Background: Approximately 16 million adolescent girls aged 15–19 years and 2 million adolescents under the age of 15 years give birth annually in the world. In Africa, where premarital sex is not accepted, especially for young women, unintended pregnancies mostly happen outside marriage. Recent data indicate that 18% of adolescent girls aged 15–19 years in eastern/southern region of Africa and 21% in western/central region of Africa had initiated childbearing. Teenage pregnancy and parenting remain important public health issues that deserve continued attention. The specific factors and beliefs that lead to contraceptive nonuse remain obscure, and up-to-date, evidence-based data on personal and environmental determinants of teenage pregnancy and case–control studies also are lacking in Ethiopia. Therefore, this study aimed to identify the determinants of teenage pregnancy to help policymakers, program managers, and health-care authorities with better decision-making in planning and problem-solving in Ethiopia. Methods: A case–control study was conducted using data set obtained from 2016 Ethiopia Demographic and Health Survey conducted throughout the country from January 18, 2016, to June 27, 2016. All teenagers who had a pregnancy history were enrolled as cases (381) and 1524 teenagers who were not pregnant were taken as controls.. Necessary variables were extracted from the DHS data set after literatures were revised. Then, variables with P ≤ 0.25 were analyzed with multivariable logistic regression. Results: Educational level, wealth index, knowledge of ovulatory cycle after period ended, knowledge of family planning method, contraceptive use, and reasons for not using contraceptives were higher among the cases and were statistically significant. Conclusion: Knowledge of family planning and ovulatory cycle, primary school educational level, richest wealth category, and contraception use were the determinants of teenage pregnancy. Hence, educational level, knowledge gap, and economy should be emphasized to eradicate teenage pregnancy from Ethiopia.

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Scrub typhus is a mite-borne acute febrile illness caused by Orientia tsutsugamushi, and is transmitted by the bite of the trombiculid mite. It presents with high-grade fever which may be associated with nonspecific signs and symptoms such as rash, muscle and abdominal pain, headache, and lymph node enlargement. Scrub typhus is, therefore, one of the differential diagnoses to be considered in a child with acute undifferentiated febrile illness, especially if the disease is endemic to the region. The presence of a painless eschar at the site of the bite is an important pointer to the diagnosis. The illness responds well to antibiotics, usually within 48 h.

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Intrauterine growth restriction is a condition where the estimated fetal weight is less than the 10^th percentile on ultrasound and the fetus has not attained its biologically determined growth potential because of a pathologic process. This review deals with the definitions of fetal growth restriction, the etiology associated with it, the types of fetal growth restriction and discusses how to differentiate between them. The various screening mechanisms available, the approach to a patient who is at risk for fetal growth restriction and whether they will benefit from any of the prophylactic measures available are also discussed.

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Rodenticides remain an important cause of morbidity and mortality among patients with deliberate self-harm. Yellow phosphorus is an important class of rodenticide due to its high toxic nature and is associated with a high mortality rate. The absence of any specific antidote is an important factor for poor prognosis among those who consume this poison. We report a case of acute liver injury secondary to yellow phosphorus poisoning which was successfully managed with intravenous N-acetylcysteine.

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The cause of infertility is said to be unexplained when there is normal ovulatory function, semen analysis is normal, and tubal patency is established by hysterosalpingography or laparoscopy. Some of the factors that may contribute to the etiology of unexplained infertility are inability to identify the subtle reproductive abnormalities, endocrine/genetic/immunological disorders, minimal/mild endometriosis, and compromised ovarian and natural fecundability that may be less than normal. Prognostic factors in unexplained infertility include maternal age, duration of infertility, and previous obstetric history. The management options depend on various factors such as age of woman, duration of infertility, couples' preferences, and the health-care setting. The options available for treatment include expectant management, clomiphene citrate, super ovulation with intrauterine insemination, and in vitro fertilization/intracytoplasmic sperm injection.

