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  • Morbidities & outcomes of a neonatal intensive care unit in a complex humanitarian conflict setting, Hajjah Yemen: 2017-2018

    Eze, P; Al-Maktari, F; Alshehari, AH; Lawani, LO (BioMed Central, 2020-07-29)
    Background The protracted conflict in Yemen has taken a massive toll on the health system, negatively impacting the health of children, especially the most vulnerable age group; the newborns. Methods A 2-year retrospective study of admissions into the Neonatal Intensive Care Unit (NICU) in Al-Gomhoury Hospital Hajjah, Northwest Yemen was conducted. Data was analyzed with IBM SPSS® version 25.0 statistical software using descriptive/inferential statistics. Results A total of 976 newborns were eligible and included in this study; 506 preterm newborns (51.8%) and 470 term newborns (48.2%). Over half, 549 (56.3%) newborns were admitted within 24 h after birth and 681 (69.8%) newborns travelled for over 60 min to arrive at the NICU. The most common admission diagnoses were complications of prematurity (341; 34.9%), perinatal asphyxia (336; 34.4%), neonatal jaundice (187; 18.8%), and neonatal sepsis (157, 16.1%). The median length of stay in the NICU was 4 days. There were 213 neonatal deaths (Facility neonatal mortality rate was 218 neonatal deaths per 1000 livebirths); 192 (90.1%) were preterm newborns, while 177 (83.1%) were amongst newborns that travelled for more 60 min to reach the NICU. Significant predictors of neonatal deaths are preterm birth (aOR = 3.09, 95% CI: 1.26–7.59, p = 0.014 for moderate preterm neonates; aOR = 6.18, 95% CI: 2.12–18.01, p = 0.001 for very preterm neonates; and aOR = 44.59, 95% CI: 9.18–216.61, p <  0.001 for extreme preterm neonates); low birth weight (aOR = 3.67, 95% CI: 1.16–12.07, p = 0.032 for very low birth weight neonates; and aOR = 17.42, 95% CI: 2.97–102.08, p = 0.002 for extreme low birth weight neonates); and traveling for more than 60 min to arrive at the NICU (aOR = 2.32, 95% CI: 1.07–5.04, p = 0.033). Neonates delivered by Caesarean section had lower odds of death (aOR = 0.38, 95% CI 0.20–0.73, p = 0.004) than those delivered by vaginal birth. Conclusions Preterm newborns bear disproportionate burden of neonatal morbidity and mortality in this setting which is aggravated by difficulties in accessing early neonatal care. Community-based model of providing basic obstetric and neonatal care could augment existing health system to improve neonatal survival in Yemen.
  • Prevalence, associated factors and clinical features of congenital syphilis among newborns in Mbarara hospital, Uganda

    Oloya, S; Lyczkowski, D; Orikiriza, P; Irama, M; Boum, Y; Migisha, R; Kiwanuka, JP; Mwanga-Amumpaire, J (BMC, 2020-07-02)
    Background While congenital syphilis is a significant public health problem that can cause severe disabilities, little is known about the situation in Uganda. We describe prevalence, associated factors and clinical presentation of congenital syphilis in Mbarara, Uganda. Methods A cross sectional study was carried out among mother- newborn dyads from the postnatal ward of Mbarara Regional Referral Hospital (MRRH). After obtaining informed consent, a structured questionnaire was used to capture data on risk factors for congenital syphilis. A finger prick was performed on the mothers for Treponema Pallidum Haemagglutination Assay (TPHA). If TPHA was positive, a venous blood sample was collected from the mother to confirm active infection using Rapid Plasma Reagin (RPR). Venous blood was drawn from a newborn if the mother tested positive by TPHA and RPR. A newborn with RPR titres 4 times higher than the mother was considered to have congenital syphilis. We fit logistic regression models to determine factors associated with congenital syphilis. Results Between June and September 2015, we enrolled 2500 mothers and 2502 newborns. Prevalence of syphilis was 3.8% (95% CI 3.1–4.6) among newborn infants and 4.1% (95% CI 3.4–5.0) among their mothers. Maternal age <25 years, past history of genital ulcer, a past history of abnormal vaginal discharge, and not receiving treatment of at least one of genital ulcer, genital itching, lower abdominal pain and abnormal vaginal discharge in the current pregnancy were the risk factors associated with congenital syphilis. The most common clinical feature was hepatosplenomegaly. Conclusions We found higher-than-expected syphilis sero-prevalence rates in a high risk population of postnatal mothers and their newborns in Uganda. Bridge populations for syphilis may include mothers not tested during pregnancy, who are usually married and not treated. In accordance with our results, the national policy for syphilis control in Uganda should be strengthened to include universal syphilis screening amongst mother-newborn pairs in postnatal clinics with subsequent partner notification.
  • Acute respiratory failure in an infant and thiamine deficiency in West Africa: a case report

