The successful acquisition of clinical skills is essential to development and competence as a clinician. Clinical skills can be assessed in undergraduate education and in the workplace after graduation. Clarity about what is being assessed, and why, should support the development of any assessment process.
Infections and rheumatic diseases have shared a close relationship since time immemorial. Some rheumatic diseases are a direct consequence of infections while others have been associated with certain microbes without an established causal link. The above relationship is becoming more and more complex due to rapid advances in therapeutics, and also because of factors such as climate change and worldwide travel.
Participation in clinical practice is key to the development of clinical skills, and so the goal of clinical work is both to deliver healthcare and facilitate learning. Four factors shape learning in the workplace: safe access to practical experience; the role of talk in the workplace; teaching opportunities; and the learning climate. The challenge is to structure and carry out work so that support for learning is built into normal work routines.
Tuberculous pericarditis is a serious problem in sub-Saharan Africa with a mortality at six months of about 40% if there is associated HIV infection and 17% without. The key to improved treatment is for the clinician to be alert to the warning features, to conclude the diagnosis promptly and institute treatment as a matter of urgency.
Many variables affect the outcome of classroom teaching. Planning is needed to consistently achieve success. This includes the creation of a lesson plan, with teacher and learner activity focused on achieving the intended learning outcomes. Key issues to be considered are class size; creating a physical and psychological environment for learning; and supporting learning with ‘scaffolding’ and formative assessment.
Prompt diagnosis and treatment of Diabetic Ketoacidosis (DKA) with the correct administration of intravenous (i.v.) fluids, fixed rate insulin infusion (FRII) and guideline-based K+ replacement are essential for optimum outcomes. However, treatment guidelines may need to be adapted in special situations such as pregnancy, end stage renal disease or where resources, such as infusion pump equipment, may not be available. Children require treatment according to specific paediatric guidelines particularly to minimise the risk of cerebral oedema. Although DKA is a serious and complex medical emergency, skilled medical care can reduce mortality rates to below 1%.
The priorities for the management of Diabetic Ketoacidosis (DKA) are to assess severity and establish intravenous (i.v.) 0.9% NaCl rehydration with the careful addition of potassium ([K+]). Ideally, a fixed rate insulin infusion should be used initially and addition of 10% glucose infusion when the blood glucose level has fallen to below 14 mmol/l. Regular clinical and laboratory monitoring, particularly of the rate of fall of blood ketones (beta-hydroxybutyrate) and of serum [K+] and glucose is essential to guide fluid and insulin infusion rates.
The metabolic derangements that lead to Diabetic Ketoacidosis (DKA) are described. Understanding the pathogenesis is the key to rapid and accurate diagnosis and hence successful management. DKA may often be prevented by clear advice to patients about how to manage their type 1 or ketosis-prone type 2 diabetes during periods of intercurrent illness. DKA must be considered in the differential diagnosis of metabolic acidosis even where other diseases that may present similarly, such as malaria, are highly prevalent.
Obstetric fistula is one of the most feared complications of labour, leaving a woman with a life of ostracism and shame due to her complete incontinence. Many women see this as a curse for something they did and many end up trying to take their life. Obstetric fistula patients present with a complicated array of physical and psychological needs which should all be addressed by the medical team caring for her. In the majority of cases, obstetric fistula is curable as long as the doctor is trained in and skilled in the right surgical techniques. However, the most important message is that obstetric fistula is preventable. Ensuring that all women receive proper, affordable and timely medical care in labour will ensure that women will not need to fear such dreadful sequalae of trying to have a baby.
This paper presents a viable solution that evolved over several years of research to mitigate the sanitation problems faced by individuals in rural areas of Uganda, particularly those with disabilities, addressed in our first paper (Schmachtenberger et al.). The solution is based on interviews and contacts with affected individuals in Lira, Northern Uganda, where the most commonly used sanitation facility is a pit latrine. To that end three types of design considerations and requirements for effective pit latrine assistive devices were adopted in the development of the technology discussed in this paper. Ultimately, three different designs were fabricated after synthesizing the requirements, preliminary user feedback, and engineering knowledge of mechanical design.
The material presented in this paper was derived from research on sources of current literature that address global sanitation problems, especially in Uganda. Information gathered from interviews with Ugandans provided a vital component. The paper presents background information on the sanitation issues faced by Ugandan children in general and by individuals with physical disabilities in particular. It reviews the global progress being made to achieve international goals of sanitation and hygiene and compares them to the situation in Uganda.
In South Sudan, health facility delivery coverage is very low despite the presence of health facilities with staff that can conduct deliveries. Some factors like inaccessibility, insecurity, low knowledge of benefits of health facility delivery, poor services, financial challenges, family influence and cultural practices might be some of the reasons that prevent some mothers from delivering in the health facilities.
This paper describes how UNICEF with other partners has started training master trainers with Basic Emergency Obstetrics and New Born Care modules in Greater Upper Nile, and includes a case of one mother who benefited from the training.
Tobacco use is a serious public health problem with smoking as the most common method of consuming tobacco. It is a major preventable cause of premature morbidity and mortality. The prevalence of tobacco smoking varies from country to country. It creates a huge economic burden on the individuals who consume it and on the healthcare system. The current approach toward the management of tobacco smoking addiction revolves around a combination of education, counselling, and pharmacotherapy.
Neuroscience is one of the most poorly addressed fields of study in Africa evidenced by the paucity of available data. Africa has a lot to do to improve neuroscience research. More government financing is needed if the continent’s research sector is to continue to expand. International scientific collaborations are an important part of integrating into the global research community. African neuroscientists must also participate in policy and decision-making to urge governments to finance research into Africa’s specific requirements.
Cough is a common complaint and may be a feature of serious underlying disease. A working knowledge of the mechanisms and differential diagnoses is crucial. A carefully taken clinical history followed by a thorough physical examination will often lead to a correct conclusion and confirmatory investigations and in turn to appropriate management.
