A scale to assess activities of daily living in persons affected by leprosy

The aim of this study was to develop a scale for identifying disability among people in the rural areas of developing countries. The studies were carried out in the Green Pastures Hospital and the leprosy field programme of the Western Region of Nepal. With the help of staff experienced in working with people with disability, a 68-question questionnaire was made, based on the International Classification of Impairments, Activities and Participation (ICIDH-2). A survey was carried out of 269 people affected by leprosy who had impairments, as well as a sample of those who were unimpaired. The survey results were used to develop the questionnaire into a scale, using standard scale development methods. This included checking of criterion validity, discrimination and reliability and stability using weighted kappa statistics. Of the 68 questions, 38 were included in the second draft of the instrument. Eight questions were added to identify difficulty in relationships, about the use of aids and about occupation and employment. The sum score of the scale against the expert score gave a Spearman correlation coefficient of 0.72. Intra- and inter-interviewer reliability coefficients were 0.77 (95% CI 0.73-0.81) and 0.61 (95% CI 0.56-0.67), respectively. The stability test gave an overall kappa of 0.76 (95% CI 0.70-0.82). Four questions with particularly poor results were omitted from the final draft of the instrument. An interview-based instrument was developed for identifying limitations in activities of daily living (disability) in people living in a rural setting in a developing country--the Green Pastures Activity Scale (GPAS). The scale performed well during validity and reliability testing. It consists of 34 activity questions, five relationship questions, and three questions on the use of aids, occupation and employment.

Reliability of Semmes Weinstein monofilament and ballpoint sensory testing, and voluntary muscle testing in Bangladesh

The reliability of methods of testing nerve function is important, since diagnostic decision making is a direct function of the quality of the test. Three methods of nerve function testing were investigated at the Danish Bangladesh Leprosy Mission (DBLM) in north Bangladesh, and assessed for inter-observer reliability. The three methods were 1) ballpoint pen test (BPT) for sensory function; 2) graded Semmes Weinstein monofilament test (SWM) for sensory function and 3) voluntary muscle testing (VMT) for motor function. The weighted kappa (kappa w) statistic was used to express inter-observer reliability. Using this statistic, 0 represents agreement no better than random, and 1.0 complete agreement. kappa w values of > or = 0.80 are reckoned to be adequate for monitoring and research. Fifty-three patients were tested, a Senior physiotechnician acting as 'gold standard' against whom four other staff physiotechnicians were assessed. All three testing methods were found to have minimal inter-observer variation, with the kappa w for inter-observer agreement using BPT being 0.86, the SWM 0.92, and VMT 0.94. It is concluded that in trained and experienced hands, all three methods are reliable and repeatable to a level allowing confident use of results obtained in monitoring and research.

Verbal retelling abilities in adolescents with and without language-learning disabilities for social studies lectures

Verbal retelling abilities for social studies lectures were examined and compared in 20 adolescent boys, ages 12-5 to 14-7, with language-learning disabilities (LLD) and 29 with normal language abilities (NL). Participants viewed one videotaped social studies lecture with a comparison expository discourse structure and one with a causation discourse structure. Following each lecture presentation, participants verbally retold the lecture. Results of several repeated-measures analyses of variance indicated that the group with LLD produced a significantly smaller number of T-units, subordinate clauses, subordinate clauses per T-unit, T-units per second, lecture components per second, and percentage of lecture components in their retellings, compared with the group with NL, regardless of lecture type. Both groups produced a significantly greater number of T-units and subordinate clauses for the comparison lecture. By contrast, both groups recalled a significantly greater number of lecture components per T-unit and per second for the causation lecture. Results indicated that the comparison discourse structure facilitated more substantive and elaborate retellings, whereas the causation discourse structure facilitated more efficient, concise retellings in both groups. Research and instructional implications are discussed.

