Case Management Guidelines Research Articles

Épidémie de méningite: évaluation de la surveillance et du traitement des cas dans les formations sanitaires d’un district du Burkina Faso

Meningococcal meningitis remains a periodical threat in the African meningitis belt. The countries concerned, such as Burkina Faso, provided guidelines for its surveillance, diagnosis, treatment, and prevention during outbreaks. The objective of this study is to assess the quality of the surveillance system and case management during an outbreak in Fada N'Gourma district. A retrospective study of the meningitis outbreak in 2007 was conducted by literature review and interviews of health caretakers across 27 health centers (CSPS) and three units in the regional hospital in the district.We reported all data available about surveillance and case management, and then we compared it with the guidelines of the Ministry of Health. The case definition and notification forms were available in all centers and units. During the outbreak, 861 cases were recorded, but only 89% was notified at the upper level and 87% of notification forms were available. The age is marked on all the forms, while the interval between the onset of symptoms and consultation is noted only in 90.7%. The forms were distributed weekly at the district level. Cerebrospinal fluid (CSF) Gram coloration was performed for a limited number of cases (150/349 samples, 42.9%); it showed Gram-negative diplococcus in 86%. Culture was performed for a limited number of patients (7 cases). According to the results of a central level laboratory study, the outbreak was due to Group A Neisseria meningitidis. The case management guidelines were available in all the centers and units which were supervised during the outbreak. Anti-biotherapy was appropriate in 93.6% of the cases. A shortage of antibiotics (free prepositioning) was observed in 7 centers (23.3%). The mortality rate was 3.5%. This assessment shows an under-notification of cases, despite the existence of a surveillance system and supervision, a weak laboratory contribution in germ identification, appropriate case management, and shortage of antibiotics during the outbreak. Management of a meningitis outbreak may become more efficient by improving the notification, the laboratory's capabilities, and the availability of drugs.

Comparison of Oral Amoxicillin with Placebo for the Treatment of World Health Organization-Defined Nonsevere Pneumonia in Children Aged 2-59 Months: A Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial in Pakistan

world Health Organization (WHO) acute respiratory illness case management guidelines classify children with fast breathing as having pneumonia and recommend treatment with an antibiotic. There is concern that many of these children may not have pneumonia and are receiving antibiotics unnecessarily. This could increase antibiotic resistance in the community. The aim was to compare the clinical outcome at 72 h in children with WHO-defined nonsevere pneumonia when treated with amoxicillin, compared with placebo. we performed a double-blind, randomized, equivalence trial in 4 tertiary hospitals in Pakistan. Nine hundred children aged 2-59 months with WHO defined nonsevere pneumonia were randomized to receive either 3 days of oral amoxicillin (45mg/kg/day) or placebo; 873 children completed the study. All children were followed up on days 3, 5, and 14. The primary outcome was therapy failure defined a priori at 72 h. in per-protocol analysis at day 3, 31 (7.2%) of the 431 children in the amoxicillin arm and 37 (8.3%) of the 442 in placebo group had therapy failure. This difference was not statistically significant (odds ratio [OR], .85; 95%CI, .50-1.43; P = .60). The multivariate analysis identified history of difficult breathing (OR, 2.86; 95% CI, 1.29-7.23; P = .027) and temperature >37.5°C 100°F at presentation (OR, 1.99; 95% CI, 1.37-2.90; P = .0001) as risk factors for treatment failure by day 5. clinical outcome in children aged 2-59 months with WHO-defined nonsevere pneumonia is not different when treated with an antibiotic or placebo. Similar trials are needed in countries with a high burden of pneumonia to rationalize the use of antibiotics in these communities.

