RESUMO
OBJECTIVES: Hypoglycaemia (glucose <2.2 mmol/l) is a defining feature of severe malaria, but the significance of other levels of blood glucose has not previously been studied in children with severe malaria. METHODS: A prospective study of 437 consecutive children with presumed severe malaria was conducted in Mali. We defined hypoglycaemia as <2.2 mmol/l, low glycaemia as 2.2-4.4 mmol/l and hyperglycaemia as >8.3 mmol/l. Associations between glycaemia and case fatality were analysed for 418 children using logistic regression models and a receiver operator curve (ROC). RESULTS: There was a significant difference between blood glucose levels in children who died (median 4.6 mmol/l) and survivors (median 7.6 mmol/l, P < 0.001). Case fatality declined from 61.5% of the hypoglycaemic children to 46.2% of those with low glycaemia, 13.4% of those with normal glycaemia and 7.6% of those with hyperglycaemia (P < 0.001). Logistic regression showed an adjusted odds ratio (AOR) of 0.75 (0.64-0.88) for case fatality per 1 mmol/l increase in baseline blood glucose. Compared to a normal blood glucose, hypoglycaemia and low glycaemia both significantly increased the odds of death (AOR 11.87, 2.10-67.00; and 5.21, 1.86-14.63, respectively), whereas hyperglycaemia reduced the odds of death (AOR 0.34, 0.13-0.91). The ROC [area under the curve at 0.753 (95% CI 0.684-0.820)] indicated that glycaemia had a moderate predictive value for death and identified an optimal threshold at glycaemia <6.1 mmol/l, (sensitivity 64.5% and specificity 75.1%). CONCLUSIONS: If there is a threshold of blood glucose which defines a worse prognosis, it is at a higher level than the current definition of 2.2 mmol/l.
Assuntos
Glicemia/análise , Hipoglicemia/parasitologia , Malária/complicações , Biomarcadores/sangue , Criança , Pré-Escolar , Métodos Epidemiológicos , Feminino , Humanos , Hipoglicemia/sangue , Hipoglicemia/diagnóstico , Lactente , Recém-Nascido , Malária/sangue , Masculino , PrognósticoRESUMO
BACKGROUND: Kawasaki disease is now the commonest cause of acquired heart disease in children in the United Kingdom. Its incidence has increased in recent years. Epidemiologic analyses have provided insights into the possible etiology, but European data are scarce. METHODS: We analyzed linked English-wide hospital admission data for Kawasaki disease in people younger than 18 years of age, during a 5-year period (1998-2003), relating incidence to geographic location, urbanization, deprivation, ethnicity, and to laboratory reports of respiratory infection. RESULTS: There were 2432 admissions with Kawasaki disease in the study period for 1704 individuals. One thousand twenty-eight (60%) of the 1704 were male and 1228 (72%) were younger than 5 years of age. The annual age-specific incidence rate in those younger than 5 years was 8.39/100,000. Incidence rates in different areas of residence were significantly and independently related to both the degree of deprivation of the area and the proportion of the population in each area who were Chinese. After adjusting for the winter peaks in both the incidence of Kawasaki disease and respiratory virus infections, there was no correlation between Kawasaki disease and specific viruses. INTERPRETATION: The previously reported increase in Kawasaki disease incidence in England has reached a plateau. These data support the concept of an infectious trigger in a genetically susceptible population, but known respiratory viral pathogens are unlikely to be the specific etiologic agents
Assuntos
Síndrome de Linfonodos Mucocutâneos/epidemiologia , Adolescente , Povo Asiático/etnologia , População Negra/etnologia , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Inglaterra/epidemiologia , Feminino , Humanos , Lactente , Masculino , Síndrome de Linfonodos Mucocutâneos/etnologia , Síndrome de Linfonodos Mucocutâneos/virologia , Análise Multivariada , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/virologia , Estatísticas não ParamétricasRESUMO
OBJECTIVE: Kawasaki disease (KD) is an increasingly common vasculitis with risk of coronary artery aneurysms (CAAs). The last UK survey was in 1990, whereas current epidemiology, treatment patterns and complication rates are unknown. The aim of this study was to address this knowledge gap. METHODS: A British Paediatric Surveillance Unit survey in the UK and Ireland from 1 January 2013 to 28 February 2015 ascertained demographics, ethnicity, seasonal incidence, treatment and complication rates. RESULTS: 553 cases were notified: 389 had complete KD, 46 had atypical KD and 116 had incomplete KD; 2 were diagnosed at postmortem with an incidence of 4.55/100 000 children under 5 years, with a male to female ratio of 1.5:1 and a median age of 2.7 years (2.5 months-15 years). Presentation was highest in January and in rural areas. Most were white (64%), and Chinese and Japanese Asians were over-represented as were black African or African mixed-race children. 94% received intravenous immunoglobulin (IVIG). The overall CAA rate was 19%, and all-cardiac complications affected 28%. Those with CAA received IVIG later than in those without (median 10 days vs 7 days). Those under 1 year had fewer symptoms, but the highest CAA rate (39%). Overall 8 of 512 cases (1.6%) had giant CAA, and 4 of 86 cases (5%) under 1 year of age developed giant CAA. Mortality from KD was 0.36%. CONCLUSIONS: The UK and Ireland incidence of KD has increased and is more frequently seen in winter and rural areas. Delayed IVIG treatment is associated with CAA, suggesting earlier and adjunctive primary treatment might reduce complications to prevent CAA, particularly in the very young.
