Critical care medicine in the French Territories in the Americas: Current situation and prospects / La medicina intensiva en los territorios franceses de la Región de las Américas: situación actual y perspectivas / Medicina intensiva nos territórios ultramarinos franceses nas Américas: situação atual e perspectivas

ABSTRACT Hospitals in the French Territories in the Americas (FTA) work according to international and French standards. This paper aims to describe different aspects of critical care in the FTA. For this, we reviewed official information about population size and intensive care unit (ICU) bed capacity in the FTA and literature on FTA ICU specificities. Persons living in or visiting the FTA are exposed to specific risks, mainly severe road traffic injuries, envenoming, stab or ballistic wounds, and emergent tropical infectious diseases. These diseases may require specific knowledge and critical care management. However, there are not enough ICU beds in the FTA. Indeed, there are 7.2 ICU beds/100 000 population in Guadeloupe, 7.2 in Martinique, and 4.5 in French Guiana. In addition, seriously ill patients in remote areas regularly have to be transferred, most often by helicopter, resulting in a delay in admission to intensive care. The COVID-19 crisis has shown that the health care system in the FTA is unready to face such an epidemic and that intensive care bed capacity must be increased. In conclusion, the critical care sector in the FTA requires upgrading of infrastructure, human resources, and equipment as well as enhancement of multidisciplinary care. Also needed are promotion of training, research, and regional and international medical and scientific cooperation.

RESUMEN Los hospitales en los territorios franceses de la Región de las Américas funcionan según las normas francesas e internacionales. El objetivo de este artículo es describir distintos aspectos de los cuidados intensivos en los territorios franceses. Para ello, hemos revisado los datos oficiales sobre el tamaño de la población y el número de camas de las unidades de cuidados intensivos (UCI), así como la bibliografía sobre algunos aspectos específicos de las UCI, en los territorios franceses. Las personas que viven en los territorios franceses, o que están de visita en ellos, están expuestas a riesgos específicos: principalmente traumatismos graves causados por el tránsito, envenenamiento por mordeduras, heridas de bala o por apuñalamiento, y enfermedades infecciosas tropicales emergentes. La atención de estos traumatismos y enfermedades puede requerir conocimientos específicos y cuidados intensivos. Sin embargo, no hay suficientes camas de UCI en los territorios franceses. De hecho, hay 7,2 camas de UCI por 100 000 habitantes en Guadalupe, 7,2 en Martinica y 4,5 en Guayana Francesa. Además, los pacientes gravemente enfermos que viven en zonas remotas a menudo tienen que ser trasladados, normalmente por helicóptero, lo que retrasa su ingreso en la unidad de cuidados intensivos. La crisis de la COVID-19 ha puesto de manifiesto que el sistema de atención de salud en los territorios franceses no está preparado para enfrentarse a una epidemia de estas dimensiones y que debe aumentarse la capacidad hospitalaria de las unidades de cuidados intensivos. En conclusión, el sector de los cuidados intensivos en los territorios franceses tiene que mejorar su infraestructura, recursos humanos y equipamiento, así como perfeccionar la atención multidisciplinaria. También es necesario promover la capacitación, la investigación y la cooperación médica y científica, tanto regional como internacional.

