Access to complementary medicine via general practice

BACKGROUND

The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing.

AIM

To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England.

DESIGN OF STUDY

A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders.

SETTING

One in eight (1226) GP partnerships in England in 1995.

METHOD

Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics.

RESULTS

A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment.

CONCLUSION

Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.

Intravesical bacillus Calmette-Guerin and dimethyl sulfoxide for treatment of classic and nonulcer interstitial cystitis: a prospective, randomized double-blind study

PURPOSE

We conducted a prospective, double-blind study with a crossover design of intravesical bacillus Calmette-Guerin (BCG) and dimethyl sulfoxide to determine whether patients with classic and nonulcer interstitial cystitis, respectively, might benefit from either regimen.

MATERIALS AND METHODS

A total of 21 patients, including 11 with classic and 10 with nonulcer interstitial cystitis, randomly underwent treatments with intravesical BCG or dimethyl sulfoxide and, if not improved, were treated with the other substance after a washout period. All 21 patients were evaluated with symptom questionnaires, including a visual analog pain scale and voiding diaries.

RESULTS

Regardless of regimen, there was no improvement in maximal functional capacity. There was a reduction in urinary frequency following dimethyl sulfoxide treatment but only in the classic subtype (p <0.05), whereas no reduction was seen following BCG in either subtype. A substantial pain decrease was noted in classic (p <0.05) as well as nonulcer (p <0.05) interstitial cystitis following dimethyl sulfoxide.

CONCLUSIONS

Intravesical BCG has been presented as a promising new option for treatment of interstitial cystitis. We failed to demonstrate benefit from this treatment. Dimethyl sulfoxide had no positive effect on maximal functional capacity but resulted in a significant reduction in pain and urinary frequency, although only in patients with classic interstitial cystitis.

[Contamination by aflatoxins of local peanut oils prepared in Senegal]

Aflatoxins are mycotoxins produced by certain strains of fungus (Aspergillus) which develop in peanut seeds. Peanut oil and peanut meal are widely used in Senegal. The risk of intoxication is quite real. We determined aflatoxin contamination levels in peanut oil and food prepared by small scale production plants in the Kaolack and Diourbel regions of Senegal. High performance liquid chromatography (HPLC) of the different samples showed that 80% of them were contaminated. Aflatoxin B(1), B(2), G(1) and G(2) were detected. The pattern of contamination was similar for the two regions. Aflatoxin B(1) was prevalent and found in over 85% of the samples. The mean content of this mycotoxin (the most dangerous toxin) was about 40 ppb, a value which largely exceeds specifications for allowable levels.

First Scandinavian experience of electrical sacral nerve stimulation in the treatment of the overactive bladder

OBJECTIVE

This study aimed to evaluate the efficacy of electrical sacral nerve stimulation (SNS) in the treatment of urinary incontinence and urinary retention refractory to conservative treatment, and to assess the impact of urodynamic abnormalities and electrode position.

MATERIAL AND METHODS

Thirty patients (10 men, 20 women) with a mean age of 59 years (range 21-79 years), all of whom had longstanding symptoms ranging from 2 to 46 years (mean 12.4 years), were subjected to a percutaneous test stimulation. Ten patients responded well, resulting in a permanent implant in nine patients. Electrode positions were determined by plain X-ray and computed tomography.

RESULTS

Radiologically, a variety of positions of the temporary electrodes was seen. In the implanted patients, long-term symptom reduction varied over time, ranging from total relief to partial or total recurrence of symptoms.

CONCLUSIONS

SNS is a new promising option for the treatment of urge incontinence. Refined instruments for proper patient selection and the optimal way to position the electrode remain to be developed.

Maximal functional electrical stimulation in routine practice

Maximal functional electrical stimulation is now an established treatment for urgency and urge incontinence. Many studies have been presented with good and consistent results. In a number of prospective studies we have previously recorded very favourable effects in stress incontinence and urge incontinence. In the present study, we have compared our previous experience with a retrospective analysis of a series of maximal functional electrical stimulation given according to a simple routine protocol and including 84 patients. The overall subjective improvement rate was 54% but the cure rate was only 5%, which is far below our experience in previous studies, as well as in others. The subjective outcome was in agreement with changes in mictrurition variables as recorded in voiding diaries. The discrepancy probably depends on a number of factors. It is suggested that the most crucial ones are patient selection, the intensity of stimulation, and the number of sessions given. It is important to realize the limitations and pitfalls of the technique when it is applied in routine practice.

Home uroflowmetry: improved accuracy in outflow assessment

To study home uroflowmetry and to compare this method to free or "traditional" uroflowmetry in the evaluation of the patient with symptomatic benign prostatic hyperplasia (BPH), and the relationship between the values of home uroflowmetry parameters and bladder outlet obstruction (BOO). Twenty-five patients (mean age, 67 years) with symptomatic BPH were examined with home uroflowmetry, free uroflowmetry, and pressure-flow measurement. The patients were assessed using the International Prostate Symptom score; digital rectal examination; routine blood chemistry, including serum prostate-specific antigen level; urinanalysis; transrectal ultrasonography; and post-void residual urine. The 24 hr were divided into "active time" (AT) and "sleep time" (ST). AT home uroflowmetry parameters were compared to ST ones. The home uroflowmetry parameters were compared to respective ones of the free uroflowmetry as well and those obtained by pressure-flow measurement. The patients were asked about their opinion of home uroflowmetry. Home uroflowmetry was found to be a simpler and more acceptable method than free uroflowmetry. The mean Qmax of AT was significantly greater than the mean Qmax of ST, but the mean voided volume and mean voiding time of ST were significantly larger than those of AT. There was a close relationship between the mean Qmax at home and the Qmax in hospital, but the voided volume and voiding time measured in hospital were significantly larger than those at home. Home uroflowmetry provided an estimation of BOO for 46% of the patients as low if the home mean Qmax was >14 ml/sec, and as high if the home mean Qmax was <10 ml/sec. Home uroflowmetry was well accepted by the patients and gave more information than free uroflowmetry. In 46% of the cases, an estimation of BOO was obtained with home uroflowmetry.

