Intracranial Fungal Granulomas: A Single Institutional Clinicopathologic Study of 66 Patients and Review of the Literature.

INTRODUCTION: Fungal granulomas of the central nervous system are rare and have a high rate of mortality and morbidity, irrespective of treatment. The authors report their experience of managing 66 patients during 15 years and discuss the clinical, radiological, surgical, and pathologic findings. This series is among the largest reported. MATERIAL AND METHODS: A retrospective analysis was performed on patients with intracranial fungal granulomas (ICFGs), treated in the authors' institution, between January 1997 and May 2011. Only mass-forming histopathologically proven ICFGs were included in this study. RESULTS: The age of the patients ranged from 7 years to 67 years (mean = 32.3 years), and most patients were in the third and fourth decades of life. The study population comprised 47 male and 19 female patients. The most common symptom was headache (41 patients), followed by vomiting (16 patients) and blurring of vision (16 patients). Only 3 patients presented with fever. The duration of symptoms was less than 6 months in all cases and less than 3 months in 39 cases. Anterior cranial fossa and frontal lobe was involved in 35 cases (54.5%), followed by middle cranial fossa in 20 cases (30.3%). Three cases had granulomas in the cerebellopontine angle. Three cases had multicompartmental involvement, and 4 had multilobar involvement. Nine patients had predisposing factors for fungal infection Based on clinical and imaging data, preoperative diagnosis of a possible fungal lesion was made in 44 (some had only computed tomography imaging) patients. All the patients were treated surgically, followed by antifungal treatment with amphotericin-B and/fluconazole/itraconazole for a period of 6 weeks. Eight patients had symptomatic recurrence of lesions 3-12 weeks after treatment and underwent reoperation. Six patients were lost to follow-up. Nine patients died in the postoperative period (within 30 days postoperatively). Fifteen patients died during follow-up because of recurrent lesions, repeat surgery, renal failure, and unrelated causes. Overall mortality was 24 (36.3%). Poor neurologic status before surgery, emergency craniotomy, severe brain edema with mass effect, and opening of ventricles during surgery were associated with poor outcome. Aspergillus species were the causative organism in an overwhelming majority of patients (n = 52) followed by Mucor in 7 cases, Cladosporium in 3 cases, eumycetoma in 2 cases, and maduramycosis and blastomycosis in 1 case each. CONCLUSION: ICFGs have high rates of morbidity and mortality. Early diagnosis, radical surgery, and antifungal treatment for 6 weeks may improve outcome. Poor neurologic status of patients at the time of presentation, immunocompromised state, contamination of ventricular cerebrospinal during surgery, and renal failure (attributable to amphotericin-B) are associated with poor outcome.

Public health manpower: an alternative model.

The Bhore committee observed that "if nation's health is to be built, the health program should be developed on the foundation of preventive health work and that such activities should proceed side by side with the treatment of patients." The committee defined two categories of workforce: one for the personal care and the other for the public health namely, public health nurses and sanitary inspectors for public health and nurse, midwife, and pharmacist for personal care. Recommendations of successive health committees lead to amalgamation of personal care services and public health services. Single focus programs and amalgamation of different cadre of Grassroots staff lead to dilution of public health services and more focused on different program-based personal care services. To carry out public health services, we need a sufficiently knowledgeable, well-skilled and competent mid-level supervisory public health workforce who can support and strengthen the performance of the existing multipurpose workers. Increased understanding of the influence of different determinants on health and well-being and also scientific progress to combat the environmental and biological effects on health has widened the gap between the actual need of human resources and expanding public health services needs. Keeping in view of the above and meet the challenges, a 3-year course of Bachelor in Public Health is conceived by the Indian Academy of Public Health. Professional responsibilities expected from this new cadre of workforce are also discussed in this article.

Prevalence and determinants of diabetes mellitus in the Indian industrial population.

