti, Shweta Chaudhary DOI:10.4103/jfmpc.jfmpc_363_18   Background: Knowledge, attitude, and practice (KAP) of contraception are influenced by a host of interdependent demographic, cultural, economic, and social factors, therefore, KAP vary not only in different countries but also from region to region in a country. A cross-sectional study was carried out among Saudi primary health care attendees at Abha city, Saudi Arabia, with the aim to help in developing strategies that may enhance family planning in Abha. Methods: A structured questionnaire was designed by the researcher to obtain the necessary information from all reproductive age group patients who attended primary health care centers in Abha for a period of 1 month (July to August 2017). Statistical analysis was done using two-tailed tests and alpha error of 0.05. P value less than or equal to 0.05 was considered to be significant. Results: The study included 314 participants, with age ranging from 18 to 55 years. Among them, 70.4% were female, and 56.1% of the sample were university graduates. Approximately 80.6% of the participants knew about family planning, and 68.1% correctly defined family planning. Hormonal pills were recognized by 53.2% of the participants followed with intrauterine devices. Family members were the most common source of information (51.8%), followed by internet reading (37.5%) and healthcare workers (21.8%). The attitude of the studied group varied. Most of them only wanted to use family planning in agreement with their spouses, and 11.8% had negative attitude due to their fear of side-effects. Currently, 29.6% of the participants were using family planning methods whereas 53.5% had used contraception in the past. Oral contraception was the most commonly used method (49.5%), followed by surgical methods (30.1%) and natural methods (16.1%). Conclusions: The present study reveals that a significantly higher proportion of respondents know about contraception and more than half had good knowledge about contraception. However, the current practice of contraception methods is lower than many regions in the country. The selection of oral contraception as the method of choice is similar to other studies.
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	Parents awareness toward antibiotics use in upper respiratory tract infection in children in Al-Qassim region, Saudi Arabia	p. 583
	Mohammed A Alsuhaibani, Renad S AlKheder, Jumanah O Alwanin, Marwa M Alharbi, Malak S Alrasheedi, Rania F Almousa DOI:10.4103/jfmpc.jfmpc_368_18   Objectives: This study aimed to evaluate parents' awareness toward antibiotics use in upper respiratory tract infection in children. Methods: This cross-sectional study conducted in Al-Qassim using validated and translated questionnaire whish was distributed using what's app. over a period of 3 months, extended from May 2018 to July 2018. Results: The number of respondents were 405, majority 81% chose physicians as the main source of information about antibiotic use. Forty-four percent of parents agreed that most URTIs are viral in origin and self-limiting without needing antibiotics. However, 19% of parents believed that antibiotics should be given to all children who have a fever. Fifty two percent were aware that inappropriate use of antibiotics reduces antibiotic efficacy and drives bacterial resistance. Sixty percent of participants chose antibiotics as the treatment they anticipated to be recommended. Fever was the dominant symptom among others of URTI, that would make (21.7%) always ask physicians to prescribe antibiotics. Parents who never asked paediatricians to prescribed antibiotics for their children were (36.5%). The attitude and practice of the participants were associated with the number of children they had; parents with five children or more had a lower attitude and practice score. Conclusion: this study found that majority of the participant were educated but with poor attitude and practice. Although parents are concerned about the use of over counter antibiotics, often demand it. Considering that parents are unaware of indications and subsequent complications of using over counter antibiotics, they often request mentioned drugs, showing concern nonetheless. the need to understand parents' knowledge, attitude and practice regarding the use of antibiotics for URTIs is required in creating suitable interventional educational programs and raise awareness to avoid futile antibiotic use.
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	Awareness about oral pathology specialty among medical professionals in hospitals under Kerala Health Services Department in Malappuram district in Kerala, India	p. 590
	Thorakkal Shamim DOI:10.4103/jfmpc.jfmpc_373_18   Background and Aim: There is a paucity of information about awareness about oral pathology speciality among medical professionals. To the best of my knowledge, this is the first study to be reported in literature. This study aimed to assess and create awareness of oral pathology specialty among medical professionals in hospitals under Kerala Health Services Department in Malappuram district in Kerala. Materials and Methods: The study was conducted between January 2018 and April 2018. The printed and validated questionnaire regarding oral pathology specialty was supplied to medical professionals in hospitals under Kerala Health Service Department in Malappuram district. The questionnaire comprised of the demographic data of the participants, including age, gender, position, and years of experience, and basic facts about oral pathology speciality. Results: Most participants surveyed (91.7%) were aware of the oral pathology specialty. In total, 77.8% of medical professionals refer oral pathology cases to general pathologists for histopathology report. However, 41.7% of medical professionals know about the new terminology potentially malignant oral disorders and their histopathological interpretation. Approximately, 33.33% of medical doctors were aware about common oral cancer (squamous cell carcinoma) grading. Conclusion: Medical professionals are aware of oral pathology specialty. The stance of referring and consulting oral pathologists for oral pathology cases for histopathology report is poor.
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	Knowledge and practices related to burn first aid among Majmaah community, Saudi Arabia	p. 594
	Fahad Ali AlQahtani, Mohammed Ayed Alanazi, Mohammed Khaled Alanazi, Khalid Saud Alshalhoub, Abdulaziz Ahmed Alfarhood, Syed Meraj Ahmed DOI:10.4103/jfmpc.jfmpc_382_18   Background: Burns in developing countries account for significant morbidity and mortality which have been shown by increasing burn first aid awareness. In general, flames, scalds, and contact burns are the most common causes, but in children scalds are the most common. Objectives: This study aims to assess the general knowledge and practices related to burn first aid among Majmaah community. Methods: This study is a cross-sectional study. Data were collected in 2018 using convenience sampling technique. Saudi men and women age 18 years and older living in Majmaah were included in the study. Data were collected from 390 males and females. The sample size was collected using precision formula. Data were encoded into Microsoft Excel worksheets and imported to Statistical Package for the Social Sciences (SPSS®) software for analysis. Results: A total of 390 individuals responded to the survey. Regarding the demographic data of the study participants, 49.2% were between 30 and 49 years old. Most of them were females (71.8%). Regarding burn first aid knowledge, 82.6% of the study participants knew that the first thing is to stop, drop, and roll when your clothes catch fire, 43.8% knew to apply cold water if hot oil spills on the hands, 41.0% knew that all burn injuries must be treated at hospital, whereas most of them 78.5% knew never to apply raw eggs or herbs to burn wounds. Conclusion: The knowledge of Majmaah community toward first aid is found to be low in spite of most of the respondents having a positive attitude toward first aid. The majority of the study participants (73.8%) were well-educated and had a bachelor's degree.