[Staphylococcus aureus purulent pleurisy in children. Experience of the Albert Royer Hospital for Children of the Fann University Hospital Center in Dakar]

The authors report here by a retrospective study 58 cases of Staphylococcus aureus empyema at Albert ROYER child hospital located in the Fann University Teaching Hospital of Fann between January 1st 1992 and December 31, 1995. In this study staphylococcus aureus is the bacterium involved in pleural effusions of the children (54%) a long way ahead Streptococcus pneumoniae (16%). Infant less than 30 month is more affected (86%). The average age of the patients is 16.8 month +/- 16.6. The resistance of the germ to usual antibiotics, the precariousness of the research field and mechanical complications linked to the outpouring explain their seriousness. The treatment lies upon an adapted antibiotic and bactericidal therapy associated to closed chest tube drainage.

[Well water pollution in the Khombole district: research on the contamination by organochlorine pesticide residues and organic substances (feces)]

The study realized in the district of Khombole (SENEGAL) has permit to estimate the contamination levels of wells waters used by the populations. The research and the dosage of the organichlorine pesticide residues, nitrites and nitrates and microbiologic analysis have been done on 19 wells chosen after a drawning of lots. The organochlorine pesticide residues which have been found prove that the wells are permanently exposed to these chemical substances which don't constitute nevertheless a major risk for the populations health. The results of our research proved also that there is a real risk of intoxication with the nitrogen oxides. In effects more than 50% of the wells have revealed nitrates contents up to the indicative value (25 mg/l). As for the nitrates, with a few exceptions (5/18), the contents are superior to the authorized norm (0.1 mg/l). By another way the bacteriologic analysis has revealed in the one hand a DBT (Total Bacterian Count) up to 10,000 germs/l for all the wells, and in the other hand the presence of Escherichia coli, Enterococcus faecalis that confirm a faecal contamination.

[Risk factors for low birth weight: influence of maternal age, parity, gestational age, nutritional status and maternal pathology]

A retrospective study carried on between april 1st and september 31st 1997 has helped in collecting. 69 cases of low birth weight new-born (weight < 2500 g) at Abass Ndao hospital center in Dakar. The above population has been compared to 79 eutrophic new-born of mean birth weight equal to 3047.7 +/- 311 g (witnesses). The goal of this study is to appreciate the relationship between the maternal age, the number of the gestation, the parity, the nutritional status, the maternal pathologies during pregnancy and the low weight at birth. There was no difference between both groups as regards to the mean age (p = 0.44), the mean number of gestation (p = 0.7) and the mean parity (p = 0.48). On the other hand, the weight of the mother is smaller as for the group of low birth weight but the mean body mass index stand at normal in both groups. The pathologies during pregnancy period were obviously more frequent in the group of low birth weight new-born. There is a real need to insist on the preventive measures to be taken and the treatment of the maternal pathologies during pregnancy.

Photophysical properties of sexi(3-methoxythiophene): evidence for energy migration in a conducting oligomer, based on fluorescence quenching

The electronic absorption and fluorescence excitation and emission spectra of poly(3-methoxythiophene) (PMOT), a soluble, electroactive oligomer mainly constituted of hexamer, were investigated in dimethylsulfoxide at room temperature. The study of PMOT photophysical properties suggests the existence of important pi-electronic delocalization in the oxidized and reduced form of the oligomer. A significant fluorescence quenching of PMOT takes place in the presence of various quenchers such as dimethylterephthalate, potassium iodide and thallium acetate. Quenching mechanisms implying a quencher-induced intersystem-crossing step are proposed. Modified Stern-Volmer relationships were obtained with large quenching bimolecular rate constants (2.7 x 10(9)-6.1 x 10(11) l mol(-1) s(-1)), which suggests electronic energy migration throughout the repeat units of the PMOT hexamer.

Treatment guidelines for classic and non-ulcer interstitial cystitis

Interstitial cystitis (IC) is a chronic disease of as yet unknown etiology. It commonly affects females, presenting with symptoms of pain on bladder filling, and urinary frequency. Accumulated evidence indicates that IC is a heterogeneous syndrome. Compared to classic IC, the non-ulcer type appears different concerning symptomatic, endoscopic and histological findings, as well as the response to various forms of treatment. This review gives an introduction to the syndrome of IC, concerning epidemiology, clinical characteristics, diagnostic criteria and etiological considerations. A variety of treatment modalities have been suggested and are assessed and reviewed, such as hydrodistension of the bladder, intravesical instillation therapy, oral medication, transcutaneous electrical nerve stimulation, transurethral resection of diseased bladder tissue, and supratrigonal cystectomy followed by enterocystoplasty and urinary diversion. Our algorithm on non-surgical and surgical treatment for classic and non-ulcer IC is presented.

