Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations

Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.

Epidemiology of Traumatic Spinal Cord Injury in Developing Countries from 2009 to 2020: a Systematic Review and Meta-analysis

INTRODUCTION

Traumatic spinal cord injury (TSCI) is a catastrophic event with a considerable health and economic burden on individuals and countries. This study was performed to update an earlier systematic review and meta-analysis on epidemiological properties of TSCI in developing countries published in 2013.

METHODS

Various search methods including online searching in database of EMBASE and PubMed, and hand searching were performed (2012 to May 2020). The keywords 'Spinal cord injury', 'epidemiology', 'incidence' and 'prevalence' were used. Based on definition of developing countries by International Monetary Fund, studies related to developing countries included. Data selection was according to PRISMA guidelines. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. Results of meta-analysis were presented as pooled frequency, and forest, funnel and drapery plots.

RESULTS

we identified 47 studies from 23 developing countries. The pooled incidence of TSCI in developing countries was 22.55/million/year (95% CI: 13.52; 37.62/million/year). Males comprised 80.09% (95% CI: 78.29%; 81.83%) of TSCIs, and under 30 years patients were the most affected age group. Two leading etiologies of TSCIs were motor vehicle crashes (43.18% (95% CI: 37.80%; 48.63%)), and falls (34.24% (95% CI: 29.08%; 39.59%)), respectively. The difference among the frequency of complete injury (49.47% (95% CI: 43.11%; 55.84%)), and incomplete injury (50.53% (95% CI: 44.16%; 56.89%)) was insignificant. The difference among frequency of tetraplegia (46.25% (95% CI: 37.78%; 54.83%)) and paraplegia (53.75% (95% CI: 45.17%; 62.22%)) was not statistically significant. The most prevalent level of TSCI was cervical injury (43.42% (95% CI: 37.38%; 49.55%).

CONCLUSION

In developing countries, TSCIs are more common in young adults and males. Motor vehicle crashes and falls are the main etiologies. Understanding epidemiological characteristics of TSCIs could lead to implant appropriate cost-effective preventive strategies to decrease TSCIs incidence and burden.

Prediction of the Vaccine-derived Poliovirus Outbreak Incidence: A Hybrid Machine Learning Approach

Recently, significant attention has been devoted to vaccine-derived poliovirus (VDPV) surveillance due to its severe consequences. Prediction of the outbreak incidence of VDPF requires an accurate analysis of the alarming data. The overarching aim to this study is to develop a novel hybrid machine learning approach to identify the key parameters that dominate the outbreak incidence of VDPV. The proposed method is based on the integration of random vector functional link (RVFL) networks with a robust optimization algorithm called whale optimization algorithm (WOA). WOA is applied to improve the accuracy of the RVFL network by finding the suitable parameter configurations for the algorithm. The classification performance of the WOA-RVFL method is successfully validated using a number of datasets from the UCI machine learning repository. Thereafter, the method is implemented to track the VDPV outbreak incidences recently occurred in several provinces in Lao People's Democratic Republic. The results demonstrate the accuracy and efficiency of the WOA-RVFL algorithm in detecting the VDPV outbreak incidences, as well as its superior performance to the traditional RVFL method.

Profile of patients with spinal cord injuries in Kwazulu-Natal, South Africa: Implications for vocational rehabilitation

Objectives: To describe the demographic and socio-economic profiles, and injury related characteristics of people who sustain SCIs in KZN in order to provide baseline information to instigate a model that guides employment outcomes amongst PLWSCI.Design: Retrospective analysis of medical files was done.Setting: King Dinizulu Hospital Spinal Unit (KDHSU), this being the biggest provider of acute care for people who sustain SCI in KwaZulu-Natal and the Eastern Cape Provinces, South Africa was the setting for our study.Participants: Medical files of individuals who sustained SCI between 2009 and 2012 were perused (n = 1049) were perused and 188 met the inclusion criteria.Outcome Measures: Key information from the KDHSU patient's files were extracted using a tool developed using literature and the international spinal cord injury core data set.Results: The average annual incidence rate was 12.3 per 100 000 population. The male to female ratio was 6:4 with the mean age of 36.69 years, ranging from 16-64. Out of those employed (34%), 72% were working fulltime, mostly in the service industry (31%) and 59% were classified as laborers. The majority (61%) of the participants completed high school. The major cause of SCI was non-traumatic (54%) and 66% were classified as incomplete (ASIA). Furthermore, 80% were classified as paraplegia and 19% tetraplegia. The mean LOS was 42.9 days, ranging from 1-764 days, influenced by level of injury, completeness and classification of injury and surgical intervention.Conclusion: The profile of SCI in KwaZulu-Natal is slightly different when compared to other provinces in South Africa and the rest of Africa. There is a need to use epidemiological information (including factors that influence employment) to develop rehabilitation models to guide employment outcomes amongst people living with spinal cord injuries in KZN.

Temporal and Spatial Dynamics of Monkeypox in Democratic Republic of Congo, 2000-2015

Monkeypox is a viral disease with a clinical presentation resembling that of smallpox. Although monkeypox is considered to be an important zoonotic viral disease, its epidemiology remains poorly understood, especially the spatial and temporal distribution of the disease. The present study examined weekly reports of monkeypox cases collected from 2000 to 2015 at the health zone scale in the Democratic Republic of Congo. SaTScan® was performed to identify spatial and temporal clusters of monkeypox cases. Significant primary spatial clusters were detected in the districts of Sankuru and Tshuapa. A centrifugal pattern was found, with significant primary spatial clusters extending over time from Sankuru and Tshuapa to several neighboring districts. Peaks of cases occurred from July to September for the 2000-2002 and 2003-2009 sub-periods and from January to March for the 2010-2015 sub-period. Despite the lack of additional data for confirmation, the increasing of monkeypox reported incidence was observed in the Democratic Republic of Congo during 2000-2015 period and this increase cannot be explain only by the improvements of surveillance systems. The detected spatial clusters were located in the dense rainforest of the Congo basin. The reasons for the excess incidence of monkeypox cases in the central region of the country are unknown, and the relative influence of ecological, environmental, and human factors on the mechanism of emergence of monkeypox has yet to be identified.

