A clinical decision rule for triage of children under 5 years of age with hydrocarbon (kerosene) aspiration in developing countries.

BACKGROUND: Unintended hydrocarbon ingestion is a common reason for pediatric hospitalization in the developing world. OBJECTIVE: To derive a clinical decision rule, to identify patients likely to require a higher level facility (resource-requiring cases), that can be used at primary health care facilities with limited diagnostic and therapeutic resources. METHODS: A prospective study of children 2 to 59 months old presenting to a poison treatment facility within 2 hours of oral hydrocarbon exposure. History and objective signs were recorded at admission and at 6, 12, 24 and, if present, 48 hours. Inclusion in the resource-requiring outcome group required: oxygen saturation <94%; any CNS depression; any treatment with (salbutamol); any care in the ICU; or death. RESULTS: 256 met the inclusion criteria and completed the study. Of these, 170 had a course requiring resources unavailable at most primary health care facilities, and 86 did not. The presence of wheezing, any alteration in consciousness (lethargy or any restlessness), or a rapid respiratory rate for age (RR >or= 50/min if age < 12 mo, >or= 40/min if age >or= 12 mo) at presentation identified 167 of 170 of these patients (sensitivity 0.98). Thirty-six of 86 patients classified as non-resource requiring were correctly identified (specificity 0.42). No combination of clinical symptoms provided better discrimination while preserving sensitivity. CONCLUSIONS: This study suggests a triage decision rule based on the presence of wheezing, altered consciousness, or a rapid respiratory rate within 2 hours of hydrocarbon exposure. Such a rule requires validation in other settings.

Malaria dipsticks beneficial for IMCI in Cambodia.

OBJECTIVES: The Integrated Management of Childhood Illness (IMCI) approach and new clinical treatment guidelines to control malaria among children less than 5 years old were introduced recently in Cambodia. This study was conducted to finalize the malaria part of the national IMCI fever chart. METHODS: A total of 323 sick children 2-59 months old were studied at rural health centres in northern Cambodia from February to April 2000. Cases with fever (by axillary temperature or history) or anaemia (by palmar pallor) were tested with dipsticks for Plasmodium falciparum and Plasmodium vivax in high and low malaria risk areas and, if positive, treated with anti-malarials. RESULTS: The draft IMCI chart identified children with malaria safely and effectively (sensitivity 14 of 15, approximately 93% and specificity 292 of 308, approximately 95%). The study confirmed the potential of malaria dipsticks as a part of IMCI case management. CONCLUSION: The Cambodian Ministry of Health will use the studied malaria chart during the Early Implementation Phase of IMCI. Dipsticks able to detect P. falciparum and P. vivax with high sensitivity and acceptable cost will be needed for this purpose. To promote the rational use of dipsticks, the National Centre for Malaria Control, Parasitology and Entomology (Centre National de Malaridogie, Parasitologie et Entomologie, CNM) should list all known malaria risk areas in the country and prepare detailed local maps guiding case management especially in transitional zones.

Costs of diarrhoeal diseases and the savings from a control programme in Cebu, Philippines.

A control of diarrhoeal diseases programme was set up in Cebu Province, Philippines, in 1986. In order to compare the reduction in treatment costs before and after implementation of the programme, and the potential savings to be made from its continuation, we collected data for 1985 and 1989 in 10 health facilities in Cebu. Since the programme's introduction, household expenditures on drugs for diarrhoea cases have decreased by a total of 1.03 million Philippine pesos (P) (US$ 41,200). At the health centre level, the costs of treating diarrhoea cases were close to optimum, but in the district hospitals treatment of inpatients with diarrhoea changed little between 1985 and 1989. This arose because such hospitals were compensated by the central authorities for inpatients but not for outpatients. Potential savings of around US$ 60,000 could have been made, however, had the district hospitals adopted the practices used in the main referral hospital.

PIP: A program to diarrheal diseases was established jn 1986 in Cebu province, Philippines. The authors calculate the reduction in treatment costs over the course of program its continuation. Findings are based upon data collected for 1985 and 1989 in 10 health facilities in Cebu. It is concluded that households expenditures on drugs for diarrhea declined by 1.03 million. Philippine pesos since the program started. Close to optimum costs have been realized for treating diarrhea cases at the health center level, yet the treatment of inpatients with diarrhea in district hospitals changed little over the period. This latter outcome stems from a structure in which hospitals were compensated by central authorities for inpatients, but not for outpatients. Had district hospitals adopted the practices of the main referral hospital, nearly 1.3 million Philippine pesos could have been saved.

May a lymphocytic infiltration have a pathogenic role in an aldosterone-producing adrenal tumor?

A 38-year-old woman is described to have a primary hyperaldosteronism due to an aldosteronoma with foci of lymphocytic infiltration. The finding suggests: a concomitant lymphoid adrenalitis; or, an immunological attack to neoplastic cells. The hypothesis is that there may be a relationship in the association. The lymphocytic infiltrates could have a pathogenic role in the development of the aldosterone-producing adrenocortical neoplasm by interrupting some inhibitory mechanism(s) of the cells that secrete aldosterone.