Laboratory malaria diagnostic capacity in health facilities in five administrative zones of Oromia Regional State, Ethiopia

Quality laboratory services are a requisite to guide rational case management of malaria. Using a pre-tested, standardized assessment tool, we assessed laboratory diagnostic capacity in 69 primary, secondary and tertiary health facilities as well as specialized laboratories in five administrative zones in Oromia Regional State, Ethiopia, during February and March 2009. There was marked variability in laboratory diagnostic capacity among the facilities assessed. Of 69 facilities surveyed, 53 provided both comprehensive malaria laboratory diagnosis and outpatient treatment services, five provided malaria microscopy services (referring elsewhere for treatment), and 11 primary care health posts provided rapid diagnostic testing and outpatient malaria treatment. The facilities' median catchment population was 39, 562 and 3581 people for secondary/tertiary and primary health facilities, respectively. Depending on facility type, facilities provided services 24 hrs a day, had inpatient capacity, and access to water and electricity. Facilities were staffed by general practitioners, health officers, nurses or health extension workers. Of the 58 facilities providing laboratory services, 24% of the 159 laboratory staff had received malaria microscopy training in the year prior to this survey, and 72% of the facilities had at least one functional electric binocular microscope. Facilities had variable levels of equipment, materials and biosafety procedures necessary for laboratory diagnosis of malaria. The mean monthly number of malaria blood films processed at secondary/tertiary facilities was 225, with a mean monthly 56 confirmed parasitologically. In primary facilities, the mean monthly number of clinical malaria cases seen was 75, of which 57 were tested by rapid diagnostic test (RDTs). None of the surveyed laboratory facilities had formal quality assurance/quality control protocols for either microscopy or RDTs. This is the first published report on malaria diagnostic capacity in Ethiopia. While our assessment indicated that malaria laboratory diagnosis was available in most facilities surveyed, we observed significant gaps in laboratory services which could significantly impact quality and accessibility of malaria diagnosis, including laboratory infrastructure, equipment, laboratory supplies and human resources.

Clinical and epidemiologic profile of breast cancer in Tanzania.

breast cancer is a highly heterogeneous disease globally. Public health prevention measures require an understanding of the burden of breast cancer and its risk factors. The purpose of this study was to describe the clinical, pathologic, and epidemiologic characteristics of breast cancer patients in Tanzania. data was abstracted from the medical records of all breast cancer patients attending Ocean Road Cancer Institute (ORCI) over a 2-year period from July 2007 to June 2009. Tumor tissue paraffin blocks were collected for all patients with available tissues for the determination of estrogen receptor (ER) and progesterone receptor (PR). Data for all patients was analyzed descriptively and by using unconditional logistic regression, by comparing early stage (ES), defined as stages I and II and late stage (LS), defined as stages III and IV patients to obtain odds ratios (ORs), 95% confidence intervals (CIs), and P-values. among the 488 patients, stage was determined for 356~patients, 90.7% of whom presented in LS. Of the 57 tumor tissues, 49.1% were ER-/PR-. Patients with ulceration (OR = 4.97; 95% CI= 1.07, 23.04; p=0.04) and peau d'orange (OR= 6.78; 95{\%} CI $=$ 1.48, 31.17; p=0.01) were more likely to present in LS rather than ES. Male breast cancer accounted for 2.9% of all breast cancers and inflammatory breast cancer (IBC) comprised 4.3-5.5% of cases based on registered t4d diagnosis or the criteria of IBC signs, if t4d was not reported in the medical records. most breast cancer patients in Tanzania are diagnosed at advanced disease stages with about half of the tumors being ER-/PR-. These data strongly support that reducing barriers to care, down-staging of disease at diagnosis, implementation of clinical guidelines for management of advanced cases, and palliative care are the four most essential factors that need to be addressed to reduce morbidity and mortality from breast cancer in Tanzania. Further research is needed to quantify the magnitude and molecular features of two relatively rare forms of breast cancer that may account for a greater proportion of the burden of breast cancer in Tanzania compared to the USA and Western Europe: male breast cancer and IBC.

