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  Citation statistics : Table of Contents
   2014| October-December  | Volume 1 | Issue 4  
    Online since October 16, 2014

 
 
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ORIGINAL ARTICLES
Prevalence of hypertension in type-2 diabetes mellitus
K Venugopal, MZ Mohammed
October-December 2014, 1(4):223-227
DOI:10.4103/2348-3334.142981  
Aims and Objectives: 1 To study the prevalence of hypertension in Type-2 diabetic patients. 2 To study the association with hypertension and diabetic complications. Materials and Methods: A total of 250 diabetic patients coming to Vijayanagara Institute of Medical Sciences Hospital and College, Bellary were studied and evaluated for blood pressure (BP), and macrovascular and microvascular complication. Study Design: A cross-sectional study. Sample Size: 250. Inclusion Criteria: All Type-2 diabetic patients who are on treatment for diabetes. Exclusion Criteria: a. Newly diagnosed diabetes, b. Seriously ill patients, c. Refused to be a part of the study, d. Pregnancy, e. Type-1 diabetes mellitus. Results and Conclusion: Prevalence of hypertension noted in 64 (25.6%) patients. BP was normal in 55 (22%), 131 (52.4%) patients were prehypertensive, 45 (18%) patients were in stage-1 hypertension, and 19 (7.6%) had stage-2 hypertension. Macrovascular complications noted in 120 (48%) and microvascular complications noted in 60 (24%) patients.
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Neonatal morbidity and mortality of sick newborns admitted in a teaching hospital of Uttarakhand
Ritu Rakholia, Vineeta Rawat, Mehar Bano, Gurpreet Singh
October-December 2014, 1(4):228-234
DOI:10.4103/2348-3334.142983  
Context: India accounts for 27.3% of total neonatal deaths in the world. This rate is highest in poor and marginalized areas like hilly regions of Uttarakhand that lack medical facilities. The newborns referred from here and admitted as outborn neonates contribute to the high neonatal mortality rate (NMR) of India. Aims : To study the demographic profile and morbidity-mortality pattern of neonates admitted in Sick Neonatal Care Unit (SNCU) and study the difference between inborn and outborn neonates. Study Design: Retrospective study of medical records for 1 year (2013-2014). Subjects and Methods: The age, sex, gestational age, and morbidity and mortality profile of all SNCU admissions in 1 year was determined, and the difference between inborn (those born in Teaching Hospital) and outborn (neonates delivered outside and referred) was calculated. Modifiable risk factors to reduce NMR in Uttarakhand were determined. Statistics: The data were analyzed using appropriate statistical tools in software Statistical Package for the Social Sciences (SPSS)-18. Results : Of the 721 neonates admitted, 63.25% neonates were males, and 53.54% were outborn and 46.46% inborn. Approximately, 60% were low birth weight and 50% preterm. Respiratory distress syndrome (RDS) (21.9%), sepsis (19%), perinatal asphyxia (16.37%), and jaundice (12.9%) were the chief morbidities. The chief causes of mortality were prematurity (25.6%), sepsis (21.6%), perinatal asphyxia (19.5%), and RDS (17.3%) with a statistically higher rate in the outborn in comparison with inborn. Total 20.5% neonates died due to poor outcome of outborn neonates. Conclusion: Huge burden of neonatal death among the outborn is due to preventable causes like asphyxia and infections in Uttarakhand. Health policies must ensure increased access to essential services to target sick neonates born here.
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A comparative study of pulse oximetry with the conventional pulp testing methods to assess vitality in immature and mature permanent maxillary incisors
Shini Susan Samuel, Abi M Thomas, Namita Singh
October-December 2014, 1(4):235-240
DOI:10.4103/2348-3334.142985  
Context: Subjective pulp tests are not reliable, particularly in children. It is important for dentists to understand the various pulp testing methods that are available in order to make an accurate diagnosis of the state of dental pulp in children. Aims: To assess pulp vitality and compare the reliability of pulse oximetry with the conventional pulp tests (electric pulp test and cold test) in immature and mature permanent maxillary incisors. Subjects and Methods: Sixty selected children aged 7-18 years with normal permanent maxillary central and lateral incisors were categorized into Group I (mature teeth) and Group II (immature teeth). Thirty endodontically treated permanent maxillary incisors were used as the negative control. Statistical Analysis Used: The sensitivity, specificity, positive predictive value, and negative predictive value were calculated and the results were analyzed. Results: The specificity for the pulse oximetry test, cold test, and electric pulp test in Group I (mature teeth) was 100%. The specificity for the pulse oximetry and cold test in Group II was 100% and 80% for electric pulp test. Conclusions: For an accurate pulpal diagnosis in children, one should not rely on one pulp test alone. In young children, pulse oximetry method was found to be as accurate as cold test but large variations were seen in electric pulp test.
