Early diagnostic indicators of dengue versus other febrile illnesses in Asia and Latin America (IDAMS study): a multicentre, prospective, observational study.

BACKGROUND: Improvements in the early diagnosis of dengue are urgently needed, especially in resource-limited settings where the distinction between dengue and other febrile illnesses is crucial for patient management. METHODS: In this prospective, observational study (IDAMS), we included patients aged 5 years and older with undifferentiated fever at presentation from 26 outpatient facilities in eight countries (Bangladesh, Brazil, Cambodia, El Salvador, Indonesia, Malaysia, Venezuela, and Viet Nam). We used multivariable logistic regression to investigate the association between clinical symptoms and laboratory tests with dengue versus other febrile illnesses between day 2 and day 5 after onset of fever (ie, illness days). We built a set of candidate regression models including clinical and laboratory variables to reflect the need of a comprehensive versus parsimonious approach. We assessed performance of these models via standard measures of diagnostic values. FINDINGS: Between Oct 18, 2011, and Aug 4, 2016, we recruited 7428 patients, of whom 2694 (36%) were diagnosed with laboratory-confirmed dengue and 2495 (34%) with (non-dengue) other febrile illnesses and met inclusion criteria, and were included in the analysis. 2703 (52%) of 5189 included patients were younger than 15 years, 2486 (48%) were aged 15 years or older, 2179 (42%) were female and 3010 (58%) were male. Platelet count, white blood cell count, and the change in these variables from the previous day of illness had a strong association with dengue. Cough and rhinitis had strong associations with other febrile illnesses, whereas bleeding, anorexia, and skin flush were generally associated with dengue. Model performance increased between day 2 and 5 of illness. The comprehensive model (18 clinical and laboratory predictors) had sensitivities of 0·80 to 0·87 and specificities of 0·80 to 0·91, whereas the parsimonious model (eight clinical and laboratory predictors) had sensitivities of 0·80 to 0·88 and specificities of 0·81 to 0·89. A model that includes laboratory markers that are easy to measure (eg, platelet count or white blood cell count) outperformed the models based on clinical variables only. INTERPRETATION: Our results confirm the important role of platelet and white blood cell counts in diagnosing dengue, and the importance of serial measurements over subsequent days. We successfully quantified the performance of clinical and laboratory markers covering the early period of dengue. Resulting algorithms performed better than published schemes for distinction of dengue from other febrile illnesses, and take into account the dynamic changes over time. Our results provide crucial information needed for the update of guidelines, including the Integrated Management of Childhood Illness handbook. FUNDING: EU's Seventh Framework Programme. TRANSLATIONS: For the Bangla, Bahasa Indonesia, Portuguese, Khmer, Spanish and Vietnamese translations of the abstract see Supplementary Materials section.

Usefulness and applicability of the revised dengue case classification by disease: multi-centre study in 18 countries.

BACKGROUND: In view of the long term discussion on the appropriateness of the dengue classification into dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS), the World Health Organization (WHO) has outlined in its new global dengue guidelines a revised classification into levels of severity: dengue fever with an intermediary group of "dengue fever with warning sings", and severe dengue. The objective of this paper was to compare the two classification systems regarding applicability in clinical practice and surveillance, as well as user-friendliness and acceptance by health staff. METHODS: A mix of quantitative (prospective and retrospective review of medical charts by expert reviewers, formal staff interviews), semi-quantitative (open questions in staff interviews) and qualitative methods (focus group discussions) were used in 18 countries. Quality control of data collected was undertaken by external monitors. RESULTS: The applicability of the DF/DHF/DSS classification was limited, even when strict DHF criteria were not applied (13.7% of dengue cases could not be classified using the DF/DHF/DSS classification by experienced reviewers, compared to only 1.6% with the revised classification). The fact that some severe dengue cases could not be classified in the DF/DHF/DSS system was of particular concern. Both acceptance and perceived user-friendliness of the revised system were high, particularly in relation to triage and case management. The applicability of the revised classification to retrospective data sets (of importance for dengue surveillance) was also favourable. However, the need for training, dissemination and further research on the warning signs was highlighted. CONCLUSIONS: The revised dengue classification has a high potential for facilitating dengue case management and surveillance.

Por qué y cómo mueren los niños con dengue? / Why and how children with dengue die?

