Nodding syndrome in Mundri county, South Sudan: environmental, nutritional and infectious factors.

BACKGROUND: Nodding Syndrome is a seizure disorder of children in Mundri County, Western Equatoria, South Sudan. The disorder is reported to be spreading in South Sudan and northern Uganda. OBJECTIVE: To describe environmental, nutritional, infectious, and other factors that existed before and during the de novo 1991 appearance and subsequent increase in cases through 2001. METHODS: Household surveys, informant interviews, and case-control studies conducted in Lui town and Amadi village in 2001-2002 were supplemented in 2012 by informant interviews in Lui and Juba, South Sudan. RESULTS: Nodding Syndrome was associated with Onchocerca volvulus and Mansonella perstans infections, with food use of a variety of sorghum (serena) introduced as part of an emergency relief program, and was inversely associated with a history of measles infection. There was no evidence to suggest exposure to a manmade neurotoxic pollutant or chemical agent, other than chemically dressed seed intended for planting but used for food. Food use of cyanogenic plants was documented, and exposure to fungal contaminants could not be excluded. CONCLUSION: Nodding Syndrome in South Sudan has an unknown etiology. Further research is recommended on the association of Nodding Syndrome with onchocerciasis/mansonelliasis and neurotoxins in plant materials used for food.

The early response to a novel coronavirus in the Middle East.

The detection of a novel coronavirus in patients from the Arabian Peninsula in late 2012 raised serious concerns of a possible international outbreak. Ministries of health of the three affected countries invited missions from the World Health Organization to participate in a review of data and capacity to detect and respond to further cases. Recommendations were made for investigations to answer critical questions about human-to-human transmission and the geographic extent of the virus. Additional recommendations were made to improve surveillance capacity by acquiring the capacity to test for the virus and enhance syndromic surveillance. Available evidence continues to suggest an unknown animal reservoir for the virus with sporadic zoonotic transmission the primary epidemiological pattern of transmission. Human-to-human transmission, while it can occur, does not appear to be sustained in the community.

The early response to a novel coronavirus in the Middle East

The detection of a novel coronavirus in patients from the Arabian Peninsula in late 2012 raised serious concerns of a possible international outbreak. Ministries of health of the three affected countries invited missions from the World Health Organization to participate in a review of data and capacity to detect and respond to further cases. Recommendations were made for investigations to answer critical questions about human-to human transmission and the geographic extent of the virus. Additional recommendations were made to improve surveillance capacity by acquiring the capacity to test for the virus and enhance syndromic surveillance. Available evidence continues to suggest an unknown animal reservoir for the virus with sporadic zoonotic transmission as the primary epidemiological pattern of transmission. Human-to-human transmission, while it can occur, does not appear to be sustained in the community

Improving influenza surveillance in sub-Saharan Africa.

PROBLEM: Little is known about the burden of influenza in sub-Saharan Africa. Routine influenza surveillance is key to getting a better understanding of the impact of acute respiratory infections on sub-Saharan African populations. APPROACH: A project known as Strengthening Influenza Sentinel Surveillance in Africa (SISA) was launched in Angola, Cameroon, Ghana, Nigeria, Rwanda, Senegal, Sierra Leone and Zambia to help improve influenza sentinel surveillance, including both epidemiological and virological data collection, and to develop routine national, regional and international reporting mechanisms. These countries received technical support through remote supervision and onsite visits. Consultants worked closely with health ministries, the World Health Organization, national influenza laboratories and other stakeholders involved in influenza surveillance. LOCAL SETTING: Influenza surveillance systems in the target countries were in different stages of development when SISA was launched. Senegal, for instance, had conducted virological surveillance for years, whereas Sierra Leone had no surveillance activity at all. RELEVANT CHANGES: Working documents such as national surveillance protocols and procedures were developed or updated and training for sentinel site staff and data managers was organized. LESSONS LEARNT: Targeted support to countries can help them strengthen national influenza surveillance, but long-term sustainability can only be achieved with external funding and strong national government leadership.

Clinical and epidemiologic characteristics of nodding syndrome in Mundri County, southern Sudan.

