Background: Inpatient case fatality from severe malaria remains high in much of sub-Saharan Africa. The majority of these deaths occur within 24 hours of admission, suggesting that pre-hospital management may have an impact on the risk of case fatality.Methods: Prospective cohort study, including questionnaire about pre-hospital treatment, of all 437 patients admitted with severe febrile illness (presumed to be severe malaria) to the paediatric ward in Sikasso Regional Hospital, Mali, in a two-month period.Findings: The case fatality rate was 17.4%. Coma, hypoglycaemia and respiratory distress at admission were associated with significantly higher mortality. In multiple logistic regression models and in a survival analysis to examine pre-admission risk factors for case fatality, the only consistent and significant risk factor was sex. Girls were twice as likely to die as boys (AOR 2.00, 95% CI 1.08-3.70). There was a wide variety of pre-hospital treatments used, both modern and traditional. None had a consistent impact on the risk of death across different analyses. Reported use of traditional treatments was not associated with post-admission outcome.Interpretation: Aside from well-recognised markers of severity, the main risk factor for death in this study was female sex, but this study cannot determine the reason why. Differences in pre-hospital treatments were not associated with case fatality.

Objectives  Hypoglycaemia (glucose <2.2 mmol/l) is a defining feature of severe malaria, but the significance of other levels of blood glucose has not previously been studied in children with severe malaria.

Background Hypoglycaemia is a poor prognostic indicator in severe malaria. Intravenous infusions are rarely feasible in rural areas. The efficacy of sublingual sugar (SLS) was assessed in a pilot randomized controlled trial among hypoglycaemic children with severe malaria in Mali. Methods Of 151 patients with presumed severe malaria, 23 children with blood glucose concentrations < 60 mg/dl (< 3.3 mmol/l) were assigned randomly to receive either intravenous 10% glucose (IVG; n = 9) or sublingual sugar (SLS; n = 14). In SLS, a teaspoon of sugar, moistened with a few drops of water, was gently placed under the tongue every 20 minutes. The child was put in the recovery position. Blood glucose concentration (BGC) was measured every 5–10 minutes for the first hour. All children were treated for malaria with intramuscular artemether. The primary outcome measure was treatment response, defined as reaching a BGC of >= 3.3 mmol/l (60 mg/dl) within 40 minutes after admission. Secondary outcome measures were early treatment response at 20 minutes, relapse (early and late), maximal BGC gain (CGmax), and treatment delay. Results There was no significant difference between the groups in the primary outcome measure. Treatment response occurred in 71% and 67% for SLS and IVG, respectively. Among the responders, relapses occurred in 30% on SLS at 40 minutes and in 17% on IVG at 20 minutes. There was one fatality in each group. Treatment failures in the SLS group were related to children with clenched teeth or swallowing the sugar, whereas in the IVG group, they were due to unavoidable delays in beginning an infusion (median time 17.5 min (range 3–40). Among SLS, the BGC increase was rapid among the nine patients who really kept the sugar sublingually. All but one increased their BGC by 10 minutes with a mean gain of 44 mg/dl (95%CI: 20.5–63.4). Conclusion Sublingual sugar appears to be a child-friendly, well-tolerated and effective promising method of raising blood glucose in severely ill children. More frequent repeated doses are needed to prevent relapse. Children should be monitored for early swallowing which leads to delayed absorption, and in this case another dose of sugar should be given. Sublingual sugar could be proposed as an immediate "first aid" measure while awaiting intravenous glucose. In many cases it may avert the need for intravenous glucose.

