Psychometric analysis of the Functional Independence Score in Haemophilia (FISH).

Joint morbidity in haemophilia has traditionally been measured using clinical and radiological scores. There have been no reliable, validated tools for the assessment of functional independence in persons with haemophilia till recently. The Functional Independence Score in Haemophilia (FISH) has been developed as a performance based assessment tool to address this need. The FISH is designed to measure the patient's independence in performing activities of daily living (grooming and eating, bathing and dressing), transfers (chair and floor), and mobility (walking, step climbing and running). On assessment of its psychometric properties in 63 patients with haemophilia (mean age 14 years), FISH was found to have good internal consistency (Cronbach's alpha of 0.85). It had moderate correlation with the World Federation of Hemophilia clinical score (r = -0.61), and a correlation with the Pettersson score of -0.38. It had good correlation with other self-rated functional scores, such as the Stanford Health Assessment Questionnaire (r = -0.75); the Western Ontario and McMaster Universities Osteoarthritis Index (r = -0.66) and the Haemophilia Activities List (HAL) (r = -0.66). It had good reliability with a pooled intra class correlation of 0.98. On assessing responsiveness following treatment of flexion deformities of the knee in 12 patients, the FISH showed significant changes in the score with a standardized responsiveness mean of -1.93. In conclusion, the FISH was found to be a reliable and valid tool with good internal consistency and responsiveness to therapy, for the assessment of functional independence in persons with haemophilia.

Functional Independence Score in Haemophilia: a new performance-based instrument to measure disability.

Morbidity in haemophilia has been described predominantly in terms of musculoskeletal dysfunction and assessed by the clinical and radiological joint scores. These scores document changes in a particular joint, but do not reflect the impact of these changes on the individual in terms of his overall musculoskeletal function. Several self-assessment instruments have been used to measure musculoskeletal function but none have been specifically validated for use in haemophilia. In order to objectively assess musculoskeletal function of patients with haemophilia, we developed Functional Independence Score in Hemophilia (FISH), a performance-based instrument. FISH measures the patient's independence in performing seven activities under three categories: self-care (grooming and eating, bathing and dressing), transfers (chair and floor) and mobility (walking and step climbing). Each function is graded from 1 to 4 depending on the amount of assistance needed in performing the function. We evaluated 35 patients who were over 10 years old and had had at least three major bleeds per year. All subjects were scored for clinical (World Federation of Hemophilia, WFH score) and radiological changes (Pettersson's score). Functional independence of the patient was assessed using the Stanford Health Assessment Questionnaire (HAQ) and the FISH. Correlation of the FISH score was modest with both the WFH clinical score (r = -0.68) and the radiological score (r = -0.44). While there was good correlation between FISH and HAQ (r = -0.90), FISH had better internal consistency than HAQ (Cronbach's alpha 0.83 vs. 0.66). FISH appears to be a promising disease-specific instrument for assessing overall musculoskeletal function in haemophilia. It requires evaluation in different patient populations.

Dose and outcome of care in haemophilia--how do we define cost-effectiveness?

Severe haemophilia (factor [F]VIII/FIX activity < 0.01 IU mL(-1)) is characterized by repeated haemarthroses resulting in severe arthropathy in adulthood. In 1958, Professor Nilsson in Sweden introduced prophylactic infusions with clotting factor concentrates at regular intervals in order to maintain clotting factor levels above 0.01 IU mL(-1) and to prevent bleeding. Since then, evidence of the long-term beneficial effects of prophylactic treatment for severe haemophilia has been increasing and it has become the recommended treatment strategy for children with severe haemophilia by both the World Health Organization and the US National Hemophilia Foundation Medical and Scientific Advisory Committee. However, the implementation of this recommendation has been hampered by issues of cost and venous access. The high costs of prophylaxis have largely prevented its use in major parts of the world. The question therefore is whether the current models of replacement of clotting factor concentrates, while certainly being effective, are also optimal. Can the data on outcome at different levels of factor replacement be used to assess their cost-effectiveness?

Re-examining the psychology of spinal cord injury: a meaning centered approach from a cultural perspective.

OBJECTIVES: To examine the impact of SCI from a non-Western cultural perspective. SETTING: India. METHODS: A philosophical approach. CONCLUSION: Management of the individual with spinal cord injury needs to take in to account the individual's beliefs and cultural context.

Psychological wellbeing among carers of people with spinal cord injury: a preliminary investigation from South India.