AIM: To highlight the regional difference in the prevalence of diabetes mellitus (DM) and to explore determinants in variability in the Indian industrial population. METHODS: A cross-sectional survey was carried out among the employees and their family members (10 930 individuals, mean age 39.6 years, 6764 male) of eleven medium-to-large industries from diverse sites in India, using a stratified random sampling technique. Information on behavioural, clinical and biochemical risk factors of DM was obtained, through standardized instruments. DM was diagnosed when fasting blood glucose was > or = 7.0 mmol/l and/or individuals took drug treatment for DM. Multiple logistic regression analysis was carried out to identify the potential predictors of DM. RESULT: In the 20 to 69-year-old age group, the crude prevalence of DM and impaired fasting glucose was 10.1 and 5.3%, respectively. Urban sites had a higher prevalence and awareness of DM status. Individuals in the lower education group had a high prevalence of DM (11.6%). In diabetic subjects, 38.4% were unaware that they had diabetes. Waist-circumference-to-height ratio had a higher DM predictive power than waist circumference and body mass index. The risk factors associated with overall prevalence of DM were: age, sex, low-education level, family history of DM, hypertension and overweight/obesity. Interaction of risk factors was observed only in urban high-prevalence sites. CONCLUSION: There are wide regional variations in the prevalence of DM in India. The high burden of undetected diabetes, even in settings with universal access to on-site health care, highlights the need for innovative prevention and control strategies.

Prevalence of hypertension and its risk factors in a tea garden community of Dibrugarh District, Assam.

A cross-sectional study was conducted during August 2003- July 2004 to assess the prevalence of hypertension among a tea garden population in a district of Assam and to ascertain the identified risk factors. 510 labourers aged 20-59 years were studied. Overall prevalence of hypertension was 33.3% with no significant sex difference. 30.2% had history of smoking and 76.7% of tobacco chewing; 78.4% consumed alcohol (regular and occasional), 5.7% were overweight and 14.3% underweight. Waist hip ratio was normal in 89.2% subjects. The association between increasing age and hypertension could be established in univariate analysis. On multiple logistic regression analysis regular alcohol intake was also found to be significantly associated factor with hypertension.

Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations.

OBJECTIVE: To establish a surveillance network for cardiovascular diseases (CVD) risk factors in industrial settings and estimate the risk factor burden using standardized tools. METHODS: We conducted a baseline cross-sectional survey (as part of a CVD surveillance programme) of industrial populations from 10 companies across India, situated in close proximity to medical colleges that served as study centres. The study subjects were employees (selected by age and sex stratified random sampling) and their family members. Information on behavioural, clinical and biochemical determinants was obtained through standardized methods (questionnaires, clinical measurements and biochemical analysis). Data collation and analyses were done at the national coordinating centre. FINDINGS: We report the prevalence of CVD risk factors among individuals aged 20-69 years (n = 19 973 for the questionnaire survey, n = 10 442 for biochemical investigations); mean age was 40 years. The overall prevalence of most risk factors was high, with 50.9% of men and 51.9% of women being overweight, central obesity was observed among 30.9% of men and 32.8% of women, and 40.2% of men and 14.9% of women reported current tobacco use. Self-reported prevalence of diabetes (5.3%) and hypertension (10.9%) was lower than when measured clinically and biochemically (10.1% and 27.7%, respectively). There was marked heterogeneity in the prevalence of risk factors among the study centres. CONCLUSION: There is a high burden of CVD risk factors among industrial populations across India. The surveillance system can be used as a model for replication in India as well as other developing countries.

Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India.

