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   Table of Contents - Current issue
January-March 2019
Volume 10 | Issue 1
Page Nos. 1-53

Online since Monday, February 18, 2019

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Listen, care, and going extra mile: Guiding principles for physicians and teachers in health-care profession p. 1
Vijay Rajput
In the medical field, emphasis has been on the development of trust between the physician and the patient, similar to that of a teacher and learner. This is because a solid foundation of trust benefits patients' overall care and students' learning. Trust is critical because it allows the patient to believe that the doctor is there to give them the best care possible. Trust improves the physician–patient relationship because the patient believes he or she is receiving high-quality care as a result. It is important for residents and physicians to be aware of their behavior in their interactions with patients and learners, even if the interaction is only for a few minutes. This awareness is key for the development of trust and long-lasting benefits for clinical care and medical education. Physicians and teachers should develop three crucial skills to develop trust early with their patients and learners: (1) listening, (2) caring, and (3) going the extra mile for patients and learners. These attributes, when applied to patient care and teaching, will travel far in a physician's career and be beneficial to their patients' overall health. This article will explore these three skills and examples of their applications, which medical professionals can use in their day-to-day practice in light of a time-restricting, multitasking, and technologically advanced world.
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Hepatitis B virus transmission and health-care workers: Prevention, management, and awareness toward the disease p. 6
Bineeta Kashyap, Urvashi Tiwari, Anupam Prakash
The risk of transmission of hepatitis B, a global communicable disease, has become a matter of concern in recent years. Health-care delivery has the potential to transmit hepatitis B virus (HBV) and hepatitis C virus to both health-care workers (HCWs) and patients. The risk of transmission is most clearly related to the frequency of exposure or the extent of direct contact with human blood and body fluids. Health care must be provided with the best practice of safety and standards of care. Adherence to recommended improved safety devices, standard precautions, and fundamental infection-control practices is a must to prevent transmission of blood-borne pathogens. Long-term treatment with the goal of clearance of HBV is often required. Safe and effective hepatitis B vaccines along with postexposure prophylaxis with hepatitis B vaccination alone or in combination with HBV immunoglobulin have been available, the impact of which has been reported in several countries in preventing HBV transmission among HCWs.
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Japanese encephalitis: Strategies for prevention and control in India p. 12
Ruchir Rustagi, Saurav Basu, Suneela Garg
Japanese Encephalitis (JE) is an important re-emerging vector-borne zoonotic disease of the 21st century which is the most important cause of morbidity and mortality due to pediatric viral encephalitis in Asian populations. India and China together report 95% of the disease burden where it is also an important cause of acute encephalitis syndrome. JE is a neglected tropical disease which disproportionately afflicts poor and economically disadvantaged populations in rural regions of low and middle-income countries which often lack well-equipped tertiary care centers for the management of JE cases presenting with central nervous system manifestations and related complications. JE has large animal reservoirs among pigs and water birds which renders JE elimination difficult. Hence, current strategy for JE prevention and control pursues a combined approach inclusive of expansion of JE vaccination coverage in endemic regions, vector control, and surveillance. Unfortunately, the lack of public health infrastructure, economic resources, and lack of political commitment has resulted in most endemic countries in the developing world failing to take adequate steps for achieving these recommended measures for JE control, especially with regard to developing surveillance capacities and reference laboratories for the diagnosis of JE. Moreover, the threat of JE has increased in recent years due to factors such as climate change and lack of economic development in several endemic zones even as the disease has begun affecting adult populations. Evidence from surveillance data in some countries also suggests that increase in vaccination coverage for JE does not necessarily correlate with decline in JE disease burden. Ultimately, JE is likely to persist as a major public health problem in the developing world and impede their economic development unless it receives adequate attention from the global health community.
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Assessment of patient's knowledge, attitude, and practice regarding pulmonary tuberculosis in a tertiary care hospital Highly accessed article p. 18
Viplav Narayan Deogaonkar, Saatchi Kuwelker, Smrati Bajpai
Background: Tuberculosis (TB) is one of the most common respiratory illnesses in India, to the extent that about 1/4th of the population afflicted by TB in the world, is found in India. The knowledge of the patient about the disease, his attitude toward it, and compliance to treatment are key factors in management of the disease. Objectives: The objective of this study is to assess the knowledge, attitude, and practices of the patients with regard to pulmonary TB. Methodology: A cross-sectional observational study was conducted among patients suspected of or diagnosed with pulmonary TB in a Tertiary Care hospital using a prestructured questionnaire. Results: A total of 100 patients participated in the study. Out of these, 74% had never suffered from TB in the past. Cough was identified as a symptom of TB by 75% participants. About 15% participants said they used no precautions while coughing. Conclusion: The study reveals that there are quite a few misconceptions regarding causes, transmission, and prevention of TB. There is still a long way to go to educate the population regarding such a common illness.
