Mini mental state examination and the Addenbrooke's cognitive examination: effect of education and norms for a multicultural population

OBJECTIVE: To derive population norms on the Malayalam adaptation of Addenbrooke's Cognitive Examination (M-ACE) and the inclusive Malayalam mini mental state examination (M-MMSE). MATERIALS AND METHODS: Education-stratified norms were obtained on randomly selected cognitively unimpaired community elders (n = 519). RESULTS: Valid data on norms was available on 488 subjects (age 68.5 +/- 7.1 and education 7.9 +/- 5.4). Education and age, but not gender had a significant effect on both M-ACE and M-MMSE. When compared to the effect of age, the effect of education was sevenfold more on the M-ACE and ninefold more on the M-MMSE. The mean composite score on the M-ACE (and the M-MMSE) was 42.8 +/- 9.8 (14.9 +/- 3.1) for those with 0 (n = 72), 55.9 +/- 12.5 (19.7 +/- 4.1) with 1-4 (n = 96), 62.6 +/- 11.4 (21.9 +/- 3.7) with 5-8 (n = 81), 77 +/- 10.2 (25.7 +/- 2.4) with 9-12 (n = 136) and 83.4 +/- 7.2 (26.7 +/- 1.6) with> 12 (n = 103) years of formal education. CONCLUSIONS: Education has the most potent effect on performance on both M-ACE and M-MMSE in the Indian cohort. Education-stratified scores on the M-ACE and the M-MMSE, will provide a more appropriate means of establishing the cognitive status of patients. It is also our feeling that these cut-off scores will be useful across India.     

Chylothorax following innominate vein thrombosis--a rare complication of transvenous pacemaker implantation

A case of chylothorax following innominate vein thrombosis which developed as a late complication of transvenous pacemaker implantation is discussed. A 78-year-old man presented with a refractory left-sided pleural effusion, which turned out to be a chylothorax. He had undergone a transvenous pacemaker implantation 6 years earlier for sick sinus syndrome. Aetiological work-up showed occlusion of the innominate vein as the cause for the chylothorax. The chylothorax resolved following pleurodesis with talc slurry, and the innominate vein was recanalized by angioplasty. To our knowledge, this is the first report of a case of this nature.     

Pseudosequestration of the left lung

Bronchovascular malformations of the lung constitute a broad spectrum of developmental disorders in which a part of the lung is perfused exclusively from the systemic arterial tree with or without tracheobronchial communication. We report the case of an infant with severe pulmonary artery hypertension whose entire left lung was supplied by collateral vessels from the celiac trunk and the left subclavian artery. The left tracheobronchial tree was normal. Coil embolization of the collateral vessels was performed to reduce the pulmonary blood flow.     

Treatment of plastic bronchitis

Plastic bronchitis may be seen after palliative surgery for cyanotic heart disease. Although type II (acellular) casts are seen more commonly, we describe a type I cast after palliative surgery for cyanotic heart disease in which ligation of thoracic duct did not result in complete resolution.     

Global immunization: status,progress, challenges and future

Vaccines have made a major contribution to public health, including the eradication of one deadly disease, small pox, and the near eradication of another, poliomyelitis.Through the introduction of new vaccines, such as those against rotavirus and pneumococcal diseases, and with further improvements in coverage, vaccination can significantly contribute to the achievement of the health-related United Nations Millennium Development Goals.The Global Immunization Vision and Strategy (GIVS) was developed by WHO and UNICEF as a framework for strengthening national immunization programmes and protect as many people as possible against more diseases by expanding the reach of immunization, including new vaccines, to every eligible person.This paper briefly reviews global progress and challenges with respect to public vaccination programmes.The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa (estimated coverage 74%), and South-East Asia, (estimated coverage 69%). Elements that have contributed to the gain in immunization coverage include national multi-year planning, district-level planning and monitoring, re-establishment of outreach services and the establishment of national budget lines for immunization services strengthening.Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritize new vaccines for introduction; strengthening immunization systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunization coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower-middle income countries.Although introduction of new vaccines is important,this should not be at the expense of sustaining existing immunization activities. Instead the introduction of new vaccine introduction should be viewed as an opportunity to strengthen immunization systems, increase vaccine coverage and reduce inequities of access to immunization services.     

Large retroperitoneal schwannoma mimicking a cystic ovarian mass in a patient with Hansen's disease

We present a rare case of retroperitoneal cystic schwannoma of the pelvis in a patient with Hansen's disease that mimicked an ovarian cyst. Due to economic constraints and because the lesion was assumed to be of ovarian origin, the patient did not undergo any cross-sectional imaging other than sonography. Sonographically guided fine needle aspiration of the cystic lesion was inconclusive. A cystic schwannoma was diagnosed at laparotomy.     

Psychosocial characteristics of cancer patients who choose to attend an educational session on cancer-related fatigue

Little is known about cancer patients who seek specific educational interventions on cancer-related fatigue (CRF). The objectives of this study were (1) to describe the level of CRF, and emotional distress; social support; coping styles; and quality of life of patients who chose to attend a 1-hour educational session on CRF and (2) to examine the relationship between the selected demographic, psychosocial, and treatment-related variables and CRF. A questionnaire-based survey of 41 cancer patients who volunteered after a 1-hour education session on CRF at the Tom Baker Cancer Centre was conducted. The sample consisted mostly of married white women who lived in an urban environment. The average age was 56 years, and participants had an average of 14 years of education; 78% of the sample reported moderate to severe fatigue, 27% had significant levels of emotional distress, and 63% had a problematic coping style. Higher fatigue was associated with emotional distress, poorer quality of life, hopelessness, and reduced social support. To conclude, patients who self-refer to an educational session on CRF present a wide range of emotional difficulties and problematic coping styles. Therefore, educational sessions with patients with CRF should emphasize coping with emotional distress and building a support system.     

Laparoscopic hernia repair--the best option?

For 100 years the Bassini-type repair for inguinal hernia was the standard method. The Lichtenstein "tension free" mesh repair replaced it on the grounds of much lower recurrence rates, < 5% vs approximately 15%. However, open procedures all have significant long-term discomfort rates of up to 53%. Laparoscopic repair has become a genuine option in the last 15 years and offers low recurrence (< 1%) and minimal long-term discomfort. However, it has not been widely taken up. There is a common misconception that it takes longer to perform, has more complications and is much more expensive. None of these caveats stand up under objective scrutiny. It is time that laparoscopic repair became the method of choice for most elective inguinal hernia repairs.     

Endomyocardial fibrosis in an adult mimicking left ventricular mass

Endomyocardial fibrosis is a rare condition that occurs primarily in tropical countries. It can often mimick a variety of other common cardiac conditions such as apical hypertrophic cardiomyopathy and Ebstein anomaly. We report a case of a left ventricular mass that at histologic examination was found to be endomyocardial fibrosis.