Magnitude and pattern of multimorbidity among adult patients attending a primary care setting in Delhi, India

Background: Multimorbidity, “the coexistence of two or more chronic diseases”, is an upcoming & less addressed public health challenge for low and middle-income countries undergoing rapid demographic and epidemiological transition. This study was done to estimate the burden & pattern of multimorbidity in adults (?18 years) in a primary care setting. Methods: This cross-sectional study was carried out from January 2021 to March 2022 at a primary health centre in South Delhi. Data was collected by conducting exit interviews with 510 adult patients using a self-designed, pre-tested interview schedule. Data was analyzed using SPSS and Microsoft Excel. Results: Out of 510 study subjects interviewed, the overall magnitude of multimorbidity was 160 (31.4%). Almost half of the study subjects with multimorbidity had dyads, one-third had triads, and the rest had quadrads multimorbidity patterns. The leading triad was diabetes mellitus+hypertension+heart disease (12.3%), followed by diabetes mellitus+hypertension+chronic lung disease (10.5%). More than half of the study subjects with multimorbidity, 89 (55.6%), suffered from concordant MM. Conclusions: The study revealed that 31.4% of subjects had multimorbidity, which was almost equally distributed across the age groups. The burden was significantly higher among those aged 18-39 years. Hypertension and Heart disease were found to be the most frequent and the most concordant multimorbidity, respectively, associated with Diabetes mellitus.

Association between waiting time, service time and patient satisfaction in the out-patient department of a tertiary care hospital in Maharashtra

Background: Quality patient care is controlled by various factors - degree of fulfilment of patients' needs being one of them. Lesser waiting times, empathetic doctors and availability of medications yield more satisfied patients. Methods: A descriptive cross-sectional study was carried out among 80 patients attending the OPD of a tertiary care hospital from 9 am to 1 pm, Monday to Saturday from 8th February 2021 to 8th April 2021. Consenting patients were shadowed and observed until they completed their visit. Actual waiting time, consultation time and overall visit duration were calculated. An exit interview was conducted to assess satisfaction with waiting time, infrastructure and doctor-patient interaction. Results: The mean waiting time in one visit was 59.025±39.497 minutes. The mean consultation time with the doctor was 6.925±7.688 minutes. Statistical analysis showed that patients with lesser waiting time were significantly more satisfied with hospital services (p=0.004). Domains of dissatisfaction were waiting time at the registration desk, outside the OPD, seating arrangement, cleanliness and availability of medications. Doctor-patient interaction and consultation time were rated highly. Conclusions: The results showed that significant changes are required in the queueing system and hospital infrastructure. The positive response received in case of doctor-patient interaction is a step in the right direction. Regular surveys can help us rectify oversights in the present healthcare system.

Parent and school modelling factors associated with physical activity practices among adolescents of Devchuli municipality

Background: Regular physical activity helps children and adolescents to remain healthy and fit, improve muscular and cardiorespiratory fitness, have psycho-social benefits. The Global School Based Student Health Survey of Nepal 2015 shows that only 15.1% of adolescents of age 13-17 years were physically active daily. Identification of these factors that affects level of physical activity among adolescents of Nepal and its better understanding will aid in promoting physically active lifestyle and designing effective interventions. Methods: The cross sectional study was conducted to determine the factors associated with physical activity among adolescents of 15 to 19 years in Devchuli Municipality. Physical activity level of adolescents were measured along with parental and school/teacher modelling variables. Results: The study shows that most of the participants (68.8%) had moderate level of physical activity while 28.8% of participants were doing high level of physical activity. Only 7% of females were doing high level of physical activities compared to 53% males doing the high level of physical activities. The result showed that male participants were more likely to do high level of physical activity (AOR=16, 95% CI=7.3-33.7) than female participants. Similarly, the participants from other than Hindu religion (which consists Buddhist and Christian) were more likely to do high level of physical activity (AOR=6.5, 95% CI=1.8-23.5) than the participants from Hindu religion. Conclusions: The study showed that male participants and the participants from other than Hindu religion (which consists Buddhist and Christian) were more likely to do high level of physical than their counterparts.

