Development of a cost of illness inventory questionnaire for children with autism spectrum disorder in South Asia

BACKGROUND

The economic burden of autism is substantial and includes a range of costs, including healthcare, education, productivity losses, informal care and respite care, among others. In India, approximately, 2 million children aged 2-9 years have autism. Given the likely substantial burden of illness and the need to identify effective and cost-effective interventions, this research aimed to produce a comprehensive cost of illness inventory (COII) suitable for children with autism in South Asia (India) to support future research.

METHODS

A structured and iterative design process was followed to create the COII, including literature reviews, interviews with caregivers, pilot testing and translation. Across the development of the COII, thirty-two families were involved in the design and piloting of the tool. The COII was forward translated (from English to Hindi) and back translated. Each stage of the process of development of the COII resulted in the further refinement of the tool.

RESULTS

Domains covered in the final COII include education, childcare, relocation, healthcare contacts (outpatient, inpatient, medical emergencies, investigations and medication), religious retreats and rituals, specialist equipment, workshops and training, special diet, support and care, certification, occupational adjustments and government rebates/schemes. Administration and completion of the COII determined it to be feasible to complete in 35 minutes by qualified and trained researchers. The final COII is hosted by REDCap Cloud and is a bilingual instrument (Hindi and English).

CONCLUSIONS

The COII was developed using experiences gathered from an iterative process in a metropolitan area within the context of one low- and middle-income country (LMIC) setting, India. Compared to COII tools used for children with autism in high-income country settings, additional domains were required, such as complimentary medication (e.g. religious retreats and homeopathy). The COII will allow future research to quantify the cost of illness of autism in India from a broad perspective and will support relevant economic evaluations. Understanding the process of developing the questionnaire will help researchers working in LMICs needing to adapt the current COII or developing similar questionnaires.

Recovery from rabies, a universally fatal disease

BACKGROUND

Rabies is a zoonosis transmitted via the bites of various mammals, primarily dogs and bats. Known since antiquity, this disease may have the deadliest human fatality rates and is responsible for approximately 65,000 deaths worldwide per year.

CASE PRESENTATION

We report the case details of a 13-year-old boy from India belonging to a South Asian ethnicity, who presented with altered sensorium one month following a dog bite. He did not receive the active rabies immunization and was managed with supportive therapy. The patient had extensive T2W (T2 weighted)/fluid attenuation and inversion recovery (FLAIR) hyper intensities involving the deep gray matter of the cerebral hemispheres, hippocampus, brainstem, and cerebellum. The diagnosis was confirmed by the demonstration of the rabies antigen from a nuchal skin biopsy and a corneal smear. The patient had a slow but significant recovery over four months and was discharged from the hospital in stable condition with severe neurological sequelae.

CONCLUSION

We report a unique case of survival after infection with a universally fatal disease.

Physical characterization of a glucose-dehydrogenase-bearing plasmid from ketoacid-producingErwinia herbicola

Erwinia herbicola (ATCC 21998), a facultative anaerobe, has two plasmids: pVQ1 and pVQ2. Curing with mitomycin C indicated that pVQ2 was cryptic but pVQ1, a 7.4-kb plasmid, bears a 4.3SacI fragment which strongly hybridized to the C-terminal region of the glucose dehydrogenase gene ofAcinetobacter calcoaceticus. A restriction map of plasmid pVQ1 is presented.

Need for a national epilepsy control program

This article briefly outlines the proposed national epilepsy control program. The content of the article is based on four meetings held by invitation of the Ministry of Health. Invitees by ministry – Drs. D. C. Jain, M. Gourie Devi, V. Saxena, S. Jain, P. Satish. Chandra, M. Gupta, K. Bala, V. Puri, K. S. Anand, S. Gulati, S. Johri, P. S. Chandra, M. Behari, K. Radhakrishnan, D. Bachani. Presentations were made by Dr. M. Tripathi.The program will involve all neurologists across the country in teaching and training at state levels and a central monitoring committee.

Singular behavior of eigenstates in Anderson's model of localization

We observe an apparent singularity in the electronic properties of the Anderson model of localization with bounded diagonal disorder, which is clearly distinct from the well-established mobility edge (localization-delocalization transition) that occurs in dimensions d > 2. We present results of numerical calculations for Anderson's original uniform (box) distribution of on-site disorder in dimensions d = 1, 2, and 3. To establish this hitherto unreported behavior, and to understand its evolution with disorder, we contrast the behavior of two different measures of the localization length of the electronic wave functions-the averaged inverse participation ratio and the Lyapunov exponent. Our data suggest that Anderson's model exhibits richer behavior than has been established so far.

