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SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comSSMJ<strong>South</strong> <strong>Sudan</strong><strong>Medical</strong> <strong>Journal</strong>Volume 5. Number 1. February 2012www.southsudanmedicaljournal.comImplementing a Routine HealthManagement Information System in<strong>South</strong> <strong>Sudan</strong>Post-conflict mental health in <strong>South</strong> <strong>Sudan</strong>Diagnosing and managing <strong>as</strong>thmaHow to get publishedDengue fever<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 2012
CONTENTSSSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comEditorialNew horizons in post graduate medical trainingPeter Newman .................................................... 3Main articlesPost-Conflict Mental Health in <strong>South</strong> <strong>Sudan</strong>:Overview of Common Psychiatric DisordersPart 1: Depression and Post-Traumatic StressDisorder Maithri Ameresekere and David C.Henderson .......................................................... 4Asthma: Diagnosis and Management - a guidesuitable for developing countries Richard ALewis ................................................................. 9Dengue fever Milada Tavodova ....................... 13How to get published Heather Mackenzie, CaroleFogg, Amy Drahota, Sue Halson-Brown, RebeccaStores and Ann Dewey ....................................... 17Reports from <strong>South</strong> <strong>Sudan</strong>HAT Call for abstracts .................................. 20Implementing a routine health managementinformation system in <strong>South</strong> <strong>Sudan</strong> RichardLaku, Carmen Maroto Camino, Norah Stoops andMohammed Ali ................................................ 21Short itemsStuck objects on fingers: pattern seen in aNigerian teaching hospital and technique forremoval Agaba-Idu Musa ................................. 25C<strong>as</strong>e Study – Left Parietal ParafalcineMeningioma Stephan Voigt ............................. 26RESOURCES .............................................. 27Examples of checklists forcommunity-b<strong>as</strong>ed frontlinehealth workers ................................. 28To receive notices of new editions, send an email toadmin@southernsudanmedicaljournal.comCover photo - Some HMIS tools used in <strong>South</strong> <strong>Sudan</strong> – see article onp21 (credit: Edward Luka).SSMJ<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong>Volume 5. No. 1. www.southsudanmedicaljournal.comA Publication of the <strong>South</strong> <strong>Sudan</strong> Doctors’ AssociationEDITOR-IN-CHIEFDr Edward Eremugo Luka<strong>South</strong> <strong>Sudan</strong> Doctors’ AssociationMinisterial ComplexJuba, <strong>South</strong> <strong>Sudan</strong>opikiza@yahoo.comASSOCIATE EDITORSDr Wani MenaDepartment of OphthalmologyJuba Teaching Hospital,PO Box 88, Juba<strong>South</strong> <strong>Sudan</strong>wanimena@gmail.comDr Eluzai Abe HakimDepartment of Adult Medicine & RehabilitationSt Mary’s Hospital, Newport,Isle of Wight PO30 5TG, UKEluzai_hakim@yahoo.co.ukEDITORIAL BOARDDr James Ayrtonjames.ayrton@gmail.comDr Charles Bakhietsakib@squ.edu.omProfessor James Gita Hakimjhakim@mweb.co.zwDr Ayat C. Jerv<strong>as</strong>eayatcj@yahoo.comDr David Tibbuttdavid@tibbutt.co.ukEDITORIAL ADVISORAnn Burgessannpatriciaburgess@yahoo.co.ukDesign and layoutDr Edward Eremugo LukaThe <strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> is a quarterly publication intended forHealthcare Professionals, both those working in the <strong>South</strong> <strong>Sudan</strong> and thosein other parts of the world seeking information on health in <strong>South</strong> <strong>Sudan</strong>.The <strong>Journal</strong> is published in mid-February, May, August and November.Reviewers are listed on the website<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 2Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comEDITORIALNew horizons in postgraduate medicaltrainingDr Peter Newman FRCPHonorary ProgrammeDirector for PGME&Tpeter.newman@stees.nhs.ukTheproblem is compoundedby a lack of career structure,properly paid posts andlonger term vocationalopportunities.Postgraduate medical training h<strong>as</strong> barely existed in <strong>South</strong> <strong>Sudan</strong>, causing a stultifyingeffect on medical services and a lack of opportunity for a generation of doctors.Training in nearby countries or overse<strong>as</strong> h<strong>as</strong> been the only option, with a patchy uptakeand inevitably leading to a substantial brain drain. The problem is compounded by alack of career structure, properly paid posts and longer term vocational opportunities.This unhappy situation may continue with a demoralised and often inadequately trainedworkforce, and a service which would collapse entirely if not propped up by NGOsand other bodies. Alternatively, new systems can be devised and emplaced to radicallyredeem this unacceptable position.How then to introduce a new structure to embed postgraduate training and continuingprofessional development? Early progress h<strong>as</strong> stemmed from the St Mary’s-JubaHospitals link, the work of the Harvard group and other internationallinks, and with the strong support of the Ministry of Health. Buildingon these initiatives is a coordinated drive from within and withoutthe country to establish a training structure for current and futuredoctors. A Business C<strong>as</strong>e h<strong>as</strong> been drawn up encomp<strong>as</strong>sing the manythreads which will be woven into the overall strategy. Funding is beingsought.In this postgraduate training:a. All trainees will have a structured training curriculumcomprising a modular system enabling the acquisition of b<strong>as</strong>ic skillsand knowledge. When satisfactorily completed this will allow for safepractice in a district or community setting. For others it will lead tospecialty training.b. A specialty training programme will be delivered by local and visiting trainers.This will be recognised at an equivalent level to the M<strong>as</strong>ter of Medicine (MMed) andsuccessful completion will allow appointment <strong>as</strong> a specialist. Until this programmeis established, MMed scholarships abroad will continue and a few trainees will beselected for a two year training period in the UK.c. Leadership, teaching skills, managerial and organisational techniques will beformally addressed.d. A College of Physicians and Surgeons of <strong>South</strong> <strong>Sudan</strong> will be establishedto coordinate postgraduate training, set and maintain standards, and overseepostgraduate activity.With good will and adequate funding, these aims will be achieved. A more detailedaccount and timetable of these developments will be published in this <strong>Journal</strong> in duecourse.The SSMJ Team welcomes Dr Ayat C Jerv<strong>as</strong>e to the Editorial Board.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 3Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesPost-conflict mental health in <strong>South</strong> <strong>Sudan</strong>:overview of common psychiatric disordersPart 1: Depression and post-traumatic stress disorderMaithri Ameresekere a , MD, MSc and David C. Henderson a , MDIntroductionMental health is “a state of well-being in which everyindividual realizes his or her own potential, can workproductively and fruitfully, and is able to contribute toher or his community.”(1) Mental illness often attracts alower priority than physical illness in post-conflict and lowand middle-income societies but the two are inextricablylinked. Untreated and unrecognized mental illness addssubstantially to poor health. Neuropsychiatric conditions,such <strong>as</strong> depression and substance abuse, account for 9.8%of total dise<strong>as</strong>e in low and middle income countries, withdepression the leading cause of years lived with disability(2). While probably greatly underestimated, more than800,000 people annually commit suicide with the majority(86%) coming from low and middle-income countries (3).Additionally, untreated mental disorders are <strong>as</strong>sociatedwith heart dise<strong>as</strong>e, stroke, injury, and impaired growthand development in children (3). Mental illness h<strong>as</strong> aprofound and often underestimated impact on the healthand functioning of individuals and communities acrosspost-conflict societies.Mental health is particularly important for <strong>South</strong><strong>Sudan</strong> <strong>as</strong> the majority of the population h<strong>as</strong> been exposedto high rates of violence, displacement, and political andsocial insecurity. Mental health data from <strong>South</strong> <strong>Sudan</strong> islimited. One post-conflict study from Juba found that 36%of the sampled population (n=1,242) met criteria for posttraumaticstress disorder (PTSD) and 50% for depression(4). Another study, conducted in northern Uganda and<strong>South</strong> <strong>Sudan</strong>, found the prevalence of PTSD w<strong>as</strong> 46%among <strong>South</strong> <strong>Sudan</strong>ese refugees and 48% among <strong>South</strong><strong>Sudan</strong>ese who stayed in the country (5). These studiesindicate a high prevalence of mental illness in <strong>South</strong><strong>Sudan</strong> <strong>as</strong> well <strong>as</strong> the potential for an incre<strong>as</strong>e in psychiatricdise<strong>as</strong>e <strong>as</strong> more refugees and internally displaced personsa The Chester M. Pierce, MD Division of Global Psychiatry,M<strong>as</strong>sachusetts General Hospital, Boston, and Harvard <strong>Medical</strong>School, 25 Shattuck Street, Boston, USA. mameresekere@partners.orgreturn home. As <strong>South</strong> <strong>Sudan</strong> attempts to reconcile recentmemories of war with optimism for the future, we mustpay close attention to its citizens’ mental health.Health care providers in <strong>South</strong> <strong>Sudan</strong> must becomeaware of the high prevalence of mental illness, its<strong>as</strong>sociated stigma, and know how to screen, diagnose andtreat common mental disorders. Part I of this two-partseries provides an overview of the common psychiatricconditions seen in post-conflict societies and generalmedical settings with a focus on depression and PTSD.Part II will focus on anxiety and substance (includingalcohol) abuse. Brief explanations, screening questions to<strong>as</strong>sess risk, signs and symptoms, and treatment suggestionsare provided for each condition.DepressionDepression is a common condition world-wide andparticularly in post-conflict settings. Studies from postconflict<strong>South</strong> <strong>Sudan</strong> found rates of depression <strong>as</strong> high <strong>as</strong>50% (4). Untreated depression often results in neglect ofpersonal and professional responsibilities and significantlyimpacts daily life. It also negatively affects the lives offamilies. Severe depression may lead to suicide. A study of<strong>South</strong> <strong>Sudan</strong>ese ex-combatants found that 15% reportedwishing they were dead, or had thoughts of self harm(6). The main symptoms of depression include low mood(sadness) or loss of interest in usually enjoyed activities(anhedonia) every day, most of the day for at le<strong>as</strong>t twoweeks plus four additional symptoms listed in table 1.Screening: The following questions help to <strong>as</strong>sess fordepression (see table 2). The first two are adapted fromthe Patient Health Questionnaire (PHQ-2) screening tool,which is used to <strong>as</strong>sess frequency of depressed mood andlow interest in the p<strong>as</strong>t month. Each question is scored <strong>as</strong>0 (NO feelings of sadness or hopelessness or continuedinterest in enjoyable activities in the p<strong>as</strong>t month) or 3(feelings of sadness or hopelessness or disinterest inenjoyable activities nearly every day for the p<strong>as</strong>t month).A total score of greater than or equal to 3 is 83% sensitiveand 92% specific for detecting depression (8). Risk ofsuicide is a serious concern so one should always <strong>as</strong>k ifsomeone h<strong>as</strong> thoughts of killing him or herself whenscreening for depression.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 4Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesTable 1. Diagnostic criteria for depressionSymptomsSeveredepressiveepisode withpsychoticsymptomsDepressionRiskSuicide Risk• Sad or low mood OR• Loss of interest in usually enjoyedactivities + 4 or more of the symptomsincluded below:• Feelings of guilt (feeling worthless/hopeless)• Decre<strong>as</strong>ed energy• Motor slowing or agitation• Poor concentration• Disturbed sleep (too much or too littlesleep)• Excessively incre<strong>as</strong>ed/decre<strong>as</strong>ed appetite• Thoughts of harming/killing oneself oractions that result in death or harm tooneselfSevere symptoms of depression include:• Psychosis (loss of contact with reality):a. Hallucinations (seeing or hearingthings other people do not see or hear)b. Delusions (beliefs that are firmlyheld despite being contradicted by whatis generally accepted <strong>as</strong> reality• Activity level so low that daily functioningis impossible (Severely sad moodthat results in lack of desire to eat ordrink or tend to personal hygiene)• SuicideTable 2. Screening questions for depression1. During the p<strong>as</strong>t month, haveyou often been bothered by feeling sad, orhopeless?2. During the p<strong>as</strong>t month, have youoften felt little interest or ple<strong>as</strong>ure in doingthings?• Not at all (0 points).