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Nepal is a mountainous Himalayan country. All the signs of underdevelopment--poverty, illiteracy, sickness, malnutrition, high birth rate, high infant mortality--are evident. Life in Panchkhal is not easy. Women work hard, fetching water from streams or ponds. There are no safe sources of water. Water-borne diseases are common because of fecal contamination of water. Unhygienic habits and unsanitary disposal of human excreta have resulted in a high incidence of parasitic infestation in the community. In 1983, community-based health care units were set up. Community members pooled funds for a community-based primary health care unit where drugs for diarrhea, scabies, dysentry, cough, fever, and eye infection would be made available at low cost. The Integrated Family Planning and Parasite Control Project has set up a sales depot to make drugs available at nominal prices. 2 health units were established in Panchkhal in 1983. There was a strong determination on the part of the community to improve the health status of the people, especially that of the uner-5s. The local village health workers were trained and assigned to work in the project area. Village health workers found the health unit a useful base. The importance of disease prevention was realized by the villagers. At present there are 9 health units. Each is run by 2 village health workers who receive salaries from either the integrated project of the government FP/MCH program. Social workers also provide services. A woman volunteer trained in basic MCH and family planning motivation assists the unit twice a week. The responsibility of the health committee is to ensure the smooth operation of the unit and to see that health care is provided to the villagers. Toilets have now been constructed in many homes. Children are healthier. Family planning is more acceptable to the community. The marketing of lacal produce is a problem, as well as funding of the health project.
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PMID:Making life easier in the rugged countryside through the Panchkhal Panchayat Health Movement. 1231 82

In late 1987, UNICEF conducted a survey of infant nutrition in 8 communes of the Rwandan capital of Kigali. The sample included 1328 infants aged 6-36 months and was especially intended to provide data on feeding customs during weaning. 2 anthropometric measures, the weight for age and the left arm circumference, were used to assess the shortterm nutritional status of the sample children. 3.6% were judged to suffer sever malnutrition and 20.3% moderate malnutrition according to a comparison of weights for age with the standards of the US National Center for Health Statistics and Center for Disease Control. The arm circumference indicated that 8.8% suffered severe and 15.4% moderate malnutrition. 53.3% of the survey children had suffered during the 2 weeks preceding the survey from fever, diarrhea, cough, intestinal parasites, or measles. 29.3% of children who had 1 or more of these conditions were malnourished, vs. 17.6% of children not sick. The rates of malnutrition of children having 0, 1, 2, 3, or 4 of the conditions during the 2 weeks preceding the survey were respectively 17.4%, 24.1%, 31.2%, 37.7%, and 50%. A very significant relationship was found between the educational status of the mother and the nutritional status of the child. 28% of infants of illiterate mothers vs. less than 9% of infants of mothers with secondary educations were malnourished. 30% of children with illiterate fathers vs. 15% with secondary-educated fathers were malnourished. 22% of fathers vs. 42% of mothers were illiterate. 27% of children of birth order 3 or higher vs. 18% of 1st or 2nd children were malnourished. Weights for age indicate that Rwandan children suffer a significant deterioration of their nutritional status during the weaning period, from 8-24 months. 2 factors appear responsible: inadequate quantity of food offered combined with unhygienic preparation and storage, and faulty hygiene of the household after the child begins crawling and walking and is able to move to objects to put into the mouth. 70% of respondents reported that the 1st supplementary food they offered or powdered milk. Children were less likely to have had diarrhea the more frequently the household prepared meals, probably due to faulty food storage. The rate of malnutrition was 28-29% in agricultural households vs. 6-15% in nonagricultural households. It is concluded that raising the educational level will be essential in combatting malnutrition. A literacy program for adults directed primarily at women, could cover topics such as appropriate weaning foods and their correct use, modern family planning methods, and household cleanliness and hygienic food preparation.
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PMID:[Infant and young child feeding in Rwanda: results of a UNICEF-Kigali survey]. 1234 88

