Clinical Guidance

Managing Epilepsy in South Sudan

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 [1].

How to interpret an unenhanced CT Brain scan. Part 2: Clinical cases

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.

How to perform a Lumbar Puncture

The first reports of a lumbar puncture (LP) being undertaken are from the late 19th century [1]. 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].

How to set up and run a nurse led diabetes clinic in a resource poor country: Focus on South Sudan

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

Answers to Quiz on infant feeding

The Role of the Diabetes Specialist Nurse

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.

How to interpret an unenhanced CT Brain scan. Part 1: Basic principles of Computed Tomography and relevant neuroanatomy

The aim of this article is to: • Cover the basics of Computed Tomography (CT) Brain imaging. • Review relevant CT neuroanatomy.

Open Appendicectomy….How I do it

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.

Hepatocellular carcinoma in South Sudan: possible aetiologies, presentation, diagnostic challenges and ways forward

Prenatal screening for congenital malformations: diagnosis and management in low and medium income countries

Major congenital malformations incompatible with life occur in 2-3% of all foetuses [1]. They are the cause of 20 – 30% of perinatal deaths [2]. Apart from occasional case reports little has been published on this topic in Tanzania.

Valvular heart disease is changing – a challenge for Africa

The pattern of valvular heart disease is changing in Western populations [1]. There are implications for Africa as healthcare improves and people live longer.

Hand washing in South Sudan health facilities: how can we improve it?

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.

Quinolone resistance in Salmonella enterica serovar Typhi: Mechanisms, factors driving the spread of resistance, current epidemiological trends and clinical significance

The human restricted bacteria,Salmonella enterica serovar Typhi is the major cause of typhoid fever (or enteric fever), a characteristic severe systemic illness [1]. In 2010, typhoid fever accounted for an estimated global burden of 27 million new cases and 200,000 deaths [2].

Do not forget tuberculous meningitis

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.

Letter to the editor

Neonatal scalp seborrhoeic dermatitis or psoriasis?

The importance of coughs

‘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.

Task-shifting: The crucial role of medical doctors in reducing maternal deaths in South Sudan

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:

Making cassava flour safe using the wetting method

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 [1].

UNICEF Infant and Young Child Feeding Counselling Card

Prioritizing resources for treatment of HIV/AIDS in resource poor settings

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% [1]. 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) [2]. Prevalence among key populations is not clearly understood because of lack of data. UNAIDS has classified South Sudan as having a generalized epidemic [2].

Tippy tap

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.

Suture associated corneal abscess three years after cataract surgery: Case report

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.

Neoplasm of the Colon: a clinical quiz

Hepatitis viruses overview

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.

Hepatitis B in Sub-Saharan Africa

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.

Cholera IEC Materials

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?

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

Answers to Image Quiz published in SSMJ vol 7 no. 1. Page 21. February 2014.

Water and sanitation hygiene in South Sudan: What needs to be done to bridge the gap?

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

Hepatitis E Virus

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

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.

Acute Brain Stem Infarction – A Case Report

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.

How to make fuel-efficient stoves

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 – a Review

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 [1]. 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 [2]. The tongue is a major site of oral malodour [3].

Helping patients in Uganda overcome weight gain and obesity using motivational interviewing

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 power of Nutrition Impact and Positive Practice (NIPP) Circles

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.

Unruptured tubal pregnancy in the second trimester

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 [4]. Many risk factors are associated with ectopic pregnancies. Tubal pregnancies generally rupture between 5 and 11 weeks of gestation [3].

How to carry out a clinical audit project

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” [1]

Answers to photo quiz from august issue

Answers to the photo Quiz from the August Issue of SSMJ

Quiz - May 2013 Answer

Photo Quiz - Aug 2013

Photo Quiz

Examples of checklists for community-based frontline health workers in South Sudan

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.

Clinical manifestations of pulmonary and extra-pulmonary tuberculosis

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 by anti-malarial drugs

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.

Viewpoint: Self directed learning is NOT an easy way out for the teacher

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

Rare abdominal wall hernias in South Sudan

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’

How I improvised an external fixator to manage open fractures

Orthopaedic surgery is a technical specialty. In Nigeria, as in most developing countries, insufficient funding is available for technological advancement [1]. Indigenous hospital technology can reduce cost of managing injuries needing surgery, many of which are caused by an epidemic of road traffic accidents [2]. 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 [3].

The baby has not come: obstructed labour

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.

Tuberculosis 2: Pathophysiology and microbiology of pulmonary tuberculosis

Pathophysiology 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 [1]. The risk of reactivation is markedly increased in patients with HIV [2]. These outcomes are determined by the interplay of factors attributable to both the organism and the host.

Poisoning with organophosphates

In a recent article in this journal [1] 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).