• Nearly every day (3 points).1. Have you had thoughts of hurtingor killing yourself? If yes, when, how oftenetc?2. Do you have a plan to kill yourself?What is your plan? (This will indicate likelyrisk). Do you have the means (methods) todo so?3. Have you ever tried to kill yourself?If yes, when and how? (This will give you anindication of the severity of prior attempts).Post-Traumatic Stress Disorder (PTSD)PTSD may result from exposure to a stressful situationof an exceptional nature (e.g. being the victim of torture,rapes or beatings, observing or acting in armed conflict,or witnessing the violent death of relatives or friends) (9).PTSD is a common disorder in individuals exposed toarmed conflict and is common in <strong>South</strong> <strong>Sudan</strong> (4, 5, 10).Individuals with PTSD may experience physical symptoms<strong>as</strong>sociated with their stress. An example is a <strong>Sudan</strong>eserefugee who presented with chronic abdominal and backpain. <strong>Medical</strong> causes were excluded and it w<strong>as</strong> realizedthat his pain w<strong>as</strong> part of his PTSD which improved withantidepressant medication (11). Depression and PTSDfrequently occur together so one must screen for bothconditions. Someone exposed to a traumatic event h<strong>as</strong>PTSD if they experience at le<strong>as</strong>t one symptom fromcluster B, at le<strong>as</strong>t 3 symptoms from cluster C, and at le<strong>as</strong>t2 symptoms from cluster D consistently for at le<strong>as</strong>t onemonth and their symptoms cause significant disruption totheir personal and professional life. (See tables 3 and 4)Treatment Approach to Patients with CommonMental DisordersAs some medical conditions can present with orimitate psychiatric symptoms, it is important to firstexclude common medical causes such <strong>as</strong> infection(malaria, typhoid, HIV), medication reactions, andtoxic/metabolic or endocrine abnormalities (13). Oncea psychiatric diagnosis is confirmed, you can considertreatment possibilities that typically include a combinationof medications and most importantly psychological andsocial interventions. Medications may help but requireclose monitoring for side effects. (see table 5)Community and Psychosocial Interventions:Psychosocial interventions in the form of religiousgroups, friends, family and tribal structures, are some ofthe most important tools to help patients with depressionand PTSD feel better. A review article on the mentalhealth of <strong>South</strong> <strong>Sudan</strong>ese refugees in the Di<strong>as</strong>pora foundthat mechanisms of coping with emotional distress,including encouraging connections with others, groupsocial support and sharing experiences, helped to e<strong>as</strong>eemotional difficulties (14). Health care providers can helppatients feel better by (14):• Focusing attention on positive things in the futureand away from negative situations• Helping patients accept difficulties in life• Helping patients create meaning from suffering• Focusing patients on productive activities<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 5Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesTable 3. Diagnostic Criteria for PTSD • Helping patients compare themselves with thosewho are less fortunateSymptoms CLUSTER B –1 or more of the followingsymptoms for at le<strong>as</strong>t one monthPharmacologic Interventions (15): There are few• Recurrent distressing memories of the psychiatric medications available in <strong>South</strong> <strong>Sudan</strong>.event, including images or thoughts Health care workers can use the following medications• Recurrent distressing dreams of the event to treat depression and PTSD – which should be used• Acting or feeling <strong>as</strong> if the trauma w<strong>as</strong> in combination with community and psychosocialrecurring (includes a sense of actually relivingthe event)interventions., <strong>as</strong> shown in table 6.Depression Treatment• Intense emotional distress when exposedto something that reminds you of thetrauma• Physical symptoms like rapid heart rate,sweating, and tremors when exposed tosomething that reminds you of the traumaRefer to table 7.PTSD TreatmentRefer to table 8.ConclusionCLUSTER C – 3 or more of the followingExposure to prolonged violence, displacement, andsymptoms for at le<strong>as</strong>t one month• Avoiding thoughts, feelings, orhardship h<strong>as</strong> put the people of <strong>South</strong> <strong>Sudan</strong> at risk ofconversations <strong>as</strong>sociated with the trauma emotional distress. Therefore, it is essential for health• Avoiding activities, places, or people that care providers in <strong>South</strong> <strong>Sudan</strong> to focus on both physical•cause you to remember the traumaInability to recall an important part of theand mental well-being. Advocacy, training, and researchare desperately needed. Broad recommendations totraum<strong>as</strong>trengthen mental health service provision are discussed• Decre<strong>as</strong>ed interest or participation in in Part II.usually important activities• Feeling disconnected from others or Referencesfeeling alone when surrounded by family 1. Organization WH. Mental Health Strengthening ouror friendsResponse Fact Sheet #220 2010 [cited 2011 July 20];• Limited range of emotions (rarely able toAvailable from: http://www.who.int/mediacentre/laugh or smile)factsheets/fs220/en/index.htm• Sense of no hope for the future (e.g.,2. Patel V. Mental health in low- and middle-income countries.does not expect to have a job, marriage,Br Med Bull. 2007; 81-82: 81-96.children)CLUSTER D: 2 or more of the following3. Prince M, Patel V, Saxena S, Maj M, M<strong>as</strong>elko J, Phillipssymptoms for at le<strong>as</strong>t one monthMR, et al. No health without mental health. Lancet. 2007;370(9590): 859-77.• Hypervigilance (always on guard forthreats)4. Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-• E<strong>as</strong>ily startled or scaredconflict mental health needs: a cross-sectional survey• Difficulty falling <strong>as</strong>leep or staying <strong>as</strong>leepof trauma, depression and <strong>as</strong>sociated factors in Juba,• Irritability or outbursts of anger<strong>South</strong>ern <strong>Sudan</strong>. BMC Psychiatry. 2009; 9: 7.• Difficulty concentrating5. Karunakara UK, Neuner F, Schauer M, Singh K, Hill K,Elbert T, et al. Traumatic events and symptoms of posttraumaticstress disorder amongst <strong>Sudan</strong>ese nationals,refugees and Ugandans in the West Nile. Afr Health Sci.2004; 4(2): 83-93.Table 4. Screening Questions for PTSDIf willing, encourage the patient to talk about the trauma.Some people are not ready to share their story immediately. Ifthis is the c<strong>as</strong>e, it is not recommended to force a person to telltheir story. The patient may begin to feel more comfortablewith time and eventually be ready to discuss their experience.Start by <strong>as</strong>king questions like:“Some people have difficult experiences like being attacked or threatened witha weapon; being raped; or seeing someone being badly injured or killed. H<strong>as</strong>anything like this ever happened to you?”IF YES:“In the p<strong>as</strong>t 3 months, have you had recurrent dreams or nightmares about thisexperience, or recurrent thoughts or times when you felt <strong>as</strong> though it w<strong>as</strong> happeningagain, even though it w<strong>as</strong>n’t?”Winkler N. Psycho-social intervention needs amongst excombatantsin <strong>South</strong> <strong>Sudan</strong>. Juba: <strong>South</strong>ern <strong>Sudan</strong> DDRCommission (SSDDRC) and the Bonn InternationalCenter for Conversion (BICC); 2010 November, 2010.American Psychiatric Association., American PsychiatricAssociation. T<strong>as</strong>k Force on DSM-IV. Diagnostic andstatistical manual of mental disorders : DSM-IV-TR. 4thed. W<strong>as</strong>hington, DC: American Psychiatric Association;2000.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 6Vol 5. No 1. February 20126.7.
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesTable 5. Treatment Algorithm• EVALUATE presence of symptoms• EXCLUDE common medical disorders that may cause psychiatric symptoms• CONSIDER the differential diagnoses for mental disorders b<strong>as</strong>ed on the symptoms mentioned above• START MEDICATION/PSYCHOSOCIAL INTERVENTION depending on the psychiatric illness• ASSESS RESPONSE: See the patient back in clinic > <strong>as</strong>sess presence of symptoms and response to medication.• If complete resolution of symptoms > continue treatment at current dose• If partial or no improvement > incre<strong>as</strong>e dose b<strong>as</strong>ed on guidelines and re<strong>as</strong>sess symptoms• REASSESS RESPONSE frequently at the beginning of treatment:a. If complete resolution of symptoms > continue medication at therapeutic dose for the recommended time framedepending on the condition (ple<strong>as</strong>e see table below).b. If no response, worsening thoughts of self-harm, or new psychotic symptoms > seek consultation with mental healthexpert by any means necessary (including phone or internet)Table 6. Pharmacologic Treatment for Depression and PTSDFluoxetine Amitriptyline Diazepam ChlorpromazineUses Depression, PTSD Depression, PTSD PTSD Severe Depression, PTSDCommonSide effectsRisks ofMedicationRe<strong>as</strong>sessOccurs whenstarting (typicallyimproves):•Nausea, diarrhea,constipation•Poor sleep•Tiredness, anxietyLong-term:•Sexual dysfunction(Treat by loweringdose)•Skin r<strong>as</strong>h (shouldstop the drug)•Assess symptoms/side effectsevery 2 weeksinitially•Incre<strong>as</strong>e by 20mgto MAX dose every3-4 weeks if noimprovement•Dry mouth, constipation,blurred vision, urinary retention•Fatigue, weakness, dizziness,sedation •Sexual dysfunction•Weight gain and incre<strong>as</strong>edappetite•Heart problems (QTc prolongation,arrhythmi<strong>as</strong>)•Seizures•Liver failure•Assess symptoms/ side effectsevery week initially•Incre<strong>as</strong>e by 25mg every 3-7days to reach MAX dose if noimprovement•Clinical response may be delayed up to severalweeks after initiation•Taper medication over >4 weeks) <strong>as</strong> withdrawalsyndrome can occur if stopped abruptly•Sedation, fatigue, depression•Dizziness, ataxia, slurredspeech, weakness•Forgetfulness, confusion•Dependence/abuseOverdose > respiratory depression> coma• Withdrawal syndrome >irritability, tremor, hallucinations,seizures•Assess symptoms/ side effectsevery 2-3 days initially•Incre<strong>as</strong>e by 1-2mg every 2-3days up to MAX dose if noimprovement•Should be used for (nolonger than 12-16 weeks)given high abuse/ dependencepotential•Taper by 1-2mg every 3-7days <strong>as</strong> withdrawal/ seizurescan occur if stopped abruptly•Sexual Dysfunction•Dry mouth, constipation,urinary retention•Weight gain•Sedation•Low blood pressure,tachycardia• Photosensitivity•Involuntary movements• Heat stroke•Bone marrow suppression• Rare seizures •Neurolepticmalignant syndrome(Temperature >38°C, delirium,sweating, rigid muscles,autonomic imbalance)•Assess symptoms andside effects every 1-2 daysinitially•Incre<strong>as</strong>e by 20-50 mg/day every 3-4 days•Start lower/titrate slowerin older patients•Taper over 6-8 weeks toavoid rebound psychosis*All medications should be used with caution in women of childbearing age given possible teratogenic effects during pregnancyand lactation. The listed side effects are not exhaustive and all medications should be monitored closely.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 20127
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesTable 7: Depression TreatmentMedications Starting Dose EffectiveDoseRangeDepressedMoodPsychosisAmitriptylineFluoxetine(Clinical responsemay bedelayed)25 mg/day / bymouth20 mg/day / bymouth50 –150mg/dayAt night orin divideddoses.20 –80mg/day (20mg-40mg usually)In themorning.•Fluoxetine is safer with fewer side effectsthan amitriptyline•If improvement in symptoms treat at samedose for 6-12 months•Consider maintenance (long-term) treatmentin patients with >3 episodes of depressionChlorpromazine30 – 75mg/daily by mouth200 –800mg/dayAt nightor divideddoses•Incre<strong>as</strong>e dose until psychotic symptoms arecontrolled; after two weeks reduce to lowesteffective dose (25 – 50mg IM can be used <strong>as</strong>needed for severe agitation)8.9.10.11.12.13.14.15.16.Kroenke K, Spitzer RL, Williams JB. The Patient HealthQuestionnaire-2: validity of a two-item depressionscreener. Med Care. 2003; 41(11): 1284-92.Organization WH. International Statistical Cl<strong>as</strong>sificationof Dise<strong>as</strong>es and Health Related Problems World HealthOrganization 2007.de Jong JT, Komproe IH, Van Ommeren M. Commonmental disorders in postconflict settings. Lancet. 2003;361(9375): 2128-30.Franco-Paredes C. An unusual clinical presentation ofposttraumatic stress disorder in a <strong>Sudan</strong>ese refugee. JImmigr Minor Health. 2010; 12(2): 267-9.Means-Christensen AJ, Sherbourne CD, Roy-Byrne PP,Cr<strong>as</strong>ke MG, Stein MB. Using five questions to screen forfive common mental disorders in primary care: diagnosticaccuracy of the Anxiety and Depression Detector. GenHosp Psychiatry. 2006; 28(2): 108-18.Williams ER, Shepherd SM. <strong>Medical</strong> clearance ofpsychiatric patients. Emerg Med Clin North Am. 2000; 18(2):185-98, vii.Tempany M. What research tells us about the mentalhealth and psychosocial wellbeing of <strong>Sudan</strong>ese refugees: aliterature review. Transcult Psychiatry. 2009; 46(2): 300-15.Henderson DC. Statewide Network of Local Care toSurvivors of Torture: Psychopharmacology Introduction.Powerpoint. Boston Harvard Program on RefugeeTrauma.Stahl SM, Grady MM. Stahl’s essential psychopharmacology:the prescriber’s guide. 