Evaluation of the perception towards different types of teaching among medical college students and staff during COVID-19 pandemic

Background: In early 2020, a global pandemic (COVID-19) broke out and severely affected the progress of education in various universities and institutions, which promoted the progress of online courses at the same time. Aims and Objectives: To evaluate the perception toward online live teaching and traditional off-line teaching among medical college students and staff during the COVID pandemic. Materials and Methods: Cross-sectional questionnaire-based survey among teachers and students was conducted at Subbaiah institute of medical sciences, Shivamogga between January and July 2021. This study was designed mainly to collect information on socio-demographic factors and participants’ perception at a given point in time to toward online and offline teaching during lockdown. Results: A total of 27.7% of study participants had experienced COVID. Preferred mode of teaching during post-COVID phase on statistical analysis revealed that every strata of study population felt that offline classes are much better than online classes across multiple variables. Gender comparison across online and offline showed statistically significant results with P ? 0.05. Among COVID experienced individuals more than 80% felt that offline teaching was better than online in terms of better doubt clearance and P-value found to be statistically significant. Conclusion: The findings of this study indicated that the majority of the participants didn’t show a positive attitude towards online learning and preferred well-structured traditional classes over online learning.

Expanding healthcare coverage: An experience from Rashtriya Swasthya Bima Yojna

Background & objective: Given that Ayushman Bharat Yojna was launched in 2018 in India, analysis of Rashtriya Swasthya Bima Yojna (RSBY) become relevant. The objective of this study was to examine the scheme design and the incentive structure under RSBY. Methods: The study was conducted in the districts of Patiala and Yamunanagar in the States of Punjab and Haryana, respectively (2011-2013). The mixed method study involved review of key documents; 20 in-depth interviews of key stakeholders; 399 exit interviews of RSBY and non-RSBY beneficiaries in Patiala and 353 in Yamunanagar from 12 selected RSBY empanelled hospitals; and analysis of secondary databases from State nodal agencies and district medical officers. Results: Insurance companies had considerable implementation responsibilities which led to conflict of interest in enrolment and empanelment. Enrolment was 15 per cent in Patiala and 42 per cent in Yamunanagar. Empanelment of health facilities was 17 (15%) in Patiala and 37 (30%) in Yamunanagar. Private-empanelled facilities were geographically clustered in the urban parts of the sub-districts. Monitoring was weak and led to breach of contracts. RSBY beneficiaries incurred out-of-pocket (OOP) expenditures (?5748); however, it was lower than that for non-RSBY (?10667). The scheme had in-built incentives for Centre, State, insurance companies and health providers (both public and private). There were no incentives for health staff for additional RSBY activities. Interpretation & conclusions: RSBY has in-built incentives for all stakeholders. Some of the gaps identified in the scheme design pertained to poor enrolment practices, distribution of roles and responsibilities, fixed package rates, weak monitoring and supervision, and incurring OOP expenditure.

Cholesteatoma in a rural setting The Nizamabad experience

Cholesteatoma is a disease of the middle ear characterized by the presence of squamous epithelium in the middle earcleft. By secreting chemical enzymes, it causes manifestations by bone erosion which is dangerous to the surrounding structures which are intracranial and extra cranial. Due to advent of antibiotics and early diagnosis of ear disease, cholesteatoma is becoming infrequent. Previously commonly seen complications of cholesteatoma like mastoid abscess, automastoidectomy and sigmoid sinus abscess and granulations are rarely seen nowadays.A retrospective study ofcases of ear discharge with cholesteatoma presented to Government Medical College/Government General Hospital, Nizamabad, Telangana, during the period of May 2013 to June 2015 was done. The experience was being presented in this study.42 cases of cholesteatoma presenting with these features we re recorded. Chronicity of the disease with varied presentations seen rarely and the prevalence of the disease in poor socioeconomic families who had no access to medical facilities and ignorance of the severity of the disease is the main factor for seeing the rare presentations not seen in other centres. Inaccessibility to medical facilities and lack of expert treatment was the reason for patients seeking medical attention with conditions due to chronicity which are rarely seen nowadays.

Nasal Endoscopic Dacryocystorhinostomy The Nizamabad experience.

Chronic dacryocystitis results very often from obstruction to the nasolacrimal duct. It manifests as epiphora or watering of the eyes. The lacrimal sac gets expanded and also the wall of the sac gets thickened as a result of collection of mucopus due to obstruction of the nasolacrimal duct. Treatment of chronic dacryocystitis is by a surgical approach which consists of making an opening between the lacrimal sac and the nasal cavity above the obstruction. This operation is called dacryocystorhinostomy which can be done by external approach or nasal endoscopic approach. The intranasal or nasal endoscopic approach is the more functional route of surgery because it preserves the lacrimal apparatus as near normal as possible. Hence this surgery is being advocated as the first line of treatment for epiphora of chronic dacryocystitis. Experience of nasal endoscopic dacryocystorhinostomy done at Government Medical College, Government General Hospital, Nizamabad, Telangana is being reported with comparison of results published in literature.

