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	Studies Institute of Progressive Medicine EFFECT OF A NEW ALTERNATIVE MEDICINE IN ACUTE DIARRHEAS, INCLUDING THOSE CAUSED BY ROTAVIRUS, IN CHILDREN LESS THAN 5 YEARS OF AGE CONSULTING AT THE EMERGENCY WARD OF B. BLOOM HOSPITAL IN SAN SALVADOR, BETWEEN AUGUST 2003 AND APRIL 2004. Rafael Ruiz Izaguirre, MD, FAAP; Miguel Reyes Guzmán, MD, MSc.; Rafael Chacón Fuentes, MD; Carlos E. Mena, MD; Emilio Peñate, MD. ABSTRACT The effect of a new alternative medication with immune modulating properties was tested in acute cases of supposedly infectious diarrhea in children less than 5 years of age. The protocol was designed to reach an 80% of statistical potency so rigid quality controls were followed when enrolling patients and following clinical changes. A total of 123 cases were enrolled, 59 in the control group and 64 in the test group, and no patients were admitted when found to have underlying infections or other conditions that may obscure results, such as urinary tract infections. Since sample size and ethical constraints limited the clinical range on which changes would become evident, a clinical score to determine improvement or deterioration was created and applied to both groups. Statistical analysis was worked through EPI-INFO and SPSS programs. Both groups were comparable statistically in terms of previous clinical evolution and physical (Age, sex, nutrition, etc.,) and laboratory findings on admission. The medication used was administered in 3 ml IM doses upon admission and 12 hours afterwards. Clinical changes were measured every 6 hours for the first 24 hours, when patients were discharged from the study. Among these clinical signs, changes were more evident in hydration, body temperature, peristalsis, number of bowel movements and total fecal output. Another follow up control was done 48 hours after discharge. Results indicated several etiologies for the diarrhea: bacterial, viral, allergic and undetermined. Results indicate non significant differences among the control and experimental groups between 0 and 18 hours but become significant at the 18 to 24 period (p = 0.026) and more so at 48 hours after discharge (p = 0.000 ). The rotavirus group included a total of 32 cases, 17 in the control and 15 in the test groups. Up to the 18 hours controls they evolved similarly to the total group but had marginal ( 0.06 ) p significance between 18 and 24 hours. At 48 hours from discharge, however, the difference was significant (p = 0.000 ), same as in the total group. A high incidence (19,7%) of possible urinary tract infection among study candidates, a male to female ratio of 3:1 among study cases and the possible causal relation between rotavirus and high counts of eosinophils in stools of rotavirus (+) cases were also documented. INTRODUCTION Infectious acute diarrhea is a problem that persists as an important public health problem, especially in developing countries, where it is one of the major causes of morbidity and mortality affecting children under 5 years of age (1). When social conditions associate diarrhea with pre-existing malnutrition, the problem worsens (2)(3)(4)(5)(6)(7)(8)(9). In El Salvador, this has been one of the major causes for consultation, hospitalization and mortality since 1950. Since malnutrition, poverty, deficient education and limited health resources are prevalent factors (10)(11)(12), the situation is most concerning. At the Benjamin Bloom National Children’s Hospital (HNNBB), the main governmental pediatric hospital in El Salvador, in the last 4 years, there have been at least 10,000 consultations per epidemic outbreak of acute diarrhea, 500 of which have been hospitalized because of the severity of the case (13) . This is twice of what is expected for this group of patients in developing countries, and it is conditioned in part by severe cases being transferred from the provincial hospitals. (13) .The cost in lives is represented by a lethality of 977 cases between 1998 and 2002 (4,2 % of admissions) at HNNBB(13) . The secondary level attention provided by this hospital represents for the state a cost of $120 to $ 550 per day, depending of the degree of complexity or technological requirements of each case (13) . The medication used in the study (Table 1) has immunomodulation properties that according to other researchers, act at the NK cell level and T-lymphocytes (14) through new pathways of energy generation and intracellular restoration, based on pigment electron donors that function independently from the classical energy pathways mediated by mitochondrias and that do not require the utilization of energetic substrates through the intermediate metabolism of carbohydrates and the production of ATP. It