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A diagnostic rule for tuberculous meningitis
CARE OF CHILDREN “A DIAGNOSTIC RULE FOR TUBERCULOUS MENINGITIS!’ Rashmi Kumar, S.N. Singh, and PK. Misra, CEU, King George’s Medical College, Lucknow, India. Objective: To determine which clinical features/simple laboratory tests can ‘predict’ the diagnosis of tuberculous meningitis (TBM) vis-a-vis other meningoencephalitides. TBM is an important cause ofchildhood hospital admissions in India. Diagnostic confusion often exists initially particularly with partially treated pyogenic meningitis. Newer diagnostic tests are unlikely to be available where they are needed most for at least the next decade. In practice for the vast majority of patients across the country treatment is started on the basis of clinical and routine CSF and blood examination only. Design: Cross-sectional with prospective enrollment. Thirty clinic-laboratory features of patients with TBM and non-TBM compared by univariate and multiple logistic regression analysis. Setting: Large teaching hospital in northern India. Participants: 232 of 248 consecutive children aged 1 month-12 years with suspected meningitis and having CSF pleocytosis hospitalized on selected week days over a 20 month period. Intervention: None. Main Outcome Measures: Diagnosis of TBM or non-TBM on predefined criteria based on investigations (cultures, CT scan features) and response to therapy. Results: Of 232 patients studied so far, 110 were TBM, 94 non-TBM and 28 were indeterminate and excluded from analysis. Five clinic-laboratory features were predictive of the diagnosis of TBM viz (1) Prodromal stage >7 days-OR = 10.26 (3.7-27.9), p = 2.328, p = 0.000; (2) Optic atrophyOR = 1.26 (1.06-1.49), @ = 0.230, p = 0.007; (3) CSF polymorphonuclear %age > 50%-OR = 30.18 (9.94-91.63), p = 3.40, p = 0.000; (4) Extrapyramidal movements-OR = 18.91 (4.21-84.90), p = 2.940, p = 0.000; (5) Focal deficits-OR = 5.76 (1.87-17.72), 0 = 1.752, p = 0.002. When any 2 or more of these features were present, sensitivity and specificity were 91.6% and 93.4% respectively. Conclusion: After validation in a different data set the results can help formulate guidelines for the diagnosis of TBM by looking at 5 clinic-laboratory features only. A diagnostic rule for TBM can be formed, which would be useful to clinicians in this area.
“MOTHERS’ ‘DIAGNOSIS’ AND TREATMENT OF CHILDREN’S FEVER IN A MALARIA ENDEMIC AREA OF UGANDA: IMPLICATIONS FOR-THE MALARIA CONTROL PROGRAM.” Rosalind Lubanga, S. Norman, D. Ewbank, and C. Karamagi, CEU, Makerere University, Kampala, Uganda. Objectives: To determine: a) mother’s interpretation of the cause of fever in children under five years; b) agreement between mothers’ diagnosis and clinical and laboratory evidence of malaria; c) drugs given to febrile children before they were brought to the health center. Design: Cross-sectional study. Setting: An outpatient pediatric clinic of Old Mulago Hospital, Kampala, a tertiary health care unit. Participants: Mothers accompanying under-five children who had fever as a major complaint. A sample of 439 mothers were interviewed and the children were physically examined and their blood tested for malaria parasites. Mothers’diagnosis was compared with clinical and laboratory diagnosis of malaria. Results: Thirty nine percent of the mothers associated the fevers with malaria. Doctors diagnosed 92% of the children to have malaria. The prevalence of malaria parasites as determined by laboratory tests was 64%. The sensitivity of mothers’ perception of malaria was 37%, specificity was 58%, false positive rate was 42% and false negative rate was 63%. Their predictive value negative was 34%. This was in contrast to clinical diagnosis which was 82%. Ninety percent of the mothers (CI: 88%-920/o) administered drugs before visiting the health unit; 76% gave modern medicines, 3% herbs only, and 21% a mixture of both. Mothers administered antimalarials to children irrespective of the perceived cause of the fever. Fifty percent of the mothers who suspected malaria gave an antimalarial. Conclusion: The majority of the mothers do not associate fever with malaria. Since malaria is a common cause of fever in children, it is recommended that mothers give antimalarials as a first aid measure.
