Persistent diarrhoea: management in algorithmic approach using a low-cost rice-based diet in severely malnourished Bangladeshi children

Easy and successful dietary management of persistent diarrhoea has been a long desired goal. Finding an efficient diet which is economically feasible, and easy to prepare in poor homes of developing countries, has not been easy. A dietary algorithm was followed to test the clinical efficacy of an inexpensive and easy to prepare diet made up with rice powder, egg white, glucose, and soya oil. We studied a cohort of 100 severely malnourished children aged between 3 and 36 months with persistent diarrhoea in Dhaka Shisu (children's) Hospital, Bangladesh, during 1990. Initially on a milk-based diet, 26 children (26 per cent) improved while on a subsequent rice-based diet; 65 (88 per cent) of the remaining 74 children improved within a week, with a mean recovery period of 4 days. Patients who did not improve with the rice-based diet were weaned earlier than those who improved. Nine patients failed to improve on the rice-based diet. They were given a soya formula, and only two improved. The remaining seven patients finally improved when a comminuted chicken diet was given. Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia. This study offers a simple and effective algorithm on the management of persistent diarrhoea and also demonstrates the success of a rice-based diet, showing promising and feasible means of management of persistent diarrhoea in patients with severe malnutrition.     

Dog bites in children admitted to Pennsylvania trauma centers

Dog bites are a major public health problem in the pediatric population, requiring emergency treatment for wound repair and possible hospitalization in a trauma center. Data from the Pennsylvania Trauma Outcome Study were analyzed, and the records of 183 pediatric dog bite patients from 1990 to 1995 were evaluated. Dog bites were found to constitute a very small proportion of the total pediatric admissions to Pennsylvania trauma centers; however, the findings were similar to other reported studies.     

Persistent diarrhoea in cholecystocolic and gastrocolic fistula after gastric surgery

In patients presenting with diarrhoea and vitamin deficiency even years after gastro-intestinal surgery, the possibility of fistulas should be considered. Four patients with persistent diarrhoea years after gastric surgery are described. Diagnosis of cholecystocolic and gastrocolic fistulas were made by barium enema and resection of the fistulas was performed.     

Acute bacterial meningitis in children admitted to the Queen Elizabeth Central Hospital, Blantyre, Malawi in 1996-97

To design appropriate interventions, we collected clinical and demographic data prospectively on all children aged one day to 14 years admitted with a diagnosis of bacterial meningitis (BM) from April 1st 1996 to March 31st 1997 to the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. During the study period 267 children (2.7% of all paediatric admissions) were found to have BM; 83% were under 5 years of age, 61% under one year and 23% under one month. The most common causative organisms in the post neonatal period (n=206) were Streptococcus pneumoniae (27%), Haemophilus influenzae type b (Hib) 21%, and Salmonella typhimurium (6%). In the neonatal group (< 1 month, n=61) the most common causes were Streptococcus agalactiae (23%), S. typhimurium (15%), S. pneumoniae (11.5%) and other Gram negative rods (11.5%). Nineteen of 21 salmonella infections were in children under one year of age and all S. agalactiae were in infants under three months. There was delay on presentation: the average length of fever was 4.6 days, 39.5% had convulsed prior to arrival and 57% had an altered level of consciousness. An initial diagnosis of malaria had probably contributed to the delay in 22.5% (42 of 186 tested). 48% were < 80% weight for age, with 18% < 60%) weight for age. The overall mortality was 40%. The outcome was worst in salmonella infections, particularly neonatal salmonella BM with a case fatality rate (CFR) of 89% (8 of 9 cases). Coma on presentation worsened prognosis (mortality 64% if Blantyre Coma Score < 3, 26% if > 3). 15% of survivors had sequelae on discharge. 20% of Hib isolates were resistant to chloramphenicol, but all salmonellae were sensitive. 5% of S. pneumoniae were resistant to penicillin and 8% to chloramphenicol. Earlier access to adequate health care and awareness of BM in a malaria-endemic area would reduce mortality and morbidity. Vaccination against Hib infection would have reduced death by 18 (17%) and prevented sequelae in 7 cases.     

