Dataset of acute respiratory infections: Epidemiological and etiological data from a cohort of 801 Moroccan children

Acute respiratory infections remain a leading cause of death among young children in low- and middle-income countries. The etiological diagnosis of these infections is challenging due to the similarity in clinical presentations and overlapping symptoms caused by various pathogens. This database provides comprehensive epidemiological, clinical, paraclinical, and biological data on 801 Moroccan children admitted to the Children's Hospital of Rabat for the management of Clinical Severe Pneumonia. Identification of the pathogens responsible of respiratory infections was carried out using blood samples for hemoculture, standard bacterial culture and multiplex RT-PCR using the TrueScience RespiFinder Pathogen Identification Panel (Applied Biosystems).

Preventive behavior against SARS-CoV-2 infection in adults according to whether or not they live with children. A combined analysis of the nationwide COSMO-SPAIN and ENE-COVID surveys

Introduction

The protection of children is a major driver of behavior among those in charge of their care. We evaluated whether compliance with preventive measures against SARS-CoV-2 infection among adults living with children was different from that of those not living with them, in 2020.

Methods

We used the COSMO-SPAIN (N = 867) and the nationally representative ENE-COVID (N = 29,926) surveys to estimate prevalence of compliance (95% confidence interval). Logistic model based standardization methods were applied to estimate standardized prevalence differences (SPrD) to the overall distribution of age, sex, education, history of COVID-19, and residence of other >60 yrs in the household.

Results

We observed that adults living with children more frequently avoided bars (SPrD_ENE-COVID: 4.2%; 95% CI: 2.3-6.1), crowded places (SPrD_COSMO: 8.0%; 95% CI: 0.6-15.1) and did not use public transportation (SPrD_ENE-COVID: 4.9%; 95% CI: 3.0-6.7). They were also more worried about work and family conciliation (SPrD_COSMO: 12.2%; 95% CI: 4.8-19.5) and about closure of education centers (SPrD_COSMO: 26.5%; 95% CI: 19.4-33.6).

Discussion

In general, adults living with children adopted slightly more frequently social distancing measures.

Identifying the research, advocacy, policy and implementation needs for the prevention and management of respiratory syncytial virus lower respiratory tract infection in low- and middle-income countries

INTRODUCTION

The high burden of respiratory syncytial virus (RSV) infection in young children disproportionately occurs in low- and middle-income countries (LMICs). The PROUD (Preventing RespiratOry syncytial virUs in unDerdeveloped countries) Taskforce of 24 RSV worldwide experts assessed key needs for RSV prevention in LMICs, including vaccine and newer preventive measures.

METHODS

A global, survey-based study was undertaken in 2021. An online questionnaire was developed following three meetings of the Taskforce panellists wherein factors related to RSV infection, its prevention and management were identified using iterative questioning. Each factor was scored, by non-panellists interested in RSV, on a scale of zero (very-low-relevance) to 100 (very-high-relevance) within two scenarios: (1) Current and (2) Future expectations for RSV management.

RESULTS

Ninety questionnaires were completed: 70 by respondents (71.4% physicians; 27.1% researchers/scientists) from 16 LMICs and 20 from nine high-income (HI) countries (90.0% physicians; 5.0% researchers/scientists), as a reference group. Within LMICs, RSV awareness was perceived to be low, and management was not prioritised. Of the 100 factors scored, those related to improved diagnosis particularly access to affordable point-of-care diagnostics, disease burden data generation, clinical and general education, prompt access to new interventions, and engagement with policymakers/payers were identified of paramount importance. There was a strong need for clinical education and local data generation in the lowest economies, whereas upper-middle income countries were more closely aligned with HI countries in terms of current RSV service provision.

CONCLUSION

Seven key actions for improving RSV prevention and management in LMICs are proposed.

Trends for rotavirus acute gastroenteritis in children under 5 years old before and after vaccine introduction, Morocco, 2006–2014

Background: In Morocco, acute gastroenteritis in children is a public health issue. Since 1987, several strategies have been conducted to reduce its burden by the Moroccan Ministry of Health, including the introduction of the anti-rotavirus vaccine into the national immunization programme in 2010. Aims: To evaluate the impact of the anti-rotavirus vaccine in outpatients and inpatients with acute gastroenteritis under 5 years old. Methods: We conducted descriptive studies and a retrospective cohort study using data from the hospital’s sentinel surveillance system and the national ambulatory surveillance registry for acute gastroenteritis from 2006 to 2014. This include the period before and after the implementation of the rotavirus (RV) vaccine on children under age 5 years. Results: The decrease in acute gastroenteritis cases was about 5.2%, mainly among children aged 0–11 months. The proportion of acute RV gastroenteritis (RVGE) decreased from 37.0% to 31.1% after the vaccine’s introduction; it was statistically significant among the children aged 0–11 months (38.8% to 28.1%; P = 0.009). The proportion of RVGE among inpatients decreased from 97.0% to 91.7% (P = 0.022). Diarrheal disease cases without dehydration increased from 7.8% to 11.1% (P < 0.001); RVGE was 2.3 times more frequent among unvaccinated children. The vaccine effectiveness was estimated at 57%. The proportion of G1P[8] genotype infections decreased after the introduction of the RV vaccine (56% to 40%; P < 0.001), while the G2P[4] genotype became more frequent (13% to 21%; P = 0.015). Conclusions: The introduction of the RV vaccination into the national immunization programme in Morocco has allowed significant reduction in the incidence and severity of RVGE among children under 5 years old