Increased tyrosine hydroxylase immunoreactivity in bladder tissue from patients with classic and nonulcer interstitial cystitis

PURPOSE

Interstitial cystitis is a chronic debilitating condition which mainly affects women. Accumulated evidence indicates that interstitial cystitis is a heterogeneous syndrome. The nonulcer subtype appears different than classic interstitial cystitis in regard to symptoms, and endoscopic and histological findings as well as response to various treatments. We further explore the neurogenic nature of this disease using indirect immunofluorescence to evaluate the presence and density of various autonomic and sensory nerve fibers.

MATERIALS AND METHODS

Specimens from the bladder wall of 6 patients with classic interstitial cystitis, 7 with nonulcer interstitial cystitis and 6 controls were evaluated to determine the presence and density of nerve fibers containing tyrosine hydroxylase, calcitonin gene-related peptide, neuropeptide Y and substance P using specific antibodies, and the general presence of nerve fibers using a mixture of antibodies against nerve filament, neuron specific enolase and S-100 protein.

RESULTS

Increased density and number of nerve fibers immunoreactive for tyrosine hydroxylase were noted in interstitial cystitis cases compared to controls. Furthermore, there was a difference between classic and nonulcer disease in the overall density of nerves using the antibody mixture.

CONCLUSIONS

Our findings indicate an altered peripheral sympathetic innervation in interstitial cystitis cases, which may be an indication of primary neurogenic etiology. The difference in nerve density observed after incubation with the antibody mixture between classic and nonulcer interstitial cystitis supports the hypothesis that the 2 forms represent separate entities.

[Empyema caused by Staphylococcus aureus in children: the experience of the Albert Royer Children's Hospital at Fann University Hospital, Dakar]

We report a retrospective study of 58 cases of empyema caused by Staphylococcus aureus at the Albert Royer Children's Hospital at the Fann University Hospital, between January 1st 1992 and December 31st 1995. Staphylococcus aureus is the principal bacterium responsible for pleural effusions in children (54%), way ahead of Streptococcus pneumoniae (19%). Most of the children affected (86%) are less than 30 months old. Theses infections are often serious due to the resistance of the bacterium to the usual antibiotics, the lack of solid research data and mechanical complications associated with the effusion. Treatment is based on the use of an appropriate bactericidal antibiotic treatment and pleural drainage.

Recruitment, distribution and phenotypes of mast cells in interstitial cystitis

PURPOSE

Interstitial cystitis (IC) is a chronic disabling condition of unknown etiology. One of its major characteristics is an increase in mast cells (MC) showing signs of activation. It has been suggested that the proteinase content defines two MC types: MC(TC), containing chymase and tryptase, and MC(T), which contains tryptase but lacks chymase. Here, we investigated the MC distribution and the MC proteinase expression in IC together with the tissue expression of the major MC growth factors, stem cell factor (SCF) and interleukin-6 (IL-6).

MATERIALS AND METHODS

MC were enumerated in bladder specimens from patients with classic IC, nonulcer IC and controls. MC were visualized in terms of metachromasia, reflecting glycosaminoglycan content, and immunohistochemically, visualizing tryptase, chymase and IL-6 as well as the surface markers CD117 and SCF.

RESULTS

Classic IC displayed a 6 to 10-fold increase of MC identified by proteinase content while in nonulcer IC there were twice as many MC as in controls. In contrast to nonulcer IC and controls, classic IC displayed an abundance of epithelial MC. Fewer CD117+ than proteinase+ MC were detected in IC but not in controls. Classic IC coexpressed SCF and IL-6 in the epithelium and displayed numerous SCF and IL-6+ cells in the mucosa and detrusor muscle, many of which were MC.

CONCLUSIONS

Redistribution of MC into the epithelium and a high bladder wall MC density distinguish classic IC from nonulcer IC. Our findings suggest an SCF/IL-6-driven MC response in IC. They also indicate a downregulation of the SCF receptor in IC.

[Infections in Senegalese children and adolescents with sickle cell anemia: epidemiological aspects]

Infection is the main factor of morbidity and mortality in children with sickle cell disease (SCD). The objective of this study is to determine it's epidemiologic outline in senegalese children and adolescents with SCD. We retrospectively studied infection data in all the charts of a cohort of 323 patients with SCD (307 SS, 13 SC and 3 s beta + thalassemia) followed at Albert Royer children hospital from january 1991 to december 1997. Serum sampling was systematically made for HIV and antigen HBs serology in all patients we received in the last 3 months (october to december 1997). Patients were aged from 5 months to 22 years (medium age = 8 years). 813 infection episodes were diagnosed, concerning 184 patients (56 per cent). SS patients were more affected (59 per cent) than the others (23 per cent, p = 0.04). ENT and broncho-pulmonary onsets were more frequent but had a generally benign course. Menigitidis, septicemia and osteomyelitis were exclusively diagnosed in SS patients. Their prevalences in this group were respectively: 1.0 per cent, 4.9 per cent and 9.8 per cent. HIV serology was determined in 155 patients, including 41 per cent with blood transfusion antecedents. All tests were negative. HBs antigen was determined in 104 patients and seroprevalence was 7.7 per cent in the whole group and 6.0 per cent in patients with transfusion antecedents and 7.7 per cent for the others. Plasmodium falciparum malaria onset was observed in 9.6 per cent of our patients and there was no case of cerebral malaria. Infection was involved in 9 of the 11 cases of death. Then infection constitute the major problem in children and adolescents with SCD in Dakar. However prevalences of severe onsets are comparable to data in Europe despite our poor follow up conditions. Senegal haplotype may lead to a good tolerance of SCD. Negative HIV serology and low HBs antigen seroprevalence in transfused patients are attributed to a relatively low level of HIV prevalence in the general population and a good transfusion security in Senegal.

