Nurturing Care Interventions for Realizing the Development Potential of Every Child: From Pilot to Scale Up in Maharashtra.

The WHO-UNICEF nurturing care framework (NCF) for early childhood development provides a roadmap for action, focusing on pregnancy and the first three years of life. It emphasizes the need to invest in capacity building and empowerment of service providers, families and communities to create a conducive environment that promotes child development. We describe our experience of implementing nurturing care interventions, beginning with a pilot project in Maharashtra covering a population of 10000 to and scaling it up to a model called Aarambh (the beginning), catering to a population of 1,500,000. Opportunities available within the existing services across multiple sectors were used; Integrated Child Development Services (ICDS) scheme, the health sector, and others. It utilized multiple approaches for promoting NCF within families; home visits by frontline workers (FLWs), mothers' meetings, growth monitoring and promotion sessions, and community-based events as key opportunities. Joint training for FLWs, establishing supervisors of FLWs as their trainers, and an interactive training curriculum were critical elements identified for the success of the model. An environment of appreciation for the FLWs and their supervisors helped build their confidence and helped them own the interventions.

T-cell assay conversions and reversions among household contacts of tuberculosis patients in rural India.

BACKGROUND: Interferon-gamma assays (IGRAs) are alternatives to the tuberculin skin test (TST), but IGRA conversions and reversions are not well understood. In a pilot study, we determined conversions and reversions using QuantiFERON-TB Gold In-Tube((R)) (QFT) among household contacts of TB cases, and evaluated the effect of using various definitions and criteria for conversions. DESIGN: In a cohort of 250 contacts in India, 46% were TST-positive at baseline and 54% were QFT-positive. We re-tested this cohort after 12 months. Conversion rates were estimated using several definitions. RESULTS: Of the 250 contacts, 205 (82%) underwent repeat testing. Among 85 contacts with baseline TST-negative/QFT-negative results, TST conversion rates ranged between 7.5% and 13.8%, and QFT conversion rates ranged between 11.8% and 21.2%, depending on the definitions used. Among 109 contacts who were QFT-positive at baseline, seven (6.4%) had QFT reversions. QFT reversions were most likely when the baseline TST was negative and QFT results were just above the diagnostic cut-off. CONCLUSIONS: QFT conversions and reversions occurred among contacts of TB cases. Conversion rates seemed to vary, depending on the test and definitions used for conversions. These findings need to be verified in larger studies in various settings.

Dorsal ulnar cutaneous nerve conduction studies in an asymptomatic population.

OBJECTIVES: To establish the average distal sensory latency and amplitude of the dorsal ulnar cutaneous nerve under controlled temperature and settings. DESIGN: Dorsal ulnar cutaneous nerve conduction studies were performed with a bar electrode between the fourth and fifth metacarpals. The nerve was stimulated at 8 and 10cm from the active electrode. The temperature of the limbs under study was kept at 32 degrees C to 35 degrees C. PARTICIPANTS: Fifty-four arms of 27 subjects were studied. RESULTS: Results showed that distal sensory latencies were normally distributed. The average distal sensory latencies at 8cm and 10cm were 1.84 +/- .20msec and 2.09 +/- .21msec, respectively, with average amplitudes of 26.5 +/- 9.7microV and 23.5 +/- 8.8microV. Comparison with a previously reported study in which the limb temperature was not controlled showed a statistically significant difference. CONCLUSION: It is important to use standardized technique and to measure and maintain optimal temperature of the arm under study to prevent erroneous results and misdiagnosis.

Somatosensory evoked potentials of the medial and lateral plantar and calcaneal nerves.

The ideal electrodiagnostic procedure to assess possible plantar neuropathies continues to elude investigators. Motor studies are rarely abnormal, pure sensory studies may be difficult to obtain, needle electromyography can demonstrate membrane instability in normal feet. Mixed nerve plantar studies may be more diagnostically valuable than the other techniques but they also have shortcomings. In this report, a technique utilizing somatosensory evoked potentials to assess the medial and lateral plantar and calcaneal nerves is demonstrated. Normative data with respect to latencies, amplitudes, and side-to-side differences are presented. Two illustrative cases are also discussed in which the more standard techniques to evaluate plantar neuropathies fail to do so, but the SEP methodology suggests compromise of the intrinsic foot nerves.