The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. Some investigators have suggested that the presence of the ossific nucleus of the femoral head at the time of closed or open reduction is associated with a lower rate of ischemic necrosis. This finding, if verified, could lead to a delay in the treatment of a dislocated hip until ossification of the femoral head has begun, which may be well after the age when the patient has started to walk. We conducted a computerized search of the medical records at our two tertiary-care children's hospitals to identify all patients with congenital dysplasia of the hip who had had a closed or open reduction between January 1, 1979, and December 31, 1993. One hundred and twenty-four patients (153 hips) who satisfied the criteria for inclusion were identified. The ossific nucleus was present in ninety hips and absent in sixty-three. Closed reduction was used in 112 hips and open reduction, in forty-one. Ischemic necrosis was identified in five hips (3 percent): four (6 percent) of the sixty-three hips that did not have an ossific nucleus and one (1 percent) of the ninety hips that had an ossific nucleus at the time of the reduction. With the numbers available for study, we could not detect a difference between these two groups. The age at reduction (p > 0.99), the method of reduction (p = 0.611), previous treatment with a Pavlik harness (p = 0.592), the use of preliminary traction (p = 0.602), concomitant procedures (p > 0.99), and a failure of the primary closed reduction (p = 0.579) were not associated with the development of ischemic necrosis after reduction. In our analysis of patients who were managed over a fifteen-year period, the data did not support the hypothesis that the presence of an ossific nucleus at the time of reduction of a congenitally dislocated hip is associated with a lower prevalence of ischemic necrosis of the femoral head. Sound operative principles dictate that operative reduction of a congenitally displaced hip should be performed when the child can be safely placed under anesthesia and without regard to the presence or absence of the ossific nucleus.

Intertester reliability of manual muscle strength testing in leprosy patients

This study reports the results of a study on the intertester reliability of manual muscle strength testing in leprosy patients with confirmed motor function loss of at least one nerve. Three testers graded the muscle strength of 72 patients in random order. Both hands and feet were graded. Strength was graded on a modified Medical Research Council Scale (9 points, 5, 4+, 4, 3+, 3, 2+, 2, 1, 0). The following movements were tested for strength: little finger and index finger abduction, intrinsic position of all four fingers, thumb abduction and opposition, foot dorsiflexion and eversion and extension of the big toe. The weighted kappa statistic was used to calculate the chance-corrected percentage of agreement between observers. Overall agreement for each of the 11 tests appeared to be good or very good (0.61-1.00). However, when data for hands or feet with normal strength or complete paralysis were excluded from the analysis, the reliability of the remaining mid-range scale was not acceptable (kappa 0.55-0.88, direct agreement range 11-41%). While the reliability of this scale could possibly be improved by special training, we feel that, for the evaluation of nerve function for leprosy patients with (suspected) nerve function loss, the extended 9-point VMT scale should only be used when direct intra- or intertester agreement is more than 80%.

Reliability and validity of a macronutrient self-selection paradigm and a food preference questionnaire

Our laboratory has developed a macronutrient self-selection paradigm (MSSP) designed to vary fat content significantly and systematically with sugar, complex carbohydrates, and protein content in a battery of foods in which fat is commonly consumed in the American diet. We have also developed a food preference questionnaire (FPQ) according to an identical design but using a list of foods mutually exclusive of those presented for selection and intake in the MSSP. Men were tested twice on both instruments, with a 4-week interval between tests. It was determined that the MSSP has strong test-retest reliability for overall fat (r = 0.91) and other macronutrient intake and total caloric intake. In addition, hunger and fullness ratings were reproducible, and fat preferences (r = 0.99) and hedonic responses to foods listed on the FPQ were highly consistent across trials. This study also demonstrated that the MSSP is a valid instrument with respect to the men's reports of habitual intake of fat (r = 0.80) and total carbohydrates on the Block food questionnaire (FQ). In addition, men's fat preferences on the FPQ were validated with respect to overall fat (r = 0.86) and total caloric intake in the MSSP and fat intake (r = 0.83) reported on the Block FQ. The MSSP also has the capability to detect a wide range of fat intake (3.06-50.35% among the present subjects), indicating that this instrument can identify individuals who differ markedly in fat intake or could detect changes in fat preference within subjects. In addition, this paradigm detected a large range of sugar and total caloric intake. It is anticipated that the use of these laboratory tools can enhance our understanding of the relationship between dietary fat intake and obesity.

