ASM Young Ambassador for DRC: Annual meeting 

Antimicrobial Resistance (AMR): a threat for the humanity

On November 25, 2017, a scientific meeting was held as part of ASM Young Ambassador activities for the year 2017 in Goma city/Democratic Republic of Congo. The main topic of the event was: Antimicrobial Resistance: a threat for the humanity.

AMR has become a real threat for public health and the entire society worldwide. Although, previous studies have shown that misuse and overuse of antibiotics is the main cause, the role of health professionals has been highlighted in over prescription of antibiotics unnecessarily. This increases the use of antibiotic without any evidence for sensitivity and presence of infection. In addition, pharmacists play a crucial negative role in delivering antibiotics without prescription. Hence, this leads to increased rate of resistance to most common used antibiotics.

Due to the above global health menace, it was important to hold this annual meeting targeting health professionals (doctors, lab technicians and nurses) for a scientific reflection which allow them to understand the role they play negatively during their daily work. Therefore, this may contribute in changing behaviour and think twice before prescribing antibiotics.

The specific objective was to gather 15 health professionals for the meeting. The second objective was to get commitment from 80% of them to change their daily habit. In addition, 60% of them should commit to become members of ASM.

During the event, 19 health professionals have attended from 9 health care institutions. Hence, this objective has been attained by 126.6%. This show at which extend the topic was interesting for health professionals who were invited for the event.

Among the attendees, 9 were medical doctors (47.3%), 8 were registered nurses who are involved in prescription (42.1%), 1 was a registered lab technician (5.3%), and 1 was medical school student (5.3%). The objectives of the ASM YA and the engagement with ASM were well explained to the participants to let them be engaged with this international scientific organization. Therefore, 17 of them (89.5%) have made commitment to join the ASM and the membership forms were filled. This leads to an achievement of this objective by 149.2%.

During the discussion, all attendees (100%) have committed to change their usual habit in prescribing antibiotics. Even though, the needed materials and equipment for infection diagnostic and antibiotic sensitivity, participants have agreed that it is important to think sufficiently before releasing a prescription and advocating for equipping hospitals and health centres to diagnose an infection before treatment. Hence, this objective was attained in 125%.

At the end of the session, 3 working groups were constituted to reflect on the following topics:
1. How veterinary service can help to avoid AMR?
2. How to avoid abusive prescription for antibiotics?
3. How to avoid the consumption of non-prescribed antibiotics in the community?

After the group work, a bunch of recommendations have been formulated among them, we can quote: 1. Awareness program for veterinary doctors and help them to create veterinary clinic for animal health and explain them to avoid using antibiotic in animal unnecessarily.
2. Make regulations for exportation of animal products.
3. Awareness program for the entire community explaining the problem to the population. This can reduce unnecessary consumption of antibiotics without prescription.
4. Conception of prescription guidelines and strict respect of protocols (when possible) and avoid non-justifiable antibiotic combinations.
5. The government should take its responsibility and pay all health care personals and equip all hospitals (public and private) with materials to diagnose infections and sensitivity.

As the topic is more interesting and new for all health professionals, it was decided to take as the topic for the year 2018. This will allow professionals to get deep understanding of how behaviour and contribute to the global effort to solve this health crisis. A certain number of scientific visits will be held next years in different health care facilities to involve a sufficient number of health professionals.

Done in Goma, December 5th, 2017
Mateus Kambale Sahani, MD, MSc
ASM Young Ambassador for DRC, Hope Medical Center (HMC).

Antibiotics resistance in Goma city: challenges and opportunity!

Antibiotic resistance has become a serious public health worldwide and special efforts are needed to inverse its trend (Goossens, H., Ferech, M., Van-der-Stichele, R. & Elseviers, M., 2005). Previous studies have argued that there is a linear relationship between increase in use of antibiotics and the increase rate of resistance. This use can be both in human and veterinary conditions and most of times, it is an unnecessary at one hand and at the other hand it may be in overuse or misuse of antibiotics. (Hutchinson, J. M., at al., 2004; Davies, J. & Davies, D., 2010). For research and monitoring purpose, antibiotic consumption is reported according to the World Health Organization (WHO) ATC/DDD classification (Hutchinson, J. M., at al., 2004; MacDonald, K. & Potvin, K., 2004). However, in many countries this classification is used in order to get reliable data on antibiotic consumption in the country. The Democratic Republic of Congo (DRC), especially Goma city, is one of the country where the rate of antibiotic consumption is not reported and no data are available in this filed. However, it is know that DRC is also one of the countries where fake antibiotics are used and even the real antibiotic drugs are more overused. In most countries where antibiotic are used at a high rate like France, most of them are prescribed. But, with our experience, we have noted that more than half of used antibiotic in Goma city are not prescribed by a physician. The population of Goma city has enacted a habit of taking antibiotics without medical prescription and then consults a physician only when they have changed antibiotic more than twice and don’t get any positive result. In addition, we have assisted to patients’ friends who blamed hospitalized patients asking them why they accepted to become inpatients thinking that they spend more money by paying the hospital bill. Their advance was to continue taking antibiotics and change more types until they could feel better. This is also poverty factor which increases the risk of resistance and complications for patients. As our hospitals are more equipped to detect the exact causal agent and test if there resistance or not, mostly physician just change the antibiotic used by patients and prescribe another without proceeding to any test for resistance or susceptibility. This is also another factor that increase resistance as physicians work as in a blinded process due lack of lab equipment for infectious diseases and antimicrobial susceptibility testing (AST). Moreover, due to what we are facing now, researches are needed to know what is the level of antibiotics consumption and resistance in Goma city and more other DRC cities, as all factors to increases resistance are observed. This will be among the opportunity for this country to know the antibiotics consumption and resistance levels and may be a way to begin using the WHO ATC classification to make data available for research. Therefore, Agir Ensemble (AE) and Hope Medical Center (HMC) are determined to work closely with hospitals and universities to enhance this field and stimulate physicians and other health professionals to pay attention on antibiotic use. Furthermore, the problem seems to be also a community problem because of using unprescribed antibiotics. We need to develop also a community-based approach showing people the danger they are exposed to by this unhealthy behavior. We are more motivated to find modern equipment at Hope Medical Center for AST which will allow us to proceed to testing for susceptibility and resistance. In this way we can serve as reference for other hospitals to get results for their patients. Therefore, we will appreciate the collaboration of the American Microbiological Association (ASM) to help us implementing this valuable program. Mateus Kambale Sahani, MD, Fellow MGH (Maastricht University). Agir Ensemble/Hope Medical Center Blog: http://agirensemblerdc.blogspot.com

Projet de revitalisation des économies perdues/recyclage artisanale des déchets (plastiques et papiers).

