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The authors make an inventory of the difficulties they have met while realizing the different stages of MDT treatment programmes in Senegal. Main problems were: Necessity of complementary training on theoretical, but even more on practical techniques for all the staff: Ridley and Jopling classification, neurological examination, bacteriological examination, data collection. Difficulty to maintain a true supervision. Necessity to settle a quality control of slit skin smears. Necessity to settle a system to trace irregular patients. Heaviness of centralized management, but its necessity to maintain "tightness" of the drugs distribution network. Difficulty to obtain a regular follow up of patients who are released for treatment. The evolution of anti-leprosy activities makes it necessary to adapt the "Service des Grandes Endémies".

An immunoperoxidase reaction was used for the titration of immunoglobulins G and M antibodies to BCG in 171 leprosy patients from Dakar. The results show mean titers decreasing from lepromatous to tuberculoid cases. The antibody profiles of some clinical forms such as reverse reactions, erythema nodosum leprosum are discussed. This test associated to the Mitsuda reaction, bacteriology and histology should allow an easier classification of the borderline forms. The main advantages of the technique are simplicity, speed, low cost and the easy availability of the BCG. These qualities are essential in endemic zone.

A new blood culture instrument, the BACTEC (Johnston Laboratories, Inc., Towson, Md.) NR-660, which utilizes infrared detection of carbon dioxide from microbial metabolism, was compared with the radiometric BACTEC 460 system. There were 1,554 isolates from 18,785 paired aerobic blood cultures. Of these isolates, 1,303 were isolated from the radiometric 6B medium, and 1,259 were isolated from the NR6A medium (P = 0.06). Analysis of the data indicated no significant differences in recovery when any individual species was considered. When organisms were considered as groups, there were no significant detection differences for gram-negative bacilli, yeasts, or anaerobes. For gram-positive cocci in aerobic medium, the BACTEC 460 detected 84.3% of the total isolates, and the BACTEC NR-660 detected 79.7% (P = 0.04). There were 891 isolates from 13,983 paired anaerobic blood cultures. Of these isolates, 725 were recovered from the radiometric 7D BACTEC medium, and 723 were recovered from the NR7A BACTEC medium (P greater than 0.9). In the anaerobic media there was no significant difference in detection of any organism group, including the gram-positive cocci. When the results of the aerobic and anaerobic media were combined, there was equivalence between the two systems for the detection of gram-positive cocci (P greater than 0.2) and other organism groups. When the ability to detect septic episodes was compared, there was no significant difference for any organism group (P = 0.12). For aerobic media, the mean times for detection were 30.5 and 29.5 h for the BACTEC 460 and NR-660, respectively. For anaerobic media, the mean times for detection were 39.8 and 41.6 h for the BACTEC 460 NR-660, respectively. Compared with the BACTEC 460, the BACTEC NR-660 system had a greater ease of operation, faster test cycle, computerized data base, and equally rapid detection of positive cultures.

The authors give the results of their cytological and bacteriological examinations of the cervix and vagina carried out routinely in a laboratory. They emphasize, in detailing their method of working, the criteria that they feel must be adopted in an attempt to code the qualitative appraisal of direct examination and the result of studying the cultures. The first part of the paper deals with an overall survey of the 4,573 examinations which were carried out over a period of 8 years. The second part is concerned with a more detailed analysis of the 883 samples which were divided into 4 categories: pregnant women, those having oral contraception, those with an intra-uterine device, and others. There are several variations revealed between these 4 categories as far as the white cell count, the bacterial flora and even pathogenic organisms are concerned.

The authors first explain the main epidemiological parameters of leprosy in Dakar, their evolution and their differences with those of the rest of the country. The second part deals with case finding and reveals the essential importance of the voluntary detection which appears as rather early: 3.5% of second degree physical disabilities; 37% of monomacular lesions in the paucibacillary lesions. The third part explains the problems encountered on leprosy control with the study of a cohort of 241 patients: 64% were missing in 4 years and half of them during the first year. At the end of 4 to 6 years, only 19% of the patients had a regular attendance at treatment. The defects are significantly more frequent with the male patients, and with the people who have been residing in Dakar for less than two years. In the suggested solutions, the authors insist on the necessity to adopt short multidrug protocols and to make health education for patients so that they care about case finding with their contacts.