    Hiffler, L; Escajadillo, K; Rocaspana, M; Janet, S (Oxford University Press, 2020-06-25)
    In paediatrics, the overall clinical picture of thiamine deficiency (TD) is not easy to recognize, because it mimics or can be confused with other diseases even in cases of classic beriberi. Unsurprisingly, the likelihood of misdiagnosis of TD is even greater where beriberi has not been described. Critically ill patients have increased thiamine body consumption and dextrose-based IV fluid increases thiamine cellular demand even further. Consequently, severe acute conditions may result in TD, or trigger TD signs in patients with borderline thiamine status, with life-threatening consequences. Here, we describe the case of a young patient admitted to a West African hospital where TD is not well documented and diagnosed with severe pneumonia who responded dramatically to thiamine injection. The lack of rapid diagnostic capacity and the severe outcome of TD justify the use of a therapeutic thiamine challenge in cases with high clinical suspicion. Increased awareness about TD and low threshold for thiamine use should guide clinicians in their practice.
  • Exploring the Relationships in Prenatal Weight Gain, Birth Outcomes, and Postnatal Growth up to 2 Years of Age Using a Longitudinal Cohort in Niger

    Kohlmann, K; Guindo, O; Soumana, I; Grais, R; Isanaka, S (Oxford University Press, 2020-05-29)
    Objectives The first 1000 days of life, from conception until a child's second birthday, is a crucial period during which life-long foundations for good health, growth, and development are established. It has been shown that poor maternal weight gain can contribute to adverse birth outcomes, such as low birth weight, small for gestational age, and prematurity, and such adverse birth outcomes can place children at greater risk for developing wasting and stunting as they age. While it has been suggested that the development of wasting and stunting may be related, the relative impact of poor birth outcomes on weight and height attainment over time is not clear. The objective of this study is to use recently collected longitudinal data to explore the inter-relationships between prenatal weight gain, birth outcomes, and postnatal risk of both wasting and stunting over time. Methods Using longitudinal data nested within a large randomized trial conducted in Madarounfa, Niger, we describe prenatal weight gain, the risk of adverse birth outcomes (preterm, small for gestational age, and low birthweight) and postnatal child growth (weight and length/height) up to 2 years of age. We use binomial regression to examine the relationship between prenatal weight gain and adverse birth outcomes. We use generalized estimating equations to examine the risk of wasting and stunting over time and evaluate potential effect modification of postnatal growth by birth outcomes. Results We followed 2796 mother-child pairs from pregnancy through 2 years of age. We found that 55.9% of the children were born preterm, 6.4% were born small for gestational weight, and 6.8% were born with low birth weight. Using longitudinal analysis, we are examining the relationship between the risk of wasting and stunting over time. Conclusions This analysis will provide evidence to describe the inter-relationships between prenatal weight gain, adverse birth outcomes, and risk of both wasting and stunting over time, with special attention to the inter-relationships between prenatal and postnatal growth.
  • Suspected paracetamol overdose in Monrovia, Liberia: a matched case–control study

    Haidar, MK; Vogt, F; Takahashi, K; Henaff, F; Umphrey, L; Morton, N; Bawo, L; Kerkula, J; Ferner, R; Porten, K; et al. (BioMed Central, 2020-03-30)
    Background- A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children’s caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case–control study. Methods- The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case–control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community). Results- Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1–21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 μg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two. Conclusions- In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.
  • Preventing tuberculosis in children: A global health emergency

