Cortisol and uncomplicated Plasmodium falciparum malaria in an area of unstable malaria transmission in eastern Sudan.

OBJECTIVE: To investigate the levels of serum cortisol in patients with uncomplicated Plasmodium falciparum (P. falciparum) malaria in an area of unstable malaria transmission in eastern Sudan. METHODS: The concentrations of cortisol were measured in sera of 25 patients with uncomplicated P. falciparum malaria (at presentation, 24 h and 7 d later) and 25 healthy volunteers using radioimmunoassay gamma counter. RESULTS: There was no significant difference in mean (SD) of total cortisol levels in patients with malaria in comparison with the control group; 602.2 (369.6) vs. 449.2(311.7) ng/mL, P=0.12. In patients with uncomplicated P. falciparum malaria, the mean (SD) presenting cortisol levels were significantly higher in comparison to the levels on day 7; 602.2 (369.6) vs. 373.6(139.1) ng/mL, P=0.009. In the patients with uncomplicated P. falciparum malaria (on presentation) cortisol levels were not correlated with initial temperature or the presenting parasitaemia. CONCLUSIONS: Thus, cortisol levels were not significantly different between the patients and the controls.

Efficacies of artesunate plus either sulfadoxine-pyrimethamine or amodiaquine, for the treatment of uncomplicated, Plasmodium falciparum malaria in eastern Sudan.

Artemisinin-based combination therapy (ACT) is increasingly being adopted as the first-line treatment for malaria in sub-Saharan Africa. In September-November 2005, in New Halfa, eastern Sudan, the efficacy of artesunate-sulfadoxine-pyrimethamine (AS-SP) for the treatment of uncomplicated, Plasmodium falciparum was compared with that of artesunate-amodiaquine (AS-AQ). The artesunate was given at 4 mg/kg. day on days 0-2, with either a single dose of SP (25 mg sulfadoxine/kg) given on day 0, or AQ, at 10 mg/kg. day, given on days 0-2. Eighty-two of the patients treated (40 given AS-SP and 42 given AS-AQ) completed the 28 days of follow-up. On day 3 all the patients were afebrile and only one patient, in the AS-AQ group, was still parasitaemic. AS-SP appeared slightly more efficacious than AS-AQ but the differences were not statistically significant. Only one patient (2.5%) given AS-SP but four (9.5%) of those given AS-AQ were initially considered to be late treatment and parasitological failures, with all other patients showing an adequate treatment response. The PCR-corrected frequencies of cure were 97.5% for AS-SP and 95.2% for AS-AQ (P>0.05). No gametocytaemias were observed during the follow-up and, although mild adverse effects (nausea, vomiting, abdominal pain, dizziness and/or rash) were detected in 14 patients, they occurred at the same frequency in each treatment arm. It therefore appears that the AS-SP and AS-AQ combinations were both effective and safe for the treatment of uncomplicated, P. falciparum malaria in eastern Sudan.

Identification of a novel G245R polymorphism in the IL-2 receptor beta membrane proximal domain associated with human visceral leishmaniasis.

Binding of the interleukin-2 (IL-2) to the IL-2 receptor (IL-2R) triggers a series of intracellular events culminating in lymphocyte proliferation and differentiation. We report here the identification of a novel G245R polymorphism in the membrane proximal domain of the IL-2 receptor beta chain (IL-2Rbeta). Present at a frequency of 7.2%, the IL-2-Rbeta G245R was identified in a population of Eastern Sudan exposed to a severe outbreak of visceral leishmaniasis (VL), a disease associated with a marked depression of T-cell antigen-specific responses. The location of the G245R polymorphism next to the box1/box2 proximal cytokine receptor homology segment and suggestive genetic association with the development of disease (P=0.043), suggest that it may affect Janus kinase (JAK) association and impair growth signal transduction. However, additional genetic association with a synonymous single nucleotide polymorphism (IL2RB+8777T) suggests that other variations of IL2RB or nearby genes participate in the highly significant linkage with VL at 22q12 previously reported for this population.

Attitudes towards euthanasia among final-year Khartoum University medical students.

To investigate the attitudes of final-year medical students at Khartoum University towards euthanasia an anonymous questionnaire was answered by 141 students. Most were familiar with the concept of euthanasia. The majority, 108 (76.6%) opposed euthanasia and their reasons included religious beliefs, belief that euthanasia was unethical and fear of misuse. The supporters of euthanasia (23.4%) stated reasons such as preventing the suffering of patients and respecting their autonomy and dignity. More students who described themselves as strongly religious were opponents of euthanasia (83/87, 95.4%) than those who were moderately religious (25/54, 46.3%).

