[Knowledge of sickle cell disease and prevention methods in an urban district of Lomé, Togo]. / Connaissances de la drépanocytose et pratiques de prévention dans la population d'un district urbain de Lomé, Togo.

Despite the important frequency of the gene "S" in Togo, essential information remains insufficient to elaborate a prevention campaign on this affection. In order to assess the knowledge on sickle cell diseases as well as the prevention practices in the Togo population in one of the five districts of the township of Lomé, a cross sectional study was conducted in the third district of the township of Lomé from January 21, 2004 to January 26, 2004 in 210 natives from Togo aged of 15 and over, through a semi-structured questionnaire. The variables studied were: - the socio-demographic features and the knowledge of sickle cell disease characteristics (symptoms, biological diagnosis, treatment and means). Data collected were analysed through software Statically Package for Social Science (SPSS) version 10.0 of Windows using the chi2 test with 5% significance in the comparison of some variables. 117 women and 93 men were interviewed. Sickle cell disease was known in almost all ethnic groups but incompletely: 79.5% of the individuals knew about premarital check up but only 12.4% knew about haemoglobin electrophoresis check up. 74,8% of the people had a good knowledge of the cause of sickle cell disease, 78.6% had a fairly good knowledge of its symptoms, 57.6% knew the factors inducing attacks, 64.3% the prognosis and 69.5% the prevention methods, but a poor knowledge of the complications (62.4%), biological diagnosis (71%) and treatment (97.2%). The prevention practices were poorly adopted: 12% had an haemoglobin electrophoresis check up and 15% of them had their husband to have one as well. Professional status influenced the level of knowledge of the biological diagnosis (p=0.001) and prevention means (p=0.018). The educational level influenced biological diagnosis knowledge (p = 0.000) and prevention means (p = 0.02). On the whole, sickle disease was linked to marital status (p = 0.00). Sickle cell disease remains quite unknown in spite of the gene "S" important frequency in Togo. These results are to be taken into account to implement information, education and communication program to struggle against sickle cell disease.

[Evolution of severe pediatric malaria in Togo between 2000 and 2002]. / Evolution du paludisme grave de l'enfant au Togo de 2000 à 2002.

The aim of this study was to analyse the clinical and evolutive aspects of severe malaria in hospitalised children in 2000, 2001, and 2002 in Togo. The study included 361 children in the pediatrics department of Lomé-Tokoin University hospital. All them received a 10% dextrose infusion, then an infusion of quinine or intramuscular artemether. Malaria accounted for 4.37% of all hospitalizations. Children aged 1 to 5 years were more affected (69.53%). The most frequent clinical forms were anaemia (55.7%) followed by cerebral manifestations. The frequency of hemoglobinuria increased (17.2%) as well as renal failure (3%) compared to previous years. Thirty-five children died (9.7%). Most of them presented with anaemia, neurological manifestations, or respiratory distress. Neurological sequels were present in 2.2% of patients.

[Diluted injectable quinine in the intramuscular and intrarectal route: comparative efficacity and tolerance in malaria treatment for children ]. / Quinine injectable diluee en intramusculaire et en intrarectal: efficacite et tolerance comparees dans le traitement du paludisme de l'enfant.

The intramuscular (i.m.) route is generally used for treatment of childhood falciparum malaria in outlying health care units in Togo. The purpose of this randomized therapeutic trial was to compare the efficacy and tolerance of diluted injectable quinine administered by the i.m. versus intrarectal (IR) route. A total of 64 children ranging in age from 8 months to 15 years were treated, i.e. 32 for each administration route. All children presented uncomplicated falciparum malaria in association with vomiting in 30 cases, a single unrecurring seizure with postictal coma lasting less than 30 minutes in 25 patients, or prostration without neurological manifestations in 9. Injectable quinimax (an association of cinchona alkaloids) was diluted to a concentration of 60 mg base/ml for i.m. injection into the thigh and 30 mg base/ml for use by the IR route. Administration was performed every 12 hours for 72 hours at a dose of 12.5 mg/kg for patients in the i.m. group or at a dose of 15 mg/kg in the IR group. The anus and lower rectal mucosa were examined using an anal valve before and after treatment using the IR route. Analysis of mean temperature curves demonstrated no significant difference between the clinical effectiveness of quinimax administered by the i.m. versus IR route (p > 0.05). Similar effect were also observed on parasitemia which disappeared completely in all patients by the end of the 72-hour treatment. The main problems were insufficient product retention requiring re-administration in 25% of patients in IR group and residual pain at the injection site in 12.5% of patients in the i.m. group. Endoscopic examination revealed no evidence of ulceration or necrosis of the anorectal mucosa. These findings indicate that administration of diluted injectable quinine by IR route is an effective, well-tolerated alternative for treatment of childhood falciparum malaria. It should be used preferentially in outlying health care units in patients presenting severe malaria pending transfer to an hospital, or signs of "intermediate severity" such as hyperpyrexia, hyperparasitemia, unrepeated seizure, or intensive vomiting.