th , 2006, with the possi- bility to pursue the exchanges begun then on different issues. Over 1200 people, com- ing from Canada and about 12 other coun- tries, were at the symposium and tried to answer the question: Is the Ottawa Charter for health promotion still useful for today's public health practice? At the end of the day, after a final vote, the "Montreal message" seemed clear: over 70% answered yes to the question. As an opener to the new sub- series, the aim of this paper is thus to explore a bit further the meaning of this message and, at the same time, to trigger additional thoughts on this subject in prepa- ration of the IUHPE's World Conference in Vancouver in June 2007 (http://iuhpecon- ference.org). Three other papers introduce the sub- series: one describing the sophisticated process that guided the planning and the realization of the Montreal symposium; one focusing on the different themes that emerged throughout the day; and, finally, another on the theatrical performances that took place during the day. In order to par- take even more in the preliminary work of IUHPE's Vancouver conference, a special call for papers has been made to the 1200 participants in the context of the sub-series, and the articles retained by a group of peer- reviewers gathered especially for the cir- cumstance will be placed online. The aim of the Symposium: bring the participants to reflect and to take position The Ottawa Charter Symposium was developed by a scientific committee of about twelve persons coming from a variety of jobs and perspectives (see JASP, 2006, for further details) under the leadership of M. O'Neill and S. Dupere, within the JASP's general rules regarding the organization of symposia. The day began with a general plenary dedi- cated to the past (from 1986 on), present and future of public health, followed by five sub- plenaries focusing on the Charter's five strate- gies. After lunch, the participants were split into 20 parallel workshops devoted to diverse forms of practice and were gathered again, in conclusion, for a final plenary. Adopting a peculiar format after a popular TV show in Quebec by the name of "Right to speech" (Droit de Parole), that plenary allowed a debate between the views of the participants, presented by the Mise au jeu theater troop (N. Roberge et P. Parent), and those of nine "key witnesses", coming from a diversified set of academic and practice environments; the plenary ended by a final vote. Principally designed by two members of the scientific committee (S. Dupere and E. Pedneault), a sophisticated approach was implemented in order to supply Mise au jeu and the facilitator of the Droit de Parole (R. Perrault) with meaningful content. The par- ticipant's viewpoints were collected using such mechanisms as vox pop, a thorough and systematic note taking process in each of the activities as well as a mural and pictures. All these elements were synthesized by two "key reporters," M. Forster and K. Perreault. A breakfast with authors of recent books on public health, over a hundred posters as well as an exhibit called "Objet: pauvrete" also nourished the reflections of the participants. The main issues that emerged during the day Among the issues raised using the tech- niques mentioned above, two seem to stand out.

A prospective, dose-escalating, quasi-experimental clinical trial was conducted with a traditional healer using a decoction of Argemone mexicana for the treatment of malaria in Mali. The remedy was prescribed in three regimens: once daily for 3 days (Group A; n=23); twice daily for 7 days (Group B; n=40); and four times daily for the first 4 days followed by twice daily for 3 days (Group C; n=17). Thus, 80 patients were included, of whom 80% were aged <5 years and 25% were aged <1 year. All presented to the traditional healer with symptoms of malaria and had a Plasmodium falciparum parasitaemia >2000/μl but no signs of severe malaria. The proportions of adequate clinical response (ACR) at Day 14 were 35%, 73% and 65% in Groups A, B and C, respectively (P=0.011). At Day 14, overall proportions of ACR were lower in children aged <1 year (45%) and higher in patients aged >5 years (81%) (P=0.027). Very few patients had complete parasite clearance, but at Day 14, 67% of patients with ACR had a parasitaemia <2000/μl. No patient needed referral for severe disease. Only minor side effects were observed. Further research should determine whether this local resource could represent a first-aid home treatment in remote areas.

This research examines the relationship between community unemployment and the physical and mental health of immigrants in comparison to non-immigrants in Montreal under the hypothesis that high unemployment in the community may generate more negative effects on the health of immigrants than on non-immigrants. Possible gender differences in these associations are also examined. Montreal residents were studied via multilevel analysis, using both individual survey data and neighbourhood data from 49 police districts. Individual-level data were excerpted from a 1998 health survey of Montreal residents, while neighbourhood data originated from survey data collected in the 49 Montreal police districts and the 1996 Canadian Census. The associations between community unemployment and self-rated health, psychological distress and obesity are examined, and hypotheses regarding the modifying mechanisms via which male and female immigrants may run a greater risk of poor health than non-immigrants when living in areas of high unemployment were tested. Between neighbourhoods, variations in the three health outcomes were slight, and differences in health were not associated with differences in community unemployment. The associations between community unemployment and health varied according to immigration status. At the individual level, immigrants do not differ from non-immigrants with respect to the three health indicators, except that second-generation males are slightly heavier. However, when living in areas of high unemployment, immigrants tend to report poor physical and mental health in comparison to non-immigrants. Among first-generation immigrants, community unemployment was associated with psychological distress. Among second-generation immigrants, the probability of obesity and poor self-rated health increased significantly for those living in areas with high unemployment, but these associations reached statistical significance only for men. Findings among first-generation immigrants are interpreted with respect to the effects of possible discrimination in areas with low job availability. Among second-generation men, poor physical health and obesity may be the result of poor health habits stemming from perceived lack of life opportunities.

