Prevalence, Clinical Predictors, and Outcome of Hypocalcaemia in Severely-malnourished Underfive Children Admitted to an Urban Hospital in Bangladesh: A Case-Control Study.

Hypocalcaemia is common in severely-malnourished children and is often associated with fatal outcome. There is very limited information on the clinical predicting factors of hypocalcaemia in hospitalized severely- malnourished under-five children. Our objective was to evaluate the prevalence, clinical predicting factors, and outcome of hypocalcaemia in such children. In this case-control study, all severely-malnourished under-five children (n=333) admitted to the Longer Stay Ward (LSW), High Dependency Unit (HDU), and Intensive Care Unit (ICU) of the Dhaka Hospital of icddr,b between April 2011 and April 2012, who also had their total serum calcium estimated, were enrolled. Those who presented with hypocalcaemia (serum calcium <2.12 mmol/L) constituted the cases (n=87), and those admitted without hypocalcaemia (n=246) constituted the control group in our analysis. The prevalence of hypocalcaemia among severelymalnourished under-five children was 26% (87/333). The fatality rate among cases was significantly higher than that in the controls (17% vs 5%; p<0.001). Using logistic regression analysis, after adjusting for potential confounders, such as vomiting, abdominal distension, and diastolic hypotension, we identified acute watery diarrhoea (AWD) (OR 2.19, 95% CI 1.08-4.43, p=0.030), convulsion on admission (OR 21.86, 95% CI 2.57-185.86, p=0.005), and lethargy (OR 2.70, 95% CI 1.633-5.46, p=0.006) as independent predictors of hypocalcaemia in severely-malnourished children. It is concluded, severely-malnourished children presenting with hypocalcaemia have an increased risk of death than those without hypocalcaemia. AWD, convulsion, and lethargy assessed on admission to hospital are the clinical predictors of hypocalcaemia in such children. Presence of these features in hospitalized children with severe acute malnutrition (SAM) should alert clinicians about the possibility of hypocalcaemia and may help undertake potential preventive measures, such as calcium supplementation, in addition to other aspects of management of such children, especially in the resource-poor settings.

Observational Follow-up Study on a Cohort of Children with Severe Pneumonia after Discharge from a Day-care Clinic in Dhaka, Bangladesh.

Compliance, morbidity, mortality, and hospitalization during fortnightly follow-up were evaluated by an observational study on a cohort of children with severe and very severe pneumonia after day-care treatment at an urban clinic. The primary outcome measures were proportions of success (compliance) and failure (non-compliance) of follow-up visits at the day-care clinic. In total, 251 children were followed up, with median (IQR) age of 5.0 (3.0-9.0) months, and their compliance dropped from 92% at the first to 85% at the sixth visit. Cough (28%), fever (20%), and rapid breathing (13%) were common morbidities. Successful follow-up visits were possible in 180 (95.2%) and 56 (90.3%) of the children with severe and very severe pneumonia respectively. Eleven (4.4%) needed hospitalization, and four (1.6%) died. Majority (≈90%) of the children could be successfully followed up; some failed to attend their scheduled follow-up visits due to hospitalization and death. The common morbidities indicate the importance of follow-up for detecting medical problems and early treatment, thus reducing risk of death.

Salovum Egg Yolk Containing Antisecretory Factor As an Adjunct Therapy in Severe Cholera in Adult Males: A Pilot Study.

Cholera involves stimulation of intestinal secretory process in response to cholera toxin leading to profuse watery diarrhoea that might cause death due to dehydration unless timely rehydration therapy is initiated. Efforts to identify and test potential antisecretory agents are ongoing. Antisecretory factor (AF) is a naturally-occurring protein produced in the human secretory organs, including the intestine, with antisectory properties demonstrated in animal and human models of secretory diarrhoea. Salovum egg yolk powder contains proteins with antisecretory properties in a much higher (500 times) concentration than that of normal hen eggs. This is achieved by feeding hens with specially-processed cereals, capable of inducing proteins with antisecretory properties in the yolk. The aim of the study was to examine the effect of Salovum egg yolk powder containing AF in the treatment of adult cholera patients. In an open, randomized controlled trial (pilot study), 40 adult male patients with severe cholera were studied: 20 received standard treatment (oral rehydration solution, antibiotic, and usual hospital diet) plus Salovum egg yolk powder (study group) and 20 received standard treatment alone (control group). All the patients received tablet doxycycline (300 mg) once immediately after randomization. Written informed consent was obtained from each subject before enrollment. The main outcome measures were stool weight and duration of diarrhoea. The demographic and baseline clinical characteristics of the study patients were comparable between the groups. No significant differences were found in the mean stool weight, g/kg of body-weight during the first 24 hours [study vs control group, mean±standard deviation (SD), 218±119 vs 195±136], second 24 hours (mean±SD, 23±39 vs 22±34), and cumulative up to 72 hours (mean±SD, 245±152 vs 218±169). The duration (hours) of diarrhoea after admission in the hospital was also similar in both the groups (mean±SD, 33±14 vs 32±10). No adverse effect was observed. Salovum egg powder containing AF as an adjunct therapy in the treatment of severe cholera could not demonstrate any beneficial effect. Further studies with higher doses of Salovum egg yolk powder might be considered in future to establish its antisecretory effect.

