Local governments and community-based rehabilitation for developmental disabilities: leaving no one behind.

SETTING: The BUDS (not an acronym) institutions comprise a community-based rehabilitation initiative for children and families affected by developmental disabilities in Kerala, India. OBJECTIVE: To explore the role of local governments in the establishment and functioning of BUDS institutions. DESIGN: We used qualitative approaches comprising document review and in-depth interviews with trainers, parents of children with developmental disabilities and elected representatives. RESULTS: BUDS was created by Kudumbasree, a decentralised women empowerment and poverty alleviation initiative. Our findings illustrate the role of local governments in facilitating expansion through the establishment of infrastructure, therapy equipment, transportation and financial allocation for these, as well as through the development of human resources, assistance with enrolment for financial assistance and insurance programmes, and coordination with education and health sectors. Programme implementation varied considerably regarding available infrastructure, staffing and services among the institutions studied. The institutions were physically closed during the COVID-19 pandemic but continued to function in alternative ways. CONCLUSION: Despite variable implementation, local governments have supported the expansion of BUDS institutions, thereby creating more spaces for inclusive and integrated education and rehabilitation of persons with disabilities in Kerala. The expansion over the past two decades and measures during the COVID-19 pandemic suggest resilience and sustainability of the model.

CONTEXTE: Les institutions BUDS (ceci n'est pas un acronyme) ont mis en place une initiative communautaire pour la réhabilitation des enfants et familles touchés par des troubles du développement au Kérala, Inde. OBJECTIF: Analyser le rôle des gouvernements locaux dans la fondation et le fonctionnement des institutions BUDS. MÉTHODES: Nous avons utilisé des approches qualitatives fondées sur une analyse documentaire et sur des entretiens approfondis avec des formateurs, des parents d'enfants atteints de troubles du développement et des représentants élus. RÉSULTATS: BUDS a été créé dans le cadre d'une initiative décentralisée de réduction de la pauvreté et d'autonomisation des femmes, dénommée Kudumbasree. Nos résultats illustrent le rôle des gouvernements locaux dans la facilitation de l'expansion par la mise à disposition d'infrastructures, d'équipements thérapeutiques, de transports et l'allocation de fonds pour ceux-ci, ainsi que par le développement des ressources humaines, l'inclusion dans des programmes d'assistance financière et d'assurances, et la coordination avec les secteurs de l'éducation et de la santé. De grandes différences de mise en œuvre du programme ont été observées entre les institutions à l'étude, en matière d'infrastructures disponibles, de personnel et de services. Les institutions ont fermé leurs portes pendant la pandémie de COVID-19, mais elles continuaient de fonctionner de manière alternative. CONCLUSION: En dépit d'une mise en œuvre variable, les gouvernements locaux ont soutenu le développement des institutions BUDS et ainsi élargi l'espace pour une éducation et une réhabilitation inclusives et intégrées des personnes porteuses de handicaps au Kérala. Le développement de ces institutions au cours des 20 dernières années et les mesures instaurées pendant la pandémie de COVID-19 laissent transparaître la résilience et le caractère durable du modèle.

Palliative care management committees: a model of collaborative governance for primary health care.

SETTING: The community-based primary palliative care programme in Kerala, India, has received international acclaim. Programme functioning is supported through Palliative Care Management Committees (PMCs) at the local government (LG) level. OBJECTIVE: To study the functioning of the PMCs within the decentralised governance space to identify achievements, gaps and notable innovations. DESIGN: This qualitative study included seven key informant interviews (KIIs), 28 in-depth interviews and a review of relevant publicly available policies and documents. Major themes were recognised from the KII transcripts. Codes emerging from the document review and in-depth interview transcripts were mapped into the identified thematic areas. RESULTS: Successful PMCs raised resources like money, human resource, equipment, had good skilled care options for symptom relief and facilitated reduced out-of-pocket expenditure by providing home care and free medicines, and improved access to interventions that addressed the social determinants of suffering like poverty. PMCs had varying managerial and technical capacities. In some LGs, the programme was weak and mostly limited to the supply of medicines, basic aids and appliances to patients' homes. CONCLUSION: Despite varied implementation patterns, PMCs in Kerala are examples of state-supported, community-owned care initiatives, that can potentially address medical and social determinants of suffering.

