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Introduction During anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. Hypothesis ALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. Material and methods Clinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3 years’ follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28 years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. Results The average follow-up was 6.8 years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3 mm in 66% of patients and less than 5 mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. Discussion When compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8 years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. Level of evidence IV, multicenter study.

BACKGROUND Little is known about early-onset neonatal bacterial infections (EONBI) in Madagascar. Our aim was to determine their epidemiology to improve their management. METHODS Inborn neonates at risk for EONBI and admitted in the neonatal unit of 2 tertiary hospitals in Antananarivo, Madagascar, were included in a prospective study from April 2012 to March 2013. Using a clinical algorithm, blood culture, gastric fluid culture and C-reactive protein dosage were performed in newborns at high risk of infection, that is, peri partum fever, prematurity

Purpose To measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion. Methods Twelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle. Results During IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location. Conclusions The ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°. Clinical Relevance Clinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Background:Rotational control of the knee is crucial for knee stability. The anterolateral ligament (ALL) has been identified as a potentially important structure involved in rotational control of the knee.Purpose/Hypothesis:The purpose of this study was to determine, utilizing a navigation system, the involvement of the anterior cruciate ligament (ACL), the iliotibial band (ITB), and the ALL in tibial internal rotational control of the knee. The hypothesis was that the ALL would be involved in rotational control of the knee at varying degrees of knee flexion.Study Design:Controlled laboratory study.Methods:Twelve fresh-frozen cadaveric knees were tested in internal rotation at 20° and 90° of flexion and then subsequently tested using a simulated pivot-shift test consisting of coupled axial rotation at 30° of flexion. Serial sectioning of the ACL, ALL, and ITB was performed. On the contralateral knee, sectioning was performed in the reverse order. Measurements were collected using a surgical navigation system before and after each sectioning.Results:After ACL sectioning, an incision of the ALL induced a significant increase in internal rotation (+19.2% [ P = .0002] at 20°; +21.8% [ P = .0029] at 90°) and in coupled axial rotation (+43.0%; P = .0035) compared with the intact knee as well as a significant increase in internal rotation at 90° (+13.4%; P = .009) and in coupled axial rotation (+30.8%; P = .0124) compared with the ACL-deficient knee. After ITB sectioning, an additional ALL section caused a significant increase in internal rotation (+39.0% [ P = .002] at 20°; +63.0% [ P = .0147] at 90°) and in coupled axial rotation (+59.7%; P = .0003) compared with the intact knee as well as a significant increase in internal rotation at 90° (+14.8%; P = .0067) in comparison to the ITB-deficient knee.Conclusion:The ALL is involved in rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift. Concomitant to an ACL or ITB transection, sectioning the ALL further increased rotational laxity.Clinical Relevance:This laboratory study demonstrated that the ALL provides rotational control of the knee in combination with the ACL and/or ITB.

Introduction Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methods A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. Results Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. Discussion The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidence IV, prospective multicenter study.

Background A careful analysis of the reasons for ACL reconstruction failure is essential to selection of the optimal surgical revision technique designed to ensure good rotational stability and to minimise the risk of re-rupture. Objective To evaluate anterolateral ligament (ALL) stabilisation during revision ACL reconstruction. Hypothesis ALL stabilisation during revision ACL reconstruction provides good rotational stability without increasing the risk of complications. Material and methods This multicentre study included 349 patients, 151 retrospectively and 198 prospectively. There were 283 males and 66 females. Inclusion criteria were an indication for revision ACL reconstruction surgery with combined intra-articular reconstruction and ALL stabilisation after failed autograft ACL reconstruction, and intact PCL. Exclusion criteria were primary ACL reconstruction and concomitant peripheral medial and/or lateral lesions. Each patient underwent a clinical and radiographic evaluation before and after revision surgery. Before revision surgery, the mean IKDC score was 56.5 ± 15.5 and 96% of patients were IKDC C or D. Results Rates were 5.0% for early and 10.5% for late postoperative complications. Lachmann's test had a hard stop at last follow-up in 97% of patients. The pivot-shift test was positive in 1% of patients. The mean subjective IKDC score was 84.5 ± 13.0 and 86.5% of patients were IKDC A or B. The proportions of patients with radiographic knee osteoarthritis at last follow-up was unchanged for the lateral tibio-femoral and patello-femoral compartments but increased by 9.7% to 21.2% for the medial tibio-femoral compartment. The re-rupture rate was 1.2% and the further surgical revision rate was 5.4%. Conclusion Anterior laxity at last follow-up was consistent with previous studies of revision ACL reconstruction. However, rotational stability and the re-rupture risk were improved. ALL stabilisation is among the techniques that deserve consideration as part of the therapeutic options for revision ACL reconstruction. Level of evidence IV, retrospective and prospective cohort study.

