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The acid should not touch the conjunctiva to fungus gnats lavender oil buy generic diflucan 150 mg on line prevent adhesions (symblepharon) between the lids and eyeball anti yeast antifungal diet cheap diflucan 50 mg without a prescription. ParacentesisAqueous is released slowly by making an opening in the lower temporal quadrant of cornea antifungal for feet order diflucan 200 mg without prescription. It prevents complications of spontaneous perforation which usually occurs in the centre of the cornea involving the visual axis antifungal drugs order genuine diflucan online. Conjunctival flapThe non-healing ulcer may be covered with the conjunctival flap. Therapeutic keratoplastyFull thickness graft is applied to enhance healing and to prevent perforation. Pressure pad and bandageBy applying extra pad and tight bandage over the eye, support is given to the cornea. Therapeutic full thickness or penetrating keratoplasty is done as the last resort. The epithelium is usually intact and therefore the fluorescein staining is negative. Evacuation of pus is done first by a sterile autoclaved fine needle or knife before starting the topical antibiotic treatment as for corneal ulcer. If perforation is small in the pupillary area and there is no prolapse of iris: i. Optical iridectomy the pupil is extended to the periphery by a slit-like iridectomy. It is indicated when the vision is quite good and where facilities for keratoplasty are not available Optical iridectomy Site 1. Full thickness keratoplasty is preferred treatment when the ulcer has healed and the vision is markedly reduced. Tattooing with gold (brown) or platinum (black) is advised for cosmetic purpose only in firm blind eyes usually. A piece of blotting paper of the same size, soaked in fresh 2% platinum chloride solution is kept over the opacity. On removing this filter paper, few drops of fresh 2% hydrazine hydrate solution are applied over the area which in turn becomes black. Corneal fistulaFull thickness keratoplasty is indicated as the fistulous tract is lined by the epithelium which prevents healing. It is important to note that hypopyon is sterile as the leucocytosis is due to the toxins and not by actual invasion of the bacteria. Pneumococcus, Pseudomonas pyocyanea, Staphylococcus, Streptococcus, Gonococcus, Moraxella, fungus, etc. Resistance of the hostIt is commonly seen in old, debilitated, alcoholic, malnourished and immunologically deficient persons. Chronic dacryocystitis is a continuous source of infection particularly of Pseudomonas pyocyanea and pneumococcus bacteria. In case of a corneal ulcer there is always associated iridocyclitis due to the liberation of toxins by the bacteria, which diffuses into the anterior chamber via the endothelium. This results in dilatation of the blood vessels and outpouring of leucocytes which become enmeshed in the fibrin network. Such hypopyons are fluid and change their position with gravity when the patients head is changed. In severe cases, it may completely fill the anterior chamber thus obscuring the iris. The hypopyon is sterile and it usually gets absorbed when hypopyon corneal ulcer is adequately treated with routine treatment for corneal ulcer. The opacity is greater at the advancing edge in one particular direction than centre. The tissues breakdown on the side of the densest infiltration (yellow crescent) and ulcer spreads in size and depth. Often there is infiltration anterior to Descemets membrane at the floor of the ulcer while the intervening stroma is normal. Marked iritis with cloudy aqueous (hypopyon), conjunctival and ciliary congestion is usually present. Panophthalmitis may occur due to rapid growth and spread of the virulent organisms. Perforation may heal resulting in leucoma, adherent leucoma, anterior staphyloma or occlusio pupillae causing marked visual impairment. Treatment It is a well-known surgical rule that pus anywhere in the body has to be removed. Early and intensive treatment of corneal ulcer as mentioned earlier is started at once after culture and sensitivity. Secondary glaucoma is the most common cause of failure of treatment in elderly persons. It is treated by Topical atropine 1% the Cornea 121 Oral acetazolamide (carbonic anhydrase inhibitor) Intravenous mannitol 20%, 200 ml (hyperosmotic agent) Paracentesis helps in lowering the tension and brings fresh aqueous and nutrient. Etiology It is commonly caused by Candida albicans, Aspergillus fumigatus, Fusarium, Cephalosporium, Streptothrix actinomycosis, etc. Fungal corneal ulcer Symptoms these are same as for the bacterial ulcer but they are less prominent than equal-sized bacterial ulcer. There is mild pain, irritation, watering and presence of yellow patch in the cornea. It is dry in appearance with small satellite lesions around the ulcer due to the stromal infiltration with delicate feathery, finger-like hyphate edges protruding into adjacent stroma. Predisposing factors Non-specific Systemic immunosuppressives, local or systemic steroids therapy 4. Marked infiltration