CONTEXTE: Le programme communautaire de soins palliatifs primaires du Kérala, Inde, a été applaudi sur la scène internationale. Le fonctionnement du programme est soutenu par des Comités de gestion des soins palliatifs (PMC) au niveau des gouvernements locaux (LG). OBJECTIF: Évaluer le fonctionnement des PMC au sein de l'espace de gouvernance décentralisée, afin d'identifier les réussites, les lacunes et les principales innovations. MÉTHODES: Dans le cadre de cette étude qualitative, sept entretiens avec des informateurs clés (KIIs), 28 entretiens approfondis et une analyse des politiques et documents accessibles au public ont été réalisés. Les transcriptions des KII ont permis de faire émerger les thèmes principaux. Les codes émergeant de l'analyse documentaire et des transcriptions des entretiens approfondis ont été associés aux domaines thématiques identifiés. RÉSULTATS: Les PMC les plus performants ont pu mobiliser des ressources, telles que de l'argent, des ressources humaines ou des équipements. Ils proposaient également des options de soins de qualité pour soulager les symptômes, facilitaient la réduction des frais à la charge du patient en fournissant des soins à domicile et des médicaments gratuits, et ont permis d'améliorer l'accès aux interventions qui s'attaquaient aux déterminants sociaux de la souffrance, tels que la pauvreté. Les capacités techniques et de gestion variaient d'un PMC à l'autre. Le programme de certains LG était faible, principalement limité à la fourniture de médicaments et d'aides et de matériels de base pour le domicile des patients. CONCLUSION: Malgré des schémas de mise en œuvre variés, les PMC du Kérala sont des exemples d'initiatives communautaires de santé soutenues par l'état qui peuvent potentiellement s'attaquer aux déterminants sociaux et médicaux de la souffrance.

Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial.

OBJECTIVES: Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India. METHODS: Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials. RESULTS: Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group. CONCLUSIONS: The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

Metformin attenuates effects of cyclophilin A on macrophages, reduces lipid uptake and secretion of cytokines by repressing decreased AMPK activity.

Growing evidence implicates cyclophilin A secreted by vascular wall cells and monocytes as a key mediator in atherosclerosis. Cyclophilin A in addition to its proliferative effects, during hyperglycemic conditions, increases lipid uptake in macrophages by increasing scavenger receptors on the cell's surface. It also promotes macrophage migration across endothelial cells and conversion of macrophages into foam cells. Given the known effects of metformin in reducing vascular complications of diabetes, we investigated the effect of metformin on cyclophilin A action in macrophages. Using an ex vivo model of cultured macrophages isolated from patients with type 2 diabetes with and without coronary artery disease (CAD), we measured the effect of metformin on cyclophilin A expression, lipid accumulation, expression of scavenger receptors, plasma cytokine levels and AMP-activated protein kinase (AMPK) activity in macrophages. In addition, the effects of metformin on migration of monocytes, reactive oxygen species (ROS) formation, lipid uptake in the presence of cyclophilin A inhibitors and comparison with pioglitazone were studied using THP-1 monocytes. Metformin reduced cyclophilin A expression in human monocyte-derived macrophages. Metformin also decreased the effects of cyclophilin A on macrophages such as oxidized low-density lipoprotein (oxLDL) uptake, scavenger receptor expression, ROS formation and secretion of inflammatory cytokines in high-glucose conditions. Metformin reversed cyclophilin A-induced decrease in AMPK-1α activity in macrophages. These effects of metformin were similar to those of cyclophilin A inhibitors. Metformin can thus function as a suppressor of pro-inflammatory effects of cyclophilin A in high-glucose conditions by attenuating its expression and repressing cyclophilin A-induced decrease in AMPK-1α activity in macrophages.

Evaluating genomic DNA extraction methods from human whole blood using endpoint and real-time PCR assays.

