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ÖZ: Kumar oynama davranışı, çalışmalarda madde ve alkol gibi bağımlılık yapıcı nesnelere göre daha az ele alınmakla birlikte bireyler üzerinde benzer etkiler gözlemlenebilmekte ve bu davranış patolojik bir sorun haline gelebilmektedir. Bu noktada psikolojik, biyolojik ve sosyal açıdan olumlu ya da olumsuz birçok faktör bireylerin kumar oynama davranışının bağımlılığa dönüşmesine aracı olurken bireyin kumar oynamayı sorunlarına karşı bir çözüm yolu olarak görmesine de sebep olabilmektedir. Bu araştırmada, kumar oynama davranışı üzerinde etkili olan yaşantısal kaçınma ve pozitif pekiştirme süreçlerinin anlaşılması ve betimlenmesi amaçlanmaktadır. Nitel araştırma yöntemi kullanıldığı çalışmada, en az bir kez kumar oynama davranışı sergilenmiş 13 katılımcı ile derinlemesine görüşmeler gerçekleştirilmiştir. Katılımcılardan elde edilen veriler betimsel analiz yönetimi ile incelenerek “Yaşantısal Kaçınmanın Bir Aracı Olarak Kumar Oynama Davranışı” ve “Kumar Oynamayı Sürdürmede Pozitif Pekiştireçler” olmak üzere iki tema altında açıklanmıştır. Araştırma sonucunda, kumarın ilk zamanlarında pozitif pekiştireçlerin bireyin davranışları üzerinde etkili olduğu, kumar oynama davranışının süreklilik kazanmasıyla birlikte pozitif pekiştireçlerin yerini negatif pekiştireçlere bıraktığı ve pekiştireçlerin bireylerin olumsuz duygu durumu içerisindeyken kaçınma davranışı sergileyerek kumar oynama davranışına yönelmesinde etkili olduğu ortaya çıkmıştır. ABSTRACT: Although gambling behavior is less addressed in studies than addictive objects such as drugs and alcohol, similar effects can be observed on individuals and this behavior can become a pathological problem. At this point, many psychological, biological and social positive or negative factors can cause individuals' gambling behavior to turn into addiction, while also causing the individual to see gambling as a solution to their problems. This research aims to understand and describe the experiential avoidance and positive reinforcement processes that affect gambling behavior. In the study using qualitative research method, in-depth interviews were conducted with 13 participants who had exhibited gambling behavior at least once. The data obtained from the participants were examined with descriptive analysis management and explained under two themes: "Gambling Behavior as a Tool of Experiential Avoidance" and "Positive Reinforcers to Continue Gambling". As a result of the research, it has been revealed that positive reinforcers are effective on the individual's behavior in the early days of gambling, and as the gambling behavior becomes more permanent, positive reinforcers are replaced by negative reinforcers, and reinforcers are effective in causing individuals to engage in gambling behavior by exhibiting avoidance behavior when they are in a negative emotional state.

Being able to forecast events has always been important for humans. Humans did forecasting by inspecting movements of material and non-material objects in ancient times. However, thanks to the technological developments and the increasing amount of data in recent years, forecasting is now done by computers, especially by machine learning methods. One of the areas where these methods are used frequently is numerical weather forecasting. In this type of forecast, short, medium and long-term weather forecasts are made using historical data. However, predictions are inherently error-prone phenomena and should be stated which error range the predictions fall. In this study, numerical weather forecasting was done by combining Genetic Programming and Inductive Conformal Prediction method. The effect of 10 and 20 days of historical data on short (1-day), medium (3-days) and long-term (5-days) weather forecasts was examined. Results suggested that Genetic Programming has a good potential to be used in this area. However, when Genetic Programming was combined with the Inductive Conformal Prediction method, it was shown that forecasts gave meaningful results only in short-term; forecasts made for medium and long-term did not produce meaningful results.

