Towards a Better Health Care Delivery System: The Tamil Nadu model.

The Tamil Nadu model of public health is renowned for its success in providing quality health services at an affordable cost especially to the rural people. Tamil Nadu is the only state with a distinctive public health cadre in the district level and also the first state to enact a Public Health Act in 1939. Tamil Nadu has gained significant ground in the various aspects of health in the last few decades largely because of the significant reforms in its health sector which dates back to 1980s which saw rigorous expansion of rural health infrastructure in the state besides deployment of thousands of multipurpose health workers as village health nurses in rural areas. Effective implementation of Universal Immunization Programme, formation of Tamil Nadu Medical Services Corporation for regulating the drug procurement and promoting generic drugs, early incorporation of indigenous system of medicine into health care service, formulation of a health policy in 2003 by the state with special emphasis on low-income, disadvantaged communities alongside efficient implementation of The Tamil Nadu Health Systems Project (TNHSP) are the major factors which contributed for the success of the state. The importance of good political commitment and leadership in the health gains of the state warrants special mention. Moreover, the economic growth of the state, improved literacy rate, gender equality, and lowered fertility rate in the last few decades and contributions from the private sector have their share in the public health success of the state. In spite of some flaws and challenges, the Tamil Nadu Model remains the prototype health care delivery system in resource-limited settings which can be emulated by other states also toward a better health care delivery system.

Microbial degradation of chitin waste for production of chitosanase and food related bioactive compounds.

Ecological samples rich in microbial diversity like cow dung, legume rhizosphere, fish waste and garden soil were used for isolation of chitosan-degrading microorganisms. Selected isolates were used for production of chitosanase and food related bioactive compounds by conversion of biowaste. Production of glucosamine (Gln), N-acetylglucosamine (NAG), chitooligosaccharides (COS), antioxidants, antibacterial compounds and prebiotics was carried out by microbial fermentation of biowaste. The highest chitosanase activity (8 U/mL) was observed in Aspergillus sp. isolated from fish market waste and it could produce Gln and NAG while Streptomyces sp. isolated from garden soil was able to produce COS along with Gln and NAG. Radical scavenging activity was observed in culture supernatants of 35% of studied isolates, and 20% isolates secreted compounds which showed positive effect on growth of Bifidobacterium. Antibacterial compounds were produced by 40% of selected isolates and culture supernatants of two microbial isolates, Streptomyces zaomyceticus C6 and one of garden soil isolates, were effective against both gram positive and negative bacteria.

Effect of classifying disease states in genetic association studies for paratuberculosis.

Genetic association studies are a means to elucidate underlying genetic regulation of host-pathogen interaction, immune response, and the fate of infection. Diseases such as paratuberculosis in cattle lack definitive diagnostic criteria, thereby complicating the definition of infection status as an outcome for genetic association studies. A study was performed to evaluate the potential bias in estimates of effect and differences in statistical power associated with parallel test interpretation, latent probability of infection adjusted for imperfect test sensitivity and specificity, and multinomial outcomes in cohorts of cattle simulated using Monte Carlo sampling methods. Test results were simulated for microbial culture of feces for Mycobacterium avium subsp. paratuberculosis (MAP) and serum ELISA for anti-MAP antibody using estimates of test sensitivity and specificity. A range of disease allele frequencies and levels of association were considered. Case-control study populations were drawn from the simulated cohorts and the association between the disease allele and infection status was evaluated using logistic regression for binary outcomes and polytomous regression for multinomial outcomes. For the majority of the classification and analytical methods evaluated, estimates of effect were biased toward the null. Frequentist approaches to analysis of the latent probability of infection and multinomial classifications based upon results of culture of feces for MAP demonstrated the smallest degree of bias. Power to detect associations was generally low for all models, but improved with larger effects and higher allele frequencies. Imperfect specificity of serum ELISA was a major factor in the degree of bias observed and statistical power. The results of this study indicate that the method of classifying infection status must be considered carefully in genetic association studies for paratuberculosis and other diseases with similar challenges in defining infection status, and study designs should be modified to accommodate relative advantages and disadvantages of available methods.

