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Context: Antenatal care (ANC) effectively reduces infant and maternal mortality rates mainly by promoting institutional deliveries. In view of this, the Government of India introduced Janani Suraksha Yojna (JSY) in 2005 and Janani Shishu Suraksha Karyakram (JSSK) in 2011. Aims: To estimate the proportion of home and institutional deliveries in the district, assess the impact of JSK and JSSY on institutional deliveries, and identify the different intranatal care providers. Settings and Design: This cross-sectional study was conducted in the Gaya district, Bihar. A total of 657 females of the reproductive age group (15-49 years) were included in the study. Methods and Material: Predesigned, pre-tested & semi-structured questionnaire was used to collect information on place of delivery, type of delivery, knowledge regarding JSY and JSSK schemes and source of information. Statistical analysis used: Data was entered into excel sheets and analyzed using SPSS version 23 utilizing appropriate statistical methods. Results: Out of 519 deliveries, 63% were institutional and 37% were home deliveries. About 91 and 11.4% of respondents were aware of JSY and JSSK schemes. There was a significant association between those who opted for institutional delivery and awareness regarding JSY and JSSK services. Conclusion: Despite awareness and running of various government programs, the percentage of institutional deliveries is still less. An increase in institutional deliveries at primary care level through JSY and JSSK will not only decrease the out of pocket expenditure of the population but also help build faith in the government health facilities. [ABSTRACT FROM AUTHOR]

Background: Diabetes mellitus (DM) is one of the common causes of morbidity and mortality globally. It has also been associated with erectile dysfunction (ED) adding to poor quality of life. The present study aimed to determine the prevalence of ED and its predictors among diabetic men. Material and Methods: A hospital-based cross-sectional observational study was conducted at a tertiary care centre including 357 diabetic men recruited over one and half years. ED was identified using International Index of Erectile Function score and independent predictors were identified using multiple logistic regression analysis. Results: ED was found in 212 (59.38%) diabetic males. A strong negative correlation was found between potency score and age (r = −0.647), and a moderate negative correlation with duration of DM (r = −0.324), systolic blood pressure (SBP), and diastolic blood pressure. BMI, fasting blood sugar, serum cholesterol, and serum creatinine showed a weak negative correlation with potency score. Serum testosterone level showed a strong positive correlation with potency score. Age, SBP, duration of diabetes, fasting blood sugar, and serum-free testosterone (P < 0.05) were independent predictors of ED. Conclusion: Prevalence of ED is high in diabetic males. Better blood sugar control and blood pressure control could reduce sexual dysfunction in diabetic men and improve quality of life. [ABSTRACT FROM AUTHOR]

