Dosing accuracy of artesunate and amodiaquine as treatment for falciparum malaria in Casamance, Senegal.

OBJECTIVES: Several products of artesunate plus amodiaquine (AS + AQ) are being deployed in malaria-endemic countries for treating uncomplicated falciparum malaria but dosing accuracy and consequential effects on efficacy and tolerability have not been examined. METHODS: Patients with parasitologically confirmed, uncomplicated falciparum malaria were treated and followed by research teams or local health centre staff in Casamance, Senegal. AS + AQ was given as: (i) loose combination (AS 50 mg, AQ 200 mg), dosed on body weight, or (ii) co-blistered product (AS 50 mg, AQ 153 mg) dosed by weight or age. Target doses were: (i) AS 4 (2-10) mg/kg/day and (ii) AQ 10 (7.5-15) mg/kg/day. Patients receiving therapeutic doses defined dosing accuracy. Treatment-emergent signs and symptoms (TESS) were recorded. RESULTS: A total of 3277 patients were treated with loose (n = 1972, weight-dosed) or co-blistered (n = 1305, 962 age-dosed, 343 weight-dosed) AS + AQ by the research team (n = 966) or clinic staff (n = 2311). AS was dosed correctly in >99% with all regimens. Loose AQ by weight was 98% correct. The co-blister AQ overdosed 18% of patients when dosed by age and underdosed 13% by weight. Low weight was an independent risk factor for overdosing. The co-blister had significantly more TESS than the loose product [117/1305 (9%) vs. 41/1972 (2%), relative risk = 4.3 (95% CI: 3.0-6.1, P < 0.0001)]. Age-based dosing accounted for the difference. TESS occurred mostly within one day (72%) and were mild or moderate (75%). CONCLUSION: Artesunate is easier to dose than AQ. Currently available age-dosed, co-blistered AS + AQ tends to overdose AQ and is less well tolerated than loose tablets. It is not the optimal presentation of AS + AQ.

[Role of US in the management of de Quervain's tenosynovitis: review of 22 cases]. / Apport de l'échographie dans la prise en charge de la ténosynovite de de Quervain: à propos de 22 cas.

PURPOSE: To assess the role of US in the management of de Quervain's tenosynovitis. MATERIALS AND METHODS: Using a high-frequency transducer (12 MHz), sagittal and axial images were obtained of the first extensor compartment. The US features of 22 symptomatic patients were reviewed (positive Finkelstein's maneuver). RESULTS: US findings included tendon thickening and synovial sheath thickening with peritendinous edematous changes resulting in a peritendinous hypoecoic halo in all patients. An intertendinous septum was identified in two patients. CONCLUSION: US can confirm the suspected diagnosis and provide follow-up of lesions. It can confirm the presence of an intertendinous septum and provide guidance at the time of steroid injection. It can increase the rate of conservative management by demonstrating the absence of septum.

[Tuberculosis and diabetes]. / Tuberculose et diabète.

INTRODUCTION: We performed a retrospective case control study for the period between 1st January 1999 and 31st August 2004, comparing the radiological appearances of tuberculosis in 100 diabetics to those in patients matched for age and sex, with pulmonary TB alone presenting to The Chest clinic of the National Hospital of Fann. METHODS AND RESULTS: Diabetes was present in 4.7% of the 2116 patients hospitalized for pulmonary tuberculosis during the period of study and occurred more commonly in men (60%) with an average age of 51 years (73%). 82% had type II, non-insulin dependent diabetes. The various types of radiological lesions classically described in tuberculosis were found in nearly identical proportions in the two groups of patients, with parenchymal shadowing the most frequent appearance in both diabetics (N=86) and controls (N=88). Cavitation occurred significantly less frequently in diabetics (72%) than controls (88%) (p=0.04). Where radiological abnormalities were bilateral, they were worse on the left in the diabetics (27% versus 15% in controls). There was a trend for basal lesions to occur more frequently in diabetics (15%) than controls (3%) (p=0.06). CONCLUSION: Mortality was higher in diabetics (18%) than controls (6%), with death generally occurring within the first 24 hours of hospitalization.

Access to medicines in Senegal: results of a sample survey.