Co-morbidities in people living with epilepsy: hospital based case-control study from a resource-poor setting.

PURPOSE: Evaluating co-morbidity in people living with epilepsy (PWE) is essential and its modification might improve their quality of life. We analyzed the various co-morbidities in PWE in comparison with the normal healthy controls. METHOD: This prospective study was conducted from July 2006 to December 2007. PWE attending neurology outpatient services (n=250) with age ranging from 16 to 60 years (29.66+/-11.31 years; M:F 116:134) were recruited after obtaining informed consent. Healthy matched controls (n=250; 30.35+/-11.05 years; M:F 114:136) were also recruited. RESULTS: The seizure types were: generalized (62.4%), complex-partial (21.6%), simple-partial (8.8%), and unclassified (7.2%). Sixty-nine percent were on monotherapy, and rest required polytherapy, with 90.8% on adequate dosages of anti-convulsants. About 83.2% were compliant and 70.4% had satisfactory control of seizures. At least 1 co-morbid condition was noted in 152 (60.8%) cases and among them, 62 (24.8%) had > or =2 co-morbidities. Control population was also evaluated for the presence of same co-morbidities and compared with cases. The various significant co-morbidities included: migraine (cases: 25.6% vs. controls: 15.2%; p=0.02), anxiety (cases: 2.4% vs. controls: 0%; p=0.04), depression (case: 5.2% vs. controls: 0.4%; p=0.0009), sleep disturbances (case: 6.8% vs. controls: 0.4%; p=0.0002), neurocysticercosis (cases: 15.6% vs. controls: 0%; p=<0.001), pulmonary tuberculosis (cases: 3.6% vs. controls: 0%; p=0.002) and extra-pulmonary tuberculosis (cases: 2.8% vs. controls: 0.4%; p=0.03). Less common co-morbidities were hypertension, diabetes, osteoarthritis, asthma, hypothyroidism, and acid-peptic disease. CONCLUSION: In people living with epilepsy attending neurology OPD services, co-morbid illnesses were commonly observed compared to healthy controls.

Continuing medical education on antiretroviral therapy in HIV/AIDS in India: needs assessment and impact on clinicians and allied health personnel.

BACKGROUND: Clinicians and associated health professionals charged with prescribing antiretroviral therapy (ART) deal with continuously evolving new drugs and combinations. To meet the needs of clinicians in India for ongoing education in this field, continuing medical education (CME) programmes on ART for HIV/AIDS were developed, conducted, evaluated and revised. Over a 2-year period, 2005-2007, 3 CME programmes for ART were conducted for physicians and a fourth (predominantly) for paediatricians. METHODS: Both 1- and 2-day CME programmes on various aspects of ART were held on weekends for professionals treating patients with AIDS in Delhi and adjacent states. Topics included characteristics of ART drugs, their dosages, monitoring and toxicity management, adherence, complications of therapy, dealing with treatment failure and HIV co-infections. These topics were addressed in lectures and group discussions and via case presentations. Programmes were evaluated by anonymous response to questionnaires, by a 1-year follow up of participants and by informal discussions with participants and faculty. Detailed analyses and a recommended format for these programmes are presented. RESULTS: The CMEs were attended primarily by clinicians (physicians and paediatricians). Nurses, laboratory scientists, and others involved in the treatment of AIDS also attended the programmes. An interactive workshop format was evolved with substantial time devoted to discussions and case analyses. One-day programmes such as the one included here can be comprehensive and effective. The educational needs of healthcare professionals who provide care and support to patients receiving ART were similar to those of the prescribing doctors. Because of new drugs being made available and with continued clinical experience, updated programme content was required each year. Participants preferred case-based interactive discussions rather than didactic lectures. Participants suggested that there should be more time for discussion after each talk. CONCLUSION: Annual CME programmes focused on ART are required to meet the professional needs of clinicians in India for providing quality care management to patients with AIDS.