Community-acquired pneumonia in HIV-infected children: a global perspective

Pneumonia is a leading cause of morbidity and death in HIV-infected children. The aim of this study was to review recent advances in the epidemiology, cause, management and prevention of pneumonia in HIV-infected children. Pneumonia remains a major cause of death and hospitalization, particularly in sub-Saharan Africa, where the paediatric HIV epidemic is concentrated. HIV-infected children have a higher risk of developing pneumonia and of more severe disease than immunocompetent children. Bacterial pathogens especially Streptococcus pneumoniae, Staphylococcus aureus and Gram-negative bacteria predominate, with rising rates of antimicrobial resistance. Mycobacterium tuberculosis is increasingly reported to cause acute pneumonia. Pneumocystis jirovecii (PCP) remains an important cause of severe pneumonia especially in infants. Viral infections, especially cytomegalovirus-associated pneumonia are common. Polymicrobial infection is increasingly recognized and associated with a worse prognosis. HIV-exposed, negative children have an increased risk of infection with opportunistic pathogens and a poorer outcome than HIV-unexposed children.Increasing access to highly active antiretroviral therapy (HAART) has reduced the incidence of severe pneumonia, eliminated most opportunistic infections and improved outcome. However, pneumonia remains the major cause of morbidity in HIV-infected children taking HAART. Standard case management guidelines are effective at decreasing mortality but require adaptation for high HIV-prevalence areas. Broad-spectrum antibiotics should be used as empiric therapy. Infants or children who are not taking pneumocystis prophylaxis should be treated for PCP.A number of general or specific preventive strategies are effective including early use of HAART at the time of HIV diagnosis, pathogen-specific immunizations, in particular pneumococcal conjugate vaccine, and antibiotic prophylaxis against PCP. Greater access to preventive and treatment strategies, especially PCP prophylaxis, pneumococcal immunization and HAART, are urgently needed in areas of high childhood HIV prevalence.

Stimulating the development of national Streptococcus suis guidelines in Viet Nam through a strategic research partnership

Streptococcus suis is a common cause of adult bacterial meningitis in Viet Nam, and possibly other parts of Asia, yet this disabling infection has been largely neglected. Prevention, diagnosis and treatment are relatively straightforward and affordable but, in early 2007, no national diagnostic, case management or prevention guidelines existed in Viet Nam. Enhanced detection of S. suis infections was established in 2007 as part of a collaborative research programme between the National Hospital for Tropical Diseases, a key national hospital with very close links to the Ministry of Health, and a research group affiliated with Oxford University based in Viet Nam. The results were reported directly to policy-makers at the Ministry of Health. Viet Nam is a low-income country with a health-care system that has seen considerable improvements and increased autonomy. However, parts of the system remain fairly centralized the Ministry of Health. Following the improved detection and reporting of S. suis cases, the Ministry of Health issued guidance to all hospitals in Viet Nam on the clinical and laboratory diagnosis, treatment and prevention of S. suis. A public health laboratory diagnostic service was established at the National Institute of Hygiene and Epidemiology and training courses were conducted for clinicians and microbiologists. Ministry of Health guidance on surveillance and control of communicable diseases was updated to include a section on S. suis. Research collaborations can efficiently inform and influence national responses if they are well positioned to reach policy-makers.

Acute respiratory infection: Boston University’s collaborative research work in the last decade

In the last decade, Boston University, in collaboration with the Child and Adolescent Health Division of the World Health Organization (WHO), has conducted a number of multi-center clinical trials aimed at reducing the childhood mortality associated with acute respiratory infections (ARI). These studies have addressed questions of program relevance and challenges faced by implementing WHO case management guidelines. The spectrum of research studies has extended from endorsing WHO guidelines for using antibiotics in all children with fast breathing to evaluation of ARI guidelines for management of severe pneumonia. Research priorities have included assessing the capacity of community health workers to provide appropriate early treatment to children with pneumonia and to manage both pneumonia and malaria in countries with a dual burden of these childhood illnesses. These contributions are likely to have a long lasting impact on reducing the mortality and morbidity associated with childhood pneumonia.

