Reference values of IGF-I in children from birth to 5 years of age, in Burkina Faso, using blood samples on filter paper.

OBJECTIVES: The aims of this study were to validate the use of filter paper to measure insulin-like growth factor-I (IGF-I) and to establish normal levels of IGF-I in children appearing healthy, from birth to 5 years of age in an African population. METHODS: We determined IGF-I from blood collected on filter paper. We validated this method by comparing the IGF-I values from dried blood spots on filter paper (kept at 4 degrees C and ambient temperature) and from serum among 13 children under 5. IGF-I were measured by the classical IGF-I RIA, after separation of the IGF-I from its binding proteins, using Sep-Pak chromatography. To establish normal levels of IGF-I, we conducted a cross-sectional study and collected blood samples with filter paper among 360 children in Ouagadougou (Burkina Faso). RESULTS: IGF-I determined from dried blood spots on filter paper were in good agreement with IGF-I levels obtained from blood serum, whether the filter papers were kept at 4 degrees C or at ambient temperature. The results of IGF-I-levels in apparently healthy children showed that geometric mean IGF-I ranged from 27 microg/l in boys younger than five months to 31 microg/l in 5-year-old boys. In girls, mean IGF-I ranged from 29 microg/l for girls younger than five months to 45 microg/l at the age of 5. From birth to 24 months, IGF-I decreased by 0.32+/-0.08 microg/l/month in boys and by 0.27+/-0.06 microg/l/month in girls and these decreases were not significantly different (p=0.95). After the age of 24 months, there was an increase in IGF-I of 4.9+/-1.3 microg/l/year in boys and of 8.4+/-0.8 microg/l/year in girls. This increase was indeed significantly different (p<0.001). CONCLUSIONS: Reference values of IGF-I for African boys and girls were determined. They will be used for endocrine evaluations and nutritional monitoring.

Substantial use of primary health care by prisoners: epidemiological description and possible explanations.

OBJECTIVES: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. DESIGN: Retrospective cohort study of a sample of prisoners' medical records. SETTING: All Belgian prisons (n = 33). PATIENTS: 513 patients over a total of 182 patient years, 3328 general practitioner (GP) contacts, 3655 reasons for encounter. MAIN RESULTS: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. CONCLUSION: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

The immunocytochemical versus cytosol measurement of the oestrogen receptor in invasive breast cancer tissue.

To compare two methods of measurement of oestrogen receptor (ER)-expression in invasive breast cancer tissue. Sections from 299 breast cancer cases were stained for the ER by immunocytochemical assay (ICA), using mouse monoclonal antibody (MAb) NCL-ER-6SF11, and by the dextran-coated charcoal assay (DCC). Concordant results were observed in 230 of the 299 cases (77%), 69 patients had discordant results (kappa=0.537). We found a moderate concordance between ICA and DCC for ER measurement in breast cancer tissue. If we change the golden standard from DCC to ICA, 23% of patients would receive a different therapeutic approach.

The unseen face of humanitarian crisis in eastern Democratic Republic of Congo: was nutritional relief properly targeted?

STUDY OBJECTIVE: Comparison of children's nutritional status in refugee populations with that of local host populations, one year after outbreak refugee crisis in the North Kivu region of Democratic Republic of Congo. DESIGN: Cross sectional surveys. SETTING: Temporary and other settlements, in the town of Goma and surrounding rural areas. SUBJECTS: Anthropometric indicators of nutritional status and presence or absence of oedema were measured among 5121 children aged 6 to 59 months recruited by cluster sampling with probability proportional to size, between June and August 1995. RESULTS: Children in all locations demonstrated a typical pattern of growth deficit relative to international reference. Prevalence of acute malnutrition (wt/ht < -2 Z score) was higher among children in the rural non-refugee populations (3.8 and 5.8%) than among those in the urban non-refugee populations (1.4%) or in the refugee population living in temporary settlements (1.7%). Presence of oedema was scarcely noticed in camps (0.4%) while it was a common observation at least in the most remote rural areas (10.1%). As compared with baseline data collected in 1989, there is evidence that nutritional status was worsening in rural non-refugee populations. CONCLUSIONS: Children living in the main town or in the refugee camps benefited the most from nutritional relief while those in the rural non-refugee areas were ignored. This is a worrying case of inequity in nutritional relief.