The survey was conducted in Senegal in April 2001 on a representative sample of providers and clients. Results show that access to medicines in Senegal was limited for three main reasons: (1) the supply of drugs was inadequate, and even critical drugs were often missing in health centres, and were somewhat less in pharmacies; (2) the health infrastructures appeared insufficient to cover the needs of the whole population, creating high opportunity costs; (3) the cost of the drugs prescribed was higher than the minimum price, sometimes exceeding the capacity of poorer people, although high cost was seldom reported as the main reason for not acquiring prescribed drugs. Improving access to medicine is a priority to help reduce health inequalities in developing countries.

[Syndrome of "Coup de fouet". A case description and literature review]. / Syndrome du "Coup de Fouet" syndrome d'un cas et revue de la litterature.

The authors bring back the observation of a 48-year-old woman having induced a big painful left calf. The dread os a thrombophlebitis drew away the strarting of an anticoagulative treatment. This treatment was later supended in front of the putting in an a bvious place in echo-Doppler of a haematoma of the calf linked to a normal side of venous fluxes. This table made recall a syndrome of "coup de fouet". It is about a desease characterised by the unpromted rupture of a deep vein of the calf accomplishing a haematoma. It happens in repose or in step as at our patient. It posed a problem of differential diagnosis with a thrombophlebitis of lower limb. Evolution was favourable under treatment linking pause, an anti inflammatory and the haematoma paracentesis under echographique guidance .

[Changes in malaria prevalence and management of fevers from 2000 to 2012 in Casamance, Senegal]. / Évolution de la prévalence du paludisme et de la prise en charge des fièvres de 2000 et 2012 en Casamance, Sénégal.

Before 2006 in Senegal, in the absence of clinical diagnosis, all fever cases were considered as malaria and treated with chloroquine. Between 2004-2006, to face the dramatic increase of Plasmodium falciparum resistance to chloroquine, the combination of amodiaquine plus sulfadoxine-pyriméthamine was recommended for treatment. In 2006, rapid diagnostic tests were introduced and the treatment with a combination of artesunate plus amodiaquine (ASAQ) became the national recommendation for malaria treatment in 2007. This coincided with a decrease of the prevalence of malaria cases and change in fever management. Since 1995 in Mlomp in Casamance, thin and thick blood smear examination has systematically been done in patients with fever and clinical signs of malaria, and treatment with ASAQ given as experimental procedure. Between 2000 and 2012, 70,892 outpatients were attending the health center, and 51.2% of them for fever. Among these fever cases, 72.4% were suspected of malaria and 27.6% were identified as bacterial and viral infections. Confirmed malaria cases decreased dramatically from 1365 in 2000 to 53 in 2012. While comparing the 2 periods 2000-2006 and 2007-2012, the number of fever cases decreased by half, the number of fever identified as non malaria doubled and malaria treatment given decreased by 86%. Improvement of fever management in Mlomp has contributed to a better identification of their cause and to a decrease of inappropriate malaria treatments.

Risk factors for negative sputum acid-fast bacilli smears in pulmonary tuberculosis: results from Dakar, Senegal, a city with low HIV seroprevalence.

SETTING: Two teaching hospitals in Dakar, Senegal, a West African country with a low prevalence of human immunodeficiency virus (HIV) infection. OBJECTIVE: To determine whether patients with HIV-associated pulmonary tuberculosis have fewer acid-fast bacilli (AFB) in their sputum as assessed by routine microscopy, and to correlate the findings with systematically obtained clinical, radiographic and laboratory variables. DESIGN: Prospective study from November 1995 to October 1996 of 450 consecutive patients diagnosed with pulmonary tuberculosis. RESULTS: Tuberculosis was diagnosed in 380 patients (84.4%) by positive bacteriology, in 61 (13.6%) by a favorable response to anti-tuberculosis chemotherapy, and in nine (2.0%) by the presence of a miliary radiographic pattern. Forty (8.9%) patients were HIV-seropositive. AFB-negative smears were found in 14/40 (35.0%) of the HIV-seropositive patients with pulmonary tuberculosis compared with 71/410 (17.3%) of the seronegative patients (risk ratio [RR] = 2.02, 95% confidence interval [CI] 1.26-3.24, P = 0.01). Multivariate analysis revealed that AFB smear negativity was associated with absence of cavitation (P = 0.002), lack of cough (P = 0.005), the presence of HIV seropositivity (P = 0.02), a CD4+ cell count above 200/mm3 (P = 0.02), and age over 40 years (P = 0.03). CONCLUSIONS: Compared with HIV-seronegative patients with pulmonary tuberculosis, seropositive patients in Dakar, Senegal, are more likely to have negative sputum-AFB smears. This phenomenon has now been observed in seven of eight sub-Saharan African countries with varying HIV seroprevalence from which reports are available.

