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Ninety eight male children aged 4 months to 10 years presenting with watery diarrhoea of less than 72 hours prior to hospitalization ware studied buy generic eurax 20 gm on-line. Stool for routine examination was done on each children and base line assessment on lactose absorption and small bowel bacterial overgrowth status were done cheap eurax 20gm otc. The results indicate that parasitic infections hinder the lactose absorption and favour the small bowel bacterial overgrowth; thus deworming could improve the lactose absorption status in children. Intestinal mucosal integrity was assessed by measurement of permeability index using dual sugar lactulose and L-rhamnose. Significantly decreased L-rhamnose excretion was observed in all of the clinical groups, in comparison to controls reflecting decreased absorption through enterocytes and villous atrophy. Raised lactulose urinary excretion was observed in all clinical groups except in children with persistent diarrhea, suggesting increased paracellular spaces and mucosal injury. It is concluded that major changes in intestinal permeability occurred in children with persistent diarrhea. There were lesser degree of damage in acute diarrhea and recovered persistent diarrhea groups. Only minor changes was observed on those who recovered from acute diarrhoeal illness. As a result persistent diarrhoeal group had lowest value of nutritional indices and grater proporation of malnourished children in comparison to acute and recovered diarrhoeal illness. The study included 20 days to 10 years old children and 239 were males and 149 were females. Faecal leukocytes were identified under a high power (40 X) field microscope by mounting of methylene blue staining method. The bacterial pathogens and protozoa pathogens were identified by standard methods. The association between the presence of faecal leukocytes and isolated pathogens from the stools were isolated in association with Shigella alone (25. They all were grown at both 37C and 42C and they were resistant to polymyxin B sulphate. This study was also carried out to describe some epidemiological features of giardiasis in these children and to monitor the efficacy of metronidazole. A total of 308 stool samples from children attending the Diarrhoeal unit were examined for the presence of Giardia lamblia cysts or trophozoites. The infected children were treated with standard regimen of metronidazole (Myanmar Pharmaceutical Industry) and their stools were again examined at the end of treatment. To have a better understanding of public health importance of domestic and personal hygienic measures on acute diarrhoea, mothers were asked to answer some variables by using a standard questionnaire forms. It was carried out on 100 patients who were under 4 months old of age, diagnose as acute diarrhoea and admitted for treatment to Yangon Children Hospital, Myanmar, during June 1997 to May 1998. It was isolated from 28 cases who had some dehydration and 20 cases who had severe dehydration. Exclusion breast feeding was only seen in age group of less than one and more than one to two months age group. It was not statistically significant when severity of dehydration with other types of feeding compared to exclusive breast feeding among less than one and more than one to two months old children. In our study most of the mothers wash their hands with water only after cleaning her child s defecation and before and after feeding her child. The severity of dehydration was statistically significant in hand washing practice and indicating a need for appropriate intervention programmes aimed at promoting exclusive breast feeding and hand washing practices with soap and water after cleansing her child s defecation, and before and after feeding her child. The study was conducted during 1993-1994 to determine the association of the pathogen with the disease. The seasonal, age and sex distribution, serotyping and susceptibility of these isolates to antibiotics were investigated, V. Dysenteric stool samples were collected from the laboratory of Infectious Diseases Hospital, Yangon during January-June 1993. Four hundred and sixty stool samples containing blood and mucous were collected in this study, and Shigella spp. The increasing antimicrobial resistance of shigellosis from 1980 to 1993 in this community was also discussed. A number of factors, including poultry farming, consumption of food and iced drinks from street venders, drinking unboiled water and lack of hygienic habits were found to be significantly associated with choler transmission. The gastroenteritis caused by these bacteria is accompanied by pain in abdomen, nausea and vomiting, fever and a mild degree of 102 Bibliography of Research Findings on Gastrointestinal Diseases in Myanmar dehydration. It is anticipated to facilitate the epidemiological study in order to provide an effective control of disease.