    Reuter, A; Seddon, JA; Marais, BJ; Furin, J (Elsevier, 2020-03-05)
    It is estimated that 20 million children are exposed to tuberculosis (TB) each year, making TB a global paediatric health emergency. TB preventative efforts have long been overlooked. With the view of achieving “TB elimination” in “our lifetime”, this paper explores challenges and potential solutions in the TB prevention cascade, including identifying children who have been exposed to TB; detecting TB infection in these children; identifying those at highest risk of progressing to disease; implementing treatment of TB infection; and mobilizing multiple stakeholders support to successfully prevent TB.
  • Evaluating lactate prognostic value in children suspected of acetaminophen-induced liver failure in Liberia

    Haidar, MK; Morton, N; Roederer, T; Mayronne, S; Bawo, L; Kerkula, J; Porten, K; Baud, FJ (Springer Nature, 2020-01-29)
    BACKGROUND: The prognostic significance of hyperlactatemia in young children with liver injury suspected to be attributed to repeated supratherapeutic doses of acetaminophen remain understudied. METHODS: We conducted a retrospective medical chart review including children aged <5 years admitted with hepatocellular injury. The study was conducted in Bardnesville Junction Hospital operated by Médecins Sans Frontières in Monrovia, Liberia. RESULTS: We analyzed 95 children with liver injury in whom a blood lactate measurement on admission was available. Eighty children (84%) were aged <2 years; 49 children (52%) died during hospitalization. The median acetaminophen concentration on admission was 20 mg/L with 60 (70%) children presenting concentrations exceeding 10 mg/L. Median lactate was significantly higher in children who died (10.7 mmol/L; interquartile range (IQR): 8.5-15.7) than those who survived (6.1 mmol/L; IQR: 4.1-8.5), P value < 0.001). The optimal threshold obtained was 7.2 mmol/L with a sensitivity of 84% and specificity 70% (area under curve = 0.80). The previously established thresholds of 3.5 and 4 mmol/L lactate had very low specificity identifying non-survival in children included in this study. CONCLUSION: In this setting, young children with ALF possibly attributed to acetaminophen toxicity were unlikely to survive if the venous blood lactate concentration exceeded 7.2 mmol/L.
  • Feasibility of Training Clinical Officers in Point-of-Care Ultrasound for Pediatric Respiratory Diseases in Aweil, South Sudan.

    Nadimpalli, A; Tsung, JW; Sanchez, R; Shah, S; Zelikova, E; Umphrey, L; Hurtado, N; Gonzalez, A; Teicher, C (American Society of Tropical Medicine and Hygiene, 2019-09-01)
    Lower respiratory tract infections (LRTIs) are the leading cause of deaths in children < 5 years old worldwide, particularly affecting low-resource settings such as Aweil, South Sudan. In these settings, diagnosis can be difficult because of either lack of access to radiography or clinical algorithms that overtreat children with antibiotics who only have viral LRTIs. Point-of-care ultrasound (POCUS) has been applied to LRTIs, but not by nonphysician clinicians, and with limited data from low-resource settings. Our goal was to examine the feasibility of training the mid-level provider cadre clinical officers (COs) in a Médecins Sans Frontières project in South Sudan to perform a POCUS algorithm to differentiate among causes of LRTI. Six COs underwent POCUS training, and each subsequently performed 60 lung POCUS studies on hospitalized pediatric patients < 5 years old with criteria for pneumonia. Two blinded experts, with a tiebreaker expert adjudicating discordant results, served as a reference standard to calculate test performance characteristics, assessed image quality and CO interpretation. The COs performed 360 studies. Reviewers rated 99.1% of the images acceptable and 86.0% CO interpretations appropriate. The inter-rater agreement (κ) between COs and experts for lung consolidation with air bronchograms was 0.73 (0.63-0.82) and for viral LRTI/bronchiolitis was 0.81 (0.74-0.87). It is feasible to train COs in South Sudan to use a POCUS algorithm to diagnose pneumonia and other pulmonary diseases in children < 5 years old.
  • Risks and seasonal pattern for mortality among hospitalized infants in a conflict-affected area of Pakistan, 2013-2016. A retrospective chart review.