The extraction of genomic DNA is the crucial first step in large-scale epidemiological studies. Though there are many popular DNA isolation methods from human whole blood, only a few reports have compared their efficiencies using both end-point and real-time PCR assays. Genomic DNA was extracted from coronary artery disease patients using solution-based conventional protocols such as the phenol-chloroform/proteinase-K method and a non-phenolic non-enzymatic Rapid-Method, which were evaluated and compared vis-a-vis a commercially available silica column-based Blood DNA isolation kit. The appropriate method for efficiently extracting relatively pure DNA was assessed based on the total DNA yield, concentration, purity ratios (A260/A280 and A260/A230), spectral profile and agarose gel electrophoresis analysis. The quality of the isolated DNA was further analysed for PCR inhibition using a murine specific ATP1A3 qPCR assay and mtDNA/Y-chromosome ratio determination assay. The suitability of the extracted DNA for downstream applications such as end-point SNP genotyping, was tested using PCR-RFLP analysis of the AGTR1-1166A>C variant, a mirSNP having pharmacogenetic relevance in cardiovascular diseases. Compared to the traditional phenol-chloroform/proteinase-K method, our results indicated the Rapid-Method to be a more suitable protocol for genomic DNA extraction from human whole blood in terms of DNA quantity, quality, safety, processing time and cost. The Rapid-Method, which is based on a simple salting-out procedure, is not only safe and cost-effective, but also has the added advantage of being scaled up to process variable sample volumes, thus enabling it to be applied in large-scale epidemiological studies.

Psychosocial factors and obesity in 17 high-, middle- and low-income countries: the Prospective Urban Rural Epidemiologic study.

BACKGROUND/OBJECTIVES: Psychosocial stress has been proposed to contribute to obesity, particularly abdominal, or central obesity, through chronic activation of the neuroendocrine systems. However, these putative relationships are complex and dependent on country and cultural context. We investigated the association between psychosocial factors and general and abdominal obesity in the Prospective Urban Rural Epidemiologic study. SUBJECTS/METHODS: This observational, cross-sectional study enrolled 151 966 individuals aged 35-70 years from 628 urban and rural communities in 17 high-, middle- and low-income countries. Data were collected for 125 290 individuals regarding education, anthropometrics, hypertension/diabetes, tobacco/alcohol use, diet and psychosocial factors (self-perceived stress and depression). RESULTS: After standardization for age, sex, country income and urban/rural location, the proportion with obesity (body mass index ≥30 kg m(-)(2)) increased from 15.7% in 40 831 individuals with no stress to 20.5% in 7720 individuals with permanent stress, with corresponding proportions for ethnicity- and sex-specific central obesity of 48.6% and 53.5%, respectively (P<0.0001 for both). Associations between stress and hypertension/diabetes tended to be inverse. Estimating the total effect of permanent stress with age, sex, physical activity, education and region as confounders, no relationship between stress and obesity persisted (adjusted prevalence ratio (PR) for obesity 1.04 (95% confidence interval: 0.99-1.10)). There was no relationship between ethnicity- and sex-specific central obesity (adjusted PR 1.00 (0.97-1.02)). Stratification by region yielded inconsistent associations. Depression was weakly but independently linked to obesity (PR 1.08 (1.04-1.12)), and very marginally to abdominal obesity (PR 1.01 (1.00-1.03)). CONCLUSIONS: Although individuals with permanent stress tended to be slightly more obese, there was no overall independent effect and no evidence that abdominal obesity or its consequences (hypertension, diabetes) increased with higher levels of stress or depression. This study does not support a causal link between psychosocial factors and abdominal obesity.

Construction and Validation of a Women's Autonomy Measurement Scale with Reference to Utilization of Maternal Health Care Services in Nepal.

INTRODUCTION: Women's autonomy is one of the predictors of maternal health care service utilization. This study aimed to construct and validate a scale for measuring women's autonomy with relevance to developing countries. METHODS: We conducted a study for construction and validation of a scale in Rupandehi and further validated in Kapilvastu districts of Nepal. Initially, we administered a 24-item preliminary scale and finalized a 23-item scale using psychometric tests. After defining the construct of women's autonomy, we pooled 194 items and selected 24 items to develop a preliminary scale. The scale development process followed different steps i.e. definition of construct, generation of items pool, pretesting, analysis of psychometric test and further validation. RESULTS: The new scale was strongly supported by Cronbach's Alpha value (0.84), test-retest Pearson correlation (0.87), average content validity ratio (0.8) and overall agreement- Kappa value of the items (0.83) whereas all values were found satisfactory. From factor analysis, we selected 23 items for the final scale which show good convergent and discriminant validity. From preliminary draft, we removed one item; the remaining 23 items were loaded in five factors. All five factors had single loading items by suppressing absolute coefficient value less than 0.45 and average coefficient was more than 0.60 of each factor. Similarly, the factors and loaded items had good convergent and discriminant validity which further showed strong measurement capacity of the scale. CONCLUSIONS: The new scale is a reliable tool for assessing women's autonomy in developing countries. We recommend for further use and validation of the scale for ensuring the measurement capacity.

