Creation of a therapeutic digestive endoscopy suite in Senegal: renovation, training and university certification. Results of a Belgian-Senegalese inter-university project.

Therapeutic digestive endoscopy did not exist in sub-Saharan Africa before 2005. However, the prevalence of digestive diseases that could potentially benefit from basic endoscopic treatment is very high in this region. Portal hypertension with variceal bleeding and severe dysphagia associated with benign or malignant upper gastrointestinal tract diseases are prominent in these countries. The aim of the Project described in this report was to create a digestive endoscopy facility in Dakar (Senegal, West Africa), that would also provide local training in therapeutic endoscopy to doctors and nurses and facilitate regional autonomy with the opening of a University Certification in Gastroenterology. It took about 10 years to achieve these targets - 5 years to prepare realistic aims that took into account local needs, available local resources, and funding, and 4 years for the Project itself (2005-2009). At the present time, Senegalese colleagues and nurses are autonomous for basic therapeutic procedures in the upper and lower gastrointestinal tract. Two years after the end of funding, the rate of therapeutic activity has increased from 0% in 2005 to 12 % of digestive endoscopic activity in 2011. Key points of success were preparation, confidence of medical personnel, university involvement, shared funding, local multidisciplinary training, and facilitation of autonomy. Belgian healthcare workers were present on-site in Dakar for a total of about 6 months over the 4-year Project period, with an annual budget of less than € 80000. The Project has enabled an efficient North-South collaboration with a minimal budget, which has changed the healthcare provision of digestive endoscopy in Senegal, and has also provided autonomy, and facilitated the development of South-South cooperation.

[Disease-modifying treatment for inflammatory rheumatism in sub-Saharan Africa: outcome at 6 months of 205 Senegalese patients with rheumatoid arthritis]. / Problématique du traitement de fond des rhumatismes inflammatoires en Afrique subsaharienne: évolution à six mois de 205 patients sénégalais atteints de polyarthrite rhumatoïde.

RATIONALE: Few data are available on the treatment of rheumatoid arthritis (RA) in sub-Saharan Africa, where the diagnosis is often substantially delayed. Disease-modifying antirheumatic drugs (DMARDs) are more effective when started early. Biotherapies are not available. Given the socioeconomic constraints in sub-Saharan Africa, treatments must be selected based on locally available resources. The objective of this study was to evaluate outcomes 6 months after initiation of conventional DMARDs in Senegalese patients with RA. METHODS: We retrospectively studied consecutive RA patients seen at the rheumatology outpatient clinic of the Le Dantec Teaching Hospital, Dakar, Senegal, from January 2005 through June 2009. All patients met the ACR criteria for RA. ACR and EULAR response criteria were evaluated 6 months after treatment initiation. RESULTS: The study included 205 patients. Corticosteroids were used in 205 patients, hydroxychloroquine in 190, methotrexate in 137, and sulfasalazine in 11. Combined corticosteroid, methotrexate, and hydroxychloroquine therapy was used in 122 patients and combined corticosteroid and hydroxychloroquine therapy in 63. DMARD treatment was interrupted for at least 5 days per month for 26% of the patients, either because the drugs were out of stock at the local pharmacies and/or because the patients could not afford to purchase them. During the first 6 months of treatment, patients had a mean of 4 clinic visits, and 48% of patients missed at least one scheduled visit. After 6 months, all clinical variables had improved significantly, except the swollen joint count. The ACR20, 50, and 70 response criteria were met in 50%, 31%, and 6.9% of patients, respectively. The EULAR response was good in 53.9% of patients, moderate in 12.7%, and poor in 23.1%. DMARD therapy failed in 10.3% of patients. Half the patients had their treatment modified during the 6-month study period. DMARD therapy was discontinued in 10 patients for the following reasons: plans to become pregnant, n = 5; pregnancy during treatment, n = 2; and tuberculosis, n = 3. CONCLUSION: In Senegal, the treatment of RA relies chiefly on variable combinations of methotrexate, hydroxychloroquine, and corticosteroids. The six-month outcomes are satisfactory. Biotherapy is required in 7% to 10% of patients, a rate that could be decreased by optimizing patient follow-up. The management of chronic inflammatory joint disease couple be improved despite the limited financial resources in sub-Saharan Africa with better physician training and the incorporation of osteoarticular diseases within a vast information and education program for the general population.

