A Case of Rosai-Dorfman Disease Successfully Treated by Corticotherapy.

Rosai-Dorfman disease (RDD) is a benign histiocytic proliferation that results in nodal and extranodal involvements. It is a rare disease, with fewer than 1,000 cases reported in the literature, which explains its lack of knowledge by physicians and the lack of codified therapeutic strategies. We report the case of an 8-year-old girl who presented a rapidly progressive cervical lymph node mass; the diagnosis of RDD was made based on histology and immunohistochemistry. The patient was treated with oral corticosteroids at a dose of 1 mg/kg/d with a favorable outcome and no recurrence after one year of follow-up. This observation illustrates the clinical presentation and diagnosis of this rare clinicopathological entity. The prognosis and treatment options are also discussed.

Measurement of cognition and profiling early learning environments in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: Childhood stunting is associated with poorer child health, growth and development including diminished cognitive abilities. Mapping out the links between child stunting and Early Childhood Education and Development is critical to increasing understanding of the causes and effects of childhood stunting, and for programme and policy development. The aim of this study is to investigate and compare the development and educational environments across India, Indonesia and Senegal, and to identify the multifactorial drivers and impacts of childhood stunting to inform a new typology. METHODS AND ANALYSIS: This current study is part of an interdisciplinary observational research study, where women are recruited during pregnancy and mother-infant pairs followed prospectively, up to 24 months after birth. Eight measures will be used to profile children's early development and learning environments in two sample cohorts: (A) children aged 12 and 24 months born to the women recruited during pregnancy (ie, 500 pregnant mothers per country) and (B) a preschool case-control cohort of siblings from the main cohort aged between 3:6 and 5:6 years of age where anthropomorphic measures will be collected to assess degrees of stunting. Profiling of the development and learning environments in the countries will include both parent/caregiver self-reported and local staff (enumerators) direct assessments of children and settings. ETHICS AND DISSEMINATION: This study was approved by the institutional ethics committees of all partner institutions. In India, Indian Council of Medical Research-National Institute of Nutrition, Hyderabad; In Indonesia, Ethics Committee of the Faculty of Medicine, University of Indonesia; and in Senegal, National Ethics Committee for Scientific Research in Senegal.The findings of the study will be disseminated in national and international meetings, seminars, conferences and peer-reviewed journals.

[Basicervical ectopic goiter associated with a eutopic thyroid gland: a case report]. / Une association d'un goitre ectopique basi-cervical et d'une glande thyroïde eutopique: à propos d'un cas.

Thyroid gland is an endocrine gland playing a major role in energy and phosphocalcic metabolism, among others. It commonly occurs in the anterior cervical and pretracheal region. Ectopic thyroid is quite rare. It is dominated by ectopic basilingual thyroid. We here report the case of a patient with goiter in normal cervical position (eutopic) and ectopic thyroid tissue in basicervical position. Cervicotomy revealed the ectopic nodule and the diagnosis was confirmed by histology. This clinical case illustrates a differential diagnosis of cervical masses.

Weber's syndrome revealing a Percheron artery infarction: A case report.

Key Clinical Message: Weber's syndrome revealing a Percheron artery infarction is a rare clinical occurrence. Its diagnosis requires careful clinical examination and brain MRI, which is the gold standard for diagnosis. If this is not available, combined cerebral CT scan with a CT angiography of supra-aortic arteries may be useful for the diagnosis. Abstract: Percheron's artery (PA) occlusion is an uncommon type of stroke involving paramedian thalamus and/or midbrain infarction. It accounts for 4%-18% of all thalamic infarcts and 0.1%-2% of all strokes. Its clinical manifestations are variable and its mode of presentation as Weber's syndrome is exceptional due to the unusual clinical presentation.

Epilepsy and stigma in Africa: Viewpoint of healthcare professionals and combat strategies.