Outcome of unsuspected pneumococcemia in children not initially admitted to the hospital

The records were reviewed of 97 episodes of unsuspected pneumococcemia in children not initially admitted to the hospital. Antimicrobial agents were prescribed at the first visit for 46 children; at the second visit 37 of them were improved and nine were not. No antimicrobial agents were prescribed at the first visit for 51; at the second visit 16 of these patients were improved and 35 were not. Pneumococcemia persisted in two treated children and in 13 untreated children. Meningitis was identified later in four children (two treated and two untreated). Although pneumococcemia in children may be a transient event, it may also persist or result in meningitis or other localized infections.     

Misuse of drugs in acute diarrhoea in under-five children

Effects of graded support loads and stimulators of the central nervous system (ephedrine and strychnine) on growth of bones and the volume of spongy bone tissue in the proximal metaphyses of the shin bones were studied in the 14-day experiment with rats suspended by tail in the orthostatic position. It is indicated that the support loads in combination with ephedrine injection prevent the suspension-induced inhibition of bone growth and development of osteopenia of spongiosa of metaphyses. The preventive effect of support loads and ephedrine relates with their stimulating influence on the functional activity of the STH-cells of adenohypophysis producing the growth hormone.     

Aetiology of acute diarrhoea in hospitalized children in Hong Kong

To determine the role of enteric pathogens in acute childhood diarrhoea in Hong Kong, 388 children with diarrhoea and 306 children of similar age without diarrhoea were evaluated in a hospital-based study during a one-year period from August 1994 to July 1995. Of the diarrhoeal cases, 55% were under 1 year and 95% were below 5 years of age. On admission, 22% had some dehydration but none was severely dehydrated. All children were well nourished. Oyer 60% of children with diarrhoea had one or more pathogens in their stool. Rotavirus was the most commonly isolated pathogen (34.6%), followed by Salmonella (23.3%), Campylobacter (4.7%) and Shigella (2.1%). Rotavirus was not assessed in the controls and was detected mainly during the winter months December to February. Bacterial pathogens were identified more commonly in diarrhoea patients (30%) than in controls (5.6%) (P < 0.001). Despite rapid recent socioeconomic development in Hong Kong, non-typhoidal Salmonella diarrhoea remains a significant local problem in infants under 1 year. Further detailed assessment of the transmission and prevention of this infection is required.     

Profile and cost of head injury patients admitted to the Waikato Hospital Intensive Care Unit

AIMS: To examine the profile and hospital costs of head injury patients admitted to the Waikato Hospital Intensive Care Unit (ICU). METHODS: Data were collected on head injury patients admitted to ICU over 41 months and costs of head injury patients in ICU, the High Dependency Unit (HDU) and other wards were calculated. RESULTS: There were 286 head injury patients admitted to ICU, of whom 62% had a Glasgow Coma Score < or = 8. Times in the ICU and hospital were 1760 and 7352 days respectively. Costs per day were $2280 in ICU, $800 in HDU and $500 in other wards. The cost for ICU was $1,174,478 per year, and for the total hospital treatment, $2.05 million (83 head injury patients) per year. Admissions of head injury patients to all New Zealand ICUs were 777 over the year to June 1996. Thus, assuming similar costs to the Waikato Hospital, New Zealand hospitals spend each year approximately 10.9 million dollars on head injury patients in ICUs and 19 million dollars on overall hospital stays (including ICU). In a selected group of 123 severe head injury patients, the six month Glasgow Outcome Scores showed that 36% were in the moderate to severe disability categories and likely to cause major ongoing ACC costs. The costs of the 80% of head injury patients admitted to hospital but not admitted to ICU, and their prehospital and postdischarge costs were not studied. CONCLUSIONS: The New Zealand epidemic of head injuries continues to consume large amounts of the health money and produce major social costs.     

Persistent parvovirus B19 infections in immunocompromised children

Significant anatomical variations within the middle ear are described as well as atypical histopathological findings in 13 selected human temporal bones. Bones studied included such vascular and bony abnormalities as carotid artery canal dehiscence, a high jugular bulb, persistent stapedial artery and facial nerve canal dehiscences. Bones also included obliterative otosclerosis, malleus head fixation and a variety of chronic inflammatory changes and/or sequelae. Those features considered to render cases prone to complications are detailed.     

Clinical features of diarrhoea in children caused by Cryptosporidium parvum

A time-series study of suicide and homicide rates in Australia and New Zealand from 1950-85 provided limited support for Durkheim's theory of suicide and no support for Henry and Short's theory of the relationship between suicide and homicide. The need for rival theories is discussed.     

