AimTo identify the risk factors in children under five years of age for severe acute lower respiratory infections (ALRI), which are the leading cause of child mortality.MethodsWe performed a systematic review of published literature available in the public domain. We conducted a quality assessment of all eligible studies according to GRADE criteria and performed a meta-analysis to report the odds ratios for all risk factors identified in these studies.ResultsWe identified 36 studies that investigated 19 risk factors for severe ALRI. Of these, 7 risk factors were significantly associated with severe ALRI in a consistent manner across studies, with the following meta-analysis estimates of odds ratios (with 95% confidence intervals): low birth weight 3.18 (1.02-9.90), lack of exclusive breastfeeding 2.34 (1.42-3.88), crowding – more than 7 persons per household 1.96 (1.53-2.52), exposure to indoor air pollution 1.57 (1.06-2.31), incomplete immunization 1.83 (1.32-2.52), undernutrition – weight-for-age less than 2 standard deviations 4.47 (2.10-9.49), and HIV infection 4.15 (2.57-9.74).ConclusionThis study highlights the role of the above seven risk factors in the development of severe pneumonia in under-five children. In addition, it emphasizes the need for further studies investigating other potential risk factors. Since these risk factors are potentially preventable, health policies targeted at reducing their prevalence provide a basis for decreasing the burden of childhood pneumonia.

SummaryA randoniised study was carried out to assess the effect of tracheal tube rotation on the passage of a tube over a gum-elastic bougie into the trachea in 100 patients. Key wordsDififficult tracheal intubation; gum-elastic bougie.Successful management of a difficult intubation using a gum-elastic bougie is completed in two phases. The first involves passage of the bougie through the larynx into the trachea. The methods employed to recognise the position of the bougie in the trachea when the vocal cords are not visible were previously investigated in this centre. ' The tracheal tube is passed over the bougie into the trachea in the second phase. The successful placement of a bougie through the larynx, in our clinical experience, may frequently be followed by difficulty in this second phase. Cossham' has suggested that rotation of the tracheal tube a quarter-turn anticlockwise may improve the success rate in these circumstances, although this has never been quantified. Therefore, a systematic study was conducted to investigate the effect of anticlockwise rotation of the tracheal tube over the bougie. We also assessed whether the presence or absence of a laryngoscope in the mouth influenced the passage of the tracheal tube because some anaesthetists withdraw the laryngoscope before passing the tube over the bougie. MethodsInformed consent was obtained from all patients, after approval from the Ethics Committee. One hundred patients aged 18-70 years, in ASA grades 1 and 2, for whom tracheal intubation was planned as part of the anaesthetic sequence were studied. Patients were excluded from the study if they were to have ocular or neurosurgical procedures; those patients with asthma and in those cases when cricoid pressure was to be used were also excluded.The normal orientation of the tracheal tube with the bevel to the left will be referred to as the 0" (neutral) position; the orientation of the tube with a quarter-turn anticlockwise such that the bevel faces posteriorly will be referred to as the -90" position. The Portex standard cuffed tracheal tubes used were of 9 mm internal diameter for men and 8 mm for women. The ECG, blood pressure and oxygen saturation (by pulse oximeter) were monitored in all patients throughout the period of anaesthesia. Patients were pre-oxygenated for 3 minutes. Anaesthesia was induced with an intravenous agent chosen by the anaesthetist present. Muscle relaxation was achieved by the administration of suxamethonium 1.5 mg/kg intravenously. Laryngoscopy was performed after 60 seconds using a Macintosh blade, size 3.The initial view of the glottic structures was classified according to Cormack and Lehane:' grade I , the glottis can be fully exposed (including anterior and posterior commissures); grade 2, the glottis is partially exposed (posterior commissure only); grade 3, the glottis cannot be exposed (epiglottis visible); grade 4, neither the glottis nor the epiglottis can be exposed.A 15-FG gum-elastic bougie (Eschmann, UK) was passed into the trachea after laryngoscopy. The...

Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. Adult patients undergoing elective and emergency general, orthopaedic, gynaecology and vascular surgery procedures in the Royal Infirmary of Edinburgh were surveyed over a 3-month period commencing November 2011. A standardised questionnaire was used to collect information on the duration of preoperative fasting and the advice administered by medical and nursing staff. 292 patients were included. Median fast from solids was 13.5 h for elective patients (IQR 11.5-16) and 17.38 h for emergency patients (IQR 13.68-28.5 h). Similarly, the median fast from fluids was 9.36 h for elective patients (IQR 5.38-12.75 h) and 12.97 h for emergency patients (IQR 8.5-16.22 h). The instructions that elective patients received contributed to prolonged fasting times. The median fast for elective patients fully compliant with fasting advice would be 10 h for solids (IQR 8.75-12 h) and 6.25 h (IQR 3.83-9.25 h) for clear fluids. Elective patients fasted for longer than recommended confirming that clinical practice is slow to change. The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.

AimTo estimate global morbidity from acute bacterial meningitis in children.MethodsWe conducted a systematic review of the PubMed and Scopus databases to identify both community-based and hospital registry-based studies that could be useful in estimation of the global morbidity from bacterial meningitis in children. We were primarily interested in the availability and quality of the information on incidence rates and case-fatality rates. We assessed the impact of the year of study, study design, study setting, the duration of study, and sample size on reported incidence values, and also any association between incidence and case-fatality rate. We also categorized the studies by 6 World Health Organization regions and analyzed the plausibility of estimates derived from the current evidence using median and inter-quartile range of the available reports in each region.ResultsWe found 71 studies that met the inclusion criteria. The only two significant associations between the reported incidence and studied covariates were the negative correlation between the incidence and sample size (P < 0.001) and positive correlation between incidence and case-fatality rate (P < 0.001). The median incidence per 100 000 child-years was highest in the African region – 143.6 (interquartile range [IQR] 115.6-174.6), followed by Western Pacific region with 42.9 (12.4-83.4), the Eastern Mediterranean region with 34.3 (9.9-42.0), South East Asia with 26.8 (21.0-60.3), Europe with 20.8 (16.2-29.7), and American region with 16.6 (10.3-33.7). The median case-fatality rate was also highest in the African region (31.3%). Globally, the median incidence for all 71 studies was 34.0 (16.0-88.0) per 100 000 child-years, with a median case-fatality rate of 14.4% (5.3%-26.2%).ConclusionsOur study showed that there was now sufficient evidence to generate improved and internally consistent estimates of the global burden of acute bacterial meningitis in children. Although some of our region-specific estimates are very uncertain due to scarcity of data from the corresponding regions, the estimates of morbidity and case-fatality from childhood bacterial meningitis derived from this study are consistent with mortality estimates derived from multi-cause mortality studies. Both lines of evidence imply that bacterial meningitis is a cause of 2% of all child deaths.