[Protein profile of Senegalese children presenting with nephrotic syndrome]

In Senegal, nephrotic syndrome usually occurs upon malnutrition that confers it its specificity and has brought us to establish the proteinic profile of Senegalese children suffering from it, in the aim to improve its treatment. Twenty children on the average of six years, hospitalized for nephrotic syndrome, were chosen. They were compared to 20 healthy children of the same age group, and 20 other children hospitalized for a non-renal inflammatory syndrome. For each subject were dosed total blood proteins and albumin. The protein electrophoresis has permitted to evaluate the alpha-1, alpha-2, beta and gamma globulins. We have observed predominance of boys with a 2.33 sex ratio. Our patients presenting a nephrotic syndrome were about six years old; no case has been noted before two years. Total proteins and albumin have decreased respectively to 52.10 g/l and 16 g/l. This diminishing is essentially linked to the massive urinary escape of plasmatic proteins and would explain partly the increase of lipids. The alpha-1 globulins were equally lowered but the alpha-2 globulins were increased by 40% of total proteins. Beta globulins have decreased, following the evolution of gamma globulins. In Senegal, The early age of nephrotic syndrome occurrence and the biological perturbations of the proteinic profile, recommend global and quick treatment considering food recovery and nutrition. The correction of these parameters being able to constitute in one hand an element of accessible and reliable supervision, and one the other hand the basis of complete treatment.

[Aflatoxin contamination level in artisanal and industrial peanut butter food in Dakar (Senegal)]

Aflatoxins are mycotoxins produced by some strains of fungus (Aspergillus) which develop in peanut seeds. Peanut oil and past are very used up in Senegal, then the aflatoxin poisoning risk is very actual. The aim of this study was to determinate the aflatoxin level in artisanal and industrial peanut pastry food from Dakar (Sénégal). High Performance Liquid Chromatography (HPLC) analysis of the different samples showed that the most contaminated by aflatoxins are artisanal pastry sold in different market of Dakar (Sénégal). Indeed, 40% of these samples contained mean values of aflatoxin B1 (the most dangerous) widely over allowable EEC specifications (5ppb). Furthermore, most of industrial and domestic peanut pastry were cleaned and could be consumed without risk.

[Protein-energy malnutrition in children less than five years old in a rural zone in Senegal (Khombole)]

A survey on 400 children less than five years old living in three villages of the sanitary district of Khombole has been realized from 17th to 25th April 1997 in order to evaluate the existence of malnutrition and the hazard factor linked to it. All children have been weighed and measured. The paraclinic assessment made up by a rate of haemoglobin and a parasitical test of the, motions have been realized on 275 children. The emaciation concerns 8% of the children and the statural backwardness 34.7% of them. The malnutrition is variable from one village to another. The percentage of children suffering from a severe malnutrition according to the classification of Gomez concerns 4.5%. Geophagy, intestinal parasitosis, and anaemia are closely related to chronic malnutrition. The results show the existence of a precarious nutritional situation in rural area requiring new policies of struggle against malnutrition.

[Cri-du-chat syndrome. A case report]

We report a documented case in Senegal with cri-du-chat syndrome diagnosed in a 3 months old girl. Our patient benefited from clinical examination, ECG (15 derivations), chest X ray and standard laboratory tests. The cry has been recorded on a magnetic band. We performed also a pulsed-Doppler, two dimensional and TM echocardiography. Chromosomal analysis has been realized. These data are discussed and compared to the literature. At admission this patient presents characteristic cat like cry. At examination, there is a facial dysmorphy, important growth retardation and feeding dyspnea. Auscultation shows a 3/6 left sub-clavicular systolic murmur. Laboratory tests show anemia (hemoglobin = 7.8 g/dl). Chest x-ray showed a cardio-thoracic ratio at 0.61 with increased pulmonary vascular markings. ECG showed right ventricular hypertrophy. Echocardiography-Doppler revealed persistent ductus arteriosus (PDA). Chromosomal analysis shows deletion of the short arm of chromosome 5. After treatment with digitalis and diuretics there was an improvement of cardiac failure. Diagnosis of cri-du-chat syndrome is easy when characteristic cat-like-cry is present. Cardiovascular abnormalities are unfrequent in this syndrome (20% of the cases). They are dominated by ventricular septal defect and PDA. Hemodynamic failure and related growth retardation can lead to cardiac surgery.

