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Preparing adult travelers for journeys abroad can be challenging and rewarding. Prevention is the cornerstone of a safe, enjoyable trip. Patient education and commonsense precautions may well prevent infection or disease. Prophylaxis for diarrhea and malaria could save one day of illness or inconvenience on an expensive trip or may save a traveler's life. And the Loa loa worm? The nurse fortunately waited until it crawled from under her cornea. Then it was gently teased from under the bulbar conjunctiva.
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PMID:Health risks of foreign travel. Preparing adults for jaunts abroad. 190 86

The World Health Organization (WHO) has developed a diagnostic and treatment algorithm to facilitate the rapid identification and management of severely ill children in developing countries. 13 indicators are listed on Sick Child Charts: inability to drink, abnormal mental status (e.g., sleepiness), convulsions, wasting, edema, chest wall retraction, stridor, abnormal skin turgor, repeated vomiting, stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and corneal ulceration. These indicators target the principal causes of child mortality: acute respiratory infection, malaria, measles, diarrheal disease, and malnutrition. The usefulness of the WHO algorithm was evaluated in 4 clinics in western Kenya's Siaya district and in the pediatric outpatient and inpatient departments of Siaya District Hospital. 770 (28%) of the 2799 children (mean age, 13 months) seen in these rural outpatient clinics had 1 or more of the 13 signs, most frequently repeated vomiting (13%). Children with any of these signs had a 2.3 times higher odds of hospitalization than those without such signs; however, 424 admitted children (54%) had none of the 13 signs. Pallor and chest wall retraction were most highly associated with hospital admission (odds ratio [OR], 8.6 and 5.3, respectively). Among the 1139 inpatients, 666 (58%) presented with at least 1 sign and 75 (7%) died, 67 (89%) of whom had at least 1 clinical sign at admission. Overall, the mortality risk associated with having at least 1 sign was 6.5 times higher than that for children with none of the signs. The signs most associated with mortality were abnormal mental status (OR, 59.6), poor skin turgor (OR, 5.6), pallor (OR, 4.3), repeated vomiting (OR, 3.6), chest wall retraction (OR, 2.7), and edema (OR, 2.4). Although studies in other settings are required to validate the WHO logarithm, this schema appears to be a feasible means for identifying high-risk children in developing countries.
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PMID:An evaluation of clinical indicators for severe paediatric illness. 906 Feb 22

The ability of pallor of the conjunctiva, palms, nailbed, and tongue to identify children with Plasmodium falciparum-related anemia in developing country settings, where laboratory measurements are not available, was investigated in children attending Siaya District Hospital in western Kenya. Enrolled were all children 2 months to 5 years of age admitted to the hospital's inpatient unit in 1993-94 (n = 1048), and every fifth child presenting to the outpatient clinic (n = 1666). Severe nailbed or severe palmar pallor had the highest sensitivities (62% and 60%, respectively) in the detection of severe anemia in outpatients, while those with moderate anemia were best identified by nailbed or palmar pallor (90% sensitivity for both signs). The addition of clinical signs of respiratory distress to pallor did not increase the identification of children requiring hospitalization for severe anemia. Among inpatients, severe nailbed, conjunctival, and palmar pallor had sensitivities of 59%, 53%, and 53%, respectively, for detecting severe anemia. In the detection of moderate anemia, the sensitivities were 74%, 70%, and 70%, respectively, for conjunctival, nailbed, and palmar pallor. Tongue pallor had a low sensitivity among all children examined. Low hemoglobin levels were significantly associated with P. falciparum infection. It is recommended that all children under 36 months of age, in areas with P. falciparum malaria, should receive antimalarial treatment if they present with pallor.
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PMID:Clinical signs for the recognition of children with moderate or severe anaemia in western Kenya. 952 22