Epilepsy is a major public health problem in developing countries where eighty percent (80%) of people with epilepsy (PWE) live. Stigma has psychological consequences as well as serious repercussions on patients' quality of life. This study assesses the perception of health professionals in Africa regarding the stigmatization of PWE. METHODOLOGY: This is a multicenter descriptive, cross-sectional study, from 1st August 2020 to 1st September 2021. Medical practitioners from African countries involved in the management of epilepsy and who agreed to fill out forms were included in the study. Sampling was nonrandom and based on respondent choice. The data were analyzed using the EPI INFO 7 software. RESULTS: A total of two hundred and twenty-nine (229) health workers from twenty-six (26) African countries participated in this survey. 24.89% of the respondents were specialists and 46.72% were neurologists. Ninety-one percent (91%) of practitioners felt that PWE were stigmatised. The main forms of stigma were isolation (68.56%), celibacy (60.70%), unemployment (53.28%), divorce (44.54%) and exclusion (37.99%)%). Community, school and family were recognized as the main places of stigmatization. The fight against this stigma was carried out mainly in hospitals and in isolation in 58.4% and 55.8% of cases, respectively. Only 0.4% of practitioners opted for mass awareness. CONCLUSION: PWE are victims of various forms of stigmatization, particularly in community settings. Measures aimed at raising awareness of the public are essential to reduce this stigma and improve patients' quality of life.

Assessment of the potential of Vachellia seyal and Prosopis chilensis for the reclamation of saline soil lands in the peanut basin production of Senegal.

Soil properties and microbial activities are indicators that shape plant communities and evolution. We aimed to determine the interdependency between trees, belowground herbaceous plants, soil characteristics, and arbuscular mycorrhizal communities. Vachellia seyal and Prosopis chilensis and their associated herb layers were targeted. Soils sampled beneath the trees and outside the canopies were subjected to physicochemical and microbial characterization. Randomly collected living roots of trees and dominant herbs were checked for arbuscular mycorrhizal colonization. A tree seedlings nursery was conducted using black bags filled with the following substrates: natural soil 100%, soil mixed with leaf tree plants (LTPs) as organic matter at 10%, soil mixed with LTP at 20%, soil mixed with LTP at 30%, and soil mixed with LTP at 50%. As a result, the presence of trees improves both herb richness and diversity. Soil mycorrhizal inoculum potentials are higher beneath V. seyal than P. chilensis and decreased significantly with increasing distance from trees. The soil MIP decreased with increasing organic matter content for both tree species but was more pronounced for P. chilensis. Soil salinity is lower beneath V. seyal and higher under P. chilensis and outside the canopies. Soil fertility parameters such as carbon, nitrogen, and available phosphorus are higher beneath the trees and then decreased as the distance to the trees increases. We conclude that microbial communities, soil properties, and herb richness and diversity increased beneath the trees but decreased with increasing distance from the trees. This effect is tree species-dependent as P. chilensis increased soil salinity and decreased the belowground density of herbs.

Facial spasms revealing a Parry-Romberg syndrome: A case report.

Introduction and importance: Parry-Romberg syndrome (PRS) is a rare clinical entity characterized by progressive atrophy of the hemifacial region, occasionally associated with systemic manifestations. The presence of facial muscles spasms is exceptional. Case presentation: We report the case of a young woman who presented with progressive atrophy of the right hemiface associated with vitiligo and facial muscles spasms. The diagnosis of Parry Romberg syndrome was retained. Electromyogram showed an intermittent motor unit potential. Cerebral MRI showed atrophy of the muscle and subcutaneous fat of the right hemiface. She received corticosteroid in combination with botulinum toxin injection, which stopped the spasms. Clinical discussion: It is a rare condition with a poorly understood etiology, which is responsible for the delay in diagnosis often noted. The association of this syndrome with neurological signs is exceptional and rarely described in the literature. Injection of botulinum toxin associated with corticosteroids can stop the spasms but only surgery can reduce the facial deformities. Conclusion: Parry-Romberg syndrome is a rare disease, more frequent in women. It poses a real diagnostic problem and its treatment is poorly codified.

Surveillance of Viral Encephalitis in the Context of COVID-19: A One-Year Observational Study among Hospitalized Patients in Dakar, Senegal.