Iodine-induced hyperthyroidism: occurrence and epidemiology.

We have critically reviewed the available information on iodine-induced hyperthyroidism (IIH) from published sources and other reports as well as the experience of the authors in Tasmania, Zaire, Zimbabwe, and Brazil. Administration of iodine in almost any chemical form may induce an episode of thyrotoxicosis (IIH). This has been observed in epidemic incidence in several countries when iodine has been given as prophylaxis in a variety of vehicles, but the attack rate as recorded has been low. IIH is most commonly encountered in older persons with long standing nodular goiter and in regions of chronic iodine deficiency, but instances in the young have been recorded. It customarily occurs after an incremental rise in mean iodine intake in the course of programs for the prevention of iodine deficiency, or when iodine-containing drugs such as radiocontrast media or amiodarone are administered. The biological basis for IIH appears most often to be mutational events in thyroid cells that lead to autonomy of function. When the mass of cells with such an event becomes sufficient and iodine supply is increased, the subject may become thyrotoxic. These changes may occur in localized foci within the gland or in the process of nodule formation. IIH may also occur with an increase in iodine intake in those whose hyperthyroidism (Graves' disease) is not expressed because of iodine deficiency. The risks of IIH are principally to the elderly who may have heart disease, and to those who live in regions where there is limited access to medical care. More information is needed on the long-term health impact of IIH or "subclinical" IIH, especially in the course of prophylaxis programs with iodized salt or iodinated oil in regions where access to health care is limited.

Deprivation and mortality: the implications of spatial autocorrelation for health resources allocation.

This paper aims at investigating whether the relationship between mortality and socio-economic deprivation is affected by the spatial autocorrelation of ecological data. A simple model is used in which mortality (all-ages and premature) is the dependent variable, and deprivation, morbidity and other socio-economic indicators are the explanatory variables. Deprivation is measured by the Townsend index; the other socio-economic variables are the median income, unequal income distribution (Gini coefficient) and population density. Morbidity is estimated on the basis of hospital admission rates and overweight prevalence. Spatial autocorrelation is measured by the Moran's I coefficient. All mortality and morbidity variables have significant, positive, and moderate-to-high spatial autocorrelation. Two multivariate models are explored: a weighted least-squares model ignoring spatial autocorrelation and a simultaneous autoregressive model. The paper concludes that spatial autocorrelation has a significant impact on the relationship between mortality and socio-economic variables. Future ecological models intended to inform health resources allocation need to pay greater attention to the spatial dimension of the data used.

Weakness of biochemical markers of nutritional and inflammatory status as prognostic indices for growth retardation and morbidity of young children in central Africa.

OBJECTIVE: To determine to what extent biochemical markers of the nutritional and inflammatory status of young children are related to subsequent growth retardation and morbidity. DESIGN: Population-based follow-up study of a cohort of children from admission to final survey round six months later. SETTING: Health area in Northern Kivu, Zaire. SUBJECTS: 842 children under two years of age of whom about one-third gave informed consent to capillary blood collection. MAIN OUTCOME MEASURES: Concentration of albumin, transferrin, transthyretin, alpha 1-acid glycoprotein, C-reactive protein, and complement component C3 at baseline, and three and six months later. Incremental growth per 1 month, 3 months and 6 months of follow-up. Cumulative incidence of disease per 1 month and 3 months interval. RESULTS: A high proportion of children was with low concentrations of transport proteins and high concentrations of acute-phase reactants. Weight growth and arm circumference growth did not vary significantly with respect to initial concentrations of biomarkers, but subsequent height growth was lower in children with high values of transferrin, alpha 1-acid glycoprotein, and complement component C3 at baseline. Cumulative incidence of malaria, respiratory illness, and diarrhoea was not significantly affected by the concentration of the biomarkers at baseline. CONCLUSIONS: In this part of central Africa performing biochemical measurements should not be encouraged as a means for risk scoring in non-hospitalized children.

Health information systems for leprosy control programmes: a case for quality assessment.