The capability of pallor and other clinical signs to identify anemia was evaluated in developing country settings with malaria (Uganda) and without malaria (Bangladesh). Enrolled were 1226 children, 2 months to 5 years of age, who presented to a rural district hospital in Fort Portal, Uganda, and 668 children from a children's hospital in Dhaka, Bangladesh. Physicians examined the children for conjunctival pallor, respiratory distress, and other clinical signs of anemia (i.e., palmar pallor) included in the World Health Organization's Integrated Management of Childhood Illness (IMCI) guidelines. 58% of Ugandan and 47% of Bangladeshi children had pallor of at least one site. Hematocrit or hemoglobin levels were measured in all children with pallor of the conjunctiva or palms and in a sample of the remaining children. In both locations, 2% of children had severe anemia; 13% and 17%, respectively, in Uganda and Bangladesh had moderate anemia, and 42% and 62%, respectively, had mild anemia. Comparison of these findings with the clinical signs indicated that use of the full IMCI process would have referred 68-90% of children with severe anemia to the hospital. Severe palmar and conjunctival pallor, individually and together, had a sensitivity of 10-50% and a specificity of 99% for severe anemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor was not as effective as conjunctival pallor for detecting anemia in Bangladesh. Combining conjunctival and palmar pallor detected 71-87% of cases of moderate anemia and half the cases of mild anemia. Anemia was more easily diagnosed in Uganda in children with malaria. These findings confirm the usefulness of clinical signs in the detection of anemia in developing countries, but suggest the feasibility of adding conjunctival pallor, and possibly grunting, to the IMCI algorithm.
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PMID:Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria. 952 23

Most primary health care facilities in Africa, must rely on physical signs, rather than expensive laboratory tests, to detect anemic patients in need of referral for blood transfusion. This study assessed the reliability of simple clinical signs to predict severe anemia in 368 children, admitted to a tertiary care hospital (Royal Victoria) in the Gambia, primarily with malaria. A trained field assistant examined each child, assessing pallor of the conjunctiva, palms, and nailbeds, on a scale of 0 (no pallor) to 3 (definite severe pallor), and looked for signs of respiratory distress. Examination of 173 of these children by a second observer confirmed inter-observer consistency in the detection of pallor. After the children's admission, their packed cell volume (PCV) was measured. 27% of the children had a PCV under 15%, indicative of severe anemia. Multiple regression analysis identified definite pallor of the conjunctiva, definite pallor of the palms, and a "sick" appearance as significant independent predictors of a PCV under 15%. The best predictor, a combination of definite pallor of the conjunctiva and definite pallor of the palms, had a positive predictive value of 67%, a sensitivity of 80%, and a specificity of 85%. Inclusion of signs of respiratory distress did not improve the prediction. These findings indicate that definite pallor of the conjunctiva, alone or in combination with definite pallor of the palms, can be used in primary health care centers to predict severe anemia with high precision.
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PMID:Pallor as a clinical sign of severe anaemia in children: an investigation in the Gambia. 952 24

A questionnaire-based study was conducted on 189 Traditional Birth Attendants (TBAs) on their knowledge and practices in prenatal services. Only 86 (45.5%) of them associated cessation of menstrual period with pregnancy while others use mystic power 46 (24.3%), early morning sickness, pallor of conjunctiva and reaction to herbs 56 (29.6%) to detect pregnancy. Fundal height n=76 (40.2%), palpation n=82 (43.4%), special soaps and soups n=52 (27.5%) and special devices n=8 (4.2%) are used to determine stages of pregnancy. Foetal health status is determined by regular foetal movements n=95 (50.3%), mystic power n=15 (8%), soap n=2 (1.1%), special concoction 9 (4.8%), health status of mother n=67 (35.4%) and foetal heart beat n=24 (12.7%). Ninety seven (51.3%) of them used herbal treatment, 77 (40.7%) used incantations, 189 (100%) used special soaps as their main methods of delivery, while only 18 (9.5%) of respondents refer difficult cases to hospitals. Instruments used for separating cord were blade 123 (65.1%) and scissors 40 (21.1%). Symptoms recognized by the TBAs as signs of complications in pregnancy were dizziness, swollen feet, pallor, tiredness, absent foetal movement, loss of appetite, heaviness, pain in back/stomach/side, weight loss, vomiting, bleeding, fever/malaria, head ache, bad dream, premature or delayed labour. Although some of them recognized some danger signs in pregnancy and labour, only very few would refer difficult cases for emergency obstetric interventions. Clear protocols for management and referral, which are necessary for improved maternal survival, should be provided through regular training of the TBAs.
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PMID:Knowledge and practices of traditional birth attendants in prenatal services in Lagos State, Nigeria. 1597 55