Background: We investigated the molecular mechanism of ß-lactam resistance in extended-spectrum ß-lactamase (ESBL)-producing Enterobacterial strains isolated in neonatal units of different hospitals in Anatnanarivo, Madagascar.Methods: Bacteria were identified by standard biochemical methods, disc diffusion antibiograms and Etest. Resistance genes were sought by PCR. Strains were characterized by Rep- PCR (Diversilab), plasmid analysis and rep-typing.Results: From April 2012 to March 2013, 29 ESBL-producing E. cloacae and 15 K. pneumoniae were isolated from blood culture (n = 32) or gastric samples (n = 12) performed at day 0 or 2 from 39/303 newborns suspected of early neonatal infection. These infants were treated with expanded spectrum cephalosporins, due to lack of carbapenems, leading to a high mortality rate (45 %). Isolates recovered were all, but 4, multidrug resistant, particularly to fluoroquinolones (FQ) except for 21 E. cloacae isolates. Isolates produced TEM-1 and CTX-M-15 ß-lactamases and their genes were located on several self- transferable plasmids of variable sizes sizes that could not be linked to a major plasmid incompatibility group. E. cloacae isolates belonged to 6 Rep-types among which two counted for 11 isolates each. The FQ resistant E. cloacae isolates belonged to one clone, whereas the FQ susceptible E. cloacae isolates belonged to four clones. The K. pneumoniae isolates belonged to 9 Rep-types among which one included five isolates.Conclusion: This study is the first molecular characterization of ESBL- producing isolates from neonatology units in Madagascar, a country with limited epidemiological data. It revealed an important multi-clonal dissemination of CTX-M-15- producing isolates reflecting both the high community carriage and the very early nosocomial contamination of the neonates.

International audience

Purpose To determine the location and variability of the anterolateral ligament (ALL) femoral origin. Methods The ALL was dissected and examined in 52 embalmed specimens, and the femoral origin was isolated. The presence of a bony or soft-tissue attachment, the relation to the lateral collateral ligament, the average diameter of the proximal origin, and the specific location of the origin relative to the lateral femoral epicondyle were recorded. Results The ALL was present in all 52 specimens, with a mean diameter of 11.85 mm, and was consistently attached to bone in all specimens. The ALL consistently overlapped the lateral collateral ligament near its attachment, with the location of the origin directly on the lateral epicondyle in 12 specimens (23%), with a shared lateral femoral condyle and with the origin slightly posterior and proximal to the lateral epicondyle in 30 specimens (58%), and with the origin completely posterior and proximal to the lateral epicondyle in 10 specimens (19%). Conclusions The ALL showed a consistent bony origin overlapping the lateral collateral ligament in all specimens, with some variability in the femoral attachment, ranging from directly on the lateral epicondyle to posterior to the lateral epicondyle. Clinical Relevance The identification and description of the femoral origin of the ALL are crucial in understanding its role in the stability of the knee, as well as determining the appropriate position for the femoral origin placement in ALL reconstruction.

Teenager sexuality is a public health issue. In teenagers attending a high school, we assessed their knowledge and behavior on sexuality, infectious transmitted diseases, human papilloma virus (HPV) vaccination, and cervical cancer. Then in girls, we estimated the anti-HPV vaccination coverage and focused on factors associated with poor knowledge of these topics.This was a knowledge, attitudes, and practices cross-sectional study conducted at the beginning of the 2010-2011 school year in the Saint-Cyr military high school, using an anonymous self-administered questionnaire.Among 669 adolescents (M/F sex-ratio, 2.3; mean age, 17 years [IC 95%, 15-20]), 40% had already had sex and 92% had used contraception. Boys and girls had a poor level of knowledge on infectious transmitted diseases. Regarding knowledge on HPV and cervical cancer, a better level was significantly associated with female gender (P=10(-4)). In multivariate analysis, male gender, age under 18 years, lack of dialogue with parents on these subjects, low socioeconomic status of parents, and absence of health education were significantly associated with poor knowledge on these topics.These data should help healthcare providers better target access and content of sexual health education training.