Moroccan National Immunization Technical Advisory Group: a valuable asset for the national immunization program and the immunization agenda in the EMRO region

The main mission of a National Immunization Technical Advisory Group (NITAG) is to provide impartial, evidence-based recommendations on immunization to the Ministry of Health. We report on the findings from an evaluation of the Moroccan NITAG with emphasis on its functionality, quality of work processes and outputs, and its integration into the immunization policy process. We conducted a cross-sectional study from October to December 2019. We used the standardized, US-CDC/WHO-developed "simplified assessment tool for national immunization technical advisory groups". The evaluation included eight participants. The evaluation has shown that it fully complies with the WHO recommendations. Among its strengths, the Moroccan NITAG has a solid legal basis, diverse expertise and many years of combined experience. This composition contributed to the credibility and strength of its recommendations and facilitated their implementation. The NITAG could, however, benefit from implementing written declarations of interests and standardized operating procedures in addition to establishing a standardized methodology to guide and document the decision-making process. The Moroccan NITAG could also gain from inviting members with public health/epidemiology research experience and from exchanging with other NITAGs in the region and globally. Finally, ensuring sustainable funding for the NITAG's activities will be crucial, so that it can continue its valuable support to the national immunization program.

Long-term asthma-related readmissions: comparison between children admitted and not admitted to the intensive care unit for critical asthma

OBJECTIVES

To compare the time to asthma-related readmission between children admitted to the intensive care unit (ICU) for asthma and those with a non-ICU hospitalization in the United States and to explore risk factors associated with readmission among children admitted in the ICU.

METHODS

In this retrospective cohort study, we included children aged 2-17 years in the State Inpatient Database (2005-2014) from four U.S. states who were hospitalized for asthma. We compared the time to asthma-related readmissions and emergency department (ED) visit between children admitted and not admitted to the ICU using the log-rank test. Among those admitted to the ICU, we explored factors associated with readmission using Cox regression.

RESULTS

66 835 children were hospitalized for asthma, with 14.0% admitted to the ICU, and 12 844 were readmitted for asthma while 22 915 had an asthma-related ED visit. The time to asthma-related readmission was shorter in the ICU group compared to the non-ICU group (p < 0.001), but the time to asthma-related ED visit did not differ between the two groups (p = 0.43). Being preschool-aged, female, Black, and having lower household income and a longer length of stay during the initial hospitalization conferred a higher risk of asthma-related readmission among children admitted to the ICU. Preschool age and Medicaid were Florida-specific risk factors while Hispanic ethnicity was New York-specific.

CONCLUSION

Compared to children not admitted to the ICU, children admitted to the ICU for asthma were at increased risk of asthma-related readmission, with certain risk factors conferring an even higher risk.

Interdevice agreement in respiratory resistance values by oscillometry in asthmatic children

BACKGROUND

With several commercially available devices measuring respiratory impedance by oscillometry, the agreement between values obtained on different instruments or frequencies remains unclear. Our aim was to examine the agreement between resistance and reactance parameters on two oscillometry instruments using different waveforms.

METHODS

We conducted a prospective cross-sectional study in asthmatic children aged 3-17 years. Reproducible oscillometry measurements were obtained in random order, by blinded operators, at three modes: 5-10-15-20-25 Hz (5-25 Hz) multifrequency mode on the MasterScreen impulse oscillometry system, and both 5-25 Hz multifrequency mode and 7 Hz monofrequency on the tremoFlo C-100 airwave sinusoidal system. Resistance, reactance and within-breath parameters were examined using the intraclass correlation coefficient (ICC), paired t-test, linear regression and Bland-Altman method.

RESULTS

Of 50 participants, 44 and 38 completed between-device and within-frequency measurements, respectively. Between-device measurements at 5-25 Hz showed high (ICC 0.88-0.91) and good (ICC 0.69-0.87) agreement in resistance and reactance, respectively, but with an absolute within-patient difference (≥0.05 kPa·L-1·s-1) and proportional bias (≥30% per kPa·L-1·s-1) in all parameters and oscillatory frequencies, apart from resistance at 5 Hz. A significant proportional bias was documented in most within-breath parameters at 5 versus 7 Hz on tremoFlo.

CONCLUSION

Observed differences in resistance and reactance suggest the need for instrument- and frequency-specific paediatric normative values.