RESUMO Os hospitais nos territórios ultramarinos franceses nas Américas funcionam segundo os padrões franceses e internacionais. O objetivo deste artigo é descrever os diversos aspectos da atenção intensiva nesta região. Analisamos os dados oficiais relativos ao tamanho da população e ao número de leitos de unidade de terapia intensiva (UTI) nestes territórios junto com uma revisão da literatura científica sobre as características particulares destes centros de terapia intensiva. Os residentes locais ou visitantes dos territórios ultramarinos franceses nas Américas são expostos a riscos específicos, sobretudo acidentes de trânsito graves, envenenamentos por animais peçonhentos, ferimentos por armas brancas ou armas de fogo e doenças infecciosas tropicais emergentes que requerem conhecimento especializado e atenção intensiva. Porém, não há leitos suficientes de UTI nos territórios ultramarinos franceses nas Américas: são 7,2 leitos de UTI por 100.000 habitantes em Guadalupe, 7,2 na Martinica e 4,5 na Guiana Francesa. Ademais, em áreas remotas, os pacientes em estado crítico frequentemente precisam ser transferidos por helicóptero, o que causa demora na internação em UTI. A crise da COVID-19 demonstra o despreparo do sistema de saúde para enfrentar a pandemia e a necessidade de aumentar o número de leitos de UTI nestes territórios. Em conclusão, é imprescindível modernizar a infraestrutura e os equipamentos, capacitar melhor os recursos humanos e melhorar a atenção multidisciplinar. Incentivar a formação profissional, pesquisa e cooperação médico-científica regional e mundial é também fundamental.

Energy expenditure and dietary intake in overweight versus non-overweight guadeloupian adults / Gasto de energía e ingesta dietética en guadalupanos adultos con sobrepeso frente a aquellos sin sobrepeso

OBJECTIVE: Obesity is the source of many health problems in Guadeloupe. The aim of this study was to describe the relationships between daily energy intake and expenditure, and weight status. METHODS: Three consecutive daily recalls for activities and food intake were used to assess energy expenditure and energy intake in 20to 60year old Guadeloupian men and women. RESULTS: The absolute daily energy expenditure was correlated to the body weight (r = 0.64, p > 0.001) and to the daily energy intake with more strength in the normalweight group (r = 0.52, p < 0.001) than in the overweight group (r = 0.26, p < 0.05). in both weight groups, the higher the metabolism was, the larger was the difference between energy intake and energy expenditure. CONCLUSION: Under-reporting was probably present in overweight women. However, higher energy intake and expenditure were observed in larger persons who were consequently not identified as less active.

OBJETIVO: La obesidad es fuente de muchos problemas de salud en Guadalupe. El objetivo de este estudio fue describir las relaciones entre la ingesta energética y el gasto de energía diarios, y el estado del peso. MÉTODOS: Tres reportes consecutivos diarios sobre las actividades y la ingesta de alimentos, fueron usados para evaluar el gasto de energía y el consumo de energía fueron usados el consume de alimentos fueron usados para evaluar el gasto de energía y la ingesta energética en hombres y mujeres guadalupanos de 20 a 60 años de edad. RESULTADOS: El valor absoluto del gasto diario de energía fue correlacionado con el del peso del cuerpo (r = 0.64, p > 0.001) y la ingesta diaria de energía con más fuerza en el grupo de peso normal (r = 0.52, p < 0.001 que en el grupo de sobrepeso (r = 0.26, p < 0.05). en ambos grupos, mientras más alto era el metabolismo, mayor era la diferencia entre la ingesta y el consumo de energía. CONCLUSIÓN: En el caso de las mujeres obesas, probablemente los reportes quedaron por debajo de la realidad. Sin embargo, se observaron ingesta y gasto de energía más altos en personas más corpulentas, que por consiguiente no fueron identificadas como menos activas.

Which anaesthesia should be recommended for prostate biopsy / ¿Qué Anestesia debe Recomendarse para la Biopsia de la Próstata?

OBJECTIVE: Although transrectal ultrasound-guided prostatic biopsies are associated with significant discomfort and pain, most urologists do not use any kind of anaesthesia. We therefore compared the efficacy of two local anaesthetics, namely, the rectal administration of lidocaine gel and lidocaine periprostatic infiltration prior to biopsies. DESIGN AND METHODS: Three hundred and fifty-six randomized patients received either 15 mL of 2 lidocaine gel administered intrarectally ten minutes before prostate biopsies in group 1 (180 patients) or 10 mL of 1 lidocaine given under ultrasound guidance in two periprostatic injections of 5 mL, four minutes before the biopsies in group 2 (176 patients). A visual analogue scale (VAS) was used to assess the pain score during anaesthesia (VAS 1), during the biopsies (VAS 2) and 30 minutes after them (VAS 3). RESULTS: Patients receiving lidocaine gel experienced statistically less pain than the lidocaine injection group for mean VAS 1 (0.1 vs 1.4, p < 0.0001) and mean VAS 3 (0.8 vs 1.4, p < 0. 001) but VAS 2 showed no statistically significant difference (2.0 vs 2.1). No major morbidity was noted with either anaesthetic. CONCLUSION: Rectal administration of lidocaine gel is both safe, simple and effective and results are more satisfactory than with lidocaine periprostatic infiltration

