The validation and use of a three dimensional goniometry system to investigate lumbar motion in healthy subjects and low back pain patients undergoing manual mobilisation

This study of lumbar spinal kinematics in healthy subjects and low back pain patients had three defined aims: The first aim was to investigate the lumbar spinal kinematics in healthy subjects during 6 gross movements and 4 functional activities using a newly developed electromagnetic measurement system and to establish a database for three dimensional kinematics with which subsequent patient data could be compared. The second aim was to investigate the effects of low back pain on lumbar spinal motion during 6 gross movements and 4 functional activities and hence contribute to the conceptual framework related to low back pain. The third aim involved a randomised controlled clinical trial to determine the immediate effects of low velocity mobilisations on pain, pattern and range of movement in acute/subacute low back pain patients and hence enhance the theory and practice of orthopaedic manipulative therapy. A series of validation tests were carried out on the measurement device (3 Space Isotrak) in order to determine its accuracy and precision. The device had a random error of 0.03 degrees and a systematic error of 0.45 degrees with a percentage linearity of 1.24%. Good linearity was shown up to ± 80 degrees whereafter the systematic error gradually increased. However, significant cross-talk between angulation recording channels limited the working range further to ±70 degrees. One-hundred healthy subjects in the age range 20 to 77 were recruited from a diverse population in Edinburgh. Excursion data for 5 age cohorts (males and females) were obtained over a 6 months period. These excursion data were obtained during a total of 10 tests (6 gross movements and 4 functional tasks). The normative data revealed that healthy subjects had a gradually decreasing - lumbar flexibility with age in both females and males with females showing greater lumbar flexibility then males. Regression analysis indicated that lumbar mobility was negatively associated with an increase in age and mass whereas height was not associated with lumbar flexibility and females showing greater flexibility than males. Statistical analysis was carried out, using independent t-tests, to test the hypothesis of no differences between healthy subjects and patients. A significant decreased mobility (p<0.05) in 5 out of the 6 gross, primary movements and 3 out of 4 functional, primary movements was found. Only small changes were observed in the associated, gross coupled movements. However, during the execution of the functional tasks significant differences (p<0.05) in the excursions of the coupled movements were recorded. Forty-one patients with uncomplicated low back pain were recruited into a randomised controlled trial. Using a blocked randomisation procedure, patients were assigned to an intervention group (n=20) and a delayed intervention group (n=21) where the former received the treatment immediately after the first measurement and the latter after 1/2 hours rest. Both groups received a low velocity mobilisation based on the Maitland concept. The mobility of the patients was measured 3 times within a time period of 2.5 hour. In addition, a visual analogue scale was used to record changes in pain or discomfort. An ANOVA-design was used to test the differences in excursion values-between and within the two groups and over the 3 tests occasions. Post-hoc analysis revealed no significant increase in mobility when the intervention group, after the treatment, was compared to the delayed intervention group before the treatment. Descriptive analysis of visual analogue scale scores revealed a reduced mean score·after intervention. However, non-parametric statistical analysis (Wilcoxon, signed rank test 2-tailed) revealed no significant reduction in pain levels experienced after a mobilisation intervention. The value of 3 dimensional motion recording in lumbar spine assessment is discussed. The clinical trial demonstrated that the newly developed system for 3 dimensional motion measurement can effectively measure small changes in lumbar spinal flexibility. It is easy to use in a physiotherapy out-patient clinic and can be successfully used to assess and evaluate three dimensional lumbar flexibility mobility in LBP-patients. The appropriateness of this newly developed system for clinical use in physiotherapy is debated. The lack of immediate effects after a lumbar mobilisation in the treatment of low back pain are discussed and potential implications for the conceptual framework regarding the use of low velocity mobilisations in the treatment of low back pain are provided

Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards.

OBJECTIVES: The objectives of this study were to estimate the accuracy of using mid-upper-arm circumference (MUAC) measurements to diagnose severe wasting by comparing the new standards from the World Health Organization (WHO) with those from the US National Center for Health Statistics (NCHS) and to analyze the age independence of the MUAC cutoff values for both curves. METHODS: We used cross-sectional anthropometric data for 34,937 children between the ages of 6 and 59 months, from 39 nutritional surveys conducted by Doctors Without Borders. Receiver operating characteristic curves were used to examine the accuracy of MUAC diagnoses. MUAC age independence was analyzed with logistic regression models. RESULTS: With the new WHO curve, the performance of MUAC measurements, in terms of sensitivity and specificity, deteriorated. With different cutoff values, however, the WHO standards significantly improved the predictive value of MUAC measurements over the NCHS standards. The sensitivity and specificity of MUAC measurements were the most age independent when the WHO curve, rather than the NCHS curve, was used. CONCLUSIONS: This study confirms the need to change the MUAC cutoff value from <110 mm to <115 mm. This increase of 5 mm produces a large change in sensitivity (from 16% to 25%) with little loss in specificity, improves the probability of diagnosing severe wasting, and reduces false-negative results by 12%. This change is needed to maintain the same diagnostic accuracy as the old curve and to identify the children at greatest risk of death resulting from severe wasting

Shortage of vaccines during a yellow fever outbreak in Guinea.