Outcomes in the Treatment of Femur Fractures in Patients with Pre-Existing Spinal Cord Injury

INTRODUCTION

Spinal cord injured patients have an estimated 25% to 34% lifetime incidence of sustaining an extremity fracture. The objective of this study is to describe the outcomes of femur fractures treated in patients with pre-existing spinal cord injury (SCI) and lower extremity paraplegia.

MATERIALS AND METHODS

An IRB approved retrospective review of patients 18 years of age and older who sustained a femur fracture a minimum of 2 years following spinal cord injury and received treatment at a regional academic level 1 trauma center over a 10-year period was performed. Patients were divided into two groups based on whether they received operative or nonoperative management of the femoral shaft fracture. The primary outcome assessed was re-operation. Additional outcomes including union, infection, implant failure, and mortality were recorded.

RESULTS

Twenty-one patients sustaining a total of 25 femur fractures were identified. The most common mechanism of injury was fall during transfer. Sixteen fractures were treated non-operatively and nine were treated operatively. At a mean of 4.1 years of follow-up (range: 1.1 to 12.1 years) six out of nine (66.7%) patients in the operative group required an unplanned secondary surgery compared to two patients (12.5%) in the non-operative group (p = 0.006). Overall, the rate of fracture union was 48%, and there was no difference seen between treatment groups (56.3% in nonoperative group versus 33.3% in operative group, p = 0.28). Six operative patients (66.7%) developed an infection as compared to one patient (6.3%) in the non-operative group (p = 0.002). Three operative patients (33.3%) had failure of fixation with implant cutout. One patient died within 2 years of fracture in the non-operative group (6.3%) as did one patient in the operative group (11.1%), (p = 1.0).

CONCLUSIONS

Surgical treatment of femur fractures in patients with a pre-existing SCI and lower extremity paraplegia had a higher rate of complications than nonoperative management in our series. Based on our experience, we recommend non-operative treatment of femur fractures in patients with pre-existing spinal cord injury and lower extremity paraplegia.

Micro-planning for immunization in Kaduna State, Nigeria: Lessons learnt, 2017

BACKGROUND

The OPV 3 coverage for Kaduna State, 12-23 months old children was 34.4%. The low OPV 3 coverage, due mainly to weak demand for routine antigens and the need to rapidly boost population immunity against the disabling Wild Polio Virus (WPV), led the Global Polio Eradication Initiatives (GPEI) to increase supplemental OPV campaigns in Kaduna State, despite the huge cost and great burden on personnel. The OPV campaigns, especially in high risk (low vaccine uptake, <80% OPV 3 coverage and high vaccines refusal rate) states of northern Nigeria with poliovirus transmission has resulted in overestimated denominators or target population, as the highest ever vaccinated is used to set OPV campaign targets.

METHODS

We utilized a cross-sectional study that assessed the impacts and possible solutions to the challenges of overestimated denominators in immunization services planning, delivery and performance evaluation in Kaduna State, Nigeria. We used both descriptive and quantitative approaches. We enumerated households and obtained the target populations for routine immunization (<1 year), polio campaign (<5 years) and acute flaccid paralysis surveillance (<15 years).

RESULTS

We found a significant difference in mean scores between the micro-planning and supplemental vaccination data on a number of <5 years (M = 102967, SD = 62405, micro-planning compared to M = 157716, SD = 72212, supplemental vaccination, p < 0.05). We also found a significant difference in mean scores between the micro-planning and projected census data on a number of <1 year (M = 26128, SD = 16828, micro-planning compared to M = 14154, SD = 4894, census, p < 0.05).

CONCLUSION

Periodic household-based micro-planning, aided with the use of technology for validation remains a useful tool in addressing gaps in immunization planning, delivery and performance evaluation in developing countries, such as Nigeria with overestimated denominators.

Outbreaks of Neuroinvasive Astrovirus Associated with Encephalomyelitis, Weakness, and Paralysis among Weaned Pigs, Hungary

A large, highly prolific swine farm in Hungary had a 2-year history of neurologic disease among newly weaned (25- to 35-day-old) pigs, with clinical signs of posterior paraplegia and a high mortality rate. Affected pigs that were necropsied had encephalomyelitis and neural necrosis. Porcine astrovirus type 3 was identified by reverse transcription PCR and in situ hybridization in brain and spinal cord samples in 6 animals from this farm. Among tissues tested by quantitative RT-PCR, the highest viral loads were detected in brain stem and spinal cord. Similar porcine astrovirus type 3 was also detected in archived brain and spinal cord samples from another 2 geographically distant farms. Viral RNA was predominantly restricted to neurons, particularly in the brain stem, cerebellum (Purkinje cells), and cervical spinal cord. Astrovirus was generally undetectable in feces but present in respiratory samples, indicating a possible respiratory infection. Astrovirus could cause common, neuroinvasive epidemic disease.

Non-polio Enterovirus detection with acute flaccid paralysis: A systematic review

Acute flaccid paralysis (AFP), as defined by the World Health Organization (WHO), is characterized by an acute onset of limb weakness. In the post-polio era, other enterovirus (EV) serotypes associated with AFP may become more prominent. This study aims to collate the data on the non-polio enteroviruses (NPEV) associated with AFP. A systematic review of published case reports, case series, and surveillance studies of AFP from 1960 through 2017 was undertaken. Data were collected including the country of the study, number of specimens positive for NPEV and available clinical data. The majority of studies originated from Asia. In surveillance studies, EV 71 (a serotype of Enterovirus A) was the most commonly detected serotype with AFP, followed by Enterovirus B serotype echovirus 11 and then Enterovirus B serotype echovirus 11. In case studies and case reports, EV 71 and EV 68 (a serotype of Enterovirus D), were the most commonly detected NPEV. As poliovirus eradication continues, there is a need to ensure that AFP surveillance will also detect other potentially vaccine preventable viruses.