Electrophysiologic investigation of thallium poisoning.

Electrophysiologic findings in thallium intoxication are usually untimely, limited in extent, and often uninformative. This report documents serial conduction and electromyographic findings in a case of thallium poisoning, beginning 10 days after symptom onset and ending 24 months later. Initially, the plantar nerves in the foot demonstrated profound axonal loss while the sural and peroneal nerves were essentially normal. The latter two nerves subsequently underwent axonal loss. Two years were required for the sural and peroneal nerves to display recovery. At 24 months, the plantar nerves continue to remain absent. A primarily distal axonopathy, significantly worse in the lower than upper extremities and requiring more than 2 years for recovery, now documents what was previously speculated: the electrophysiologic course of thallium intoxication. Additionally, this case emphasizes the need to examine the plantar nerves of the foot to avoid missing distal axonopathies during the early course of the disease process. The clinical course and pathophysiology of thallium poisoning are also reviewed.

Axilla to elbow radial nerve conduction.

Numerous techniques that evaluate radial nerve conduction from the axilla or supraclavicular fossa to the elbow have been reported. A shortcoming of most protocols is determining the precise radial nerve length as it proceeds along the spiral groove. The present study dissected out and measured directly eight cadaver radial nerves from the axilla to the elbow. These values were compared with a new surface tape measurement technique from axilla to elbow across the bicep muscle, obstetrical calipers over this region, and a surface determination approximating the course of the radial nerve posteriorly in the spiral groove. The anterior surface tape-measuring procedure compared most favorably with the actual anatomic length. Nerve conduction velocities were then calculated in 20 volunteers using all 3 techniques and compared with the median nerve in the arm. The anterior and posterior tape measurements yielded a conduction velocity of 72.5 +/- 4.7 and 86.6 +/- 7.0 m/s, respectively, whereas the caliper resulted in 65.7 +/- 3.9 m/s. We conclude that proximal radial nerve length assessment employing an anterior tape measurement from axilla to elbow across the bicep musculature is precise and compares favorably with the actual anatomic length of the radial nerve.

Brachial neuritis involving the bilateral phrenic nerves.

Brachial neuritis with bilateral hemidiaphragmatic paralysis has been reported in two previous cases in the literature. We report a patient who experienced severe right shoulder discomfort three weeks prior to hospital admission which evolved to include both shoulders. Two weeks prior to admission he noticed the onset of discomfort in breathing in the supine position and shortness of breath with minor exertion. The admitting diagnoses were myocardial infarction due to significant ECG changes and idiopathic elevated bilateral hemidiaphragms. The patient had findings significant for tachypnea, dyspnea, decreased breath sounds at the bases bilaterally, impaired motion of the bilateral lung bases on inspiration and paradoxical respirations. Comprehensive medical testing and evaluation revealed bilateral elevated hemidiaphragms and vital capacity 40% of normal. Weakness of the proximal shoulder girdle and bicep musculature bilaterally was noted. Electromyography was significant for reduced recruitment pattern in the bilateral shoulder girdle musculature. Nerve conduction studies suggested bilateral phrenic neuropathy. This case is an unusual presentation of brachial neuritis affecting the bilateral shoulder girdle with phrenic nerve involvement. The differential diagnosis of acute shoulder pain associated with respiratory symptomatology should therefore include brachial neuritis.

Immune response gene control of lymphocyte proliferation induced by acetylcholine receptor-specific helper factor derived from lymphocytes of myasthenic mice.

The role of lymphokines secreted by acetylcholine receptor (AChR)-reactive lymphocytes in the regulation of an autoimmune response to AChR has not been studied in the human or murine model of myasthenia gravis. We investigated whether AChR-immune lymphocytes derived from mice with experimental autoimmune myasthenia gravis (EAMG) can produce an AChR-specific, genetically controlled soluble factor with biologic activity. AChR-reactive lymphocytes of mice with EAMG secreted an AChR-specific helper factor in vitro, which induced proliferation of AChR-immune but not Mycobacterium tuberculosis-immune lymphocytes. Recombinant, I-A mutant, and monoclonal anti-I-A antibody analyses suggest that AChR-specific helper factor-induced lymphocyte proliferation is controlled by an immune response gene at the I-A subregion of the murine major histocompatibility complex, and is mediated by the I-A molecule.