HIV infection with myasthenia gravis

A soldier presented in Jan 2002 with features of proximal myopathy and diplopia. Clinically he had features of myasthenia gravis, which was confirmed by significantly positive neostigmine test, decremental response on electrophysiological study and raised acetylcholine receptor antibody titres. He also tested positive for HIV during evaluation of a cervical lymph node detected incidentally. He responded well to neostigmine and has remained asymptomatic on follow up.

Cloning, sequencing and partial characterisation of sorbitol transporter (srlT) gene encoding phosphotransferase system, glucitol/sorbitol-specific IIBC components of Erwinia herbicola ATCC 21998

A DNA fragment of approximately 1500 bp, harbouring the sorbitol transport gene (srlT), was amplified from the chromosomal DNA of Erwinia herbicola ATCC 21998 by PCR and cloned in Escherichia coli JM109. Degenerate oligonucleotide primers used were designed based on the conserved regions in the gene sequences within the gut operon of E. coli (Gene Bank accession no. J02708) and the srl operon of Erwinia amylovora (Gene Bank accession no. Y14603). The cloned DNA fragment was sequenced and found to contain an open reading frame of 1473 nucleotides coding for a protein of 491 amino acids, corresponding to a mass of 52410 Da. The nucleotide sequence of this ORF was highly homologous to that of the gutA gene of Escherichia coli gut operon, the srlE gene of Shigella flexrni and the sorbitol transporter gene sequence of Escherichia coli K12 (Gene Bank accession nos. J02708, AE016987 and D90892 respectively). The protein sequence showed significant homology to that of the phosphotransferase system i.e. the glucitol/sorbitol-specific IIBC components of Escherichia coli and Erwinia amylovora (P56580, O32522). The cloned DNA fragment was introduced into a pRA90 vector and the recombinant was used for developing srlT mutants of Erwinia herbicola, by homologous recombination. Mutants obtained were unable to grow on minimal medium with sorbitol. The insertion of the pRA90 vector inside the srlT gene sequence of the mutants was confirmed by DNA-DNA hybridisation.

Increased cortical excitability with longer duration of Parkinson's disease as evaluated by transcranial magnetic stimulation

Transcranial Magnetic Stimulation (TMS) was used to evaluate the cortical excitability and central motor pathways in Parkinson's disease (PD) and correlate with severity and duration of disease. 19 cases of PD and 13 controls were enrolled. The threshold intensity (TI), cortical latency (CL), central conduction time (CCT), motor evoked potential amplitude (MEP) obtained with TMS were correlated with Hoehn and Yahr and duration of disease. The threshold intensity (TI) was significantly lower in patients of PD than controls. The TI in patients with PD was 53.16-/+8.4% patients and 67.1-/+21.6% in controls (p<0.05). This strongly correlated with duration of disease, TI being lower in patients with disease duration more than 5 years. There was no difference in the other TMS parameters - CL, CCT, MEP between patients and controls. Our study revealed increased excitability in PD which was related to longer duration of disease.

Eales' disease with neurological manifestations

Eales' disease is a primary retinal perivasculitis of an undetermined etiology seen predominantly in the Indian subcontinent. However, neurological involvement is rare. We report here a patient of retinal perivasculitis with neurological dysfunction. Our patient is a 39 years male who developed acute diminished vision right eye in March 99, which progressed for four days and remained static. In April 99 he developed acute diminished vision left eye, which progressed to near total blindness in 48 hours. He was undergoing ophthalmic evaluation. Fourty five days later he developed incoordination and weakness left half of body. The examination revealed bilateral retinal perivasculitis with pyramidal signs and left sided cerebellar signs. Investigations revealed an ESR of 40 mm at the end of first hour. His CT head revealed bilateral basal ganglionic infarcts. MRI head revealed enhancing lesions both basal ganglia and right parietal region. Cerebrospinal fluid examination showed xanthochromic fluid with markedly elevated protein and lymphocytic pleocytosis. His workup for connective tissue disorders was negative. He was put on ATT with steroids. Eales' disease is presumed allergy to tuberculoprotein. A trial of ATT with steroids has been tried with varying results. Our patient had bilateral retinal perivasculitis and neurological dysfunction. He had lymphocytic pleocytosis with markedly elevated protein in the CSF.