[Treatment of cerebral malaria in African children by intravenous quinine: comparison of a loading dose regimen to a regimen without a loading dose]. / Traitement du paludisme cérébral de l'enfant africain par les sels de quinine: comparaison d'un schéma avec dose de charge à un schéma classique sans dose de charge.

OBJECTIVE: To compare in a randomized study the efficacy and the toxicity of the new WHO intravenous quinine treatment of cerebral malaria including a loading dose regimen to a regimen without loading dose. PATIENTS AND METHODS: Seventy-two children eight months to 15 years of age with cerebral malaria were included. Quinine formiate was administered to a group of 35 patients in an initial loading dose of 20 mg salt/kg (equivalent to 17.5 mg/kg of the base) in 10 mL/kg of 5% glucose over four hours, followed eight hours later by a maintenance dose quinine of 10 mg salt/kg (equivalent to 8.7 mg/kg of the base) dissolved in 15 mL/kg of 5% glucose over and every 12 hours. The second group of 37 patients received intravenous quinine 15 mg salt/kg (13.1 mg of base) dissolved in 15 mL/kg of 5% glucose infused over 6 to 8 hours, every 12 hours. In both groups this treatment was continued until the patient could swallow, then quinine tablets were given to complete seven days treatment. The assessment of cardiovascular side effects was made by an ECG at admission, the 4th hour, the 24th hour and at the end of treatment for each patient. RESULTS: Coma mean durations were similar in the two groups: 35.5 +/- 17.8 hours and 28.6 +/- 14.4 hours respectively for the loading dose group and the group without loading dose. The two groups were comparable also for the decrease evolution of parasitemia. Case-fatality rates were also similar: 95% of healing at the 72nd hour and a lethality rate between 5 and 6% in the two groups. But a significant increase of the body temperature was noted between the 51st and the 63rd hour in the group without loading dose. No significant cardiovascular toxicity was noticed in the two groups. The mean cost of the loading dose regimen was less than that of the second regimen. CONCLUSION: The loading dose regimen of quinine is well tolerated and it seemed slightly more effective than the regimen without loading dose. In cases of contra-indications (patients who recently received quinine, mefloquine or halofantrine), regimens without loading dose, which remains effective, should be used.

[Upper arm circumference reference values for children aged 1 to 36 months in Lome (Togo)]. / Croissance du périmètre brachial chez l'enfant de un à 36 mois à Lomé (Togo).

BACKGROUND: Mid-upper-arm circumference (MUAC) is widely used as a nutritional status index for children. The aim of our study was to construct MUAC-for-age curves for well-fed 1-36-month-old children of a developing country and to compare them with the WHO reference charts based on samples of American children. POPULATION AND METHODS: Five thousand thirty-eight boys and 4,972 girls aged 1-36 months were recruited cross-sectionally from 1994 to 1997. Their MUAC were measured as recommended by the WHO. To develop the curves, estimations were first obtained for the mean and standard deviation (SD) of MUAC for each month of age using a 7-month segmental regression equation; the Count model and 2nd degree polynomial in age were then used to describe the mean and SD respectively. RESULTS: These curves showed important differences for age and sex and were lower than the reference curves, particularly for the older children. The mean curve was -0.44 to -0.75 SD for boys and 0 to -0.8 SD for girls, far from the WHO's reference. CONCLUSIONS: The authors proposed to take into account the WHO's nutritional recommendations and developing country features in the construction of the reference charts.

[Ambulatory management of sickle cell disease: evaluation of the first year follow up of patients in the pediatric department of Lomé (Togo)]. / Prise en charge ambulatoire des drépanocytaires: évaluation de la première année de suivi des patients dans le service de pédiatrie de Lomé (Togo).