The pharmacist's role in managing and ameliorating childhood's asthma care: a descriptive and transversal study about 104 pharmacists in the city of Rabat in Morocco

This work aims at enhancing the management of childhood asthma, with a focus on pharmacists in particular, by evaluating their knowledge of childhood asthma and assessing their attitude while they are providing asthma medicines. Consequently, it will look at the necessity of introducing training days about childhood asthma for pharmacists. This is a transversal and descriptive study which lingered from August to October 2015. Data has been collected using a questionnaire that was self-administered to every surveyed pharmacist in the city of Rabat. The 104 pharmacists who replied to the questionnaire have an average general understanding about asthma and its treatment. Only a quarter of them managed an asthma crisis in their pharmacy before directing the child to the emergency. 50% of them do not know the difference between the basic asthma therapy and the asthma attack therapy. However, all of them recommended the parents to see a physician regarding their child’s asthma. 75% advise the systematic use of an asthma spacer with the inhaler. 87.5% of them give advice to parents regarding the good measures for environmental control, and 98% estimate that the therapeutic education is important in childhood asthma management. 88.5% among them are interested in training days about childhood asthma.This study shows the necessity of further pharmacists’ education about asthma and its management.

Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study

BACKGROUND

We have previously estimated that respiratory syncytial virus (RSV) was associated with 22% of all episodes of (severe) acute lower respiratory infection (ALRI) resulting in 55 000 to 199 000 deaths in children younger than 5 years in 2005. In the past 5 years, major research activity on RSV has yielded substantial new data from developing countries. With a considerably expanded dataset from a large international collaboration, we aimed to estimate the global incidence, hospital admission rate, and mortality from RSV-ALRI episodes in young children in 2015.

METHODS

We estimated the incidence and hospital admission rate of RSV-associated ALRI (RSV-ALRI) in children younger than 5 years stratified by age and World Bank income regions from a systematic review of studies published between Jan 1, 1995, and Dec 31, 2016, and unpublished data from 76 high quality population-based studies. We estimated the RSV-ALRI incidence for 132 developing countries using a risk factor-based model and 2015 population estimates. We estimated the in-hospital RSV-ALRI mortality by combining in-hospital case fatality ratios with hospital admission estimates from hospital-based (published and unpublished) studies. We also estimated overall RSV-ALRI mortality by identifying studies reporting monthly data for ALRI mortality in the community and RSV activity.

FINDINGS

We estimated that globally in 2015, 33·1 million (uncertainty range [UR] 21·6-50·3) episodes of RSV-ALRI, resulted in about 3·2 million (2·7-3·8) hospital admissions, and 59 600 (48 000-74 500) in-hospital deaths in children younger than 5 years. In children younger than 6 months, 1·4 million (UR 1·2-1·7) hospital admissions, and 27 300 (UR 20 700-36 200) in-hospital deaths were due to RSV-ALRI. We also estimated that the overall RSV-ALRI mortality could be as high as 118 200 (UR 94 600-149 400). Incidence and mortality varied substantially from year to year in any given population.

INTERPRETATION

Globally, RSV is a common cause of childhood ALRI and a major cause of hospital admissions in young children, resulting in a substantial burden on health-care services. About 45% of hospital admissions and in-hospital deaths due to RSV-ALRI occur in children younger than 6 months. An effective maternal RSV vaccine or monoclonal antibody could have a substantial effect on disease burden in this age group.

FUNDING

The Bill & Melinda Gates Foundation.

Foodborne outbreak simulation to teach field epidemiology: the Moroccan Field Epidemiology Training Program

BACKGROUND

Morocco in 2010 launched a new field epidemiology training program to enhance the skills of health professionals in charge of epidemiological surveillance and to investigate outbreaks; including foodborne diseases that represent a very substantial burden of disease.

AIM

To apply an active learning method to teach outbreak investigation within a controled environment for field epidemiology trainees program at the Moroccan National school of public Health.

METHODS

A scenario describing digestive symptoms evoking a restaurant-associated foodborne outbreak that would affect the school staff was designed for the residents to investigate, to assess their organizational capacity and application of all stages of epidemiological investigation.

RESULTS

Nine Residents applied study design, database management and statistical analysis to investigate the foodborne outbreak, to estimate attack rates, classify cases and controls, to identify the contaminated foods and pathogens and to issue preventive recommendations for the control and the prevention of further transmission. The overall resident's satisfaction of the learning method was 67%.

CONCLUSION

A simulation of an outbreak investigation within an academic setting is an active learning method to be used in the curriculum for introducing the residents on field epidemiology program to the principles and practices of outbreak investigation before their implication in a real situation.