BACKGROUND:The purpose of this paper is to establish the reliability and validity of a neighborhood-level measure of active living potential by applying principles of ecometrics. METHODS:Following a 3-day training session, observers (n =8) were provided with a map of a predetermined walking route constructed through the joining of ten randomly selected street blocks. Then, using an 18-item observation grid, pairs of observers performed ratings of 112 neighborhoods. Resulting observations produced a hierarchically structured data set including 4032 observations nested within observers, which in turn were nested within neighborhoods. Data from the 2001 Canadian census were linked to the neighborhood data. RESULTS:Application of ecometric multilevel modeling analyses showed that once interitem and interobserver variability were statistically controlled, about one third of the variability in observations were at the between-neighborhood level. Reliability estimates were 0.78 for items measuring activity-friendliness, 0.76 for safety, and 0.83 for density of destinations. Assessment of the convergent validity of the instrument identified that safety of the environment was positively associated with neighborhood affluence. Density of destinations was negatively associated with affluence and positively associated with higher proportions of persons in the neighborhood walking to work. CONCLUSIONS:The three dimensions of the neighborhood active-living potential measure have good reliability and convergent validity and are able to capture between neighborhood differences. Measurement characteristics would have been difficult to ascertain without the ecometrics methodology.

This work is an introduction to repeated measurement analysis for longitudinal studies. It uses a two stage modelling framework, using hierarchical linear models with two levels. The first level pertains to the repeated measures, the second level pertains to the individual. For the last 25 years, hierarchical linear models have been used in the Social Sciences to analyse data coming from organizations with multiple levels. Their applications have been extended to the study of change in populations, both to describe the average change in an outcome variable in a population and to analyse the factors associated with variability in the individual trajectories of change. In this article, the basic concepts are introduced: between subjects and within subjects variability, the person-specific model for the individual trajectory and the between person model to describe how individuals vary in their trajectories, fixed and random effects, linear and quadratic growth models. At the end of each section, an illustration is given for the study of cognitive function of the older people cohort "Aging in Leganés", followed in four occasions between 1993 and 1999. Results from fitting the models to answer the most frequently asked research questions in the descriptions and analysis of individual change are presented. Lastly, we present possible generalizations of these linear models to non linear situations which arise when outcomes are dichotomous, nominal or ordinal.

Este trabajo es una introduccion al analisis de medidas repetidas en estudios longitudinales. Se utiliza un marco analitico con dos etapas, ajustando modelos jerarquicos lineales con dos niveles. El primer nivel corresponde a la ocasion (tiempo) de medida y el segundo al individuo. Estos modelos estadisticos proceden de las ciencias sociales, en las que se han utilizado durante mas de 25 anos para analizar datos en organizaciones con multiples niveles. Su aplicacion permite estudiar los cambios en alguna caracteristica de interes (estado de salud o factor de riesgo) y analizar las circunstancias que explican la variabilidad en las trayectorias individuales. En este trabajo se introducen los conceptos basicos de este metodo: variabilidad entre individuos y dentro de cada individuo a lo largo del tiempo, modelo del nivel individual para describir la trayectoria de cada individuo y modelo «entre individuos» para describir como cambian las trayectorias entre individuos, efectos fijos y efectos aleatorios, modelos de crecimiento lineal y cuadratico. Para ello se ha realizado un analisis de los cambios en la funcion cognitiva de una cohorte de personas mayores, el estudio «Envejecer en Leganes», seguida cada dos anos, entre 1993 y 1999. Se presentan los resultados de modelos ajustados para resolver las preguntas de investigacion mas frecuentes en la descripcion y el analisis de las trayectorias de cambio individual. Por ultimo, se comentan posibles generalizaciones de estos modelos lineales jerarquicos a situaciones en las que la variable de interes no es continua, como es el caso de las variables dependientes dicotomicas, nominales u ordinales.