Novel GREM1 Variations in Sub-Saharan African Patients With Cleft Lip and/or Cleft Palate.

OBJECTIVE: Cleft lip and/or cleft palate (CL/P) are congenital anomalies of the face and have multifactorial etiology, with both environmental and genetic risk factors playing crucial roles. Though at least 40 loci have attained genomewide significant association with nonsyndromic CL/P, these loci largely reside in noncoding regions of the human genome, and subsequent resequencing studies of neighboring candidate genes have revealed only a limited number of etiologic coding variants. The present study was conducted to identify etiologic coding variants in GREM1, a locus that has been shown to be largely associated with cleft of both lip and soft palate. PATIENTS AND METHOD: We resequenced DNA from 397 sub-Saharan Africans with CL/P and 192 controls using Sanger sequencing. Following analyses of the sequence data, we observed 2 novel coding variants in GREM1. These variants were not found in the 192 African controls and have never been previously reported in any public genetic variant database that includes more than 5000 combined African and African American controls or from the CL/P literature. RESULTS: The novel variants include p.Pro164Ser in an individual with soft palate cleft only and p.Gly61Asp in an individual with bilateral cleft lip and palate. The proband with the p.Gly61Asp GREM1 variant is a van der Woude (VWS) case who also has an etiologic variant in IRF6 gene. CONCLUSION: Our study demonstrated that there is low number of etiologic coding variants in GREM1, confirming earlier suggestions that variants in regulatory elements may largely account for the association between this locus and CL/P.

Effects of Community Health Nurse-Led Intervention on Childhood Routine Immunization Completion in Primary Health Care Centers in Ibadan, Nigeria.

Immunization coverage of vulnerable children is often sub-optimal in many low- and middle-income countries. The use of a reminder/recall (R/R) system has been one of the strategies shown to be effective in improving immunization rates. In the resent study, we evaluated the effect of R/R and Primary Health Care Immunization Providers' Training (PHCIPT) intervention on routine immunization completion among 595 infants in Ibadan, Nigeria. The design was a group randomized controlled trial with Local Government Area (LGA) being the unit of randomization. Four randomly selected LGAs were randomized to receive a cellphone R/R only (A), a PHCIPT only (B); combined R/R and PHCIPT (C) intervention or serve as a control group (D). Children aged 0-12 weeks were consecutively recruited into each group and followed up for 12 months. The primary outcome measure was routine immunization completion at 12 months of age. At the study endpoint, immunization completion rates were: group A, 98.6 %; group B, 70 %; group C, 97.3 %; and group D, 57.3 %. Compared to the control group, the cellphone R/R group was 72 % (RR 1.72, 95 % CI 1.50-1.98) and the combined RR/PHCIPT group 70 % (RR 1.70, 95 % CI 1.47-1.95) more likely to complete immunization. In contrast, immunization completion in the PHCIPT group was marginally different from the control group (RR 1.22, 95 % CI 1.03-1.45). These findings remained robust to adjustment for potential predictors of immunization completion as covariates. In conclusion, cellphone reminder/recall was effective in improving immunization completion in this Nigerian setting. Its use is recommended for large scale implementation.

ASYMPTOMATIC BACTERIURIA AS A PREDICTOR OF PRE-ECLAMPSIA: A CASECONTROLLED STUDY.

Background: Pre-eclampsia, an important cause of maternal and perinatal morbidity and mortality world-wide has been linked to subclinical infections, with maternal infection and inflammation postulated in its aetio-pathogenesis including asymptomatic bacteriuria which is common in pregnancy. The Obejctive of the study is to determine the relationship of asymptomatic bacteriuria as a risk factor for pre-eclampsia. Methodology: A hospital-based case-control study among 28 pre-eclamptic pregnant women (cases) and 56 healthy pregnant women (controls) at gestational age of at least 28 weeks at the University College Hospital, Ibadan, between January 2019 and August 2019. Controls were matched with cases in age, parity and gestational age. Asymptomatic bacteriuria was determined with mid-stream urine analysis for microscopy and culture and data collected using an interviewer administered questionnaire with other details from medical records extracts. Chi- square, and multivariate regression analysis were used to assess statistical significance, odds ratio and adjusted odds ratio respectively, with P-value <0.05 and 95% confidence interval (CI). Results: There was a significant association between asymptomatic bacteriuria and pre-eclampsia. The rate of asymptomatic bacteriuria was about three times higher in women with pre-eclampsia compared to those without pre-eclampsia and 1.23 times higher after adjusting for confounders (OR: 2.9, AOR:1.23). There was no significant relationship between sterile pyuria and pre-eclampsia (p-value: 0.92). Conclusion: This study supports the proposition that asymptomatic bacteriuria is a risk factor for pre-eclampsia. It has not however shown whether the association is causal or casual. Further studies will be needed to explain this.