Neoplasie endocrinienne multiple de type 2A : prise en charge diagnostique et therapeutique d'un cas

Introduction : La Neoplasie Endocrinienne Multiple de type 2A (NEM 2A) est une affection tumorale multiglandulaire; hereditaire; de transmission autosomique dominante; liee a une mutation du gene RET. Elle associe de facon simultanee ou successive un cancer medullaire de la thyroide (CMT); une hyperparathyroidie primaire (HPP) et un pheochromocytome. Observation : Nous rapportons l'observation d'une patiente de 53 ans qui nous a ete adressee pour exploration d'une lithiase urinaire recidivante liee a une hyperparathyroidie primaire. La notion de NEM2A deja diagnostiquee chez sa sour cadette nous a permis d'explorer et de mettre en evidence une hypercalcitoninemie correspondant a un microcancer medullaire de la thyroide a l'histologie; et la mutation constitutionnelle familiale sur l'exon 11 du gene RET. Elle ne presentait pas de signe biologique de pheochromocytome. Sa prise en charge chirurgicale a consiste en une thyroidectomie totale et parathyroidectomie partielle. L'evolution a ete favorable sous supplementation en levothyroxine et normalisation stable de son taux de calcemie et de calcitonine; apres un an de suivi. Conclusion : Cette observation souligne la necessite d'une exploration parathyroidienne devant toute lithiase urinaire; et l'obligation de pousser l'exploration d'une hyperparathyroidie primaire vers la recherche d'une neoplasie endocrinienne multiple des lors qu'il existe un contexte familial

Lupus nephritis in Senegal: a study of 42 cases.

Renal involvement determines the prognosis of systemic lupus erythematosus (SLE). The aims of this study were to assess the clinical, laboratory and therapeutic aspects of lupus nephritis (LN) in Senegal in order to improve its management. We included all patients presenting with SLE followed-up in the Internal Medicine and Dermatology Clinics of the Aristide Le Dantec University Teaching Hospital of Dakar, from January 1993 to December 2002. Patients with SLE without evidence of LN (defined by proteinuria more than 0.5 g/24 hours and/or hematuria) were excluded. A total of 74 patients with a diagnosis of SLE were studied, 42 of whom (56.75%) had features of LN. Their mean age was 29.6 years and male-female ratio was 0.13. The nephrotic syndrome was seen in 45.23% of the cases and renal insufficiency in 37.71%. Renal biopsy was performed in 52.38% of the cases, which showed predominantly WHO classes IV and V lesions. The main treatment modality employed was corticosteroids, while immunosuppressive drugs in addition were used in 35.71% of the patients. The short-term prognosis was favorable but in the middle-term, many patients were lost to follow-up. We conclude that early diagnosis by systematic urine screening, good patient information, percutaneous renal biopsy and use of appropriate immunosuppressive therapy will help improving the prognosis of LN in Senegal.

[Frequency of hematological and immunological manifestations of lupus in Dakar]. / Frequence des manifestations hematologiques et immunilogiques de la maladie lipique a Dakar.

INTRODUCTION: The systemic erythematosus lupus (SEL) or lupic disease is a systemic auto-immun pathology characterized primarily by the presence of antibodies directed against native antibodies anti-DNA. The discovery circumstances of diagnosis are variable and polymorphic. The hematologic signs and the immunological disorders constitute the diagnosis criteria of the lupic disease. METHODOLOGY: It is a multicentric and retrospective study undertaken study from January 1, 1997 to September 30, 2006. Patients were followed up in the Internal Medicine of Dakar. We have studied the hematological and immunological aspects of the SEL and have evaluated the prevalence of lupic disease. RESULTS: 142 patients with lupic disease were included with 125 women and 17 men; the ratio--sex was 0.13. The mean age was 34 years with extremes of 6 and 72 years. Our patients had hematological and immunological manifestations in 32.4% and 76.8% of the cases. The immunological tests showed the presence of antinuclear antibodies in 97.9% of the cases, native antibody anti-DNA in 45.7% of the cases, the anti-ECT in 8.95% (with the anti-RNP in 78.3 % of the cases, anti-Sm in 56.5% and of anti-SSA in 87% of the cases). Antibodies anti-DNAand anti-ECT were associated the hematologic demonstrations respectively in 92% and 95% of the cases (p 0.08). CONCLUSION: The hematologic and immunoligical signs of lupus disease are frequent and constitute diagnostic criteria of the disease.