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Public forum by undergraduate medical students during clinical postings: A way to improve the communication skill p. 22
Sumedha Sharma, Aruna Nigam
Introduction: Excellent communication skills are essential to the practice of medicine as good doctor–patient communication is necessary to elicit information from the patient to arrive at an accurate diagnosis. Aim: The aim of this study was to assess the improvement in the communication skills of undergraduate medical students using public forum as a tool. Methodology: A total of 80 students of 5th-semester MBBS were invited to participate in public forum on the topic of “contraception.” Their communication skills were assessed using the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) assessment of communication skills tool. Each student performed four public forums over 2 months, one every fortnight. Each student delivered 15 min talk once in 2 weeks in front of a group of patients regarding the different contraceptive methods. The assessment of communication skill was done twice, i.e., they were assessed at the first and after the fourth public forum. Paired t-test was applied to assess the improvement in communication skill. Results: The mean score on RANZCOG assessment at the first public forum was 11.92 ± 3.89 and after the fourth public forum was 19.75 ± 6.13 (P < 0.00). An overall improvement in scores was 22.3%. There was a statistically significant improvement in the scores for all the points on the RANZCOG checklist. All the students felt more confident after the public forums. Conclusion: Involving students in small public forums (or patient education programs) helps in improving communication skills and can, in turn, be of great help improving the personality of the future medical professionals as well as in the development of better health-care providers.
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Assessment of economic Burden and quality of life in stable coronary artery disease patients p. 26
Lalit Kumar, Anupam Prakash, SK Gupta
Background: Coronary artery disease (CAD) is known to adversely impact the quality of life (QOL) of the patients and poses an economic burden to the family and society. However, the same has not been estimated in India. Objectives: To estimate the annual economic burden (direct and indirect cost) and QOL in stable CAD patients at a Government Tertiary Care Hospital of Delhi, India. Materials and Methods: A cross-sectional study was carried out in a Government Tertiary Care Hospital of Delhi using a convenient sample of 113 CAD patients. A prestructured pretested questionnaire was used to collect information on direct and indirect costs of therapy for CAD patients, and QOL assessment was done using SF-36 questionnaire. Results: The total average annual cost incurred by patients of stable CAD was Indian National Rupees 15691.45, of which 78.49% was attributable to direct cost (drugs, supplements, diagnostic tests, and transportation charges) while 21.5% to the indirect costs (wage loss of the patient and caretaker, during the days of hospitalization). Both the components of QOL, namely, physical component score (PCS) and mental component score (MCS) were reduced in the stable CAD patients. PCS was 35.53 and MCS was 39.16. Conclusion: CAD poses not only an economic burden on the patient, family, and the society but is also associated with impairment of QOL of the patient too.
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Cardiac manifestations in dengue p. 30
Parag Viren Papalkar, Rajesh R Sarode, Sourya Acharya, Sunil Kumar
Aim: To study the prevalence of cardiac manifestations in patients of dengue fever. Settings and Design: This cross-sectional study was done in a tertiary care hospital conducted for a period of 2 years from September 2016 to October 2018. Methods: Patients with complaints of fever and suspected to have dengue were subjected to dengue serology. Confirmed cases of dengue were then classified according to the World Health Organization criteria into dengue fever, dengue hemorrhagic fever (DHF), and dengue shock syndrome. The assessment of cardiac manifestations was done based on electrocardiogram (ECG), echocardiogram, and cardiac marker. The data was analyzed using statistical significance tests. Results: Out of 60 patients, 36 (60%) were male and 24 (40%) were female, and the male-to-female ratio was 1.5:1. The mean age of the patients was 38 ± 16.69 years. Patients of dengue fever, DHF, and dengue shock syndrome were 51, 7, and 2 respectively. The most common ECG abnormality was sinus bradycardia seen in 9 (15%) patients, followed by sinus tachycardia in 6 (10%) and ST-T changes in 5 (8.33%). Echocardiography was normal in 54 (90%) patients, systolic dysfunction was found in 4 (6.67%) patients, and pericardial effusion was found in 2 (3.33%) patients. Eight (13.33%) patients had abnormal creatine kinase-muscle/brain values. Conclusion: Cardiac manifestations are common in dengue fever, seen in one-third of the patients. Platelet counts < 100,000/mm3 and a higher hematocrit are more likely to be associated with cardiac manifestations.
