Role of chest X-ray in predicting outcome of acute severe pneumonia.

OBJECTIVE: Radiological appraisal in children with clinically diagnosed severe pneumonia and its association with clinical outcome. DESIGN: Prospective. SETTING: Civil Hospital in Himachal Pradesh. PATIENTS: Eighty-three children hospitalized with severe pneumonia. RESULTS: Lobar consolidation (n=43, 51.8%) was the most common radiological abnormality. Twenty six (31.3%) had interstitial abnormalities and 14(16.9%) had normal chest radiographs. Clinical characteristics at admission could not predict a radiographic abnormality. Time to defervescence for outcome measures of fever and tachypnea was similar in children with consolidation, interstitial pneumonia or normal radiograph. However, length of hospital stay was significantly longer in children with abnormal chest radiographs on univariate analysis. CONCLUSION: Radiological findings in hospitalized children with clinically defined severe pneumonia have limited value in predicting clinical improvement.

Role of Acute Illness Observation Scale (AIOS) in managing severe childhood pneumonia.

OBJECTIVE: In the perspective of integrated management of childhood illness (IMCI) strategy and recent evidence favoring use of oral antibiotics in severe pneumonia, a generic illness severity index--Acute Illness Observation Scale (AIOS)--was prospectively validated in children with severe pneumonia in a civil hospital in remote hilly region. METHODS: AIOS was used in quantifying overall severity of illness for eighty-nine consecutive children (age, 2-59 months) hospitalized with community-acquired severe pneumonia. A detailed clinimetric evaluation of scale was carried out and logistic regression analyses predicted the following outcomes: 1) mode of initial antimicrobial therapy (oral vs. parenteral); and 2) need for intravenous fluids at admission. RESULTS: Majority of children (80.9%) with severe pneumonia scored abnormally (AIOS score> 10) at initial evaluation. Children with abnormal AIOS scores (>10) had significantly greater severity of respiratory distress and higher incidence of radiological pneumonia. Outcome measures i.e. time to defervescence and length of hospital stay were also positively and significantly correlated with the scores. The six-item scale had good internal consistency (Cronbach's alpha 0.81); and its factor analysis yielded a single latent factor explaining 54% of variance in illness severity at admission. Furthermore, logistic regression analyses revealed an independent predictive ability of AIOS in aiding clinician to decide the mode of initial antimicrobial therapy (oral or parenteral), as well as need for intravenous fluids. CONCLUSION: Authors study indicates the clinimetric validity of AIOS in managing, Severe childhood pneumonia and suggests its role in further enriching IMCI strategy.

Severe pneumonia in a remote hilly area: integrated management of childhood illness.

OBJECTIVE: This study aims to profile children with severe pneumonia in the perspective of Integrated Management of Childhood Illness (IMCI) strategy in a resource-constrained environment. METHODS: 115 consecutive children, aged 2 months to 10 yr, hospitalized with severe pneumonia were prospectively evaluated between May 1997 and June 1998 at a civil hospital in the northern hilly state of India. RESULTS: All children had tachypnea and lower chest wall indrawing. Grunting was observed in 39.7%, inability to drink in 16.5%, and cyanosis in 1.7% cases. Radiological investigation was carried out only in 90 children that included abnormal chest radiographs (CXRs) in 76.6% cases. Feeding malpractices, vaccination inconsistencies, exposure hazards to smoking, micronutrient as well as macronutrient deficiencies, treatment from unqualified practitioners, inconsequential involvement of health care workers, predominant burden on mothers in the care of sick children, failure to recognize signs and symptoms of pneumonia by parents at home, lack of oxygen facilities, problems of accessibility and less faith on primary health care services were widely prevalent bottlenecks for effective implementation of 3 components of IMCI. CONCLUSION: Our study offers practical insights that can be useful in customizing IMCI to needs of children with pneumonia in a resource-constrained environment.

Feasibility of "directly observed home-based twice-daily iron therapy" (DOHBIT) for management of anemia in rural patients: a pilot study.

BACKGROUND: Iron deficiency anemia (IDA) is a significant public health challenge in resource-poor settings, despite strong evidence for efficacy of iron supplementation. We hypothesized, modeled on the successful initiatives in disorders like tuberculosis or HIV, that directly observed therapy is an effective and practical strategy for control of IDA in such settings. OBJECTIVE: To overcome practical constraints and optimize compliance and effectiveness of iron supplementation by "Directly Observed Home-Based twice daily Iron Therapy" (DOHBIT) through village youth volunteers. DESIGN: Prospective longitudinal evaluation of DOHBIT. SETTING: A remote rural hilly hamlet with 25 families. METHODS AND MATERIAL: 100 mg elemental iron was administered twice daily under direct supervision to 33 anemic patients at home for 90 days. Outcome measures included hemoglobin rise, weight gain and side-effects. STATISTICS: Pre- and post-intervention weight and hemoglobin values were compared using paired t-test. RESULTS: 29 patients completed 3-months twice-daily iron therapy without interruption (compliance 87%). There was significant increase in mean weight (43.3 +/- 6.8 kg vs. 45.1+/- 6.9 kg; P < 0.0001) as well mean hemoglobin concentration (9.5 +/- 0.9 gm% vs. 11.7 +/- 0.7 gm%; P < 0.0001) and prevalence of anemia decreased by 40% from recruitment through the 3-months therapy. In terms of side effects, occasional constipation was stated by 3 patients, transient heartburn by two and diarrhea by none. Vomiting prompted withdrawal of iron therapy in one patient. CONCLUSIONS: Providing iron supplementation as directly observed home based therapy is feasible and successful in decreasing the prevalence of anemia in resource-poor settings.

Measles in a hilly hamlet of northern India.

OBJECTIVE: To ascertain the epidemiological links and risk factors responsible for the epidemic of measles in the village Astani in Himachal Pradesh. METHODS: All the children less than twelve years who were present on 27th July 1997 were evaluated. A questionnaire requesting data on vaccination history and symptoms of measles was administered and complete physical examination including anthropometry was recorded in each child by the authors. The data also included complications (including that of death) secondary to measles infection. RESULTS: A total of 48 children less than 12 years, present in the hamlet on 27th July 1997, were examined, out of which 28 (58%) were affected and 20 (42%) were unaffected. The immunization coverage in the affected children was 33% in contrast to 70% coverage in the unaffected group. Vaccine efficacy in the present epidemic was 51%. The complication rate was 59%, which included one death. The anthropometric data showed that 92% of the affected children were malnourished. All the children were given age appropriate dose of Vitamin A and children of the nearby villages were vaccinated against measles as a part of outbreak control. CONCLUSION: This study clearly highlights the need to achieve and sustain high immunization coverage along with strengthening of the routine surveillance systems in remote village of India.