Maternal periodontal status and preterm delivery: a hospital based case-control study.

BACKGROUND AND OBJECTIVE: Recent studies have presented evidence that periodontal disease in pregnant women may be a determining factor for preterm delivery. However, this finding has not been consistently observed. The present investigation was carried out to explore the association between maternal periodontal disease and preterm delivery in the state of Kerala, India. MATERIAL AND METHODS: The case-control study had a sample of 300 (100 cases and 200 controls) postpartum women over 18 years of age. Cases were women who had undergone spontaneous preterm delivery (< 37 wk of gestation) and controls were women who delivered at term (≥ 37 wk of gestation). Standard, clinical and periodontal examinations were performed at the maternity wards, and the existence of an association between periodontal disease and preterm delivery was evaluated by means of a multivariate logistic regression model that also considered other risk factors for preterm delivery. RESULTS: Periodontitis was diagnosed in 25% of the mothers in the case group and in 14.5% of the mothers in the control group. Logistic regression analysis indicated a risk of nearly threefold for preterm delivery in mothers with periodontitis [adjusted odds ratio (OR(a) ) = 2.72; 95% confidence interval (CI): 1.68-6.84]. The other factors significantly associated with preterm birth were physical exertion (OR(a) = 2.80; 95% CI: 1.18-6.65), a previous history of preterm birth (OR(a) = 2.65; 95% CI: 1.20-5.83) and previous abortion/death of infant (OR(a) = 4.08; 95% CI: 1.56-10.65). CONCLUSION: Periodontal disease is a possible risk factor for preterm delivery in this population.

All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults.

BACKGROUND AND AIM: In India, Kerala has the best health indicators, having experienced dramatic shifts in mortality and fertility. However, the mortality pattern in Kerala has not been studied. In this article, the authors analyze and report the pattern of mortality in the PROLIFE cohort (n = 161,942). METHODS: Data on death were collected through regular home visits using a pretested, structured questionnaire. The data were validated by a physician. The deaths were grouped under disease categories using ICD 10. RESULTS: Out of 4271 deaths recorded during 5 years, diseases of the circulatory system contributed 40%. Coronary heart disease was the leading cause of death in men (31.1%) and women (17.6%). Age-standardized cardiovascular disease (CVD) death rates were 490 for men and 231 for women per 100,000 person years. CONCLUSION: The burden of CVD deaths in this community now exceeds that of industrialized countries.

High prevalence of type 2 diabetes mellitus and other metabolic disorders in rural Central Kerala.

BACKGROUND: Within India, inter-regional disparities in burden of type 2 diabetes mellitus (DM) are expected because of varying lifestyles and demographic patterns. Hence, to estimate the prevalence of DM and impaired fasting glycaemia (IFG), and to explore the predictors of DM, a study was conducted in rural Kerala. METHODS: In 2007, a cross-sectional survey was conducted among 1990 adults (women: 1149; men: 841) of two Panchayat Wards in Venmony Panchayat, Chengannur Taluk, Kerala, India. Those who were already on drugs for DM and/or having fasting plasma glucose (FBS) > or = 126 mg/dL were considered as DMs; those with FBS 100 -125 mg/dL were considered as IFGs. Pearson's Chi-Square test and multiple logistic regression were used for statistical analysis. RESULTS: The response rate was 82.7 percent. The crude- and age-adjusted prevalence of DM was 14.6 percent and 12.5 percent respectively, and that of IFG was 5.1 percent and 4.6 percent respectively. The crude prevalence of hypertension (BP > or = 140/90), hypercholesterolemia (fasting total serum cholesterol > or = 200 mg/dL) and central obesity (WHR > or = 0.80 [women] and > or = 0.90 [men]) was 36.1 percent, 37.0 percent and 85.6 percent respectively. Adjusted for age and sex, DM was significantly associated with positive family history of DM [Odds ratio: 2.81; 95% CI (2.04-3.86)], high socioeconomic status [1.43; (1.04-1.95)], central obesity [3.91; (1.77-8.64)], hypercholesterolemia [1.93; (1.42-2.62)], and hypertension [1.71; (1.24-2.37)]. CONCLUSION: High prevalence of DM even in rural community validates the pandemic trend of DM. The coexistence of other non-communicable diseases amplifies the burden of DM. The impact of socioeconomic transition on the occurrence of DM needs to be explored further.