Paediatric Active Enhanced Disease Surveillance (PAEDS) annual report 2015: Prospective hospital-based surveillance for serious paediatric conditions

INTRODUCTION

The Paediatric Active Enhanced Disease Surveillance (PAEDS) network is a hospital-based active surveillance system employing prospective case ascertainment for selected serious childhood conditions, particularly vaccine preventable diseases and potential adverse events following immunisation (AEFI). PAEDS data is used to better understand these conditions, inform policy and practice under the National Immunisation Program, and enable rapid public health responses for certain conditions of public health importance. PAEDS enhances data available from other Australian surveillance systems by providing prospective, detailed clinical and laboratory information on children with selected conditions. This is the second of the planned annual PAEDS reporting series, and presents surveillance data for 2015.

METHODS

Specialist surveillance nurses screened hospital admissions, emergency department records, laboratory and other data, on a daily basis in 5 paediatric tertiary referral hospitals in New South Wales, Victoria, South Australia, Western Australia and Queensland to identify children with the selected conditions. Standardised protocols and case definitions were used across all sites. Conditions under surveillance in 2015 included acute flaccid paralysis (a syndrome associated with poliovirus infection), acute childhood encephalitis (ACE), influenza, intussusception (IS; a potential AEFI with rotavirus vaccines), pertussis and varicella-zoster virus infection (varicella and herpes zoster). Most protocols restrict eligibility to hospitalisations, ED only presentations are also included for some conditions.

METHODS

: In 2015, there were 674 cases identified across all conditions under surveillance. Key outcomes of PAEDS included: contribution to national AFP surveillance to reach WHO reporting targets; identification of signals for Mycoplasma pneumoniae and parechovirus-related outbreaks (ACE surveillance); and demonstration of high influenza activity with vaccine effectiveness (VE) analysis supportive of vaccination. Surveillance for IS remains ongoing with any identified AEFIs reported to the relevant State Health Department; varicella and herpes zoster case numbers decreased slightly from previous years in older children not eligible for catch-up. Pertussis case numbers increased in early 2015 and analysis of cases in children aged <1 year demonstrated the importance of timely childhood and maternal immunisation.

CONCLUSIONS

PAEDS continues to provide unique policy-relevant data on serious paediatric conditions using hospital-based sentinel surveillance.

Australian National Enterovirus Reference Laboratory annual report, 2014

Following the World Health Organization (WHO) recommendation, Australia conducts surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years of age as the main method to monitor its polio-free status. Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2014, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.4 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Non-polio enteroviruses can also be associated with AFP and enterovirus A71 and echovirus types 6 and 7 were identified from clinical specimens from cases of AFP. Globally, 359 cases of polio were reported in 2014, with the 3 endemic countries, Afghanistan, Nigeria and Pakistan, accounting for 95% of the cases. In May 2014, the WHO declared the international spread of wild poliovirus to be a public health emergency of international concern and has since maintained recommendations for polio vaccination of travellers from countries reporting cases of wild polio.

Atraumatic Spinal Cord Injury in the Novice Surfer: A Comprehensive Review and Update

Novice surfers are at risk for a rare but potentially devastating form of atraumatic myelopathy. There are 16 published studies on this condition, including 66 cases. The most common suggested mechanism of injury is static hyperextension. However, active mechanisms, in contrast to static, have also been proposed and may be contributory. First time surfers, defined as those who have never been on a surfboard prior to the day of injury, are at particular risk. These individuals make up 89.5%-100% of the reported novice surfers found in the various reports. Multiple neurologic deficits occur and often include paraparesis, paraplegia, urinary retention, and hyperesthesia. While these deficits resolve in some cases, there are reports of multiple instances of permanent injury. Increased awareness of this condition is arguably the most effective preventative measure, as it may lead to avoidance of the predisposing postures. It may also lead to earlier diagnosis in the acute setting, which will become relevant as treatment modalities continue to be refined.

Paediatric Active Enhanced Disease Surveillance inaugural annual report, 2014

INTRODUCTION

The Paediatric Active Enhanced Disease Surveillance (PAEDS) network is a hospital-based active surveillance system employing prospective case ascertainment of selected uncommon vaccine preventable diseases and potential adverse events following immunisation (AEFI). PAEDS enhances other Australian surveillance systems by providing prospective detailed clinical and laboratory data for the same child.

METHODS

Specialist surveillance nurses screen hospital admissions, emergency department records, laboratory and other data, to prospectively identify hospitalised children aged under 15 years in 5 paediatric tertiary referral hospitals in New South Wales, Victoria, South Australia, Western Australia and Queensland. Standardised protocols and case definitions are used across all sites. Conditions under surveillance include vaccine preventable diseases: acute flaccid paralysis, varicella, pandemic and seasonal influenza and pertussis, and potential AEFIs: febrile seizures and intussusception. PAEDS also conducts surveillance for acute childhood encephalitis.

RESULTS

Since August 2007, PAEDS has recruited a total of 6,227 hospitalised cases in total, for all conditions. From January to December 2014, there were 1,220 cases recruited across all conditions. Key outcomes include: enhanced acute flaccid paralysis surveillance to reach World Health Organization targets; supporting varicella and influenza vaccination in children; confirmation of a known low risk of febrile seizures following the 1st dose of measles-mumps-rubella vaccine but no increased risk of febrile seizures after measles-mumps-rubella-varicella vaccine, and a slightly increased risk of developing intussusception 1-7 days after rotavirus vaccination in infants aged less than 3 months. Acute childhood encephalitis data facilitated rapid investigation and response to the enterovirus 71 outbreak in 2013-2014.