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	Study of needle stick injuries among healthcare providers: Evidence from a teaching hospital in India	p. 599
	Shyamkumar Sriram DOI:10.4103/jfmpc.jfmpc_454_18   Background: Needle stick injuries (NSIs) are the injuries that are caused by needles, such as hypodermic needles, blood collection needles, intravenous stylets, and needles used to connect parts of intravenous delivery systems. NSIs are very common and in many instances unavoidable among healthcare providers when they are delivering patient care. Around 75% of the NSIs in developing countries are not reported. This study aimed to estimate the prevalence and other correlates and attributes of NSIs among healthcare providers in a tertiary care teaching hospital in South India. Methods: This is a cross-sectional study conducted in Narayana Medical College and Hospital in Nellore, Andhra Pradesh, between June 2012 and February 2013. Data using a structured questionnaire were collected among all the 1525 healthcare providers working in the teaching hospital. Results: Around 10.81% of the total healthcare providers in the teaching hospital were exposed to NSIs. Syringe needles (75%) were the most common devices leading to NSIs. Majority of NSIs took place in the wards of the different departments (75%). Morning shift (70%) was the most common time of the day for the occurrence of NSIs. Only 65% of the healthcare providers were wearing gloves at the time of injury. Majority (82%) took immediate treatment after NSIs. Conclusions: Establishment of formal reporting mechanisms, immediate reporting of NSIs, and the establishment of a comprehensive NSI prevention program will help in the reduction in the occurrence of NSIs and help in taking immediate remedial action in the form of prophylaxis and treatment.
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	Anxiety, depression, self-esteem among children of alcoholic and nonalcoholic parents	p. 604
	Dayananda Bittenahalli Omkarappa, Sreevani Rentala DOI:10.4103/jfmpc.jfmpc_282_18   Context: Children of alcoholics (COAs) face risks of behavioral problems during childhood and mental health problems in adult life. Identifying these problems at the earliest can significantly reduce the problems in future. Aims: To compare the anxiety, depression, and self-esteem between COA and non-COA parents. Settings and Design: A cross-sectional comparative survey research design was adopted for the present study. The study was conducted at selected government high school located in Bangalore urban. Subjects and Methods: The simple random sampling technique was used. A total of 200 children comprising 100 children of each alcoholic parents and nonalcoholic were recruited for the study. A screening test (modified) was used for identifying COA. Spence Children's Anxiety Scale, Center for Epidemiological Studies Depression Scale for Children (CES-DC), and Rosenberg Self-Esteem Scale were used to assess anxiety, depression, and self-esteem, respectively. Statistical Analysis Used: Data were analyzed using Statistical Package for the Social Sciences software package (version 23). Results: The results show that there is statistically significant difference between COA and non-COA group with regard to anxiety, depression, self-esteem, separation anxiety, social phobia, obsessive compulsive problems, and physical injury. Conclusion: The study concludes that COAs are having higher rate of anxiety, depression, and low self-esteem compared with children of nonalcoholics.
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	Knowledge about menstrual hygiene, sexual health, and contraception in educated late adolescent age girls	p. 610
	Sarada Mamilla, Sandhya Goundla DOI:10.4103/jfmpc.jfmpc_320_18   Aim: Adolescents are future generation of our country. It is a vulnerable age making them susceptible to many health issues such as reproductive tract infections because of improper menstrual hygiene, sexually transmitted infections (STIs), human immunodeficiency virus (HIV), unexpected pregnancies because of lack of awareness about contraceptive practices, and no proper guidance about sexual health. The aim of this study is to assess the knowledge of college-going adolescent girls regarding menstrual hygiene and their awareness about HIV/AIDS, other STIs, and also their knowledge about contraception. Materials and Methods: Girls studying diploma in government polytechnic college were assessed on the basis of a questionnaire survey. A predesigned questionnaire was prepared with reference from WHO adolescent health questionnaire and a health talk was organized in college. The questionnaire survey was done for 150 college girls. A health talk was given after girls filled the questionnaire. Only 125 girls gave filled questionnaire, whereas 25 returned without filling it. Data were analyzed using SPSS software and results were interpreted into percentages. Menstrual hygiene was given a score based on five parameters in the questionnaire. Correlation between mother's education and menstrual hygiene was assessed by Chi-square method. Similarly, correlation between mother's education and contraceptive knowledge was assessed by Chi-square test. Results: Forty percent did not answer the question from where they knew about puberty. Mother was the most common source of information about puberty (28%). There was a high level of knowledge about menstrual hygiene; 88% of study population knew about HIV, but only 30.4% knew about other STIs. Fifty percent of them did not know about contraceptive options, and of the study population who knew about contraception, condom (32%) was the most aware method. There was no correlation between mother's education and knowledge about contraception (P value 0.16) by Chi-square test. Similarly, there was no correlation between mother's education and menstrual hygiene score (P value 0.222). Conclusions: Educated adolescents even though they belong to low socioeconomic class, irrespective of their mother's educational status, have a good knowledge about menstrual hygiene but lack knowledge about sexual health. School-based programs/Compulsory curriculum should be included by universities and colleges to encourage universal knowledge about contraception and sexual health.
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	Sexual healthcare knowledge, attitudes, and practices among primary care physicians in Trinidad and Tobago	p. 614
	Patrice A Rabathaly, Vijay Kumar Chattu DOI:10.4103/jfmpc.jfmpc_322_18   Background: Our understanding of healthcare professionals' competence level in both their sexual history taking practices and their attitudes in addressing sexual health concerns of patients in middle and old age is lacking. This research aimed to assess primary care physicians' (PCPs) knowledge, attitudes, and sexual healthcare practices toward patients who are ≥45 years in Trinidad and Tobago. Materials and Methods: A self-reported survey instrument assessing clinical sexual health knowledge, attitudes, and practices was administered nationwide to all registered PCPs (n = 155) in the public healthcare service. Descriptive and inferential statistical analyses were conducted using STATA. Results: PCPs, who were foreign medical graduates, middle-aged, male, and worked in urban centers, had improved odds of discussing sexual health with middle-aged and older patients. PCPs with any training in sexual health communication or sexual history taking were three times more likely to initiate a sexual health discussion or take a sexual history. Over 90% of physicians reported taking a sexual history only if the discussion was patient initiated and over 50% of PCPs indicated they will not ask these older patients about their sexual orientation, sexual partners, sexual abuse, or violence. Conclusions: Even though PCPs reported having a positive willing attitude toward offering sexual health care to these patients, they had a low level of knowledge of sexual function in later life and inconsistent sexual history taking practices. There is a great need for training physicians' on sexual health communication and history taking and on sexual function in older adults.
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	A study on elder abuse in an urban resettlement colony of Delhi	p. 621
	Pritish Kumar, Somdatta Patra DOI:10.4103/jfmpc.jfmpc_323_17   Background: In India, proportion of elderly is increasing with decrease in mortality rate and increase in life expectancy. There is a paucity of studies on elder abuse, a problem faced frequently by an elderly. The present study planned to find out the prevalence of abuse and associated risk factors among community dwelling elderly in an urban resettlement colony of east Delhi. Methods: It is a community-based cross-sectional study. This study was done among elderly residents aged 60 years and above in an urban resettlement colony of east Delhi. Study participants were interviewed using a pretested, semi-structured questionnaire. Data were collected regarding sociodemographic profile and prevalence of abuse. Simple descriptive tables were generated to denote frequencies. Cross-tabulation and chi-square test were applied to study the association between various sociodemographic characteristics and elder abuse. Results: A total of 125 elderly were interviewed. Twelve (9.6%) reported experience of abuse. All abused participants faced neglect, four faced verbal abuse, and two participants reported physical and one financial abuse. Abused elderly belonged to a higher age group >70 years and did not have regular contact with family and friends (P = 0.00; no involvement in social activities (P = 0.001). Abuse was more likely when "finances were managed by others" (P = 0.02) and having dependency for daily needs (P = 0.00). Conclusion: Elder abuse is prevalent in India. The victims of abuse lack social support and network and are reluctant to report abuse.