Hyphate margins, satellite with gross destruction lesions, immune ring of tissue iv. Slit-lamp examinationEndothelial plaque and immune ring may be seen around the ulcer. Diagnosis Scraping of the ulcer at the margin and inoculation of media should be done promptly. As the organism is often situated deep within the stroma, corneal biopsy may be taken at times. Culture in Sabourauds medium, blood-agar plate or brain-heart infusion broth is essential. Antifungal drugsThe role of these drugs is limited due to the few approved antifungal drugs and their poor penetration. Topical antifungals are to be instilled for a long-time, as the response is often delayed. Taper over several weeks Subconjunctival100 -300 mg on alternate day 1-2 doses Intravitreal5-10 g SystemicBy infusion, 5-10 mg total dose is given/day. SystemicSystemic antifungals are indicated if the infection spreads to the sclera and there is impending perforation. Cycloplegics such as atropine is used to prevent posterior synechiae formation and to control iritis by paralysing the ciliary muscle. Therapeutic full-thickness keratoplasty is much better solution in cases of non-healing fungal keratitis. Deep marginal ulcer may occur rarely in cases of polyarteritis nodosa, systemic lupus erythematosus due to antigen-antibody complexes. Marginal ulcer Chemical cautery may be done with 1% silver nitrate in mild recurrent ulcers. Etiology It occurs as a result of degenerative process due to ischaemia of cornea. Characteristic white overhanging edges are seen as the ulcer spreads below the epithelium and superficial layers of stroma. Rodent ulcer the Cornea 125 Treatment It is very difficult because of corneal ischaemia. Excision of 4-6 mm strip of adjacent conjunctiva with or without cryotherapy is often effective. Etiology this condition is commonly seen, In eyes insufficiently covered by the lids due to paralysis of the orbicularis muscle.
This limited access is further compromised by lack of reimbursement and coverage for services related to fungus amongus buy cheap diflucan 200mg online comprehensive pain management garlic antifungal yeast infection generic diflucan 200 mg on line, including nonpharmacologic evidence-based pain therapies jalapeno antifungal diflucan 150 mg with mastercard. However fungus and animal predation purchase diflucan without prescription, a risk factor of a medication should not necessarily be an automatic reason not to give this medication to an elderly patient. Clinicians must assess the risk versus beneft of using medications while considering other modalities in this patient population. An estimated 40% of cancer survivors continue to experience persistent pain as a result of treatments such as surgery, chemotherapy, and radiation therapy. Persistent pain is also common and signifcant in patients with a limited prognosis, as often encountered in hospice and palliative care environments. Many oncologists and primary care physicians are not trained to recognize or treat persistent pain associated with cancer or other chronic medical problems with limited prognosis. Causes of pain such as recurrent disease, second malignancy, or late-onset treatment efects should be evaluated, treated, and monitored. Women use the health care system as patients, caregivers, and family representatives and can be particularly afected by costs, access issues, and gender insensitivity from health care providers and staf. Several diseases associated with pain in particular, chronic high-impact pain have a higher prevalence in women or are sex specifc, including endometriosis, musculoskeletal and orofacial pain, fbromyalgia, migraines, and abdominal and pelvic pain. Acute pain fares on top of the chronic pain condition can be a common occurrence that may afect daily routines and overall functionality, resulting in additional morbidity and the need for comprehensive pain care. I struggled with depression for a while and as recently as last February, I went through a period of depression. I would still go out and have fun with my friends, even though I was still going through all this pain. And that was so touching because at that time I didnt believe I was a strong person. I barely go to a hospital for my crisis now because I try to fnd ways at home to get rid of my pain. Constraints on opioid treatment duration can make individualization of pain management difcult. Further, limited access to oral opioids at home for the treatment of unplanned acute pain can result in increased use of health care services that could have been avoided. Efective strategies and plans to address these issues specifcally in these disparate communities are necessary to address these gaps to improve patient outcomes. Evidence exists of racial and ethnic disparities in pain treatment and treatment outcomes in the United States, yet few interventions have been designed to address these disparities. Veterans die by suicide at higher rates compared with civilians in the United States. Assessment and treatment of pain conditions in active duty service members and Veterans require