Profiling ß-thalassaemia mutations in India at state and regional levels: implications for genetic education, screening and counselling programmes.

UNLABELLED: Thalassaemia and sickle cell disease have been recognized by the World Health Organization as important inherited disorders principally impacting on the populations of low income countries. To create a national and regional profile of ß-thalassaemia mutations in the population of India, a meta-analysis was conducted on 17 selected studies comprising 8,505 alleles and offering near-national coverage for the disease. At the national level 52 mutations accounted for 97.5% of all ß-thalassaemia alleles, with IVSI-5(G>C) the most common disease allele (54.7%). Population stratification was apparent in the mutation profiles at regional level with, for example, the prevalence of IVSI-5(G>C) varying from 44.8% in the North to 71.4% in the East. A number of major mutations, such as Poly A(T>C), were apparently restricted to a particular region of the country, although these findings may in part reflect the variant test protocols adopted by different centres. Given the size and genetic complexity of the Indian population, and with specific mutations for ß-thalassaemia known to be strongly associated with individual communities, comprehensive disease registries need to be compiled at state, district and community levels to ensure the efficacy of genetic education, screening and counselling programmes. At the same, time appropriately designed community-based studies are required as a health priority to correct earlier sampling inequities which resulted in the under-representation of many communities, in particular rural and socioeconomically under-privileged groups. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11568-010-9132-3) contains supplementary material, which is available to authorized users.

Withdrawal of penicillamine from zinc sulphate-penicillamine maintenance therapy in Wilson's disease: promising, safe and cheap.

BACKGROUND: Penicillamine, once considered the cornerstone of treatment for Wilson disease (WD), is rather expensive and toxic, and often causes neurological worsening. Zinc sulphate, aiming at the treatment of free-copper toxicosis, has emerged as effective, safe and cheap alternative. AIM: To assess the effect of withdrawal of penicillamine from maintenance treatment with penicillamine and zinc sulphate. PATIENTS AND METHODS: 45 patients of WD (M:F: 28:17; age at diagnosis: 13.5+/-63 years), on both penicillamine (P) and zinc sulphate (Zn), couldn't continue penicillamine due to financial constraints. Their clinical data, disability and impairment scores (Schwab and England (S&E) score, Neurological Symptom Score (NSS), and Chu staging) and follow-up data of patients maintained only on zinc sulphate were recorded. RESULTS: Majority of patients (84.4%) had neuropsychiatric manifestations. The mean duration of treatment with penicillamine (P) and zinc sulphate (P+Zn), before stopping penicillamine, was 107.4+/-67.3 months. 40 patients improved variably, while the rest didn't. They received only zinc sulphate for 27.2+/-8.5 months (range: 12 to 34) and 44 patients (97.7%) remained status quo or improved marginally. Only one patient reported worsening in dysarthria. Their disability and impairment scores during combination (penicillamine and zinc sulphate) and Zn alone were: Chu (1.3+/-0.5 vs. 1.5+/-1.9; p=0.4), NSS (1.8+/-3.1 vs. 1.5+/-2.3; p=0.03) and S&E (96.4+/-5.6 vs. 98.6+/-3.5; p=0.03). There were no adverse effects. CONCLUSIONS: Withdrawal of penicillamine from zinc sulphate/penicillamine maintenance therapy for patients with Wilson's disease was effective, safe and economic, for almost all patients. This retrospective study reiterates that zinc sulphate may be used as a preferred mode of treatment for patients with Wilson's disease.

A prospective assessment of carpal tunnel surgery with respect to age.