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	An exploratory study to assess primary care physicians' attitudes toward talking about sexual health with older patients in Trinidad and Tobago	p. 626
	Patrice A Rabathaly, Vijay Kumar Chattu DOI:10.4103/jfmpc.jfmpc_325_18   Background: A good quality sex life and interest in sex are positively associated with health in middle-aged and later life. For effective diagnosis of sexual health problems, an appropriate discussion about sexual health issues including a sexual history is advised. The sexual health care delivery and management during consultations by primary care physicians is relatively unexplored, especially for older patients. This paper aims to explore primary health care physicians' (PCPs) attitudes to sexual health care and management of middle-aged and older patients in Trinidad and Tobago. Methods: In-depth, semi-structured interviews were conducted with 35 PCPs in Trinidad and Tobago. Topics examined included physician-patient relations, sexual health care management challenges, communication and sexual history taking practices, and training needs of PCPs. The framework analysis method was adopted for analysis. Results: Most doctors stated that they were not comfortable with conducting a sexual history with their older patients, and they rarely discussed or initiated talking about sexual health with them. Barriers included time constraints, inappropriate environmental conditions for privacy, inadequate professional referral services, insufficient medical training in sexual function in middle and old age, reluctant patient behavior, conflicting personal beliefs on sexuality, and socio-cultural factors. Conclusion: PCPs may be reluctant to raise sexual health-related issues with their older patients, and these older patients may not initiate this discussion because of discomfort and embarrassment. Consequently, physicians' inability to effectively communicate with these patients could result in missed opportunities for interventions and patients' concerns may remain unheard and their sexual problems untreated.
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	Promising pain-relieving activity of an ancient Persian remedy (mixture of white Lily in sesame oil) in patients with chronic low back pain	p. 634
	Saeed Rasoulinezhad, Nafiseh Hosseini Yekta, Ehsan Fallah DOI:10.4103/jfmpc.jfmpc_423_18   Background and Objectives: Chronic low back pain (CLBP) is one the frequent musculoskeletal issues among adults mostly without a specific etiology. In this study, we investigated a traditional Persian remedy for back pain which is based on topical application of a mixture of sesame oil (SO) and white lily (LSM). Materials and Methods: The chemical profile, phenol content, and antioxidant activity of the herbal samples were determined using GC-MS, total phenol content (TPC) assay, and DPPH assay, respectively. Clinical efficacy of the herbal samples by a double-blind placebo was examined. Results: TPC of SO and LSM was 45 ± 5.7 and 68.3 ± 11.2 mg GAE/g oil mixture, respectively. The SO could inhibit 59.7% of free radicals, whereas LSM showed a radical inhibition rate of 74.7% in DPPH assay. LSM could reduce the pain feeling and obtained the lowest pain scores (Oswestry disability index and numeric rating scale) in weeks 4 and 8 of therapy in comparison to other treatment groups (diclofenac gel and SO) and placebo control (Vaseline). Conclusions: The results implicate the LSM as a novel therapeutic alternative for the therapy of the CLBP.
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	Premenstrual syndrome in Anand District, Gujarat: A cross-sectional survey	p. 640
	Shruti V Kamat, Archana Nimbalkar, Ajay G Phatak, Somashekhar M Nimbalkar DOI:10.4103/jfmpc.jfmpc_302_18   Aim of Study: We assessed the prevalence and severity of premenstrual syndrome (PMS) in adolescents and identified probable associations of PMS and premenstrual dysphoric disorder (PMDD) with age, locality, food habits, obesity, stress, genetic influence, menorrhagia and dysmenorrhoea. Methods: Cross-sectional study in schools of Anand District in State of Gujarat, India. We conducted the study in 1702 girls in the age group of 8–23 years who had achieved menarche. Main Outcome Measures: Prevalence of PMS and PMDD using the self-administered Premenstrual Symptoms Screening Tool for Adolescents (PSST-A). Results: The prevalence of moderate to severe PMS was 19.3% and PMDD was 4.6%. Almost all (94.8%) girls had at least one PMS symptom with 65.7% having moderate to severe symptoms. We found dysmenorrhoea in 71.2% girls and menorrhagia in 15.2%. Physical symptoms were reported by 53.5%, disruption of daily activities by 41.7%, while 25.1% had to miss school/college. Majority (81.3%) felt that PMS was a normal part of menstruation and 53.0% reported moderate to severe stress. Multivariate logistic regression model revealed older age, dysmenorrhoea, menorrhagia, high levels of stress and PMS in mother to be significantly associated with PMS. In addition to these, lower age at menarche and junk food significantly contributed to PMDD. Conclusion: Prevalence of moderate to severe PMS and PMDD in this population falls within the range reported elsewhere. PMS/PMDD affects the lives of many, significantly reducing their efficiency and worsening the quality of life.
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	Why psychiatry as a career: Effect of factors on medical students' motivation	p. 648
	Fahad Marzouq Shafi AlOsaimi, Husam M AlShehri, Waleed I AlHasson, Sajida Agha, Amir Omair DOI:10.4103/jfmpc.jfmpc_399_18   Context: The number of Saudi psychiatrists in Saudi Arabia is not sufficient to keep up with the increasing need.[1] Approximately out of 6873 physicians, only 148 are psychiatrists, which is barely 2.1%.[2] Despite the high number of medical students graduating each year and the high demand for psychiatry physicians, only few medical graduates choose psychiatry as a career option.[3] Aims: To investigate the profile of final year medical students of both sexes at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia. In terms of their decisions regarding specialization, this study aimed to identify the motivators and deterrents that impact the choice of psychiatry as specialty. Subjects and Methods: Students filled in a self-reported questionnaire focusing on the several factors that act as motivators, deterrents, or have no impact on psychiatry career choice. Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences (SPSS)® version 20. Different factors were expressed in terms of numbers and percentages. Chi-square test was used to compare responses to the questionnaire between male and female students and whether the GPA had an effect on their choice. P value less than 0.05 was considered significant. Results: It was noted that 85% did not choose psychiatry, with the most important deterrent being "Family member is psychologically ill" and "Available job position" being the most common motivator for choosing a specialty. Conclusion: In conclusion, there are many factors that play an important role in career choice. No difference was found among male and female students, and no effect was identified while comparing GPA with career choice.