Formatting the surgical management of Tessier cleft types 3 and 4

ABSTRACTTessier cleft types 3 and 4 are rare entities even among what are considered other rare craniofacial clefts. Very few cases have been reported worldwide, especially in the bilateral form. In the absence of any well-laid guidelines for management of such rare cases, plastic surgeons operate on such cases due to the inherent complexities in technique. To overcome this problem and provide a ground rule for surgical management of such cases, we propose an easier format with a ‘split approach’ of the affected areas. In our proposed formatting, we have divided the affected areas of the cleft into three components: 1. Lid component; 2. Lip component; and 3. Nasomalar component. Any person skilled in the plastic surgical art would appreciate that individual management of the aforesaid demarcated areas is easy as compared to the surgery of the entire craniofacial cleft, that too with the contemporary approach. We have evaluated this formatting technique with a ‘split approach’ in seven cases and found the results more convincing compared to those of classical methods. We invite the surgical fraternity to validate the surgical formatting in their settings and provide us with feedback on the same to consolidate these results.

Globalization of Healthcare

This article explains the current state of the global healthcare market with respect to international medical travel (medical tourism) and worldwide provider sourcing. Emphasis is placed on the traditional twin pillars of oversight: program accreditation and branding affiliation. These are discussed for their main strength, which is their ability to operate at a system-strata level. This strength also represents a primary weakness from the international patient's perspective, which is the functional gap between systemic oversight and bedside surveillance. International case management (ICM) is identified as the right conduit of patient-level service delivery that fills the gap between system and bedside. The ICM professional is introduced and defined as the provider of patient-centered quality and safety improvements, who coordinates and collaborates using international network connections and culture-sensitive in-country communication skills. The article's information is useful for healthcare practitioners who want to learn about the global medical marketplace. Practitioners who are preparing to or who already have business enterprises associated with the global healthcare market will also find the information helpful. Explanations and content are useful to case management generalists, specialists, and business developers. The content is intended for uptake by interested parties within and outside the healthcare practice arena. All research and syntheses were executed by the authors. Sources included business correspondences, medical tourism literature, corporate Internet profiles, news releases, and healthcare industry investigative and monitoring agencies. Clinical competencies stem from the international practice experiences of one author (K. Craig). International health insurance, economics, and financing expertise stems from other author (L. Beichl). This article launches the platform for development of checklists, tools, and guidelines for international case management practice. The article focuses on (1) the examination of traditional quality safeguards of accreditation and branding and (2) the introduction of patient-centered ICM practices. The article aims to identify sources of risk for individual medical consumers who travel across national borders to seek medical care and methods of risk mitigation, especially international case management.

Management of community-acquired pneumonia in HIV-infected children

Pneumonia is a major cause of childhood mortality and morbidity worldwide, particularly in low-income countries. Often, these are also the countries most affected by the HIV epidemic. Pneumonia is the leading cause of death in HIV-infected children and a major cause of hospitalization and healthcare utilization. A broader spectrum of organisms, such as Pneumocystis jiroveci and Gram-negative bacteria, cause pneumonia in HIV-infected children compared with uninfected children. Etiologic organisms have higher rates of antimicrobial resistance in HIV-infected children. Polymicrobial disease is more common in HIV-infected children and associated with an exponential increase in mortality rate. HIV-infected children develop more severe pneumonia and have a worse outcome than HIV-uninfected children. HIV-exposed but HIV-negative children are also at higher risk of severe pneumonia and death compared with HIV-unexposed children. Although case-management guidelines for childhood pneumonia have led to an overall decrease in global childhood morbidity and mortality, HIV-infected children continue to have unacceptably high treatment failure and case fatality rates despite adherence to these guidelines. Standard guidelines require adaptation for use in high HIV-prevalence areas. Specific preventive interventions, including chemoprophylaxis for P. jiroveci pneumonia or for TB and early initiation of highly active antiretroviral therapy, may significantly reduce the burden of pneumonia in HIV-infected children.

