Management of congenital giant inguinal scrotal hernias in the newborn.

Giant inguinoscrotal hernias are a rare entity seen largely in the adult population. Presentation in the child is more unusual, with only one case previously documented. As there is scant literature regarding these hernias in children, their management may be challenging. Here, we present the case of a newborn born with giant bilateral inguinal hernias complicated by in utero perforation and meconium peritonitis managed by laparoscopy and then laparotomy for repair. The case illustrates several points that may be useful for pediatric surgeons who may encounter this condition.

[Epidemiologic evaluation of malaria in endemic areas]. / Evaluation épidémiologique du paludisme en zone d'endémie.

For decades malarial control has been implemented to control the impact of the disease on the health of populations living in endemic zones. The use of artemisinine combination therapy, intermittent preventive treatment for children and pregnant women, vector-control methods such as long-lasting insecticide-impregnated mosquito nets and indoor remanent insecticide spraying has proven to be effective. These practices have lead to such an extensive reduction of the malaria burden in some endemic areas that the objective of eradication that was unimaginable a few years ago is now back to the forefront. Regardless of the method chosen, careful evaluation and surveillance of its effectiveness in man is necessary. Achieving epidemiologic impact is the main goal of malaria control methods. The main measures for evaluation involve parasitological and clinical aspects of human malaria. The purpose of this article is to review methods used for epidemiologic evaluation of malaria burden.

[Guidelines for phase III evaluation of vector control methods against malaria]. / Guide pour l'évaluation en Phase III de la lutte antivectorielle contre le paludisme.

Most new vector control methods against malaria involve the use of pesticides. Prior to release of these products for general use, their efficacy, persistence, and cross-resistance must be tested on mosquito colonies raised in the laboratory (phase I) then on wild mosquitoes in the field (small-scale), individual dwellings, or experimental huts (phase II). The goal of phase III studies is to evaluate the efficacy and effectiveness of the vector-control product or method against malaria in a population at regular risk for transmission. The main objective of phase III tests is to measure the epidemiologic impact, e.g. on the incidence or prevalence of malaria in humans. This article presents guidelines for carrying out phase III tests of vector-control methods against malaria (e.g. home insecticide spraying or insecticide-impregnated bednet use). It was written by participants in a workgroup formed to define recommendations for the WHOPES (WHO Pesticide Evaluation Scheme).

[Methods for the phase IV evaluation of malaria vector control interventions: a case-control study of the effectiveness of long lasting impregnated bed nets after their deployment in Benin]. / Méthodes d'évaluation en phase IV de l'efficacité de la lutte antivectorielle: l'exemple d'une étude cas-témoin de l'impact des moustiquaires imprégnées d'insecticide à longue durée d'action après leur déploiement au Bénin.

Vector-control measures are a component of integrated malaria control strategies. After evaluation in phase III pilot studies, these measures are currently being deployed in many endemic malaria zones. Their effectiveness must be evaluated under actual conditions of use but it is not ethically acceptable to use unexposed individuals for control groups. In a attempt to overcome this problem, a case-control study was undertaken to evaluate the effectiveness of long-lasting insecticide treated mosquito nets (LLITN) against clinical malaria attacks due to Plasmodium falciparum in an endemic area of southern Benin. During a 4-month period (July to October 2008), 35 clinically documented cases of uncomplicated malaria (fever + parasite density > 3000/microL) were diagnosed in children less than 5 years old from 6 villages in the Tori Bossito medical district. The parents of these children were interviewed at the same time as the parents of 181 children randomly selected from the same 6 villages. A total of 115 of the randomly selected children who had not been feverish during study period were used as controls. The proportion of children having consistently slept under LLITN throughout the study period was 46% in the case group and 78% in the control group (OR=0.32, 95%CI: 0.15-0.71). These data show that the LLITN provided a significant level of protection, i.e., 68% (IC95%: 29%-85%). This case-control study shows that vector control measures can be effectively evaluated after deployment in population. The limitations of this methodology are discussed.

[Will climate and demography have a major impact on malaria in sub-Saharan Africa in the next 20 years?]. / Le climat et la démographie peuvent-ils avoir un impact important sur le paludisme en afrique subsaharienne dans les 20 prochaines années?