The purpose of this study was to test the hypothesis that the surgical technique using alternating fluid irrigation and carbon dioxide (CO2) gas medium as a means of knee joint distension during arthroscopy is a safe and effective method, compared to traditional fluid arthroscopy. This prospective randomized comparative study involved 94 patients undergoing the same arthroscopic ACL reconstruction surgical procedure except for the medium used to distend the joint: In a first group of 48 patients (“ACL gas” group), CO2 insufflation was mainly used, at a low pressure of 40–50 mmHg, alternating with a fluid medium for knee joint washout only. In the second group of 46 patients, classical arthroscopic joint distension by fluid was used, with a pump pressure of 50–70 mmHg. Early pre- and post-operative complications, duration of surgery, intraoperative monitoring data and particularly the end-tidal carbon dioxide (EtCO2) as a marker of CO2 blood diffusion were prospectively collected. EtCO2 and other monitoring data changes before and after tourniquet release were not different between the two groups. Tourniquet time was significantly longer when using fluid rather than gas. We observed 3 cases of small and localized subcutaneous emphysema, resolving completely within hours. Hematoma and reflex sympathetic dystrophy occurred more often in the “ACL fluid” group, with no statistical significance. Low-pressure CO2 knee joint insufflation proved to be a safe technique capable of improving surgical comfort compared with the use of fluid alone. The CO2 blood diffusion measured by end-tidal carbon dioxide monitoring during ACL arthroscopic reconstruction was similar with or without gas insufflation. Randomized controlled trial, Level I.

Mycobacterium bovis is responsible for a zoonosis originating in cattle. This disease has rarely affected man in industrialised countries since the establishment of veterinary surveillance in cattle. We report the case of a young female patient who developed a Mycobacterium bovis primary infection revealed by erythema nodosum. Infection was probably due to the consumption of non-pasteurised milk in Morocco. This clinical manifestation is rare and physicians ought to be aware of this imported pathology.

Giant hydatid cyst located in the retroperitoneal space is rare. The purpose of this report is to present a case cured by surgery in an adult traveller.In August 2009, a 67-year-old female who traveled frequently to Lebanon was admitted for assessment of a giant retroperitoneal hydatid cyst discovered coincidentally following palpation of an abdominal mass in 1997. From 1966 to 1975, the patient had undergone several surgical procedures for pulmonary and hepatic hydatidosis, complicated by vomica and anaphylactic shock. In 1997, computed tomography showed that the retroperitoneal cyst measured 100 mm at the widest point. At that time, the patient refused to undergo further surgery and was treated medically using albendazole initially in association with praziquantel. In 2009, the cyst had expanded to 180 mm at the widest point and the patient finally consented to perikystectomy. Excision was total and recovery was uneventful. Histology examination confirmed the viability of the cyst. Follow-up examination at 12 months indicated no relapse.The retroperitoneal space is a rare location for hydatidosis. Occurrence in this location is generally primary. In case of discovery of a liquid-filled retroperitoneal mass, a history of travel to an endemic area for hydatid disease should be elicited. Diagnosis relies on radiological findings and positive serology. Since retroperitoneal cysts are often giant, they respond poorly to medical treatment. Similarly radiological treatment is difficult due to retroperitoneal location. Surgery, preferably perikystectomy, is the treatment of choice.

International audience; Since the start of 2010 there has been a flare-up of measles in France, following on the resurgence observed in 2008. The aim of this study was to present results of the epidemiological surveillance of measles in the French armed forces and to describe the increase in incidence. Measles was surveyed from 1992 to 2010. Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were provided by the physicians in the armed forces using anonymous data collection forms. Between 1992 and July 2010, 689 cases of measles were notified. Since 2002, the mean incidence rate was 1 case per 100,000. A significant increase has been observed for 2010 (13.9 cases per 100,000 in 2010 versus 1.8 in 2009). The 28 cases reported in 2010 involved five clusters and three isolated cases. The mean age of affected subjects was 27 years. Only 30% of cases had been vaccinated. The epidemic resurgence of measles observed in 2010 in the French armed forces follows the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination cover.

Neurological complications are rare following hepatitis A. Acute myelitis is even more uncommon. The purpose of this report is to describe a case of acute myelitis related to hepatitis A virus (HAV) in a 43-year-old-woman returning from Senegal. Diagnosis of myelitis was confirmed by spinal MRI and detection of anti-HAV Ig M antibodies in serum. The patient made a spontaneous clinical recovery in one month. Spinal MRI findings were normal at three months. Hepatitis A should be considered in the diagnostic approach to acute myelitis in returning travelers and patients living in highly endemic countries where prophylactic vaccination is unavailable.