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	Effect of gabapentin in comparison with hydrocortisone on postlaparoscopic cholecystectomy pain control	p. 652
	Negin Ghadami, Arvin Barzanji, Karim Nasseri, Farzad Sarshivi, Bijan Nouri DOI:10.4103/jfmpc.jfmpc_407_18   Background and Aim: Although laparoscopic cholecystectomy causes less pain than open cholecystectomy, it is still not completely painless. Several methods have been used to relieve the pain of laparoscopic surgery. The aim of this research was to compare the effect of gabapentin and hydrocortisone on pain control after laparoscopic cholecystectomy. Materials and Methods: In this double-blind clinical trial, a total of 60 adult patients aged 18–70 years from both sexes American Society of Anesthesiologists Classification (ASA Classification 1 and 2) who were selected for laparoscopic cholecystectomy were divided into two groups of 30 subjects to be studied. 150 mg gabapentin and 100 mg hydrocortisone were administered to the first and second groups before the operation, respectively. Pain score and vital signs (systolic blood pressure and heart rate) were recorded. Data were fed into SPSS 23 software and analyzed using Fisher-test, independent t-test, and repeated measurement. P < 0.05 was considered as significance level. Results: Patients were similar in terms of age and sex. Mean score of visual analog scale (VAS) in the first 4 h after operation was 5.84 ± 2.33 and 5.20 ± 1.74 in the gabapentin group and was 7.03 ± 1.23 and 6.50 ± 1.30 in the hydrocortisone group (P < 0.05), respectively. Although mean VAS scores at 6, 12, and 18 h after operation showed no significant differences between gabapentin and hydrocortisone groups (P > 0.05), VAS score 24 hours after operation was 2.87 ± 1.57 and 3.92 ± 1.28 in gabapentin and hydrocortisone groups, respectively (P < 0.05), indicating a significant difference in VAS score between the two groups 2 and 24 h postoperation. Conclusion: The results of this study showed that gabapentin was more effective than hydrocortisone within the first 4 h of laparoscopic cholecystectomy. In addition, gabapentin was shown to be a better pain controller 24 h postoperation.
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	Prevalence and associated factors of burnout among family medicine residents in Al Madina, Saudi Arabia	p. 657
	Sami A. R. Aldubai, Abdullah M Aljohani, Abdulwahab G Alghamdi, Khalid S Alghamdi, Kuru Ganasegeran, Ayman M Yenbaawi DOI:10.4103/jfmpc.jfmpc_268_18   Background and Aim: Burnout is a common problem for interns and residents. It has been associated with physical and mental health of health care providers as well as low job satisfaction and medical errors. Few studies have investigated this problem among residents. This study aimed to determine the prevalence of burnout and its associated factors among family residents in Al Madina city, Saudi Arabia. Materials and Methods: This cross-sectional study was conducted among 75 residents in the family medicine residency programs in Al Madina, Saudi Arabia. A self-administered questionnaire was used that includes questions on sociodemographic characteristics and sources of stress and burnout. T test, analysis of variance (ANOVA) test, and multiple linear regression analysis were employed. Results: Majority were female (54.7%) and aged 26 to 30 years (84.0%). The significant predictors of burnout in the final model were "tests/examinations" (P = 0.014), "large amount of content to be learnt" (P = 0.016), "unfair assessment from superiors" (P = 0.001), "work demands affect personal/home life" (P = 0.001), and "lack of support from superiors" (P = 0.006). Conclusion:Burnout is present among family medicine residents at a relatively high percentage. This situation is strongly triggered by work-related stressors, organizational attributes, and system-related attributes, but not socio-demographics of the respondents. Systemic changes to relieve the workload of family medicine residents are recommended to promote effective management of burnout.
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	Severity and prevalence of allergic rhinitis among school children, Jazan Region Saudi Arabia	p. 663
	Taher Abdullah Mahnashi, Mohammed Ali Faqihi, Abdulrahman Nasser Moafa, Abdulhameed Ahmed Basudan, Mohammed Nasser Alhazmi, Alhussen Fahad Khawaji, Yaseen Mohammed Y. Haddadi DOI:10.4103/jfmpc.jfmpc_294_18   Background: Allergic diseases such as allergic rhinitis (AR) represent a global health problem, affecting 10–25% of the world population. There is clear evidence to support the concept that allergic diseases are influenced by genetic predisposition and environmental exposure. Objectives: To assess the severity and prevalence of AR among school children in Jazan Region, Saudi Arabia. Methods: This is a cross-sectional study using a modified International Study of Asthma and Allergies in Children (ISAAC) questionnaire. Results: The nasal blocking is considered to be one of the most common symptoms of AR. Regarding the frequency of AR-related symptoms which indicate severity in the last 12 months according to the gender, our statistical analysis results found that the severity regarding nasal symptoms varied from nasal block to disturbed sleep due to nasal block where 97 (6.9%) had nasal block, 109 (7.8%) had nasal block interfering with daily activities, 12.1% had nasal block resulting in breathing difficulties, and 67 (4.7%) had disturbed sleep due to nasal block/problem. About 258 (18.4%) of all population urgently visited the emergency department due to nasal problems. Sixty-four (4.5%) were admitted due to nasal problems and 92 (6.6%) missed school days due to nasal block. The prevalence in elementary and intermediate school was 209 (14.9) and 170 (12.2), respectively with P value of 0.013, according to gender of study population showed no statistical significance according to all parameters. The prevalence was higher among Saudi population, regarding education level the prevalence was higher among intermediate school children. Conclusion: In conclusion, it was clear that the prevalence of AR among Saudi school children is 27.1%. Living in urban areas, intermediate school education level, lowlander population are significant risk factors for the prevalence and severity of AR.
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	Trends of HIV prevalence in rural South India	p. 669
	K Manjunath, Anne George Cherian, Vinod Abraham, Shantidani Minz, Kuryan George, Jasmin Helan DOI:10.4103/jfmpc.jfmpc_326_18   Background: India, with its large number of migrant workers, had a large number of people affected by HIV. This included antenatal women who are a vulnerable population. The Government of India along with nongovernmental organizations worked on a large number of programs to screen and decrease mother-to-child transmission. This in turn has brought down the prevalence of HIV. Materials and Methods: Retrospective analysis of data from the block being provided with healthcare was carried out over a period of 14 years from January 2002 to December 2016. Results: The observed HIV prevalence was 5.9 per 1000 in 2002 and showed a declining trend to 1.2 per 1000 in 2016. Conclusion: Consistent work at health education and preventive methods has helped bring down the prevalence of HIV over the years.