Examining Agreement between Clinicians when Assessing Sick Children

BackgroundCase management guidelines use a limited set of clinical features to guide assessment and treatment for common childhood diseases in poor countries. Using video records of clinical signs we assessed agreement among experts and assessed whether Kenyan health workers could identify signs defined by expert consensus.Methodology104 videos representing 11 clinical sign categories were presented to experts using a web questionnaire. Proportionate agreement and agreement beyond chance were calculated using kappa and the AC1 statistic. 31 videos were selected and presented to local health workers, 20 for which experts had demonstrated clear agreement and 11 for which experts could not demonstrate agreement.Principal FindingsExperts reached very high level of chance adjusted agreement for some videos while for a few videos no agreement beyond chance was found. Where experts agreed Kenyan hospital staff of all cadres recognised signs with high mean sensitivity and specificity (sensitivity: 0.897–0.975, specificity: 0.813–0.894); years of experience, gender and hospital had no influence on mean sensitivity or specificity. Local health workers did not agree on videos where experts had low or no agreement. Results of different agreement statistics for multiple observers, the AC1 and Fleiss' kappa, differ across the range of proportionate agreement.ConclusionVideos provide a useful means to test agreement amongst geographically diverse groups of health workers. Kenyan health workers are in agreement with experts where clinical signs are clear-cut supporting the potential value of assessment and management guidelines. However, clinical signs are not always clear-cut. Video recordings offer one means to help standardise interpretation of clinical signs.

Formatting the surgical management of Tessier cleft types 3 and 4

Tessier cleft types 3 and 4 are rare entities even among what are considered other rare craniofacial clefts. Very few cases have been reported worldwide, especially in the bilateral form. In the absence of any well-laid guidelines for management of such rare cases, plastic surgeons operate on such cases due to the inherent complexities in technique. To overcome this problem and provide a ground rule for surgical management of such cases, we propose an easier format with a ‘split approach’ of the affected areas. In our proposed formatting, we have divided the affected areas of the cleft into three components: 1. Lid component; 2. Lip component; and 3. Nasomalar component. Any person skilled in the plastic surgical art would appreciate that individual management of the aforesaid demarcated areas is easy as compared to the surgery of the entire craniofacial cleft, that too with the contemporary approach. We have evaluated this formatting technique with a ‘split approach’ in seven cases and found the results more convincing compared to those of classical methods. We invite the surgical fraternity to validate the surgical formatting in their settings and provide us with feedback on the same to consolidate these results.

Training on the Practical Approach to Lung Health: effect on drug prescribing in PHC settings in Jordan

This study assessed whether training physicians on the Practical Approach to Lung Health (PAL) reduces drug prescribing and the cost of drugs prescribed to respiratory patients in the primary health care setting. Data were compared before and after training general practitioners on standard guidelines for case management of respiratory conditions in primary care. A total of 56 general practitioners practising in 25 health centres in 3 out of 12 governorates of Jordan participated in both the baseline survey (n = 6260 respiratory patients) and the impact survey (n = 2709 patients). Training in PAL decreased by 12.2% the number of drugs prescribed per patient, increased the prescription of inhaled medications and reduced the mean cost of a drug prescription per patient by 8.7%.

What is the future for global case management guidelines for common childhood diseases?

Others have made the point convincingly that Millennium Development Goal 4, a reinvigorated commitment to reduce child mortality by two-thirds before 2015, could be achieved if existing interventions were implemented on a massive scale [1,2]. Widespread access to simple therapeutic interventions, in accordance with World Heath Organization (WHO) case management guidelines, is a substantial part of this package. Assuming that the coverage of existing interventions can be improved, what will be the next major challenge? We believe it will be enabling groups of countries, individual countries, or even large states to take increasing responsibility for the future of their case management strategies. Here we bring together insights from a wide range of disciplines to propose a framework for national surveillance, monitoring, and research that could help inform guideline development in low-income settings. Although our focus is on childhood illness, the principles might be applied more widely.