Drugs in the parallel market for the treatment of urethral discharge in Dakar: epidemiologic investigation and physicochemical tests.

OBJECTIVE: Sexually transmitted diseases (STDs) constitute a major public health concern in developing countries. Their interest lies mainly in their diagnosis and their early treatment. Owing to lack of health education and poor living conditions inherent in underdevelopment, self-medication is common practice in these Third World countries. Therefore, the illegal sale of drugs is an important phenomenon in Africa and Asia. METHODS: An investigation, with a view to evaluating the importance of drug sales in the parallel market for the treatment of urethral discharge in Dakar, was carried out in 50 different locations in the working-class districts of the capital from 13 February to 6 March 1997. These drugs, obtained from vendors in the illegal market, were tested and analyzed using the standard physicochemical methods. RESULTS: The most frequently proposed drugs to treat male urethritis are: ampicillin 250-mg capsules (44%); oxytetracyline 250-mg capsules (24%); and cotrimoxazole 450-mg tablets (12%). In most cases (88%), these drugs were sold unpackaged; 12% were sold in blisters. Furthermore, in 90% of cases, the expiry date was not indicated. The dosage and duration of treatment were correct in only 6% of cases. The physicochemical analysis was based on the external appearance, the identification, and the dosage of the active principle. Of these drugs offered by street vendors, 53.1% had an unusual appearance; they were mainly ampicillin 250 mg (21 of 22 samples) and oxytetracycline 250 mg (6 of 12 samples). Furthermore, all active principles were identified as positive, with the exception of ampicillin 250 mg, for which only one sample of the 22 was positive; the others appeared to be flour, with no trace of the active principle. CONCLUSION: Given the extent of these illegal sales of drug and their harmful consequences for the health of the population, adequate measures should be taken to eradicate this blight. For this mission to succeed, public authorities, health professionals and populations should combine their efforts.

[Sonographic evaluation of periportal fibrosis in children living in a Schistosoma mansoni endemic region]. / Fibrose périportale chez les enfants en zone d'endémie à Schistosoma mansoni: évaluation échographique.

PURPOSE: To assess with ultrasound periportal fibrosis due to chronic Schistosoma mansoni infection in children living in an endemic region. Materials and methods. A total of 441 children underwent two stool examinations and abdominal sonography. Liver echotexture was assessed by two observers and compared to pre-defined image patterns and a fibrosis score was assigned ranging from 0 to 8. Ultrasound features were correlated to age, sex, and parasitologic findings. RESULTS: Prevalence of Schistosoma mansoni infestation was 63%. Two cases of advanced fibrosis (E pattern or fibrosis score of 6) were observed. Fibrosis correlated with age. No correlation existed between fibrosis and intensity of egg-output. A correlation between the two examinors was noted in 84% of examinations with a kappa coefficient of 0.7. CONCLUSION: Although severe periportal fibrosis is a rare finding in this endemic region, follow-up sonography must be performed because it is the only non invasive and reliable tool for detection of periportal fibrosis.

[Cholelithiasis and homozygote drepanocytosis in children in Dakar (Senegal)]. / Lithiase biliaire et drépanocytose homozygote en pédiatrie à Dakar (Sénégal).

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.

[Aspects of antihyperglycemic oral bitherapy in 76 cases of non insulindependent diabetes in Dakar]. / Aspects de la bithérapie antihyperglycémiante orale chez 76 patients diabétiques non insulinodépendants à Dakar.

