Health Problems and Healthcare-Seeking Practices of Workers Processing E-Waste in the Unorganized Sector in the Slums of a South Indian City: An Exploratory Study.

Context: The precarious nature of the work in the unorganized e-waste processing sector poses a threat to workers' health by making them vulnerable to occupational injuries as well as other work-related diseases in addition to job insecurity and related issues. Aims: To systematically explore and quantify employment and working conditions along with the occupational health problems and healthcare-seeking practices of workers processing e-waste in the slums of a south Indian city. Settings and Design: Cross-sectional study conducted in the slums of a south Indian city. Methods and Material: We used a structured interview schedule among 248 randomly selected workers. Statistical Analysis Used: Descriptive statistics were utilized to summarize the results. 95% CI was calculated for select proportions. Chi-square tests were used to determine statistical significance. Results: We found a predominance of self-employment; unclear employment relationship; no paid holidays; long working hours; unequal wages; absence of work-related social security; absent workers' organization; rented units; minimal/no use of safety equipment, no concept of good ergonomic practices. The commonest occupational health concerns were injuries (17% & 41% respectively) and musculoskeletal problems (43.5%). Private/charitable clinics were the commonest source of seeking healthcare which contributed to 'irrational' practices in the form of repeated TT injections. Conclusions: Findings suggest that the precarious work in the unorganized e-waste processing sector could not only give rise to health problems but also make workers undermine the severity of their health problems. The non-responsiveness of the local public healthcare system compels them to rely on private and charitable clinics and pay for services that are otherwise freely available in UPHCs.

Facilitators and barriers to medication adherence among stroke survivors in India.

Strict compliance with medication and life style modification are integral to secondary stroke prevention. This study was undertaken to find out medication adherence among stroke survivors and factors associated with it. Cross sectional survey among stroke survivors was conducted. Interview based self-reported medication adherence was defined as consumption at least >80% of their medications for last two weeks, based on last prescription. Structured interview using pretested interview schedule was done to collect other data. Sequential step wise logistic regression analysis was done to find out the facilitators and barriers to medication adherence. Two hundred and forty stroke survivors (mean age 58.64 ± 10.96 years; 25.4% females) with a mean post-stroke period of 6.65 ± 3.36 months were participated. Overall medication adherence was 43.8% (n = 105). Medication adherence was 34.3% (n = 134), 52.6% (n = 190) and 56.7% (n = 224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio (OR) = 4.85; 95% Confidence Interval (CI) 2.12-11.08, Hypertension: OR = 3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR = 3.88; 95% CI 1.96-4.04). Having daily routine (OR = 2.82; 95% CI 1.52-5.25), perceived need of medication (OR = 2.33; 95% CI 1.04-5.2) and perceived poor state of health (OR = 2.65; 95% CI 1.30-5.40) were facilitators. Memory issues (OR = 0.34; 95% CI 0.16-0.71), side effects (OR = 0.24; 95% CI 0.11-0.42) and financial constraints (OR = 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Establishing daily routines, periodic reminders, financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.

Results of Endovascular-First Approach for Treatment of Scalp Arteriovenous Malformations and the Effect of Simplified Angiographic Classification in Therapeutic Decision-Making and Outcomes.

BACKGROUND: Scalp arteriovenous malformation (SAVM) is primarily treated by surgery and reports on endovascular treatment are scarce. We report the results of an endovascular-first approach in the treatment of SAVM. We also have proposed a simple dichotomized classification using the angiographically determined morphology findings and discussed its effect on therapeutic decision-making and outcomes. METHODS: A consecutive series of 25 patients with SAVM treated by initial or endovascular-only methods were included in the final analysis. The SAVM was categorized as a plexiform or fistulous type according to the angiographic morphology. The demographic data, treatment variables, and final clinical outcomes were analyzed and correlated with the proposed classification. RESULTS: Of the 25 patients, 21 were treated with n-butyl cyanoacrylate (n-BCA) and 3 with liquid ethylene vinyl alcohol. One patient had been treated initially with polyvinyl alcohol particles and later with n-BCA. Overall, complete or near complete obliteration (>90%) was achieved in 72%. Surgical excision was performed in 76%, most often after n-BCA embolization. Fistulous-type SAVMs required greater n-BCA concentrations (median, 33% vs. 20%; P = 0.024) and achieved greater rates of complete or near-complete obliteration (90% vs. 63%). Two patients with fistulous-type SAVMs treated with liquid ethylene vinyl alcohol showed complete resolution, and further treatment was not necessary. Overall, regardless of the embolic material used, the fistulous type demonstrated a significantly greater rate of complete obliteration (75% vs. 33%; P = 0.041) compared with plexiform type. CONCLUSION: High rates of complete and durable obliteration of SAVM are achievable with endovascular embolization. The proposed simplified classification is easy to implement and can aid in choosing the appropriate embolic agent and predicting the therapeutic outcome.