Objetivo: Aunque las biopsias prostáticas transrectales guiadas mediante ultrasonido se asocian con considerable malestar y dolor, la mayoría de los urólogos no usa cualquier tipo de anestesia. Por lo tanto, comparamos la eficacia de dos anestésicos locales, a saber, la administración rectal de gel de lidocaína y la infiltración con lidocaína del área periprostática antes de las biopsias. Diseño y métodos: Trescientos cincuenta y seis pacientes randomizados recibieron o bien 15 mL de lidocaína en gel al 2%, administrada intrarectalmente diez minutos antes de las biopsias de la próstata en el grupo 1 (180 pacientes); o alternativamente 10 mL de lidocaína al 1% administrada bajo la guía de ultrasonido en dos inyecciones periprostáticas de 5 mL, cuatro minutos antes de las biopsias en el grupo 2 (176 pacientes). Se usó una escala analógica visual (EAV) para evaluar el grado de dolor durante la anestesia (EAV 1), durante las biopsias (EAV 2) y 30 minutos después de realizarlas (EAV 3). Resultados: Los pacientes que recibieron lidocaína en gel, experimentaron menos dolor estadísticamente, que el grupo de la inyección de lidocaína, para la VAS 1 media (0.1 frente a 1.4, p <0.0001) y VAS 3 media (0.8 frente a 1.4, p <0.001). Sin embargo, la VAS 2 no mostró diferencia significativa alguna en términos estadísticos (2.0 frente a 2.1). No se vio morbosidad de consideración con ninguno de los anestésicos. Conclusión: La administración rectal de gel de lidocaína es tan segura y simple como efectiva, y siendo los resultados más satisfactorio que aquellos producidos con la infiltración periprostática de lidocaína..

Retrospective review of leptospirosis in Guadeloupe, French West Indies 1994-2001 / Revisión retrospectiva de la leptospirosis en Guadalupe, Indias Occidentales Francesas 1994­2001

Demographic, clinical, biological and personal data were obtained from patients hospitalized with symptoms of leptospirosis in the Hospital of Pointe a Pitre, Guadeloupe, French West Indies from 1994 to 2001. Of the 897 screened patients, 212 were acute cases, 607 were non-infected and 78 were undetermined cases. There was no predominant age group. Leptospirosis transmission followed the rainfall cycle and was greater in rural areas. Jaundice and conjunctival suffusion were significantly more frequent in cases than non-cases. Males, professions considered to be at risk and contact with swine or bovine were associated with infection. Serogroups Icterohaemorrhagiae, Cynopteri, Australis, Sejroe, Pomona and Ballum were serovars presumed responsible for acute cases

Se obtuvieron los datos demográficos, clínicos, biológicos y personales de pacientes hospitalizados con síntomas de leptospirosis en el Hospital de Pointe à Pitre, Guadalupe, Indias Orientales Francesas, en el período comprendido de 1994 a 2001. De los 897 pacientes investigados, 212 eran casos graves, 607 eran no infectados y 78 eran casos indeterminados. No hubo grupo etario predominante. La transmisión de la leptospirosis seguía el ciclo hidrológico y era mayor en las áreas rurales. La ictericia y sufusión conjuntival fueron significativamente más frecuentes en los casos que en los no casos. Los varones, las profesiones consideradas en riesgo, y el contacto con cerdos o bovinos estuvieron asociados con la infección. Los serogrupos Icterohemorragia, Cynopteri, Australis, Sejroe, Pomona y Ballum fueron serovares presumiblemente responsables de los casos graves