Globally, millions of infants under six months (u6m) are small and nutritionally at-risk, but many do not get the care they need to survive and thrive. Although the 2013 World Health Organisation (WHO) guidelines for severe malnutrition management recommend outpatient care for clinically stable infants u6m, most national guidelines still recommend inpatient care for all infants u6m. To help put the WHO recommendations into action, the MAMI Global Network has developed the MAMI Care Pathway Package – a resource to facilitate the screening, assessment, and management of small and nutritionally at-risk infants u6m and their mothers.
South Sudan confirmed its first case of COVID-19 on April 5th 2020; since that time; the cases continued to increase exponentially to the extent that the fragile health capacity of our nascent nation was almost overwhelmed by the surge of the novel corona virus pandemic and the other health related ailments were unfortunately brought to a standstill condition.
A living WHO guideline on drugs treatment of COVID-19
Corona Scanner is a free online dashboard solution which offers real-time coronavirus statistics like the amount of infections, deaths, still sick and recovered people per country.
ebrain is a large online elearning environment that can be used by both trainees and trainers to support continuing professional development. It is owned jointly by all the major UK and European Clinical Neuroscience Organisations.
This paper summarises the present recommendations on counselling breastfeeding mothers during the COVID-19 pandemic. Present research shows that breastfeeding by infected, and vaccinated, mothers is safe. So, the overriding advice to mothers in South Sudan, and elsewhere, is to carry on giving the same messages: to start suckling immediately after birth, to exclusively breastfeed for the first six months and to breastfeed with complementary foods until at least two years of age.
This paper summarises the main points in the World Health Organization’s ‘Roadmap on human resource strategies to improve newborn care in health facilities in low- and middle-income countries.’
“Nurturing newborns in South Sudan” is a series of clinical guidance reviews on newborn care for the South Sudan context. The first part of this series focused on essential care of the newborn giving standard recommendations for the birth, delivery and care of all newborns not in need of emergency lifesaving care immediately after birth.
Studies have shown that elderly people with co-morbidities are at a higher risk of dying from the SARS-CoV-2 virus. The situation is worse for the 70% of the elderly population who reside in low-and-middle income countries (LMICs) with poor access to good healthcare systems. Elderly patients with cancer in LMICs face numerous barriers to accessing quality health information and services. These barriers have been further exacerbated by the ongoing COVID-19 pandemic.
Epilepsy is usually a chronic condition. In many regions of the world care is compromised by limited recognition, access to medication and stigma. Quality of life for people with epilepsy and their families can improve substantially when seizures are recognised and better control instituted with the appropriate medication. Recognition and classification of seizures, coupled with evidence-based and rational pharmacological management, can help resolve the many issues around this chronic neurological condition.
WHO has produced an update to the living guideline on drugs for COVID-19 in the article published by by BMJ. It replaces earlier versions (4 September and 20 November 2020) and supersedes the BMJ Rapid Recommendations on remdesivir published on 2 July 2020. The previous versions can be found as data supplements. New recommendations will be published as updates to this guideline.
Antimicrobial drugs are the basis of modern medicine, saving lives and allowing surgery and chemotherapy to be possible. Inappropriate use of antimicrobials has led to resistance, meaning we can no longer rely on them being effective. This is further complicated by a lack of new drugs coming to market. Antimicrobial resistance is a well-documented global problem and threatens low and middle-income countries (LMIC) disproportionately.
Elbow injuries are common in the paediatric population. Diagnosing these injuries relies on X-rays taken on initial presentation in the emergency department. Interpreting these radiographs can occasionally be challenging, partly because of the sequential appearance of secondary ossification centres in the paediatric elbow. We propose a methodical approach that would help a clinician identify these injuries, especially the radiographically subtle ones.
Globally, malaria is the most widely spread infectious disease, with 228 million cases and an estimated 405,000 deaths in 2018. Unfortunately, the African region carries a disproportionately high share of the malaria burden. For instance, in 2018, almost 93% of malaria cases and 94% of deaths were from the African region. Plasmodium falciparum is responsible for 99.7% of malaria cases in Africa making this region the most affected in the world.
PubMed was searched using the MeSH terms of malaria or prevalence or diagnosis or medication or prevention or strategies or policies or South Sudan or chemoprophylaxis or immunity or humans. Filters were on humans, free full text, in English, up to five years old, clinical studies and trials, journals, multicentre studies, observational studies. The MeSH terms were also used as keywords to search the South Sudan Medical Journal.
The whole of South Sudan is endemic for malaria, with high transmission in the country throughout the year. Malaria accounts for about 66.8% of all health facility visits in the outpatient departments 30% of all hospital admissions and 50% of all cause of deaths in the hospitals. Malaria is the leading cause of illness and death in children under five years. Malaria transmission is all year-round, peaking at the end of the annual rainy season from June to November. Transmission is higher in the southern parts of the country compared with the northern parts.
The SolarSPELL initiative, based out of Arizona State University (ASU), is developing an offline Digital Nursing and Midwifery Library to empower nursing and midwifery educators and students at the Juba School of Nursing and Midwifery (JSNM) in South Sudan. While visiting Juba in 2019, the co-founders of SolarSPELL and an ASU Edson College of Nursing and Health Innovation professor saw first-hand the lack of infrastructure and resources in hospitals and healthcare training facilities.
This is a WHO guideline on how to wear a mask properly
Guidelines on preventing COVID-19 are constantly being updated. The information below was prepared in April 2020 and is based on guidelines given in the materials listed below[. Check them for updates.
The end of 2019 ushered in a new decade and the spread of a novel coronavirus causing respiratory symptoms and disease confirmed as an outbreak by the World Health Organization (WHO) in January 2020. The International Committee on Taxonomy of Viruses (ICTV) declared on 11 February 2020 that “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) was the name of this new virus due to its genetic similarity to the coronavirus responsible for the SARS outbreak of 2003.