Occult Pneumonia: An Unusual but Perilous Entity Presenting with Severe Malnutrition and Dehydrating Diarrhoea.

A three-month old boy was admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh, with the problems of acute watery diarrhoea with some dehydration and suspected dyseletrolytaemia, severe malnutrition, and reduced activity. Occult pneumonia was added to the problem list after demonstration of radiologic consolidation in right upper lung, despite the lack of clinical signs, both on admission and after correction of dehydration. The problem list was further expanded to include bacteraemia due to Staphylococcus aureus when the blood culture report was available. Severely-malnourished children may not exhibit typical clinical signs of pneumonia, and the possibility of existence of such problems should be remembered in the assessment and provision of care to hospitalized young children with severe malnutrition.

Childhood anemia and vitamin a deficiency in rural Bangladesh.

The study aimed to assess the prevalence of anemia and vitamin A deficiency in preschool children in rural Bangladesh. A cross-sectional study was done on eight randomly-selected sub-districts of rural Bangladesh. Children (n=1,302) aged 2-6 years were studied. Families of 43% of the study participants had a monthly household expenditure of US$ 60 or less. Fifty-six percent of the children were underweight, and 17% were severely underweight; 18% were wasted, and 1% were severely wasted; and 45% were stunted while 20% were severely stunted. The mean+/-SD serum retinol of the children was1.0+/-0.4 micromol/l, and 3% of them had serum retinol levels of <0.35 micromol/l, about one-fifth (20%) had a serum retinol level of <0.70 micromol/l and 55% had serum retinol levels of <1.05 pmol/l. The mean hemoglobin concentration of the children was 110+/-11 g/l, and 48% had a Hb of <11 g/l signifying anemia in this age group. Thirty-one percent (31 %) of children had low serum ferritin (<12 microg/l), and 14% had elevated CRP (> or = 15 mg/l) indicating the presence of a sub-clinical infection. Male and female children had similar nutritional status and biochemical profiles although boys tended to be heavier than girls (p=0.013). The proportion of children with anemia and iron deficiency anemia (IDA) declined significantly (p<0.001) with advancing age. Five percent of the study children had IDA and concomitant low serum retinol. The proportion of children with IDA and serum retinol also declined significantly with increasing age from 8% in children aged 35 months or younger, to 3% in children aged 60 months and more (p=0.025). Results of our study clearly demonstrated the public health importance of anemia and vitamin A deficiency among children of rural Bangladesh.

Analysis of fecal leukocytes and erythrocytes in Shigella infections in urban Bangladesh.

We evaluated the usefulness of enumeration of fecal leukocytes and erythrocytes in making an early diagnosis of Shigella infection, where Shigella is a leading cause of invasive diarrhea. Stool specimens from 561 invasive diarrhea patients were submitted for microscopic examination. A presumptive diagnosis of shigellosis based on microscopic examination was made in 389 of them; 227 had stool cultures positive for Shigella spp (Shigella patients). One hundred sixty-two patients with no detectable Shigella infection (non-Shigella invasive diarrhea cases) served as a comparison group. Two hundred twenty-seven randomly selected Shigella patients and 227 non-Shigella infectious diarrhea cases from the surveillance system database of the hospital constituted another group for comparative evaluation. The stool specimens of the patients were examined under the microscope, and isolation, biochemical characterization and serotyping of Shigella were performed. In comparison with non-Shigella invasive diarrhea cases, the presence of >50 WBC/hpf in association with any number of RBC in the fecal sample had a modest sensitivity of 67%, specificity of 59%, positive predictive value of 70%, negative predictive value of 56%, accuracy of 64%, and positive likelihood ratio of 1.6 in predicting shigellosis. Comparison between Shigella and non-Shigella infectious diarrhea patients revealed the presence of >20 WBC/hpf was a less accurate predictor of shigellosis (sensitivity 51%, specificity 88%, positive predictive value 81%, negative predictive value 64%, accuracy 69%, and positive likelihood ratio 4.1). Direct microscopical examination of stool specimens for the presence of WBC and RBC may facilitate the early diagnosis of shigellosis, and may be a cheap alternative to stool culture in this setting.