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Malaria remains a heavy burden in sub-saharan Africa and accounts for over one million deaths per annum. Prompt and appropriate management of severe cases is critical in both disease control and reduction in mortality. This study explores the management actions of doctors in urban settings in Nigeria. A survey of medical practitioners in four urban local government areas (LGAs) in two states in South- Eastern Nigeria was conducted. Using simple random sampling technique, sixty doctors were chosen in each of the four LGAs giving a total of two hundred and forty. They were interviewed on their management actions for children with severe malaria. The mean age of the doctors was 34.6 years. 83.5%(167) of them were males while 16.5% (33) were females. 65.5% (131) of the doctors attend to children regularly. The common features of severe malaria seen include; high fever 52.7% (69), persistent vomiting 27.5% (36), severe anaemia 24.4% (32), refusal of drinks 7.6% (10), convulsion 7.6% (10), loss of consciousness 4.6% (6) and respiratory distress 2.3% (3). 79.4% (104/131) of the doctors that see children regularly have diagnosed cerebral malaria in the last five years. Quinine is the drug of choice for the treatment of cerebral malaria 87.8% (115/ 131). 56.5% (74/131) of the practitioners see patients with severe anaemia requiring blood transfusion on a monthly basis. The monthly mean of such anaemic patient per physician is 6.7 patients. The median time for blood transfusion from time of request to onset of transfusion is 3 - 4 hours. The current state of health facilities and personnel is not meeting up with the malaria challenge. Urgent efforts need to be made to curb the scourge.
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PMID:Assessment of doctors' management of severe malaria in urban centres in Eastern Nigeria. 1556 34

Hospital emergency department (ED) syndromic surveillance has been proposed for early detection of a large-scale biologic terrorist attack. However, questions remain regarding its usefulness. The authors examined the use of active syndromic surveillance at hospital EDs in Virginia for early detection of disease events and analyzed the effectiveness of the cumulative sum (CUSUM) algorithm in identifying disease events from syndromic data. Daily chief-complaint data were collected for 10 months at seven hospital EDs in southeastern Virginia. Data were categorized into seven syndromes (fever, respiratory distress, vomiting, diarrhea, rash, disorientation, and sepsis), and the CUSUM algorithm was used to detect anomalies in each of the seven syndromes at each hospital. Fever and respiratory distress syndromes exhibited monthly and ambient-temperature-specific trends consistent with southeastern Virginia's influenza season. Furthermore, preliminary frequencies of hospital ED patient chief complaints in southeastern Virginia during a 10-month period were produced by using syndromic data. This system represents an example of a local syndromic surveillance program serving multiple cities in a limited geographic region.
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PMID:Syndromic surveillance at hospital emergency departments--southeastern Virginia. 1571 30

The pine processionary moth (Thaumetopoea wilkinsoni) is an insect of medical significance in the eastern Mediterranean. This report describes three exposure cases in dogs due to ingestion of this moth's caterpillars in Israel. All three dogs were observed in direct contact with caterpillars or pinecones in infested gardens. The disease course and progression of signs were acute in all three cases, and included vomiting and severe tongue swelling. Physical examination findings included hyperthermia, tachypnoea, respiratory distress, cyanosis and tongue oedema, labial angioedema, ptyalism, bilateral submandibular lymphadenomegaly and conjunctivitis. Severe tongue necrosis and sloughing of its distal portion occurred 2-5 days after admission to the hospital. All dogs recovered and were discharged within 2-7 days of admission. Two staff members, attending one of the dogs, experienced an itchy rash and wheals on their arms, wrists and necks. To the best of our knowledge, this should be the first report of severe oral lesions and tongue necrosis due to contact with T. wilkinsoni caterpillars.
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PMID:Severe tongue necrosis associated with pine processionary moth (Thaumetopoea wilkinsoni) ingestion in three dogs. 1573 65

Significant mortality, high incidences of complications and permanent neurological sequel are still noted in patients suffering fro herpetic encephalitis. They result mainly from delayed diagnosis and treatment of the specific cause. The aim of our paper was the analysis o a clinical course of patients with Herpes simplex encephalitis. From 1999 to 2001 7 patients aged 2 weeks to 15 years, treated in Children' Neurology Department of Silesian School of Medicine, were diagnosed to have herpetic encephalitis. Fever, headache, vomiting, as well as alteration of consciousness, all typical for neuroinfection were main clinical symptoms present on admission. Three children presented with respiratory distress requiring admission to Intensive Care Unit. On examination "cold sores" were found in 2 patients, in remaining 5 the history of exposition to herpes labialis was obtained. On neurological examination we found either right or left hemiparesis in all patients, motor aphasia in 2 and left sided central facial nerve palsy in 1. Lumbar puncture revealed lymphocytosis in 5 patients. Anti-HSV type IgG an IgM antibodies were found in serum of all 6 patients, while only in 2 of them were detected in cerebrospinal fluid (CSF). These were the 2 most severely ill children. In 2 patients DNA HSV using PCR (polymerase chain reaction) method was found in CSF and in serum. Magnetic resonance imaging (MRI) of the head confirmed diagnosis. Although herpetic encephalitis is an uncommon, sporadic disease, the diagnosis should be considered in any child with neuroinfection and early treatment started before laboratory confirmation.
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PMID:[Herpes encephalitis at children]. 1576 59