Six hundred and thirty five carpal tunnel decompressions in 490 patients were studied prospectively in two hand surgery centres to assess the effect of increasing age on the outcome after surgery. The outcome was assessed using the Levine-Katz carpal tunnel questionnaire, Tinel's sign, Phalen's test, Semmes-Weinstein monofilaments and pinch and grip strengths. Assessments were made pre-operatively, at 2 weeks and 6 months postoperatively. Information was also sought concerning co-morbid conditions. Cases were divided into four groups (less than 40 years of age, 40 to 60, 61 to 80, and over 80 years of age). Patients improved significantly in all age groups after carpal tunnel surgery. Despite a relatively high number of co-morbidities, older patients had an acceptable complication rate and their improvement was comparable to all other age groups.

Dietary fiber assessment of patients with irritable bowel syndrome from Northern India.

BACKGROUND: Data on the absolute fiber intake and the source of dietary fiber intake in patients with irritable bowel syndrome (IBS) have been lacking in northern Indians. OBJECTIVE: To find out the absolute fiber intake from different sources of food items in patients with IBS and healthy subjects from northern India. METHODS: Using the 72-hour recall method, dietary intake of macronutrients and fiber was determined in 33 consecutive adult patients with IBS and 33 age- and gender-matched healthy controls. RESULTS: The patients consumed lower amounts of macronutrients (protein 60.4 g vs 79.3 g, fat 47.7 g vs 65.7 g, and carbohydrates 294.6 g vs 339.8 g) and dietary fiber (8.1 g vs 15.7 g) than the control subjects. Though the patients consumed similar amount of pulses as the controls (46.6 [25.0] vs 46 [19.6] g/day), their fiber intake from pulses was lower (0.8 [0.7] vs 1.4 [0.9] g/day). The intake of fiber from vegetables and fruits was also significantly lower in patients (2.1 and 0.5 g/day, respectively) than in control subjects (5.8 and 3.9 g/day, respectively; p< 0.001 each). CONCLUSION: Total dietary fiber intake and intake of fiber from vegetables, fruits and pulses are lower in patients with IBS from northern India than in control subjects.

Study of impact of nutrition & health day strategy on the coverage rates of supplementary nutrition and health interventions among the ICDS beneficiaries in a rural block of Madhya Pradesh.

To study the trends of beneficiary coverage (pregnant and lactating women and children less than two years of age) for utilization of supplementary nutrition and health services in a rural block before and after the launch of a strategy to converge Health & Integrated Child Development Services (ICDS) on a single day christened "Nutrition and Health Day" (NHD). It is a before and after intervention design in rural ICDS block Amarwada in district Chhindwada. As a part of intervention, NHD were organised on which convergent services of Health & ICDS were made available to the beneficiaries. On the weekly NHDs, uncooked supplementary nutrition for the week was distributed to pregnant and lactating mothers and children under two. The Health worker visited the Anganwadi Centre (AWC) and immunized children and pregnant women, distributed IFA, Vitamin A and provided health and nutrition education. The study assessed the impact of these interventions on the coverage rates of the services. Study was conducted between May 97 and March 98. The routine monitoring reports of the ICDS and Health System of the state government were used as study tools. The study sample comprised of AWC beneficiaries in the project area. The total population of the block was 89,476. Participation in the supplementary nutrition program (SNP) increased two to three folds in all categories of the target population. Immunization and Vitamin A coverage levels for children also showed an increase of about 3 and 5-8 times from baseline status respectively in a year's time. Among pregnant women, Tetanus Toxoid (TT) and Iron and Folic Acid (IFA) utilization rates have also shown two and five fold increase respectively.

A leg ulcer clinic: audit of the first three years.

This study documents the establishment in 1994 of a leg ulcer clinic in Hobart, Tasmania. Information relating to patient demographics, results of treatment and costs required to successfully operate the clinic were studied prospectively. Over a 40-month period, 345 patients attended the clinic on 1154 occasions. Ulcers were classified as venous (59%), arterial (19%), mixed venous and arterial disease (13%), pressure injury (3%), traumatic injury (2%) or rheumatoid disease (1%). A wide range of dressings and bandages were used during treatment. The clinic cost an average of A$42,683 per annum to run. This information has the potential to be of use as a guide for any organisation planning to open a similar clinic.

