[Effects of Dacryodes edulis fruit oil on anxiety symptoms and cognitive performance in mice, after prolonged administration]. / Effets de l'huile des fruits de Dacryodes edulis sur les symptômes de l'anxiété et les performances cognitives chez la souris, après administration prolongée.

OBJECTIVE: To study the effects of prolonged administration of Dacryodes edulis (G. Don) H.J. Lam (HDE) fruit oil on the symptoms of anxiety and cognitive performance in mice. METHODS: Anxiolytic activity and effects of HDE (5 and 10 ml/kg) on cognitive performance were evaluated in male mice after oral administration for 45 days. Anxiolytic effects were investigated in open field test, elevated plus Maze and hole board test. The Morris Water Maze test was used to evaluate cognitive performance in mice. Efficacy of HDE (5 and 10 ml/kg) was compared with that of fluoxetine (2 mg/kg p.o). RESULTS: HDE decreases the total distance traveled, significantly increases the number of adjustments and the number of entries in the central area of open field. In the elevated cross labyrinth test, HDE increases the number of entries and the time spent in the open arms. HDE significantly increases the number of head insertion into the holes. In the Morris Water Maze test, HDE reduces latency before finding the platform and increases the time spent in the target quadrant. CONCLUSION: The results confirm anxiolytic effects and improved cognitive performance after prolonged oral administration of HDE in rodents.

Marker of coxsackievirus-B4 infection in saliva of patients with type 1 diabetes.

BACKGROUND: Coxsackieviruses B (CV-B) are enteroviruses that have been reported to play a role in the pathogenesis of type 1 diabetes. Enteroviral RNA was detected in the gut mucosa of patients. The mucosal immunity is an interconnected network; therefore, the response to enteroviruses possibly present in the gastrointestinal mucosa can be reflected by specific antibodies in the saliva. In the present study, the anti-CV-B neutralizing activity of saliva samples from patients with type 1 diabetes was investigated. METHODS: Saliva samples were collected from patients and controls of 3 countries, and plasma was obtained from some of them. The anti-CV-B activity of clinical samples was determined by neutralization of the cytopathic effect induced by challenging viruses in vitro and expressed as titre value. RESULTS: Overall prevalence and levels of anti-CV-B4 activity of saliva were higher in patients (n = 181) than in controls (n = 135; P = .0002; titre values ≥ 16: odds ratio = 4.22 95% CI: 1.90-9.38 P = .0002). It has been shown that IgA1 played a role in this activity. There was no correlation between the saliva and the plasma anti-CV-B4 neutralizing activity. The neutralizing activity of saliva against CV-B1, CV-B2, CV-B3, and CV-B5 existed rarely, if at all. Increased levels of anti-CV-B4 activity were observed all along a 4 year follow-up period in patients but not in matched controls (P = .01). CONCLUSION: There is an anti-CV-B4 activity in saliva of patients with type 1 diabetes that may be a useful marker to study the role of CV-B in the pathogenesis of the disease.

Molecular detection of high-risk papillomaviruses and vaccination status in normal cytology in Congo.

OBJECTIVE: The aim of this study was to identify the molecular prevalence of high-risk HPV infection and the distribution of genotypes present in normal cytology, as well as to determine the vaccination status of our study population. METHODS: 110 cervical samples were taken from individuals, and 1 ml of each sample was added to the Xpert HPV cartridge in the sample compartment before it was placed in the Cepheid GeneXpert system. Detection was performed simultaneously via amplification of the E6 and E7 genes in five fluorescent channels (HPV16, HPV18/45, HPV31/33/35/52/58, HPV51/59, and HPV39/56/66/68a). RESULTS: 36/110 (33%) of all samples tested were positive for HPV DNA. The predominant genotypes were HPV16 (12.7%) and other pooled HR-HPV types (8.2%). All women who received the Gardasil-9 vaccine (3.6%) had HPV, and infection was associated with travel outside Africa. 96.4% of the screened individuals had not received any HPV vaccine. CONCLUSION: Our research confirms a widespread HR-HPV infection in our population and extends the importance of studies on the molecular prevalence of HPV, particularly in women with normal cytology and apparent good health, in view of the cruel lack of public awareness of HPV infections.

Gene expression profiling of p53 and c-myc in HTLV-1 positive blood donors in Congo.