military-specifc expertise and a coordinated, collaborative approach between medical and mental health providers. This integration should include coordination of the transition from active duty to Veteran status and care coordination across the health care spectrum that includes a smooth transition to primary care, mental health and pain specialty physicians, and health care providers. Clinicians evaluating pain, whether acute or chronic, must conduct a thorough history, physical exam, and risk assessment, especially when considering medications such as opioids in the treatment plan. For example, it is important for pharmacists to know that doctors often work as teams and to ensure that the conclusion of inappropriate multiple provider use is made only after the pharmacist has communicated directly with the prescribing clinician. Concerns that physicians, nurses, dentists, and pharmacies may have should be communicated among one another or to the relevant state regulatory agencies, including state medical boards, nursing boards, dental boards, and pharmacy boards, when appropriate. Evaluations of patient physical and psychological history can screen for risk factors and characterize pain to inform treatment decisions. This includes screening for drug and alcohol use and the use of urine drug testing, when clinically indicated. Efective screening can include single questions, such as, How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons The agreement should be viewed as an opportunity for ongoing dialogue about the risks of opioids and what the patient and clinician can expect from each other. Clinicians should also screen for factors that predict risk for poor outcomes and substance abuse, such as sleep disturbance, mood disorder, and stress, either by using a pain rating scale such as the Defense and Veterans Pain Rating Scale, which includes brief questions, or by routinely asking about these factors on clinical examination. Lack of sufcient compensation for time and payment for services have contributed to barriers in best practices for opioid therapy. These are vital aspects of risk assessment and stratifcation for patients on opioids and other medications. Treatment agreements should include the responsibilities of both the patient and the provider. Studies suggest that patients who are receiving or who have previously received long-term opioid therapy for nonmalignant pain face both subtle and overt stigma from their family, friends, coworkers, the health care system, and society at large for their opioid treatment modality. I hate that I everyone assume the person was depressed am being treated like a drug abuser or anxious rst He yelled at My wife has Cervical Spinal me, shamed me, and Stenosis with Myelopathy. Within one month she was bed ridden and had talked to her September 2018 employer explaining why she may have to quit her accounting job. Stigma, combined with the enhanced time required to efectively evaluate and treat pain, leads to over-referral and patient abandonment. I ended up going to multiple doctors to fnd help for my pain orthopedists, physiatrists, a neurologist, and four top neurosurgeons. This was also the most vulnerable time for my family, who were my caregivers, because they had no knowledge or understanding or tools to deal with me and my pain. I had no prior psychiatric history and had never been to a psychiatrist in my life. My family didnt know what to do to help me and the situation caused a lot of family stress. During one hospital stay, I was labeled chemically dependent and recommended for a 30-day drug-rehabilitation program. I refused to go because all I wanted was for the pain to stop and to go back to my normal life. About two years later, I fnally ended up in a pain management clinic headed by fellowship-trained pain management anesthesiologists. Contributing to this stigmatization are the lack of objective biomarkers for pain, the invisible nature of the disease, and societal attitudes that equate acknowledging pain with weakness. This confusion has created a stigma that contributes to barriers to proper access to care. This is how my and necessary for optimizing patient outcomes, promoting appropriate use of pain medication, and reducing the risk nightmare began. I was told that I was not a candidate for surgery, but few other solutions were given. I had no prior psychiatric history and had Public Patient Provider Legistlators, never been to a psychiatrist in my life. Education Education Education Regulators Education Each time I would return home, but nothing had changed. I refused + E ective, patient-centered care to go because all I wanted was for the pain to stop and to go back to my normal life. About two years later, I fnally ended up in a pain management clinic headed by fellowship-trained + Optimize patient functional outcomes pain management anesthesiologists. I was treated with understanding and respect and given + Appropriate use of pain medication the medical care that I needed to help improve my quality of life + Eliminate stigma + Reduced risk