4th ed. Cambridge ; New York:Cambridge University Press; 2011.Table 8: PTSD treatmentTargetSymptomsAngry outburstsDisturbing imagerySevere agitationDepressionNightmaresFl<strong>as</strong>hbacksIrritability HypervigilanceMedications Starting Dose EffectiveDose RangeChlorpromazineFluoxetineAmitriptylineDiazepamSECOND LINE30 – 75mg/dailyBy mouth10 – 20mg/dayBy mouth10– 25 mg/dayBy mouth2– 5 mg/dayBy mouth200 – 800mg/dayAt night or in divided doses.Can be used IM <strong>as</strong> needed forsevere agitation/violence10 – 80mg/dayIn morning(Can start with 20mg everyother day)10– 150 mg/dayAt night or in divided doses2– 40 mg/dayDivided doses•Use medications to target symptoms described by patient•If symptoms improve continue medication for at le<strong>as</strong>t 6-12 months except for diazepamgiven dependence/addiction potential•If symptoms recur, restart therapy and continue indefinitely<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 8Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesAsthma: diagnosis and managementA guide suitable for developing countriesRichard A Lewis a BSc DM FRCPIntroductionThe prevalence of <strong>as</strong>thma is highest in ‘developed’ countriesand lowest in developing and emerging countries. Theprevalence incre<strong>as</strong>es <strong>as</strong> development progresses (1) andis higher in urban compared to rural are<strong>as</strong> in developingcountries. This incre<strong>as</strong>e may be a result of several factorsincluding:• The population facing new allergens in an urbanenvironment (2).• A reduced exposure to infectious agents,symbiotic micro-organisms and par<strong>as</strong>ites which leads to areduction of T helper 1 mediated immune responses andthus an incre<strong>as</strong>e in T helper 2 mediated responses whichstimulate antibody mediated immunity leading to allergicdise<strong>as</strong>e. This h<strong>as</strong> been called the ‘hygiene hypothesis’ (3).• Incre<strong>as</strong>ed awareness of <strong>as</strong>thma in are<strong>as</strong> withmore health provision.Even a small rise in <strong>as</strong>thma prevalence in developingcountries h<strong>as</strong> important public health implications (4).This guide should be read together with local guidelinesincluding the ‘Prevention and Treatment Guidelines forPrimary Health Care Centres and Hospitals’ (5). It is notmeant to replace any of the recommendations of localguidelines. It is designed to help those managing <strong>as</strong>thmato think about why <strong>as</strong>thma may be a problem and how toovercome that problem.Management of <strong>as</strong>thma - The 5 ‘D’sI use a simple checklist of 5 ‘D’s (Diagnosis, Drugs, Dose,Delivery, Dirty air) when faced with a c<strong>as</strong>e of difficult<strong>as</strong>thma. This checklist explains why the <strong>as</strong>thma is difficultto control.DiagnosisThe diagnosis of <strong>as</strong>thma is more difficult in developingcountries with a high prevalence of tuberculosis and otherpoverty related lung conditions, and HIV <strong>as</strong>sociated lungdise<strong>as</strong>es. It is likely that many patients with <strong>as</strong>thma arenot recognised. Diagnosis in the under 5-year-olds is evenmore difficult due to a high incidence of viral respiratoryinfections <strong>as</strong>sociated with wheeze. I have noted anincre<strong>as</strong>e in bronchial hyper-reactivity in patients witha Consultant Physician, Worcestershire Royal Hospital, WorcesterWR5 1DD UK. Professor of Respiratory Medicine, University ofWorcester, Senior Research Fellow. National Pollen and AerobiologyResearch Unit.tropical pulmonary eosinophilia in a deprived communityin India. In the UK I find the following conditions couldmimic or exacerbate <strong>as</strong>thma so, rather than add anotherlayer of anti-<strong>as</strong>thma medication, I always check for:1. A for Aspergillus related dise<strong>as</strong>e. Both allergicbronchopulmonary <strong>as</strong>pergillosis (ABPA) andSevere Asthma with Fungal Sensitisation(SAFS) (6) results in <strong>as</strong>thma which is difficult tocontrol. The chest X-ray may show segmentalor subsegmental collapse, sputum may containAspergillus fumigatus and blood tests may showa raised IgE and raised <strong>as</strong>pergillus RAST or<strong>as</strong>pergillus precipitins. Anti-fungal treatmentwith intraconazole for one month or more helpsboth conditions. This may be combined with oralsteroids.2. B for Bronchitis, especially in children whereviral illness may mimic <strong>as</strong>thma. There may also bea prolonged period of bronchial hyper-reactivityafter a respiratory viral illness.3. C for COPD. Chronic obstructive pulmonarydise<strong>as</strong>e may be difficult to distinguish from <strong>as</strong>thma.The diagnosis is helped by a history of exposureto tobacco smoke or biom<strong>as</strong>s smoke (‘biom<strong>as</strong>s’ isbiological material from living or recently livingorganisms such <strong>as</strong> dead branches, wood chippings,crop remains) (7). A symptom-b<strong>as</strong>ed questionnaireis available to distinguish COPD from <strong>as</strong>thma (8)4. D for Diffuse lung dise<strong>as</strong>e. This can be difficultto diagnose without X-ray. Fine crackles, especiallyat the lateral lung b<strong>as</strong>es should alert you to thepossibility of an interstitial lung dise<strong>as</strong>e such <strong>as</strong>idiopathic pulmonary fibrosis. Spirometry isrestrictive rather than obstructive. Peak flow maybe normal.5. E for Embolus. Pulmonary embolus can causerapid onset of breathlessness and should alwaysbe considered in patients in whom the degree ofbreathlessness is disproportionate to the severityof their other underlying lung dise<strong>as</strong>e or lungfunction.F for Failure.6. Heart failure may mimic <strong>as</strong>thmawith wheeze and indeed used to be called ‘cardiac<strong>as</strong>thma’. There may be significant reversibility to<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 9Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesinhaled beta agonists. A history of heart dise<strong>as</strong>eand the presence of b<strong>as</strong>al crepitations help tomake the diagnosis.7. G for G<strong>as</strong>tro-oesophageal reflux (GORD)which is frequent in <strong>as</strong>thma patients and may beexacerbated by the <strong>as</strong>thma or be a re<strong>as</strong>on for poor<strong>as</strong>thma control. Always <strong>as</strong>k whether patients have“heart burn” or acid reflux, and treat aggressively.Note that use of anti-acid therapy such <strong>as</strong> a protonpump inhibitor may remove the symptoms ofacid reflux without stopping the refluxate whichmay still inflame the larynx or airways due to thepresence of pepsin (9).8. H for Hyperventilation. Hyperventilation isfrequently <strong>as</strong>sociated with <strong>as</strong>thma and may bethe cause of failure of <strong>as</strong>thma control. Use of <strong>as</strong>imple tool such <strong>as</strong> the Nijmegen Questionnairemay help pick up these c<strong>as</strong>es (10).9. I for Inhaled foreign body which may causewheeze both in the acute and chronic ph<strong>as</strong>e. If<strong>as</strong>thma h<strong>as</strong> been of rapid onset always <strong>as</strong>k aboutthis possibility. Unilateral wheeze is an importantsign and indicates the need to try and obtain anX-ray. Many foreign bodies however may notshow on X-ray or CT scan and bronchoscopy isrequired10. J for Just never forget local common dise<strong>as</strong>essuch <strong>as</strong> tuberculosis which can mimic <strong>as</strong>thma withbreathlessness, noisy breathing and cough.A major problem in diagnosing and treating <strong>as</strong>thma incountries like <strong>South</strong> <strong>Sudan</strong> is the lack of medical equipment.Clear history taking is therefore very important. Table 1lists important questions to <strong>as</strong>k to diagnose <strong>as</strong>thma.International guidelines for the management ofTable 1. Important questions to <strong>as</strong>k to diagnose <strong>as</strong>thmaFrom Global Strategy for Asthma Management andPrevention, 2010 Global Initiative for Asthma (11)1. H<strong>as</strong> the patients had an attack or recurrent attacks ofwheezing?2. Does the patient have a troublesome cough at night?3. Does the patient wheeze or cough after exercise?4. Does the patient experience wheezing, chest tightnessor cough after exposure to airborne allergens orpollutants?5. Do the patient’s colds ‘go onto the chest’ or take morethan 10 days to clear up?6. Are symptoms improved by appropriate <strong>as</strong>thmatreatment?<strong>as</strong>thma usually mention the fundamental need forspirometry and blood g<strong>as</strong>es to <strong>as</strong>sess patients and oxygenand nebulisers for management. In a questionnaire studywe undertook of 41 centres in 24 developing countries inAfrica and Asia (12) we found that continuous electricityw<strong>as</strong> available in 25 centres, oxygen in 23 are<strong>as</strong>, peakflow me<strong>as</strong>urement in 26, and spirometry in 3 centres.Nebulisers were available in 19 centres and oxygen in 23.Peak flow me<strong>as</strong>urement can be a useful and inexpensivetool in the diagnosis of <strong>as</strong>thma when a 15% improvementfollowing administration of 400mcg salbutamol supportsthe diagnosis. Spirometry, particularly using a machinewhich can provide a flow volume loop, is more helpfulto diagnose COPD and to exclude restrictive lungdise<strong>as</strong>es <strong>as</strong> a cause of breathlessness. Peak flow meters,if available, can also be used to confirm variation overtime or show the characteristic morning dip of <strong>as</strong>thma.We have successfully used colours and symbols on peakflow meters to enable home use in an illiterate population(see Figures 1a and b.) (13)DrugsAlways check whether the patient is taking drugs whichmay exacerbate <strong>as</strong>thma such <strong>as</strong> beta blockers which maybe taken orally or <strong>as</strong> eye drops.The problem in developing countries is that the mostb<strong>as</strong>ic drugs required for the management of <strong>as</strong>thma(such <strong>as</strong> inhaled bronchodilators and inhaled steroids) areunaffordable. In the questionnaire study we undertook(12) inhaled steroids were prescribed in only 2 out of 41centres. Where they were available, the median (range)cost of a beclometh<strong>as</strong>one 50 micrograms inhaler w<strong>as</strong>20% (6.8-100%) of average local monthly income anda salbutamol inhaler 13% (3.3-250%). Following thepublication of this paper the Asthma Drug Facility (ADF)(14) w<strong>as</strong> established by the International Union AgainstTuberculosis and Lung Dise<strong>as</strong>e. Through the ADF, lowand middle income countries can purch<strong>as</strong>e the quality<strong>as</strong>sured<strong>as</strong>thma medicines they need at affordable cost.The ADF h<strong>as</strong> a quality <strong>as</strong>surance system b<strong>as</strong>ed on WorldHealth Organization norms and standards. It keeps pricesdown by having a competitive process among selectedmanufacturers. However it is probable that oral medicationsuch <strong>as</strong> oral beta agonists, theophyllines and steroids maybe the only affordable drugs. For recommendations for themanagement of acute <strong>as</strong>thma and maintenance therapy in<strong>South</strong> <strong>Sudan</strong> see MOH/GOSS 2006 (5).DoseThe most important <strong>as</strong>pect of ‘dose’ is not thedose prescribed but the dose that the patient is actually<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 10Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesFigures 1a and b. Example of a colour coded peak flow meter and chart for home use by illiterate patients.taking. Lack of funds, fear of side effects or lack ofunderstanding of the need to take regular medication mayresult in the patient taking a much lower dose of drugthan that prescribed, or stopping the medication when thesymptoms resolve. It is important to:• Establish the actual dose being taken.• Explain the difference in action of the variousinhalers, and the fact that the ‘preventer’ steroid inhalershould be taken on a regular b<strong>as</strong>is while the ‘reliever’bronchodilator is taken <strong>as</strong> required. ‘Stepping up’ the doseof inhaled steroids when <strong>as</strong>thma control is not establishedis frequently considered, but ‘stepping down’ once controlis established is not so frequently considered. This isimportant <strong>as</strong> it reduces costs and long term side effects.DeliveryThe metered dose inhaler (MDI) is the cheapest formof delivery of <strong>as</strong>thma medication in most countries andtherefore the most commonly used and misused (15).In my experience the lack of ability to use the MDI isthe most common cause of failure of <strong>as</strong>thma control. Asimple rule is to <strong>as</strong>sume that patients fail to use an MDIcorrectly until proved otherwise . Unfortunately demanddelivery devices such <strong>as</strong> dry powder inhalers, or autodelivery inhalers are more expensive. The use of a spacingdevice with an MDI overcomes the problems of coordination,markedly improves response (16) and reducesoropharyngeal side effects of inhaled steroids. A spaceris an additional expense, but a cheap spacer may be madefrom a pl<strong>as</strong>tic bottle. It is important to stress the need forcompliance with the spacer since many patients do notfeel they are benefitting from their MDI unless they feelthe spray hitting the back of the mouth!The use of inhalers should not be a problem forMuslims f<strong>as</strong>ting during Ramadan because using a spacerdevice means that most of the inhaled medication goesdirectly to the lungs and the small amount delivered to theoro-pharynx can be rinsed out.Dirty AirThe three types of ‘dirty air’ to consider are inhaledsmoke, occupational lung dise<strong>as</strong>e and allergens.• Inhaled tobacco smoke may be p<strong>as</strong>sive inchildren and those living with smokers or due to activesmoking. In the UK many smokers deny smoking, butbrown discolouration of the nails, smell of smoke onthe breath or, if necessary, me<strong>as</strong>urement of end-tidalcarbon monoxide helps confirm the truth. In developingcountries smoke inhalation due to the use of biom<strong>as</strong>s fuelsin unventilated huts is an important cause of respiratorydise<strong>as</strong>e (17). Education and cultural changes may benecessary, but these have to adapt to users' needs (18).The education level h<strong>as</strong> shown a strong correlation withthe risk of respiratory dise<strong>as</strong>es from biom<strong>as</strong>s exposure inwomen; illiterate women are at three to six times higherrisk for all respiratory dise<strong>as</strong>es compared with literatewomen (19).• Occupational lung dise<strong>as</strong>e. Ask patients with<strong>as</strong>thma about their occupation and whether <strong>as</strong>thm<strong>as</strong>ymptoms are better on days they are not working.There are many occupational exposures which causeor exacerbate <strong>as</strong>thma and appropriate health and safetyprecautions may not be in place or followed.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201211