Ce projet est une action innovante dans la protection de l’environnement. Actuellement, la gestion des déchets est qui nécessite une attention particulière surtout dans les grandes villes. Cette alternative de recyclage des déchets est une action importante qu’Agir Ensemble mène pour lutter efficacement contre l’insalubrité en ville de Goma. Actuellement, Agir Ensemble se spécialise dans le recyclage des sachets et cartons (papiers) qui, le seul mode de gestion est l’incinération en ville de Goma qui est une méthode inappropriée dans le nouveau dynamisme de gestion durable de l’environnement au vue de ces conséquences. Face à ce défis, Agir Ensemble à mis en œuvre un projet de recyclage artisanale des déchets plastiques dont les sachets et les papiers. Nous produisons des sacs à mains, des poupins, des portes clés, des plumiers, des foulards, des chênettes, des bracelets,…. qui sont d’une qualité exceptionnelle et appréciable. C’est une action qui nécessite un accompagnement car réalisée avec des moyens de bord dans une unité (centre) de recyclage. Grace à cette activité, un impact est visible écologiquement et socialement : 1.Ecologiquement: la réduction significative des déchets grâce au recyclage ; 2.Socialement: l’encadrement socioprofessionnel de 32 filles mères victimes de marginalisation et d’exclusion ; une source de revenue dans la revitalisation des économies perdues. Il sied de signaler que cette activité de recyclage s’inscrit dans la politique de la promotion de la femme via l’entrepreneuriat féminin. Nous pouvons transformer positivement notre environnement en adoptant des comportements responsables. Notre apport est là. Votre geste peut contribuer à améliorer d’avantage cette action. Grace à ce projet, nous appuyons l’entrepreneuriat féminin. Analyse du contexte L’analyse de la situation montre que les femmes (filles mères) sont d’autant plus exposées à divers pandémies suite à leurs conditions de vulnérabilités. La prévalence du VIH/SIDA est relativement croissant, surtout observé chez les professionnels (le) s du sexe ; elles sont exposées à un risque accru au VIH et accroit leur vulnérabilité aux infections du VIH/SIDA, c’est la dimension Genre du VIH/SIDA. Il est démontré que le taux d’infection sont beaucoup plus élevés chez les jeunes femmes que chez les jeunes hommes, en partie à cause de facteurs biologiques, mais surtout à cause de l’inégalité des relations de pouvoir entre le sexe notamment : le mariage précoce, les accouchement avant l’âge ; ainsi que les rapports entre jeunes femmes/filles et les hommes plus âgées sont des facteurs économiques qui ont une incidence sur la prévalence et le taux élevé du VIH/SIDA parmi le groupe est sont aussi victime de discrimination, d’exclusion et de désocialisation. Sont d’autant des circonstances dont sont victimes et exposées les femmes/filles du fait d’un faible niveau économique qui s’inscrit dans les annales de lutte et priorités du gouvernement dans la Convention sur l’élimination de toutes les formes de discrimination à l’égard des femmes (CEDEF), le plan d’action national 1325.

L’alphabétisation doit être un droit pour tous

L’alphabétisation doit être un droit pour tous En marge de la journée internationale de l’alphabétisation qui a été célébré sous le thème : « Alphabétisation et sociétés durables », nous avons tenu une journée porte ouverte et d’exposition pour sensibiliser le public sur l’importance de l’alphabétisation. Les apprenants ont eu à démontrer les acquis de la formation qu’elles sont acquis chez Agir Ensemble asbl-RDC. Signalons que ces activités ont été rendu possibles grâce à l’appui technique du Collectif Alpha-Ujuvi qui assurait la coordination des activités. Par contre, avec nos efforts, nous nous rendons compte que l’alphabétisation contribue efficacement à autonomiser les femmes analphabètes dans nos sociétés. Donc, nous devons unir nos forces pour que la maitrise de la lecture et de l’écriture soit un droit pour tous. La route est longue, mais nous menons dans la bonne direction.

Clinical trial at Hope Medical Center

The Woman trial is an international randomised trial conducted and coordinated by the London School of Hygiene and Tropical Medicine (LSHTM) in London/UK. The trial is conducted worldwide and Hope Medical Center was proud to be selected as the first collaborator for the trial in Democratic Republic of Congo and its director, Dr Mateus Kambale Sahani as the principal investigator at Hope Medical Center. Dr Mateus has been also selected as the National Coordinator of the woman trial and with his efforts, more than 10 hospitals were included in the trial. This trial consists of treating women with post-partum haemorrhage using tranexamic acid and the result was a real success for every sites of the trial.

Analyse du contexte projet de vulgarisation du processus électoral

Analyse du contexte projet de vulgarisation du processus électoral La démocratie et le processus électoral semblent être de l’apanage des politiques en République Démocratique du Congo et les couches sociales les plus démunies sont sauvant écartées des planifications et, ainsi, ces paisibles citoyens lors du vote ne connaissent pas qui voter, pourquoi voter et comment voter. 2006, première expérience en matière électorale de la République Démocratique du Congo suivi de ceux du 28 Novembre 2011 qui ont donnée des résultats contestants par toutes les couches sociales surtout ceux des classes politiques et la société civile. En outre, l’histoire africaine récente a montré en suffisance à quel point le déroulement des élections est souvant source des conflits et d’instabilité. Bien que la maitrise du processus électoral soit considérée comme le résultat d’un long apprentissage, nous pensons qu’au niveau d’Agir Ensemble que si les jeunes sont conscientisés et mobilisé d’avance, on pourra éviter des troubles et tensions. D’aurez avant, la population du territoire de Lubero et celle de la ville de Goma n’ayant pas assez d’informations sur le rôle qu’elles doivent jouée dans le processus électoral, nous pensons que les informer et les conscientiser est un atout important pour la réussite du processus électoral. Nous devons vulgariser le processus électoral à tous les niveaux, par des sensibilisations en donnant des outils qui leurs permettrons d’être des citoyens à part entière. Nous sommes convaincus qu’avec cela, on pourra accroitre l’efficacité et la neutralité du processus électoral en cours en République Démocratique du Congo. Ainsi, les élections étant considérés comme une thématique à la une en RD Congo et que la jeunesse constitue une base importante pour la réussite de ces élections, la vulgarisation des élections constitue une opportunité majeure pour conscientiser et mobiliser les jeunes à l’auto-appropriation du processus électoral en leurs donnant des outils et informations nécessaires. De ce fait, l’urgent d’outiller la jeunesse sur le rôle du citoyen dans le processus électoral s’impose en se basant sur les questions suivantes: pourquoi voter, comment voter et pour qui voter. La mobilisation des jeunes au processus électoral c’est le vif souhait d’Agir Ensemble asbl.