through risk-benet assessment Figure 19: Education Is Critical to the Delivery of E ective, Patient-Centered Pain Care and Reducing the Risk Associated With Prescription Opioids To begin to address the growing need for educational initiatives, multiple entities, including government agencies, nonproft organizations, pharmaceuticals manufacturers, academic institutions, and health systems, have developed and disseminated pain and opioid-related patient education programs, toolkits, pamphlets, and other interventions. Similarly, state-level continuing education requirements have been established for several provider types. Addressing multiple education gaps simultaneously will likely be necessary to optimize patient outcomes tied to public, patient, and provider education. Other programs that could be considered are the development and efectiveness testing of a reimbursable pain self-management training program that incorporates a pain educator, or evaluation of the role of a certifed pain educator, in optimizing pain care and improving patient education. Whereas some evaluation of mass media campaigns for low-back pain have been conducted in other countries, analyses in the United States are lacking. An estimated 50 million to 100 million people have chronic pain, making it the most prevalent, costly, and disabling health condition in the United States. Patients beneft from a greater understanding of their underlying disease process and pain triggers as well as knowing how to seek appropriate professional care. It is important for patients to know that pain as a symptom is typically a warning of injury or disease that can afect the body and mind. Finding the precipitating and perpetuating causes of the pain and addressing them with appropriate multimodal therapy is considered the best management strategy for improving patient outcomes. It is also important for patients to understand that pain can be a disease in its own right, particularly when pain becomes chronic and loses its protective function.
Do you have a system in place or can you create one to pesticide for fungus gnats buy 50mg diflucan with amex capture revenue increases resulting from the intervention Can you identify a quality bonus that can wholly or partially be attributed to fungus gnats taxonomy discount 150 mg diflucan overnight delivery the existence of this project Can you identify additional revenues from ofering services that had not been ofered prior to antifungal barrier cream generic 150 mg diflucan with mastercard the initiation of this intervention antifungal eo buy diflucan us. Determining the changes will require that you are able to identify and measure specifc quality indicators that you expect the intervention to afect. Do you have a system in place or can you create one to capture indirect benefts from the interven tion, such as improvements in your organizations sustainability Can you measure decreases in days lost from work or days lost from school that could reasonably be attributed to improvements in the quality of care United States Department of Veterans Afairs, Health Economics Resource Center, April 2004. All organizations, even that although the framework for a business case is those with a strong proft motive, recognize that conceptually straightforward, actually quantifying other fnancial measures of organizational perfor the costs, savings and revenue consequences of an mance are useful and that fnancial measures alone intervention may exceed the capacity of an organi are not sufcient for long-term organizational zations cost accounting and information technol survival. Tese concerns extend to even the and Norton1 have developed in their balanced most sophisticated of service delivery organiza scorecard approach to the measurement of tions or health insurers, whose accounting systems organizational performance. This may be the result of misaligned measures by four perspectives: fnancial, customer, Business Case Perspectives Financial Perspective Internal Customer Business Perspective Perspective Innovative Regulatory and Learning Community Perspective Perspective Perspective 13 internal business, and innovation and learning. This approach is ties all present and future expenditures required usually called cost-efectiveness analysis. It requires for a given quality intervention to all the present that the organization gather two essential kinds of and future savings or revenue increases generated information. Identifca in the current climate of constrained resources is tion of the desired process and outcome measures, budget neutrality. If by implementing supports for the design of data-gathering instruments and self management an organization can simultane processes, and the means of analyzing and report ously show increases in quality of care and improve ing these data will clearly need to be developed and the efciency of the care delivery process by other in place before the intervention begins. If for patient education from Wellmark, which covers potential quality enhancements for diferent types 25 percent of its