[Stress urinary incontinence in women. Physiopathology and surgical treatment using Burch's technique and TVT]. / Incontinence urinaire d'effort chez la femme. Physiopathologie et traitement chirurgical par les techniques de Burch et TVT.

FROM PHYSIOPATHOLOGY TO TREATMENT: Urinary incontinence on effort in women is due to a default in sub-urethral anatomical structure, which leads to incontinence on effort (coughing, laughing, carrying heavy weights, physical activity). When re-education fails, surgical treatment using Burch's technique or the placing of sub-urethral TVT (Tension free Vaginal Tape) is generally proposed. BURCH'S TECHNIQUE: Burch's technique consists in an upper tract colposuspension via coelioscopy or laparotomy, under rachis or general anaesthesia. In the literature, the following rates of complete cure have been presented: 64 to 87%, 75 to 95% and 63 to 89% respectively in the short, median and long term together with the cure of certain complications (vesicular instability, dysuria, secondary prolapse, infections). THE TVT TECHNIQUE: Developed in the early nineties, the placing of TVT is a mini-invasive technique requiring the use of polypropylene tape inserted vaginally under the urethra under rachis or local anaesthesia. It is associated with over 80% median term clinical efficacy and rare complications (vesicular perforation, arterial wounds, perineal haematoma, dysuria, infections).

[Economic comparison of 2 surgical techniques fr the treatment of stress urinary incontinence in women: Burch's technique versus the TVT technique]. / Comparaison économique de deux techniques chirurgicales de traitement de l'incontinence urinaire d'effort chez la femme: technique de Burch contre technique TVT.

The TVT device (Tension-free Vaginal Tape) is used in our Hospital to treat stress urinary incontinence, resulting in an excess cost for the Pharmacy. The Burch technique, used previously, does not require any specific medical device, but is invasive and requires a longer hospital stay. The objective of this study was to compare the financial impact of these two techniques, by defining the discriminant costs. Seventeen isolated Burch procedures and twenty one TVT procedures were included. The costs analysed concerned medical devices, medicinal products, laboratory procedures, operating time, hospital stay and duration of postoperative follow-up. The Burch procedure cost FFR 26,322 and the TVT procedure cost FFR 10,958. The TVT technique reduces the cost of hospitalisation and represents an economy of operative equipment and nursing workload (reduction of operating time and postoperative stay).

The management of severe malnutrition in Burundi: an NGO's perspective of the practical constraints to effective emergency and medium-term programmes.

The NGO, Action contre la Faim (ACF), has been operating in Burundi since 1994, where the situation has dramatically hampered humanitarian programmes. These include poor security resulting in an inability to maintain 24-hour care for the severely malnourished and poor access to the beneficiaries, all within a politically and economically unstable context. However, ACF has been able to capitalise on lessons learnt and reflect on ways to move forward, which have included the improvement of their capacities in the treatment of severe malnutrition and the integration within broader disciplines and national structures. The protocols for the treatment of severe malnutrition currently used in Burundi have been developed as a result of the research of ACF over the past five years. Other aspects of the nutrition programme remain to be further developed. These include, for example, an improved capacity to care for severely malnourished adolescents and adults; and also a better knowledge of the beneficiaries to allow for stronger links between the provision of treatment and support for their longer-term food security.

[Definition and evaluation of therapeutic food for severely malnourished children in situations of humanitarian emergencies]. / Définition et évaluation d'un aliment thérapeutique pour les enfants sévèrement malnutris, en situation d'urgence humanitaire.

Nowadays, median case fatality rate of severely malnourished children treated in hospitals is 23.5%, a rate which has not changed for the last 50 years. This is probably related to the use of inappropriate or even unsafe treatment protocols. This work aimed at reducing case fatality rates of severe malnutrition by developing a treatment protocol and assessing its effectiveness during humanitarian crises. A therapeutic food was designed from pathophysiologic studies and its use adapted to therapeutic feeding centres. This food (F100) contains 100 Kcal/100 ml, with 10% of its energy derived from proteins; it has a low sodium and iron content but is fortified with vitamins and minerals. It can be prepared either at the treatment centre or at an industrial level. Industrial production, which started in 1993 reached 1,500 MT in 1997. In refugee camps, F100 was used according to a strict protocol adapted to local conditions. Intakes started at 100 Kcal/kg/day and reached 200 kcal/kg/day once appetite was restored. A model to assess the risk of death according to weight, height and oedema was developed. First results show that mortality was often below 5%. Hence, it is possible to standardise and evaluate a nutritional treatment in such unfavourable conditions as a refugee camp. Standardised use of F100 can markedly reduce mortality of severely malnourished children.