Assuntos
Síndrome de Linfonodos Mucocutâneos/epidemiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Irlanda/epidemiologia , Masculino , Síndrome de Linfonodos Mucocutâneos/etiologia , Vigilância da População , Estudos Prospectivos , Inquéritos e Questionários , Reino Unido/epidemiologiaRESUMO
BACKGROUND: GPs are advised to measure vital signs in children presenting with acute infections. Current evidence supports the value of GPs' overall assessment in determining how unwell a child is, but the additional benefit of measuring vital signs is not known. AIM: To describe the vital signs and clinical features that GPs use to assess children (aged <5 years) with acute infections. DESIGN OF STUDY: Questionnaire survey. SETTING: All 210 GP principals working within a 10 mile radius of Oxford, UK. METHOD: Data were collected on reported frequency, methods, and utility of measuring vital signs. Description of clinical features was used to assess the overall severity of illness. RESULTS: One hundred and sixty-two (77%) GPs responded. Half (54%, 95% confidence interval [CI] = 47 to 62) measured temperature at least weekly, compared to pulse (21%, 95% CI = 15 to 27), and respiratory rates (17%, 95% CI = 11 to 23). Almost half of GPs (77, 48%) never measured capillary refill time. Temperature was measured most frequently using electronic aural thermometers (131/152; 86%); auscultation or counting were used for pulse and respiratory rates. A minority used pulse oximeters to assess respiratory status (30/151, 20%). GPs' thresholds for tachypnoea were similar to published values, but there was no consensus on the threshold of tachycardia. Observations of behaviour and activity were considered more useful than vital signs in assessing severity of illness. CONCLUSION: Vital signs are uncommonly measured in children in general practice and are considered less useful than observation in assessing the severity of illness. If measurement of vital signs is to become part of standard practice, the issues of inaccurate measurement and diagnostic value need to be addressed urgently.
Assuntos
Medicina de Família e Comunidade , Infecções/diagnóstico , Exame Físico/normas , Prática Profissional/estatística & dados numéricos , Doença Aguda , Temperatura Corporal , Pré-Escolar , Inglaterra , Inquéritos Epidemiológicos , Humanos , Lactente , Exame Físico/métodos , Pulso Arterial , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Meningococcal disease is a rapidly progressive childhood infection of global importance. To our knowledge, no systematic quantitative research exists into the occurrence of symptoms before admission to hospital. METHODS: Data were obtained from questionnaires answered by parents and from primary-care records for the course of illness before admission to hospital in 448 children (103 fatal, 345 non-fatal), aged 16 years or younger, with meningococcal disease. In 373 cases, diagnosis was confirmed with microbiological techniques. The rest of the children were included because they had a purpuric rash, and either meningitis or evidence of septicaemic shock. Results were standardised to UK case-fatality rates. FINDINGS: The time-window for clinical diagnosis was narrow. Most children had only non-specific symptoms in the first 4-6 h, but were close to death by 24 h. Only 165 (51%) children were sent to hospital after the first consultation. The classic features of haemorrhagic rash, meningism, and impaired consciousness developed late (median onset 13-22 h). By contrast, 72% of children had early symptoms of sepsis (leg pains, cold hands and feet, abnormal skin colour) that first developed at a median time of 8 h, much earlier than the median time to hospital admission of 19 h. INTERPRETATION: Classic clinical features of meningococcal disease appear late in the illness. Recognising early symptoms of sepsis could increase the proportion of children identified by primary-care clinicians and shorten the time to hospital admission. The framework within which meningococcal disease is diagnosed should be changed to emphasise identification of these early symptoms by parents and clinicians.