Life in Northern Uganda’s Kiryandongo refugee settlement is difficult at the best of times. Nearly 60,000 refugees, who are predominantly South Sudanese, contend with overcrowding and limited access to healthcare services, especially mental health and psychosocial support.. It is into this environment that the COVID-19 pandemic will soon be introduced.
Infection prevention and control (IPC) is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers. According to the World Health Organization (WHO), IPC is vital for patient safety and quality universal health coverage since it is relevant to health workers and patients at every single health-care encounter.
The nations of the world were confronted with a global health emergency after the World health Organization declared the COVID-19 outbreak a pandemic. Restrictions and regulations were imposed to reduce the spread of COVID-19. The recommendations from WHO and CDC (Centers for Disease Control and Prevention) formed the basis for limiting the spread of the virus but implementation has varied between countries.
Based on data from relatively more affluent countries coronavirus can cause more severe symptoms in people with weakened immune systems, older people (over 60 years) and those with long term conditions like diabetes mellitus, cancer, chronic lung disease and high blood pressure. It is not known if it will be the same in South Sudan.
Coronavirus disease (COVID-19) was first reported to the World Health Organization (WHO) on 31 December 2019 from Wuhan province of China as a cluster of pneumonia cases. The WHO on 11 March 2020 declared this as a global pandemic. COVID-19 is caused by SARS-CoV-2 virus which is a member of coronaviruses.
South Sudan has 35 confirmed cases by 30 April 2020 with the first case announced on 4 April, 2020 while the last case (of the 35) declared on 29 April 2020.
The first 28 days of life is the neonatal or newborn period. Most children who die do so in their first month of life and most especially in the first week. The global rate of newborn deaths is 18 per 1,000 live births as of 2018. South Sudan has one of the highest neonatal mortality rates (NMR) estimated at more than 40 per 1,000 live births.
Worldwide, measles is a significant cause of preventable deaths among children below the age of five years. Globally, in 2015, it accounted for 134,200 deaths which was equivalent to 367 deaths daily or 15 deaths every hour. The vast majority of these deaths occur in low-income countries, especially sub-Saharan Africa.
Misusing and overusing antibiotics puts us all at risk
Diabetic retinopathy (DR) is the commonest microvascular complication of diabetes and a leading cause of blindness in working age adults. The global prevalence of diabetic retinopathy is estimated at 34% and varies from region to region. Its prevalence is increasing in Sub Saharan Africa and other low and middle low income countries, fuelled by the increasing number of people living in poverty with diabetes, poor control of blood sugar, lipids and blood pressure as well as lack of services for early detection and treatment of DR.
It is an undoubted fact that vaccines have proven to be one of the most successful public health interventions to combat the burden of infectious diseases in a cost effective manner thereby alleviating adverse health consequences and improving quality of life in the population. Vaccines can save countless lives in a country provided there is an ongoing successful immunization programme with high vaccine uptake rates.
The existing model of healthcare in most developing countries is predominantly hospital-based and inherited from colonial systems without much modification. The founding vision of Primary Health Care (PHC) adopted in Alma Atta in 1978 has not worked in that it puts emphasis on the already poor communities to support their own health workers.
Most fistulae are caused by ischaemic necrosis of the genital tract and adjacent organs through prolonged obstructed labour. This article provides a brief overview and refer the reader to resources that cover the practical aspects of the surgery and holistic care of the patient.
South Sudan is now in the pre-certification phase, having gone over sixteen months as of April 2018, with zero reports for cases of Guinea worm disease (GWD). The South Sudan Guinea Worm Eradication Programme (SSGWEP) mobilizes the efforts of thousands of communities, village volunteers, various government institutions and partners, to establish an extensive surveillance system for detection of GWD cases in post-war South Sudan. The Programme Director explains how South Sudan achieved the great fit despite the difficult circumstances.
Stroke disease in Ghana has been of increasing concern since the mid to late 20th century, in association with the increasing westernisation of diet and lifestyle. Two thirds of world-wide mortality cases from stroke occur in sub-Saharan Africa, and in the Ghanaian capital city region of Accra, stroke is now attributed as the second largest cause of death. The burden of stroke in sub-Saharan Africa is significant.
Careful interpretation of liver function tests within the clinical context can help elucidate the cause and severity of the underlying pathology. Predominantly raised alkaline phosphatase represents the cholestatic pattern of biliary pathology, whilst predominantly raised alanine aminotransferase and aspartate aminotransferase represent the hepatocellular pattern of hepatocellular pathology.
South Sudan has a huge burden of blindness with an estimated prevalence in excess of 1.5% and it is a common reason for patients attending a primary care facility . Seventy five percent of this blindness can be prevented or treated by properly trained middle cadre eye health worker working with simple diagnostic tools in a primary health care setting or by referring to secondary care in a timely manner.
Epilepsy is the most common serious chronic disorder of the brain. According to estimates, at least 50 million people and their families are affected worldwide across different socio-economic groups, of which one in five is resident in Africa .
The aim of this article is to illustrate common pathological findings involving the brain encountered in every day practice. This builds upon our first article titled "How to interpret an unenhanced CT Brain scan.
The first reports of a lumbar puncture (LP) being undertaken are from the late 19th century . Heinrich Irenaeus Quince (with whom the Lumbar Puncture is commonly associated with) reported to the tenth congress of Internal Medicine in April 1891¬¬ that he had performed in one case 3 lumbar punctures in a patient with suspected tuberculous meningitis who was comatose [1,2].
Although this paper draws on the author’s experience of a NLDC in the UK, the generic ideas in the process of developing a NLDC in a developing country are similar. The author has not been to South Sudan but has had discussions with Dr Hakim whose knowledge of South Sudan has helped to inform the writing of this paper.
Answers to Quiz on infant feeding
The following article focuses upon the essential role of the Diabetes Specialist Nurse (DSN) in the care and management of patients with diabetes. The author is a DSN in the United Kingdom (UK), where the specialist nursing role has become a fundamental and crucial part of the diabetes multidisciplinary team (MDT) and service. The author draws upon her own experiences within the UK as a DSN and discusses ways in which the role could prove advantageous for a low income country such as South Sudan. The article considers key targets for developing countries and how the DSN role could help them to be achieved.