Background: Insulin resistance is an integral component of a multi-organ dysfunction syndrome (MODS) associated with increased mortality. We determined a cutoff value for the homeostatic model assessment of insulin resistance (HOMA-IR) during an ICU admission that could predict 28-day mortality of nondiabetic MODS patients. Materials and methods: In this prospective, outcome assessor blinded cohort design, we evaluated 82 such patients for fasting blood glucose (FBG)/insulin levels (FIL) during an ICU admission and followed their outcome for 28 days. The primary outcome variable was the HOMA-IR score calculated from the above variables. The statistical tool included receiver operating characteristic curve, Youden index, and correlation and regression analysis. Results: Overall, 38 patients succumbed to their illness. The optimal cutoff value for HOMA-IR was ≥1.61 (area under curve: 0.684, sensitivity: 36.8%, specificity: 95.5%). The 28-day survival was significantly lower (p = 0.001) at HOMA-IR threshold ≥1.61 (odds ratio: 12.25, hazard ratio: 2.98). The mean HOMA-IR among survivors vs nonsurvivors was 0.76 ± 0.61 and 1.38 ± 1.14, respectively (p = 0.004). Except for FIL and FBG, HOMA-IR values did not correlate with any other baseline or outcome parameters (demographics, APACHE II/sequential organ failure assessment score, vasopressor needs, or ICU/hospital stay). On comparing these parameters across the HOMA-IR threshold, only FIL and the hospital stay varied significantly. Most of the outcome parameters, however, varied significantly among nonsurvivors vs survivors. Conclusion: The HOMA-IR is a significant predictor of mortality in MODS. Its cutoff value may assist in determining a reference range for critically ill patients. Its routine use in the light of other disease severity scores may serve in their better prognostication. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the management methods of female urethral stricture (FUS) and analyze the outcomes of surgical treatments. A meta‐analysis was done in an attempt to identify the best approach of urethroplasty and the graft‐of‐choice. Materials and Methods: A systematic search of Pubmed/Medline and Embase databases was performed according to the Preferred Reporting Items For Systematic Review And Meta‐Analysis statement, for articles reporting on FUS management in the last decade. The Newcastle‐Ottawa scale was used to assess the quality of 28 included non‐randomized studies. The data on FUS management was summarized and pooled success rates (taken as symptom improvement and no need for further instrumentation) were compared. The secondary outcome was to establish a diagnostic modality of choice and define a "successful‐outcome" of repair. Results: The outcome was separately reported for 554 women undergoing surgical intervention for FUS in the literature. The criteria defining FUS were varied. A combination of tests was used for diagnosis as none was singularly conclusive. A total of 301 patients had previous urethral instrumentations. The pooled success rate of urethral dilatation (234 women) was 49% at a mean follow‐up of 32 months; flap urethroplasty (108 cases) was 92% at a mean follow‐up of 42 months; buccal mucosal graft (BMG) urethroplasty (133 cases) was 89% at a mean follow‐up of 19 months; vaginal graft augmentation (44 cases) was 87% at a mean follow‐up of 15 months; and labial graft reconstruction (19 cases) was 89% at a mean follow‐up of 18.4 months. The dorsal approach of graft augmentation met with 88% (95% confidence interval [CI] 0.79–0.95) success compared with 95% (95% CI 0.86–1) for the ventral approach. Conclusion: FUS is a rare condition requiring a meticulous diagnostic workup using multiple tests. All urethroplasties have shown better pooled success rates (86%–93%) compared with dilatation (49%). BMG is equally effective as vaginal graft urethroplasty. [ABSTRACT FROM AUTHOR]

Background: Globally, ocular morbidities are one of the most underdiagnosed, underreported, and undertreated public health concern. Among estimated 39 billion blind in world, India shares major proportions, with majority of them living in rural population. In India, religious festivals like Kumbh Mela that involve mass gatherings are mainly attended by middle and elderly population who are usually susceptible to various ocular diseases. Therefore, we analyzed the data of our eye camp to document pattern and magnitude of ocular morbidities among pilgrims attending a mega religious festive event. Methods: In a cross‑sectional, descriptive study, we included all those patients who participated in a mega eye camp “Netrakumbh” from January to March 2019 at Kumbh Mela, Prayagraj, India and were attended by voluntary ophthalmologist from All India Institute of Medical Sciences, Rishikesh. Presenting chief complaints and detailed history were collected from all participants. All patients underwent comprehensive eye examination including visual acuity, slit lamp biomicroscopic examination, tonometry, etc., Data were compiled and analyzed utilizing SPSS 22.0. Results: A total of 47142 eyes of 23571 persons of all age groups (range 5 years to 70 years) with approximate equal gender distribution attending the mega eye camp were examined. The most common ocular morbidity noticed after ocular examination was refractive error with underlying cause majorly as presbyopia, followed by cataract, after cataract, convergence insufficiency, lids, and adnexal disease, etc. Conclusions: This study highlights the changing pattern of common ocular morbidities presently among middle and elderly populations in developing countries like India. [ABSTRACT FROM AUTHOR]