“RISK FACTORS FOR ORAL REHYDRATION THERAPY FAILURE IN CHILDREN WITH DIARRHEA. RESULTS OF A PILOT STUDY.” Juan Manuel Lozano, Claudia Granados, Maria Nelcy Rodriguez, and Kris Weigle, CEU, Pontificia Universidad Javeriana, Bogota, Colombia. Objectives: Main study: to identify risk factors for failure of oral rehydration therapy (ORT), and to develop and evaluate a prediction rule for ORT failure. Pilot study: to estimate the number of eligible patients per month, to test feasibility and success rate of the study logistics, to refine the baseline questionnaires and to evaluate personnel’s understanding of the project variables definitions. Design: Analytic cohort. Setting: A tertiary care center that provides outpatient primary care. Participants: Children one to 24 months receiving ORT for acute diarrhea. If 5%-14% of cases receiving ORT fail and if about ten failures for each independent variable included in the regression model are needed, 1,400 subjects should be recruited. During pilot study 50 children were followed. Main Outcome Measures: Information about risk factors was collected before starting ORT, which followed the World Health Organization (WHO) guidelines. Parents were contacted one, three and seven days afterwards to determine if there was failure of ORT (use of parenteral rehydration, persistent or worsening dehydration, electrolytic disturbances, persistent or worsening vomiting, abdominal distention or ileus, glucose malabsorption or death). Results were analyzed using descriptive statistics. Results: Fifty subjects (44% males) were recruited during one month. Mean age was 12.5 months (SD = 5.35). Eight children (16%, 95%CI II%-21%) required parenteral rehydration following ORT, seven within the first four hours and one 24 hours later. All participants could be contacted using the study procedures. Few minor changes were made to data collection forms. Conclusions: Study procedures and data collection forms proved to be adequate. Observed failure rate suggests that the number of ORT failures required for the model might be obtained following up fewer patients than those previously estimated.
“MORBIDITY AND RISK FACTORS FOR MORTALITY IN CHILDREN HOSPITALIZED WITH DYSENTERY IN ZIMBABWE.” Kusum Nathoo, M. Wellington, and S. Siziya, CEU, University of Zimbabwe, Harare, Zimbabwe. Objectives: Dysentery causes substantial morbidity and mortality in Developing Countries. The objective of this study was to document the pattern of complications and identify risk factors for subsequent mortality in a hospitalized pediatric population during a Shigella dysenteriae type 1 epidemic. Design: Hospital-based prognostic study. Setting: Pediatric wards in Parirenyatwa and Harare tertiary referral hospitals. Participants: All children aged 1 month to 8 years admitted to Parirenyatwa and Harare Hospitals with a history of bloody diarrhea between January 1 1993 to June 30 1994 were included in the study (n=336). Interventions: N/A Main Outcome Measures: Patterns of complications and survival during hospitalization. Preliminary Results: The median age of participants was 24 months (interquartile range 18 to 43 months). 101 children died giving an overall case fatality rate (CFR) of 30%. One third (n = 96) developed features of haemolytic uremic syndrome (HUS), among whom the CFR was 43%. Other complications included dehydration (56%), hyponatremia (42%), tender abdominal distension (16%), hypothermia (14%), hyperkalemia (14%) and hypokalemia (10%). Preliminary analyses suggest that hyperkalemia (OR 5.3; 95%CI 2.5-12.2), hypothermia (OR 5.1; 95%CI 2.1-12.2), hyponatremia (OR 3.5; 95%CI 2.0-6.8), dehydration (OR 2.7; 95%CI 1.5-4.7), HUS (OR 2.3,95%CI 1.4-3.9). tender distended abdomen (OR 2.1: 95%CI 1.0-4.1) and hvookalemia (OR 2.I; 95%CI 1.1-6.5) were all associated with significantly in&eased risk of death. Final and additional multivariate analyses will be presented in January. Conclusions: Clinical features allowing the early identification of children at increased risk of dying during dysentery outbreaks have been delineated. Early recognition of these signs, together with the institution of appropriate management may reduce the high case fatality rate currently being observed.
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“MOTHERS’ ‘DIAGNOSIS’ AND TREATMENT OF CHILDREN’S FEVER IN A MALARIA ENDEMIC AREA OF UGANDA: IMPLICATIONS FOR-THE MALARIA CONTROL PROGRAM.” Rosalind Lubanga, S. Norman, D. Ewbank, and C. Karamagi, CEU, Makerere University, Kampala, Uganda. Objectives: To determine: a) mother’s interpretation of the cause of fever in children under five years; b) agreement between mothers’ diagnosis and clinical and laboratory evidence of malaria; c) drugs given to febrile children before they were brought to the health center. Design: Cross-sectional study. Setting: An outpatient pediatric clinic of Old Mulago Hospital, Kampala, a tertiary health care unit. Participants: Mothers accompanying under-five children who had fever as a major complaint. A sample of 439 mothers were interviewed and the children were physically examined and their blood tested for malaria parasites. Mothers’diagnosis was compared with clinical and laboratory diagnosis of malaria. Results: Thirty nine percent of the mothers associated the fevers with malaria. Doctors diagnosed 92% of the children to have malaria. The prevalence of malaria parasites as determined by laboratory tests was 64%. The sensitivity of mothers’ perception of malaria was 37%, specificity was 58%, false positive rate was 42% and false negative rate was 63%. Their predictive value negative was 34%. This was in contrast to clinical diagnosis which was 82%. Ninety percent of the mothers (CI: 88%-920/o) administered drugs before visiting the health unit; 76% gave modern medicines, 3% herbs only, and 21% a mixture of both. Mothers administered antimalarials to children irrespective of the perceived cause of the fever. Fifty percent of the mothers who suspected malaria gave an antimalarial. Conclusion: The majority of the mothers do not associate fever with malaria. Since malaria is a common cause of fever in children, it is recommended that mothers give antimalarials as a first aid measure.
