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Introduction During anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. Hypothesis ALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. Material and methods Clinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3 years’ follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28 years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. Results The average follow-up was 6.8 years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3 mm in 66% of patients and less than 5 mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. Discussion When compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8 years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. Level of evidence IV, multicenter study.

Purpose To measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion. Methods Twelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle. Results During IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location. Conclusions The ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°. Clinical Relevance Clinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Background:Rotational control of the knee is crucial for knee stability. The anterolateral ligament (ALL) has been identified as a potentially important structure involved in rotational control of the knee.Purpose/Hypothesis:The purpose of this study was to determine, utilizing a navigation system, the involvement of the anterior cruciate ligament (ACL), the iliotibial band (ITB), and the ALL in tibial internal rotational control of the knee. The hypothesis was that the ALL would be involved in rotational control of the knee at varying degrees of knee flexion.Study Design:Controlled laboratory study.Methods:Twelve fresh-frozen cadaveric knees were tested in internal rotation at 20° and 90° of flexion and then subsequently tested using a simulated pivot-shift test consisting of coupled axial rotation at 30° of flexion. Serial sectioning of the ACL, ALL, and ITB was performed. On the contralateral knee, sectioning was performed in the reverse order. Measurements were collected using a surgical navigation system before and after each sectioning.Results:After ACL sectioning, an incision of the ALL induced a significant increase in internal rotation (+19.2% [ P = .0002] at 20°; +21.8% [ P = .0029] at 90°) and in coupled axial rotation (+43.0%; P = .0035) compared with the intact knee as well as a significant increase in internal rotation at 90° (+13.4%; P = .009) and in coupled axial rotation (+30.8%; P = .0124) compared with the ACL-deficient knee. After ITB sectioning, an additional ALL section caused a significant increase in internal rotation (+39.0% [ P = .002] at 20°; +63.0% [ P = .0147] at 90°) and in coupled axial rotation (+59.7%; P = .0003) compared with the intact knee as well as a significant increase in internal rotation at 90° (+14.8%; P = .0067) in comparison to the ITB-deficient knee.Conclusion:The ALL is involved in rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift. Concomitant to an ACL or ITB transection, sectioning the ALL further increased rotational laxity.Clinical Relevance:This laboratory study demonstrated that the ALL provides rotational control of the knee in combination with the ACL and/or ITB.

BACKGROUND Little is known about early-onset neonatal bacterial infections (EONBI) in Madagascar. Our aim was to determine their epidemiology to improve their management. METHODS Inborn neonates at risk for EONBI and admitted in the neonatal unit of 2 tertiary hospitals in Antananarivo, Madagascar, were included in a prospective study from April 2012 to March 2013. Using a clinical algorithm, blood culture, gastric fluid culture and C-reactive protein dosage were performed in newborns at high risk of infection, that is, peri partum fever, prematurity

Introduction Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methods A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. Results Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. Discussion The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidence IV, prospective multicenter study.

Background A careful analysis of the reasons for ACL reconstruction failure is essential to selection of the optimal surgical revision technique designed to ensure good rotational stability and to minimise the risk of re-rupture. Objective To evaluate anterolateral ligament (ALL) stabilisation during revision ACL reconstruction. Hypothesis ALL stabilisation during revision ACL reconstruction provides good rotational stability without increasing the risk of complications. Material and methods This multicentre study included 349 patients, 151 retrospectively and 198 prospectively. There were 283 males and 66 females. Inclusion criteria were an indication for revision ACL reconstruction surgery with combined intra-articular reconstruction and ALL stabilisation after failed autograft ACL reconstruction, and intact PCL. Exclusion criteria were primary ACL reconstruction and concomitant peripheral medial and/or lateral lesions. Each patient underwent a clinical and radiographic evaluation before and after revision surgery. Before revision surgery, the mean IKDC score was 56.5 ± 15.5 and 96% of patients were IKDC C or D. Results Rates were 5.0% for early and 10.5% for late postoperative complications. Lachmann's test had a hard stop at last follow-up in 97% of patients. The pivot-shift test was positive in 1% of patients. The mean subjective IKDC score was 84.5 ± 13.0 and 86.5% of patients were IKDC A or B. The proportions of patients with radiographic knee osteoarthritis at last follow-up was unchanged for the lateral tibio-femoral and patello-femoral compartments but increased by 9.7% to 21.2% for the medial tibio-femoral compartment. The re-rupture rate was 1.2% and the further surgical revision rate was 5.4%. Conclusion Anterior laxity at last follow-up was consistent with previous studies of revision ACL reconstruction. However, rotational stability and the re-rupture risk were improved. ALL stabilisation is among the techniques that deserve consideration as part of the therapeutic options for revision ACL reconstruction. Level of evidence IV, retrospective and prospective cohort study.

