Clinical, logistic, and geographic factors in ensuring adequate access to implant removals: A cross-sectional survey of public facilities and GIS modeling of geographic access in two districts of Senegal.

Introduction: Ensuring adequate access to contraceptive implant removal services requires an understanding of potential clinical, logistical, and geographic challenges. Methods: We conducted a cross-sectional survey of 39 public health facilities in two districts of Senegal. To assess facility readiness, we reported the proportion of facilities meeting all minimum conditions for regular and difficult implant removals. We then describe characteristics of referral networks. Geographic access modeling was conducted in a geographic information system to estimate the proportion of women of reproductive age living within specific travel times of facilities ready for regular and difficult removals. Results: 72% of facilities met all conditions for regular removals, and 8% for difficult removals. In both cases, the main gaps related to equipment availability (79% of facilities had the minimum equipment for regular removals and 8% for difficult removals). 72% of facilities organized in three referral networks sent clients to other facilities for cases they could not manage. Of 11 receiving or single-network facilities, seven were ready for regular removals and one for difficult removals. Altogether, 36% of women in Dakar Centre and 99% of women in Kolda lived within two hours of a facility that was equipped to handle regular removals, compared to 15% and 69%, respectively, for difficult removals. Conclusion: Data such as those provided in this assessment are important to provide a realistic picture of the state of readiness of the health system and its ability to meet the inevitable demand for implant removals. Referral networks should be considered as an emerging strategy to avail sufficient capacity at the systems level, including for managing difficult removals. However, careful thought should be given to the location of facilities that are ready to receive cases in order to target upgrades.

Making Removals Part of Informed Choice: A Mixed-Method Study of Client Experiences With Removal of Long-Acting Reversible Contraceptives in Senegal.

BACKGROUND: Ensuring access to removal services for implants and intrauterine devices (IUDs) is essential to realize informed choice and voluntary family planning. We document removal desires and experiences among women who received an implant or IUD from the public sector in 3 districts of Senegal. METHODS: We conducted a phone survey of 1,868 implant and IUD users, 598 follow-up surveys with those who had ever asked a provider for a removal, and 24 in-depth interviews (IDIs) with women who had ever wanted an implant removal. We analyzed survey data descriptively and IDI data thematically. RESULTS: Fifty-eight percent of implant users and 54% of IUD users reported having wanted a removal. Desired pregnancy and contraceptive-induced menstrual changes (CIMCs) were the main reasons for removal desires. Fifty-four percent of implant users and 55% of IUD users who asked a provider for a removal reported challenges accessing services, with over two-thirds noting long lines or wait times. Sixty-three percent of implant users and 73% of IUD users who saw a provider were satisfied with the outcome of their first interaction. Over 90% of participants had not been told about the removal cost at insertion. Almost all participants who had their method removed obtained a complete removal during their first clinical procedure. Around two-thirds of participants who obtained a removal did not take up another method at that time. IDIs confirmed the influence of CIMCs on removal desires and show some partner influence is common in removal decision making. Barriers include lack of available qualified providers and supplies. Provider interactions play an important role in satisfaction with removal services. CONCLUSION: Participants' experiences accessing removal services were generally positive. Areas of potential improvement include client flow, counseling messages at insertion, and when advising clients to keep their method, pricing, and post-removal reinsertion or method switching.

Ensuring sufficient service capacity for removals of long-acting reversible contraceptives: a mixed-method study of provider experiences in Senegal.

