Autism in Children: Clinical Features, Management and Challenges

Background: The prevalence of autism world-wide is estimated to be between 1 per 91-110 children. Awareness in the USA and many other developed countries is relatively high and increasing, information on this condition in Nigeria among the public and the medical community is sparse.Objective: This paper highlights the clinical features and management of autism. It also discusses current challenges of autism and its management.Method: Data was sourced from literature in world health organization (WHO) and published articles on autism and internet Medline publications.Results: Autism is characterized by impaired social interaction, problems with verbal and nonverbal communication, unusual repetitive or severely limited activities and interests. The impact of these behaviors can range from mild to disabling. Autism affects all races, ethnic groups and socioeconomic levels, the exact cause is unknown and there is no cure for it. Management is multidisciplinary including educational therapy,psychotherapy, drug treatment amongst others. The combined problems of malaria, malnutrition, pneumonia, HIV/AIDS and other infectious illnesses may be masking emphasis on this neurodevelopmental condition.Conclusions: Autism is a common neurodevelopmental disorder worldwide. Management of the condition is challenging. Creating awareness, improving skills in its diagnosis and optimal management will promote better outcome in affected children.Key Words: Autism, features, poor awareness, management, challenge

Drug induced aseptic meningitis: A diagnostic challenge

Drug-induced aseptic meningitis (DIAM) is a rare but important and often challenging diagnosis for the physician. Intake of antimicrobials, steroids, analgesics amongst others has been implicated. Signs and symptoms generally develop within 24-48 hours of drug ingestion. The patient often exhibits the classic symptoms of meningitis.Aim: Two cases of drug induced meningitis are presented with review of literature.Case reports:Case I: A 13 year old male with a three days history of persistent fever, vomiting, abdominal pain and poor appetite. He also had generalized throbbing headache and neck pain of a day’s duration. He had been on Bactrim® for urinary tract infection (UTI) three days prior to the onset of the present symptoms. On examination, he had altered mental status (confused), neck stiffness and a positive Kerning’s and Brudzinski's signs. Muscle tone and deep tendon reflexes were normal with no cranial nerve deficits. Other systems examinations were unremarkable.Case II: 15 year old male with no significant past medical history presented with a day’s history of altered mental status, headache with no fever. He had been on selfmedication with over the counter Ibuprofen tablets for intractable headache three days prior to presentation. Examination showed equivocal neck stiffness clouded by profound altered mental status. They were both initially managed for meningitis. Cerebrospinal fluid work-up for both cases ruled out infectious etiologies. Possible drug induced meningitis was then considered.Conclusion: Drug-induced aseptic meningitis is rare but should be considered in the differential diagnosis of patients presenting with acute or recurrent symptoms and signs of meningitis, especially after infectious causes have been ruled out

Long term neurological complications of bacterial meningitis in Nigerian children

Background: Neurological disorders in children are common occurrence in clinical practice. The disorder account for more than 170,000 deaths  worldwide each year and contributes to the world's disease burden withmajority of people affected living in Africa. When affected by such illnesses, a person's memory, motor and cognitive abilities, concentration,speech, and physique can be drastically altered. Many of these disorders are chronic, frustrating to caregivers and parents and require adequate understanding to cope with management. Bacterial meningitis contributessignificantly to this morbidity and mortality in sub-Saharan Africa, known as the “meningitis belt”.This study highlights the long term neurological complications of bacterial meningitis amongst children who were on follow up at the neurology unit at the University of Port Harcourt Teaching Hospital (UPTH), a tertiary hospitalin Southern Nigeria.Method: This is a three year follow up prospective study of children with meningitis at the Paediatric neurology unit of the University of Port Harcourt Teaching Hospital, Nigeria between January 1st 2010 and December, 31st 2012. Descriptive analysis was done using SPSS® version 17.Result and Conclusion: Out of 7,644 patients seen in the department,624 of them were diagnosed with meningitis given a prevalence of 8.16%.These patients were followed up at least one year in the neurological outpatient clinic to assess the outcome post admission.Those with neurological sequelae were 94 cases (given a prevalenceof 15.06%) comprising 58 males and 36 females which gave a ratio of 1:0.6. The most common complication was recurrent seizure disorder in 28(29.79%) of them and motor developmental delay in almost 20% of them. Others are focal neurologic deficits and neuropsychologic impairment. The impact and consequences of meningitis is grave, it is important to prevent the disease at all cost. Key words: Meningitis, children, Neurologic complications, longterm

