Improving immunization coverage

A study was made on the causes of unsatisfactory progress in immunization coverage in an area of Tamil Nadu, southern India. The findings led to the appointment of additional community health workers (CHW), improvement in supervision, the enhancement of accessibility to services through an increase in the number of peripheral clinics and the organizing of temporary clinics, and the concentration of effort on underprivileged groups. As a result, immunization coverage was more than doubled. The Community Health and Development Project, a primary health care program serving 68 villages since 1981 with a population of about 80,000 was the site of the study which was conducted by discussions with staff and various members of the community. Issues explored were nonacceptance or dropout reasons, and specific factors affecting immunization coverage. A special effort was made to obtain the views of staff working at the periphery, particularly CHWS. The service area was divided into 4 sectors and the CHWS, auxiliary nurse midwives, community health nurses and other development staff in each were brought together for discussions. Views were also solicited from mothers' clubs and youth groups and in meetings with village leaders. Issues raised were further considered by supervisory staff. Statistical studies and other studies were done to clarify doubtful issues and test hypotheses emerging from the discussion. Poor immunization coverage was linked to inadequate supervision of CHWs, scattered communities (village with houses clustered together had better acceptance rates), difficulty of access to health services (distance factors), and low economic and educational status. In light of the study findings, community health workers were increased from 42 in 1984 to 57 in 1987 to cover all the villages, with modifications in selection method to make the worker acceptable to all sections of the villages; abolishment of the auxiliary nurse midwife and addition of a new category, health aide, to link the CHW and the community health nurse, increase of peripheral clinics from 37 to 75 and holding of more temporary clinics, more efforts to reach all socioeconomic groups and increased health education through film shows, drama, and work with village groups.     

The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: requirements for diagnostics

BACKGROUND: Knowledge of the prevalence of peripheral arterial disease (PAD) in patients with chronic renal failure (CRF) is limited because of a lack of uniformity in disease definition and recognition. Furthermore, little is known of the prevalence of medial arterial calcification (MAC) in patients with CRF. Our goal is to study the prevalence of PAD and MAC defined by ankle brachial index (ABI) or toe brachial index (TBI) measurements in a Finnish population of patients with CRF consisting of predialysis and dialysis patients, as well as renal transplant recipients. METHODS: We examined 136 patients with CRF and 59 control subjects. Fifty-nine of the patients with CRF had moderate to severe predialysis CRF, 36 patients were on dialysis treatment, and 41 were renal transplant recipients. Mean age of patients was 51.9 +/- 11.5 years, and 39 patients (29%) had diabetes. ABI and TBI were measured by means of photoplethysmography. The definition of PAD required an ABI value of 0.90 or less, a TBI value of 0.60 or less, or a previous positive lower-extremity angiogram result. ABI values of 1.3 or greater or incompressible arteries at ankle level indicated MAC. The presence of claudication was determined by an interview. RESULTS: Prevalences of PAD on this study were 22.0% in patients with predialysis CRF, 30.6% in patients on dialysis treatment, 14.6% in renal transplant recipients, and 1.7% in the control group (P = 0.001). Prevalences of MAC were 23.7%, 41.7%, 23.1%, and 3.4% (P < 0.001), respectively. Only 9 patients had claudication, and 6 of those patients had PAD. CONCLUSION: Both asymptomatic PAD and MAC are common in patients with CRF. Therefore, we recommend the use of both ABI and TBI measurements in the evaluation of PAD in patients with CRF.     

Shoulder instability: impact of glenohumeral arthrotomography on treatment

We used arthrotomography to study the glenoid labrum in 114 patients. Sixty-nine of the patients had anatomic instability of the shoulder (including recurrent dislocation and subluxation of the shoulder), and 45 patients had functional instability of the shoulder (denoted by chronic pain, clicking of the joint, and the sensation that an unstable condition exists without the objective signs of it). Labral tears were revealed arthrotomographically in 86% of the patients with anatomic instability, while only 40% of the patients with functional instability had labral abnormalities, and these were primarily of minor severity. Fifty-six patients (44 of whom had anatomic instability; 12, functional instability) required surgery. The surgical findings were correlated with the arthrotomographic findings, and no false-positive results were revealed. However, arthrotomography demonstrated only part of the pathologic condition of two patients. These results confirm that there is a strong correlation between labral pathologic conditions and anatomic instability of the shoulder. Arthrotomographic studies have a great impact on the selection of therapy in cases of both anatomic and functional instability of the shoulder.