Introducción: es importante conocer el modo en que agravan y fallecen los pacientes con dengue para diseñar las estrategias en la prevención de su mortalidad. Objetivo: identificar las condiciones (complicaciones y otras situaciones clínicas) a las cuales estuvo asociada la muerte, así como el tipo de afectación particular que mostraron algunos órganos. Métodos: se hizo un estudio clínico-patológico de 30 niños fallecidos por dengue en El Salvador, entre 1999 y 2000. Todos los casos cumplieron los criterios clínico-humorales que establece la Organización Mundial de la Salud para ser considerados fiebre hemorrágica dengue/síndrome de choque por dengue. Mediante el análisis de la evolución diaria y horaria de cada caso, el colectivo de investigadores identificó la condición clínica o clínico-humoral a la cual estuvo asociado el fallecimiento. Se estudiaron las autopsias de 8 casos confirmados por serología o mediante inmunohistoquímica. Resultados: en 20 de los 24 casos (83 por ciento) que fallecieron durante los primeros 3 d del ingreso hospitalario, la condición asociada a la muerte fue el choque hipovolémico, a veces asociado a hemorragias, coagulación intravascular diseminada, síndrome de dificultad respiratoria por edema pulmonar no cardiogénico y daño múltiple de órganos, que fueron complicaciones del choque recurrente más que complicaciones del dengue. La coinfección bacteriana fue la condición más frecuente asociada a la muerte por dengue en los niños que fallecieron después del tercer día de hospitalización. Mediante autopsia se apreció afectación importante de hígado, corazón y riñones de estos enfermos. Conclusiones: la muerte por dengue es evitable en buena medida si se hace prevención del choque o se le trata de manera precoz y enérgicamente, con soluciones cristaloides por vía intravenosa a partir de la identificación de los signos de alarma que anuncian el inicio del deterioro clínico del enfermo con dengue.

Introduction: It is important to find out how the patients with dengue become critical and die, with a view to designing the mortality prevention strategies. Objective: to identify the death-associated conditions (complications and other clinical situations) as well as the specific type of damage observed in some body organs. Methods: A clinical-pathological study of 30 dead children with dengue in El Salvador was performed from 1999 to 2000. All the cases met the WHO clinical and humoral criteria for being classified as either dengue hemorrhagic fever or dengue shock syndrome. Through the analysis of daily and hourly evolution of each case, the research team identified the clinical or the clinical-humoral condition that was associated to the death of a patient. The autopsies of 8 serology or immunohistochemistry confirmed cases were studied. Results: In 20(83percent) of 24 cases that died in the first three days of admission, the associated condition was hypovolemic shock, sometimes related to hemorrhage, disseminated intravascular coagulation, respiratory distress caused by non-cardiogenic pulmonary edema and multiple organ damage, all of which were recurrent shock complications rather than dengue complications. The bacterial co-infection was the most frequent condition associated to death of children with dengue after the third day of hospitalization. The autopsies showed considerable damage of liver, heart and kidneys. Conclusiones: Death from dengue is generally preventable if hypovolemic shock is either prevented or treated timely and energetically using intravenously administered crystalloid preparations at the time of detecting alarming signs that would indicate the onset of clinical deterioration of the patient with dengue.

Farmacología clínica: tratamento com antibióticos y quimioterápicos / Pharmacology clinical: treatment with antibiotics and chemotherapeutic

Ofrece valiosos conceptos de decisión terapéutica prática, orientación en la toma de esa decisión y una información terapéutica al día. Está escrito para todos los niveles del conocimiento médico que continuamente buscan soluciones al problema de las infecciones

Importancia de la artritis séptica en niños: análisis de cien casos del Instituto Nacional de Pediatría / Importance of the septic arthritis in children: analysis of one hundred cases at the National Institute of Pediatrics

Se revisaron los expedientes clínicos de 100 pacientes hospitalizados en el Instituto Nacional de Pediatría entre enero de 1985 y diciembre de 1987, con el diagnóstico de artritis séptica. El 36% de los casos correspondió a menores de 1 año de edad. Las articulaciones más afectadas fueron la cadera, la rodilla y el hombro. El estafilococo fue el agente causal más frecuente en todas las edades, aunque en recién nacidos los gramnegativos juegan un papel muy importante. Se encontró H. influenzae en el grupo de 4 meses a 5 años. La mortalidad por complicaciones fué del 5%; el 30% de los egresados quedaron con secuelas. Los resultados globales no difieren notablemente de lo revisado en la literatura.