has been postulated that these pigments are a new class of therapeutic elements in the area of the so called energy medicine, and are capable of inducing cell shape restoration and function and thus induce a physiological normalization of previously deficitary tissues, in this case the regional immunological defense (15). () Enercel^® Plus, provided by World Health Advanced Technologies, from Sarasota, Florida, U.S. This could be the reason for the results that we have seen when using it in acute respiratory diseases (16)(17) and the reason why it was used in other infections such as diarrheas in private patients, where in a series of 17 unreported cases, evident improvement occurred in short periods of 12 to 18 hours, including three adults, one of whom was clinically diagnosed as hemorrhagic bacillary dysentery that ceased in 18 hours, after 2 doses IM of 5 ml each separated 12 hours (18) . Since T-Lymphocytes and NK cells are vital elements (19)(20)(21)(22)(23) in the so-called Gut Associated Lymphoid Tissue (GALT) (2), its physiological restoration would be the fundamental reason why bacterial translocation falls under control in this area and infections would not progress into an invasive stage, particularly in children whose immune response is compromised. If this could be documented, the use of this medication could become an important therapeutic tool in countries on which the triad infectious diarrhea + malnutrition + limited public health resources exist, since in most of them, as anticipated in 1966 by Dr Jesús Kumate, the expansion of the resistance transfer factor has rendered a wide range of antibiotics ineffective, and the adequate response to this problem would have to be investigated through immunological science. (24) Considering these concepts (2)(4)(21)(22)(25) ,that a fast recovery and avoiding secondary level care would be most important for our malnourished patients to be expected in the study (2)(10)(26)(27)(28) in whom the stress generated by being hospitalized would be an added negative factor against them (29) and that the hospital may save vital human and material resources when caring for over 1200 children per week during epidemics (13) we decided to document the true potentialities of the medication, since if it was truly capable of decreasing the morbidity of acute infectious diarrhea, it should also decrease the length of stay in the hospital and the occurrence of other posterior complications. If our expectations were confirmed, it’s widespread and routinely use could imply important budgetary savings, bed space availability and lives in developing countries in which this problem is prevalent. We are glad to report significant results in the treated group as a whole and in cases with positive agglutination tests to rotavirus. Given the evident significance of our findings and the potential benefits of the use of this medication worldwide, we confirm the need to do larger and more detailed studies to overcome the sample size and other technical limitations of our study in order to corroborate our findings. METHODOLOGY* General Description This experimental investigation involved 177 children, out of which 54 were excluded, leaving a sample of 123, which consulted because of supposedly infectious acute diarrhea to the outpatient clinic of the emergency ward at HNNBB, between 7 am and 4 pm, from Monday to Friday, during the period of August 20, 2003 and April 1st, 2004. They were admitted in company of their parents or guardians for a lapse of 24 hours, during which they were submitted to clinical observation, diagnosis and oral or parenteral rehydratation, as decided by the criteria of the staff and the HNNBB guidelines. At their discharge, they were instructed to return in 48 hours for a final evaluation. (72 hours post admission). Two groups were confirm as follows: the ones that were exposed to the medicine, 64 patients, and the control group made of 59 patients. Their group assignation was given by a correlative number according to admission, the odd numbers drafted into the control group and the even numbers into the test group. In the test group, the intervention consisted in 3 cc IM doses of the medicine, the first at admission and the second one at 12 hours. Criteria that were followed through the study Criteria for inclusion: 1- Children between 6 months and 5 years of age at the time of consultation. 2- Two or more stool depositions with consistency alteration during the 24 hours prior to consultation. 3- Clinical evidence of dehydration, preferably mild, with or without electrolytic imbalance. 4- Consultation at the emergency ward of the HNNBB. 5- Accept and sign a written document of consent. Criteria for Exclusion 1- More than 24 hours of evolution since the symptoms began. 