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Background: Skin and soft-tissue infections (SSTIs) vary in presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. Early diagnosis is vital to reduce the complications. Materials and Methods: This prospective, observational, cohort study conducted between April 1, 2018 and June 30, 2018, in the emergency department (ED) of large tertiary care hospital in South India. In this study, all patients >15 years of age with traumatic or nontraumatic SSTI were enrolled consecutively, and SSTI associated with burns were excluded. The 353 patients were interviewed with a prestructured questionnaire and the statistical analysis was performed using SPSS 25.0. This study was aimed to find the incidence of SSTI and the outcome. Results: The cohort consists of… patients with age group between 40 and 65 years, and there was male predominance. Nonnecrotizing SSTI was the most common presentation. The incidence rate was 1.9%. Diabetes mellitus (DM) was the common risk factor n (%). Lower limbs were the most commonly affected site. The most common organism isolated in the blood and pus culture were Staphylococcus epidermidis and mixed flora. A large number (33.9%) of patients required in-patient care and surgical interventions. The mortality rate in our cohort was n (14%). Conclusion: The incidence of SSTI in patients presenting to the ED remains high. DM was the common risk factor, and many required inpatient care, and surgical intervention including amputation. Despite prompt diagnosis and management, mortality rate was still significant.

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Background: In both developed and developing countries, the proportion of people over 60 years of age is growing faster than any other age group as a result of longer life expectancy due to improved health care. As a result, emergency department (ED) visits are on the rise. Materials and Methods: This retrospective observational study was conducted in the ED of a large tertiary level hospital between September 2014 and December 2014. All patients >65 years presenting to the ED were included in the analysis. Results: During the study period, 1090 geriatric patients comprised 13.9% of the ED admissions. The mean age of the patients was 74.2 ± 20.32 years. There was a male predominance (65.4%). The most common presenting complaints were breathing difficulty (28%), fever (21.6%), vomiting (14%), chest pain (11.5%), abdominal pain (11.5%), trauma (11%), giddiness (10.4%), and altered sensorium (10%). The distribution of the most common organ systems involved are as follows: Cardiovascular system (18.7%), respiratory system (15.8%), trauma (13.9%), genitourinary system (13.8%), neurological system (12.3%), skin and soft tissue infections (6%), and others (25.1%). Among the respiratory conditions, acute exacerbation of asthma/chronic obstructive pulmonary disease was the most common (61.2%), followed by pneumonia (28.9). More than half (51.5%) were discharged from ED, 47.5% (518 patients) were admitted to the hospital, and 0.91% (10 patients) expired in the ED. A further 64 patients expired during the hospital stay. The overall inhospital mortality among the geriatric emergencies was 6.8% (79/1090). The mean length of hospital stay was 8.06 days. Conclusion: The admission profile among this geriatric population showed that cardiorespiratory conditions are the most common emergencies, followed by trauma. ED of India should be aware of this demographic profile and be prepared to handle these emergencies efficiently.

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Methemoglobinemia is an altered state of the hemoglobin moiety resulting in impaired oxygen delivery to the tissues. It is a potentially fatal condition that occurs when the ferrous iron of heme is oxidized to ferric iron. Methemoglobinemia has been linked to a wide array of drugs, chemicals, and substances such as local anesthetics, industrial chemicals, and insecticides. Many of these compounds have no details of the composition and can result in severe methemoglobinemia. Clinical suspicion should be aroused with low oxygen saturation on pulse oximetry and the presence of chocolate-colored blood. Immediate administration of the antidote, methylene blue when indicated, effectively decreases methemoglobin levels to tolerable levels.

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In the Indian subcontinent, the “Big four” snakes of cobra, krait, Russell's viper, and saw-scaled viper are responsible for most of the venomous snakebites. Diagnosing envenomation is a pure clinical skill with no diagnostic kit available yet. Anti-snake venom (ASV) is a precious commodity, and clinicians across the country must be aware of the process of production of ASV so that they may use it judiciously for the treatment of envenomation.

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Secondary hemophagocytic lymphohistiocytosis (sHLH) may be responsible for some of the deaths in adult patients with severe COVID-19. We present our experience of low-volume plasma exchange (PLEX) with low-dose steroid in the treatment of adult patients with sHLH and acute liver failure caused by dengue virus and other nonviral triggers and discuss how this may be effective in the management of severe COVID-19. sHLH is poorly understood and without effective treatment. Endothelium of the capillaries of the lungs and kidneys and of liver sinusoids does not express von Willebrand factor (VWF) in health and is where most macrophages are located. Plasma VWF levels are high in sHLH and require clearance by macrophages, which when activated enlarge and likely block the lumen. Current histology studies neither appreciate microcirculatory sludge nor display endothelial–macrophage interactions. We hypothesize that low-volume PLEX and low-dose steroid may reverse sHLH and improve survival in severe COVID-19 patients with acute lung injury.