Modern treatment of leprosy must take into account the contagiosity of the disease and the risk of inducing the appearance of drug resistant strains. It must be adapted to the estimated charge of bacilli presented by the patient and, in all possible extent, ambulatory. Several therapeutic schemes are proposed. A periodic monitoring of the patient and of its human environment is necessary.

Our recent segregation analysis, carried out on 27 large pedigrees from a Caribbean island (Desirade), has shown the presence of recessive major gene(s) controlling susceptibility to leprosy per se and nonlepromatous leprosy, respectively. Linkage analysis was performed between each of these two detected genes and each of five markers typed in the Desirade population: HLA, ABO, Rhesus, Gm and Km. No positive significant lod score was observed. However, for leprosy per se close linkage was excluded with Rhesus and Gm (and also with ABO and HLA, considering a lower value for the frequency of the gene controlling susceptibility to leprosy per se). The highest lod score, although not significant, was obtained between the gene for nonlepromatous leprosy and ABO. Our overall results, joined with previous studies and experimental data, suggest that the gene controlling susceptibility to leprosy per se and that controlling susceptibility to nonlepromatous leprosy might be different, acting at successive stages of the immune response to infection with Mycobacterium leprae.

Unlabelled: This work was undertaken because there were only few reports on neurological aspects on lepromatous leprosy. We studied 30 patients suffering from lepromatous leprosy who, at their first visit to the Institute had never been treated. The clinical examination included a quantitative evaluation of the neurological status following the method developed by Pearson. Motor and sensory nerve conduction velocities were measured: values of conduction velocity and distal amplitude were analysed and compared to those of a group of 22 healthy subjects., In Conclusion: (a) There is a high frequency of clinical and especially electrophysiological neurological impairment. This impairment can be extremely precocious and may happen shortly after the first cutaneous signs. (b) Nervous impairment is diffuse, bilateral but not homogeneous. These are characteristics of mononeuritis multiplex. Impairement is predominantly sensitive and tactile sensibility is more involved than thermo-algic sensation. (c) The radial superficial nerve is the most frequently involved clinically and electrophysiologically. (d) The electrophysiological results, showing a normal or slightly reduced conduction velocity and a low amplitude of evoked potentiel are in favour of a predominantly axonal damage.

A study is presented about the evolution of the breast cancer mortality in Spain between 1961 and 1980. This has been increasing strongly of several factors: 1) In actual increase of this disease, rising its adjusted death rates by age from 8/100,000 (1961) to 13/100,000 (1980) (increase = 62%); the truncated standardized rates between 35 and 64 years raised from 18/100,000 (1961) to 28/100,000 (1980): there is high correlation between both types of rates. 2) An increase of the female population at breast cancer risk (over 45 yr). A selective and significative rise of mortality from this cancer for the age groups under menopause, especially for the group 30-34 years (160%). The increase of female breast cancer mortality is statistically significant. It is necessary researching the causes of such increase.

The French department of Guadeloupe gets good health structures and a high number of physicians in regard to its population. The Institut Pasteur of Guadeloupe is in charge of the leprosy control, with a team of specialized physicians who are in the same time microbiologists. The control methodology must take into account the fear still caused by the disease in the population, the patient's request to remain anonymous, the rquirements of the law concerning the notification and the registration of every new patient, and the real contagiosity of leprosy. In thirty years, a pragmatic, effective and not too compelling approach has been set up. A full cooperation, has been developed between the private practioners, the Public health service with its hospitals for specialized treatments, and the Institut Pasteur in charge of epidemiological control.

Increasing resistance to dapsone (DDS) leads to recommend triple drug chemotherapy (TCT) in multibacillary leprosy (ML). To determinate long term evolution, we evaluated patients who received TCT 8 years ago. Between 1974 and 1976, 30 patients with ML received TCT (rifampicin, prothionamid, and DDS) during 6 or 12 months. At this time satisfactory clinical and bacteriological findings were reported, and from then DDS was given alone. Twelve of the thirty patients have been evaluated in 1983. Six patients had bacteriological index greater than or equal to 2+, three of them had clinical relapse. Seven of the twelve patients did not take regularly DDS; the six relapses belong to this group.

