DOCSLIB.ORG

Clinical Characteristics, Potential Causes, and Its Relationship with Recently Described Nodding Syndrome

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Clinical Characteristics, Potential Causes, and Its Relationship with Recently Described Nodding Syndrome Technische Universität München, Fakultät für Medizin Comprehensive analysis of current knowledge of Nodding Syndrome Kathrin Maria Miehle Vollständiger Abdruck der von der Fakultät für Medizin der Technischen Universität München zur Erlangung des akademischen Grades eines Doktors der Medizin (Dr. med) genehmigten Dissertation. Vorsitzender: Prof. Dr. Ernst Rummeny Prüfer der Dissertation: 1. Prof. Dr. Bernhard Hemmer 2. Priv.-Doz. Dr. Jan St. Kirschke Die Dissertation wurde am 25.01.2018 bei der Technischen Universität München eingereicht und durch die Fakultät für Medizin am 20.02.2019 angenommen. Table of contents Table of contents ......................................................................................................................... 1 Directory of abbreviations ............................................................................................................ 4 Acknowledgements ...................................................................................................................... 5 1. Abstract ................................................................................................................................ 5 2. Introduction.......................................................................................................................... 6 3. Methods ............................................................................................................................... 6 3.1 Search results for Nodding syndrome ..................................................................................... 6 3.2 Search results for Nakalanga syndrome .................................................................................. 9 Part I: Literature research on Nodding syndrome 4 Nodding syndrome: Results ................................................................................................. 12 4.1 Demographic and geographical features .............................................................................. 12 4.1.1 Affected age group ........................................................................................................ 12 4.1.2 Distribution across the sexes ......................................................................................... 12 4.1.3 Tribal distribution .......................................................................................................... 12 4.1.4 Familial clustering .......................................................................................................... 12 4.1.5 Geographical distribution .............................................................................................. 12 4.1.6 Interpreting figures on Nodding syndrome prevalence ................................................ 15 4.2 Clinical presentation .............................................................................................................. 15 4.2.1 Nodding episodes .......................................................................................................... 15 4.2.2 Cognitive impairment .................................................................................................... 16 4.2.3 Psychiatric signs/symptoms .......................................................................................... 17 4.2.4 Malnutrition, stunting and wasting .............................................................................. 17 4.2.5 Stunting, wasting and impaired sexual development ................................................... 18 4.2.6 Other signs/symptoms .................................................................................................. 18 4.2.7 Prognosis ....................................................................................................................... 18 4.3 Diagnostic findings ................................................................................................................ 19 4.3.1 Cerebro-spinal fluid ....................................................................................................... 19 4.3.2 Infections ....................................................................................................................... 20 4.3.3 Electroencephalography ................................................................................................ 24 4.3.4 Magnetic resonance imaging and computed tomography ........................................... 27 4.3.5 Histopathologic findings ................................................................................................ 28 4.3.6 Other findings ................................................................................................................ 28 4.4 Treatment .............................................................................................................................. 30 1 4.4.1 Antiepileptic drugs ............................................................................................................... 30 4.4.2 Immunomodulatory therapy ......................................................................................... 31 4.4.3 Other treatment goals ................................................................................................... 31 4.4.4 Treatment according to severity of disease .................................................................. 33 4.5 Prognosis/natural history ...................................................................................................... 33 4.5.1 Tanzania ......................................................................................................................... 33 4.5.2 Uganda........................................................................................................................... 34 4.5.3 South Sudan ................................................................................................................... 34 4.5.4 Conclusion ..................................................................................................................... 34 4.6 Management at national and international level ................................................................. 35 4.6.1 South Sudan ................................................................................................................... 35 4.6.2 Uganda........................................................................................................................... 35 4.7 Community perspective ........................................................................................................ 