Some reasons justify the introduction of the association of sulfonylurea and metformine when monotherapy is ineffective. Hereafter a period of monotherapy by sulfonylurea or metformine only bitherapy has been instituted. Socio-demography, number of consultations, type of monotherapy and of association, duration of treatment, body mass index, fasting blood glycemia and post-prandial glycemia, blood pressure and type of complication were studied. There were 2.5 times more women than men with lower mean age for women. The majority of patients were from Dakar (81.6%). More than half of patients were women at home (60.5%). Present obesity (plethoric diabetes) or past obesity (metaplethoric diabetes) concerned 90.3% of patients. Patients have done 9.14 4.39 consultations under bitherapy. The gliclazide-metformin association was observed 37 times and the glibenclamide-metformin association 67 times. The duration of monotherapy was 45.9 39.7 months and that of bitherapy 92.5 43.7 months. The variations of body mass index showed a diminution of 1.26 kg/m2 and for fasting blood glycemia and augmentation of 0.011 g/L and post-prandial a diminution of 0.05 g/L. The body mass index variations in diabetic patients showed a diminution of weight more in plethoric patients in bitherapy compared to monotherapy. This study is retrospective and cannot show the optimal efficacy of bitherapy. But the combination of enhancement of glucose captation and lowering of hepatic glucose production has been shown during this bitherapeutic association. Addition of metformine and treatment with sulfonylurea make a combination that significatively improves glycemic control but also cholesterol level and allows obtation of better weight in type 2 non insulin-dependent diabetes with insulinoresistance.

[Selective salpingography in the treatment of infertility caused by proximal tubal obstruction: apropos of 122 cases treated in Dakar]. / La salpingographie sélective dans le traitement des infertilités par obstacle tubaire proximal: à propos de 122 cas traités à Dakar.

One hundred and twenty-two women who had not conceived after more than one year of unprotected sexual relations underwent selective salpingography. All had been shown to have proximal obstruction of the fallopian tube by standard hysterosalpingography. The women underwent the procedure as outpatients during the follicular period. They were given prophylactic antibiotic treatment and salpingography was performed by a radiologist in an X-ray room. We used the commercial sets of Cook and Zorn. The mean age of patients was 34 years (range 28 to 46) and the mean duration of infertility was 7.7 years (range 2.2 to 14 years). Two hundred and forty tubes were examined, of which 213 were cleared of obstruction (88.7%), with both tubes affected in 66% of cases and only one tube affected in 33% of cases. All patients had at least one patent tube after the procedure. The patent tube was normal in 73% of cases (177 tubes) and abnormal in 15% (36 tubes). Catheterization failed in 11.3% of cases (27 tubes). Forty-nine women conceived spontaneously during the 2- to 12-month follow-up period, and 39 of these women delivered healthy babies. No extrauterine pregnancies or serious complications were reported. The most frequent side effects were slight pain, bleeding and nausea. One perforated tube was reported and none of the patients died. The greatest difficulties encountered were a lack of cooperation in patients with previous painful experiences of hysterogram and catheterization problems in women with a strongly flexed or distorted uterus. Complications were minimal and the one case of tubal perforation at the beginning of the series had no serious consequences. Thus, selective salpingography should be used more widely because it is simple and more cost-effective than the surgical management of tubal obstruction and artificial insemination. Our results suggest that this procedure should be the first-line treatment of infertility caused by proximally obstructed fallopian tubes.

[Contribution of ultrasonography in the pathology of the scrotum and its contents]. / Apport de l'Echotomographie dans la pathologie du scrotum et de son contenu.

Echography must, henceforth, be considered a method of investigation in Scrotum pathology. It is certainly of interest for diagnosis and close supervision of this pathology--this is the recommendation of the authors following 46 observations correlating echographical aspects with anatomopathological results.

[Prenatal echographic diagnosis of esophageal atresia. Apropos ofa case]. / Diagnostic échographique anténatal de l'atrésie de l'oesophage. A propos d'un cas.

We reported an antenatal diagnosis case of oesophageal atresia in 21 years aged woman in second pregnancy. The echographic diagnosis of antenatal oesophageal atresia was suspected from the non visualisation of stomach liquid after separate following examinations at 8 days interval, the presence of a great abundant hydramnios and a very important delay of in utero foetal growth. This study permitted us to emphasize the antenatal diagnosis interest in supporting a child with oesophageal atresia during neonatal period. The vital prognosis was essentially conditioned in this context of neonatal emergency by putting a feeding tube (cul-de-sac) and the absolute prohibition of any oral alimentation, waiting for the transfer of the child to a specialized institution.

[Radiological bone age in medico-legal identification]. / Apport de l'âge osseux radiologique dans l'identification médico-légale.

Sauvegrain-Nahum and Bronstein's grading methods was used to study the relationship between bone age and chronological age in a sample of 88 Senegalese children aged between 12 and 13 1/2 years, as compared to French norms. This applied study in infantile forensic medicine evokes a number or commentaries and reactions.

[Hydranencephaly: report of a case]. / Hydranencéphalie: à propos d'un cas.