Küresel piyasalar tarafından aşırı tüketimin teşvik edildiği bir dönemde borç yüklenen bir kimse borcun ifasında giderek daha fazla sorunlar yaşamakta, faiz yüküyle bu sorun daha da derinleşmekte ve bu durumun yarattığı stres doğrudan aile ilişkilerine etki etmektedir. Banka ile kurulan borç ilişkisinde kredi geri ödemelerinde yaşanan her aksama aile içinde şiddet, geçimsizlik, boşanma, intihar ve ruh sağlığı problemlerini beraberinde getirmekte ve toplum sağlığı giderek bozulmaktadır. Bu tehlike özellikle orta ve alt gelir gruplarında daha fazla kendini göstermektedir, zira refah seviyesi ve birikmiş sermayesi sınırlı olan bu grupların borç sarmalına girme olasılığı diğer üst gelir gruplarına göre daha yüksektir. Bu çalışma, orta ve alt gelir düzeyine sahip aile bireylerinin içinde bulundukları maddi zorlukları aşma niyetiyle başvurdukları banka kredisinin zamanla aile sistemine olan çok boyutlu etkisini incelemeyi amaçlamaktadır. Bu anlamda, çalışmada banka kredisi ile ilk temas öncesi ailedeki roller ve aile içi iletişimin sağlığı ile kredi kullanımı sonrası bu rollerin ve ilişkilerin değişimi mukayese edilmektedir. Çalışmada, zorlukları aşma konusunda banka kredisinin kısa vadeli çözümler getirme olanağı yaratmasına rağmen orta ve uzun vadede borçluluğun ve kredi geri ödemesinin yarattığı stres ve potansiyel geri ödeme aksamaları sebebiyle aile sisteminin bu süreçten olumsuz etkilendiği varsayımı, görüşmelerden elde edilen bulgularla mukayese edilmiştir. Araştırmaya katılan örneklem, 24 evli, boşanmış ya da ayrı yaşayan yetişkin bireyden oluşmaktadır. Katılımcıların en az bir defa banka kredisine başvurmuş olmaları, özellikle tüketim, ihtiyaç veya taşıt kredisi başvuruları, dâhil edilme kriteri olarak belirlenmiştir. Yatırım kredileri ise çalışmanın kapsamı dışında tutulmuştur. Veri toplama sürecinde, yarı yapılandırılmış görüşmeler aracılığı ile veriler toplanmıştır. Ses kayıtları deşifre edilerek elde edilen veriler betimsel analiz yöntemi ile analiz edilmiştir. Çalışma, 15 farklı kod ve 4 farklı tema ile sonuçları değerlendirmekte ve aktarmaktadır. Verilerin doygunluğa ulaştığı ve yeni verilerin öncekileri tekrar ettiği noktada, veri toplama süreci durdurulmuştur. Bu temalardan elde edilen sonuçlara göre katılımcıların önemli bir bölümünün mevcut borçlarını ödemek veya daha önce çekilmiş kredileri kapatmak için yeni kredilere başvurdukları gözlenmektedir. Katılımcıların pek çoğu için bu durum bir sarmal haline gelmiş ve mevcut borcu kapatmak niyetiyle çekilen bir krediyi kapatmak üzere sürekli yeni başvurulan krediler birbirini takip etmiştir. İkinci temada ortaya çıkan din faktörüne göre faiz yükü ve kredi borcunun zamanında ödenememesi planlanan işin başarısızlığına ve ailenin mali durumunun daha da kötüleşmesine neden olduğunu ortaya çıkarmaktadır. Bu, katılımcının ifade ettiği "bereketsizlik" kavramını somutlaştırmakta ve hem finansal hem de kişisel refah açısından verimlilik, huzur ve memnuniyetin azaldığı bir duruma yol açmaktadır. Sonraki temada dikkat çeken borç stresinin aile dinamiklerinde ve ilişkilerinde önemli değişikliklere yol açtığı katılımcılar tarafından sıklıkla dile getirilmiştir. Bu bağlamda, eşler arasındaki tartışmalar, çocuklar üzerindeki baskı ve genel aile huzurunda yaşanan kayıp finansal stres ve baskının sonuçları olarak düşünülebilir. Benzer şekilde, dördüncü tema kredi geri ödemesinde borç stresi ile birlikte sosyal ve maddi şartların aile ilişkilerini daha da kötüleştirdiğini açıklamaktadır.

ÖZ: Bu çalışma ile bağımlı bireylerle çalışan profesyonellerin gözlemlerinden yola çıkarak gençlerde madde kullanımının oluşumu ve tedavi süreçlerinde aile etkisinin etiyolojini ortaya çıkarabilmek ve bağımlılık öyküsü içerisinde aile deneyimlerini daha yakından inceleyebilmek amaçlanmıştır. Araştırma, nitel araştırma yöntemine ve fenomenolojik desene uygun olarak yürütülmüştür. Birbirinden farklı kurumlarda görev yapan, farklı mesleklere sahip ve madde bağımlısı bireylerle çalışan 15 kişiyle derinlemesine mülakat gerçekleştirilmiştir. Elde edilen veriler sonucunda; bağımlılığa evrilen aşamadan bağımlılık sonrası aşamalara kadarki her bir süreç içerisinde aile faktörünün farklı etki ve deneyimlere sahip olduğu tespit edilmiştir. Bağımlılık öncesi süreçte krizler, problemler, iletişimsizlikler, travmatik yaşam deneyimleri sıklıkla karşılaşılan aile özellikleri olurken; bağımlılık sürecinde madde kullanımından geç haberdar olma, şok-panik-öfke-gizleme gibi davranışsal tepkiler verme ve eş bağımlılık geliştirme gibi aile deneyimleri öne çıkmaktadır. Bağımlılığın tedavisi aşamasında ise sürecin başarılı olabilmesi için aile katılımı ve desteği en önemli unsurlardan biridir. Tedavi aşamasında hızlı ve kolay çözüm yolları talep eden veya var olan tedavinin aksaması durumunda hızlı şekilde motivasyon kaybı yaşayabilen aile deneyimleri tespit edilmiştir. Yine annelerin babalardan daha uzun süre ve daha aktif şekilde tedavi sürecine katıldıkları aileler çoğunluktadır. Sonuç olarak aile faktörü bağımlılığın her aşamasında kendi özel şartları içerisinde değerlendirilmeli ve tedavi sürecine dahil edilmelidir. Tedavi süreçleri sadece bağımlı bireylerle sınırlandırılmamalı, sosyal çevrenin ve özellikle ailelerin de tedaviye uyumu desteklenmelidir. ABSTRACT: Based on the observations of professionals who work with addicted individuals, this study aims to reveal the etiological origins of the family effect in the formation and treatment processes of substance using in young people, and to understand family experiences in the addiction history better. The research was carried out in accordance with the qualitative research method and the phenomenological approach. In-depth interviews have been conducted with 15 people with different professions working in different institutions with drug addicts. As a result of the data that have been obtained, it has been determined that the family factor has different effects and experiences in each process from the stage that turns into addiction to the stages after addiction. While we see family problems, miscommunication, and traumatic life experiences occur in the pre-addiction process, during the addiction processes family members that become aware of the substance use later, that give behavioral responses like shock-panic-anger-hiding and develop co-dependence become prominent. During the treatment of addiction, the necessity and support of family participation is one of the most important elements for this process to be successful. Families that demand quick and easy solutions during the treatment or that can quickly lose motivation in case of disruption of the existing treatment have been identified. Likewise, it is far more frequent to see the mother participating in the treatment process longer and more actively than the father in a family. As a result, the family factor should be evaluated in its own special conditions at every stage of addiction and should be included in the treatment process. Treatment processes should not be limited only to addicted individuals, and the adaptation of the social environment and especially the families to treatment should be supported.