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Background: Health-care workers have a major role to play in ensuring that malaria treatment is carried out in accordance to treatment guidelines, to ensure the quality of patient care. Having the requisite knowledge of the ailment and its management is a necessity in achieving optimal treatment outcomes. Objectives: The purpose of this study was to assess and compare health-care workers' knowledge on malaria and its treatment across public and private primary health-care facilities of Bassa Local Government Area, Nigeria. Materials and Methods: Two hundred pretested semi-structured questionnaires were administered to health-care workers across selected public and private facilities; and the generated data were analyzed using Statistical Package for Social Sciences software version 20. Results: A total of 184 health-care workers (92% of the study population of 200) participated in the study. The majority of the health-care workers (65.8%) were from the public sector, while 34.2% were from private health facilities. Most of the respondents were Junior Community Health Extension Workers (23.4%) and Community Health Extension Workers (22.8%). The other health workers included in the study were nurses and laboratory and pharmacy technicians involved in the management of malaria. The respondents had a good knowledge of the cause, symptoms, and diagnosis of malaria across the facilities, based on their item scores; however, their knowledge on anti-malarial drugs was poor. Workers with >10 years in practice had significantly better knowledge (45.3%) than those with lesser experience (28.4%) (P = 0.018). Those in private practice had marginally better knowledge (44.4%) than those in public sectors (38.8%). Conclusion: The respondents had good knowledge of the etiology, symptoms, and diagnosis of uncomplicated malaria across the facilities, but knowledge of the recommended antimalarials and symptoms of complicated malaria was poor. The outcomes will be useful in educating health-care professionals in the facilities, with an emphasis on the recommended drugs for malaria.

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Quality has become an important buzzword for the current generation of healthcare providers. Most hospitals and healthcare providers are differentiated and evaluated according to their organization performance and quality. National Accreditation Board for Hospitals and Healthcare Providers (NABH) is an integral board of Quality Council of India, established to operate accreditation program for healthcare organizations/institutions. Accreditation is a public recognition awarded to healthcare organizations which fulfill the standards laid by NABH through an independent external assessment conducted by qualified team of assessors.

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Diuretics are often the cornerstone of treatment for volume overload in the emergency setting. The pharmacokinetic and pharmacodynamic properties of diuretics differ in various clinical scenarios. The choice of a diuretic, its maximum dosage, and spacing of doses are important clinical issues which every medical practitioner needs to be aware of. In this review, we discuss the pharmacokinetic and pharmacodynamic properties of diuretics, their therapeutic implications, and best strategies for use in various clinical conditions.

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Background: Trauma is an increasing cause of morbidity and mortality in India. Blunt injury to the abdomen frequently results in life-threatening splenic injuries. Materials and Methods: This was a retrospective observational study of all patients more than 18 years old presenting to our emergency department with blunt abdominal trauma resulting in a splenic injury between 2006 and 2011. Details of the incident, injuries, and outcome were noted. Results: During the study of 2006–2011, 51 patients with splenic injury following blunt trauma to the abdomen were enrolled. There was a significant male predominance (94.1%). Road traffic accident (RTA) was the predominant mode of injury (66.7%) followed by fall from height (25.5%). On examination, the majority of the patients (82.4%) had abdominal tenderness while abdominal distension and guarding were seen in 60.8% and 31.4% of patients, respectively. A third (35.3%) of the patients was hypotensive at presentation. All the patients were started on crystalloids while blood products were transfused in 70.6% of the patients. Splenic injury was diagnosed during the primary survey in 92% of the patients. Emergency department (ED) physicians diagnosed free fluid and solid organ injuries on focused abdominal sonography in trauma (FAST) in 80.4% and 47.1% of patients, respectively. Computed tomography scan of the abdomen was performed in 57% of the patients. More than half (58.8%) were managed conservatively. The mortality rate was 10%. Conclusions: RTAs are the most common cause of splenic injury. ED physicians are quite reliable in diagnosing free fluid in the abdomen with FAST. Aggressive fluid resuscitation with blood products is the key to survival in both conservatively and surgically managed patients.