Background: As the number of implants and intrauterine devices (IUD) used in sub-Saharan Africa continues to grow, ensuring sufficient service capacity for removals is critical. This study describes public sector providers' experiences with implant and IUD removals in two districts of Senegal. Methods: We conducted a cross-sectional study with providers trained to insert implants and IUDs from all public facilities offering long-acting reversible contraceptives. Data collection elements included a survey with 55 providers and in-depth interviews (IDIs) with eight other providers. We performed descriptive analysis of survey responses and analyzed qualitative data thematically. Results: Nearly all providers surveyed were trained in both implant and IUD insertion and removal; 42% had received training in the last two years. Over 90% of providers felt confident inserting and removing implants and removing IUDs; 15% were not confident removing non-palpable implants and 27% IUDs with non-visible strings. Challenges causing providers to refer clients or postpone removals include lack of consumables (38%) for implants, and short duration of use for implants (35%) and IUDs (20%). Many providers reported counseling clients presenting for removals to keep their method (58% implant, 31% IUD), primarily to attempt managing side effects. Among providers with removal experience, 78% had ever received a removal client with a deeply-placed implant and 33% with an IUD with non-visible strings. Qualitative findings noted that providers were willing to remove implants and IUDs before their expiration date but first attempted treatment or counseling to manage side effects. Providers reported lack of equipment and supplies as challenges, and mixed success with difficult removals. Conclusions: Findings on provider capacity to perform insertions and regular removals are positive overall. Potential areas for improvement include availability of equipment and supplies, strengthening of counseling on side effects, and support for managing difficult removals.

[Atrial fibrillation in three cardiological reference centers in Dakar: Senegal data from the AFRICA register survey]. / La fibrillation atriale dans trois centres cardiologiques de référence de Dakar: données sénégalaises de l'enquête du registre AFRICA.

Introduction: atrial fibrillation (AF) is the most common cardiac rhythm disorder. Its prevalence is underestimated in Africa, hence the initiation of the Atrial Fibrillation Registry In Countries of Africa (AFRICA). The aim of our study was to describe, within the framework of the AFRICA registry, the epidemiological, clinical, paraclinical, therapeutic and evolutionary aspects of atrial fibrillation (AF) in Africa, particularly in Senegal. Methods: we performed a cross-sectional, retrospective, multicentric study conducted from January 1st to December 31st 2017, in three referral cardiology wards in Senegal. Results: one hundred and sixty-eight patients, with a mean age of 63 years, were selected, representing a hospital prevalence of 5.99%. There was a predominance of women with sex-ratio of 0.69. High blood pressure was the most frequent risk factor (24.4%). Heart failure was the most frequent circumstance of discovery (59.52%). AF was persistent in 52.24% and valvular AF accounted for 31% and was more frequent in young people (p= 0.005). Left ventricular systolic function was impaired in 55.7%, the left atrium was dilated in 70.83%. The strategy to reduce heart rate was the most used. Patients with CHA2DS2VASC ≥ 2 received anticoagulation with LMWH and oral relay maid mostly of VKA. The complications were dominated by heart failure (66.6%) and ischemic stroke cerebral (28%). Conclusion: atrial fibrillation (AF) is the most frequent cardiac rhythm disorder. It is a major public health concern.

Cardiac pacing challenge in Sub-Saharan Africa environnement: experience of the Cardiology Department of Teaching Hospital Aristide Le Dantec in Dakar.

BACKGROUND: Cardiac pacing is a growing activity in Sub-Saharan Africa. There is little data on the characteristics of this interventional treatment in our regions. The goal was to evaluate the results of cardiac pacing in a referral service in sub-Saharan Africa. METHODS: We carried out a twelve-year retrospective study (from January 1st, 2004 to December 31st, 2015) in the Cardiology Department of Aristide Le Dantec University Hospital. This work included all patients who received definitive cardiac pacing during the study period and followed up in the service. RESULTS: In total we included 606 patients. There was a growing trend in activity with a peak in 2015 (17%). The average age was 70.6 ± 12.03 years. Some patients (15.4%) came from the subregion. The patients were mostly of medium socio-economic level (53%); 14% were of low socio-economic level. Patients were symptomatic in 85% of cases (37.4% syncope). The indications were dominated by complete atrioventricular block (81.5%); sinus dysfunction accounted for 1.9% of them. A temporary pacemaker was used in 60% of cases for an average duration of 5.1 ± 6.3 days. Antibiotics, local anesthesia and analgesics were used in all cases. Implanted pacemakers were single chamber in 56% of cases and double chamber in 44% of cases. In 39 patients (6.4%), the pacemaker was a « re-used ¼ one. The atrial leads were most often placed in a lateral position (94.5%). The ventricular ones were predominantly tined (95.7%) and more often located at the apical level. Complications were noted in 24 patients (3.9%), dominated by devices externalizations and infections, which together accounted for 2.7% of cases. The number of people in the cathlab was significantly higher and the duration of the temporary pacemaker was longer for patients who had a complication. There was no significant difference depending on the type of pacemaker used (new or reused). Seven (7) in hospital death cases were reported. CONCLUSION: Cardiac pacing is a growing activity in Dakar.

