Amal Bassili

Identification of clinical criteria for group A-β hemolytic streptococcal pharyngitis in children living in a rheumatic fever endemic area

A cross-sectional study was conducted over a 1-year period (1 January-31 December 2000) during which cases suffering from uncomplicated tonsillopharyngitis were recruited from the private and public health services in Alexandria. The objective was to determine the prevalence of group A-beta haemolytic streptococci (GABHS) among children suffering from tonsillopharyngitis and to identify the clinical criteria predicting GABHS pharyngitis in children. A total of 578 children aged between 1 and 15 years with a mean of 6.3 +/- 3.7 years, presenting with sore throat were enrolled in the study. Demographic data and presenting signs and symptoms for each patient were recorded on a standardized form and a throat swab was taken using the filter paper technique. The overall prevalence of GABHS was 17 per cent and the highest isolation rate was reported in children aged 10-15 years. Non-GABHS comprised 11.9 per cent of the total isolates. The most prevalent of them were group C and G streptococci. The highest frequency of both GABHS and non-GABHS was in early spring. Significant predictors of GABHS pharyngitis were: age 10-15 years, the presence of dysphagia, vomiting, pharyngeal exudate, and scarlatiniform rash. Watery eyes and/or rhinitis had a protective value against the diagnosis of GABHS pharyngitis, while fever was considered to be a non-specific finding in cases with GABHS pharyngitis. Antibiotic sensitivity test showed higher sensitivity to both penicillin and erythromycin. Only 1 per cent of the GABHS isolates showed resistance to cephadroxil. We concluded that a syndrome of signs and symptoms could be used as a clinical predictor for the diagnosis of GABHS pharyngitis.

The adequacy of diabetic care for children in a developing country

UNLABELLED A cross-sectional study was conducted over 4 months evaluating the quality of care provided to diabetic children in public childrens hospitals in Alexandria, Egypt. RESULTS Adult diabetologists were the main healthcare providers (HCP) (60.4%) in the School Health Insurance Hospital followed by paediatric diabetologists in the University Hospital. Insured children had a significantly higher frequency of physical examination, investigations and diabetes education compared to uninsured children. One-quarter of insured and 22% of uninsured children were performing self monitoring of blood glucose, while 45.2% of insured children were checking glucosuria at home compared to 34.0% of uninsured children. Premixed suspensions of biosynthetic human insulin, administered mainly via a syringe, was the most commonly prescribed insulin type with little possibility for personal initiative. Acute diabetic complications were also higher in uninsured compared to insured children. The frequency of these life threatening acute diabetic complications in the school health insurance system is estimated to be approximately 12.7 severe hypoglycaemic and 57.2 hyperglycaemic/ketoacidotic episodes per 1000 diabetic children per year. Recurrence of diabetic emergencies was significantly higher among children of parents with lower educational levels and children living in semiurban and rural residence. Children with recurrent diabetic emergencies had lower educational achievement, and more grade repeating and school absence during the year. CONCLUSION The results of this study appear to reflect marked deficiencies in the provision of information to children with diabetes and their parents in a developing country. A need for public-education strategies, consensus about treatment recommendations, use of more flexible insulin regimens, and devices for home monitoring is identified.

Quality of Care of Children With Chronic Diseases in Alexandria, Egypt: The Models of Asthma, Type I Diabetes, Epilepsy, and Rheumatic Heart Disease