To describe the epidemiological and clinical features of enteroviral meningitis as well as the biological profile of the cerebrospinal fluid (CSF).A retrospective study conducted in a single centre between 2004 and 2008. All aseptic meningitis due to Enterovirus were included.Fifty-nine patients were included. The triad including fever, headache and neck stiffness was reported in 62% of patients. Twelve patients (20%) had a neutrophilic leukocytosis and 23 (39%) an elevated CRP level. Twenty-eight patients (47%) had a prominent neutrophilic reaction in the CSF and nine (15.2%) had a low glucose concentration. A presumptive anti-bacterial treatment was initiated in 47 patients (80%) for an average of 3.2 days.Due to the lack of specificity of clinical features and biological manifestations of Enterovirus meningitis, the widespread use of real-time Enterovirus PCR is a priority for reducing the number of unnecessary anti-bacterial treatment. Guidelines based on clinical and biological features may be associated to help physicians in the differential diagnosis between bacterial and viral meningitides.

Kawasaki disease is recognized as a leading cause of acquired heart disease in some Western countries. It has rarely been described in Africa. The purpose of this report is to describe a case of typical Kawasaki disease in a 9-year-old girl from Madagascar. Despite administration of acetylsalicylic acid upon admission (80 mg/kg/d), the patient developed pancarditis on day 6 that was complicated by acute left heart failure confirmed by echocardiography. A clearcut improvement was obtained using prednisone (2 mg/kg/day) before treatment using intravenous immunoglobulins imported from France on day 11 (0.5 mg/kg/day for 5 days). Echocardiography on day 24 demonstrated a 5 mm aneurysm in the left coronary artery. Acetylsalicylic acid was discontinued at 6 months after control examinations at 4 and 6 months demonstrated disappearance of the aneurysm. In addition to further documenting the presence of Kawasaki disease in Madagascar, this case report illustrates the difficulty of management in a developing country.

Intracranial suppurations (ICSs) are poorly assessed in sub-Saharan Africa, especially in children.A retrospective study from 1st January 1996 to 31st December 2004 in children admitted to the pediatric department of the Hôpital Principal de Dakar, Senegal, for a sinogenic or otitic ICS. All cases were diagnosed by CT scan.Sixteen children (12 boys and 4 girls), mean age of 11.2 years (range, 7-15 years), were admitted with the primary diagnosis of ICS. The mean time from the beginning of fever or neurological disorders to admission was 12 days (range, 1-60 days) and 6 days (range, 1-22 days), respectively. At admission, fever was noted in 14 patients and neurological signs in all patients. Otolaryngologic infections were sinusitis (n=14) or otitis (n=2). ICSs were subdural empyema (n=8), single (n=6) or multiple (n=1) cerebral abscesses, or association of subdural empyema and cerebral abscess (n=1). Bacteriological cultures were seldom positive because of frequent previous antibiotic therapies and showed Staphylococcus aureus (n=2), nongroupable Streptococcus (n=1), or Pseudomonas aeruginosa and Proteus mirabilis (n=1). Antibiotics were given initially intravenously for 30 days, then orally for 30 days. Additionally, some patients received corticosteroids (n=4) or phenobarbitone (n=9). Aspiration drainage of the ICS was undertaken in 13 patients. All the children were cured, 4 of whom had neurological sequelae at follow-up.This pediatric series provides important data on the characteristics of ICS in sub-Saharan Africa. Therapeutic measures adapted to this context are proposed.Access to CT scan was fundamental in guiding medical and surgical management and ensuring a mostly favorable outcome despite long delays in treatment initiation.

An outbreak of cutaneous leishmaniasis occurred among 71 soldiers who had participated in various missions during a 4-month's period in French Guiana. The aims of this study were (i) to describe outbreak and (ii) to determine risk factors of cutaneous leishmaniasis.All patients were hospitalised. Cutaneous lesions were biopsied and cultured for species identification. Individual information was collected by a physician or a nurse, using on a standardised, anonymous chart. Data were processed with EpiInfo 6.04 and SAS.Mean age of the 71 soldiers was about 25.9 years (19-37 years). Twelve soldiers presented 56 lesions due to Leishmania (Viannia) guyanensis (attack rate = 16.9 for 100). Among 56 lesions, 13 lesions were localized on the trunk, usually an unexposed body area. Logistic regression highlighted military exercises in the forest during a high risk period of leishmaniasis transmission (OR = 11.2; p0.01), and the young age (OR = 1.33; p = 0.04). Vector control measures were not statistically significant.Military authorities should restrict deep forest activities during periods of high risk transmission. Vector control measures are essential. Officers should motivate their soldiers and supervise vector control measures. As ecotourism is developing, tourists as well as workers staying in deep forest must be informed of the risk and about vector control measures.