CONCLUSIONS

PAEDS provides unique policy-relevant data. This is the first of planned PAEDS annual reports to Communicable Diseases Intelligence.

Traumatic spinal cord injuries in Ile-Ife, Nigeria, and its environs

In Ile-Ife, Nigeria, traumatic brain injuries are largely due to traffic accidents caused mainly by the bad maintenance of the roads and unsafe driving. Young men in the productive stage of their lives are those most affected. The resultant disabilities include quadriplegia (in more than half the patients) and paraplegia. The cost of treating and providing adequate facilities for these patients imposes a heavy economic burden upon developing countries.

Clinical and Aetiological Spectrum of Hypokalemic Flaccid Paralysis in Western Odisha

OBJECTIVE

To study the clinical profile of hypokalemic flaccid paralysis (HKFP) and to evaluate its causes.

METHODS

Fifty cases of hypokalemic flaccid paralysis (HKFP) admitted between November 2012 to October 2014 were taken up in the study. Serum potassium level < 3.5 mmol/ltr has been taken as hypokalemia. All cases were studied for spot and/or 24 hour urinary sodium / potassium, serum potassium / calcium / magnesium. Hypokalemic periodic paralysis (HPP) were diagnosed if there was spot/24 hour urine potassium excretion < 20mmol/ltr in presence of hypokalemia and flaccid weakness without other causes. EMG and nerve conduction study were done to exclude polyneuropathy and myopathic cases.

RESULTS

Out of 50 cases of HKFP, male gender predominated (88%). Maximum number of cases (70%) occurred in 21 to 40 years of age. It occurred in all seasons but more in summer (58%). The precipitating factors were present in 76% of cases out of which high carbohydrate meal (28%), vomiting (16%), excessive sweating (8%), diarrhea (8%) and increased urination (12%) were present. Twenty percent of cases had recurrence (2 to 3 episodes most often) and 6% of cases had family history. Quadriparesis was seen in (54%), paraparesis (36%), hemiparesis (10%) and neck muscle weakness (32%). No case was present with respiratory paralysis or cranial nerve palsy. Twenty-one cases (42%) have very low potassium < 2.5 mmol/ltr, 11 cases (22%) with potassium level between 2.5 to 2.9 mmol/ltr and 18 cases (36%) with 3 to 3.5 mmol/ltr. There was no correlation between severity weakness and potassium level. Eleven cases (22%) had thyrotoxicosis and 3 cases (6%) were hypothyroid. Thirteen cases (26%) have excess urinary loss of potassium (≥20 mmol/ltr) of which 5 cases (10%) were distal renal tubular acidosis (dRTA), four cases (8%) were Gitelman's syndrome (GS) and in 4 cases exact cause could not be diagnosed. Non-renal / prior renal loss of potassium like diarrhea and excessive sweating was responsible in 8% cases each and vomiting in 10% of cases. One unique case of hypernatraemic hypokalemic paralysis (HHP) was found. Only 9 (18%) cases are hypokalemic periodic paralysis (HPP).

CONCLUSIONS

HKFP is a hetergenous group of disease of which a significant number of patients had thyroid disorders mostly in the form of thyrotoxicosis followed by renal tubular dysfunctions like dRTA and GS; non-renal and prior renal loss of potassium like diarrhea, excessive sweating and vomiting respectively. Early recognition and prompt management of these conditions will give gratifying result and prevent further attacks in some cases.

Outcome of extensive descending aorta repair adopting present concepts of spinal cord preservation

BACKGROUND

Preoperative radiological identification of the Adamkiewicz artery and intraoperative neurologic monitoring are known to be helpful for preventing paraplegia after thoracoabdominal aorta replacement. To answer whether they should be used routinely, we investigated the incidence of spinal cord ischemia after extensive descending aortic repair without using such modalities.

METHODS

We retrospectively reviewed the outcome of 95 patients who underwent extensive descending thoracic (DTA) or thoracoabdominal aorta (TAA) repair without the Adamkiewicz artery identification or neurologic monitoring from 2006 through 2010. Spinal cord protection strategy consisted of distal aortic perfusion, cerebrospinal fluid drainage, mild hypothermia, and maintenance of hypertension (systolic≥120mmHg) through the second postoperative day. A few segmental arteries were empirically selected for reimplantation based on the size and the amount of backbleeding; overall 1.4 per patient, 0.3 for DTA, 1.4 for type I, 2.4 for type II, 0.9 for type III, and 0 for type IV TAA.

RESULTS

Two patients died early after surgery. All the remaining patients awoke without paraplegia or paraparesis. Delayed deficit occurred in 7 patients (7.4%) after hypotensive events caused by sedation, bleeding, respiratory distress, or cardiac dysfunction. Three patients (3.2%) became permanently paraplegic and the other four recovered completely within 48 hours after cerebrospinal fluid drainage and elevation of systemic blood pressure.

CONCLUSION

Even without the Adamkiewicz artery identification and neuromonitoring, the incidence of immediate paraplegia could be kept low by applying the strategy based on the modern concept of cord perfusion. The relatively high incidence of delayed deficit suggests the importance of postoperative hemodynamic management and prevention of cardiopulmonary complications.