A model to standardise mortality of severely malnourished children using nutritional status on admission to therapeutic feeding centres.

OBJECTIVE: To determine a simple model to calculate the number of deaths which could be expected in a therapeutic feeding centre from the height, weight and oedema of children on admission. DESIGN: Admission weight, height, presence of oedema of the children and outcome were prospectively recorded. SETTING: Data were recorded in 18 feeding centres set-up during emergency operations in Africa. Ten of the feeding centres were selected, a priori, as reference centres and eight centres as test centres. SUBJECTS: Data for 3858 children were recorded. 837 children absconded from the centres and were excluded from the analysis. Analysis was performed on data from 2753 children who left the centre after recovery and 268 children who died during treatment. INTERVENTIONS: The relation between the risk of death and, anthropometric measurements and presence of oedema has been determined in a previous paper. The maximum likelihood estimate of the constant of the model was determined from global analysis of the data of the reference centres. The model was applied to the data of the reference and test centres. RESULTS: The model to predict the individual probability of death was: P(death) = 1/(1 + exp[-(20.63 - 9.99 1n(weight/height1.74) + 1.36 oedema)]) The predicted number of deaths was close to the recorded number of deaths for each reference centre. For three of the eight test centres there was a significant excess of observed deaths over predicted. CONCLUSION: This model can be easily used by the supervisor of a centre to assess the expected number of deaths during treatment of malnutrition from simple measurements on children that are routinely taken on admission and thus help to determine the nature of variation in observed mortality rates.

PIP: Data on children treated at 18 emergency feeding centers in 9 African countries were used to develop a simple model to calculate the number of child deaths expectable in severely malnourished children on the basis of height, weight, and edema at admission. Overall crude mortality was 7.6% at the 10 reference centers and 11.3% in the 8 test centers. Included in the analysis were 2753 children treated at the feeding centers and released and 268 children who died during treatment. The association between mortality and the anthropometric measurements and presence of edema had been determined in a previous study. The maximum likelihood estimate of the constant of the model was determined from global analysis of data from the reference centers. The model to predict the individual probability of death was: P(death) = 1/(1 = exp[-(20.63 - 9.99 in optimal ratio of weight to height + 1.36 edema)]). The predicted number of deaths closely approximated the actual number at each reference center, while there was a significant excess of observed over predicted deaths at 3 of the 8 test centers. This simple tool can be used to calculate the predicted number of deaths, evaluate the efficacy of a feeding center, and examine mortality trends over time or in relation to administrative changes.

Comparison of weight- and height-based indices for assessing the risk of death in severely malnourished children.

To compare the effectiveness of treating malnourished children in different centers, the authors believe there is a need to have a simple method of adjusting mortality rates so that differences in the nutritional status of the children are taken into account. The authors compared different anthropometric indices based on weight and height to predict the risk of death among severely malnourished children. Anthropometric data from 1,047 children who survived were compared with those of 147 children who died during treatment in therapeutic feeding centers set up in African countries in 1993. The optimal ratio of weight to height determined by logistic regression was weight (kg)/height (m)1.74 (95% confidence interval of beta estimate 1.65-1.84). The receiver operating curves (sensitivity vs. specificity) showed that the body mass index (weight (kg)/height (m)2), optimal ratio of weight to height, and weight/height index expressed as the percentage of the median of the National Center for Health Statistics' standard were equivalent and superior to the weight/height index expressed as the z score of the National Center for Health Statistics' standard to predict death. As the optimal ratio of weight to height is easier to calculate than the weight/height index expressed as the percentage of the median or z score and does not depend upon either standards or tables, the optimal ratio of weight to height could be conveniently used to adjust mortality rates for nutritional status in therapeutic feeding centers.