Background: We investigated the molecular mechanism of ß-lactam resistance in extended-spectrum ß-lactamase (ESBL)-producing Enterobacterial strains isolated in neonatal units of different hospitals in Anatnanarivo, Madagascar.Methods: Bacteria were identified by standard biochemical methods, disc diffusion antibiograms and Etest. Resistance genes were sought by PCR. Strains were characterized by Rep- PCR (Diversilab), plasmid analysis and rep-typing.Results: From April 2012 to March 2013, 29 ESBL-producing E. cloacae and 15 K. pneumoniae were isolated from blood culture (n = 32) or gastric samples (n = 12) performed at day 0 or 2 from 39/303 newborns suspected of early neonatal infection. These infants were treated with expanded spectrum cephalosporins, due to lack of carbapenems, leading to a high mortality rate (45 %). Isolates recovered were all, but 4, multidrug resistant, particularly to fluoroquinolones (FQ) except for 21 E. cloacae isolates. Isolates produced TEM-1 and CTX-M-15 ß-lactamases and their genes were located on several self- transferable plasmids of variable sizes sizes that could not be linked to a major plasmid incompatibility group. E. cloacae isolates belonged to 6 Rep-types among which two counted for 11 isolates each. The FQ resistant E. cloacae isolates belonged to one clone, whereas the FQ susceptible E. cloacae isolates belonged to four clones. The K. pneumoniae isolates belonged to 9 Rep-types among which one included five isolates.Conclusion: This study is the first molecular characterization of ESBL- producing isolates from neonatology units in Madagascar, a country with limited epidemiological data. It revealed an important multi-clonal dissemination of CTX-M-15- producing isolates reflecting both the high community carriage and the very early nosocomial contamination of the neonates.

International audience

Purpose To determine the location and variability of the anterolateral ligament (ALL) femoral origin. Methods The ALL was dissected and examined in 52 embalmed specimens, and the femoral origin was isolated. The presence of a bony or soft-tissue attachment, the relation to the lateral collateral ligament, the average diameter of the proximal origin, and the specific location of the origin relative to the lateral femoral epicondyle were recorded. Results The ALL was present in all 52 specimens, with a mean diameter of 11.85 mm, and was consistently attached to bone in all specimens. The ALL consistently overlapped the lateral collateral ligament near its attachment, with the location of the origin directly on the lateral epicondyle in 12 specimens (23%), with a shared lateral femoral condyle and with the origin slightly posterior and proximal to the lateral epicondyle in 30 specimens (58%), and with the origin completely posterior and proximal to the lateral epicondyle in 10 specimens (19%). Conclusions The ALL showed a consistent bony origin overlapping the lateral collateral ligament in all specimens, with some variability in the femoral attachment, ranging from directly on the lateral epicondyle to posterior to the lateral epicondyle. Clinical Relevance The identification and description of the femoral origin of the ALL are crucial in understanding its role in the stability of the knee, as well as determining the appropriate position for the femoral origin placement in ALL reconstruction.

Teenager sexuality is a public health issue. In teenagers attending a high school, we assessed their knowledge and behavior on sexuality, infectious transmitted diseases, human papilloma virus (HPV) vaccination, and cervical cancer. Then in girls, we estimated the anti-HPV vaccination coverage and focused on factors associated with poor knowledge of these topics.This was a knowledge, attitudes, and practices cross-sectional study conducted at the beginning of the 2010-2011 school year in the Saint-Cyr military high school, using an anonymous self-administered questionnaire.Among 669 adolescents (M/F sex-ratio, 2.3; mean age, 17 years [IC 95%, 15-20]), 40% had already had sex and 92% had used contraception. Boys and girls had a poor level of knowledge on infectious transmitted diseases. Regarding knowledge on HPV and cervical cancer, a better level was significantly associated with female gender (P=10(-4)). In multivariate analysis, male gender, age under 18 years, lack of dialogue with parents on these subjects, low socioeconomic status of parents, and absence of health education were significantly associated with poor knowledge on these topics.These data should help healthcare providers better target access and content of sexual health education training.

The purpose of this study was to test the hypothesis that the surgical technique using alternating fluid irrigation and carbon dioxide (CO2) gas medium as a means of knee joint distension during arthroscopy is a safe and effective method, compared to traditional fluid arthroscopy. This prospective randomized comparative study involved 94 patients undergoing the same arthroscopic ACL reconstruction surgical procedure except for the medium used to distend the joint: In a first group of 48 patients (“ACL gas” group), CO2 insufflation was mainly used, at a low pressure of 40–50 mmHg, alternating with a fluid medium for knee joint washout only. In the second group of 46 patients, classical arthroscopic joint distension by fluid was used, with a pump pressure of 50–70 mmHg. Early pre- and post-operative complications, duration of surgery, intraoperative monitoring data and particularly the end-tidal carbon dioxide (EtCO2) as a marker of CO2 blood diffusion were prospectively collected. EtCO2 and other monitoring data changes before and after tourniquet release were not different between the two groups. Tourniquet time was significantly longer when using fluid rather than gas. We observed 3 cases of small and localized subcutaneous emphysema, resolving completely within hours. Hematoma and reflex sympathetic dystrophy occurred more often in the “ACL fluid” group, with no statistical significance. Low-pressure CO2 knee joint insufflation proved to be a safe technique capable of improving surgical comfort compared with the use of fluid alone. The CO2 blood diffusion measured by end-tidal carbon dioxide monitoring during ACL arthroscopic reconstruction was similar with or without gas insufflation. Randomized controlled trial, Level I.