Enterovirus D68 Infection

First described in 1962 in children hospitalized for pneumonia and bronchiolitis, the Enterovirus D68 (EV-D68) is an emergent viral pathogen. Since its discovery, during the long period of surveillance up to 2005, EV-D68 was reported only as a cause of sporadic outbreaks. In recent years, many reports from different countries have described an increasing number of patients with respiratory diseases due to EV-D68 associated with relevant clinical severity. In particular, an unexpectedly high number of children have been hospitalized for severe respiratory disease due to EV-D68, requiring intensive care such as intubation and mechanical ventilation. Moreover, EV-D68 has been associated with acute flaccid paralysis and cranial nerve dysfunction in children, which has caused concerns in the community. As no specific antiviral therapy is available, treatment is mainly supportive. Moreover, because no vaccines are available, conventional infection control measures (i.e., standard, for contacts and droplets) in both community and healthcare settings are recommended. However, further studies are required to fully understand the real importance of this virus. Prompt diagnosis and continued surveillance of EV-D68 infections are essential to managing and preventing new outbreaks. Moreover, if the association between EV-D68 and severe diseases will be confirmed, the development of adequate preventive and therapeutic approaches are a priority.

Molecular characterization of coxsackievirus A21 in Shandong, China

Coxsackievirus A21 (CV-A21) is a rarely detected serotype belonging to the species Enterovirus C (EV-C). In this study, we report the isolation and genetic characterization of CV-A21 in Shandong Province, China, during 1997 to 2013. A total of 13 strains were obtained from surveillance of cases of acute flaccid paralysis (AFP) (n = 9) and from environmental sewage (n = 4). Sequence comparison of the VP1 genes revealed high nucleotide sequence similarity (94.1 % to 99.8 % identity) among these Shandong strains during the period of 17 years and 75.8 % to 98.5 % sequence identity to foreign strains. Bayesian phylodynamic evolutionary analysis of Shandong and global CV-A21 VP1 sequences revealed that the inferred CV-A21 ancestral sequence dated back to 1750 (1643-1841) and evolved with 2.943 × 10(-3) substitutions per site per year. Alignment of the deduced VP1 amino acid sequences revealed changes that might alter the hydropathicity of the encoded protein. The complete genome of one strain from 2013 was sequenced and evidence of recombination was detected by similarity plot and bootscanning analyses. This study describes the complete genome characterization and molecular epidemiology of CV-A21 in China and gives further insight into CV-A21 evolution.

ACUTE FLACCID PARALYSIS SURVEILLANCE: A 5 YEARS STUDY OF BANNU, PAKISTAN

BACKGROUND

Acute flaccid paralysis (AFP) is clinical presentation marked by acute onset of weakness and reduced tone. Aetiologies of AFP are diverse including infectious agents, trauma or autoimmune reaction. Currently only three countries in the world that are Nigeria, Pakistan and Afghanistan have endemic poliomyelitis. Pakistan's polio crisis represents one of the last hurdles in a 23-year campaign run by the World Health Organization. Bannu due to its geographical location stands out to be one of highest risk areas for Poliomyelitis. The objective of this study was to determine frequency of AFP and their aetiologies in District of Bannu during time period of four years from 2007 to 2011.

METHODS

It was a cross-sectional descriptive study. Data was collected from EDO office District Bannu and analysed using Microsoft Excel 2007. Results: During this period there were 180 cases of AFP in district Bannu. 15% of cases were diagnosed as Guillian Barre Syndrome, making it the leading aetiology. Only 3 (1.66%) cases were diagnosed with Poliomyelitis. Out of 180 AFP cases 104 cases were male and 76 cases were female.

CONCLUSION

Bannu needs enthusiastic educational and vaccination campaigns to eradicate Polio from the area and henceforth from the Pakistan.

REVISITING THE 2005 EARTHQUAKE PARAPLEGICS: WHAT HAS CHANGED IN A DECADE?

Oct 2005 earthquake was a great tragedy, which resulted in hundreds of paraplegics. This was the largest number of Spinal cord injuries (SCI) reported in a natural disaster. The health care system of Pakistan was not well equipped to handle such a large number of major neurological disabilities. Despite these limitations, the initial response was adequate, aided by involvement and guidance from foreign medical teams skilled in management of SCI. It also resulted in strengthening and establishment of better centers for management of SCI. We hoped that this enthusiasm would continue and result in better rehabilitation and community re-integration of these individuals with a long-term disability. Unfortunately, this goal did not materialize. This editorial highlights the current situation of 2005 paraplegics, discusses the shortcomings in long term planning and presents some viable solutions for comprehensive management and rehabilitation of these SCI patients.

Australian Paediatric Surveillance Unit annual report, 2013

This report provides an update on the surveillance conducted by the Australian Paediatric Surveillance Unit (APSU) during the period January to December 2013. The APSU facilitates national active surveillance of uncommon diseases of childhood including selected communicable diseases. This report includes data on the following conditions: acute flaccid paralysis (AFP), congenital cytomegalovirus (cCMV), congenital rubella, perinatal exposure to HIV and paediatric HIV infection, neonatal herpes simplex virus (HSV), congenital varicella, neonatal varicella, severe complications of varicella and juvenile onset recurrent respiratory papillomatosis (JoRRP). Surveillance of severe complications of influenza was undertaken during the influenza season (July to September 2013).

Estimating the incidence and prevalence of traumatic spinal cord injury in Australia

OBJECTIVES

To determine estimates of the incidence and prevalence of traumatic spinal cord injury (TSCI) in Australia as of June 30, 2011.

DESIGN

Population modeling using cohort survival.

SETTING

Australia.

PARTICIPANTS

Hospital data regarding people with TSCI in Australia.

INTERVENTIONS

Modeling using the following data: 2 population-based databases of hospital separations of patients with TSCI, giving upper and lower estimates of incidence; national population profiles and life tables; levels of TSCI based on Australian Spinal Cord Injury Registry; and life expectancy for persons with spinal cord injury under 3 scenarios--1 constant and 2 with a trend standardized mortality ratio (SMR).

MAIN OUTCOME MEASURES

Age- and sex-specific incidence and prevalence estimates.