[Diffuse interstitial lung disease and connective tissue diseases: study of seven cases in Dakar]. / Les pneumopathies interstitielles diffuses non specifiques au cours des connectivites: à propos de 7 observations à Dakar.

INTRODUCTION: The diagnosis of diffuse interstitial lung disease non specific in connective tissue disease is difficult because of many differential diagnoses. Lung involvement can affect functional or vital prognosis. We report 7 cases. CASES: We collected data from 60 years old mean patients. Pulmonary localisation was diagnosed after 19 years of evolution of the auto-immune disease. Discovering circumstances were dyspnea and chronic cough. The radiographic and scannographic signs were diffuse because of long diagnosis delay. The underlying auto immune disease was scleroderma, rheumatoid arthritis, Sjögren's syndrome, ankylosing spondylitis, Sharp's syndrome, and multiple autoimmune syndrome. The main treatment was corticosteroids and respiratory physiotherapy. CONCLUSION: Throughout these 7 cases we discuss clinical, radiological and evolutive aspects and we focus on the need of early diagnosis for a better prognosis.

[Autoimmune cholangitis or seronegative biliary cirrhosis: report of one case]. / Cholangite auto-immune ou cirrhose biliaire séronégative: une observation chez un homme.

INTRODUCTION: Auto-immune cholangitis appears by a table of cholestatic jaundice without anomalies of the hepatic bile ducts. It is a primitive biliary cirrhosis without antimitochondrial antibodies. This disease is reported at adult women in 90 % of cases. We report a 59 years old man case. OBSERVATION: The patient was admitted for a diffuse melanodermy, a physical asthenia and a slimming which preceded 4 months by a pruritus with cholestatic jaundice. Biology showed a normal rate of transaminase. Alkaline phosphatases and direct bilirubine were high. Hepatitis (B and C) and HIV serologies were negative. Abdominal ultrasound showed a homogeneous liver. There were no dilations of the bile ducts. Antimitochondrial antibodies were negative and the histological examination confirms diagnosis. CONCLUSION: Progress was good with ursodesoxycholic acid even if interval is short (5 months of evolution).

[Current aspects of systemic lupus erythematosus in Dakar. About 74 cases]. / Aspects actuels du lupus erythemateux systemique a Dakar. A propos de 74 observations.

INTRODUCTION: previously reported studies on systemic lupus erythematosus in Senegal were more then ten years old and reported few cases of patients. Our objectives were to update epidemiological, clinical, laboratory and evolutive aspects of systemic lupus erythematosus throughout a study of 74 patients. PATIENTS AND METHODS: we conducted a retrospective study in the internal medicine and the dermatology units of the university teaching hospital Aristide Le Dantec from January 1993 to December 2002. All patients with systemic lupus erythematosus according to the ACR criteria were included. Those who didn't meet ACR criteria were excluded. RESULTS: we included 74 patients; their mean age was 32 years and the sex ratio 0.1 (male to female). At the entry general symptoms were constants, and cutaneous signs were found in 96% of cases, joints signs in 58.1% and renal sign in 56.8%. Haematological and immunologic abnormalities were nearly constant. All the patients received corticosteroids and in 35.71% they had in addition immunosuppressive drugs. Shorts term evolution was satisfactory. At the medium term 27.02% of the patients were lost and 10.81% of them died. CONCLUSION: currents aspects of systemic lupus erythematosus in Dakar are improved by the early diagnosis when the disease is pauci-symptomatic and by the use immunosuppressive drugs in association with corticosteroids.

[Lupus nephritis in Senegal: study of 42 cases]. / La néphropathie lupique au Sénégal: a propos de 42 cas.