Assuntos
Infecções Meningocócicas/fisiopatologia , Adolescente , Criança , Pré-Escolar , Hospitalização , Humanos , Lactente , Infecções Meningocócicas/diagnóstico , Infecções Meningocócicas/mortalidade , Fatores de TempoRESUMO
Streptococcus pneumoniae is a major cause of early childhood morbidity and mortality. A heptavalent pneumococcal conjugate vaccine (PnC7) is licensed for use and could prevent the majority of infant invasive pneumococcal infections. A recent announcement confirmed its inclusion into the U.K. childhood immunisation programme. In anticipation of PnC7 being recommended for use, this study explored parental understanding of pneumococcal disease and their views on the possible introduction of this vaccine. Twenty three interviews and two focus groups were held with parents of children under two years of age. Four main themes emerged from the data analysis: 'Confidence and belief in immunisation'; 'Anxiety about immunisation'; 'Trust and understanding of immunisation information' and 'Response to a new immunisation'. Overall parental confidence in immunisation has been affected by the MMR controversy. With little knowledge of pneumococcal disease, parents want information about the safety and effectiveness of PnC7. Information needs to be conveyed in a way that restores parents' trust in immunisation.
Assuntos
Atitude Frente a Saúde , Vacinas Meningocócicas , Pais/psicologia , Vacinas Pneumocócicas , Vacinação/psicologia , Adulto , Ansiedade/psicologia , Conscientização , Inglaterra , Feminino , Grupos Focais , Conhecimentos, Atitudes e Prática em Saúde , Vacina Pneumocócica Conjugada Heptavalente , Humanos , Programas de Imunização , Lactente , Masculino , Vacinas Meningocócicas/efeitos adversos , Pesquisa Metodológica em Enfermagem , Pais/educação , Vacinas Pneumocócicas/efeitos adversos , Pesquisa Qualitativa , Inquéritos e Questionários , Confiança , Vacinação/efeitos adversosRESUMO
Infection control in British nursing homes is different from that in U.S. nursing homes in seveal ways. Most British nursing homes, for example, do not have a designated on-site infection control nurse, and several agencies are responsible for regulatory oversight. This article discusses the state of infection control in British nursing homes.
Assuntos
Controle de Infecções/métodos , Casas de Saúde , Pesquisas sobre Atenção à Saúde , Política de Saúde , Humanos , Recursos Humanos de Enfermagem , Reino UnidoRESUMO
BACKGROUND: Community prescribing of antibiotics has decreased substantially in the UK in recent years. We examine the association between pneumonia mortality and recent changes in community-based antibiotic prescribing for lower respiratory tract infections (LRTI). METHODS: Retrospective analysis of aggregated data for pneumonia mortality, influenza incidence, and antibiotic prescribing for LRTI in England and Wales during 12-week winter periods between 1993/94 and 1999/2000. RESULTS: Winter antibiotic prescribing for LRTI showed a 30.0% decline since 1995/96. Over the same period, there was a 50.6% increase in winter excess pneumonia mortality adjusted for influenza incidence. Negative binomial regression analysis showed that the incidence of influenza alone had a significant association with winter pneumonia mortality (P<0.001). The analysis also showed the reduction in antibiotic prescribing had a small but significant association with mortality (P<0.001), when simultaneously modelling for influenza incidence. CONCLUSIONS: Our findings suggest an association between recent reductions in antibiotic prescribing for LRTI in general practice and an increase in pneumonia mortality in England and Wales. This retrospective study of aggregate data represents the first attempt to assess the effect of limiting antibiotic prescribing on patient outcomes, and highlights the need to identify which patients benefit from antibiotic treatment for LRTI.