A normal electrocardiogram precludes the need for left ventriculography in the assessment of coronary artery disease.

OBJECTIVE: To assess whether a normal electrocardiogram can identify good left ventricular function and obviate the need for routine left ventriculography in patients undergoing cardiac catheterization for suspected coronary artery disease. DESIGN: A prospective study of patients undergoing cardiac catheterisation. SETTING: A regional cardiac centre. PATIENTS: The electrocardiograms, coronary angiograms, and left ventriculograms of 391 consecutive patients undergoing investigations for suspected coronary artery disease were entered into the study. Patients with arrhythmias and cardiac pathologies other than coronary artery disease were excluded. MAIN OUTCOME MEASURES: The electrocardiogram was assessed using a 29 point QRS scoring system, and classified by two cardiologists and a trainee cardiologist as normal or abnormal. Left ventricular function was assessed by digital ventriculography. RESULTS: The sensitivity, specificity, and negative predictive value of a QRS score of 0 (normal QRS complexes) for discriminating good left ventricular function (ejection fraction > or = 50%) were 92.6%, 41.5%, and 97.2%, respectively. The figures for a normal electrocardiogram as assessed by a doctor were 96.3%, 40.4%, and 98.6% for cardiologist A; 96.3%, 37.4%, and 98.4% for cardiologist B; and 94.4%, 49.6%, and 98.2% for the cardiology trainee. CONCLUSIONS: If a cardiologist judges the ECG to be normal, left ventriculography is unnecessary and a formal QRS score does not improve reliability of this clinical judgment. Adopting this strategy would save 30-40,000 Pounds in consumables and 65-87 hours of catheter laboratory and staff time for a department catheterising 3000 patients with suspected coronary artery disease annually.

Cell mediated immune status in malignancy--pretherapy and post-therapy assessment.

Twenty-eight cases of malignancies of different kinds were studied to assess T-cell activity and population before and after institution of therapy. Fifteen cases were diagnosed as non-metastasising squamous cell carcinoma of larynx, pharynx, laryngopharynx, hypopharynx and tonsils. Seven cases were non-metastasising infiltrating duct carcinoma of breast and 6 cases were non-Hodgkin's lymphoma (NHL). It was observed that 3 out of 15 cases (20%) of squamous cell carcinoma cases were Mantoux test (MT) negative with a T-cell population of less than 40%, 2 out of 7 cases (28.6%) of infiltrating duct carcinoma of breast were MT negative with a T-cell population of less than 40% and 3 out of 6 cases (50%) of NHL were MT negative with a T-cell population of less than 40%. The normal controls, consisting of apparently normal healthy adults, had a T-cell population of more than 40% and were all MT positive. The patients who showed a negative skin test and a T-cell population less than 40% were further subjected to assessment of T-cell population and activity after appropriate therapy, and clinical cure of the disease. It was observed that 2 out of 3 cases (66.66%) of squamous cell carcinomas, 2 out of 2 cases (100%) of adenocarcinomas and one out of 3 cases (33.33%) of NHL showed positive conversion with a T-cell population of more than 40%.

Gender disparities in social well-being: an overview.

PIP: The authors report on the status of the literature on gender disparities in social well-being, document current research trends in the field, identify gaps in current research, and suggest new areas/methods of analyzing the question of social well-being with regard to gender inequalities. The causes of female subordination and lower status are discussed in sections on participation in economic activities and marginalizing the effects of economic development, female reproductive roles, the family, and male control over female sexuality and monogamous marriage. Education, work and employment, empowerment, and nutrition and health are then considered as indicators of social well-being and gender disparities. The model proposed for the study of gender disparities in social well-being calls for such a study in the overall societal context, the use of more primary source empirical evidence, the designation of the household as the unit of analysis, the inclusion of various social categories in the analysis, and the study of all aspects of social well-being.^ieng