This symptom normally arises when a patient s exer- r Palpitations lasting just a few seconds are often due cise tolerance is already reduced order 20gm eurax otc. The patient becomes aware of the mechanisms are responsible for this phenomenon: a pause that occurs in the normal rhythm after a prema- redistribution of uid through gravity in the lungs ture beat and may sense the following stronger beat order 20gm eurax with amex. Some patients may know how to terminate propping themselves up on pillows at night, or, in se- their rapid palpitations with manoeuvres such as vere cases, sleeping in a chair. Orthopnoea is highly squatting, straining or splashing ice-cold water on the suggestive of a cardiac cause of dyspnoea, although it face. These features are very suggestive of a distinct may also occur in severe respiratory disease due to the tachyarrhythmia rather than general anxiety or pre- second mechanism. It is thought to occur by a simi- Syncope lar mechanism to orthopnoea coupled to a decreased sensory response whilst asleep. Patients awake breath- Syncope is dened as a transient loss of conscious- less and anxious, they often describe having to sit up ness due to inadequate cerebral blood ow. There may be no warning, or patients may describe feel- The distance a patient can usually walk on the at be- ing faint, cold and clammy prior to the onset. Asthenarrowing tend to be ushed and sweaty but not confused (unless ofthearteriesbecomesmoresignicant,theclaudication prolonged hypoxia leads to a tonic-clonic seizure). Eventually rest pain may occur, this r Vasovagal syncope is very common and occurs in the often precedes ischaemia and gangrene of the affected absence of cardiac pathology. The heart contracts force- fully, which may lead to a reex bradycardia via vagal Oedema stimulation and hence a loss of consciousness. A number of mechanisms tion, hypovolaemia or due to certain drugs especially arethoughttobeinvolvedinthedevelopmentofoedema. Normally tissue uid is formed by a balance of hydro- r Cardiac arrhythmias may result in syncope if there is a static and osmotic pressure. This may oc- Hydrostatic pressure is the pressure within the blood cur in bradycardias or tachycardias (inadequate ven- vessel (high in arteries, low in veins). The loss of consciousness occurs produced by the large molecules within the blood (albu- irrespective of the patient s posture. A Stokes Adams min, haemoglobin) and draws water osmotically back attack is a loss of consciousness related to a sudden into the vessel. The hydrostatic pressure is high at the loss of ventricular contraction particularly seen dur- arterial end of a capillary bed hence uid is forced out of ing the progression from second to third degree heart the vasculature (see Fig. The colloid osmotic pressure then draws uid back in r Carotid sinus syncope is a rare condition mainly seen at the venous end of the capillary bed as the hydrostatic in the elderly. As a result of hypersensitivity of the carotid sinus, light pressure, such as that exerted by atight collar, causes a severe reex bradycardia and hence syncope. The syncope results from an inability of the heart to increase cardiac output in response to in- Hydrostatic Oncotic 0ncotic Hydrostatic creased demand. Intermittent claudication Artery Vein Claudication describes a cramp-like pain felt in one or both calves, thighs or buttocks on exertion. This may be a result of blood bypassing uid is then returned to the circulation via the lymphatic the lungs (right to left shunting) or due to severe lung system. Mechanismsofcardiovascularoedemaincludethefol- lowing: r The arterial pulse Raised venous pressure raising the hydrostatic pres- sure at the venous end of the capillary bed (right ven- The pulse should be palpated at the radial and carotid tricularfailure,pericardialconstriction,venacavalob- artery looking for the following features: struction). The normal pulse is dened as a rate be- which increases the circulating blood volume with tween 60 and 100 beats per minute. Outside this range pooling on the venous side again raising the hydro- it is described as either a bradycardia or a tachycardia. Albumin is the major factor respon- r The character and volume of the pulse are normally sible for the generation of the colloid osmotic pressure assessedatthebrachialorcarotidartery. A drop volume felt at the carotid may be described according in albumin therefore results in an accumulation of to the waveform palpated (see Fig. Radio-femoral delay is suggestive of coarcta- is left after pressing with a thumb for several seconds) tion of the aorta, the lesion being just distal to the or nonpitting. Cardiac oedema is pitting unless long origin of the subclavian artery (at the point where the standing when secondary changes in the lymphatics may ductus arteriosus joined the aorta). Distribution is dependent lay suggests arterial occlusion due to an aneurysm or on the patient. Pleural effusions and Jugular venous pressure ascites may develop in severe failure. The internal jugular vein is most easily seen with the pa- tient reclining (usually at 45), with the head supported Cyanosis and the neck muscles relaxed and in good lighting con- Cyanosis is a blue discolouration of the skin and mu- ditions. It is due to the presence of desaturated toid muscle in the upper third of the neck, behind it haemoglobin and becomes visible when levels rise above in the middle third and between the two heads of ster- 5 g/dL. Cyanosis is not present in very anaemic patients nocleidomastoid in the lower third. Cyanosis is divided from the carotid pulse by its double waveform, it is non- into two categories: palpable, it is occluded by pressure and pressure on the r Peripheral cyanosis, which is seen in the ngertips and liver causes a rise in the level of the pulsation (hepato- peripheries.