Rhinovirus C is associated with wheezing and rhinovirus A is associated with pneumonia in hospitalized children in Morocco

Human rhinovirus (RV) is commonly associated with severe acute lower respiratory infections (ALRI) in children. We aimed to describe the distribution of RV species and associations between RV species and clinical features in children hospitalized with clinically severe pneumonia (CSP) in Morocco. Nasopharyngeal aspirates (NPAs) were collected from 700 children, 2–59 months of age, admitted with CSP to the Hôpital d'Enfants de Rabat in Morocco. At least one respiratory virus was identified in 92% of children, of which RV was the most common (53%). PCR assays, sequencing, and phylogenetic tree analyses were carried out on 183 RV‐positive NPAs to determine RV species and genotypes. Of 157 successfully genotyped NPAs, 60 (38.2%) were RV‐A, 8 (5.1%) were RV‐B, and 89 (56.7%) were RV‐C. Wheezing and cyanosis were more common in RV‐C‐positive than RV‐A‐positive children (80.9% vs. 56.7%; P = 0.001 for wheezing and 10.1% vs. 0%; P = 0.011 for cyanosis). Physician's discharge diagnosis of pneumonia was more frequent among RV‐A‐positive (40.0%) than RV‐C‐positive children (20.2%; P = 0.009). RV‐A and RV‐C showed distinct seasonal patterns. Our findings suggest that RV‐C is associated with wheezing illness while RV‐A is associated with pneumonia. J. Med. Virol. 89:582–588, 2017. © 2016 Wiley Periodicals, Inc.

Knowledge gaps on paediatric respiratory infections in Morocco, Northern Africa

BACKGROUND

The burden of acute respiratory infections (ARI) among Moroccan children remains significant. However, scarce information is available regarding trends in its epidemiology and etiology, or regarding its associated prognostic factors. The purpose of this work was to review available data on the burden of ARI among children under five years of age in Morocco.

METHODS

A systematic review was conducted for the period 1997-2014 using the PRISMA proposed methodology. Various online databases were screened, in addition to physical libraries of Moroccan medical schools, and official reports of the Moroccan Ministry of Health. Search queries in English and French languages included: Respiratory Tract Infections, pneumonia, epidemiology, etiology, microbiology, mortality and Morocco. The documents were included for analysis when they reported original data on the incidence, distribution, or a clinical description of the diseases or their etiology or described clinical management or national preventive strategies.

RESULTS

Thirty-two documents were included in the final analysis. 21 of which had been published. In 2012, ARI caused 13% of paediatric deaths, half of the consultations at health facilities and third of the paediatric admissions. The microorganisms more frequently identified among hospitalized children were Streptococcus pneumoniae (38%) and Haemophilus influenza type b (Hib) (15%). The MOH introduced Hib vaccines into the national immunization program (PNI) in 2007and the 13-valent vaccine against pneumococcus in 2010. The national first line antibiotics recommended for non-severe ambulatory treatment is Amoxicillin. Studies of antibiotic resistance showed from 1998 to 2008 a 22% increase in the rate of penicillin non-susceptibility among Streptococcus pneumoniae isolates. Viral respiratory infections and the role attributed to air pollution in the incidence of ARI have been poorly characterized.

CONCLUSIONS

Further efforts should be made towards the development of adequate surveillance programs to better clarify the epidemiology, etiology, antimicrobial susceptibility patterns and the effectiveness of the preventives and curatives strategies in place against paediatric ARIs in Morocco. Additionally, a holistical approach should be used to identify the heath determinants of ARIs among children.

Aetiology, epidemiology and clinical characteristics of acute moderate-to-severe diarrhoea in children under 5 years of age hospitalized in a referral paediatric hospital in Rabat, Morocco

The objective of the study was to describe the aetiology, epidemiology and clinical characteristics of the principal causes of acute infectious diarrhoea requiring hospitalization among children under 5 years of age in Rabat, Morocco. A prospective study was conducted from March 2011 to March 2012, designed to describe the main pathogens causing diarrhoea in hospitalized children >2 months and less than 5 years of age. Among the 122 children included in the study, enteroaggregative Escherichia coli (EAEC) and rotavirus were the main aetiological causes of diarrhoea detected. Twelve (9.8 %) children were referred to an intensive care unit, while two, presenting infection by EAEC, and EAEC plus Shigella sonnei, developed a haemolytic uraemic syndrome. Additionally, six (4.9 %) deaths occurred, with EAEC being isolated in four of these cases. Diarrhoeagenic E. coli and rotavirus play a significant role as the two main causes of severe diarrhoea, while other pathogens, such as norovirus and parasites, seem to have a minimal contribution. Surveillance and prevention programmes to facilitate early recognition and improved management of potentially life-threatening diarrhoea episodes are needed.

Risk factors for a poor outcome among children admitted with clinically severe pneumonia to a university hospital in Rabat, Morocco

•

Pneumonia remains one of the major killers of children in a middle-income country such as Morocco.

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A history of prematurity, a history of fever, leaving in a house with smokers, impaired consciousness, cyanosis, pallor, having ronchi on auscultation and human metapneumovirus infection are all independent risk factors for an adverse outcome.

•

A history of asthma is independently associated with a positive outcome.

•

Early identification of risk factors for an adverse outcome could improve overall prognosis.