Projet de Promotion de l’éducation pour tous

Chez Agir Ensemble, l’éducation est au premier plan. C’est pourquoi, nous mettons en œuvres des projets visant à promouvoir l’émulation des enfants victimes des catastrophes et guerres, ce qui nous a permis de mettre en œuvre une Ecole pour l’Education Formelle ; le Complexe Scolaire ISULI/KATASOHIRE. A notre niveau, nous pensons que plaidoyer en faveur d'une éducation de base de qualité pour tous les enfants et les jeunes en Afrique serait notre profond encagement pour matérialiser nos rêves. Actuellement, les enfants qui sont privés de leurs droits à l’éducation sont surtout les enfants vivants dans les familles pauvres, enfants vivants dans les camps des déplacés, enfants orphelins. Nous avons répertoriés des nombres si gigantesques dans les territoires de Rutshuru, Masisi en province du Nord-Kivu. En ville de Goma, les enquêtes nous ont prouvé que le Camps Militaire de Katindo compte des nombreux enfants orphelins dont leurs pères sont morts au champ de bataille (sous le drapeau) mais ils n’ont pas accès à nombreux de leurs droits dont l’Education de base. Nous sommes conscient qu’en joignant nos forces pour défendre la cause de l'éducation de l’Enfant Africain ; nous pouvons développer le monde. Tout peut changer, et le sourire peut naitre sur le visage de ces enfants. Un espoir pour le développement. Actions en cours en faveur de la jeunesse qui nécessitent un accompagnement: • Projet de réinsertion des enfants sortis des groupes armées : Actuellement, nous encadrons 82 enfants soldats dans le territoire de Rutshuru. Ils sont encadrés par un projet intégrateur dans le domaine agricole et d’élevage (en cours de mise en œuvre). • Projet de formation en métier : 14 jeunes sont formés à Rubare dans le centre de formation dont 7 personnes en hydraulique rurale et 7 en coupe et couture (en cours de mise en œuvre). • Projet de réinsertion socioprofessionnel des filles mères et autres vulnérables en ville de Goma d’ici 2015 (en cours de mise en œuvre). • Projet d’Encadrement des personnes de 3èmes âges en ville de Goma (en cours de mise en œuvre) • Projet de Vulgarisation des cultures maraichères et relance de l’élevage : ce projet de résilience qui s’inscrit dans la thématique de lutte contre la pauvreté (sécurité alimentaire ) et moyens de subsistance de base en faveur de 150 ménages des groupements Mudja-Rusayo en territoire de Nyiragongo où le taux d’insécurité est supérieur à la moyenne, populations victimes des astres des guerres et des conséquences du Wiltz Bactérien du bananier qui constitut la base économique de survit pour les ménages. Il se base aussi sur 309 ménages des cités de Kirumba, Kayna en territoire de Lubero, province du Nord-Kivu déplacées suite aux attaques menées par l’armée Congolaise aux éléments de la Force Démocratique pour la Libération du Rwanda, qui, ces populations jusque-là n’ont reçue aucune assistance nécessaire. Nous pensons mettre en œuvre un projet de résilience pour ces populations. Ce projet nécessite une cours des partenaires. • Projet de création des jardins potagers dans les écoles en faveur des enfants pour susciter l’émulation. Cible écoles de la Ville de Goma et du territoire de Rutshuru. • Projet de vulgarisation du processus électoral en cours en République Démocratique du Congo.

Projet de réinsertion socio-professionnelle de la jeune fille mère en ville de Goma victimes jadis stigmatisée et marginalisée

En ville de Goma (Province du Nord-Kivu), les nombreuses situations de guerre et de pauvreté ont fortement bouleversé le vécu quotidien de la population. De ce fait, les mariages précoces et les naissances avant l’âge a fortement amplifié les relations sociales dans divers ménages et les filles qui en sont victimes sont stigmatisées, rejetées par la société. De ce fait, au vue du vagabondage sexuel, la conséquence résultante c’est soit les grossesses précoces et les maladies sexuellement transmissibles dont principalement le VIH/SIDA. Dans ces deux cas, victime de ces là, la fille est stigmatisé et isolée (exclue) dans la vie sociale familiale et les uns sont même rejeté du toit paternel et vivent dans la rue. Elles sont déconsidérées et marginalisées. Ce comportement de désocialisation qu’affiche la communauté et la famille à l’égard de ces jeunes mamans laisse indésirable vue que la fille mère vit dans la rue dans des conditions déplorable : pas de minimum de survie, vit de solitude. Au vue de cela, nous pensons au niveau d’Agir Ensemble que ce problème résulte du manque d’encadrement et du faible revenue économique des filles qui les poussent à courir vers les jeunes garçons sous prétexte de ramasser quelques billets des francs congolais. De ce fait, si ces filles sont encadrées, conscientisées et autonomes économiquement, nous pouvons les responsabilisées et faciliter leurs intégration dans la société. Au vue de nos larges expériences dans le domaine d’encadrement et réinsertion professionnelle des filles mères, notamment dans divers projets financés par le Programme des Nations Unies pour le Développement, l’autonomisation financière grâce à recettes générées par les ventes en faveurs de ces filles pourra faciliter l’intégration communautaire de ces filles comme là toujours été dans nos projets de ce genre (détraumatisation par la création d’un lien social). Le fait que ces filles mères travaillent ensemble se libère des traumatismes qu’elles ont subis et facilite leur épanouissement. Ces activités leurs rendent autonomes financièrement et plus aisé socialement. Nous allons y arriver avec votre concours. Pour tout contact : -Email : aensemble@yahoo.fr ou agirense@yahoo.fr -Tel : +243-9 98 62 56 35 ou +243-9 98 78 76 88

Projet d’appui à l’Entrepreneuriat innovatrice féminin et protection de l’environnement