Responses of captive and free-ranging coyotes to simulated oral rabies vaccine baits

The objective of this study was to develop a bait for delivering an oral rabies vaccine to free-ranging coyotes (Canis latrans) in southern Texas. Captive trials were conducted from January to April, 1994, to determine bait preferences and behavioral responses of coyotes (n = 42) to selected baits and attractants. Baits were hollow rectangular cubes made of polymer dog food or fish meal. Attractants had sweet (watermelon), fruity (raspberry), sulfurous (synthetic WU), and lard (beef lard) fragrances. Captive coyotes did not exhibit a preference for either bait bases or attractants; however, coyotes chewed dog food baits 1.6 times more than fish meal baits. Average proximity of coyotes eliciting a response to baits was 2.2 +/- 1.3 m (mean +/- SE). Captive coyotes readily accepted dog food baits containing 2 ml of liquid rhodamine B, a biological marker. Rhodamine B staining of the oropharyngeal region was evident in each captive coyote. Results from the field evaluation of baits and attractants were consistent with that of the captive trials. Of 2,070 bait station-nights conducted from February to April, 1994, coyotes comprised the greatest single species visitation and uptake rates with 31% and 28%, respectively. Bait uptake rates of free-ranging coyotes did not differ among bait-attractant combinations. Coyotes took baits 93% of the time they encountered a bait, regardless of bait type.

Ocular impairments in an impairment survey of leprosy-affected persons in Nepal

An impairment survey was carried out in Nepal. The study subjects (n = 318) were a mixture of out-patients and patients admitted less than one month before the survey. Of the subjects, 101 were attending the hospital out-patients clinic or were admitted and the rest were examined in the field. The patients studied included those on MDT and care-after-cure cases. Ocular impairments were found in 25% of these cases. The most common ocular impairment was poor vision followed by lagophthalmos and insensitive cornea.

Listening comprehension and recall abilities in adolescents with language-learning disabilities and without disabilities for social studies lectures

Listening comprehension and recall abilities for social studies lectures were examined and compared in 20 adolescent males with language-learning disabilities (LLD) and 29 without disabilities (WD). Subjects viewed two social studies lectures with comparison and causation expository discourse structures and verbally responded to literal and inferential comprehension questions. Regardless of lecture type or question type, the group with LLD performed significantly more poorly than did the group WD. Both groups responded accurately to significantly more inferential questions for the causation lecture over the comparison lecture. Neither group demonstrated a significant difference with respect to their response accuracy for the literal questions across lecture types.

Impairment and disability in leprosy: in search of the missing link

This paper describes the results of a survey aimed at studying the relationship between impairment and disability in leprosy. Persons affected by leprosy attending the Green Pastures Hospital, Pokhara, or one of the field clinics in the Western Region of Nepal visited during the study period were interviewed using a standardized questionnaire. Two hundred and sixty-nine subjects were included in the study. For the analysis, 'disability', was defined as activities being done with 'much difficulty', 'only with help' or being 'impossible'. The most commonly affected indoor activities were cutting nails (22%), washing clothes (16%), using scissors (17%) and tying a knot (18%). Among the outdoor activities, cutting grass, digging, harvesting, threshing and milking a cow or buffalo were the most commonly affected (22%-26%). Sensory impairment of the thumb and/or index finger at the 2 g level was a very significant risk factor for disability activities involving the hand(s). Muscle weakness of the thumb and mobile clawing of the fingers had a strong association with disability in several activities. Sensory impairment of the sole was the strongest determinant of disability in activities involving the lower limb. We recommend that efforts should be made to include disability as a standard activity for monitoring and evaluation of rehabilitation, both for individuals and on programme level.