Abstract Few studies have evaluated the effects of pulmonary arterial hypertension therapies on pericardial effusion. We evaluated hemodynamics, echocardiograms, and outcomes for 119 parenteral prostanoid‐treated patients. We discovered an increased frequency of pericardial effusions posttreatment, and that a moderate‐large pericardial effusion at initiation, but not at 1st follow‐up, was significantly associated with mortality.

This case illustrates a novel percutaneous treatment of a highly vascular thoracic tumor impinging on the left atrium and right pulmonary artery by delivery of coils and alcohol ablation via a circumflex coronary artery feeder branch. (Level of Difficulty: Advanced.)

Please cite this paper as: Carlson V, Omer M, Ibrahim S, Ahmed S, O'Byrne K, Kenny L, Ryan C. Fifty years of Sudanese hospital-based obstetric outcomes and an international partnership. BJOG 2011;118:1608-1616. Objective To present 50 years of hospital-based maternal and perinatal outcomes in Sudan, and the role of an international collaboration with an Irish maternity hospital, over the period 2002-2009, in recent health-indicator improvements. Design Retrospective descriptive study. Setting Omdurman Maternity Hospital, Sudan. Population All women who delivered at Omdurman Maternity Hospital, and their newborn infants, from July 1957 to October 2007, comprising 339 448 births. Methods The original logbook data was extracted. Infant and maternal health indicators were calculated according to World Health Organization definitions. Main outcomes measures Total annual births, maternal mortality ratio and maternal complications, neonatal mortality and stillbirth rates, and rates of delivery methods. Results Total births increased 50-fold from 499 in 1958 to 24 913 in 2007. Significant reductions in morbidity and mortality began in the mid-1990s. From 2001 to 2007, maternal mortality fell from 329 to 36 per 100 000 live births: an 85% reduction. Stillbirth rates almost halved, from 35 to 19 per 1000 births in 2001 and 2007, respectively. Neonatal mortality rates remained largely static, at 24 per 1000 live births in 2007, but there is recent evidence of a decline. Conclusion This hospital-based data offers a unique historical portrait of health outcomes in one of the largest maternity hospitals in Africa, and shows steady, sustained improvements in maternal, stillbirth and neonatal mortality rates since the 1990s. The partnership was associated with a number of positive infrastructural, educational, and staffing achievements. Whether it directly contributed to improved health outcomes has not been established. [ABSTRACT FROM AUTHOR]

BackgroundCirculating immune cells including autoreactive T cells and monocytes have been documented as key players in maintaining, protecting and repairing the central nervous system (CNS) in health and disease. Here, we hypothesized that neurodegenerative diseases might be associated, similarly to tumors, with increased levels of circulating peripheral myeloid derived suppressor cells (MDSCs), representing a subset of suppressor cells that often expand under pathological conditions and inhibit possible recruitment of helper T cells needed for fighting off the disease.Methods and findingsWe tested this working hypothesis in amyotrophic lateral sclerosis (ALS) and its mouse model, which are characterized by a rapid progression once clinical symptoms are evident. Adaptive transfer of alternatively activated myeloid (M2) cells, which homed to the spleen and exhibited immune suppressive activity in G93A mutant superoxide dismutase-1 (mSOD1) mice at a stage before emergence of disease symptoms, resulted in earlier appearance of disease symptoms and shorter life expectancy. The same protocol mitigated the inflammation-induced disease model of multiple sclerosis, experimental autoimmune encephalomyelitis (EAE), which requires circulating T cells for disease induction. Analysis of whole peripheral blood samples obtained from 28 patients suffering from sporadic ALS (sALS), revealed a two-fold increase in the percentage of circulating MDSCs (LIN(-/Low)HLA-DR(-)CD33(+)) compared to controls.ConclusionsTaken together, these results emphasize the distinct requirements for fighting the inflammatory neurodegenerative disease, multiple sclerosis, and the neurodegenerative disease, ALS, though both share a local inflammatory component. Moreover, the increased levels of circulating MDSCs in ALS patients indicates the operation of systemic mechanisms that might lead to an impairment of T cell reactivity needed to overcome the disease conditions within the CNS. This high level of suppressive immune cells might represent a risk factor and a novel target for therapeutic intervention in ALS at least at the early stage.

While extensive research has driven the rapid efficiency trajectory noted to date for organic-inorganic perovskite solar cells (PSCs), their thermal stability remains one of the key issues hindering their commercialization. Herein, a significant reduction in surface defects (a precursor to perovskite instability) could be attained by introducing triphenylphosphine (TPP), an effective Lewis base passivator, to the vulnerable perovskite/spiro-OMeTAD interface. Not only did TPP passivation enable a high power conversion efficiency (PCE) of 20.22 % to be achieved, these devices also exhibited superior ambient and thermal stability. Unlike the pristine device, which exhibited a sharp descend to 16 % of its initial PCE on storing in relative humidity of 10 %, at 85 °C for more than 720 h, the TPP-passivated devices retained 71 % of its initial PCE. Hence, this study presents a facile yet excellent approach to attain high-performing yet thermally stable PSCs., (© 2022 Wiley-VCH GmbH.)

We describe the clinical characteristics of 3 siblings from 1 family with congenital myasthenic syndrome due to homozygous mutations of the gene coding for the epsilon subunit of the acetylcholine receptor (CHRNE). Onset of symptoms occurred in the first few months of life with ptosis, restricted ocular motility, mild proximal weakness, and difficulty swallowing. Multiple hospital admissions were required due to recurrent pulmonary infections. There was no decremental conduction on repetitive nerve stimulation, but jitter was increased on single fiber electromyographic. Since early childhood, our patients have done well without pulmonary or bulbar symptoms and with partial improvement on pyridostigmine therapy. Response of ptosis to diagnostic ice pack test was striking. Although these siblings have a clinical history and examination findings typical of homozygous CHRNE mutations, the clinical presentation of congenital myasthenia subtypes is variable, and accurate genotyping is essential in choosing the appropriate treatment.