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesFigure 2. Inhalation of smoke from biom<strong>as</strong>s fuel may cause respiratorydise<strong>as</strong>e in adults and children.• Allergens may be an important cause of <strong>as</strong>thma.In 2003 locusts were <strong>as</strong>sociated with 11 deaths and 1600hospital visits in central <strong>Sudan</strong>. Asthma and rhinitis in<strong>Sudan</strong> h<strong>as</strong> also been <strong>as</strong>sociated with exposure to airborneallergen from the “green nimitti” midge Cladotanytarsuslewisi. Urbanisation is <strong>as</strong>sociated with an incre<strong>as</strong>e inexposure to indoor allergens such <strong>as</strong> the house dust miteor pet dander (2), and incre<strong>as</strong>ed air pollution incre<strong>as</strong>essensitisation to allergens.References1. Be<strong>as</strong>ley R, Crane L, Lai CK el al. Prevalence andaetiology of <strong>as</strong>thma J Allergy Clin Immunol. 2000; 105 (2Pt 2): S466-S4722. Weinberg EG. Urbanization and childhood <strong>as</strong>thma: AnAfrican perspective J Allergy Clin Immunol. 2000; 105:224-313. Strachan DP. Family size, infection and atopy: the firstdecade of the hygiene hypothesis Thorax. 2000; 55(Suppl 1): S2-S104. Zar H. 2008 URL http://www.cipp-meeting.org/proceedings2008/CONTENT/2-SATURDAY_AFTERNOON/7-KEYNOTE/Heather_Zar.pdf(accessed 26 Aug 2011)5. MOH/GOSS. Prevention and Treatment Guidelinesfor Primary Health Care Centres and Hospitals, Ministryof Health, Government of <strong>South</strong>ern <strong>Sudan</strong>. 2006. p232-235 http://www.southsudanmedicaljournal.com/<strong>as</strong>sets/files/misc/SS_Treatment_Guidelines07.pdf(l<strong>as</strong>t accessed 13 Sept 2011)6. O’Driscoll BR, Hopkinson LC, Denning DW. Mouldsensitization is common amongst patients with severe<strong>as</strong>thma requiring multiple hospital admissions. BMCPulm Med. 2005; 5: 4.7. Guoping H, Yumin Z, Jia T et al. Risk of COPD fromexposure to biom<strong>as</strong>s smoke: a metaanalysis Chest. 2010;138(1): 20 - 31.8. Tinkelman DG, Price DB, Nordyke RJ et al. Symptomb<strong>as</strong>edquestionnaire for differentiating COPD and<strong>as</strong>thma Respiration 2006; 73 (3): 296-3059. Johnston N, Knight J, Dettmar PW, Lively MO,Koufman J. Pepsin and carbonic anhydr<strong>as</strong>e isoenzymeIII <strong>as</strong> diagnostic markers for laryngopharyngeal refluxdise<strong>as</strong>e Laryngoscope. 2004; 114(12): 2129-2134.10. van Dixhoorn J, Duivenvoorden HJ. Efficacy ofNijmegen Questionnaire in recognition of thehyperventilation syndrome J Psychosom Res. 1985; 29(2):199-20611. GINA. URL http://www.gin<strong>as</strong>thma.org/pdf/GINA_Report_2010.pdf (accessed 26 Aug 2011)12. Watson JP, Lewis RA. Is <strong>as</strong>thma treatment affordablein developing countries Thorax. 1997; 52: 605-60713. Tenzing C, Lewis RA. Personal communication14. ADF. URL http://www.globaladf.org/ (accessed 26Aug 2011)15. Crompton GK. Problems patients have usingpressurized aerosol inhalers.Eur J Respir Dis. 1982; 63:(Suppl 119): 101 – 10416. Cushley MJ, Lewis RA, Tattersfield AE. Comparison ofthree techniques of inhalation of the airway responseto terbutaline Thorax. 1983; 38: 908-91317. Torres-Duque C, Maldonado D, Pérez-Padilla R et al.Biom<strong>as</strong>s fuels and respiratory dise<strong>as</strong>es. Proc Am ThorSoc. 2008; 5:577 – 59018. Budds J, Biran A, Rouse J. 2001.What's cooking? Areview of the healthy impacts of indoor air pollution andtechnical interventions for its reduction. Leicestershire,UK: Loughborough University Water, Engineering andDevelopment Centre. WELL T<strong>as</strong>k No. 512.19. Parikh J, Parikh K, Laxmi Pandey V. Lack of energy,water and sanitation and its impact on rural India. In:Parikh K, editor. India Development Report, 2004–2005: Oxford University Press, p. 84–95.Conflicts of interest: none.I thank Dr Chris Lewis for his comments on the manuscript and forsupplying Figure 2. Other images are the property of the author.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 12Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesDengue feverMilada Tavodova a MD PgDipIntroductionDengue fever is caused by dengue viruses(DENV). Transmission of DENVh<strong>as</strong> incre<strong>as</strong>ed dramatically in the p<strong>as</strong>ttwo decades making DENV the mostimportant human pathogens amongarthropod-borne viruses (1). About 50-100 million dengue fever infections occurevery year in tropical and subtropicalcountries (2) – see Figure 1.The emergence of denguehaemorrhagic fever (DHF) in mosttropical countries is a public health priority.Little is understood about dengue viruspathogenesis. No other animals developsymptoms and research h<strong>as</strong> been limitedto studies involving humans (1).DENV comprise four serotypes (DENV 1 to 4)but are epidemiologically similar (3). Dengue viruses areRNA viruses with a positive RNA strand, which belongsto the family Flaviviridae. There is a high mutation rateincre<strong>as</strong>ing biodiversity (4) and possibly incre<strong>as</strong>ing dise<strong>as</strong>eseverity and problems with vaccination (4).History of dengue feverThe earliest record appears in a Chinese medicalencyclopaedia (5). It may have spread via sailing ships,where mosquitoes used the stored water <strong>as</strong> a breeding siteand could maintain the transmission cycle.The global epidemiology and transmission of dengueviruses changed in <strong>South</strong>e<strong>as</strong>t Asia during World WarII. Troop movement accelerated the spread of virusesbetween populations and a few years later the firstdocumented outbreaks of DHF occurred in Manila,Philippines in 1953/54 (6).The successful eradication of Aedes aegypti in theAmeric<strong>as</strong> in 1970s reduced the spread of dengue fever.After this programme w<strong>as</strong> abandoned, A. aegypti reinvadedmost of the countries causing a significant healthproblem (7). The true prevalence of dengue fever in Africais unclear because of inadequate surveillance (2, 7).Dengue viruses originated from an animal reservoir.Two distinct DENV transmission cycles are recogniseda Pathology Department, Kings Mill Hospital, Sutton in Ashfield, UKmilada.tavodova@gmail.comFigure 1. Dengue fever risk map 2008. (Source: WHO)(Figure 2):• endemic/ epidemic cycle and• sylvatic /zoonotic cycle.Endemic and epidemic cycles involve the human hostand viruses are transmitted by A. aegypti, A. albopictus andother mosquitoes <strong>as</strong> secondary vectors (3). The sylvatictransmission cycle involves monkeys and several differentAedes mosquitoes identified in Asia and West Africa (7).Transmission to humansTransmission to humans is through the bite of an infectedmosquito, A. aegypti (Figure 3). This mosquito lays its eggsin containers found around the home (e.g. old car tyres,water storage containers). The adult mosquitoes feed onhumans during daylight hours. There are two peaks ofbiting activity, early morning for 2 to 3 hours after daybreakand in the afternoon for several hours before dark. A.aegyptii females often feed on several persons during <strong>as</strong>ingle blood meal hence incre<strong>as</strong>ing the transmission rate(5).The incubation period is 3 - 14 days (average 4 to 7days). There follows an acute febrile period of 2 – 10days accompanied by nonspecific symptoms. During thisperiod dengue viruses circulate in the peripheral blood.During this viraemic stage other biting mosquitoesbecome infected.Clinical pictureDengue fever is mostly occurs in children and youngadults (8). Clinical features vary with the age of the patient<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 13Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlescirculatory failure and hepatomegaly (11). Patients eitherrecover or progress to the pl<strong>as</strong>ma leakage stage remainingill despite normalisation of temperature. Pl<strong>as</strong>ma leakageis characterized by tachycardia and hypotension withsweating, restlessness and cold extremities. Most patientsrecover, but in severe c<strong>as</strong>es patients may develop circulatoryshock (11). Mortality may reach 10 – 20% without earlyappropriate treatment but can be reduced to less than 1%with aggressive fluid replacement therapy.Figure 2. The two DENV transmission cycles. (Source: Nature reviewsMicrobiology 2007; 5: 518 – 528)although clinically occult infection occurs in about 80%(9). There are four presentations (Figure 3):• Non-specific febrile illness• Cl<strong>as</strong>sical dengue fever• Dengue haemorrhagic fever• Dengue haemorrhagic fever with dengue shocksyndrome, encephalopathy and liver failureNon-specific febrile illness: A maculo-papularr<strong>as</strong>h occurs mostly in young children. Upper respiratoryfeatures, especially pharyngitis, are common (10).Cl<strong>as</strong>sical dengue fever (DF) is primarily a dise<strong>as</strong>eof older children and adults. It begins abruptly followedby three ph<strong>as</strong>es – febrile, critical and recovery (Figure4). The fever may be biph<strong>as</strong>ic l<strong>as</strong>ting 3 to 7 days andaccompanied by a variety of symptoms including severeheadache, retro-orbital pain, fatigue, nausea, vomiting,generalised aches, arthralgia and myalgia, hence the term“break bone dise<strong>as</strong>e”(9). A flushed skin (face and neck)and maculo-papular r<strong>as</strong>h are common (11).Haemorrhagic manifestations range from mildto severe; cutaneous petechiae and purpura,gum bleeding, epistaxis, g<strong>as</strong>trointestinalhaemorrhage all can occur (5).Leucopaenia and thrombocytopaenia (lessthan100,000/mm3) are usually found between days 3 and8. Elevated liver enzymes are common.Dengue shock syndrome (DSS) is <strong>as</strong>sociated withalmost 50% mortality. Warning signs include sustainedabdominal pain, vomiting, irritability or somnolence, a fallin body temperature and decre<strong>as</strong>e in platelet count (10).Patients die from multi-organ failure and disseminatedintrav<strong>as</strong>cular coagulation. DSS may be accompaniedby encephalopathy caused by metabolic and electrolytedisturbances (11).Haemostatic disturbances result from v<strong>as</strong>cularchanges, thrombocytopaenia and coagulation disordersarising from, for example,. a decre<strong>as</strong>ed fibrinogen level,and incre<strong>as</strong>ed level of fibrinogen degradation products(5). Other reported complications include liver failure,disseminated intrav<strong>as</strong>cular coagulation, myocarditis andacute renal failure.PathogenesisThis is poorly understood. It is likely that viral,immunopathogenic and other host factors have a role.The main risk factors for severe dise<strong>as</strong>e include thevirulence of the strain of the virus, previous infectionwith heterotypic DENV, age and genetic background ofthe person (12).Recovery may be prolonged withweakness and depression (10). Laboratoryfindings include neutropaenia, lymphocytosis,thrombocytopaenia and elevated liverenzymes.Dengue haemorrhagic fever (DHF)is primarily a dise<strong>as</strong>e of children under15 years in hyperendemic are<strong>as</strong>. It usuallyfollows a secondary dengue infection and ischaracterized by high fever, haemorrhages,Figure 3. Dengue fever flow chart. (Source: WHO 1997 Dengue haemorrhagic fever:Diagnosis, Treatment, Prevention and Control, 2nd edition)<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 14Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesThe two main theories of pathogenesis(5) are:1. The secondary-infection orimmune enhancement hypothesis. Thisimplies that patients having a secondinfection with heterologous virus serotypehave a significantly higher chance ofdeveloping DHF and DSS (13). Preexistingantibodies cross-react withthe virus and form antigen-antibodycomplexes, which then bind to the cellmembrane of leucocytes. Because theantibody is heterologous, the virus is notneutralised. This facilitates virus entry tocells resulting in higher viral titres (5, 13).Higher viral titres may result in an amplifiedc<strong>as</strong>cade of cytokines and complementactivation causing endothelial dysfunction,platelets destruction and consumptionof coagulation factors leading to pl<strong>as</strong>ma leakage andhaemorrhage (10).2. The other hypothesis <strong>as</strong>sumes that dengue virusesvary and some are <strong>as</strong>sociated with higher virulence, severedise<strong>as</strong>e and have greater epidemic potential (14).Laboratory diagnosisLaboratory diagnosis depends on virus isolation andidentification of virus-specific antibodies. Each methodh<strong>as</strong> its advantages and limitations and requires laboratorieswith the necessary infr<strong>as</strong>tructure and technical expertise(15). Dengue viruses can be isolated from serum, pl<strong>as</strong>maor leucocytes during the febrile ph<strong>as</strong>e of the