Assuntos
Antibacterianos/administração & dosagem , Pneumonia/mortalidade , Padrões de Prática Médica/tendências , Infecções Comunitárias Adquiridas/mortalidade , Inglaterra/epidemiologia , Medicina de Família e Comunidade/estatística & dados numéricos , Humanos , Incidência , Influenza Humana/epidemiologia , Mortalidade/tendências , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Estações do Ano , País de Gales/epidemiologiaRESUMO
BACKGROUND: Kawasaki disease is a rare childhood illness that can present non-specifically, making it a diagnostic challenge. The clinical presentation of Kawasaki disease has not been previously described in primary care. AIM: To describe how children with an eventual diagnosis of Kawasaki disease initially present to primary care in the UK. DESIGN AND SETTING: The Clinical Practice Research Datalink was used to find cases coded as Kawasaki disease. Hospital Episode Statistics, hospital admissions, and hospital outpatient attendances were used to identify the children with a convincing diagnosis of Kawasaki disease. METHOD: Questionnaires and a request for copies of relevant hospital summaries, discharge letters, and reports were sent to GPs of the 104 children with a diagnosis of Kawasaki disease between 2007 and 2011. RESULTS: Most children presented with few clinical features typical of Kawasaki disease. Of those with just one feature, a fever or a polymorphous rash were the most common. By the time that most children were admitted to hospital they had a more recognisable syndrome, with three or more clinical features diagnostic of Kawasaki disease. Most GPs did not consider Kawasaki disease among their differential diagnoses, but some GPs did suspect that the child's illness was unusual. CONCLUSION: The study highlighted the difficulty of early diagnosis, with most children having a non-specific presentation to primary care. GPs are encouraged to implement good safety netting, and to keep Kawasaki disease in mind when children present with fever and rashes.
Assuntos
Clínicos Gerais , Síndrome de Linfonodos Mucocutâneos/diagnóstico , Atenção Primária à Saúde/métodos , Pesquisa Biomédica , Criança , Pré-Escolar , Bases de Dados Factuais , Diagnóstico Diferencial , Feminino , Clínicos Gerais/educação , Humanos , Lactente , Masculino , Síndrome de Linfonodos Mucocutâneos/epidemiologia , Valor Preditivo dos Testes , Inquéritos e Questionários , Reino Unido/epidemiologiaRESUMO
IMPORTANCE: Topical corticosteroids are indicated for pregnant women with skin conditions, but their safety in pregnancy is not fully understood. OBJECTIVE: To investigate whether maternal exposure to topical corticosteroids results in adverse pregnancy outcomes. DESIGN: Retrospective cohort study. SETTING: United Kingdom National Health Service. PARTICIPANTS: A total of 2658 pregnant women exposed to topical corticosteroid and 7246 unexposed pregnant women. EXPOSURE: Topical corticosteroids dispensed during pregnancy. MAIN OUTCOMES AND MEASURES: Orofacial cleft, low birth weight, preterm delivery, fetal death, low Apgar score, and mode of delivery. RESULTS: No associations of maternal topical corticosteroid exposure with orofacial cleft, low birth weight, preterm delivery, fetal death, low Apgar score, and mode of delivery were found in the primary analysis (adjusted risk ratio [RR], 1.85 [95% CI, 0.22-15.20] [P = .57]; 0.97 [95% CI, 0.78-1.19] [P = .75]; 1.20 [95% CI, 0.73-1.96] [P = .48]; 1.07 [95% CI, 0.56-2.05] [P = .84]; 0.84 [95% CI, 0.54-1.31] [P = .45]; and P = .76, respectively). Stratified analyses based on potency did not reveal any significant associations in most of these categories either, but an exploratory analysis showed a significantly increased risk of low birth weight when the dispensed amount of potent or very potent topical corticosteroids exceeded 300 g during the entire pregnancy (adjusted RR, 7.74 [95% CI, 1.49-40.11]; P = .02). CONCLUSIONS AND RELEVANCE: This study reassuringly showed no associations of maternal topical corticosteroid exposure with orofacial cleft, preterm delivery, fetal death, low Apgar score, and mode of delivery. With this study and all available evidence taken together, the risk of low birth weight seems to correlate with the quantity of topical corticosteroid exposure.
