Impact of Training on Assessment of Diarrhoea and Acute Respiratory Infection at Government Health Facilities in Egypt

Egypt began training of physicians in case management of diarrhoea and acute respiratory infection (ARI) in the 1980s and 1990s respectively. Data from an independent assessment demonstrate the impact of training in the use of clinical practice guidelines on the quality of clinical examinations of 579 children presenting with diarrhoea or ARI. These examinations were conducted by 115 government physicians in 80 government health facilities and in two Egyptian governorates. The quality of care, although better than that in the past, remains poor, and training had little effect. Poor examinations were related to misclassification and inappropriate treatment of serious illnesses. Such errors have potentially serious consequences. Egypt is now implementing the Integrated Management of Childhood Illness strategy. This effort should be independently assessed to measure the improvement in the quality of care provided by government health facilities in Egypt

Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials

BACKGROUND: Despite treatment recommendations from various organizations, oral rehydration therapy (ORT) continues to be underused, particularly by physicians in high-income countries. We conducted a systematic review of randomised controlled trials (RCTs) to compare ORT and intravenous therapy (IVT) for the treatment of dehydration secondary to acute gastroenteritis in children. METHODS: RCTs were identified through MEDLINE, EMBASE, CENTRAL, authors and references of included trials, pharmaceutical companies, and relevant organizations. Screening and inclusion were performed independently by two reviewers in order to identify randomised or quasi-randomised controlled trials comparing ORT and IVT in children with acute diarrhea and dehydration. Two reviewers independently assessed study quality using the Jadad scale and allocation concealment. Data were extracted by one reviewer and checked by a second. The primary outcome measure was failure of rehydration. We analyzed data using standard meta-analytic techniques. RESULTS: The quality of the 14 included trials ranged from 0 to 3 (Jadad score); allocation concealment was unclear in all but one study. Using a random effects model, there was no significant difference in treatment failures (risk difference [RD] 3%; 95% confidence intervals [CI]: 0, 6). The Mantel-Haenzsel fixed effects model gave a significant difference between treatment groups (RD 4%; 95% CI: 2, 5) favoring IVT. Based on the four studies that reported deaths, there were six in the IVT groups and two in ORT. There were no significant differences in total fluid intake at six and 24 hours, weight gain, duration of diarrhea, or hypo/hypernatremia. Length of stay was significantly shorter for the ORT group (weighted mean difference [WMD] -1.2 days; 95% CI: -2.4,-0.02). Phlebitis occurred significantly more often with IVT (number needed to treat [NNT] 33; 95% CI: 25,100); paralytic ileus occurred more often with ORT (NNT 33; 95% CI: 20,100). These results may not be generalizable to children with persistent vomiting. CONCLUSION: There were no clinically important differences between ORT and IVT in terms of efficacy and safety. For every 25 children (95% CI: 20, 50) treated with ORT, one would fail and require IVT. The results support existing practice guidelines recommending ORT as the first course of treatment in appropriate children with dehydration secondary to gastroenteritis

Lactobacillus casei strain GG in the treatment of infants with acute watery diarrhea: A randomized, double-blind, placebo controlled clinical trial [ISRCTN67363048]

BACKGROUND: Adjuvant therapy to ORT with probiotic bacteria for infants with acute watery diarrhea has been under active investigation. Most studies have been done in the developed world showing benefit only for viral mild gastroenteritis. We evaluated the effect of a milk formula containing one billion (10(9)) cfu/ml of Lactobacillus casei strain GG (LGG) upon duration and severity of diarrhea in infants in an environment with more severe acute diarrhea, where etiologic agents other than rotavirus are involved more frequently, and where mixed infections are more prevalent. METHODS: Male infants aged 3–36 months brought for treatment of acute watery diarrhea of less than 48 hours were eligible. After rehydration was completed with the WHO's oral rehydration solution, patients were randomly assigned to receive a milk formula either containing LGG or not. Stool volume was periodically measured using a devise suited to collect stools separate from urine. Duration of diarrhea was estimated based on stools physical characteristics. RESULTS: Eighty nine patients received the placebo milk formula and ninety received the LGG containing formula. Both groups were comparable in their baseline characteristics. Total stool output was significantly larger (p = 0.047) in the LGG group (247.8 ml/kg) than in the placebo group (195.0 ml/kg). No significant differences were found in duration of diarrhea (58.5 hours with LGG vs. 50.4 hours with placebo), rate of treatment failure (21.1% with LGG vs. 18.0% with placebo), and proportion of patients with unresolved diarrhea after 120 hours (12.2% with LGG vs. 12.5% with placebo). The rate of stools with reducing substances after 24 hours of treatment increased significantly in both groups (from 41.4% to 72.2% with LGG and from 45.9% to 68.0% with placebo). CONCLUSION: This study did not show a positive effect of LGG on the clinical course of acute watery diarrhea. Positive beneficial effects of LGG, as had been reported elsewhere, could have been masked in our study by worsening diarrhea due to transient lactose malabsorption. Further studies with low-lactose or non-lactose conveyors of LGG are desirable

The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality

Background Most diarrhoeal deaths can be prevented through the prevention and treatment of dehydration. Oral rehydration solution (ORS) and recommended home fluids (RHFs) have been recommended since 1970s and 1980s to prevent and treat diarrhoeal dehydration. We sought to estimate the effects of these interventions on diarrhoea mortality in children aged <5 years

The stability of multitrophic communities under habitat loss

Habitat loss (HL) affects species and their interactions, ultimately altering community dynamics. Yet, a challenge for community ecology is to understand how communities with multiple interaction types—hybrid communities—respond to HL prior to species extinctions. To this end, we develop a model to investigate the response of hybrid terrestrial communities to two types of HL: random and contiguous. Our model reveals changes in stability—temporal variability in population abundances—that are dependent on the spatial configuration of HL. Our findings highlight that habitat area determines the variability of populations via changes in the distribution of species interaction strengths. The divergent responses of communities to random and contiguous HL result from different constraints imposed on individuals’ mobility, impacting diversity and network structure in the random case, and destabilising communities by increasing interaction strength in the contiguous case. Analysis of intermediate HL suggests a gradual transition between the two extreme cases

Impact of training on assessment of diarrhoea and acute respiratory infection at government health facilities in Egypt

Egypt began training of physicians in case management of diarrhoea and acute respiratory infection (ARI) in the 1980s and 1990s respectively. Data from an independent assessment demonstrate the impact of training in the use of clinical practice guidelines on the quality of clinical examinations of 579 children presenting with diarrhoea or ARI. These examinations were conducted by 115 government physicians in 80 government health facilities and in two Egyptian governorates. The quality of care, although better than that in the past, remains poor, and training had little effect. Poor examinations were related to misclassification and inappropriate treatment of serious illnesses. Such errors have potentially serious consequences. Egypt is now implementing the Integrated Management of Childhood Illness strategy. This effort should be independently assessed to measure the improvement in the quality of care provided by government health facilities in Egypt