STUDY DESIGN: A cross-sectional study that assessed people with spinal cord injury (SCI) and their carers who attended the 3-day health care program. OBJECTIVES: The study examined the nature and prevalence of the factors associated with psychological morbidity among carers of people with SCI. SETTING: A community reintegrated population of persons with SCI and their carers attended the 3-day program in the Department of Physical Medicine and Rehabilitation, Christian Medical College Hospitals, Vellore, South India. METHODS: Thirty-eight people with SCI and their carers participated in this cross-sectional study. RESULTS: Thirty (78.9%) carers of people with SCI were psychologically distressed. While carers were distressed, they were not significantly depressed. Educational level of carers and suicidal behavior of people with SCI were significantly associated with psychological distress. CONCLUSION: The findings of this study suggest that health care workers should have a high index of suspicion of psychological morbidity, in carers of people with SCI. Identification of risk factors may lead to useful target interventions.

Persistent rhinorrhoea in rural Indian children: prevalence and consequences.

To determine whether persistent rhinorrhoea constitutes a significant problem requiring intervention, 17 rural day care centres (Balwadis) in Tamilnadu, India, were visited. Among 414 children in the Balwadis 92 (22 per cent) children with persistent rhinorrhoea (15 days duration or longer) were identified. Demographic and clinical data and nasopharyngeal swabs for bacterial culture were obtained from 56 such children and 91 age-matched controls from the same Balwadi. Type of housing or nutritional status did not appear to be significant risk factors. There was a significantly higher number of children aged 5-15 years in the household of cases as compared to controls (1.23 +/- 1.08 vs. 0.83 +/- 0.95, p = 0.02). Other illnesses were noted in 25 (44.6 per cent) cases and seven (7.7 per cent) controls (OR 11.5; CI, 4.13-33.4; p < 0.00001). Notably, chronic ear discharge was noted in 6 (11.7 per cent) cases but in none of the controls (p = 0.007). Streptococcus pneumoniae was isolated from nasopharyngeal swabs in 42/49 (85.7 per cent) cases and 44/80 (55 per cent) controls (p < 0.001) and H. influenzae from seven cases and five controls; S. pneumoniae was isolated in all children with chronic ear discharge and H. influenzae from one child. Serotypes of pneumococci commonly associated with otitis media, i.e., types 6, 14, 19, and 23 were isolated from 25 (51 per cent) cases and 16 (20 per cent) controls (OR 4.17; 95% CI, 1.78-9.85; p < 0.001). Persistent rhinorrhoea, presumably due to pneumococcus, is a common condition among rural Indian children and appears to be associated with chronic otitis media.

Measles vaccination before nine months.

OBJECTIVE: To measure the protective effect of measles vaccine administered before 9 months of age and compare overall mortality of children vaccinated at 6-8 months and at 9-11 months. METHOD: Non-concurrent cohort study involving all 13 134 children born between 16 January 1986 and 31st December 1991 in Kaniyambadi block near Vellore who had not left the area by six months of age. Main outcome measures were risk of disease and death among the under-five-year-olds according to age at measles immunization. RESULTS: Unimmunized children had a higher risk of developing measles compared to the immunized (P < 0.05). There was no significant difference in risk of measles among those vaccinated prior to and after nine months of age. Unvaccinated children were at significantly higher risk of death than vaccinated children (P < 0.001). There was no difference in risk of death between infants vaccinated between 6 and 8 months and those vaccinated between 9 and 11 months. There was no difference in the risk of death between boys and girls vaccinated between 6 and 8 months with standard-titre Edmonston-Zagreb vaccine. CONCLUSION: Administration of standard-titre Edmonston-Zagreb measles vaccine at 6-8 months is an effective and safe preventive measure for measles, especially where the age-specific attack rate for children < 9 months is high.

Glucose intolerance and dyslipidaemias in persons with paraplegia and tetraplegia in south India.

Glucose intolerance and dyslipidaemias have been reported among paraplegics and tetraplegics. In this study we determined the lipid profiles and the glucose tolerance in a group of 48 persons with spinal cord lesions who had been rehabilitated in our Department of Physical Medicine and Rehabilitation. This non-randomised, descriptive study was conducted as part of the annual medical follow-up of these individuals. Hypertension was observed in only 6% of the subjects. Fasting hyperglycemia was observed in 19% and glucose intolerance in 23% of the subjects. Total cholesterol was abnormal in 2%, but 58% had low levels of high density lipoprotein (HDL). 10% of the subjects had raised low density lipoprotein (LDL) levels. The cardioprotective HDL fraction may remain very low even while the total cholesterol level is within normal limits, and unless a lipid profile estimation is done, this group of individuals who are at cardiovascular risk may remain undetected. We conclude that glucose intolerance and dyslipidaemias are common among paraplegic and tetraplegic individuals, and these metabolic derangements may contribute to increased cardiovascular morbidity.

Malignant secondary deposit in the iliac crest masquerading as meralgia paresthetica.