Paediatric paranasal sinus fibrous dysplasia.

Fibrous dysplasia in the bony walls of a paranasal sinus is a developmental tumour that is associated with a marked facial deformity. Delay in hospital presentation contributes to the destructive resection techniques employed and the management outcome. Our study looks at the factors for delay in hospital presentation and the management outcome by a retrospective review between January 1997 and December 2018. Of 43 children (M: F 1:1.2) with a mean age of 12 ± 1.75 years, the maxillary bones were mostly affected. All underwent surgical resection with good management outcomes except for maxillectomy. Tumour recurrence was noted in five and there was no mitotic cell at histology. The clinical symptoms of fibrous dysplasia vary in severity and age of onset, often with late hospital presentation already with complications. Health education is needed to reverse this trend.

Genome-wide Gene-by-Sex Interaction Studies Identify Novel Nonsyndromic Orofacial Clefts Risk Locus.

Risk loci identified through genome-wide association studies have explained about 25% of the phenotypic variations in nonsyndromic orofacial clefts (nsOFCs) on the liability scale. Despite the notable sex differences in the incidences of the different cleft types, investigation of loci for sex-specific effects has been understudied. To explore the sex-specific effects in genetic etiology of nsOFCs, we conducted a genome-wide gene × sex (GxSex) interaction study in a sub-Saharan African orofacial cleft cohort. The sample included 1,019 nonsyndromic orofacial cleft cases (814 cleft lip with or without cleft palate and 205 cleft palate only) and 2,159 controls recruited from 3 sites (Ethiopia, Ghana, and Nigeria). An additive logistic model was used to examine the joint effects of the genotype and GxSex interaction. Furthermore, we examined loci with suggestive significance (P < 1E-5) in the additive model for the effect of the GxSex interaction only. We identified a novel risk locus on chromosome 8p22 with genome-wide significant joint and GxSex interaction effects (rs2720555, p2df = 1.16E-08, pGxSex = 1.49E-09, odds ratio [OR] = 0.44, 95% CI = 0.34 to 0.57). For males, the risk of cleft lip with or without cleft palate at this locus decreases with additional copies of the minor allele (p < 0.0001, OR = 0.60, 95% CI = 0.48 to 0.74), but the effect is reversed for females (p = 0.0004, OR = 1.36, 95% CI = 1.15 to 1.60). We replicated the female-specific effect of this locus in an independent cohort (p = 0.037, OR = 1.30, 95% CI = 1.02 to 1.65), but no significant effect was found for the males (p = 0.29, OR = 0.86, 95% CI = 0.65 to 1.14). This locus is in topologically associating domain with craniofacially expressed and enriched genes during embryonic development. Rare coding mutations of some of these genes were identified in nsOFC cohorts through whole exome sequencing analysis. Our study is additional proof that genome-wide GxSex interaction analysis provides an opportunity for novel findings of loci and genes that contribute to the risk of nsOFCs.

EVOLVING TELEMEDICINE PRACTICE: EXPERIENCES OF HEALTH CARE WORKERS DURING COVID-19 PANDEMIC.