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	Prevalence of constipation among central region population, Riyadh and Qassim provinces, Saudi Arabia, 2018-2019	p. 673
	Mohammed Alhassan, Abdulaziz Alhassan, Abdulaziz Alfarhood, Khalid Alotaibi, Nashmi Alrashidy, Khalid Alshalhoub, Meshal Almeshal DOI:10.4103/jfmpc.jfmpc_369_18   Background: Due to the lack of data and studies concerning the prevalence of constipation in Saudi Arabia, this study aimed at determining the level of prevalence among central region population in Saudi Arabia, specifically in Riyadh and Qassim provinces. Aims: To determine the prevalence of constipation, to estimate the overall prevalence of constipation among the society, and to identify risk factors of constipation. Materials and Methods: In this cross-sectional study, 543 individuals were covered, both males and females in the targeted areas. A standardized questionnaire was used to cover eight different aspects concerning constipation. SPSS package was used to analyze the data collected from the sample. Results: The results of the scoring system showed that the prevalence of constipation among the sampled individuals is only 4.4%, whereas those whose result indicates no suffering from constipation represented 95.6%. Constipation is more prevalent among females (79.2%) rather than males (20.8%). Moreover, constipation is more sever among those who are between 20- and 35-year old, while it reaches 0% among old people (over 51 years). Riyadh residents are more likely to suffer from constipation rather than Qassim residents. In Riyadh, 83.3% suffered from constipation, whereas the percentage in Qassim was 16.7%. The results show also that constipation is more prevalent among those who eat fiber-rich food once in a week, who are getting stressed all the time, nonsmokers, and who get dehydrated and do not carry a bottle of water. There is a significant relationship between suffering from constipation and only two variables, which are regularity of being stressed and regularity of getting dehydrated. The test value for these two variables were (0.0) in the two cases. Conclusion: The prevalence of constipation is relatively very low among population of central region in Saudi Arabia.
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	Patterns of healthcare seeking behavior among persons with diabetes in Central India: A mixed method study	p. 677
	VV Nimesh, Anupam Halder, Arun Mitra, Sanjeev Kumar, Ankur Joshi, Rajnish Joshi, Abhijit Pakhare DOI:10.4103/jfmpc.jfmpc_433_18   Background: Management of diabetes is complex and requires multiple lifestyle modifications, drug therapy, and a sustained regular follow-up. Complexities of health-seeking pattern in individuals with diabetes have been poorly characterized. Objectives: To understand the health-seeking patterns, and reasons of provider preference and switching among persons with diabetes. Materials and Methods: We performed a mixed methods study in an urban slum setting of Bhopal. This urban slum was chosen as being a field practice area of the institute, a complete sampling frame with listing of households, and individuals with chronic disease conditions (including diabetes) was available. To be included in the study, the individual should have been an adult, aged ≥20 years, and diagnosed as type 2 diabetes mellitus. Descriptive statistical analysis of sociodemographic and disease management variables was performed. For qualitative component, interviews were transcribed and primary coding was done by two investigators followed by condensation of codes into themes or categories. The frequency of these content categories was presented with count and proportions. Results: In total, 60 individuals with diabetes were interviewed. Of all individuals, 36 (60%) were asymptomatic at the time of the first diagnosis, and 57 (95%) were currently under treatment from some healthcare provider. About 25 (41.6%) switched their first provider and remaining continued with the same provider. Second provider was sought by 9 (36%) of 25 patients. Reasons for switching were perceived nonrelief, cost of care, distance of facility, and behavior of care provider. Conclusions: Healthcare provider switching is common among persons with diabetes which has implications on continuity of care.
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	Assessment of knowledge, attitude, and practice about first aid among male school teachers and administrators in Riyadh, Saudi Arabia	p. 684
	Ibrahim Adel AlYahya, Hamad Adel Almohsen, Ibrahim Ahmed AlSaleem, Mishari Mohammed Al-Hamid, Ali Mohammedirfan Arafah, Yousef Abdullah Al Turki, Abdulmajeed Abdulrahman Aljasser, Mohammad Abdullah Alkharfi DOI:10.4103/jfmpc.jfmpc_316_18   Background: Children are more exposed to harm and have a higher risk. Teachers are facing many circumstances of students in schools, and this needs medical attention and perception of what to do. Aim: To assess the levels of knowledge of teachers and school instructors that live in the city of Riyadh related to basic first-aid practices and some variables which influenced these levels of information. Material and Methods: In this cross-sectional study which was conducted on teachers and school instructors in Riyadh, a questionnaire containing sociodemographic properties and the level of knowledge related to first-aid practices was applied under supervision. The level of perception was evaluated on a 25-point scale. This study was approved by the King Saud University School of Medicine. Results: The mean score of knowledge about the first aid of the population was found to be 10.36. It was found that teachers who have good knowledge of first aid (≥15 out of 25 points) are 14.9% (N = 65). Also, it was found that first-aid scores of knowledge showed a significant difference in age and having received first-aid training. Conclusions: We concluded that most of the teachers show weak knowledge of first aid and inappropriate response for common emergency scenarios. Also, the teachers who have training for first aid has a higher likelihood to respond better in those given scenarios, but the majority of the sample have not received any training to deal with those scenarios. We recommend that teachers must undergo a first-aid training program.
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	Questionnaire to assess adherence to diet and exercise advices for weight management in lifestyle-related diseases	p. 689
	Sravan Kumar Dubasi, Piyush Ranjan, Charu Arora, Naval K Vikram, Sada N Dwivedi, Namrata Singh, Gauri S Kaloiya, Shalimar  DOI:10.4103/jfmpc.jfmpc_338_18   Background: Lifestyle-related diseases have assumed significant public health problem across the globe including developing nations. High rate of nonadherence to treatment poses challenges to family physicians in its treatment. Objective: To develop a valid and reliable questionnaire for assessment of adherence to lifestyle modification advices. Materials and Methods: The questionnaire was developed following a systematic, scientifically accepted methodology which included literature review, focused group discussions, detailed interviews, and expert evaluation. Comprehensibility, replicability, face validity, content validity, patient acceptance, and ease of usage of the questionnaire were analyzed. Five-point Likert scale was employed as response options. Cronbach's alpha was calculated to assess internal consistency of overall questionnaire. A cross-sectional survey was then performed on 100 obese patients with nonalcoholic fatty liver disease to validate the questionnaire. Results: The developed questionnaire consists of 14 questions under two domains, 12 items under diet and 2 items under the physical activity domain. Each of these questions is on a 5-point Likert scale. The tool has shown satisfactory validity. It also has adequate reliability and internal consistency with Cronbach's alpha value of 0.9. Conclusion: It is a valid and reliable tool which can be used in clinical practice to assess adherence to lifestyle modification advices by family physicians.
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	Higher risk of developing active TB among adult diabetics exposed to TB during childhood: A study from Kerala, India	p. 695
	Shibu Balakrishnan, PS Rakesh, Krishnaveni Viswanathan, Vincy Nelson, Sony Simon, Sreenivas A Nair, Manu E Mathew, M Sunilkumar DOI:10.4103/jfmpc.jfmpc_344_18   Introduction: Factors associated with tuberculosis (TB) in Kerala, the southern Indian state that notifies approximately 33 microbiologically confirmed new cases per 100,000 population every year for the past two decades, are still unclear. We did a community-based case–control study in Kollam district, Kerala, to identify the individual-level risk factors for TB. Methods: Structured questionnaire was applied to 101 microbiologically confirmed new TB cases registered under Revised National Tuberculosis Control Program and 202 age- and gender-matched neighborhood controls without present or past TB. Information was sought on socioeconomic status (SES), smoking, consumption of alcohol, close contact with active TB during childhood or recent past, diabetes mellitus (DM), and other comorbid conditions. Results: Close contact with TB during childhood [odds ratio (OR) 15.88, 95% confidence interval (CI) 3.21–78.55], recent close contact with TB (OR 4.81, 95% CI 2.09–11.07), DM (OR 1.64, 95% CI 1.04–3.06), SES (OR 2.16, 95% CI 1.16–4.03), smoking more than 10 cigarettes/beedis per day (OR 3.32, 95% CI 1.27–8.96), consuming more than 10 standard drinks per week (OR 2.91, 95% CI 1.33–6.37), and the interaction term of having close contact with TB during childhood and DM at present (OR 7.37, 95% CI 1.18–50.29) were found to be associated with TB. Conclusion: Close contact with a case of TB, presence of DM, lower SES, smoking, and alcohol consumption were associated with active TB in Kollam. Having close contact with a case of TB during childhood and development of DM in later life together are significantly associated with active TB in the study population. The findings also direct further studies to confirm and explore mechanisms of interaction of diabetes with childhood exposure to TB.