Impact of non-contrast enhanced volumetric MRI-based feeder localization in the treatment of spinal dural arteriovenous fistula.

BACKGROUND: The preoperative localization of the feeder of spinal dural arteriovenous fistula (SDAVF) could simplify the diagnostic spinal angiographic procedure. Localization by non-contrast-enhanced MRI-based techniques is an attractive option. However, the usefulness of such an approach for evaluation of SDAVF has not yet been reported. OBJECTIVE: To study the impact of non-contrast MRI-based feeder localization, followed by targeted spinal angiography, in the evaluation of SDAVF before endovascular intervention. MATERIALS AND METHODS: Prospectively collected data were analyzed and the level of the feeder was localized preoperatively. The procedural time for targeted spinal angiography was calculated and compared with that of a historical cohort, who underwent routine spinal angiographic examination before the study period. Follow-up MRI was carried out to assess the reliability of this model for detection of occasional metachronous lesions that might be missed with this approach. RESULTS: Seven patients underwent targeted spinal angiography during the study. The feeder level was accurately identified in five patients and was localized to one vertebral level in six patients. The correlation between MRI and DSA was statistically significant. The number of spinal levels assessed was fewer and overall procedure time was significantly shorter compared to historical cohort (58 min vs 162 min, respectively; p<0.001). Intervention was coupled with targeted angiography in two patients. Follow-up MRI demonstrated flow voids in one patient, who had recurrent fistula at one vertebral level below the previously embolized feeder. CONCLUSIONS: The non-contrast MRI-based localization technique can reliably detect the level of feeder and help in therapeutic planning of SDAVF. The localization techniques potentially shorten the angiographic procedure and may facilitate simultaneous endovascular definitive treatment. Inclusion of follow-up MRI may be useful for detection of synchronous or metachronous lesions if a targeted approach is adopted. Additionally, this helps to identify failed endovascular therapy.

Utility of 3D SPACE T2-weighted volumetric sequence in the localization of spinal dural arteriovenous fistula.

OBJECTIVE The aim of this study was to investigate the utility of a heavily T2-weighted volumetric MRI sequence (3D sampling perfection with application-optimized contrasts using different flip-angle evolutions [SPACE]) in the feeder localization of spinal dural arteriovenous fistula (SDAVF). METHODS Patients who were diagnosed with SDAVF and who had 3D SPACE source images available for review were identified from a retrospective review of medical records. A total of 16 patients were identified, and MR images were analyzed separately by 2 blinded observers. The accuracy of the observation and interobserver agreement were measured by Kendall's tau and kappa statistics. RESULTS The site of fistula was accurately predicted by Observers 1 and 2 in 81% and 88% of cases, respectively, which improved to 94% when the level was considered within 1 vertebral level. The observer agreement with gold-standard angiography and interobserver agreement were found to be highly significant (p < 0.0001). CONCLUSIONS The 3D SPACE MRI sequence is valuable in the precise detection of the site of SDAVF. It may help to tailor digital subtraction angiography and thereby reduce the radiation exposure, contrast load, and study time.

Selection of ideal candidates for extratemporal resective epilepsy surgery in a country with limited resources.

AIM: To investigate how to select ideal candidates for extratemporal resective epilepsy surgery, without compromising efficacy and safety, in countries with limited pre-surgical diagnostic facilities. METHOD: From the prospective database maintained at an epilepsy surgery centre in southern India, we reviewed the attributes of consecutive patients who had completed at least two years of follow-up after resections involving frontal, parietal and occipital lobes for medically refractory focal seizures. RESULTS: Of 386 patients diagnosed with extratemporal refractory epilepsies during the study period, 61 (15.8%) were selected based on the presence of magnetic resonance imaging (MRI)-identified lesions (in all) and concordant scalp recorded electroencephalographic (EEG) data (in nearly two thirds). Seventeen (27.8%) required invasive investigations either to define the ictal onset zone, eloquent area, or both. During a median follow-up period of five years, 63% of our patients were seizure-free, excluding the presence of auras. Permanent disabling neurological sequelae occurred in three (4.9%) patients. According to univariate analysis, pre-operative secondary generalised seizures and interictal epileptiform discharges (IEDs), during a one-year post-operative EEG monitoring period, portended unfavourable seizure outcome. In multivariate analysis, frontal lobe resections and IEDs in post-operative EEGs were independent predictors of unfavourable outcome. CONCLUSIONS: Extratemporal resective epilepsy surgery can be undertaken in countries with limited resources with efficacy and safety, comparable to that in developed countries, when patients are selected based on the presence of MRI-identified lesions and scalp EEG concordance. In such patients, invasive EEG examinations, when necessary, can be undertaken by limited coverage of cortical areas at an affordable cost.