Objectives

Data on prognostic factors among children with severe pneumonia are scarce in middle-income countries. We investigated prognostic factors for an adverse outcome among children admitted to the Hôpital d’Enfants de Rabat, Morocco with World Health Organization-defined clinically severe pneumonia (CSP).

Methods

Children aged 2–59 months admitted to the hospital and fulfilling the CSP definition were recruited into this 13-month prospective study. A poor prognosis was defined as death, a need for intensive care, or a Respiratory Index of Severity in Children (RISC) score ≥3. Multivariate logistic regression was performed to ascertain independent predictive factors for a poor prognosis.

Results

Of the 689 children included in this analysis, 55 (8.0%) required intensive care and 28 died (4.0%). Five hundred and two (72.8%) children were classified as having a good prognosis and 187 (27.2%) as having a poor prognosis. A history of prematurity (odds ratio (OR) 2.50, 95% confidence interval (CI) 1.24–5.04), of fever (OR 2.25, 95% CI 1.32–3.83), living in a house with smokers (OR 1.79, 95% CI 1.18–2.72), impaired consciousness (OR 10.96, 95% CI 2.88–41.73), cyanosis (OR 2.09, 95% CI 1.05–4.15), pallor (OR 2.27, 95% CI 1.34–3.84), having rhonchi on auscultation (OR 2.45, 95% CI 1.58–3.79), and human metapneumovirus infection (OR 2.13, 95% CI 1.13–4.02) were all independent risk factors for an adverse outcome, whereas a history of asthma (OR 0.46, 95% CI 0.25–0.84) was the only independent risk factor for a positive outcome.

Conclusions

The early identification of factors associated with a poor prognosis could improve management strategies and the likelihood of survival of Moroccan children with severe pneumonia.

The epidemiology and aetiology of infections in children admitted with clinical severe pneumonia to a university hospital in Rabat, Morocco

OBJECTIVES

Scarce and limited epidemiological, clinical and microbiological data are available regarding paediatric respiratory tract infections in the Kingdom of Morocco, a middle-income country in northwestern Africa. The results of hospital-based surveillance aiming at describing the aetiology and epidemiology of respiratory distress among children <5 years of age are presented.

METHODS

Children admitted to the Hôpital d'Enfants de Rabat, Morocco, and meeting the World Health Organization clinical criteria for severe pneumonia were recruited over a period of 14 months and were thoroughly investigated to ascertain a definitive diagnosis.

RESULTS

In total, 700 children were recruited for the study. Most frequent clinical diagnoses included wheezing-related conditions (bronchitis/asthma, 46%; bronchiolitis, 15%), while typical bacterial pneumonia was infrequent (only 19% of the cases). Invasive bacterial disease detected by classical microbiology or molecular methods was also uncommon, affecting only 3.5% of the patients, and with an overall low detection of pneumococcal or Haemophilus influenzae type b disease. Conversely, coverage of respiratory viral detection in the nasopharynx was almost universal among cases (92%), with the three most frequent viruses detected being rhinovirus (53%), respiratory syncytial virus (18%) and adenovirus (17%). The overall case fatality rate (CFR) among recruited patients with a known outcome was 4.1% (28/690).

CONCLUSIONS

In Morocco, the epidemiological profile of paediatric acute respiratory infections is markedly shifted towards wheezing-related diseases and thus resembles that of high-income countries. However, the high associated CFRs found in this study call for an improvement in preventive and clinical management strategies.

Antibiotic Usage Prior and During Hospitalization for Clinical Severe Pneumonia in Children under Five Years of Age in Rabat, Morocco

Scarce and limited epidemiological, clinical and microbiological data are available regarding pediatric respiratory tract infections in the Kingdom of Morocco, a middle-income country in Northwestern Africa. Data on antibiotic usage for such infections are also scarce. A good understanding of pre-admission and intra-hospital usage of antibiotics in children with respiratory infections linked with an adequate surveillance of the antibiotic susceptibility from circulating pathogens could help policy makers improve their recommendations on management of respiratory infections. We hereby present data on antibiotic usage prior and during admission and antibiotic susceptibility of major circulating respiratory pathogens in children under five years of age admitted to the Hôpital d’Enfants de Rabat, Morocco, with a diagnosis of clinical severe pneumonia (using World Health Organization (WHO) standardized case definitions) during a period of 14 months (November 2010–December 2011), as part of a larger hospital-based surveillance study designed to understand the etiology and epidemiology of severe pneumonia cases among children.

