Vol 8, Issue 1, Jan-Mar, 2018

Introduction: Under-five mortality rate (U5MR) serves as an indicator for the health and socioeconomic status of a given population. Earlier MDGs and now SDGs pledge to bring down the U5MR. Verbal autopsy enables to make a retrospective enquiry into events leading to death, identify delays contributing to death and establish probable cause of death. This study aimed to compare the determinants and delays leading to infant and child deaths. Methodology: A cross sectional study was carried out in a rural block of district Rohtak from July 2015 to June 2016. All the under-five deaths that took place during study period were reviewed through verbal autopsy using NRHM death review formats. The data collection was done through house-tohouse visits. Data was analysed using SPSS. Results: The infant mortality rate was be 34.1 per 1000 live births and the under-five mortality rate was 38.2 per 1000 live births. Educational and socio-economic status of the parents significantly affected deaths. Accident/injury and diarrhoea were the major causes of child deaths. Conclusion: Factors contributing to the mortality among the under-five children were the lower educational status of parents especially mothers, not practising EBF, inadequate knowledge regarding danger signs among parents, socio- economic barriers to care seeking and cultural beliefs. Key words: Under-five mortality, Verbal autopsy, Determinants, Care seeking.

Purpose: Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease of intestines. The high cost of second line drugs along with the need for lifelong therapy are the most distressing factors demanding innovative therapy for treating this disease. Fecal microbial transplantation (FMT) can be used as an adjunct for treating UC. We performed FMT in a six year old male child who was being treated for ulcerative colitis with conventional therapy for the last two years with variable response to therapy. This therapy also has good potential as salvage therapy for refractory multidrug resistant Gram negative organisms and Clostridium difficile infection. Methods: After taking appropriate informed consent, a healthy adult donor from the family was thoroughly screened for various infections (as per protocol). Donor fecal preparation was done taking strict aseptic precautions and FMT was given as retention enema for 1 h (60 ml enema every 15 min) daily for 5 days. Patient was monitored for adverse event (as per protocol). Results: The patient tolerated the enema well. The Paediatric Ulcerative Colitis Activity Index (PUCAI) reduced from 35 to 15 after completion of five days of therapy. There has been no relapse since FMT and the child continues to be asymptomatic with a stable low PUCAI score 6 months post therapy. Conclusion: Our study is a step and encouragement towards the usage of FMT for pediatric patients with ulcerative colitis showing variable response to conventional treatment. However, more future studies are required to authenticate this treatment modality. Key words: Enema, Fecal Microbial Transplantation (FMT), PUCAI score, Ulcerative colitis.

Introduction: The prevalence of hypertension is rapidly rising in low and middle income countries. Detection of hypertension largely depends on screening of healthy individuals. Therefore, screening behaviour is very important in early diagnosis and treatment. Objectives: This study aimed at surveying the health beliefs with respect to hypertension screening, of a typical urban community in Chennai, south India and segmenting the population into clusters based on their health beliefs in order to effectively target behaviour change interventions. Methods: A cross sectional survey was conducted among 140 adult men and women selected by a multistage random sampling method in Chennai. A questionnaire to collect information on hypertension screening behaviours, health belief model domains such as perceived susceptibility, severity, benefits, barriers and cues to action was administered. Results: Factor analysis of the questions revealed the same five health belief domains with good factor loadings on each question. Based on their responses the participants were clustered into 6 groups by k means cluster analysis namely, (1) extrinsically motivated with perception of severity and (2) without, (3) intrinsically motivated with risk acceptance and (4) risk denial, (5) unfavourable health belief with negative attitudes focussing mainly on barriers and (6) overall apathy towards screening. Older age, male gender, married status and nuclear type of family were important factors positively influencing health beliefs regarding hypertension screening. Conclusions: The health belief model can be effectively used to segment the population into groups that are different by virtue of their motivation types and attitudes towards screening for hypertension. Key words: Health belief, Hypertension Screening, Screening behaviour.