Chloroquine-proguanil association is recommended for prophylaxis against falciparum malaria in countries with a low prevalence of chloroquine resistance. It is usually well tolerated with mild side effects consisting mainly of transient digestive discomfort and buccal manifestations (mouth sores or ulcers). The purpose of this report is to describe a case of duodenal ulcers presenting as epigastric pain with 10-kg weight-loss in a 32-year-old man taking chloroquine-proguanil for malaria prophylaxis during a stay in Haiti. No other causes of duodenal ulcers or weight-loss were found. Chloroquine-proguanil prophylaxis was discontinued and replaced by omeprazole for four weeks. Symptoms improved quickly and full recovery was observed within one month. To our knowledge, the occurrence of duodenal ulcers under chloroquine-proguanil association is quite rare, but possibly severe. Upper digestive endoscopy should be performed if a patient under chloroquine-proguanil develops abdominal pain especially in association with weight-loss. If endoscopy reveals duodenal ulcers, chloroquine-proguanil should be discontinued and replaced by another prophylactic regimen.

International audience; Since the start of 2010 there has been a flare-up of measles in France, following on the resurgence observed in 2008. The aim of this study was to present results of the epidemiological surveillance of measles in the French armed forces and to describe the increase in incidence. Measles was surveyed from 1992 to 2010. Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were provided by the physicians in the armed forces using anonymous data collection forms. Between 1992 and July 2010, 689 cases of measles were notified. Since 2002, the mean incidence rate was 1 case per 100,000. A significant increase has been observed for 2010 (13.9 cases per 100,000 in 2010 versus 1.8 in 2009). The 28 cases reported in 2010 involved five clusters and three isolated cases. The mean age of affected subjects was 27 years. Only 30% of cases had been vaccinated. The epidemic resurgence of measles observed in 2010 in the French armed forces follows the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination cover.

To describe the epidemiological and clinical features of enteroviral meningitis as well as the biological profile of the cerebrospinal fluid (CSF).A retrospective study conducted in a single centre between 2004 and 2008. All aseptic meningitis due to Enterovirus were included.Fifty-nine patients were included. The triad including fever, headache and neck stiffness was reported in 62% of patients. Twelve patients (20%) had a neutrophilic leukocytosis and 23 (39%) an elevated CRP level. Twenty-eight patients (47%) had a prominent neutrophilic reaction in the CSF and nine (15.2%) had a low glucose concentration. A presumptive anti-bacterial treatment was initiated in 47 patients (80%) for an average of 3.2 days.Due to the lack of specificity of clinical features and biological manifestations of Enterovirus meningitis, the widespread use of real-time Enterovirus PCR is a priority for reducing the number of unnecessary anti-bacterial treatment. Guidelines based on clinical and biological features may be associated to help physicians in the differential diagnosis between bacterial and viral meningitides.

Intracranial suppurations (ICSs) are poorly assessed in sub-Saharan Africa, especially in children.A retrospective study from 1st January 1996 to 31st December 2004 in children admitted to the pediatric department of the Hôpital Principal de Dakar, Senegal, for a sinogenic or otitic ICS. All cases were diagnosed by CT scan.Sixteen children (12 boys and 4 girls), mean age of 11.2 years (range, 7-15 years), were admitted with the primary diagnosis of ICS. The mean time from the beginning of fever or neurological disorders to admission was 12 days (range, 1-60 days) and 6 days (range, 1-22 days), respectively. At admission, fever was noted in 14 patients and neurological signs in all patients. Otolaryngologic infections were sinusitis (n=14) or otitis (n=2). ICSs were subdural empyema (n=8), single (n=6) or multiple (n=1) cerebral abscesses, or association of subdural empyema and cerebral abscess (n=1). Bacteriological cultures were seldom positive because of frequent previous antibiotic therapies and showed Staphylococcus aureus (n=2), nongroupable Streptococcus (n=1), or Pseudomonas aeruginosa and Proteus mirabilis (n=1). Antibiotics were given initially intravenously for 30 days, then orally for 30 days. Additionally, some patients received corticosteroids (n=4) or phenobarbitone (n=9). Aspiration drainage of the ICS was undertaken in 13 patients. All the children were cured, 4 of whom had neurological sequelae at follow-up.This pediatric series provides important data on the characteristics of ICS in sub-Saharan Africa. Therapeutic measures adapted to this context are proposed.Access to CT scan was fundamental in guiding medical and surgical management and ensuring a mostly favorable outcome despite long delays in treatment initiation.