We present the clinical features, radiological findings and outcome of infants with non-accidental head injury presenting to our department between 2001 and 2003. There were 26 male and 13 female infants, aged between 7 days and 5 months. Presenting symptoms included seizures, vomiting, bulging fontanel, decreased level of consciousness, focal neurological signs, anemia and respiratory distress. We classified the patients into three groups: mild head injury (8 patients), moderate head injury (11 patients) and severe head injury (20 patients). Detailed history taking and thorough physical examination, did not reveal obvious injury or abuse (by the parents), other external visible injury or significant incidence of retinal bleeding. CT scan showed intracranial hemorrhage in all patients, most commonly including acute or acute on chronic subdural hematoma (SDH) and subarachnoid hemorrhage (SAH) in the parafalcine and tentorial regions and over the brain convexity, associated with focal or diffuse hypodensity of the parenchyma. Intracranial lesions were mostly bilateral (80%). These patients generally had a poor outcome; 31% died, 23% had a good outcome, and the remainder recovered with neurological impairment of varying types and degrees. After comprehensive assessment, we concluded that all the cases in our series were "non-accidental" head injuries. However, the absence of retinal bleeding, visible external injury and recognised abuse in our series differed from reports by other investigators. In our opinion these features are not absolute requirements in diagnosing "non-accidental" injury and detailed history taking, thorough clinical examination and radiological studies were the key indicators of the diagnosis.
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PMID:Clinical analysis of non-accidental head injury in infants. 1585 Oct 71

Epidemics of malaria have occurred in highland areas of East Africa since the 1980s, but the clinical spectrum of severe malaria in these areas has not been described. Over a 17-month period from 2001 to 2002, we assessed 117 consecutive patients admitted to Kabale Hospital in highland Uganda who met the World Health Organization 2000 criteria for severe malaria. Sixty-six persons (56.4%) were age 5 years or older, and 51 (43.6%) were under 5 years of age. Fever, vomiting, and cough were the most frequent symptoms. Hepatomegaly and splenomegaly were infrequent. Prostration was the most frequent manifestation of severe malaria in children under 5 years of age (45.1%) and persons 5 years or older (65.2%), followed by respiratory distress (29.4%) and severe anemia (19.6%) in children under 5 years, and respiratory distress (15.2%) and impaired consciousness (13.6%) in persons 5 years or older. Strictly defined cerebral malaria was uncommon (3.4%). In a multivariate regression model, children under 5 years were more likely than persons 5 years or older to present with severe anemia (OR 5.2, 95% confidence interval [CI] 1.2-21.9) and respiratory distress (OR 3.5, 95% CI 1.3-11.1) and less likely to present with prostration (OR 0.3, 95% CI 0.1-0.7) and impaired consciousness (OR 0.2, 95% CI 0.0-0.9). In highland Uganda, severe malaria often occurs in persons older than 5 years of age. "Typical" signs like splenomegaly are frequently absent, prostration is the major manifestation, and other manifestations vary in frequency according to age.
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PMID:Clinical manifestations of severe malaria in the highlands of southwestern Uganda. 1589 Nov 30

A boy aged 6 months and a girl aged 9 months were admitted due to vomiting, among others, and a boy aged 11 months due to pneumonia. It turned out that they had a congenital diaphragmatic hernia. Primary operative repair was performed successfully in all patients, followed by recovery. The older boy experienced a relapse nearly 1 year later, which was treated by surgical correction. Most congenital diaphragmatic hernias present directly after birth, with cyanosis and respiratory distress. However, 10-20% of the cases are discovered after this period. In these children diagnosis can be difficult because of the diverse symptoms such as vomiting, feeding difficulties, tachypnoea or recurrent respiratory tract infections. Physical signs include the absence of breath sounds or the presence of bowel sounds in the chest. Chest X-ray, contrast upper gastrointestinal series or ultrasound imaging confirms the diagnosis. Delay in treatment can lead to complications such as necrosis of the bowel. In young children with acute or chronic respiratory infections or gastrointestinal complaints, a congenital diaphragmatic defect should be considered.
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PMID:[Late presentation of congenital diaphragmatic hernia]. 1593 31