Background: Leaving against medical advice (LAMA) is a common but undesirable clinical situation seen worldwide. We planned to determine the incidence and factors responsible of LAMA in the emergency and intensive care unit of our multidisciplinary tertiary care hospital. Methods: All consecutive patients who left against medical advice from the emergency and surgical intensive care units were included in the study. We prospectively collected data on patients demographic profile, diagnosis, duration of hospital stay, reasons for DAMA and socio-economic status using the Kuppuswamy’s Socio-Economic Status Scale (modified in 2014, Appendix1) to categorize the patient’s socio-economic status. Results: The rate of DAMA from emergency and ICU was 2.4% and 15%, respectively. The mean age of the study patients was 50.4 +17.39 years (range: 14-94 years)) with a male-to-female ratio of 2:1. In our study findings the major reasons to leave DAMA in decreasing order of frequency were lack of improvement in patient’s condition or terminal illness, financial constraints, attending to family matters, dis-satisfaction with treatment and tendency to seek alternative therapy. Dis-satisfaction with the management plan was more common in ICU than emergency (p=0.00001). About 40% of the DAMA patients from emergency were semi-skilled and unskilled workers with an average income of <10,000/month whereas the average monthly income of patients going DAMA from ICU was up to 40,000/month in all except 14.2% cases. In our study population, patients leaving the ICU were more educated (p=0.000007) and belonged to the upper socioeconomic status (p=0.46) as compared to those in emergency who mainly belonged to the upper lower class (p=0.0004). Conclusion: The number of people leaving AMA from the ICU is relatively high. To reduce LAMA rate, it is important to have a good knowledge of reasons for LAMA and understanding the problem in context to disease, outcome and socioeconomic status. Communication with the patient and family extensively with respect to all facets of care is the corner-stone to deal with this problem. Key words: Left against medical advice, Discharge against medical advice, Emergency, Intensive care unit. Key Message: The rate of patients leaving AMA is relatively higher from the ICU than the emergency department. The key solution to this problem is to understand the reasons for LAMA and have good communication with the patient and family in context to disease and outcome.

Background: Hypothyroidism (both subclinical and overt) is associated with increased cardiovascular morbidity. About 3% hypertensive patients found to have hypothyroidism during the routine investigations. Objectives: To assess the effect of thyroid hormone replacement on the level of blood pressure in the cases of newly diagnosed subclinical hypothyroidism. Methods: Patients above the a e of 15 years admitted to various wards (Indoor) or attending Endocrinology OPD at teriatary care health centre of north India were enrolled during the period of one year. The cases were divided into two groups, normotensive and hypertensive. Cases with subclinical hypothyroidism after evaluation were prescribed thyroxine replacement therapy to achieve euthyroid function. Each group followed periodically at 1 ½, 03 and 06 month with measurement of blood pressure and serum TSH, T3 and T4 level. Results: The prevalence of hypertension in cases of subclinical hypothyroidism in this study was 33.4 per 100 populations. There was no correlation between serum TSH level and blood pressure level in hypertensive group (p>0.05). In hypertensive group mean fall in blood pressure after thyroxine replacement therapy was systolic blood pressure 20.10±11.2 diastolic blood pressure 13.16±3.8 and in mean arterial pressure 15.2±4.7. With replacement of thyroxine hormone, the blood pressure was normalized in 47.4% (45 out of 95 cases) cases with elevated blood pressure. Conclusion: The effect of thyroxine replacement therapy in cases of hypertension with subclinical hypothyroidism on blood pressure was significant reduction in blood pressure after achieving normal thyroid function. Key words: Subclinical hypothyroidism, Hypertension, Thyroxine replacement.

Introduction: Empirical research reported that Janani Suraksha Yojana (JSY) accomplished the proximate target of increasing institutional delivery. However, discontents existed on the process and other outcomes of the scheme. Methods: To assess the implementation process of JSY in West Bengal, a cross-sectional study was conducted in six districts with population of 29.5 million covering 80 health sub-centers, 12 Primary health centers, 12 community health centers and six district hospitals. Data regarding barriers for utilization were collected through structured interview of the women who delivered within last 12 months. In-depth interviews of health personnel at different levels of government health system and review of relevant records were conducted to assess their awareness as well as flow of fund, record keeping and community-based monitoring of the scheme. Results: Almost universal awareness regarding benefits and conditionality of JSY among beneficiaries and health personnel, flexibility from health institutions for making the process of disbursement more users’ friendly, regular record keeping in cash books are the strengths of this scheme. Delay in disbursement and multiple visits from beneficiaries for receipt of incentive, almost no system of assessing the requirement of fund, inequitable distribution of fund, and diversion of fund from other head to meet the expenses of JSY, lack of community-level monitoring of the scheme might potentially affect the success of the scheme. Conclusion: Removal of procedural complexities for beneficiaries, smooth flow of fund based on actual need and community-level monitoring are a few challenges that are to be redressed urgently. Key words: JSY, Process, Assessment, Cash incentives, Pregnant women, India.