The purpose of this review of the literature is to present factors possibly affecting the spread of malaria in sub-Saharan Africa over the next 20 years. Malaria is a vector-borne disease that depends on environmental and human constraints. The main environmental limitations involve susceptibility of the vector (mosquitoes of the Anopheles genus) and parasite (Plasmodium falciparum) to climate. Malaria is a stable, endemic disease over most of the African continent. Climatic change can only affect a few regions on the fringes of stable zones (e.g. altitude areas or Sahel) where malaria is an unstable, epidemic disease. Higher temperatures could induce a decrease of malaria transmission in regions of the Sahel or an increase in the highlands. The extent of these overall trends will depend on the unpredictable occurrence of major meteorological phenomenon as well as on human activities affecting the environment that could lead to dramatic but limited outbreaks in some locations. The most influential human factors could be runaway demographic growth and urban development. Estimations based on modeling studies indicate that urbanization will lead to a 53.5% drop in exposure to malaria by 2030. However this reduction could be less than expected because of adaptation of Anopheles gambiae and An. arabiensis, the main vectors of malaria in sub-Saharan Africa, to the urban environment as well as increasing vector resistance to insecticides. Another unforeseeable factor that could induce unexpected malaria epidemics is mass migration due to war or famine. Finally immunosuppressive illnesses (e.g. HIV and malnutrition) could alter individual susceptibility to malaria. Social constraints also include human activities that modify land use. In this regard land use (e.g. forest clearance and irrigation) is known to influence the burden of malaria that is itself dependent on local determinants of transmission. Overall the most important social constraint for the population will be access to malarial prevention and implementation action to control this scourge.

Le climat et la demographie peuvent-ils avoir un impact important sur le paludisme en Afrique subsaharienne dans les 20 prochaines annees?

Cette revue de la litterature presente les conditions d'evolution du paludisme en Afrique subsaharienne dans les 20 prochaines annees. Le paludisme est une maladie vectorielle limitee par des contraintes environnementales et humaines. Les limites environnementales sont essentiellement dictees par la sensibilite du vecteur (moustiques du genreAnopheles) et du parasite Plasmodium falciparum au climat. Le paludisme est stable; dit endemique; sur une grande superficie de l'Afrique. Seules les zones ou le paludisme est instable; dit epidemique; principalement les franges de la zone stable (Sahel; altitude) pourront etre influencees par les changements climatiques. L'accroissement de la temperature; notamment; pourrait induire une reduction du paludisme en zone sahelienne ou une augmentation en altitude. Ces tendances globales devraient etre modulees par des evenements meteorologiques exceptionnels conjugues aux activites humaines s'exercant sur l'environnement qui pourront entrainer localement des epidemies dramatiques de paludisme. Les contraintes humaines impliquent en particulier une demographie galopante et un developpement des villes. Des modelisateurs projettent que l'urbanisation va entrainer une reduction de l'exposition palustre de 53;5en 2030. Toutefois; l'adaptation au milieu urbain d'Anopheles gambiae et d'An. arabiensis; principaux vecteurs du paludisme en Afrique subsaharienne; ainsi que leur resistance croissante aux insecticides; pourraient influencer cette diminution. De maniere imprevisible; les mouvements massifs de population resultant de guerres ou de famines pourront aussi entrainer des epidemies palustres inattendues. Enfin les maladies immunosuppressives (HIV; malnutrition) pourraient alterer la susceptibilite des individus au paludisme. Les contraintes sociales impliquent l'activite anthropique qui modifie l'utilisation des sols. On sait que l'utilisation des terres (deforestation; irrigation)peut influencer le poids du paludisme qui lui-meme depend des determinants locaux de la transmission. In fine; la contrainte sociale la plus importante demeure l'acces des populations aux interventions pour prevenir et lutter contre le paludisme

[Popular nosology of infantile diseases in West Côte-d'Ivoire and consequences for malaria care management]. / Nosologie populaire des maladies infantiles dans l'Ouest de la Côte-d'Ivoire. Implications pour le paludisme.

In a rural area of intense and permanent malaria transmission in Southwest Côte-d'lvoire, traditional midwifes of the Yacouba ethnic group, with also an important function for the children health and care, were interviewed in 2002 about their knowledge of the infantile pathologies. Their nosology is greatly based on symptoms and etiologic explanations of the disorder of secretions. The accumulation of a viscous liquid in different parts of the body, especially in the chest, the throat or the head, explains numerous febrile or afebrile diseases, including malnutrition. Some pathologies, particularly convulsions, are described by analogy with animals behaviour Relations between these entities and the biomedical ones are difficult to establish. The traditional care and treatments result from these concepts. A vomiting child or a child suffering from diarrhoea is subject to devices to evacuate his excess of liquid. Yellow brews are used against jaundice. Furthermore, an important mistrust remains towards medical treatments particularly for all parenteral therapies. Health facilities are only used as a the last resort. Their bad reputation is confirmed by the high rate of mortality of patients coming often too late. To improve malaria care management, health-care workers have to take into consideration these concepts and also prove their abilities to ensure good medical practices.

