A follow-up experience of 6 months after treatment of children with severe acute malnutrition in Dhaka, Bangladesh.

AIM: As there is lack of information about what happens to children after recovery from severe acute malnutrition (SAM), we report their relapse, morbidity, mortality and referral during follow-up period. METHODS: From February 2001 to November 2003, 180 children completing acute and nutrition rehabilitation (NR) phases of protocolized management were advised for 6-months follow-up. The mean (SD) age was 12 (5) months, 55% were infants, 53% were male and 68% were breast-fed. RESULTS: The follow-up compliance rate dropped from 91% at first to 49% at tenth visit. The common morbidities following discharge included fever (26%), cough (24%) and diarrhoea (20%). Successful follow-up done in 124 children [68.9% (95% CI 61.8-75.2%)], partial follow-up in 45 [25% (95% CI 19.2-31.8%)], relapse in 32 [17.8% (95% CI 12.9-24%)] and 5 [2.8% (95% CI 1.2-6.3%)] died. CONCLUSION: Our findings highlight need for follow-up as part of overall management of SAM and recommend an effective community follow-up.

L-isoleucine-supplemented oral rehydration solution in the treatment of acute diarrhoea in children: a randomized controlled trial.

Antimicrobial peptides represent an important component of the innate immune defenses of living organisms, including humans. They are broad-spectrum surface-acting agents secreted by the epithelial cells of the body in response to infection. Recently, L-isoleucine and its analogues have been found to induce antimicrobial peptides. The objectives of the study were to examine if addition of L-isoleucine to oral rehydration salts (ORS) solution would reduce stool output and/or duration of acute diarrhoea in children and induce antimicrobial peptides in intestine. This double-blind randomized controlled trial was conducted at the Dhaka Hospital of ICDDR,B. Fifty male children, aged 6-36 months, with acute diarrhoea and some dehydration, attending the hospital, were included in the study. Twenty-five children received L-isoleucine (2 g/L)-added ORS (study), and 25 received ORS without L-isoleucine (control). Stool weight, ORS intake, and duration of diarrhoea were the primary outcomes. There was a trend in reduction in mean +/- standard deviation (SD) daily stool output (g) of children in the L-isoleucine group from day 2 but it was significant on day 3 (388 +/- 261 vs. 653 +/- 446; the difference between mean [95% confidence interval (CI) (-)265 (-509, -20); p = 0.035]. Although the cumulative stool output from day 1 to day 3 reduced by 26% in the isoleucine group, it was not significant. Also, there was a trend in reduction in the mean +/- SD intake of ORS solution (mL) in the L-isoleucine group but it was significant only on day 1 (410 +/- 169 vs. 564 +/- 301), the difference between mean (95% CI) (-)154 (-288, -18); p = 0.04. The duration (hours) of diarrhoea was similar in both the groups. A gradual increase in stool concentrations of beta-defensin 2 and 3 was noted but they were not significantly different between the groups. L-isoleucine-supplemented ORS might be beneficial in reducing stool output and ORS intake in children with acute watery diarrhoea. A further study is warranted to substantiate the therapeutic effect of L-isoleucine.

Mental disorders of people with disability pension in Georgia.

Correct assessment due to mental diseases is rather important. WHO developed International Classification for Functioning, Disability and Health (ICF) and there are two approaches to its implementation - development of disease specific or generic core sets. In order to know which way to choose up to date information is needed on disorders that most frequently lead to disability in Georgia. The study aimed at identification of the most prevalent mental diseases that led to disability pension in Georgia in 2010. Cross-sectional study of the population of pension beneficiaries was conducted. We have calculated 10% of 607 (diagnosed with disability in 2010) to be included in the survey. They were selected using random sampling method. Patient data were collected from the case histories. Paranoid schizophrenia (F 20.0) was the leading cause of disability both in men and women - 51.6% in men and 50% in women. In men persistent delusional disorder and mild mental retardation with significant impairment of behavior accounted for 9.7% each, while in women persistent delusional disorder led to disability in 15.0% of cases and moderate mental retardation - in 10.0%. All children receiving disability pension are mentally retarded. Paranoid schizophrenia - relatively less common disorder has high associated impairment among adults in Georgia, whereas in children mental retardation is the most frequent disabling condition. However, there are many other diseases that lead to disability. Therefore the best way to move further might be to first develop a generic core set for all psychiatric disability.