2- One or more bloody-stained evacuations. 3- Having received at least one of the following medications: antibiotics, antiparasitaries, antipyretics, antispasmodics, antidiarrhetics, laxatives or any other products that can alter the natural evolution of the process, 24 hours previously the beginning of the study. 4- Findings on the clinical exams or lab work that confirmed the presence of underlying conditions that can worsen the course of the illness, such as sepsis, urinary tract infection, amoebas, or any other added chronic conditions of importance. 5- Refusal to participate in the study on the part of the parent or guardian. Criteria for elimination 1- Verbal request of lack of cooperation on the part of the parent or guardian taking care of the child. 2- Findings or discovery of causes for non-inclusion. 3- Conditions beyond our control that preclude the correct following of the protocol of the study. Observed Parameters In an ad-hoc form aside from his clinical chart, information such as ID, date, hours and demographic data pertinent to each child were registered. Also eight other parameters to measure the severity of the process were documented and recorded: oral intake refusal, vomiting, abdominal pain, temperature, intestinal peristalsis, hydratation status, number and volume of fecal depositions and those included in the Yale Observation Scale (30) .Seven of these parameters had numerical quantification, on which an ascending number was assigned in order to facilitate its analysis. The rest were collected as raw data that was later standardized. Using these parameters, a retrospective assessment of the patient’s condition during the 24-hour period prior to admission was performed. Later, while admitted this was implemented at 0, 6, 12, 18 y 24 hours throughout admission. A final evaluation was performed 72 hours after admission (48 hours post discharge). Laboratory Exams All the children once admitted were put through protocol testing, or as soon as a good sample was obtained for lab processing during their 24 hour stay. The laboratory exams included in the study were: 1-CBC, performed with a Hematological counter SF 300 made by Sysmex. 2-General urine exam according to conventional protocol. 3-General stool exam, according to conventional protocol plus Wright stain. 4-Search for Coccidian in stool, using acid resistant stained smears. 5-Search for Rotavirus in stool through VIROTECT-ROTA (Omega Diagnostic). 6-Stool culture, searching exclusively for Salmonella, Shigella y E. Coli O157. This testing was performed on an automated machine made by VITEK SYSTEM. Work plan and distribution of responsibilities According to the work plan, the presence of a full time medical supervisor was implemented, whose functions were consultation, vigilance, quality control and study facilitator. Also four full time positions were created in order to have a Maternal & Child Health Professional to assist the mother and child and the house staff as well. While on duty, they participated in each clinical evaluation, aside from coordinating, facilitating, collecting information, reporting in writing pertinent information relevant to the daily chart, and transporting the biological samples to the lab. Each one of these professionals was relieved from her shift every 24 hours by her next shift colleague. The medical residents were fully instructed as to the goals and methodology of the study before they intervened. They actively carried on the enrollment of new patients, the initial clinical evaluation, taking the consent of the parents, signing the admission orders, lab work orders, gave their opinions on the result of the later and verifying the clinical evaluations during the stay and the post admission control. Only on infrequent occasions of non-availability by the resident because of excessive workload, the supervisor or the Maternal and Child Health Professional performed these evaluations. A signature and seal of the responsible person backed all these observations. While they were at observation and treatment, both groups received the same rehydration and early feeding protocols in effect at the hospital, following OMS/OPS recommendations. The entire participating personnel was instructed to search and identify possible signs and symptoms that could in any way be related to non desirable side effects induced by the medication. Once the information on each patient was completed, it was data entered using the program Epi-Info 2000 for preliminary analysis and the SPSS for the definitive analysis, in the Epidemiology unit at HNNBB. Bivariate association tests with time sequences were done, using the Student test or chi-square, according to each case. The processing