An outbreak of cutaneous leishmaniasis occurred among 71 soldiers who had participated in various missions during a 4-month's period in French Guiana. The aims of this study were (i) to describe outbreak and (ii) to determine risk factors of cutaneous leishmaniasis.All patients were hospitalised. Cutaneous lesions were biopsied and cultured for species identification. Individual information was collected by a physician or a nurse, using on a standardised, anonymous chart. Data were processed with EpiInfo 6.04 and SAS.Mean age of the 71 soldiers was about 25.9 years (19-37 years). Twelve soldiers presented 56 lesions due to Leishmania (Viannia) guyanensis (attack rate = 16.9 for 100). Among 56 lesions, 13 lesions were localized on the trunk, usually an unexposed body area. Logistic regression highlighted military exercises in the forest during a high risk period of leishmaniasis transmission (OR = 11.2; p0.01), and the young age (OR = 1.33; p = 0.04). Vector control measures were not statistically significant.Military authorities should restrict deep forest activities during periods of high risk transmission. Vector control measures are essential. Officers should motivate their soldiers and supervise vector control measures. As ecotourism is developing, tourists as well as workers staying in deep forest must be informed of the risk and about vector control measures.

The influence of age on the clinical presentation of severe malaria and especially on its 2 most commonly encountered manifestations, cerebral malaria and severe anaemia, has been retrospectively examined in 161 children (< 16 years old) admitted to the paediatric department of Hopital Principal de Dakar from 1 January 1990 to 29 February 1996. They lived in Dakar and its suburbs, a region of Senegal where the malaria transmission rate is very low. Cases were defined by at least one of the World Health Organization criteria of severe malaria and the presence of Plasmodium falciparum in blood smears. Severe anaemia was present in 73.1%, 52.1% and 26.2% cases of severe malaria among children aged 0-3 years, 4-7 years and 8-15 years, respectively (P < 0.0001). The frequency of cerebral malaria was 11.3%, 28.2% and 60.6%, respectively, in the same age groups (P < 0.0001). Severe anaemia and cerebral malaria were associated in 8.7% of the cases of severe malaria. The fatality rate was significantly lower in cases of severe anaemia without cerebral malaria (3%) than in cases of cerebral malaria without severe anaemia (17.5%; P < 0.02). Among young children, severe anaemia was associated with brief hyperparasitaemia or with prolonged lower parasitaemia. Other things being equal, older children had a lower risk of severe anaemia. The results suggest that the high prevalence of severe anaemia in young children, even in an area of very low endemicity, depends more on age and parasitaemia than on the transmission level.

Campylobacter fetus subspecies fetus is an opportunist Gram-negative bacillus, which is known to be a cause of systemic infections, mainly in immunocompromised patients. We report a C. fetus bacteremia and cellulitis complicating a venous access port infection in a patient with acquired immunodeficiency syndrome (AIDS). This bacillus seems to have a predilection for the vascular endothelium and its isolation is difficult. Physicians should be aware of C. fetus infection in patients with vascular devices. Microbiologists should accurately isolate this organism from clinical specimens by modifying incubation techniques and performing molecular biology. The prognosis seems to be improved by a prolonged betalactam antibiotic regimen, especially amoxicilline plus clavulanic acid. In HIV infected patients, quinolones that were successful in our case, should be used with caution because of increasing resistance to antibiotics.

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

The incidence of childhood heart disease in developing countries is high, but access to cardiac surgery is limited. This mismatch has given rise to numerous humanitarian programs aimed at sending children abroad for surgical treatment. However little is available about the long-term outcome of these interventions. In 1999 we conducted a retrospective study of 168 Senegalese children undergoing follow-up at the Principal Hospital in Dakar after being transferred to Europe or the Ivory Coast for surgical treatment thanks to the Terre des Hommes Association. A total of 85 children presented congenital heart disease (CHD) and 83 presented acquired heart disease (AHD). Fifteen patients did not undergo surgery due to either contraindications or preoperative death. At the end of study, 23 children had been lost to follow-up mostly from the CHA group and presumably some were cured. Outcome was verifiable in the remaining 145 patients with a median follow-up of 5.6 years. Ninety-seven patients were cured or undergoing surveillance. Quality of life was better in the CHD group (p = 0.047). Forty-eight patients died including 16 in the CHD group and 32 in the AHD group. Perioperative mortality (n = 19) was lower and late mortality (n = 29) was higher in the AHD group (p = 0.005). In the AHD group compliance with surveillance was better for children with valve prostheses. In children treated for isolated mitral valve insufficiency, late mortality was higher after valve replacement than valve repair (p = 0.04). In absence of comparative study data, high mortality was due in part to the long delay between the decision to send the patient abroad and the actual evacuation. These findings support humanitarian action to promote cardiac surgery in developing countries.