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Lipid profile in subclinical hypothyroidism: A biochemical study from tertiary care hospital
Mounika Guntaka, Babulreddy Hanmayyagari, Manne Rosaline, V Nagesh
October-December 2014, 1(4):266-270
DOI:10.4103/2348-3334.143014  
Objective: To study lipid profile in patients of subclinical hypothyroidism and compare the same with matched controls. Materials and Methods: This single exposure observational study was conducted from June 2010 to March 2011 at our department of Biochemistry. Thirty patients with subclinical hypothyroidism were selected after careful exclusion; lipid profile was compared with matched controls. Statistical analysis was done with Student's t test. All values were expressed as mean ± SEM, where value of P ≤ 0.05 was considered statistically significant. Results: Between the two groups (group I - controls vs. group II - cases), the values were as follows: Mean serum total T 3 value was 115.03 ± 28.22 ng/dl vs. 107.13 ± 35.26 ng/dl (P = 0.3474); mean total T 4 was 7.0787 ± 1.6952 μg/dl vs. 6.8633 ± 1.3106 μg/dl (P = 0.532); mean TSH was 3.1730 ± 1.2772 μIU/ml vs. 9.7607 ± 4.1853 μIU/ml (P < 0.0001). Lipid profile pattern (group I vs. group II) was as follows: Mean total cholesterol (TC) 127.50 ± 7.18 mg/dl vs. 163.07 ± 41.32 mg/dl (P < 0.0001), mean triglycerides (TG) is 135.67 ± 13.84 mg/dl vs. 147.90 ± 66.27 mg/dl (P = 0.3231), low-density lipoprotein (LDL)-cholesterol is 61.17 ± 7.60 mg/dl vs. 99.83 ± 32.24 mg/dl (P < 0.0001), high-density lipoprotein (HDL)-cholesterol 39.13 ± 6.66 mg/dl vs. 35.27 ± 8.63 mg/dl (P = 0.0701), very low-density lipoprotein (VLDL) levels are 33.533 ± 14.375 mg/dl vs. 31.077 ± 14.202 mg/dl (P = 0.5235). Conclusion: Subclinical hypothyroidism is associated with increased serum total cholesterol and LDL-Cholesterol levels. Therefore, there is a potential association between Subclinical hypothyroidism and atherosclerosis.
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Vibrio isolates from cases of acute diarrhea and their antibiotic susceptibility pattern in a tertiary care hospital of Punjab
Atul Kumar, Aroma Oberoi
October-December 2014, 1(4):254-257
DOI:10.4103/2348-3334.142995  
Introduction: Vibrio cholerae, the cause of cholera, is one of the leading causes of morbidity and mortality in many developing countries. Especially during monsoon season, cholera outbreaks have been frequently reported from one or the other part of this country. However, occasional sporadic cases have also been reported, majorly due to lack of proper sanitation and impure water supply. Aim: To determine the prevalence of serotypes of Vibrio isolates from cases of acute diarrhea and their antibiotic susceptibility pattern in a tertiary care hospital, North India. Materials and Methods: A retrospective study was conducted over a period of 1 year from January 2013 to December 2013 in the department of microbiology, in a tertiary care hospital in Punjab. The diagnosis was suggested by the clinical picture and confirmed by stool culture. The stool samples received in the laboratory were processed by standard microbiological techniques for identification of V. cholerae. The suspected colonies of Vibrio were identified by standard biochemical tests and serotyping was done by group specific antisera. The susceptibility of all the isolated Vibrio species to different antibiotics were done by Kirby-Bauer's disk diffusion technique as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: V. cholerae were isolated from 41 (3.8%) of total 1063 stool samples received during the study period. On serotyping, 100% (41) of these positive samples were identified as V. cholerae 01 ogawa serotype. 95% (39) cases were encountered during monsoon season. In the present study analysis of the antibiotic susceptibility data showed highest susceptibility to gentamicin, amikacin, tetracycline and chloramphenicol. There is gradual increase in resistance to ampicillin and high level of resistance was observed for furazolidone and trimethoprim-sulphamethoxazole during the same period. Conclusions: Our study reveals a significant increase in cases of Vibrio infection during monsoon season, with V. cholerae 01ogawa as the predominant serotype. The results also suggest that this organism has begun to develop resistance against ampicillin, trimethoprim-sulphamethoxazole and furazolidone drugs and therefore these should not be used in the first line treatment.