The influence of age on the clinical presentation of severe malaria and especially on its 2 most commonly encountered manifestations, cerebral malaria and severe anaemia, has been retrospectively examined in 161 children (< 16 years old) admitted to the paediatric department of Hopital Principal de Dakar from 1 January 1990 to 29 February 1996. They lived in Dakar and its suburbs, a region of Senegal where the malaria transmission rate is very low. Cases were defined by at least one of the World Health Organization criteria of severe malaria and the presence of Plasmodium falciparum in blood smears. Severe anaemia was present in 73.1%, 52.1% and 26.2% cases of severe malaria among children aged 0-3 years, 4-7 years and 8-15 years, respectively (P < 0.0001). The frequency of cerebral malaria was 11.3%, 28.2% and 60.6%, respectively, in the same age groups (P < 0.0001). Severe anaemia and cerebral malaria were associated in 8.7% of the cases of severe malaria. The fatality rate was significantly lower in cases of severe anaemia without cerebral malaria (3%) than in cases of cerebral malaria without severe anaemia (17.5%; P < 0.02). Among young children, severe anaemia was associated with brief hyperparasitaemia or with prolonged lower parasitaemia. Other things being equal, older children had a lower risk of severe anaemia. The results suggest that the high prevalence of severe anaemia in young children, even in an area of very low endemicity, depends more on age and parasitaemia than on the transmission level.

The authors report two cases of hypertrophic obstructive cardiomyopathy in young girls, age 3 months and 8 years old. The disease manifested itself as a cardiac heart failure in the infant's case and a syncop in the other case. Cardiac echocardiography showed in he first case asymetric hypertrophic cardiomyopathy with ventricular outflow tract obstruction gradient of 100 mmhg, and concentric hypertrophic with 120 mmhg in the second case. Its evolution was fatal in both cases and led to sudden death at home. This disease is severe as no therapeutic treatment can modify its course.

The incidence of childhood heart disease in developing countries is high, but access to cardiac surgery is limited. This mismatch has given rise to numerous humanitarian programs aimed at sending children abroad for surgical treatment. However little is available about the long-term outcome of these interventions. In 1999 we conducted a retrospective study of 168 Senegalese children undergoing follow-up at the Principal Hospital in Dakar after being transferred to Europe or the Ivory Coast for surgical treatment thanks to the Terre des Hommes Association. A total of 85 children presented congenital heart disease (CHD) and 83 presented acquired heart disease (AHD). Fifteen patients did not undergo surgery due to either contraindications or preoperative death. At the end of study, 23 children had been lost to follow-up mostly from the CHA group and presumably some were cured. Outcome was verifiable in the remaining 145 patients with a median follow-up of 5.6 years. Ninety-seven patients were cured or undergoing surveillance. Quality of life was better in the CHD group (p = 0.047). Forty-eight patients died including 16 in the CHD group and 32 in the AHD group. Perioperative mortality (n = 19) was lower and late mortality (n = 29) was higher in the AHD group (p = 0.005). In the AHD group compliance with surveillance was better for children with valve prostheses. In children treated for isolated mitral valve insufficiency, late mortality was higher after valve replacement than valve repair (p = 0.04). In absence of comparative study data, high mortality was due in part to the long delay between the decision to send the patient abroad and the actual evacuation. These findings support humanitarian action to promote cardiac surgery in developing countries.

Data from numerous surveys conducted by UNICEF using standardized methods in most developing countries over the last 10 years now enable evaluation of the status of breastfeeding in the world. The purpose of this report is to present findings concerning the duration of exclusive breastfeeding, appropriate complementary feeding, and continued breastfeeding after 6 months. Analysis of these data indicates that progress is being made but that various problems remain. In an effort to improve the situation, the WHO/UNICEF has undertaken a number of initiatives and issued several recommendations.

The prognosis of emergency cesarean section is poor for both the mother and child in developing countries. The respective impact of obstetrical and surgical factors has rarely been analyzed. This prospective study was carried out in 370 women (mean age, 30.5 years) who underwent emergency cesarean section at Principal Hospital in Dakar, Senegal, between January 1 and December 31, 1997. Fifty percent of these women had been transferred from an outside maternity clinic. Indications related to the mother (75% of cases) or fetus (25% of cases) were divided into two groups according to degree of emergency: absolute (n = 163) and relative (n = 207). Placental hematoma (n = 64) and fetus-pelvis size mismatching (n = 49) were the main indications in both groups. The technique chosen for initial anesthesia performed by a specialized nurse in most cases was either spinal anesthesia if there were no contraindications (50.8%) or general anesthesia (49.2%). There were 5 complications including 1 that was fatal (aspiration during intubation for general anesthesia). The postoperative maternal morbidity rate was low (n = 7) and outcome was favorable. A total of 7 patients (1.9%) died due to anesthesia-related events in 1 case and obstetrical factors in 6. Mortality in the absolute emergency group was significantly higher for women who were transferred from other clinics (p0.02). Child mortality (n = 87) occurred prior to delivery in two thirds of cases and after delivery in one third. Child mortality was significantly higher in the absolute emergency group (RR = 5.4; IC95% = 3.2-8.9, p10(-6)). Mother and child mortality rates were correlated with the severity of obstetrical manifestations and delay of care. Findings also showed that a well-organized care system lowers the operative risk of emergency cesarean section even in developing countries.