    van Deursen, B; Lenglet, A; Ariti, C; Hussain, B; Karsten, J; Roggeveen, H; Price, D; Fernhout, J; Abdi, A; Carrion Martin, AI (F1000Research, 2019-06-24)
    Background: In recent years, Médecins Sans Frontières has observed high mortality rates among hospitalized infants in Pakistan. We describe the clinical characteristics of the infants admitted between 2013 and 2016 in order to acquire a better understanding on the risk factors for mortality. Methods: We analyzed routinely collected medical data from infants (<7 months) admitted in Chaman and Dera Murad Jamali (DMJ) hospitals. The association between clinical characteristics and mortality was estimated using Poisson regression. Results: Between 2013 and 2016, 5,214 children were admitted (male/female ratio: 1.60) and 1,178 (23%) died. Days since admission was associated with a higher risk of mortality and decreased with each extra day of admission after seven days. The first 48 hours of admission was strongly associated with a higher risk of mortality. A primary diagnosis of tetanus, necrotizing enterocolitis, prematurity, sepsis and hypoxic-ischemic encephalopathy were strongly associated with higher rates of mortality. We observed an annual peak in the mortality rate in September. Conclusions: The first days of admission are critical for infant survival. Furthermore, the found male/female ratio was exceedingly higher than the national ratio of Pakistan. The observed seasonality in mortality rate by week has not been previously reported. It is fully recommended to do further in-depth research on male/female ratio differences and the reasons behind the annual peaks in mortality rate by week.
  • A screening tool for psychological difficulties in children aged 6 to 36 months: cross-cultural validation in Kenya, Cambodia and Uganda.

    Nackers, F; Roederer, T; Marquer, C; Ashaba, S; Maling, S; Mwanga-Amumpaire, J; Muny, S; Sokeo, C; Shom, V; Palha, M; et al. (BioMed Central, 2019-04-12)
    In low-resource settings, the lack of mental health professionals and cross-culturally validated screening instruments complicates mental health care delivery. This is especially the case for very young children. Here, we aimed to develop and cross-culturally validate a simple and rapid tool, the PSYCa 6-36, that can be administered by non-professionals to screen for psychological difficulties among children aged six to 36 months. A primary validation of the PSYCa 6-36 was conducted in Kenya (n = 319 children aged 6 to 36 months; 2014), followed by additional validations in Kenya (n = 215; 2014) Cambodia (n = 189; 2015) and Uganda (n = 182; 2016). After informed consent, trained interviewers administered the PSYCa 6-36 to caregivers participating in the study. We assessed the psychometric properties of the PSYCa 6-36 and external validity was assessed by comparing the results of the PSYCa 6-36 against a clinical global impression severity [CGIS] score rated by an independent psychologist after a structured clinical interview with each participant. The PSYCa 6-36 showed satisfactory psychometric properties (Cronbach's alpha > 0.60 in Uganda and > 0.70 in Kenya and Cambodia), temporal stability (intra-class correlation coefficient [ICC] > 0.8), and inter-rater reliability (ICC from 0.6 in Uganda to 0.8 in Kenya). Psychologists identified psychological difficulties (CGIS score > 1) in 11 children (5.1%) in Kenya, 13 children (8.7%) in Cambodia and 15 (10.5%) in Uganda, with an area under the receiver operating characteristic curve of 0.65 in Uganda and 0.80 in Kenya and Cambodia. The PSYCa 6-36 allowed for rapid screening of psychological difficulties among children aged 6 to 36 months among the populations studied. Use of the tool also increased awareness of children's psychological difficulties and the importance of early recognition to prevent long-term consequences. The PSYCa 6-36 would benefit from further use and validation studies in popula`tions with higher prevalence of psychological difficulties.
  • Pattern of skin diseases in children attending a dermatology clinic in a referral hospital in Wolaita Sodo, southern Ethiopia.