Risk assessment of the occurrence of sudden death related to hypertrophic cardiomyopathy in Dakar.

AIM: The aim of this study was to assess of the risk of sudden death in a population of hypertrophic cardiomyopathy patients in Dakar. METHODS: This was a transverse study at the cardiology clinic of Aristide Le Dantec Hospital from January 2014 to June 2015. We used the European Society of Cardiology risk score to calculate this risk. RESULTS: The average age of patients was 53 years. Unexplained syncope was found in two patients and two others had a family history of sudden death. The septal hypertrophy average was 20.9 mm. Seven patients had left intraventricular obstruction. One patient had a high risk of sudden death, three had intermediate risk and 13 had low risk. Competitive sport was not allowed, 13 patients were under medical treatment, one had an implantable cardioverter defibrillator and two had no treatment. CONCLUSION: Our study highlighted a low and intermediate risk of the occurrence of sudden death at five years. One patient had a high risk of sudden death.

[Epidemiological features of cardiorenal syndrome: a study of 36 cases in the Cardiology Department in Dakar]. / Syndrome cardio-rénal: aspects épidémiologiques, à propos de 36 cas dans un service de cardiologie de Dakar.

INTRODUCTION: Cardiorenal syndrome (CRS) is a pathophysiologic disorder of the heart and the kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. In Africa, particularly in Senegal, the incidence of cardiorenal syndrome is not accurately known. This study aimed to assess the prevalence of CRS in the Cardiology Department. METHODS: We conducted a retrospective study including all patients with heart failure associated with alteration of renal function, hospitalized in the Cardiology Department between April 2010 and April 2011. Data were analyzed with the statistical software Epi-Info 3.5.3. RESULTS: 36 patients were included in the study. The prevalence rate was 3.7% with male predominance (sex-ratio 1.77) and an average age of 56.9 years [30-92]. Patients' medical history was dominated by high blood pressure (52.77%) and diabetes (19.4%). The main etiologies were hypertensive cardiomyopathy (39%) and coronary heart disease (19.44%). The symptomatology was dominated by dyspnoea (69.4%) and edema (50%). 17 patients had anemia. The mean measured clearance (MDRD) was 46 ml/min. Doppler echocardiography showed mainly kinetic disorders (89.3%) and left ventricular systolic dysfunction (71%). The three renal ultrasound examinations were normal. Six deaths (16.7%) were recorded. CONCLUSION: Cardiorenal syndrome is a reality and marks a turning point in the evolution of heart and kidney diseases. In Senegal, its prevalence in the Cardiology Department is low. Prospective multicentric studies should be conducted in order to better evaluate this syndrome in Senegal.

Marfan syndrome and cardiovascular complications: results of a family investigation.