of this information and its evaluation were the responsibility of independent members of the team. Additional information source The chart of every patient completed at the ward was examined extensively as complementary information to the protocol forms, and cross checking was performed between the original clinical charts and the information entered in the computer, confirming a highly reliable level of confidence of 99.7 % between them. Measurement of environmental factors Measurements of temperatures and humidity were performed at the ward, when patients were admitted, at 6 and 10 am, 2 and 4 p.m. and 0 hours. The temperature measurement was started on Sept 8th and humidity measurement on Nov 19th of 2003. From then on the measurements were recorded simultaneously. Ethical requisites A document was prepared based on following internationally accepted ethical requirements (30), and given to or read to the person in charge of the child. This document was signed as a sign of acceptance by that parent or guardian and a witness who could be the medical resident or the Maternal & Child Health Professional. Creation of a measurement instrument for the observed parameters A scale to measure clinical improvement or deterioration was designed following the recollection of the clinical information. This scale was based on an equation that considered the following criteria: hydration status, vomiting, oral feeding rejection, the Yale Observation Scale (31), number of bowel movements, body temperature, peristalsis and abdominal pain, all of them for each 6 hour time lapse. Since our protocol established a period out of the hospital from discharge at 24 hours to 72 hours when the patient returned for a final evaluation, the volume of fecal output could not be measured during this time since the patient was ambulatory. This parameter was then separately evaluated. Twenty-one pediatricians of well known capacity and experience were required to contribute their expertise through a questionnaire and to assign an ascending score to each and every one of the eight clinical parameters followed through the study on each patient. A scale of 0 to 10 was created so they would define their opinion on the importance of each parameter, in ascending order. Thus, a numeric average was created for each item as evaluator of the state of wellness or seriousness of its clinical status. With these numbers an equation was built to evaluate the condition of each patient. · Hydratation status 10 points · Vomits 09 points · YOS scale 09 points · Rejection of oral feedings 08 points · Number of depositions 08 points · Body temperature 06 points · Peristaltic waves 05 points · Abdominal cramps 05 points Table 2 From the outset we were aware that the size of the sample and the ethical limitation of not enrolling very sick patients would give us a narrow field to document our results. Thus, we decided to create a wider perspective of the figures obtained in Table 2 as follows: · 5 and 6 points: applying 0,5 of their numerical value. · 8 and 9 points: applying 1,0 of their numerical value. · 10 poits: applying an multiplying factor of their numerical value. Each category had to be standardized on one of three levels, with the exception of oral feedings tolerance, of which only two were used (Yes or no). In all others, the lowest value was 0 and the highest was 2. All parameters were then added to a total for each group, for a determined time period and these values submitted to a special score to determine favorable or disfavorable clinical changes whose statistical differences were determined using the p values between the two groups. The clinical improvement score equation we worked with is as follows: (( Body temperature + abdominal cramps + peristaltic waves points ) x 0,5 + ( Number of fecal depositions + YOS clinical appearance score + oral feedings compliance + vomiting ) x 1,0)) x hydration points. This score gave a minimal score of 0 and a maximum score of 30 for each patient by which moving down along time periods meant improvement and moving up meant deterioration. RESULTS The first finding of our research that surprised us was the fact that 35 patients out of 177 drafted for the study (19,7 %) had to be discharged because they gave lab results suggesting that they had an underlying urinary tract infection that was, at least an important coexisting pathology, if not the true cause of the diarrhea. In this group, 68,6% were females and 31,4% males. Another practical finding was that 19 (10,7%) out of 54 cases that were initially enrolled had to be later eliminated from the study because they had miscellaneous underlying conditions or simply because their parents or guardians, having initially accepted to participate