RESULTS

The lower estimate of incidence was 21.0 per million population per year, and the upper estimate was 32.3 per million population per year. The derived prevalence rates ranged from 490 per million population (10,944 persons--lower incidence, trend SMR with survival from 1948) up to 886 per million population (19,784 persons--higher incidence, constant SMR). The prevalence was highest in males, persons aged 46 to 60 years, and those with tetraplegia.

CONCLUSIONS

We have reported a method for calculating an estimate of the prevalence of TSCI which provides information that will be vital to optimize health care planning for this group of highly disabled members of society.

Molecular epidemiology and recombination of human enteroviruses from AFP surveillance in Yunnan, China from 2006 to 2010

The study represents the genetic overview of non-polio enteroviruses (NPEV) isolated from acute flaccid paralysis (AFP) cases in Yunnan Province from 2006 to 2010. Molecular typing based on VP1 nucleotide sequence was carried out on 98 NPEV isolates, and 33 serotypes were identified. EV-B was detected most frequently with an overall prevalence of 71.4%, followed by EV-A (18.4%) and EV-C (10.2%). No EV-D was identified. NPEV positive rate was higher in children <3 years of age and in summer and autumn months. Clinically, 68.4% patients presented with fever, and 16 cases (16.3%) were classified as Guillain-Barré syndrome, followed by myositis (13.3%). The phylogenetic analysis on the VP1 and 3D regions of prevalent serotypes provided evidence for recombination events among them. EV-A71, an important pathogen previously demonstrated to be associated with paralysis, had also been detected (n = 8) in this study and they all belonged to genotype C4. Great genetic divergence between Yunnan isolates and strains from other regions of the world was revealed. The findings of the study are of great importance for further research on molecular evolution of EV under the circumstance of no specialized EV surveillance system in China.

A retrospective chart review of heart rate and blood pressure abnormalities in veterans with spinal cord injury

OBJECTIVE

Autonomic impairment may lead to increased prevalence of heart rate (HR) and blood pressure (BP) abnormalities in veterans with spinal cord injury (SCI). In addition, comorbid medical conditions and prescription medication use may influence these abnormalities, including bradycardia, and tachycardia, hypotension, hypertension as well as autonomic dysreflexia (AD), and orthostatic hypotension (OH).

DESIGN

A retrospective review of clinical and administrative datasets in veterans with SCI and compared the prevalence rates between clinical values and ICD-9 diagnostic codes in individuals with tetraplegia (T: C1-C8), high paraplegia (HP: T1-T6), and low paraplegia (LP: T7 and below).

RESULTS

The prevalence of clinical values indicative of a HR ≥ 80 beats per minute was higher in the HP compared to the LP and T groups. A systolic BP (SBP) ≤ 110 mmHg was more common in the T compared to the HP and LP groups, whereas the prevalence of a SBP ≥ 140 mmHg was increased in the LP compared to the HP and T groups. Diagnosis of hypertension was 39-60% whereas the diagnosis of hypotension was less than 1%. Diagnosis of AD and OH was highest in the T group, but remained below 10%, regardless of categorical lesion level. Antihypertensive medications were commonly prescribed (55%), and patients on these medications were less likely to have high BP. The odds ratio of higher SBP and DBP increased with age and body mass index (BMI).

CONCLUSION

In veterans with SCI, the prevalence of HR and BP abnormalities varied depending on level of lesion, age, BMI, and prescription medication use.

Chronic osteomyelitis of the pelvis

The aim of this study was to examine the aetiology and response to treatment of a series of patients with pelvic osteomyelitis. Criteria for selection were multiple positive intra-operative cultures and/or a positive radiological diagnosis. Twenty patients met these criteria (age range: 21-78 years, mean = 46). Data was recorded on host status using the Cierny-Mader classification, neurological status, causative organisms; sensitivities were recorded and the treatment and its outcome. Pelvic osteomyelitis was frequently caused by unusual organisms; a high incidence (45%) of neurologically compromised patients was noted. There were important differences in infective organisms, treatment and outcome in the paraplegic and non-paraplegic population. A high mortality and a high incidence of squamous cell carcinoma was observed. Pelvic osteomyelitis should be managed differently to long bone osteomyelitis as far as the antibiotic therapy is concerned, with a greater need for broad spectrum antibiotics in pelvic osteomyelitis. The response to surgical resection was similar to long bone osteomyelitis with a high chance of success with marginal resection in type A hosts and with wide resection in type B hosts.

[The role of epidemiologic surveillance of migrants in the system of poliomyelitis control]

AIM

Analysis of results of virological study of material from children of migrants and evaluation of intensity of immunity against polioviruses in these children.

MATERIALS AND METHODS

1668 feces samples from patients with acute flaccid paralysis and contact individuals and 479 feces samples from healthy children from families of migrants, as well as 1012 blood sera of children aged 3 - 4 and 14 - 15 years living in the same territory of Russia, and 169 blood sera of children of migrants were studied. Polioviruses and non-polio enteroviruses were isolated by standard procedures recommended by WHO in 3 cell cultures - RD, L20B and Hep-2. Virus identification was carried out by microneutralization test with rabbit antisera against poliomyelitisvirus, RIVM (Bilthoven, Netherlands). For intra-type differentiation EIA and PCRwere used. Antibody titers were determined in microneutralization reaction with reference poliovirus vaccines strains in Hep-2 cell culture.

RESULTS

The frequency of detection of polioviruses in children of migrants was significantly higher than in patients with acute flaccid paralysis. In a larger percent of cases children of migrants did not have protective antibody titers against polioviruses of all the 3 serotypes.

CONCLUSION

Migrants as a significant source of poliovirus detection may be an indicator group for detection of signs of unfavorable epidemic situation. Based on the results of epidemiologic surveillance of migrants the fact of import of wild poliovirus into North-West of Russia with the absence of poliomyelitis was proven, which confirms an important role of this form of monitoring in the system of poliomyelitis control.

Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury

OBJECTIVE

To assess the associations of race and socioeconomic status (SES) with pressure ulcers (PUs) after accounting for health care access among persons with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Large specialty hospital in the southeastern United States.

PARTICIPANTS

Persons with traumatic SCI who (1) had residual effects from their injury, (2) were 18 years or older at the time of the survey, and (3) were a year or more postinjury at the time of survey (N=2549).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Outcomes were measured by a mail-in survey: having a current PU (yes vs no), having a PU in the past year with or without reduced sitting time (no PU, no reduced sitting time, month or less, ≥5wk), and having at least 1 PU surgery since SCI onset (yes vs no).

RESULTS

Of participants, 39.3% reported a PU in the past year, 19.9% had a current PU, and 21.9% reported having had surgery for a PU since their SCI onset. While race was preliminarily associated with each PU outcome, it became nonsignificant after controlling for SES and health care access. In each analysis, household income was significantly associated with PU outcomes after controlling for demographic and injury factors and remained significant after accounting for the health care access factors. Persons with lower income had higher odds of each PU outcome. Health care access was not consistently related to PU outcomes.

CONCLUSIONS

Even after accounting for health care access, household income, a measure of SES, remained significantly associated with PU outcomes after SCI; however, race became nonsignificant.

[Poliomyelitis in Tajikistan. Protection of Russia from emergence and spread of wild poliomyelitis virus]

Problem of emergence and spread of poliomyelitis in Russian Federation and neighboring states is examined. Measures taken in Russian Federation to prevent emergence of poliomyelitis cases caused by wild type virus are discussed, as well as treaties and agreements between Russia, Commonwealth of Independent States, Shanghai Cooperation Organization states regarding epidemiological control of poliomyelitis and acute flaccid paralysis. Measure planned by Federal Service for Surveillance for Protection of Consumers Rights and Human Welfare to prevent emergence of poliomyelitis and acute flaccid paralysis cases in Russian Federation and neighboring countries are presented.

[Open surgery and endovascular treatment on the descending thoracic aorta: 15 years' experience]

OBJECTIVE

Outcomes of surgical treatment of the descending thoracic aorta have improved markedly, although high associated morbidity and mortality continue to be a concern. Endovascular treatments are therefore attractive alternatives to open surgery. We compared outcomes of endovascular treatment to outcomes of open surgery on both aortic segments.

MATERIAL AND METHODS

Retrospective study of patients treated for descending thoracic and thoracoabdominal aorta disease by means of open surgery or endovascular treatment in our hospital between 1995 and 2009. We analyzed preoperative characteristics, intraoperative variables, and postoperative results in both groups.

RESULTS

We retrieved the cases of 22 patients, 10 who underwent open surgery and 12 who received endovascular treatment. Surgery was indicated to treat aneurysm (40%), aortic dissection (30%), or both (30%) in the open surgery group. In the endovascular treatment group, 66.7% had aneurysm, 33.3% dissection, and 0% both. Trauma was involved in 20% of the open surgeries and 16.7% of the endovascular procedures. Forty percent of the open surgery cases and 16.2% of the endovascular interventions were emergencies. Patient age was the only statistically significant between-group difference in preoperative characteristics. Postoperative complication rates were similar. Significant differences were observed in duration of surgery, lengths of critical care unit and total hospital stays, and intubation time (P < .05).

CONCLUSIONS

The incidence of postoperative complications in the group of patients undergoing open surgery on the descending thoracic aorta was similar to incidences reported by other hospitals with moderate caseloads. A trend toward reduced morbidity and mortality in the endovascular treatment group was observed, and this group had significantly shorter times of intubation and lengths of critical care unit and hospital stays.

Implications of a circulating vaccine-derived poliovirus in Nigeria

BACKGROUND

The largest recorded outbreak of a circulating vaccine-derived poliovirus (cVDPV), detected in Nigeria, provides a unique opportunity to analyze the pathogenicity of the virus, the clinical severity of the disease, and the effectiveness of control measures for cVDPVs as compared with wild-type poliovirus (WPV).

METHODS

We identified cases of acute flaccid paralysis associated with fecal excretion of type 2 cVDPV, type 1 WPV, or type 3 WPV reported in Nigeria through routine surveillance from January 1, 2005, through June 30, 2009. The clinical characteristics of these cases, the clinical attack rates for each virus, and the effectiveness of oral polio vaccines in preventing paralysis from each virus were compared.

RESULTS

No significant differences were found in the clinical severity of paralysis among the 278 cases of type 2 cVDPV, the 2323 cases of type 1 WPV, and the 1059 cases of type 3 WPV. The estimated average annual clinical attack rates of type 1 WPV, type 2 cVDPV, and type 3 WPV per 100,000 susceptible children under 5 years of age were 6.8 (95% confidence interval [CI], 5.9 to 7.7), 2.7 (95% CI, 1.9 to 3.6), and 4.0 (95% CI, 3.4 to 4.7), respectively. The estimated effectiveness of trivalent oral polio vaccine against paralysis from type 2 cVDPV was 38% (95% CI, 15 to 54%) per dose, which was substantially higher than that against paralysis from type 1 WPV (13%; 95% CI, 8 to 18%), or type 3 WPV (20%; 95% CI, 12 to 26%). The more frequent use of serotype 1 and serotype 3 monovalent oral polio vaccines has resulted in improvements in vaccine-induced population immunity against these serotypes and in declines in immunity to type 2 cVDPV.

CONCLUSIONS

The attack rate and severity of disease associated with the recent cVDPV identified in Nigeria are similar to those associated with WPV. International planning for the management of the risk of WPV, both before and after eradication, must include scenarios in which equally virulent and pathogenic cVDPVs could emerge.

