Recognition Of Danger Signs Research Articles

Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail District, Bangladesh.

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.

Danger signs of neonatal illnesses: perceptions of caregivers and health workers in northern India

To assess household practices that can affect neonatal health, from the perspective of caregivers and health workers; to identify signs in neonates leading either to recognition of illness or health-care seeking; and to ascertain the proportion of caregivers who recognize the individual items of the integrated management of neonatal and childhood illnesses (IMNCI) programme. The study was carried out in a rural community in Sarojininagar Block, Uttar Pradesh, India, using qualitative and quantitative research designs. Study participants were mothers, grandmothers, grandfathers, fathers or "nannies" (other female relatives) caring for infants younger than 6 months of age and recognized health-care providers serving the area. Focus group discussions (n = 7), key informant interviews (n = 35) and structured interviews (n = 210) were conducted with these participants. Many household practices were observed which could adversely affect maternal and neonatal health. Among 200 caregivers, 70.5% reported home deliveries conducted by local untrained nurses or relatives, and most mothers initiated breastfeeding only on day 3. More than half of the caregivers recognized fever, irritability, weakness, abdominal distension/vomiting, slow breathing and diarrhoea as danger signs in neonates. Seventy-nine (39.5%) of the caregivers had seen a sick neonate in the family in the past 2 years, with 30.38% in whom illness manifested as continuous crying. Health care was sought for 46 (23%) neonates. Traditional medicines were used for treatment of bulging fontanelle, chest in-drawing and rapid breathing. Because there is no universal recognition of danger signs in neonates, and potentially harmful antenatal and birthing practices are followed, there is a need to give priority to implementing IMNCI, and possible incorporation of continuous crying as an additional danger sign.

Immediate type drug hypersensitivity: clinical signs, danger signs and pitfalls

Drugs and drug allergens may elicit a wide variety of clinical manifestations and also a variety of pathogenetic mechanisms are involved. Therefore the diagnosis of a drug hypersensitivity reaction is often a major challenge for the diagnosing physician. Early recognition of danger signs of drug allergy may help to reduce sequelae. The knowledge of morphological signs helps to differentiate drug-induced manifestations from other disorders or mimics of drug allergy. Due to the often not specific manifestation of drug-induced allergic reactions, it is important to evaluate a morphological differential diagnosis. Here the emphasis is on immediate type manifestations particularly urticaria and angioedema including anaphylaxis. The typical clinical manifestations, danger signs, and some pitfalls are presented. Médicaments et allergènes médicamenteux peuvent induire des réactions adverses très variées répondant à des mécanismes différents. Le diagnostic d'hypersensibilité à un médicament peut donc poser problème au médecin. Les signes d'alarme précoces peuvent contribuer à diminuer les séquelles. Il faut savoir distinguer les manifestations d'intolérance médicamenteuse, souvent non spécifiques au plan séméiologique, de celles dues à d'autres affections. Ce travail met l'accent sur les manifestations de chronologie immédiate, en particulier urticaire, angioœdème et anaphylaxie. Les manifestations cliniques typiques, les signes d'alarme mais les difficultés et risques d'erreur y seront présentés.

Integrated care of childhood disease in Brazil: Mothers' response to the recommendations of health workers

Aim: To describe the process of follow-up in primary care facilities where the Integrated Management of Childhood Illness (IMCI) strategy was implemented. IMCI was developed by WHO and UNICEF as an integrated approach to manage sick children under 5 y of age and aims to reduce mortality and morbidity. Methods: From August 2001 to February 2002, 229 sick children who had a health condition included in the IMCI case management guidelines were seen in six family healthcare facilities in Brazil. We analysed the care provided to 153 children who were recommended for a 2- or 5-d follow-up visit. Children who did not return were visited and assessed at home. Results: Only 87 children (56.9%) timely returned for follow-up: 70 had improved, eight presented the same health conditions, five were worse and four had a new problem. The main reasons given for not returning for follow-up were: the child had improved (35.1%) and other family priorities (47.4%). Home visits showed that, although most children had improved (n=49), some had a new health problem and one child was sick enough to be referred. Prescription of antibiotics was associated with increased probability of returning for a follow-up visit (RR =1.64 [1.22–2.20], p=0.001). Conclusion: Adherence to follow-up was just over 50%, mostly because the condition had already resolved, but some children were still sick and needed intervention. Training on counselling on the recognition of danger signs and when to return for a follow-up visit must be reinforced.

