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AIMS: To prospectively assess the WHO clinical decision rule (CDR) for group A beta haemolytic streptococcal (GABHS) pharyngitis in three countries. METHODS: A prospective, observational cohort study in urban outpatient clinics in Rio de Janeiro, Cairo, and Zagreb. There were 2225 children aged 2-12 years with cough, rhinorrhoea, red or sore throat; 1810 of these with sore throat were included in the analysis. RESULTS: The proportion of children presenting with sore throat and found to have GABHS pharyngitis ranged from 24.6% (Brazil) to 42.0% (Croatia). WHO CDR sensitivity was low for all sites in both age groups. In children age 5 or older, sensitivity ranged from 3.8% in Egypt to 10.8% in Brazil. In children under 5, sensitivity was low (0.0-4.6%) Specificity was high in both age groups in all countries (93.8-97.4%). CONCLUSIONS: In these populations, the current WHO CDR has high specificity, but low sensitivity; it did not detect up to 96.0% of children who have laboratory confirmed GABHS pharyngitis. A CDR with higher sensitivity should be developed for use in regions where rheumatic fever and rheumatic heart disease are still major health problems.

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To determine the effect of respiratory infections on oxyhemoglobin saturation in a high-altitude population, we recorded clinical signs, oxyhemoglobin saturation determined by pulse oximetry, and findings on radiographs of the chest of 423 children with acute respiratory infections; the children were living at an altitude of 3750 m in the Peruvian Andes. We defined hypoxemia as an oxyhemoglobin saturation value greater than 2 SD below the mean value for 153 well children in this population. Eighty-three percent of children with clinical bronchopneumonia, but only 10% of children with upper respiratory tract infection, had hypoxemia (p less than 0.001). Compared with previous studies of children living at lower altitudes, the presence of tachypnea was relatively nonspecific as a predictor of radiographically determined pneumonia or of hypoxemia, especially in infants. A history of rapid breathing was 74% sensitive and 64% specific in the prediction of hypoxemia, and performed as well as a standard World Health Organization case management algorithm in the prediction of radiographic pneumonia or hypoxemia. Radiographic pneumonia was not a sensitive predictor of hypoxemia or clinically severe illness. In contrast, the presence of hypoxemia was a useful predictor of radiographic pneumonia, with both sensitivity and specificity of 75% in infants. We conclude that acute lower respiratory tract infection in children living at high altitude is frequently associated with hypoxemia, and that oxygen should be administered to children with a diagnosis of pneumonia in these regions. Case management algorithms developed in low-altitude regions may have to be modified for high-altitude settings. In this setting, pulse oximetry is a good predictor of pneumonia. Because pulse oximetry is more objective and cheaper than radiography, its role as a clinical and investigative tool merits further exploration.

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PIP: I read with great interest Finberg's recommendations regarding oral rehydrating solutions for use in the U.S. Being unable to obtain a suitable commercial solution and unwilling to wait the hours required for preparation of a prescribed solution by the pharmacy, I have since 1973 used the following formula consisting of .95% NaC1, 5% glucose, KC1 injection, and 8.4% NaHCO3 (seen in tabular form) to mix an (OR) oral rehydrating solution from solutions readily available in emergency rooms and hospital wards. This mixture was designed to resemble the ORS described by Hirshhorn et al; the Na/glucose ratio was selected to utilize effectively the glucose-coupled transport of sodium. This ORS has been used successfully for the initial therapy of selected infants and children with mild-to-moderate dehydration. It was supplemented with breastmilk or clear liquid in the later phases of therapy. Because of the novel route of therapy, the patients receiving this ORS were monitored with respect to physical findings, fluid balance, and serum electrolytes even more carefully than intravenously treated patients. Hypernatremia resulting from its supervised use in our emergency or pediatric wards has not occurred. Most of the infants and children who received this ORS would have been treated intravenously before 1973. Mixing this solution took no more time than starting an IV, the absence of which was appreciated by patients, parents, and ward staff. Until industry does provide an oral solution more suitable for initial rehydration, others may wish to utilize this mixture in selected patients who are monitored carefully.^ieng

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