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CASE REPORTS
Leiomyosarcoma of tongue
SV Dhanasekaran, Jiji Sanjeevan Nair, Mithun Eldhose Joyce
October-December 2014, 1(4):271-273
DOI:10.4103/2348-3334.143003  
Leiomyosarcoma is a malignant smooth muscle tumour. Oral leiomyosarcoma in particular of the tongue is extremely rare and poorly documented. We report a case of 38 year old woman with 1 year history of painless growing mass on the left hemi tongue with difficulty in swallowing diagnosed as Leiomyosarcoma tongue on histopathology. Surgical excision was done under general anesthesia. After 3 months of regular follow up and radiotherapy patient is doing fine without any recurrence or metastasis.
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An unusual case of altered sensorium in a young child: Datura poisoning
Bindu T Nair, RK Sanjeev, Sumit Lakhanpal
October-December 2014, 1(4):274-276
DOI:10.4103/2348-3334.143004  
Datura stramonium (DS) is a wildly growing plant which is widely distributed and easily accessible. It contains a variety of toxic anticholinergic alkaloids such as atropine, hyoscamine, and scopolamine. Voluntary or accidental ingestion can produce severe anticholinergic poisoning. We report an unusual case of DS intoxication occurring in a young child after accidental ingestion of the plant fruit. Our case is unusual because of the young age of the victim and the underlying inquisitiveness of children facilitating the occurrence of such poisoning.
  - 1,994 137
Pleomorphic adenoma of palate
Manisha Chauhan Solanki, Sumir Gandhi, George Koshy, Inderjot Singh
October-December 2014, 1(4):277-280
DOI:10.4103/2348-3334.143005  
A case of 55-year-old female has been presented, who reported to our centre with an unnoticed painless swelling in the posterior part of hard palate, which was interfering in posterior palatal seal formation during denture fabrication. This swelling was diagnosed as pleomorphic adenoma and complete surgical excision was done along with capsule.
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Incarcerated right inguinal hernia containing sigmoid colon: A rare case report
Amit Mahajan, Anil Luther
October-December 2014, 1(4):281-282
DOI:10.4103/2348-3334.143006  
Incarcerated inguinal hernia is a common diagnosis in patients presenting with a painful and non-reducible groin mass. Although the diagnosis is usually made by physical examination, the content of the hernia sac and the extent of the following operation may vary. The usual finding is a segment of small bowel and less commonly large bowel. However, an unusually large number of pathological processes have been recorded in literature, which also present in this manner. Except in sliding hernia, the sigmoid colon is uncommonly found in an inguinal hernia, especially on the right side. We present an extremely rare case of an incarcerated right inguinal hernia containing the sigmoid colon and review relevant literature.
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Stroke after cold bath
Paulin S Benedict, Jeyaraj Durai Pandian
October-December 2014, 1(4):283-285
DOI:10.4103/2348-3334.143007  
Seasonal variation in stroke occurrence is well described. However, correlation between sudden cold water exposure and stroke is not documented in literature. We report two cases of ischemic stroke on sudden cold water exposure. Case 1: A 73-year-old male developed sudden left face, arm and leg weakness immediately after taking a dip in the holy waters of Amritsar Golden Temple, during peak winter. Case 2: A 48-year-old male developed right side weakness and fell in bathroom while taking bath in cold water at 6am. Studies show that both stroke and atrial fibrillation peak in winter. Pathophysiologically, sudden cold water exposure increases sympathetic tone, which is mediated by thermo-receptors, activated by the rapid fall in skin temperature. Superimposed on the hyper-dynamic circulatory situation during short-term cold water immersion, it induces a further increase in blood pressure. Cold water immersion or simply an exposure might increase the propensity for stroke, especially in high risk individuals.