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Non-convulsive status epilepticus presenting as acute confusional state in a young adult p. 35
BD Sharma, Amit Kumar Batra
Nonconvulsive status epilepticus (NCSE) can occur in a variety of clinical conditions and is characterized by prolonged electrographic seizures without clinically discernible seizure activity. It may be one of the most frequently missed diagnoses in patients with altered neurologic function because it is often seen in patients with other serious illnesses. For accurate diagnosis of NCSE, an alteration in baseline cognition or behavior and a concurrent epileptiform seizure pattern on electroencephalography (EEG) must be present. This case of a young adult male presented to our emergency room with an acute onset of confusional state and behavioral changes with no clue for its etiology on initial clinical or after routine investigations including CT brain until EEG picked up continuous epileptic discharges. He responded dramatically to antiepileptic drugs without any recurrence during follow-up of 4 months. Many cases like this are being diagnosed with the use of continuous EEG monitoring (cEEG) in Neurological Intensive Care Units. The advent of cEEG is instrumental in the diagnosis as well as monitoring the response to treatment of this condition with antiepileptic drugs. Increased awareness and a high index of suspicion are needed for timely diagnosis of NCSE if a patient presents with acute onset of unexplainable cognitive or behavioral change of at least 30–60 min duration. Patients with NCSE need to be managed exactly as convulsive SE, using EEG as a guide rather than clinical observations as the determinant of response to treatment.
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Myocarditis with sinus exit block: A rare presentation of Plasmodium vivax malaria p. 39
Aanchal Arora, Manasa Mudalagiri, Deepali Sharma, Yogesh Chandra Porwal
Although malaria is caused most commonly by falciparum species, vivax malaria counts the second most common in India. Until recently, severe malaria infection was attributed to falciparum species. Various systemic complications including arrhythmia, heart failure, conduction disturbances, and myocarditis have been typically seen in association with Plasmodium falciparum infections. Nowadays, severe vivax malaria encompasses varied complications including cardiac complication as well. We report a case of sinus exit block due to myocarditis in a 40-year-old male infected with vivax malaria without any cardiovascular risk factors. Recovery was complete with a favorable outcome in this case.
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Gastric ascariasis mimicking rapunzel syndrome in an epileptic patient: Learning points galore Highly accessed article p. 42
Paras Passi, Sumita Kanwar, Swati Chaurasiya, Sumit Vats, Ravinder Kumar, Shalini Singh
Rapunzel syndrome refers to a very rare condition in which swallowed hair forms a gastric trichobezoar that has a long tail extending into the small bowel. It presents with early satiety, malnutrition, obstructive symptoms, and sometimes, gastric-outlet obstruction. Despite the varied manifestations of Ascaris infestation in man, gastric ascariasis is rare which is demonstrated in the stomach by radiology and by endoscopic examination. We present a rare case of trichobezoar in a 14 years epileptic female with recurrent seizure episodes and no prior history of psychiatric illness or worm infestation where the final diagnosis of gastric ascariasis was made on upper gastrointestinal-endoscopy revealing the presence of worms at the level of the fundus and body of the stomach. Endoscopically some worms were removed, and the rest passed down dead in stools after antihelminthic treatment. Recovery was uneventful and free of complications. Frequent seizures could also be attributed to malabsorption of anti-epileptic drugs because of gastric ascariasis. A prompt diagnosis (tissue diagnosis and direct visualization) always scores above characteristic radiologic findings and appropriate therapy can reduce comorbidities.
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A case of flaccid quadriparesis p. 45
Kashish Gupta, Subhash Kumar, Narendra Bishnoi, Mayank Gupta, Sunil Kumar Mahavar, Raman Sharma
Inclusion body myositis (IBM) is the most common inflammatory myopathy above the age of 50 years and three times more common in males than females. It presents as a distal more than proximal myopathy and has an indolent progressive course. Despite the latest advancements, it is challenging to diagnose this disease as it may resemble amyotrophic lateral sclerosis (ALS) clinically and polymyositis histopathologically. What sets it apart from the other myopathies is the fact that it has a very poor response to standard therapies of steroids and immunosuppressants. We present a case of a 30-year-old female patient presenting with relatively rapid onset of quadriparesis and dysphagia which was ultimately diagnosed with IBM. This case report attempts to highlight the difficulties in diagnosing this rare disease and the limited modalities of treatment.
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Tackling noncommunicable diseases effectively to attain universal health coverage p. 48
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Disseminated lymphadenopathy: Time is the best diagnostician p. 50
Manas Mengar, Pranav Ish, Shibdas Chakrabarti
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“Boomerang sign” in dengue encephalitis p. 52
Priyansh Bhayani, Sourya Acharya, Samarth Shukla
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