in the study and signed all the consent forms, requested to be discharged in the course of their stay, due to a variety of personal reasons. When all excluded cases are considered, 30% of the initially drafted cases could not be studied. This procedure left 123 good cases, 64 in the test group and 59 in the control group, assigned by either having an odd file number (Control group) or an even file number (Test group). Our analysis strategy was (1) to compare both groups, (2) to establish a baseline and (3) to define results and the significance among them. The control group was called Group A and the test group Group B. (1) GROUP COMPARISON In order to confirm that both groups were comparable, the variables that could induce error were compared, and no statistically significant differences were found. These variables were: age, sex, time between disease was begun and admission, nutritional status, environmental temperature, antibiotics and antipyretics use as well as the clinical condition at admission (Table 3). A- Age and sex: In both groups the males predominated (76% in Group A and 74% in Group B) Age median was similar in both groups ( 13 months vrs 12 months). B- Time from disease start to admission: The median in hours was 13 hours in Group A and 15 hours in Group B. C- Nutritional Status: The Z points median (Standard deviations) for anthropometrical indicators of height-age, weight-age and height-weight had no statistical difference between both groups. D- Symptomatology previous to admission: More than three bowel movements were present in 78% of cases (Group A) and 83% (Group B). Body temperature > 38,5° C was present in 76% (Group A) and 83% (Group B). Frequent vomiting was found in 51% (Group A) and 48% (Group B). Oral feeding rejection was present in 53% (Group A) and 55% (Group B). Frequent abdominal cramps were reported in 7% (Group A) and 5% (Group B). E- Environmental temperature and humidity under which study subjects were during their stay were measured. Temperature median in Group A was 31,2° C and 30,9°C for Group B for a p = 0,553. Humidity was 66% for Group A and 65,5% for Group B. F- Antibiotics were used in 8,5% (Group A) and 4,7% (Group B) for a p = 0,314. G- Antipyretics were used in 53,1% (Group A) and 46,9% (Group B) cases, for a p value of 0,359. 2- CREATING A BASELINE A - ETIOLOGY Besides the previous criteria, it was important to us to compare the results obtained in several basic lab tests. a- Fresh stool examination. The fresh stool and cultures yielded allergic, viral, bacterial and non-specific characteristics at the beginning in both study groups without significant statistical differences: allergic 46% vrs 30% chi2 = 3.388 p = 0,066; bacterial 22% vrs 34% chi2 2.297 p = 0,163; viral 12% vrs 17% and unspecific 19% vrs 16%. b- Rotavirus. In the control (A) group, rotavirus was identified in 29% of the cases, while rotavirus positivity was found in 23% of cases in the test (B) group. c- Bacteria. Bacterias were isolated in 10% (A) vs. 8%(B), in both predominating Shigellas. d- Blood WCC was similar in both groups ( A = 12.000; B = 13.600 ) same as the neutrophil counts (61% vs. 59%) B – CLINICAL CONDITION IN THE BEGINNING OF OBSERVATIONS. The changes in both groups variables were compared. These variables were: ( 3 ) RESULTS DEFINITION All clinical criteria for detecting and measuring changes were integrated in the score created by the contribution of 21 pediatricians of well-known capacity and expertise in this area (Above) and subjected to the clinical improvement equation described earlier. Median values were obtained and the below scale became the evaluating tool for both groups. Using this methodology we found that means of possible clinical improvement was always under 10 points for each patient, with small differences between groups A and B becoming apparent until 18 hours of observation. A deflection upwards (Deterioration) was found in the B (Control) group versus a plateau or down trend (Improvement) in the B (Test) group after 18 hours, when significant differences were detected between both groups from 18 to 24 hours (Median points 0,94 (Control Group) vs. 1,35 points (Test Group) for a t = - 2,3 and a p = 0.02. Between 24 and 72 hours this became more evident (means points 0.80 (Control Group) vs. 1,64 (Test Group) points for a t = - 4.3 and p = 0.0000. Graphic 1 . Means scores of clinical improvements in both groups of patients. To measure results, the probability of change was taken into account in each domain of the illness scale, according to their evolution in the temporary observation blocks. To that end the findings of each variable dominion were conditioned standardizing them in three categories each one with a specific numeric grading