[Creation of emergency care services in developing countries: luxury or necessity?]. / Creer un service d'aide medicale d'urgence dans un pays en developpement: luxe ou necessite?

Organization of emergency care services prior to hospital admission has progressed at a satisfactory pace in developed countries. A performance model in this field is the French emergency service called service d'aide médicale d'urgence (SAMU). Socioeconomic conditions prevailing in developing countries have pushed authorities to give priority to preventive medicine. However numerous patients especially young people and women during childbirth die as a result of inadequate facilities for transportation from hospitals and dwellings in outlying areas to major medical centers where the best medical equipment and staff are available. As a result, it may be asked if emergency care services is really a luxury. The authors base their conclusion on analysis of the conditions and outcome of emergency patient care in three African countries in which it is essentially a requirement.

[Practice of spinal anesthesia in a developing country: usefulness of vascular preloading with a 7.5% hypertonic saline solution]. / Pratique de la rachianesthésie dans un pays en voie de développement: intérêt du remplissage vasculaire par un soluté salé hypertonique à 7,5%.

OBJECTIVE: To assess the efficacy of hypertonic saline for prevention of arterial hypotension in patients undergoing spinal anaesthesia in Niger. STUDY DESIGN: Prospective, randomized, double-blinded study. PATIENTS: Fifty adults undergoing scheduled surgery under spinal anaesthesia, allocated either to a hypertonic saline group (HSG) or a isotonic saline group (ISG). METHODS: Over the 15 min prior to anaesthesia, 100 mL of 7.5% saline were infused in patients of HSG, and 100 mL of 0.9% saline in those of ISG respectively. Spinal anaesthesia was performed at the L3-L4 or L4-L5 interspace using either lidocaine 5%, or bupivacaine 0.5% or a mixture of both supplemented with fentanyl. Arterial pressure (AP) and heart rate (HR) were measured the day before surgery, prior to and after spinal anaesthesia, thereafter every 5 min over 30 min and every 10 min thereafter until completion of surgery. Hypotension (30% decrease of systolic AP control value was treated with 500 mL of Ringer lactate solution and in case of failure with ephedrine (5-30 mg i.v.). An isolated bradycardia (HR < 60 b.min-1) was treated with atropine (0.5-1 mg i.v.). RESULTS: Hypotension occurred in two out of 24 patients of the HSG and eight out of 24 of the ISG (P < 0.05). The mean infused volumes of Ringer lactate solution were 387 +/- 218 mL vs 623 +/- 318 mL respectively (P < 0.05). Ephedrine and/or atropine were not required in HSG, however in 7 out of the 24 patients of the ISG. Adverse clinical effects did not occur. CONCLUSION: Hypertonic saline prevents efficiently the occurrence of hypotension during spinal anaesthesia. Considering its ease of preparation, the lack of adverse effects, in patients not suffering arterial hypertension or congestive heart failure, and low cost, hypertonic saline is well adapted for use in a developing country, if isotonic solutions are not available.

[Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin]. / Urétroplastie labiale pédiculée: un procédé original de traitement des lésions urétrales étendues d'origine obstétricale.

Destruction of the urethra is the most severe complication of pregnancy-related vesicovaginal fistula. Although uncommon in Europe, pregnancy-related urethral destruction is still observed in Africa. In this study we describe our experience with a new reconstruction technique using a pedunculated skin flap raised from the labia majora. Between January 1992 and June 1996 we treated 35 patients in the Urology Department of Niamey Hospital in Niger. All patients were black. Mean age was 18 years and mean follow-up was 19 months. Two plasty techniques were used, i.e. extension (16 cases) and tubulisation (19 cases). Urinary incontinence was treated using a suburethral loop system created using a fatty flap taken from the labia majora (Martius method). Urethrocervico-suspension of the vagina was necessary in 6 cases. Normal micturition with no leakage was obtained in 24 patients (68.6%) and functional improvement in 6 cases (17.1%) Treatment failed in 5 cases (4.2%). In comparison with previously reported techniques, urethral reconstruction using a pedunculated labial flap and suburethral looping system allows successful treatment of pregnancy-related urethral destruction in 70% of cases. This technique is particularly well suited for use in developing countries where occurrence of this complication is most frequent. However even with the greatest skill, creation of a physiologically perfect closure system is currently impossible.