BACKGROUND: Cardiovascular complications in Marfan syndrome (MFS) make all its seriousness. Taking as a basis the Ghent criteria, we conducted a family screening from an index case. The objective was to describe the clinical characteristics of MFS anomalies and to detect cardiovascular complications in our patients. CASE PRESENTATION: Six subjects were evaluated. Patients had to be in the same uterine siblings of the index case or be a descendant. The objective was to search for MFS based on the diagnostic criteria of Ghent and, subsequently, detecting cardiovascular damage. The average age was 24 years. The examination revealed three cases of sudden death in a context of chest pain. Five subjects had systemic involvement with a score ≥ 7 that allowed to the diagnosis of MFS. Two patients had simultaneously ectopia lentis and myopia. In terms of cardiovascular damage, there were three cases of dilatation of the aortic root, two cases of aortic dissection of Stanford's type A with severe aortic regurgitation in one case and moderate in the other. There were three patients with moderate mitral regurgitation with a case by valve prolapse. CONCLUSION: The family screening is crucial in Marfan syndrome. It revealed serious cardiovascular complications including sudden death and aortic dissection.

Obstructive Primary Cardiac T-Cell Lymphoma: A Case Report from Senegal.

BACKGROUND Cardiac lymphoma is a rare entity, defined by the non-extra cardiac location at diagnosis. CASE REPORT Our patient was a 32-year-old female with no particular medical history, who presented with right heart failure with recurrent ascites and pleural effusion. There was a progressive worsening exertional dyspnea. On admission, examination revealed an irregular tachycardia at 170 beats per minute (bpm) and congestive heart failure. The electrocardiogram scored full tachyarrhythmia by atrial fibrillation with an average ventricular rate of 179 cycles per minute. Doppler echocardiography showed dilatation and systolic dysfunction of the left ventricle. There were dilated atria. We noted a large mass in the right atrium, which was less mobile, heterogeneous, integral with the wall, and filling three quarters of the cavity. It clogged the tricuspid valve in diastole. CT scan showed a tissue process enhanced after contrast injection, occupying the predominant cavities in the right atrium and filling it. Its borders were irregular. The lesion was extended to the posterior mediastinum, in front of the vertebral axis. In addition, there was a thrombosis of the jugular vein and the inferior vena cava. There was no other tumor site noted. The patient died after presenting with cardiovascular shock associated with refractory right heart failure. Pathology examination confirmed T-cell lymphoma. CONCLUSIONS The primitive cardiac lymphoma is an entity of intra-cardiac masses. It is therefore to be considered even if the diagnosis is challenging.

Accelerated Cardiac Rhabdomyoma Regression with Everolimus in Infants with Tuberous Sclerosis Complex.

Tuberous sclerosis complex is associated with benign tumors such as cardiac rhabdomyomas (RHM) caused by the disinhibition of the mammalian target of rapamycin (mTOR) protein. Recent reports on everolimus, an mTOR inhibitor, have shown size reduction of RHM. We compared cases recently treated with everolimus to historic controls whose first echocardiography was within first month of life. The largest dimension of the largest RHM was reported as a percentage compared to the earliest echocardiography study. Treatment of the four cases was started at a median age of 6.5 days (range 2-20) with an initial enteral dose of 0.1 mg daily, aiming at a therapeutic serum trough level of 5-15 ng/mL. Median duration of everolimus treatment was 73 days (range 34-138). Compared to 10 historic controls, everolimus-treated patients had 11.8 times faster RHM size regression rate (slope -0.0285 vs. -0.0024; p < 0.001). The average time to 50% size reduction was 1.13 ± 0.33 month (range 0.66-1.4 months) with everolimus versus 72.9 ± 53.03 months in controls (p = 0.026). Following treatment with everolimus, one case was operated for congenital heart disease, without requirement of RHM resection, two others had the massive left ventricle RHM shrink to non-consequential size. The latter had a disappearance of RHM, but everolimus therapy was maintained to prevent the regrowth of a significant cerebral tumor. Everolimus is efficacious for size reduction of RHM during the neonatal period. With limited safety data, this approach should be used with caution in selective cases.

Prevalence of rheumatic heart disease in Senegalese school children: a clinical and echocardiographic screening.