Why do some hospitals achieve better care of severely malnourished children than others? Five-year follow-up of rural hospitals in Eastern Cape, South Africa

Staff at 11 rural hospitals in an under-resourced region of Eastern Cape Province, South Africa, participated in an intervention to improve the quality of care of severely malnourished children through training and support aimed at implementing the WHO case-management guidelines. Despite similar intervention inputs, some hospitals reduced their case-fatality rates by at least half, whereas others did not. The aim of this study was to investigate reasons for this disparity. Two successful and two poorly performing hospitals were purposively selected based on their case-fatality rates, which were <10% in the successful hospitals and >30% in those performing poorly. Comparative data were collected during June to October 2004 through structured observations of ward procedures, compilation of hospital data on case-loads and resources, and staff interviews and discussions related to attitudes, teamwork, training, supervision, managerial support and leadership. The four study hospitals had broadly similar resources, infrastructure and child:nurse ratios, and all had made changes to their clinical and dietary management following training. Case-management was broadly in line with WHO guidelines but the study revealed clear differences in institutional culture which influenced quality of care. Staff in the successful hospitals were more attentive and assiduous than staff in the poorly performing hospitals, especially in relation to rehydration procedures, feeding and the recording of vital signs. There was a strong emphasis on in-service training and induction of incoming staff in the successful hospitals and better supervision of junior staff and carers. Nurses had more positive attitudes towards malnourished children and their carers, and were less judgmental. Underlying factors were differences in leadership, teamwork, and managerial supervision and support. We conclude that unless there are supportive structures at managerial level, the potential benefits of efficacious interventions and related training programmes to improve health worker performance can be thwarted.

Can the burden of pneumonia among HIV-infected children be reduced?