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Background: The sickest patients who visit the emergency department (ED) are triaged as priority one based on guidelines. To improve the quality of Emergency medicine (EM) care, a better understanding of patients is needed; hence, this study was done on priority one patients of the ED. Materials and Methods: This retrospective study included all priority one patients during a 4-month period (February, May, September, and December), over 1 year (2017). Demographic details, vital signs at the time of presentation, and details of disposition were noted. Results: Among 2333 priority one patients, majority (89.3%) had non trauma-related diseases, while only 10.7% had trauma as the cause of disease. Males were predominant (64%) and females accounted for 36%. Adults were more than half (59.16%), followed by the geriatric age group. Bradycardia was noted in 6.4% (149) patients, while 52.1% (1212) had tachycardia and 29.7% of the population presented with hypotension. Breathlessness was the most common complaint (44.6%); trauma specialty departments were referred to include neurosurgery (43.1%) and orthopedics (27.5%). Broader specialties such as general medicine and general surgery had majority of their spectrum-related cases referred to them, 44.9% (n = 716) and 39.3% (n = 50), respectively. More than a quarter of patients (27.2%) were discharged from the ED, one-third (68.1%) of the patients were discharged from the hospital overall, and 7.4% succumbed to death. Conclusion: The patient demographics and other characteristics identified by this study help us to guide and shape Indian EM training programs, infrastructure, and faculty development, to more accurately reflect the burden of acute disease in India.

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Background: Trauma is one of the major causes of long bone injuries in India. This study was done to improve the understanding of the mode of trauma, type of injury and severity and outcome of trauma victims with long bone injuries in our hospital. Materials and Methods: This was a retrospective observational study of all trauma patients aged 18 years or more with long bone injuries presenting to our emergency department. Details of the incident, injuries, management, and outcome were noted. Results: We received a total of 2207 trauma patients during the 4-month study period with 14.31% (316/2207) being adult patients with long bone injuries. Male (71.8%) predominance were noted. The mean age was 45.7 (±17.9) years. Road traffic accident (68.35%) was the most common mechanism of the incident followed by slip and fall (20.56%). Majority of patients (43.98%) came during 15.00–22.00 h. The most common long bone injured was the tibia in the young (51.68%)- and middle-aged (58%) patients. In the elderly, femur (58.19%) was the most common bone involved. Head injury accounted for 13% of the associated injuries. Among these 316 trauma patients 186 were admitted, 105 (57.37%) patients had to undergo an emergency operation on the same day of arrival, whereas 78 (42.62%) patients were managed conservatively in the wards or had an elective surgery done at a later date. Conclusions: The tibia is the most common long bone injured in young adults, whereas the femur is the most common in the elderly. Prevention, education, legislative enforcement, and prehospital management and transportation of trauma-inflicted patients would impact immensely on the health of the people.

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Background: Accelerated urbanization and industrialization have led to an alarming increase in the rates of trauma that eventually increases the financial burden of society. Understanding the direct medical costs associated with trauma provides a window for assessing the potential cost reductions with improved quality care in the Emergency department (ED). Aim: The aim is to analyze the possibilities of minimizing the expenditure of trauma patients presenting to priority I and priority II of the emergency department (ED), without compromising care and treatment. Materials and Methods: This is a retrospective study done in the ED of CMC Vellore in the month of January 2017. Multiple regression was used to categorize patients into major or minor trauma on the basis of Glasgow Coma Scale, hemodynamic stability, unstable abdominal/pelvic fractures, chest trauma (subcutaneous emphysema/open pneumothorax/penetrating chest injury), hypovolemic shock, and polytrauma. The costs of each type of trauma were then calculated after adjusting for differences in age, gender, mode of injury, influence of alcohol, and system(s) involvement. Results: A total of 119 trauma patients who were admitted in priority I and II were studied in a period of 1 month, among which majority were male 97 (81.5%) patients. It was noted that the incidence of trauma was the highest in the adult age group, i.e., 91 (76.5%) patients. Road traffic accident was the most common mode of injury and seen in 83 (69.7%) patients. In injury profile, lower limb injuries were most commonly involved and contributed to 37 (31.1%) patients, followed by upper limb injuries in 21 (17.6%) patients and isolated head injuries in 15 (12.6%) patients. The average cost was more in patients suffering from major trauma (Rs. 10,983/-) in comparison to minor trauma (Rs. 6464/-), with the maximum expenditure in radiological investigation. In about 18 (15%) patients, blood tests and imaging were done without proper indication which led to additional expenditure. Among all these trauma patients, 40.3% of patients needed admission either in ICU or ward and underwent major surgical procedures, 44.5% of patients were discharged in a stable condition, 13.5% of patients were either discharged against medical advice or discharged at request after primary care and 1.7% of the patients died during their stay (primary Resuscitation) in the ED. Conclusions: This study shows the cost-benefit analysis in major trauma while maintaining high quality care and treatment.