BACKGROUND: Nodding syndrome (repetitive nodding and progressive generalized seizures) is assuming epidemic proportions in South Sudan, Tanzania and Uganda. OBJECTIVE: To describe clinical and epidemiological features of nodding syndrome in southern Sudan based on preliminary investigations conducted in 2001 and 2002. METHOD: Household surveys, clinical, electrophysiological (EEG) assessments, informant interviews and case-control studies were conducted in the town of Lui and the village of Amadi in southern Sudan. RESULTS: Nodding syndrome is characterized by involuntary repetitive nodding of the head, progressing to generalized seizures; mental and physical deterioration. The EEGs were consistent with progressive epileptic encephalopathy. Prevalence of Nodding syndrome in Lui and Amadi was 2.3% and 6.7% respectively. All case control studies showed a positive association between cases and Onchocerca volvulus. A history of measles was negatively associated with being a case: 2/13 of cases and 11/19 of controls had had measles: odds ratio 0.13 (95% CI 0.02, 0.76). Environmental assessment did not reveal any naturally occurring or manmade neurotoxic factors to explain Nodding Syndrome, although fungal contamination of food could not be ruled out. CONCLUSION: Nodding Syndrome was strongly associated with Onchocerca volvulus. There was no evidence to suggest an environmental pollutant, chemical agent, or other toxic factor.

Oesophageal pH monitoring in infants: elimination of gastric buffering does not modify reflux index.

BACKGROUND: Oesophageal pH monitoring is considered to be the gold standard investigation in the diagnosis of gastro-oesophageal reflux disease. Results of pH monitoring in regurgitating infants, however, may be within normal ranges. Therefore it was hypothesized that prolonged buffering of gastric acidity caused by milk-feeding may falsely normalize the pH data. Therefore, it may be relevant to omit the periods of gastric acid buffering in the analysis of the oesophageal pH monitoring data. METHODS: Combined gastric and oesophageal pH monitoring (Digitrapper Mark III, two-channel antimony electrode, Synectics) was performed in 90 consecutive infants, 0.5-10 months old, who were referred to the unit by outdoor paediatricians for pH measurement. The data were analysed in three different ways. The reflux index (RI), or the percentage time that the pH in the oesophagus was < 4.0, was calculated in three different ways: (i) the total duration of the investigation; (ii) excluding 90-min postprandial periods, starting from the beginning of a feeding; and (iii) excluding all periods with a gastric pH > 4.0, which are the periods of gastric buffering with a theoretical impossibility of recording an oesophageal pH < 4.0. RESULTS: The mean duration of the pHmetries was 19.20+/-2.01h (A; mean +/- 1 SD), with a RI of 5.38+/-5.39% (B; median 3.45%). If the 90-min postprandial periods were not considered, the mean duration decreased to 12.21+/-2.41h (C; P(A vs C) < 0.001), with an oesophageal RI of 6.82+/-6.57% (D; median: 4.65; P(B vs D) = NS; r (B vs D) = 0.97). If all periods with a gastric pH > 4.0 were elminated, the duration available for analysis of the data with a gastric pH < 4.0 was 12.53+/-4.00 h (E; P(A vs E) < 0.001; P(C vs E) = NS), with an oesophageal RI of 7.06+/-7.52% (F; median: 4.50; P(B vs D vs F) = NS; r(B vs F), (D vs F) = 0.96). CONCLUSION: Overall the data do not support a benefit from including periods of gastric buffering in the routine analysis of oesophageal pH monitoring data. Therefore standard oesophageal pH monitoring should be with a single electrode and should not include periods of gastric buffering.

Normal ranges of continuous pH monitoring in the proximal esophagus.