35 4.7.1 Nodding syndrome in Tanzania ..................................................................................... 35 4.7.2 Nodding syndrome in South Sudan ............................................................................... 35 4.7.3 Nodding syndrome in Uganda ....................................................................................... 35 5. Discussion of potential pathomechanisms in Nodding syndrome .......................................... 38 5.1 Onchocerciasis ....................................................................................................................... 38 5.1.1 The fight to control onchocerciasis ............................................................................... 38 5.1.2 Strains of O. volvulus and clinical manifestations of onchocerciasis ............................ 38 5.1.3 Pathogenetic concepts regarding the link between onchocerciasis and Nodding syndrome ....................................................................................................................................... 39 5.2 Measles .................................................................................................................................. 40 5.3 Other infectious diseases ...................................................................................................... 41 5.4 Toxins ..................................................................................................................................... 41 5.5 Malnutrition and vitamin B6 deficiency ................................................................................ 41 5.6 Metabolic causes and mitochondriopathy ............................................................................ 42 5.7 Psychiatric disorders .............................................................................................................. 42 5.8 Genetic predisposition .......................................................................................................... 43 5.9 Proposed approach to future research and treatment ......................................................... 44 Part II: Literature research on Nakalanga syndrome and a comparison to Nodding syndrome 6. Nakalanga syndrome........................................................................................................... 45 6.1 The ters of „Nakalaga ad „Noddig sydroe ........................................................... 45 6.2 Characterization of Nakalanga syndrome and a proposed definition .................................. 47 2 6.3 Information on etiology and possible causes of Nakalanga syndrome ................................. 51 6.4 Comparison between Nakalanga syndrome and Nodding syndrome ................................... 52 6.5 Conclusions and recommendations ...................................................................................... 56 7. Summary ...........................................................................................................................
Load more

Recommended publications
  • Nodding Syndrome Southern Sudan Medical Journal
    Southern Sudan Medical Journal SSMJVolume 4. Number 1. February 2011 www.southernsudanmedicaljournal.com Two children with Nodding syndrome and their father at Lui Hospital, South Sudan. (credit: Thomas Akim). Investigation into the NODDING SYNDROME in Witto Payam Malaria in South Sudan KAP of caretakers of malnourished children Vol 4. No 1. February 2011 Southern Sudan Medical Journal CONTENTS EDITORIAL The Southern Sudan Medical Journal is a quarterly publication intended for Healthcare Professionals, Nodding Syndrome: challenges for a bizarre both those working in the Southern Sudan and those in condition Edward Eremugo Luka ...................... 2 other parts of the world seeking information on health in the Southern Sudan. It aims to offer education and information in all specialities, and to identify research MAIN ARTICLES that will inform the development of Health Services in the Southern Sudan. We plan to include reports Investigation into the Nodding syndrome of original research, critical/systematic reviews, case in Witto Payam, Western Equatoria State reports, clinical photographic materials, letters to the in 2010 John Lagu Nyungura, Thomas Akim, Editor, use of drugs, medical news of public interest, and nutrition and public health issues. Anthony Lako, Abe Gordon, Lily Lejeng and Gibson William .................................................. 3 The Journal is published in mid-February, May, August and November and is free online at Malaria in South Sudan: 1. Introduction and pathophysiology Charles Ochero Cornelio and www.southernsudanmedicaljournal.com Oromo Francis Seriano ........................................ 7 EDITORS Dr Wani Mena Malaria in South Sudan: 2. Clinical features Department of Ophthalmology and diagnosis David Attwood .......................... 10 Juba Teaching Hospital, Malaria in South Sudan: 3. Laboratory PO Box 88, Juba diagnosis Charles Ochero Cornelio Langoya ......
    [Show full text]
  • Nodding Syndrome in Ugandan Children—Clinical Features, Brain Imaging and Complications: a Case Series
    Open Access Research BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from Nodding syndrome in Ugandan children—clinical features, brain imaging and complications: a case series Richard Idro,1,2 Robert Opika Opoka,1 Hellen T Aanyu,1 Angelina Kakooza- Mwesige,1 Theresa Piloya-Were,1 Hanifa Namusoke,1 Sarah Bonita Musoke,1 Joyce Nalugya,3 Paul Bangirana,3 Amos Deogratius Mwaka,4 Steven White,5 Kling Chong,6 Anne D Atai-Omoruto,7 Edison Mworozi,1 Jolly Nankunda,1 Sarah Kiguli,1 Jane Ruth Aceng,8 James K Tumwine1 To cite: Idro R, Opoka RO, ABSTRACT ARTICLE SUMMARY Aanyu HT, et al.Nodding Objectives: Nodding syndrome is a devastating syndrome in Ugandan neurological disorder of uncertain aetiology affecting children—clinical features, Article focus children in Africa. There is no diagnostic test, and risk brain imaging and ▪ This paper offers detailed descriptions of the complications: a case series. factors and symptoms that would allow early diagnosis clinical features and complications of nodding BMJ Open 2013;3:e002540. are poorly documented. This study aimed to describe syndrome in Ugandan children and the electro- doi:10.1136/bmjopen-2012- the clinical, electrophysiological and brain imaging physiological and brain imaging features. 002540 (MRI) features and complications of nodding syndrome ▪ It also proposes a clinical staging system for the in Ugandan children. disease. ▸ Prepublication history for Design: Case series. this paper are available Participants: 22 children with nodding syndrome Key messages ▪ online. To view these files brought to Mulago National Referral Hospital for Nodding syndrome is an epidemic neurological please visit the journal online assessment.