Dans le cadre de la promotion de l’entrepreneuriat féminin et la protection de l’environnement, Agir Ensemble a lancé depuis Avril 2015 un projet de recyclage qui s’inscrit dans la thématique « Revitalisation des Economies perdues ». Ce projet vise à recycler les sachets (déchets plastiques) qui constituent une menace à l’environnement ; telle est le cas en ville de Goma où l’unique méthode d’élimination est l’incinération. Cette méthode ne fait qu’aggraver les conséquences du changement climatique avec l’émission des gaz à effet de serre. Il n’est pas rare de vivre des smogs en ville de Goma lors des journées d’assainissement. Nous pensons que notre méthode est efficace du point de vie environnemental et économique. Nous produisons des sacs à mains, des portes clés, des chapeaux, des poupins, tortis, des foulards, des sous plants,.... mais avec nos moyens, nous n’arrivons pas à faire mieux comme nous le souhaitons. Nos perspectives est de créer un centre de recyclage des déchets, spécialement les sachets après usages et de mener une transition des emballages plastiques en emballages Papier. C’est possible avec votre concours. Pour tout contact : -Email : aensemble@yahoo.fr ou agirense@yahoo.fr -Tel : +243-9 98 62 56 35 ou +243-9 98 78 76 88

Emory University Colposcopy clinic visit for Dr Mateus

After the CDC Meeting on Wednesday March 26, 2014, a mentorship program was built between Dr Lisa Flowers, professor at Emory University School of Medicine (mentor) and Dr Mateus, doctor at Hope Medical Center and Agir Ensemble (mentee) to allow the Emory University serving as US Collaborator for research grants programs issued the NIH. A visit of 2 days (Thursday March 27 and Friday March 28, 2014) was held to allow Dr Mateus increasing his skills in Colposcopy and to be more familiar with the Emory University Colposcopy Clinic environment. On Wednesday March 26, after noon, a contact visit was organized for a brief meeting between Dr Lisa Flowers (Emory), Dr Makeda Williams (NCI) and Dr Mateus Sahani (Hope Medical Center/Agir Ensemble). On Thursday March 27, 2014 Dr Mateus assisted to many cases of Colposcopy at the Emory Grady Campus and visited the laboratory department for biopsy analysis and HPV testing machine. On Friday March 28, 2014 Dr Mateus assisted and learnt how to use many kinds of colposcopes with laptop for monitoring and taking images. For the visit, Dr Mateus was accompanied by his mentor, Dr Lisa Flowers from the Emory University, School of Medicine. We sincerely thank all people who were involved for the success of our visit, especially Dr Ted Trimble (NCI), Dr Makeda Williams (NCI), Dr Lisa Flowers (Emory University), etc.

Cervical cancer situation in D.R.Congo: Dr Sahani’s presentation at CDC, Atlanta/GA-USA

After the SGO Annual Meeting in Tampa/FL, another meeting was held in Atlanta/Georgia-USA to allow Dr Mateus meeting with some people at CDC headquarter and can help building partnership to sustain the cervical cancer prevention program in Democratic Republic of Congo. Dr Mateus met with many people on Wednesday, March 26, 2014 at different time and different places in the headquarter’s office. From 11:00 to 12:00, Dr Mateus did a presentation on cervical cancer situation in Democratic Republic of Congo, the leadership role that Agir Ensemble and Hope Medical Center are undertaking to initiate the program in the country, the way to change things, the way help DRC and specified what are the main challenges and how to overcome them. For the visit, Dr Mateus was accompanied by his mentor, Dr Makeda Williams from the NCI, Center for Global Health and the visit was directed by Jeff Glen from CDC. We sincerely thank all people who were involved for the success of our visit, especially Dr Ted Trimble (NCI), Dr Makeda Williams (NCI), Jeff Glen (CDC), Jackie Miller (CDC), etc. The agenda of Dr Mateus’s visit at CDC is detailed below: Dr. Mateus Sahani visit to CDC Wednesday, March 26th, 2014 Agenda POC: Jeff Glen, 801-550-2142 8:15 – 9:00 am Travel and entry to CDC Chamblee Campus 4770 Buford Highway NE, Atlanta, GA 30341 9:00 – 10:00 am Meeting with DCPC National Breast and Cervical Cancer Early Detection Program • Jackie Miller, Medical Officer Chamblee Campus, Bldg 107, Room 4D 10:00 – 11:00 am Meeting with DCPC HPV Workgroup Chamblee Campus, Bldg 107 , Room 1A 11:00 – 12:00 pm Presentation Chamblee Campus, Bldg 107, Room 1A 12:00 – 1:00 pm Lunch Travel and entry to CDC Roybal Campus 1600 Clifton Rd. NE, Atlanta, GA 30333 1:00 – 1:30 pm Meeting with Global Immunization Division • Ben Dahl, Epidemiologist Roybal Campus, Bldg 19, Room 246 1:30 – 3:00 pm Meeting with CDC HPV laboratory • Beth Unger, Director Roybal Campus, Bldg 23, 4th Floor 3:00 – 4:00 pm Tour of CDC Museum Roybal Campus After the different meetings, a tour was organized to visit the CDC Museum with Jeff Glen and Makeda Williams.