The burden of encephalitis and its associated viral etiology is poorly described in Africa. Moreover, neurological manifestations of COVID-19 are increasingly reported in many countries, but less so in Africa. Our prospective study aimed to characterize the main viral etiologies of patients hospitalized for encephalitis in two hospitals in Dakar. From January to December 2021, all adult patients that met the inclusion criteria for clinical infectious encephalitis were enrolled. Cerebrospinal fluids, blood, and nasopharyngeal swabs were taken and tested for 27 viruses. During the study period, 122 patients were enrolled. Viral etiology was confirmed or probable in 27 patients (22.1%), with SARS-CoV-2 (n = 8), HSV-1 (n = 7), HHV-7 (n = 5), and EBV (n = 4) being the most detected viruses. Age groups 40-49 was more likely to be positive for at least one virus with an odds ratio of 7.7. The mortality was high among infected patients, with 11 (41%) deaths notified during hospitalization. Interestingly, SARS-CoV-2 was the most prevalent virus in hospitalized patients presenting with encephalitis. Our results reveal the crucial need to establish a country-wide surveillance of encephalitis in Senegal to estimate the burden of this disease in our population and implement strategies to improve care and reduce mortality.

Spectrum of movement disorders: Experience of a one and half year of existence of the first specialized center in Senegal.

BACKGROUND: Movement disorders have different prevalence in different regions and they are little studied in Africa. OBJECTIVES: Evaluate the prevalence and determine the spectrum of movement disorders in the first specialized center in Senegal. METHODS: It was a prospective study over on 18 months in adult outpatient clinic. Demographic, clinical, paraclinical data, including genetic test in collaboration with the Queen Square Institute of Neurology at UCL were collected. RESULTS: One hundred and thirty four patients were followed up, representing a prevalence of 4.7%. Men represented 56% for a sex ratio of 1.3. The mean age of population was 47.7 ± 18 years with limits ranging from 16 to 81 years. Eighty-one patients (60.4%) had hyperkinetic and 53 patients (39.6%) had hypokinetic movements. Twenty-nine patients (21.6%) had tremors and 18 (13.4%) had dystonic movements. Ataxia and choreic movements were respectively in 11 (8.2%) and 10 patients (7.5%). Twenty-four patients (17.9%) were from a first-degree consanguineous. A genetic test on saliva samples was done in 16 patients (11.9%) and confirmed Huntington's disease in 8 patients of 6 families. Parkinson disease was the most frequent etiology (32.8%) followed by essential tremor (12.7%) and psychogenic tremor in 7.5%. Stroke accounted for 6% of the causes of MD (tremor, ballism, dystonia, ataxia and parkinsonism) and no etiology was found in 9%. CONCLUSION: The spectrum of movement disorders is very heterogeneous with a non-negligible frequency and diverse etiologies in neurological practice in Senegal.

Gingival metastasis of a breast carcinoma.

We report a case of metastasis to the gingiva of breast carcinoma. The breast tumor was treated with neoadjuvant chemotherapy followed by a radical mastectomy associated with axillary dissection. The gingival lesion occurred 7 months after surgery; the metastasis was confirmed by a biopsy.

Are Sub-Saharan epileptic people less photosensitive? A Senegalese study of photoparoxysmal response in a reference epilepsy centre.

The photoparoxysmal response (PPR) is defined as the occurrence of generalized spike, spike-wave or polyspike-wave discharges consistently elicited by intermittent photic stimulation (IPS). PPR is not well studied in Sub-Saharan African people. We prospectively studied the epidemiological, clinical, and EEG characteristics of PPR among consecutive patients recorded at the clinical neurophysiology unit of Fann University Hospital (Dakar, Senegal). Among 6,808 EEG recordings including 3,065 pathological EEGs, we collected 56 EEGs with PPR (0.8% of all recorded EEGs and 1.8% of anormal EEGs), from 31 women and 25 men (sex ratio: 0.8). The mean age was 13.3 years (range: 8 months to 59 years). The peak of photosensitivity was found in the range of 6 to 10 years. Of the PPR cases, 12 had clinical manifestations during IPS. Generalized epilepsy was diagnosed in 23 (41%) patients and 18 (32%) had focal epilepsies. The most epileptogenic stimulation frequencies were between 12 and 24 Hz (range: 1-28 Hz). PPR were mainly triggered during eye closure (64%), and 41 patients (73% of PPR cases) were classified as Type 4 (Waltz classification). Our results confirm lower rates of photosensitivity in African Sub-Saharan people compared with others. Although the current data do not support a role of short-term ambient light levels, subject to consistent data from larger cohorts, it may be interesting to study the probable epigenetic-mediated protective role of sunshine against photosensitivity.