In the face of the worsening health crisis in Africa, educationalists there and beyond are challenged to identify their role in resolving the crisis. The training of doctors has to be re-orientated so that they are well equipped to lead the way towards improving the health situation and effectively participating in improving the general condition of the people. This can be achieved by medical schools having control of their duties and functions and using these powers to train doctors who are community-orientated, able to identify clinical and epidemiological problems and find suitable solutions. Doctors of the future should be comfortable working in the community with other members of health teams and confident in addressing all health-related matters in the community. During their formative years in medical school they should acquire the skills to continue self-education. This paper discusses some of the important steps that should be taken by medical schools, taking into account the present situation in Africa.

Objective: The study was conducted as part of an overall evaluation for an outreach program to evaluate the clinical status of all the participating children, identify management problems, if any, and offer relevant recommendations., Methods: All the participating children were subjected to a detailed clinical evaluation using a structured questionnaire developed for the purpose. The subjects of this study were registered in the Center for Disabled Children in Buraidah and Unaizah, Al-Qassim region, Kingdom of Saudi Arabia. This study was conducted in 1998 to include all registered children in the centers, which were established in 1994., Results: One hundred and eleven children were evaluated, 51.8% were males. Average age was 72.31 months (standard deviation 32.99). The children fell into 3 diagnostic groups: Cerebral palsy (CP) group (n=41), chromosomal abnormalities group (n=36) and miscellaneous group (n=34). Mothers were the direct care-givers in 98.1% of cases. The sample as a whole suffered from a number of disabilities, the most common of which was severe speech difficulty (88.3%). Fifty seven percent of the children were severely malnourished. The CP group suffered most, as they were significantly fewer mobiles and more dependants on the care-giver. History of neonatal asphyxia and severe malnutrition at the time of examination were also significantly more common in this group., Conclusion: This group of disabled children is enjoying a comprehensive rehabilitation service delivered through an efficient outreach program. It was observed that the families need extra support to improve mobility, nutrition and communication abilities of the participating children.

Objective: To evaluate CME activities in Al-Qassim region in the Kingdom of Saudi Arabia, Methods: A study using a pre-structured questionnaire was conducted in Al-Qassim, targeting physicians working in the hospitals. The survey was conducted in two phases. The first phase was conducted at the inception of the department of professional education and the second one year later. Questionnaires were given to a sample of physicians working in the hospitals., Results: Mean CME hours in the region increased from 5.5(±5.9) to 14.2(±19.7), p=0.0001. 50% said that the CME should be presented differently. There was a need for regular courses (61%), departmental and bedside activities (52%) and visiting speakers (45%). Only 47% of the physicians were using the Internet., Conclusion: There is a need to shift from credit counting to a process that can yield professional development through practical courses and departmental activities. The use of the Internet in CME activities should be encouraged.

Background: Increased mortality rates have been reported after high titer measles [>10(5.0) plaque-forming units (PFU)] vaccination in several large studies in the developing world. An increased titer measles vaccine study conducted in Sudan included a prolonged prospective evaluation of childhood morbidity after vaccination., Methods: Five hundred ten children (170 per group) were randomized to receive 1 of 3 regimens at 5 and 9 months of age: (1) meningococcal vaccine, then standard titer (50% tissue culture-infective dose, 103.8) Schwarz measles vaccine; (2) increased titer (10(4.7) PFU) Edmonston-Zagreb measles vaccine followed by meningococcal vaccine; and (3) increased titer (10(4.7) PFU) Connaught vaccine followed by standard titer Schwarz measles vaccine., Results: Health workers collected information at 31,582 semi-monthly and monthly visits during 5 years. No increase in infant mortality was observed, but the statistical power was limited. There were 13, 13 and 10 deaths in the Schwarz, Edmonston-Zagreb and Connaught groups, respectively. There were no differences in duration or incidence of illness between groups at any time during the 5-year follow-up, with comparisons stratified by age and sex. Statistical power for each pairwise comparison was good, with at least 80% power to detect a difference of 1 day per month of illness and a 12% difference in the proportion of visits with an illness recorded., Conclusions: We were unable to document increased morbidity in recipients of the increased titer measles vaccines used in this study. These data do not support the hypothesis that increased mortality after increased titer vaccine exposure is the result of increased and cumulative morbidity.

The incidence of measles is on the decline but it still claims the lives of one million children annually worldwide. The devastating effects of the disease on the health and nutrition of children in developing countries and its high mortality are well documented. The rapid decay of maternal antibodies in infants in developing countries results in early susceptibility to the disease and hence the general recommendation to vaccinate at the age of 9 months. Sustained international efforts have raised global vaccination coverage rates to around 80% at which level it has remained static. Many countries in the western hemisphere have eliminated the disease by adopting aggressive strategies, which include one-off 'catch-up' mass campaigns to vaccinate all children aged 1-14 years, 'mop-up' campaigns targeting children who were missed during the 'catch-up' campaign, efficient routine vaccination services capable of reaching 90% of infants, strong surveillance activities, prompt outbreak response, and 'follow-up' campaigns every 2-4 years which target 1-4-year-old children. This success story coupled with the fact that measles has many biological features favouring eradication, and considering that it is a severe and lethal disease still prevailing in many areas, calls for immediate international adoption of eradication goals within a specified period of time.

The study describes the epidemiological and clinical features of whooping cough among eighty one Sudanese children (42 cases and 39 contacts aged below fifteen years) within 37 households who were under surveillance for a period of over six months. Using Khartoum Children's Emergency Hospital as the entry point, eleven patients were initially enrolled between July 1989 and August 1990 and led to the identification of another twenty six cases during home surveys. Subsequently, five of their contacts became secondary cases. The clinical criteria adopted by the Expanded Programme on Immunisation of the World Health Organization were used to identify the total of forty two cases included in the study. They were predominantly females (male: female ratio of 1:1.6), twenty (47.6%) were under five years of age and eight (19%) were infants. The attack rate was significantly higher among unimmunised infants (100%) compared to unimmunised children aged ten years and above (14.3%, p = 0.001). Half of the patients were from periurban areas, the majority (83.3%), were living in crowded households (room index > 5) and the primary immunisation rate was low (2.8%). Abnormal chest x-ray findings were detected in 26 (68.4%) patients and consisted mainly of bronchovascular thickening observed in 50%. During the follow-up period, a trend towards drop in patients' weight was observed. In four weeks, thirty (71.4%) children had a mean loss of 0.4 kg whereas eleven (26.2%) had static weight. A group of fifteen cases showed significant decrease in weight when compared to a control group of contacts that had been matched for age, sex and socio-economic status (p = 0.0001).