BACKGROUND: Nutritional anemia is one of India's major public health problems. The prevalence of anemia ranges from 33% to 89% among pregnant women and is more than 60% among adolescent girls. Under the anemia prevention and control program of the Government of India, iron and folic acid tablets are distributed to pregnant women, but no such program exists for adolescent girls. OBJECTIVE: To assess the status of anemia among pregnant women and adolescent girls from 16 districts of 11 states of India. METHODS: A two-stage random sampling method was used to select 30 clusters on the basis of probability proportional to size. Anemia was diagnosed by estimating the hemoglobin concentration in the blood with the use of the indirect cyanmethemoglobin method. RESULTS: The survey data showed that 84.9% of pregnant women (n = 6,923) were anemic (hemoglobin < 110 g/L); 13.1% had severe anemia (hemoglobin < 70 g/L), and 60.1% had moderate anemia (hemoglobin > or = 70 to 100 g/L). Among adolescent girls (n = 4,337)from 16 districts, the overall prevalence of anemia (defined as hemoglobin < 120 g/L) was 90.1%, with 7.1% having severe anemia (hemoglobin < 70 g/L). CONCLUSIONS: Any intervention strategy for this population must address not only the problem of iron deficiency, but also deficiencies of other micronutrients, such as B12 and folic acid and other possible causal factors.

Mid-arm circumference at birth as predictor of low birth weight and neonatal mortality.

In Bangladesh, like other developing countries, most births occur at home or in the community, so logistic problems and taboos prevent the weighing of every newborn child. This study was performed to see whether other simpler measurements could be substituted for weight to identify neonates of low birth weight. A total of 1676 live births at the Chittagong Medical College Hospital constituted the study sample, and this showed a high correlation between mid-arm circumference and birth weight (r=0.792, p<0.000). A mid-arm circumference of <9.0 cm had the best sensitivity and specificity for identifying newborns with a birth weight of less than 2500 g. These neonates were followed up to record neonatal deaths. Neonatal mortality showed an inverse relation with mid-arm circumference. A mid-arm circumference of <9.0 cm and a birth weight of <2500 g were equally useful in predicting neonatal outcome. Mid-arm circumference is a simple, quick and reliable indicator for predicting low birth weight and neonatal outcome, and can be easily measured by medical practitioners and traditional birth attendants (TBAs) in the community of developing countries like Bangladesh.

Vitamin A deficiency in children with acute diarrhoea: a community-based study in Bangladesh.

The prevalences of nightblindness and xerophthalmia were assessed in 400 children, aged 6-59 months, with acute diarrhoea in a rural community in Bangladesh. The prevalences of nightblindness, conjunctival xerosis, and Bitot's spot were 7.8%, 9.5%, and 2.7% respectively. Fifty-two percent of the children who complained of nightblindness had ocular signs of vitamin A deficiency compared to 9% of those without nightblindness (p < 0.000). The nightblindness was significantly higher among the male children, aged 24-59 months, who were dysenteric and undernourished, did not consume vitamin A-containing foods daily, and were not breastfed. The coverage of periodic administration of vitamin A capsule was inversely related to the prevalence of nightblindness. This finding was determined by logistic regression analysis of data indicating that a combination of male sex, history of dysentery, absence of periodic administration of vitamin A treatment, and daily intake of vitamin A-containing foods gave the best-fitted model with an overall prediction of 92.5% of being nightblind. The findings of the study suggest that mothers should be educated to observe their diarrhoeal children about development of nightblindness and to seek treatment for it. The locally-relevant nutrition education should also be offered to them.

Mothers' skills in preparing oral rehydration salt solution.

This was a community based thirty cluster survey, carried out in rural Chittagong district, Bangladesh during 1996 with the objective to assess the skill of mothers in preparing packet ORS solution. A total of 420 mothers whose children had been suffering from acute diarrhoea were investigated. There were 377 (89.8%) mothers who demonstrated the preparation of ORS and 43 (10.2%) mothers never ever prepared the solution and were unable to demonstrate the preparation. One hundred and forty (33.3%) mothers were able to demonstrate the preparation correctly and the rest 237 (56.4%) demonstrated the preparation incorrectly. The incorrect preparation was found to be associated significantly with the refusal of ORS solution by the children (p < 0.01). None of the maternal factors were found to be associated with the correctness of preparation of ORS solution except previous exposure of the mother to the demonstration of ORS solution preparation (p < 0.000). Therefore, demonstration of preparation of ORS solution to the mothers should be in built in the health education package of oral rehydration therapy for diarrhoeal diseases.

Economic evaluation of water iodization program in Thailand.