in which the zero label (0) corresponded to the best clinical status of the variable in question and the two label (2) to the worst clinical status of the same. This did not apply to the variable of rejection of oral means which was dichotomy to start with and was left as such (0 and 1) and the measurement of total fecal output that would need more than three categories. The concept of Clinical Improvement Unit (CIU) was then built, which represents the modification in one unit (positive = improvement or negative = worsening)(See ahead) of the categories comprised in each variable in the temporary observations. Each variable will then have a set number of potential CIUs (PCIU) which will be determined by multiplying the highest value of the categories (2) by the amount of participants in each group. In this way an estimate is made of the largest amount of CIUs that could be improved if all the participants of each group began the observation period in their worst clinical status regarding the variable. The above might not correspond to reality because some participants in each group could have had, when initially evaluated (time zero) grades below 2 which corresponds to a better clinical status in relation to the variable. For this motive the concept of available CIUs (ACIUs) was created for the beginning of each temporal block of observation. This is estimated by establishing the proportion (%) of the PCIUs that can really be modified (improved or worsened) during the observation in each block. Thus, for each time of observation and for each participant, the modification, unit by unit, in the condition of his/her previous category (in each variable) was labeled POSITIVE if there was an improvement (nearing zero) and NEGATIVE if it had deteriorated (drawing away from zero) . To estimate the behavior of the group variable, for each temporary block, an arithmetical addition was made of the modification units of each participant. In this way, if the sum gave a positive result it was considered that as a whole, the group has improved and if the addition gave a negative result, the group’s condition had worsened. These units were called achieved CIUs (aCIU ). If the participants in each group improved as a whole in each temporary block it would be expected that the proportion of aCIU/ PCIU would approach zero. In other words, if this % increases in relation to the previous % (from the previous temporary block) it is considered that the group deteriorated in the observation time in question, if on the other hand, this % is less than the previous one, it is considered that the group improved in this observation time when compared to the previous one. a- Hydration. The following categories were used: · Normal hydration = 0 CIU · Dehydration, mild or moderate = 1 CIU · Dehydration, severe = 2 CIU An increase (Deterioration) becomes evident in the ratio ACIU/PCIU in the control group (A) alter the 18 hours while the test group shows a sustained decrease (Improvement) in this ratio b- Yale Observation Scale. The following categories were used: · Normal appearance (<11 pts) = 0 CIU · Moderately ill (11-16 pts) = 1 UMC · Gravely ill (>16 pts) = 2 UMC An increase (Deterioration) in the ratio ACIU/PCIU was found in the control group (A) alter the 18th tour, while the test group (B) maintains a slow decrease (Improvement) in this ratio. c- Vomits. The following categories were used : · No vomits = 0 CIU · Some vomits = 1 CIU · Frequent vomits = 2 CIU An increase (Deterioration) of the ratio ACIU/PCIU is evident in both groups alter the 18th tour, but this tendency is less in the test group (B). d- Oral feedings rejection. The following categories were used: · Oral feeding tolerated = 0 CIU · Oral feeding accepted = 1 CIU A steady reduction (Improvement) of the ratio ACIU/PCIU was observed in both groups, but this was more evident in the test group. e- Number of bowel movements: The following categories were used: · 0 to 1 BMs = 0 CIU · 2 to 3 BMs = 1 CIU · 4 to 5 BMs = 2 CIU · 6 to 7 BMs = 3 CIU · 8 to 10 BMs = 4 CIU · More than 10 BMs= 5 CIU The ACIU/PCIU ratio decrease (Improvement) is less evident in the Control Group (A) between Time 0 and 18 hours, and a rebound shows after that. The Test Group (B) improves more evidently from Time 0 through 18 hours, rebounds slightly at 18-24 hours and then continues to improve to the 72 hours control. f- Body Temperature. The following categories were used: · 36.5 to 37.5 oC = 0 CIU · 37.5 to 38.5 oC = 1 CIU · 38.5 to 39.5 oC = 2 CIU · Above 39.5 oC = 3 CIU Both groups showed a decrease (Improvement) in the ACIU/PCIU ratio, but this was much more evident in the test group (B) after 18 hours of observation. g- Peristalsis. The following categories were used: · 1 