RESUMEN
AIM: To test whether standardising the use of blood transfusions and intravenous (IV) infusions could reduce fatality in severely malnourished children admitted to Mulago Hospital, Kampala. METHODS: Improved adherence to the WHO protocol for blood transfusion and IV fluids was effected in patients with severe malnutrition by continuous medical education. A 'before and after' design was used to study 450 severely malnourished children (weight-for-height < -3 Z-score or presence of oedema) under 60 months of age. A total of 220 pre- and 230 post-'improved practice' patients were enrolled consecutively during the periods September to November 2003 and September to December 2004, respectively. Patients were followed up until discharge or death. The Kaplan-Meier survival curve and the Cox regression hazard model were used for univariate and multivariate analyses, respectively. RESULTS: Overall case fatality was 23.6% (52/220) in the pre-period and 24.8% (57/230) in the post-period (p=0.78). Most of the deaths occurred in the 1st week of admission (73%, 38/52 in the pre-period and 61%, 35/57 in the post-period) and were of children who had received blood transfusion or IV infusion or both in the pre-period. Mortality in children transfused and/or infused was significantly reduced in the post-period (82%, 31/38 in the pre-period vs 23%, 8/35 in the post-period, p=0.008). In the post-period, there was a significant reduction in the number of inappropriate blood transfusions (18%, 34/194 vs 3.5%, 8/230, p=0.01) and IV fluid infusions (27%, 52/194 vs 9%, 20/230, p<0.001). Survival improved in children who received blood transfusions in the post-period [hazards ratio (HR) 0.22, 95% CI 0.30-1.67 vs HR 4.80, 95% CI 1.71-13.51], as did that of children who received IV infusions (HR 2.10, 95% CI 0.84-5.23 vs HR 3.91, 95% CI 1.10-14.04). CONCLUSION: Management according to the WHO protocol for severe malnutrition can reduce the need for blood and IV infusions. However, further studies are required to verify whether full implementation of the WHO protocol reduces the high case fatality in sub-Saharan hospitals.
Asunto(s)
Transfusión Sanguínea/normas , Fluidoterapia/normas , Desnutrición/terapia , Procedimientos Innecesarios/estadística & datos numéricos , Transfusión Sanguínea/estadística & datos numéricos , Preescolar , Protocolos Clínicos , Deshidratación/terapia , Países en Desarrollo , Educación Médica Continua , Métodos Epidemiológicos , Femenino , Fluidoterapia/estadística & datos numéricos , Adhesión a Directriz , Infecciones por VIH/complicaciones , VIH-1 , Humanos , Lactante , Recién Nacido , Infusiones Intravenosas , Masculino , Desnutrición/complicaciones , Pediatría/educación , UgandaRESUMEN
BACKGROUND: Although the risk factors for increased fatality among severely malnourished children have been reported, recent information from Africa, during a period of HIV pandemic and constrained health services, remains sketchy. The aim of this study has been to establish the risk factors for excess deaths among hospitalized severely malnourished children of below five years of age. METHOD: In 2003, two hundred and twenty consecutively admitted, severely malnourished children were followed in the paediatric wards of Mulago, Uganda's national referral and teaching hospital. The children's baseline health conditions were established by physical examination, along with haematological, biochemical, microbiological and immunological indices. RESULTS: Of the 220 children, 52 (24%) died, with over 70% of the deaths occurring in the first week of admission. There was no significant difference by sex or age group. The presence of oedema increased the adjusted odds-ratio, but did not reach significance (OR = 2.0; 95% CI = 0.8 - 4.7), similarly for a positive HIV status (OR = 2.6, 95% CI = 0.8 - 8.6). Twenty four out of 52 children who received blood transfusion died (OR = 5.0, 95% CI = 2 - 12); while, 26 out of 62 children who received intravenous infusion died (OR = 4.8, 95% CI = 2 - 12). The outcome of children who received blood or intravenous fluids was less favourable than of children who did not receive them. Adjustment for severity of disease did not change this. CONCLUSION: The main risk factors for excess hospital deaths among severely malnourished children in Mulago hospital include blood transfusion and intravenous infusion. An intervention to reduce deaths needs to focus on guideline compliance with respect to blood transfusions/infusions.
Asunto(s)
Mortalidad Hospitalaria , Desnutrición/mortalidad , Bacteriemia/epidemiología , Transfusión Sanguínea , Preescolar , Deshidratación/terapia , Femenino , Hemoglobinas/análisis , Humanos , Lactante , Infusiones Intravenosas , Masculino , Desnutrición/sangre , Análisis Multivariante , Neumonía/epidemiología , Factores de Riesgo , Factores de Tiempo , Uganda/epidemiología , Infecciones Urinarias/epidemiologíaRESUMEN
This study examined whether street food vendors sell a sufficient variety of foods for a healthful diet. It was hypothesized that vendors sold only low-cost food groups to enable the buyer to afford the food while the vendor also made a profit. A structured questionnaire was administered to 580 vendors in three selected locations. Data included product names, ingredients, methods of preparation, and the sex of the vendor. A little more than half of the vendors (53%) sold food of only one group; 44% sold cereals. Overall, 36% of vendors, mostly men, sold only carbohydrate products. The percentage of vendors selling foods of more than one group was higher in the working area (53%) than in the slum area (43%, p < .05), and it was higher in both of these areas taken together than in the lower-middle income area (21%, p < .001). Micronutrient and mixed-nutrient products were associated with female vendors. Although a slight majority of all street vendors sell foods of only one group, women vendors are capable of supplying a sufficient variety of food groups that consumers can afford. It appears that consumer purchasing power dictates the food groups provided by vendors, especially cereal-based-foods. A policy on micronutrient fortification of cereal flours and fats used in popular street food preparation needs to be considered. This could be coupled with consumer and vendor education programs focusing on the importance of healthful diets.