Intraepithelial lymphocyte counts in small intestinal biopsies from children with diarrhoea

We have investigated small intestinal biopsies from children with coeliac disease, acute gastroenteritis, failure to thrive and giardiasis, to find out if a high intraepithelial lymphocyte count is a feature specific to coeliac disease, or whether it is always associated with partial or subtotal villous atrophy. The results indicate that the normal range for childrens' intraepithelial lymphocyte counts is similar to that for adults (around 6-40 lymphocytes per 100 epithelial cells); that counts are high in coeliac disease, but also in some children with giardiasis or with failure to thrive in whom the jejunal biopsy appears otherwise normal; and that intraepithelial lymphocyte counts are normal in acute gastroenteritis even when there is partial villous atrophy with increased lamina propria lymphoid cell infiltrate. Thus, this measurement of small intestinal lymphocyte infiltration may be of diagnostic value is differentiating the diarrhoea of food intolerance from infectious diarrhoeas in young children.     

Impact of zinc supplementation on persistent diarrhoea in malnourished Bangladeshi children

To evaluate the impact of zinc supplementation on the clinical recovery and body weight of children with persistent diarrhoea, a randomized, double-blind, controlled trial was conducted in 190 children with persistent diarrhoea aged between 3 and 24 months. Children were randomly allocated to receive either zinc (20 mg d(-1)) syrup with multivitamin (2 x RDA) or multivitamin alone in three divided daily doses for 2 weeks. The trial was conducted in a diarrhoeal disease hospital in Dhaka, Bangladesh. Duration until clinical recovery (d), impact on body weight and serum zinc level after 2 weeks of zinc supplementation were recorded. The duration of illness was significantly reduced (33%) with zinc supplementation among children who were underweight (< or =70% wt/age, p = 0.03). Supplemented male children also had a significant reduction (27%) in duration for recovery compared with unsupplemented children (p = 0.05). From baseline to convalescence, zinc-supplemented children maintained their serum zinc concentration (13.4 vs 13.6 micromol l(-1)), whereas unsupplemented children had a decrease in serum zinc after the 2 weeks of diarrhoea (13.6 vs 11.8 micromol l(-1),p < 0.03). The mean body weight of the children in the supplemented group was maintained (5.72 vs 5.70 kg, p = 0.62) during hospitalization, unlike that of the control group, in which there was a reduction in body weight (5.75 vs 5.67 kg, p = 0.05). Five children in the unsupplemented group and one child in the zinc-supplemented group died during the 2 weeks of supplementation (p = 0.06). Zinc supplementation in persistent diarrhoea significantly reduced the length of the recovery period in malnourished children and prevented a fall in body weight and serum zinc concentration, indicating that zinc is a beneficial therapeutic strategy in this high-risk childhood illness.     

Impact of bicycle helmet safety legislation on children admitted to a regional pediatric trauma center

A new approach to silent MR imaging using a rotating DC gradient has been explored and experimentally studied. Acoustic or sound noise has been one of the problems in examining patients, mainly due to the fast gradient pulsings in interaction with the main magnetic field. The sound noise has been noted to be proportionately louder as the magnetic field strength becomes larger. In this report, we describe a new imaging technique using a mechanically rotating DC gradient coil. The rotating DC gradient coil can effectively replace both phase encoding as well as readout gradient pulsings, and data obtained in this manner can provide a set of projection data that later can be used for projection reconstruction. With some interpolation techniques one can also perform conventional two-dimensional fast Fourier transform image reconstruction. The sound noise intensity compared with the conventional imaging technique, such as the spin-echo sequence, has been reduced down to about -20.7 dB or 117.5 times with this new technique. The experimental pulse sequence and its principle are described and images obtained by the new silent MR imaging technique are reported.     

Risk factors of persistent diarrhoea in children below five years of age

Persistent diarrhoea has been identified as a major source of morbidity in the developing world. This study was conducted to evaluate the risk factors of persistent diarrhoea in children below five years of age. The data used is from a prospective analytical case control study carried out in the Department of Paediatrics, Dow Medical College and Civil Hospital, Karachi, during 1993-94. A total of 50 cases of persistent diarrhoea and 50 acute diarrhoeal controls (matched for age and sex) under 5 comprised the study subjects in this analysis. The maximum incidence of persistent diarrhoeal episodes occurred in children below one year of age. Male to female ratio was 3:2. The seasonal variation showed a peak incidence in summer rainy season. Risk factors for persistent diarrhoea recorded were young age, poor nutritional status, irrational use of antibiotics during acute diarrhoea, lack of exclusive breast feeding, incomplete vaccination, lack of tap water supply and sanitation facility at home and income < Rupees 2000/month of the earning members of the family. Thus, it is concluded that discouraging the irrational use of antibiotics and other drugs for the treatment of diarrhoea, promotion of breast feeding and Expanded Programme of Immunization (EPI), Standard Diarrhoea Case Management courses for doctors, medical students and paramedical staff and provision of safe drinking water and sanitation facility are important for the prevention of persistent diarrhoea.     