Employment outcome and satisfaction after anterior temporal lobectomy for refractory epilepsy: a developing country's perspective.

We examined employment outcome and its determinants in 172 south Indian patients who had undergone anterior temporal lobectomy (ATL) for medically refractory epilepsy. Despite seizure-free outcome in the majority, a significant change in post-ATL employment status occurred only in those involved in skilled jobs. Although factors such as younger age at surgery, shorter duration of epilepsy, longer post-ATL follow-up duration, and lower income were associated with favorable employment outcome in univariate analysis, only shorter duration of epilepsy was independently predictive in the multivariate model. A majority of homemakers appreciated marked improvement in their own day-to-day activities. Our patients did not express their desire to work as a principal aim of epilepsy surgery. To enhance occupational attainment, patients require, before epilepsy surgery, occupational assessment to identify their individual abilities and limitations and counseling in formulating realistic goals. After surgery, they require continued support in vocational training and job seeking.

Risk factors for epilepsy: a population-based case-control study in Kerala, southern India.

We undertook a community-based case-control study on persons with active epilepsy residing in Kerala, southern India. Using a standardized questionnaire, we collected information from 362 cases and 362 controls. In the final multivariate model, family history of epilepsy (odds ratio=7.8, 95% confidence interval=3.2-18.8, P=0.000), antecedent history of febrile seizures (7.7, 4.3-14.0, 0.000), birth by complicated delivery (6.8, 2.1-21.8, 0.001), and neonatal seizures (7.8, 1.7-35.4, 008) emerged as strong independent predictors of epilepsy, followed in decreasing order by mental retardation, prematurity, maternal age 30, perinatal distress, and incomplete immunization. There were more similarities than differences in the distribution of risk factors between generalized and localization-related epilepsy syndromes. Our findings suggest interplay between genetic and acquired factors in the pathogenesis of epilepsies, and underscore the need for improvement in obstetric and neonatal care to minimize the epilepsy burden in low-income countries.

Outcome after corpus callosotomy in children with injurious drop attacks and severe mental retardation.

Wide variability in patient selection, extent of callosal section and definition of successful outcome between studies make impact of corpus callosotomy on patients with medically refractory epilepsies difficult to interpret. Severe mental retardation is considered to be predictive of unfavorable seizure outcome after callosotomy. Very little attention has been paid on the influence of callosotomy on the psychosocial burden on the patients' families. We evaluated the seizure outcome, and parental perception about change in cognition and behavior of 17 children (median age 9.5 years, range 3.5-18 years) with severe mental retardation (IQ<30 in all, except one) and injurious drop attacks, who have completed >or=1-year postoperative follow-up after callosotomy. Nearly two-thirds of our patients had >or=90% reduction in drop attacks and generalized tonic-clonic seizures. In the one-stage total callosotomy group, 9 of 11 (82%) patients had favorable outcome, compared to 2 of the 6 (33%) in the partial callosotomy group. Absence of generalized epileptiform discharges on the 1-year postoperative EEG was significantly associated with a favorable seizure outcome. The mean duration of epilepsy prior to callosotomy tended to be shorter among patients with favorable seizure outcome. Postoperative complications were trivial and transient. Nearly three-fourths of the parents appreciated improvements in behavior and attentiveness of their children and were satisfied with the outcome. We conclude that, in children with severe mental retardation and injurious drop attacks, total callosotomy can be undertaken as a one-stage procedure with insignificant morbidity and results in highly favorable seizure outcome.

Employment concerns of people with epilepsy in Kerala, south India.

We examined current employment status, reasons for unemployment, and related psychosocial concerns of 202 persons with epilepsy from the south Indian state of Kerala. Compared with 19% of the general population, 58% of persons with epilepsy were unemployed. Seizure remission for > or = 2 years, monotherapy, better education, ability to travel alone, and ability to drive were significantly associated with being employed. More than three-fourths of the persons with epilepsy had disclosed their epilepsy to their employers and co-workers, which did not adversely affect employment for the majority. The unemployed perceived fear of having seizures and seizure-related falls in the workplace, inadequate education, and antiepileptic drug-induced fatigue as reasons for unemployment. We conclude that unemployment is a major concern of people with epilepsy in this developing region. In addition to optimum seizure control, persons with epilepsy need support in job seeking, in reducing fear of seizures and falls in the workplace, and in identifying their individual abilities and limitations.

