A Retrospective Analysis of Integrative Group Medical Visits for Low-Income Patients With Anxiety Disorders in Primary Care

High utilization of the emergency department (ED) by patients with anxiety symptoms has brought attention to mental health access disparities among low-income racially/ethnically diverse populations. The health system in this study attempted to increase access to mental health care with integrative group medical visits (IGMVs), a nonpharmacological intervention with biomedical care consultation, health education, and peer support. The purpose of this retrospective comparative analysis, guided by integrative health equity in primary care framework, was to determine whether patients with diagnoses of anxiety who attended four or more IGMVs had reduced nonemergent ED utilization, reduced prescribed doses of benzodiazepine (BZD), and reduced severity of anxiety symptoms compared to usual care (no IGMV attendance). The 2017-2018 records of a sample of 85 patients (43 IGMVs, 42 usual care) with anxiety diagnoses were reviewed from one U.S. racially/ethnically diverse health system database. Nonemergent ED utilization, BZD use, and anxiety symptom severity data were analyzed using repeated-measures analysis of variance. Results demonstrated that the IGMV group had no statistically significant difference in ED utilization (p = 0.82), BZD use (p = 0.67), and anxiety symptom severity (p = 0.89) compared to usual care. Future research could focus on cost-effectiveness studies of allopathic versus nonallopathic practitioners facilitating IGMVs for integrated behavioral health in the primary care home for low-income diverse populations. This study contributes to social change by adding to the literature on the effect of IGMV access on behavioral health and health outcomes for racially/ethnically diverse low-income patients

Congenital cystic adenomatoid malformation (CCAM): antenatal and postnatal management

Background: Congenital cystic adenomatoid malformation (CCAM) is a rare abnormality of lung development. The estimated incidence ranges from 1: 10,000 to 1.35,000 live births. It is diagnosed by prenatal screening at 18-20 weeks of gestation. Surgical excision of symptomatic lesions is relatively straight forward, but management of asymptomatic lesions is controversial.Methods: Among women who delivered at St. Johns medical college and hospital, Bangalore between Jan 2011 to Dec 2016, those with the diagnosis of CCAM during anomaly scan were included in the study. Antenatal and Post-natal period and their outcomes were evaluated. Follow up was extend up to the childhood in the affected foetus.Results: There were 5 cases of CCAM in 13057 deliveries during 5-year study. Incidence was 1:2611. Mean gestational age at diagnosis was 21.6±2.5weeks. All foetus had CVR (CCAM volume) ratio more than 1.6 and there was no compromise on lung volume. Mean lung volume was 62.8±8.6 cc. and mean Apgar score at 1minute was 6.8±2.7 and at 5 minutes was 8.0±2.2. Among 5 foetuses, 2 foetuses had regression of cyst by birth and 3 underwent surgery for resection after birth.Conclusions: CCAM remains a challenge for obstetricians, neonatologists and paediatric surgeons. The combination of prenatal MRI and serial ultrasound studies optimize foetal surveillance and postnatal care. In asymptomatic CCAM, babies should be followed up to adolescence and adulthood, as they can manifest with malignant changes

Fertility preservation by conservative approach in a primiparous woman with placental adherence

Placenta accreta spectrum (PAS) describes a group of disorders in which all, or part of the placenta remains adherent to the uterine wall. Early identification of risk factors, accurate diagnosis and treatment in accordance with the resources available are essential and can help in reducing maternal morbidity and mortality. In the absence of risk factors, placental adherence is a rare entity, and conservative management becomes essential, especially in primiparous women to preserve future fertility. A primigravida in her late twenties presented in labour at 35 weeks of pregnancy to deliver a live baby of 2200 gm. The placenta did not separate with uterotonics and multiple attempts at manual removal of placenta under general anaesthesia. Medical management to conserve the uterus was decided, and two doses of methotrexate (50 mg) were given intramuscularly a week apart. Placental products were expelled after 2 months and the patient resumed her normal menses. She conceived spontaneously 8 months later. PAS is a possibility, though rare, in low-risk primigravidae and preparedness to confront such situations is of utmost importance. Intramuscular single dose or multiple dose methotrexate can be considered as a viable option in stable patients who wish to retain their fertility.

A CASE REPORT ON LUDWIG’S ANGINA: AN ENT EMERGENCY

Ludwig’s angina is defined as a rapidly progressive cellulitis of the floor of the mouth which involves both the submandibular and sublingual spaces of the face. The presented case was a 78-year-old female patient with a history of tooth extraction. Based on the clinical symptoms and computed tomography scan, the patient was diagnosed with Ludwig’s angina and was treated appropriately by antibiotics and steroids after emergency tracheostomy and airway management. Early diagnosis and proper management can limit the morbidity and mortality rate of Ludwig’s angin

Review of maternal mortality in a tertiary care urban teaching hospital: 10 year retrospective study