A qualitative study was carried out aimed at checking the level of understanding and the actual use of the indicators recommended in leprosy control programmes by either the World Health Organization or the International Federation of Anti-Leprosy Associations. Two successive questionnaires were sent to 268 leprosy control programme managers. The first one concerned information about the main characteristics of the programme, the information system in operation, and the data regarded as indispensable or useful for programme monitoring. The respondents to the first questionnaire (n = 64) proposed an extraordinarily wide range of indicators, mainly ill-defined. The respondents to the second questionnaire (n = 37) to whom a limited list of precisely defined indicators was submitted did not succeed in reaching a complete agreement on any of these indicators. Although the question of programme monitoring has been dealt with at an international level for years, there is an urgent need for a real agreement of international agencies and managers of leprosy control programmes on the indicators to be used. Programme managers in the field are obviously open to the idea of greater intervention by international organizations to improve data collection and to encourage standardization of computerized information systems.

[Is evidence-based medicine useful for public health?]. / La médecine basée sur les preuves peut-elle servir un projet de santé publique?

Evidence-based medicine is a fashionable topic although the discussions is open regarding whether it has any practical interest for daily medical practice or public health policy. One needs therefore to focus on the way evidence-based medicine can improve matters for physicians, but also on some serious challenges facing health professionals. Upon close examination, it appears that evidence-based medicine provides us with concepts and methods likely to be useful in three directions: improvement of the health care decision-making process, reinforcement of professional accountability dedicated to the promotion of human rights, implementation of fair health policy regulations taking into account the intricate relationships between participants dealing with individual or community oriented interventions. When facing these challenges, evidence-based medicine certainly deserves further attention in the field of community and public health.

[Value of nutritional indicators for the prognosis of intrahospital mortality in children in Kivu]. / Valeur des indicateurs nutritionnels pour le pronostic de la mortalité intra-hospitalière chez les enfants du Kivu.

From 1986 to 1988, 1,129 children were hospitalized in Lwiro (South-Kivu, Zaïre) 3/4 of which were severely malnourished. Anthropometric, clinical and biological indicators were measured at admission. Observed mortality rate was 17.4%. Survival curves differ significantly for each anthropometric parameter measured at inclusion. In multivariate analysis, weight for age calculated with local reference or arm circumference is significantly associated with survival. The addition of serum albumin concentration to the multivariate model, shows this variable to be important. However, the use of an anthropometric indicator, such as weight for age or arm circumference is still important because it maintains an independent and significant effect on survival.

[Periodontal disease in Belgian adults]. / Prévalence de la maladie parodontale chez les adultes belges.

BACKGROUND: To date, no epidemiological study has been published on the periodontal health of the Belgian population. The aim of this study was to rectify this situation and determine the extent of the problem in Belgium. METHODS: A prevalence survey was carried out in a representative sample of employees of the Catholic University of Louvain. A total of 402 people aged between 35 and 65 were examined. Periodontal suffering was estimated using the CPITN index (WHO), which determines the most affected sextant of a mouth in order to assign a code to the mouth as a whole. At the same time, treatment needs were evaluated. RESULTS: Only one subject was considered healthy, i.e. there was no bleeding of the gums in any part of the mouth. At the same time, 41.4% of the subjects examined exhibited a deep periodontal pocket in at least one sextant of the mouth likely to progress to the loss of the teeth. Many mouths (28.5%), which were free from moderate or deep pockets, had to be scaled and polished or to be treated in order to eliminate other factors which could lead to a build-up of tartar. CONCLUSION: In this study population representative of a socio-economically favored stratum of the Belgian population, we observed a high prevalence of periodontal diseases, grading from mild chronic gingivitis to the deep cavities which are observed when the bone supporting the tooth has been lost. At the same time, we uncovered many needs for periodontal care, ranging from instruction on how to control the dental plaque to specialized periodontal care via careful scaling and polishing.

[Nutritional status on admission and hospital mortality of under-five year old children with infectious diseases in Ouagadougou, Burkina Faso]. / Etat nutritionnel à l'admission et mortalité hospitalière des enfants de moins de 5ans atteints de maladies infectieuses à Ouagadougou, Burkina Faso.