Access to pocket money and low educational performance predict tobacco use among adolescent boys in Kerala, India.

BACKGROUND: Tobacco use is increasing among adolescents. We conducted this study to find prevalence and correlates of tobacco use among adolescent boys in Trivandrum city, Kerala. METHODS: Using a two-stage cluster sampling technique, 1323 boys (12-19 years) were selected from 14 schools. Information on tobacco use, academic performance, pocket money, and other variables was collected using a questionnaire. Multivariate analyses were done to find associations between current use of tobacco and other variables. RESULTS: Prevalence of current tobacco use was 11.3% (95% CI 9.6-13.0). Current tobacco use was 2.9 times higher among older boys compared to younger boys (OR 2.9, CI 1.6-5.3), 2 times higher among boys whose fathers used tobacco (OR 2.0, CI 1.3-3.1), 2.9 times higher among boys whose friends used tobacco (OR 2.9, CI 1.6-5.1) compared to their counterparts, 3 times higher among boys securing poor (<40% marks) grade compared to those securing excellent (>80% marks) grade (OR 3.0, CI 1.4-6.6), and 4 times higher among those who received pocket money compared to those who did not (OR 4.0, CI 2.2-7.4). CONCLUSIONS: Health programs to quit tobacco are suggested in schools with special emphasis on poor performers, those receiving pocket money, and those whose fathers and friends use tobacco.

Tobacco use among medical students in Orissa.

BACKGROUND: Tobacco use is the most important cause of preventable morbidity, disability and premature mortality. There is a lack of adequate and reliable data on tobacco use among medical students and their perceived role as future doctors in tobacco control. We aimed to find out factors associated with tobacco use among medical students and their perceived role in tobacco control as future doctors. METHODS: A cross-sectional study was conducted among 1189 undergraduate medical students (68.5% men, median age: 21 years, age range: 17-27 years) in all 3 medical colleges of Orissa. Information on tobacco use, associated factors and their perceived role in tobacco control as future doctors was collected using a pre-tested anonymous questionnaire. Bivariate and multivariate analyses were done among the men respondents to find out associations between current tobacco use and predictor variables. RESULTS: The prevalence of current tobacco use was 8.7% (95% CI: 7.1-10.3); men: 12.4%, women: 0.8%. Among 286 ever users, 34% started using tobacco after joining medical college. Students with a higher personal monthly expenditure and with a family history of tobacco use were more likely to be current users. Third-year students were 3.2-times more likely to be currenttobacco users (OR: 3.21; CI: 1.43-7.19) compared to first-year students. Students who reported own tobacco use as not very harmful were 4.7-times more likely to be current users compared with those who reported otherwise (OR: 4.7; CI: 2.64-8.37). Compared to non-users, current tobacco users were less likely (p = 0.026) to assess tobacco use in their patients and were less likely (p = 0.012) to advise patients against tobacco use. CONCLUSION: Steps should be initiated early in medical colleges to prevent tobacco use, particularly among men students and those with a family history of tobacco use.

Differential diagnosis of patients with intracranial sinus venous thrombosis related isolated intracranial hypertension from those with idiopathic intracranial hypertension.

In patients presenting with intracranial hypertension without hydrocephalus, mass lesions, and with normal cerebrospinal fluid (CSF) composition (pseudotumor cerebri syndrome), the diagnosis of intracranial sinus venous thrombosis (ISVT) has crucial etiological, therapeutic and prognostic implications. Utilizing two well-defined groups of pseudotumor cerebri patients, one with magnetic resonance imaging (MRI) or angiography confirmed ISVT (17 patients) and the other in whom ISVT has been excluded (idiopathic intracranial hypertension [IIH], 27 patients), we investigated the characteristics that might be helpful in distinguishing them. No clinical or auxiliary findings differed between the ISVT and IIH groups except for female gender and lower CSF protein level, which were significantly associated with the latter. While the syndrome pseudotumor cerebri could be due to multiple causes including ISVT, the term IIH should be restricted for patients with isolated intracranial hypertension attributable to no other neurological or systemic disease. Since CT frequently misses ISVT, patients with pseudotumor cerebri syndrome should undergo MRI and MR venography before being labeled as IIH. We conclude that Modified Dandy's Diagnostic Criteria of pseudotumor cerebri, formulated prior to MRI era, can no longer be applied for the diagnosis of IIH.