The aim of this article is to:
• Cover the basics of Computed Tomography (CT) Brain imaging.
• Review relevant CT neuroanatomy.
This article is meant for medical officers and surgeons in training who might be called upon to perform this procedure in the absence of a trained general surgeon. The techniques described here are the ones used by the author for this procedure and might differ from those used by other surgeons. However, the principles of the operation are universal.
Major congenital malformations incompatible with life occur in 2-3% of all foetuses . They are the cause of 20 – 30% of perinatal deaths . Apart from occasional case reports little has been published on this topic in Tanzania.
The pattern of valvular heart disease is changing in Western populations . There are implications for Africa as healthcare improves and people live longer.
The article on page 60 shows that there is patchy knowledge about hand hygiene among the health staff at Juba Teaching Hospital (JTH), and that hand hygiene practices there need improving. As the situation in JTH probably reflects that throughout the country, this article suggests ways to ensure better hand hygiene in all health facilities in South Sudan.
The human restricted bacteria,Salmonella enterica serovar Typhi is the major cause of typhoid fever (or enteric fever), a characteristic severe systemic illness . In 2010, typhoid fever accounted for an estimated global burden of 27 million new cases and 200,000 deaths .
Tuberculous meningitis (TBM) is relatively uncommon compared with other types of meningitis and so it is easy to forget to consider it as an explanation for a patient’s presenting problem. If untreated TBM is fatal in most cases.
Neonatal scalp seborrhoeic dermatitis or psoriasis?
‘Cough’ is so common we sometimes do not realise just how important it can be. It is at best annoying to patients (and families) especially if nocturnal and, at worst, very distressing particularly if associated with dyspnoea, copious sputum and/or pain. It may be associated with many serious diseases including lung cancer and tuberculosis.
Millennium Development Goal (MDG) 5 is related to reducing maternal mortality. Against the background of the failure of this MDG, South Sudan has two features that make it interesting for the international donor community:
Cassava is the third most important food source in the tropics and the staple food of tropical Africa. Cassava:
• is easy to grow,
• produces a good yield of starchy roots in 6-9 months even in poor soils without added fertilizer,
• is drought resistant; the roots are a reserve source of food in drought and famine conditions .
After two decades of war, South Sudan is facing a new challenge of having to deal with the AIDS epidemic. In 2010 an antenatal sentinel survey showed a national HIV prevalence of 3% . It is estimated that about 230,000 people are living with HIV/AIDS and another 46,000 are urgently in need of antiretroviral therapy (ART) . Prevalence among key populations is not clearly understood because of lack of data. UNAIDS has classified South Sudan as having a generalized epidemic .
The tippy tap is a hands-free way to wash your hands that is especially appropriate for rural areas where there is no running water. It is operated by a foot lever and thus reduces the chance for bacteria transmission as the user touches only the soap. It uses only 40 millilitres of water to wash your hands versus 500 millilitres using a mug. Additionally, the used “waste” water can go to plants or back into the water table.
We describe a case of corneal abscess presenting three years after uneventful cataract extraction with posterior chamber lens implantation through a limbal incision secured with three sutures placed in the clear cornea. After removing the abscess, a loose 10/0 nylon suture was found at the base of an ulcer.
Hepatitis is major cause of morbidity and mortality worldwide, particularly in the developing world. The major causes of infective hepatitis are hepatitis viruses A, B, C, D or E. In the acute phase, there are no clinical features that can reliably differentiate between these viruses. Infection may be asymptomatic or can present as jaundice, fevers, abdominal pain, fatigue or vomiting. An acute hepatitis infection can last days to months, but can also cause fulminant liver failure.
In this article, we outline the state of HBV prevalence, screening and management in sub-Saharan Africa (SSA). We highlight the urgent need for greater international support to improve local infrastructure for effective prevention and clinical management strategies for HBV infection.
Contents of the PDF
Treatment Flowchart for Cholera Cases Using Standard Case Definition
How can you Control Cholera?
How can you Prevent Cholera?
What is cholera?
Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. ...
Answers to Image Quiz published in SSMJ vol 7 no. 1. Page 21. February 2014.
Water, and sanitation hygiene (WASH) is a major public health challenge, not only globally, but also in the Republic of South Sudan. It is estimated that 1 in 10 (768 million) of the world’s population do not have access to safe drinking water, most of whom are in developing countries, while a third of the world’s population (2.5 billion people) do not have access to adequate sanitation
Before the discovery of hepatitis E virus (HEV), many epidemics of hepatitis in the developing world were found to be from a cause other then the known hepatitis A, B and C viruses. HEV was discovered in 1983 in the stool samples of a human volunteer infected with the combined stool samples of patients with non-A, non-B hepatitis (Balayan et al., 1983). HEV is a small single-stranded RNA virus spread by contaminated water.
Clostridium difficile is an anaerobic, spore forming Gram positive bacillus which is a worldwide enteric pathogen. It is a common cause of antibiotic associated diarrhoea and colitis and was identified as the cause of antibiotic associated pseudomembranous colitis in the late 1970s.
A 79 years old lady was admitted with recurrent headaches, a sudden onset of left upper and lower limb weakness and progressive drowsiness.
She had a history of hypertension, transient cerebral ischaemic attacks, hypercholesterolaemia and chronic renal disease presumed to be secondary to renovascular disease. She was treated with regular erythropoietin injections in the Renal clinic.
Often communities have their own methodology for constructing FES. So the first step is to investigate what local methodology is used to build FES. This will incorporate only locally-available resources and use techniques of which the community is already aware. This methodology is used for the NIPP circle project.