Risk factors in facial hyperpigmentation in Maghrebian population - a case-control study

Triggering factors seem to be multiple in the pathogenesis of facial hyperpigmentation (FH), as dark skin types, pregnancy, sun exposure… The aim of this study was to investigate the risk factors for FH in Maghrebian population. Patients with FH were included in a case-controlled study. Following data were recorded: age, sex, parity, phototype, FH and hormonal-related history, endocrinological features, sunlight exposure, specific cultural behaviours, use of topic corticosteroids and sunscreens. One hundred women (mean age 29.5 ± 13.7 years) were included with 200 age-matched controls. Duration of FH was 32.9 ± 42.2 months. There was a statistically significant relation between FH and hirsutism (P = 0.009), troubles of menstruations (P = 0.008), but not with acne (P = 0.23) and contraceptive oral (P = 0.06) drugs or with history of thyroid disorders (P = 0.13). For cultural factors, there were a statistical significant relation with rubbing by flannel glove (P < 0.05), use of dark soap (P = 0.009) and traditional masks (P < 0.05) but both groups were used to go to hammam. A strong relation was observed between FH and use of topical corticosteroids: 40% in the FH group vs. 5% in the control group (P < 0.05). Both groups used to apply sunscreens: 70% in the FH group and 67% in the control group where as there were no differences in the two groups for sun exposure. No statistical differences were observed regarding to age, phototypes and grade of parity. Our study demonstrated a relation between FH and hyperestrogenemia, rubbing with a friction glove, use of moroccan traditional masks and application of topical steroids. The eviction of all these triggering factors could be an adjuvant recommendation in the assessment of FH.

[Sympathetic response in primary hypertension]

High blood pressure (BP) is a major cause of cardiovascular disease and primary hypertension is a frequent pathological condition. Sympathetic hyperactivity may be involved in primary hypertension. The purpose of this study was mainly to evaluate sympathetic activity when performing cardiovascular autonomic profile examination in patients with primary hypertension in comparison with normotensive subjects.

PATIENTS AND METHODS

This prospective study included one group of hypertensive patients (n=120, mean age 54 years) compared with a control group (n=120, mean age 52 years) of normotensive subjects. Autonomic tests included deep-breathing (DB), hand-grip (HG) and echostress test (ES). Comparison tests between the two groups, similar in age, were expressed as mean+/-SE and made using the t Student test, p<0.05 was considered significant.

RESULTS

Alpha-adrenergic sympathetic response using ES method produced a BP response of 20,0%+/-9,8 in hypertensive patients group and 15,2%+/-8,6 in the control group (p<0.001). Alpha-adrenergic sympathetic response using three minutes HG test was of 16,7%+/-7,5 in hypertensive patients group and 13,3%+/-6,5 in the control group (p<0.001). Vagal stimulation in hypertensive group after DB showed that electrocardiographic: ECG (EKG) waves R (RR) interval variation was of 30,2%+/-8,1 meanwhile in the control group this RR variation was of 46,1%+/-21,1 p<0.001, and the one of HG of 15 seconds was 17,6%+/-10,2 versus 32,5%+/-12,7 p<0.001.

CONCLUSION

Hypertensive patients had a significantly higher sympathetic response to central and peripheral stimulations and a significantly lower parasympathetic response when compared to normotensive controls.

[Primary gastric lymphoma: a retrospective series of 35 cases]

BACKGROUND

Primary gastric non Hodgkin's lymphoma (PGNHL) is the most common site of extranodal malignant lymphoma. It is a rare subtype of malignancy, for which no consensus exists about treatment.

AIM

The purpose of This paper was to assess the managemnt of PGNHL.

METHODS

Between January 1992 and December 2001, 35 patients were retrospectively evaluated.

RESULTS

Of the 35 patients, with a mean age of 44 years old Signs and symptoms are unspecific. 20 (57.1%) were in stage IE/IIE1. 15 patients (42.8%) were in stage IIE2,IIIE,IVE. These patients were treated with primary surgery with or without chemotherapy (11; 31.4%); primary chemotherapy (CT) alone with surgery in one patient (21; 60%) and three patients with gastric MALT lymphoma were treated by Helicobacter pylori eradication. The 5 year survival rates of the 35 patients are 62, 86%. There was no significant difference in the 5 year survival rate between the patients with low grade lymphoma and the patients with large grade lymphoma (75% versus 60%, P = 0.467). The 5-year survival rates for stage I/IIE1 and IIE2/III/IV patients were 80%, 53.3% respectively (p < 0.144). Of the 11 primary surgical groups with or without chemotherapy, the 5 year survival rate is 90.9%. Of the 21 patients who received CT, alone or combined with surgery, the survival rate is 52.4%. There was significant difference between the two groups (P = 0.05). Of the 3 patients with low-grade mucosa-associated lymphoid tissue (MALT) lymphoma with only oral anti-Helicobacter pylori regimen remained disease-free after a median follow-up of two years.

CONCLUSIONS

This study suggested that primary surgical resection may be important factor predicting the long-term survival of patients with primary gastric NHL. H. pylori eradication therapy was an effective first-line treatment for patients with gastric MALT lymphoma.

Prevalence of hospital-acquired infection in a Moroccan university hospital

BACKGROUND

Infection control and hospital-acquired infection (HAI) prevalence reports from developing countries are often not well established because of the lack of staff and resources. The aim of this study was to estimate the prevalence of HAI in a Moroccan hospital as well as to identify its predisposing factors.