BACKGROUND: This study is an evaluation of the first year ambulatory follow up of patients from the sickle-cell care centre of the paediatric ward of the teaching hospital in Lomé-Tokoin. PATIENTS AND METHODS: Togo is situated in the epicentre of the Benin haplotype. A total of 132 patients (109 SS, 22 SC and 1 S beta zero thal) followed up during one year from their admission date (period of 1st January 1996 to 31st December 1997). 132 patients were included in the study. RESULTS: The patients' age varied, for the majority, between 2 months and 15 years, but a few adults (15%) were included in the study. Information was collected from the hospital files and health cards, which unfortunately did not have specific entrees for sickle cell disease. Clinical features revealed that the frequency of tooth decay and chronic persistent splenomegaly was low when compared to the rates in central Africa (Bantu haplotype). Laboratory findings lead to the conclusion that some analysis are relevant such as the dosage of the G6PD activity (24.1% of patients were deficient), parasitologic analysis of faeces (positive in 22.5%), retinal fluoro-angiography (32.2% of ocular lesions), and cardiologic check-up. On the other hand, scanning of biliary tracts and systematic X-rays of the hips seems to be secondary. Some positive results were noticed by the scanning of biliary tracts without any therapeutic decisions in non-symptomatic patients; no case of osteonecrosis was detected by the X-rays. The mean haemoglobin level was 7.4 +/- 1.4 g/dl for the SS and 10.7 +/- 2.4 g/dl for the SC. The mean MCV were 91.3 +/- 10.1 fl and 82.1 +/- 7.7 fl, respectively. Specific vaccinations were not well performed because of their high cost. CONCLUSION: In order to carry on and improve the ambulatory management of patients with sickle cell disease, it is important in low income countries, such as Togo, to target the necessary laboratory tests for an initial and annual check-up. Solidarity networks for patients should be promoted and effective involvement of the health authorities ensured.

Management of sickle cell priapism with etilefrine.

Intracavernous injections of etilefrine were effective in seven children with acute sickle cell priapism, and stuttering priapism resolved in five children after one to seven months of oral etilefrine. Compared with our previous reports in adults, etilefrine appears to be more effective in childhood.

[Acute osteomyelitis in the child with sickle cell disease in a tropical zone: value of oral fluoroquinolones]. / Ostéomyélites aiguës de l'enfant drépanocytaire en zone tropicale: intérêt de l'utilisation des fluoroquinolones par voie orale.

AIM: This study was designed to assess the efficacy and the safety of fluoroquinolones in their compassionate use for acute osteomyelitis in children with sickle cell disease in a tropical country. PATIENTS AND METHODS: This study was non comparative, including twelve children (eight SS, three SC and one SEzerothalassemia) treated for acute osteomyelitis with oral ciprofloxacin or ofloxacin because of the following reasons: financial inability to afford conventional parenteral beta-lactams therapy (nine patients), refusal of hospitalization (two patients), and failure of conventional treatment (one patient). RESULTS: The mean age of patients was 9.5 +/- 2.6 years. The long bones were the predominantly site. Salmonella species were present in 75% of cases, followed by other enterobacteriaceae (16.7%), and Staphylococcus aureus (8.3%). Successful outcome occurred in all cases after three to four-weeks of treatment and 45 days of plaster immobilization. Transient bilateral Achilles tendon tendinitis was noted in a five-year-old patient. CONCLUSION: In economically developing countries, oral fluoroquinolones may be a therapeutic alternative for acute osteomyelitis in patients with sickle cell disease particularly in cases of financial hardship or failure with conventional therapy.

Priapism in sickle cell anemia in Togo: prevalence and knowledge of this complication.

Prevalence of priapism and knowledge on this disease was assessed by interviewing a group of 114 sickle cell anemia patients, 5 years and older, considered to be genotypically homogenous (Benin or #19 haplotype). Prevalence of priapism in homozygous sickle cell patients was 26.3% (30/114) and that of the control group of subjects with Hb AA was 2% (2/102) (the difference was very significant: p = 5.10-7). Actuarial probability of having priapism by 20 years of age was 69 +/- 8.5%. Few homozygous patients without a history of priapism (15.8%) have heard about priapism. This lack of knowledge, added to low accessibility of a health care system, may explain the high rate of impotence (31.6%). The results of this study led us to plan a large program of infonnation about priapism and sickle cell disease in the Togolese population.

[Sickle cell disease priapism: treatment with intracavernous injections of etilefrine]. / Priapisme drépanocytaire: prise en charge par injections intracaverneuses d'étilefrine.