Halitosis (bad breath) is an oral condition characterized by unpleasant odours from the oral cavity. It is estimated to be the third most frequent reason for people seeking dental care, following tooth decay and periodontal disease . In 90% of cases the causes of halitosis arise in the mouth and caused by deep carious lesions, periodontal diseases, oral infections, peri-implant diseases, pericoronitis, mucosal ulcerations, impacted food or debris, factors causing decreased salivary flow rate and tongue coating . The tongue is a major site of oral malodour .
Obesity is one of the fastest growing health problems in Uganda and across the world and its rising prevalence is placing additional strain on medical resources. At its simplest level obesity is a consequence of unhealthy lifestyles. Preventing its spread in Uganda will rest on the ability of society to motivate individuals to make positive healthy choices in their daily lives and many of the same techniques may be applicable to the situation in South Sudan.
The Nutrition Impact and Positive Practice (NIPP) circle model was designed to provide alternative, community-based treatment and prevention of moderate acute malnutrition (MAM) to food-aid initiatives, including blanket supplementary feeding programmes (BSFP) and/or targeted supplementary feeding programmes (TSFP). Through both treatment and prevention of MAM, it is hoped that this will reduce the high rates of chronic malnutrition and intra-uterine growth restriction.
The incidence of ectopic pregnancies varies from 10 to 39.5/1,000 deliveries [1,2,3]. The ampullary portion of the fallopian tube is the most common location . Many risk factors are associated with ectopic pregnancies. Tubal pregnancies generally rupture between 5 and 11 weeks of gestation .
It is, “A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual team or service level and further monitoring is used to confirm improvement in health care delivery” 
Answers to the photo Quiz from the August Issue of SSMJ
Here are two more of the nine checklists from the Maternal, Newborn, and Child Survival (MNCS) Initiative, which was developed and implemented countrywide among community-based providers by Massachusetts General Hospital and the Ministry of Health.
The clinical manifestations of tuberculosis are dependent on a number of factors: age, immune status, co-existing diseases, immunization status to the bacillus Calmette-Guerin (BCG); virulence of the infecting organism and host-microbe interaction.
Poisoning, deliberate or accidental, with drugs used to treat malaria, seems to be uncommon although data is not available from South Sudan. A study in Uganda suggested around 3% of all cases of poisoning admitted to hospital had taken chloroquine: no other anti-malarial drugs were involved.
The practice of medicine changes so rapidly that it is essential for health care professionals to continue to learn throughout their career. Self directed learning helps the learner to remain up-to-date on developments that occur in their profession. Therefore, the new learning technologies have placed an increasing emphasis on self directed learning
The repair of abdominal wall hernias (AWH’s) is the most common surgical procedure in the world. In South Sudan there are two unusual aspects. As elsewhere, the most frequent types of AWH are inguinal and umbilical in adults and femoral and epigastric in children and babies. However in South Sudan there is a high incidence of what the Western medical literature describes as ‘rare AWH’s’
Orthopaedic surgery is a technical specialty. In Nigeria, as in most developing countries, insufficient funding is available for technological advancement . Indigenous hospital technology can reduce cost of managing injuries needing surgery, many of which are caused by an epidemic of road traffic accidents . This paper explains how to make and use an improvised external fixator for the management of open fractures and instruments used for its clinical application. This is an improved version of an earlier external fixator .
This article is about how to recognize obstructed labour and deal with it in a way that preserves the life and health of mother and child. It is for midwives and others who work in maternity care and is based on our experiences in Yei, South Sudan. Obstructed labour means that the baby is too big to pass through the birth canal. It can be associated with prolonged labour. Prolonged labour can sometimes be treated, resulting in a normal delivery but a woman in true obstructed labour should be delivered by Caesarean section.
Inhalation of Mycobacterium tuberculosis leads to one of four possible outcomes:
• Immediate clearance of the organism
• Latent infection
• The onset of active disease (primary disease)
• Active disease many years later (reactivation disease).
Among individuals with latent infection, and no underlying medical problems, reactivation disease occurs in 5 to 10 percent of cases . The risk of reactivation is markedly increased in patients with HIV . These outcomes are determined by the interplay of factors attributable to both the organism and the host.
In a recent article in this journal  I discussed the question of poisoning in South Sudan in an attempt to generate information about the size of the problem. As I pointed out from my experience in Uganda I was concerned about the occurrence of, and mortality from, poisoning with organophosphates. Seventy-one cases of poisoning from organophosphates were reported from forty hospitals and health centres over a six months’ period with a 27% mortality. No other agent was associated with a death in this series (Table 1).
Spot diagnosis and Quiz
World Health Organization and Global Malaria Programme
During the last few years, WHO has observed a slowing of efforts to scale-up intermittent preventive treatment of pregnant women (IPTp) for malaria with Sulfadoxine-Pyrimethamine (SP) in a number of countries in Africa. While there are several reasons for this, confusion among health workers about SP administration for IPTp may also be playing a role. For this reason, WHO is clarifying its recommendations, and urging national health authorities to disseminate these recommendations widely and ensure their correct application.
17-year male student presented with vague constitutional symptoms and jaundice. His clinical chest findings initially suggested a discord with radiological findings. It turned out that the patient had a rare congenital disorder in addition to a seemingly common condition that brought him to the hospital.
The purpose of this case presentation is to share some challenges of a clinical-radiological discord in a teaching hospital in Zimbabwe. It shows a flow of teamwork from House Officers to the Consultants as well as radiological back up.
Below are two more of the nine checklists from the Maternal, Newborn, and Child Survival (MNCS) Initiative, which was developed and is being implemented countrywide by Massachusetts General Hospital and the Ministry of Health. These two checklists illustrate the basic steps that community-based providers can use to diagnose and manage the danger signs of labour, and heavy bleeding. For more information, please contact: Dr Thomas Burke, [email protected]
Examples of checklists for community-based frontline health workers in South Sudan.
Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune inflammatory disorder targeting diarthrodial synovial lined joints, usually in a symmetric distribution. The lungs, pericardium of the heart, skin, and eyes may be affected in up to twenty percent of patients. If uncontrolled, RA leads to joint destruction, disability, and a significantly shortened life span.