    [Show full text]
  • Environmental, Dietary and Case-Control Study of Nodding Syndrome in Uganda: a Post-Measles Brain Disorder Triggered by Malnutrition?
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Journal of the Neurological Sciences 369 (2016) 191–203 Contents lists available at ScienceDirect Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns Environmental, dietary and case-control study of Nodding Syndrome in Uganda: A post-measles brain disorder triggered by malnutrition? Peter S. Spencer a,b,c,d,⁎, Rajarshi Mazumder a,1, Valerie S. Palmer a,b,d, Michael R. Lasarev c, Ryan C. Stadnik a,2, Peter King a,3, Margaret Kabahenda e, David L. Kitara c, Diane Stadler f, Breanna McArdle g, James K. Tumwine h, other Members of the Oregon-Uganda Nodding Syndrome Research Team 4: a Global Health Center (former), Oregon Health & Science University, Portland, OR, USA b Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA c Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA d Faculty of Medicine, Gulu University, Gulu, Uganda e Department of Food Technology and Nutrition, College of Agricultural and Environmental Sciences, Makerere University, Kampala, Uganda f Graduate Program in Human Nutrition, School of Medicine, Oregon Health & Science University, Portland, OR, USA g Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR, USA h Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Makerere University, Kampala, Uganda article info abstract Article history: Nodding Syndrome (NS) is an epileptic encephalopathy characterized by involuntary vertical head nodding, Received 5 August 2016 other types of seizures, and progressive neurological deficits.
    [Show full text]
  • International Journal of Multicultural and Multireligious Understanding (IJMMU) Vol
    Comparative Study of Post-Marriage Nationality Of Women in Legal Systems of Different Countries http://ijmmu.com [email protected] International Journal of Multicultural ISSN 2364-5369 Volume 8, Issue 5 and Multireligious Understanding May, 2021 Pages: 238-259 Anthropological Narratives of Nodding Disease among the Acholi of Northern Uganda Alexander Paul Isiko1; Keddy Olanya Acayo2 1 Faculty of Arts and Social Sciences, Department of Religious Studies and Philosophy, Kyambogo University, Uganda 2 Department of Religious Studies and Philosophy, Kyambogo University, Uganda http://dx.doi.org/10.18415/ijmmu.v8i4.2554 Abstract Despite the scientific and specific medical interventions, nodding disease with neither a cure nor plausible explanation to its cause continues to affect the people of Acholi sub region. The disease continues to be a mystery to both the medical professionals and its victims. The World Health Organisation (WHO) affirms no known aetiology. It is so mystical that it affects only children between the ages of five and fifteen years; the disease has only been reported in Acholi sub region in Uganda without a previous history of existence in the area. In spite of the disease’s association to the Lord’s Resistance Army (LRA) war and Internally Displaced People’s (IDP) camps, other areas like Lango and Teso sub regions affected by the same have not experienced this disease. Nodding disease, therefore, seems to have defeated Western science of biomedicine and needs a different approach to explain its existence. Overtime, African societies, the Acholi inclusive, find solace in their cultural and religious beliefs to explain the existence and treatment of diseases.