[Mango leaves (Manguifera indica, Anacardiacea) used as biomarker of pollution by pp'Dichlorodiphenyltrichloroethane (pp'DDT)]

Dichlorodiphenyltrichloroethane (DDT), organochlorine pesticide, byanother way cumulative pesticide is banned in mostdeveloped countries. Whatever, it is still used in many countries in the Third World. This work consist to check whether this chemical compound is still used in Senegal. The biomarker of pollution by this pesticide for this research was mango leaves (mango tree is widespread in Senegal) open to accumulate halogenated hydrocarbons. Leaves sample were taken in many sites in the centerline of Dakar-Thiès (Senegal), then analysed by gas chromatography. The results allowed to note the presence of DDT and its metabolites [(dichlorodiphenyltrichloroethylen (DDE), (dichlorodiphenyltrichloroethane (DDD)] in most of samples. The comparison of DDT content in relation to those of the principal metabolite allowed to make the difference according to sample sites, an old contamination of an utilisation more or less recent of this pesticide. From those results, we can conclude that DDT, typical pesticide by its big persistence is still used in some spherical zones in this country, in particular in farming gardening zones.

[Sickle cell disease in children in Dakar, Senegal]

AIM OF THE STUDY

To determine the socioeconomic, clinical and biological aspects of sickle cell disease (SCD) in Senegalese children and adolescents, we retrospectively analysed all records of follow-up attending patients in the Albert Royer Children Hospital of Dakar (Senegal).

RESULTS

Homozygous sickle cell (SS) was the most frequent genotype (307 cases). Sickle cell hemoglobin C (13 cases) and sickle cell beta-thalassemia (three cases) were uncommon. Patients were aged from five months to 22 years (mean age: eight years). Most of them came from poor families. The mean number of children was five in patients' families, with at least two cases of SCD in 60% of them. Immunization against hepatitis B virus (10.2%), Haemophilus influenzae b (8.4%), Salmonella (8.7%) and Streptococcus pneumoniae (21.4%) was insufficiently performed, because of its relatively high cost. Only 30% of the patients had received a blood transfusion. Painful crises occurred less than three times a year in 74% of the cases. Complications such as acute chest syndrome (1%), stroke (1%), cholelithiasis (9%), meningitis (0.4%), septicemia (2%) and osteomyelitis (6%) were rare. Mean steady state hemoglobin (Hb) and hemoglobin F(HbF) levels were 8.27 +/- 1.36 g/dL and 6.8 +/- 5.9% respectively among SS patients. No correlations were found neither between Hb and HbF nor between these parameters and the frequency of complications. Eleven patients (1.1% per year of follow-up) died, and infection was the main cause of death (73%).

CONCLUSION

In comparison with published data, SCD seems to have mild severity in Senegalese children and adolescents in spite of poor follow-up conditions. In addition to genetic factors, environmental factors might have an important role in disease tolerance.

[Facial nerve paralysis in the newborn infant: apropos of 8 cases]

The authors report 8 cases of facial palsy collected in the Abass Ndao hospital center. Risk factors are dominated by the instrumental manipulations during delivery. Prognosis is however generally good.

The bladder cooling reflex and the use of cooling as stimulus to the lower urinary tract

PURPOSE

We review the physiology of bladder cooling response in experimental animals and humans, and present its clinical usefulness.

MATERIALS AND METHODS

We describe experimental studies of the bladder cooling response, and more recent clinical retrospective and prospective studies of the bladder cooling test in adults and children.

RESULTS

Studies indicate the existence of a segmental spinal bladder cooling reflex that originates from specific cold receptors in the bladder and urethral walls supplied by unmyelinated C-afferents. The reflex is positive in neurologically normal infants and children until about age 4 years. It becomes negative with further maturation of the nervous system but may be unmasked by pathological processes that disturb the descending neuronal control of normal voiding. A positive test in a patient with an overactive bladder requires further neurourological evaluation.

CONCLUSIONS

The bladder cooling response originates from cold receptors within the walls of the lower urinary tract. The cooling response represents a neonatal reflex that may be unmasked by central neuropathology, analogous to the appearance of the Basbinki sign in pyramidal tract lesions. The bladder cooling test is a simple and valuable tool to support the diagnosis of neurourological disorders.

[Cholelithiasis and homozygote drepanocytosis in children in Dakar (Senegal)]

BACKGROUND

Cholelithiasis is a well recognized complication of sickle-cell anemia (SCA) because of chronic hemolysis. It is usually asymptomatic but may result in acute cholecystitis or cholangitis. The aim of this study was to assess prevalence of cholelithiasis and its associated factors among Senegalese children and adolescents with SCA.

PATIENTS AND METHODS

We analyzed the follow-up records and results of systematic clinical, biological and ultrasonographic examinations in 106 patients with SCA aged 11 months to 22 years (median: 10 years, 6 months), followed up in the Albert-Royer Children's Hospital (Dakar).

RESULTS

Cholelithiasis was detected in 9.4% of the patients. Gender, ethnic group, geographic origin and socioeconomic conditions did not have any association with cholelithiasis frequency. The youngest patient with cholelithiasis was 7 years old, and prevalence of cholelithiasis increased with age. The mean age at the beginning of SCA follow-up was higher among patients with cholelithiasis. They were more frequently transfused and tended to present more frequent pain crises and other complications of SCA. We found no spontaneous clinical manifestations attributed to cholelithiasis. Nevertheless, provoked right upper quadrant pain was more frequently observed in patients with cholelithiasis. Fetal hemoglobin, steady-state hemoglobin, reticulocytes count, serum bilirubin, alkaline phosphatase and transaminase levels were not significantly different in these patients, compared to the others. However, those with cholelithiasis had significantly higher mean red cell volume.