[A risk of thyroid surgery: the non-recurrent inferior laryngeal nerve: a clinical case]. / Un danger de la chirurgie thyroïdienne: le nerf laryngé inférieur non récurrent (cas clinique).

Lesions of the inferior laryngeal nerve are the most devastating complications of thyroid surgery. Identifying the inferior laryngeal nerve is all the more difficult when its path is atypical. We report a case of right non-recurrent inferior laryngeal nerve detected during thyroidectomy.

[Clinical and paramedical features of epilepsy in children at the Ziguinchor Peace Hospital: a documentation review]. / Aspects cliniques et paracliniques de l´épilepsie de l´enfant à l´Hôpital de la Paix de Ziguinchor: étude documentaire.

Epilepsy poses a public health problem in Senegal. The purpose of the study was to describe the clinical and paramedical features of epilepsy in children at the Ziguinchor Peace Hospital (ZPH). We conducted a literature review of the medical records of children with epilepsy, from January 1, 2015 to December 31, 2018. Patients aged < 15 years followed up for epilepsy at the ZPH were included. Incomplete medical records were excluded. Data from fifty-five (37 boys and 18 girls) children were collected; 70.9% of them were ≤5 years of age. Mean age of patients was 4.3 years. Patients were from rural (60%) and disadvantaged families (67.3%). Seizures were generalized (72.7%) and focal (27.3%). Eighteen patients had idiopathic epilepsy, 17 had non-idiopathic epilepsy. Etiological factors were dominated by abnormalities associated with pregnancy and childbirth (29.1%). Epilepsy is common at the ZPH. It is most common in rural areas among boys under the age of 5 years from disadvantaged families. Generalized tonic-clonic and focal seizures are the most frequent clinical state and abnormalities associated with pregnancy and childbirth are the most commonly found etiologies.

[Inverted papilloma: a study of 13 cases in the Oto-Rhino-Laryngology at the National University Hospital of Fann]. / Papillome inversé: à propos de 13 cas au Service d'Oto-Rhino-Laryngologie du Centre Hospitalier National Universitaire de Fann.

INTRODUCTION: Inverted Papilloma (IP) is a rare benign tumour of the nose and paranasal sinuses histologically characterized by invagination of the outer layer of the epithelium in the underlying chorion. Its most distinctive feature is a strong local aggressiveness, a tendency to recur and an unpredictable risk of association with epidermoid carcinoma. The purpose of this study was to report the epidemiological, clinical, paraclinical data as well as to assess the outcomes of endoscopic endonasal surgery. METHODS: We conducted a retrospective study on a series of 13 patients whose data were collected in the Oto-Rhino-Laryngology at the National University Hospital Center of Fann, from 1st January 2012 to 31st December 2017. All patients followed up for inverted papilloma confirmed by anathomopathological examination were included in the study. RESULTS: The average age of patients was 44 years, the sex-ratio was 2.25. All patients had nasal obstruction; 53% of them had rhinorrhea followed by epistaxis in 30% of cases. Right-sided symptoms were reported by 69% of patients, left-sided symptoms by 23% and bilateral symptoms by 7% of patients. Anterior rhinoscopy showed endonasal mass in all patients. All patients underwent CT scan; the MRI was performed in a single patient. Endoscopic resection of IP was performed in 10 patients (76.9%) while external approach was used in 23% of cases. Surgery helped to clarify where the tumor had originated: in 46% of cases in the maxillary sinus, in 15% in the lower nasal turbinate, in 15% in the mid-turbinate, in 7% in the ethmoid bulla and in 7% in the lateral wall of the nasal fossa. One patient had recurrence after an average period of 26 months. Malignant transformation to squamous cell carcinoma occurred in one patient. CONCLUSION: Inverted papilloma is a very aggressive tumor. CT scan is essential to highlight its spread, especially to bone. The advent of endoscopic surgery has revolutionised treatment, providing excellent results. But, there is nevertheless a risk of recurrence after surgery which motivates an indication for long term monitoring.

Neuromyelitis optica spectrum disorders (NMO-SD) in a Sub-Saharan Africa country: A preliminary study of sixteen Senegalese cases.