OBJECTIVES: The HTLV-1 infection persists for life, remaining as asymptomatic viral reservoirs in most patients, ensuring the chain of transmission, but around 4% develop adult T-cell leukemia/lymphoma (ATLL). HTLV-1 is an oncogenic retrovirus that transforms CD4+ T lymphocytes and deregulates the lymphoproliferative pathways that contribute to the development of ATLL. To achieve cell transformation, most oncogenic retroviruses use proto-oncogene capture transduction, with proviral integration disrupting the expression of tumor suppressors or proto-oncogenes. THE AIM: We conducted this study on the prevalence of HTLV-1 infection in blood donors to expand the HTLV-1 database, assess the risk of transmission via blood products, as well as evaluate the risk of persistent infection or development of neoplastic diseases in HTLV-1 carriers. MATERIALS AND METHODS: This is a cross-sectional study of blood donors of all categories. For this study, 265 blood donors were recruited at the Centre National de Transfusion Sanguine in Brazzaville. After testing for HTLV-1 antibodies by ELISA, proviral DNA was extracted from all ELISA-positive samples for detection by nested PCR, followed by RT qPCR using specific primers p53 and c-myc for gene expression. RESULTS: 20/265 were positive for anti-HTLV-1 antibody, 5 donors were positive for proviral DNA. The prevalence of HTLV-1 was 1.8%. All HTLV-1-positive donors were male (1.8%), with a positive correlation (p = 0.05); the 1.1% of positive donors were regular, with the majority aged between 31 and 45 years (1.5%), and concubine donors were the most frequent (1.1%). All samples showed normal expression of the p53 and c-myc genes. CONCLUSION: The prevalence, though low, remains a serious problem. No abnormal p53 or c-myc gene expression was detected in HTLV-1-positive donors, which could mean that none of the T lymphocytes in these donors had been transformed by HTLV-1.

Molecular detection and genotyping of human herpes virus 8 in blood donors in Congo.

OBJECTIVES: Human herpesvirus 8 (HHV8) is rarely studied in Congo, despite its prevalence in Africa. Among healthy individuals, HHV-8 does not always lead to a life-threatening infection; however, in immunocompromised individuals, it could lead to more severe disease. The distribution of HHV-8 genotypes varies depending on ethnicity and geographic region. METHOD: A prospective cross-sectional study included 265 samples from healthy blood donors from the National Blood Transfusion Center in Brazzaville, with an average age of 35 years, with extremes ranging from 18 to 60 years. After DNA extraction, a nested PCR was carried out for molecular detection, followed by genotyping by amplification of specific primers. RESULT: In this study, 4.9% were positive for molecular detection of HHV-8 DNA. All HHV-8 positive DNA samples that were subjected to genotyping by amplification with specific primers allowing discrimination of two major genotypes (A and B). Genotype A was identified in 5 (1.9%) samples and genotype B in 2 (0.7%) samples, indicating that both genotypes were predominant. The remaining viral DNA samples not identified as the major genotypes were classified as «indeterminate¼ and consisted of 6 (2.3%) samples. CONCLUSION: The results of the study suggest that Congo is an area where HHV-8 infection is endemic.

Human milk can neutralize Coxsackievirus B4 in vitro.

The role of enteroviruses in type 1 diabetes has long been suspected. A lower risk of type 1 diabetes is associated with breastfeeding, which could be due to a protective effect against enteroviruses. The neutralizing activity of breast milk against CVB4, a representative of enteroviruses was investigated in this study in vitro. Breast milk was cytotoxic to Hep-2 cells up to a dilution of 1/32, whereas the aqueous fraction obtained after centrifugation was not cytotoxic; although it inhibited the cytopathic effect of CVB4 on Hep-2 cell monolayers. The anti-CVB4 neutralizing activity of aqueous fractions of breast milk from 49 donors living in Northern France and 15 donors living in Congo, where enteroviral infections are more prevalent, were determined. The levels of colostrum activity expressed as titre ranged from <2 to 32 in 36% of the donors from France whereas they were >128 in every donor from Congo. Pasteurized colostrum had a lower anti-CVB4 activity compared to fresh samples (P < 0.0001, n = 49). The treatment of colostrum samples with jacalin-coated beads that bind specifically to human IgA, showed that IgA plays a role in anti-CVB4 activity. There was no correlation between the neutralizing activities of breast milk and serum (P = 0.37, n = 25). The current study showed that the variations in anti-CVB4 activity in breast milk can be attributed to environmental and living conditions. Whether a low protective activity of breast milk against enteroviruses expose newborns to a higher risk of type 1 diabetes deserves further investigation.