PIP: The development of a simple anthropometric index closely related to child survival prognosis could enhance the treatment of severely malnourished children at therapeutic feeding centers in Africa. This study examined whether simple ratios of weight to powers of height could be used to adjust the observed mortality rates for differences in the anthropometric state of 1194 children 6-59 months of age admitted to 9 feeding centers in Sierra Leone, Rwanda, and Madagascar. 147 of these children died during treatment. The optimal ratio of weight to height determined by logistic regression was weight (kg)/height (m). The receiver operating curves showed that the body mass index (weight (kg)/height (m)2), optimal ratio of weight to height, and weight/height index expressed as the percentage of the median of the US National Center for Health Statistics (NCHS) standard were equivalent and superior to the weight/height index expressed as the z score of the NCHS standard to predict death. Edema was a significant risk factor for death (odds ratio, 3.8; 95% confidence interval, 2.2-6.6). The optimal ratio of weight to height can be computed on a pocket calculator and does not require reference to standards or tables, making it appropriate for conditions in the feeding centers.

Serum osteocalcin regulation in protein-energy malnourished children.

To evaluate bone turnover changes occurring during protein-energy malnutrition, serum osteocalcin, a marker of bone formation, has been studied in healthy control, stunted, and severely malnourished (kwashiorkor and marasmus) Senegalese children. Serum osteocalcin levels were dramatically reduced in stunted, kwashiorkor, and marasmic children compared with control children. In addition serum osteocalcin levels of control children living in Senegal were lower (-46%) than those of African children living in France. Interestingly, serum osteocalcin level was not related to its major known regulators (1 alpha,25-dihydroxycholecalciferol, 25-hydroxycholecalciferol, and PTH) nor to stunting, but was related to serum transthyretin and thyroid hormones concentrations. These data suggest that serum osteocalcin level is related to protein-energy status and that bone formation was affected in apparently healthy and in malnourished Senegalese children. Serum osteocalcin could be a potent tool in the study of the alterations of bone formation in malnutrition.

Rat serum osteocalcin concentration is determined by food intake and not by inflammation.

Osteocalcin, or bone gla protein, is the major noncollagenous protein in bone. Previous findings of decreased serum osteocalcin concentrations in children with Kwashiorkor led us to analyze the respective influence of nutritional status and inflammation on circulating osteocalcin in growing rats. Food deprivation for 72 h induced a significant 24% decrease in serum osteocalcin. Refeeding produced a rapid rise in serum osteocalcin, which reached control concentrations after 24 h of refeeding. Bone osteocalcin was not affected by these dietary manipulations. The changes in serum osteocalcin were not correlated with serum 1,25-dihydroxycholecalciferol, whereas they could be related to serum 25-hydroxycholecalciferol concentrations. Turpentine injection reduced serum osteocalcin concentration, but pair-feeding showed that this decrease was entirely attributable to spontaneous food restriction and not to inflammation. By contrast, the sensitive nutritional marker, serum transthyretin, was affected by both inflammation and food restriction. These results indicate that serum osteocalcin is closely related to food intake but not to inflammation, suggesting that the dramatic decrease in serum osteocalcin that we previously observed in children with Kwashiorkor is due to malnutrition per se.

[Nutritional regulation of serum osteocalcin: study in kwashiorkor]. / Régulation nutritionnelle de l'ostéocalcine sérique: étude dans le kwashiorkor.

The serum levels of osteocalcin (bone gla protein) in two groups of Senegalese children, healthy controls and severely malnourished (kwashiorkor) children during nutritional rehabilitation, were measured. The serum osteocalcin of all kwashiorkor children was dramatically decreased on admission to hospital, but increased fourfold during rehabilitation. Serum osteocalcin was low in the control group. In both groups these low levels seemed to be independent of those of 1,25-dihydroxyvitamine D3 which were in the normal range. The results suggest that serum osteocalcin levels might be related to protein-energy status.