[Evaluation on running status of Chinese Polio Laboratories Network in 2008]

OBJECTIVE

In order to evaluate the running status and provide the laboratory data for maintaining polio-free status in China, the virology surveillance database of Chinese Polio Laboratories Network (not include Hong Kong, Macao, and Taiwan)in 2008 were analyzed.

METHODS

The case investigation data of Acute Flaccid Paralysis(AFP)cases reported by 31 provinces (municipal, autonomous regions) through EPI surveillance information management system and the database of National Polio Laboratory (NPL) were analyzed, and the indicators of running status of Chinese Polio Laboratories Network were evaluated.

RESULTS

10,116 stool samples were collected from 5116 AFP cases by Chinese Polio Laboratories Network in 2008, and viral isolation and identification of all stool samples were done according to 4th World Health Organization (WHO) Polio Laboratory Manual. The rate of viral isolation and identification performed within 28d was 94.9%. 189 polioviruses (PV) and 597 of non-polio enteroviruses (NPEV) were isolated from AFP cases, the isolatien rates were 3.72% and 11.74% respectively. 251 polio positive isolates were sent to NPL from 31 provincial polio laboratories. There were 318 single serotype PVs were performed VPI sequencing. And no wild polioviruses and Vaccine-derived Polioviruses (VDPVs) were found in 2008. NPL passed the proficiency test and got full accreditation for on-site review by WHO experts in 2008. All 31 provincial Polio laboratories passed the proficiency test with the same panel as NPL, and 13 provincial Polio laboratories joined and passed the on-site review by WHO experts.

CONCLUSION

The running status of Chinese Polio Laboratories Network was good, polio-free status was maintained in China in 2008. The Chinese polio laboratories network running is normaly, the laboratory surveillance system was sensitive and laboratory data were provided for maintaining the polio-free status in China.

[Analysis on genetic characteristic of type I poliovirus in China in 2009]

OBJECTIVE

To study the molecular characteristics of type 1 poliovirus isolated from the acute flaccid paralysis (AFP)surveillance system in China in 2009, to provide a scientific basis for maintaining polio-free status for China.

METHOD

Polymerase chain reaction (RT-PCR) method was used to amplify the VP1 code region of all the type I poliovirus, and the VP1 coding region of the isolated stains was sequenced and analyzed, the hot-spots and nuerovirulence determinant were analyzed. The phylogenetic tree was constructed based on VP1 region to analyze the evolutionary relationship between the strains.

RESULT

The results of VP1 sequencing showed that no wild strains or vaccine-derived poliovirus (VDPVs) were detected. However, five pre-VDPVs were found. And nucleotide sequences of two isolates were in high degree of similarity (100%). Sequence alignment showed that two nucleotides in the VP1 region. nt2747 and nt2749 were two mutation hot spots.

CONCLUSION

According to the epidemiological and laboratory test results of two high variation strains, the short-term circulation may occur probably, and further research are needed. Meanwhile, the existence of mutation hot spots indicated that strains are easy to reverse into wild-type substitutions, and lead to a series changes of neurological and other virulence when the strains are under selective pressure.

[Analysis on vaccine-derived poliovirus found from acute flaccid paralysis cases and effectiveness for emergency response in Binzhou in 2007]

OBJECTIVE

To analyze VDPV found from acute flaccid paralysis cases and effectiveness for emergency response in Binzhou, Shandong in 2007.

METHODS

Outbreak investigation, rapid evaluation for oral poliomyelitis attenuate live vaccine (OPV) coverage rate, active searched for acute flaccid paralysis (AFP)cases, supervision for VDPV case, virology and serology surveillance, mopping-up of OPV were used for this emergency response to prevent the possible VDPV spread.

RESULTS

The case was reported from the AFP surveillance system. The poliovirus type I was isolated from stool specimen, which was identified as VDPV by gene sequencing. This AFP case was diagnosed as Guillain-barre syndrome (GBS) with 11 doses of OPV and normal self-immunity function test. The investigation results showed that the OPV coverage rates and the neutralization antibody to poliovirus type 1-3 were at high level among the local children, no similar VDPV was isolated from stools of healthy children around the case. The quality of AFP surveillance system was good, and had not found additional similar case in Bizhou city. Additional VDPV was not found in continuous stool specimen from this case. The case was diagnosed as VDPV infected vector but not VDPV case by the national and provincial expert group.

CONCLUSION

This VDPV was found in the area with high coverage rate OPV, There was no evidence for the VDPV circulation. The emergency response for the VDPV was rapid and effective. The VDPV surveillance and research related should be strengthened.

[Analysis of 4 clustered high risk acute flaccid paralysis cases in Shanxi Province in 2006]

OBJECTIVE

Analysis of epidemiology of 4 clustered high risk acute flaccid paralysis(AFP) cases reported by Shanxi province in 2006 and VP1 gene characteristic for type III poliovirus isolated from the four AFP cases.

METHODS

Virus isolation and identification were conducted according to the 4th edition of WHO polio laboratory manual. The sequence of VP1 region were amplified and sequenced. The phylogenetic trees based on VP1 region were constructed.

RESULT

Three of four high risk AFP cases were suspected as vaccine associated paralysis poliomyelitis (VAPP), the onset date of them were close. VP1 sequencing of the four type III isolates revealed that the identity were 99.7%, 99.9%, 99.4% and 99.9% respectively compared with vaccine reference strain-BJOPV3. According to WHO criteria, the four isolates were identified as type III vaccine-related poliovirus. Phylogenetic analysis based on VP1 coding sequence showed that the four type III poliovirus were not related significantly. The type III poliovirus isolated from 3 suspected VAPP cases shared one nucleotide mutation at 2637 (C-->U), which result in the amino acid mutation from Val into Ala.

CONCLUSION

The improvement of laboratory surveillance for clustered high risk AFP cases should be strengthened so as to detect and prevent poliovirus circulation timely.