patients and is its largest insurer. Mercy Clinics had been common quality metric such as quality-adjusted tracking data on adult diabetes care in two prac life-years must be used for both groups of tices, and it had data on the percentage of patients patients. Unfortunately, in the real world of whose testing was completed and the percentage fnancial management, quality-adjusted life-years who were meeting their goals. Wellmark wanted to do not resonate strongly with the chief fnancial test a pay-for-performance (P4P) system for ofcers of organizations. Hard data on increased meeting guidelines, and Mercy Clinics had the cash fows or reduced operating costs resulting disease registry in place that could provide the from an intervention are likely to be more required data. In this case, the ultimate benef from internal laboratory services provided a ciary of the savings would be the health insurer for positive business case for the clinics expanded the afected patients. Enlightened health the changes they need to deliver excel insurers have provided quality bonuses or incen lent care and still make money. They must tive payments to individual group practices and look for new ways to deliver care, work in 15 teams, and have trained folks around them program encourages high-quality health care by to help. In the Washington state market, Aetna pro Another example of P4P is provided by the vides health benefts to approximately 280,000 Monroe Plan for Medical Care in Rochester, New members, who have access to a network of 90 York. Excellus per year per diabetic patient and $100 per year per BlueCross BlueShield in New York state contracts heart/stroke patient. Excellus, in turn, con maintained on the Healthcare Financial Manage ment Association Web site. This added Kaplan and Norton1 characterized the internal revenue has amounted to approximately $1 million business perspective as identifying customer needs, annually in recent years. A proportional share of translating those needs into products, improving this added revenue can be attributed to the plans the production and delivery processes, and follow diabetes initiative. Tese was initiated to encourage the provision of high elements can also be considered in our current quality health care, which the state expects will context. Moreover, it is useful to step back and lower the total cost of Medicaid services. The 16 may still pursue the intervention if it is consistent is demonstrably no cheaper, more efec with its mission and goals. However, the its our tive way to do this than helping people to mission argument does not relieve the organization quit smoking (with the possible exception of its obligation to know what the intervention costs of childhood immunizations). Rather, step up to the plate on this, then you arent when the actual or projected costs and outcomes are really in the business of helping people available, the organization can make an informed preserve, restore, and improve their health; decision that the level of increase in quality is you are just in the business of trying to sufciently large that it should be undertaken as make money by lowering costs. The internal enrollees or for enrollees of other plans to which it benefts can include a higher level of staf satisfac sold the program. In that time, the successful developed a culture of quality at Baptist Health quitter may be employed elsewhere or participate System. Furthermore, the health by transforming an organization that was perform care costs of former smokers are still greater than ing poorly on virtually every measure of patient those who have never smoked, thereby attenuating and staf satisfaction into one that is now consid the potential savings from the program. The Joint Commission accreditation staf and other scarce resources, and patient process provides a formal link to a private organi waiting time. A comprehensive summary of tools zation making a determination that afects the and techniques available to produce a business case Medicare and Medicaid certifcation of a provider. To obtain commer accreditation as a mechanism to assist its health cial contracts, providers must also meet the plans to meet state managed care requirements. A delivery organization can improve its reputa The National Quality Forum, the Hospital tion for quality through some of the formal Quality Alliance, and the Agency for Healthcare regulatory or quasiregulatory means discussed Research and Quality (through its National Quality above. Accreditation at the highest status levels Measures Clearinghouse), among others, all confers bragging rights that can be exploited in provide guidance on quality measures and bench advertising or in campaigns to attract third-party marks that providers should meet. In some states, Medicaid uses its power these standards are voluntary, but nothing cur of autoassignment to reward providers that have rently prevents a state Medicaid agency or com distinguished themselves as high-quality providers. An organi landscape regarding the kinds of information on zation delivering