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	Prevalence of medication adherence and its associated factors among patients with noncommunicable disease in rural Puducherry, South India – A facility-based cross-sectional study	p. 701
	K Yuvaraj, S Gokul, K Sivaranjini, S Manikandanesan, Sharan Murali, Gayathri Surendran, Marie Gilbert Majella, S Ganesh Kumar DOI:10.4103/jfmpc.jfmpc_350_18   Background: Trends in morbidity and mortality due to noncommunicable diseases (NCDs) are rising because of poor control status. Medication nonadherence is one of the most common and modifiable causes of inadequate control status. Objectives: To determine the prevalence of drug adherence among patients with NCD in rural Puducherry. Methods: A facility-based cross-sectional study was done among 260 patients with NCD receiving treatment from rural primary health center in Puducherry during February and March 2018. Information regarding sociodemographic profile and household was collected using pretested semi-structured questionnaire. Morisky Medication Adherence Scale was done to assess the adherence. We calculated adjusted prevalence ratios (aPRs) to identify the factors associated with medication adherence. Results: Among the 260 participants, 42.7% belonged to elderly age group; 66.2% were females; 44% did not have any formal education; 70% were unemployed. The majority were suffering from hypertension (71.2%) followed by diabetes (56.2%). This study found that almost one-third (32.7%) of the study participants were not properly adherent to medications. Elderly [aPR 2.51 95% confidence interval (CI): 1.70–3.70] and female participants (aPR 1.64 95% CI: 1.04–2.58) were found to have more chance being nonadherent to medications after adjusting for possible confounding variables. Conclusion: This study reported that almost one-third of the study participants were nonadherent to medications. Elderly age group and female gender were found to be the determinants of nonadherence. Corrective measures need to be started at patient level first by motivating and educating them regarding the importance of drug intake.
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	Knowledge and attitude regarding child abuse among primary health care physician in Abha, Saudi Arabia, 2018	p. 706
	Safar A Alsaleem, Mohammed A Alsaleem, Ahmed M Asiri, Saif S Alkhidhran, Waleed S. S. Alqahtani, Mohammad S Alzahrani, Huda A Assiri, Khadejah M Alshahrany, Awad S Alsamghan DOI:10.4103/jfmpc.jfmpc_442_18   Backgrounds: Child abuse or child maltreatment is physical, sexual, or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. Child abuse may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child, and can occur in a child's home or in the organizations, schools, or communities the child interacts with. This study was conducted to assess the primary health care (PHC) centers' physicians' knowledge and attitude toward child abuse including its types, and child neglect with their behavior regarding reporting of abuse cases. Methods: A cross-sectional study was conducted in Abha which is the capital of Aseer Province, including all PHC physicians (about 475) working in PHC centers. Data regarding physicians' demographic characteristics, perception, and awareness regarding child abuse and neglect were collected by self-administrative questionnaire in the PHC center during their time between patients' consultation. Results: The study included 300 PHC physicians whose ages ranged from 25 to 50 years old with mean age of 28 years. About 65% of the physicians were males and 69% of them were married with about 73% having at least one child. Overall, 96.3% of the physicians recorded good awareness level regarding types of child abuse and 97.3% recorded good awareness level regarding child neglect patterns. Underreporting of child abuse cases was recorded by about 64% of physicians. Conclusion: Regarding child abuse and neglect, PHC physicians have good knowledge, optimal attitude, and positive perception. There was also the problem of underreporting of suspected child abuse cases among PHC physicians in Saudi Arabia, with many barriers to report, such as community traditions; unclear reporting strategy was identified.
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	The effect of family-centered education on the quality of life of adolescents with spinal cord injuries	p. 711
	Sedigheh Khanjari, Zahra Tajik, Hamid Haghani DOI:10.4103/jfmpc.jfmpc_305_17   Background and Purpose: Spinal injury is a destructive complication creating huge changes in the teen health and lifestyle, depending on its extent and severity. Although most of the complications of this disease are treatable, they impose huge costs on the healthcare system, the patient, and his family. The present study was conducted to investigate the effect of family-centered education on the quality of life and self-esteem of adolescents with spinal cord injuries. Method: The present study is a quasi-experimental study. Adolescents (108 old) with spinal cord injuries entered the present study through stratified sampling with appropriate allocation. The participants were compared in two groups of experimental and control. The data was collected using demographic information questionnaire as well as Ferrans and Powers' quality of life index in spinal cord injury. Four weeks after the intervention, the research questionnaires were completed once more by the adolescents of both groups. Data analysis was conducted by using T-square test, independent t-test, Fisher's exact test, and analysis of variance. Finding: According to results, quality of life mean score of adolescents with spinal cord injuries was 23.05 ± 122.65 before the intervention. It became 22.64 ± 148.15 after the intervention. With respect to importance, quality of life mean score of these adolescents changed from 20.83 ± 164.07 to 21.62 ± 174.99. Conclusion: Given the effect of family-centered education on the quality of life in adolescents with spinal cord injuries, it seems essential to create necessary grounds for training families having adolescents with spinal cord injuries by nurses to improve their quality of life as well as conducting researches on their problems.
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	Evaluating the trend of cutaneous malignant tumors in Ilam from 2002 to 2011	p. 717
	Mohammad R. Hafezi Ahmadi, Zeinab Bakhtari, Behrang Kazeminezhad, Samiramis Ghavam DOI:10.4103/jfmpc.jfmpc_178_17   Introduction: Skin cancer, the melanoma type of which causes high mortality, is the most common malignancy in Iran and all over the world. UV is the most important cause of the incidence of this disease. This study evaluates the frequency of different types of cancer and their trajectory in Ilam province from 2012 to 2011. Materials and Methods: This analytical–descriptive study covered and evaluated all skin cancer patients who were registered in Ilam Province Cancer Registry during 20002 to 2011. Required information of each individual patient, such as age, sex, residence, pathological type of skin cancer, the location of the incidence of the disorder, and the year, was collected and studied. Findings: Out of total 347 cases, 240 cases (69.2%) were diagnosed with basal cell carcinoma (BCC), 63 cases (18.2%) with squamous cell carcinoma (SCC), 16 cases (4.6%) with malignant melanoma (MM), 8 cases (2.3%) with metastatic cancer, and 20 cases (37.7%) with other skin cancers. Mean age of patients was 62/42 ± 16/11 years, and the majority of them (37.7%) were men and lived in the city. Face was the most common place of the incidence of this disease (81.6%) and hand was the least common one (1.7%). The rate of incidence of cancer has experienced considerable growth in men and a slight decrease in the case of women between 2002 and 2011 in Ilam. Conclusion: According to the results of this study, the rate of skin cancer has increased among men during the studied period; thus, necessary measures are required to prevent and reduce the incidence of this disease, especially in people who are exposed to the sun's ultraviolet rays because of their jobs.