Childhood cancer has often been considered as a problem mainly affecting industrialized countries. In reality more than half of cases occur in developing countries where management and diagnosis are major issues. This retrospective study includes 130 children (0.3% of admissions) between the ages of 0 and 15 years hospitalized for malignant disease at the Principal Hospital in Dakar, Senegal between January 1, 1990 and December 31, 2000. Mean age was 97 months and M/F sex ratio was 1.2. Mean delay for admission was 3 months. The five most frequent cancers, accounting for 75% of cases, were leukemia (n = 28), lymphoma (n = 21), nephroblastoma (n = 21), retinoblastoma (n = 16) and osteochondrosarcoma (n = 10). Treatment was completed in 18% of cases. Half of patient were lost from follow-up. The cure rate was 10% overall and 50% for patients receiving complete treatment. The highest cure rate was achieved for nephroblastoma, i.e., 58% of cases treated. Management of childhood cancer in Africa is confronted with numerous problems, namely, paucity of specialized staff, absence of expert centers, shortage of anticancer drugs, lack of financial resources, and delay in treatment. These factors associated with frequent malnutrition and recurrent infectious diseases, greatly lower cure rates in comparison with industrialized countries.

Pentavalent antimony (PA) compounds remain the main therapeutic agents of cutaneous leishmaniasis (CL). CL infection resistant to PA is difficult to cure, limited by severe side effects and requiring a long course treatment of parenteral administration of recommended second line drugs. We report a case of CL unresponsive to meglumine antimoniate contracted in Djibouti, successfully treated with a short course treatment of AmBisome. In this case the subject had a recurrent thick crusted erythematous lesion on his left elbow associated with spreading micropapula on arms and thorax. The diagnosis of CL was confirmed by direct examination and genomic amplification by PCR of skin samples, cultures were negative. A short course treatment of parenteral AmBisome (18 mg/kg) has lead to clinical cure with no side effects and no relapse. In our hospital, the high cost of medication was counterbalanced by easiest administration, reduction of hospitalization duration, absence of adverse events and a gain of comfort. For this patient, a short course treatment of AmBisome proved to be a suitable alternative to traditional drugs used in CL resistant to PA.

Since the Diama dam on the Senegal river became operative in 1986, an exceptional outbreak of intestinal schistosomiasis occurred in northern Senegal. This is the first case report from this region of a splenorenal derivation performed in Dakar to cure decompensated portal hypertension due to Schistosoma mansoni.In June 1998, a 16-year old boy, native from Richard-Toll in the Senegal River Basin, was admitted to the paediatric department of Hôpital Principal, Dakar, Senegal, with a 3 years of recurrent hematemesis. Blood transfusions were required despite propranolol and multiple oesophageal varices sclerotherapies. On admission he weighed 33 kg and was noted to have pallor and moderate hepatosplenomegaly. Lab work included normal liver function tests, a Hgb of 58 mg/L, negative HBs antigen, and high titers of schistosomiasis antibodies (1/2000 by the hemagglutination method). Ultrasound revealed an homogeneously enlarged liver, periportal fibrosis and spleen with a grade 2 portal hypertension (WHO score). Endoscopy showed stage 3 oesophageal varices with red spots but no active haemorrhage. After transfusions, a Warren distal splenorenal anastomosis was performed. During the operation, a liver biopsy was obtained, showing periportal fibrosis and schistosomiasis granulomas. The patient was discharged without complication. After 4 years he remains free of any recurrence of his upper gastrointestinal haemorrhage and haemoglobin rate is normal.Before the inauguration of the dam in 1986, S. mansoni infection was never reported from the Senegal River Basin. But as early as 1988, the first cases of intestinal schistosomiasis began to show up. A few years later, this focus had dramatically extended and in 1991 the first cases of hepatic fibrosis were detected in ultrasonography surveys. The present case involves the first patient from northern Senegal who required surgery for haemorrhagic complications of schistosomiasis induced by liver disease. Considering the high prevalence in this area, and the difficulties of medical management, the need for porto-systemic derivations is likely to rise. These operations are difficult and require specially trained surgeons. They have been largely unavailable in Senegal until now. This case report, involving a child only 10 years after the beginning of the epidemic, underlines the acute need for improving both prevention and medical treatment in order to avoid progression to clinical stages of hepatic schistosomiasis where surgery is unavoidable. In addition, the training of local surgical teams able to deal with these complications is urgently needed in Senegal.