Efficacy of partially hydrolyzed guar gum-added oral rehydration solution in the treatment of severe cholera in adults.

BACKGROUND: Partially hydrolyzed guar gum (PHGG) is a water-soluble fiber if added to oral rehydration solution (ORS) and undergoes fermentation in the colon liberating short chain fatty acids (SCFAs). SCFAs potentiate the effect of ORS, reducing the severity of diarrhea. AIM: To examine the effect of PHGG-added ORS in reducing the stool output and duration of diarrhea in adult cholera. METHODS: 195 male patients were studied in a randomized controlled trial: (a) 65 received ORS + 25 g PHGG; (b) 65 received ORS + 50 g PHGG, and (c) 65 received ORS alone (control). Major outcomes were stool weight and duration of diarrhea. RESULTS: No significant differences were found in mean +/- SD stool weight (g/kg b.w.) during the first and second 24 h. In the subgroup analysis (excluding very high purging patients, stool weight in the first 24 h was >10 kg), the stool weight (g/kg b.w.) was significantly reduced in the first 24 h in both groups receiving PHGG (PHGG 25 g, 136 +/- 68 vs. PHGG 50 g, 144 +/- 49 vs. control, 176 +/- 43, p = 0.01). CONCLUSION: PHGG-added ORS might have a beneficial effect in moderately purging adult cholera. However, further studies are warranted to confirm the preliminary findings.

[Incapacity to work, occupational disability and disability in inflammatory bowel disease]. / Arbeitsunfähigkeit, Erwerbsunfähigkeit und Invalidität bei entzündlichen Darmkrankheiten.

Crohn's disease (CD) and ulcerative colitis (UC) are chronic-inflammatory bowel diseases with unknown etiology. The major symptoms in CD are pain and abdominal discomfort, sometimes associated with weight loss and a series of intestinal and/or extraintestinal symptoms. UC, on the other hand, is characterized by diarrhea which can be bloody and lead to iron deficiency anemia. The course of both diseases can be quite variabel: the extent of the disease, the severity and the complications are variable and unpredictable. Many patients have acute flare-ups followed by long phases of remission. Flare-ups can be associated with complications. From the perspective of an insurance, the variable course of disease, the unpredicatable complications and the variable quality of life make it difficult to make valid judgements and predictions. This is partly due to the fact that very little longterm data are available. It is therefore important to generate this information in the next few years.

Multiple organ failure and coma as initial presentation of pheochromocytoma in a patient with multiple endocrine neoplasia (MEN) type II A.

The unusual case of a 65-year-old woman with intermittent hypotension, fever, pulmonary edema and coma as initial presentation of pheochromocytoma is reported. The patient developed respiratory, cardiac and renal failure, disseminated intravascular coagulation and liver dysfunction. She had to be defibrillated on multiple occasions, occurring in periods of severe hypertension. After successful surgical removal of a pheochromocytoma a thyroid medullary carcinoma was detected. Several members of the patients family had presented with multiple endocrine neoplasia (MEN II).

Lack of R117H mutation in the cationic trypsinogen gene in patients with tropical pancreatitis from Bangladesh.

The etiology of nonalcoholic chronic pancreatitis, occurring in tropical regions, is unknown. Although environmental factors may play a role in its pathogenesis, a specific genetic predisposition may be necessary. The genetic mutation responsible for hereditary pancreatitis was described recently. Unlike in patients with hereditary pancreatitis, we found a lack of the R117H mutation in the cationic trypsinogen gene in all patients with tropical pancreatitis from Bangladesh.

Onset and pattern of substance use in intravenous drug users of an opiate maintenance program.