    [Show full text]
  • Nodding Syndrome: the Unresolved Mystery of a Pediatric Disease in Sub-Saharan Africa
    HOT TOPICS FROM THE OXFORD INFECTION AND IMMUNITY IN CHILDREN COURSE Nodding Syndrome: The Unresolved Mystery of a Pediatric Disease in Sub-Saharan Africa Gasim Abd-Elfarag, MD and Michaël Boele van Hensbroek, MD, PhD are generally poor and often had a history of displacement as a Nodding syndrome is a mysterious neurologic illness of unknown result of civil conflict.1 etiology, presenting with distinctive clinical features often at early age. Currently, it affects children in restricted geographical areas in South Sudan, Northern Uganda and Southern Tanzania and is associated with CLINICAL PRESENTATION high mortality and morbidity, especially in the children with severe dis- The early stage of NS is often characterized by the occur- ease. In this paper, we will give an outline of what is known about nodding rence of a repetitive head nodding, with a frequency of 5–20 nods syndrome with respect to epidemiology, clinical presentation, etiology per minute, which is the result of a brief loss of neck muscle tone and treatment. In addition, a possible approach to resolving the mystery is due to generalized seizure activity recorded by electroencephalo- presented. gram.8,10,17,18 Nodding episodes may be provoked by food and cold weather8,10,17,18,20 and in 20% are preceded by prodromal symptoms, (Pediatr Infect Dis J 2019;38:S67–S71) including dizziness, inattention, excessive sleepiness or expres- sionless staring when food is offered.17 EPIDEMIOLOGY When the disease progresses, which occur in over 80% of Nodding syndrome (NS) poses a major public health con- cases, other types of seizures, including partial complex, generalized cern in parts of Tanzania, Uganda and South Sudan, with thousands tonic-clonic and atypical absence seizures may develop.10,12,15,17–19 of children affected.1–4 However, it is not a new disease.
    [Show full text]
  • Nodding Syndrome-A Mysterious Disease Affecting Children
    International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571 Review Article Nodding Syndrome - A Mysterious Disease Affecting Children Arun Kumar VN Assistant Professor, Rama Nursing College, Kanpur, UP. Received: 19/07/2016 Revised: 14/08/2016 Accepted: 16/08/2016 ABSTRACT Nodding Syndrome is a disorder of brain that affects children and adolescents in African countries. It is characterized by episodes of repetitive dropping forward of the head, often accompanied by other seizure-like activity, such as convulsions or staring spells. Studies have suggested that the head nods are due to atonic seizures. Since the cause is not known cause, symptomatic treatment was given. The objective is to relieve symptoms, and to provide primary and secondary prevention for disability and to improve function. The most important aspect of treatment was seizure control, management of behavioral and psychiatric difficulties, nursing care, nutritional and physical and cognitive rehabilitation. Key words: Nodding Syndrome, Seizure, Convulsions. INTRODUCTION are investigating to find out the exact cause Nodding Syndrome is a neurologic and pathophysiology for nodding disease. disorder of unknown etiology that affects The cause for the nodding is a children and adolescents in some parts of special seizure called an atonic seizure. Africa. There are probably between 5000 - Associations of the disease with 10,000 affected children in East Africa. This malnutrition and with onchocerciasis was first reported in Tanzania in 1960’s and (parasitic infection) later from Liberia, South Sudan and Signs and symptoms Northern Uganda where there are several Head Nodding is defined as thousand affected individuals. The repeated, involuntary drooping of the head syndrome is characterized by head nodding on two or more occasions.
    [Show full text]
  • Nodding Syndrome—We Can Now Prevent It
    International Journal of Infectious Diseases 44 (2016) 61–63 Contents lists available at ScienceDirect International Journal of Infectious Diseases jou rnal homepage: www.elsevier.com/locate/ijid Editorial Nodding syndrome—we can now prevent it On Monday December 21, 2015, an information session was infected patients presenting with an ocular form of onchocercia- 10 organized by the Ugandan Health minister Dr Elioda Tumwesigye sis. Patients with O. volvulus infection receiving diethylcarbam- in Pader district, northern Uganda, to explain the results of the azine have also been reported to develop optic atrophy, probably investigations performed in Uganda to identify the cause of because of a Mazzotti reaction caused by the death of microfilariae 1 11 nodding syndrome (NS). present in the optic nerve. O. volvulus microfilariae have been 12 NS was first reported in Uganda in the districts of Kitgum, Pader, detected in the optic nerve and optic nerve sheets, but so far not and Lamwo in 2009. Retrospective studies would suggest cases as in the brain. Recently, functional lymphatic vessels lining the dural 13 early as 1997. By May 2014, a total of 3320 cases of NS had been sinuses were discovered; could these vessels be an entry point registered and treated, as well as 5185 cases of epilepsy in the for microfilariae? 2 affected districts. NS is a form of atonic epilepsy. Patients with Brain samples from NS patients who died in Uganda were flown NS present with episodes of uncontrollable nodding of the head to the US Centers for Disease Control and Prevention in the USA for (the head drops forward), mental retardation, and stunted growth, analysis.