[Chronic renal failure's profile in hemodialysis at the Edith Lucie Bongo Ondimba General Hospital]. / Profil epidemiologique des patients en hemodialyse a l'Hopital General Edith Lucie Bongo Ondimba.

INTRODUCTION: Our objective was to evaluate the management of chronic renal failure in hemodialysis at the Edith Lucie Bongo Ondimba General Hospital (HGELBO). MATERIALS AND METHODS: This was a cross-sectional and analytical study over a 10-month period from March 1, 2018 to December 31, 2018. This included all patients aged 16 and over whohad at least one treatment session hemodialysis during the study period. The sociodemographic, clinical, biological, therapeutic and evolutionaryparameters of the patients werenoted. And data entry wasdoneusing Excel 2013 and EPI Infos version 3 software with a p <0.05 consideredstatisticallysignificant. RESULTS: The number of patients hospitalized for chronic and acute renal failurein 10 months was 101 patients, of whom 97 received hemodialysis treatment. The sex ratio was 1.4 with 59% males. The meanagewas 49.19 ± 28.4 years. The most affected intervalisbetween 50 and 59 years old with 19 patients or 29.68%. The patients came from Brazzaville in 60.93%. The first indication of hemodialysis wasuremiapoorlytoleratedin 81, 25% of cases. Diabeticnephropathywas the leading cause of CKD in hemodialysis. Meanserumcreatinine at initiation of hemodialysis was128.5 ± 75.12 mg / l. The incidence of HIV in hemodialysis is 6.4%, those of hepatitis B and C are 1.25% respectively. There were 54 patients (84.37%) whobenefited from femoralcatheter placement at baseline. We have so far 7 deaths out of 64 patients. CONCLUSION: This center of hemodialysis contributes to the improvement of the management of the renal insufficiency in the stage of hemodialysis. The assessment of this work reveals strong and weak points and we are consideringother work, more hemodialysis stations and itwould be interesting to do some work on the prevalence of renal disease in the Republic of Congo.

INTRODUCTION: Notre étude avait pour objectif d'évaluer la prise en charge des insuffisants rénaux chroniques en hémodialyse à l'Hôpital Général Edith Lucie Bongo Ondimba (HGELBO). MATÉRIELS ET MÉTHODES: Il s'agissait d'une étude transversale et analytique sur une période de dix mois s'étendant du 1er mars 2018 au 31 decembre 2018. Étaient inclus tous lespatients âgés de 16 ans ou plus, ayant bénéficié d'au moins une séance d'hémodialyse durant la période de l'étude. Les paramètres sociodémographique, clinique, biologique, thérapeutique et évolutif des patients ont été relevés. Et la saisie des données a été réalisée en utilisant les logiciels Excel 2013 et EPI Infos version 3 avec un p <0,05 considérée comme statistiquement significative. RÉSULTATS: Le nombre de patients hospitalisés pour insuffisance rénale chronique et aigue en 10 mois a été de 101 patients parmi lesquels 97 ont bénéficié du traitement d'hémodialyse. Le sex ratio a été de 1,4 avec 59 % de sexe masculin. L'âge moyen a été de 49,19 ± 28,4 ans. L'intervalle le plus touché est compris entre 50 et 59 ans avec 19 patients soit 29,68%. Les patients venaient de Brazzaville dans 60,93%. La première indication d'hémodialyse a été l'urémie mal tolérée dans 81, 25% des cas. La néphropathie diabétique a été la première cause de l'IRC en hémodialyse.La moyenne dela créatininémie à l'initiation de l'hémodialyse a été de128,5±75,12 mg/l. L'incidence du VIH en hémodialyse est de 6,4%, celles des hépatites B et C sont de 1,25% respectivement. Il y a 54 patients soit 84,37 % qui ont bénéficié de la pose cathéter fémoral à l'inclusion. Nous avons à ce jour 7 décès sur 64 patients. CONCLUSION: Ce centre d'hémodialyse contribue à l'amélioration de la prise en charge des insuffisants rénaux en stade d'hémodialyse. L'évaluation de ce travail révèle des points fort et faible et nous envisageons d'autres travaux, plus des postes d'hémodialyse et il serait intéressant de faire un travail sur la prévalence de la maladie renale en République du Congo.