OBJECTIVES: To assess the initiation of substance use of participants in an opiate maintenance program by a cross-sectional survey. METHOD: Participants (n=184) filled out a questionnaire assessing age at initial substance use and age at onset of regular drug use. RESULTS: Of 15 substances investigated, alcohol, nicotine, analgesics and marijuana were initiated and consumed regularly before the age of 18 years. Barbiturates, benzodiazepines, cocaine, and opiates were begun later. The time gap between initial and regular use varied depending on the substance. Regular use exceeded 50% for alcohol, benzodiazepines, cocaine, heroin, marijuana and nicotine. CONCLUSIONS: Specific knowledge about the age of onset and sequence of substances used by drug addicts may help to prevent substance use more age specifically.

Hospital admissions for malaria in Basel, Switzerland: an epidemiological review of 150 cases.

The increase in international travel and immigration from tropical countries has led to a growing number of imported malaria cases in industrialized countries. We analyzed the charts of every patient hospitalized for malaria from 1970-1992 in Basel, Switzerland. A period lasting from 1970-1986 was compared to 1987-1992. There were 150 malaria-episodes recorded. Over time, the number of immigrants increased from 12 to 27% (p <.05). More patients were admitted with Plasmodium falciparum-infection (49 vs. 75%, p <.005). The number of untypable malaria decreased from 30 to 9% (p <.005). In the more recent period, more diagnosis were done within a week (66 vs. 50%, p <.05). Twenty-three (15%) patients were admitted to the ICU, four (2. 6%) patients died of cerebral malaria. Twenty-seven (18%) patients developed malaria while taking correct prophylaxis. Despite some progress, malaria is still causing considerable morbidity and mortality. Non adherence to chemoprophylaxis was a major risk factor for acquiring malaria in hospitalized patients.

[Erroneous diagnoses in the retrograde demonstration of the biliary and pancreatic ducts. Results of a prospective study involving 197 examinations (author's transl)]. / Fehldiagnosen retrograder Gallen- und Pankreasgangdarstellungen--Erfahrungen einer prospektiven Studie von 197 Untersuchungen.

The results of endoscopic retrograde cholangio-pancreatography were evaluated in a prospective study of 126 patients in respect of diagnostic accuracy, as compared with surgery and clinical follow-up. The diagnosis was incorrect in 11 patients; in seven it failed to differentiate between acute and chronic pancreatitis. The discrepancies in the other four patients are described in detail, particularly with reference to prepapillary filling defects. The indications, advantages and limitations of ERCP are discussed.

Prevalence of hookworm infection, anaemia and faecal blood loss among the Yupno people of Papua New Guinea.

The present report describes a study of hookworm infection, anaemia and the presence of blood in stool among the inhabitants of the Yupno area in Madang Province, Papua New Guinea. The study group comprised 588 persons of all age groups. A second group of 45 patients attending the Madang General Hospital, in the provincial capital on the coast, was used for comparison. In the Yupno area, 59% of the subjects were infected with hookworm; in the coastal group the infection rate was 82%, which was significantly higher. There is therefore a moderate prevalence of hookworm infection in the Yupno area, which does not impair the health of the population to any great extent. In both places there was a clear increase in the infection rate between the group of children 1-5 years old and the older groups. The mean blood haemoglobin level was 15.1 g/dl among the Yupno, which was significantly higher than that of the second group (10.7 g/dl). There was a significant negative linear correlation between the intensity of hookworm infection and blood haemoglobin level. The Colo-Rectal-Test for blood in stool was used on samples from 145 persons in the Yupno and from 43 in the coastal group. The test gave positive results in 17% of the cases without worm infection. In infected persons, the Colo-Rectal-Test gave an increasing rate of positive results as the parasite burden increased: 24% for subjects with low levels of infection, and 57% and 67% for moderate and high levels, respectively. The Colo-Rectal-Test is therefore a simple method for the detection of faecal blood loss in populations with a high prevalence of hookworm infection. However, it is not useful as an instrument for general screening for hookworm infections.

Day-care management of severe and very severe pneumonia, without associated co-morbidities such as severe malnutrition, in an urban health clinic in Dhaka, Bangladesh.