BACKGROUND: Telemedicine is employed in patient care when direct physical contact is not possible or discouraged, as was seen during the COVID-19 pandemic. The use of smartphone technology could make telemedicine affordable and available in low and medium-income countries (LMICs). However, the evolution of telemedicine care depends on multiple factors. AIM: To explore the practice of telemedicine by Nigerian health care workers (HCWs) during the COVID-19 pandemic. METHODS: A cross-sectional study of the Nigerian HCWs on telemedicine practice in patient care during the COVID-19 pandemic period. Recruitment of respondents was done through dedicated WhatsApp and Telegram social media platforms for HCWs over a period of 40 days (May 1st and June 10th, 2020). RESULTS: A total of 481 HCWs participated in the study consisting of 153(31.8%) doctors, 150(31.2%) nurses and 178(37%) other HCWs. Though 89.2% of the HCWs agreed that telemedicine is important, it was only 266 (55.3%) that practiced telemedicine, phone consultation was the form of telemedicine used in all the health institutions. Telemedicine was practiced more by doctors 91(18.9%), nurses 79(16.4%) and pharmacists 35(7.3%) than other groups of health care workers. Inadequate COVID-19 screening test and lack of personal protective equipment were strong motivators for the attending HCWs to practice telemedicine. CONCLUSION: There was widespread use of phone consultation by all cadres of health care workers during the pandemic. Hence there should be a health policy that will encourage greater use and acceptance of telemedicine in clinical practice and in the patients care beyond the pandemic period.

DENTURE IMPACTION IN THE OESOPHAGUS: CORRELATION OF SITE AND DURATION OF IMPACTION WITH SEQUELAE.

BACKGROUND: Denture restores aesthesis and function of missing teeth. Accidentally swallowed denture is an otorhinolaryngology emergency. The types of denture base and oesophageal anatomy infuluence the site of impaction. OBJECTIVE: To review site of denture impaction and factors associated with site of impaction. To correlate site and duration of denture impaction before removal with associated sequelae. METHOD: A retrospective study of 27 patients managed in Otorhinolaryngology Department of University College Hospital Ibadan, Nigeria for oesophageal partial denture impaction, between August 2006 and September 2016. The demographic and clinical data of the patients were extracted from the hospital records, and statistical tables were used to illustrate the data. RESULTS: A total of 27 patients; 14(51.9%) males and 13(48.1%) females, (M: F, 1.1:1) were studied. The age ranged from 24 to 77 years (mean age 49.0 ± 14.2years). Dentures were worn for 3 to 30 years (mean 3.8 ± 2.3years) without follow-up visit to dentist and 85.2% were upper dentures. All patients had history of accidental ingestion of denture, and the mean site of impaction was 18.2 ± 3.2cm from upper incisor, typically at upper cervical oesophagus in elderly patients and in lower oesophagus in females. There was no association between site of denture impaction, duration of denture impaction and operative findings. CONCLUSION: Advanced age and female gender are associated with site of denture impaction. Late hospital presentation significantly promotes sequelae associated with management of impacted dentures. It is recommended that fundamental changes in denture designs, education on regular follow-ups and avoidance of ill-fitting dentures would reduce the prevalence of denture impaction.

Loss-of-Function GRHL3 Variants Detected in African Patients with Isolated Cleft Palate.

In contrast to the progress that has been made toward understanding the genetic etiology of cleft lip with or without cleft palate, relatively little is known about the genetic etiology for cleft palate only (CPO). A common coding variant of grainyhead like transcription factor 3 ( GRHL3) was recently shown to be associated with risk for CPO in Europeans. Mutations in this gene were also reported in families with Van der Woude syndrome. To identify rare mutations in GRHL3 that might explain the missing heritability for CPO, we sequenced GRHL3 in cases of CPO from Africa. We recruited participants from Ghana, Ethiopia, and Nigeria. This cohort included case-parent trios, cases and other family members, as well as controls. We sequenced exons of this gene in DNA from a total of 134 nonsyndromic cases. When possible, we sequenced them in parents to identify de novo mutations. Five novel mutations were identified: 2 missense (c.497C>A; p.Pro166His and c.1229A>G; p.Asp410Gly), 1 splice site (c.1282A>C p.Ser428Arg), 1 frameshift (c.470delC; p.Gly158Alafster55), and 1 nonsense (c.1677C>A; p.Tyr559Ter). These mutations were absent from 270 sequenced controls and from all public exome and whole genome databases, including the 1000 Genomes database (which includes data from Africa). However, 4 of the 5 mutations were present in unaffected mothers, indicating that their penetrance is incomplete. Interestingly, 1 mutation damaged a predicted sumoylation site, and another disrupted a predicted CK1 phosphorylation site. Overexpression assays in zebrafish and reporter assays in vitro indicated that 4 variants were functionally null or hypomorphic, while 1 was dominant negative. This study provides evidence that, as in Caucasian populations, mutations in GRHL3 contribute to the risk of nonsyndromic CPO in the African population.