Integrated care of childhood disease in Brazil: Mothers' response to the recommendations of health workers

To describe the process of follow-up in primary care facilities where the Integrated Management of Childhood Illness (IMCI) strategy was implemented. IMCI was developed by WHO and UNICEF as an integrated approach to manage sick children under 5 y of age and aims to reduce mortality and morbidity. From August 2001 to February 2002, 229 sick children who had a health condition included in the IMCI case management guidelines were seen in six family healthcare facilities in Brazil. We analysed the care provided to 153 children who were recommended for a 2- or 5-d follow-up visit. Children who did not return were visited and assessed at home. Only 87 children (56.9%) timely returned for follow-up: 70 had improved, eight presented the same health conditions, five were worse and four had a new problem. The main reasons given for not returning for follow-up were: the child had improved (35.1%) and other family priorities (47.4%). Home visits showed that, although most children had improved (n=49), some had a new health problem and one child was sick enough to be referred. Prescription of antibiotics was associated with increased probability of returning for a follow-up visit (RR =1.64 [1.22-2.20], p=0.001). Adherence to follow-up was just over 50%, mostly because the condition had already resolved, but some children were still sick and needed intervention. Training on counselling on the recognition of danger signs and when to return for a follow-up visit must be reinforced.

CAN WE MANAGE NEONATAL INFECTION IN THE COMMUNITY ?

As infant mortality rates have fallen in many developing countries, the problem of neonatal mortality hasbecome more obvious. The biggest causes of mortality in the first month of life are infection, birth asphyxia,and low birth weight. Infection is implicated in about a third of neonatal deaths in Nepal. Communitybaseddata are limited, but neonatal sepsis is likely to be the result of infection by Gram positive bacteriasuch as Staphylococci and Streptococci, and enteric Gram negatives.The appropriate management for neonatal sepsis is parenteral, hospital-based treatment with a penicillinand an aminoglycoside. However, about 90% of births in Nepal take place at home, and many infants neverreach hospital. For these infants, the next best management strategy is to give parenteral antibiotics at aprimary care facility. Before referral, it would be appropriate to give a dose of oral antibiotic such ascotrimoxazole, which is already incorporated into the acute respiratory infection programme. If referralfor parenteral treatment is not successful, we propose that community-based cadres be allowed to give a fullcourse of oral antibiotic in cases of neonatal sepsis.Community health workers should receive training and pictorial guidelines for the recognition of dangersigns for neonatal sepsis, and we recommend pilot studies to compare and evaluate oral treatment in thecommunity. For Nepal, a national policy on the community management of neonatal infection is an extremelyurgent priority.Key Words: Neonatal infection, community management, antibiotic use.

E MERGENCY M EDICAL S ERVICES AND C ULTURAL D ETERMINANTS OF AN E MERGENCY IN K ARACHI , P AKISTAN

Objectives. The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. Methods. The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. Results. Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). Conclusion. In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.

Tacrine-Induced Hepatotoxicity

Summary Tacrine, a centrally acting, reversible acetylcholinesterase inhibitor, is effective in the treatment of Alzheimer’s disease. However, a major adverse effect of the drug is hepatotoxicity, which affects about one-half of patients treated. The pathogenic mechanisms of this hepatotoxicity are poorly understood, but probably involve reactive metabolites. The liver injury is predominantly that of hepatocellular necrosis, and manifests as an increase in serum alanine aminotransferase (ALT) levels; 25 and 2% of patients will experience ALT levels greater than 3 times and 20 times the upper limit of the normal range, respectively. Although hepatotoxicity is generally asymptomatic and has not led to death, severe reactions have been reported, and careful monitoring of ALT levels is mandatory in all patients, especially during initiation of therapy and following dose escalation. An ALT level exceeding 3 times the upper limit of the normal range should prompt withdrawal of the drug. Following cessation of tacrine, ALT levels generally decrease rapidly and usually normalise within 6 weeks. Rechallenge can be safely attempted once ALT levels are near normal, except in patients whose ALT levels were markedly increased or in whom a moderate increase of ALT levels was associated with features of hypersensitivity (e.g. rash, fever, eosinophilia). Approximately 90% of those patients rechallenged with tacrine will tolerate the drug and continue with therapy on a long term basis. Minimisation of morbidity and maximisation of the number of patients treated in the long term can be achieved by following sensible guidelines and by the early recognition of danger signs.