dise<strong>as</strong>e(within 6 days) and from post-mortem specimens of liver,lung, spleen, lymph nodes, cerebrospinal fluid or pleural/<strong>as</strong>citic fluid.Serological diagnosis is more readily available. It iscomplicated by the existence of cross-reactive antigenicdeterminants shared by all four dengue virus serotypesand members of the flavivirus family (2).IgM antibodies are the first to appear and are detectablein 50% of patients by days 3 – 5 after onset of illness,incre<strong>as</strong>ing to 80% by day 5. IgG antibody is detectable atlow titres at the end of first week, incre<strong>as</strong>ing thereafterand still detectable after several months. During secondarydengue infection antibody titres rise rapidly and reactbroadly against many flaviviruses (15).Molecular methods (nucleic acid detection <strong>as</strong>says) mayidentify virus within 24 – 48 hours, but these methods areexpensive and require experienced personnel.Figure 4. Ph<strong>as</strong>es of infection resulting in dengue haemmorhagic fever. (Source: Centers forDise<strong>as</strong>e Control and Prevention, Atlanta, USA)Management of dengue infectionsThere is no specific therapy. Uncomplicated dengueinfection usually resolves spontaneously. Patients withlife threatening complications should be managed inhospital with supportive treatment. Fluid replacementand close monitoring of fluid and electrolytes balance arevital. Isotonic solutions (e.g. 0.9% saline, Ringer’s lactateor Hartmann’s solution) should be used (15). Signs ofsuccessful therapy are:• Improving central and peripheral circulation(decre<strong>as</strong>ing tachycardia, incre<strong>as</strong>ing blood pressure,capillary refill time < 2 seconds) and• Improving end-organ perfusion e.g. stableconscious level, urine output >=0.5 ml/kg/hour,degre<strong>as</strong>ing metabolic acidosis (15).Give paracetamol for fever and analgesia. Avoid <strong>as</strong>pirin,ibuprofen and other non-steroidal anti-inflammatoryagents <strong>as</strong> they may aggravate g<strong>as</strong>tritis or bleeding (15).Acetylsalicylic acid (<strong>as</strong>pirin) may be <strong>as</strong>sociated with Reye’ssyndrome.Monitor patients at le<strong>as</strong>t 6 hourly in 24 hoursand particularly around the time of defervescence ofsymptoms <strong>as</strong> shock may develop. The indications forhospitalisation are:• Poor oral intake• Bleeding• Change in level of consciousness• Laboratory evidence of DHF• Pregnancy, infancy, old age, obesity and diabetes<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201215
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesmellitus (15).Impact of global changes to the spread ofdengue viruses.Several factors contribute to the incre<strong>as</strong>e of dengueviruses (Figure 5):• Incre<strong>as</strong>ing human population and urbanisationwere critical factors in the p<strong>as</strong>t enabling the spread ofviruses. The dengue virus broke free of its sylvatic cycleand established itself <strong>as</strong> the endemic human dise<strong>as</strong>e wesee today (7).• Incre<strong>as</strong>ed urbanisation. The industrialisationand urbanisation are creating large populations ofsusceptible hosts and fertile habitats for mosquitovectors.• Poverty <strong>as</strong>sociated with rapid population growthleads to concentration of people without the necessaryinfr<strong>as</strong>tructure for the safe storage and distribution ofwater and drainage. Used containers and tyres providebreeding sites for mosquito vectors.• Decre<strong>as</strong>ed vector control in are<strong>as</strong> where dengueis epidemic.• Human travel and particularly air travel.References1. Ricco-Hesse R. Dengue Virus Evolution and VirulenceModels Clinical Infectious Dise<strong>as</strong>es 2007; 44: 1462 – 1466.2. Gubler DJ. Epidemic dengue/dengue haemorrhagicfever <strong>as</strong> a public health, social and economic problemin the 21st century Trends in Microbiology 2002; 10 (2):100 – 103.3. Wang E, Ni H, Xu R, et al. Evolutionary Relationshipof Endemic/Epidemic and Sylvatic Dengue Viruses.<strong>Journal</strong> of Virology 2000: 74 (7): 3227 – 3234.4. Holmes EC, Burch SS. The causes and consequences ofgenetic variation in dengue virus. Trends in Microbiology2000; 8 (2): 74 – 77.5. Gubler DJ. Dengue and dengue haemorrhagic fever.Clinical Microbiology Reviews 1998; 11: 480-496.6. Halstead SB. Dengue haemorrhagic fever – a publichealth problem and a field for research. Bull WorldHealth 1980; 58: 1 – 21.7. Holmes EC, Twiddy SS. The origin, emergence andevolutionary genetics of dengue virus. Infection, Geneticsand Evolution 2003; 3: 19 – 28.Figure 5. Average annual number of DF/DHF c<strong>as</strong>es. (Source:WHO -http://www.who.int/csr/dise<strong>as</strong>e/dengue/impact/en/)8. Garg A, Garg J, Rao YK et al. Prevalence of dengueamong clinically suspected febrile episodes at a teachinghospital in North India. <strong>Journal</strong> of Infectious Dise<strong>as</strong>es andImmunity 2011; 3 (5): 85 – 89.9. Reiter P. Yellow fever and dengue: a threat to Europe?Euro Surveill 2010; 15 (10): 11 – 16.10. Gibbons RV, Vaughn DW. Dengue: an escalatingproblem. BMJ 2002; 324: 1563 – 1566.11. Gurugama P, Garg P, Wijewickrama A, Seneviratne SL.Dengue viral infections Indian J Deratol 2010; 55: 68 –78.12. Mackenzie JS, Gubler DJ, Petersen LR. Emergingflaviviruses: the spread and resurgence of Japaneseencephalitis, West Nile and dengue viruses. NatureMedicine Supplement 2004; 10(12): S98 – S109.13. Halstead SB. Pathogenesis of dengue: challenges tomolecular biology Science 1988; 239: 476-48114. Ricco-Hesse R. Microevolution and virulence ofDengue viruses Advances in Virus Research 2003; 59: 315– 340.15. WHO. Dengue - Guidelines for diagnosis, treatment,prevention and control 2009. http://apps.who.int/tdr/svc/publications/training-guideline-publications/dengue-diagnosis-treatment.Acknowledgements: I thank the World Health Organization,the Centers for Dise<strong>as</strong>e Control and Prevention, Atlanta andDr Steve Whitehead for permission to use their images - andDr Aleksandar Vodovnik for his encouragement and technicalsupport.Many thanks to John Vaughan and all the other reviewers for their help in preparing this issue<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 16Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesHow to get publishedHeather Mackenzie a,b, Carole Fogg a , Amy Drahota a , Sue Halson-Brown a , Rebecca Stores a andAnn Dewey aThe purpose of this article is to guide you through thepublication process from start to finish. It will help youto think about where to publish, and provide guidance onwriting and submitting your article, and the peer reviewprocess.Why do you want to publish?Firstly, think about why you want to publish. Forhealthcare professionals the primary re<strong>as</strong>on is sharingresearch findings which contribute to knowledge, andinfluence practice and/or policy. Other re<strong>as</strong>ons includecareer progression or personal satisfaction (1). Secondly,think about your target audience. Do you want to shareyour findings with healthcare professionals working in yourarea, academics or policy makers? How many people doyou want to reach? Thirdly, think about time. How muchtime do you have available? How quickly do you want yourfindings to be available for others to read?Publishing in academic journalsAcademic journals are good places to publish if youwish to contribute to knowledge in the field and/or toinfluence practice or policy. There are a lot of academicjournals – for example, <strong>as</strong> of July 2011, 5560 journals wereindexed in Medline alone (2).To identify a list of potentially relevant journals searchfor keywords in the journal field of PubMed (www.ncbi.nlm.nih.gov/pubmed) and also see where key papers inyour field have been published. When you have a rough list,try to find out whether your work is likely to be of interestto the journal. Most journals have information about theirscope on their website. It is very informative to look at whattypes of research the journal h<strong>as</strong> previously published; forexample, if you have conducted a qualitative study, h<strong>as</strong> thejournal ever published qualitative research? For your targetjournals consider the issues raised in Table 1 below.Style and ContentWhen you have selected your target journal, it isimportant to follow the journal guidelines (and template,if provided) regarding the formatting, style, word count,and type of information provided (this guidance should beon the journal’s website). Submitting an article which doesnot conform to a journal’s guidelines may get it rejecteda School of Health Sciences and Social Work, University ofPortsmouth, James Watson West, 2 King Richard I Road, PortsmouthPO1 2FR, UKb Correspondence to Heather.Mackenzie@port.ac.ukimmediately even if the content is very interesting. It is alsogood practice to follow international standard reportingguidelines for the type of research you are reporting, evenif the journal does not explicitly request this.Remember that when your article h<strong>as</strong> been published,it will take on a life of its own. Other people will read,appraise, and learn from it; they apply the findings in theirpractice, to inform guidelines, or to include in a systematicreview. It is important therefore that your standard ofreporting is appropriate for these purposes, so your articlecan have the best opportunity to make a difference tohealthcare. The EQUATOR Network is an internationalinitiative, which promotes better reporting standards forhealth research. The EQUATOR Network website (http://www.equator-network.org/) h<strong>as</strong> a library hosting guidelinesand checklists for a range of research methods (includingsystematic reviews, experimental designs, observationalstudies, quality improvement studies, qualitative, and mixedmethods studies).When trying to get published, do not lose your integrity<strong>as</strong> a researcher! For example, it may be tempting to elaborateon a statistically significant finding discovered in a posthocexploration of your data, whilst forgetting that youroriginal primary outcome w<strong>as</strong> non-significant (3). Goodresearch begins with a protocol (you should aim to publishthis too) that sets out, before research begins, how the studywill proceed. This should primarily describe the rationale,aim(s) and methods of the study, including informationabout study design, how participants will be recruited, datacollection procedures, the outcomes you intend to me<strong>as</strong>ureand the approach to data analysis. The World HealthOrganization offer guidance on writing research protocolsat http://www.who.int/rpc/research_ethics/format_rp/en/index.html. When reporting your research keep to yourprotocol <strong>as</strong> much <strong>as</strong> possible.Remember, it is just <strong>as</strong> important to know that somethingmay not work, than to know what might work. Users of thatinformation may make decisions to disinvest in something,which may save money and avoid unnecessary treatmentof patients. So called ‘outcome reporting bi<strong>as</strong>’ (where nonsignificantfindings tend to go under-reported) can causebig problems for decision-makers and the consumers ofhealthcare. As a conscientious researcher, you will not wantto contribute to this issue, so you should report the primaryand secondary outcomes <strong>as</strong> originally intended.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 17Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesTable 1. Considerations when choosing a journal to which to submit your research articleQuestion Important if… Advantages DisadvantagesIs the journal peer-reviewed?Academic journals are usually peerreviewedby “experts in the field”.Their role is to advise editors on themerits of the article and whether toaccept it for publication or not.Does the journal have an impactfactor?The impact factor of a journal (orIF) is the average number of citationsreceived per paper published in thatjournal during the two precedingyears.Check out the impact factor of yourtarget journal by going to the ISI Webof Knowledge which indexes morethan 11,000 Science and social sciencejournals. Impact factors vary widelywith journals such <strong>as</strong> New England<strong>Journal</strong> of Medicine and Lancetholding the highest.Is the journal subscription only, openaccessor a mixture of both?Some journals can only be accessedby fee paying subscribers. Others areavailable by “open access” because theauthor typically pays a fee to publish.Other journals may have alternativefunding which allows readers toaccess articles for free without authorspaying a fee to publish.• You want to contributeto knowledge in the fieldand academics are yourtarget audience.• You want to establishan academic or researchcareer.• If you want to reachacademic readers, manywill have access (via theirinstitution) to subscription-onlyjournals.• If you want to reach alarge number of healthprofessionals go foropen-access journals.• Peer review commentscan provide“constructive”feedback, to informand improve yourarticle.• Publishing ina journal with ahigh impact factorconveys a messageabout what calibreresearcher you are• The IF will helpyou to evaluate ajournal’s relativeimportance,especially when youcompare it to othersin the same field in agiven year.• Subscription-onlyjournals allow youto publish yourwork at no cost.• Open access journalsallow any readerto read your work.• In some c<strong>as</strong>es (but not all), peerreview can take some time.• It is worth checking the journal’swebsite to find out how long thepeer review process is likely to take.• Criticisms have been made of theuse of the impact factor, mainlyrelating to its validity• It’s a highly competitive process.• More likely to accept novel, wellconductedstudies that have obviousimplications for theory and/orpractice.