Association Studies and Direct DNA Sequencing Implicate Genetic Susceptibility Loci in the Etiology of Nonsyndromic Orofacial Clefts in Sub-Saharan African Populations.

Orofacial clefts (OFCs) are congenital dysmorphologies of the human face and oral cavity, with a global incidence of 1 per 700 live births. These anomalies exhibit a multifactorial pattern of inheritance, with genetic and environmental factors both playing crucial roles. Many loci have been implicated in the etiology of nonsyndromic cleft lip with or without cleft palate (NSCL/P) in populations of Asian and European ancestries, through genome-wide association studies and candidate gene studies. However, few populations of African descent have been studied to date. Here, the authors show evidence of an association of some loci with NSCL/P and nonsyndromic cleft palate only (NSCPO) in cohorts from Africa (Ghana, Ethiopia, and Nigeria). The authors genotyped 48 single-nucleotide polymorphisms that were selected from previous genome-wide association studies and candidate gene studies. These markers were successfully genotyped on 701 NSCL/P and 163 NSCPO cases, 1,070 unaffected relatives, and 1,078 unrelated controls. The authors also directly sequenced 7 genes in 184 nonsyndromic OFC (NSOFC) cases and 96 controls from Ghana. Population-specific associations were observed in the case-control analyses of the subpopulations, with West African subpopulations (Ghana and Nigeria) showing a similar pattern of associations. In meta-analyses of the case-control cohort, PAX7 (rs742071, P = 5.10 × 10(-3)), 8q24 (rs987525, P = 1.22 × 10(-3)), and VAX1 (rs7078160, P = 0.04) were nominally associated with NSCL/P, and MSX1 (rs115200552, P = 0.01), TULP4 (rs651333, P = 0.04), CRISPLD2 (rs4783099, P = 0.02), and NOG1 (rs17760296, P = 0.04) were nominally associated with NSCPO. Moreover, 7 loci exhibited evidence of threshold overtransmission in NSOFC cases through the transmission disequilibrium test and through analyses of the family-based association for disease traits. Through DNA sequencing, the authors also identified 2 novel, rare, potentially pathogenic variants (p.Asn323Asp and p.Lys426IlefsTer6) in ARHGAP29 In conclusion, the authors have shown evidence for the association of many loci with NSCL/P and NSCPO. To the best of this knowledge, this study is the first to demonstrate any of these association signals in any African population.

Genetic diversity of the msp-1 locus and symptomatic malaria in south-west Nigeria.

Genetic characteristics of Plasmodium falciparum may play a role in the clinical severity of malaria infection. We have studied the association between diversity at the merozoite surface protein-1 (msp-1) locus and the severity of disease in childhood malaria in Ibadan, south-west Nigeria. Two hundred and twenty-three children (median age of 34.5 months) presenting with malaria were enrolled into the study. They comprised 53 children with asymptomatic malaria (ASM), 101 with acute uncomplicated malaria (UM) and 69 with severe malaria (SM). Genotyping of the msp-1 locus was by polymerase chain reaction. The distribution of msp-1 alleles was significantly different between the three groups. Asymptomatic malaria samples had a higher median number of alleles than the other two groups. The type of msp-1 allele detected was significantly associated with the clinical category of malaria. The absence of K1 alleles was associated with a three-fold increase risk of UM and a four-fold increased risk of SM when compared with asymptomatic malaria. The absence of MAD20 alleles was associated with a five-fold increase risk of UM and an eight-fold increase of SM. We have found an association between the msp-1 locus of P. falciparum and clinical severity of malaria in a sample of Nigerian children. Our findings show that the presence of the K1 and MAD20 alleles was significantly associated with ASM and consequently a reduced risk of developing the symptomatic disease.

Plasmodium falciparum malaria in south-west Nigerian children: is the polymorphism of ICAM-1 and E-selectin genes contributing to the clinical severity of malaria?