Assuntos
Anormalidades Induzidas por Medicamentos/etiologia , Fármacos Dermatológicos/efeitos adversos , Glucocorticoides/efeitos adversos , Exposição Materna/efeitos adversos , Complicações na Gravidez/induzido quimicamente , Resultado da Gravidez , Anormalidades Induzidas por Medicamentos/diagnóstico , Administração Tópica , Índice de Apgar , Peso ao Nascer , Estudos de Coortes , Fármacos Dermatológicos/administração & dosagem , Feminino , Glucocorticoides/administração & dosagem , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Gravidez , Estudos Retrospectivos , Creme para a Pele , Dermatopatias/tratamento farmacológico , Reino UnidoRESUMO
OBJECTIVE: To compare maternal morbidity in HIV-infected and uninfected pregnant women. METHODS: Major maternal morbidity (severe febrile illness, illnesses requiring hospital admissions, surgical revisions, or illnesses resulting in death) was measured prospectively in a cohort of HIV-infected and uninfected women followed from 36 weeks of pregnancy to 6 weeks after delivery. Odds ratios of major morbidity and associated factors were examined using logistic regression. RESULTS: Major morbidity was observed in 46/129 (36%) and 104/390 (27%) of the HIV-infected and HIV-uninfected women, respectively, who remained in followup. In the multivariable analysis, major morbidity was independently associated with HIV infection, adjusted odds ratio (AOR) 1.7 (1.1 to 2.7), nulliparity (AOR 2.0 (1.3 to 3.0)), and lack of, or minimal, formal education (AOR 2.1 (1.1 to 3.8)). CONCLUSIONS: HIV was associated with a 70% increase in the odds of major maternal morbidity in these Ugandan mothers.
Assuntos
Infecções por HIV/complicações , Complicações na Gravidez/etiologia , Adulto , Estudos de Casos e Controles , Feminino , Febre/epidemiologia , Febre/etiologia , Seguimentos , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Mortalidade Materna , Morbidade , Análise Multivariada , Razão de Chances , Gravidez , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/cirurgia , Complicações Infecciosas na Gravidez , Estudos Prospectivos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Uganda/epidemiologiaRESUMO
Topical corticosteroids may be indicated in pregnant women with skin conditions, but their safety in pregnancy is unclear. We used the UK General Practice Research Database to conduct a population-based cohort study to investigate whether maternal exposure to topical corticosteroids results in adverse pregnancy outcomes. We identified 35,503 pregnant women prescribed topical corticosteroids during the period from 85 days before last menstrual period (LMP) to delivery or fetal death and 48,630 unexposed women. We found no associations of maternal exposure to topical corticosteroids with orofacial cleft (and its two subtypes, i.e., cleft lip ± palate (CLP) and cleft palate alone (CP)), preterm delivery, and fetal death (including miscarriage and stillbirth). The findings were similar when excluding exposure before LMP. In contrast, maternal exposure to potent/very potent topical corticosteroids shortly before and during pregnancy was significantly associated with fetal growth restriction (adjusted relative risk 2.08; 95% confidence interval 1.40-3.10; number needed to harm, 168), which was confirmed by a significant dose-response relationship (P=0.025) and the sensitivity analysis excluding exposure before LMP. The increased risk for fetal growth restriction should be considered when prescribing potent/very potent topical corticosteroids to pregnant women, and appropriate obstetric care should be provided.
Assuntos
Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Complicações na Gravidez/epidemiologia , Dermatopatias/tratamento farmacológico , Dermatopatias/epidemiologia , Aborto Espontâneo/epidemiologia , Administração Tópica , Adolescente , Adulto , Fissura Palatina/epidemiologia , Estudos de Coortes , Bases de Dados Factuais , Relação Dose-Resposta a Droga , Feminino , Retardo do Crescimento Fetal/epidemiologia , Humanos , Gravidez , Nascimento Prematuro/epidemiologia , Prevalência , Fatores de Risco , Natimorto/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Symptoms are part of the initial evaluation of children with acute illness, and are often used to help identify those who may have serious infections. Meningococcal disease is a rapidly progressive infection that needs to be recognised early among children presenting to primary care. AIM: To determine the diagnostic value of presenting symptoms in primary care for meningococcal disease. DESIGN OF STUDY: Data on a series of presenting symptoms were collected using a parental symptoms checklist at point of care for children presenting to a GP with acute infection. Symptom frequencies were compared with existing data on the pre-hospital features of 345 children with meningococcal disease. SETTING: UK primary care. METHOD: The study recruited a total of 1212 children aged under 16 years presenting to their GP with an acute illness, of whom 924 had an acute self-limiting infection, including 407 who were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with meningococcal disease. Main outcome measures were diagnostic characteristics of individual symptoms for meningococcal disease. RESULTS: Five symptoms have clinically useful positive likelihood ratios (LR+) for meningococcal disease: confusion (LR+ = 24.2, 95% confidence interval [CI] = 11.5 to 51.3), leg pain (LR+ = 7.6, 95% CI = 4.9 to 11.9), photophobia (LR+ = 6.5, 95% CI = 3.8 to 11.0), rash (LR+ = 5.5, 95% CI = 4.3 to 7.1), and neck pain/stiffness (LR+ = 5.3, 95% CI = 3.5 to 8.3). Cold hands and feet had limited diagnostic value (LR+ = 2.3, 95% CI = 1.9 to 3.0), while headache (LR+ = 1.0, 95% CI = 0.8 to 1.3), and pale colour (LR+ = 0.3, 95% CI = 0.2 to 0.5) did not discriminate meningococcal disease in children. CONCLUSION: This study confirms the diagnostic value of classic 'red flag' symptoms of neck stiffness, rash, and photophobia, but also suggests that the presence of confusion or leg pain in a child with an unexplained acute febrile illness should also usually prompt a face-to-face assessment to exclude meningococcal disease. Telephone triage systems and primary care clinicians should consider these as 'red flags' for serious infection.