Abstract: Background & Aims: Acute kidney injury is a frequent and ominous complication in cirrhosis. An episode of AKI damages the functional nephron mass, compromising the renal functional reserve. We aimed to study the incidence of AKI, probability of subsequent episodes, whether AKI itself predisposes to future AKI and the reliability of serum cystatin C(sCyC) as a biomarker in a prospective cohort of cirrhotics. Patients and Methods: Five hundred and thirty‐one cirrhotics without ongoing AKI were followed for development/resolution of AKI. Predictive models for AKI and mortality were developed and validated (Gr. A, Derivative cohort [n = 273], Gr. B, Validation Cohort [n = 258]). Results: 365 episodes of AKI occurred in 233 patients; yielding a mean of 1.56 episodes of AKI per patient. In Gr. A and B, 97 (35.5%) and 78 (30%) patients had prior AKI episodes and were predisposed to further attacks (Gr. A, HR 3.9, 95% CI 2.7‐5.6, Gr. B, HR 3.6, 95% CI 2.5‐5.4). AKI was thus an independent predictor of the development of new AKI(P < .05) and this risk increased significantly with increase in the number of AKI episodes (P < .001). S.CysC but not s.Cr was an independent predictor of new AKI on multivariate analysis. “AKI‐Score” incorporating CysC; and the addition of Cyst into components of MELD, that is the “MELD‐Cystatin” score predicted the development of AKI and mortality, respectively, and performed significantly better than the MELD and CTP scores. Conclusions: An episode of AKI itself predisposes to subsequent attacks of AKI in cirrhotics. Scores incorporating CysC can accurately predict the development of AKI and mortality in these patients. [ABSTRACT FROM AUTHOR]

Background & Aims The choice of vasopressor for treating cirrhosis with septic shock is unclear. While noradrenaline in general is the preferred vasopressor, terlipressin improves microcirculation in addition to vasopressor action in non-cirrhotics. We compared the efficacy and safety of noradrenaline and terlipressin in cirrhotics with septic shock. Patients and Methods Cirrhotics with septic shock underwent open label randomization to receive either terlipressin (n=42) or noradrenaline (n=42) infusion at a titrated dose. The primary outcome was mean arterial pressure ( MAP) >65 mm Hg at 48 h. Results Baseline characteristics were comparable between the terlipressin and noradrenaline groups. SBP and pneumonia were major sources of sepsis. A higher proportion of patients on terlipressin were able to achieve MAP >65 mm of Hg (92.9% vs 69.1% P=.005) at 48 h. Subsequent discontinuation of vasopressor after hemodynamic stability was better with terlipressin (33.3% vs 11.9%, P<.05). Terlipressin compared to noradrenaline prevented variceal bleed (0% vs 9.5%, P=.01) and improved survival at 48 h (95.2% vs 71.4%, P=.003). Percentage lactate clearance ( LC) is an independent predictor of survival [ P=.0001, HR=3.9 (95% CI: 1.85-8.22)] after achieving the target MAP.Therapy related adverse effect were comparable in both the arms (40.5% vs 21.4%, P=.06), mostly minor (Grade II-88%) and reversible. Conclusions Terlipressin is as effective as noradrenaline as a vasopressor in cirrhotics with septic shock and can serve as a useful drug. Terlipressin additionally provides early survival benefit and reduces the risk of variceal bleed. Lactate clearance is a better predictor of outcome even after achieving target MAP, suggesting the role of microcirculation in septic shock. [ABSTRACT FROM AUTHOR]

Background/Aims: Literature regarding safe doses of carvedilol is limited, and safe doses across different Child classes of chronic liver disease are not clear. Patients and Methods: A total of 102 consecutive cirrhotic patients with significant portal hypertension were included in this study. Hepatic venous pressure gradient was measured at baseline and 3 months after dose optimization. Results: A total of 102 patients (63 males, 39 females) with a mean age of 58.3 ± 6.6 years were included. Among these patients, 42.2% had Child Class A, 31.9% had Class B, and 26.6% had Child Class C liver disease. The mean baseline hepatic venous pressure gradient was 16.75 ± 2.12 mmHg, and after dose optimization and reassessment of hepatic venous pressure gradient at 3 months, the mean reduction in the hepatic venous pressure gradient was 5.5 ± 1.7 mmHg and 2.8 ± 1.6 mmHg among responders and nonresponders respectively. The mean dose of carvedilol was higher in nonresponders (19.2 ± 5.7 mg) than responders (18.75 ± 5.1 mg). However, this difference was not statistically significant (P > 0.05). The univariate analysis determined that the absence of adverse events, the absence of ascites, and low baseline cardiac output were significantly associated with chronic response, whereas, the etiology, Child class, variceal size (large vs small), and gender were not. On multivariate analysis, the absence of any adverse event was determined to be an independent predictor of chronic response (OR 11.3, 95% CI; 1.9-67.8). Conclusion: The proper optimization of the dose of carvedilol, when administered chronically, may enable carvedilol treatment to achieve a greater response with minimum side effects among different Child classes of liver disease. [ABSTRACT FROM AUTHOR]

Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized. [ABSTRACT FROM AUTHOR]

Background/Aims: Minimal hepatic encephalopathy (MHE) implies subtle impairment of cognitive functions in the absence of features of overt encephalopathy. We aimed to determine the prevalence of MHE in patients with liver cirrhosis and to find out the effect of rifaximin, probiotics, and l‑ornithine l‑aspartate (LOLA) individually in reversal of MHE by comparing it with placebo group. Patients and Methods: This study was carried out in two phases. Phase I included the recruitment of 250 apparently healthy controls and extraction of normative data utilizing three neuropsychometric tests (NPTs) and critical flicker frequency (CFF) test. Phase II consisted of screening and recruitment of patients of MHE followed by drugs trial. A total of 317 cirrhotics were screened; 111 were excluded and the remaining 206 cirrhotics were screened for MHE using NPTs and/ or CFF test. Of these, 124 patients with MHE were randomized to receive LOLA (n = 31), rifaximin (n = 31), probiotics (n = 32), for 2 months and were compared with patients who were given placebo (n = 30). Results: Out of 206 cirrhotics, 124 (60.19%) had MHE. Among these 124 MHE patients, 87 (70.16%) patients had CFF <39Hz, 112 (90.32%) patients with MHE had two or more abnormal NPTs, and 75 (60.48%) patients had abnormality on both the CFF values and more than two abnormal NPTs. Intention‑to‑treat analysis showed the number of patients who improved after giving treatment were 67.7% (21/31), 70.9% (22/31), 50% (16/32), and 30% (9/30) for LOLA, rifaximin, probiotics, and placebo, respectively. CFF scores and improvement in psychometric tests after treatment were significantly higher (P < 0.05) for LOLA, rifaximin, and probiotics as compared with placebo group. Conclusions: Prevalence of MHE is high in patients with cirrhosis of liver. Rifaximin, LOLA, and probiotics are better than giving placebo in patients with MHE. [ABSTRACT FROM AUTHOR]

Objectives: To study the difference in the prevalence of hypertension and associated risk factors in urban and rural populations and the association of hypertension with various determinants. Materials and Methods: A community-based cross-sectional study was conducted in 48 villages and 15 urban wards of Jabalpur District of Central India. Nine hundred and thirty-nine individuals aged 20 years and above (624 from rural areas and 315 from urban areas) were included in the study. The prevalence of hypertension and associated cardiovascular risk factors was assessed in the urban and rural populations. A pretested questionnaire was used to collect data on socio-demographic, behavioral, and dietary factors. Anthropometric measurements of weight, height, waist and hip circumference, and blood pressure measurements were taken using the standard methodology. The glucose oxidase-peroxidase and cholesterol oxidase-cholesterol peroxidase methods were used to measure plasma glucose and serum cholesterol, respectively. Bivariate analysis was followed by multivariate analysis to detect the odds of getting hypertension with various risk factors for the urban and rural populations separately. Hypertension was defined as per Joint National Committee (JNC) - VII criteria. Results: The response rate was 97%. Overall prevalence of hypertension was 17%, with 21.4% in the urban population and 14.8% in the rural population. Significantly higher mean values of weight, height, body mass index (BMI), hip circumference (HC), waist circumference (WC), waist hip ratio (WHR), systolic blood pressure (SBP), fasting blood sugar (FBS), and serum cholesterol levels were mapped in the urban population in comparison with the rural population. Multivariate logistic regression analysis identified increasing age, parental history of hypertension, tobacco smoking, tobacco chewing, physical inactivity, high estimated per capita salt consumption, and BMI ≥27.5 kg/ m2 as independent predictors for hypertension in the urban population, while in the rural population, increasing age, physical inactivity, central obesity, tobacco chewing and tobacco smoking were independent predictors for hypertension. Conclusion: The prevalence of hypertension and other cardiovascular risk factors was high in both urban and rural communities. Therefore, there is a need for comprehensive health promotion programs to encourage lifestyle modification. [ABSTRACT FROM AUTHOR]