Of the approximately 2.1 million children who are infected with human immunodeficiency virus type 1 (HIV-1),1 more than 80% will develop a respiratory illness sometime during the course of their disease.2 The prevalence of HIV-1 infection among African children admitted for very severe pneumonia (under the WHO case definition) varies from 55% to 65% and is associated with a case fatality rate of 20% to 34%; three- to six-times higher than children who are not infected with HIV.3,4 In infancy, pneumonia caused by Pneumocystis jiroveci is often the first HIV/AIDS indicator disease that prompts HIV testing and, consequently, early antiretroviral treatment for those infected.5 Approximately 2 million children less than 5 years of age die of pneumonia each year in countries with a high prevalence of HIV. The standard case management guidelines for pneumonia recommended by WHO for use in areas with low HIV burdens are less effective in areas where HIV burdens are high.6 Modifications to these guidelines have been suggested, but their use, as reported in a recently published study of children with very severe pneumonia, resulted in a 45% treatment failure rate among HIV-infected infants in tertiary care settings.4 Polymicrobial infections with Staphylococcus aureus, nontyphoidal Salmonella spp. and other Gram-negative pathogens, Mycobacterium tuberculosis, P. jiroveci, cytomegalovirus and other viruses were commonly seen among the treatment failures and carried a greater than 10-fold risk of a poorer outcome. Randomized controlled studies of alternative antimicrobial agents that are active against some of the pathogens identified among these treatment failures are urgently required. A second major challenge for standard case management in the HIV era is to develop a management guideline to care for the largest group of HIV-affected children: HIV-exposed but HIV-uninfected children, who are at increased risk of acquiring pneumonia. Such children, who live in close contact with HIV-infected persons who persistently harbour a multitude of different pathogens, are at higher risk of pneumonia treatment failure than HIV-unexposed control children; however, the risk of an adverse outcome is lower than for HIV-infected children.7 Studies on the impact of pneumonia on HIV-exposed but HIV-uninfected children are essential. The other major intervention to reduce pneumonia-related morbidity and mortality among HIV-infected children requires the implementation of preventive strategies. Routine immunizations against Streptococcus pneumoniae, Haemophilus influenzae and varicella are safe and effective in HIV-infected children, even though their primary immunological response is inferior and they experience faster decay in immunological memory. Despite the lower efficacy of the conjugate pneumococcal (65% versus 83%) and H. influenzae type b vaccines (55% versus 91%) against invasive disease in HIV-infected and HIV-uninfected control children, respectively, introduction of these vaccines would considerably reduce the 1.6 million pneumococcal and 300 000 H. influenzae deaths that occur each year.8–10 Other preventive strategies, such as the provision of co-trimoxazole prophylaxis against bacterial and P. jiroveci infections, improvement in the provision of prevention of mother-to-child transmission (PMTCT) interventions and early use of highly active antiretroviral therapy (HAART) require urgent scaling-up. In a randomized controlled study of co-trimoxazole prophylaxis versus placebo in HIV-infected older Zambian children, a significant reduction in the hazards ratio for death of 0.57 (95% confidence interval: 0.43–0.77) was seen in the treated group.11 Although there is undoubted benefit in providing co-trimoxazole prophylaxis to HIV-infected children, its widespread implementation does carry risks such as development of resistance to a drug used for treating P. jiroveci pneumonia. This needs to be studied urgently as ineffective treatment of these conditions could increase mortality substantially. The effective implementation of PMTCT programmes, involving at least dual antiretroviral therapy and effective nutritional advice, will help to reduce to less than 4% the incidence of transmission of HIV to newborns and infants.12 Such a reduction is likely to have a significant impact on cutting the prevalence of pneumonia among HIV-infected children. Furthermore, use of HAART with HIV-infected children has been associated with a fourfold reduction in the rate of opportunistic infections and a threefold reduction in hospitalizations.13 The role of nutritional inventions, such as exclusive breastfeeding and zinc supplements, in the prevention of pneumonia among HIV-infected children needs to be explored more thoroughly. In conclusion, significant attention has to be paid to revising the standard case management guidelines for HIV-infected children with pneumonia through properly conducted randomized controlled studies. The implementation of preventative strategies that include co-trimoxazole prophylaxis, pneumococcal and H. influenzae type b vaccinations, PMTCT programmes and early introduction of HAART carry the greatest immediate hope for helping these children. There is a need to rapidly scale up these measures globally. ■

Ambulatory short-course high-dose oral amoxicillin for treatment of severe pneumonia in children: a randomised equivalency trial

WHO case management guidelines for severe pneumonia involve referral to hospital for treatment with parenteral antibiotics. If equally as effective as parenteral treatment, home-based oral antibiotic treatment could reduce referral, admission, and treatment costs. Our aim was to determine whether home treatment with high-dose oral amoxicillin and inpatient treatment with parenteral ampicillin were equivalent for the treatment of severe pneumonia in children. This randomised, open-label equivalency trial was done at seven study sites in Pakistan. 2037 children aged 3-59 months with severe pneumonia were randomly allocated to either initial hospitalisation and parenteral ampicillin (100 mg/kg per day in four doses) for 48 h, followed by 3 days of oral amoxicillin (80-90 mg/kg per day; n=1012) or to home-based treatment for 5 days with oral amoxicillin (80-90 mg/kg per day in two doses; n=1025). Follow-up assessments were done at 1, 3, 6, and 14 days after enrollment. The primary outcome was treatment failure (clinical deterioration) by day 6. Analyses were done per protocol and by intention to treat. This trial is registered, ISRCTN95821329. In the per-protocol population, 36 individuals were excluded from the hospitalised group and 37 from the ambulatory group, mainly because of protocol violations or loss to follow-up. There were 87 (8.6%) treatment failures in the hospitalised group and 77 (7.5%) in the ambulatory group (risk difference 1.1%; 95% CI -1.3 to 3.5) by day 6. Five (0.2%) children died within 14 days of enrollment, one in the ambulatory group and four in the hospitalised group. In each case, treatment failure was declared before death and the antibiotic had been changed. None of the deaths were considered to be associated with treatment allocation; there were no serious adverse events reported in the trial. Home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalisation and parenteral ampicillin for treatment of severe pneumonia without underlying complications, suggesting that WHO recommendations for treatment of severe pneumonia need to be revised.