BACKGROUND: Neuromyelitis optica (NMO) is an autoimmune disease of the central nervous system. In Sub-Saharan Africa, publications are rare and deal with isolated cases. Our goal was to analyze the characteristics of NMO spectrum disorders in a Senegalese cohort compiled in Dakar. PATIENTS AND METHOD: This was a retrospective descriptive study conducted at the Neurology Department of Fann Teaching Hospital. We included all patients with NMO-SD according to the 2014 diagnostic criteria. RESULTS: Sixteen patients were enrolled, 4 men and 12 women with an average age of 30 years. Ten patients (62.5%) presented an acute myelopathy associated with retrobulbar optic neuritis and 5 (31.25%) had isolated spinal cord injury. Spinal MRI showed abnormal cervical (6 patients), dorsal (4 patients), bulbar-cervical (3 patients) or cervico-dorsal (2 patients) signal extended (≥3 vertebral segments) of the spinal cord. Visual evoked potentials (VEP) showed demyelinating optic nerve involvement in 8 patients. Ten patients were positive to AQP-4 IgG. Systemic corticosteroid therapy was the rule in all patients, associated with azathioprine in 10 of them. The clinical course at 3 months was predominantly favourable (10 patients). CONCLUSION: This cohort is the first one compiled in Dakar. African multicentric epidemiological studies are needed.

Le magnésium et le calcium réduisent la sévérité des troubles de la mémoire spatiale pour le modèle kaïnique d'épilepsie mésiale temporale chez la souris.

Calcium and magnesium are divalent multipotent ions playing a major role in metabolism, excitability and neuroglial plasticity. Because of these multiple properties, their deficiency induces complex brain processes leading to acute or even lasting disorders in excitability and neural networks. These ions are usually prescribed in clinical contexts of neuronal hyperexcitability such as preeclampsia and chronic stress. Our aim was to evaluate whether magnesium at 20 mg/kg and calcium at 100 mg/kg could improve the memory prognosis in the kainic model of mesial temporal epilepsy in mice. The animals were organized into 6 groups: control group (without kainate), reference group (GR) without administration of ions, groups treated with magnesium or calcium from the third day (respectively G1m, G1c), groups treated with magnesium or calcium from the third week (respectively G2m, G2c). The mice treated by ions performed better than GR mice, but magnesium was more effective. Memory (short term-long term) was differently affected by kainate or improved by magnesium-calcium. In addition, magnesium demonstrated an increasing therapeutic effect over time while calcium had an acute and apparently decreasing action in the G1c group that received calcium early.

Le calcium et le magnésium sont des ions divalents multipotents importants pour le métabolisme, l'excitabilité, et la plasticité de la névroglie. En raison de leurs multiples propriétés, leur carence provoque des processus cérébraux complexes menant à des aberrations aigües voire durables au niveau de l'excitabilité et des réseaux neuronaux. Ces ions sont habituellement prescrits dans des contextes cliniques d'hyperexcitabilité neuronale comme la prééclampsie et le stress chronique. Notre objectif était d'évaluer si le magnésium à 20 mg/kg et le calcium à 100 mg/kg pouvaient améliorer le pronostic mnésique dans le modèle kaïnique d'épilepsie mésiale temporale chez les souris. Les animaux furent organisés en six groupes : groupe témoin (sans kaïnate), groupe de référence sans administration d'ions (GR), groupes traités au magnésium ou au calcium dès le troisième jour (respectivement G1m, G1c), groupes traités au magnésium ou au calcium à partir de la troisième semaine (respectivement G2m, G2c). Les souris traitées ont toutes présenté de meilleures performances que les souris GR, mais le magnésium était plus efficace. La mémoire (court terme­long terme) était touchée différemment par le kaïnate ou améliorée par le magnésium et le calcium. De plus, le magnésium a démontré un effet thérapeutique croissant avec le temps alors que le calcium avait un effet aigu qui semblait se dégrader pour le groupe G1c qui reçut précocement du calcium.

Metastatic Spinal Cord Compression Secondary to Liver Cancer.