Impact of vitamin A supplementation through different dosages of red palm oil and retinol palmitate on preschool children.

Red palm oil (5 ml and 10 ml), ground nut oil fortified with 400 and 800 retinol equivalent retinol palmitate, and ground nut oil (5 and 10 ml), were administered to six groups of preschool children (four experimental and two control groups) in randomly assigned balwadis of Ramanathapuram District of Tamil Nadu for a period of 7 months, to monitor the difference in the efficacy of the mode of supplementation and the optimum dose for improving vitamin A status. Results show that red palm oil groups recorded more gain in retinol and beta-carotene levels compared to other dosage groups, and that administration of 10 ml did not offer any substantial improvement over the 5-ml daily dose.

Mortality among epilepsy patients attending a tertiary referral center in a developing country.

Epilepsy is associated with excess mortality of two to three times in developed countries. Precise epidemiological data on mortality and cause of death are not available from India or most other developing countries. This study was carried out to estimate the mortality rates and to identify the demographic and clinical characteristics associated with mortality in a hospital based cohort of epilepsy patients. A cohort of patients enrolled in the epilepsy clinic in 1985 was followed up till 1997 (12 years). The mortality rate, demographic and clinical correlate of mortality were analysed for 246 patients (men 161, women 85) who had complete data. Cause of death was not examined in this study. Eighteen (men 15, women 3) of the 246 patients (7.3%) had died during the follow up period of 12 years. The crude death rate for the state of Kerala for the year 1990 (mid period of the study) was 5.9 per thousand population. The demographic and clinical characteristics of those who died (corresponding figures for survivors are given in brackets) were as follows: mean age 33.6 years (22.8 years), presence of abnormal neurological examination 38.9% (15.4%), mental retardation 33.3% (12.8%), abnormal CT scan 38% (21.5%). Regarding the seizure frequency at the time of enrollment and eventual mortality, there were no deaths among patients who had an Engel's seizure score of less than or equal to 4 (no seizures or nocturnal seizures only). The mortality was 5% for an Engel's score of 5 or 6 and 11% for an Engel's score greater than 6. Within the group with epilepsy, higher seizure frequency at the time of initial evaluation was associated with excess mortality. Abnormality on neurological examination, older age group and male sex were other factors that correlated with excess mortality.

Impact of beta-carotene supplementation through red palm.

A 10-month long feeding trial was conducted to assess the impact of beta-carotene supplementation through red palm oil (RPO) with the focus on vitamin A status, morbidity status and acceptability of an RPO-incorporated noon-meal as a dietary supplement among two cohorts of 409 (experimental) and 346 (control) preschool children in two southern districts of rural Tamil Nadu, selected by stratified random sampling. Information was gathered on ocular symptoms of vitamin A deficiency and anthropometry, and blood samples were drawn at baseline and final rounds for estimation of serum beta-carotene, retinol and tocopherol. Data about Socioeconomic Status (SES) were collected once during the study period, while information on attendance, consumption and morbidity was recorded by preschool teachers. The results showed the following. 1. Significant improvement in the vitamin A status of children in terms of disappearance of Bitot's spots (50.0 per cent) in the experimental group vs. 28.0 per cent in the control group. 2. After feeding of RPO, incidence rate of new Bitot's spots cases was low at 2.13 in the experimental children vs. 4.78 in control children. 3. Marked improvement in the serum beta-carotene levels after 10 months of feeding. 4. RPO is acceptable to children as an edible grade oil as there is no perceptible difference in the consumption pattern between experimental and control children.

Neuropsychological impairment and altered thyroid hormone levels in epilepsy.

BACKGROUND: Neuropsychological impairment is a common problem in epilepsy which interferes with the quality of life of patients. Similarly, thyroid hormone levels have been observed to be abnormal in patients with epilepsy on various treatments. This study aimed to ascertain any possible correlation between neuropsychological performance and thyroid hormone levels among epilepsy patients. METHODS: Thyroid hormone levels, indices of neuropsychological performance and social adaptation of 43 epilepsy patients were compared with those of age- and sex-matched healthy control subjects. RESULTS: Epilepsy patients exhibited significantly (p < 0.001) lower scores on attention, memory, constructional praxis, finger tapping time, and verbal intelligence quotient (i.q.) when compared with controls. Their T3, T4 and Free T3 levels were significantly lower; and TSH and Free T4 levels were significantly higher than that of controls. There was no statistically significant correlation between the indices of neuropsychological performance and thyroid hormone levels. CONCLUSION: We did not observe any correlation between neuropsychological impairment and thyroid hormone levels among patients with epilepsy.