This is a review of 147 patients suspected of foreign body (FB) inhalation, admitted to King Fahd Specialist Hospital in Al Gassim, Saudi Arabia from July 1989 to December 1994. Age, sex, foreign body type and site, presenting symptoms and signs, radiological findings, diagnosis and complications are analyzed and discussed. All foreign bodies were removed by rigid bronchoscopy under general anaesthesia. The study highlights the magnitude of the problem in the region and reviews the clinical presentation of patients who have inhaled an FB and recommends bronchoscopy as a means of early diagnosis and management.

A retrospective neonatal tetanus survey was conducted among rural and displaced communities in the East Nile Province in the Sudan. The results showed that neonatal tetanus was a major cause of neonatal mortality. The incidence in the displaced community was more than double that in the stable rural community, 7.1 and 3.2 per 1000 live births, respectively. Coverage with two doses of tetanus toxoid was about 58 per cent in both areas, with a drop-off rate of 15 per cent. Making use of missed opportunities to vaccinate regular attendants of antenatal care services would have increased coverage in both areas. Wrong beliefs and attitudes towards tetanus toxoid were detected among schoolgirls and teachers in the two areas.

In a community-based prospective study, 6275 deliveries resulting in 6084 livebirths, 150 stillbirths (SB) and 167 neonatal deaths (NND) were monitored over a period of 3 years. The risk of an unfavourable outcome (SB or NND) in multiple pregnancies was more than ninefold that of singletons. Teenage mothers and those over 34 years of age ran nearly twice the risk of having an unfavourable outcome of pregnancy compared with mothers aged 20-29 years. First pregnancy and grand-multiparity (greater than eight previous pregnancies) carried a similar risk of an unfavourable outcome compared with mothers with 1-4 previous pregnancies. The most serious risk factor was the adverse outcome of the previous pregnancy. Compared with mothers whose last outcome had resulted in a livebirth surviving at least 30 days, mothers with a previous SB had seven times the risk (adjusted for age and parity) of SB and more than twice the risk of NND in the current pregnancy. Maternal illiteracy was associated with significantly higher risk of NND, and this rate decreased with increasing years of education. Frequency of antenatal visits had a marginally significant effect on the SB rate. Socioeconomic factors, diet and iron supplementation during pregnancy did not seem to affect the outcome.

Overnight urinary albumin excretion (UAE) was measured in 51 patients, nine to 18 years old, with type 1 (insulin-dependent) diabetes mellitus and in 22 healthy subjects using radioimmunoassay. Thirteen diabetic patients (25.5%) had microalbuminuria defined as UAE rate between 20 and 200 microg/min. Eleven of these patients were over 13 years of age. This gives a frequency of microalbuminuria of 42% (11/26) in the diabetic children and adolescents in the age group 14-18 years. UAE rate was positively correlated with both age at diagnosis and duration of diabetes. Arterial blood pressure, systolic and diastolic, glycosylated hemoglobin (HbA1c) and insulin dosage U.kg- 1.day-1 were significantly higher (P<0.001) in the diabetic patients with microalbuminuria compared to the diabetic patients with normal UAE rate. Retinal changes were also more common in the microalbuminuric diabetic patients than in the diabetic patients without microalbuminuria (P<0.01). This study has revealed a high prevalence of microalbuminuria in young Sudanese patients with type 1 (insulin-dependent) diabetes mellitus and emphasized the importance of routine screening of diabetic children after the age of 12 years.

Objective: To determine the incidence of type I diabetes in children 0-14 yr of age in Khartoum, Sudan., Research Design and Methods: Prospective registration of newly diagnosed patients in a hospital-based registry with independent validation of completeness of case ascertainment. Eligible patients were Sudanese children < 15 yr of age, who developed type I diabetes during the period 1 January 1987 through 31 December 1990, and who were living in Khartoum city at the time of diagnosis. The denominator is the stable childhood population of Khartoum city, as estimated by the National Bureau of Statistics., Results: In 4 yr, 239 cases were notified in the primary source and 268 in the secondary source. Some 196 patients were registered in both sources. Using the capture-recapture method to correct for underascertainment, the estimated total number of cases was 327, and the overall degree of ascertainment was 95%. The incidence of type I diabetes in children 0-14 yr of age increased from 5.9/10(5) in 1987 to 10.1/10(5) in 1990 (P < 0.001). Girls exhibited slightly higher incidence rates than boys in the 10-14-yr age-group throughout the 4 yr, but the differences were not statistically significant. The age distribution at onset was bimodal with a clear peak at age 12 yr in girls and age 14 yr in boys and another smaller peak at age 7 yr in both sexes. The number of new cases was markedly higher in the cooler months of the year, with a peak in January and a nadir in June (P < 0.01). This trend was consistent over the period of observation., Conclusions: Childhood diabetes is increasing in Sudan. Our incidence figures are higher than those reported from other Arab countries and is similar to reports from France and Italy.

The preliminary findings of a prospective study of perinatal, neonatal and maternal mortality carried out in a rural community of Sudan are reported. Out of 6275 deliveries monitored over a period of 3 years, 150 stillbirths, 167 neonatal deaths and 27 maternal deaths were observed. An intervention program to upgrade the skills of the village midwives started in the middle of the second year. There was a 25% reduction in the risk of unfavorable outcome of pregnancy (i.e. stillbirth and neonatal death) in the third year relative to the first 2 years. Peer review of the 40 village midwives who took part in the study revealed their tremendous potentials in mobilization of mothers as well as participation in primary health care. Their role in detection of high risk pregnancies and newborns cannot be overemphasized.