Pericardial effusion is fluid in the space between the heart and the pericardial sac. There are many causes of pericardial effusion, with infection (viral and TB) as the most common. If fluid rapidly accumulates in the pericardial space, like in chest trauma, this fluid can compress the heart (cardiac tamponade) and cause circulatory failure. With slow accumulation of fluid, the pericardial sac will stretch to accommodate the fluid. However, if fluid continues to accumulate, tamponade will eventually occur. This is an emergency situation requiring aspiration of pericardial fluid (pericardiocentesis).
Mental illness has a profound and often underestimated impact on the health and functioning of individuals and communities in post-conflict societies. Part I of this series provided an overview of depression and post-traumatic stress disorder (PTSD); Part II focuses on anxiety and substance use, including alcohol withdrawal.
It is generally believed that ischaemic heart disease and the serious consequence of myocardial infarction is uncommon in indigenous South Sudanese. This belief may be misplaced as evidenced by this case report.
We are pleased to publish the article ‘Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders’ by Maithri Ameresekere and David C. Henderson. This outlines the disorders commonly seen and suggests ways of diagnosing and managing them
Mental health is “a state of well-being in which every individual realizes his or her own potential, can work productively and fruitfully, and is able to contribute to her or his community.”(1) Mental illness often attracts a lower priority than physical illness in post-conflict and low and middle-income societies but the two are inextricably linked
The prevalence of asthma is highest in ‘developed’ countries and lowest in developing and emerging countries. The prevalence increases as development progresses and is higher in urban compared to rural areas in developing countries. This increase may be a result of several factors including:
Dengue fever is caused by dengue viruses (DENV). Transmission of DENV has increased dramatically in the past two decades making DENV the most important human pathogens among arthropod-borne viruses. About 50-100 million dengue fever infections occur every year in tropical and subtropical countries
This is a common problem among young children. In a study reported in this journal (1) it accounted for over half of the children with all forms of poisoning admitted to 20 health units in Uganda. This problem usually seems to arise from kerosene being kept in an unlabelled container (e.g. a cola bottle) and within reach of the child.
Improving maternal, newborn, and child health is a leading priority worldwide. It is a particularly urgent issue in South Sudan, which suffers from the world’s worst maternal mortality and among the worst newborn and child mortalities
Examples of checklists for maternal, newborn and child health workers
Faced with the magnitude of health care challenges in South Sudan, one could argue that epilepsy is a minor problem and that resources should not be diverted from more pressing needs. Yet epilepsy is a common and often devastating condition which in South Sudan burdens the lives of more than 100,000 sufferers and their families. In most cases it could be effectively and cheaply treated if resources and systems were available
Charts 7 and 8. How to give IV fluids to children without and with severe malnutrition from ‘Pocket Book of
Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO
2005. See the whole book at http://www.ichrc.org/. Charts 1 – 6 were reproduced in previous issues of this journal.
The overall responsibility for health research in South Sudan falls under the Division of Research, Monitoring and Evaluation and has been the remit of the Directorate of Planning and Coordination in the Ministry of Health, Republic of South Sudan. The existing structure of the research department includes the research data hub, the ethical committee and the research secretariats.
Wherever we are in the world there never seems to be enough money for healthcare provision. So the key is to make what resources we have go as far as possible. Any laboratory test that we request should always be preceded by the questions “Why are we making the request, what are the possible results and what decisions might those results lead us to make?” Then we should ask “Have we gained all possible information from that test?”
Onchocerciasis is an insect-borne disease caused by the parasite Onchocerca volvulus and transmitted by blackflies of the species Simulium damnosum. It is often called ‘river blindness’ because the blackfly lives in fertile riverside areas, that frequently remain uninhabited for fear of infection. Onchocerca volvulus is almost exclusively a parasite of humans. Adult worms live in nodules in the body where the female worms produce large numbers of first-stage larvae known as microfilariae. These migrate from the nodules to the sub-epidermal layer of the skin where they are ingested by blackflies. The microfilariae develop in the body of the blackfly and are transmitted to humans when the fly bites them (1).
We thank the Director of Nutrition, Ministry of Health, Government of Southern Sudan for permission to publish the Ministry’s Interim Guidelines on the Integrated Management of Severe Acute Malnutrition. These cover all aspects of the modern management of acute malnutrition including community outreach, outpatient and inpatient care and monitoring and reporting.
Chart 6. How to position the unconscious child from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005. See the whole book at http://www.ichrc.org/. Charts 1 – 5 were reproduced in previous issues of this journal.
You can use these charts in different ways. For example, you can print them and display them in relevant wards or clinics (laminated if possible), or use them as a ‘memory aid’ in your pocket, as handouts or as training aids.
We thank the WHO for permission to reproduce these charts, and Dr O’Hare who gave us the idea of making the charts more widely available.
In the February 2011 issue of SSMJ we covered the pathophysiology, and clinical and laboratory diagnosis of malaria (1, 2, 3). In this article we deal with the treatment of uncomplicated malaria. Management of malaria among pregnant women and children, and treatment of severe malana will be published in future issues of this journal.
The previous article described the clinical features and diagnosis of malaria. However, for a definite diagnosis, the malaria parasite must be seen in a blood film. In this article we cover laboratory tests used to diagnose malaria...
In Kenya we are trying to focus on confirming the diagnosis of malaria using microscopy or rapid test diagnostic kits (RDTs) rather than just treating a presumed clinical diagnosis. Many health staff in dispensaries and health centres still believe that every fever is malaria and that malaria tops the list of diseases even in non-endemic area. This belief is strong particularly among those who have had training in IMCI (Integrated Management of Childhood Illness). One result of this belief is that many patients are given artemether-lumefantrine treatment (AL) unnecessarily with the additional risk that other causes of fever go untreated. I wonder if it is the same in South Sudan?