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LETTERS TO EDITOR
Terminology ambiguity related to calcifying cystic odontogenic tumor and need for its universalisation
Kanu Jain, Monica Mehendiratta, Shweta Rehani, Madhumani Kumra
October-December 2014, 1(4):293-294
DOI:10.4103/2348-3334.143010  
  - 1,756 130
Bilateral facial palsy in acute seroconversion illness: An uncommon scenario
Subrata Chakrabarti
October-December 2014, 1(4):295-296
DOI:10.4103/2348-3334.143011  
  - 1,096 107
Tobacco use and knowledge, attitude, and practice study
Kanica Kaushal
October-December 2014, 1(4):297-297
DOI:10.4103/2348-3334.143012  
  - 832 107
Tobacco use among teenagers in Ludhiana, Punjab, India: A survey of initiation, prevalence, knowledge and attitude
Ritu Jain
October-December 2014, 1(4):298-298
DOI:10.4103/2348-3334.143013  
  - 783 102
MISSION HOSPITAL SECTION
Approach to malaria in rural hospitals
Jency Maria Koshy, Jacob Koshy, Vineeth Jaison, Preethi Paul
October-December 2014, 1(4):286-290
DOI:10.4103/2348-3334.143008  
Malaria is one of the most common parasitic infections in the developing countries. In Rural India, most patients would be treated by primary and secondary care physicians. This article is aimed at providing a feasible approach to the cases of malaria in mission hospitals and other rural hospitals taking into account all the resource limitations. A study done over one year on patients detected to have malaria at Jiwan Jyoti Christian Hospital in Sonbhadra district has helped the authors to identify the various challenges faced by doctors working in the rural hospitals. The article has looked at the various complications associated with malaria and their management. It has also stressed upon the increasing incidence of chloroquine resistance.
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ORIGINAL ARTICLES
Quality of life among nurses working in different health care setting in the state of Karnataka, India
Pamila N R Jathanna, Jeal D'Silva
October-December 2014, 1(4):241-244
DOI:10.4103/2348-3334.142986  
Context: Nurses reactions on stressors can be physiological, psychological and behavioral leading to stress related to mental and physical diseases that decrease well-being, satisfaction and quality of life. Aim: To investigate the quality of life (QOL) among nurses working in different healthcare settings in hospitals of Karnataka State, India. Settings and Design: This is a cross-sectional study carried out in two regions of Karnataka State, India with a total sample size of 501. Subjects and Methods: WHO evaluation instrument on Quality of Life World Health Organization Quality of Life-Brief Version (WHOQOL-BREF) is the tool used for collecting and analysing data. It composed of four domains: Physical health, psychological health, social relationships and the environmental domain. Statistical Analysis Used: The mean score of items within each domain is used to calculate the domain score. Transformed scores were estimated using the tables for standardizing scores from 0-100. SPSS 16.0 Version is used for statistical analysis. Results: For overall physical health status of nurses was "ill" in both the hospitals (34%; 23%) with significance at 0.01 levels. The mean score for psychological domain was least (41.83). Overall perception of QOL result showed significance at 0.01 level for all domains except for psychological domain. Conclusions: Hospital authorities and health managers of any type of health care setting need to plan for enhancing better quality of life for nurses by planning for better working environment by providing facilities for coping mental demands, software systems and work-rest schedules to reduce the jobs physical demands. Thus, enhance QOL of nurses resulting in better healthcare services to the community.