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

Childhood cancer has often been considered as a problem mainly affecting industrialized countries. In reality more than half of cases occur in developing countries where management and diagnosis are major issues. This retrospective study includes 130 children (0.3% of admissions) between the ages of 0 and 15 years hospitalized for malignant disease at the Principal Hospital in Dakar, Senegal between January 1, 1990 and December 31, 2000. Mean age was 97 months and M/F sex ratio was 1.2. Mean delay for admission was 3 months. The five most frequent cancers, accounting for 75% of cases, were leukemia (n = 28), lymphoma (n = 21), nephroblastoma (n = 21), retinoblastoma (n = 16) and osteochondrosarcoma (n = 10). Treatment was completed in 18% of cases. Half of patient were lost from follow-up. The cure rate was 10% overall and 50% for patients receiving complete treatment. The highest cure rate was achieved for nephroblastoma, i.e., 58% of cases treated. Management of childhood cancer in Africa is confronted with numerous problems, namely, paucity of specialized staff, absence of expert centers, shortage of anticancer drugs, lack of financial resources, and delay in treatment. These factors associated with frequent malnutrition and recurrent infectious diseases, greatly lower cure rates in comparison with industrialized countries.

Objective : To determine the relative effects of abdominal, vaginal or laparoscopic approaches for hysterectomy on female sexuality. Study design : One hundred and seventy women who underwent abdominal ( n =68), vaginal ( n =67), and laparoscopic ( n =35) hysterectomy for benign disease were studied. Pre- and postoperative sexuality was assessed by questionnaire. Results : Overall, sexuality after hysterectomy remained unchanged in 60.4% of cases, and improved or deteriorated in 21.3 and 18.3%, respectively. Postoperative delay in resuming sexual activity was shorter after vaginal (45.2±6.7 days) hysterectomy than after abdominal hysterectomy (62.4±9.3 days). Deterioration of sexual function occurred more frequently after abdominal hysterectomy (24%) than after vaginal (13.5%) or laparoscopic (8.5%) hysterectomy. Conclusion : These results indicate that the impact of vaginal and laparoscopic hysterectomy on women’s sexuality may be milder than that of abdominal hysterectomy.

A multicentric, open, prospective, observational and no-randomized clinical trial was carried out in Spain with 190 postmenopausal women receiving a soy preparation rich in isoflavones (PHYTO SOYA, capsules containing 17.5 mg isoflavones). The main object of the present study was to investigate its efficacy in alleviating the symptomatology derived from the lack of estrogen, mainly hot flushes, but also other symptoms such as sleep disorder, anxiety, depression, vaginal dryness, loss of libido and bone pain. Each patient received 35 mg isoflavones per day in two doses. During the four months' treatment, a statistically significant decrease in the number of hot flushes with PHYTO SOYA was experienced by 80.82% women; only 5,48% patients did not improve with the treatment. The average reduction was 47.8%, which is equivalent to 4 hot flushes. All the other studied parameters also showed a statistically significant decrease. No severe side-effects were reported and tolerance was excellent. Treatment with PHYTO SOYA resulted in a significant improvement of the symptomatology that accompanies the lack of estrogen during menopause.

To determine the importance of prolonged QT interval and electrocardiographic changes in children treated with halofantrin for an acute malaria attack.Out of 25 children treated with halofantrin, nine had an increase of QTc interval440 ms and ten a QTc440 ms on control 24 h after the first dose. A 9-year-old girl, treated with halofantrin, had bradycardia and increase of QTc interval for six days, with a normal halofantrin blood level.These data show that cardiac monitoring during halofantrin treatment is mandatory in children as in adults. Contraindications of halofantrin treatment must be respected, particularly a long congenital QT interval.