Risk factors for acute ischaemic stroke in young adults in South India.

BACKGROUND: Stroke is a leading cause of death and disability in developing countries, afflicting individuals at a young age. The contribution of established vascular risk factors to ischaemic stroke in young adults has not been evaluated systematically in Indians. METHODS: We conducted a case control study in 214 South Indian patients with first acute ischaemic stroke that occurred between the ages of 15 and 45 years, 99 age and sex matched hospital controls and 96 community controls. We compared the prevalence of the following risk factors: smoking, elevated blood pressure, high fasting blood glucose and abnormal lipids. RESULTS: Compared with community controls, stroke patients had a higher prevalence of smoking (multivariable adjusted odds ratio (OR) 7.77, 95% CI 1.93 to 31.27), higher systolic blood pressure (OR per SD increment of 1.88, 95% CI 1.01 to 3.49) and fasting blood glucose (OR per SD increment of 4.55, 95% CI 1.63 to 12.67), but lower high density lipoprotein (HDL) cholesterol (OR per SD increment of 0.17, 95% CI 0.09 to 0.30). Compared with hospital controls, stroke patients had a higher prevalence of smoking (OR 3.95, 95% CI 1.61 to 9.71) and lower HDL cholesterol (OR per SD increment 0.27, 95% CI 0.17 to 0.44). The presence of > or = 3 metabolic syndrome components was associated strongly with stroke (OR 4.76, 95% CI 1.93 to 11.76; OR 2.09, 95% CI 1.06 to 4.13) compared with community and hospital controls. CONCLUSIONS: Key components of the metabolic syndrome and smoking are associated with ischaemic stroke in young South Indian adults. Our observations underscore the importance of targeting adolescents and young adults for screening and prevention to reduce the burden of ischaemic stroke in young adults.

Serum 25-hydroxyvitamin D3 levels are elevated in South Indian patients with ischemic heart disease.

Several lines of evidence point to a possible relationship between vitamin D and cardiovascular disease. Animal experiments and observational studies in humans suggest vitamin D to be arteriotoxic and an association of high intake of vitamin D with increased incidence of ischemic heart disease (IHD). The major source of vitamin D in adults is vitamin D synthesized in the skin through exposure to the sun. In tropical environment there is a possibility of high level of solar exposure and enhanced serum levels of vitamin D in the population. We explored the relation between serum level of 25-hydroxyvitamin D3 and IHD in a case-control study involving 143 patients with either angiographic evidence of coronary artery disease or patients with acute myocardial infarction and 70 controls, all men in the age group of 45-65 years. Fasting blood samples were collected, serum separated and serum levels of 25-hydroxyvitamin D3 was measured by protein binding radioligand assay. Serum levels of cholesterol, triglyceride, calcium, magnesium and inorganic phosphate were also determined. Prevalences of diabetes, hypertension and smoking history were noted. Statistical comparisons of variables between cases and controls were done using chi2-tests. Multivariate logistic regression analysis was done to examine the association of IHD with serum levels of 25-hydroxyvitamin D3 controlling for selected variables. Serum levels of 25-hydroxyvitamin D3, calcium, inorganic phosphate, total cholesterol, low density lipoprotein and triglycerides were elevated in a higher proportion of patients, compared to controls. Serum levels of 25-OH-D3 above 222.5 nmol/l (89 ng/ml) was observed in 59.4% of cases compared to 22.1% in controls (p < 0.001; unadjusted odds ratio (OR): 5.17; 95% confidence interval (CI): 2.62-10.21). When controlled for age and selected variables using the multivariate logistic regression, the adjusted OR relating elevated serum 25-hydroxyvitamin D3 levels (> or = 222.5 nmol/l, > or = 89 ng/ml) and IHD is 3.18 (95% CI: 1.31-7.73). Given the evidences for the arteriotoxicity of vitamin D, further investigations are warranted to probe whether the elevated serum levels of 25-hydroxyvitamin D3 observed in patients with IHD in a tropical environment has any pathogenic significance.