The authors report the first Senegalese observation of hydranencephaly in a three-week-old baby to underline the unusualness of this deformity and the efficiency of transfrontal echography in its diagnosis.

[Seckel's nanism: apropos of 1 case]. / Le nanisme de Seckel: à propos d'un cas.

This report covers the first case of Seckel's syndrome diagnosed at Dakar UHC. It concerns the main type of bird head nanism. The interesting thing about this observation is that it is associated with hepatoma. Would this be just a coincidence, or could the two afflictions be connected?

[Value of post coital and cytological sperm tests in conjugal sterility in Senegal]. / Intérêt des tests post-coitaux et cyto-spermiologiques dans l'exploration de la stérilite conjugale au Sénégal.

Conjugal infertility in Senegal is surrounded with accusatory believes most oftenly unfavourable to woman who is generally incriminated and, in somes cases, repudied. This study is an account of a research work carried out on conjugal infertility causes analysis, using post coital and cytospermiologic tests. It aims to help our populations to better appreciate the conjugal infertility by giving them elements for an objective appraisal of this flail, particulary about the mutual responsabilities of the two partners. In a first stage, we run post coital tests with 4636 Negro-African infertile couples living in Senegal, at the Clinical Cytology, Cytogenetics, and Reproductive Biology Laboratory of Aristide Le Dantec Hospital in a period dated from 1983 to 1996. Post coital tests were abnormal for 3838 couples and 3150 of them had anomalies incriminating the husbands. In a second stage, post coital tests were suggested to these 3150 husbands, but only 2842 accepted the post coital test suggestion. The others refused it for sociocultural reasons. It stooks out of this study that: the responsability in the conjugal sterility is mixed and shared by both partners in 43.78% cases, the masculine responsability (38.30%) ruled the feminine one (17.92%) contrary to local believes, almost one husband out of four (23.89%) presented azoospermy, the feminine responsability is ruled by infection factors that represented half of the glair abnormalities (50%). These results contradict the present local mentalities and believes which accuse principally the woman.

[Prevalence of the use of skin bleaching cosmetics in two areas in Dakar (Sénégal)]. / Prévalence de l'utilisation de produits cosmétiques dépigmentants dans deux quartiers à Dakar (Sénégal).

The use of skin bleaching cosmetics is an increasingly widespread phenomenon in Africa. If the negative sanitary effects of this practice are today well known, reliable statistics on the importance of the problem within the global population are rare. Our study, conducted in two popular areas in Dakar, Usine bene taly and Usine Niary Taly, had 2 objectives: to determine the prevalence of the use of skin bleaching cosmetics in the studied zones, to describe the prevalence according to the following variables: age, matrimonial situation, level and/or type of instruction, job, type of agents used. For that purpose, we conducted a transverse study on a representative sample of 600 women from 15 to 55 years old. This study reveals a prevalence of the use of skin bleaching cosmetics of 67.2%. The agents found are hydroquinone derivatives (61%), topical corticosteroids (37%) and agents from unknown origin (2%). The use of skin bleaching cosmetics is more important among young women between 30 to 44 years (72.5%), married (72.2%), analphabets (75%), working (77.6%). Studies conducted in Mali and Togo gave comparable results, which give perspectives for a prevention based on education an awareness.

[Contribution of mammography and echography to the diagnosis of breast cancer in Dakar: apropos of 25 cases]. / Apport de la mammographie et de l'échographie dans le diagnostic du cancer du sein à Dakar: à propos de 25 cas.

The authors studied mammographic features of 25 patients with malignant breast disease. 24 of them had ultrasonographic (US) exploration. The study appreciates epidemiological, mammographic and US aspects; It also appreciates the correlation between images and histology. The mean age is 40. Six women (26%) had family history cancer. The mean reason of the exploration is a mass in 76%. At mammography, contours of cancerous opacities are irregular in 56%, regular in 16%. In 20%, the cancer showed no opacity. At US, we find a lack that appears irregular in 48%, regular in 24%, without traduction in 4%, non precised in 24%. Mammography sensitivity was 80%, false negative rate 28% and false positive rate 8% against respectively 96%, 32% et 12% for echography. This study shows that US is more sensitive but less specific than mammography. However, we recommend the use of mammography and echography together because in Senegal, cancer happens at an earlier age at with breast is easier to analyze at US.