Infantile myofibromatosis is a disorder of infancy and early childhood, typically presenting as a solitary lesion or multiple widespread nodular tumors localized to skin, subcutaneous tissue, muscle, bone, viscera, or central nervous system. We present a case of infantile myofibromatosis, multicentric type, in a 4-month-old male infant who initially presented with an occipital scalp mass and other skin-colored nodular mass lesions over his face, trunk, and four limbs. He received tissue biopsy to establish a definite diagnosis. Craniotomy was also arranged for tumor removal due to dural involvement with internal extension and compression of adjacent sigmoid sinus. The patient eventually died of cardiopulmonary failure secondary to primary pulmonary hypertension at age 11 months. Before his death, he had suffered from abdominal distention and frequent vomiting, followed by aggravated respiratory distress and cyanosis. Aggressive surveillance for cardiopulmonary or gastrointestinal involvement is recommended in such cases because prognosis varies according to the involvement of vital organs.
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PMID:Infantile myofibromatosis presenting with scalp dermoid cyst. 1619 33

Lithium (Eskalith) is commonly used in the treatment of depressive and bipolar affective disorders, in a population at relatively high risk for overdose. Lithium may help correct a chemical imbalance in the brain; however, it has a comparatively narrow therapeutic index. Thus, lithium intoxication is a frequent complication of chronic lithium therapy. The central nervous system (CNS) is the major organ system affected, although the renal, gastrointestinal (GI), endocrine, and cardiovascular (CV) systems also may be involved. Here we present a forty-two-year-old Caucasian female with altered mental status, inability to eat, speak or walk properly, with shaking and vomiting for three days. Past medical history was significant for hepatitis C and bipolar disorder. Vital signs were within normal limits. Physical exam revealed a patient with aphasia, tremor, and an expressionless face, able to make eye contact and move all four extremities. However, she was unable to follow commands and she expressed rigidity of extremities, mild tachycardia, and stupor. Severely elevated serum lithium levels were found. A diagnosis of severe lithium toxicity was made and the patient was admitted to the telemetry unit. Intravenous hydration with normal saline was initiated as the patient had normal kidney function, and urinary output was monitored. All psychotropic medications were held except for a benzodiazepine. In the meantime the patient developed acute respiratory distress, was intubated on clinical grounds and was transferred to the intensive care unit. Acute cardiogenic pulmonary edema and other causes of respiratory distress were ruled out; diagnosis of Adult Respiratory Distress Syndrome (ARDS) was made. After two months of mechanical ventilation, the patient was stabilized. Mental status, vital signs, and all laboratory parameters including thyroid function tests, normalized. The patient was transferred to a rehabilitation center. This is a rare case of ARDS associated with lithium intoxication.
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PMID:Prolonged requirement for ventilatory support in a patient with Eskalith overdose. 1641 84

Current data concerning epidemiology, clinical picture, pathogenesis, prevention and treatment of Avian influenza H5N1, data of pharmacodynamics and pharmacokinetics of antiviral drugs--neuraminidase inhibitors and M2 channels inhibitors, also the recommendation of WHO for prevention prevalence of infection were discussed in the review. Strategic measures of WHO aims to protect humans from contact with infected poultry, in case of contact, to prevent transmission of this infection from human to human and occurrence of pandemic. Infected birds were the major source of the H5N1 influenza virus among humans in Asia. Mainly humans became infected by eating infected birds, by poor hygiene procedures when cooking infected birds, or by close contact with infected poultry. At present transmission of the H5N1 influenza from human to human by aerosol way hasn't been registered, but ongoing monitoring for identification mutation and adaptation of H5N1 influenza virus to human is needed. Season influenza and avian H5N1 influenza differ by the ways of transmission, clinical picture, severity, pathogenesis, response to treatment. Diagnostic of infection is difficult due to non-specific initial symptoms, in most cases disease begins with disturbance of under respiratory ways and in rare cases--from upper respiratory ways. High viral titre is identified in pharynx but not in nose. Initial symptoms of the H5N1 influenza are: fever greater then 38 degrees Celsius, mild cold, cough and shortness of breath, practically all patient have viral pneumonia, later secondary bacterial infection occurs, mild to severe respiratory distress, diarrhea, vomiting and abdominal pain. Conjunctivitis is rarely diagnosed contrary to season influenza. Sometimes gastrointestinal disorder begins a week early then respiratory symptoms. Complication also includes renal and multi organ failure. The cytokine storm is commonly developed during H5N1 influenza. For treatment and for prevention (under certain conditions) of the H5N1 influenza neuraminidase inhibitors such as oseltamivir (Tamiflu) and zanamivir (Relenza) are recommended. Currently circulatory of the H5N1 strains are fully resistant to an older class of antiviral drugs--the M2 channels inhibitors (amantadine and rimantadine). The knowledge of epidemiology, pathogenesis, clinical picture, treatment of the H5N1 influenza in humans, in spite of progress isn't complete. Future coordination of scientific investigation of the H5N1 influenza in humans should be provided not only in the countries where infection was revealed, but all around the world.
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PMID:[Epidemiology, clinical picture, prevention and treatment of Avian influenza]. 1657 38


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