  - 2,460 352
Prevalence of possible Alzheimer's disease in an urban elderly population of Ludhiana: A pilot study
Neena Bhatti, Paramita Sengupta, Anoop Ivan Benjamin
October-December 2014, 1(4):245-249
DOI:10.4103/2348-3334.142988  
Background : Dementias in the elderly, of which Alzheimer's disease (AD) is the most common form, may emerge as important public health problems in the elderly in low-resource developing countries whose populations are ageing rapidly. Aims: 1. To find out the prevalence of possible AD in the elderly population of an urban area of Ludhiana. 2. To identify major socio-demographic risk factors for "possible AD" in the population under study. Materials and Methods: A cross-sectional study was conducted on >60 year old residents of an urban area of Ludhiana. Data was collected from 200 consenting individuals chosen by simple random sampling, using a pre-tested questionnaire with standardized batteries, "10 Warning Signs of Alzheimer's Disease" to screen for possible AD, Everyday Abilities Scale for India (EASI) to assess physical impairment and the Hindi version of the Mini-Mental State Examination (MMSE) to assess cognitive impairment. The presence of >1 warning signs was considered as "possible AD", EASI score >3 as "functional impairment" and MMSE score <24 as "cognitive impairment". A respondent with "possible AD" as well as cognitive and functional impairment was labelled as "probable AD". Results: The prevalence of "possible AD" in the study population was 12.0% and "probable AD" 2.0%. Higher age (>80-years-old) was observed to be a significant risk factor for "possible AD" [odd ratio (OR) = 3.93, confidence interval (CI) = 1.10-13.26). Gender, educational status, marital status, family type, employment status, and addictions were not found to be statistically significant risk factors (P > 0.05). One-third of those with "possible AD" had "probable AD". Those with "possible AD" were at high risk of having functional impairment (OR = 17.10, 95%, CI = 5.00-58.46).
  - 1,691 135
Knowledge regarding palliative care amongst medical and dental postgraduate students of medical university in western Maharashtra, India
Purushottam A Giri, Deepak B Phalke
October-December 2014, 1(4):250-253
DOI:10.4103/2348-3334.142989  
Background: Palliative care is a relatively new field of medicine. The goal of palliative care is not to cure, but to provide comfort and maintain the highest possible quality of life for as long as life remains. However, there is a paucity of studies on knowledge among postgraduate students from medical and dental disciplines. Objectives: The present study was conducted to assess the knowledge about palliative care amongst postgraduate students of Medical University in Western Maharashtra. Materials and Methods: A cross-sectional study was conducted amongst a total of 178 postgraduate students which includes 112 medical and 66 dental disciplines of Medical University in Western Maharashtra during the period of June-August 2013. Data was analyzed in the form of percentage and proportions and Chi-square test was applied whenever necessary. Results: In the present study, 42.1% students didn't know the concept of 'autonomy' in palliative care, while 107 (60.1%) of students believed that most preferable route of administration in palliative care for treating chronic cases is oral. Among medical students 41.6% had shown overall good level of knowledge, while only 16.6% of dental students showed overall good level of knowledge. There was a significant difference found in the level of knowledge among the postgraduates between two disciplines. Conclusion: The study revealed the inadequacy in knowledge amongst postgraduate students of both disciplines; however knowledge level of dental was poor as compared to medical students. There is need to introduce palliative care in postgraduate curriculum of all health professional education.
  - 3,069 535
Th1/Th2 profile in patients suffering with osteoarthritis and rheumatoid arthritis: An analytical observational study
Yatendra Singh, Shadab Ahmad Khan, Mohammad Owais, Mazhar Abbas, Anjum Parvez, Athar Kamal
October-December 2014, 1(4):258-262
DOI:10.4103/2348-3334.142998  
Aims: To compare the cytokine (Th1/Th2) profile in serum as well as in synovial fluid of patients suffering with osteoarthritis (OA) and rheumatoid arthritis (RA). Settings and Design: Hospital-based analytical observational study. Materials and Methods: The present study comprised of 70 patients of arthritis, out of which, 40 patients were patients suffering from RA and 30 patients suffering from OA. Patients fulfilling the revised ARA Criteria for the Classification of Rheumatoid Arthritis are diagnosed as a case of RA and recruited for this study. Patients fulfilling the clinical and radiological features of osteoarthritis included in the study. Cytokine assay estimated using Western Blot (Immuno-blot transfer). Statistical Analysis Used: Analysis was performed using SPSS version 16.0 Statistical package for windows (SPSS, Chicago, IL). Results: Arthritis is commonly seen in females than males. Proinflammatory cytokines (IL-1, IL-2 and IFN-γ), anti-inflammatory cytokines (IL-4 and IL-10), regulatory cytokine (TGF-β) of blood as well as serum levels were raised in RA patients as compared with OA patients (P < 0.01). Tumor necrosis factor (TNF-α), an proinflammatory cytokine, levels were also raised significantly in OA. Conclusions: Our study shows that both Th1 and Th2 cells derived inflammatory markers as well as levels of IL-1 and TNF-α (both blood as well as synovial fluid) were significantly raised in RA as compared with OA patients. Thus, high levels of these substances have been found in inflammatory arthropathies, in particular in those characterized by a more aggressive and destructive outcome, such as RA.