    Kelbore, AG; Owiti, P; Reid, AJ; Bogino, EA; Wondewosen, L; Dessu, BK (BioMed Central, 2019-04-08)
    Epidemiological studies to determine the pattern of skin diseases among children are important for proper health care planning and management. The purpose of this study was to describe the pattern of skin diseases among pediatric patients seen at a dermatology outpatient clinic of Wolaita Sodo Teaching and Referral Hospital, southern Ethiopia. We conducted a retrospective hospital-based, cross-sectional study between January 2016 and December 2017 at a teaching and referral hospital dermatology outpatient department. All children younger than 15 years presenting with newly-diagnosed skin diseases were included. Diagnosis was mainly made clinically, with some laboratory support. A total of 1704 children with 1869 new skin diagnoses were included, of whom 139 (8.2%) had more than one disease. Of the children, 52.4% were males and 44.9% within the age-group 5-10 years. Eczematous dermatitis accounted for the largest group (23.9%, n = 447) of skin conditions followed by bacterial infections (21.3%, n = 398), fungal infections (18.8%, n = 351) and infestations (9.9%, n = 185). Seasonal variation was demonstrated, with eczematous conditions and bacterial infections being higher during autumn and winter. Overall, eczema, bacterial and fungal infections were the three major pediatric skin diseases occurring among children attending this hospital's outpatient department. There was seasonal variation in some of the skin diseases. This study gives a snapshot of skin disorders presenting to hospital in children in southern Ethiopia and may help to plan dermatology service expansion, educational programs and preventive measures.
  • The role of pediatric nursing in the provision of quality care in humanitarian settings: a qualitative study in Tonkolili District, Sierra Leone

    Gilday, J; Chantler, T; Gray, N; Treacy-Wong, V; Yillia, J; Pascal Gbla, A; Howard, N; Stringer, B (Innovational Publishers, 2018-12)
  • The Role of Pediatric Nursing in the Provision of Quality Care in Humanitarian Settings: a Qualitative Study in Tonkolili District, Sierra Leone

    Gilday, J; Chantler, T; Gray, N; Treacy-Wong, V; Yillia, J; Gbla, AP; Howard, N; Stringer, B (Innovational Publishers, 2018-12)
    Purpose: Evaluate nurses' and caretakers' perspectives of quality care, barriers to its delivery, and its study in a humanitarian setting. Methods: A qualitative study using semi-structured interviews and direct observation was conducted in the pediatric department of Magburaka Hospital, Tonkolili district, Sierra Leone. Interviews were recorded, transcribed, and inductive coding was used to identify prevalent themes. The observation was used to compare and elaborate on interview findings. Results: Three themes emerged holistic care; the nursing community; and organization and systems of care. For caretakers, holistic care related to their child‟s survival, with quality care described as the availability of free medication, provision for basic needs (food, water, shelter, sanitation), hospital cleanliness, and psychosocial support. For nurses, this involved medication administration, cleanliness, and carrying out nursing tasks (e.g., taking vital signs). Observation revealed caretakers, without nursing involvement, performed the majority of “activities of daily living” (e.g., bathing, toileting). The nursing community describes nursing employment types, attitudes, and how a lack of teamwork impacted quality nursing care. The third theme outlines the importance of organization and systems of care, in which training and a good salary were perceived as prerequisites for quality nursing care, whilst a lack of resources and inadequate operational systems were barriers. Conclusion: Caretakers play an integral role in the delivery of quality care. This and important quality care components outlined by nurses and caretakers identified a patient and family-centered approach could contribute to improving quality nursing care in humanitarian settings.
  • Antimicrobial treatment practices among Ugandan children with suspicion of central nervous system infection