The influence of age on the clinical presentation of severe malaria and especially on its two most commonly encountered manifestations, cerebral malaria and severe anaemia, has been retrospectively examined in 161 children (16 years old) admitted in the paediatric department of Hospital Principal de Dakar from January 1st 1990 to February, 29th 1996. They lived in Dakar and its suburbs, a region of Senegal were the malaria transmission rate is very low. Cases were defined by at least one of the World Health Organization criteria of severe malaria and the presence of Plasmodium falciparum in blood smears. Severe anaemia was present in 73.1%, 52.1% and 26.2% cases of severe malaria among children aged 0-3 years, 4-7 years and 8-15 years, respectively, (p0.0001). The frequency of cerebral malaria was 11.3%, 28.2% and 60.6% in the same age groups, respectively, (p0.0001). Severe anaemia and cerebral malaria were associated in 8.7% of the cases of severe malaria. The fatality rate was significantly lower in cases of severe anaemia without cerebral malaria (3%) than in cases of cerebral malaria without severe anaemia (17.5%; p0.02). Among young children, severe anaemia was associated with brief hyperparasitaemia or with prolonged lower parasitaemia. Other things being equal, older patients had a lower risk of severe anaemia. The results suggest that the high prevalence of severe anaemia in young children, even in an area of very low endemicity, depends more on age and parasitaemia than on the transmission level.

The authors describe three cases of Histoplasma capsulatum histoplasmosis that occurred in black AIDS patients living in France but originally from Guinea and Ivory Coast. In all three cases histoplasmosis was disseminated with fever. In two cases there were cutaneous manifestations. One patient had renal insufficiency and nephrotic syndrome and another presented ulcerative colitis with histoplasma in the chorion. The outcome was favorable in two patients. These three cases are in addition to the five previously reported cases in african AIDS patients. These cases stress the need for awareness of this opportunistic infection as a complication of AIDS in patients from Black Africa.

Most authors agree on the importance of medial meniscus preservation in the case of A.C.L. reconstructive surgery. The purpose of this study was to analyze the anatomical results of sutures of medial meniscus tears by the means of arthrography.Medial meniscus 42 sutures for peripheral tears at the posterior horn (length between 10 and 50 mm, 70 per cent greater than 20 mm) had been performed through an open procedure using a posterior approach. The average age of the patients was 24 years (17-54) with a clear male predominance (64 per cent). The average age at the time of injury was 22 years, 6 months.The patients were operated on by the same surgeon, with the same technique. Resorbable sutures were used spaced every-3 mm, and tightened outside the joint. The A.C.L. was reconstructed by a bone-patellar tendon-bone technique (modified K.G. Jones). A first series of 13-patients were no weight bearing allowed for 6 weeks post-operatively. A second series of 29 patients were allowed immediate partial weight bearing. All the patients were permitted active flexion. All the patients had been examined with a minimum of 6 months follow-up. They were all controlled clinically (results evaluated with the I.K.D.C. score) and with passive dynamic X rays to measure residual laxity. 32 patients had an arthrogram before the operation in the aim to compare with the postoperative arthrogram. 30 patients had an arthrogram after an average of 21 months. 12 patients refused follow-up arthrograms. 9 patients had arthroscopy for pain or effusion.All the patients obtained a range of flexion-between 90 degrees and 110 degrees at 4 weeks. A flexed contracture of 10 degrees was noted in only 1 case. Meniscal functional results were good for 32 cases after a mean follow-up of 4 years and 4 months. Arthrograms in 30 cases showed no residual tear in 19 cases (63 per cent), 3 cases had incomplete healing and 8 cases had failed. The healing was influenced by the size of the tear, its situation near the posterior wall. In the first series (no weight bearing), there were 2 failures for 9 cases and 6 out of 21 in the second series and 3 incomplete healing. There was no correlation between meniscal functional results and functional ligamentous results evaluated with the I.K.D.C. score. 9 patients had an arthroscopy and 7 out of them a meniscectomy (after 17 months 3).This study confirms the possibility of healing following suture of peripheral medial meniscal tears in the case of ACL reconstructive surgery (even if the tear is long). The use of arthrogram, before the operation and for anatomical control after the operation, ensures complete healing (better than M.R.I. for the suture control). Arthrography is certainly a less invasive technique than arthroscopy.

Up till now, in the French Polynesia and in New Caledonia, people showing ciguatera intoxication receive a standard treatment: calcium + vitamins B6 and C by intravenous way and in addition, some drugs arriving to cure some symptomatic manifestations. In 1988, an investigation carried out in Majuro, Marshall Islands concluded that intravenous mannitol is efficient in the treatment of serious intoxications with suspecting cerebral oedema. Since, such a treatment has been utilized with success in several endemic areas. Our therapeutic evaluation was arrived to determine whether mannitol's efficiency is higher than the standard treatment in the ciguatera intoxications of mean seriousness. This investigation was carried out on two randomized groups: The first one receiving mannitol (250 cc intravenous at 20% injected in 1 h) the second one receiving the standard treatment (intravenous perfusion glucose serum 250 cc with 1 g of vitamins C, 250 mg of vitamin B6 and 1 g of calcium gluconate injected in 1 h). Seriousness of clinical status was evaluated according to a scale of score from 0 to 50, based on the importance of the clinical manifestations paresthesia, aches, asthenia, cardiovascular and digestive signs. Only patients getting a score at least 20 were included in this investigation. Clinical status of each patient was evaluated before any treatment (initial score) at the end of perfusion and at the 24th hour. Efficiency of each treatment respectively was evaluated according to the differences between these three different scores. CHI 2 and U Mann's and Whitney's tests were utilized for the statistical analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a retrospective study of 25 cases of hepatic amebiasis which were observed from 1988 to 1990 in Tahiti. The symptoms were typical in 20 patients and incomplete in 5 other patients. The ultrasonic examinations showed one (n = 14) or several abscesses (n = 11). The majority were located at the right lobe of the liver (84%). Except in one case where the abscess had a high echo response (it was a pseudo-tumour), the others showed a low echo response or were liquid. The serology (hemagglutination) was always positive but once, at the first examination or afterwards. Recovery was obtained by all patients on an average of 6 days for clinical signs and of three months for ultrasonic features, by administering Metronidazole, combined twice with a drainage (transcutaneous = 1 case, surgical = 1 case). Neither rupture, nor relapse occurred. This series is related to other studies made in South Pacific, Africa and France. It underlines the topicality of amebiasis in French Polynesia, and the interest for the Health Services to carry out a program against this endemy.

Introduction Since the recent descriptions of the anterolateral ligament (ALL), the role played by the anterolateral peripheral structures in the rotational control of the knee is again being debated. The objective of this study was to identify the structures during internal tibial rotation and then to define their anatomical characteristics. We hypothesized that internal rotation would tighten several anatomical formations, both superficial and deep, with the ALL one part of these structures. Material and methods Nine fresh-frozen cadaver knee specimens were studied. The anterolateral structures tightened were identified from superficial to deep at 30° of flexion. Each was selectively dissected, identifying its insertions and orientations, and measuring its size. The length variations of the ALL during internal tibial rotation were measured by applying a 30-N force using a dynamometric torque wrench at the tibiofibular mortise. Results The superficial structures tightened were the iliotibial tract and the Kaplan fibers. In internal tibial rotation, the Kaplan fibers held the iliotibial tract against the lateral epicondyle, allowing it to play the role of a stabilizing ligament. The Kaplan fibers were 73.11 ± 19.09 mm long (range, 63–82 mm) and at their femoral insertion they were 12.1 ± 1.61 mm wide (range, 10–15 mm). The deep structures tightened covered a triangular area including the ALL and the anterolateral capsule. The ALL was 39.11 ± 3.4 mm long (range, 35–46 mm) in neutral rotation and 49.88 ± 5.3 mm long (range, 42–58 mm) in internal rotation (p

Results of dorsal sympathectomy in patients (67 operations) for vasomotor disorders of the upper limbs were assessed after follow-up for between 6 months and 15 years, in order to determine the best indications for surgery. Based on clinical results, sympathectomy should be performed not only when medical treatment fails, but also in the presence of a severe clinical picture of trophic disturbances or pain of the ischemic type. Two types of investigation are essential before deciding on operative therapy:--plethysmography with a hyperemia test,--arteriography of the hand. Assessment of results as a function of etiology demonstrated that they were excellent in cases of hyperhidrosis, very satisfactory in atheromatous digital arteritis or a thoracic inlet syndrome (associated with rib resection in the latter case), but only moderately good in scleroderma or post-traumatic lesions. Finally, Raynaud's disease or thromboangiitis do not appear to be indications for this operative procedure.

The authors studied 223 new-borns in an African Pediatric Department over a eight month period. The death rate was 47.5 p. cent (106 cases). It was explained by infectious diseases in 53 cases, respiratory distress syndrome in 37 cases, acute foetal distress in 9 cases, jaundice in 6 cases, and malformation syndrome in one case. A birth-weight less than 2.500 g is correlated with a poor prognosis. The authors define target populations in tropical zones to be looked after by aims of prophylactic and curative actions.

The authors report on 22 observations made from june 1982 to december 1984 in African children having presented an intolerance against metoclopramide. After recalling briefly the pharmacology of this drug, they describe the symptomatology similar to neuroleptic intoxication syndrome: parkinsonian syndrome, motor excitation syndrome. Posology was correct in 2/3 of the cases, when it was known. Overdose was observed in 5 cases only. Recovery was complete after the administration of the drug was stopped, but it was accelerated by antiparkinsonian drugs.