Determination of N-nitrosodimethylamine in environmental aqueous samples by isotope-dilution GC/MS-SIM

An analytical method for the determination of N-nitrosodimethylamine (N-NDMA) in environmental aqueous samples has been developed using isotope dilution gas chromatography/mass spectrometry in the selected ion monitoring mode (GC/MS-SIM). After deuterated N-nitrosodimethylamine (d6-N-NDMA) as surrogate standard was added to the samples, the analytes were extracted with methylene chloride, dried with anhydrous sodium sulfate, and concentrated in a rotary evaporator. The concentrated extracts were analyzed by GC/MS-SIM after adding N-nitrosodiethylamine as an internal standard. The method detection limit for N-NDMA was 0.003 pg/microL and was validated by an analysis of a fortified water sample. The method was applied to real samples.

Purification and characterisation of an ester hydrolase from a strain of Arthrobacter species: its application in asymmetrisation of 2-benzyl-1,3-propanediol acylates

An ester hydrolase (ABL) has been isolated from a strain of Arthrobacter species (RRLJ-1/95) maintained in the culture collection of this laboratory. The purified enzyme has a specific activity of 1700 U/mg protein and is found to be composed of a single subunit (Mr 32,000), exhibiting both lipase and esterase activities shown by hydrolysis of triglycerides and p-nitrophenyl acetate respectively. Potential application of the enzyme concerns the asymmetrisation of prochiral 2-benzyl-1,3-propanediol esters besides enantioselective hydrolysis of alkyl esters of unsubstituted and substituted 1-phenyl ethanols.

Beryllium-induced toxicity and its prevention by treatment with chelating agents

The efficacy of Tiron and calcium disodium EDTA in the treatment of experimental beryllium intoxication was investigated in rats. Beryllium nitrate was administered intramuscularly (50 mg kg(-1)) once only, provoking duration-dependent changes. Maximum changes were recorded after a 7-day regimen. Considerable inhibition was recorded in protein and glycogen contents, as well as in the activity of alkaline phosphatase, glucose-6-phosphatase, acid phosphatase and lipid peroxidation. These parameters were restored considerably with chelation therapy, but comparatively Tiron offered better protection. These findings were further confirmed by atomic adsorption spectrophotometry. Tiron was found to be significantly more effective than CaNa(2)EDTA in reducing the beryllium concentration in the liver, kidney and lungs.

Visual scanning of facial expressions in schizophrenia

The authors previously observed that schizophrenic patients generated fewer fixations of < or = 50.1 ms in response to faces than did a clinical control group. This study examined whether deficits in short-duration eye movements were related to patients' problems in gestalt perception of faces. Faces were presented in upright and inverted orientations to examine the effects of distorting facial gestalts on eye movements. Normal subjects generated more saccades of < or = 50.1 ms to upright than to inverted faces. Patients' saccades of < or = 50.1 ms did not differ between orientations. Patterns of fixations and of saccades > 50.1 ms did not differ between groups. The results may indicate deficits in these patients in search strategies that underlie perception of facial gestalts.

Pupillometric changes during gradual opiate detoxification correlate with changes in symptoms of opiate withdrawal as measured by the Weak Opiate Withdrawal Scale

The relationship between pupil size and subjective symptoms of opiate withdrawal during gradual opiate agonist detoxification has not yet been studied. In the current study, the authors sought to determine the relationship between pupil size and intensity of opiate withdrawal symptoms. To accomplish this, they examined 19 subjects meeting DSM-IV criteria for opiate dependence (304.00) on agonist therapy. All subjects were undergoing opiate detoxification with either methadone or the longer-acting 1-alpha acetylmethadol (LAMM). During two separate visits, subjects' pupil sizes were assessed in the dark using a pupillometer. At each visit, subjects completed two standardized assessment tools (the Subjective Opiate Withdrawal Scale [SOWS] and the Weak Opiate Withdrawal Scale [WOWS]) for measuring subjective symptoms of opiate withdrawal. It was found that changes in pupil size significantly correlated with WOWS, but not with SOWS, scores. Larger pupil sizes were associated with less withdrawal distress. The sensitivity of the pupillometric test to detect increases in opiate craving during opiate agonist medication reduction was 92%, with a specificity of 57%. The predictive value of a positive test was 79%, whereas the predictive value of a negative test was 80%. Pupillometry may provide an objective measure of the intensity of opiate withdrawal in subjects during gradual methadone detoxification.