Symptom dimensions and needs of care among patients with schizophrenia in hospital and the community

The purpose of the present paper was to examine the psychiatric symptom dimensions related to needs of care among patients with schizophrenia in hospital and in the community. Subjects were 217 patients with F2 ICD-10 diagnoses. Hospital patients included 102 inpatients (47.0%) in psychiatric long-term care units. Community patients included 115 outpatients (53.0%) living in their homes or residential facilities. Psychiatrists used the Brief Psychiatric Rating Scale (BPRS) to assess patients' psychiatric symptoms. Formal care providers assessed needs of care using a scale developed by the Committee on Case Management Guidelines for People with Mental Disabilities in Japan. Instrumental Activities of Daily Living (IADL) self-performance and difficulty were also measured using a scale from the Minimum Data Set-Home Care (MDS-HC). Multiple regression analyses were applied, using the symptom dimensions as dependent variables and needs of care as independent variables. Patient group (hospital or community) was also used as an independent variable. Hospital patients demonstrated more severe psychiatric symptoms and greater needs of care than community patients. Multiple regression analyses showed that the total needs of care were greater among male patients (B = 0.142, P = 0.005), hospital patients (B = 0.310, P < 0.001), patients with poor IADL self-performance (B = 0.217, P = 0.047), and patients with severe negative symptoms (B = 0.240, P = 0.002; R(2) = 0.515). The present results suggested an association between negative symptoms and needs of care in schizophrenia. Hospital patients had greater needs of care, even though their psychiatric symptoms were controlled for. Further research should examine the relationships between psychiatric symptoms and needs of care in a cohort study following patients when hospitalized and when living in the community.

Food-based dietary guidelines and nutrition interventions for children at primary healthcare facilities in South Africa.

Existing dietary recommendations and nutrition counselling provided to mothers/caregivers at primary healthcare (PHC) facilities are reviewed and analysed to be consistent with food-based dietary guidelines (FBDGs) that are being developed for preschool children. Recommendations provided by the Integrated Management of Childhood Illness and the provincial Paediatric Case Management Guidelines, which are currently implemented at PHC facilities were reviewed. For FBDGs to be consistent with nutrition counselling that is provided to mothers/caregivers at these facilities, various principles need to be promoted. These include among others, exclusive and on-demand breastfeeding in the HIV-negative mother; exclusive breastfeeding with abrupt cessation preferably at 6 months or exclusive, safe and adequate formula feeding in the HIV-infected mother; the introduction of complementary feeds in all infants at 6 months; the provision of energy-dense and micronutrient-enriched (particularly, iron, zinc, calcium and vitamin A) complementary feeds; frequent visits to the healthcare facility; and physical activity aimed at encouraging a healthy lifestyle and preventing overweight and obesity in childhood. The FBDGs should be incorporated into nutrition and child health programmes and be reviewed and modified regularly.

The sources of treatment of sexually transmissible infections in a rural community in central Thailand

Sexually transmissible infection (STI) rates in Thailand declined from 1986 to 1994, but levelled off until 2002. This study documents the distribution of STI cases attending major treatment venues and the quality of treatment in a rural area. A cross sectional study was conducted in January and June 2001 in all 42 health-care facilities in the study district, including the hospital STI and outpatient clinics, private clinics, local health centres and pharmacies. Quality of care was assessed by documenting appropriate syndromic treatment according to the World Health Organization Syndromic Case Management Guidelines. Over half of STI patients (60%) sought treatment from pharmacies (35%) and health centres (25%), the facilities least capable of accurately diagnosing and treating STI. Only 0-59% were adequately treated. The quality of services needs to be improved and innovative strategies developed and implemented to address the problems of acceptability, stigmatisation, access and quality of STI services in Thailand.