• Can be a time consuming routewith no guarantee – even high qualityresearch is not always acceptedby such journals.• If you want to reach a professionalaudience, they may not have accessto subscription only journals.• Cost may prohibit publishingin some (but not all) open accessjournals. It is sensible to find outhow much a journal charges beforechoosing to submit a paper to them.Contribution of authorsMany journals have clear guidelines on who can be anauthor for a research article, typically specifying that to beconsidered an author an individual must have:• made a significant contribution to either theconception/design of the research, data collectionand/or analysis• been involved in writing or making critical commenton drafts of the article and• given final approval of the submitted manuscript.Only (and all) those individuals who meet these criteri<strong>as</strong>hould be listed <strong>as</strong> authors. Individuals who have mademinor contributions (e.g. someone who h<strong>as</strong> <strong>as</strong>sisted withdata collection) would not typically be considered anauthor and should be identified in the acknowledgementssection. Some journals <strong>as</strong>k for the specific contribution ofeach author to be made explicit upon submission of themanuscript. You should check a journal’s ‘Instructionsfor authors’ for their guidelines. If a journal does nothave its own guidelines, the International Committee of<strong>Medical</strong> <strong>Journal</strong> Editors (ICMJE) offer clear guidance onauthorship and contributorship (http://www.icmje.org/ethical_1author.html).Declarations of funding and conflicts ofinterestPersonal or financial interests of authors mayinappropriately influence the actions of authors, eventhough they may not be aware that it h<strong>as</strong>. Such influence maybe small or large. Any and all conflicts of interest should bedeclared to the journal to which you are submitting, <strong>as</strong> shouldall sources of funding for the research. This is commonlypresented <strong>as</strong> a section in the manuscript, and most journalsrequire a signed conflict of interest declaration from allauthors prior to publication. If authors do have conflictsof interest, this is not necessarily problematic. However, a<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 18Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesclear declaration helps the editor, and the readers of yourpaper, to make an informed judgment about the potentialinfluence your own interests may have had on the outcomeof the research. Further guidance on potential conflicts ofinterest can be found at the ICMJE’s website (http://www.icmje.org/ethical_4conflicts.html) .What can I expect from the peer reviewprocess?The peer review process is important for journals to be<strong>as</strong>sured of the quality and relevance of the material theypublish. Each submission is sent out to several reviewerswho are chosen according to their expertise in the field, andtheir own record of publications. Some journals <strong>as</strong>k you torecommend people outside your research team who couldprovide a review. Each journal provides peer reviewers witha format for the review and some guidelines <strong>as</strong> to what thereviewers should focus on. Below are examples of commonare<strong>as</strong> that reviewers are <strong>as</strong>ked to look at. You should haveconsidered these before submitting your article, <strong>as</strong> thismakes the peer review process smoother and reduces delaysin the path to publication.• Is the research question clearly defined? Theresearch question and the purpose of the research have tobe clear to the reader, and the question should be reflectedthroughout the article – i.e. the results and conclusionsshould relate directly to the question outlined in theintroduction.• Are the chosen methods appropriate and welldescribed? The study design used to answer the researchquestion should be appropriate and also clearly stated inthe text. The described methods should be an accuraterepresentation of the study design. Ideally, anotherresearcher should be able to replicate the research fromreading the methodology of the paper.• Are the data presented in the results clear andappropriate? Relevant data and analyses should be clearlydisplayed in tables and figures. An explanation for thepresence of any potential bi<strong>as</strong>es and/or missing data(including how they were addressed) should be given. Somestudy designs have recommended reporting guidelines, e.g.the CONSORT statement for clinical trials. Where they do,reviewers will check if the guidelines have been followed.To ensure that the analyses you conduct are sound andappropriate consult a statistician at an early stage, preferablywhen you are writing your protocol. Mention this in yourpaper <strong>as</strong> it will re<strong>as</strong>sure the peer reviewer of the robustnessof your analyses.• Are the discussion and conclusions well balancedand adequately supported by the data? The reviewerswill <strong>as</strong>certain whether the discussion of the data and theresulting conclusions are justified, and whether limitationsof the work have been clearly stated, and the implicationsof limitations been taken into account.• Is the work clearly placed within the currentknowledge b<strong>as</strong>e and ongoing research initiatives? As peerreviewers are experts in the field, they will identify whetherthe authors are aware of currently available literature andwill expect to see acknowledgement of the key topicswithin the subject area and the necessary links made to putthe submission into the wider context.• Does the work make an original contribution toknowledge? Peer reviewers will want to be <strong>as</strong>sured that yourresearch makes an original contribution to knowledge inthe field, so you need to be explicit about the contributionyour work makes. Peer reviewers will not expect you to havemade giant leaps in knowledge, such <strong>as</strong> a cure for cancer,in one small research study. So be realistic; knowledge isgained incrementally; a small, but important, contributionis sufficient. Be aware that leading journals in the field maypublish only the most novel research studies.• Do the title and abstract accurately convey themain points of the article? Reviewers will check whetherthe title and abstract truly reflect the purpose, method,main results and conclusions of the article, and whetherany significant information is missing.• Is the writing acceptable? Reviewers are notexpected to ‘proof read’ your article, but they mayrecommend major editing before publication if there aremany grammatical and spelling errors, and if are<strong>as</strong> of textare unclear.Reviewers will make suggestions for revisions which areeither discretionary (i.e. the author can choose to ignorethem), minor essential revisions (e.g. missing labels onfigures or the wrong use of a term) or major compulsoryrevisions, to which the author must respond before adecision on publication can be reached. Peer reviewerswill also examine the plausibility of the results primarilyto identify any likely issues with the data analysis but alsoto be <strong>as</strong>sured of the veracity of the data (although a rareoccurrence, some researchers have been found to havedeliberately falsified their data).Finally, the reviewers will recommend to the journalwhether the article should be accepted or rejected, withthe decision b<strong>as</strong>ed upon the level and type of revisionsto be made and the scientific soundness of the article.They may also be <strong>as</strong>ked to comment on the relevance andimportance of the article to the journal and within the field.The journal editor will then make a decision b<strong>as</strong>ed on therecommendations of the reviewers, and provide you withthe peer reviews to <strong>as</strong>sist you in producing a further versionof the article if necessary.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201219
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.commain articlesOther ways of getting publishedThe traditional methods of publishing research inacademic journals can take a long time. If you want todisseminate your work immediately or solicit peer review/comment before submission for publication then the WorldWide Web may provide an answer.A blog (or web log) is an interactive website which ismaintained by an individual or group with regular entries.Visitors to the site can leave comments about the text,images or links contained within the blog. It may provide avery f<strong>as</strong>t way of receiving peer review or comment on ide<strong>as</strong>or research. The collective community of all blogs, theblogosphere, can be searched by topic and there are severalSearch Engines available such <strong>as</strong> Bloglines (www.bloglines.com), Blogscope (www.blogscope.net ) and Technorati(www.technorati.com). Google Blogs (www.google.com/blogsearch ) is readily available and free of charge. Forexample a simple search of “<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong>”in the Google search engine yields several relevant blogs,for example, one relating to maternity service provision.Other suitable search phr<strong>as</strong>es may be “health and socialcare <strong>South</strong> <strong>Sudan</strong>”.An extension of the blog is the “microblogging” servicetwitter (www.twitter.com ) which enables authors to rapidlysend and receive thoughts/ide<strong>as</strong> using just 140 characters.This could be a useful tool for communicating, say, withina research group. An example of a relevant search on thetwitter website using “health care <strong>South</strong> <strong>Sudan</strong>” yielded acomment from Keith Martin on maternity services withuseful links to further information. Researchers can useboth blogs and twitter to formulate and develop ide<strong>as</strong> andto quickly disseminate information.A note of caution to potential bloggers – do rememberto take responsibility for the comments within the blog andalso the comments from visitors to the site. There is a legalliability regarding defamation of character and liability.Final pearls of wisdom• If you are early in the process of planning your ownresearch study, do the study with the paper you wantto write in mind• Do <strong>as</strong>k colleagues to help you write the article – youcan halve the pain and hard work involved. Thisshort article involved some six members of academicstaff, snatching time to work together, discussing andreviewing each section. It w<strong>as</strong> great fun and reducedindividual effort!• Finally, practice, practice, and practice the craft ofwriting.So remember with careful preparation, lots of hard workand determination, anybody can publish! Good luck.References1. Murray, R. 2009. Writing for academic journals (2nded.). Maidenhead: McGraw Hill Education.2. National Library of Medicine 2011. Number ofTitles Currently Indexed for Index Medicus® andMEDLINE® on PubMed ®. Retrieved August 15,2011, from http://www.nlm.nih.gov/bsd/num_titles.html .3. Dwan K, Altman DG, Cresswell L, Blundell M, GambleCL, Williamson PR. Comparison of protocols andregistry entries to published reports for randomisedcontrolled trials. Cochrane Datab<strong>as</strong>e of SystematicReviews 2011, Issue 1. Art. No.: MR000031. DOI:10.1002/14651858.MR000031.pub2.More resources to improve our writing skills? AuthorAIDat www.authoraid.info is global online network that providessupport, mentoring and training for researchers in developingcountries. It h<strong>as</strong> an excellent library of resources (e.g. writingCVs, scientific papers, etc).Human African Trypanosomi<strong>as</strong>is (HAT)Regional Platform for Clinical Researchcall for abstract2 nd HAT Platform / EANETT Biennial Scientific Conference onNeglected Tropical Dise<strong>as</strong>es“Strengthening Capacity of African Researchers for Sustained Development”Juba, <strong>South</strong> <strong>Sudan</strong>11 th to 14 th September, 2012Abstract Deadline: 15th June, 2012 EmailS: aebeja@dndi.org & richardlaku@yahoo.com<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 20Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comREPORTS FROM SOUTH SUDANImplementing a routine health managementinformation system in <strong>South</strong> <strong>Sudan</strong>Richard Laku a , Carmen Maroto Camino b , Norah Stoops c and Mohammed Ali dAbstract<strong>South</strong> <strong>Sudan</strong> h<strong>as</strong> recently acquired statehood. Planning and management of the health care system, b<strong>as</strong>ed on evidence, requiresa constant flow of information from health services. The Division of Monitoring and Evaluation (M&E) of the Ministry ofHealth developed the framework for the health sector of the country in 2008. At that time data were collected through surveysand <strong>as</strong>sessments.Two health system <strong>as</strong>sessments conducted in 2007 (1) and 2009 (2) highlighted the absence of a working routine Health ManagementInformation System (HMIS). An M&E Scoping Mission conducted in March 2010 (3) noted the lack of tools and proceduresfor data collection, the inconsistent data flow and the limited capacity for analysis and use of data for action at all levels of thesystem. A plan to develop the system b<strong>as</strong>ed on the ‘3-ones’ strategy (one datab<strong>as</strong>e, one monitoring system, one leadership) w<strong>as</strong>put in place under the leadership of the Ministry of Health (MOH). The MOH h<strong>as</strong> since developed, tested and refined the toolsand procedures for the routine HMIS, produced a comprehensive roll out plan and started the integration of health programmesinto the system.The design of the routine HMIS tools w<strong>as</strong> followed by their pre-test in Jonglei and Upper Nile States. In these two states, thecombination of appropriate tools, training and support resulted in health facilities, counties and states officers able to provideconsistent