    [Show full text]
  • Harnessing Genomic Technologies Toward Improving Health in Africa: OPPORTUNITIES and CHALLENGES
    JANUARY 2011 Harnessing Genomic Technologies Toward Improving Health in Africa: OPPORTUNITIES AND CHALLENGES Recommendations for the Human Heredity and Health in Africa (H3Africa) Initiative to the Wellcome Trust and the National Institutes of Health Harnessing Genomic Technologies Toward Improving Health in Africa: OPPORTUNITIES AND CHALLENGES January 2011 This white paper is a community-generated document outlining the opportunities and challenges for the National Institutes of Health (NIH) and the Wellcome Trust (WT) in creating a genomics-focused, population-based research initiative in Africa. This document discusses problems and solutions for the Human Heredity and Health in Africa (H3Africa) Initiative identified by senior African scientists and others that have worked extensively on the continent. The document was prepared by the H3Africa Working Group, with editing and composition provided by Emmanuel K. Peprah, Ph.D., and Charles N. Rotimi, Ph.D., M.P.H., both of the Center for Research on Genomics and Global Health, National Human Genome Research Institute, NIH. Harnessing Genomic Technologies Toward Improving Health in Africa OPPORTUNITIES AND CHALLENGES CONTENTS I. Executive Summary ...............................................................................................................................................................1 � Background ........................................................................................................................................................................1 �
    [Show full text]
  • Investigation Into the Nodding Syndrome in Witto Payam, Western
    MAIN articles Investigation into the Nodding syndrome in Witto Payam, Western Equatoria State, 2010 John Lagu Nyunguraa, Thomas Akimb, Anthony Lakoc, Abe Gordond, Lily Lejenge, Gibson Williamf Introduction community leaders, administrators and families at Witto IDP camp, Lui town and Jambo town. ‘Nodding syndrome’ is found in South Sudan mainly in Western Equatoria where it was first reported in the 1980s At Witto IDP camp the community leader explained the (1) and where WHO did a series of assessments in 2001, purpose of our visit (the first government-led delegation 2004 and 2006 (2). It has also been described in Western to investigate the mysterious nodding phenomenon) to Uganda (3) and Tanzania (4). a large crowd of affected children and their parents. We then had a one-hour brainstorming session with a focus Nodding syndrome is a progressive condition characterised group of 25 parents, elders of the community and church by head nodding (hence the name), mental retardation and leaders. We used unstructured questions and answers to stunted growth (4) affecting mainly children and young find out: adults. • when the community noticed the first case of nodding Some reports suggest that the episodes of nodding occur syndrome when the child begins to eat food or feels cold (1, 4). These episodes are said to be brief and disappear when • events that happened, including eating habits, during the child stops eating or feels warm again. the civil war and Little is known about the prognosis of the nodding • what the community thinks causes the disease. syndromebut it is thought to be a very debilitating We asked individuals to give a history of the syndrome physically and mentally.