INTRODUCTION : An estimated 300 to 500 million clinical cases of malaria occur each year worldwide, 90% in Africa, mostly among young children. In Cote d'Ivoire, malaria is 46.03% of disease states and 62.44% of hospital admissions. In children under 5 years, it is 42.67% of the reasons for consultation and 59.68% of hospital admissions. In pregnant women, it represents 22.91% of disease states and 36.07% of hospital admissions. In Africa, traditional medicine is the first resort for the vast majority of people, because of its accessibility both geographically, economically and culturally. However, some modern practitioners show an attitude of distrust of traditional medicine and its players, calling them irrational. This work had set out to assess knowledge, attitudes and practices of traditional healers in the uncomplicated and complicated in the context of collaboration between traditional and modern medicine for the optimal management of critical cases. MATERIALS AND METHOD : The study focused on traditional healers practicing in the city of Abidjan. The study was conducted using individual interviews over a period of 30 days. The interviews were conducted in local languages, with the assistance, if necessary, translators. For data collection, we used a questionnaire containing four items: the socio-demographic characteristics of traditional healers, their knowledge on malaria, diagnostic practices and traditional therapies. RESULTS : Of the 60 healers and included in the study, only six were women (10%), a sex-ratio of a woman to 9 men. 66.7% of respondents traditional healers are herbalists and 25% of naturopaths.Only 8.3% were spiritualists. The etiology of malaria most commonly cited by the traditional healers were mosquito bites (16.7%), food (1.7%), solar (1.7%) and fatigue (1.7%) . 25% of traditional healers are associated with mosquitoes, sun and fatigue. Symptomatology most cited were fever (100%), dark urine (86%), the yellow or pale conjunctiva (80%), vomiting (71.7%), nausea (58.3%) and abdominal pain (48.3%). Traditional healers recognized three types of malaria: the white shape, form yellow / red and the black form. Traditional healers malarious patients surveyed were receiving both first (58.3%) than second-line (41.7%). 78.3% of them practiced an interview and physical examination of theirpatients before the diagnosis. In 13.3% of cases they were divinatory consultation. Medications used to treat malaria were herbal in 95% of cases. The main sign of healing was the lack of fever (58.3%). 90%of traditional healers interviewed referring cases of malaria black (severe malaria). This reference is made to modern health facilities (90.2%). 68.3% of respondents practiced traditional healers of malaria prophylaxis among pregnant women and children under 5 years.CONCLUSION : A description of clinical malaria by traditional practitioners in health is not very far from that of modern medicine. Nevertheless, the logics of our respondents are etiological more complex and linked to their cultural context. The management of cases is made from medicinal plants in treatment failure patients are usually referred to modern health facilities. The involvement of traditional healers in the detection and quick reference risk cases can contribute to reducing child mortality due to severe malaria.
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PMID:[In process citation]. 2294

A 46-year-old Japanese man was referred to our travel clinic because of high fever for the past 7 days. He worked as an engineer for a month in Zambia and returned to Japan 2 days ago. He had a high-grade fever of 40.5 degrees C. Examination of the palpebral conjunctiva showed no evidence of anemia. Liver and spleen were not palpable. Blood sample was collected at the time of the febrile paroxysm. Malaria parasites were detected by examination of Giemsa-stained thin blood films. The dominant feature of parasite was early trophozoit with a low parasitemia (0.0469%, 1,857.6/microL). The James' stippling was absent. Schizonts and gametocytes were scarce. As ring morphology was quite variable, identification of species might not be possible. Identification of species is more difficult than usual, on the grounds that: 1) the blood sample contains rare early trophozoites, 2) the level of parasitemia is low, and 3) it is quite possible for parasites to be transformed due to the inappropriate treatment. Finally, the diagnosis was confirmed by nested PCR. Examination of Giemsa-stained blood films is the "gold standard" for detection and identification of organisms. However, in non-endemic countries, trained laboratory personnel are scarce and the most may be inexperienced in malaria diagnosis. It is recommended that personnel continue to gain experience by participating in external quality assurance schemes, and that routine laboratories utilize rapid diagnostic tests (RDTs) concurrently. The availability of simple and accurate RDTs could aid the diagnosis in no-endemic countries.
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PMID:[A case of Plasmodium ovale malaria--morphological diagnostic difficulty and utility of rapid diagnostic tests]. 2367 79