A study of prevalence of worm infestation and associated risk factors among the school children of Dharan, Eastern Region of Nepal.

Background: Worm infestation has remained major zoonotic diseases in Nepal especially among children. Objectives: To measure the prevalence of worm infestation and to identify risk factors associated with worm infestation among the school children of Dharan. Material and Methods: A cross sectional study was conducted among school children of Dharan. Stratified random sampling method was applied to choose the schools and the study subjects. The Chi-square test was used to measure the association of risk factors and worm infestation. Results: Overall prevalence of worm infestation among the school children was 11.3 percent. Taenia species was found very high (5.3%) in comparison to other worms i.e. Hookworm (2%), Ascaris lumbricoides (1.9%), Trichuris trichiura (1%), Hymenolepsis nana (0.7%) and Enterobius vermicularis (0.3%). No significant relationship was traced among the factors in the causation of worm infestation although slight indications present. Conclusions: Overall prevalence of worm infestation among the school children has remained high.

Unusual cause of unilateral epistaxis: nasal leech infestation.

Common causes for unilateral nasal bleeding in adults are benign or malignant tumors and deviated nasal septum. Here we present two cases of recurrent unilateral nasal bleeding due to leech infestation. Though it is not a common cause for nasal bleeding, a clinician should suspect leech infestation for a recurrent nasal bleeding specially in tropical countries like Nepal.

Characterization and susceptibility patterns of clinically important Enterococcus species in eastern Nepal.

Life threatening infections caused by enterococcus species with multidrug resistance has emerged as a threat to medical care in the present era. This study was conducted to characterize enterococcus species isolated from different clinical samples and to detect the pattern of susceptibility to some of the commonly used antibiotics in B.P Koirala Institute of Health Sciences (BPKIHS), a tertiary care hospital in eastern Nepal. Clinical samples submitted to the microbiology unit of Central Laboratory Service (CLS) for culture and sensitivity during March 2002 - February 2003 was analyzed. Enterococcus species were identified by colony characteristics, gram staining and relevant biochemical tests. Antibiotic susceptibility test was done by the Kirby Bauer disc diffusion technique. Of 50 Enterococcus species isolated, E. faecalis was the predominant isolate (48.0%) followed by E. faecium (32.0%) and E. avium (20.0%). Eighty-eight percent of E. faecalis showed sensitivity to cephotaxime and 87.0% to vancomycin. Multiple drug resistance was observed most commonly in E. faecium. Seventeen percent of E. faecium were resistant to vancomycin and 63.0% to ciprofloxacin and 44.0% to ampicillin. On the contrary E. avium rarely showed resistance to the antimicrobials tested including vancomycin. Enterococcal infections are common nowadays specially in hospitalized patients. Inappropriate use of antibiotics in clinical practice and poultry should be discouraged to prevent the emergence of multidrug resistant species.

Intestinal trematode infection in North Bihar.

Reports of intestinal trematode infections are not common from Bihar, India. However, we herewith report one case of fasciolopsiasis from North Bihar, India. A 14 years old girl presented with diarrhea, vomiting, generalized pain abdomen and loss of weight. Routine stool examination and upper gastrointestinal endoscopy revealed fasciolopsis buski in large numbers. Her rural life style and food habit (ingestion of raw vegetables- caltrops and water chest nuts) supported the cause of infestation. Despite treatment with praziquantel, the patient died after two days. Mild infestations of Fasciolopsis buski may pass on unnoticed. However, heavy infestations may cause considerable prostration, illness and even death in younger age groups. Awareness regarding this parasitic infestation (endemic in some regions), especially in the rural set up is still a much needed entity.

Brain abscess due to Scedosporium apiospermum in a non immunocompromised child.

Scedosporium apiospermum is a filamentous fungi that commonly causes cutaneous infection. In certain circumstances, S. apiospermum can also cause invasive disease, which can involve the central nervous system (CNS). When the CNS becomes involved, treatment is difficult, therapeutic options are limited and the prognosis is poor. Early identification and treatment can decrease the mortality rate. Here we present a case of brain abscess with chronic suppurative otitis media, caused by S. apiospermum. This is the first such case report from Nepal. We could identify the organism only post mortem. We could not save the patient, probably due to delay in diagnosis.

Anaesthesia-related maternal mortality.