    [Show full text]
  • The Health Status and Demographics of a Conflicting Country: the Sudan Experience
    European Journal of Environment and Public Health 2020, 4(1), em0032 e-ISSN: 2542-4904 https://www.ejeph.com The Health Status and Demographics of a Conflicting Country: The Sudan Experience Miracle Ayomikun Adesina 1,2,3,4,5* 1 Slum and Rural Health Initiative Research with Purpose Academy, NIGERIA 2 Cephas Health Research Initiative Inc, Ibadan, NIGERIA 3 Mental and Oral Health Development Organization, Kebbi State, NIGERIA 4 Universal Care for Africa Foundation, St. Loius, USA 5 Department of Physiotherapy, University of Ibadan, Ibadan, NIGERIA *Corresponding Author: [email protected] Citation: Adesina, M. A. (2020). The Health Status and Demographics of a Conflicting Country: The Sudan Experience. European Journal of Environment and Public Health, 4(1), em0032. https://doi.org/10.29333/ejeph/5933 ARTICLE INFO ABSTRACT Received: 17 Jul. 2019 The Republic of Sudan is a country located in the Northeastern region of Africa. It has a very diverse culture with Revised: 02 Sep. 2019 about 597 ethnic groups communicating in 400 different languages and dialects. Sudan is the third-largest country in Africa and the sixteenth largest in the world. This country is blessed with numerous mineral resources Accepted: 02 Sep. 2019 such as asbestos, chromite, copper, gold, iron, lead, mica, nickel, petroleum, silver, uranium, zinc and many more. However, Sudan is not a peaceful nation. The government of Sudan has been engaged in military warfare against the Sudan Revolutionary Front since 2011. There are widespread human rights violations and religious persecutions. There are allegations that Sudan is a safe haven for terrorist. This study therefore gives an overview of the health status and demographics of the populace inhabiting this conflicting nation.
    [Show full text]
  • The Effect of Bi-Annual Community-Directed Treatment With
    Abd-Elfarag et al. Infectious Diseases of Poverty (2018) 7:112 https://doi.org/10.1186/s40249-018-0496-2 STUDYPROTOCOL Open Access The effect of bi-annual community-directed treatment with ivermectin on the incidence of epilepsy in onchocerciasis endemic villages in South Sudan: a study protocol Gasim Abd-Elfarag1,2, Makoy Yibi Logora3, Jane Y. Carter4, Morrish Ojok5, Jackson Songok5, Sonia Menon6, Ferdinand Wit1,2, Richard Lako7 and Robert Colebunders8* Abstract Background: Nodding syndrome (NS) is a devastating epileptic illness of unknown aetiology mainly affecting children 5–15 years of age. Head nodding distinguishes NS from other forms of epilepsy. Other manifestations of the illness include mental and physical growth retardation. Many children die as a result of falling in fires or drowning. Recently, it was shown that NS is only one of the phenotypic presentations of onchocerciasis associated epilepsy (OAE). Despite the strong epidemiological association between epilepsy and onchocerciasis, the causal mechanism is unknown. After implementation of bi-annual community directed treatment with ivermectin (CDTi) and larviciding of rivers in northern Uganda, new cases of NS have ceased, while new cases continue to emerge in South Sudanese onchocerciasis-endemic areas with an interrupted CDTi programme. This study is designed to evaluate the potential effects of bi-annual CDTi on reducing the incidence of NS/OAE in onchocerciasis- endemic areas in South Sudan. Methods: A pre-intervention door-to-door population-based household survey will be conducted in selected onchocerciasis-endemic villages in Mundri and Maridi Counties, which have a high prevalence of epilepsy. Using a validated questionnaire, the entire village will be screened by community research assistants for suspected epilepsy cases.
    [Show full text]
  • For Peer Review Only Journal: BMJ Open
    BMJ Open BMJ Open: first published as 10.1136/bmjopen-2012-002540 on 3 May 2013. Downloaded from Nodding Syndrome in Ugandan Children - Clinical features, Brain imaging and Complications; an observational case series For peer review only Journal: BMJ Open Manuscript ID: bmjopen-2012-002540 Article Type: Research Date Submitted by the Author: 27-Dec-2012 Complete List of Authors: Idro, Richard; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health; Oxford University , Nuffield Department of Medicine Opoka, Robert; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Aanyu, Hellen; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Kakooza, Angelina; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Piloya, Theresa; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Namusoke, Hanifa; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health http://bmjopen.bmj.com/ Musoke, Sarah; Mulago Hospital/Makerere University, Department of Paediatrics and Child Health Nalugya, Joyce; Mulago Hospital/Makerere University, Department of Psychiatry Mwaka, Amos; Mulago Hospital/Makerere University, Department of Internal Medicine White, Steven; Great Ormond Street hospital for Children, Department of Neurophysiology Chong, Kling; Great Ormond Street hospital for Children, Department of on September 23, 2021 by guest. Protected copyright. Neuroradiology Atai-Omoruto, Anne; Mulago Hospital/Makerere
    [Show full text]