Difficulty of Single Visit Approach for Colposcopy in Goma/DRC

The SGO (Society of Gynecologic Oncology) 2014 Annual Meeting was held in Tampa/Florida-USA from March 21-26, 2014 and Agir Ensemble/DRC was represented by Dr Mateus K. Sahani with an oral presentation related to colposcopy, a young service in DRC initiated at Hope Medical Center in Goma city. The attendance to this valuable meeting was supported by the U.S. NCI (National Cancer Institute), Center for Global Health and the SGO (Society of Gynecologic Oncology) and we would like to sincerely thank these organizations for their support which allowed us attending the meeting and present our work. It was found that women who are totally healthy don’t come to colposcopy clinic because they are not aware of the program and they are not committed to pay for a service while not having any clinical sign that motivate them to consult the doctor/colposcopist. The abstract presented is below: Background and justification: Cervical cancer is a major public health issue worldwide and particularly in Democratic Republic of Congo it is the first cause of death by cancer. Our colposcopy unit is too young (only 6 months of existence) and is the only one colposcopy center in the country. No woman could get access to cervical cancer screening before in whole the country and almost all women and other people don’t know much about cervical cancer screening. This study has objectives to inform more health professionals in our community and more donors and funders worldwide of the reasons of challenges for SVA for colposcopy in Goma. Method: We are performing cervical cancer screening at Hope Medical Center (HMC) and we have analyzed the feasibility of single visit approach for colposcopy during the screening. This is a descriptive and analytic study with data found from the screening procedure reports at HMC. Statistical test like comparison of percentages has been applied to analyze our data. From these 6 months we have screened 115 women, n=115. We have used EPI-INFO 6 software to analyze our data. Results: According to the age: Age: 20-30 31-40 41-50 >50 Total Number: 40 52 18 5 115 Percentage: 34.78% 45.22% 15.65% 4.35% 100% When we compare these different percentages, there a significant difference and this means that there more women with precancerous lesions in the age group of 31-40 years old. Among 115 women screened, we have found 31 (26.95%) women with precancer and 84 (73.04%) women with negative result. WHO has an estimate of 20.3%as reference cervical cancer prevalence in Democratic Republic of Congo. When we compare these 2 proportions, we find that the difference is not statistically significant. This to say that cervical cancer situation in this local community is the same as what was expected by WHO (X2 = 3.15 and p = 0.075972). Among the 31 women with positive results, 9 (29.03%) have CIN I, 17 (54.84%) have CIN II and 5 (16.13%) have CIN III. Those with CIN II and CIN III require treatment by excision (22 women). Among the 22 women who require treatment, all of them didn’t accept to be treated at the first visit for many reasons: 1. To talk first with the husband before being treated: 7 (31.82%) 2. To look for money for the treatment: 13 (59.09%) 3. Need to think about it before accepting to be treated: 2 (9.09%) When we compare these 3 proportions, we find that the difference is statistically significant and this means that more women are not ready to be treated at the first visit because of missing money for the treatment (X2 = 12.41; p = 0.002020). Conclusions: Almost all women are not ready to be treated at the first visit because of missing money (1st cause), involve the husband to the decision (2nd cause) and need to be convinced to accept treatment (3rd cause). It is very important that colposcopy program in Low and Middle Income Countries get financial supports from committed donors and funders to overcome the big challenge.

Colposcopy in D.R.Congo, a contribution to reduce mortality by cervical cancer

Dr Mateus from Agir Ensemble/Hope Medical Center has attended the AORTIC 2013 Conference to presente the abstract below: Author(s): Dr Mateus Kambale Sahani1,2, Dr Roger P. Hamuli2, Mr Désiré Tshombe2 Institute(s):1Health Department, AGIR ENSEMBLE, 2Hope Medical Center-GOMA, The Democratic Republic of the Congo. Background and justification Cervical cancer is the most common cancer in DRC and the first cause of death by cancer in the country. As the service is not available in almost whole the country, people are not aware of it and arrive at the hospital at the very advanced stage of the disease. Methodology We have initiated a colposcopy center in Goma city, east of the country which is the first in this part and we have proceeded to raising awareness to let women being informed of the relevance of this service. This study is prospective and descriptive for 52 women screened at Hope Medical Center (n = 52). The women screened have age between 25 to 45 years old. Results In 2 months (August and September), we have screened 52 women among them 1 has advanced cervical cancer (1.92%), 3 have carcinoma in situ (5.77%), 3 have LSIL (5.77%) and 5 have HSIL (9.62%) and 40 have negative results (76.92%). Among all the women screened, only 10 were totaly healthy (19.23%), 42 consulted because they had one or more signs and symptoms (80.77%). When we compare these percentages, we find that the difference is statistically significant; X2 =39.38 and p = 0.000001. This means that more women come to colposcopy when there is an alarm sign. The most common sign that alarm women for colposcopy is hypogastric and lower back pain (29/42, 69.05%) and the second is dysparenia (8/42, 19.05%) ; other signs (5 people, 11.90%). When we compare these percentages, we find that the difference is statistically significant; X2 =36.64 and p = 0.000001. This means that the most sign that motivate women to come to colposcopy is hypogastric and lower back pain. All women screened positive with CIN have accepted to be treated. This means that when women are aware of their health status regarding cervical cancer/precancer, they are adherent to colposcopy program. Conclusion Awareness program is important for adherence of women to colposcopy program, we should publish a list of warning signs to allow women coming to colposcopy clinic very early. Colposcopy will allow women to be diagnosed very early.

ACLI PROGRAM IN DURBAN/SOUTH AFRICA-AORTIC CONFERENCE 2013.

Agir Ensemble has been honored by the award offered to its director of health department, Dr Mateus Kambale Sahani, by the University of Chicago/USA to attend the AORTIC 2013 conference and the ACLI program in Durban/Africa. There were 12 ACLI recipients from different countries in Africa among which 1 francophone country, Democratic Republic of Congo, represented by, Dr Mateus of Agir Ensemble. ACLI is the African Cancer Leaders Institute and has the aims to develop and improve leadership for young oncologists in Africa The selection was very competitive and only the best could be selected. For this first class, 67 applications were submitted and only 12 were selected. A number of mentors were appointed for the recipients and this award allows recipients to remain in permanent contact with their mentors and develop a long friendship and their career in oncology. This to say it is just a beginning and many things are coming in the future. Career development in this field, especially in our country, needs efforts from every one, stakeholders and political commitments. Many topics have been developed at the conference among them how to disseminate skills gained and how to improve program in the respective countries. At the end of the ACLI Meeting certificates were awarded to the 12 members. A lot of things have been learnt and it can be useful for people in Democratic Republic of Congo. Six African countries represented by 12 oncologists have attended the program activities. The delegates were from the following countries: 1. Nigeria: 5 delegates 2. D.R.Congo: 1 delegate 3. Kenya: 2 delegates 4. Zambia: 1 delegate 5. Ghana: 1 delegate 6. South Africa: 2 delegates Done in Goma, January 20, 2014. Mateus Kambale Sahani, M.D. Agir Ensemble/Health Department/Hope Medical Center Goma-D.R.Congo, Tel: +243-998625635/+250-788884503, Email: kambalesahani@yahoo.fr or agirense@yahoo.fr, Blog: http://agirensemblerdc.blogspot.com