BACKGROUND: Management of severe and very severe pneumonia in children relies on hospital-based treatment, but practical barriers often prevent children in areas with the highest rates from receiving hospital care. OBJECTIVE: To develop and prospectively evaluate a day-care clinic approach, which provided antibiotics, feeding and supportive care during the day with continued care provided by parents at home, as an effective alternative to hospitalisation. METHODS: Children aged 2-59 months with severe or very severe pneumonia without associated co-morbidities, denied admission to hospital because of lack of beds, were enrolled at Radda Clinic, Dhaka and received antibiotics, feeding and supportive care from 08:00 to 17:00 every day, while mothers were educated on continuation of care at home during the night. RESULTS: From June 2003 to May 2005, 251 children were enrolled. Severe and very severe pneumonia was present in 189 (75%) and 62 (25%) children, respectively, and 143 (57%) were hypoxaemic with a mean (SD) oxygen saturation of 93 (4)%, which increased to 98 (3)% on oxygen therapy. The mean (SD) day-care period was 7 (2) days. Successful management was possible in 234 children (93% (95% CI 89% to 96%)), but 11 (4.4% (95% CI 2.5% to 7.7%)) had to be referred to hospital, and six (2.4% (95% CI 1.1% to 5.1%)) discontinued treatment. There were no deaths during the day-care study period; however, four children (1.6% (95% CI 0.6% to 4.0%)) died during the 3-month follow-up period, and 11 (4.4% (95% CI 2.5% to 7.7%)) required hospital admission. CONCLUSION: Severe and very severe pneumonia in children without associated co-morbidities such as severe malnutrition can be successfully managed at day-care clinics.

Partially hydrolysed guar gum supplemented comminuted chicken diet in persistent diarrhoea: a randomised controlled trial.

BACKGROUND: Partially hydrolysed guar gum (Benefiber) added to a diet is fermented in the colon, producing short chain fatty acids, which improve intestinal function, including colonic salt and water absorption. AIMS: To evaluate the effect of Benefiber supplemented comminuted chicken diet in the treatment of persistent diarrhoea. METHODS: One hundred and sixteen children (aged 5-24 months), presenting to Dhaka Hospital with a history of watery diarrhoea for more than 14 days (persistent diarrhoea), were randomised to receive either: (1) comminuted chicken diet with Benefiber (study diet); or (2) comminuted chicken diet without Benefiber (control diet). The study period was seven days. RESULTS: Of 116 children, 57 received the study diet and 59 received the control diet. Diarrhoea resolved in a greater number of children with the study than with the control diet (46/55 (84%) v 36/58 (62%); odds ratio 3.12, 95% CI 1.19 to 8.4). Survival analysis for the duration of diarrhoea also showed a reduced duration of diarrhoea in children receiving the study diet. There was also a trend in daily stool reduction in children receiving the study diet, significant on days 4-7. CONCLUSION: Results show that Benefiber supplemented comminuted chicken diet enhances recovery of children with persistent diarrhoea, indicating its therapeutic potential.

Leucopenia and abnormal liver function in travellers on malaria chemoprophylaxis.

Of 2887 travellers between the years 1984-1985, 451 on prophylactic antimalarials were studied retrospectively for adverse haematological or hepatic drug reactions and compared to 296 drug non-users. Travellers using amodiaquine, chloroquine, or pyrimethamine for less than 10 weeks had significantly lower total leucocyte counts than non-users. This was due to diminution of lymphocytes, not neutrophils. Travellers using amodiaquine for less than 10 weeks also had significantly higher serum aspartate aminotransferase (SGPT) levels than non-users. Amodiaquine was associated with a 3.1-times increased risk (95% confidence limits 1.8-5.4) of abnormal SGPT values. We consider toxic products, including metabolites of amodiaquine, the most likely cause of amodiaquine-related hepatotoxicity in travellers.

[Differential diagnostic value of occult blood in stool in hookworm infection in the Third World. Study from Papua New Guinea]. / Differentialdiagnostische Wertigkeit von okkultem Blut im Stuhl bei Hakenwurmbefall in der Dritten Welt. Studie aus Papua Neu Guinea.