METHODS

A one-day prevalence survey was conducted in April 2005 at Ibn Sina University Hospital which included all inpatients who had been in the hospital for at least 48 hours.

RESULTS

Among 658 patients surveyed, the prevalence of HAI was 17.8%. The prevalence was higher in intensive care units (50%). The most frequently infected sites were urinary tract (35%) and surgical wounds (32.5%). Microbiological documentation was available in only 31.6% of HAIs. The most frequently isolated organisms were Staphylococcus aureus (30%) and Proteus mirabilis (25%). Results of multiple logistic regression analysis indicated that HAI is linked to the surgical category, a hospital stay of more than 10 days, and the use of intravascular and urinary devices.

CONCLUSIONS

The prevalence of HAI is high at our center. This survey provided the principal information for future surveillance and prevention programs in Morocco.

[Prevalence of syphilis and HIV infection in female prison population in Morocco]

We studied the prevalence of syphilis and HIV infection in 217 female prisoners at Oukacha prison, Casablanca and associated risk factors. The mean age was 32.0 years and mean length of imprisonment 22.8 months. As regards risk factors, 9% of the women said they used condoms, homosexuality was not admitted, 1.8% were intravenous drug users and the average number of sexual partners was 5.17. Fifty-one women (23%) were positive for syphilis and 4 (2%) were HIV-positive. Multivariate analysis found that being married was protective (OR = 0.75, 95% CI: 0.57-0.97), while high number of partners was a positive risk factor (OR = 2, 95% CI: 1.2-3.51).

[Therapeutic maintenance level of methotrexate in rheumatoid arthritis]

OBJECTIVES

To determine the probability of drug continuation, the reasons for discontinuation of methotrexate (MTX), and risk factors of treatment termination in rheumatoid arthritis.

MATERIALS AND METHODS

Retrospective cohort study of a 100 case follow-up between 1983 and 2003, all treated with MTX. Factors associated with toxicity, and efficacy of MTX were studied. Logistic regression was used to study the relation between baseline variables and various dependent factors.

RESULTS

Eighty three women and seventeen men were included in this study. The mean age at commencement of MTX was 45+/-13.7 (18-81) years. The mean duration of disease was 9.5+/-8.7 (0.25-40) years. The mean weekly dose of MTX was 9.8+/-3.4 mg/week. The therapeutic maintenance level of MTX was 76% at one year, 63% at 2 years and 45% at 5 years. The median of treatment duration was 10 (0. 5-40) months. Reasons for patients stopping MTX were: Adverse effects (15), lack of effect (1), non medical reasons (14) essentially because of financial difficulties. Baseline white blood cell counts >9 giga/mm3 (RR: 3.17) [95 %:1.03-9.74] (p=0.04) and baseline serum creatinine level >72 micromol/L (RR: 8.6) [95 %:1.04-71.17] (p=0.04) were associated with an increased risk of treatment termination.

CONCLUSION

The continuation rate of methotrexate in our study was good, despite the poor compliance with the treatment due to financial difficulties.

Socioeconomic impact of rheumatoid arthritis in Morocco

OBJECTIVE

To estimate the socioeconomic impact of rheumatoid arthritis (RA) in Morocco.

MATERIALS AND METHODS

We identified 100 consecutive patients (88 women and 12 men) with RA receiving follow-up either at a teaching hospital or from office-based physicians. For each patient, we recorded direct costs, indirect costs (productivity losses), and intangible costs (deterioration in the social domain of quality of life).

RESULTS

Mean age at symptom onset was 31+/- 13.6 years and mean disease duration was 12.8 +/- 7.8 years. RA-related expenses caused financial difficulties for 90% of patients, resulting in poor treatment compliance (61% of cases) and school absenteeism in the children (19% of cases). Of the 34 patients who had paid jobs at symptom onset, 65% stopped working, 6.9 years on average after the diagnosis. Older age, male gender, and a physically strenuous job were associated with stopping work. Six women (10% of married patients) divorced because of their disease. Sexual problems were reported by 67% of patients. The ability to perform domestic chores was affected in 84% of cases and participation in leisure activities in 46% of cases.

CONCLUSION

RA has a major socioeconomic impact on affected families. In addition to the disease itself, the low socioeconomic status of many patients and the inadequate social welfare and health insurance systems contribute to the burden.