Plasmodium falciparum malaria remains a major public health hazard in sub-Saharan African children. While the factors that determine the variations in clinical outcome of a malaria have not been completely defined, both host and parasite factors, as well as the complex molecular interactions between them have been implicated. The cyto-adherent properties of the P. falciparum-infected red blood cells are considered as key properties in the pathogenesis of malaria and the polymorphisms of the host adhesion molecules could contribute to the severity of malaria. Clinical information and blood samples were collected from 223 children from Ibadan (south-west Nigeria), median age of 34.5 months, presenting with different clinical manifestations of malaria--clinically asymptomatic parasitism (ACP), acute uncomplicated malaria (UM) and severe malaria (SM)--as defined by WHO criteria. The polymorphisms of genes coding for four human adhesion molecules at six different loci (ICAM-1 exons 2, 4 and 6, E-selectin exon 2, CD36 exon 10, and PECAM exon 3) were studied. DNA samples were prepared for further genotyping of the six exons mentioned above by PCR-RFLPs using the appropriate restriction digests for each loci. The ICAM-1 exon 4 locus was monomorphic. All the other loci were at Hardy-Weinberg equilibrium (HWE). The E-selectin locus had very low heterozygosity (approximately 0.06) in contrast to the other loci under study (0.23-0.44). Once the data was further processed for covariates (age and parasite density) and taking as the reference category the ACP group, results show that in the presence of the G allele at the ICAM-1 exon 6 there is an increased risk (3.6 times) of severe malaria. As far as the T allele in the E-selectin exon is concerned, the number of sampled DNAs with the T allele within both the UM and SM categories is too low for drawing any relevant conclusion at this stage. In conclusion, these results suggest that genetic polymorphisms at host adhesion molecules loci are an important variable in the susceptibility to severe malaria. Further studies of host loci are needed to further delineate which polymorphisms are associated with severe malaria and increase our knowledge of the biology of host-parasite interactions.

Beta cell function and response to treatment in Nigerians with Type 2 diabetes mellitus.

There are scant data from African populations on the association between beta-cell function and response to treatment with oral hypoglycaemic agents in Type 2 diabetes mellitus (T2DM). Fasting plasma C-peptide (FCP) and glucagon-stimulated C-peptide (GSCP) levels were measured in 116 Nigerians with T2DM at a university teaching hospital. After 9 months of follow-up and treatment, they were categorized into three groups based on response to treatment: (A) good control but not on maximum sulphonylurea (SU) therapy, (B) inadequate control but not on maximum SU therapy and (C) on maximum SU therapy+/-insulin or biguanide. Logistic regression models were used to investigate how well C-peptide levels predicted the subjects belonging to Group C who are likely to require insulin. The mean FCP and mean GSCP levels of Group C were significantly lower than in the other groups (p=0.024; p= <0.001 respectively). A GSCP cut-off value of < or =1.3 ng/mL predicted membership of Group C with 85% sensitivity and 89% specificity while a cut-off of < or =1.8 ng/mL was associated with 91% sensitivity and 66% specificity. In resource-poor settings where inadequate treatment are common, estimation of GSCP may be useful in predicting treatment response and should be weighed against the cost of inadequate therapy with higher morbidity and mortality.

Lack of association between falciparum malaria parasitemia and acute diarrhea in Nigerian children.

