Feasibility of canine oral rabies vaccination in Sri Lanka--a preliminary report

OBJECTIVE: To test the feasibility of introducing oral rabies vaccine (vaccinia recombinant rabies glycoprotein) to improve domestic dog immunisation coverage in a selected area. DESIGN: A prospective field trial. SETTING: Panadura, an area relatively isolated by waterways, making it a suitable field laboratory. METHODS: A routine parenteral vaccination program was carried out. A house to house survey identified the residual non-vaccinated dogs in the selected area. Oral vaccine was offered to the non-vaccinated domestic dogs. RESULTS: Of 4322 dogs in the households, 1242 dogs (28.7%) were eligible for oral vaccine. 659 (53%) were considered to have accepted the oral vaccine with release of the vaccine in the oral cavity. CONCLUSION: It is feasible to use oral rabies vaccine to enhance immunisation coverage.     

Efficacy and cost effectiveness of inhaled steroids in asthma in a developing country.

Eighty six children with troublesome wheezing were studied, in a semiprospective clinical trial with the patients acting as their own controls, to assess the efficacy and cost effectiveness of inhaled steroids. Improvement in school attendance, hospitalisations, breakthrough wheezing, and acute severe attacks were used to assess clinical efficacy. Expenditure for the family, on a cost of illness framework, before and after treatment, was used to estimate cost effectiveness. Highly significant numbers of patients showed improvement in clinical parameters, confirming efficacy. Mean monthly cost before inhaled steroid treatment was Rs 2652.33 (36.33 pounds) and Rs 449.42 (6.16 pounds) after starting treatment. The mean cost per unit satisfaction (cost utility value) which was Rs 255.54 (3.50 pounds) before starting prophylaxis came down to Rs 5.42 (0.07 pound) after starting treatment. There are no previous reports of cost-benefit assessment of inhaled steroids in childhood asthma. It is concluded that, even for developing countries with financial constraints, inhaled steroid treatment for prophylaxis of asthma is a cost effective and rational form of treatment.     

Commissurotomy and pregnancy. A study of 245 cases

We present a retrospective study of 245 pregnancies in 157 women who had undergone commissurotomy (closed surgery) and whose delivery was assisted at the Maternity La Paz (Madrid, Spain) between 1965 and 1981. There was a statistically significant increase in the rate of fetal complications (perinatal mortality, 44.3 per 1,000; pre-term 8.5%; intra-uterine growth retardation, 17.3%; low weight, 12.5%) and maternal mortality. The most frequent and severe maternal complication was congestive heart failure which was more common among primigravidas and was of statistical significance. In patients with atrial fibrillation or heart failure during pregnancy or puerperium, the results were even more remarkable. There were no complications in patients who underwent commissurotomy during pregnancy. Preterm delivery was three times more common in patients undergoing digitalis therapy.     

Outpatient drug-induced parenchymal liver disease requiring hospitalization

A case-history study of drug-induced liver disorders requiring hospitalization was carried out at the Group Health Cooperative of Puget Sound, a health maintenance organization with about 280,000 members, for the five-year period from January 1, 1977 to December 31, 1981. During this time, there were 12 instances of hospitalization for liver disorders judged to be probably (nine cases) or possibly (three cases) attributable to outpatient drug ingestion (other than antitumor agents). The rate was on the order of one per 100,000 person-years at risk. Drugs implicated as probable causes were ampicillin (two cases), carbamazepine (one case), erythromycin (one case), methyldopa (one case), sulfasalazine (one case), quinidine (one case), trimethoprim/sulfamethoxazole (one case), and multiple drugs (one case).     

Pharmacokinetics of azapropazone in the elderly.

Plasma concentrations of azapropazone have been measured in young and elderly subjects after a single dose of 600 mg azapropazone. Maximum concentrations were higher in the elderly. Renal function was impaired in the older subjects. Mean azapropazone clearance was significantly reduced (P less than 0.001) in the old, compared to the young. Elimination half-life was prolonged but the difference did not reach statistical significance due to the wide variation of the values in the elderly. The volume of distribution of azapropazone and degree of adipose tissue did not differ between the two groups. Azapropazone clearance correlated well with creatinine clearance (P less than 0.001) when all the subjects were included and for the younger subjects only but not for the elderly patients alone. The addition of fat mass into the regression equation improved the relationship in all groups but in the older group levels of statistical significance were not achieved. Reasons for the difference between young and old are discussed. The effects of age on the pharmacokinetics of azapropazone suggest that therapeutic plasma levels may be achieved with a dose of 600 mg daily.     