Reproducibility of bone mineral density measurements using dual X-ray absorptiometry in daily clinical practice

Bone mineral density (BMD) measurements are frequently performed repeatedly for each patient. Subsequent BMD measurements allow reproducibility to be assessed. Previous studies have suggested that reproducibility may be influenced by age and clinical status. The purpose of the study was to examine the reproducibility of BMD by dual energy X-ray absorptiometry (DXA) and to investigate the practical value of different measures of reproducibility in three distinct groups of subjects: healthy young volunteers, postmenopausal women and patients with chronic rheumatic diseases. Two hundred twenty-two subjects underwent two subsequent BMD measurements of the spine and hip. There were 60 young healthy subjects, 102 postmenopausal women and 60 patients with chronic rheumatic diseases (33 rheumatoid arthritis, 10 ankylosing spondylitis and 10 other systemic diseases). Forty-five patients (75%) among the third group were receiving corticosteroids. Reproducibility was expressed as the smallest detectable difference (SDD), coefficient of variation (CV), least significant change (LSC) and intraclass correlation coefficient (ICC). Sources of variation were investigated by linear regression analysis. The median interval between measurements was 0 days (range 0-7). The mean difference (SD) between the measurements (g/cm2) was -0.0001 (+/-0.003) and -0.0004 (+/-0.002) at L1-L4 and the total hip, respectively. At L1-L4 and the total hip, SDD (g/cm2) was +/-0.04 and +/-0.02, CV (%) was 2.02 and 1.29, and LSC (%) 5.60 and 3.56, respectively. The ICC at the spine and hip was 0.99 and 0.99, respectively. Only a minimal difference existed between the groups. Reproducibility in the three groups studied was good. In a repeated DXA scan, a BMD change, the least significant change (LSC) or the SDD should be regarded as significant. Use of the SDD is preferable to use of the CV and LSC because of its independence from BMD and its expression in absolute units. Expressed as SDD, a BMD change of at least +/-0.04 g/cm2 at L1-L4 and +/-0.02 g/cm2 at the total hip should be considered significant. This reproducibility seems independent from age and clinical status and improved in the hips by measuring the dual femur.

Profil autonomique des patients migraineux

OBJECT

Dysfunction of autonomic nervous system (ANS) is implicated in the genesis and persistence of migraine. The objective of this study was to compare autonomic nervous system (ANS) profile of migraineurs during headache-free periods to a group of normal subjects based on cardio-vascular reactivity.

METHODS

Patients with migraine according to the criteria of IHS 2004 were selected for the study. After a 30 min resting blood pressure (BP), the following standard tests were performed: deep-breathing (DB), hand grip (HG) of 15 s and 3 min, valsalva maneuver, echo stress, (ES) and tilt test (TT). Results were compared to 44 normal subjects, age similar, 37 female, (84.1%) using the Student test, with P < 0.005 as significant.

RESULTS

Thirty-two patients (27 female (84.38%), 16-51 years, mean 40.41 +/- 7.8) were studied. Twenty-two patients (69%) had systolic blood pressure below 94 mmHg and 25 patients (78%) had diastolic blood pressure below 60 mmHg. Compared to normal, migraineurs exhibited a significantly higher vagal response (P < 0.001) and a significantly lower alpha sympathetic response, central by using ES as well as peripheral by using HG of 3 min (P < 0.001).

CONCLUSIONS

Autonomic cardiovascular reactivity of patients with migraine showed a vagal hyperactivity and a deficiency of the alpha sympathetic system. This leads to further studies with new therapeutical approaches.

Epidemiology of hip fractures in 2002 in Rabat, Morocco

Hip fracture has never been studied before, either in Morocco or in the adjacent countries of the south bank of the Mediterranean Sea. The aim of this study was to investigate the incidence rate of hip fracture in 2002 in Rabat Province, a large area in the northwest of The Kingdom of Morocco, by the use of register information and medical records collected from the five public hospitals of the region. The hip fracture data were restricted to cervical or trochanteric types. There was a total of 150 hip fractures (83 in women and 67 in men) in the over-50-year-old population in the Province of Rabat during 2002. The age-adjusted 1-year cumulative incidence of hip fracture was 52.1/100,000 [95% confidence interval (CI) 40.9-63.3/100,000] in women and 43.7/100,000 (95% CI 33.3-52.2/100,000) in men. The standardized incidence rate against the 1985 US population was 80.7/100,000 (95% CI 78.5-93.0/100,000) for women and 58.5/100,000 (95% CI 47.9-68.1/100,000) for men. The mean (standard deviation) age of patients with a hip fracture was 70.7 (9.4) years for women and 70.4 (10.0) years for men. The overall female-to-male ratio of hip fracture was 1.19 for age-adjusted hip fracture incidence and 1.30 for standardized incidence. A marked increase in incidence rate was found for both men and women with increasing age, becoming exponential after the age of 50 years. The mean age for hip fracture was 70.7 (9.4) years in women and 70.4 (10.0) years in men (P > 0.05). Women had a cervical-to-trochanteric ratio of 0.97 compared to men, at 1.03. The characteristics of hip fractures described in this study suggest that fragility fractures occur in North Africa, although substantially less frequently than in most European, North American and Asian countries but more frequently than sub-Saharan African countries, in agreement with the north-south gradient observed in the epidemiology of osteoporosis. The low incidence of hip fragility fracture rate is most likely the result of reduced longevity in Morocco.