OBJECTIVE: To study the prevalence of rheumatic heart disease (RHD) in schools (locally referred to as 'daaras') located in the city of Dakar and its suburbs using both clinical examination and echocardiography. METHODS: This is a cross-sectional study conducted from 9 August to 24 December 2011 involving 2019 pupils, aged between 5 and 18 years selected from the 16 'daaras' of the Academic Inspectorate (Inspection d'Académie) of the city of Dakar and its suburbs. Anamnestic, clinical and echocardiographic data were collected and entered into a questionnaire designed for the study. The World Heart Federation criteria for echocardiographic diagnosis were used to diagnose RHD. p<0.05 was considered statistically significant in bivariate analysis. RESULTS: About 60.1% of the pupils were men and the mean age was 9.7±3.3 years. 10 cases of definite RHD were detected, prevalence being 4.96 per 1000 (95% CI 2.4 to 9.1). This prevalence was five times higher with echocardiographic screening compared with clinical screening. 23 cases (11.4 per 1000) of borderline forms were detected. The populations at risk of definite RHD identified in our study were children over 14 years (p<0.001), those with recurrent sore throat (p=0.003) and those residing in the suburbs of the city of Dakar (p<0.001). CONCLUSION: Our study shows a relatively high prevalence of RHD. Reducing its prevalence should focus on the implementation of appropriate policies, targeting at-risk populations and focusing on raising awareness and early detection.

A case of pericardial tuberculoma presenting as a left anterior chest wall mass.

INTRODUCTION: Tuberculosis (TB) can present both in its pulmonary or extra-pulmonary forms. Cardiac tuberculoma previously described only after autopsy is continuously seen with the advent of more advanced imaging modalities. CASE REPORT: A 23-year-old male with a four month history of a progressively increasing left anterior thoracic wall mass of 5 cm in diameter was referred from oncology for clinical re-evaluation and for echocardiography. Systemic examination was essentially normal. Transthoracic and trans-oesophageal echocardiography showed the presence of a pericardial mass around the right atrioventricular junction. Thoracic CT scan showed an anterior mass in left chest wall extending to the pericardium and also the presence of mediastinal lymphadenopathy. Mantoux test was positive and histological examination of tissue biopsy confirmed the presence of TB. However, blood tests and culture of aspirated purulent fluid were unyielding. A diagnosis of pericardial tuberculoma with mediastinal and parietal extension was made and patient was successfully treated with standard anti-TB chemotherapy. DISCUSSION: The possible differential diagnoses for chest wall tumors are varied and a high degree of suspicion is needed to diagnose cardiac tuberculoma especially in endemic regions. Imaging though helpful in morphological description cannot make precise diagnosis. The diagnosis depends on histological and culture studies. There is usually a good evolution with anti-TB treatment. CONCLUSION: In an era of an increasing number of acquired immune-compromised patients, and with increasing number of diagnoses of tuberculosis, a diagnosis of cardiac tuberculoma should be considered in patients presenting with a thoracic wall mass.

Sinus venosus atrial septal defect: a rare cause of misplacement of pacemaker leads.

Routine implantation of pacemakers and implantable cardioverter defibrillators is not commonly associated with complications. However, in some cases we see misplacement of pacemaker leads which is most often related to the presence of underlying cardiac anomalies. We report the case of misplacement of a pacemaker lead into the left ventricle of a 56-year-old patient paced in VVI/R mode and with a tined type pacemaker lead because of a symptomatic complete atrioventricular block. Electrocardiogram showed a pacemaker-generated rhythm with a right bundle branch block pattern. Chest X-ray showed the pacemaker lead located relatively high in relation to the diaphragm. Echocardiography visualized the pacemaker lead in the left heart chambers (atrium and ventricle), hence confirming its aberrant course. Further, the defect causing its passage to the left heart chambers was a sinus venosus atrial septal defect. The patient reported no complication related to the misplacement of the lead. After a brief period of oral anticoagulation, the lead was inserted into the right ventricle by percutaneous technique.