[Therapeutic efficiency of chloroquine in the savannah region in the north of Côte d'Ivoire (1997)]. / Efficacité thérapeutique de la chloroquine en région de savane du nord de la Côte d'Ivoire en 1997.

We evaluated from August to December 1997 the therapeutic effect of chloroquine (CQ) in treatment of mild malaria. Five villages of the savannah area of Côte d'Ivoire were selected for this study In this area and season, the transmission of malaria is of hyper-endemic type. The 14-day protocol of WHO was used and all the patients were treated with CQ 25 mg/kg over three days. 360 febrile children between 6 and 83 months old out of 545 were selected, and 286 were fully followed. At the beginning of the study axillary temperatures and parasitemia showed no difference in the 5 villages. The average therapy failure rate was 11.5% (IC to 95%; 7.8-15.2) with a maximum of 18.5%. The failure rates estimated in the various villages showed a hardly significant difference (p = 0.05). In the North of Côte d'Ivoire, the good efficiency of CQ can be explained by the low drugs pressure related to the behaviour of populations who use traditional phytotherapy in first resort to treat the fevers.

Inland valley rice production systems and malaria infection and disease in the savannah of Côte d'Ivoire.

In sub-Saharan Africa, lowlands developed for rice cultivation favour the development of Anopheles gambiae s. l. populations. However, the epidemiological impact is not clearly determined. The importance of malaria was compared in terms of prevalence and parasite density of infections as well as in terms of disease incidence between three agroecosystems: (i) uncultivated lowlands, 'R0', (ii) lowlands with one annual rice cultivation in the rainy season, 'R1' and (iii) developed lowlands with two annual rice cultivation cycles, 'R2'. We clinically monitored 2000 people of all age groups, selected randomly in each agroecosystem, for 40 days (in eight periods of five consecutive days scheduled every 6 weeks for 1 year). During each survey, a systematic blood sample was taken from every sick and asymptomatic person. The three agroecosystems presented a high endemic situation with a malaria transmission rate of 139-158 infective bites per person per year. The age-standardized annual malaria incidence reached 0.9 malaria episodes per person in R0, 0.6 in R1 and 0.8 in R2. Children from 0 to 9-year-old in R0 and R2 had two malarial attacks annually, but this was less in R1 (1.4 malaria episodes per child per year). Malaria incidence varied with season and agroecosystem. In parallel with transmission, a high malaria risk occurs temporarily at the beginning of the dry season in R2, but not in R0 and R1. Development of areas for rice cultivation does not modify the annual incidence of malarial attacks despite their seasonal influence on malaria risk. However, the lower malaria morbidity rate in R1 could be explained by socio-economic and cultural factors.

Malaria and property accumulation in rice production systems in the savannah zone of Côte d'Ivoire.

Irrigation stabilizes agricultural production and hence improves farmers' living standards and conditions. The permanent presence of water may, however, increase the burden of water-related parasitic diseases and counter the economic benefits of irrigation by reducing farmers' health. The purpose of this study was to assess the impact of malaria on farm household property, beyond the health risk (studied elsewhere). The research question was: by weakening individuals, does malaria reduce productive capacities and income workers, and consequently limit their property accumulation? To test this hypothesis, we use data on property (farming equipment, livestock and durable consumer goods) and Plasmodium falciparum indicators generated by a study carried out in 1998 in the Ivorian savannah zone characterized by inland valley rice cultivation, with a sample of nearly 750 farming households. Property is influenced by many factors related to the size of the family, the area under cultivation and high parasite density infection rate of P. falciparum. A significant negative correlation between high-density infection rate and the property values confirms that by reducing the living standards of households, malaria is a limiting factor for property accumulation.

[The epidemiology of malaria in the southwestern forests of the Ivory Coast (Tai region)]. / Epidémiologie du paludisme dans le sud-ouest forestier de la Côte d'Ivoire (région de Taï).