The previous article, ‘Introduction and patho-physiology’, reviewed the mechanism of transmission of malaria, the types of parasite and the life cycle of the malarial parasite. In South Sudan, 90% of malaria is caused by Plasmodium falciparum (P. falciparum). This article focuses on the clinical features and diagnosis of P. falciparum but for completeness will also discuss the other main species of malarial parasites.
This is the first in a series of articles on malaria. It is intended for everyone in South Sudan who diagnoses and treats malaria, and advises on how to prevent it. This article gives an overview of the epidemiology of malaria, the parasite’s lifecycle and the pathophysiology of the disease. There is more information in items listed at the end of the article. Also in this issue of the journal are two articles on the diagnosis of malaria. Treatment and prevention will be covered in future issues.
This is the second in a series of articles that aim to help readers to understand and interpret recordings of the surface ECG. The first article introduced the basic principles of the ECG including the electrophysiology of the heart and the features of a normal ECG (1). This one describes some of the common abnormalities of electrical conduction which can be seen on the ECG.
we reproduce Chart 4. How to manage the airway in a child with obstructed breathing from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005 – see the whole book at http://www.ichrc.org/. We published Charts 1, 2 and 3 in previous issues of this journal (vol 3 nos 1, 2 and 3) and plan to publish more in future issues.
You can use these charts in different ways. For example, you can print them and display them in relevant wards or clinics (laminated if possible), or use them as a ‘memory aid’ in your pocket, as handouts or as training aids.
We thank the WHO for permission to reproduce these charts, and Dr O’Hare who gave us the idea of making the charts more widely available.
Over the last few years I have visited Rwanda many times working at a beautiful but remote rural health centre (Kirambi, about 100km south–west of Kigali). The “Land of a thousand hills”, as Rwanda is sometimes called, is a land that is difficult to cultivate needing a lot of hard work. The people there attend the health centre at Kirambi with a wide variety of complaints but, at my recent visit in July, the striking fact was...
Chart 3. How to manage the choking infant and child is from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ WHO 2005 – see the whole book at http://www.ichrc.org/. We published Charts 1 and 2 in previous issues of this journal (vol 3 nos 1 & 2) and plan to publish more charts in future issues.
This short review was inspired by an article in "Hospital Medicine" . The availability of plasma liver function tests (LFTs) to monitor hepatotoxicity (liver [hepatic] damage) is uncommon in many resource-poor countries. Even so we must be aware of and not ignore the risk of hepatic damage from many commonly used drugs. It is important to realise that drugs are the commonest cause of liver failure.
Like doctors and other healthcare professionals worldwide, many of us see children with injuries caused by physical violence and girls who have been raped. Sometimes we know that a child is malnourished, sick or traumatised because of abuse or neglect.
The aim of this article is to raise the issue of child abuse and neglect and to start a dialogue on how healthcare and other professionals can better protect South Sudan's children. So please send us your views and suggestions for tackling this problem.
Leprosy is the oldest disease known to man. The earliest written records describing true leprosy came from India around the period 600 BC. Leprosy is caused by Mycobacterium leprae; the Norwegian, Dr Amauer Hansen, isolated the bacterium in 1873. Leprosy is also called Hansen’s disease after him. Although it is the first human pathogenic bacterium to be defined, M. leprae is the only bacterium causing disease in man that has not been cultured in the laboratory.
There are no recent international guidelines for the management of moderate malnutrition in spite of the fact that it: Increases the risk of death from common diseases and may result in severe acute malnutrition and/or severe stunting (both life-threatening conditions)...
In the last issue I covered the use of PubMed to retrieve primary sources of evidence (individual research studies). However, if you need quick or more definite answers to your clinical questions you may prefer to start with secondary sources - where individual studies have already undergone analysis and have often been compared with others to provide a summarised, more definitive conclusion...
The electrocardiogram (ECG) is one of the simplest and oldest cardiac investigations available, yet it can provide a wealth of useful information and remains an essential part of the assessment of cardiac patients.
With modern machines, surface ECGs are quick and easy to obtain at the bedside and are based on relatively simple electrophysiological concepts. However junior doctors often find them difficult to interpret.
This is the first in a short series of articles that aim to...
This is the second chart from ‘Pocket Book of Hospital Care for Children - Guidelines for the Management of Common Illnesses with Limited Resources’ (WHO 2005). This is ‘Chart 2. Triage of all sick children’ [page 4-5].
We plan to publish more charts from this book in future issues of the Journal. We hope you will find them useful.
The Prevention and Treatment Guidelines for Primary Healthcare Centres and Hospitals was produced by the Ministry of Health, Government of Southern Sudan (MOH/GOSS) in 2006.
The management of alcohol dependence consists of psychological, social and pharmacotherapeutic interventions aimed at reducing alcohol associated problems. This involves detoxification and rehabilitation...
Chest drains are commonly used in the treatment and management of various acute and chronic conditions in many different clinical settings, especially when respiratory function is compromised. Whilst it is usually the responsibility of the doctor to insert the chest drain, it is the responsibility of both the nurse and doctor to maintain the drain and monitor the patient...
The prevalence of alcohol related illness in the Southern Sudan is unknown, though there is anecdotal information that alcohol related violence, marital discord, absenteeism from work and road traffic accidents which are related to the use of alcohol are common.
Humans have drunk alcohol for at least twelve thousand years. It has been used in religious rituals, in ancient cultures as diverse as Samaria, Babylon, Egypt, China and Anglo-Saxon Britain. According to the World Health Organisation (WHO) 1.8 million people worldwide died in 2000 from alcohol related causes, 3% of all deaths worldwide...
At a time when food is in short supply it is essential to have a simple method of identifying malnourished young children. The mid upper arm circumference (MUAC) of children aged 6 – 59 months gives an indication of the degree of wasting and is a good predictor of mortality. Research shows that it is equally good, if not better, than other measurements for screening young children and selecting those needing therapeutic feeding...
Assessment includes the following:
Confirmation of hypertension,
Risk factors for cardiovascular disease,
End organ damage,
Indications and contraindications for anti-hypertensive drugs.