INTRODUCTION: Renal involvement determines the prognosis of systemic lupus erythematosus. The aims of this study were to precise clinical, laboratory, therapeutic and evolutive aspects of lupus nephritis in Senegal in order to improve its management. PATIENTS AND METHODS: According to ACR criteria we included all patients presenting a systemic lupus erythematosus followed in internal medicine and in the dermatology services of university teaching hospital Aristide le Dantec of Dakar from January 1993 to December 2002. All the patients who didn't have a lupus nephritis defined by the existence of more than 0.5 g/24 h of proteinuria and or hematuria were excluded. RESULTS: The prevalence of lupus nephritis was 56.75% among 74 patients with systemic lupus erythematosus. Mean age was 29.6 years and sex ratio 0.13 (male to female). There was a nephritic syndrome in 45.23% of the cases and renal insufficiency in 37.71%. Renal biopsy performed in 52.38% of cases showed predominantly WHO classes IV and V. The key treatment was corticotherapy while immunosuppressive were used in 35.71%. The short term evolution was favourable but in the medium term, many patients were lost or followed up irregularly. CONCLUSION: To improve the management and the prognosis of lupus nephritis in Senegal it is necessary to make patients with a systemic lupus erythematosus sensitive to it and to make systematically urine tests aiming the screening for an early diagnosis of lupus nephritis. In addition we should have aggressive policies in order to lower the costs of immunosuppressive therapy and haemodialysis.

La nephropathie lupique au Senegal : a propos de 42 cas

Introduction : La nephropathie lupique fixe le pronostic du lupus systemique. Nos buts etaient de determiner au Senegal ses aspects; cliniques; paracliniques; therapeutiques et evolutifs afin de contribuer a sa meilleure prise en charge. Patients et methode : Nous avons; selon les criteres diagnostiques de l'ACR; inclus les patients lupiques; suivis dans les services de Medecine Interne et de Dermatologie du CHU Aristide Le Dantec de Dakar de Janvier 1993 a Decembre 2002. Etaient exclus ceux qui n'avaient pas une nephropathie lupique definie par l'existence d'une proteinurie superieure a 0;5 g/24 heures et/ou d'une hematurie. Resultats : La frequence hospitaliere de la nephropathie lupique etait de 56;75parmi 74 patients lupiques. L'age moyen etait de 29;6 ans et le sex-ratio de 0;13 (5 hommes; 37 femmes). Un syndrome nephrotique existait dans 45;23des cas et une insuffisance renale dans 37;71des cas. La ponction biopsie renale faite dans 52;38des cas; montrait une predominance des classes V et IV de l'OMS. Le traitement de base etait la corticotherapie. Les immunosuppresseurs etaient utilises dans 35;71des cas. L'evolution a court terme etait favorable mais a moyen terme elle ne pouvait pas etre appreciee du fait du nombre eleve de perdus de vue et de patients suivis irregulierement. Conclusion : Un depistage precoce; une meilleure sensibilisation des patients; une baisse du cout des immunosuppresseurs et une accessibilite des moyens d'epuration extra-renale; amelioreraient la prise en charge de la nephropathie lupique au Senegal

[Polyarticular gout in young adults: a curable rheumatic disease]. / La goutre polyarticulaire de l'adulte jeune: un rhumatisme curable.

Juvenile chronic gout in its polyarticular deformative form has rarely been described in medical literature. We report a rare case of destructive polyarticular tophaceous gout in a 31-year-old Senegalese man. He consulted for bilateral asymmetric polyarthritis with deformities of the hands and feet that had been ongoing in recurrent episodes since the age of 18 years in association with tophus. He had received no previous medication. All laboratory investigations were normal except hyperuricemia 104 mg/l. Radiographs of affected joints demonstrated evidence of destructive polyarthritis, i.e., articular narrowing and osteo-condensation of the left great toe. The patient responded favourably to colchicine, allopurinol and diet. Gouty arthropathy must be differentiated from rheumatoid arthritis, psoriasic arthritis and distal chronic osteoarthrosis. In our case, definitive diagnosis of gouty arthropathy was based on chronic polyarthritis associated with tophus, hyperuricemia and therapeutic response to colchicine. Polyarticular gout can be suspected in case of chronic seronegative polyarthritis and diagnosis can be confirmed on the basis of plain radiographs and laboratory investigations showing uricemia. Treatment is effective, well tolerated and inexpensive.

[Senegalese case of thromboangeitis obliterans or Buerger's disease]. / Premiere observation Senegalaise de thromboangeite obliterante ou maladie de Buerger.