A children's acute respiratory illness scale (CARIFS) predicted functional severity and family burden

OBJECTIVE: The Canadian Acute Respiratory Illness and Flu Scale (CARIFS) was developed to measure illness severity in children with acute respiratory infection. The objective of this study was to evaluate its performance in a European primary care setting. STUDY DESIGN AND SETTING: 178 children (median age 3 years) with cough and fever were recruited in UK general practice. Perceived severity of illness at recruitment was recorded by parents, doctors, and nurses. Parents also completed an illness diary, including the CARIF scale, until their child had recovered. In-depth interviews were conducted with 24 parents. RESULTS: Parents found CARIFS relatively easy and quick to complete (78% of parents returned a fully completed diary covering the duration of the illness), internal consistency was high (minimum item correlation with total score 0.22; overall Cronbach's alpha statistic 0.85), and responsiveness to improvement in health was good (observed effect size of 0.45 at 8 h). At presentation, however, neither the overall CARIFS score nor the clinical element of the score correlated with physician assessment of clinical severity. CONCLUSION: Of the three recognized domains of illness severity, CARIFS appears to be a good and valid measure of functional severity and burden of illness to the parent but it may not be a good measure of physiological severity.     

Rasch analysis of a new stroke-specific outcome scale: the Stroke Impact Scale

OBJECTIVES: To assess multiple psychometric characteristics of a new stroke outcome measure, the Stroke Impact Scale (SIS), using Rasch analysis, and to identify and remove misfitting items from the 8 domains that comprise the SIS. DESIGN: Secondary analysis of 3-month outcomes for the Glycine Antagonist in Neuroprotection (GAIN) Americas randomized stroke trial. SETTING: A multicenter randomized trial performed in 132 centers in the United States and Canada. PARTICIPANTS: A total of 696 individuals with stroke who were community-dwelling and independent prior to acute stroke. INTERVENTIONS: Not applicable.Main Outcome Measures: Rasch analysis was performed using WINSTEPS, version 3.31, to evaluate 4 psychometric characteristics of the SIS: (1) unidimensionality or fit (the extent to which items measure a single construct), (2) targeting (the extent to which the items are of appropriate difficulty for the sample), (3) item difficulty (the ordering of items from least to most difficult to perform), and (4) separation (the extent to which the items distinguish distinct levels of functioning within the sample). RESULTS: (1) Within each domain, most of the items measured a single construct. Only 3 items misfit the constructs and were deleted ("add and subtract numbers," "get up from a chair," "feel emotionally connected") and 2 items ("handle money," "manage money") misfit the combined physical domain. These items were deleted to create SIS, version 3.0. (2) Overall, the items are well targeted to the sample. The physical and participation domains have a wide range of items that capture difficulties that most individuals with stroke experience in physical and role functions, while the memory, emotion, and communication domains include items that capture limitations in the most impaired patients. (3) The order of items from less to more difficult was clinically meaningful. (4) The individual physical domains differentiated at least 3 (high, average, low) levels of functioning and the composite physical domain differentiated more than 4 levels of functioning. However, because difficulties with communication, memory, and emotion were not as frequently reported and difficulties with hand function were more frequently reported, these domains only differentiated 2 (high, low) to 3 (high, average, low) strata of patients. Time from stroke onset to administration of the SIS had little effect on item functioning. CONCLUSION: Rasch analysis further established the validity of the SIS. The domains are unidimensional, the items have an excellent range of difficulty, and the domain scores differentiated patients into multiple strata. The activities of daily living/instrumental activities of daily living, mobility, strength, composite physical, and participation domains have the most robust psychometric characteristics. The composite physical domain is most able to discriminate difficulty in function in individuals after stroke, while the communication, memory, and emotion domain items only capture limitations in function in the more impaired groups of patients.