50 lepromatous patients among whom 34 shared repeating ENL reactions and a reference group of 150 blood donors were typed for HLA antigens. In the comparison of the lepromatous group to the reference group, the HLA-B 8 was the only antigen which turned out to be significantly increased within the lepromatous patients. Some changes reported by other authors have also been pointed out (decrease in HLA-A2 and HLA-A3, increase in HLA-AW 23 within the lepromatous patients) but those are not significant in this study. In the lepromatous group itself, not any significant change has been pointed out between the patients sharing ENL and those who did not show any. Nevertheless a non-significant increase in HLA-BW 35 in the patients with ENL is to be pointed out.

Screening of abnormal hemoglobins on 25 136 samples allowed us to detect from 1974-1979 rare or uncommon hemoglobins as N Baltimore, Korle Bu, Lepore, K Woolwich, J Broussais and J Baltimore. Hemoglobins N Baltimore, J Broussais, and J Baltimore are detected for the first time in Guadedoupe. The identification of these asymptomatic hemoglobins in this part of the Carribbean region provides information concerning the exact origin of the black population of these islands; e.g., hemoglobin K Woolwich and N Baltimore are found only in specific regions of West Africa.

Time trends and the geographical variation of mortality from gastric cancer in Spain are analysed. The national (1961-1980) and the provincial (1975-1980) crude death rates as well as the age adjusted death rates were calculated using the population census (years 1960 and 1970) and the figures for national and provincial mortality. Mortality increased until 1963-1965 and then decreased significantly (P less than 0.01). Analysis of the geographic distribution reveals that the mortality rate is significantly higher in the interior than in the coastal provinces of the country, and higher in the provinces over 600 m above sea level.

Three patients with visceral Staphylococcal aureus infections, but no evidence of endocarditis, developed signs of acute glomerulonephritis. Renal biopsy in two patients showed a mesangial proliferative glomerulonephritis and mesangial deposits containing IgA, IgG, and C3; autopsy material in a third patient showed acute diffuse proliferative glomerulonephritis. The clinical setting and pathologic findings of our patients with visceral Staphylococcal infection and glomerulonephritis are different than those found in the better-understood syndromes of glomerulonephritis associated with endocarditis or infected ventriculojugular shunts. Our patients provide support for the contention that some cases of primary or idiopathic glomerulonephritis may by caused by Staphylococcal infections.

A mass case-finding survey has been carried out among the pupils as a test measure: in an ordinary rural village: 2204 examined children; prevalence rate of leprosy: 0.90 per 1000; in two leper villages: 333 examined children; prevalence rate of leprosy: 125 per 1000. The authors have emphasized: the difficulty of school survey and the necessity to entrust a skilled staff with this job. The general low prevalence of leprosy cases with children in Senegal: 0.96 per 1000, inferior to the threshold of 4 per 1000 above which school survey is advised to be carried out. The high prevalence rate of leprosy with the children of the leper villages (140 times as much as general prevalence rate). This situation could be the result of: the inefficiency of the chemoprophylaxis by DDS; the existence of primary resistance cases to DDS (some of them clinically proved), consequence of the numerous secondary resistance cases which have already been witnessed in these villages.

The authors have studied tolerance of multibacillary patients to 4 MDT regimens. These 4 regimens consist of: One supervised part in which RMP-ETH combination in once-monthly administered; furthermore, in 2 of these regimens, is included one "starter phase" with daily doses of that combination for 2 months. One self-administered part during which CLO is associated either to DDS for new cases, or to ETH for relapses. Clinical Supervision: Out to 310 multibacillary patients, 7 cases of hepatitis with or without icterus, but no death due to the treatment. Interruptions of MDT have been temporary and have been observed in 0.9 to 5.6% of the patients according to the therapeutic regimen. Checking SGOT: The SGOT were abnormally high in 16.3% of the patients before treatment. These pre-existing liver damages do not favour the appearance of intolerance disorders. During MDT, abnormal increases in SGOT are observed in 27% of the patients but there is no exact correlation between the absorbed doses of ETH and the frequency in SGOT increases. The clinical or biological evidence of liver damages occur rather early (1st, 2nd month) in regimens with "starter phase", and later (4th-8th month) in those without "starter phase". But introduction of "Starter phase" does not increase the global frequency of such intolerance accidents. ETH combined with RMP, must be used under steady clinical and biological supervision. Recalling the results of a previous survey, the authors consider that a long duration of MDT is not necessary. For the multibacillary leprosy treatment, they propose a diphasic regimen, more easily applicable in the field than the WHO protocols. In this diphasic regimen, the only part which must be supervised is the initial "starter phase" of 2 month. It consists of daily administration of 3 antibacillary drug among which RMP and ETH. The second phase is a relay treatment using 2 drugs, CLO combined with DDS or ETH, self-administered until smear negativity.