Risk factors for mortality among hospitalized children with persistent diarrhoea in Pakistan

We evaluated factors associated with mortality among a cohort of malnourished children with persistent diarrhoea (PD) admitted for nutritional rehabilitation with a defined rice-lentil (Khitchri) and yoghurt diet. Of 302 children consecutively admitted with PD, 13 (4 per cent) died, mostly (62 per cent) within 72 h of admission. Univariate analysis of risk factors at admission associated with mortality indicated significantly increased risk of death with severe stunting [relative risk (RR) 3.1, 95 per cent confidence interval (CI) 1.1-9.0], hypoalbuminaemia (RR 4.3, 95 per cent CI 1.5-12.3), stool frequency > 12/day (RR 6.0, 96 per cent CI 2.0-17.6), stool volume > 100 g/kg/day (RR 10.7, 95 per cent CI 3.0-37.6) and severe dehydration (RR 7.5, 95 per cent CI 2.6-21.8). Children who died also had comparatively shorter duration of diarrhoea at admission, and were also associated with higher rate of bacteremia at admission (Fisher's exact test P < 0.01). The logistic regression model evaluating multivariate risk of mortality identified weight-for-age z-score and sepsis as significant risk factors. Our data suggest that severe malnutrition and sepsis are associated with significantly increased risk of mortality in children with PD. Stringent screening for infections and recognition of subgroups with severe malnutrition and severe diarrhoea may improve screening and case management strategies for this disorder.     

The prevalence of hepatitis C in patients admitted with acute hepatitis to Fairfield Infectious Diseases Hospital, 1971-1975

OBJECTIVE: To identify and determine trends in the prevalence of hepatitis C virus (HCV) antibody in stored sera from 1971 to 1975 and to determine associations with HCV seropositivity, including markers for other hepatitis infections and possible routes of transmission. DESIGN: A retrospective cross-sectional study. PATIENTS AND SETTING: 1511 adults admitted to Fairfield Infectious Diseases Hospital, Victoria, with a clinical and biochemical diagnosis of hepatitis between 1 January 1971 and 31 December 1975. MAIN OUTCOME MEASURES: Prevalence over study period of hepatitis A virus antibody (anti-HAV) IgM, hepatitis B core antibody (anti-HBc), hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) in stored sera; sociodemographic data and risk factors for blood-borne viruses documented in original medical records. RESULTS: Anti-HCV was detected in 17% of adults admitted with hepatitis from 1971 through 1975. Prevalence increased significantly over this period. Most cases were in young men who had a history of injecting drug use. HCV seropositivity was also significantly associated with markers for hepatitis B infection. CONCLUSIONS: Given the 20-30-year period between infection with hepatitis and the development of liver disease, our findings predict significant liver-related morbidity in Australia in the next decade. The increase in prevalence over the five years studied suggests rapid spread of HCV through susceptible populations, principally injecting drug users.     

Mortality in geriatric patients in the Hospital General of Mexico

In order to define the main diseases of the elderly and a possible changes of mortality causes at Hospital General of Mexico, SSA, the authors studied 586 autopsy reports of individuals over sixty years old, deceased between 1960 and 1965 and of 625 individuals of similar characteristics deceased between 1981 and 1985. The analysis of diseases showed qualitative and quantitative changes in the ten principal causes of death at each period: some of the most frequent diseases in the 60's, for instance, amebiasis, were not included among the then principal causes of death in the 80's. On the other hand, malignant neoplasms persisted as one of the principal death causes in both periods, but the most frequent carcinoma in the 60's, gastric carcinoma, was substituted in the 80's by bronchogenic carcinoma. This study suggests that great technical and sanitary interventions are necessary to promote health of third age persons, an increasing but poorly protected population in our country.