A yellow fever epidemic erupted in Guinea in September, 2000. From Sept 4, 2000, to Jan 7, 2001, 688 instances of the disease and 225 deaths were reported. The diagnosis was laboratory confirmed by IgM detection in more than 40 patients. A mass vaccination campaign was limited by insufficient international stocks. After the epidemic in Guinea, the International Coordinating Group on Vaccine Provision for Epidemic Meningitis Control decided that 2 million doses of 17D yellow fever vaccine, being stored as part of a UNICEF stockpile, should be used only in response to outbreaks

Mortality, violence and lack of access to healthcare in the Democratic Republic of Congo.

The people of the Democratic Republic of Congo for decades have been living in a situation of chronic crisis. Violence, population displacement and the destruction of infrastructure and health services have devastated the health of the population. In 2001, Médicins Sans Frontières conducted a survey in five areas of western and central DRC to assess mortality, access to health-care, vaccination coverage and exposure to violence. High mortality rates were found in front-line zones, mainly due to malnutrition and infectious diseases. In Basankusu approximately 10 per cent of the total population and 25 per cent of the under-five population had perished in the year before the survey. Humanitarian needs remain acute across the country, particularly near the front line. Infectious-disease control and treatment are a priority, as is increasing access to health-care. Humanitarian assistance must be increased considerably, especially in rural areas and zones that have been affected directly by conflict

Dry supplementary feeding programmes: an effective short-term strategy in food crisis situations.

Malnutrition is frequently a predominant problem in disasters, and supplementary feeding programmes (SFPs) are often set up in food emergencies. This review analyses the effectiveness of such programmes in crisis situations in Liberia, Burundi and Goma (Congo), concluding that it is feasible to enrol large numbers of children in SFPs and achieve proportions of recovery above 75% if these programmes are implemented as a short-term measure in emergency situations. However, satisfactory SFP results do not necessarily indicate improved nutritional status of the whole population

Short report: molecular markers associated with Plasmodium falciparum resistance to sulfadoxine-pyrimethamine in the Democratic Republic of Congo.

Sulfadoxine-pyrimethamine (SP) is the first line antimalarial treatment in the Democratic Republic of Congo. Using polymerase chain reaction, we assessed the prevalence of mutations in the dihydrofolate reductase (dhfr) (codons 108, 51, 59) and dihydropteroate synthase (dhps) (codons 437, 540) genes of Plasmodium falciparum, which have been associated with resistance to pyrimethamine and sulfadoxine, respectively. Four hundred seventy-four patients were sampled in Kilwa (N = 138), Kisangani (N = 112), Boende (N = 106), and Basankusu (N = 118). The proportion of triple mutations dhfr varied between sites but was always > 50%. The proportion of dhps double mutations was < 20%, with some sites as low as 0.9%. A quintuple mutation was present in 12.8% (16/125) samples in Kilwa; 11.9% (13/109) in Kisangani, 2.9% (3/102) in Boende, and 0.9% (1/112) in Basankusu. These results suggest high resistance to pyrimethamine alone or combined with sulfadoxine. Adding artesunate to SP does not seem a valid alternative to the current monotherapy

Financial access to health care in Karuzi, Burundi: a household-survey based performance evaluation.

ABSTRACT: BACKGROUND: In 2003, Médecins Sans Frontières, the provincial government, and the provincial health authority began a community project to guarantee financial access to primary health care in Karuzi province, Burundi. The project used a community-based assessment to provide exemption cards for indigent households and a reduced flat fee for consultations for all other households. METHODS: An evaluation was carried out in 2005 to assess the impact of this project. Primary data collection was through a cross-sectional household survey of the catchment areas of 10 public health centres. A questionnaire was used to determine the accuracy of the community-identification method, households' access to health care, and costs of care. Household socioeconomic status was determined by reported expenditures and access to land. RESULTS: Financial access to care at the nearest health centre was ensured for 70% of the population. Of the remaining 30%, half experienced financial barriers to access and the other half chose alternative sites of care. The community-based assessment increased the number of people of the population who qualified for fee exemptions to 8.6% but many people who met the indigent criteria did not receive a card. Eighty-eight percent of the population lived under the poverty threshold. Referring to the last sickness episode, 87% of households reported having no money available and 25% risked further impoverishment because of healthcare costs even with the financial support system in place. CONCLUSION: The flat fee policy was found to reduce cost barriers for some households but, given the generalized poverty in the area, the fee still posed a significant financial burden. This report showed the limits of a programme of fee exemption for indigent households and a flat fee for others in a context of widespread poverty

Spatial targeted vector control is able to reduce malaria prevalence in the highlands of Burundi.

In a highland province of Burundi, indoor residual spraying and long-lasting insecticidal net distribution were targeted in the valley, aiming also to protect the population living on the hilltops. The impact on malaria indicators was assessed, and the potential additional effect of nets evaluated. After the intervention--and compared with the control valleys--children 1-9 years old in the treated valleys had lower risks of malaria infection (odds ratio, OR: 0.55), high parasite density (OR: 0.48), and clinical malaria (OR: 0.57). The impact on malaria prevalence was even higher in infants (OR: 0.14). Using nets did not confer an additional protective effect to spraying. Targeted vector control had a major impact on malaria in the high-risk valleys but not in the less-exposed hilltops. Investment in targeted and regular control measures associated with effective case management should be able to control malaria in the highlands