BACKGROUND: To determine normal ranges of gastroesophageal reflux (GER) in the proximal esophagus, measured with continuous pH monitoring. Normal ranges in the distal esophagus have been published. Because esophageal pH monitoring is frequently performed in children with atypical manifestations such as chronic respiratory disease, and because one of the possible pathophysiologic mechanisms may be (micro-)aspiration, it may be relevant to establish normal ranges in the proximal esophagus. METHODS: Twenty-four-hour pH monitoring was performed in 200 children with suspected GER disease. The mean age of the patients was 4.5 months (range, 0.5-17.0 months). After initial analysis, patients were divided into three groups according to the reflux index (RI) in the distal esophagus, because it could be speculated that the amount of reflux reaching the proximal esophagus depends on the amount of reflux in the distal esophagus: Group I (n: 120) children had a distal RI of less than 5% and were considered normal, group II (n:50) had a distal RI of 5% to 10% and was considered to have intermediate disease, and group III (n:30) had a distal RI of more than 10% and was regarded as pathologic. The following parameters are calculated: the RI, the total number of reflux episodes, the number of reflux episodes lasting more than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT). RESULTS: The median RI in the distal esophagus was 3.8 +/- 0.34 (standard error of the mean [SEM]), and in the proximal esophagus, the RI was 1.2 +/- 0.23. In group I patients, the RI in the proximal esophagus was 0.5% +/- 0.09%, in group II the RI increased significantly to 2.75% +/- 0.34% (P [group I compared with group II] < 0.01), and in group III the RI was 6.15% +/- 0.96% (P [II-III] < 0.01). The number of acid reflux episodes in group I was 17.0 +/- 2.27, in group II the number increased to 62.5 +/- 8.18 (P [I-II] < 0.01), and in group III it reached 102.0 +/- 23.9 (P [II-III] < 0.05). Also the duration of the longest reflux episodes and the number of reflux episodes lasting more than 5 minutes increased from group I to group II, and from group II to group III. The ACT was shorter in the proximal esophagus (group I 0.3 +/- 0.06 minutes; group II 0.48 +/- 0.07 minutes, P [I-II] = not significant [NS]; group III 0.56 +/- 0.17 minutes P [II-III] = NS) than in the distal esophagus (group I 0.49 +/- 0.03 minutes, P [proximal ACT compared with distal ACT] < 0.05; Group II 0.76 +/- 0.05 minutes, P [proximal-distal] < 0.01; Group III 0.89 +/- 0.09 minutes, P [proximal-distal] = NS) suggesting more effective esophageal clearance in the proximal esophagus. CONCLUSIONS: Protection of the proximal esophagus from acid reflux is significantly related to the incidence and duration of reflux measured in the distal esophagus. These normal ranges in the upper esophagus will be helpful in the interpretation of upper esophageal pH monitoring data.

Intragastric balloons in adolescents with morbid obesity.

OBJECTIVES: Morbid obesity inducing medical pathologies such as hypertension, hypercholesterolaemia or orthopaedic abnormalities is an increasing problem in adolescents. Intragastric balloons have been used, with a varying degree of success, in adults. METHODS: An intragastric silicone balloon was filled with 500-700 ml physiological serum in five adolescents (11-17 years old) with a morbid obesity (body mass index percentage (BMI %, calculated as a percentage of normal BMI for patient's sex and age, range 148-293%), and was left in place for six months. RESULTS: The balloons were well tolerated. A transient beneficial effect was noted, with a non-significant trend in decrease of the BMI % after 3 months (P = 0.07). However, 3 months later (6 months after the insertion), the BMI % in all five adolescents was significantly higher than before insertion of the balloon (P < 0.05). CONCLUSION: We observed a failure to lose weight with the help of an intragastric balloon in five selected adolescents. Since the beneficial effect of intragastric balloons in the five adolescents studied was only temporary, these balloons seem not to be indicated in adolescents with morbid obesity.

Effect of prokinetics in children with recurrent nocturnal retrosternal pain.

BACKGROUND: Children rarely present with vague complaints of nocturnal recurrent retrosternal or upper-abdominal, epigastric, pain. Dysmotility of the upper gastrointestinal tract, including gastro-oesophageal reflux, might be at the origin of these manifestations. OBJECTIVE: To evaluate the clinical effect of prokinetics (cisapride) in children with recurrent nocturnal retrosternal pain, and to measure the effect of cisapride with a combined oesophageal ambulatory 24 h pH and pressure monitoring. PATIENTS: Twelve children, mean age 9.5 years (range 4.1-14.0 years), with nocturnal recurrent retrosternal pain for more than 6 months, occurring at least three times a week. METHODS: Single-blinded prospective study, with two periods of 2-3 weeks during which cisapride was administered, alternated with two placebo periods of the same duration. Clinical evaluation, and assessment with oesophageal pH and pressure monitoring. RESULTS: Cisapride was related to a temporary relief of the symptoms in 10/12 children. The improvement was demonstrated through a normalization of pH monitoring, and an increase in amplitude and duration of the contractions in the lower oesophagus. CONCLUSION: Cisapride improves complaints of recurrent nocturnal retrosternal pain in children.