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	Evaluation the efficacy of prophylactic tamsulosin in preventing acute urinary retention and other obstructive urinary symptoms following colporrhaphy surgery	p. 722
	Maryam Shokrpour, Elmira Shakiba, Ali Sirous, Alireza Kamali DOI:10.4103/jfmpc.jfmpc_18_19   Background and Aim: Postoperative urinary retention (POUR) is defined as a disability in urinary excision after surgery. There are several strategies to prevent POUR, such as tamsulosin, which is a selective antagonist at alpha-1A and alpha-1B-adrenoceptors which reduces the bladder outlet resistance. The aim of this study was to investigate the efficacy of prophylactic tamsulosin in preventing acute urinary retention and other obstructive urinary symptoms following colporrhaphy surgery. Materials and Methods: This study was a randomized, double-blind clinical trial. A total of 130 patients who were candidates for colporrhaphy were divided into two groups: the intervention group (65 subjects received 0.4 mg tamsulosin in a single dose at the time of sleeping) and the control group (65 subjects received placebo at the same time as the intervention group). The incidence of acute urinary retention and other obstructive urethral symptoms and the mean urination volume after catheterization were recorded 24 h after operation. Patients' demographic and clinical data were analyzed using SPSS version 20 software using Chi-square and Fisher's tests. Results: There was a significant difference in the incidence of acute urinary retention, decrease in urine flow diameter, and the mean residual urine volume Post Void Residual (PVR) in the bladder, and the incidence of these symptoms decreased in the tamsulosin recipient group. The incidence of other symptoms of acute urinary retention was not significantly different when compared between both the groups. Conclusion: It seems that the use of prophylactic tamsulosin is more effective in decreasing the incidence of acute urinary retention, decreasing the PVR in the bladder, and decreasing the diameter of the urine flow in patients after colporrhaphy.
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	Assessing mental health and the relation with variables of demographic and clinical in Crohn's disease patients; 2016-2017	p. 728
	Masoumeh Nazarinasab, Sorour Nematpour, Seyed Saeed Seyedian, Nilufar Esfahanian DOI:10.4103/jfmpc.jfmpc_236_18   Background: Crohn's disease is a group of special diseases that are considered in psychiatric studies because there is a contrast between the physical and psychological diseases among the affected patients. Aim: The aim of this study was assessing mental health and the relation with variables of demographic and clinical in Crohn's disease patients. Methods: In this epidemiological study, 96 patients with Crohn's disease who referred to educational hospitals in Ahvaz during 2016--2017 were evaluated by demographic and clinical questionnaires and SCL-90 questionnaires for mental health, and the information was analyzed by SPSS software version 22. Results: The mean physical complaints in subjects was 24.63 ± 4.08 and the mean mental health was calculated to be 187.75 ± 25.17. Multivariate analysis of mental health showed that steroid consumption (P value < 0.001) and nonsmoking (P value = 0.038) were associated with higher mental health in the individuals. Conclusions: Crohn's patients suffered from decreased mental parameters in dimensions such as physical complaints, obsession--compulsion behavior, sensitivity to interactions, depression, anxiety, aggression, phobia, psychosis, and paranoid thoughts.
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	An investigation into the sensitivity of endoscopic ultrasound in the diagnosis of malignant bile duct in patients with idiopathic acute pancreatitis	p. 733
	Abazar Parsi, Abdolrahim Masjedizadeh, Seyed Saeid Seyedian, Seyed Jalal Hashemi, Farzad Jasemi, Razieh Nourinejad DOI:10.4103/jfmpc.jfmpc_463_18   Introduction and Objective: Acute pancreatitis (AP) is an inflammatory process of the pancreas characterized by abdominal pain and increased pancreatic enzymes. This disease is diagnosed clinically. Endoscopic ultrasound (EUS), which is a technique with high sensitivity and specificity, is used to diagnose biliary disease. This study aimed to determine the sensitivity of EUS in the diagnosis of malignant bile duct in patients with idiopathic AP. Methods: This descriptive study was performed on 146 patients with pancreatitis hospitalized in the gastrointestinal tract section of the Imam Khomeini Hospital of Ahwaz Jundishapur University of Medical Sciences. The collected data were analyzed by the SPSS 22.0 and the significance level of the test was <0.05. Results: According to the results, 79 (54%) out of the 146 patients were female and 67 (46%) were male. The mean and standard deviation of the patients' age were 52.5 and 19.6 years, respectively. The findings showed that the sensitivity and specificity of the EUS were 33% and 99%, respectively. Compared to the endoscopic retrograde cholangiopancreatography (ERCP), the sensitivity and specificity of the abdominal ultrasound were 62% and 62.5%, respectively. Compared to the ERCP, the sensitivity and specificity of EUS were 92% and 50%, respectively. Conclusion: The findings of this study showed that the sensitivity and specificity of EUS were higher than those of abdominal ultrasound. Moreover, EUS was the preferred method to detect common bile duct stones (CBDS).
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	Relationship between serum procalcitonin level and chronic obstructive pulmonary disease	p. 738
	Hamid Borsi, Elham Pajohan Nia, Mehrdad Dargahi Mal-Amir, Hanieh Raji DOI:10.4103/jfmpc.jfmpc_468_18   Background: Differentiation of the etiologies of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and differential diagnosis of other causes of respiratory attacks in chronic obstructive pulmonary disease (COPD) patients are challenging. Serum procalcitonin (PCT) which is a biomarker of bacterial infection, but not viral infections, could possibly recognize AECOPD requiring antibiotic treatment from other etiologies of respiratory attack. Methods: Patients aged from 40–80 years who were diagnosed with COPD according to the GOLD criteria and who referred to the Imam Khomeini Hospital of Ahvaz in 2016 were divided into two groups of exacerbated and stable COPD. Exacerbation of COPD is defined as worsening of the patient's condition from the stable state and behind normal day-to-day variations that is acute in onset and may necessitate treatment in a patient with underlying COPD. BODE Index and 6MWDT were used to assess the patients, and the severity of their disease was determined based on the GOLD criteria. Subsequently, PCT testing using electrochemiluminescence (ECL) method was carried out on patients on the same day. Results: PCT level in the exacerbation group was 0.272 ± 0.586 and 0.066 ± 0.027 in the non-exacerbation group, and their difference was statistically significant with P value = 0.001. Based on the results, the cut point of differentiating between the AECOPD and the stable groups with a sensitivity of 68% and a specificity of 80% is 0.085. Conclusion: Overall, the findings of this study indicate that PCT levels could be regarded as a good diagnostic marker for patients with COPD, and for the differentiation of AECOPD patients from stable COPD patients.
