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Evaluation of the WHO / UNICEF algorithm for integrated management of childhood illness between the age of two months to five years.
Indian Pediatrics. 1999 Aug; 36(8):767-8.Objective: To evaluate the utility of the "WHO/UNICEF algorithm for integrated management of childhood illness (IMCI) between the age of 2 months to 5 years. Design: Prospective observational. The Outpatient Department and Emergency Room of a medical college hospital. 203 children presenting to Outpatient Department (n= 101) or Emergency Room (n=102) were assessed and classified as per 'IMCr algorithm and treatment required was identified. A detailed evaluation with all relevant investigations was also done for these subjects. The final diagnoses made and therapies instituted on this basis served as "gold standard'. The diagnostic and therapeutic agreements between the "gold standard' and the IMCI and vertical (on the basis of primary presenting complaint) algorithms were computed. Results: More than one illness was present in 135 (66.5%) of subjects as per "gold standard'. The mean (SD) numbers of morbidities as per the gold standard and IMCI- low and high malaria risks were 2.1 (1.1), 1.8 (1.0) and 2.2 (1.1), respectively. Subjects having any referral criteria as per IMCI module had a greater co-existence of illnesses (mean 2.6 vs. 1.6 illnesses per child, respectively). The referral criteria proved useful in predicting hospitalization and a combination of hospitalization and observation; their sensitivity and specificity were 81% and 69% and 74% and 85%, respectively. IMCI algorithms covered majority (92%) of the recorded illnesses. A total agreement with IMCI (malaria low risk) was found in 129 (64%) cases while in 43 (22%) cases, there was partial agreement. Corresponding figures for vertical (split IMCI) program were 93 (46%; p<0.001) and 41 (25%). The difference was primarily due to under diagnoses (30%). Diagnostic discordance of IMCI algorithm and gold standard was evident for the cough category due to under diagnosis of bronchial asthma and bronchiolitis and an over diagnosis of pneumonia whereas the discordance for fever was due to an over diagnosis of malaria. Identical results were found for broad treatment categories. The IMCI algorithm had a provision for preventive services of immunization (16.3% possibility of availing missed opportunities) and feeding advice. There is a sound scientific basis for adopting the IMCI approach since: (i) co-existence of morbidities is frequent; (ii) severe illness is assessed with good sensitivity and specificity; and (iii) the IMCI algorithm is diagnostically and therapeutically superior to the vertical disease specific algorithms. The generic IMCI algorithm needs adaptation to reflect the regional morbidity profile. (author's)
The prognostic value of the World Health Organisation staging system for HIV infection and disease in rural Uganda.
AIDS. 1999; 13(18):2555-62.The objective was to assess whether the WHO staging classification for HIV provides prognostically valuable and applicable information in rural Uganda. Data were obtained from a population-based cohort of 232 HIV-infected individuals. Clinical information was obtained using a detailed questionnaire and ascertained by physical examination. Participants were seen routinely every 3 months and when they were sick. A computer algorithm based on clinical history, examination and laboratory findings was used to stage HIV-positive participants at each routine visit. Kaplan-Meier survival estimates and the Cox proportional hazard model were used to assess the prognostic strength of the clinical and laboratory categories of the system. An attendance rate of 81% and 799 person-years of follow-up were achieved. Survival probability estimates at 6 years from being seen in clinical stages 1, 2, 3, and 4 were 63%, 46%, 24%, and 6%, respectively. When staging was revised to incorporate lymphocyte categories, the survival probabilities were 73%, 62%, 39%, and 6%, respectively. Unexplained prolonged fever and severe bacterial infection had survival probabilities closer to stage 2 conditions, mucocutaneous herpes simplex virus infection for more than 1 month and cryptosporidiosis with diarrhea for more than 1 month closer to stage 3 and oral candidiasis closer to stage 4 conditions. Even without the laboratory markers, the clinical category of the WHO staging system is useful for predicting survival in individuals with HIV disease. This is important for areas with limited access to laboratory markers. A simple rearrangement of a few clinical conditions could improve the prognostic significance of the WHO system. (author's)
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. IV. Postpartum bleeding and lochia in breast-feeding women.
FERTILITY AND STERILITY.. 1999 Sep; 72(3):441-7.The main purpose of this study was to compare the duration of postpartum lochia among 7 groups of breast-feeding women, and in addition, to investigate whether age, parity, birth weight, or the amount of breast-feeding affects this duration. The participants included 4118 breast-feeding women aged 20-37 years living in China, Guatemala, Australia, India, Nigeria, Chile, or Sweden. The duration of lochia, frequency of an end-of-puerperium bleeding episode, and frequency of post-lochia bleeding episodes within 56 days of delivery were measured. This study revealed that the median duration of lochia was 27 days and varied significantly among the centers (range, 22-34 days). In about 11% of the women, lochia lasted >40 days. An end-of-puerperium bleeding episode around the 40th day postpartum was reported by 20.3% of the women. Bleeding within 56 days of delivery (separated from lochia by at least 14 days) occurred in 11.3% of the women and usually was followed by a confirmatory bleeding episode 21-70 days later. This study was able to quantify the average duration of postpartum lochia at 3-5 weeks, with significant variations by population. Lochia durations of >40 days were not unusual. A separate and distinct end-of-puerperium bleeding episode occurred in 1 out of every 4-5 women, although it is unclear how this phenomenon is clinically, socially, or culturally significant.
The World Health Organization multinational study of breast-feeding and lactational amenorrhea. III. Pregnancy during breast-feeding.
FERTILITY AND STERILITY.. 1999 Sep; 72(3):431-40.This prospective longitudinal study aimed to determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status. The participants included 4118 breast-feeding mother-infant pairs, with maternal age of 20-37 years, recruited from 7 study centers located in China, Guatemala, Australia, India, Nigeria, Chile, and Sweden. Infant feeding practices, menstrual status, and the number of pregnancies were recorded. The results revealed that in the first 6 months after childbirth, cumulative pregnancy rate during amenorrhea, depending on how the end of amenorrhea was defined, ranged from 0.9% (95% confidential interval (CI) = 0-2%) to 1.2% (95% CI = 0-2.4%) during full breast-feeding, and from 0.7% (95% CI = 0.1-1.3%) to 0.8% (95% CI = 0.2-1.4%) up to the end of partial breast-feeding. At 12 months, the rates ranged from 6.6% (95% CI = 1.9-11.2%) to 7.4% (95% CI = 2.5-12.3%) during full breast-feeding, and from 3.7% (95% CI = 1.9-5.5%) to 5.2% (95% CI = 3.1-7.4%) up to the end of partial breast-feeding. Regardless of the degree of supplementation, the pregnancy rate increased with time from 6th to the 12th month postpartum. Overall, the rate of pregnancy during amenorrhea was unaffected by variations in the return of menses. This large, multicenter study found that the cumulative 6-month rate of pregnancy during lactational amenorrhea was between 0.8% (95% CI = 0-1.4%) and 1.2% (95% CI = 0-2.4%). This is equivalent to the protection provided by many nonpermanent contraceptive methods as they are actually used and upholds the 1988 Bellagio Consensus.