BACKGROUND: It is known that malnutrition in childhood interacting with infectious diseases contributes to increase mortality. In Burkina Faso, infectious pathologies and malnutrition are public health problems. We examined the impact of malnutrition status, using the Weight-for-age (WA) index, on mortality of children hospitalized for infectious diseases. METHODS: This retrospective study uses a systematic sample derived from the year 1999 hospital register. In total data of 1573 children from 0 to 59 months were analyzed. The association between mortality and dependent variables was measured by relative risks (RR) in univariate analysis. A logistic regression was realized and attributable risk percent (etiologic fraction among exposed) of death was calculated. RESULTS: The total intra-hospital lethality amounted to 15.3%. Age, diagnosis, type of care recourse and malnutrition (low WA index) on admission were associated to mortality. The logistic regression model confirmed the high risks of deaths for young children (0-11m), children in malnutrition (low WA index) and those with severe malaria. The attributable risk percent of death indicates that, 87% of deaths are statically attributable to severe malnutrition (WA Z-score<=-3) and 64.3% of deaths are statically attributable to moderate malnutrition (WA Z-score]-3, -2]). CONCLUSION: Nutritional status evaluation would allow to select children at risk and reduce mortality by including nutritional intervention in standard treatment of children hospitalized for infectious diseases.

Serum albumin concentration, arm circumference, and oedema and subsequent risk of dying in children in central Africa.

OBJECTIVE: To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children. DESIGN: Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire. SUBJECTS: 1129 children consecutively admitted between August 1986 and October 1988. MAIN OUTCOME MEASURES: Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality. RESULTS: Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality. CONCLUSIONS: In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

Insulin Growth Factor-I in Protein-Energy Malnutrition during Rehabilitation in Two Nutritional Rehabilitation Centres in Burkina Faso.

Objective. To investigate the relationship between IGF-I and the nutritional status of West-African children hospitalised for nutritional rehabilitation. Patients and methods. A cohort study was performed in two centres for nutritional rehabilitation and education (CREN) in Burkina Faso. Children were followed and the anthropometric data as well as the capillary blood samples were taken on the 7th and on the 14th days after their admission. IGF-I levels were determined from dried blood spots on filter paper on IGF-I RIA, after separation of the IGF-I from its binding proteins, using Sep-Pak chromatography. Results. A total of 59 children was included in the cohort. The IGF-I mean geometric values (SD) were 6.3 (1.4) mug/L on admission, 8.6 (1.8) mug/L at day 7 and 13.6 (2.0) mug/L at day 14. The differences between these values were statistically significant (P < .001). There is a significant correlation between the changes of IGF-I with the change of weight for height Z-score (P = .01). Conclusion. These results suggest that IGF-I can be considered as a potential marker to follow the nutritional status of children admitted in hospital for protein and energy malnutrition.

Efficacy of low oral doses of iodized oil in the control of iodine deficiency in Zaire.

BACKGROUND: About one billion people worldwide are at risk for iodine deficiency. Despite existing programs of prophylaxis, the prevention of iodine deficiency is still a challenge throughout the developing world. We studied the efficacy of low doses of iodized oil in an area of severe iodine deficiency in Zaire. METHODS: Seventy-five subjects with visible goiter were randomly assigned to receive a single oral dose of placebo or either 0.1 or 0.25 ml of iodized oil, corresponding to 0, 47, and 118 mg of iodine, respectively. The mean ages of the subjects in the three groups were 23, 22, and 22 years, respectively, and the ratios of males to females were 0.25, 0.32, and 0.19. Efficacy was assessed by evaluating goiter size and measuring urinary iodine and serum thyroid hormone concentrations for 12 months. RESULTS: Goiter size decreased in most of the subjects who received either dose of iodized oil. Their urinary iodine concentrations were normal for six to nine months and their serum thyroxine and thyrotropin concentrations were nearly all normal throughout the study period. There were no side effects, even in subjects whose serum thyroxine concentrations had initially been low. In the placebo group, neither goiter size nor any of the biochemical values changed. CONCLUSIONS: The oral administration of a single small dose of iodized oil is capable of correcting iodine deficiency for about a year. This method of supplementation is likely to be more effective, efficient, and acceptable than the administration of either intramuscular or large oral doses of iodized oil.

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.