Spontaneous splenic ruptures are rare but life-threatening complications of infectious diseases. Splenectomy is still the treatment of choice but numerous recent reports have documented favorable outcome with conservative treatment.We report three cases of splenic rupture occurring respectively with infectious mononucleosis, P. vivax infection and dengue fever. Diagnosis, treatment and indications are reviewed, an approach to management is suggested. The study included three military men respectively aged 23, 24 and 35 years, admitted for acute abdominal pain in the left upper quadrant. The abdominal computed tomography confirmed partial rupture (splenic hematoma) in the first two cases, and an hemoperitoneum in the dengue case. Splenic ruptures can reveal or complicate an evolving infection. Rupture can happen spontaneously or as a result of trauma, which may be minor and unnoticed. The typical presentation is acute, but progressive forms are described. The diagnosis is made by ultrasound and CT scan. Splenectomy dogma tends to be supplanted by conservative treatment. Non-operative management can be successful if appropriate criteria and a long period of follow-up are applied in carefully selected cases. When an operative approach is selected, conservative surgical treatment is attractive. Splenectomy should be reserved for patients with uncontrollable rupture or with recurrent splenic bleeding.Spontaneous splenic rupture are uncommon in infectious diseases. A multidisciplinary management is necessary. A conservative treatment should be considered in selected, closely monitored patients.

To determine the importance of prolonged QT interval and electrocardiographic changes in children treated with halofantrin for an acute malaria attack.Out of 25 children treated with halofantrin, nine had an increase of QTc interval440 ms and ten a QTc440 ms on control 24 h after the first dose. A 9-year-old girl, treated with halofantrin, had bradycardia and increase of QTc interval for six days, with a normal halofantrin blood level.These data show that cardiac monitoring during halofantrin treatment is mandatory in children as in adults. Contraindications of halofantrin treatment must be respected, particularly a long congenital QT interval.

Flexor tendon rupture in the palm of the hand is very infrequent. It usually occurs in association with an underlying pathological condition. We report a case of hand tendon rupture in a patient with osteogenesis imperfecta (OI). This disease is typically characterised by brittle bones but other tissues rich in collagen, such as tendons, may also be involved. The ruptured tendon was diagnosed one month post-injury and was treated by tendon graft. Six months later, tenolysis was performed and one year post-injury flexion was still limited at the distal interphalangeal joint. Few cases of tendon lesions and OI have been reported in the literature. Rupture occurs at the bony insertion and the outcome is good the poor outcome in our case could be due to alteration of the collagen tissue of the tendon.

Management of blood eosinophilia in travelers returning from the tropics is controversial. In this prospective study, 102 asymptomatic tropical travelers underwent investigation and treatment for hypereosinophilia. In contrast with direct tests for parasitic infection which were positive in only 15% of cases, immunological tests were suggestive of helminthic infection is 77%. The most common diagnoses were toxocarosis (49%), strongyloidiasis (30%), and filariasis (19%). Anti-parasite treatment was undertaken based on laboratory findings (12 cases) or on presumptive diagnosis using two-agent therapy (ivermectin and praziquantel) in 13 cases or three-agent therapy (ivermectin, praziquantel, flubendazole) in 77 cases. As a result of treatment, eosinophil count returned to normal in 61% of cases and decreased in 30%. These findings suggest that presumptive treatment of blood eosinophilia can be undertaken in tropical travelers using three anti-parasitic drugs: ivermectin (1 x 0.4 mg/kg), flubendazole (2 x 100 mg per day for 3 days), and praziquantel (1 x 40 mg). As a precaution before using ivermectin, tests should be performed to detect loiasis which can lead to adverse reactions.

We report a case of human African trypanosomiasis caused by Trypanosoma brucei rhodesiense. After the febrile period of parasite dissemination, the patient had meningeal involvement but normal CT. MRI showed the appearances of meningitis. After two periods of arsenical treatment, a severe encephalopathy occurred suggesting post-therapeutic reactive encephalitis (PTRE). Nevertheless, T2-weighted MRI showed no oedema, but focal bilateral high signal areas in the white matter. PTRE was excluded and a third course of treatment was undertaken. The lesions progressively disappeared.

The influence of age on the clinical presentation of severe malaria and especially on its two most commonly encountered manifestations, cerebral malaria and severe anaemia, has been retrospectively examined in 161 children (16 years old) admitted in the paediatric department of Hospital Principal de Dakar from January 1st 1990 to February, 29th 1996. They lived in Dakar and its suburbs, a region of Senegal were the malaria transmission rate is very low. Cases were defined by at least one of the World Health Organization criteria of severe malaria and the presence of Plasmodium falciparum in blood smears. Severe anaemia was present in 73.1%, 52.1% and 26.2% cases of severe malaria among children aged 0-3 years, 4-7 years and 8-15 years, respectively, (p0.0001). The frequency of cerebral malaria was 11.3%, 28.2% and 60.6% in the same age groups, respectively, (p0.0001). Severe anaemia and cerebral malaria were associated in 8.7% of the cases of severe malaria. The fatality rate was significantly lower in cases of severe anaemia without cerebral malaria (3%) than in cases of cerebral malaria without severe anaemia (17.5%; p0.02). Among young children, severe anaemia was associated with brief hyperparasitaemia or with prolonged lower parasitaemia. Other things being equal, older patients had a lower risk of severe anaemia. The results suggest that the high prevalence of severe anaemia in young children, even in an area of very low endemicity, depends more on age and parasitaemia than on the transmission level.