Sociocultural issues and causes of cerebral palsy in Port Harcourt, Nigeria

Background: Cerebral palsy (CP) is a common neurological disorder of childhood with significant neurological complications and associated comorbidities. The aim of this study was to determine the socio- cultural characteristics and causes of CP in children who presented to the Paediatric neurology clinic in Port Harcourt, Nigeria. Method: Hospital records of 834 children with CP who presented between 1 June 2008 and 1 June .2010 were reviewed Demographic data were extracted and a validated socio-economic classification of parents was used. Data was analyzed using SPSS version 15 software. Results: of the 2,288 patients with neurological disorders seen. 834 had cerebral palsy giving a prevalence of 36.45%. Theirages ranged from 5 months to 13 years. Socio-economic stratification of the patients showed concentration in the lower socioeconomic groups IV (35.73%) andV(56.35%). Majority of the children 668 (80.09%) had spastic CP. Eighty seven (10.43%) had hypotonic and 57 (6.83%) extrapyramidal types, the mixed type 22 (2.64%) was the least common. Asphyxia (27.94%), kernicterus (26.26%) and Central Nerves System infections (15.95%) were the leading identified causes. Co-morbidities such as seizures, microcephaly and speech and auditory deficits were present in majority of the subjects. Seizures and microcephaly were commoner among CP cases associated with asphyxia than those associated with kernicterus. Conclusion: Cerebral palsy was commoner amongst those in low socio-economic status with perinatal problems. Improved perinatal care will reduce the burden of CP. Continuing training of health workers and traditional birth attendants are essential.Keywords: Cerebral palsy, Social cultural issues, Port Harcourt

Conduct Disorder amongst Children in an Urban School in Nigeria

Background: Conduct disorder is a childhood behavioral disorder characterized by aggressive and destructive activities that cause disruptions in the child's natural environments such as home, school, church, or the neighbourhood. It is a source of concern to the clinicians as it is comorbid with other mental disorders, particularly anxiety, depression and learning disabilities. The aim of this research was to evaluate the prevalence of conduct disorder amongst secondary school children in urban schools in Port Harcourt.Method: A structured questionnaire based on Vanderbilt ADHD Diagnostic Teacher Rating Scale for oppositional defiant and conduct disorder symptoms was used. A list of signs taken from the Diagnostic and Statistical Manual text revision (American Psychiatric Association, 2000) that indicates a child may have Conduct Disorder was also used. A child must show a pattern of at least three of these behaviour groups for at least a year before the diagnosis was considered. The questionnaires administered to the students were filled with the assistance of the researchers and the classroom teachers. Direct verbal interview was conducted for those noted to have signs of conduct disorder.Result: There were 885 students studied and 140 were diagnosed with conduct disorder, giving a prevalence of 15.82%. The age range of the entire students ranged from 9-18 years with a modal age of 13 years. Sex distribution of those with the conduct disorder was 112 males and 28 females (male: female ratio of 4:1). The various behaviours exhibited included bullying and or threatening classmates and other students, poor school attendance, stealing, and poor academic performance.Conclusions: The prevalence of conduct disorder amongst school children is high. Poor academic performance and other associated comorbidities impair the quality of life of these children. Early identification and appropriate treatment will improve the course of this behavioral disorder.Keywords: Conduct disorder, urban schools, children

Mothers' Perception of Fever Management in Children

Background: Fever is a common problem in childhood. Most febrile episodes are managed at home before consultation in a health facility. Caregivers' response to fever will depend on their perception of its cause and knowledge of its management. This study aimed to evaluate mothers' perceptions of fever and its management in childhood.Methods: This was a descriptive hospital based study. It involved the distribution of 11 itemed questionnaires on fever and related questions to 151 mothers who brought their children to the Paediatrics outpatient clinic of University of Port Harcourt Teaching Hospital. Data was analyzed using descriptive statistics.Results: A total of 151 mothers participated with age range 19 years to 54 years with mean of 31.4±5.7SD. One hundred and thirteen (74.8%) defined fever as hotness of the body. Commonest associated symptom with fever was loss of appetite (71.5%). Commonest identified cause of fever was malaria (71 (47%) mothers). 115 (76.2%) mothers measured their children's body temperature by touching their forehead, while 21 (13.9%) used thermometer. Commonest action taken when there was fever was to administer Paracetamol (107 (70.9%)). Commonest identified complication of fever was convulsion (86(67.7%)).Conclusion: Knowledge of fever is good amongst mothers in Port Harcourt; however there is need to educate them on the use of thermometer and appropriate use of drugs.Keywords: Mothers Perception; Fever; Childre

Bronchopulmonary dysplasia in a premature infant case report and literature review