Assuntos
Infecções Meningocócicas/diagnóstico , Adolescente , Criança , Pré-Escolar , Métodos Epidemiológicos , Medicina Geral , Humanos , LactenteAssuntos
Surtos de Doenças , Síndrome Respiratória Aguda Grave/virologia , Medicina de Família e Comunidade , Saúde Global , Humanos , Coronavírus Relacionado à Síndrome Respiratória Aguda Grave/genética , Coronavírus Relacionado à Síndrome Respiratória Aguda Grave/isolamento & purificação , Síndrome Respiratória Aguda Grave/epidemiologia , Síndrome Respiratória Aguda Grave/transmissãoRESUMO
BACKGROUND: In 2006 the Confidential Enquiry into Maternal and Perinatal Deaths was extended to pilot a collection of child deaths. This helped optimise data collection for local safeguarding children's boards, which, since April 2008, have a statutory responsibility to review all child deaths. Reviewing primary care records may highlight areas in which systems, skills, and care could be improved. AIM: To review the role and quality of primary care in child deaths. DESIGN OF STUDY: Confidential enquiry into child deaths. SETTING: Five regions of the UK: North-East, South-West and West Midlands, Wales, and Northern Ireland. METHOD: The confidential enquiry collected core data for all child deaths (age range 28 days to 17 years) and an age-stratified sample was assessed by multidisciplinary panels for avoidable factors. An independent detailed review was conducted of the primary care records on all children in the North-East region and all children who were reviewed by panel in the other four regions. RESULTS: Primary care records were reviewed for 168 child deaths. There were 25 (15%) deaths from acute infection, 22 (13%) from cancer, and 11 (7%) from asthma or epilepsy. Fifty-nine (35%) deaths were sudden: sudden unexplained death in infancy, suicides, and assaults. Of 149 with immunisation records, only 88 (59%) had been fully vaccinated on time. One or more primary care professionals were involved in the management of 90 (54%) children. Avoidable primary care factors were identified in 18 (20%) of these deaths. Avoidable primary care factors included failure in the recognition and management of serious infection, failure to vaccinate, and inadequate management of asthma and epilepsy. CONCLUSION: Decisions made about diagnosis and management in primary care may affect the cause, time, and circumstances of a child's death. Maintaining skills in assessing the acutely ill child remains an essential part of good clinical practice.
Assuntos
Doença Aguda/mortalidade , Doença Crônica/mortalidade , Estado Terminal/mortalidade , Atenção Primária à Saúde/normas , Adolescente , Criança , Mortalidade da Criança , Pré-Escolar , Anormalidades Congênitas/mortalidade , Morte Súbita/epidemiologia , Feminino , Humanos , Imunização/estatística & dados numéricos , Lactente , Masculino , Neoplasias/mortalidade , Neoplasias/terapia , Atenção Primária à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Apoio Social , Reino Unido/epidemiologiaRESUMO
OBJECTIVE: To determine the viral aetiology of respiratory infections in children presenting to primary care with "more than a simple cold". DESIGN: Observational study in 18 Oxfordshire general practices over four winters (2000-01 to 2003-04). PATIENTS: 425 children aged 6 months to 12 years with cough and fever for whom general practitioners considered prescribing an antibiotic. METHODS: Nasopharyngeal aspirate obtained from 408 (96%) children was subjected to PCR for respiratory viruses. Parents completed an illness diary for the duration of illness. RESULTS: A viral cause of infection was detected in most (77%) children. Clinical symptoms correctly identified the infecting virus in 45% of cases. The duration of illness was short and the time course was very similar for all infecting viruses. One third of children were prescribed an antibiotic (34%), but this made no difference to the rate of parent-assessed recovery (Kruskal-Wallis, p = 0.67). About one in five children with influenza who did not receive an antibiotic had persistent fever on day 7 compared to no children receiving antibiotics (p = 0.02); this difference remained after adjustment for severity and other factors and was not seen with other viruses. CONCLUSIONS: Most children receiving antibiotics for respiratory symptoms in general practice have an identifiable viral illness. In routine clinical practice, neither the specific infecting virus nor the use of antibiotics has a significant effect on the time course of illness. Antibiotics may reduce the duration of fever in children with influenza which could reflect an increased risk of secondary bacterial infection for such children.