It is widely believed that malaria causes diarrhea. Yet, national and international diarrheal diseases control programs are silent about the overlap between these two major public health problems that coexist in most tropical countries. To test the hypothesis that malaria is associated with diarrhea and to define the role of malaria in morbidity due to diarrhea, 522 children 6-60 months of age presenting with acute diarrhea to the Children's Emergency Ward of the University College Hospital in Ibadan, Nigeria were routinely screened by means of thin and thick blood films for malaria parasitemia. Controls, without diarrhea, were studied in parallel. Detailed clinical features were recorded for every patient. Sixty-eight (13%) of the 522 diarrhea patients screened had malaria parasitemia. Among the controls (who had similar distributions of admission temperature, hemoglobin types, glucose-6-phosphate dehydrogenase deficiency, and prior treatment with antimalarial drugs), parasitemia was not significantly different, occurring in 56 (17.9%) of 313. In the dry season, however, a significantly higher prevalence of parasitemia was observed among the control group (15.5%) than in the diarrhea group (7.0%) (P = 0.004). Parasitemia was significantly more common in the dehydrated diarrhea patients than their well-hydrated counterparts (25% of 56 versus 11% of 466; P < 0.005). There were no significant differences in admission temperature, the presence of vomiting, or the home use of oral rehydration fluids between the dehydrated and the well-hydrated subsets of diarrhea patients. Consideration of parasite densities did not alter any of the foregoing relationships. These data contradict the widely held view that diarrhea is a symptom of malaria or that malaria causes diarrhea. They do, however, provide support for examining blood smears at least in dehydrated children with diarrhea in malaria-endemic areas and giving immediate antimalarial therapy to those who have malaria parasitemia.

Chloroquine resistance of Plasmodium falciparum is associated with severity of disease in Nigerian children.

Chloroquine resistance of Plasmodium falciparum in vitro was significantly higher in isolates from patients with severe malaria than those with uncomplicated disease. This association may be due to either progression of uncomplicated to severe disease following chloroquine failure or increased virulence of chloroquine-resistant parasites. The implication of this for antimalarial treatment policy is discussed.

Intraleucocytic malaria pigment and clinical severity of malaria in children.

Intraleucocytic malaria pigment has been suggested as a measure of disease severity in malaria. We have tested this hypothesis by studying 146 children aged 6 months to 14 years in 4 categories--cerebral malaria, mild malaria, asymptomatic malaria and 'no malaria'--in Ibadan, Nigeria, an area of intense malaria transmission in Africa. Children with cerebral malaria were studied at the university hospital, those with mild malaria at 2 primary health centres and the other 2 groups were studied in a primary school. The proportion of pigment-containing neutrophils showed a clear rise across the spectrum no malaria--asymptomatic malaria--mild malaria--cerebral malaria (median values 2.0%, 6.5%, 9.0% and 27.0%, respectively; P < 0.0001). The proportion of pigment-containing monocytes did not differ significantly between the mild malaria, asymptomatic malaria and no malaria groups but the cerebral malaria group had a higher median value than the other 3 groups. The ratio of pigment-containing neutrophils to pigment-containing monocytes showed the same trend across the groups of subjects as was observed with the number of pigment-containing neutrophils. It is concluded that the pigment-containing neutrophil count is a simple marker of disease severity in childhood malaria in addition to the parasite count.

Comparative efficacy of intramuscular artemether and intravenous quinine in Nigerian children with cerebral malaria.

The efficacy of a 5-day treatment with intramuscular artemether (3.2-mg/kg loading dose followed by 1.6 mg/kg daily) was compared to that of the standard 7-day treatment with quinine (20-mg/kg loading dose followed by 10 mg/kg every 8 h) in a randomised clinical trial including 103 children aged 12-60 months with cerebral malaria between 1994 and 1996. No statistical difference of immediate efficacy was found between the two treatments. There were 11 (20%) deaths in the artemether group and 14 (28%) in the children who received quinine. The respective artemether versus quinine median fever clearance times (h) were 39 (interquartile ranges [IQ] 30-54) vs. 48 (IQ 30-60), and parasite clearance 42 (IQ 24-60) vs. 36 (IQ 30-48). However, one patient who received artemether had a recrudescence on day 14, which was successfully treated with sulphadoxine-pyrimethamine. Times to recovery from coma were 24 h (IQ 18-45) and 33 h (IQ 19-57), respectively. The occurrence of transient neurological sequelae including motor disabilities, cortical blindness, and afebrile seizures was also similar in the two groups. No adverse reactions to the two drugs were recorded during the study period. Artemether represents an important option in the management of cerebral malaria in Nigeria especially in rural areas where facilities for intravenous administration may not yet be optimal.

Energetic determinants of glucose tolerance status in Jamaican adults.