Cytoplasmic islet-cell antibodies (ICA) and endogenous insulin secretion were studied in 46 Sudanese children (mean age 11.6 years) with newly diagnosed insulin-dependent diabetes mellitus (IDDM). Islet-cell antibodies were detected both by the indirect immunofluorescence (IF) and complement fixation (CF) methods. Endogenous insulin levels were measured as C-peptide concentration using radio-immunoassays. The degree of metabolic control of diabetics was judged by the presence of diabetic ketoacidosis (DKA) at onset, glycated haemoglobin (HbA1c) level and insulin requirement, expressed as dose per kg body weight per day, at the time of presentation. Twenty-nine patients (63%) had either IF-ICA or CF-ICA or both in their sera. These figures are significantly higher than those reported for African populations. Islet-cell antibody positive patients had significantly lower C-peptide concentration, higher HbA1c level, higher insulin requirement and higher prevalence of ketoacidosis at presentation. Furthermore, the C-peptide levels were higher in CF-ICA positive patients than in subjects who showed only IF-ICA positivity. Our findings show a clear association between ICA and severity of diabetes at clinical onset and also suggest that the presence of CF-ICA at or shortly after diagnosis of IDDM is indicative of preservation of some functioning beta-cell mass.

Ninety homozygous patients with Hb S haemoglobinopathy from Sudan were reported with respect to clinical findings, haematological and serum parameters. For comparison, 27 Hb AS heterozygous subjects and 28 Hb AA controls were investigated also. The patients showed an extreme type of illness presenting with severe clinical signs such as dactylitis, liver enlargement and cardiac complications. There was marked haemolytic anaemia (mean haemoglobin 66 g/l). Some patients also presented with low serum (S)-iron levels, indicating iron deficiency. S-bilirubin, S-ASAT, S-ALAT, S-GT and S-urate were notably raised, most probably as a consequence of haemolysis with liver involvement. The patients had lower S-calcium levels when compared with the AS and AA subjects. This may suggest a possible role of HB S in the production of this feature.

Blood glucose and glycosylated haemoglobin levels measured at delivery in 27 normal and 19 diabetic women were compared with those of the corresponding fetuses and their birthweights. In both groups, neonatal blood glucose levels were significantly higher (p much less than 0.001) than the maternal levels despite significantly lower (p much less than 0.001) glycosylated haemoglobin values in the neonates. In the control group, there was a significant correlation of maternal glycosylated haemoglobin with both cord glycosylated haemoglobin and birthweight ratio (p less than 0.01). The same was not obtained in the diabetic group, suggesting a dissociation in glucose homeostasis between the diabetic pregnant mother and her fetus.

During the period April 1985 to November 1986 (18 months), 196 children (of age greater than 1 month) admitted to the Children's Emergency Hospital in Khartoum, Sudan, with clinical suspicion of meningitis/meningoencephalitis were followed up prospectively. Bacterial meningitis was diagnosed by culture, direct microscopy and/or antigen-detecting assays (co-agglutination and enzyme immunoassay) in 44 infants (25 Haemophilus influenzae type b, 8 Neisseria meningitidis, 7 Streptococcus pneumoniae, 3 enterobacteria and one mixed infection), aseptic meningitis in 52, cerebral malaria in 4 and febrile convulsions in 96. The majority of cases of bacterial meningitis were boys and 57% of those in whom H. influenzae was the commonest isolate were less than 1 year old. The presenting signs and symptoms are described as well as the transient and permanent short-term sequelae. The total mortality from bacterial meningitis was 19%, permanent neurological sequelae were seen in 26% of survivors. Prospective follow-up, including audiometry, of 35 children 1-2 months after discharge showed that 11% had hemiplegia and 20% had hearing impairment. The potential impact of vaccination against invasive H. influenzae infections is discussed.

The aetiology and pathogenesis of kwashiorkor remains obscure. Clinical and epidemiological studies are in progress in Sudan to determine whether aflatoxins play a role in the pathogenesis of kwashiorkor. Local foods are screened for their aflatoxin content and children with kwashiorkor and age and sex matched children with marasmus and with normal nutrition are being investigated for aflatoxins in their blood and urine. Autopsy liver samples of children with kwashiorkor and other nutritional disorders in Nigeria and South Africa have been examined for their aflatoxin content. Aflatoxins are detected using two dimensional thin layer chromatography and high performance liquid chromatography. Results to date on over 350 children studied show that aflatoxins occur more frequently and at higher concentrations in the sera of children with kwashiorkor than in children with marasmus or in normal children. Urinary excretion of aflatoxins in kwashiorkor appears to be less than in other groups. In the autopsy liver samples, aflatoxins have been detected in all kwashiorkor livers but not in livers from marasmic children. These findings seem to implicate aflatoxins in the pathogenesis of kwashiorkor. If this is confirmed it would have very wide implications for the management and prevention of kwashiorkor.

One hundred and sixty-six children aged 3-30/12 were enrolled in this study. Initially all children were given a single injection containing live measles vaccine, diphtheria and tetanus toxoids, inactivated polio vaccine and meningococcal, A & C polysaccharide, plus an intradermal injection of BCG. In a second visit 6 months later each child was tuberculin tested and given a second dose of all the above vaccines with the exception of BCG. Blood samples were obtained before and 1 month after each vaccination. Following the second dose there was satisfactory seroconversion for all the vaccines. Tuberculin positivity rose from 5.4% before BCG vaccination to 94.4% 6 months after its administration. It is concluded that it is safe and effective to give these antigens simultaneously and that this particular schedule lends itself for use with nomadic and other unaccessible groups of population.