History: A thorough history is essential - note particularly...
Anaemia, often due to iron deficiency, is one of the most widespread causes of mortality and morbidity in Southern Sudan, which probably has probably one of the highest rates in the world...
Microbial Keratitis, also referred to as Suppurative Keratitis or Corneal Ulcer, is a potentially sight threatening condition that may present to doctors and nurses working in State hospitals and eye units in Southern Sudan.
Delay in treatment can result in development of complications that may lead to loss of sight or destruction of the eye...
Many newborns, especially in developing countries, die unnecessarily because health staff have not had the opportunity to learn how to give simple resuscitation. Birth asphyxia (fail ure to establish breathing at birth) ac counts for about 900 000 deaths each year and is one of the primary causes of early neonatal mortality. However resuscitation can be successful in low-resource settings...
Undernutrition occurs when people do not eat (or absorb) enough nutrients to cover their needs for energy and growth, or to maintain a healthy immune system. Micronutrient deficiencies are a sub-category of undernutrition and occur when the body lacks one or more micronutrients (e.g. iron, iodine, zinc, vitamin A or folate). These deficiencies usually affect growth and immunity but some cause specific clinical conditions such as anaemia (iron deficiency), hypothyroidism (iodine deficiency) or xerophthalmia (vitamin A deficiency).
When our bodies do not get enough food, or the right foods, we become weak and cannot develop or function properly. Healthy and balanced nutrition means eating the right type of food in the right quantities. People with HIV have higher than normal energy needs (see Box 1). So a healthy diet is especially important if you are infected with HIV. Food cannot cure HIV infection, or treat the virus, but it can certainly improve fitness and quality of life. Eating enough and a balance of different foods helps
More than two million children under age 5 years die each year from pneumonia. This is more than the combined mortality from HIV, malaria and measles: an astonishing and not widely realised fact! Appropriate vaccination could prevent half of these deaths. Inexpensive antibiotics (about $0.27 for an average course of treatment) are available for treating most cases yet only...
This article is an attempt to give the reader guidance how to read a chest Xray and below are two methods. There is no perfect way to read an x-ray. However, the important message I would like to give is, to adopt one or the other approach, and to use the chosen approach consistently.
On all Xrays check the following...
Gonorrhoea is caused by the sexually transmitted bacterium Neisseria gonorrhoeae. The incubation period ranges from two to 30 days. The risk of infection differs between the sexes: Males: 20% risk after sexual contact with an infected female. Females: 60-80% risk after sexual contact with an infected male. During childbirth an infected woman may transmit gonorrhoea to her newborn and cause ophthalmia neonatorum...
All health professions should be practising 'evidence-based care'. This is defined as the "integration of the best research evidence with our clinical expertise, and our patient’s unique values and circumstances"...
Among the under 5-year-olds worldwide there are about 156,000,000 cases of pneumonia each year. This causes about 20% of all deaths in this age group. Effective implementation of the WHO Integrated Management of Childhood Illness (IMCI) reduces this morbidity and mortality. The recommendations for treating pneumonia for first-level health facilities were made over ten years ago although there was an update in 2005
Handwashing at critical times – including after using the toilet and before eating or preparing food – can reduce diarrhoea rates by almost 44 percent among children under 5.
More than 5,000 children every day – 1.7 million children every year – under the age of 5 die from diarrheal diseases. Diarrhoea is the second most common cause of death in children, accounting for...
1. Use oxytocin 10 iu im alone for prophylaxis, with delayed cord clamping (especially in settings with high anaemia rates)
2. If oxytocin is not available, use misoprostol 600mcg orally.
Acquired Immune Deficiency Syndrome (AIDS) is the leading cause of sickness and death among young adults in developing countries. The introduction of highly active anti-retroretroviral therapy (HAART) has changed the epidemiology of AIDS from being a universally fatal illness to a chronic debilitating infection attended by multi-organ complications. Improved survival as a result of HAART has lead to increase in systemic and ocular complications...
Feeding from birth to 6 months:
The way a HIV+ mother feeds her baby affects the child's risk of:
Becoming infected with HIV,
dying from other infections.
Table 1 shows that the risks to the baby of exclusive breastfeeding...
Western countries are experiencing an explosion in the prevalence of type 2 diabetes (T2DM) linked to increasing obesity and a steady year on year rise in the incidence of type 1 diabetes (T1DM) in children. However, for reasons that are not currently understood, the situation in Sub-Saharan Africa is less clear. Many factors contribute to this. Problems reported in other African countries include:
Oncocerciasis is a parasitic disease that primarily affects economically disadvantaged communities in Africa and Latin America. It results from infection with filarial nematode Oncocerca volvulus, transmitted to man through the bite of infected black fly of genius simulium. It is the second commonest infectious cause of blindness responsible for an estimated 340,000 cases of blindness and one million cases of visual impairment
Undernutrition among mothers and children is the underlying cause of a third of all child deaths and more than 10% of the total global disease burden. The situation is probably worse in Southern Sudan where rates of undernutrition are high. The immediate causes of undernutrition are a nutrient-deficient diet and frequent infections. Here we describe vitamin A deficiency, future articles will cover other types of malnutrition.
The risk for H1N1 influenza transmission through breast milk is unknown. However, reports of viraemia with seasonal influenza infection are rare. Also unknown is the specific protection to the baby of the antibodies the mother passes through her breastmilk. However the strong recommendations from Centres for Disease Control and Prevention (CDC)1 and the UK National Health Service2 are that mothers with swine flu should continue to breastfeed
Arterial hypertension is a common and preventable cardiovascular risk factor, leading to about 1.7 million deaths/year worldwide.
Previously1 we have discussed the diagnosis, classification and prevention of diabetes mellitus. In this article we provide an overview of management of glycaemic control in diabetes mellitus as well as managing hypoglycaemia. We also look at the management of diabetic complications and provide a basis by which to run a diabetes clinic.