In 633 persons of the Madang province in Papua-New Guinea hookworm-infection, blood hemoglobin and the presence of blood in stools were studied. 60% of the subjects were infected with hookworm (Necator americanus). There was a significant linear correlation between the intensity of hookworm infection and blood haemoglobin level. The Colo-Rectal test gave positive results in 17% of the cases without worm-infection. In infected persons, the Colo-Rectal test gave an increasing rate of positive results as the parasite infection increased: 24% for subjects with low levels of infection, and 57% and 67% for moderate and high levels, respectively. The mean blood-haemoglobin level was lower in persons with positive Colo-Rectal-Test and hookworm infection (11.8 g%) than among those with negative Colo-Rectal-Test and hookworm infection (15.0 g%, p < 0.01). In young populations with a known high prevalence of hookworm infection, Colo-Rectal test is therefore suitable for the detection of moderate or severe hookworm infections. It may serve as a simple and useful method to work up anaemia is such populations.

Abdominal pain, indigestion, anorexia, nausea and vomiting.

Non-specific abdominal complaints are a very frequent cause of discomfort. Even if only comparatively few are brought to the attention of the physician, they account for a considerable portion of the reasons for seeking medical care, both in acute and chronic conditions. On the other hand, few drugs are free of the suspicion of causing abdominal complaints, which make up between one-tenth and one-third of reported adverse reactions. A wide variety of possible alternative or concomitant causes makes a clear causative attribution to suspected drugs very difficult. This holds especially true for the ill-defined conditions of indigestion and anorexia. For nausea and vomiting, specific scales have been developed which facilitate differentiation between drugs causing these effects most frequently and most intensively. They have been applied in cytostatic therapy, where this is one of the most frequently encountered problems, but nausea and vomiting can seriously affect compliance in many other treatments. Somatic abdominal pain results in most instances from the irritation of the parietal peritoneum and is usually the effect of a lesion. This may or may not be caused by a drug, but this cause should be the first consideration. Visceral pain may result from functional disturbance of secretory glands or of the muscular coat, from drug action on bowel content or from irritation of the mucosa, all of which are frequently interrelated. Most frequently suspected pharmacological causes are drugs with anticholinergic action, antibiotics, potassium supplements and non-steroidal, anti-inflammatory agents. Drug-induced hyperinsulinism and porphyria are rare cases. Abuse of laxatives should always be considered because of its prevalence. A great number of other untoward drug effects have been described in the literature, but rarely merit first consideration. With the exception of promptly occurring or persistent emesis, gastrointestinal symptoms usually are not pathognomonic for drug effects and are the result of several factors. The usual approach to identifying an adverse drug effect is to delineate the functional or structural disorder, and to associate this diagnosis with possible pharmacodynamic aetiologies.

[The Basel Medical University Polyclinic on the brink of the 21st century: retrospective and prospective view]. / Die Medizinische Universitätspoliklinik Basel an der Schwelle zum 21. Jahrhundert: Retro- und Perspektiven.

At the occasion of its 125th anniversary the outpatient department of internal medicine is being analysed with regard to its history, development and future. Originally it was founded to improve practical patient-oriented teaching of students and to serve the poor population of Basel. While today the Swiss Health Insurance system warrants proper care for every citizen and thus renders the latter purpose unnecessary, new marginal patient groups have evolved that need proper attention such as HIV patients, asylum-seekers, geriatric patients and others. Teaching obligations have even increased, especially with regard to primary care and family medicine. Thus the reasons for running a medical outpatient department have changed considerably, but still include teaching, research and provision of care to special patient groups. Outpatient departments have to be flexible and to adapt to modern trends in health care.

[Benign symmetric lipomatosis--symptom of alcoholic liver disease]. / Die benigne symmetrische Lipomatose--ein Symptom der äthylischen Hepatopathie.

Benign symmetric lipomatosis (BSL) leads to characteristic multiple lipomas of the neck and submandibullar region. Seven men with BSL, aged 36--65 years, were investigated with regard to alcohol consumption, clinical findings and liver histology. They admitted a long standing ethanol intake (x = 107 ml/day) prior to the development of BSL. The growth of the lipomas was irregular and occurred over a period of months. There was no correlation with overweight or hyperlipidemia. However, liver biopsy revealed features consistent with alcoholic liver disease in all subjects. It is concluded that BSL represents a symptom of alcoholic liver disease affecting middle aged men.