Metastatic spinal cord compression (MSCC) is a medical emergency that requires rapid diagnosis and treatment to reduce pain, to preserve neurological functioning, and to prolong survival. The diagnosis of liver cancer is often neglected in the differential diagnosis of MSCC. Treatment is usually palliative and evolution is often fatal. This is a case report of a 28-year-old patient living in Mauritania hospitalized in November 2014 at the neurology department of Fann national teaching hospital in Dakar, for the management of a chronic dorsal spinal cord compression. The radiological and laboratory investigations done revealed the metastatic compression originating from a liver cancer with elevated alpha-fetoprotein and aspartate transaminase, positive hepatitis B surface antigen, and multiple metastasis in the lungs, mediastinum, ribs, iliac, and peritoneum. The hip joint X-ray showed a spontaneous fracture of the right femoral neck. The multidisciplinary treatment was palliative and the evolution was fatal within the month of hospitalization. Earlier diagnosis and treatment of MSCC may not have saved the life of the patient but may have prevented much suffering and would likely have prolonged the life of a young man.

Post-ivermectin encephalopathy in Senegal: a case report.

Ivermectin is an ant parasitic drug used for combating onchocerciasis and lymphatic filariasis. It works by inhibiting the function of neurons and muscles, thus causing paralysis of microfilariae. Side effects of this drug have been reported including post-ivermectin encephalopathy requiring emergency care in hospital. We report the case of a 35 years old patient living in rural areas of Senegal who presented two days after a mistake in administration of a second dose of ivermectin, headaches, altered consciousness and bilateral blindness. The workup revealed brain white matter lesions, abnormal liver function tests and biological inflammation without evidence of Loa loa microfilariae in blood and cerebrospinal fluid. Corticosteroid treatment was administered in emergency and patient recovered despite the persistence of bilateral blindness. Inflammatory process seems to have an important role in the pathophysiology of this encephalopathy. We should therefore carefully control the administration of this drugs.

[Epidemiological and socio-economic support patients living with epilepsy in Dakar, Senegal]. / Profil épidémiologique et prise en charge socioéconomique des patients vivant avec l'épilepsie à Dakar, Senegal.

BACKGROUND: Epilepsy remains a major public health problem especially in developing countries where access to new therapies remains limited. OBJECTIVE: The aim of this work was to study the socio-demographic profile of patients living with epilepsy in Dakar and supported. METHODS: We conducted a cross-sectional study over a period of eight months from November 2009 to June 2010 at Fann University Hospital and Health Center Pikine through research on adherence. RESULTS: The study involved patients living with epilepsy aged over 15 years, diagnosed clinically with epilepsy and/or confirmed by an electroencephalogram and put under antiepileptic drug for more than 3 months. We recruited 411 patients aged 15-74 years with a mean age of 28.93 years. The age range was 15-24 years with 44.6 % majority. The male sex predominated with 52.3 % and the sex ratio was 1.09. Singles outnumbered with 64.7 %. The level of education was the most representative secondary with 29.4 % and patients without profession were 35.5 %. Most of the patients was from semi-urban areas with 47.7 %. Generalized seizures were more frequent with about 70 %. Most of the patients was supported either by their family or by themselves. CONCLUSION: The management should be multisectoral for epilepsy out of darkness.

Neuromeningeal cryptococcosis in sub-Saharan Africa: Killer disease with sparse data.

INTRODUCTION: The extent of neuromeningeal cryptococcosis (NMC) has increased since the advent of HIV/AIDS. It has non-specific clinical signs but marked by high mortality. OBJECTIVE: To analyze the characteristics of the NMC in sub-Saharan Africa. MATERIALS AND METHODS: We have conducted a literature reviewed on the NMC in sub-Saharan Africa from the publications available on the basis of national and international data with keywords such as "Cryptococcus, Epidemiology, Symptoms, Outcomes and Mortality" and their equivalent in French in July 2011. All publications from 1990 to 2010 with 202 references were analyzed. The following results are the means of different studied variables. RESULTS: We selected in final 43 publications dealing with the NMC which 24 involved 17 countries in Africa. The average age was 36 years old. The average prevalence was 3.41% and the average incidence was 10.48% (range 6.90% to 12%). The most common signs were fever (75%), headaches (62.50%) and impaired consciousness. Meningeal signs were present in 49% of cases. The mean CD4 count was 44.8cells/mm(3). The India ink and latex agglutination tests were the most sensitive. The average time before the consultation and the hospital stay was almost identical to 27.71 days. The average death rate was 45.90%. Fluconazole has been the most commonly used molecule. CONCLUSION: The epidemiological indicators of NMC varied more depending on the region of sub-Saharan Africa. Early and effective taking care of patients to reduce diagnostic delay and heavy mortality remains the challenges.