to 5 waves / 15 seconds = 0 CIU · 6 to 15 waves / 15 seconds = 1 CIU · Constant waves = 2 CIU · Íleus and distensión = 3 CIU The ACIU/PCIU ratio decreased (Improved) sustainedly in both groups, but after 18 hours of observation this improvement was much more evident in the test (B) group, while the control group (A) did an important increase (Deterioration). h- Abdominal cramps. The following categories were used: · None = 0 UMC · Some cramps = 1 UMC · Frequent cramps = 2 UMC The ACIU/PCIU ratio showed an important reduction (Improvement) in both groups after the first 6 hours of observation, more evident in the Test Group (B). Between the 24 and 72 hours controls, there was a deterioration of less than 10% in both groups. C- VOLUME OF FECAL OUTPUT A difference between the groups was documented. In Graph 6, the medians of fecal volume per Kilo of body weight show a progressive decrease in the Test Group (B) at each time interval. This was not so in the Control Group (A) was this decrement was minor. Medians were used after some misleading stray values were found that could alter the perspective when using average values. Graph 6 Medians of the cc/Kg fecal volume during time and study group. D- ROTAVIRUS CASES A total of 32 cases with latex agglutination tests for rotavirus antigens were identified. Of them, 17 were distributed among the Control Group and 15 in the Test Group. Using the clinical improvement scale described earlier, it was found that the median values descended through the study time intervals in a similar way that the group as a whole. Statistical significance was marginal (p = 0,06) between 18 and 24 hours but became significant (p = 0,000) in the 24 to 72 hours period, were the median was smaller in the Test Group than in the Control Group. Graphic 7 - Comparison of Rotavirus-positive cases in both groups during study time intervals DISCUSSION Since acute diarrhea in children under five years of age is a complex clinical entity, of multiple symptoms and varied etiology, the therapeutic approach per se has explored many options that range from antibiotics in special circumstances (27) ,probiotics (3)(32)(33), lactobacilli (34) , immunoglobulins of different origins (35), intestinal secretion inhibiters (36), vaccines (37),etc., obtaining several degrees of success in attaining clinical improvement and impact on the morbidity episode. Concurrent with this effort, our research reports a non-conventional approach since it uses a homeopathic based medication with claimed immunomodulation properties mediated by cellular energy regeneration that, given its origin, does not have side effects. Other investigators (38)(39) have also published their favorable experiences with other homeopathic compounds in this kind of approach. Our results are based on the comparison of two groups of children with acute diarrhea, that upon statistical analysis showed to be homogenous and susceptible of comparison and to serve as a baseline, since their general characteristics (Age, sex, etc.) were very similar. Both groups were also under the same interfering factors such as environmental heath and humidity, and a small fraction of patients were also under the use of antipyretics and antibiotics during their hospital stay. In the first part, where the effect of the medication was measured following eight clinical severity parameters processed by a mathematical equation for each time interval observed, clinical improvement differences were obtained with a significance p value for the periods between 18 and 24 hours after admission (p = 0.026) and even more significant in the 48 hours post-discharge evaluation (0.000). This trend persisted when each parameter was processed individually by our Clinical Improvement Units (CIU) score, being more significant in those following dehydration, number of stools, peristalsis and fever. The fecal output volume was analyzed separately. Since hydration and frequency of stools had improved, diuresis also did and we believe that was the reason why we observed a few stray high values due to fecal contamination with urine. When means values for the time periods were analyzed, a steady decrease was observed in the test group. We want to do a special reference as to 32 cases of rotavirus found, since this etiology causes 6% of acute diarrheas and up to 20% of the mortality in developing countries worldwide (40). When analyzed as a sub-group, these patients evolved in a similar way as the group as a whole. Since the case number reduction implied also a sample size reduction, this did not allow findings as evident as those of the total group. So, for the 18 and 24 hours observations, a marginal p value ( p = 067 ) was found. At the 48 hours post discharge (72 hours post