[Closed-heart mitral commissurotomy: our experience at the Main Hospital in Dakar]. / La commissurotomie mitrale à coeur fermé: notre expérience à l'Hôpital Principal de Dakar.

Confronted with difficulties of medical evacuation to cardiovascular surgical hospitals in Europe, the authors decided to bring up to date closed heart mitral commissurotomy. The aim of the study was to estimate possibility to select patients, to operate them safety to appreciate the results in medium and short time and the intervention's cost. 8 women and 7 men had a closed heart mitral commissurotomy from June 1995 to January 1997 in Dakar Principal Hospital; inclusion criteria were a symptomatic mitral stenosis with area less 1.5 cm2; exclusion criteria were an other valvulopathy, a Wilkin score above 8, a severe pulmonary arterial hypertension, an auricular thrombosis. One patient died on the forth day; a completely regressive hemiplegia was the only complication; 14 patients were clinically very improved: the average mitral area by planimetry form 0.89 cm2 +/- 0.15 became 1.64 cm2 +/- 0.33 and by Hatle formula from 0.82 cm2 +/- 0.12 to 1.71 cm2 +/- 0.37; the intervention cost was in second class 1,000,000 F CFA, in third class 820,000 F CFA. This study shows closed mitral commissurotomy can be realised in an african hospital as Dakar Principal Hospital; short and medium results are good; African surgeons must go on studying this surgical technic.

Managed care and the infectious diseases specialist.

There is growing demand to contain health care costs and to reassess the value of medical services. The traditional hospital, academic, and research roles of the infectious disease (ID) specialist are threatened, yet there is an increasing need for expertise because of growing antimicrobial resistance and emerging pathogens. Opportunities exist to develop and expand services for the care of patients infected with human immunodeficiency virus and in infection control, epidemiology, outcomes research, outpatient intravenous therapy, and resource management. It is important for ID physicians to appreciate the principles involved in managed care and the areas in which ID services can be valuable. To be effective, physicians need to know about tools such as practice guidelines, physician profiling, outcomes monitoring, computerized information management, risk sharing, networking, and marketing, as well as related legal issues. With a positive attitude toward learning, application, and leadership, ID physicians can redefine their role and expand their services through managed care.

Care manager/nurse manager: a blending of roles.

Excellent clinicians often are "promoted" to management positions. Lack of involvement in patient care can lead to diminished nurse manager satisfaction, so job enrichment and enhancement must be as important as efficiency and economy as healthcare undergoes reform. A study of 314 patients from 20 DRG categories revealed a statistically significant shortened length of stay and a savings of at least $552 per care-managed patient. Satisfaction was widespread among nurses, patients and physicians and a collaborative spirit developed between nurses and physicians. The blended care manager/nurse manager role alleviates much frustration and conflict and enriches the performance of the manager.

The development of a measure of job satisfaction for use in evaluating change in the system of care delivery.

The aim of the study was to produce a reliable, valid measure of job satisfaction in order to monitor the effect of a change in the method of care delivery. Principal components analysis of questionnaire responses by 121 nurses yielded two scales labelled "Intrinsic Job Satisfaction" and "Patient Focus". Cronbach's alpha was 0.88 and 0.82 respectively. Further analyses revealed significant differences in scores on both scales for different grades of staff and significant differences in scores on "Patient Focus" for nurses working in different specialties. Significant increases in scores on both scales were found for registered nurses following changes in organisation on a surgical ward. This increase was maintained over time. For enrolled nurses an increase in "Intrinsic Job Satisfaction" was less well maintained and no differences were found over time on "Patient Focus". The two scales are reliable and sufficiently sensitive to monitor the relationship between job satisfaction and system of care delivery for different grades of staff working in different specialties.

[Results of a survey on breastfeeding in several Senegal cities]. / Resultats d'une enquete sur l'allaitement maternel dans quelques villes du Senegal.

PIP: Breast feeding is customary in Senegal and most of Africa, but as in other potential markets, multinational companies have attempted to introduce infant formula for bottle feeding. 100 mothers each were interviewed in Dakar, Pikine, Saint Louis, Kaolack, and Ziguinchor between December 1981 and May 1983 to assess the spread of bottle feeding. Mothers were classified in good, average, or poor income and educational groups. Women not breast feeding exclusively were asked their reasons why not. 368 of the mothers (73.6%) breast fed exclusively, 117 (23.4%) mixed breast and bottle feeding, and 15 (3%) bottle fed exclusively. The duration of breast feeding ranged from 6-24 months and averaged 14 months. In Saint Louis, Kaolack, and Ziguinchor between 80-84% of mothers breast fed exclusively, but in Pikine 39% and in Dakar 34% of mothers mixed breast and bottle feeding. Their reasons for doing so included employment of the mother, urbanization, and the impact of advertising. The trend to exclusive bottle feeding is still weak in cities and towns of Senegal, ranging from 1-5%. Breast feeding was the predominant mode at all socioeconomic levels except in Dakar, where wealthier women tended to employ mixed feeding. In Ziguinchor, Saint Louis, and Kaolack, breast feeding predominated at all educational levels. More educated women in Dakar and Pikine tended to mix breast and bottle feeding, but women with average educational levels breast fed. Women who bottle fed did so exclusively for professional or medical reasons.^ieng

[Strategies for maintaining the practice of breastfeeding in urban Senegal]. / Strategies pour le maintien de la pratique de l'allaitement maternel en milieu urbain au Senegal.

PIP: A survey of breastfeeding practices in the principal cities and towns of Senegal demonstrated that bottle feeding is making inroads. Strategies are therefore needed to maintain breastfeeding and avoid further spread of bottle feeding. Factors unfavorable to breast feeding are essentially socioeconomic and cultural; urbanization, industrialization, increased female labor force participation, hospital organization, lack of health education at all levels, declining interest in and prestige of breast feeding, use of contraceptives which inhibit lactation, and especially the numerous and powerful advertising campaigns for infant formula. 4 types of measures are needed to stem the decline of breast feeding: education, a more complete preparation for maternity among expectant mothers, legislation and social action, and actions by health personnel. Mothers should not just be told to breast feed their infants; the reasons for the superiority of human milk should be explained to them. Educational measures might include strengthening the supportive role of husbands in breastfeeding and increasing the availability of information in urban and suburban areas to make women aware of services available. During pregnancy, all women should be prepared to breast feed and those at risk of not breast feeding should be identified and followed up. Infant-maternal contact in hospitals should begin immediately and efforts to breast feed should commence within 3 hours of birth. Samples of infant formula should not be provided and complementary feedings should be discouraged. Health personnel should provide practical advice on breast feeding and hygiene. Infants should be breast fed exclusively for at least 4 months. Prenatal leave for working women should be increased and the time should be used to prepare women psychologically for breast feeding. Postpartum leave should be increased to 12 weeks for all women. Nurseries should be erected in all workplaces. Midwives and other health personnel should be informed of the need to encourage breast feeding and should set a good example by breast feeding their own infants. Advertising of infant formula should be prohibited and such products should distributed as pharmaceuticals. Health personnel should be knowledgable enough to answer the questions and objections of new mothers.^ieng