Nutrient intake patterns, body mass index, and vitamin levels in patients with rheumatoid arthritis

OBJECTIVE

To assess nutrient intakes and vitamin levels in 79 patients with rheumatoid arthritis participating in a trial and to determine whether changes in body mass index were associated with changes in disease activity.

METHODS

This study evaluated baseline vitamin levels, 1-day dietary intakes, and weight every 3 months for 1 year. Linear regression analysis was used to evaluate the relationship of time to body mass index. Analysis of covariance was used to determine if body mass index, time, or treatment had an effect on disease activity.

RESULTS

Deficient vitamin levels and poor nutrient intake patterns were prevalent in the study population. Changes in body mass index over time did not correlate with changes in disease activity.

CONCLUSIONS

Rheumatoid arthritis patients are at high risk of obesity, abnormal vitamin levels, and poor nutrient intakes. Changes in body mass index failed to correlate with changes in disease activity.

Disqualifying family communication and childhood social competence as predictors of offspring's mental health and hospitalization. A 10- to 14-year longitudinal study of children at risk of psychopathology

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents had been hospitalized for a functional psychiatric disorder before initial assessment and, second, the male index offspring should be 18 years or older at follow-up. Initial measures included observationally based coding of the family's level of disqualifying communication toward the index offspring, index child's scores on the Child Manifest Anxiety Scale, and ratings of the index child's social competence carried out by peers, teachers, and parents. Offspring outcome was measured by the Mental Health Inventory, Global Assessment Scale (GAS), and hospitalization for psychiatric disorder. The results showed that every measure of offspring outcome was predicted by the amount of disqualification directed to the offspring from the other family members. In addition, GAS score and mental health were predicted by the offspring's competence as a child. Family disqualification, childhood competence, and socioeconomic status accounted for 63% of the variance in adult GAS scores.

The father-infant relationship: becoming connected

PURPOSE

To explore fathers' experiences of developing a relationship with their infants during the infant's first 2 months of life

DESIGN

Grounded theory approach

SETTING

Fathers' homes or other mutually agreed-upon site

PARTICIPANTS

First-time fathers (N = 14), ages 28-44, Caucasian, middle class

MAIN OUTCOME MEASURES

Tape-recorded semistructured interviews to elicit fathers' perceptions of their fathering selves, their infants, and the father-infant relationship.

RESULTS

Using constant comparative method for analysis, three major categories were identified as operative in the initial development of the father-infant relationship: (a) making a commitment, (b) becoming connected, and (c) making room for the baby

CONCLUSIONS

With an increased understanding of the father-infant relationship, nurses can provide humanistic, thoughtful care to assist fathers in developing this significant relationship.

Confirmatory and disconfirmatory family communication as predictor of offspring socio-emotional functioning. A 10 to 14 year follow-up of children at risk

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents should have been hospitalized for a functional psychiatric disorder before initial assessment and the male index offspring should be 18 years or older at follow-up. Family communication was observed by the Consensus Rorschach procedure and coded with the Confirmation-Disconfirmation Coding System. Offspring childhood social competence was rated by peers, teachers and parents. Outcome measures included the Denver Community Mental Health Questionnaire, the Global Assessment Scale and hospitalization for a psychiatric disorder. Results showed that the family's level of confirmation and disconfirmation communication during Consensus Rorschach at initial testing predicted offspring interpersonal functioning and hospitalization for psychiatric disorders. These findings were not due to the initial social competence or IQ of the child, the level of functional impairment in parents or their social class.

A novel sustained-release formulation of ibuprofen provides effective once-daily therapy in the treatment of rheumatoid arthritis and osteoarthritis

The efficacy and safety of a novel sustained-release formulation of ibuprofen given once-daily was compared with conventional-release ibuprofen tablets 400 mg given four times daily, in a single-blind, parallel-group study. This study was conducted at 84 general practice centres throughout the UK among patients with osteoarthritis or rheumatoid arthritis. An unequal randomisation in the ratio of 4:1 was carried out, with 463 patients who received sustained-release and 115 who received conventional-release ibuprofen providing evaluable data. In this study sustained-release ibuprofen was shown to be a more effective alternative to conventional ibuprofen therapy for the treatment of arthritic diseases in general practice, offering the convenience of once-daily dosing and the associated potential benefit of improved patient compliance.