Algorithms which specify procedures for proper diagnosis and treatment of common diseases have been available to primary health care services in less developed countries for the past decade. Whereas each algorithm has usually been limited to a single ailment, children often present with the need for more comprehensive assessment and treatment. Treating just one illness in these children leads to incomplete treatment or missed opportunities for preventive services. To address this problem, the World Health Organization has recently developed a Sick Child Algorithm (SCA) for children aged 2 months-5 years. In addition to specifying case management procedures for acute respiratory illness, diarrhea/dehydration, fever, otitis, and malnutrition, the SCA prompts a check of the child's immunization status. The specificity and sensitivity of this SCA were field-tested in Kenya and the Gambia. In Kenya, the Malaria Branch of the US Centers for Disease Control and Prevention tested the SCA under typical conditions in Siaya District. The Quality Assurance Project of the Center for Human Services carried out a parallel facility-based systems analysis at the request of the Malaria Branch. The assessment which took place in September-October 1993, took the form of observations of provider/patient interactions, provider interviews, and verification of supplies and equipment in 19 rural health facilities to determine how current practices compare to actions prescribed by the SCA. This will reveal the type and amount of technical support needed to achieve conformity to the SCA's clinical practice recommendations. The data will allow officials to devise the proper training programs and will predict quality improvements likely to be achieved through adoption of the SCA in terms of effective case treatment and fewer missed immunization opportunities. Preliminary analysis indicates that the primary health care delivery in Siya deviates in several significant respects from performance standards (not counting respirations in the presence of a cough as the primary complaint, not checking for dehydration in cases of diarrhea, and checking immunization records in only 51% of the 235 cases observed). The report is scheduled for completion in early 1994 and will likely provide data vital to the successful adoption of the SCA.
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PMID:QAP collaborates in development of the sick child algorithm. 1234 42

During October 1992 to June 1993 in eight villages covered by the Primary Health Center Machhra in Meerut District, India, interviews with mothers and examinations of 1600 children aged less than 5 years (under-fives) were conducted to examine the relationship between acute respiratory infection (ARI) and malnutrition. 42.25% of all children had an ARI within the last 15 days. Most ARIs (73.4%) were considered mild (cough and cold with no pneumonia). Pneumonia accounted for 19.5% of all ARI cases, which were considered moderate. The remaining ARI cases were severe (severe and very severe pneumonia). 57.5% of all children suffered from protein energy malnutrition (PEM). 78.6% of children aged 12-14 months had PEM. ARI was more common among malnourished children than well-nourished children (52.2% vs. 28.8%; p 0.001). The incidence of ARI increased as the nutritional status deteriorated (p 0.05). It also increased as the midarm circumference decreased (p 0.001). These findings confirm the synergistic action between malnutrition and infection, in this case ARI. Malnourished children suffer considerable impairment in immunity, especially cellular immunity, which makes them more prone to ARI. These findings reinforce the need to strengthen the quality, quantity, and accessibility of nutritional services, particularly promotion of breast feeding and vitamin A supplementation.
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PMID:Nutritional correlates of acute respiratory infections. 1234

Dysphagia is a common complication after stroke, being reported in 30-50% in acute stage patients. It is also critical that dysphagia may occur 3 to 5 days after onset because of brain edema, so clinicians must be careful to treat stroke patients with close observation. Especially elderly patients with dysphagia have a high risk of aspiration pneumonia, which might be life threatening condition for them. Dysphagia generally recovers spontaneously and frequency of the chronic stage cases is thought to be less 6%. The 30 ml water swallow test is used to screen dysphagia. If cough or some symptom of aspiration such as wet voice or breathing difficulties are seen, dysphagia is strongly suspected. Oral care is essential and diet modification and rehabilitation techniques are applied. Fiberoptic evaluation or fluoroscopic examination is recommended for severe dysphagia. The treatment plan should be established according to the pathological conditions. The goal of dysphagia management is to prevent aspiration pneumonia, dehydration and malnutrition. If swallowing difficulties continue, alternative nutrition. PEG or intermittent tube feeding, could be helpfull. Multidisciplinary team approach should be adopted for dysphagia management.
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PMID:[Evaluation and management of dysphagia after stroke]. 1270 45

Pneumonia has been estimated to be the second most common infection in nursing-home residents. However, to the authors' knowledge, no such Swedish data are available. Therefore, this study investigated the incidence, risk factors, and 30 d case-fatality rate and clinical presentation of nursing home-acquired pneumonia (NHAP) in 234 nursing-home residents aged 66-99 y. Activities of daily living (ADL status), malnutrition and body mass index were measured at baseline. The residents were then followed prospectively during 1 y for symptoms and signs of pneumonia. Pneumonia was verified clinically and/or radiologically in 32 residents, corresponding to a yearly incidence of 13.7%. The 30 d case-fatality rate was 28%. Cough and sputum production were the most specific, and fever > or = 38.0 degrees C rectally and cognitive decline were the most common non-specific presenting symptoms. Chronic obstructive pulmonary disease, ADL status > 5 and male gender were risk factors for acquiring pneumonia. In conclusion, NHAP is associated with high morbidity and mortality in Sweden. In order not to delay treatment, it is necessary to be aware that specific symptoms of pneumonia may be lacking in the clinical presentation in the nursing-home setting.
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PMID:Morbidity, mortality and clinical presentation of nursing home-acquired pneumonia in a Swedish population. 1287 15