health care services seeks to quality available to consumers. Similarly, the community will attempt ratings for hospitals, nursing homes, physicians to mold the health care delivery organization to and other providers. Patient satisfaction and meet its needs, which sometimes are in direct surgical complications data are projected to be confict with the business objectives of the organi added within the next year,12 and later the system is zation. This is especially true for delivery organiza expected to include quality of care information for tions such as community health centers, which are hospital outpatient settings. Enhancing a providers reputation diabetes care in their area and see how they rate. Baldrige pushes an organization beyond the requirements of Innovation and Learning Perspective accreditation to become consumer focused, quality An organizations efectiveness in the short term oriented and data driven. Tese invest An organizations effectiveness in the ments are treated as accounting costs and directly short term and sustainability in the reduce proftability or cash retention in the current long term depend on the investment it period. However, the business case for an organiza makes in its people, production pro tion to invest in innovation and learning is so cesses and information systems. As the investment in resources required to compete previously noted, investment in quality can in successfully for the award. Programs the government or foundations, the principal like these have a huge intangible beneft fnancial objective of the organization is to provide in the kind of people we recruit, the kind services of acceptable quality to the maximum of organization you have, the spirit of the number of patients. The business case from the place, and the kind of consumers who communitys perspective is made by reducing lost 20 choose you. Other customers may have specifc outcomes, and the enhancement of information interests beyond clinical quality of care that, if systems to track progress. Whether the change is a properly addressed, could garner their support for new disease registry to identify and track patients, the intervention. Although not tangible messages to reinforce a culture of quality directly related to either the mission of the health in the organization. If coupled with other approaches to payer or funding organization look good, then empowering employees, such as expanding the future support from these sources is more likely rewards for employee suggestions for improve to be forthcoming. The business case resulting from customer acquisition, customer retention, custom this shif in culture can be substantially more er satisfaction and customer proftability. It has been our purpose in this chapter to context, our immediate association is with patients suggest customer perspectives and measures that or clients.
Syndromes
- Elbow strains
- Calcifications, which are caused by tiny deposits of calcium in your breast tissue. Most calcifications are not a sign of cancer.
- Urinary hesitancy
- Urine bilirubin
- Injury to the pancreas from an accident
- Nitrates to help prevent angina
- Young children
- Skin sore or rash that starts suddenly, and grows quickly in the first 24 hours
- Decreased lung function as a result of the pneumonia
- Redness, swelling, pain, and burning of the eyes
Initial treatment that includes identifying and treating problems that endanger life in a hospital or clinic (hypothermia fungus structure order diflucan with mastercard, hypoglycemia fungus gnats wiki order generic diflucan online, dehydration fungus gnats pupa order diflucan now, infection): Clinicians should promptly correct the specific deficiencies antifungal tablets buy diflucan american express, detected metabolic abnormalities and cautiously start feeding. Rehabilitation: in this stage, intensive feeding is administered to recover most of the lost weight, micronutrient deficiency supplementation and deworming. The mother or the person responsible for care is trained to continue care at home and preparations are made for discharge of the child. Follow-up: this corresponds to the stage after discharge in which an adequate control of the child and family to prevent relapse and ensure the physical, mental and emotional progressive child should be put in place. Successful treatment of children with severe malnutrition does not require any sophisticated facilities and equipment or highly qualified personnel. However, it requires treating every child with proper care and affection and that each phase of treatment is carried out properly by health professionals with a dedication and proper training. When this is done, the risk of death can be reduced significantly and the chances of a full recovery are increased. Though, if considering that the disease is only a medical disorder, it is likely that the child relapses when at home and that other children in the family remain at risk of suffering the same problem. Thus, adequate treatment of severely malnourished child requires identifying and correcting also social