Quiz - Feb 2013

Spot diagnosis and Quiz

Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine

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.

Suspected clinical-radiological discord

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.

Checklists 2013

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]

MNCS Checklists

Examples of checklists for community-based frontline health workers in South Sudan.

Rheumatoid arthritis: Diagnosis and treatment with a particular emphasis on 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 complicated by tamponade: A case report

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).

Examples of checklists for community-based frontline health workers in South Sudan

Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders - Part 2: Anxiety and substance abuse

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.

Is myocardial infarction common in the South Sudan?

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.

Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders

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

Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders. Part 1: Depression and post-traumatic stress disorder.

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

Asthma: Diagnosis and Management - a guide suitable for developing countries

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

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

How to treat kerosene (paraffin) poisoning

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.

Innovative package for frontline maternal, newborn and child health workers in South Sudan

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

Examples of checklists for maternal, newborn and child health workers

Epilepsy in South Sudan

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

WHO charts for everyone caring for children in hospital

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 Charts 1 – 6 were reproduced in previous issues of this journal.

Guidance for undertaking research in the Republic of South Sudan.

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.

The Full Blood Count and Blood Film ("Haemogram")

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 Control in South Sudan

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).

Interim Guidelines on the Integrated Management of Severe Acute Malnutrition

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.

WHO Charts for Everyone Caring for Children in Hospital - Chart 6

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 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.

Malaria in South Sudan 4: Treatment of uncomplicated P. falciparum malaria

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.

Malaria in South Sudan: 3. Laboratory diagnosis

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...

Every fever is not malaria – a message from Kenya

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?

Malaria in South Sudan: 2. Clinical features and diagnosis

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.

Malaria in South Sudan: 1. Introduction and pathophysiology

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.

How to read an electrocardiogram (ECG). Part 2: Abnormalities of Electrical Conduction

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.

WHO Charts for Everyone Caring for Children in Hospital - Chart 4

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 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.

Low back pain - look for the “Red Flag Signs”

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...

WHO Charts for Everyone Caring for Children in Hospital - Chart 3

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 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.

Drug Reviews

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.

What shall we do about: Preventing Child abuse and neglect?

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.

Understanding the Stigma of Leprosy

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.

Moderate Malnutrition: Do We Know How To Manage It?

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)...

Evidence Based Medicine - How To Search the Literature. Part 2

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...

How to read an Electrocardiogram (ECG). Part One: Basic principles of the ECG. The normal ECG

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...

WHO Charts For Everyone Caring For Children in Hospital - Chart 2

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.

Southern Sudan Treatment Guidelines

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.

Management of Dependence on Alcohol - Part 2

The management of alcohol dependence consists of psychological, social and pharmacotherapeutic interventions aimed at reducing alcohol associated problems. This involves detoxification and rehabilitation...

How to Insert a Chest Drain

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 Medical and Social Consequences of Alcohol Abuse- the first of two articles

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...

Tapes for measuring Mid Upper Arm Circumference (MUAC)

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...

Hypertension in Adults: Part 2. Assessment and management

Assessment includes the following: Confirmation of hypertension, Risk factors for cardiovascular disease, Underlying cause(s), End organ damage, Indications and contraindications for anti-hypertensive drugs. History: A thorough history is essential - note particularly...

Preventing Iron Deficiency and Anaemia

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...

Guidelines for the Management of Suspected Microbial Keratitis in Settings with Limited Laboratory Facilities

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...

Resuscitation of Newborn Babies

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 in Adults and Children: causes, consequences and what we can do

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).

Guidelines for Patients: The benefits of good nutrition when you are infected with HIV

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

Action Against Childhood Pneumonia

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...

How to Read a Chest X-ray – A Step By Step Approach

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...

What do you know about Gonorrhoea?

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...

Evidence Based Medicine - How To Search the Literature

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"...

Non-severe pneumonia in childhood: guidelines for management in first-level health facilities

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

What do you know about Hand Washing?

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...

How to Manage Post Partum Haemorrhage (PPH) A PPH text book in 9 lines!

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.

Eye Complications of Acquired Immune Deficiency Syndrome (AIDS) Part 1. Ocular surface and anterior segment manifestations

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 infants whose mothers are HIV-positive

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...

Diabetes Part 1. Definition, Diagnosis and Prevention

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

Mother and Child Undernutrition - Vitamin A Deficiency

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.

Can mothers who have swine flu continue to breastfeed? Yes!

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

Hypertension in Adults: Part 1. Prevalence, types, causes and effects

Arterial hypertension is a common and preventable cardiovascular risk factor, leading to about 1.7 million deaths/year worldwide.

Diabetes: Part 2. Management of Diabetes Including Hypoglycaemia and Complications

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.