Fever of unknown origin (FUO) is a common syndrome. A total of 94 patients (57 men and 37 women; mean age, 56.3 +/- 19 years, range, 18-86 years) who met the criteria of FUO were included in this study. Mycobacteriosis was diagnosed in 22 (23%) of these patients (13 men and 9 women), including 9 with disseminated disease and 13 with pulmonary disease. There was no significant statistical difference in age, sex, short-term survival status (3 months), and other clinical parameters between patients with and without mycobacteriosis. Clinical manifestations may be specific or nonspecific. The most common initial presentations in patients with mycobacteriosis were respiratory tract symptoms, mainly of cough and dyspnea, observed in 11 (50%) patients, and disturbance of consciousness in 6 (27%). The associated conditions included malnutrition (4 patients, 18%), diabetes mellitus (3, 14%), and renal failure (3, 14%). Four (18%) patients had a history of pulmonary tuberculosis or tuberculous spondylitis in their early adulthood. The 2 most common findings on chest radiograph were interstitial (41%) and nonspecific infiltrative (32%) patterns. In conclusion, mycobacteriosis remains the leading cause of FUO in southern Taiwan and it is important to screen for this treatable disease in all cases of FUO.
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PMID:Mycobacteriosis in patients with fever of unknown origin. 1472 53

In most low-income countries, clinical assessment is the only tool available to distinguish an upper respiratory infection (cough or cold) from pneumonia requiring antibiotics. The severity of the pneumonia, determined from the clinical signs, will determine which patients require more potent antibiotic regimens and supplementary oxygen. Careful assessment of the respiratory rate, chest in-drawing, ability to feed normally, cyanosis and level of consciousness are used to make the diagnosis of pneumonia and determine the severity. Co-morbid disease such as malnutrition, measles, HIV infection and malaria increase mortality due to pneumonia, and signs of these diseases must be looked for so that appropriate treatment can be started. This article carefully describes the signs that should be looked for in children presenting with a cough or difficult breathing to any health care worker.
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PMID:Assessing the child with cough or difficult breathing. 1610 27

A 70-year-old man with liver cirrhosis and previous gastrectomy admitted for fever, coughing, and bloody sputum soon after convalescing from pulmonary tuberculosis had a peripheral white blood cell count of 9,900/microL, C-reactive protein of 14.1mg/dL, serum albumin of 2.0g/dL, and serum positive for antiaspergillus and beta-D glucan antibodies. Chest radiography showed thickening of the walls of the large residual cavities with previous tuberculosis lesions and infiltrates around them. On day 2 of hospitalization, Aspergillus fumigatus without other bacillus was detected in sputum culture taken on admission. Despite immediate treatment with intravenous micafungin and oral itraconazole and improved brief initial improvement, his general condition abruptly deteriorated into frequent massive hemoptysis and he developed of shock, respiratory failure, and severe malnutrition, dying 30 days later. Autopsy findings showed pulmonary aspergillosis in and around the large cavities and on the other side of the lungs. Pulmonary aspergillosis without hematological malignanciy and immunosuppression can thus be abruptly severe and fatal due to malnourishment stemming from pre-existing conditions such as chronic hepatitis despite prompt, ordinarily adequate medical treatment.
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PMID:[Autopsy case of pulmonary aspergillosis soon after convalescence from pulmonary tuberculosis]. 1644 78

The current approach to the anesthetic procedure and postoperative intensive therapy after esophageal resection for esophageal carcinoma, as well as characteristic perioperative pathophysiological events are presented. The contributory factors of severe postsurgical morbidity are considered too. Esophagectomy is an extented procedure which includes laparotomy, thoracotomy and often cervicotomy, and carries a great surgical stress with a huge fluid shift. It is mostly performed in the aged population with a certain co-morbidity: malnutrition, compromized immune status, respiratory and cardiovascular diseases. Standardization of esophageal resection and reconstructive techniques together with the optimal perioperative management significantly reduce operative mortality. Preoperatively, the patients' nutritive, respiratory and cardiac status should be improved. Intraoperatively, beside adequate depth of anesthesia which enables the optimal metabolic response to surgical stress, the invasive hemodynamic monitoring with insertion of pulmonary artery catheter is of great importance. The aim is to ensure adequate tissue perfusion and oxygenation avoiding pulmonary overhydration at the same time. Postoperatively, important role has epidural analgesia, allowing proper breathing and coughing and routine usage of fiberbronchoscopy for clearance of pulmonary secretion. After resection there are several conditions which contribute to cough and swallow disturbances: bilateral vagotomy, the absence of upper and lower esophageal sphincters, transient aperistalsis of the substitute, sometimes a transient vocal cord paresis. All of these make patients prone to regurgitation and aspiration of duodenal and gastric juice. Currently, the pulmonary complications are the leading problems after this procedure, so their prevention and early treatment are the key tasks for the clinicians.
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PMID:[Anesthesia and perioperative management of patients with resection for esophageal carcinoma]. 1658 36


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