Objectives. To evaluate the quality of care delivered to children suffering from index chronic diseases using specific indicators of health care delivery and to study the predictors of suboptimal quality of care (SQC) and its outcome on children. Design. Over a 9-month period, guidelines for optimal care were formulated. A specific questionnaire for every studied chronic disease was prepared in collaboration with the clinicians in charge of the diseased children (66% pediatricians and pediatric specialists and 34% adult specialists). The clinicians were asked to write the details of daily practice, ie, how these children were managed on a routine basis as well as in an emergency situation. A cross-sectional study was conducted over a 4-month period and included 953 children suffering from bronchial asthma (BA), childhood epilepsy (CE), type I diabetes mellitus (IDDM), and rheumatic heart disease (RHD). A systematic random sample of children was selected from children visiting the ambulatory settings of all childrens hospitals. Every fourth child was selected on 2 randomly chosen days each week, while all diseased children admitted in the hospital settings of the childrens hospitals during the study were included. A general form describing the impact of the diseases on the child was prepared. A network of clinicians was created in all childrens hospitals; seminars were held during which the content validity of the questionnaire was tested. Items were evaluated for their internal consistency using the Cronbach α. According to the degree of adherence to the recent therapeutic guidelines concerning selected indicators of the quality of care specific to every disease, children were categorized as receiving optimal quality of care or SQC. These indicators were: the use of inhaled bronchodilators in acute asthmatic attacks in mild asthma and the use of the prophylactic drugs (inhaled sodium cromoglycate or inhaled beclomethasone) in moderate to severe chronic BA in between acute asthmatic attacks; compliance with antiepileptic drugs in epileptic children; regular performance of self-monitoring of blood glucose and/or urine testing in diabetic children; and compliance with prophylactic antibiotics in children suffering from RHD. The records of the outpatient clinics for ambulatory and hospitalized cases were reviewed to assess the degree of compliance with the prescribed management before the index visit. Sociodemographic characteristics and health care system-related predictors of SQC were analyzed via stepwise logistic regression analysis. The impact of illness on the child was assessed by 7 items which were: dependence on parents in domestic activities, level of activity compared with peers, mood compared with peers, level of socializing, degree of discomfort attributable to illness, level of physical disadvantage, and urinary incontinence. Factor analysis with Varimax rotation was performed on items related to the impact of illness. Parental satisfaction with care was rated as excellent, very good, fair, or poor. Information on school outcome was obtained by asking the caretakers whether the child was able to attend school regularly despite his sickness. Scholastic achievement was also rated as excellent, very good, good, and acceptable. Parents were asked whether the child had ever repeated a grade because of his sickness. Setting. Ambulatory and hospital settings of all childrens hospitals in Alexandria, Egypt. Results. Only 52% of mild asthmatics were given inhaled bronchodilators during acute attacks and 6.84% of moderate to severe asthmatics were taking prophylactic drugs (inhaled sodium cromoglycate and/or inhaled beclomethasone) between acute attacks. Similarly, only 53 of 134 (39.6%) of diabetic children were regularly performing self-monitoring of blood glucose and/or urine testing. In contrast, in epileptic children, 121 of 173 (69.9%) were judged as being compliant by their managing clinicians and more than two thirds 82/123 (66.7%) of children with RHD were compliant with the secondary prophylactic antibiotic. Predictors of SQC were younger age of the child (in BA and CE), lower maternal education (in BA and IDDM), charged medication (in BA, IDDM, and RHD), suburban residence (in moderate to severe BA), lower paternal education (in CE), and management in health facilities other than university hospital (in IDDM). Regarding the outcome of chronic diseases on children, factor analysis revealed 2 factors (physical and psychosocial impact) that explained 41.5% of variance with moderate adequacy (Kaiser-Meyer-Olkin test of sampling adequacy = .67). Dependence on parents in domestic activities, urinary incontinence, physical disadvantage, and the degree of discomfort attributable to illness were all aggregated into the physical impact factor, whereas the level of socializing, mood, and the level of activity compared with peers were aggregated into the psychosocial impact factor. There was a strong association between the severity of psychosocial impact and the quality of delivered care in CE and RHD, as well as between the parental satisfaction with care and the quality of delivered care for the 4 index diseases. However, there was no significant association between the severity of physical impact or school performance parameters and the quality of delivered care (apart from grade repeating in RHD). Conclusions. With respect to the declared primary goal of the study, the most interesting findings could be summarized as follows: Cultural and economic factors are the primary predictors of SQC for childhood chronic diseases. Noncompliance to medication reflects the quality of delivered care in terms of defective health education rather than problems in the availability of medications in the local market as in many other developing countries or problems in the access to pharmacy or health services. Parental satisfaction with care seems to be a reliable marker of the quality of health care delivery regardless of the educational level of the community. Therefore, it could be used as a sensitive marker for the quality of health care even in developing countries. Chronic diseases have a profound impact on children, especially those belonging to the lower socioeconomic levels of the society, their scholastic performance, and the health care system. Regular monitoring of the health system performance is warranted, along with emphasis on health education programs for caretakers of children with chronic diseases. quality of care, chronic diseases, outcome.