  - 2,010 246
A morphometric study of measurements of heart in adults and its relation with age and height of the individual: A post-mortem study
Chandni Gupta, Vikram Palimar, Anshul Saxena, Antony Sylvan D'souza
October-December 2014, 1(4):263-265
DOI:10.4103/2348-3334.143000  
Objective: Reconstructive and replacement operations of diseased cardiac valves are commonly practiced these days. It may be noted that the choice of proper reconstructive intervention and prosthetic replacement might require the normal morphometric measurements of heart in relation with general body parameters, like age and height. So, this study was undertaken to measure various measurements of heart and its relation with age and height of the individual. Materials and Methods: Sixty five normal post-mortem hearts of adults were taken from the mortuary of Department of Forensic Medicine. Age of the individual was noted. Length of the deceased was measured with a measuring tape from the level of vertex to the outer border of heel. Length (from apex to base), breadth (at broadest diameter) and thickness of the heart were measured with slide callipers. Weight was measured with weighing machine. Results: The mean length, breadth, thickness of heart in males and females are 11.25, 8.78, 3.97 cm and 10.60, 8.31, 3.63 cm. The mean weight of heart in males and females was 323 and 276 gms. There was significant correlation with weight of individual and weight of heart in males. There was significant correlation with age of individual and length of heart in females. Conclusion: This study will be helpful for cardiothoracic surgeons while doing surgery on hearts.
  - 3,214 193
Clostridium difficile associated diarrhea - 'suspect, inspect, treat, and prevent'
Shivani Tyagi, Aroma Oberoi
October-December 2014, 1(4):219-222
DOI:10.4103/2348-3334.142980  
Context: Clostridium difficile is a fastidious, gram-positive, spore-forming bacterium responsible for infectious diarrhea and pseudomembranous colitis associated with significant morbidity and mortality. Only toxigenic strains produce disease in humans. Pathogenicity is dependent on the presence of diarrhea-producing toxins, named toxin A (TcdA) and toxin B (TcdB). Risk factors include depletion of protective gut flora by antibiotics and diminished immune response to C. difficile due to age and medical co morbidities; and increased use of proton-pump inhibitors (PPI). Treatment includes the stoppage of inciting antibiotics if possible, to allow regeneration of the normal gut microflora, and starting an antibiotic with activity against C. difficile. A good clinical suspicion in patient with co morbidities developing diarrhea during hospital stay can help reduce the burden of this treatable morbid infection. Our aim of doing this study was to determine the prevalence of this infection in our tertiary care hospital, so as to monitor its burden in future. Aims: To determine the prevalence of this infection in our tertiary care hospital. Settings and Design: A retrospective study was conducted in the department of Microbiology in a tertiary care hospital in North India. Materials and Methods: A total of 195 stool samples received over a period of 2 years were included in the study. An enzyme immunoassay was performed for the qualitative determination of toxins A and B from Clostridium difficile in stool samples. Results: A total of 13 (6.67%) stool samples out of 195 samples processed were positive for the presence of Clostridium difficile toxins A/B. Conclusions: CDI has become a global public health challenge today. Various studies show a prevalence rate between 11% - 22%. Lower prevalence rate revealed from our study (6.7%), makes it imperative to maintain a strict surveillance in our patients to ensure opportune detection and treatment
  - 2,052 3,390
SHORT COMMUNICATION
Feasibility of community diagnosis in ensuring prioritization of health concerns: Perspective of developing countries
Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy
October-December 2014, 1(4):291-292
DOI:10.4103/2348-3334.143009  
A community refers to a group of people who share the same stakes and concerns, the members of which knows and interact with each other. The process of diagnosing the health, health-related problems and their determinants, in a community is called community diagnosis, whose ultimate aim is to identify where the community is now?, where does it want to be?, and how it will get there? The principles of community diagnosis have been tried and found of extreme utility in developing countries where multiple health problems are prevalent, but only scarce resources are available. To conclude, the process of community diagnosis enables developing countries in reaching a consensus about the priority health problems in their individual communities and in developing strategies to address the identified issues.
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