Intracavernous injection (ICI) of adrenergic agonists has recently been proposed for treatment of priapism associated with sickle cell hemoglobinopathy and appears to be effective in cases less than 28 hours old. The purpose of this study was to confirm the usefulness of this technique in a large series of patients. From January 1996 through September 1998, 19 patients with sickle cell disease were treated by ICI of etilefrine for one or several episodes of low-flow priapism lasting between 2 hours and 15 days. A total of 72 consecutive ICI were performed alone in patients with priapism less than 6 hours old or in combination with prior drainage in patients with priapism more than 6 hours old. Results depended mainly on the delay to treatment. Detumescence was achieved in all 10 cases treated within 29 hours as opposed to only 2 of 9 cases treated beyond 29 hours. This finding is in agreement with experimental findings demonstrating histological evidence of necrosis of endothelial cells and cavernous smooth muscle fibers after 24 hours. However based on our experience showing that good results with preservation of erectile function can be achieved after delays longer than 40 hours (42 hours and 5 days in two of our patients), we recommend that treatment by ICI be tried before surgery in sickle cell anemia patients even with long-standing priapism. Untoward side effects including intense pain in the penis and retrosternal pain were observed in 4 patients. ICI of adrenergic agonists is one of the best treatment currently available for management of priapism in patients with sickle cell disease. Surgery should be used only after failure of ICI.

[The impact on families of sickle cell disease in Togo]. / L'impact familial de la drépanocytose au Togo.

AIM: In order to master the difficulties due to sickle cell disease, this work aimed at assessing the effects on the families of the presence of a child with sickle cell disease in Togo. POPULATION AND METHODS: From April 1 to November 31, 1998, 103 families with one or many sickle cell patients followed up in the Sickle Cell Care Unit of the pediatric department of the Lome Teaching Hospital were surveyed. Main care takers of patients with sickle cell disease, especially mothers (90.3% of cases), were surveyed. RESULTS: Many parents were disturbed; the most common troubles were: compassion (pity) toward the child, 92.2%; insomnia, 82.5%; frustration, 76.7%; and fear of the death of the child, 73.5%. Less educated parents and those who lived alone (single parents, widows, separated) were more affected. Sickle cell disease caused the separation of seven couples out of 26 (26.9%), while in 11 couples of the 63 who still live together, relationships had deteriorated (17.5%). Most of the parents (83.3%) exaggerated the protection of their child and 65% mentioned financial problems. CONCLUSION: There is no doubt about the unfortunate effects of the presence of children with sickle cell disease in a family in Lome. Many joint actions should be taken toward the sick children and their families in order to reduce their sufferings.

[An epidemiological study of health care seeking behavior by children under the age of 5 years at hospital emergency services in Togo]. / Etude épidémiologique du recours aux consultations hospitalières d'urgence chez les enfants de moins de 5 ans au Togo.

The functioning and efficacy of pediatric emergency services are currently being questioned in many Northern countries, as well as in the South, for example in North Africa. Reference is often made to unjustified medical emergencies in the face of an influx of patients with benign problems who come from socially disadvantaged families. In the university and regional hospitals in three regions in Togo, we compared three categories of under-5 patients: children sent to "day-time" emergency services after triage done by health personnel; those sent to the "ordinary consultation"; and children brought after hours by their family (without referral by a health professional in 92% of cases) and seen in the "after-hours" emergency service. Serious tropical pathology (cerebral malaria, malaria, sickle cell disease) is mainly seen in emergency consultations, in which high hospitalization rates are noted (83% during the day, 67% at night) and a lethality of 3.4%. One cannot therefore use terms such as "false emergencies", "felt" and "medically unjustified" and the pediatric supervisor for the research considered that recourse to after-hours emergency services was justified in 75% of cases. Families using night services have higher educational levels than those sent to day emergency services, the mother's educational level being the main factor associated with certain characteristics of health seeking behavior (duration of symptoms prior to arrival at hospital, recourse to modern medical drugs). There is often a long delay before recourse to hospital: only 45% of children seen after hours and half of those who died came the 1st or 2nd day of the illness. Self-medication at home is usual but recourse to tradi-practitioners appears rare (4%). Several solutions can be envisaged and should be linked: strengthening of the first level of care, technical improvements in emergency services, training of tradi-practitioners in the recognition and referral of emergency cases, improvement of reception practices at the hospital level, prophylactic and preventive measures for tropical diseases.