Transarterial chemoembolization (TACE) is the most common locoregional therapy for hepatocellular carcinoma (HCC). Postembolization syndrome is not an uncommon complication. At present, there is no specific treatment for management of this complication. We aimed to study the role of N-acetyl cysteine (NAC), an antioxidant, in management of this complication. In a prospective observational study, consecutive patients with HCC undergoing TACE from January 2016 to January 2017 were included. Patients with postembolization syndrome, defined as an elevation of transaminase levels more than 3–4 times the upper limit of normal, were administered intravenous NAC for 72 h (150 mg/kg for 1 h, then 12.5 mg/kg/h for 4 h, and continuous infusion 6.25 mg/h for the remaining 67 h). The other group received only supportive standard of care. The primary end point was reduction in post-TACE transaminitis. Of 112 patients with HCC, 53 (47.3%) received NAC. The majority were cirrhotics in both the groups. Both groups were well matched in demographic, laboratory, and tumor characteristics. In the NAC group, there was significant reduction in Aspartate transaminase (AST) and Alanine transaminase (ALT) levels from day 1 to day 3 (p = 0.000) compared with the non-NAC group, with no significant change in bilirubin or international normalized ratio levels. The duration of hospital stay was similar in both the groups. None had any major adverse events to NAC. This is a prospective, single-center experience, showing that early initiation of N-acetyl cysteine in those with post-TACE embolization syndrome reduces the transaminase level significantly. [ABSTRACT FROM AUTHOR]

Background & objectives: Coagulation and haemostasis are dynamic processes. The haemostatic changes in liver disease affect all aspects of coagulation. The prothrombin time (PT)/ international normalized ratio (INR) was developed to monitor oral anticoagulant therapy and the activated partial thromboplastin time to investigate inheritable single factor deficiencies. Viscoelastic tests such as thromboelastogram (TEG) give information about dynamics of clot formation (coagulation factor and anticoagulant activity), clot strength (platelets and fibrinogen) and clot stability (finbrinolysis and factor XIII). Administration of blood products before invasive procedures is still guided by INR and platelet count in patients of liver disease. This study was aimed to evaluate the validity of TEG to predict post-procedural bleed after central venous cannulation in patients with cirrhosis. Methods: Ninety patients aged 20-70 yr diagnosed with liver cirrhosis requiring elective central venous catheter (CVC) insertion were studied. Platelet count, INR, serum creatinine, TEG and Child- Turcotte-Pugh (CTP) score were recorded before the procedure. Right-sided internal jugular vein was cannulated. On the basis of presence or absence of post-procedural bleed, patients were divided into bleeding and non-bleeding groups. The CTP score, component of TEG (R - reaction time, K - coagulation time, MA - maximum amplitude and α - angle) and laboratory parameters of both the groups were compared. Results: Bleeding was seen more when CTP scores were ⩾10 (P=0.05). The K time of 3.05 min or more on thromboelastograph was a significant predictor of bleeding [area under the curve (AUC) 0.694, P=0.047]. MA of 48.8 mm or more was a significant predictor of non-bleeding. INR ⩾2.6 was a significant predictor of bleeding (AUC 0.765, P=0.005). K time had a low-positive predictive value of 20 per cent and the positive and negative likelihood ratios of 1.87 and 0.48, respectively. Interpretation & conclusions: Our results show that the cut-off value for INR ⩾2.6 and K time ⩾3.05 min predict bleeding and MA ⩾48.8 mm predicts non-bleeding in patients with cirrhosis undergoing central venous pressure catheter cannulation. [ABSTRACT FROM AUTHOR]