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Objectives: The aim of this study is to assess the utility of plasma von-Willebrand factor (VWF) levels in predicting in-hospital survival for patients with severe alcoholic hepatitis. Methods: From a prospectively collected database of acute-on-chronic liver failure (ACLF) patients, we retrospectively selected all severe alcoholic hepatitis (discriminant function [DF] ≥32) patients and correlated baseline plasma VWF (antigen, Ag and collagen-binding activity [CBA]) levels with disease severity. In-hospital survival was classified as discharged alive (or) died/discharged in a terminal condition (poor outcome). Results: Of 34 consecutive severe alcoholic hepatitis patients (age: 40.5, 30–63 years; median, range, hospital stay: 6, 2–15 days) studied, 15 had a poor outcome. Plasma VWF-CBA was higher in patients with poor outcome (736 [396–1157] IU/dL) as compared to patients discharged in stable state (492 [97–986] IU/dL; P = 0.03). VWF-CBA correlated well with VWF-Ag, model for end-stage liver disease (MELD) score, sequential organ failure assessment score and ACLF grades. AUROC to predict composite poor outcome was similar for plasma VWF-CBA (0.72, 0.54–0.89) and MELD score (0.71, 0.53–0.89). Plasma VWF-CBA was higher in 23 “very severe” alcoholic hepatitis (DF >60 or MELD >30) patients. Combining plasma VWF-CBA (>750 IU/dL) and criteria for “very severe” alcoholic hepatitis had a sensitivity of 100% (81%–100%) and negative predictive value of 100% (68%–100%) for predicting poor outcome. Conclusions: Plasma VWF levels are markedly elevated, correlate with organ failure, and predict in-hospital survival in severe alcoholic hepatitis, and also in “very severe” alcoholic hepatitis, patients.

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Background: Laryngoscopy and intubation form an indispensable step in general anesthesia. They elicit significant sympathoadrenal responses. Suppression of these responses forms an essential step in general anesthesia. The aim of our study is to compare the efficacy of nebulized lidocaine versus intravenous (IV) lidocaine in suppressing the pressor response to laryngoscopy and intubation. Materials and Methods: One hundred patients within the age group of 18–65 years undergoing elective surgery under general anesthesia were randomly allocated into two groups: group IV lignocaine (IVL) (n = 50) and group nebulized lignocaine (NL) (n = 50). Baseline values of heart rate (HR), systolic blood pressure (BP), diastolic BP, mean arterial pressure (MAP), and saturation were noted. Patients received either nebulized or IV lidocaine according to the group. HR, saturation, BP, MAP, and arrhythmias were noted every minute from laryngoscopy up to 5 min postlaryngoscopy and intubation. Results: There was an increase in HR and BP from baseline in both the groups with laryngoscopy and intubation, and the increase is significantly less in NL (P < 0.05). The parameters in both the groups attained the baseline values at the 3^rd min postintubation. However, the 4^th- and 5^th-min readings showed values below baseline in the nebulization group. Conclusion: This study suggests that NL may be more effective than IVL in suppressing pressor response to laryngoscopy and intubation.

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Paraquat a rapidly acting, nonselective herbicide is a leading cause of fatal poisoning in many parts of Asia. After rapid absorption, paraquat is concentrated inside many cells where it undergoes redox cycling. Clinical features are largely due to intracellular effects. Paraquat is actively concentrated into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes gastrointestinal, renal, and liver injuries. Activated charcoal and Fuller's earth can minimize further absorption. Gastric lavage is contraindicated. Hemodialysis and hemoperfusion are unlikely to change the clinical course. The use of immunosuppression with dexamethasone, cyclophosphamide, and methylprednisolone evidence for efficacy is weak. Antioxidants such as acetylcysteine and salicylate used as free radical scavenging might be beneficial. The case fatality is very high in this herbicide due to the lack of effective treatment options.