Attitudes towards euthanasia among final-year Khartoum University medical students

To investigate the attitudes of final-year medical students at KhartoumUniversity towards euthanasia an anonymous questionnaire was answered by 141 students. Most were familiar with the concept of euthanasia. The majority, 108 [76.6%] opposed euthanasia and their reasons included religious beliefs, belief that euthanasia was unethical and fear of misuse. The supporters of euthanasia [23.4%] stated reasons such as preventing the suffering of patients and respecting their autonomy and dignity. More students who described themselves as strongly religious were opponents of euthanasia [83/87, 95.4%] than those who were moderately religious [25/54, 46.3%]

Low-dose quinine is effective in the treatment of chloroquine-resistant Plasmodium falciparum malaria in eastern Sudan.

In November-December 2002, 98 patients presented at the Elhara Eloula health centre, in the New Halfa area of eastern Sudan, with Plasmodium falciparum malaria that had failed to respond to chloroquine treatment. After informed consent was obtained, 93 of these patients were randomly allocated to one of three regimens for quinine treatment, being given the drug, orally and sometimes intravenously, for 7 days, at doses of 10 mg/kg thrice daily (32 patients), 10 mg/kg twice daily (31 patients) or 15 mg/kg once daily (30 patients). All the patients were followed daily until day 7 and then weekly until day 28. There was no significant difference in the parasite-clearance times observed in the three groups. Parasitaemias re-occurred by day 28 in 12 patients: two (6.3%) of the patients treated thrice daily, five (16.1%) of those treated twice daily, and five (16.7%) of those treated once daily (P > 0.05). Genotyping indicated that in nine of these 12 patients the parasitaemias that developed post-treatment represented true recrudescences and not re-infections. In the treatment of chloroquine-resistant, P. falciparum malaria in Sudan, once-daily treatment with quinine, in a relatively low daily dose (15 mg/kg. day), appears as effective as the thrice-daily treatment (at 30 mg/kg. day) often recommended.

Genetic control of visceral leishmaniasis in a Sudanese population: candidate gene testing indicates a linkage to the NRAMP1 region.

There is some evidence showing that genetic factors are involved in human susceptibility to parasitic diseases such as schistosomiasis and malaria. Studies have shown that the Nramp1 and H-2 genes are implicated in the control of Leishmania donovani infection in mice. We sought genetic loci involved in the control of susceptibility to visceral disease caused by L. donovani in humans. We studied 37 families with at least two affected sibs living in a village in eastern Sudan, where an outbreak of visceral leishmaniasis occurred between 1995 and 2000. The genetic markers located in five chromosomal regions containing candidate genes were typed: 2q35 (NRAMP1), 5q31-q33 (Th2 cytokine cluster), 6p21 (HLA/TNF-alpha), 6q23 (INFGRI) and 12q15 (INF-gamma). Linkage (multipoint lod-score=1.08; P=0.01) was observed for the 5'(CA) repeat polymorphism in the NRAMP1 promoter. This suggests that genetic variations of this gene affect susceptibility to visceral leishmaniasis in this population.

Antileishmanial antibodies in an outbreak of visceral leishmaniasis in eastern Sudan: high antibody responses occur in resistant subjects and are not predictive of disease.

A 3-year longitudinal survey was carried out from 1998 to 2000 in a village in eastern Sudan where a visceral leishmaniasis (VL) outbreak occurred. Leishmania-specific antibodies were analysed by enzyme-linked immunosorbent assay and immunoblotting. Immunoblot analysis detected antibodies to Leishmania in 80% of the healthy subjects and half of them harboured high immunoglobulin (Ig) G antibody levels, similar to those of VL patients. These antibodies belonged to the IgG1 and IgG3 subclasses but neither their respective levels nor the immunoblot recognition patterns were predictive of VL. During this epidemic, a large proportion of subjects had a high antileishmanial antibody response, indicating that they were infected by Leishmania though most of them remained healthy during the whole study period. These results obtained in the context of an outbreak contrast with those obtained from studies performed in endemic areas characterized by lower parasite transmission levels. Furthermore, the clinical and serological follow-up of our study subjects showed that VL occurred mainly in subjects who had been serologically positive for 5-24 months rather than resulting from primo infection by the parasite.

Attitudes towards euthanasia and assisted suicide among Sudanese doctors.

An anonymous questionnaire was used to survey the attitudes of 382 doctors towards euthanasia and assisted suicide at Khartoum's two main hospitals. Of the 382, 248 responded (65% response rate). The mean age was 38 +/- 13.5 years; male:female ratio was 130:118; 66% were house staff, 34% specialists; 92% Muslim, 8% Christian. The vast majority (85%) strongly opposed the practices, while 15% thought they should be performed only in certain situations, subject to strict safeguards. Reasons given for opposition included religious beliefs, inconsistency with the doctor's role, presence of subtle pressures on patients, and potential for misuse among the physically and intellectually handicapped.

Thyroid functional status in leprosy patients in Sudan.

We studied 45 adult patients with untreated lepromatous leprosy and borderline leprosy, presenting at clinics in Khartoum and Omdurman, to assess clinical and biochemical effects of the disease on thyroid function. A matching control group of 30 subjects, without symptoms or signs of thyroid disease, were included for comparison. Thyroxine, triiodothyronine and thyrotrophin levels were within normal range. Mean serum thyroxine was low in both groups (significant in lepromatous leprosy patients only). Mean serum triiodothyronine was high in both groups (significant in neither group). Mean thyrotrophin was significantly higher in both groups compared with controls.