GLOBE ATHON EVENT IN GOMA CITY-AGIR ENSEMBLE

AGIR ENSEMBLE/HOPE MEDICAL CENTER: GLOBE ATHON EVENT IN GOMA On October 5, 2013 Agir Ensemble has hold the Globe-athon event which consists of a 2 hours meeting with women who brought kids at vaccination at Virunga Health Center and cervical cancer screening for 20 women free of charge at Hope Medical Center. The objectives of the event were: 1. To gather 40 women for the meeting 2. To get commitment of proceeding to BSE of 90% of attendees 3. To do cervical cancer screening for 20 women free of charge at Hope Medical center. We have gathered 53 women at Virunga health center and we taught them how to do Breast Self Examination (BSE) for breast cancer early detection. Almost all women (51) found this information very important for their life and have committed to proceed to the BSE every day and to consult doctor for any change to their breasts. All attendees (53) committed to leverage the message to their friend. After this meeting we went to the Hope Medical Center and we got a round table with 10 women before beginning the cervical cancer screening. During this round table we explained to women the relevance of colposcopy to prevent cervical cancer screening and all of them committed to spread the message to their friends. Then we begun colposcopy and other women arrived progressively during the day and in total we screened 18 women among them: 15 had negative results (83.33%), 1 has LSIL (5.56%) and 2 have HSIL (11.11%). Indicators of success: 1. Attendees: 53/ 40 expected => 132.5% 2. We have got commitment of 51 women/53 attendees to practice BSE in their life => 96.23% 3. All women who attended the event (100%) committed to leverage the message to their friends. 4. Screened women: 18/20 expected => 90%. This event was a valuable day to allow us raising awareness of women cancer, especially cervical cancer and breast cancer to let women know what can be done for prevention and early detection. Done in Goma, October 9, 2013. Mateus Kambale Sahani, MD Agir Ensemble/Hope Medical Center.

Colposcopy in DRC, now possible

Agir Ensemble and its medical clinic, Hope Medical Center (HMC) is please to announce to all that it has been able to launch the Colposcopy service this month of May 2013. It is clearly known that cervical cancer is the most common cancer in prevalence and in mortality in D.R.Congo and the second one is breast cancer. For a very long period no colposcopy could be done in Congo and Agir Ensemble took this program in mind as its first priority for women of Congo. I had assisted to unnecessary deaths by cervical cancer, a fully preventable disease, in many hospitals in the country and no body could stop it happen. No one could imagine that colposcopy could be possible in this country; no one could help women getting access to this service in the country ! But we did it! We have begun this fight against cancer, especially cervical cancer and breast cancer since 2004 (there are now 11 years), a fight for a long period and we went slowly but surely towards our goal to make available prevention and early detection services for cancers. And now colposcopy is possible in D.R. Congo, city of GOMA at the east of the republic. The coloposcopy center was launched on May 2, 2013 and this there we have got 5 women attending the service among them 1 has advanced cervical, 1 has precancer (CIN) and 3 have negative results. The main challenge we have is that people in our country are not aware of what is colposcopy and what is its relevance, that is why women didn’t begin coming to this service. We have begun awareness campaign for women in the city to increase the number of people who consult for colposcopy. The second challenge is that most of them don’t have possibility of paying for their colposcopy examination and they need a service free of charge. It could be better to begin with a pilot project for a specific number of women and this could let people aware of the service and then they can pay for it while they are aware of its relevance. Personnaly, I’m very pleased and proud to be the first person to initiate colposcopy in the Democratic Republic of Congo and I’m sure that in the coming days this service will serve also other neighbor countries like Rwanda, Burundi, etc. I would like to thank greatly the IFCPCP for the training provided to me, especially prof Walter Prendiville, prof Lynnette Denny, Patrick Walker, Fidelma and others. I would like to thank also prof Walter for the donation of the colposcope and other materials. Many thanks to Mrs. Robin Glazer in New York for her contribution, many thanks also to prof Linus Chuang in New York at Mount Sinai School of Medicine for the additional training in colposcopy and mammography. The women seen here is the one who has inaugurate our colposcopy service at HOPE MEDICAL CENTER (HMC). The date of June 1, 2013 will be a historical date for me, for all the team and for our organization because it is the date that we get the first women with positive result on colposcopy (CIN) after examination of 5 women during the month. Our young service needs sustainability and strength, support, help and donations from evry one to be more effective to help women in the region. We have a long road ahead of us to let women adhere to it and to increase service utilisation indicators for colposcopy. Done in Goma, June 3, 2013. Mateus Kambale Sahani, M.D. Director of Health Department/Agir Ensemble Medical director of Hope Medical Center (HMC).

IDEA PROGRAM ACTIVITIES REPORT-ASCO ANNUAL MEETING 2012-CHICAGO & NEW YORK

Agir Ensemble has been honored by the award offered to its director of health department, Dr Mateus Kambale Sahani, by ASCO to cover airfare, accommodation, food, transportation to attend the ASCO Annual Meeting in Chicago and an extension for practical course in New York at Mount Sinai School of Medicine in gynecological oncology. There were 24 IDEA recipients from different countries among which 1 francophone country, Democratic Republic of Congo, represented by, Dr Mateus of Agir Ensemble. On Mai 31, 2012, all IDEA (International Development and Education Award) recipients had a visit tour of a cancer center in Chicago, the Northwestern University cancer centre and after the visit scientific presentations were scheduled by staffs of ASCO and of the Northwestern Hospital. ASCO Annual Meeting is the first great and fabulous conference in the world and there were a lot of things to learn in each aspect of clinical oncology. Among the 24 recipients, 20 were for IDEA program and 4 for IDEA-Palliative care program. The selection was very competitive and only the best could be selected. For IDEA program, 100 applications were submitted and only 20 were selected. We have to note that Dr Mateus is the first from Democratic Republic of Congo to receive this award and has been honored accordingly at the award ceremony at the meeting and mentored by Prof Dr Linus Chuang and Dr David Fishman of Mount Sinai School of Medicine of New York. This award allows recipients to remain in permanent contact with their mentors and develop a long friendship and their career in oncology. This to say it is just a beginning and many things are coming in the future. Career development in this field, especially in our country needs efforts from every one, stakeholders and political commitments. Many topics have been developed at the conference among them how to disseminate skills gained and how to improve program in the respective countries. At the end of the ASCO Annual Meeting on June 5, 2012 every IDEA recipient went to the chosen site for ETA (Extended Tour Award) in different cities of USA. Dr Mateus has been placed in New York for 3 days of practical courses from June 6-9, 2012. A lot of things have been learnt and it can be useful for people in Democratic Republic of Congo. I got many skills in mammography (how it is performed and how to read the results), I’ve assisted to 2 cases of radical hysterectomy under laparoscopy and many cases of colposcopy. This is a lot to help people in DRC but assistance is really needed to allow us setting this program. Fifteen countries from every where in the world represented by 24 oncologists have attended the IDEA and IDEA-PC program activities. The delegates were from the following countries: 1. Nepal: 2 delegates 2. Georgia: 1 delegate 3. Honduras: 1 delegate 4. Russia: 2 delegates 5. Jordan: 1 delegate 6. India: 5 delegates 7. Argentina: 1 delegates 8. China: 2 delegates 9. Pakistan: 1 delegate 10. Brazil: 1 delegate 11. Nigeria: 3 delegates 12. D.R.Congo: 1 delegate 13. Kenya: 1 delegate 14. Zambia: 1 delegate 15. Egypt: 1 delegate Done in Goma, June 20, 2012. Mateus Kambale Sahani, M.D. Agir Ensemble/Goma-D.R.Congo, Tel: +243-998625635/+250-788884503, Email: kambalesahani@yahoo.fr or agirense@yahoo.fr, Blog: http://agirensemblerdc.blogspot.com