CONCLUSION

Prevalence of cholelithiasis appears relatively low in Senegalese patients with SCA, probably owing to the tolerance of the Senegal haplotype. Advanced age and severe chronic hemolysis are etiologic factors in evidence. We recommend systematic abdominal ultrasound at least once a year for patients older than 5 years, or when right upper quadrant pain is observed. Cholecystectomy should be performed in cases of cholelithiasis in order to prevent complications.

[Unicapsula marquesi n. sp. (Mysxosporea, Multivalvulida) a gill parasite of Polydactylus quadrifilis (Cuvier, 1829) (Pisces, Polynemidae) from the senegalese coast (West Africa)]

Unicapsula marquesi n. sp. (Myxosporea) is described from gill filaments of Polydactylus quadrifilis (Pisces, Polynemidae) obtained from coats of Senegal. The cysts were elongated and their length was 1 to 3 mm. The spores were pyramidal and composed of three valves. Only one of theses valves contained a developed polar capsule measuring 3.01 +/- 0.09 microns in diameter. Length of spore was 6.13 +/- 0.21 microns and the width was 7.18 +/- 0.17. No filament like appendage at the extremity of shell valves. Data on ultrastructure of spores are presented.

[Malaria lethality in Dakar pediatric environment: study of risk factors]

To determine risk factors for fatal malaria in Senegalese children, a 3-year case-control study was carried out between October 1992 and November 1995 at the Albert Royer Hospital in Dakar. The case group included 52 children who died from documented malaria in the hospital. The matched control group consisted of children who responded favorably to hospital treatment. Exposure to risk was measured with regard to age, nutritional status, educational level of parents, self-medication prior to hospitalization, socioeconomic level, degree of fever, and blood parasite levels. Cases and controls were compared using statistical tests for matched groups. Age lower than 5 years, poor educational level of parents, delay of treatment more than 24 hours, nutritional status, and blood parasite levels greater than 5% were associated with a significantly higher risk of fatal outcome. Conversely, low socio-economic level, recent self-medication, and fever over 41 degrees C were not associated with higher fatality. These findings emphasize the need for more information campaigns to encourage people to seek institutionalized care when fever appears. Our results also suggest that prophylactic treatment may be advisable in children under 5 years of age and in some high risk groups.

[Urinary incontinence in men--a neglected problem? A quarter of all 80-year old men suffer of urinary leakage]

Urinary incontinence is an increasing health problem in industrialised countries, and has been shown to affect more the eight per cent of the adult population. Incontinence accounted for about two per cent of Swedish health care costs in 1990, and the costs are rising. Although the diagnosis and treatment of female incontinence has attracted more attention since the condition is more prevalent among women, the impact on quality of life is no less among men. As a variety of causes and underlying diseases may result in involuntary urine leakage, careful evaluation is mandatory before treatment is initiated. The article consists in a review of common diagnoses and treatment options in cases of male incontinence.

Reflex interaction between the proximal urethra and the bladder. A clinical experimental study

OBJECTIVE

Animal experiments have shown that the bladder-cooling reflex is activated by cold stimulation of the bladder and urethra, causing a reflex bladder contraction. In this clinical experimental study, the bladder reflex responses to distension and cooling of the bladder neck and the proximal urethra were investigated.

MATERIAL AND METHODS

Twenty-one patients with overactive bladders and documented positive ice water tests were studied.

RESULTS

Three patients (14%) responded with reflex bladder contraction by urethral infusion of ice water only, and another 4 patients responded to urethral distension with both warm and cold water. In 4 patients, bladder contraction was induced by a catheter pulling on the bladder neck.

CONCLUSION

This study supports the existence of a cold-sensitive reflex system in the human urethra. However, in the experimental situation, both cold and tension-mediated reflexes were more difficult to evoke from the urethra than from the bladder.

[Measurement and levels of aflatoxins in small-scale pressed peanut oil prepared in the Diourbel and Kaolack regions of Senegal]

Aflatoxins are mycotoxins produced by some strains of fungus (Aspergillus) which develops in peanuts seeds. Peanuts oil and past are very used up in Senegal, then the aflatoxins poisoning risk are very actual. This study relates to the determination of contamination levels by aflatoxins from peanut oil food prepared by small scale production in areas of Kaolack and Diourbel. High Performance Liquid Chromatography (HPLC) analysis of the different samples showed that 80% of them were contaminated in the areas of Kaolack and Diourbel. Aflatoxin B1, B2, G1 and G2 has been detected with a profile of contamination almost identical in the both areas. Aflatoxin B1 was prevalent and has been found in over 85% of samples. Mean contents of this mycotoxin (the most dangerous toxin) is about 40 ppb, value widely superior to allowable specifications.

Decreased levels of S-100 protein in non-ulcer interstitial cystitis

Interstitial cystitis (IC) is a chronic debilitating condition which mainly affects women. Accumulated evidence indicates that IC is a heterogeneous syndrome. As compared to classic IC, the non-ulcer type of IC appears to be different concerning symptomatic, endoscopical and histological findings, as well as in response to various forms of treatment. S-100 is a neural protein considered to be located primarily in the axons. To explore further the neurogenic nature of the disease, we compared bladder wall S-100 content in controls and in patients with classic and non-ulcer IC. We noticed a decrease in S-100 content in non-ulcer IC as compared to controls. This may be an expression of altered peripheral innervation in non-ulcer IC, which, in turn, may be an indication of primary neurogenic etiology. The difference in S-100 content between classic and non-ulcer IC supports the hypothesis that they represent separate entities, which may explain differences in response to various treatments.