In Thailand, iodine deficiency disorders (IDD) are endemic in 57 out of 75 provinces with an estimated 15 million people at risk of IDD. A three pronged control program with iodized salt, iodized water and iodized oil capsules is being implemented. The water iodization program is both school based and household based. In the household, the residents are given iodine solution, two drops of which is to be added to 10 l of drinking water. In the schools, in addition to this method, an iodinator is used. This releases a fixed amount of iodine into the drinking water. This study examines the cost of the water iodization program in Thailand for the year 1996 in terms of cost per beneficiary, cost per microg iodine consumed daily and cost per goiter person years averted. We used a discount rate of 5%. Field visit and interviews of health personnel from Ministry to village level were conducted to gather primary data. Review of existing papers and reports of the Department of Health, Government of Thailand was done for secondary data. The costs included the capital cost of equipments, initial training and the recurrent costs of potassium iodate, proportional salaries of personnel involved, monitoring and communication activities. The cost per beneficiary of school based iodinator method (US$ 0.72) and school based drop method (US$ 0.64) were similar and much higher than the household based approach (US$ 0.12). The cost per microg of iodine consumed daily was ten times higher in the school based approach (US$ 0.01) compared to the household approach (US$ 0.001). The cost per goiter case averted for the whole strategy of water iodization was US$ 194.50. Water iodization appears to be a low cost intervention. However, the need for behavioral modification raises the issue of long term sustainability.

Limiting factors of ORS intake.

This was a thirty cluster survey; carried out to identify the factors which limit ORS intake during a diarrhoeal episode in rural Bangladesh. 420 mother-child pairs were investigated. In addition to the verbal interview, the index child was examined physically and mother's skill of preparing ORS was assessed. The ORS was known to more than 95% mothers but used by only 33.3%. The average intake of ORS was 320 ml per diarrhoea day. The correct amount of oral rehydration fluid was received by 145(34.5%) cases. Twenty eight socio-demographic-maternal-host(child)-environmental factors were studied for their probable influence on intake of correct amount of oral rehydration fluid. In bivariate analysis, fourteen factors were found to be associated significantly with oral rehydration fluid intake (P < 0.05-< 0.0001). These fourteen factors were treated with stepwise logistic regression analysis. Sensitivity and specificity were the key measures for decision of best fitted model. A combination of child age, mother's education, socio-economic condition and method of feeding ORS provide the maximum sensitivity (90.20%) and specificity (74.19%) for predicting oral rehydration fluid intake. The study emphasized the need for further strengthening of health education incorporating the findings of the research to ensure required amount of oral rehydration fluid intake during diarrhoeal episode.

Outcome of children rehydrated in a hospital ORT corner in Bangladesh: a follow-up study.

This prospective follow-up study was carried out during 1996 to identify the outcome of children rehydrated in the ORT Corner of the Chittagong Medical College Hospital. In total, 269 children, aged less than five years, who attended the ORT Corner, accompanied by their mothers, for treatment of uncomplicated acute watery diarrhoea with 'no signs of dehydration' and 'some dehydration,' were selected for the study. Mothers of the children were interviewed at the ORT Corner, and children were followed-up at home on the 5th post-ORT Corner visit day. The follow-up was completed for 260 cases (96.7%). At follow-up, 227 cases (87.3%) were found to be cured, and 33 cases (12.7%) still had diarrhoea. Of the cured, the mean duration of the episode was 5.84 +/- 2.34 days (95% CI.5.55-6.13 days). All the cases received oral rehydration therapy (ORT) after attending the ORT Corner. Eighty-one cases (31.2%), however, reconsulted the private doctors. Of those who reconsulted, only 3 (3.7%) received WHO-recommended treatment of acute watery diarrhoea, and the rest 78 (96.3%) received medication. The medication prolonged the episode of diarrhoea significantly (6.22 days vs 5.48 days, p < 0.001). None of the cases, who reconsulted the private doctors, revisited the ORT Corner. Treatment by 'ORS only' was mentioned by 64% of the mothers as the reason for non-revisit of the ORT Corner, and 20% of the mothers denied the receipt of any advice about when to revisit the ORT Corner which calls for further strengthening of communication activities of the ORT Corner.