High risk for coronary heart disease in Thiruvananthapuram city: a study of serum lipids and other risk factors.

There is a trend towards increase in the incidence of coronary heart disease among Indian population. Also, little information is available on the population distribution of serum lipid components and risk factors for coronary heart disease in Kerala, a state fast turning urban. To study the serum lipid profile and the prevalence of other risk factors for coronary heart disease in the residents of an urban housing settlement in Thiruvananthapuram, fasting blood sample was collected from 206 (64%) residents above the age of 19 years and analysed for plasma glucose and various fractions of serum lipids. A detailed questionnaire on the clinical profile and history of the subjects, and measured weights and heights was also administered. Mean serum total cholesterol was 223.7 +/- 45.3 mg/dL; 223.7 +/- 44.9 mg/dL among males and 223.7 +/- 45.8 mg/dL among females. Mean high-density lipoprotein cholesterol was consistently higher in females in all age groups, while mean low-density lipoprotein cholesterol was higher in males till the age group 40-49 after which the pattern was reversed. Mean total cholesterol in the age range 35-64, after age standardisation, was 229.4 mg/dL. Mean serum total cholesterol was higher in this sample when compared to US population, as well as north and west Indian populations. Thirty-two percent subjects were in the highest risk category with serum cholesterol exceeding 239 mg/dL, while in the US population this fraction constituted only 18 percent. Other risk factors such as high blood pressure, obesity, diabetes, sedentary lifestyle and smoking also had a high prevalence in this population. In this settlement of urban residents in Thiruvananthapuram, serum total cholesterol and low-density lipoprotein cholesterol are high. The causes are likely to be dietary. Combined with the high prevalence of other risk factors such as obesity, hypertension, smoking, diabetes and lack of exercise, this situation demands a preventive programme.

Historical analysis of the development of health care facilities in Kerala State, India.

Kerala's development experience has been distinguished by the primacy of the social sectors. Traditionally, education and health accounted for the greatest shares of the state government's expenditure. Health sector spending continued to grow even after 1980 when generally the fiscal deficit in the state budget was growing and government was looking for ways to control expenditure. But growth in the number of beds and institutions in the public sector had slowed down by the mid-1980s. From 1986-1996, growth in the private sector surpassed that in the public sector by a wide margin. Public sector spending reveals that in recent years, expansion has been limited to revenue expenditure rather than capital, and salaries at the cost of supplies. Many developments outside health, such as growing literacy, increasing household incomes and population ageing (leading to increased numbers of people with chronic afflictions), probably fueled the demand for health care already created by the increased access to health facilities. Since the government institutions could not grow in number and quality at a rate that would have satisfied this demand, health sector development in Kerala after the mid-1980s has been dominated by the private sector. Expansion in private facilities in health has been closely linked to developments in the government health sector. Public institutions play by far the dominant role in training personnel. They have also sensitized people to the need for timely health interventions and thus helped to create demand. At this point in time, the government must take the lead in quality maintenance and setting of standards. Current legislation, which has brought government health institutions under local government control, can perhaps facilitate this change by helping to improve standards in public institutions.

Type 2 diabetes in southern Kerala: variation in prevalence among geographic divisions within a region.