INTRODUCTION: Thromboangeitis obliterans (TAO) is an inflammatory, non atheromatous arteriopathy of smoking young adults. It is diagnosed on an association of non specific criteria that we discuss throughout this case. CASE REPORT AND DISCUSSION: A forty years old tabagical, Senegalese black man, had peripheral destructive lesions preceded by Raynaud phenomenon. He was admitted in our Internal Medicine department in November 2002. Actually this clinical presentation was evolving since 11 years. At that time, hypo aesthesia and ulceration of the fingers led to successive amputations in the leprology centre. The diagnosis of Hansen disease had been suspected but there were no evidence of mycobacterium. At the admission in our service, biological tests showed a moderated non-specific inflammatory syndrome. Ultra sound Doppler and arteriography showed a peripheral arterial stenosis without atheromatous lesions, in favour of TAO. To meet all the criteria the patient didn't have any thrombotic or systemic disease. The evolution was favourable after tobacco weaning. CONCLUSION: TAO can bring to difficulties of diagnosis by its way of presentation. Physicians should practice a systematic vascular screening in case of distal arteriopathy.

[Hemorrhoids in Dakar: epidemiological, clinical and endoscopic aspects of 168 cases]. / Aspects epidemiologiques, cliniques et endoscopiques de la maladie hemorroidaire a Dakar. A propos de 168 cas.

INTRODUCTION: haemorrhoidal disease symptoms lead frequently to medical consultation. The aims of our study were to determine its epidemiological, clinical and endoscopic characteristics in Dakar. PATIENTS AND METHODS: we conducted a prospective multicentric study in the hospitals and in the private offices with endoscopic unit in Dakar from November 2nd 2003 to July 31 2004. A questionnaire with clinical and epidemiological features was applied to patients who presented haemorrhoid to the endoscopic exam. We included those who accepted the questionnaire. RESULTS: We recruited 168 patients. The mean age was 39.6 years. The sex ratio was 1.66 (male to female). The mean duration of symptoms was 6 years (range 1 month - 32 years). The symptoms that lead to medical visit were mainly: rectal haemorrhage (50.5%), anal pain (23.2%), constipation (13.1%) and anal tumefaction (9.5%). At the anamnesis the most frequently symptoms noted were constipation (80.4%), anal tumefaction (74.4%), anal pain (73.8%), rectal haemorrhage (64.9%) and anal pruritus (58.3%). The haemorrhoids were internal in 116 cases and external in 52 cases. According to the endoscopic classification, 35% of patients were at the first stage, 43% at stage II, 18% at stage III and 4% at the stage IV. An anitis was noted in 29.1% cases. We noted as associated lesions 18 fistulas and 15 anal fissures. CONCLUSION: The epidemiological, clinical and endoscopic characteristics of haemorrhoidal disease in Dakar are similar to those described in medical literature.

[Dakar physicians' therapeutic attitude towards non complicated peptic ulcer disease]. / Attitude therapeutique des praticiens de la ville de dakar fa ce a la maladie ulcereuse gastro-duodenale non compliquee.

Peptic ulcer disease is topic of guidelines in developed countries. In South area, without consensus conference, physicians' attitude towards this disease is varied. So, we aimed to describe therapeutic decisions of physicians in Dakar, regarding literature and the role of Helicobacter pylori in gastro-intestinal diseases. From 2001 december first to 2002 January 31, a survey was made in a sample of 171 physicians in Dakar with a questionnaire. All generalists, internists and gastroenterologists working in public or private health places of Dakar were concerned. The rate of responses was 68%. 65.5% of physicians had not read guidelines about peptic ulcer disease and H. pylori but 89% of them had read articles on these topics. Most of the physicians (76%) ordered systematically or mainly treatment to eradicate H. pylori. 95% of them did not require proof of infection before treatment. Association of gastric antisecretory drug with amoxicillin and metronidazole was mostly used (77.5%). Double dose of antisecretory drug was prescribed by 51.5% of physicians. For 40.5% of them, the duration of treatment was 7 days while 53.5% prolonged duration to 10 or 14 days. Complementary antisecretory drug was systematic for most of physicians (83.5%). These multiple therapeutic options, sometimes not in accordance with recommandations, militate in favour of more intensive participation of Dakar physicians to scientific meetings, in order to rationalize their therapeutic attitude towards peptic ulcer disease and take into account local data.

[Prescription of morphinics in the management of pain in Dakar teaching hospitals]. / La prescription des morphiniques dans la prise en charge de la douleur dans les centres hospitalo-universitaires de Dakar.