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	The effect of willpower workshop on anxiety, depression, and the excitement components in the students of Shiraz university of medical sciences	p. 741
	Seyed Ziaeddin Tabei, Mohammad Hasan Ehrampoush, Seyed Saeed Mazloomy Mahmoodabad, Hossein Fallahzadeh, Mohammad Nami, Atefeh Zare, Nahid Ardian, Firoozeh Nourimand, Forouhari Sedighe DOI:10.4103/jfmpc.jfmpc_406_18   Introduction and Aim: The current study aimed at evaluating the effect of willpower workshop on anxiety, depression, and the Granovsky excitement components among the students of Shiraz University of Medical Sciences in the academic year 2016--2017. Materials and Methods: Students (140) were selected by the simple random sampling method and allocated into two equal groups of intervention (willing) and control, each of 52 individuals. Data collection instruments were the Garnefski cognitive emotion regulation scale and the Beck depression and anxiety inventories. The data were collected twice, before intervention and after the intervention (9 months after the study completion and holding the workshops). The control subjects received no intervention but were interviewed every 3 months. Results: The results of the current study indicated no significant differences in demographic variables and pretest scores between the groups, which indicate the homogeneity of the groups. In other words, there were no significant differences between the groups regarding demographic characteristics before the intervention (P > 0.05). In addition, to compare the intervention and control groups, the Mann--Whitney U test was used and the results showed a significant difference in posttest results between the study groups (P < 0.05). Also, there was a significant difference between the pretest and posttest results of each group (P < 0.05). Conclusion: Results of the current study indicated that training the stress, coping and willpower strengthening skills, based on the Granovsky excitement components, could promote psychophysical health and reduce anxiety and stress among the studied students.
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CASE REPORTS
	Mucormycotic osteomyelitis of maxilla following maxillofacial trauma: The disease of the diseased	p. 748
	Dhirendra Srivastava, Sonal Mishra, Lokesh Chandra, Deepak Passi DOI:10.4103/jfmpc.jfmpc_410_18   Mucormycosis is a rare opportunistic fungal infection with acute, aggressive, and invasive nature, seen in immunocompromised/debilitated patients, especially with diabetes mellitus. The key to successful therapy is the early diagnosis of signs and symptoms of the disease, correction of the underlying medical disorder(s), and aggressive medical and surgical intervention. The case presented here is mucormycotic osteomyelitis of the nasomaxillary–zygomatic complex following trauma in a middle-aged man. Preoperative amphotericin B therapy along with surgical resection of necrotic tissue was done followed by prosthetic rehabilitation with an obturator. There was no sign of recurrence of the diseases for the follow-up period of 1 year.
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	Does this HIV-positive patient have progressive multifocal leukoencephalopathy or PML-immune reconstitution inflammatory syndrome?	p. 751
	Rahul R Abraham, Ashoojit Kaur Anand, Ramakrishna Prasad, BC Rao, Praneeth Pillala DOI:10.4103/jfmpc.jfmpc_460_18   We describe the case of an HIV/AIDS patient with progressive multifocal leukoencephalopathy (PML) associated with immune reconstitution inflammatory syndrome (IRIS) and the diagnostic and management dilemmas in distinguishing between PML and PML-IRIS. This case is relevant to physicians including family physicians who manage immunocompromised patients in their practice.
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	Dermatomyositis associated with adenocarcinoma of the lung: A case report	p. 754
	Naseem Palakkuzhiyil, R Namitha, SV Rakhesh, Rinu Thomas, NA Uvais DOI:10.4103/jfmpc.jfmpc_467_18   The association of dermatomyositis and underlying malignancies, especially small cell and squamous cell carcinoma of the lung, has been recognized a long time ago. We report the case of a 63-year-old male chronic smoker with adenocarcinoma lung associated with dermatomyositis. The occurrence of dermatomyositis should be considered as a potential presentation of paraneoplastic syndromes and physicians encountering similar clinical situations should perform extensive diagnostic work-up to exclude underlying neoplastic lesions.
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	Mucor menace in an immunocompetent young male after dental manipulation	p. 757
	Nitin Gupta, Rajeev Kumar, Manish Soneja, Gagandeep Singh, Wasim Khot, Sundeep Malla, Immaculata Xess DOI:10.4103/jfmpc.jfmpc_412_18   Fungal rhino-orbital sinusitis due to mucormycetes is a rapidly progressive condition with high mortality, rarely seen in immunocompetent individuals. A 26-year-old immunocompetent male presented with rhino-orbital mucormycosis after a history of dental manipulation. The patient was successfully managed with a combination of surgery, amphotericin B, and posaconazole. Here, we highlight the delay in diagnosis and challenges faced in the management.
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	Designing culturally acceptable screening for breast cancer through artificial intelligence-two case studies	p. 760
	Sudip Bhattacharya, Neha Sharma, Amarjeet Singh DOI:10.4103/jfmpc.jfmpc_391_18   Diffusion of Innovation (DOI) theory explains how, over a period of time, an idea or behavior diffuses (or spreads) through a targeted population or society. The major thing about adoption is that the people must perceive the idea, behavior, or product as new or innovative and it should be useful to them. The more the perceived benefit, the quicker is the diffusion. Same thing can be expected for adoption of new technology in healthcare also. In this paper, we have described two novel breast cancer screening technologies and have concluded that implementation of a new technology should consider the cultural aspect and mindset of local people so that quick diffusion of healthcare technology takes place among all segments in our society to make it a better world.
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	Uncommon cause of persistent hypoxia in a patient with obstructive sleep apnea	p. 763
	Subodh Kumar Mahto, Pankaj Kumar Gupta, Pritam Majumdar, Gwenette Andrea War, Vishakha Mittal, Atul Goel DOI:10.4103/jfmpc.jfmpc_3_19   We report a case of hypothyroidism, obstructive sleep apnea (OSA) with persistent daytime hypoxemia. Cause of hypoxemia was two arteriovenous (AV) malformations in the lower lobe of the lung. We must be alert to other causes of hypoxemia in patients of OSA with persistent daytime hypoxemia.
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	Scedosporium apiospermum as a rare cause of fungal rhinosinusitis	p. 766
	Ankita Baidya, Nitin Gupta, Ayan Basu, Parul Kodan, Karan Aggarwal, Chirom A Singh, Gagandeep Singh, Manish Soneja, Immaculata Xess DOI:10.4103/jfmpc.jfmpc_434_18   Fungal rhinosinusitis is not very uncommon in diabetic patients, but Scedosporium apiospermum as a cause of this infection is rare. We report a case of fungal rhinosinusitis by Scedosporium spp. in a diabetic male along with literature review. The patient is on voriconazole, with adequate therapeutic response after 6 months of follow up.
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LETTER TO EDITOR
	Effect of intravenous iron sucrose on hemoglobin level, when administered in a standard dose, to anemic pregnant women in rural Northern India	p. 769
	Sakiyeva Kanshaiym, Ibrahim A Abdelazim, Tatyana Starchenko, Gulmira Mukhambetalyeva DOI:10.4103/jfmpc.jfmpc_438_18
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