problems. It is the gateway to individual care, responsible for the ongoing monitoring of users and is in a better position to interpret and contextualize their health problems to the social environment in which they live. This process depends on a number of factors that can be schematically divided in four groups of explanatory determinants of health utilization: 1) the perceived need; 2) the predisposing determinants (age, sex, household size and education/culture); 3) the enabling determinants (location, access roads, public transport and economic status) (95, 96); and finally 4) the health services system determinants (97). Indeed, diarrhea is among the most common presentation to health care facilities and during the last years the number of cases in children aged less than 5 years has steadily increased through the country from 120,000 in the year 2000 to 240,000 by the end of the decade (100). In this respect, it has been estimated that only 35-40% of the population receives some curative facilities from the National Health System, which means that >60% of the population have important access constrains. In such cases, epidemiological studies become necessary for obtaining reliable data to guide the planning and conduct of control strategies, as the silent burden of diarrhea is greatest in those rural areas with a potentially highest burden in relation to a higher presence of the commonest risk factors. The few epidemiological studies realized in this country indicate that diarrhea is estimated to be the third leading cause of death (accounting for at least 10% of all mortality) among children aged 0-14 years in the city of Maputo, the capital and an urban environment (101). In the district of Manhica, predominantly rural, diarrhea is the third leading cause of hospital admission among children aged 0-14 years and the fourth leading cause of death among children between 12 and 59 months, according to verbal autopsies performed in the area (102). In another study, pediatric diarrheal disease 57 was estimated to account for over 13,000 annual deaths, circa 7-12% of the 110,420 estimated annual Mozambican under five deaths (9). In Mozambique, as usually occurs in most other of sub-Saharan African a multitude of factors contribute to the high diarrheal disease burden, especially among younger children. In this country, 44% of children under the age of five are stunted due to chronic illness and poor diet (103). Around 18% of children are underweight, with children living in rural areas being almost twice as underweight as those living in towns and cities (103). In the district of Manhica, malnutrition is the fourth leading cause of hospitalization and third cause of death according to reports from the hospital and verbal autopsies (102). Measles immunization that is recognized to substantially reduce the incidence and severity of diarrheal diseases is the only currently available vaccine in Mozambique that may prevent diarrhea, but its estimated coverage is very high (97%) (98). While considerable progress has been made over the past years to bring water supply and sanitation to more people, water and sanitation remains one of Mozambiques most under developed areas. According to the latest data available, only 43% of the population has access to safe water and 19% of the population has access to improved sanitation. The 58 situation in rural areas is far worse than that of urban areas with only 30% of the rural areas having access to water and a mere 6% having access to safe sanitation (105). A marked seasonality characterizes diarrhea in Mozambique, which tends to occur more frequently during the rainy season with frequently occurrence of cholera outbreaks (firstly reported in 1959). In Mozambique cholera began to pose a health problem in 1983, since then the country has suffered cholera epidemics consecutive (100). In this country, an estimated 65-70% of population lives in rural areas and people who live in rural areas are disadvantaged in terms of health in several ways compared with their urban counterparts. These disadvantages include limited access to health care as a result of geographic barriers, such as time and distance to care sites, and availability of transportation. The for-profit sector is largely confined to major cities, and virtually non-existent in majorly rural areas. In rural areas, traditional healers and herbalists provide the first link in the chain of access to health care and referral in the country. The National Health System in Mozambique is managed at three levels: 1) Ministry of Health (with four offices: National health direction, Planning and Cooperation direction, Human Resource direction and Administration and Management direction); 2) Provincial Health direction; and 3) District Health direction. It is organized into four service delivery levels (Table 2): Level I, which include health posts and health centers. These infrastructures are able to offer basic diagnostic services, including microscopy, blood counts, biochemistry and X-rays, while health centers with limited capacity