Attitudes towards euthanasia and assisted suicide among Sudanese doctors

An anonymous questionnaire was used to survey the attitudes of 382 doctors towards euthanasia and assisted suicide at Khartoum's two main hospitals. Of the 382, 248 responded [65% response rate]. The mean age was 38 +/- 13.5 years; male:female ratio was 130:118; 66% were house staff, 34% specialists; 92% Muslim, 8% Christian. The vast majority [85%] strongly opposed the practices, while 15% thought they should be performed only in certain situations, subject to strict safeguards. Reasons given for opposition included religious beliefs, inconsistency with the doctor's role, presence of subtle pressures on patients, and potential for misuse among the physically and intellectually handicapped

Thyroid functional status in leprosy patients in Sudan

We studied 45 adult patients with untreated lepromatous leprosy and borderline leprosy, presenting at clinics in Khartoum and Omdurman, to assess clinical and biochemical effects of the disease on thyroid function. A matching control group of 30 subjects, without symptoms or signs of thyroid disease, were included for comparison. Thyroxine, triiodothyronine and thyrotrophin levels were within normal range. Mean serum thyroxine was low in both groups [significant in lepromatous leprosy patients only]. Mean serum triiodothyronine was high in both groups [significant in neither group]. Mean thyrotrophin was significantly higher in both groups compared with controls

Effects of single-dose praziquantel on morbidity and mortality resulting from intestinal schistosomiasis.

The long-term effect of single-dose praziquantel on morbidity and mortality from Schistosoma mansoni was investigated in surveys in 1987 and 1994 in central Sudan. Prevalence of infection dropped from 53% to 34%, and intensity of infection (> or = 400 eggs/g of faeces) from 31% to 18%. There was a reduction in hepatomegaly and hepatosplenomegaly, although splenomegaly alone was unchanged. Prevalence of periportal fibrosis decreased from 14% to 10%. Endoscopic investigation of patients with fibrosis showed a reduction in oesophageal varices from 47% to 30%. Mortality due to bleeding varices was high (community-wide, up to 11/100 infected patients with bleeding). Thus praziquantel mass treatment can be spaced to a much longer period, reducing the expense of treatment, delivery and distribution.

Effects of single-dose praziquantel on morbidity and mortality resulting from intestinal schistosomiasis

The long-term effect of single-dose praziquantel on morbidity and mortality from Schistosoma mansoni was investigated in surveys in 1987 and 1994 in central Sudan. Prevalence of infection dropped from 53% to 34%, and intensity of infection [400 eggs/g of faeces] from 31% to 18%. There was a reduction in hepatomegaly and hepatosplenomegaly, although splenomegaly alone was unchanged. Prevalence of periportal fibrosis decreased from 14% to 10%. Endoscopic investigation of patients with fibrosis showed a reduction in oesophageal varices from 47% to 30%. Mortality due to bleeding varices was high [community-wide, up to 11/100 infected patients with bleeding]. Thus praziquantel mass treatment can be spaced to a much longer period, reducing the expense of treatment, delivery and distribution

Mortality due to schistosomiasis mansoni: a field study in Sudan.

Although schistosomiasis affects 200 million persons, 20 million of whom have advanced disease, little is known about the mortality pattern in areas of endemic schistosomiasis mansoni. In an attempt to assess the mortality rates in an endemic area in Sudan, we conducted two demographic surveys in a village in the Gezira area. Clinical, sonographic, and parasitologic examinations were performed in a randomly selected sample of 25% of the population in 1987 and 1994. One of us asked each head of household about the names, sex, and age of family members. Particularly, we asked about death in the family if any, history of schistosomiasis, abdominal swelling, and hematemesis. Possible causes of death were ascertained by reviewing medical records in the village dispensary and the district hospital. There were 42 deaths in the village. Four males died of hematemesis secondary to portal fibrosis. The crude mortality rate of schistosomiasis was is 51/100,000/year. The overall schistosomiasis fatality rate per year was 1/1,000 infected persons, but was as high as 11/100/infected patients with bleeding varices. These findings showed the impact of schistosomiasis on public health in this economically important region of Sudan.

Seasonal variation in the incidence of endoscopically diagnosed duodenal ulcer in Sudan.

The seasonal pattern of endoscopically diagnosed duodenal ulcer disease in an endoscopy unit in Suba University Hospital and Ibn Sina Hospital, Sudan, was evaluated retrospectively for the period 1980-1988. We reviewed all the 12443 endoscopy records and found 1348 cases of duodenal ulcers. The incidence of duodenal ulcer was then calculated for each month separately. We found that in Sudan the frequency of duodenal ulcer is significantly higher during winter (January-February), and significantly lower during summer (May-August).