[Newborn infant with macrosomia: etiologic factors and perinatal complications]

A retrospective study conducted between january 1st and december 31st 1993 allowed for the identification and comparison of 100 cases of new born with macrosomia accounting for 1.34% of birth. Males constitute the majority of those cases (60%) and the average weight found is 4212 g. Foetal complications are in the main made of lesions of the brachial plexus (9%). Hypoglycemia is found in 4% of cases. These complications are more frequent in forceps assisted deliveries or cesareans (P < 0.05). Obesity (20%), Fat child related past history (15%), Maternal diabetes (5%) are the most common risk factors. We therefore advocate a more effective prevention of foeto-pelvic disproportions through a close supervision of pregnancy among women at risk.

[Tetralogy of Fallot. Anatomo-clinical, prognostic and therapeutic features]

Between Feb. 1992 and Aug. 1995 during a prospective study Tetralogy of Fallot (TF) has been diagnosed in 34 children among 207 with congenital heart disease (CHD). Our purpose is to assess prevalence of TF among CHD, to analyse clinical and paraclinical aspects in patients with TF and to point out associated abnormalities in that disease. In all patients diagnosis was made by echocardiography-Doppler (ATL MK 600). In our patients with CHD, TF represent the third abnormality encountered accounting for 16.49% after ventricular septal defect (30.9%) and persistent ductus arteriosus (18.8%). Mean age of patients with TF is 8.36 years. History showed cardiopathy in the family of one patient. The brother had persistent ductus arteriosus. In our patients with TF, clubbing is present in 70.58% of the cases, cyanosis in 79.41% and squatting in 76.47%. Anoxic spells are present in six patients. On chest x-ray mean cardio-thoracic ratio is 0.57 +/- 0.076. On ECG mean QRS axis is +121 +/- 22.91 degrees. In one patient with Cornélia Delange syndrome TF is associated with complete endocardial cushion defect. Mean follow-up is 332,42 days. Endocarditis on the pulmonary valves is present in one case. Four patients died after complications. Because of poor clinical tolerance and complications, surgery is indicated for all our patients. Only 7 patients underwent surgery. Two of them were operated in Dakar. There was two postoperative complications, one patient had brain abscess which necessitate reoperation, and the other had hypertension in the right ventricle and atrial right to left shunt. Our study shows that TF is an important nosologic group. In our country this frequent malformation have a poor prognosis in the majority of cases because late detection and frequent complications. Because palliative surgery for TF is now available in Senegal prognosis of the patients is going to improve. Future Development of open heart surgery will offer a corrective approach for patients with TF in Senegal.

[Congenital cardiopathies: anatomo-clinical, prognostic, and therapeutic features apropos of 103 cases seen at the Cardiology Clinic of the Dakar University Hospital Center]

We have studied retrospectively 103 patients with congenital heart disease from july 1989 to december 1991. The mean age is 7.8 years +/- 8.6. Epidemiological factors, clinical, morphological and prognostic data have been reviewed. All the patients had been evaluated with echocardiography based on an anatomical and segmental approach. Sex-ratio is 1.11. Situs is solitus in 101 cases (98%). Atrio-ventricular connexions are concordant in 97 patients (94%). The ventriculo-arterial connexions are concordant in 91 patients (88%). We found an anomaly of the spatial relation between great vessels in 9 cases (8.7%). Echocardiographic diagnosis have been confirmed by catheterism and at surgery in 10 patients, and by post-mortem examination in 2 cases. Isolated ventricular septal defect is the most frequent anomaly (19.4%), followed by Tetralogy of Fallot (17.5%). Only 13 patients among the 75 (17.3%) needing surgery have been operated. Six patients (5.8%) died following complications of the malformation. The prognosis without surgery is poor for the majority of our patients with congenital heart disease. Improved early detection and acquisition of adequate diagnosis technology are needed to realize surgical corrections.

[Rupture of a sinus of Valsalva aneurysm into the right ventricle. A case report in the cardiology clinic at the University Hospital Center of Dakar]

We report a case with ruptured aneurysm of the sinus of Valsava into the right ventricle, diagnosed during heart failure in a 22 years old patient. Etiology and prognosis based on our observation and the literature are discussed. Our patient benefited from clinical examination, ECG (15 derivations), pulmonary X ray and standard laboratory test. Pulsed-Doppler and contrast echocardiography have been realized with an ATL MK 600 echocardiograph. These data are discussed and compared to the literature. Cardiac examination revealed a continuous murmur predominantly diastolic 5/6 and an increase of peripheral artery pulsatility. Chest x-ray showed cardiomegaly and ECG bilateral atrial and left ventricular hypertrophy. Two-dimensional echocardiography revealed the diastolic prolapse of an aneurysmal right coronary sinus in the right ventricle. The rupture was confirmed by contrast echocardiography and pulsed-Doppler. Rupture which is a major complication of aneurysm of the sinus of Valsava, is the usual feature of detection. The consequences of rupture are heart failure and pulmonary edema. Our observation shows that conventional Doppler and contrast echocardiography are important for diagnosis and follow-up of aneurysm of the sinus of Valsava. Aortography, hemodynamic and angiocardiographic data, are also important for a precise diagnosis and the detection of associated malformations when pre-operative investigations of aneurysm of the sinus of valsava are needed.