Background: The objectives of this study were to calculate the maternal mortality ratio, causes for maternal death in our institution and the duration of hospital admission to death interval.Methods: The study included collecting and analyzing the details of maternal death in women who were admitted to St. Johns Medical College Hospital, Bengaluru, from January 2007 to December 2016. Results: Total maternal deaths were 61 and live births were 26,001 during the study period. The maternal mortality ratio (MMR) was 234.6 per 100,000 live births. Majority of maternal deaths occurred in women aged 18 - 35 years 56 (91.80%) women, primipara 45 (73.77%) and referred cases to our institution from other hospitals 52 (85.24%).                      Most of the women died in the postnatal period 54 (88.52%). Direct obstetric causes accounted for 44 (72.13%) maternal deaths and indirect causes 17 (27.86%) deaths. Preeclampsia and eclampsia were the leading causes for death 13 (21.31%) followed by acute fatty liver of pregnancy 12 (19.67%), hemorrhage 7 (13.11%) and sepsis 6 (9.83%). Anemia was present in 77.04% of women at the time of admission to our hospital. Thirty six (59.01%) women died within a week of admission to the hospital, in which 13 (21.31%) women died in less than 24hours of admission. Twenty five (40.98%) women died after a week of admission to hospital.Conclusions: Apart from the triad of preeclampsia, obstetric haemorrhage and sepsis, acute fatty liver of pregnancy has emerged as an important cause of maternal death. Most of the maternal deaths are preventable. Early detection of complications and timely referral to tertiary care hospital in St. Johns Medical College Hospital, Bengaluru, Karnataka, India decreases maternal morbidity and mortality

Intractable hypoglycemia in pregnancy

Insulinomas are rare tumours developed from pancreatic beta cells; 27 cases of insulinoma associated with pregnancy have been reported till date, mostly diagnosed before the 16th week. Triad of insulinoma; hypoglycemic symptoms, plasma glucose < 3.0 mmol/L, symptomatic relief with glucose administration. 28-year-old primi presented to us at 29 weeks with high BP and neuroglycopenic symptoms. Repeated episodes of loss of consciousness with hypoglycemia since 14 weeks. On evaluation diagnosed to have insulinoma and managed conservatively with dietary modifications, and medical treatment. She failed to respond and pregnancy was terminated due to high BP, hypoglycemia and Doppler changes. Delivered a stillborn girl at 31 weeks. Underwent laparotomy post-delivery for enucleation of the lesion. Quick normalization of sugar levels and overall recovery remarkable. Patient is on regular follow up. Insulinoma is a rare cause of severe repeated episodes of hypoglycemia early in pregnancy

Estimation of protein requirements in Indian pregnant women using a whole-body potassium counter

Background: The 2007 World Health Organization/Food and Agriculture Organization/United Nations University (WHO/FAO/UNU) recommendation for the Estimated Average Requirement (EAR) of additional protein during pregnancy for a gestational weight gain (GWG) of 12 kg (recalculated from a GWG of 13.8 kg) is 6.7 and 21.7 g/d in the second and the third trimester, respectively. This EAR is based on measurements of potassium accretion in high-income country (HIC) pregnant women. It is not known if low- to middle-income country, but well-nourished, pregnant women have comparable requirements. Objective: We aimed to estimate total body potassium (TBK) accretion during pregnancy in Indian pregnant women, using a whole-body potassium counter (WBKC), to measure their additional protein EAR. Methods: Well-nourished pregnant women (20–40 y, n = 38, middle socioeconomic stratum) were recruited in the first trimester of pregnancy. Anthropometric, dietary, and physical activity measurements, and measurements of TBK using a WBKC, were performed at each trimester and at birth. Results: The mid-trimester weight gain was 2.7 kg and 8.0 kg in the second and the third trimester, respectively, for an average 37-wk GWG of 10.7 kg and a mean birth weight of 3.0 kg. Protein accretion was 2.7 and 5.7 g/d, for an EAR of 8.2 and 18.9 g/d in the second and the third trimester, respectively. The additional protein EAR, calculated for a GWG of 12 kg, was 9.1 and 21.2 g/d in the second and the third trimester, respectively. Conclusion: The additional protein requirements of well-nourished Indian pregnant women for a GWG of 12 kg in the second and third trimesters were similar to the recalculated 2007 WHO/FAO/UNU requirements for 12 kg

Sharing best practices through online communities of practice: a case study

<p>Abstract</p> <p>Introduction</p> <p>The USAID-funded Capacity Project established the Global Alliance for Pre-Service Education (GAPS) to provide an online forum to discuss issues related to teaching and acquiring competence in family planning, with a focus on developing countries' health related training institutions. The success of the Global Alliance for Nursing and Midwifery's ongoing web-based community of practice (CoP) provided a strong example of the successful use of this medium to reach many participants in a range of settings.</p> <p>Case description</p> <p>GAPS functioned as a moderated set of forums that were analyzed by a small group of experts in family planning and pre-service education from three organizations. The cost of the program included the effort provided by the moderators and the time to administer responses and conduct the analysis.</p> <p>Discussion and evaluation</p> <p>Family planning is still considered a minor topic in health related training institutions. Rather than focusing solely on family planning competencies, GAPS members suggested a focus on several professional competencies (e.g. communication, leadership, cultural sensitivity, teamwork and problem solving) that would enhance the resulting health care graduate's ability to operate in a complex health environment. Resources to support competency-based education in the academic setting must be sufficient and appropriately distributed. Where clinical competencies are incorporated into pre-service education, responsible faculty and preceptors must be clinically proficient. The interdisciplinary GAPS memberships allowed for a comparison and contrast of competencies, opportunities, promising practices, documents, lessons learned and key teaching strategies.</p> <p>Conclusions</p> <p>Online CoPs are a useful interface for connecting developing country experiences. From CoPs, we may uncover challenges and opportunities that are faced in the absorption of key public health competencies required for decreasing maternal mortality and morbidity. Use of the World Health Organization (WHO) Implementing Best Practices Knowledge Gateway, which requires only a low bandwidth connection, gave educators an opportunity to engage in the discussion even in the most Internet access-restricted places (e.g. Ethiopia). In order to sustain an online CoP, funds must come from an international organization (e.g. WHO regional office) or university that can program the costs long-term. Eventually, the long-term effectiveness and sustainability of GAPS rests on its transfer to the members themselves.</p