Partnership Agir Ensemble, D.R.Congo and Solutions4Health, UK

Partnership Agir Ensemble, D.R.Congo and Solutions4Health, UK Agir Ensemble is a NGO based in the city of Goma, Democratic Republic of Congo which is involved in cancer control and tobacco control since 2004. It is member of UICC, ALIAM, partner with AORTIC, member of FCA, ATCA and has realized a lot of actions against tobacco, cancer, palliative care. We have demonstrated an international involvement in the fight against NCDs. During the Afro WHO consultation meeting in Brazzaville April 4-6, 2011, Agir Ensemble has given a delegate as a representative of UICC to discuss the declaration that was adopted at the UN High level summit in September 2011 in New York. Agir Ensemble has been represented by its director of Health Department at the 15th World Conference on Tobacco Or Health in Singapore from March 20-24, 2012 and before the conference, we have been in contact with Solutions4Health of UK to build a partnership in smoking cessation with our medical clinic to help people in D.R.Congo have access to tobacco control service with technical support from Solutions4Health. During the conference, we met with delegates from Solutions4Health to see how we can improve our partnership and setup strategies to look for funding for our health link. So, THET program was one of opportunities to strengthen our link. Mateus Kambale Sahani, M.D. Director of Health Department Agir Ensemble.

Singapore Conference (15th WCTOH) urges UN, Governments to incorporate tobacco Control in Development Agenda, MDGs

Singapore Conference (15th WCTOH) urges UN, Governments to incorporate tobacco Control in Development Agenda, MDGs

Delegates from across the globe that participated at the 15th World Conference on Tobacco or Health (15th WCTOH) which was held March 20-24, 2012 in Singapore have called on the United Nations and national governments to incorporate tobacco control into the development agenda at national and global levels and at the next round of the Millennium Development Goals (MDGs).
In the declaration at the end of the convergence, delegates reaffirmed that the tobacco industry continues to develop new tobacco products and obstruct effective tobacco control measures and demanded that tobacco should be incorporated in future UN development indicators and the UN Development Assistance Framework (UNDAF).
They recognised that tobacco use is the leading preventable risk factor for non-communicable diseases and that all forms of tobacco products (including new and emerging tobacco products) and their by-products are harmful and noted that to improve the quality of life, enhance human development, and reduce the social, environmental, economic, and healthcare burdens of countries, the global tobacco control community must increase the scope and intensity of tobacco control efforts.
A comprehensive collaboration and coordination at the global, regional, and national levels between tobacco control communities as well as sectors outside health were recommended as essential to move tobacco control efforts forward.
They reaffirmed that the WHO Framework Convention on Tobacco Control (FCTC) is an effective and cost-effective tool for tobacco control and recommend that by 2015 all new bilateral and multilateral agreements and treaties should have a clause that allows governments to take any measures necessary to protect human life or health, provided that such measures are not used for trade protectionist purposes.
National governments were urged to incorporate tobacco control as a core item in country-level NCDs national plans, while partners (academics, NGOs, government’s agencies) are urged to initiate a study on the economic effects of tobacco.
Specific recommendations were also made on Articles 7 to 12 of the WHO FCTC. On Article 5.3, delegates recommended that by incorporating tobacco in development initiatives, by 2025 all parties will have adopted measures to address tobacco industry interference in public health policies.

Many things should be done by governments if they are really responsible and have commitment to protect their population but commitments and willing of donors and partners are very important to move forward all efforts done by tobacco control activists and advocates. Things to be done are very well known but there is lack of financial support for activists and local NGO. Apart of the Bloomberg Initiative Fund, no other donors are committed to fund tobacco control efforts. This is a big challenge to be solved.
Even the Bloomberg fund is not used equitably for all countries; only a small number of countries benefit of this fund. This is a second challenge to be solved.

Thanks for your attention.

Goma, April 24th, 2012.

Mateus Kambale Sahani, M.D.

Agir Ensemble/Goma-DRC.

RETINOBLASTOMA-EYE CANCER

RETINOBLASTOMA-EYE CANCER
1. What is retinoblastoma?
Retinoblastoma is a cancer of one or both eyes which occurs in young children. There are approximately 350 new diagnosed cases per year in the United States. Retinoblastoma affects one in every 15,000 to 30,000 live babies that are born in the United States. Retinoblastoma affects children of all races and both boys and girls.
The retinoblastoma tumor(s) originate in the retina, the light sensitive layer of the eye which enables the eye to see. When the tumors are present in one eye, it is referred to as unilateral retinoblastoma, and when it occurs in both eyes it is referred to as bilateral retinoblastoma. Most cases (75%) involve only one eye (unilateral); the rest (25%) affect both eyes (bilateral). The majority (90%) of retinoblastoma patients have no family history of the disease; only a small percentage of newly diagnosed patients have other family members with retinoblastoma (10%).
2. Signs and symptoms
Retinoblastoma can present in a variety of ways. The majority of retinoblastoma patients present with a white pupil reflex or leukocoria instead of a normal healthy black pupil or red reflex similar to the one seen when photographs are taken of a child looking directly into the camera. This abnormal white pupillary reflex is sometimes referred to as a cat's eye reflex.
Many times the parent is the first one to notice the cat's eye reflex. Other eye diseases can also present with this white pupillary reflex; leukocoria does not always indicate retinoblastoma. An ophthalmologist can determine the correct diagnosis.
A crossed eye or strabismus is the second most common manner in which retinoblastoma presents. The child's eye may turn out (towards the ear), called exotropia, or turn in (towards the nose), called esotropia.
Retinoblastoma may also present with a red, painful eye, poor vision, inflammation of tissue surrounding the eye, an enlarged or dilated pupil, different colored irides (heterochromia), failure to thrive (trouble eating or drinking), extra fingers or toes, malformed ears, or retardation. On rare occasions, retinoblastoma is discovered on a well-baby examination. Most often, the symptoms of retinoblastoma are first detected by a parent.
When there is a family history of retinoblastoma, newborn babies should be examined in the nursery at birth by an ophthalmologist, or an eye doctor. When there is no family history, it is frequently the parents who notice leukocoria or strabismus and bring their child in for an examination. Often the general ophthalmologist refers the child to an ophthalmologist who specializes in children with retinoblastoma and other cancer of the eye.
The ophthalmic examination by the specialist is best done under general anesthesia. Some very young and older patients can be examined without general anesthesia; this decision is made by the ophthalmologist. When the examination is performed without general anesthesia, the child is placed on his or her back and is wrapped in a sheet like a mummy to restrict the movement of the child's arms and legs. Dilating drops (which sting for approximately 30 seconds after they are placed in the eye) are placed into both eyes prior to the examination. These drops dilate the pupils of the eyes and allow the ophthalmologist to view the retina. Sometimes numbing drops are also placed in both eyes to numb the surface.
If the child is to be examined under anesthesia, the anesthesiologist will put him or her to sleep by placing a mask over his or her mouth or nose. A tube may also be placed in the child's throat to aid breathing and an intravenous line may be started. In order to minimize the risks of anesthesia, the anesthesiologist will ask that the child not be given food or fluids for several hours before the examination. The child will usually fall asleep within a few minutes and the parent may stay until the child is anesthetized. If you have any doubts or questions about whether your child should have anesthesia, you should ask your ophthalmologist, anesthesiologist or nurse.