[Congenital heart disease surgery in Senegal. Indications, evaluation and perspectives]

In Senegal, congenital heart diseases (CHD) raise important issues. Their late detection makes more complicated the non yet resolved issue of the medico-surgical care. 108 patients with congenital heart diseases have been studied prospectively from February 1992 to May 1994. Epidemiological, clinical, paraclinical data are analysed. Prognosis and treatment are discussed. Congenital heart diseases represent 1% of the outpatient cardiovascular pathology. Diagnosis of the malformation based on echocardiography shows that most of congenital heart diseases are ventricular septal defect (25%); followed by Tetralogy of Fallot (13%). Average age of the patients is 6.86 years. 31% of the cases have heart failure. ECG is abnormal in 103 patients. On the radiologic side, average cardio-thoracic ration is 0.61. Because of heart failure, pulmonary hypertension and hypoxia, the spontaneous prognosis is cautious in 71 patients (66%) who should receive surgical treatment. Among them, 5 patients non operated died and 10 (14%) have been operated. Among the 10 patients who got surgery, 3 with wide persistent ductus arteriosus got in Dakar. All these patients have excellent operative results. In Senegal, only close heart surgery is available and prognosis of the vast majority of patients, including those with valvular and coronary heart diseases, is very cautious. Intervention of Europe-based aid organizations for evacuation is not useful. It is very important to promote, in Senegal, open heart surgery.

[Complete D-transposition of the great vessels diagnosed late in a 10-month infant. Rashkind manoeuvre]

We report a first documented case in Senegal with simple transposition of the great arteries diagnosed in a 2 months old girl treated by Rashkind atrioseptostomy. Our patient benefited from clinical examination, ECG (15 derivations), chest X ray and standard laboratory tests. Pulsed-Doppler, two dimensional and TM echocardiography have been performed with an ATL MK 600 echocardiograph. Cardiac catheterism, angiocardiography and Rashkind procedure have been realized in our Department. These data are discussed and compared to the literature. At admission this patient presents with major cyanosis and polypnea. At examination, there is a 3/6 murmur at the left sternal border and a subclavicular continuous murmur. Laboratory tests showed metabolic acidosis and severe hypoxemia. Chest x-ray showed a cardio-thoracic ratio at 0.64 with increased pulmonary vascular markings. ECG showed right ventricular hypertrophy. Echocardiography-Doppler revealed ventriculo-arterial discordance with restrictive atrial septal defect and persistent ductus arteriosus. Rashkind procedure was followed by an increased aortic saturation. After 6 weeks there was an improvement of cyanosis and cardiac failure. Diagnosis of transposition of the great arteries is actually easier with development of ultrasonography which is useful when performed by experienced cardiologist. Spontaneous prognosis of this malformation is very poor. Rashkind atrioseptostomy is an important step for the initial treatment of transposition of the great arteries in terms of survival before open heart surgery.

Advantages and pitfalls of functional electrical stimulation

Functional electrical stimulation has many theoretical advantages. In clinical practice, very favorable results have been repeatedly presented. The experience now encompasses thirty years and a very large number of incontinent patients. Although the methods are widely used, they are differently appreciated. Problems include the fact that functional electrical stimulation does not belong to the therapeutic traditions in urology and gynecology, there is a need of personal training for successful treatment and there is a lack of systematic studies on different clinical applications. Significant advantages are a rational physiological basis, applicability in a variety of lower urinary tract dysfunctions, few side effects and a potential curative effect.

Metaplastic transformation of urinary bladder epithelium: effect on mast cell recruitment, distribution, and phenotype expression

Mucosal mast cells (MCs) are normally found in the connective tissue stroma but are redistributed into the epithelium in conditions associated with immunoglobulin E responses, such as allergic inflammation and nematode infections, as well as in interstitial cystitis, a condition of unknown etiology. The potential role of epithelium-derived factors in this response prompted this inquiry into growth and differentiation signaling in normal tissue as well as in tissues from five different metaplastic conditions of the urothelium (cystitic cystica, cystitis glandularis, colonic metaplasia, squamous cell metaplasia, and nephrogenic metaplasia). Expression of the two major human MC growth factors, stem cell factor (or kit ligand) and interleukin 6, was detected using immunohistochemistry. In the case of interleukin 6, its mRNA expression was also detected using in situ reverse transcription-polymerase chain reaction. Among the different metaplastic lesions, nephrogenic metaplasia was the only one associated with an abundance of MCs, which were distributed within or in close relationship to the epithelium. Unlike in the other types of metaplasia, the epithelium strongly co-expressed interleukin 6 and stem cell factor. The MCs expressed the stem cell factor receptor CD117 and exhibited a variable tryptase immunoreactivity, but lacked chymase. They also displayed a relative deficiency of granular glycosaminoglycan, as indicated by a lack of metachromasia, and were sensitive to strong aldehyde fixation. The findings suggest that the MC response in nephrogenic metaplasia may be the result of local epithelial stem cell factor/interleukin 6 expression.