The prevalence of insulin-dependent diabetes mellitus (IDDM) in 42,981 schoolchildren (aged 7-14 yr) in Khartoum, Sudan, was determined. With the 1985 World Health Organization revised criteria for diagnosis and classification of diabetes mellitus, the overall crude prevalence rate of IDDM was 0.95/1000 in the age groups studied. This figure is thought to reflect the minimum prevalence of IDDM in that population, because there is an inherent tendency in the method of screening used toward underestimating the true prevalence rate. The prevalence of IDDM was found to increase significantly with age and was slightly higher in girls than boys, but this was not statistically significant. Of 41 children with IDDM detected in the survey, 7 were not known to have IDDM before but were showing suggestive symptoms at the time of the study. This study showed that IDDM in childhood is not rare in Sudan and that probably a substantial number of undiagnosed cases exist.

Twenty-three patients with typhoid fever diagnosed by blood culture were treated with co-trimoxazole (trimethoprim/sulphamethoxazole, 1 :5) at a dosage of 10 mg trimethoprim/kg/day in two divided daily doses for 10 days. Twenty-two patients responded, the mean period to defervescence being three days and to relief of toxaemia being 1-7 days. Another nineteen patients with similarly proven typhoid were treated with chloramphenicol (100 mg/kg/day) in four divided daily doses for 10 days. Eighteen patients responded, defervescence occurring in an average of 4-1 days and relief of toxaemia in a mean of 2-6 days. None of the patients included in the study developed complications, relapses or became a convalescent carrier during the period of observation.

The clinical manifestations, biochemical, electrocardiographic, histological and histochemical features of a severe autosomal recessive muscular dystrophy (MD)--as seen in 15 members of a large Sudanese kindred, both male and female--are reported and discussed. The age of onset ranged from three to five years, the pattern of muscular weakness was similar to that of Duchenne MD and pseudohypertrophy was a remarkable feature. Both sexes became completely dependent by 16 years, and died at or before 20 years of age. The clinical picture in this family and the histological features are compared with those of Duchenne MD and with cases reported from Tunisia, Qatar and Libya. Certain clinical and histological features distinguish all of these types from each other and from the milder autosomal recessive MD of childhood which is more usual in the United Kingdom, Europe, Australia and North America.

Gestational age was assessed in 200 Sudanese newborns using the method of external superficial characteristics. Breast size, skin texture and ear firmness were found to be the best. Skin colour was not found to be of value.

An extended kindred in the Sudan, where a severe muscular dystrophy has been interpreted as of autosomal recessive inheritance, has been further analysed. The within-sibship ratio, the autosomal and X-linked inbreeding coefficients, and the creatine kinase levels suggest a possible alternative interpretation: X-linked muscular dystrophy with failure of clinical expression in some males.

Breast milk from 99 Sudanese mothers was analysed for aflatoxins. Aflatoxins M1 and/or M2 were detected in 37 of the milks. No other aflatoxin was detected. M1 occurred alone in 13 milks, (mean 19.0 pg/ml), M2 in 11 milks (mean 12.2 pg/ml), and in 13 samples both M1 and M2 were detected. There appeared to be a linear relationship between M1 and M2 where both were excreted. No aflatoxin was detected in subcutaneous abdominal wall fat removed during Caesarian section from 15 women, but was present in three out of 14 bloods taken during anaesthesia. The presence of aflatoxins in mothers' milk showed no correlation with duration of lactation, the infants' nutrition, presence of aflatoxin in mothers' blood, or the infant's blood and urine. It is concluded that some Sudanese women excrete aflatoxins in breast-milk at levels similar to or higher than those considered safe in animal milk, for human consumption.

The medical history, clinical features and investigations of 145 children with kwashiorkor were compared with 113 marasmic kwashiorkor, 158 marasmic children and 186 nutritionally normal controls of similar age admitted to hospital in Khartoum. Factors in the group with protein-energy malnutrition (PEM) which could relate to aetiology include: a history of prolonged illness and anorexia, frequent and prolonged episodes of diarrhoea and recent measles. The delay in achievement of developmental milestones in PEM children probably reflects the frequent and chronic illnesses in this group. An episode of previous oedema was reported in 22 per cent of marasmic kwashiorkor, 12 per cent of kwashiorkor and 12 per cent of marasmic children. Though hair and mucosal changes and enlarged liver were more common in the marasmic kwashiorkor and kwashiorkor groups, they were also common in marasmic children. There was no significant difference in behaviour (apathy, irritability, anorexia) between kwashiorkor and marasmic children. The classical skin changes of kwashiorkor were only seen in the oedematous children. The mortality was 19 per cent in kwashiorkor, 35 per cent in marasmic kwashiorkor, and 14.5 per cent in the marasmic group. The major differences between marasmus and kwashiorkor children were that the kwashiorkor children were reported larger at birth, achieved more normal developmental milestones, were taller and had larger head circumference than the marasmic children. The implications of these findings in relation to aetiology are discussed.

The socio-economic and family background and the nutrition of 145 children with kwashiorkor admitted to hospital in Khartoum over a 2-year period were compared with 113 marasmic kwashiorkor, 158 marasmic, and 186 nutritionally normal controls of similar age. Peak admissions for kwashiorkor were in the wet and post-wet season and the mean (SD) age was 1.6 (0.6) months. Mothers of malnourished children were more likely to be pregnant, and had poorer housing, sanitation and water supply, a lower income and food expenditure and less education than controls. Mothers of controls breastfed their children longer, introduced mixed feeding earlier, offered a wider variety of foods, and were more likely to have had their infants immunized. Neither family instability nor cultural practices which result in separation of children from their mothers appear to have an important role in protein-energy malnutrition in the Sudan. Families of kwashiorkor children had a higher food expenditure and better maternal education than marasmic children. There was no significant difference between the two groups in duration of breastfeeding or in the age of introduction of mixed diet. However, kwashiorkor children appeared to be offered more meat. Differences in food availability could account for the relative retardation of growth and lack of subcutaneous fat in marasmus compared to kwashiorkor.