The authors describe three cases of Histoplasma capsulatum histoplasmosis that occurred in black AIDS patients living in France but originally from Guinea and Ivory Coast. In all three cases histoplasmosis was disseminated with fever. In two cases there were cutaneous manifestations. One patient had renal insufficiency and nephrotic syndrome and another presented ulcerative colitis with histoplasma in the chorion. The outcome was favorable in two patients. These three cases are in addition to the five previously reported cases in african AIDS patients. These cases stress the need for awareness of this opportunistic infection as a complication of AIDS in patients from Black Africa.

Most authors agree on the importance of medial meniscus preservation in the case of A.C.L. reconstructive surgery. The purpose of this study was to analyze the anatomical results of sutures of medial meniscus tears by the means of arthrography.Medial meniscus 42 sutures for peripheral tears at the posterior horn (length between 10 and 50 mm, 70 per cent greater than 20 mm) had been performed through an open procedure using a posterior approach. The average age of the patients was 24 years (17-54) with a clear male predominance (64 per cent). The average age at the time of injury was 22 years, 6 months.The patients were operated on by the same surgeon, with the same technique. Resorbable sutures were used spaced every-3 mm, and tightened outside the joint. The A.C.L. was reconstructed by a bone-patellar tendon-bone technique (modified K.G. Jones). A first series of 13-patients were no weight bearing allowed for 6 weeks post-operatively. A second series of 29 patients were allowed immediate partial weight bearing. All the patients were permitted active flexion. All the patients had been examined with a minimum of 6 months follow-up. They were all controlled clinically (results evaluated with the I.K.D.C. score) and with passive dynamic X rays to measure residual laxity. 32 patients had an arthrogram before the operation in the aim to compare with the postoperative arthrogram. 30 patients had an arthrogram after an average of 21 months. 12 patients refused follow-up arthrograms. 9 patients had arthroscopy for pain or effusion.All the patients obtained a range of flexion-between 90 degrees and 110 degrees at 4 weeks. A flexed contracture of 10 degrees was noted in only 1 case. Meniscal functional results were good for 32 cases after a mean follow-up of 4 years and 4 months. Arthrograms in 30 cases showed no residual tear in 19 cases (63 per cent), 3 cases had incomplete healing and 8 cases had failed. The healing was influenced by the size of the tear, its situation near the posterior wall. In the first series (no weight bearing), there were 2 failures for 9 cases and 6 out of 21 in the second series and 3 incomplete healing. There was no correlation between meniscal functional results and functional ligamentous results evaluated with the I.K.D.C. score. 9 patients had an arthroscopy and 7 out of them a meniscectomy (after 17 months 3).This study confirms the possibility of healing following suture of peripheral medial meniscal tears in the case of ACL reconstructive surgery (even if the tear is long). The use of arthrogram, before the operation and for anatomical control after the operation, ensures complete healing (better than M.R.I. for the suture control). Arthrography is certainly a less invasive technique than arthroscopy.

Polysomnography was performed in two military personnel who contracted human African trypanosomiasis (HAT) in Rwanda. They were evacuated to France and gramined during the fourth, sixth and eleventh months of evolution. Patient A presented a meningoencephalitis with Trypanosoma brucei rhodesiense (T. b. r.) in the cerebrospinal fluid. Between the second and third treatments with melarsoprol, the patient presented an acute encephalitic attack with pyramidal and cerebellar symptoms, which were improved by corticotherapy and disappeared progressively in 6 months. Patient B presented a major inflammatory syndrome with T. b. r. in the blood and the medulla. Cerebrospinal fluid and serology remained normal. The patient received only one session of melarsoprol treatment. Polysomnography recordings were continuously taken on an ambulatory Oxford Medilog system during 48 hours. The different stages of vigilance were scored according to the classical Rechtschaffen and Kales criteria. During the fourth month, both subjects presented several long diurnal naps, with the presence of rapid-eye-movement sleep at the end of the sleep episodes. These abnormalities disappeared progressively during the following recordings. Electroencephalographic abnormalities were observed in patient A, particularly during the eleventh month. They consisted in transitory arousal phases concomitant with myoclonic jerks and with the persistence of slow waves during slow-wave sleep. The various anomalies noted in the two patients allow us to recommend the supervision of the evolution of HAT by polysomnographic recording in a sleep laboratory.

A case of rupture of the spleen is described secondary to dengue 1 fever in an adult patient. This exceptional complication occurred during an outbreak of dengue in French Polynesia. After failure of conservative management, splenectomy was performed. Examination of the surgical specimen confirmed softening and enlargement organ with the formation of a subcapsular hematoma.