Since 1983, primary resistance of M. leprae to DDS and rifampicin has been evaluated in new cases of lepromatous leprosy observed in the Cap-Verde region in Senegal. Out of the 13 strains isolated, 10 (77%) have been found resistant to DDS, 7 at low level, 2 at intermediate level, 1 at high level; all of them have been found sensible to rifampicin. Similar results have been obtained with 57 strains isolated from patients not yet treated coming from different geographical areas, seeing that 37, i.e. 65%, were resistant to DDS, 27 at low level, 5 at intermediate level and 5 at high level; all of them were sensible to rifampicin. Level of resistance to DDS is very different in case of acquired resistance. In 69 lepromatous patients treated for more than 5 years and showing a relapse, M. leprae was 62 times, i.e. 90%, resistant to DDS, 6 times at low level, 21 at intermediate level and 35 at high level; in addition, 13 times M. leprae was resistant to rifampicin. In order to avoid and to solve problems set by resistance of M. leprae to antibiotics, strict application of polychemotherapy of leprosy is compulsory.

The target of this survey carried out in Guadeloupe (F.W.I.) is to search for eventual relationship between leprosy forms and ethnic features--Made in people subjected to same environmental factors, such a study avoids usual bias of investigations on the epidemiological aspect of "racial" factors. The 1522 investigated patients have been divided into 2 categories: allergic paucibacillary (Mitsuda +), and anergic multibacillary (Mitsuda -) patients. -). Three parameters were studied: morphological type empirically determined according to cutaneous pigmentation; ABO blood groups; and Rhesus phenotype. The results bring to the fore: Significant linkage between clinical forms and morphotype: the dominant Caucasian morphological typed subjects, with integument poor in melanin, are more numerous among multibacillary patients. This might confirm high sensitiveness of Caucasians to leprosy. No significant linkage between clinical forms and ABO blood groups. Nevertheless, variations are found already reported in more homogeneous populations: predominance of A group in multibacillary patients, of B and O groups in paucibacillary patients. Significant linkage between clinical forms and Rhesus phenotype. But this link does not seem to be imputable to ethnic factors because clinical forms distribution is the same in ccDee sub-population (the most frequent in West Africa), and in ccddee subpopulation (quite frequent phenotype in West Europe). In fact, only the ccDEe phenotype sub-population is significantly different from all the others, because multibacillary forms are particularly frequent (49.3%) and strike evenly women and men in this sub-population.

Aims: to prevent the appearance of plantar ulcerations and then mutilations, by going in the field in order to: make suitable footwear, educate the patients, train the paramedical staff. Means: 1 fitted lorry, 1 physiotherapist, 1 shoemaker, and 1 educator., Results: In one year, 206 patients have been provided with shoes and followed up. Advice have been taken exactly in the leper villages in which the attendance rate is of 98%; this rate varies between 47 to 70% in the all-purpose dispensaries. Paramedical workers of all-purpose Health Centers did not take great interest in this action. After 6-12 months under observation: 84% of good results for the feet without deformity or slightly deformed; 51% for the deformed feet. The results are quite satisfactory for the feet without plantar ulcer at the beginning, and that whatever the food deformity stage. But for the feet wounded by plantar ulcer at the beginning, 33% of recovery have been reported after wearing these shoes.