[Precancerous lesions of the uterine cervix in Pointe-Noire, Congo]. / Lésions précancéreuses du cancer du col utérin a Pointe-Noire: analyse de situation.

The purpose of this study was to determine the cytological profile and risk factors for intraepithelial precancerous lesions of the uterine cervix in an urban community of Pointe-Noire, an industrialized seaport located in the southeast region of Congo-Brazzaville. A transverse study was carried out over a period of 18 months (January 2003 to July 2004) in the Center for the Study of Human and Animal Diseases (CSHAD) at the General Adolphe Sie Hospital in Pointe-Noire. A total of 1347 files of women benefiting from cervico-vaginal smears were included in the study. Testing was undertaken either at the request of the patient (voluntary screening) or at the request of a health care provider (physician, midwife or nurse) in relation with various gynecological problems. The relative frequency of intraepithelial lesions was estimated to be 15.36% including 9.17% of low-grade intraepithelial lesions (Ig IEL) and 6.19% of high-grade intraepithelial lesions (hg IEL). The mean age of patients with hg IEL was 42.25 years (range, 12 to 17). Study of the interval between actual age at the time of sample collection and age of first sexual relations showed that women presenting IEL had an interval of at least 20 years. This interval probably corresponds to the time necessary for the interaction between human papillomavirus (HPV) and epithelial cells of the uterine cervix to induce intraepithelial lesions that lead to development of cancer of the uterine cervix. Comparative analysis of the number of sexual partners between the group of women with normal smears and the group with smears showing hg IEL indicated a clear predominance of the mean number of partners in the latter group, i.e., 2 +/- 1,2 versus 5 +/- 1,8 (p < 0.05). Most IEL were observed in multigestational women who accounted for 75.39% with a mean of 6.21 for hg IEL. This preliminary study provides a sound factual basis in terms of epidemiological data on these precancerous lesions of the uterine cervix in the Kouilou department of Congo-Brazzaville. These data will serve as benchmarks and guidance for forthcoming screening campaigns for early detection of uterine cervix cancer.

[Massive haemoptysis associated with pulmonary Strongyloides stercoralis hyperinfestation]. / Hémoptysie massive associée à une hyperinfestation pulmonaire à Strongyloides stercoralis.

INTRODUCTION: Pulmonary infestation with Strongyloides stercoralis is an exceptionally rare cause of haemoptysis, the diagnosis being difficult and often delayed. CASE REPORT: We report the case of a retired coal miner suffering from pneumoconiosis who presented with acute respiratory insufficiency and massive haemoptysis, with a fatal outcome, associated with pulmonary stongyloidosis. The only identified source of infestation with Strongyloides stercoralis was his period in the coal mine and the only risk factors for the hyperinfestation were a short course of systemic corticosteroid therapy and the presence of a peritoneal-auricular valve. CONCLUSION: This observation illustrates the importance of a systematic search for anguillosis in ex coal miners prior to any immunosuppressant treatment in order to avoid the serious and frequently fatal form of hyperinfestation with Strongyloides stercoralis.

Cardiac valve papillary fibroelastomas: clinical, histological and immunohistochemical studies and a physiopathogenic hypothesis.