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Rodenticide is a broad term, and there are a wide variety of such compounds depending on the geographical region and availability. These compounds differ in their chemical composition, mechanism of action, toxic doses, and lethal effects. Coumarins, aluminum phosphide, zinc phosphide, and yellow phosphorous are the most easily available and commonly used rodenticides for deliberate self-harm. Aluminum phosphide poisoning is rapidly fatal, whereas yellow phosphorous poisoning too is associated with a high mortality within 1–2 weeks of consumption.

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COVID-19 outbreak is likely to have started from a zoonotic transmission event associated with a large seafood market that also traded in live wild animals. Initial epidemiological studies suggested a predilection for older adult males with comorbidities due to their immunocompromised status and very rarely, coinfection with bacteria and fungi. An exponential increase in the number of nonlinked cases in the late December 2019 pointed toward the risk of human-to-human transmission. Similar to its predecessor, severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) also acts on the angiotensin-converting enzyme-2 (ACE2) present on the type 1 and type 2 alveolar epithelial cells. ACE2 expression has been found to be higher in males than females and in Asian populations compared to White and African-American populations. This led to an agreement that the Asian males were more susceptible to SARS-CoV-2 infection. The ability of SARS-CoV-2 to bind to ACE2 receptor was found to be 10–20 times more than that of the SARS-CoV, thus making the new pathogen much more aggressive. At the time of writing this article, the global burden of confirmed cases of COVID-19 has risen to half a million with death toll touching 25,000 people. For the first time, we may be looking at a pandemic which could be controlled on a short-term basis and prevented on a long term with adequate research and clinical trials for newer therapeutic agents.

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Thyroid function tests are one of the most common endocrine panels in general practice because a good understanding of when to order them, interpretation of their results and indications for treatment are important for the optimal treatment of thyroid dysfunction. Thyroid-stimulating hormone (TSH) should be the first test to be performed on any patient with suspected thyroid dysfunction and in follow-up of individuals on treatment. It is useful as a first-line test because even small changes in thyroid function are sufficient to cause a significant increase in TSH secretion. Thyroxine levels may be assessed in a patient with hyperthyroidism, to determine the severity of hyperthyroxinemia. Antithyroid peroxidase measurements should be considered while evaluating patients with subclinical hypothyroidism and can facilitate the identification of autoimmune thyroiditis during the evaluation of nodular thyroid disease. The measurement of TSH receptor antibody must be considered when confirmation of Graves' disease is needed and radioactive iodine uptake cannot be done.

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Oral anti-diabetic agents form an important therapeutic strategy in the management of diabetes, after lifestyle modification. There are several new agents available, like dipeptidyl peptidase 4 (DPP4) inhibitors and sodium- glucose cotransporter 2 (SGLT2) inhibitors have been approved for use as monotherapy when diet and exercise are inadequate and when metformin is not tolerated, and can also be utilized as an add on to other glucose-lowering agents, including insulin. The therapeutic, pharmacokinetic and safety profiles of these agents are different from the older agents. Hydroxychloroquine (hcq) and bromocriptine have been recently cleared for use and show beneficial effects in control of blood glucose and HbA1C levels.

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Neuropathy is the most common symptomatic complication of diabetes mellitus (DM) and accounts for a large share of morbidity and hospitalization associated with the disease. The symptoms of neuropathy in diabetes may present with somatic, autonomic, motor or sensory symptoms. Symmetric distal sensory polyneuropathy is the most common form, affecting the distal lower extremities and hands in a “glove and stocking” pattern. Cardiac autonomic neuropathy can, in particular, contribute to 6% of sudden deaths (painless myocardial infarction) among those with long-standing diabetes. Neuropathy whether sensory, motor, or autonomic may lead to the formation of fissures or calluses which lead to ulceration. Tight glycemic control is the only strategy which has demonstrated to show prevention and progress of diabetic peripheral neuropathy and autonomic neuropathy. Early treatment of diabetic neuropathy should, therefore, include tight glycemic control. All patients should be screened for diabetic neuropathy starting at diagnosis of type 2 DM and 5 years after diagnosis of type 1 DM and at least annually thereafter. An annual comprehensive foot examination is a must for all patients with diabetes and consists of examination of foot and footwear, neuropathy screening, vascular assessment, and musculoskeletal assessment of feet. This would help in identification of risk factor predictive of ulcers and amputation.

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