Assuntos
Antibacterianos/administração & dosagem , Medicina de Família e Comunidade/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Infecções Respiratórias/tratamento farmacológico , Infecções Respiratórias/virologia , Viroses/diagnóstico , Doença Aguda , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Prescrições de Medicamentos/estatística & dados numéricos , Febre/tratamento farmacológico , Humanos , Lactente , Nasofaringe/virologia , Infecções Oportunistas/tratamento farmacológico , Estudos Prospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To assess the effect of community prescribing of an antibiotic for acute respiratory infection on the prevalence of antibiotic resistant bacteria in an individual child. STUDY DESIGN: Observational cohort study with follow-up at two and 12 weeks. SETTING: General practices in Oxfordshire. PARTICIPANTS: 119 children with acute respiratory tract infection, of whom 71 received a beta lactam antibiotic. MAIN OUTCOME MEASURES: Antibiotic resistance was assessed by the geometric mean minimum inhibitory concentration (MIC) for ampicillin and presence of the ICEHin1056 resistance element in up to four isolates of Haemophilus species recovered from throat swabs at recruitment, two weeks, and 12 weeks. RESULTS: Prescribing amoxicillin to a child in general practice more than triples the mean minimum inhibitory concentration for ampicillin (9.2 microg/ml v 2.7 microg/ml, P=0.005) and doubles the risk of isolation of Haemophilus isolates possessing homologues of ICEHin1056 (67% v 36%; relative risk 1.9, 95% confidence interval 1.2 to 2.9) two weeks later. Although this increase is transient (by 12 weeks ampicillin resistance had fallen close to baseline), it is in the context of recovery of the element from 35% of children with Haemophilus isolates at recruitment and from 83% (76% to 89%) at some point in the study. CONCLUSION: The short term effect of amoxicillin prescribed in primary care is transitory in the individual child but sufficient to sustain a high level of antibiotic resistance in the population.
Assuntos
Antibacterianos/uso terapêutico , Medicina de Família e Comunidade/estatística & dados numéricos , Infecções por Haemophilus/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Infecções Respiratórias/tratamento farmacológico , Amoxicilina/uso terapêutico , Ampicilina/uso terapêutico , Criança , Pré-Escolar , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Humanos , Lactente , Testes de Sensibilidade Microbiana , Reação em Cadeia da Polimerase/métodos , Estudos Prospectivos , Proteínas do Envelope Viral/análise , Resistência beta-LactâmicaRESUMO
OBJECTIVE: To explore the impact on mortality and morbidity of parenteral penicillin given to children before admission to hospital with suspected meningococcal disease. DESIGN: Retrospective comparison of fatal and non-fatal cases. SETTING: England, Wales, and Northern Ireland; December 1997 to February 1999. PARTICIPANTS: 158 children aged 0-16 years (26 died, 132 survived) in whom a general practitioner had made the diagnosis of meningococcal disease before hospital admission. RESULTS: Administration of parenteral penicillin by general practitioners was associated with increased odds ratios for death (7.4, 95% confidence interval 1.5 to 37.7) and complications in survivors (5.0, 1.7 to 15.0). Children who received penicillin had more severe disease on admission (median Glasgow meningococcal septicaemia prognostic score (GMSPS) 6.5 v 4.0, P = 0.002). Severity on admission did not differ significantly with time taken to reach hospital. CONCLUSIONS: Children who were given parenteral penicillin by a general practitioner had more severe disease on reaching hospital than those who were not given penicillin before admission. The association with poor outcome may be because children who are more severely ill are being given penicillin before admission.