and quality routine reports. While this happened in the two states, at central level tools were refined and explained toMOH programmes staff and partners staff; consensus w<strong>as</strong> built on the need for collecting only the relevant data for action and thedatab<strong>as</strong>e for the <strong>South</strong> <strong>Sudan</strong> information system w<strong>as</strong> developed in the District Health Information Software (DHIS). This jointapproach provided the needed impulse for the health agencies to adhere to the MOH system. From February 2011, a flurry ofactivities happened to support M&E in states and counties including provision of equipment, printing and distribution of registersand manuals and training in HMIS and DHIS of MOH officers, partners and programmes staff.This approach h<strong>as</strong> started to pay off and the routine information system is progressing. This paper presents the path followed,challenges met, advances made, and the way forward in establishing an integrated routine HMIS in <strong>South</strong> <strong>Sudan</strong>.Background<strong>South</strong> <strong>Sudan</strong> is a country coming out of more than twodecades of civil war and h<strong>as</strong> a history of marginalisationand under-development. Since <strong>Sudan</strong>’s independence littlehappened to develop the health care system or servicesin the <strong>South</strong>. During the conflict years health care w<strong>as</strong>provided by Non-Governmental Organisations (NGOs)and Faith B<strong>as</strong>ed Organisations with access estimatedat 20-25%. The health status of inhabitants w<strong>as</strong> one ofthe worst in Africa. For the major part of the war, thehealth information system w<strong>as</strong> non-existent and reducedto surveys conducted by humanitarian organizations anddevelopment partners usually for their own purposes.The signing of the Comprehensive Peace Agreement in2005, which led to a referendum in 2010 and the creationof a new country in 2011, represented the start of <strong>South</strong>a Director Monitoring and Evaluation Division, Ministry of Healthrichardlaku@yahoo.comb Liverpool Associates in Tropical Healthc Health Information Systems Programd Malaria Consortium/ Inter-Church <strong>Medical</strong> Assistance (IMA)World Health<strong>Sudan</strong> developing a health service again and building thisfrom almost nothing. However, the development of aHealth Management Information System (HMIS) couldnot happen overnight. With the MOH in its infancy therew<strong>as</strong> not a coordinated approach to collect and reportinformation from health services. Stakeholders ‘did theirown thing’, created their own tools and procedures tocollect, transmit and analyze data from health services totheir head offices or donors.The newly formed MOH set about developing thehealth care system in line with the health policy of theGovernment of <strong>South</strong> <strong>Sudan</strong>, 2006-2011. Accordingly,the health care system w<strong>as</strong> to be b<strong>as</strong>ed on evidence andmonitored by regular information from health servicesso <strong>as</strong> to guide planning and management. In line withthese principles, the MOH started the long process ofdeveloping an efficient and relevant HMIS, to provideinformation to each management level – health facilities,counties, states and central MOH. The M&E frameworkw<strong>as</strong> published in 2008 (4), but still most of the data weregenerated from surveys starting with the HouseholdSurvey (5) and also periodic data from health facilities,NGOs, international agencies and donors or through the<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201221
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comREPORTS FROM SOUTH SUDANFigure 1. Data flow of the routine HMISMOH, using the Federal Ministry of Health (Khartoumgovernment) procedures and indicators.In March 2010 (6) a rapid <strong>as</strong>sessment took place to<strong>as</strong>sess the status of the routine HMIS – the conclusionswere sobering: there w<strong>as</strong> not a system in place – datacollection w<strong>as</strong> piecemeal and in various formats; thelist of indicators for collection w<strong>as</strong> not defined or notrelevant; reports (when available) were often incompleteand, when completed, were not understood by the healthstaff. Perhaps more importantly, there w<strong>as</strong> a lack ofunderstanding by health workers of the b<strong>as</strong>ic conceptsof data collection, analysis and feedback. To compoundmatters NGOs and donors collected their indicatorsmore to serve their own individual purposes of reportingto donors than to reinforce the management b<strong>as</strong>ed onevidence principle. As providers of services, and whilethe government w<strong>as</strong> strengthening its managementcapabilities of the health care system, the NGO communityestablished their information systems b<strong>as</strong>ed on their owninformation needs.ProcessAs a result of the evidence of the rapid <strong>as</strong>sessmentthe consensus w<strong>as</strong> that to establish a working routineHMIS two principles were essential: simplicity andrelevance. The first, simplicity, required development ofuncomplicated tools to be understood and used by healthstaff and managers at all levels. The second principle,relevance, required understanding and responding to theinformation needs of health care services staff, countiesand states officers, programmes, health partners, donorsand the MOH.The first step w<strong>as</strong> to define what information shouldbe collected by the routine and the non routine systems,particularly the routine system, taking into accountlimitations for data collection inhealth services and low capacityfor analysis and interpretation athigher levels. B<strong>as</strong>ed on the M&Eframework of the health sectorand the capacity of health facilitiesstaff to calculate and use the dataelements, a list of indicators w<strong>as</strong>defined and a simple data flow putforward. The data flow (Figure 1)follows the management lines ofthe health care system:• Health facilities collectnumerical indicators on paper forthe County Health Department• Counties enter data into theDHIS, calculate coverage indicatorsand send reports to the SMOH• SMOH aggregate counties results and send Stateindicators to the central level.NGOs operating at county level report to Counties;if operating at State level they send reports to the SMOHM&E Department. Feedback follows an inverse path:from MOH to SMOH, County Health Departments andhealth facilities.The implementation milestones were:• The priority list of indicators, a sample one pagemonthly report and the quantified supervisorychecklist with guidelines were developed,discussed, pretested and refined.• Registers for all health facilities (Antenatal Care,Delivery, Outpatient Department for Adultsand Children, and Expanded Programme ofImmunization) were fine-tuned, so that registerscontained all the information needed for theroutine monthly report. Requirements for eachcategory of health services were calculated b<strong>as</strong>edon activity recorded by the health mapping of2009-2011 (7). MOH and health partners thenstarted printing and distributing the registers.• Training in HMIS and DHIS started at central,state and county levels, with very f<strong>as</strong>t achievementof computer literacy and knowledge by MOH,state and county officers (Figure 2).• Programmes’ staff and information wereprogressively integrated into the system: Malariaand Tuberculosis were the first, followed bythe Expanded Programme of Immunization,<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 22Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comREPORTS FROM SOUTH SUDANIntegrated Dise<strong>as</strong>e Surveillance and Response,and HIV.Six months after the start of activities, the MOHorganized a review meeting (8). State and countiesrepresentatives, NGOs, UN Agencies and donorscontributed their experience and helped finalise toolsand discuss strategies. The main achievement w<strong>as</strong> anagreed reformed list of indicators with programme dataelements and the first integrated routine monthly reportfor all health facilities. The report had two sections.Part 1 included all routine service indicators to me<strong>as</strong>ureperformance of high impact services; Part 2 incorporatedinformation on communicable dise<strong>as</strong>es relevant for theFigure 2. County Health Officers practice their skills in HMIS and DHID duringtraining conducted in Bor, Jonglei State in 2010, organized by IMA and the StateMinistry of Health.Integrated Dise<strong>as</strong>e Surveillance and Response division,on drugs for the pharmaceuticals directorate and ofvaccinations and vaccines for the Expanded Programmeof Immunization.Major organizational challenges were discussed to lookfor solutions:• How to improve data flow and ensure that countiesand states were not byp<strong>as</strong>sed.• How to integrate all reports (programmes,NGOs, donors) into the MOH system to reduceduplication and workload to health facilities andcounties’ staff and still get all information neededfor action.• How to improve the deficit of equipment andtools in rural are<strong>as</strong> and capacity of and supportBox 1. “Some programmes have funds, human resources andtools but they say their mission is to collect their own report ...They do not inform us or help us and we don’t have the samemeans they have. They byp<strong>as</strong>s us but we are responsible for theM&E in each state. Now that we understand the tools they mayhave to consider us <strong>as</strong> part of the team” (comment shared byM&E officers during September 2011 meeting).for the M &E officers in states and counties.Adopted Solutions1. Participants agreed that to maintain the flow ofinformation without byp<strong>as</strong>sing the lower managementlevels of the public health system (Figure 1),state and county officers had to be perceived <strong>as</strong>leaders and decision makers in HMIS/DHIS.To achieve this proficiency, an intensive trainingprogramme w<strong>as</strong> prepared and implemented:MOH, state and county officers were trained byexperts in HMIS and DHIS while other healthpartners trained programmes, health facilitiesand NGOs staff a . HMIS and DHIS manualswere finalized and shared (9). Preliminarytraining materials have been developed and ab<strong>as</strong>ic training curriculum agreed with the SMOHofficers. Feedback and performance reportshave been defined. The result is best expressedby the comments of one of the SMOH M&EDirectors quoted in Box 1.2. M&E activities have incorporatedprogrammes staff and SMOH M&E Directorsreinforce links between them and progresstowards the establishment of a national M&ETeam (Figure 3); in September 2011 trainingaddressed to M&E officers included participation ofstaff from programmes and contributed to sharing ofknowledge and experiences.3. The MOH and partners have purch<strong>as</strong>ed anddistributed equipment to reach all counties. IT equipmenth<strong>as</strong> been sent and installed to state capitals and most area Liverpool Associates for Tropical Health (LATH)- HealthInformation Systems Programme (HISP) and Inter-Church <strong>Medical</strong>Assistance (IMA) World Health trained MOH and SMOH officers,<strong>South</strong> <strong>Sudan</strong> AIDs commission and programmes staff; IMA WorldHealth focused on Upper Nile and Jonglei states staff; WHOsupported training of the Epidemiological Surveillance Officers;B<strong>as</strong>ic Services Fund (BSF) of NGO staff and counties wherethey operate; Norwegian People’s Aid (NPA) is <strong>as</strong>sisting Centraland E<strong>as</strong>tern Equatoria; Warrap State h<strong>as</strong> trained county staff withsupport from UNICEF and WHO.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201223