An epidemiological study on malaria was undertaken between July 1995 and July 1996 in two villages (Zaïpobly and Gahably) and their encampments (Kouassikro, Hamanikro and Konankro), in the south-western forest area of Côte d'Ivoire (region of Taï). The parasitological scheme comprised a total of 2023 tests performed on children aged from 0 to 14 years. The species found were Plasmodium falciparum, P. malariae and P. ovale with a proportion of 84%, 14% and 2% respectively. The global parasite prevalence of all Plasmodium species was 85% and malaria was holoendemic. The average parasitic density decreased progressively as the age increased, in contrast to the plasmodic index which did not vary. All the malarial indexes were similar in the villages and their encampments. Only overall fever prevalence was permanent and in all age groups it was higher in the encampments than in the villages. The entomological findings showed that transmission was permanent and intense throughout the year, with a recrudescence during the rainy season. Transmission was attributed to Anopheles gambiae s.l. in 85% of the cases whereas An. funestus played a secondary role. The average sporozoïtic index was 7.6% and varied between 1.1% and 16.7%. The entomological inoculation rate was of 400 infected bites per person-year for An. gambiae s.l. In such conditions of intense transmission, acquisition of premunition starts at a very early age. This assertion is verified by the average parasite density and the frequency of high parasitic densities which were at their maximum between 1 and 4 years of age and decreased thereafter as the age increased. The paludometric and entomologic indexes obtained are the most elevated ever to have been observed in Côte d'Ivoire, as a result of considerable ecological changes linked to the deterioration of the forest environment over the past 30 years. This deterioration has probably been caused by demographic pressure resulting from internal and foreign immigration to the Taï region and more especially by the influx of Liberian refugees.

[Which medication should be used to treat uncomplicated malaria when chloroquine becomes ineffective in Western Côte d'Ivoire?]. / Quel medicament pour traiter le paludisme simple quand la chloroquine devient inefficace dans l'Ouest de la Cote d'Ivoire?

Study of children treated for uncomplicated malaria in the sub-prefecture of Zouan Hounien in Western Côte d'Ivoire demonstrated that clinical failure rates (WHO 14-day test) were 43% for chloroquine and 6% for pyrimethamine-sulfadoxine (PS). Two issues raise serious doubts about the use of PS as a replacement for chloroquine. The first is detection of persistent asymptomatic parasitemia at day 7 in children treated with PS. The second is widespread use of one PS component (sulfadoxine) to prevent opportunistic infection in AIDS patients or to treat infection. Further study will be needed to evaluate the therapeutic and parasitological efficacy of amodiaquine in the region.

Alternative polymerase chain reaction method to identify Plasmodium species in human blood samples: the semi-nested multiplex malaria PCR (SnM-PCR).

A simplified protocol for the identification of Plasmodium species by semi-nested multiplex polymerase chain reaction (SnM-PCR) in human blood samples is compared with microscopical examination of thin and thick blood films in 2 field trials in Côte d'Ivoire and Cameroon. Also, dried blood spots or liquid blood collected from Dutch soldiers returning from Goma, Zaire (n = 141), Angola (n = 40), and from Marechaussee (Dutch border police) returning from various parts of the world (n = 161) were examined, together with miscellaneous other material obtained from laboratories and hospitals. The method is based on features of the small subunit nuclear ribosomal ribonucleic acid (RNA) gene (ssrDNA), a multicopy gene which possesses both highly conserved domains and domains characteristic for each of the 4 human malaria parasites. The first reaction of the SnM-PCR includes a universal reverse primer with 2 forward primers specific for Plasmodium and mammals, respectively. The mammalian-specific primer was included as a positive control to distinguish uninfected cases from simple PCR failures. The second PCR reaction includes a Plasmodium-specific forward primer plus species-specific reverse primers for P. vivax, P. ovale, P. falciparum and P. malariae. The technique worked better with samples collected in the field as dried blood spots on filter paper and heparinized blood rather than with frozen pelleted blood; it was more sensitive and more specific than the standard microscopical examination.

[Diagnosis of malaria attacks in endemic areas: theoretical aspects and practical implications]. / Diagnostic des accès palustres en zone d'endémie: bases théoriques et implications pratiques.

What criteria can be used to diagnose malaria in health centers located in endemic areas? Can an algorithm be developed for management of fever episodes? What parameters should be used to assess the morbidity of malaria for public health surveys or for studies to determine the efficacy insecticide-impregnated bednets, drug prophylaxis protocols, or anti-malarial vaccinations? Finding a useful definition for malaria attack is a perennial problem that becomes more difficult to resolve as the transmission rate and immunity level of the population increases. This review presents the fundamental aspects of diagnosing malaria. The choice of diagnostic technique requires knowledge of physiopathological, epidemiological, and clinical features. There is no single method. It depends on the circumstances, epidemiological context, available facilities, and goals. Diagnosis for treatment is one thing. Diagnosis for evaluation is another. In addition to discussing these concepts, this article provides references from the recent literature and up-to-date information needed to deal with the problem of diagnosing malaria attacks in endemic areas.

The role of prospective randomized clinical trials in pediatric surgery: state of the art?