Bronchopulmonary dysplasia is an important cause of morbidity and mortality in premature infants. The aim of this study is to present a premature, extremely low birth weight infant with bronchopulmonary dysplasia. A reviewof the case records of a child with recurrent respiratory distress and the relevant literature. A preterm, extremely low birth weight baby (birth weight was 0.8 Kg), delivered by emergency caesarian section for previous caesarian section and prolonged rupture of fetal membranes at 27 weeks gestational age. She had spontaneous breathing at birth (APGAR scores were 8 in one minute and 10 in 5 minutes). She developed respiratory distress with cyanosis and became oxygen dependent from the second week of life. Examination revealed severe dyspnoea with grunting respiration, tachypnoea, cyanosis and crackles in the lung fields. Chest X-ray showed hyper inf lat ion, r ight lower zone patchy consolidation with obliteration of the costophrenic angle. Echocardiography was however normal. She was successively managed with intermittent oxygen, dexamethasone, salbutamol and antibiotics (ceftriaxone). She was nursed in the incubator for 3 months. There was no episode of apneic attack throughout admission. She responded to treatment and was discharged home on intermittent oxygen therapy and nebulisation. The weight on discharge was 1.6kg. At 6 months of age, she is still having recurrent respiratory distress and supplemental oxygen at home. She is regular to follow up with recurrent episodes of wheeze requiring admissions. Bronchopulmonary dysplasia should be suspected in a premature extremely low birth weight infant with early recurrent respiratory distress.Key words: Bronchopulmonary dysplasia, prematurity, extreme lowbirth weight

Mobilization of HIV Spread by Diaphanous 2 Dependent Filopodia in Infected Dendritic Cells

Paramount to the success of persistent viral infection is the ability of viruses to navigate hostile environments en route to future targets. In response to such obstacles, many viruses have developed the ability of establishing actin rich-membrane bridges to aid in future infections. Herein through dynamic imaging of HIV infected dendritic cells, we have observed how viral high-jacking of the actin/membrane network facilitates one of the most efficient forms of HIV spread. Within infected DC, viral egress is coupled to viral filopodia formation, with more than 90% of filopodia bearing immature HIV on their tips at extensions of 10 to 20 µm. Live imaging showed HIV filopodia routinely pivoting at their base, and projecting HIV virions at µm.sec−1 along repetitive arc trajectories. HIV filopodial dynamics lead to up to 800 DC to CD4 T cell contacts per hour, with selection of T cells culminating in multiple filopodia tethering and converging to envelope the CD4 T-cell membrane with budding HIV particles. Long viral filopodial formation was dependent on the formin diaphanous 2 (Diaph2), and not a dominant Arp2/3 filopodial pathway often associated with pathogenic actin polymerization. Manipulation of HIV Nef reduced HIV transfer 25-fold by reducing viral filopodia frequency, supporting the potency of DC HIV transfer was dependent on viral filopodia abundance. Thus our observations show HIV corrupts DC to CD4 T cell interactions by physically embedding at the leading edge contacts of long DC filopodial networks

First Large-Scale DNA Barcoding Assessment of Reptiles in the Biodiversity Hotspot of Madagascar, Based on Newly Designed COI Primers

BACKGROUND: DNA barcoding of non-avian reptiles based on the cytochrome oxidase subunit I (COI) gene is still in a very early stage, mainly due to technical problems. Using a newly developed set of reptile-specific primers for COI we present the first comprehensive study targeting the entire reptile fauna of the fourth-largest island in the world, the biodiversity hotspot of Madagascar. METHODOLOGY/PRINCIPAL FINDINGS: Representatives of the majority of Madagascan non-avian reptile species (including Squamata and Testudines) were sampled and successfully DNA barcoded. The new primer pair achieved a constantly high success rate (72.7-100%) for most squamates. More than 250 species of reptiles (out of the 393 described ones; representing around 64% of the known diversity of species) were barcoded. The average interspecific genetic distance within families ranged from a low of 13.4% in the Boidae to a high of 29.8% in the Gekkonidae. Using the average genetic divergence between sister species as a threshold, 41-48 new candidate (undescribed) species were identified. Simulations were used to evaluate the performance of DNA barcoding as a function of completeness of taxon sampling and fragment length. Compared with available multi-gene phylogenies, DNA barcoding correctly assigned most samples to species, genus and family with high confidence and the analysis of fewer taxa resulted in an increased number of well supported lineages. Shorter marker-lengths generally decreased the number of well supported nodes, but even mini-barcodes of 100 bp correctly assigned many samples to genus and family. CONCLUSIONS/SIGNIFICANCE: The new protocols might help to promote DNA barcoding of reptiles and the established library of reference DNA barcodes will facilitate the molecular identification of Madagascan reptiles. Our results might be useful to easily recognize undescribed diversity (i.e. novel taxa), to resolve taxonomic problems, and to monitor the international pet trade without specialized expert knowledge

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019 : A systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC