French national diagnostic and care protocol for Kawasaki disease.

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

Parent and adolescent communication with healthcare professionals about Type 1 diabetes management at adolescents' outpatient clinic appointments.

AIM: This study aimed to identify the ways in which adolescents living with Type 1 diabetes and their parents communicate about Type 1 diabetes management with healthcare professionals in a clinical setting. METHODS: Twenty-nine adolescents (aged 11-17 years) and their parents were purposively recruited from two outpatient clinics for non-participant observations. Outpatient clinic appointments, which consisted of multiple consultations with healthcare professionals, were observed and audio-recorded. Outpatient clinic appointments were categorized based on the nature and extent of communication by the adolescent and their parent(s) in relation to Type 1 diabetes management activities. RESULTS: Data from 29 outpatient clinic appointments, consisting of a total of 68 observed consultations, were analysed and a continuum consisting of three patterns of communication was identified (parent-led, collaborative and adolescent-led). Healthcare professionals should attend to the nature and extent of communication by adolescents and their parents in relation to Type 1 diabetes management activities because parent and adolescent engagement in communication during clinic appointments may also reflect their degree of involvement in daily Type 1 diabetes management. CONCLUSIONS: This continuum provides a framework for healthcare professionals to use to identify communication patterns in consultations which in turn may allow healthcare professionals to encourage more effective communication about Type 1 diabetes management from adolescents and their parents in clinic consultations. This may have a positive impact on the sharing of Type 1 diabetes management responsibilities and adolescents' developing self-management skills as roles change during this developmental period.

Placental infection by Zika virus in French Guiana.

OBJECTIVES: To describe placental findings on prenatal ultrasound and anatomopathological examination in women with Zika virus (ZIKV) infection, and to assess their association with congenital ZIKV infection and severe adverse outcome, defined as fetal loss or congenital Zika syndrome (CZS). METHODS: This was a prospective study of pregnancies undergoing testing for maternal ZIKV infection at a center in French Guiana during the ZIKV epidemic. In ZIKV-positive women, congenital infection was defined as either a positive reverse transcription polymerase chain reaction result or identification of ZIKV-specific immunoglobulin-M in at least one placental, fetal or neonatal sample. Placental ZIKV-infection status was classified as non-exposed (placentae from non-infected women), exposed (placentae from ZIKV-infected women without congenital infection) or infected (placentae from ZIKV-infected women with proven congenital infection). Placentae were assessed by monthly prenatal ultrasound examinations, measuring placental thickness and umbilical artery Doppler parameters, and by anatomopathological examination after live birth or intrauterine death in women with ZIKV infection. The association of placental thickness during pregnancy and anatomopathological findings with the ZIKV status of the placenta was assessed. The association between placental findings and severe adverse outcome (CZS or fetal loss) in the infected group was also assessed. RESULTS: Among 291 fetuses/neonates/placentae from women with proven ZIKV infection, congenital infection was confirmed in 76 cases, of which 16 resulted in CZS and 11 resulted in fetal loss. The 215 remaining placentae from ZIKV-positive women without evidence of congenital ZIKV infection represented the exposed group. A total of 334 placentae from ZIKV-negative pregnant women represented the non-exposed control group. Placentomegaly (placental thickness > 40 mm) was observed more frequently in infected placentae (39.5%) than in exposed placentae (17.2%) or controls (7.2%), even when adjusting for gestational age at diagnosis and comorbidities (adjusted hazard ratio (aHR), 2.02 (95% CI, 1.22-3.36) and aHR, 3.23 (95% CI, 1.86-5.61), respectively), and appeared earlier in infected placentae. In the infected group, placentomegaly was observed more frequently in cases of CZS (62.5%) or fetal loss (45.5%) than in those with asymptomatic congenital infection (30.6%) (aHR, 5.43 (95% CI, 2.17-13.56) and aHR, 4.95 (95% CI, 1.65-14.83), respectively). Abnormal umbilical artery Doppler was observed more frequently in cases of congenital infection resulting in fetal loss than in those with asymptomatic congenital infection (30.0% vs 6.1%; adjusted relative risk (aRR), 4.83 (95% CI, 1.09-20.64)). Infected placentae also exhibited a higher risk for any pathological anomaly than did exposed placentae (62.8% vs 21.6%; aRR, 2.60 (95% CI, 1.40-4.83)). CONCLUSIONS: Early placentomegaly may represent the first sign of congenital infection in ZIKV-infected women, and should prompt enhanced follow-up of these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Physical activity behaviours of persons living with HIV of low socioeconomic status: domain, intensity and sociodemographic correlates.

Physical activity (PA) is healthy for People Living with HIV and AIDS (PLWHA). This study examined the PA profile of 978 PLWHA based on PA domains and PA intensity. The study also sought to determine whether employment status and level of education can predict PA among PLWHA of low SES. PA and sociodemographic data of 978 PLWHA of mean age 35 (8.77) years were collected using the global physical activity questionnaire and a sociodemographic questionnaire. Results showed that, participants engaged more in work-related PA [160.11 (346.95) min/wk], followed by transport related PA [115.21(SD = 142.04) min/wk], and lastly in leisure related PA [40.84 (SD = 110.37) min/wk]. Participants also engaged more in moderate PA [265.86 (SD = 335.45) min/wk], than in vigorous PA [50.29 (SD = 205.30) min/wk]. Employment was a significant predictor of overall PA controlling for age, CD4 count and education level. The model explained 2.5% of the variance (R2 = 0.025) on overall PA and tested significant at a 0.01 alpha level (p < 0.01). PA interventions for this population should be domain- and intensity-specific. Researchers promoting healthy lifestyle behaviour change can benefit from determining the factors that facilitate domain-specific PA.

Sanger sequencing versus INNO-LiPA® HBV PreCore assay for routine detection of precore and basal core promoter mutations in hepatitis virus B chronically infected patients.

We compared the Sanger sequencing and the commercial INNO-LiPA® HBV assay for the routine detection of precore (PC) and basal core promoter (BCP) mutations of hepatitis B virus in chronically infected patients. The overall agreement rate between assays was 94.2% and 98.8% for the detection of PC and BCP mutations, respectively.

Association between Zika virus and fetopathy: a prospective cohort study in French Guiana.

OBJECTIVE: To establish the incidence of fetal central nervous system (CNS) anomalies (including microcephaly), signs of congenital infection and fetal loss in pregnant women infected with Zika virus (ZIKV) and non-infected pregnant women in western French Guiana. METHODS: This prospective cohort study was conducted between 1 January and 15 July 2016. We evaluated and compared clinical and fetal ultrasound examinations of 301 pregnant women with biological confirmation of ZIKV infection and 399 pregnant women who were negative for ZIKV infection. RESULTS: Overall, the total number of fetuses with CNS involvement was higher in the infected than in the control group (9.0% vs 4.3%; relative risk, 2.11 (95% CI, 1.18-4.13)). Anomalies of the corpus callosum and presence of cerebral hyperechogenicities were significantly more common in the infected group. There was an increased risk of microcephaly in the infected compared with the control group (1.7% vs 0.3%; relative risk, 6.63 (95% CI, 0.78-57.83)), although this was not statistically significant. When the mother was infected during the first or second trimester, there was a greater risk of severe CNS involvement, more signs of infection and intrauterine fetal death than with infection in the third trimester. The rate of vertical transmission in the exposed group was 10.9%. CONCLUSION: ZIKV infection during pregnancy is associated with a significant risk of fetal CNS involvement and intrauterine fetal death, particularly when infection occurs during the first or second trimesters. Microcephaly was not present in every case of congenital ZIKV syndrome that we observed. Until more is known about this disease, it is paramount to evaluate suspected cases by detailed neurosonography on a monthly basis, paying particular attention to the corpus callosum and the presence of hyperechogenic foci. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[Prostate cancer of elderly patients: Place and role of geriatric assessment]. / Cancer de prostate des sujets âgés : place et rôle de l'évaluation gériatrique.

INTRODUCTION: The aim of this study was to appreciate the place and role of geriatric assessment in elderly patients with prostate cancer. MATERIALS AND METHODS: We performed a retrospective analysis of prostate cancer patients who underwent geriatric assessment during the therapeutic management from 2008 to 2014. Patient, tumor, treatment characteristics and their associated toxicity as well as the parameters of geriatric assessment were studied. The occurrence of geriatric assessment within the 3 months preceding a therapeutic decision was reviewed. RESULTS: Data of seventy-four patients were analyzed with a median follow-up of 15.6 years. The average age at diagnosis was 74.3 and 80.6 at the geriatric assessment. At the time of the geriatric assessment 64 patients had metastatic disease, 39 were in poor condition more than 50% of patients had walking ability disorders. Thirteen patients underwent radical surgery, 28 received radiotherapy, 30 patients had chemotherapy and hormonotherapy was prescribed for 72 patients. The geriatric assessment, requested on average 15 years after diagnosis, was not carried out within the 3 months preceding treatment decision for 55 patients. CONCLUSION: The recourse to geriatric assessment is predominantly used to endorse a decision of supportive care for elderly patients with prostate cancer. An early intervention by a geriatrician consultant for the initial management and then at each therapeutic event is a sine qua non condition for efficient personalized therapeutic management suitable to every patient according to physiological age. LEVEL OF EVIDENCE: 4.

Sparks creating light? Strengthening peripheral disease surveillance in the Democratic Republic of Congo.

SETTING: The Democratic Republic of Congo suffers from an amalgam of disease outbreaks and other medical emergencies. An efficient response to these relies strongly on the national surveillance system. The Pool d'Urgence Congo (PUC, Congo Emergency Team) of Médecins Sans Frontières is a project that responds to emergencies in highly remote areas through short-term vertical interventions, during which it uses the opportunity of its presence to reinforce the local surveillance system. OBJECTIVE: To investigate whether the ancillary strengthening of the peripheral surveillance system during short-term interventions leads to improved disease notification. DESIGN: A descriptive paired study measuring disease notification before and after 12 PUC interventions in 2013-2014. RESULTS: A significant increase in disease notification was observed after seven mass-vaccination campaigns and was sustained over 6 months. For the remaining five smaller-scaled interventions, no significant effects were observed. CONCLUSION: The observed improvements after even short-term interventions underline, on the one hand, how external emergency actors can positively affect the system through their punctuated actions, and, on the other hand, the dire need for investment in surveillance at peripheral level.

Contexte : La République Démocratique du Congo souffre d'un amalgame de flambées épidémiques et d'autres urgences médicales. Une réponse efficace à ces problèmes est basée sur le système national de surveillance. Le Pool d'Urgence Congo (PUC) de Médecins Sans Frontières est un projet répondant aux urgences dans les zones très reculées grâce à des interventions verticales à court terme, pendant lesquelles le projet met à profit l'opportunité de sa présence pour renforcer le système de surveillance local.Objectif : Vérifier si le renforcement complémentaire du système de surveillance périphérique pendant des interventions à court terme amène une amélioration de la notification des maladies.Schéma : Une étude descriptive par paires mesurant la notification des maladies avant et après 12 interventions PUC en 2013­2014.Résultats : Une augmentation significative de la notification des maladies a été observée après sept campagnes de vaccination de masse et elle s'est maintenue pendant 6 mois. En ce qui concerne les cinq interventions restantes à plus petite échelle, aucun effet significatif n'a été observé.Conclusion : Les améliorations observées, même après des interventions à court terme, soulignent d'un côté comment des acteurs externes de l'urgence peuvent affecter positivement le système à travers leurs actions ponctuelles et, d'un autre côté, le besoin pressant d'investir dans la surveillance au niveau périphérique.

Marco de referencia: La República Democrática del Congo adolece de una amalgama de brotes epidémicos y otras urgencias médicas y la eficiencia de la respuesta a esta situación depende en gran medida del sistema nacional de vigilancia. El proyecto 'Pool d'Urgence Congo' (PUC, en francés) de Médecins Sans Frontières responde a las situaciones de urgencia en zonas muy remotas, mediante intervenciones verticales a corto plazo, durante las cuales se aprovecha la presencia en el terreno con el fin de reforzar el sistema local de vigilancia sanitaria.Objetivo: Investigar si el fortalecimiento complementario del sistema periférico de vigilancia sanitaria durante las intervenciones de corta duración contribuye a mejorar la notificación de las enfermedades.Método: Un estudio descriptivo emparejado, en el cual se midió la notificación de las enfermedades antes y después de 12 intervenciones del PUC del 2013 al 2014.Resultados: Se observó un aumento estadísticamente significativo de la notificación de las enfermedades después de siete campañas de vacunación colectiva, el cual se mantuvo durante 6 meses. En las cinco intervenciones restantes de menor escala no se observaron efectos considerables.Conclusión: El progreso observado incluso después de intervenciones a corto plazo, por una parte, pone de manifiesto que los actores externos en situaciones de emergencia pueden inducir modificaciones positivas del sistema mediante sus actividades puntuales y, en segundo lugar, destaca la necesidad urgente de invertir en el sistema de vigilancia sanitaria a nivel periférico.

"I don't like talking about it because that's not who I am": Challenges children face during epilepsy-related family communication.

OBJECTIVES: Childhood epilepsy not only significantly impacts a child's social relationships and psychosocial wellbeing, but it can also cause disruptions in family relations. Children living with epilepsy often rely on parental figures for guidance in relation to their condition. A paucity of research has examined the challenges for children when communicating about epilepsy with parental figures. This qualitative study explored the challenges faced by children when talking about epilepsy with their parent(s). METHODS: Semi-structured interviews were conducted with 29 children (aged 6-16 years) living with epilepsy. Participants were recruited from a neurology department of a major pediatric hospital and from a national epilepsy association. Interviews were transcribed verbatim and thematically analyzed. RESULTS: Findings revealed four themes: communication impeding normalcy, parental overprotection, parental reactions to epilepsy-related communication, and restriction of activities as a consequence of epilepsy-related communication. DISCUSSION: The study highlights the need for a greater understanding of parent-child dialogue surrounding epilepsy and where challenges lie for children in conversing about their condition. Parents and health care professionals play a pivotal role in facilitating an environment where children feel comfortable talking about epilepsy. This information will be instrumental in the development of a communication-based intervention for families living with epilepsy.

To tell or not to tell: A systematic review of the disclosure practices of children living with epilepsy and their parents.

Disclosing an epilepsy diagnosis to others is complex due to the condition's largely invisible nature and associated stigma. Despite this, little has been documented in terms of what this process involves for children living with epilepsy (CWE) and their parents. A systematic review was conducted to examine and synthesize evidence pertaining to: (i) the disclosure practices of CWE and their parents, (ii) enablers and barriers for disclosure, (iii) the impact of disclosure practices, and (iv) the relationship between disclosure management and other variables. The electronic databases PsycINFO, PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched systematically. Any empirical, peer-reviewed journal articles with findings reported regarding the self- or proxy-reported disclosure practices of children aged 0-18years with any type of epilepsy and/or their parents were deemed eligible for inclusion. Two review authors completed all stages of screening, data extraction, and quality assessment independently with two additional review authors resolving any discrepancies. A total of 32 articles were included in the review. Only one dated study examined disclosure as a primary focus; in the remaining studies, disclosure was a subfocus of larger studies or pertinent qualitative themes/subthemes incidentally emerged. The limited evidence suggests that: 1) CWE and parents adopt varying disclosure management strategies - from concealment to voluntary disclosure; 2) disclosure decisions are challenging for CWE and parents; 3) many barriers to disclosure exist (e.g., fear of stigmatization and rejection); 4) only a limited number of factors that enable disclosure are known (e.g., openness by others to engage with and learn about epilepsy); 5) disclosure management is significantly related to a number of variables (e.g., child/maternal perceived stigma and seizure control); and 6) there are varying outcomes for CWE and/or their parents in accordance with the adoption of specific disclosure management strategies (e.g., disclosure resulting in greater acceptance and the receipt of support or evoking anxiety/fear in others; and concealment resulting in misunderstandings, embarrassment, and stigma-coaching), but the evidence remains inconclusive in terms of which disclosure management strategy is optimal. While some preliminary work has been conducted, disclosure of epilepsy is a topic that has been largely neglected to date. This is despite the fact that disclosure is a significant source of concern for CWE and parent populations. Future studies should focus on elucidating the unique contextual factors that inform disclosure decisions in order to develop a theoretical framework that can explain the epilepsy disclosure decision-making process.

Family communication in the context of pediatric epilepsy: A systematic review.

In childhood chronic illness, family communication can impact the child's and parents' psychosocial well-being. However, little is known about family communication in the context of epilepsy in childhood. The aim of this systematic review was to identify the existing evidence available on communication strategies adopted by families living with childhood epilepsy, including; the facilitators, barriers and challenges experienced by families when choosing to communicate, or not, about epilepsy; and the consequences of this communication. Papers published in the English language prior to March 2015 were identified following a search of six electronic databases: PubMed, MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus. Studies were included if they involved a sample of parents of children with epilepsy or children/young people with epilepsy (0-18years of age) and used qualitative, quantitative, or mixed methods. Following a comprehensive search and screening process, 26 studies were identified as eligible for inclusion in the review. No studies identified specific communication strategies adopted by families living with childhood epilepsy. Some studies found that talking about epilepsy with family members had positive consequences (e.g., communication as an effective coping strategy), with no negative consequences reported in any of the studies. The main barrier to communication for parents was an unwillingness to use the word "epilepsy" because of the perceived negative social connotations associated with the health condition. For children with epilepsy, barriers were as follows: parental desire to keep epilepsy a secret, parents' tendency to deny that the child had epilepsy, parental overprotection, and parents' tendency to impose greater restrictions on the child with epilepsy than on siblings without epilepsy. Future research investigating the communication strategies of families living with epilepsy is needed in order to create effective communication-based interventions for discussing epilepsy within the home.

[Acute pancreatitis and pregnancy: Cases study and literature review]. / Pancréatites aiguës et grossesse: cas cliniques et revue de la littérature.

OBJECTIVE: To describe issues associated with the diagnosis of acute pregnancy-associated pancreatitis. MATERIALS AND METHODS: Retrospective study of cases presenting at our establishment from 2002 to 2012. These cases were defined on the basis of the association of abdominal pain, serum lipase levels three times normal values, or signs of pancreatitis on ultrasound scans carried out on women pregnant at the time of diagnosis. A retrospective analysis of the medical files of these patients was carried out, considering epidemiological and etiological criteria, the treatments administered and maternal/fetal fate. RESULTS: We identified 10 cases during the study period, corresponding to an incidence of 1/1942. In 70% of cases, the patient was in the last three months of pregnancy. The pain was atypical in 70% of cases and ultrasound revealed biliary lithiasis in 30% of cases. None of the women died. In terms of neonatal morbidity, there were five preterm births, including one of an infant that died at the age of seven days. We then carried out a literature review, from which we determined the most appropriate course of action in cases of acute pancreatitis during pregnancy. CONCLUSION: Pancreatitis should be considered in pregnant women with abdominal pains because this diagnosis is easy to confirm and maternal and fetal outcomes are essentially dependent on the early etiological management of this condition. Preterm birth is the predominant factor for neonatal morbidity.

First description of scrotal testicles in a dog affected by 78, XX testicular disorder of sex development.

An eight-month-old female dog presented with ambiguous external genitalia. A thorough clinical examination together with various imaging techniques and a histology examination showed the presence of two testicles linked to both the Mullerian and Wolffian ducts. The discovery of the 78,XX SRY-negative karyotype led to the diagnosis of incoherence between the chromosomal and gonadal sex, which is typical for a 78,XX testicular disorder of sex development. Our case was unique because the testicles were still located in their normal scrotal position, whereas the literature contains reports of the presence of cryptorchid testicles in this karyotype setting. To our knowledge, this is the first case that describes an SRY-negative 78,XX testicular disorder of sex development with bilateral scrotal testicles.

[Contribution of volume ultrasound in the evaluation and prenatal care of fetal cardiovascular anomalies]. / Apport de l'échographie volumique dans l'évaluation et la prise en charge prénatale anténatale des anomalies cardiovasculaires fœtales.

OBJECTIVES: To highlight the value of 3D ultrasound in the prenatal assessment of fetal cardiovascular abnormalities. PATIENTS AND METHODS: A retrospective offline analysis of volume datasets of fetuses diagnosed with cardiovascular anomalies by 2D ultrasound was performed. RESULTS: Thirty-four fetuses with 38 cardiac malformations were evaluated. Mean gestational age at diagnosis was 26 weeks. Isolated cardiovascular malformations were detected in 23 fetuses. Extracardiac abnormalities were identified in eight fetuses. Ten terminations of pregnancy were performed. CONCLUSION: Offline analysis of cardiovascular anomalies conferred significant diagnostic advantages over 2D ultrasound. 3D ultrasound is a valuable tool for the prenatal diagnosis and the management of congenital heart diseases.

Social spaces for young children in hospital.

BACKGROUND: In the last number of years heightened interest has been attributed to the impact of hospital environments on children's psychosocial well-being. With policy largely built around adult assumptions, knowledge about what constitutes a child-friendly hospital environment from young children's perspectives has been lacking. If hospital environments are to aspire to being child friendly then the views of younger aged children must be taken into account. The current study investigated young children's perspectives of hospital social spaces to inform the design of the built environment of a new children's hospital. METHODS: An exploratory qualitative participatory design was employed. Data were collected through semi-structured interviews (one-to-one and group workshops) which incorporated art-based activities to actively engage young children. Fifty-five young children aged 5 to 8 years with various acute and chronic illnesses were recruited from inpatient, outpatient and emergency departments of three children's hospitals. RESULTS: Young children want a diversity of readily available, independently accessible, age, gender and developmentally appropriate leisure and entertainment facilities seamlessly integrated throughout the hospital environment. Such activities were invaluable for creating a positive hospital experience for children by combating boredom, enriching choice and control and reducing a sense of isolation through enhanced socialization. When in hospital, young children want to feel socially connected to the internal hospital community as well as to the outside world. Technology can assist to broaden the spectrum of children's social connectivity when in hospital - to home, school and the wider outside world. CONCLUSION: While technology offers many opportunities to support children's psychosocial well-being when in confined healthcare spaces, the implementation and operation of such services and systems require much further research in the areas of ethics, facilitation, organizational impact and evaluation.

[Geophagy and pregnancy: current knowledge and management. Clinical experiences of an obstetrical department in French Guiana]. / Géophagie et grossesse: état des connaissances et conduite à tenir. Expérience d'une maternité de Guyane française.

OBJECTIVE: To provide an overview of the current state of knowledge concerning the determinants and consequences of geophagy during pregnancy. METHOD: Bibliographic searching of articles published in English or French and included in the Scopus database, and reporting of our experience with the management of geophagic pregnant women at the maternity unit of Saint-Laurent-du-Maroni (French Guiana). RESULTS: Geophagy is a little known practice initiated by various stimuli, including nausea and iron deficiency. Sustained geophagy during pregnancy has many consequences, due to complex ionic interactions with the digestive tract. Clay consumption may lead to iron deficiency, which may even be life-threatening in cases of post-partum haemorrhage in severely anaemic women. For the foetus, in addition to the known risk of preterm birth associated with maternal anaemia, maternal geophagy may lead to overexposure to heavy metals, including aluminium in particular. This practice should therefore be considered potentially damaging to the neurological development of the child. The ionic imbalances caused by the ingestion of clay over a long period should be systematically evaluated and corrected, given the secondary malabsorption they may cause, often necessitating parenteral feeding.

An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality.

OBJECTIVES: In 2006, Médecins sans Frontières (MSF) established an emergency obstetric and neonatal care (EmONC) referral facility linked to an ambulance referral system for the transfer of women with obstetric complications from peripheral maternity units in Kabezi district, rural Burundi. This study aimed to (i) describe the communication and ambulance service together with the cost; (ii) examine the association between referral times and maternal and early neonatal deaths; and (iii) assess the impact of the referral service on coverage of complicated obstetric cases and caesarean sections. METHODS: Data were collected for the period January to December 2011, using ambulance log books, patient registers and logistics records. RESULTS: In 2011, there were 1478 ambulance call-outs. The median referral time (time from maternity calling for an ambulance to the time the patient arrived at the MSF referral facility) was 78 min (interquartile range, 52-130 min). The total annual cost of the referral system (comprising 1.6 ambulances linked with nine maternity units) was € 85 586 (€ 61/obstetric case transferred or € 0.43/capita/year). Referral times exceeding 3 h were associated with a significantly higher risk of early neonatal deaths (OR, 1.9; 95% CI, 1.1-3.2). MSF coverage of complicated obstetric cases and caesarean sections was estimated to be 80% and 92%, respectively. CONCLUSION: This study demonstrates that it is possible to implement an effective communication and transport system to ensure access to EmONC and also highlights some of the important operational factors to consider, particularly in relation to minimising referral delays.

[Geophagia: progress toward understanding its causes and consequences]. / La géophagie : avancées dans la compréhension de ses causes et conséquences.

Geophagia is an ancient practice subject to many prejudices. Recent animal experiments have shed light on its causes and consequences. Geophagia, a form of pica, may be induced by various factors. Clay, the material preferentially ingested by geophagic subjects, interacts with the food bolus and the digestive mucosa. Its capacity to form colloids and to adsorb and exchange ions results in both beneficial and harmful effects. In a less civilized age, the ingestion of clay may have reinforced digestive barriers against alkaloids and toxins, conferring a selective advantage on individuals practicing geophagia. However, in the modern Western world, complex interactions of clay with metals and ions are likely to generate low-level poisoning and deficiencies, potentially damaging the health of geophagic individuals and their offspring.