The study was done to find out the association between mid-upper arm circumference (MUAC) and body mass index (BMI) and to estimate the cut-off values of MUAC in elderly. Methods: A community-based cross-sectional study was done in a resettlement colony in Delhi. Persons aged 60 years and above were selected by cluster random sampling. House-to-house visits were made, and weight, arm span, mid-upper-arm circumference were measured. Mid-upper arm circumference and body mass index of participants are expressed as mean ± standard deviation (SD). Scatter diagrams and regression lines were plotted to study the relationships. Receiver operating characteristics (ROC) analysis was done and area under ROC curve was assessed. The sensitivity and specificity for different values of mid-upper arm circumference was calculated. Results: 711 elderly persons were recruited. Positive correlation was seen between BMI and MUAC in men and women (r=0.76), with 0.67 in men and 0.76 in women (p<0.001). Cut-off values for detecting undernutrition were explored by ROC. In men, 25.7 cm yielded sensitivity and specificity of 80.2% and 78.6% respectively, AUC (95%CI) was 0.85 (0.80, 0.90). In women, with a cut-off 24.3 cm both the sensitivity and specificity were 79%, AUC (95%CI) was 0.86(0.81, 0.91). Conclusion: The study authenticates that MUAC correlates positively and significantly with BMI. MUAC values of 25.7 cm in men and 24.3 cm in women are useful cut-off points for undernutrition, while 28.5 cm in men and 27.5 cm in women could be useful for overweight/obesity. Key words: Mid-upper arm circumference, Elderly, India, Nutritional status, Body mass index.

Introduction: Urinary tract infection (UTI) is one of the most common infections seen in the community. Knowledge of common uropathogen and their antimicrobial susceptibility is necessary for initiation of empirical therapy. This study aimed to determine the spectrum of organisms responsible for UTI and their antimicrobial susceptibility pattern in a Medical College Hospital situated in an Island in the Bay of Bengal. Material and Methods: Urine samples received in Microbiology Laboratory between April 2015 to March 2016 were processed according to standard guidelines. The antimicrobial susceptibility testing was performed by the Kirby-Bauer’s disc diffusion method and interpreted as per CLSI guidelines. Results: Total of 7850 urine samples were processed during the study period, 956 (12.18%) had significant bacterial growth, of which 65.27% belonged to women and 34.73% to men. Gram negative bacteria (GNB) were isolated in 74.79% followed by Gram Positive bacteria 20.40% and yeast 4.81% isolates. The commonest uropathogen was Escherichia coli (48.01%). The uropathogens were most resistant to Ampicillin (91.5%), while they were highly sensitive to Levofloxacin and Meropenem. The GPCs were most resistant to Penicillin (66.67%). Conclusion: Uropathogens were most commonly isolated in 15-30 years age group and the most common isolated microorganism was Escherichia coli. Regular prevalence studies on uropathogens is warranted to assess the trends of the ever changing scenario. Key words: UTI, Cystitis, Antimicrobial resistance.

Unsafe abortions continue to cause maternal morbidity and mortality in developing countries. Much of this is avoidable. Many factors are responsible for occurrence of unsafe abortions even in 21st century. To rectify the situation, we need to have a relook at the circumstances involved. Here we present a case who suffered catastrophic consequences due to her forced decision to undergo an abortion by an unqualified doctor. The lady first tried to get aborted from government health facilities. But due to various barriers, she had to contact an incompetent medical practitioner for termination of her pregnancy. This case also represents the diverse system-related obstacles which often deny the underprivileged sections of society from obtaining quality health care. Unless and until these barriers are removed, the practice of unsafe abortions would continue to plague the developing nations like India. Key words: Abortions, Barriers, Maternal mortality.

SGLT2 inhibitors are a new class of anti-diabetic drugs recently approved by the FDA which act by a novel beta cell independent mechanism. Acute pancreatitis is a very rare adverse effect of this group of drugs, with only three cases described so far in medical literature. Our case describes the occurrence of diabetic ketoacidosis precipitated by acute pancreatitis in a middle aged diabetic individual who was recently started on therapy with Dapagliflozin. Timely diagnosis and management lead to complete recovery of the condition with no residual disabilities. This highlights the importance of awareness of this rare adverse effect associated with SGLT2 inhibitors to facilitate prompt detection, management and preventing morbidity. Key words: Dapagliflozin, Acute pancreatitis, Diabetic ketoacidosis, Type 2 diabetes mellitus. Sodium-glucose co-transporter-2 (SGLT2) inhibitor,