Up till now, in the French Polynesia and in New Caledonia, people showing ciguatera intoxication receive a standard treatment: calcium + vitamins B6 and C by intravenous way and in addition, some drugs arriving to cure some symptomatic manifestations. In 1988, an investigation carried out in Majuro, Marshall Islands concluded that intravenous mannitol is efficient in the treatment of serious intoxications with suspecting cerebral oedema. Since, such a treatment has been utilized with success in several endemic areas. Our therapeutic evaluation was arrived to determine whether mannitol's efficiency is higher than the standard treatment in the ciguatera intoxications of mean seriousness. This investigation was carried out on two randomized groups: The first one receiving mannitol (250 cc intravenous at 20% injected in 1 h) the second one receiving the standard treatment (intravenous perfusion glucose serum 250 cc with 1 g of vitamins C, 250 mg of vitamin B6 and 1 g of calcium gluconate injected in 1 h). Seriousness of clinical status was evaluated according to a scale of score from 0 to 50, based on the importance of the clinical manifestations paresthesia, aches, asthenia, cardiovascular and digestive signs. Only patients getting a score at least 20 were included in this investigation. Clinical status of each patient was evaluated before any treatment (initial score) at the end of perfusion and at the 24th hour. Efficiency of each treatment respectively was evaluated according to the differences between these three different scores. CHI 2 and U Mann's and Whitney's tests were utilized for the statistical analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report a retrospective study of 25 cases of hepatic amebiasis which were observed from 1988 to 1990 in Tahiti. The symptoms were typical in 20 patients and incomplete in 5 other patients. The ultrasonic examinations showed one (n = 14) or several abscesses (n = 11). The majority were located at the right lobe of the liver (84%). Except in one case where the abscess had a high echo response (it was a pseudo-tumour), the others showed a low echo response or were liquid. The serology (hemagglutination) was always positive but once, at the first examination or afterwards. Recovery was obtained by all patients on an average of 6 days for clinical signs and of three months for ultrasonic features, by administering Metronidazole, combined twice with a drainage (transcutaneous = 1 case, surgical = 1 case). Neither rupture, nor relapse occurred. This series is related to other studies made in South Pacific, Africa and France. It underlines the topicality of amebiasis in French Polynesia, and the interest for the Health Services to carry out a program against this endemy.

The conjunctival and corneal lesions usually observed in the floppy eyelid syndrome are benign and reversible as soon as the specific treatment of superior palpebral hyperlaxity is performed. A case of bilateral corneal vascularization, a rare but severe complication of floppy eyelid syndrome is reported. The floppy eyelid syndrome was identified late because keratoconjunctivitis was clinically predominant and palpebral tonicity was not initially considered. The treatment of palpebral hyperlaxity was the prerequisite for good results with keratoplasty.

Introduction Since the recent descriptions of the anterolateral ligament (ALL), the role played by the anterolateral peripheral structures in the rotational control of the knee is again being debated. The objective of this study was to identify the structures during internal tibial rotation and then to define their anatomical characteristics. We hypothesized that internal rotation would tighten several anatomical formations, both superficial and deep, with the ALL one part of these structures. Material and methods Nine fresh-frozen cadaver knee specimens were studied. The anterolateral structures tightened were identified from superficial to deep at 30° of flexion. Each was selectively dissected, identifying its insertions and orientations, and measuring its size. The length variations of the ALL during internal tibial rotation were measured by applying a 30-N force using a dynamometric torque wrench at the tibiofibular mortise. Results The superficial structures tightened were the iliotibial tract and the Kaplan fibers. In internal tibial rotation, the Kaplan fibers held the iliotibial tract against the lateral epicondyle, allowing it to play the role of a stabilizing ligament. The Kaplan fibers were 73.11 ± 19.09 mm long (range, 63–82 mm) and at their femoral insertion they were 12.1 ± 1.61 mm wide (range, 10–15 mm). The deep structures tightened covered a triangular area including the ALL and the anterolateral capsule. The ALL was 39.11 ± 3.4 mm long (range, 35–46 mm) in neutral rotation and 49.88 ± 5.3 mm long (range, 42–58 mm) in internal rotation (p

Results of dorsal sympathectomy in patients (67 operations) for vasomotor disorders of the upper limbs were assessed after follow-up for between 6 months and 15 years, in order to determine the best indications for surgery. Based on clinical results, sympathectomy should be performed not only when medical treatment fails, but also in the presence of a severe clinical picture of trophic disturbances or pain of the ischemic type. Two types of investigation are essential before deciding on operative therapy:--plethysmography with a hyperemia test,--arteriography of the hand. Assessment of results as a function of etiology demonstrated that they were excellent in cases of hyperhidrosis, very satisfactory in atheromatous digital arteritis or a thoracic inlet syndrome (associated with rib resection in the latter case), but only moderately good in scleroderma or post-traumatic lesions. Finally, Raynaud's disease or thromboangiitis do not appear to be indications for this operative procedure.