PURPOSE: This study sought to determine the role of randomized controlled trials (RCT) in the evolution of pediatric surgical practice. METHODS: The authors used a computer-assisted literature search to identify all clinical trials related to pediatric surgery published in the English-language literature from 1966 through 1999. Each article was reviewed in detail for purpose, content, conduct, and quality of the trial. The authors assessed quality with a previously validated instrument (Chalmers Qualitative Assessment). RESULTS: The authors identified 134 RCTs related to pediatric surgery over the past 33 years. This accounts for 0.17% of 80,377 articles published in the field. The areas of surgery studied were analgesia 65 (49%), antibiotics 17 (13%), extracorporeal membrane oxygenation (ECMO) 9 (7%), gastrointestinal, burns, oncology, minimally invasive surgery, vascular access, congenital anomalies, and trauma (each <5%). Only 16 (12%) trials compared 2 surgical therapies, 9 (7%) compared a medical versus a surgical therapy, and 109 (81%) compared 2 medical therapies in surgical patients. Fourteen (10%) RCTs were funded by peer-reviewed agencies. Only 17 (13%) RCTs included a biostatistician as an author or a consultant. Trial design included calculation of sample size and statistical power in 21 (16%) RCTs. Method of randomization was reported in only 51 (38%). The test statistic and observed probability value was reported in 15 (11%). CONCLUSIONS: Clinical trials are used infrequently to answer questions related to pediatric surgery. When RCTs are utilized, they often suffer from poor trial design, inadequate statistical analysis, and incomplete reporting. Pediatric surgery could benefit from increased expertise, funding, and participation in clinical trials.

Venoarterial versus venovenous extracorporeal membrane oxygenation in congenital diaphragmatic hernia: the Extracorporeal Life Support Organization Registry, 1990-1999.

BACKGROUND/PURPOSE: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) traditionally has been the mode of support used in congenital diaphragmatic hernia (CDH). A few studies report success using venovenous (VV) ECMO. The purpose of this study is to compare outcomes in CDH patients treated with VA and VV. METHODS: The authors queried the Extracorporeal Life Support Organization Registry for newborns with CDH treated with ECMO from January 1, 1990 through December 31, 1999. They analyzed the pre-ECMO data, ECMO course, and complications. RESULTS: VA was utilized in 2,257 (86%) and VV in 371 (14%) patients. The pre-ECMO status was similar, with greater use of nitric oxide, surfactant, and pressors in VV. Survival rate was similar (58.4% for VV and 52.2% for VA, P =.057). VA was associated with more seizures (12.3% v 6.7%, P =.0024) and cerebral infarction (10.5% v 6.7%, P =.03). Sixty-four treatments were converted from VV to VA (VV-->VA). Survival rate in VV-->VA was not significantly different than VA (43.8% v 52.2%, respectively; P =.23). VV-->VA and VA patients had similar neurologic complications. CONCLUSIONS: CDH patients treated with VV and VA have similar survival rates. VA had more neurologic complications. The authors identified no disadvantage to the use of VV as an initial mode of ECMO for CDH, although some infants may need conversion to VA.

A meta-analysis of peritoneal drainage versus laparotomy for perforated necrotizing enterocolitis.

BACKGROUND/PURPOSE: Both primary peritoneal drainage (PPD) and laparotomy (LAP) are used widely for treatment of perforated necrotizing enterocolitis (NEC). Published reports include only anecdotes and small series. The authors used techniques of meta-analysis to determine which treatment is most effective. METHODS: The authors identified published studies reporting surgical treatment of NEC from January 1, 1978 to December 31, 1999; there were 10 studies (n = 475). The authors were contacted and all available raw patient data for use in meta-analysis (n = 190) were obtained. The authors used logistic regression to determine the relative survival rate after PPD and LAP, controlling for the effect of gestational age and institution. RESULTS: The combined probability of survival in the 10 published studies did not show an advantage for PPD (55%) or LAP (67%; P =.27). When the authors corrected for the effect of birth weight on survival rate, they still did not observe a difference (P =.67). A marked bias in treatment assignment was found with smaller babies undergoing PPD than LAP (931 g versus 1,615 g, respectively; P =.0004). Analysis of raw data showed an even greater bias in treatment assignment. The authors found increased survival rate for LAP versus PPD (62.3% v 35.6%; P =.0009). However, a logistic regression model could not overcome the bias in assignment of patients with a much higher expected mortality rate to PPD. CONCLUSIONS: Using currently available data, it is not possible to determine whether PPD or LAP is superior. Bias in treatment assignment precludes conclusions regarding comparative survival. Only a randomized trial will determine which operation is best for the treatment of perforated NEC.