Case definition Suspected case: A person with diarrhea and with visible blood in stool purchase 20 gm eurax amex. Confirmed case: Suspected case with stool culture positive for shigella dysentariae 1 generic 20gm eurax amex. Investigation Interrogate the case to determine factors contributing to transmission. General Management Report the suspected case to the next higher level of the health system. The incubation period is from a few hours to 5 days, usually in the range from 2 to 3 days. Another 20% show mild diarrhea that cannot be distinguished from other causes of diarrhea. Determinants: Environmental factors: Areas without safe and adequate water supply Areas without good sanitation Seasonality not well understood Host factors: Persons with gastric achlorhydria The organism: Only serogroups 01 and 0139 cause epidemics; other serogroups can cause diarrhea, but not epidemics Case definition Suspected case (where cholera is not known to be present): Any person aged 5 years or more, who develops severe dehydration or dies from acute watery diarrhea. Investigation Maintain surveillance through watching for increase in the baseline number of cases of cholera in endemic areas and be alert for a single case in non-endemic area. Antibiotic drugs of choice to treat cholera Antibiotic Children Adults Doxycycline --- 300 mg Tetracycline (4 times 12. Tetracycline is equally effective, but may not be available for pediatric use in some countries. Use erythromycin or chloramphenicol if the other recommended antibiotics are not available, or where V. It is the leading cause of death in children under 5 years in sub- Saharan Africa and, in some countries, accounts for one quarter of such deaths. It has been consistently reported as one of the three leading causes of morbidity and mortality in the past years. The magnitude of the problem in 2002/2003 has even worsened and the disease has been reported as the first cause of morbidity and mortality accounting for 15. In non- epidemic year, 5-6 million clinical malaria cases and over 600,000 confirmed cases are reported from health facilities. Four species of plasmodium can produce the disease in its various forms-Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malariae. Transmission: Parasites are transmitted from one person to another by the female anopheline mosquito. Epidemic precipitating factors: Possible precipitating factors of malaria epidemics include: a) Increase in vectorial capacity, e. Severe malaria Any person hospitalized with a primary diagnosis of malaria and confirmed by a positive blood smear or other diagnostic tests for malaria. Investigation An epidemic should be suspected when there is an unusual increase in the number of new malaria cases or deaths compared to the same period in previous non-epidemic years. A threshold level rd is established using the 3 quartile of a 5 years period of time (see annex 3). General management Provision of early diagnosis and prompt treatment to all people who are sick. For infants less than three months or five kg of body weight and pregnant women in the first trimester, oral quinine administered 3 times a day for 7 days. In addition, ask the patient if he/she has vomited the drug or had diarrhea after treatment. If the blood film is positive for asexual malaria parasites and other conditions are excluded, administer oral quinine if condition of the patient permits. Measles virus is spread via the respiratory route and is transmitted extremely efficiently. Before widespread use of measles vaccine, measles was consistently one of the leading causes of death among children worldwide, accounting for an estimated 20-30%of such deaths. Large epidemics occur every few years in areas with low vaccine 98 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia coverage and where there is an accumulation of persons who have never been infected or vaccinated. The World Health Organization estimates that measles still causes 45 million cases and 1 million child deaths, with over 50% of these in Sub-Saharan Africa. Transmission: Airborne by droplet spread and direct with nasal or throat secretions of infected persons. Determinants: In the absence of vaccination, every child in an area where measles virus is circulating would be expected to contract measles. Confirmed case: A suspected case with laboratory confirmation (positive IgM antibody) or epidemiological link to confirmed cases in an epidemic. Case management of uncomplicated measles Many children will experience uncomplicated measles and will require only supportive measures: Give vitamin A, first dose in the health facility or clinic; give the mother one dose to give at home the next day.