may only offer medical admission with medical and non-surgical obstetric conditions. In this level, health center facilities are staffed with general medical doctors while in posts health, care is provided by clinical officers, nurses, and medical technicians; however most health facilities are understaffed. Despite improvements in recent years, the health situation in Mozambique remains particularly worrying. The facilities often have limited supplies and drugs, lack suitable sources of water and are staffed by overstretched health workers with insufficient 60 training. It is necessary to strengthen the training of health personnel and promote gender equity. Thus, there is a need to improve strategies that may diminish morbidity and mortality from diarrheal disease and malnutrition. Since these two diseases are bi-directionally related and as well some of the risk factors like poor access to health services and the worst social conditions appear to be commonly shared, one might assume that strategies to combat one of these diseases will have an implication also in the other. Thus, with the purpose of guiding public health policies and target appropriate interventions; there is a compelling need to determine the etiology, burden and sequelae of diarrheal disease (including malnutrition) in settings where diarrheal diseases remain a major contributor to child mortality. These data must be produced using robust methodologies that can subsequently inform on the most adequate strategies to diminish morbidity and mortality from diarrheal and malnutrition diseases, with a clear emphasis on children living in regions where mortality is high, such as those in sub-Saharan Africa. The scope of the work that is the basis for this thesis is to respond to such necessity with complementary data that will provide an overall adequate picture of the current situation of diarrheal and malnutrition disease in a Mozambican rural area, ranging from the basic social investigation of the determinants of use of health services in such cases, to the most specific analyses of clinical and microbiological determinants of the disease. The study confirms rotavirus as the leading cause of diarrheal disease, and the massive underlying role that a vaccine against rotavirus could have in reducing diarrheal disease morbidity in Mozambique and other developing countries (first and second papers). Additional attention is also drawn to the importance of risk factors associated with moderate-to-severe diarrhea (third paper). The second section within this thesis is based on two community surveys about attitudes and health care utilization in case of diarrhea performed during the above described case-control study, through interviews conducted with primary caretakers of children aged 0-59 months using a standardized questionnaire. The fourth paper of this thesis is a result of these surveys on health-care utilization in case of diarrhea. The paper describes the level of health care utilization, some components of the functioning of these health systems and the constraints associated with their use. This paper also provides an opportunity to understand the population perceptions about their attitudes and knowledge regarding diarrhea severity, prevention and treatment and highlights the importance of promoting breastfeeding and increased liquid intake during a diarrheal episode, in addition to oral rehydration solution as an essential part of any community based training program to improve the prognosis of diarrheal disease. Detailed description of the clinical presentation of malnutrition diseases and risk factors associated with a bad prognosis are scarce in the Mozambican literature, and were unavailable for rural areas. These data provide invaluable guidance to help identify children who are at the highest risk of death and tailor accordingly and most efficiently the limited available resources in areas where health systems are chronically fragile. Particular attention is drawn to the description of the high burden of severe malnutrition cases detected at the Manhica District Hospital. The full description of geographic and socio demographic characteristics of the study community has been detailed elsewhere (106-108). All children involved in the studies within this thesis belong to Manhica District. Figure 4: Map of Mozambique, and location of Manhica District 71 Figure 5: Map of Manhica District 72 7. There are five other nearby health posts (Maragra, Ilha Josina, Taninga, Nwamatibzuana and Malavele) which deliver outpatient care and mother and child health services. A passive detection system has been progressively established since 1996 to cover all pediatric outpatient and inpatient visits to the above hospitals. Standardized forms are routinely completed for all outpatients and inpatients visits. Information collected include demographic, clinical (signs/symptoms and their duration), laboratory data, final diagnoses, antimalarial and antibiotic treatment received as well as the outcome.
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