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comREPORTS FROM SOUTH SUDANFigure 3. John Mading, Director of M&E of Lakes States installsDHIS in his laptop with the support of the M&E Directors ofWarrap, Western Bahr El Ghazal, Unity and Upper Nile states,September 2011.operative, although the budget for recurrent expenses inM&E still needs to be addressed, to ensure autonomy ofthe M&E Department in each state.ConclusionThe implementing of a routine HMIS from scratchis challenging but possible. The system requires toolsand procedures but also an enthusi<strong>as</strong>tic, motivated andproficient team who understands the value of data forplanners and managers. <strong>South</strong> <strong>Sudan</strong> h<strong>as</strong> professionals inthe public health care system who are working to makethe routine HMIS a reality and to implement the mandateof the Government of a system b<strong>as</strong>ed on evidence. Whilethere are still challenges ahead there is also me<strong>as</strong>urableprogress. This is a joint effort between stakeholders inwhich negotiation and pragmatism are key concepts.What’s next?1. Complete the printing and distribution of registersso that all health facilities have data collectiontools.2. Provide a small allocation of funds to M&Edepartments in states and counties for printingessentials (toner and paper), fuel for the generatorand/or visits to the counties to collect reports.References3. Continue delivering training to SMOH officersso they can in turn start training their fellowcolleagues in states and counties.4. Proceed with integration of programmes into thesystem and with the integration of staff into the<strong>South</strong> <strong>Sudan</strong> M&E Team.5. Support the central HMIS Unit in Juba toundertake a country wide monitoring function.6. Ensure that the information collected is used toimprove service provision and the health of thepeople of <strong>South</strong> <strong>Sudan</strong>.1. Rajkotia Yogesh, Stephanie Boulenger, and WillaPressman. July 2007. <strong>South</strong>ern <strong>Sudan</strong> Health SystemAssessment. Bethesda, MD: Health Systems 20/20project, Abt Associates Inc2. Ministry of Health, March 2009. Assessment of<strong>South</strong> <strong>Sudan</strong> Health System Performance. Programof Technical Assistance to Health Priorities of <strong>South</strong><strong>Sudan</strong>, Liverpool Associates in Tropical Health.3. Carmen M. Camino, William Varg<strong>as</strong> and Joe Valadez,March 2010. M&E Scoping Mission, Program ofTechnical Assistance to Health Priorities of <strong>South</strong><strong>Sudan</strong>, Liverpool Associates in Tropical Health.4. Division of Monitoring and Evaluation, Ministry ofHealth, Republic of <strong>South</strong> <strong>Sudan</strong>: The Monitoring andEvaluation Framework for the health care system of<strong>South</strong> <strong>Sudan</strong>, 2009.5. <strong>South</strong>ern <strong>Sudan</strong> Household Survey report, 2006.6. Carmen M. Camino, William Varg<strong>as</strong> and Joe Valadez,March 2010. M&E Scoping Mission, Program ofTechnical Assistance to Health Priorities of <strong>South</strong><strong>Sudan</strong>, Liverpool Associates in Tropical Health.7. Ministry of Health, Division of Monitoring andEvaluation: Health Facilities Mapping report, 2009-2011.8. Division of Monitoring and Evaluation of the Ministryof Health, February 2011: Report of the review oftools and procedures of the routine HMIS.9. Mohamed Ali and Norah Stoops N: DHIS Foundationand DHIS Advanced Training Manuals for <strong>South</strong><strong>Sudan</strong> Health Care System. 2011.Nodding syndrome in Uganada According to recent reports (1,2) Nodding Syndrome (see SSMJ 4/1)h<strong>as</strong> hit Kitgum, Pader and Gulu districts in northern Uganda. More than 1000 c<strong>as</strong>es were diagnosed betweenAugust and mid-December. It h<strong>as</strong> now reached Yumbe, which borders <strong>South</strong> <strong>Sudan</strong> – where c<strong>as</strong>es have also beenreported.1.Mysterious nodding syndrome spreading through Uganda. New Scientist Health 23 December 2011.2. Daily Monitor. Kampala. 20 January 2011.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 24Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comSHORT ITEMSStuck objects on fingers: pattern seen in aNigerian teaching hospital and technique forremovalAgaba-Idu Musa aIntroductionAn ordinary ring can get stuck on a finger if it h<strong>as</strong> beenworn for a long time. This is most often due to swellingof the finger. Different techniques have been describedfor removal of such rings but when the finger is grosslyswollen and the ring is very thick or a band, these methodsare not successful (1, 2).From January 1994 to January 2011, 33 patientswho had stuck objects on their fingers were treated atthe Accident and Emergency Department, UsmanuDanfodiyo University Teaching Hospital, Sokoto, Nigeria(Figure 1). Some of the objects were rings. The rest werenuts, w<strong>as</strong>hers (width between 0.8 and 1cm; thicknessbetween 0.5 and 0.7cm) and pl<strong>as</strong>tic bands. The patientswere healthy children and mentally ill adults. In womenthe preferred finger on which these objects were wornw<strong>as</strong> the left ring finger. In children and men there w<strong>as</strong> nopreferred finger. The youngest and oldest patients were 5and 64 years respectively. Most were women. Mean age ofthe patients w<strong>as</strong> 34.2 (+.5) years. The male to female ratiow<strong>as</strong> 1:5. There w<strong>as</strong> no gangrene of any of the fingers atpresentation.Figure 1. Object stuck on adult’s finger.The technique for removalUsual ring cutters cannot cut these objects. Thepreferred instruments are technician’s instruments that aree<strong>as</strong>ily available – see Figure 2. The screw driver withouta handle is inserted between the ring and the finger. Thisprevents further injury to the finger during cutting of theobject with the junior hack saw. The object is cut at twospots along its circumference. After cutting the first spota Dept. of Orthopaedics, Usmanu Danfodiyo University TeachingHospital, PMB. 2370, Sokoto, Nigeria.agabaidu@ymail.comFigure 2. Technician’s instruments for removing objectsstuck on fingers (from left to right: screw driver without ahandle, wire stripers, wire cutters and a junior hack saw).on the ring, the wire cutters are used to widen the gapcreated on the ring. This widens the circumference of thering. Further cutting of the ring at another spot removesan arc. The space created is usually wide enough for thering to slip off. Wide bands are e<strong>as</strong>ily cut with a pair ofwire strippers.ResultOnly manual instruments are safe for the removalof these objects because powered drills generate a lot ofheat and can burn the finger and further compromise thecirculation. Ischaemia of the fingers resolved after healingof the pressure sores (Figure 1) on the proximal phalanges.The microorganism isolated from the pressure sores w<strong>as</strong>Staphylococcus aureus and most sensitive to ciprofloxacin.There w<strong>as</strong> deficiency in movement in all the joints of thefinger after healing of the pressure sores and flexion w<strong>as</strong>initially painful. This resolved with time.ConclusionThese types of patients have a poor sense of judgmentand those who take care of them should always be attentiveto what is worn on their fingers. Cheap expansible ringscan be given to them. Children can be trained to avoidwearing tight objects over their fingers. None of thepatients ever had an object stuck again on the finger.References1. WikiHow: How to remove a stuck ring. http://www.wikihow.com/Remove-a-Stuck-Ring (browsed18/11/2011).2. Harvard <strong>Medical</strong> School Family Health Guide.http://www.health.harvard.edu/fhg/firstaid/ring.shtml(browsed 18/11/2011).Photographs are the property of the author.<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201225
SHORT ITEMSSSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comC<strong>as</strong>e Study – Left Parietal Parafalcine MeningiomaClinical HistorySudden onset of right sided weakness, facial droop, previous medical history of multiple TIAs and hypertension.Figure 1. Figure 2.Pictures 1 and 2: Non-enhanced CT of the brain. These images have been acquired at patient admission featuring apoorly defined isodense extra-axial left parietal m<strong>as</strong>s lesion barely distinguishable from the adjacent normal cerebralcortex.Figure 3. Figure 4.Pictures 3 and 4: Axial and sagittal T1W MRI images post iv contr<strong>as</strong>t application. The lesion features a vividhomogenous contr<strong>as</strong>t uptake with broad b<strong>as</strong>ed dural contact and perifocal thickening of the adjacent dura resemblinga “dural tail” sign consistent with a meningioma.Radiological ReportThe non enhanced CT of the brain h<strong>as</strong> been acquired at patient admission (Pictures 1 and 2). There is no evidenceof an intracranial haemorrhage or haematoma. There is also no evidence of recent demarcated ischaemic changes,midline shift or signs of raised intracranial pressure. However, an isodense extra-axial left parafalcine soft tissue m<strong>as</strong>sis identified causing a subtle perifocal m<strong>as</strong>s effect resulting in perifocal sulcal effacement.A subsequent pre and post iv contr<strong>as</strong>t MRI of the brain confirms the initial CT findings. The suspicious lesion displaysa homogenous hypointense signal appearance in T1W images featuring a thin capsule. The T2W images display ahyperintense signal pattern of the lesion concerned. Post contr<strong>as</strong>t T1W images (Pictures 3 and 4) demonstrate a denselyenhanced lesion with broad b<strong>as</strong>ed dural attachment and an enhanced meningeal tail <strong>as</strong> well moderate compressionof the adjacent slightly displaced parietal par<strong>as</strong>agittal gyri. No perifocal oedema is identified. No malignant growthpattern or bony destruction is noted.CT and MRI findings are consistent with a benign parietal parafalcine meningioma.Contributed by Dr med. Stephan Voigt, Consultant Radiologist, St. Mary’s Hospital, Isle of Wight, UK. stephan.voigt@iow.nhs.uk<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> 26Vol 5. No 1. February 2012
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comRESOURCESResourcesThese are listed under:••General informationNon-communicable dise<strong>as</strong>esGeneral informationInformation and Evidence of Effectiveness for PublicHealth in Low and Middle-Income Countries:This site gives an excellent summary and very many usefulwebsites on key health issues and conditions that arecommon in resource poor settings and which are relatedto the Millennium Development Goals. They have beencompiled by Wessex Deanery and are freely available at:http://www.wessexdeanery.nhs.uk/public_health/international_public_health/sources_of_help__effectivenes.<strong>as</strong>px.From John Acres, Training Programme Director (PublicHealth) Hants & IoW, UK. via HIFA2015.Infographics on malaria, child health etc.The Bill & Melinda Gates Foundation also offers anexcellent set of Infographics on their web sitehttp://www.gatesfoundation.org/infographics/Pages/infographics.<strong>as</strong>px. Topics covered include: Malaria;Maternal, Newborn, & Child Health; Simple Tools toSave the Lives of Mothers and Kids; Nutrition; Polio;Vaccines; Family Planning.Supplied by The Mother and Child Health and EducationTrust. www.motherchildtrust.org. From CHILD2015weekly digest 10/24/11Global Health PortalThe Lancet h<strong>as</strong> launched a Global Health Portal at http://www.thelancet.com/global-health, which offers freeaccess to all global health content in one location includingSeries, Regional Reports, multimedia content, and theirWorld Report and Perspectives sections. World Reportsand Perspectives articles are ideal for anyone who wants apersonal view on a subject, and The Lancet Global HealthSeries, and Regional Reports and Commissions providein-depth views for anyone seeking dise<strong>as</strong>e-specific orregional information. Recent Global Health Series includeObesity, New Decade of Vaccines, and Chronic Dise<strong>as</strong>esand Development.[From HIFA2015 28Aug2011 www.hifa2015.org ]Special Programme for Research and Training inTropical Dise<strong>as</strong>es (TDR)TDR is a WHO-b<strong>as</strong>ed global programme of scientificcollaboration that helps coordinate, support and influenceglobal efforts to combat a portfolio of major dise<strong>as</strong>es ofthe poor and disadvantaged. On the website are manydownloadable and free publications and images. Seehttp://www.who.int/tdrNon-communicable dise<strong>as</strong>esNon - communicable dise<strong>as</strong>es (NCD): TrainingdocumentsThe following websites provide a set of useful materials fortraining on NCD. They have been prepared or compiledby Dr Richard Smith for use in low- and middle-incomecountries.1. A very good PowerPoint presentation at http://bit.ly/x0eEgc.2. The WHO Global Status Report on NCDsproduced for the UN High-level meeting at http://bit.ly/gMgU1z. This contains a huge amount of informationand is e<strong>as</strong>y to use.3. The Secretary General's report from for the UNHigh-level Meeting at http://bit.ly/x0eEgc . Also verywell presented.SSMJ thanks Richard Smith and ProCor for permission topublish and David Tibbutt for reviewing the documents.[Seen at ProCor http://www.procor.org which is aglobal community promoting cardiov<strong>as</strong>cular health andinformation sharing. Join the group by emailing subscribeprocor@list.procor.org].E<strong>as</strong>t Africa: Deaths result from insufficient fruit andvegetable intakeAround 27% of all deaths in the E<strong>as</strong>t Africa region canbe attributed to low fruit and vegetable intake, accordingto a recent WHO and FAO report. Although the reportrecommends 146 kg per capita consumption of fruits andvegetables, countries in the region fail to meet the standard.Kenya's consumption of fruits and vegetables is 115 kg percapita, Uganda is 65 kg per capita, and Tanzania is 60 kg percapita - just 41% of the recommended minimum. Expertsbelieve the insufficient intake of fruits and vegetables isnot only a c<strong>as</strong>e of affordability or accessibility, but alsoof perception and behaviour change. Do you think thesituation is the same in <strong>South</strong> <strong>Sudan</strong>?See the report at http://bit.ly/sd9cdg [from procor2Nov11]<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> Vol 5. No 1. February 201227
SSMJ Vol 5. No 1. February 2012 <strong>Download</strong>ed from www.southsudanmedicaljournal.comExamples of checklists for community-b<strong>as</strong>ed frontline health workers in <strong>South</strong> <strong>Sudan</strong>.Here are two of nine checklists from the Maternal, Newborn, and Child Survival (MNCS) Initiative, which were developed andis being implemented countrywide by M<strong>as</strong>sachusetts General Hospital and the Ministry of Health. These two checklists illustrate theb<strong>as</strong>ic steps community-b<strong>as</strong>ed providers can use to address newborn resuscitation (e.g. warming and drying, <strong>as</strong>sessment of breathing,clearing airway and stimulation, tying and cutting cord, and bag-m<strong>as</strong>k ventilation) and to recognize danger signs in children (tachypnea,seizure, lethargy, fever, and poor appetite). For more information, ple<strong>as</strong>e contact: Dr Thom<strong>as</strong> Burke, tfburke@partners.org.Every effort h<strong>as</strong> been made to ensure that the information and the drug names and doses quoted in this <strong>Journal</strong> arecorrect. However readers are advised to check information and doses before making prescriptions. Unless otherwise<strong>South</strong> <strong>Sudan</strong> <strong>Medical</strong> <strong>Journal</strong> stated the doses quoted are for adults. Vol 5. No 1. February 2012