Since 1982, in Dakar, a controlled essay tests the suitability of several short protocols of multidrug therapy (MDT), some of them being close to those advised by the WHO, others showing a starter stage of a two month daily MDT. In three years, 198 paucibacillary and 123 multibacillary patients have been treated. The short duration of these treatments leads to an important decrease in the load of the Department. The total rate of those who have not attended for the treatment is of 15.2% whereas it was of 52% with DDS monotherapy for a similar treatment duration. Those who gave up don't seem to live in Dakar. To judge by the diligence of the patients, the compliance seems excellent even for the protocols requiring a daily dose of ethionamide: 95% of paucibacillary, 76% of multibacillary patients have maximal attendance. The authors think that any MDT program: must be preceded by a retraining of staffs; must give a priority to the health education of the patients; must involve a home patient search for system.

Primary and secondary dapsone resistance were studied among lepromatous patients living in Martinique, Guadeloupe, New Caledonia, Tahiti, Senegal, and Paris. Four hundred fifteen biopsies were taken from clinically active and bacteriologically positive (bacterial index greater than 2) patients in the 6-year period of 1980-1985. Among these, 280 biopsies that contained 5 x 10(4) acid-fast bacilli per ml with a morphological index of at least 0.10 were inoculated into the mouse foot pad, and 229 harbored infective Mycobacterium leprae. Among the 129 infective M. leprae isolated from new cases, 54% had some degree of dapsone resistance, a low degree being prominent in all cases. Among the 100 infective M. leprae isolated from relapsed cases, 79% had a high or an intermediate degree of dapsone resistance. The annual incidence of secondary dapsone resistance was estimated to be about 0.55% in Guadeloupe.

In the experimental infection of mice by Mycobacterium leprae, the bactericidal effect of 4 weekly doses of rifampicin (RMP) is completely suppressed if this administration is preceded by a daily treatment of dapsone (DDS) during one month then continued in conjunction with rifampicin. The application of this methodology: the delayed adding of rifampicin clearly shows the bacillary persistence induced by dapsone (DDS). The rifampicin appears to be less effective on Mycobacterium leprae when its metabolism is inhibited either by the action of a drug such as dapsone (DDS), or spontaneously. The highlighting of this late-appearing antagonism between rifampicin and dapsone in mice, should not at present lead to the questioning of the therapeutic procedures recommended by the WHO, because of the limits of this experimental model, namely the small size of bacillary populations studied over relatively short periods of time.

Hepatitis B Virus (HBV) seric markers (HBs Ag, anti-HBs, and HBe Ag) were studied in 987 Senegalese leprosy patients (lepromatous: LL; tuberculoid: TT) in comparison with 6187 healthy adults (controls). Two populations of leprosy patients from ILAD (Institut de Léprologie Appliquée de Dakar) were studied: The First study (i.e.: study I) between 1973 and 1977 included 553 patients (329 LL; 224 TT). The Second study (i.e.: study II) between 1982 and 1986 included 434 patients (236 LL; 198 TT). HBV serological markers were tested by various techniques. By RIA, they were present in 98% and 96.5% in the studies I and II respectively. Each marker was studied and compared to the control population. HBs Ag detected by RIA was present in 25.5% (study I) and 23.0% (study II) when comparing to 15.2% in the control group. This marker was correlated with leprosy forms (LL and TT), age, sex, ethnic group.

Activation of the respiratory metabolic channel (F.O.R.), responsible in part for the bactericidal effect, was measured in vitro by a chemoluminescence test on circulating phagocytes. All mycobacteria tested, except for Mycobacterium leprae, induced a significant response. Its effect on lepromatous leprosy pathology is a subject for discussion.

The authors expose a retrospective study about 133 nervous contingents treated exclusivement by steroid-therapy. The objective is to study the influence on nerve-function recovery of the following parameters: clinic form, function (sensitive or motor) of the nerve, position of the nerve (ulnar, median...), nature of the antibiotherapy. The method is based on the comparison for average progress in relation with the initial score. It appears that tuberculoid nerves recovery is better and faster than the lepromatous one. But lepromatous nerves improvement keeps on the end of the second year. On the other hand, the results are not influenced by the nerve itself or its function. Concerning antibiotherapy, our results show à significant difference, in consideration of a better improvement in PCT-treated nerves. Nevertheless, these results have to be confirmed by a comparative experimentation.