Epidemiologic study of the association between human T-cell lymphotropic virus type 1 and Strongyloides stercoralis infection in female blood donors (Guadeloupe, French West Indies)

This case control study was conducted among female blood donors in Guadeloupe. A total of 85 HTLV-1 positive subjects were matched by age (+/- 5 years) in a 1:3 ratio to 255 HTLV-1 negative controls. The mean age was 48.5 and 48.9 years respectively. Ethnic, environmental and socio-economic risk factors were studied. Four risk factors were found independently associated with HTLV-1 seropositivity: Strongyloides stercoralis antibodies (OR = 3.6, CI 1.8, 7.3), low socio-economic status (OR = 2.0 CI 1.0, 4.0), low educational level (OR = 2.0 CI 1.0, 4.0) and agricultural activity (OR = 2.8 CI 1.4, 5.6). This logistic regression analysis demonstrates the reality of the association between HTLV-1 carriers and Strongyloides stercoralis, and its association with socio-economic and environmental risk factors

Malaria in Guadeloupe (French West Indies) 1991-2000

The only islands in the Caribbean that still have endemic malaria are Haiti and the Dominican Republic. Cases of imported malaria occur on the other islands, particularly Martinique and Guadeloupe, due to the movement of people to and from endemic regions that are geographically and/or culturally close. The re-emergence of transmission cannot be ruled out due to the local persistence of the potential vectors, the anopheles mosquitoes. This retrospective study, over a ten year-period (1991-2000), included all of the cases of malaria confirmed by blood tests at Pointe-à-Pitre University Hospital. This hospital is the main healthcare facility in Guadeloupe. Fifty-nine bouts of malaria occurred in 56 patients. The annual incidence was estimated at 2 to 2.5 cases per 100,000 inhabitants. Plasmodium falciparum largely predominated, accounting for over 80 of cases. The only pernicious case observed resulted in the death of the patient. In all cases the patient had recently travelled to an endemic region, except in one case, caused by P ovale which has never been endemic in the Caribbean. African countries accounted for 43 of cases. No Asian or Pacific strains were identified. In all cases, anti-malarial drugs were not taken, taken incorrectly or were inappropriate. All of the cases of malaria reported in Guadeloupe in the last decade were imported and this region cannot be considered to be at risk of malaria infection. However, long-term epidemiological monitoring is necessary, together with specific entomological monitoring

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate its results, and try to identify possible necessary modifications to the existing protocol. Although more than 90 of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75 of mothers who were heavily colonized group B streptococcus (GBS) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great proportion of neonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factors such as fever and premature rupture of membranes. Intrapartum chemoprophylaxis was associated with an approximate threefold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemoprophylaxis as it accounted for the majority of cases of neonatal bacteraemia that escaped the existing protocol.

Evaluation of neonatal sepsis screening in a tropical area. Part I: Major risk factors for bacterial carriage at birth in Guadeloupe

This prospective study reports on screening for neonatal sepsis among 3,372 live births out of 6,060 consecutive deliveries at the University Hospital of Pointe-Ó-Pitre, Guadeloupe, during a 30-month period. Group B Streptococcus (GBS) was the most common pathogen, representing 46 (89/194) of positive blood cultures and 52 (335/637) of positive gastric aspirates. Although only 3,372 (55) of all live births were screened, 637 (10) had gastric bacterial carriage at birth; of those, 335 (5.5) involved GBS. Similarly, there were 194 (3.2) positive blood cultures, of which 89 (1.5) involved GBS. In this report, all newborns who presented with a positive GBS blood culture had at least one of the external tests positive for GBS (gastric, ear canal, rectum and placenta). Thirty-seven per cent (14/38) of positive neonatal blood cultures occurred in newborns with foetid liquor while in deliveries with intrapartum fever 16.5 (32/195) of blood cultures were positive. In our clinical practice, characteristics that were evident in the delivery room (without knowledge of prenatal follow-up) such as foetid liquor, intrapartum fever, prolonged rupture of membranes, foetal tachycardia and meconium staining were associated with the great majority of neonatal sepsis.