    Kemigisha, E; Nanjebe, D; Boum, Y; Langendorf, Céline; Aberrane, S; Nyehangane, D; Nackers, F; Mueller, Y; Charrel, R; Murphy, RA; et al. (PLoS One, 2018-10-09)
    Acute central nervous system (CNS) infections in children in sub-Saharan Africa are often fatal. Potential contributors include late presentation, limited diagnostic capacity and inadequate treatment. A more nuanced understanding of treatment practices with a goal of optimizing such practices is critical to prevent avoidable case fatality. We describe empiric antimicrobial treatment, antibiotic resistance and treatment adequacy in a prospective cohort of 459 children aged two months to 12 years hospitalised for suspected acute CNS infections in Mbarara, Uganda, from 2009 to 2012. Among these 459 children, 155 had a laboratory-confirmed diagnosis of malaria (case-fatality rate [CFR] 14%), 58 had bacterial infections (CFR 24%) and 6 children had mixed malaria and bacterial infections (CFR 17%). Overall case fatality was 18.1% (n = 83). Of 219 children with laboratory-confirmed malaria and/or bacterial infections, 182 (83.1%) received an adequate antimalarial and/or antibiotic on the day of admission and 211 (96.3%) within 48 hours of admission. The proportion of those receiving adequate treatment was similar among survivors and non-survivors. All bacterial isolates were sensitive to ceftriaxone except one Escherichia coli isolate with extended-spectrum beta-lactamase (ESBL). The observed high mortality was not a result of inadequate initial antimicrobial treatment at the hospital. The epidemiology of CNS infection in this setting justifies empirical use of a third-generation cephalosporin, however antibiotic resistance should be monitored closely.
  • Delivering paediatric critical care in humanitarian settings

    Umphrey, L; Brown, A; Hiffler, L; Lafferty, N; Garcia, DM; Morton, N; Ogundipe, O (Elsevier, 2018-10-05)
  • Navigating a Mid-Level Gap in Neonatal Resuscitation

    Umphrey, L; Blennow, M; Breindahl, M; Brown, A; Roehr, CC; Saugstad, OD; Thio, M; Trevisanuto, D (Karger Publishers, 2018-08-22)
  • When Helping Babies Breathe Is Not Enough: Designing a Novel, Mid-Level Neonatal Resuscitation Algorithm for Médecins Sans Frontières Field Teams Working in Low-Resource Hospital Settings

    Umphrey, L; Breindahl, M; Brown, A; Saugstad, OD; Thio, M; Trevisanuto, D; Roehrg, CC; Blennow, M (Karger Publishers, 2018-05-25)
    Neonatal resuscitation (NR) combines a set of life-saving interventions in order to stabilize compromised newborns at birth or when critically ill. Médecins Sans Frontières/Doctors Without Borders (MSF), as an international medical-humanitarian organization working particularly in low-resource settings (LRS), assisted over 250,000 births in obstetric and newborn care aid projects in 2016 and provides thousands of newborn resuscitations annually. The Helping Babies Breathe (HBB) program has been used as formal guidance for basic resuscitation since 2012. However, in some MSF projects with the capacity to provide more advanced NR interventions but a lack of adapted guidance, staff have felt prompted to create their own advanced algorithms, which runs counter to the organization's aim for standardized protocols in all aspects of its care.
  • A Nosocomial Outbreak of Clinical Sepsis in a Neonatal Care Unit (NCU) in Port-Au-Prince Haiti, July 2014 - September 2015

    Lenglet, A; Faniyan, O; Hopman, J (Public Library of Science, 2018-03-21)
    Between July 2014 and September 2015, a neonatal care unit (NCU) in Port Au Prince, Haiti, experienced an outbreak of sepsis, most probably due to nosocomial transmission of Extended Beta Lactamase (ESBL) producing gram negative bacteria, included Klebsiella pneumoniae.
  • Infant formula in Iraq: part of the problem and not a simple solution - Authors' reply

    Haidar, MK; Alayyan, A; Farhat, JB; Saim, M; Defourny, I (Elsevier, 2018-02-09)
  • 2nd Doctors Without Borders Pediatric Days, Dakar December 15-16, 2017

    Kadir, A; Hiffler, L; Nejat, S; Garcia, DM (John Libbey Eurotext, 2018-02-01)

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