A CHO cell line resistant to deoxycholic acid

Spontaneous mutants resistant to deoxycholic acid (DCA) have been selected from a CHO cell line AuxBl. One of the colonies or 'lines' selected was subsequently mutagenized by ethylmethanesulfonate (250 micrograms/ml) and a more resistant cell, named alpha 3, has been selected. When AuxBl and alpha 3 were exposed to graded concentrations of DCA for 1 h, the LD50 for the mutant strain alpha 3 was 0.66 mM compared to 0.26 mM for the parental line. AuxBl. alpha 3 showed a cross-resistance compared to AuxBl with respect to cholic acid and chenodeoxycholic acid and to other acidic lipids such as linoleic and oleic acids. As an initial step in characterization of the cell lines, the amounts of different phospholipids from whole cell extracts of the parental and mutant strains have been measured after thin-layer chromatography (TLC) separation. The results obtained demonstrated that the fraction of sphingomyelin and phosphatidylcholine over the total phospholipids was slightly increased in the resistant cell line, alpha 3, compared to the parental line, AuxBl (54.9% +/- 1.04 compared to 51.2% +/- 0.3, P = 0.01). Further characterization of cell lines resistant to bile acids could lead to the identification of the cellular target of bile acid action.

A two-year analysis of DRG #288, procedures for obesity

DRG #288 is composed of operative procedures performed for obesity, both gastric and plastic. A two-year cost analysis of 103 consecutive gastric reduction operations performed for morbid obesity was conducted at Robert Wood Johnson University Hospital. It showed a net loss to the hospital of $18,033 in 1984 and $24,126 in 1985. Although the mean length of stay was 1.43 days less in 1985 than in 1984, DRG #288 was still a money loser. A detailed cost breakdown of nine active cost-center categories showed large financial disincentives (losses) in surgical supplies, OR/recovery room time and X ray utilization during both years of the study. These losses were not offset by substantial profits in the room-and-board category, which is directly related to length of stay. It is intuitively obvious that plastic surgical procedures for obesity require less expensive surgical supplies, fewer X rays, and shorter OR/recovery room times than gastrointestinal operations performed for morbid obesity. We conclude that DRG #288 is improperly constructed because it contains a clinically incoherent, heterogeneous mixture of operations that cannot be expected to consume similar amounts of resources and incur similar costs. Hospitals in which the preponderance of operations performed for obesity are gastrointestinal as opposed to plastic are inherently penalized by the current aggregation of DRG #288.

Cellular toxicity of fecal water depends on diet

To determine whether concentrations of potentially toxic lipids in the aqueous phase of human stool are responsive to changes in dietary fat, calcium, and fiber, 20 male volunteers were placed on a high-fat, low-calcium, low-fiber or a low-fat, high-calcium, high-fiber diet for 4 days. To assess toxicity of the fecal fractions, we examined the ability of fecal supernatants to lyse human erythrocytes. Bile acid concentrations in fecal water from the low-fat group were reduced significantly from 180 +/- 60 microM to 100 +/- 70 microM; in the high-fat group, increased from 190 +/- 60 microM to 250 +/- 100 microM. Erythrocyte lysis was 76% for the high-fat group, 37% for the low-fat group. There was a significant weak correlation between aqueous bile acid concentration and cell lysis. Results suggest that diet can influence concentrations of detergents in the aqueous phase of human stool and the potential toxicity of this fraction to cell membranes.

Collagen types present at human fracture sites--a preliminary report

Collagen has been examined from normally and abnormally healing fractures. A higher proportion of type III collagen than was expected was found in abnormally healing fractures. Very little is known about collagen synthesis in healing fractures and how it is altered in abnormal healing states such as delayed and non-union.