The correct management of pain is one of the most frequent problems in a daily medical practice. To achieve this goal physicians have to use many drugs. Among these drugs morphinics represent a special category with specific rules of administration. To assess the use of morphinics in the management of pain in Dakar teaching hospitals and to determine the reasons of under or over prescription, we carried out this study A questionnaire was sent to 200 medical doctors in two teaching hospitals in Dakar between February and April 1999. The response rate was 89.5% (179). According to 73.2% of medical doctors who answered the questionnaire, pain frequently leads to consultation but surprisingly only 14 physicians (7.8%) recognize a regular use of morphinics while 70.1% of them prescribe morphinics exceptionally Morphinics are mainly used to control pain in cancerology (37.2%) and post-operative pain (21.3%). The main reasons to explain the under-use of morphinics were: the fear of respiratory side-effects of morphinics (35.3%), the ignorance of prescription rules (23.5%). The training regarding prescription of morphinics was provided during medical studies and only 10 out of the medical doctors had an adequate postgraduate training in this domain. As expected 51.4% of physicians thought that their training during medical studies was inadequate. To improve the management of pain in our country we recommend a better training of medical doctors during medical studies and the promotion of postgraduate seminars on the use of these molecules. The legislation and rules of administration must be cleared and these drugs should be more available in drugstores and hospital pharmacies. All of these modifications are necessary to help medical doctors to overcome the fear of morphinics for a better management of pain in our country.

[Secondary hyperparathyroidism of chronic hemodialysis]. / Hyperparathyroïdie secondaire chez les hémodialyses chroniques a Dakar.

Secondary hyperparathyroidism is defined as autonomic secretion of parathormon (PTH) whose 1-84 fraction level is up to 60 ng/l. The aim of this study was to determine incidence of secondary hyperparathyroidism on patients undergoing hemodialysis in Le Dantec Hospital of Dakar, and describe its diagnostic and therapeutical aspects. Between 22 patients followed in chronically hemodialysis, 11 patients had effective blood test of parathormon. Seven of them had high level of PTH and the other had normal rate. They were 5 men and 7 women with a mean age of 56 years. The mean duration undergoing hemodialysis was 42 months. Clinical signs were rare and non specific, dominated bony pains and anemia. Ectopic calcifications had been found in 3 cases. Hypocalcemia was present in 5 cases and high level of phosphoremia in all cases. The D3 vitamin was at a normal rate in all cases up to 10 ng/ml. Calcium supplementation with 1.5 to 2.5 g/day was effective associated with rich calcium dietary. This level of calcium supplementation appeared too low even though it must be closely estimated because of the possibility of improving ectopic calcifications. At the opposite, D3 vitamin supplementation seems to be unuseful under tropical areas.

[Non iatrogenic primary hypothyrodism in adults at Le Dantec Hospital : clinical features, diagnosis and treatment. Review of 19 cases]. / Hypothyroïdie primaire non iatrogène de l'adulte au CHU Le Dantec: aspects cliniques, diagnostiques et thérapeutiques (a propos de 19 observations).

The authors report 19 cases of non iatrogenic primary hypothyroidism in adults at Le Dantec Hospital of Dakar. Those cases had been found during a period of 6 years and half in the internal medicine service. The aim was to study clinical features, diagnosis and outcome of patients after treatment. The mean age of patients was 42.2 years with a sex-ratio of 0.33 M/F. The diagnosis delay was around 6,1 years. All patients presented clinical signs of hypometabolism: physical asthenia (63.15%), frilosity (26.3%), bradycardia (47.3%), constipation (36.8%). The cutaneomucal syndrom was composed by myxoedema (73.6%), macroglossia (26.3%), raucousness of voice (26.3%), alopecia (57.9%). Muscle weakness was found in 2 cases and genital troubles in 3 cases. Five patients presented goiter and 9 others had spontaneous thyroid atrophy. All patients presented a high level of TSH associated with decreased level of T4. Anemia was found in 7 cases and hypercholesterolemia in 13 cases. Treatment was based on substitutive hormonotherapy with L-Thyroxin (75 to 250 microg/day). Evolution was favorable after 10 month mean duration of processing. More alertness is necessary on behalf of the practitioners in front of any sign suggesting hypometabolism to reduce the diagnostic delay and prevent complete form of hypothyroidism that might be complicated, by cardiac involvement in particular.