BACKGROUND: Numerous surveys carried out in India report the high prevalence of type 2 diabetes. Such studies have not included the population of Kerala. We estimated the prevalence of type 2 diabetes mellitus in Neyyattinkara taluk, Thiruvananthapuram district, Kerala state. METHODS: All panchayat wards in the taluk were grouped into urban, highland, midland or coastal, and one ward from each stratum was randomly selected for the study. All households were listed and adults, 20 years or older, screened for high (> 110 mg/dl) random blood sugar (RBS) by a glucometer test. Those with high RBS were reassessed by a fasting oral glucose tolerance test (OGTT), consisting of initial examination of venous blood for fasting plasma glucose (FPG) values, administration of 75 g of glucose dissolved in distilled water, and examination of venous blood for postprandial plasma glucose (PPPG) exactly 2 hours after the administration of glucose. Diabetes was diagnosed according to the World Health Organization criteria as either FPG > 139 mg/dl, or PPPG > 199 mg/dl, or both. Impaired glucose tolerance (IGT) was diagnosed if PPPG was 140-199 mg/dl. RESULTS: Out of 4988 eligible subjects, 3899 were available for the study, a response rate of 78.2%. Response was highest in the highland area (86.2%), and lowest in the coastal area (73.6%). The overall crude prevalence rate of type 2 diabetes was 5.9%. It was highest in the urban (12.4%), followed by midland (8.1%), highland (5.8%), and coastal (2.5%) regions. Ageing was associated with greater prevalence of type 2 diabetes in all regions and both sexes. Women showed a higher prevalence in the highland and coastal areas and men in the urban and midland areas. When compared to a population with standard age structure suggested by the World Health Organization for international comparisons, prevalence in the age group 30-64 years was found to be 16.9% in the urban, 10.1% in the midland, 6.8% in the highland and 3.6% in the coastal regions, respectively. Overall age-adjusted prevalence of type 2 diabetes in 30-64-year-olds in Neyyattinkara was 9.2% among men, 7.4% among women, and 8.2% for all persons. There was not much difference in prevalence if the American Diabetes Association criteria for diagnosis were used. The prevalence of impaired glucose tolerance was fairly low in this population. Out of 229 diabetics in the sample, 175 (76.5%) were already diagnosed and under treatment, while our survey identified 54 new diabetics (23.5%). CONCLUSION: Though prevalence of type 2 diabetes is high in this population, the detection rate is also high. However, impaired fasting glucose and impaired glucose tolerance are low. The reasons for this need to be elucidated.

Pattern of cardiac fibrosis in rabbits periodically fed a magnesium-restricted diet and administered rare earth chloride through drinking water.

It has been postulated that causation of the tropical cardiomyopathy endomyocardial fibrosis (EMF) is linked to magnesium (Mg) deficiency and cardiac toxicity of the rare earth element cerium (Ce). The aim of the present study was to define the myocardial lesions in rabbits that were fed on Mg-restricted diet (70-80 ppm) periodically and were provided drinking water contaminated with rare earth chloride (1 g/L). Forty New Zealand white rabbits were divided into four groups following a 2 x 2 factorial design. Two groups were periodically fed on Mg-restricted diet with one of them receiving water contaminated with rare earth chloride. The other two groups were continuously fed on Mg-sufficient diet (350-400 ppm) with one of them receiving water contaminated with rare earth chloride. All animals were sacrificed at the end of 6 mo. Cardiac tissues were subjected to histology, elemental analysis (calcium [Ca], Mg, and Ce) and estimation of collagen content and collagen phenotypes. Histological lesions were compared with those of EMF in humans and those of acute Mg deficiency in animals. The results suggest that in rabbits, recurrent episodes of Mg deficiency lead to myocardial fibrosis similar to the pattern observed in human EMF.

Geographical distribution of endomyocardial fibrosis in south Kerala.

BACKGROUND: Endomyocardial fibrosis (EMF) is a chronic heart disease confined to a few geographically specific locations within 15 degrees of the equator. Several aetiological hypotheses exist, among them filarial infection, eosinophilia, and toxic effect of the monazite element cerium from the soil. This study attempts to find out whether the pattern of distribution of EMF in south Kerala in India is consistent with the geochemical hypothesis. METHODS: From hospital records we identified all patients from south Kerala who had a confirmed diagnosis of EMF during the period 1978-1994. Our controls were patients from the southern districts diagnosed to have rheumatic heart disease (RHD) during the same period. We traced their residence address to the administrative subunit of taluk, and plotted the distribution of patients with EMF and RHD for each taluk in south Kerala. The taluks were then grouped into areas of high (> 4/100,000), medium (2.01-4/100,000), and low (< or = 2/100,000) density in each case. RESULTS: We identified an area of high density of EMF comprising four taluks near the coastline situated within the districts of Alapuzha, Kollam, and Pathanamthitta. Two coastal taluks in Kollam and Alapuzha districts are known areas of deposits of monazite elements in the state. Geographical distribution is not related to prevalence of filariasis and eosinophilia. CONCLUSION: Coexistence of high density of occurrence of EMF and deposits of monazite elements support the geochemical hypothesis.