Influence of chelating agents on the toxicity and distribution of beryllium in rats

The effect of two new chelating agents-Tiron (4,5-dihydroxy-1,3-benzene disulphonic acid disodium salt) and succinic acid--on the mobilization of beryllium was studied. Animals were exposed to beryllium nitrate (1 mg kg(-1) i.p.) daily for 21 days. Administration of beryllium nitrate showed a marked decrease in haemoglobin percentage, blood sugar, serum alkaline phosphatase and serum protein and a significant increase in the activity of transaminases. Tissue protein and glycogen contents and the activity of alkaline phosphatase, adenosine triphosphatase and succinic dehydrogenase showed significantly decreased values, but beryllium nitrate provoked a considerable increase in the activity of acid phosphatase and glucose-6-phosphatase in the vital and reproductive organs. Significant improvement in the haematological and biochemical parameters was observed with Tiron but no therapeutic effect was seen with succinic acid. Atomic absorption spectrophotometry (AAS) also showed a decreased level of beryllium concentration in the liver and kidney after Tiron therapy.

Visual scanning of faces correlates with schizophrenia symptomatology

1. The purpose of this study was to examine whether quantitative measures of visual scanning of faces correlated with the severity of symptoms in patients with schizophrenia. 2. Preattentive visual fixations (fixations less than or equal to 50.1 ms in duration) were measured while 16 subjects with chronic schizophrenia and 38 comparison subjects scanned slides of human faces. 3. A significant inverse correlation was found between the number of preattentive fixations exhibited during 10 seconds of facial scanning and total Brief Psychiatric Rating Scale (BPRS) scores. 4. This study suggests that measures that probe preattentive processing during scanning of faces could represent a novel paradigm for studying the symptoms of schizophrenia.

Preattentive and attentive eye movements during visual scanning of a cocaine cue: correlation with intensity of cocaine cravings

The visual scanning of 19 recently abstinent crack cocaine-dependent men was assessed while they viewed a picture of a cocaine cue and a picture of a neutral cue. Cocaine craving scores were inversely correlated with the number of preattentive fixations and saccades and were positively correlated with the number of attentive fixations.

Falciparum malaria--present day problems. An experience with 425 cases

Clinical details and present day problems encountered in 425 cases of falciparum malaria (PF) are reported. 10.11% had taken chloroquine prior to reporting to us. Parasitic count done in 23.05% cases lacked correlation with severity of disease. Pattern of fever varied markedly but 5.4% were afebrile throughout and presented only with bodyache and malaise. Apyrexial spell was noted in 5.64%. 28.70% had typical facial looks of anaemia and sallow complexion. Cerebral symptoms were noted in 3.05%. Other symptoms were severe headache 33.4%, pain abdomen 3.29%, gastroenteritis 5.64%, jaundice 2.58% and bronchitis in 7.50%. We encountered subconjunctival haemorrhages with purpura and/or urticaria in four cases, symptoms suggestive of shock lung in 3, pulmonary oedema in 2, severe anaemia (HB less than 4 g%) in seven pregnant ladies, extrapyramidal symptoms in follow up period in 5 and congenital malaria in 2 cases. 83.25% were cured with chloroquine and oxytetracycline. 8.47% (who deteriorated despite the above treatment) were treated with quinine for 6 days. 5.17% (with severe disease) were also given quinine as first line drug. 2.82% (unresponsive to chloroquine and oxytetracycline but with mild disease) were treated with pyrimethamine-sulphamezathine combination for 5 days. One case who did not respond to quinine was treated with quinidine. Recrudescence was seen in 3.67% of patients treated with chloroquine and oxytetracycline. There was no case with renal failure, haemolysis due to G6PD deficiency and black water fever. There was only one death (0.23%) in our series. Self-medication, haphazard therapy and the slogan "Fever may be malaria-take chloroquine" can lead to problems in falciparum malaria.

Hepatic epithelioid haemangioendothelioma: difficult name, difficult diagnosis?

Two patients with epithelioid haemangioendotheliomata of the liver are described. Both presented with abdominal pain and malaise, with hepatomegaly and a variable degree of hepatocellular dysfunction. Diagnosis was delayed in both cases, each patient undergoing a protracted series of investigations including repeated liver biopsies. The major obstacles to early diagnosis were a lack of clinical awareness of the condition and difficulties in interpretation of the liver histology: the widespread sclerosis in the tumour tissue is easily mistaken for a post-necrotic or cirrhotic process. The key to the diagnosis is the demonstration of cells containing Factor-VIII-related antigen confirming the endothelial origin of the tumour. One patient died within three months of presentation and the other after 18 months. The tumour may, therefore, be more aggressive than earlier reports seem to suggest. It seems likely that the tumour is being under-diagnosed and although no specific therapy has been shown to be of value, a greater awareness of the condition, resulting in a more prompt diagnosis, should save patients from undergoing unnecessary investigation.