Meralgia paresthetica is an entrapment neuropathy from compression of lateral femoral cutaneous nerve of the thigh as it passes under the inguinal ligament. The entrapment produces pain, paresthesia, and sensory loss over the anterolateral aspect of the thigh, without motor loss. The etiology of this condition is often obscure and the pathogenesis is thought to be an entrapment of this nerve at the inguinal ligament where it pierces the fascia to reach the skin. Rarely, retroperitoneal lymphomas or other neoplasms can mimic symptoms of meralgia paresthetica. We report a case of a 60-year-old man who presented with clinical features of meralgia paresthetica. On investigation, he was found to have a secondary malignant deposit in the iliac crest from an adenocarcinoma of the lung. This neuropathy, although often caused by a benign lesion, can at times be the presenting symptom of a malignancy.

Aspirin in chloroform as an effective adjuvant in the management of chronic neurogenic pain.

OBJECTIVE: To evaluate the effectiveness of topical application of aspirin in chloroform as an adjuvant in the management of chronic neurogenic pain. DESIGN: Intervention study, nonrandomized before-and-after trial. SETTING: A department of physical medicine and rehabilitation in a tertiary-care university teaching hospital. PARTICIPANTS: Fifteen adults who presented with severe, chronic neurogenic pain in whom, conventional methods of treatment were unsuccessful in alleviating the pain. INTERVENTION: A solution of aspirin (acetyl salicylic acid) in chloroform was applied over the painful areas. MAIN OUTCOME MEASURES: A numerical scale from 0 to 100 was used to measure the severity of pain. RESULTS: Seventy-four percent of patients showed a good response, 13% had fair response, and in 13% there was no response. CONCLUSION: Aspirin in chloroform solution is a simple and effective adjuvant in the management of chronic neurogenic pain.

General and reproductive health of adolescent girls in rural south India.

PIP: Both quantitative and qualitative methods were used to assess the general and reproductive health of female adolescents in a rural district in Tamil Nadu, India. In focus group discussions, adolescents spoke of having headaches, body pains, and fatigue. There was a reluctance to discuss sexual health problems, but many reported concerns about menstrual irregularities. Girls participating in groups stated they would feel more comfortable attending a separate adolescent clinic run by female physicians. In interviews with 190 girls, the most frequently cited health complaints were fatigue, palpitations, frequent headaches, backache, and abdominal pain. Over 20% suffered from joint pains, weight loss, poor appetite, and recurrent respiratory problems. Those with higher educational status had fewer health complaints. 30% were anemic, and heights, weights, and body mass indexes were typical of those found in chronically undernourished populations. Adequate knowledge levels of topics such as menstruation, contraception, nutrition, and AIDS were extremely low. Overall, these findings indicate a need for both health education and special treatment services for girls from India who have suffered the health consequences of low socioeconomic status, unhygienic practices, and poor nutrition.^ieng

A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India.

INTRODUCTION: In India, approximately 20 percent of children under the age of four suffer from severe malnutrition, while half of all the children suffer from undernutrition. The contributions of knowledge and attitudes of nutrition-conscious behaviors of the mothers to childhood malnutrition has been unclear. The purpose of this study was to explore maternal knowledge of the causes of malnutrition, health-care-seeking attitudes and socioeconomic risk factors in relation to children's nutritional status in rural south India. METHODS: A case-controlled study was conducted in a rural area in Tamil Nadu, India. Thirty-four cases and 34 controls were selected from the population of approximately 97,000 by using the local hospital's list of young children. A case was defined as a mother of a severely malnourished child under four years of age. Severe malnutrition was defined as having less than 60 percent of expected median weight-for-age. A control had a well-nourished child and was matched by the location and the age of the child. Interviews obtained: (1) socioeconomic information on the family, (2) knowledge of the cause of malnutrition and (3) health-care-seeking attitudes for common childhood illnesses, including malnutrition. RESULTS: Poor nutritional status was associated with socioeconomic variables such as sex of the child and father's occupation. Female gender (OR = 3.44, p = .02) and father's occupation as a laborer (OR = 2.98, p = .05) were significant risk factors for severe malnutrition. The two groups showed a significant difference in nutrition-related knowledge of mild mixed malnutrition (OR = 2.62, p = .05). No significant difference was apparent in health-care-seeking attitudes. Based on their traditional beliefs, the mothers did not believe that medical care was an appropriate intervention for childhood illnesses such as malnutrition or measles. DISCUSSION: The results suggested that the gender of the child and socioeconomic factors were stronger risk factors for malnutrition than health-care availability and health-care-seeking attitudes. The father's occupation was a more accurate indicator for malnutrition than household income. These results suggest a need for intensive nutritional programs targeted toward poor female children and their mothers.