BACKGROUND AND AIM OF THE STUDY: Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumor, but may have a malignant propensity for life-threatening complications; thus, surgical removal is justified. Case histories were reviewed of four patients who underwent surgical management after diagnosis of CPF located on aortic (n = 2) or mitral (n = 2) valves. Our aim was to provide explanations for the clinical diversity of the lesions and, using histological and immunohistochemical methods, to hypothesize the genesis of these tumors. METHODS: Among four patients with a diagnosis of valvular CPF, two had previous and recent history of neurological embolic symptoms with small echographically located tumors attached to the ventricular side of aortic cusps. Two other patients (one with paroxysmal atrial fibrillation, one with no neurological or rhythmically related stroke) had CPFs located on the posterior or anterior mitral leaflets. RESULTS: Surgical excision was performed with a conservative valve-sparing approach. Histological and specific immunohistochemical (IHC) studies were conducted on all samples. The postoperative course was uneventful, and histological analysis confirmed the diagnosis of CPF with typical fronds characterized by three successive layers. In the first two patients there was correlation between neurological events and the presence of thrombus aggregated on the injured superficial endothelial layer. In the other patients, no endothelial damage or thrombus was found. IHC studies showed dysfunction of the superficial endothelium, a centrifugal mesenchymal cellular migration arising from the central layer to the superficial layer with differentiation steps, the presence of dendritic cells in the intermediate layer, and remnants of cytomegalovirus (CMV) in the intermediate layer. CONCLUSION: Despite their benign histological aspect, and independent of their size, CPFs justify surgical excision because of their high potential to systemic embolization. In most cases, valve sparing management is possible with no observed recurrence after complete excision. The presence of dendritic cells and CMV strongly suggests the possibility of a virus-induced tumor, therefore evoking the concept of a chronic form of viral endocarditis.

[Esophageal tuberculosis: an unusual localization in an immunocompetent patient]. / Tuberculose oesophagienne: une localisation inhabituelle chez une patiente immunocompétente.

Oesophageal tuberculosis is a rare localisation for extrapulmonary tuberculosis. This report describes the case of a 30-year-old immunocompetent woman with dysphagia, fever and weight loss. Endoscopic examination revealed an ulcerated lesion in the third part of the oesophagus strongly suggesting oesophageal carcinoma. Histologic samples showed epithelioid cells granuloma in the submucosa. Diagnosis was later confirmed by acid-fast bacilli positive gastric aspirates and a positive Mantoux test using the tuberculin reaction. Barium swallow revealed a narrowing in the third oesophagus. A chest x-ray revealed a infiltrated lesion and a mediastinal lymph node. The patient was put on antitubercular treatment. On follow-up after 3 months, dysphagia, fever, weight loss had disappeared and the ulcerated lesion of oesophagus had improved. The subsequent course of the patient is not known, since she was lost to follow-up.

[Malignant mesenchymoma of mesentery. A controversial entity]. / Mésenchymome malin du mésentère. Une entité controversée.

We report a case of malignant mesenchymoma developed in the mesentery in a 62-year-old man with no past history. It was an huge mass in the mesentery of the ileum. The tumor was composed of areas of chondrosarcoma and rhabdomyosarcoma in addition to an undifferentiated fusiform component. Malignant mesenchymoma is a rare sarcoma occurring preferentially in the retroperitoneum or the thigh. The location in the mesentery is exceptional. Malignant mesenchymoma is discussed more particularly with dedifferentiated liposarcoma with heterologous elements. The patient is alive without recurrence three years after surgery.

[Malignant solitary fibrous tumor of pleura with focal expression of cytokeratin]. / Tumeur fibreuse solitaire pleurale maligne avec expression focale de cytokératine.

Solitary fibrous tumor is a rare circumscribed neoplasm involving usually the pleura and now described in many organs and in the soft tissues with a favorable outcome when completely excised. We report herein a malignant solitary fibrous tumor of the pleura occurring in a 59-year-old woman. The tumor cells strongly expressed vimentin and CD 34. In addition a weak positive staining was obtained using CD 99 and bcl 2. A disconcerting focal immunoreactivity with cytokeratin was observed. Solitary fibrous tumor is composed of loosely arranged spindle cells of variable density and may occasionally mimic malignant mesothelioma, an hemangiopericytoma or synovial sarcoma. Immunohistochemical study is helpful demonstrating a strong positivity for vimentin and CD 34 and absence of staining for epithelial markers and S-100 protein.

[Primary large cell neuroendocrine carcinoma of the kidney: morphologic and immunohistochemical features of two cases]. / Le carcinome neuroendocrine à grandes cellules du rein: étude morphologique et immunohistochimique de deux cas.

Primary neuroendocrine carcinomas of the kidney are infrequent. The large cell neuroendocrine carcinoma is a subtype with an aggressive course and a worse prognosis. We report two cases, a 35-year-old man and a 75-year-old woman who died within 6 and 5-months after surgery despite radical nephrectomy and chemotherapy. Histological and immunohistochemical features are presented.

[Juvenile xanthogranuloma localized in the parotid gland]. / Xanthogranulome juvénile de localisation parotidienne.