Introduction:  Hypertension and diabetes were the two pertinent comorbidities of non-communicable disease which was most deadly affected during the COVID-19 pandemic, globally. Therefore, the present study was carried out to assess the progression of risk factors in patients with hypertension and diabetes, and behavioural risk factors during the COVID-19 pandemic., Material and Methods: A community-based longitudinal study was carried out for a period of one year in patients with pre-existing hypertension and diabetes in the field practise area of urban primary health centres (UPHC) in Rishikesh. The sample size is estimated to be 274, Only 100 study participants could be enrolled due to the COVID-19 pandemic. A convenience sampling method was used. Data were analysed using SPSS Version 23 (IBM Corp., Armonk, NY). Mean ± SD was calculated for continuous variables. The Chi-square test and the Fischer exact test were employed as appropriate to examine the association. To compare the means, the paired "T-test" was utilised., Result: Mean age of 100 study participants was 56 years ± 11SD. A significant difference (p=0.03) in random blood sugar and diastolic blood pressure was observed before and during the pandemic Proportion of tobacco users and alcoholics was 33% and 22%, respectively. The progression of hypertension and diabetes was reported to be significant among the participants with unhealthy diets and unhealthy lifestyles., Conclusion: COVID-19 pandemic poses an increase in risk factors like the adoption of unhealthy and sedentary lifestyles, tobacco, and alcohol consumption. All these factors were significantly (p=0.02) associated with the progression of diabetes and hypertension., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kumar et al.)

Competing Interests: There are no conflicts of interest.

Context: Control of COVID-19 has now become a critical issue for public health. Many ecological factors are proven to influence the transmission and survival of the virus. However, the association between different climatic factors and spread and mortality due to COVID-19 is unknown., Aim: To determine the association of different climatic factors with the spread and mortality due to COVID-19 during January 2020 to May 2020., Methods and Material: The climatic indicators included in the study were duration of sunshine, average minimum temperature, and average maximum temperature, with cumulative confirmed cases, deceased, and recovered cases. The data was performed for 138 different countries of the world, from January 2020 to May 2020., Statistical Analysis Used: Spearman's correlation analysis was used to assess the correlation between temperature and the spread and mortality of COVID-19 cases. Both univariate and multivariate analysis was performed for cumulative and month-wise analysis, using SPSS software., Results: Average maximum temperature and sunshine duration were significantly associated with COVID-19 confirmed cases, deceased, and recovered. For every 1° increase in average temperature, the confirmed, deceased, and recovered cases decreased by 2047 ( P = 0.03), 157 ( P = 0.016), and 743 ( P = 0.005) individuals. The association remained significant even after adjusting for environmental as well as non-environmental variables. Average sunshine duration was inversely correlated with an increase in daily new cases ( r = - 2261) and deaths ( r = - 0.2985)., Conclusion: Higher average temperature and longer sunshine duration are strongly associated with COVID-19 cases and deaths in 138 countries., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: Awareness about disease among tuberculosis (TB) patients plays a crucial role toward successfully achieving targets for control, prevention, and their relatives treatment adherence and is not well studied or documented. This study sought to explore the awareness and perceptions of TB patients in a tertiary care centre in northern India., Methods: This was an exploratory study conducted between January and December 2016 among 1,000 pulmonary TB patients and their relatives. Structured and validated interview schedule was used to assess participants knowledge and perception regarding TB, which comprised of 41 questions. Ethical clearance was taken and written informed consent was obtained from each study participants. Data analysis was done using SPSS 22.0 version., Results: A total of 1,000 study participants (mean age 40.2 ± 9.6 years, females 51%) were enrolled. More than two-third of the study participants were from Uttarakhand. Study participants had highest knowledge score (61.85%) regarding sign and symptoms, followed by scores in the aspect of prevention and treatment of TB (52.7%). However, a lower proportion (51.5%) knew about its causation. Overall knowledge score was 54.8%. Around half of the subjects (49.7%) disagreed that TB is a major health problem., Conclusions: Regardless of non-satisfactory knowledge of participants, their perception regarding TB was better. As to the associated factors, we found that participants' knowledge had significant association with religion, educational status, occupation, family income per month, type of family, and source of health information. Although there was insignificant difference between family monthly incomes, source of health information and perception regarding TB., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)