Risk factors associated with ischaemic stroke in Guadeloupe

We carried out a case control study at the University Hospital of Pointe-Ó-Pitre, Guadeloupe, during eight months. Seventy patients with ischaemic stroke and seventy age- and sex-matched controls were involved. A standard questionnaire reported clinical characteristics and medical history. Seventy-six per cent of patients suffered from hypertension. Obesity and diabetes were more frequent in the case group than in the control group. Serum creatinine concentration (86 vs 74 mumol/l; p < 0.001), total cholesterol (5.9 vs. 5.2 mmol/l; p < 0.001), apolipoprotein B (1.2 vs 1.0 g/l; p < 0.001) and lipoprotein (a) (82 vs 48 mg/dl; p < 0.001) were significantly higher in patients than controls. Multiple logistic regression analysis revealed that in addition to serum creatinine, serum apolipoprotein B, hypertension, obesity, serum lipoprotein (a) and diabetes mellitus were associated independently and significantly with ischaemic stroke. These findings have implications for clinical practice and further research particularly with respect to serum creatinine concentration as a marker of renal damage from hypertension and as a risk factor itself for cerebrovascular disease.

Trends of AIDS in Guadeloupe (French West Indies): a longitudinal survey from 1998 to 1997

The study objective was to describe morbidity and mortality from HIV infection and the acquired immunodeficiency syndrome (AIDS) in Guadeloupe from 1998 to 1997 and to evaluate survival and prognostic factors. The HIV infected patients database of Guadeloupe included 1771 adult patients up to December 31, 1997. Annual incidence of AIDS defining illnesses were calculated and compared using Poisson regression. Survival analysis with log-rank test and multivariate analysis with Cox's model were performed for patients with AIDS. At the end of December 1997, 599 cases of AIDS (33.8 percent) and 367 deaths (20.7 percent) were reported. For 32.1 percent of the patients, AIDS was diagnosed before inclusion. Incidence of most AIDS-defining events decreased over time, especially after the introduction of protease inhibitor therapy. Before the introduction of protease inhibitors in September 1996, overall median survival after AIDS was 11.8 months (95 percent Confidence Interval (CI), 95 percent CI 10.2 - 14.1.) After this date median survival increased to 17.8 months (95 percent CI 18.6 - 22.5 ) and probability of survival was significantly higher for patients treated with protease inhibitor in combination regimen (mean 19.0 months. Standard deviation (SD) 1.3) compared to those who were not (mean 7.9 months, SD 0.6, p<0.0001). Prognosis factors of death after AIDS were older age (Relative Hazard, RH : 1.17, 95 percent CI 1.07 - 1.28), occurrence of two or more AIDS-defining events at the beginning of the disease (RH: 1.70, 95 percent CI 1.32 - 2.19), and a CD4 cell count less than 50/mm3 (RH: 2.33, 95 percent CI 1.71- 3.17). On the other hand, occurrence of AIDS during follow-up had a better prognosis (RH : 0.68, 95 percent CI 0.52 - 0.89) and protease inhibitor therapy was strongly associated with a longer survival (RH 0.26, 95 percent CI 0.13 - 0.53). We concluded that HIV infection in Guadeloupe was frequently diagnosed at the stage of AIDS. However, survival of patients and trends of major AIDS defining illnesses were more similar to the European pattern than to the Caribbean one, as a consequence of the availability of modern therapy.