[Health care seeking behavior of children in Togo]. / Le recours aux soins des enfants au Togo.

Epidemiological and anthropological studies were carried out in Togo on health seeking behavior for under 5 children to determine causes of dysfunctions in health services. This article reports on the main findings of the anthropological study. Anthropological literature on health seeking behavior has identified labeling and associated explanatory models of illness as important factors for making choices in the use of health services. This study, carried out among 100 families in Togo on health seeking behavior for under-five children, found little difference in the signs and symptoms of illness recalled and the health resources used. Different causal explanations similarly showed little variation in signs and symptoms of illness. The only causal explanation for illness which appeared to correspond to place of recourse was related to social causes, where traditional practitioners were more often consulted. Families explained choices more on the basis of the accessibility and quality of health services (geographical and financial accessibility, reception by health personnel, organization of services, drug availability) than on the basis of the particular signs and symptoms of the illness. Improving the organization and functioning of health services should contribute more to appropriate use of the modern health care sector than interventions targeting user populations, since the latter appear to be aware of the advantages of modern medicine, but find financial, social and organizational features of services unsatisfactory.

Musculoskeletal conditions in children attending two Togolese hospitals.

OBJECTIVE: A retrospective study was conducted in order to point out the different kinds of musculoskeletal conditions observed in children attending two Togolese hospitals. RESULTS: A total of 434 (242 females, 192 males) of the 29 620 children examined (1.5%) were suffering from these conditions. Probable joint and bone infections (187 patients, 43%), limb deformities (106 patients, 24%), osteochondrosis (60 patients, 14%) and vaso-occlusive crisis due to haemoglobinopathies (29 patients, 7%) were the main conditions observed. Osteomyelitis observed in 128 patients affected the humerus (25 patients), radius (10 patients), femur (68 patients), tibia (15 patients), fibula (five patients), and both tibia and fibula (five patients). Probably, infectious arthritis seen in 30 patients affected mainly the hip (11 patients) and the knee (13 patients). In the spine, infection affected the midthoracic and upper lumbar areas. Underdevelopment, sickle cell anaemia and sickle cell haemoglobin C disease were the main risk factors in determining susceptibility to infections. Vaso-occlusive crises were due to sickle cell anaemia (11 patients) and sickle cell haemoglobin C disease (18 patients). Osteochondrosis seen in 60 patients free from haemoglobinopathy involved the spine (Scheuermann's disease, 38 patients) and the hip (Legg-Calvé-Perthes disease, 22 patients). Limb deformities were observed in the knee (varus and valgus deformities in 64 patients) and the foot (talipes varus equin in 40 patients). CONCLUSION: This study's findings, which require further confirmation, suggest some conclusions. Scheuermann's disease can explain in part the degenerative disc conditions observed in African adults. Valgus and varus deformities play an important role in the development of knee osteoarthritis in Black Africa. An African child with joint or bone pain should be investigated for sickle cell anaemia. In the future, improved lifestyle and better health care will be essential to reduce bone and joint infections, and allow refined diagnosis of connective tissue diseases now probably underestimated in African children.

[Home care of vaso-occlusive crisis in sickle cell disease in Togo]. / Traitement à domicile de la crise vaso-occlusive par les drépanocytaires au Togo.

BACKGROUND: Many people with sickle cell disease manage their pain crises at home. This study aims to describe the home management of sickle cell pain by Togolese patients. PATIENTS AND METHODS: From July 1996 to April 1997, parents of children with sickle cell disease, and some adults with sickle cell disease living in rural and urban regions were interviewed about their home treatment habits during pain crises. RESULTS: A total of 165 patients with sickle cell disease (82 from urban and 83 from rural areas) were selected. The techniques most frequently used for pain management included salicylates (61.8%), paracetamol (37%), non-steroidal anti-inflammatory drugs (15.1%), vasodilators and pentoxifylline (5.4%). Only 4.2% of the patients mentioned adequate hydration. None used other antalgics (weak or strong opium derivatives). No difference was noticed between the treatment habits of rural regions and those of urban regions. CONCLUSION: In order to improve the quality of life of patients with sickle cell disease, information and awareness programs must be organized in order to establish a standard home pain management. Emphasis must be put on the use of salicylates and paracetamol at the correct dosage, the intake of abundant fluids, the easy use of analgesic of the second step of the Word Health Organization, and the systematic treatment of malaria which can induce pain crises.