Juvenile xanthogranuloma of parotid gland is reported in a 9-year-old boy. This kind of tumor is thought to be very rare in salivary glands. Histological, immunohistochemical and ultrastructural data showed characteristic features and excluded a Langerhans cell histiocytosis. Follow-up was uneventful after 18 months.

[Early isosexual precocious pseudopuberty revealing a juvenile granulosa cell tumor in a 3-year-old Congolese girl]. / Pseudo-puberté précoce isosexuelle révélatrice d'une tumeur de la granulosa juvénile chez une fillette congolaise de 3 ans.

We describe a juvenile granulosa cell tumor expressed by an early pseudopuberty occurring in a 3-year-old black child. Clinically, an endocrine syndrome was associated with a pelvic mass and ascites. Hyperoestrogenia and serum alphafetoprotein level were biologically detected. Histological examination showed typical microscopic features of a granulosa cell tumor. The patient is well four years after surgery. Growth and mental development are normal.

Cervical samples dried on filter paper and dried vaginal tampons can be useful to investigate the circulation of high-risk HPV in Congo.

BACKGROUND: High-risk HPV (HR-HPV) are associated with the development of cervical cancer, the most common cancer in women in developing countries. Reliable diagnosis of HR-HPV infection combined with simple procedures to collect and store biological samples, could improve primary screening programs and vaccine strategies in these areas. OBJECTIVE: To evaluate HR-HPV detection in conventional and dried samples. STUDY DESIGN: The presence of HR-HPV in 31 women in Republic of Congo (Central Africa) has been investigated by using standard cervical samples and dried cervical samples collected on filter paper and vaginal tampons. The detection of HPV DNA was performed in the Laboratory of virology in Lille (France) by using Hybrid capture 2 and HPV 16/18/45 Probe Set Test. RESULTS: 22 standard samples were found positive for the detection of HR-HPV (71%). HPV 16/18/45 was displayed in 15 out of 22 samples positive for HR-HPV (68%). The correlations between HPV detection by using standard samples and samples dried on filter paper and dried tampons were 90.3% (kappa = 0.77) and 80.6% (kappa = 0.5) respectively. The sensitivity and the specificity of HPV detection reached 91% and 89%, respectively, with samples dried on filter paper and were 86% and 67%, respectively, for dried tampons compared with standard samples. CONCLUSION: Dried cervical samples and dried vaginal tampons can represent an alternative to conventional sampling to reduce barriers to large screening programs in developing countries and to facilitate storage and transport to reference centers.

[Professional absenteeism in the pediatric service of the general hospital of Loandjili in Pointe-Noire (Congo)]. / Absentéisme professionnel dans le service de pédiatrie de l'hôpital général de Loandjili de Pointe-Noire (Congo).

The supply and the quality of care dispensed in a service depend on the quality of the technical and human tray, but also from effective presence of the staff during the work time. The purpose of this study is to determine the absenteeism level of the paramedical staff in General Pediatric and Neonatology of Loandjili General Hospital (Pointe Noire) and identifying causes. A cross-sectional study has been conducted from January 1(st) to June 30(th) 2011 on 21 nurses in General Pediatric and 20 in Neonatology. The absenteeism level was obtained by the link of the number of missing days out of the number of the work days x 100. The absence was justified when it relieved from a reason informed by the administrative texts of the firm; and authorized when it requested the authorization of the administration of the firm. In total, 370 absences have been unregistered, the average absenteeism level was of 8.4%. The absence was justified in 242 cases (65.4%) and authorized in 178 cases (48.1%) which 84 times in writing and 94 times verbally. When the absence was justified, it was the fact of the disease of a member of the family in 82 cases, of the death or the burial of a member of the family in 81 cases, of the agent disease, 84 cases, or other reasons in the remains of cases. The absence occurred between 7 a.m. and 14 p.m. in 57.3%, 14 p.m. and 7 p.m.in, 25.7% and between 7 p.m. and 7 a.m. in 17.0%. The absenteeism was mainly observed (85.7%) for the nurses of about 30 years old and those (59.5%) whom the seniority in the service was inferior or equal 5 years. The absences justified were more observed (p< 10(-4)) for nurses of about 30 years old and those whom the seniority did not pass 5 years. The absenteeism of nurses constitutes a real social and administrative problem that deserves a particular attention considering its impact on the supply and the quality of cares.