This paper presents preliminary findings about morbidity observed in a prospective epidemiological study in a village community near Khartoum during 1977-1979. A total of 293 under-five children in 310 households were followed up for two years. Each household was visited twice monthly and information of the disease pattern was collected. Cough, fever and diarrhoea were found to be the commonest cause of morbidity. The average incidence being 296, 292 and 217 episodes respectively per 100 children per year. Vomiting, skin disease and conjunctivitis occurred at a much lower rate. Measles was observed in 14% of children under one year of age. The incidence of whooping cough was low an no outbreak occurred during the two years of observation. The seasonality of various diseases, their severity and age distribution is discussed and compared over the two year period.

Blood and urine samples from 252 Sudanese children were investigated for their aflatoxin content by high-performance liquid chromatography. The children comprised 44 with kwashiorkor, 32 with marasmic kwashiorkor, 70 with marasmus, and 106 age-matched, normally nourished controls. Aflatoxins were detected more often and at higher concentrations in sera from children with kwashiorkor than in the other malnourished and control groups. Aflatoxicol, a metabolite of aflatoxins B1 and B2, was detected in the sera of children with kwashiorkor and marasmic kwashiorkor but not in the controls and only once in a marasmic child. The difference between children with kwashiorkor or marasmic kwashiorkor and those in the control or marasmus groups was significant. Urinary aflatoxin was most often detected in children with kwashiorkor but their mean concentration was lower than in the other groups. Aflatoxicol was not detected in urine in any group. These findings suggest either that the children with kwashiorkor have a greater exposure to aflatoxins or that their ability to transport and excrete aflatoxins is impaired by the metabolic derangements associated with kwashiorkor. The presence of aflatoxicol in the sera of children with kwashiorkor but not in the others suggests a difference in metabolism between the two groups. Further studies are needed, and measurement of aflatoxins in the food eaten by these children is already underway.

A single injection of iodized oil was administered intramuscularly in a dose of 0.2-2 ml (475 mg iodine per ml) to 383 children from the villages of Kas and Dibbis of the Darfur region in Western Sudan, where goitre is prevalent. After one year the prevalence of goitre had declined from 76% to 49.6%. Of the goitrous children, 81.1% showed either complete resolution of goitre or definite regression of its size. None of the nongoitrous children developed goitre and none of the existing goitres became larger. No cases of hyper- or hypothyroidism were observed. The full 270 children were followed up for four-and-a-half years after treatment and compared with untreated controls from the same area. The prevalence of goitre was significantly lower in the treated than in the untreated group. In treated children the mean urinary iodine excretion three-and-a-half years after treatment was 188.7 micrograms/g creatinine. This was significantly higher than in the untreated group (P less than 0.001). One year later the mean urinary excretion of iodine in the treated children had decreased to 87.1 micrograms/g creatinine. There was no difference in the mean serum values of T3 and T4 in the treated and untreated groups. The level of thyroid stimulating hormone was significantly lower in the treated [mean (S.D.) = 3.5 (0.9)] than in the untreated children [6.0 (3.5)]. It is concluded that a single injection of iodized oil is safe and effective in prevention of goitre development, reduces goitre size and maintains a sufficient iodine supply to prevent goitre for at least four-and-a-half years in children from goitre-endemic areas in Western Sudan.

The prevalence of goitre in the town of Kosti, Central Sudan and the city of Khartoum was investigated on account of the increasing number of goitrous patients in the wards and out-patient clinics of Khartoum Hospital coming from the county of Kosti. The frequency of goitre among 7173 school children from Kosti was 74.8%, and was higher in girls (82.1%) than in boys (67.3%). The frequency among 7075 school-children of Khartoum was 17.5%. The mean urinary iodine excretion in subjects from Kosti was significantly lower (41.8 micrograms/g creatinine) than in those from Khartoum (83.6 micrograms/g creatinine) (p less than 0.001). The water content of iodine in Kosti was low (0.1 micrograms/1). There were no significant differences in the mean serum concentrations of triiodothyronine, thyroxine and thyroid stimulating hormone (TSH) between goitrous and non-goitrous subjects from Kosti. The mean serum level of TSH was higher in goitrous subjects from Kosti (5.2 +/- 1.4 mU/1) than in non-goitrous subjects from Khartoum. These data indicate a high prevalence of goitre in Central Sudan, mainly attributable to iodine deficiency, a fact which has not previously been recognized. Recent environmental goitrogenic factors might have modified the adaptation of the thyroid gland and promoted the occurrence of goitre.

Aflatoxin analysis of blood and urine by high performance liquid chromatography in 584 Sudanese children is reported. The results in 404 malnourished children comprising 141 kwashiorkor, 111 marasmic kwashiorkor and 152 with marasmus are compared with 180 age-matched controls and correlated with clinical findings. The aflatoxin detection rate and mean concentration were higher in serum of children with kwashiorkor than the other groups. The difference between the detection rate in kwashiorkor and controls was significant (p less than 0.05). The aflatoxin detection rate in urine was highest in the marasmic kwashiorkor group and the mean concentration was higher in the marasmic kwashiorkor and marasmic groups than in the kwashiorkor and control groups. There were important differences in the detection of certain aflatoxins between the groups. Aflatoxicol was detected in the sera of 16 (11.6%) kwashiorkor, in six (6.1%) marasmic kwashiorkor, but in none of the controls and only once in marasmus. These differences are highly significant (p less than 0.0001). The ratio of AFB1 to AFM1 was higher in the sera and urines of kwashiorkors than in controls, suggesting that the normal transformation of AFB1 to AFM1 may be impaired in kwashiorkor with consequent increase in transformation of AFB1 to aflatoxicol. The study therefore provides evidence of differences in the metabolism of aflatoxins in children with kwashiorkor compared with children with other forms of malnutrition and normally nourished children and confirms the association between aflatoxins and kwashiorkor contained in a preliminary report on this work.