Complications of anaesthesia leading to death in young pregnant women might be prevented if more experienced personnel could be entrusted with the job. The contribution of anaesthesia to maternal mortality in the United Kingdom is 1.7 per million pregnancies with almost similar incidence from United States. The commonest single factor responsible for anaesthesia-related death is difficult or failed intubation. A pregnant woman with a potentially difficult airway should receive aspiration prophylaxis (mechanical or pharmacological) as soon as operative delivery is anticipated. Anaesthetists should make a plan that comes into effect as soon as failure to view the larynx or to intubate the trachea becomes evident. Unsuspected difficult airway can be managed if the skill of the anaesthetists is of high standard. Pulmonary aspiration is one cause of death in obstetric anaesthesia. Regurgitation and vomiting prevention can minimise pulmonary aspiration. In regional anaesthesia, local anaesthetics toxicity is another cause of concern. This should be tackled with some safe local anaesthetics. Preventing a high spinal or epidural block involves ways to detect inadvertent injection of local anaesthetic into the cerebrospinal fluid. Postoperative care after anaesthesia in obstetric cases is very important.

Precontrol observations on lymphatic filariasis & geo-helminthiases in two coastal districts of rural Orrisa.

BACKGROUND & OBJECTIVE: Lymphatic filariasis (LF) is a major public health problem in India, accounting for 40 per cent of the global burden. The World Health Organization has launched a global programme to eliminate LF by 2020 and India is a signatory to it. Orissa, an eastern Indian State has long been known to be endemic for LF. Prior to implementation of mass drug administration programme it is important to collect baseline data on filariasis and geo-helminthiases in the State. The present cross-sectional survey was therefore carried out between February and December 2001 to obtain baseline information on both LF and geo-helminthiases before application of the control measures. METHODS: The study was carried out in rural areas of Puri and Ganjam districts in two phases. In phase I, the distribution of microfilaraemia in two district was mapped out in randomly selected primary health centres (PHCs), and 12 microfilaraemic villages were identified in each district by cluster analysis for the phase II study. In phase II, detailed clinical and parasitological survey for LF and geo-helminthiases was carried out following the standard procedures. RESULTS: Wuchereria bancrofti was found to be widely prevalent in Puri district with certain pockets of Brugia malayi while W. bancrofti was the only species in Ganjam district. The microfilaraemia (Mf) rate was found to be 9.5 and 11.1 per cent; and circulating filarial antigenaemia (CFA) was 16.8 and 17.8 per cent in Puri and Ganjam respectively. The geometric mean intensity (GMI) of Mf per ml of blood among positive individuals was 387 in Puri and 454 in Ganjam. The overall disease rate in Puri was 7.9 and 8.9 per cent in Ganjam. The prevalence of chronic manifestations was found to be significantly higher (P<0.001) than the acute manifestations in both the districts. The prevalence of geo-helminthiases was 31.8 per cent in Puri and 42.1 per cent in Ganjam; and the heavy infection was found to be significantly higher (P<0.001) in Ganjam compared to Puri district. INTERPRETATION & CONCLUSION: The present study identified LF and geo-helminthiases as widely distributed health problem in rural areas of coastal Orissa which warrants intervention measures along the lines recommended by the global programme for elimination of LF and geo-helminthiases to reduce the disease burden.

Drug abusers - A new high risk population for HIV infection in Orissa.

The present study reports the prevalence of HIV infection among the drug addicts undergoing counselling and treatment in a drug deaddiction centre located in Bhubaneswar, during July 1996 to August 1997. All subjects were males. The coded serum samples were tested by ELISA and rapid spot test for the detection of HIV antibodies. The positive samples were finally confirmed by the line immunoassay for HIV infection. A high prevalence of 7% HIV infection was noticed among the drug addicts (n=100). Oral drug abusers and IDUs were positive for HIV-1 infection in 5.26% and 21.74% cases respectively. The present study reveals a high prevalence of HIV infection among the drug addicts for the first time from Orissa which needs a careful monitoring and surveillance.

Recurrent pyogenic cholangitis.

A 26-year-old male presented with jaundice and recurrent cholangitis. Ultrasonography revealed dilated intra- and extrahepatic biliary tree packed with multiple calculi. Endoscopic retrograde cholangiopancreatography and computerised tomography scan confirmed the findings and a diagnosis of recurrent pyogenic cholangitis was made. Cholecystectomy, choledocholithotomy with removal of stones and Roux-en-Y choledochojejunostomy were performed.

An alternative approach for screening active bam HI variants: overexpression in T-7 RNA polymerase based system.

The type II restriction endonuclease, Bam HI, has been overexpressed in E. coli by cloning the Bam HI gene in frame with an E. coli Ribosome Binding Site (RBS) under the T7 promoter of an E. coli expression vector pRSET A. The expression level of Bam HI endonuclease using this construct was found to be higher than that reported of the overexpressing clone pAEK14. Our overexpressing clone, pAABRw in BL21 cells in presence of Bam HI methylase in pMAP6 following induction with IPTG yields about 9.2 x 10(6) units per gram wet cell paste. In vivo activity of the recombinant endonuclease could be confirmed by the SOS induction assay in JH139 cells even in the absence of T7 polymerase and cognate Bam HI methylase because of leaky expression in E. coli. This provides an alternate way to screen the active endonuclease and its variants.

A clinico-epidemiological perspective of lymphatic filariasis in Satyabadi block of Puri district, Orissa.

BACKGROUND & OBJECTIVES: Lymphatic filariasis is a major public health problem in the coastal district of Orissa. However, no systematic studies have been done to document the prevalence of microfilaraemia/disease in different regions of the State. Therefore, the present cross sectional study was undertaken during 1996-97 to obtain information on the clinical and epidemiological status of the disease in Satyabadi block area of Puri district, known to be endemic for filariasis. METHODS: Night blood smear survey and clinical examinations were performed on 4646 individuals aged 0-> or = 60 yr from systematically selected households of 17 randomly selected villages of the Block. Microfilaraemia was detected by thick drop technique using 20 microliters of peripheral blood and microfilariae (mf) density by nucleopore filtration technique collected during 1900-2300 h. RESULTS: The prevalence of microfilaraemia was observed to be 14.8 per cent; 13.3 per cent Wuchereria bancrofti, 1.4 per cent Brugia malayi and 0.09 per cent had mixed infections. Geometric mean microfilaraemia density (infected persons only) was found to be 1288 per ml in case of W. bancrofti and 204 per ml in case of B. malayi. The disease rate was observed to be 19.8 per cent; 12.85 per cent had acute manifestations and 6.97 per cent had chronic manifestations. INTERPRETATION & CONCLUSION: The rate of acute disease manifestations was observed to be significantly higher (P < 0.001) than chronic manifestations. There was a male preponderence among the affected individuals (P < 0.001). The interesting observations of the study were the occurrence of occult filarial manifestations viz., tropical pulmonary eosinophilia (TPE) in 0.47 per cent cases and other associated manifestations like asymptomatic microscopic haematuria, monoarticular arthritis and filarial associated respiratory diseases in 0.50, 0.24 and 0.19 per cent of cases respectively. The present study indicates that the area is highly endemic for lymphatic filariasis with active transmission.

Lymphatic filariasis in Khurda district of Orissa, India: an epidemiological study.

A cross-sectional survey was undertaken to determine the prevalence of disease due to lymphatic filariasis in Khurda district of Orissa, India. The total disease attributable to filariasis was significantly higher in males (14.79%) than females (10.04%). However, elephantiasis is more prevalent in females, and adenolymphangitis is more prevalent in males than their counterparts. The prevalences of various forms of the disease are age dependent in both sexes. About one-seventh of men and women of higher age groups suffered from chronic debilitation forms of the disease. The study suggests that overt clinical forms of lymphatic filariasis constitute a major public health problem in the study area.

Treatment of chronic anal fissure with topical glyceryl trinitrate: a double-blind, placebo-controlled trial.

BACKGROUND: Topical glyceryl trinitrate (GTN) may produce healing of anal fissure by decreasing the high resting anal sphincter pressure in these patients. The present study assessed the efficacy of GTN in chronic anal fissure in a double-blind placebo-controlled trial. METHOD: Patients with chronic anal fissure (for more than 8 weeks) underwent measurement of maximum anal resting pressure (MARP) before and 12 minutes after application of either 0.2% GTN or placebo ointment in a randomized manner. They then received twice-daily local application of their respective ointment for 6 weeks. Symptoms and healing of fissure were assessed; patients were evaluated at 3 months for evidence of relapse. RESULTS: 19 adult patients (12 men) were studied; 10 received GTN and 9 placebo. Mean (SD) MARP decreased from 131.0 (32.3) cm H2O to 93.5 (28.4) cm H2O (p<0.05) with GTN and from 150.5 (36.9) cm H2O to 142.8 (35.0) cm H2O (p=ns) with placebo. Fissure healed in 7 of 10 patients treated with GTN and 2 of 9 patients treated with placebo (p<0.05). There was no relapse of fissure in either group. CONCLUSION: Local application of GTN was effective in healing chronic anal fissure.