admission) control, however, this became significant ( p = 0.000). An incidental finding was to discover that 2:3 of rotavirus positive cases had abundant eosinophils counts in stools when the Wright stain was used. This could not be related to intestinal parasites or other allergic causes, since all of those possibilities had been ruled out. We did not find an immediate cause for the phenomena, but report this peculiar finding because if a causal relationship in fact exists, it can be useful during epidemic outbreaks of rotavirus, since finding high eosinophils counts in Wright stool stained feces can contribute to this diagnosis through a less expensive and more readily available laboratory method. Another finding that deserves mention is that 1:5 of the cases initially screened to take part in the study had to be discarded after initial urine samples suggested an underlying urinary tract infection. Not surprisingly, 2/3 of these cases were baby girls. One of the authors (RRI) has repeatedly confirmed that peristaltic waves above 10 per 15 seconds indicate diarrhea will continue to be frequent in the following 6 to 8 hours and it is well known that ileus and distention are a bad immediate prognostic sign. Our findings (Please see Graph 5) indicate an evidently more frequent peristalsis in the Control Group (B), that at this same time interval was passing more bowel movements (Please see Graph 3) and had a higher fecal loss (Please see Graph 6). We were not surprised to find a predominance of male over female patients as 3:1. Summarizing our report, we can affirm that our findings suggest that in the subjects of this study the medication induced a positive effect, whether they had a bacterial, viral or allergic cause. Our contention is limited however from a more general statement due to our sample size, some limitations in our study design and some environmental conditions that kept us from finding true efficacy values beyond the favorable effectivity reported here. Therefore, it is necessary to do larger and more detailed studies to confirm these findings, expand their scope and prove its external validity for the general population. CONCLUSIONS AND RECOMMENDATIONS (1) It was found that the researched medication induced statistically significant improvement in the experimental group in the 18 to 24 hour block after admission and in the 24 to 72 hour one. (2) In the sub group positive to rotavirus the medication produced statistically meaningful improvement in the 24 to 72 hour block. (3) The clinical improvement was more evident in the experimental group regarding hydration, body temperature, peristalsis and number of stools. (4) Fecal loss (cc/Kg), analyzed separately also showed an improvement that favored the experimental group. (5) An apparent causal relation was found between the presences of large amounts of eosinophils in Wright stains in feces of positive patients to rotavirus, in absence of other causes. If a cause-effect relation were to be confirmed, this would be useful in the indirect diagnosis of rotavirus in cases where that etiology is suspected. (6) The clinical value of altered peristalsis, if confirmed by other investigators, can become a simple yet useful way to anticipate the course of diarrhea in the next few hours. This could be an important criteria to admit or not for house staff that confronts this disjunctive, sometimes under workload pressure and without enough valid clinical criteria to do either. (7) It was found that 1:5 of the cases entered into the study had lab findings that suggested underlying urinary infections, and were discarded for this reason. Among these patients, females predominated over males 2:1. (8) Among the study as a whole, boys were more frequent than girls on a 3:1 ratio. (9) In view of the global importance of the problem of acute diarrhea in children under 5 in underdeveloped countries, and considering the potential benefits of this medication in this scenario, we strongly recommend more extensive, double blind studies to confirm our results, to measure in more detail the efficacy of this medication and to improve its external validity. (10) In view of the absence of undesirable side effects in this cohort, we suggest a dose increase to 3 ml IM every 8 hours in the first 24 hours, for future clinical trials enrolling patients under 5 years of age, specially if more dehydrated and /or malnourished patients are treated. We are tempted to recommend this dosage to be maintained for at least three more days in severely afflicted patients, but have no documented or published works to base this on, and do so only relying in our own anecdotal experience with the medication. REFERENCES 1. 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