Data give evidence of: 1) a progressive decrease of the infections with a significant fall in the school age group; 2) an almost constant number of infectious patients; 3) a growing importance of the detection by private practioners. Passive detection detects patients who, in most cases, are more seriously infected than those detected by active detection. Active detection is the only effective leprosy prophylactic method.

Pneumatic perforation of the bowel is a rare complication of colonoscopy. Pneumatic ileal perforation complicating this procedure has not been reported. We describe a case of pneumatic ileal perforation during colonoscopy in an elderly lady who also had adhesions from previous abdominal surgery. A relative lack of symptomatology, the finding of a clean ileal perforation at surgery, and a benign postoperative period characterized her course. Possible etiological factors are discussed with reference to the literature dealing with intraluminal pressures in the bowel. Pressure much higher than the physiological pressure is likely to be reached during colonoscopy, with reflux of air across the ileocecal sphincter acting as a safety mechanism. Bursting pressures differ for different layers of the bowel and from segment to segment. This report calls attention to certain risk factors which might lead to a remote perforation during colonoscopy.

In Guadeloupe, from January 1980 to December 1984, 420 leprosy patients were put under daily multidrug therapy: 10 mg/kg RMP plus 100 mg DDS during six months for paucibacillary patients, 10 mg/kg RMP plus 100 mg DDS during 24 months supplemented during the 12 first months with 10 mg/kg of a thioamide, ethionamide or protionamide, for multibacillary patients. The approval to the treatment was satisfactory in all the patients with active leprosy, new cases and relapse cases, less in the inactive patients already treated with dapsone only. The patients's compliance to treatment was satisfactory too. The lepra reactions were observed with a 19% frequency which is not different of the 15% frequency of lepra reactions observed in patients treated with DDS only. Hepatitis were observed only in multibacillary patients treated with PTH and RMP with a 14% frequency. Discontinuing treatment with RMP and PTH but not DDS resulted in recovery. When RMP was resumed without PTH, the hepatitis did not recur. All patients responded favorably under multidrug therapy and no relapse was observed among the 45 paucibacillary patients after a four year-surveillance and among the 16 multibacillary patients after a three year-surveillance.

Unlabelled: With the aim of increasing complete responses and improving survival in advanced recurrent (after surgery and/or RXT) squamous cell carcinoma of the head and neck, we scheduled 31 patients to receive the following regimen: VP-16, 100 mg/m2 i.v. on days 1, 3 and 5; bleomycin, 10 mg/m2 i.v. on days 4, 11 and 18; cisplatin, 120 mg/m2 on day 6, and 6-methylprednisolone, 40 mg/m2 on days 1-7. Courses were repeated every 21 days. In all, 29 patients were evaluable., Results: complete responses (CR) were achieved in 7 cases (24%); partial responses (PR) in 7 cases (24%); the overall response rate was 48%; stable disease in 7 cases (24%), and progressive disease in 8 cases (27.5%). In 20 cases of the N3 category there were 4 CR (20%) and 6 PR (30%). Survival: entire groups, 32.7 weeks; CR 63.8 (22+28+72+); PR, 30.2; cases of no change, 29 weeks and in nonresponders, 10 weeks., Toxicity: leukopenia, 5/29 (17%); thrombocytopenia, 3/29 (10.3%); anemia, 10/29 (34.4%); nephrotoxicity, 8/29 (10.3%), and alopecia, reversible, 100%., Conclusion: this therapeutic regimen improves the CR rate and survival time with a tolerable toxicity.

This report describes a renal transplant recipient in whom Pseudomonas septicemia and ecthyma gangrenosum developed within days of renal transplantation. Microscopic skin sections showed perivascular bacillary invasion. Pseudomonas organisms were cultured and microscopically visualized in sections from the transplanted kidney. Although cultures from the donor kidney preservation perfusate fluid showed no growth, Pseudomonas aeruginosa was found in the recipient's urine, blood, and peritoneal fluid. The recipient's course was complicated by septic shock, cardiopulmonary arrest, coma, and extensive skin lesions; but his condition improved with appropriate antibiotic therapy, wound debridement, and an aggressive rehabilitative program. He is now a candidate for retransplantation. This is the first known case of ecthyma gangrenosum in a renal transplant recipient.