3. Long term complication of Retinoblastoma.


The majority of children in the United States (over 95%) survive the cancer and have perfectly normal lives. All the children with unilateral retinoblastoma have one normal eye whose sight is not affected even though they may have had one eye removed. Children with one eye have normal vision, play sports, and later drive cars. It is, however, especially important for children with vision in only one eye to wear protective eyewear during sports and other hazardous activities. These children grow up and become famous actors, physicians, lawyers, nurses, accountants, and parents themselves.
The majority of children with bilateral retinoblastoma retain at least one eye with good vision and many are able to retain the use of both eyes. They also live normal lives, go to school, enjoy life, have careers and have families themselves. However, all children with bilateral disease and the 15% of unilateral patients who have the familial form of retinoblastoma will be at much higher risk for other cancers not involving the eyes throughout their lives. Five years after the initial diagnosis of retinoblastoma, more children with the genetic form of retinoblastoma have died from these second tumors than from the original retinoblastoma. The most common second tumors are osteogenic sarcoma, a cancerous tumor which affects the bones, soft tissue sarcomas, and cutaneous melanomas (tumors of the skin, muscle and connective tissue). Although the reported incidences of these tumors vary widely, the risk appears to be about 1% a year. This risk is also increased by the use of external beam radiation, although the amount of increase depends on the age at which the child was treated.
Follow-up appointments are very important when a child is diagnosed with retinoblastoma. All children should be followed by an ophthalmologist and by a pediatric oncologist. Frequency of examinations depends upon the age of the child, the ophthalmologist's suspicion of new tumors, the involvement of one or both eyes, and the type of treatment that the child has received. Mothers and fathers are encouraged to talk to the nurse and to call with questions between visits.
Many parents meet other parents in the waiting room of the physician’s office, clinic, or hospital who also have children with retinoblastoma. Some have found it very helpful to talk to other parents who share similar concerns. Some institutions have newsletters or formal support groups for parents of children with retinoblastoma. Finally, some institutions have programs which can make a child's return to school, home, and the community a bit easier.
Retinoblastoma is a life-threatening disease, but it is rarely a fatal one if treated appropriately. With the correct treatment in the hands of an experienced ophthalmologist and appropriate follow-up both for eyes and for other cancers, the retinoblastoma patient has a very good chance of living a long, full, and happy life.
4. Clinical case: a kid of 8 year old Congolese (DRC) living in Goma has leukocoria and strabismus, eye pruritis since 2006. He has been operated 3 times for cataracts and capsular fibrosis as it was diagnosed by doctors in 3 different hospitals but till there the symptoms remain and he continues having the same signs. See pictures in this document. We suspect Retinoblastoma for this kid and we can’t find appropriate treatment for him in the country. He needs support and every one who knows to help him can contact the NGO Agir Ensemble at agirense@yahoo.fr and a referral to St Jude Hospital could be better for him.

5. References
Bramson DH. Pediatric Emergency Casebook: Retinoblastoma. New York: Burroughs-Wellcome, 1985. pp 3-13.
Abramson DH. Retinoblastoma: diagnosis and management. CA: A Cancer Journal for Clinicians 1982. Volume 32, pp 130-142
Abramson DH. The diagnosis of retinoblastoma. Bull NY Acad Med 1988. Volume 64, pp 283-317.
Abramson DH, Ellsworth RM. Ancillary tests for the diagnosis of retinoblastoma. Bull NY Acad Med 1980. Volume 56, pp 221-231.
Abramson DH, Ellsworth RM, Kitchin FD, Tung G. Second monocular tumors in retinoblastoma survivors: are they radiation induced? Ophthalmology 1984. Volume 91, pp 1351-1355.
Abramson DH, Dunkel I, McCormick BM. Neoplasms of the Eye, in Cancer Medicine, 4th ed. Williams & Wilkins, Holland, 1996. pp 1517-1536.
Abramson DH, Servodidio CA. Retinoblastoma in the first year of life. Ophthalmic Paediatric Genetics 1992. Volume 13, pp 191-203.
Char DH, Hedges TR 3rd, Norman D. Retinoblastoma CT diagnosis. Ophthalmology 1984. Volume 91, pp 1347-1350.
Donaldson SS, Egbert PR. Retinoblastoma. In: Pizzo PA, Poplack DG. Principles and Practice of Pediatric Oncology. Philadelphia, PA: Lippincott, 1989. pp555-568.
Dryja, TP. Assessment of risk in hereditary retinoblastoma. In: Albert DA and Jakobiec FA. Principles and Practice of Ophthalmology. Philadelphia, PA: WB Saunders Co. 1996. Volume 5, pp 3270-3279.
Gallie BL, Dunn JM, Hamel PA, et al. How do retinoblastoma tumors form? Eye 1992. Volume 6, pp. 226-231.
Grabowski E, Abramson DH. Retinoblastoma in Clinical Pediatric Oncology, 4th ed. Fernbach DJ and Vietti TJ, ed. 1991. Mosby Books, pp 427-436.
Done in Goma, April 22, 2012.
Mateus Kambale Sahani, M.D.
Agir Ensemble/Goma-DRC.