As type 2 diabetes mellitus (DM2), obesity and sedentary lifestyles are increasing in developing countries, this observational study investigated the role of physical activity on DM2 in Jamaica. Anthropometry, body composition (by bioelectrical impedance analysis) and glucose tolerance status was assessed in 722 adults in 1993 and 1997. Energy expenditure was estimated in a subset using measured resting energy expenditure in combination with self-reported activity recalls. The rates of impaired glucose tolerance (IGT) were 23.7 and 27.3%, and DM2 were 16.3 and 23.7% among men and women, respectively. After adjusting for body composition, a one-unit increase in physical activity significantly reduced the odds of having diabetes (OR = 0.05; 95% CI: 0.004, 0.66), but not IGT. Hence, decreased physical activity is a significant independent contributor to the high rates of glucose intolerance in Jamaica. Efforts must be directed at minimizing obesity and increasing physical activity in developing countries.

Variation in fontanelle size with gestational age.

There is scanty data in the literature on the variation of fontanelle size with gestational age. This relationship was studied in 250 neonates delivered at gestational ages of 29-41 weeks at the University College Hospital, Ibadan, Nigeria. Anterior fontanelle size showed a low positive correlation with gestational age (r = 0.15). However, controlling for occipitofrontal circumference reduced this correlation to 0.12. Mean anterior fontanelle size increased with increasing gestational age but the anterior fontanelle size: occipitofrontal circumference ratio remained remarkably constant over the range of gestational age studied. The posterior fontanelle size did not show a significant correlation with gestational age and the prevalence of closed posterior fontanelles at birth did not differ significantly between term and preterm neonates. It is concluded that anterior fontanelle size does show a low positive correlation with gestational age but maintains the same ratio with head circumference at least during the third trimester of intrauterine life. Posterior fontanelle size shows no linear relationship with gestational age.

Treatment of childhood diarrhoea in Nigeria: need for adaptation of health policy and programmes to cultural norms.

A community survey of treatment regimens for acute diarrhoea in children was carried out in 10 villages in the Ona Ara Local Government Area of Oyo State, Nigeria, using a combination of qualitative (focus-group discussions) and quantitative (weekly surveillance of diarrhoea) methods. Focus-group discussions were conducted with parents of children aged less than 5 years, while a surveillance of diarrhoea among 550 children of same age was carried out during a 6-month period. The findings of the study showed that not all types of diarrhoea were recognized as illnesses, and only those considered to be illnesses were treated. Treatment often involved an adhoc group which comprised adults who were present at the time the illness occurred (including parents, neighbours, relatives, and elders). Certain beliefs and practices, such as associating types of diarrhoea with occupation or ethnic groups, categorizing the severity on perceived causes, and withholding certain foods during episodes of diarrhoea, were common factors in decision-making for seeking treatment. Antimicrobial agents were used in the case of 46.8% of 205 diarrhoeal episodes, and 28.5% were not at all treated. The usual practice of focusing on a target group, such as mothers, during educational interventions may need to be modified in communities where nearly every adult has a role in decision-making in relation to health. The need to adapt health policy and programmes to cultural norms should be addressed to improve the impact of programmes.

Facial and ear dimensions in term Nigerian neonates.

A study of selected facial and ear dimensions in 200 term and appropriate-for-gestational age neonates delivered at the University College Hospital, Ibadan, Nigeria, was carried out with the aim of describing their normal range of variation and providing reference values for clinical use. The features studied included inner canthal distance, outer canthal distance, palpebral fissure length, nasolabial distance, oral intercommissural length, total ear length and ear length above the eyeline. The inner canthal distance ranged from 1.6 to 2.5 cm with a mean of 2.1 (SD 0.2) cm while the outer canthal distance ranged from 5.2 to 7.2 cm with a mean of 6.1 (SD 0.4) cm. The oral intercommissural length ranged from 2.5 to 4.0 cm with a mean of 3.1 (0.3) cm and the total ear length ranged from 2.4 to 4.0 cm with a mean of 3.2 (SD 0.3) cm. Three per cent of the neonates had the whole ear located completely below the eye line. No significant sex differences in the mean values of any of the dimensions studied were found. The findings of the study are consistent with those of other workers who have documented shorter ears in the Negro neonate compared to his Caucasian counterpart. It is suggested that local values derived from well-defined populations be used as reference in the evaluation of the child with dysmorphic features in order to avoid errors of classification due to racial variations in the range of normal.