Misuse of drugs in acute diarrhoea in under-five children.

This was a community based, thirty cluster survey, carried out in Chittagong metropolitan area of Bangladesh, aimed to determine the extent of misuse of drugs in acute diarrhoea among under-five children. Data were collected from 360 mothers whose under-five children had suffered from acute diarrhoea during the preceding two weeks of interview. Data were pertained to type and duration of diarrhoea and treatment received. There were 339(94.2%) cases of acute watery diarrhoea and 21 (5.8%) cases of dysentery i.e. blood in stool. The mean duration of the diarrhoeal episode was 3.17 +/- 1.69 days (95% CI, 2.99-3.34). Three hundred twenty eight (91.1%) cases received treatment. There was a total of 401 consultations, out of which 328(81.8%) had first, 69(17.2%) had second and 4(1.0%) had third consultations. The first and second treatment were provided predominantly by care-providers (43.3%) and physicians (5.5%) respectively. Only 82(26.7%) cases of acute watery diarrhoea received WHO recommended treatment and only 5(23.8%) cases of dysentery received appropriate antibiotics. The rest 241(73.5%) cases received inappropriate treatment either antibiotic or drugs other than WHO recommendation. The average number of drugs prescribed per patient was 1.5 during the episode. The commonly prescribed drugs were metronidazole (38.6%) and antibiotics (17.3%). Those who consulted health professionals were at 5.7 times higher risk of receiving drugs. The mean duration of the episode of acute watery diarrhoea was increased significantly when drug is used in the treatment. It is concluded that there was high prevalence of misuse of drugs in the treatment of acute diarrhoea among under-five children which calls for intervention to improve the prescribing pattern as per WHO recommendation.

PIP: This study determines the extent of drug misuse in acute diarrhea among under-five children in Chittagong, Bangladesh. Data were collected from 360 mothers whose under-five children suffered acute diarrhea 2 weeks prior to interview. Information gathered pertained to the type and duration of diarrhea and the treatment received. The were 339 cases of acute watery diarrhea and 21 cases of dysentery (i.e., bloody stools). The mean duration of the diarrheal episode lasted 3.17 +or- 1.69 days. From the total cases, only 328 received treatment. Moreover, only 82 cases of acute watery diarrhea received WHO recommended treatment and only 5 from the total number of cases received appropriate antibiotic treatment, while the 241 cases received inappropriate medication. The commonly prescribed drugs were metronidazole and antibiotics. Unfortunately, those who consulted health professionals were at 5.7 times higher risk of receiving the drugs and even experienced longer episodes of acute diarrhea. Results suggest that there is a significant misuse of antidiarrheal drugs among under-five children.

Effect of health warning on the use of breast milk substitutes by lactating mothers.

This cross-sectional study was carried out with the objectives to determine the awareness, readability and understandability of health warning and its effect on the use of breast milk substitutes(BMS) by lactating mothers. A total of 400 mothers who had infant of less than 5 months of age & able to read the bangla newspaper were interviewed at urban EPI centres. The mothers were requested to locate and read the health warning on BMS container. The BMS were used by 189(47.25%) mothers but only 137(34.3%) mothers knew the health warning. The mean time taken by mothers to locate the health warning in the BMS container was 40.4 +/- 40.9 seconds(95% CI 35-45). The health warning in the container could not be located by 97(24.2%) mothers and another 51(12.2%) located it with difficulty. There were 263(65.8%) mothers who were able to read the health warning easily and the rest either read with difficulty (10.0%) or unable to read(24.24%). More than one third of the mothers did not understand the meaning of health warning. Even after the education on health warning during the course of interview, 170(42.5%) mothers responded in favour of using BMS. The low level of awareness and poor understanding of the meaning of health warning by the lactating mothers might be the cause of a high rate of BMS use which calls for strengthening of information, education and communication (IEC) activities.