Dengue hemorrágico febril en la Región del Caribe / Dengue haemorrhagic fever in Caribbean Region

1. El Dengue febril clásico (benigno), se mantiene en los países de la cuenca del Caribe en forma endemo-epidémica. 2. La situación anterior, se ha empeorado desde el año 1981, en que la forma clínica grave del Dengue, el Dengue hemorrágico febril causó una importante epidemia en Cuba. Posteriormente en 1984, en México y en Aruba, en el período noviembre de 1984 a marzo de 1985, en epidemias de Dengue ocurridas en estas zonas, se comprobaron muertes por Dengue hemorrágico. 3. La transimisión de los cuatro serotipos de Dengue, en el área del Caribe, y la gran facilidad del desplazamiento humano por vía aérea, hace que la difusión de la forma de Dengue hemorrágico tienda a aumentar en vez de disminuir. 4. Es necesario mayor investigación a objeto de determinar: a) la posible existencia de ciclos naturales selváticos de Dengue, monos, mosquitos, en el continente americano, y b) qué factores influyen en la ocurrencia de las dos formas clínicas del Dengue en el humanos. 5. Se hace necesario una vigilancia epidemiológica de esta enfermedad, que tenga como objetivo el incremento de la toma de muestras, por los servicios médicos locales, en aquellos cuadros febriles inespecíficos y casos sospechosos de Dengue. El procesamiento de estas muestras por el laboratorio podrá confirmar la actividad del Dengue y serotipos de los virus circulantes. 6. Ante la inexistencia de medidas de prevención efectivas, tales como la protección de la población mediante la aplicación de vacunas, y el abandono de la lucha contra el Aedes aegypti, se debe tratar que la población a través de campañas de educación sanitaria, participe activamente en la lucha contra el vector. 7. Se debe estar preparado para dar asistencia médica a los casos que requieran hospitalización, específicamente la reposición de plasma, administración de soluciones de electrolitos y transfusión sanguínea, a los casos de Dengue hemorrágico. No olvidar que Cuba en 1981, tuvo que proveer facilidades de hospitalización, para 1116.000 enfermos de Dengue en el corto lapso de tres meses

Epidemiología de la lepra en Guadalupe de 1970 a 1983 / The epidemiology of leprosy in Guadeloupe from 1970 to 1983

Se estudiaron la prevalencia y la evolución de la incidencia anual de lepra en Guadalupe entre 1970 y 1983. El análisis de los datos acopiados en el servicio de control de lepra indicó que en 1981 la prevalencia era de 380 por cada 100 000 habitantes, calculada según el número de enfermos incluidos en el archivo activo del registro departamental durante 12 años en el caso de enfermos paucibacilares y durante toda la vida en el caso de enfermos multibacilares. De 1970 a 1983 la incidencia anual disminuyó de 24,0 a 13,0 por 100 000 habitantes. La disminución fue más importante en las formas de lepra paucibacilar que en las de lepra multibacilar, y mucho más importante en menores que en mayores de 15 años. El análisis de la forma de detección reveló que 80% de los enfermos se encontraron mediante la búsqueda pasiva (enfermos sintomáticos que acudieron a consulta), 10% mediante la búsqueda entre la población escolar y 10% mediante la búsqueda entre los contactos domiciliarios de enfermos conocidos. A partir de 1980 se inoculó a ratones con Mycobacterium leprae provenientes de biopsias de enfermos multibacilares para efectuar cultivos y estudiar la sensibilidad del microorganismo a la dapsona y a la rifampicina. Las 16 cepas de M. leprae provenientes de pacientes que padecían recidivas de lepra multibacilar demonstraron ser resistentes a la dapsona, y 15 de estas pusieron de manifiesto una elevada resistencia. De las 19 cepas de M. leprae provenientes de casos nuevos que nunca habían recebido tratamiento, solo ocho eran sensibles a la dapsona. Todas las cepas de M. leprae, tanto de pacientes con recidivas como de casos nuevos, resultaron ser sensibles a la rifampicina. En términos generales, los diferentes parámetros considerados indican que desde el punto devista epidemiológico la lepra ha tenido una evolución favorable en Guadalupe. Por ende, se deben mantener la infraestructura y la organización actual del control de lepra, aunque la frecuencia de la resistencia a la dapsona impone una utilización estricta de la poliquimioterapia