PIP: The contribution of maternal nutritional knowledge and attitudes to children's nutritional status was investigated in a case-control study conducted in a rural area in Tamil Nadu, India. 34 cases (mothers of a severely malnourished child under 4 years of age) and 34 controls (mothers of a well-nourished age- and location-matched child) were selected from the Christian Medical Center and Hospital registry. The 68 mothers interviewed were predominantly young (mean age, 25 years), poor, and illiterate (67.6%). Severe malnutrition, defined as less than 60% of expected weight-for-age, was significantly associated with female gender (odds ratio (OR), 3.44) and father's occupation as a laborer (OR, 2.98), as opposed to a civil servant or private sector professional. Knowledge of the role of lack of food or nutrition in mild marasmus-kwashiorkor mixed malnutrition was significantly higher among controls (59%) than cases (35%), but there were no significant differences in health-seeking behaviors. In general, mothers from this area did not regard medical care as an appropriate intervention for malnutrition or measles. Only 28% of mothers indicated they would seek medical care for malnutrition. Conversely, medical care was considered indicated for diarrhea, colds, and worms. These findings indicate a need for intensive nutritional programs targeted toward the families of low-income female children.

An outbreak of food poisoning in Tamil Nadu associated with Yersinia enterocolitica.

An outbreak of food poisoning in a Tamil Nadu village, affecting 25 of 48 individuals who participated in a feast, was investigated. The risk of developing illness was associated with consumption of buttermilk (relative risk 3.8). None of the food items consumed during the feast was available for analysis. Toxin-producing Y. enterocolitica (serotype 3, biotype 4) was grown from 1 of 11 stool samples from affected individuals, as well as from a water sample from the source used to dilute the buttermilk. High titres of antibody of Yersinia were detected in 2 of 12 patients but in neither of the two groups of controls. Toxin production was noted in buttermilk incubated for 6 h with Y. enterocolitica. This is the first report from India of a food poisoning outbreak associated with this organism.

Depression in individuals with spinal cord injury: methodological issues.

The methodological problems in research related to depression in individuals with spinal cord injury (SCI) are examined. These include relation to normal emotional reactions following injury, the use of physical and vegetative symptoms in the diagnosis of depression, the utilisation of rating scales primarily designed for use in psychiatric populations, the heterogeneity of patients with SCI, the role of preexisting psychiatric morbidity, the selection of controls for comparison and the necessity for multivariate statistical approaches to analysis. The issues and possible solutions are discussed.

The teaching of behavioural sciences.

Medical science over the last few decades has undergone vast changes. Technologically it has advanced at a rapid pace. There has been a realization as well that the behaviour of individuals and communities also influences the occurrence of disease. Medical schools around the globe have realized the need for incorporating behavioural sciences as an integral part of the basic sciences taught to medical students. This paper presents the experience of Christian Medical College, Vellore in teaching behavioural sciences. Students are taught sociology, psychology and medical anthropology through a community-based, problem-oriented teaching programme. The students have first-hand experience of living in a community and learn by observation and interaction. Pre- and post-assessment has shown a significant improvement of their knowledge and attitude. Feedback from students also indicates that they find this programme relevant and interesting.

N-acetyl-beta-D-glucosaminidase in the localisation of urinary tract infection in patients with spinal cord injury.

This study evaluates the pattern of urinary N-acetyl-beta-D-glucosaminidase (NAG) isoenzyme excretion in patients with spinal cord injury (SCI) and its use as a diagnostic tool in localising the site of urinary tract infection (UTI). NAG-B excretion in 27 control SCI patients (mean 207.78 units) was significantly higher than in 10 normal controls (mean 12.6 units) p less than 0.001). The relative isoenzyme distribution as represented by NAG-B/Total NAG percentage is however similar in both groups, 24.27 and 20.38% respectively. NAG-B excretion in 6 SCI patients with upper UTI was not significantly higher than in 12 SCI patients with lower UTI. NAG-B/Total NAG percentage was significantly different between these two groups (35.3% and 24.98% respectively, p less than 0.05). There was no significant difference in NAG-B excretion or NAG-B/Total NAG percentage between control SCI patients and those with lower UTI. The results indicate that there is a non-selective increase in urinary NAG excretion in control SCI patients and those with lower UTI. In SCI patients with upper urinary UTI there is a selective increase in NAG-B excretion. The overlap in enzyme values between the different groups suggests that the test may not be clinically useful in localising the site of UTI.

Teaching nutrition to medical students: a community-based problem-solving approach.

This paper presents a community-based problem-solving educational programme which aims at teaching medical and other health science students the importance of nutrition and its application. Through community surveys students assess the nutritional status of children under five using different anthropometric methods. They understand the cultural beliefs and customs related to food fads and the reasons for them. They also acquire the skill to educate the community using the information gathered. They use epidemiological methods such as case control study to find associations between malnutrition and other causative factors. Feedback from students has been positive and evaluation of students' knowledge before and after the programme has shown significant improvement.