“RISK FACTORS FOR ORAL REHYDRATION THERAPY FAILURE IN CHILDREN WITH DIARRHEA. RESULTS OF A PILOT STUDY.” Juan Manuel Lozano, Claudia Granados, Maria Nelcy Rodriguez, and Kris Weigle, CEU, Pontificia Universidad Javeriana, Bogota, Colombia. Objectives: Main study: to identify risk factors for failure of oral rehydration therapy (ORT), and to develop and evaluate a prediction rule for ORT failure. Pilot study: to estimate the number of eligible patients per month, to test feasibility and success rate of the study logistics, to refine the baseline questionnaires and to evaluate personnel’s understanding of the project variables definitions. Design: Analytic cohort. Setting: A tertiary care center that provides outpatient primary care. Participants: Children one to 24 months receiving ORT for acute diarrhea. If 5%-14% of cases receiving ORT fail and if about ten failures for each independent variable included in the regression model are needed, 1,400 subjects should be recruited. During pilot study 50 children were followed. Main Outcome Measures: Information about risk factors was collected before starting ORT, which followed the World Health Organization (WHO) guidelines. Parents were contacted one, three and seven days afterwards to determine if there was failure of ORT (use of parenteral rehydration, persistent or worsening dehydration, electrolytic disturbances, persistent or worsening vomiting, abdominal distention or ileus, glucose malabsorption or death). Results were analyzed using descriptive statistics. Results: Fifty subjects (44% males) were recruited during one month. Mean age was 12.5 months (SD = 5.35). Eight children (16%, 95%CI II%-21%) required parenteral rehydration following ORT, seven within the first four hours and one 24 hours later. All participants could be contacted using the study procedures. Few minor changes were made to data collection forms. Conclusions: Study procedures and data collection forms proved to be adequate. Observed failure rate suggests that the number of ORT failures required for the model might be obtained following up fewer patients than those previously estimated.
“MORBIDITY AND RISK FACTORS FOR MORTALITY IN CHILDREN HOSPITALIZED WITH DYSENTERY IN ZIMBABWE.” Kusum Nathoo, M. Wellington, and S. Siziya, CEU, University of Zimbabwe, Harare, Zimbabwe. Objectives: Dysentery causes substantial morbidity and mortality in Developing Countries. The objective of this study was to document the pattern of complications and identify risk factors for subsequent mortality in a hospitalized pediatric population during a Shigella dysenteriae type 1 epidemic. Design: Hospital-based prognostic study. Setting: Pediatric wards in Parirenyatwa and Harare tertiary referral hospitals. Participants: All children aged 1 month to 8 years admitted to Parirenyatwa and Harare Hospitals with a history of bloody diarrhea between January 1 1993 to June 30 1994 were included in the study (n=336). Interventions: N/A Main Outcome Measures: Patterns of complications and survival during hospitalization. Preliminary Results: The median age of participants was 24 months (interquartile range 18 to 43 months). 101 children died giving an overall case fatality rate (CFR) of 30%. One third (n = 96) developed features of haemolytic uremic syndrome (HUS), among whom the CFR was 43%. Other complications included dehydration (56%), hyponatremia (42%), tender abdominal distension (16%), hypothermia (14%), hyperkalemia (14%) and hypokalemia (10%). Preliminary analyses suggest that hyperkalemia (OR 5.3; 95%CI 2.5-12.2), hypothermia (OR 5.1; 95%CI 2.1-12.2), hyponatremia (OR 3.5; 95%CI 2.0-6.8), dehydration (OR 2.7; 95%CI 1.5-4.7), HUS (OR 2.3,95%CI 1.4-3.9). tender distended abdomen (OR 2.1: 95%CI 1.0-4.1) and hvookalemia (OR 2.I; 95%CI 1.1-6.5) were all associated with significantly in&eased risk of death. Final and additional multivariate analyses will be presented in January. Conclusions: Clinical features allowing the early identification of children at increased risk of dying during dysentery outbreaks have been delineated. Early recognition of these signs, together with the institution of appropriate management may reduce the high case fatality rate currently being observed.
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