Contribution of brain CT in the diagnosis of tuberculous meningitis: a case report from Djibouti.

Tuberculous meningitis, a serious disease with high mortality and morbidity, remains frequent in countries with endemic tuberculosis. Its non-specific presentation often delays the introduction of appropriate treatment. Its definitive diagnosis requires isolation of Mycobacterium tuberculosis from cerebrospinal fluid, although this test may be negative without conclusively ruling out this diagnosis. A presumptive diagnosis should be reached as soon as possible through a body of clinical evidence, including the lumbar puncture findings. Brain computed tomography (CT) with and without contrast medium injection is helpful for the diagnosis of tuberculous meningitis and its complications. We discuss the features of CT and their value in relation to a case of tuberculous meningitis in Djibouti, as well as the role of CT in managing this disease.

Local-regional anesthesia in the management of stingray stings: Experience of the Bouffard medical-surgical hospital in Djibouti.

Stingray injuries are very painful. Systemic analgesics are ineffective, and the use of local-regional anesthesia has been reported. This retrospective descriptive study reviewed all cases of stingray injuries seen at the emergency department of the Bouffard Hospital (Djbouti, Africa) between 2011 and 2014. The study included 35 patients. Most of the injuries (n= 31, 89%) concerned the lower limbs. Median pain intensity was 6 [5-8] on a visual analog scale of 0 (no pain) to 10. The following systemic medications were administered: acetaminophen to 13 (27%) patients, morphine to 8 (23%), and tramadol to 6 (17%). In all, 25 (71%) patients received local-regional anesthesia, 15 (60%) by injections at the ankle. All procedures were successful, and no adverse event was reported. This study reports clinical data about stingray injuries in the Red Sea area and highlights the interest of local-regional anesthesia in their management. Most of the procedures were distal and could be performed by trained emergency physicians.

[Aeromedical evacuation of critically ill patients in developing countries A retrospective study on 244 patients in Djibouti]. / Évacuation sanitaire des patients admis en réanimation dans un pays en développement Étude rétrospective sur 244 cas à Djibouti.

INTRODUCTION: The pratice of intensive care in Africa is marked by a wide variety of health care delivery. Only a few centers offer specialized intensive care units, as cardiac or neurological units. That may explain the need for aeromedical evacuations for patients whose condition exceeds local capacity. Our objective was to assess whether the proportion of patients admitted to intensive care and evacuated had increased between 1997 and 2013 in a developing country, Djibouti. MATERIALS AND METHODS: We examined the activity register of Bouffard Hospital intensive care unit in Djibouti to determine the number and characteristics of patients evacuated by air ambulance during a 16 years period. RESULTS: From January 1997 to December 2013, a total of 244 patients were evacuated. The evacuation rate was 5.74ù of the patients admitted to the entire duration of the study. The rate of patients evacuated was not different between 1997 and 2013 (5,69ù versus 8,33ù respectively, p = 0,269). However, the rate of djiboutian evacuated patients was statistically different between 1997 and 2013 (0,96ù versus 4,46ù, p = 0,02). The main causes were severe trauma injuries, cardiovascular diseases and neurological diseases. CONCLUSION: The aeromedical evacuation of a critically ill patient in a developing country is a process requiring heavy logistics and depending on the medical skills available in the area, and financial resources that can be implemented for the patient. Our study shows that medical evacuations in favor of Djiboutian patients are marginal but are increasing over the past decade.

[Acute liver failure and severe exertional heat stroke: uneasy management in Africa]. / Coup de chaleur d'exercice grave et insuffisance hépatique aiguë: difficultés de prise en charge outre-mer.

Exertional heat stroke (EHS) is a medical emergency defined as tissue injury secondary to a prolonged period of extreme hyperthemia during strenuous physical activity. In the vast majority of cases, EHS is associated with minimal liver involvement with no clinical manifestations. However acute hepatic insufficiency has been reported including a few cases treated by liver transplantation but with poor results suggesting that conservative management is preferable. The purpose of this report is to describe a patient who developed EHS with acute liver insufficiency and multiple organ failure in Djibouti. Despite the remote location and limited medical resources available, full recovery was achieved with conservative therapy and intensive care.

[Morbidity and mortality after intensive care management of hemorrhagic stroke in Djibouti]. / Morbi-mortalité des accidents vasculaires cérébraux hémorragiques après prise en charge en réanimation a Djibouti.

Prospective data on management and outcome of stroke in Africa is scarce. The purpose of this prospective descriptive study is to present epidemiologic, clinical and outcome data for a series of patients with hemorrhagic stroke in Djibouti. All patients admitted to the intensive care unit of the Bouffard Medical-Surgical Center in Djibouti for cerebral hemorrhage documented by CT-scan of the brain were recruited in this study. A total of 18 patients including 16 men were enrolled. The median patient age in this series was 51.5 years [range, 20-72]. The median duration of intensive care was 3 days [range, 1-38]. Mean Glasgow score at time of admission was 9 [range, 3-14]. Five patients were brought in by emergency medical airlift. The main risk factors for stroke were arterial hypertension, smoking, and regular khat use. Mechanical ventilation was performed in 10 patients with a survival rate of 40%. Six patients (33%) died in the intensive care unit. Hospital mortality within one month was 39% and mortality at 6 months was 44.4%. One-year survival for patients with a Glasgow score < or = 7 at the time of admission was 33%. Arterial hypertension, khat use, and smoking appeared to be major risk factors for male Djiboutians. Neurologic intensive care techniques provided hospital mortality rates similar to those reported in hospitals located in Western countries. Functional outcome in local survivors appeared to be good despite the absence of functional intensive care. These data argue against the passive, fatalistic approach to management of hemorrhagic stroke and for primary prevention of cardiovascular risk factors.

[Management of transdermal therapeutics in perioperative care]. / Gestion des thérapeutiques transdermiques en anesthésie.

OBJECTIVE: To provide guidance on perioperative management of most frequently encountered transdermal therapeutics in anaesthesiology: nicotine, fentanyl, nitroglycerin, scopolamine and estradiol. DATA SOURCES: A review of the last decade literature was carried out on the Pubmed database using the following keywords (transcutaneous or percutaneous or transdermal or transdermic or skin or dermal) and (drug delivery systems or therapeutic systems or drug administration) grouped under the Mesh terms cutaneous administration, perioperative care, surgery, pharmacokinetics, nicotine, fentanyl, nitroglycerin, scopolamine, estradiol. STUDY SELECTION: Original articles, general articles reviews, guidelines, letters to the editor and case reports have been selected. DATA EXTRACTION: Articles were analyzed for each transdermal treatment in terms of pharmacokinetics as well as anaesthetics and surgical interactions. DATA SYNTHESIS: Transdermal nicotine must be removed before anaesthesia of patients with coronary disease or with high risk of inhalation and in case of reconstructive surgery. Transdermal fentanyl must be maintained during the perioperative period and associated with preventive treatments of hyperalgesia. Transdermal administration of fentanyl by iontophoresis is a promising system for postoperative analgesia. Transdermal nitroglycerin must be maintained before scheduled surgery of a coronary patient. Transdermal scopolamine must be removed the day before surgery because of its side effects. It could have an interest in the prevention of postoperative nausea and vomiting, but its therapeutic method remain to be defined. Transdermal estradiol can be maintained during the perioperative period. CONCLUSION: The management of transdermal therapeutics in peri operative care can be adapted for each treatment and for each patient by knowing pharmacokinetics as well as anaesthetics and surgical interactions. In emergency situations, the actions to be taken do not generally differ, but one must be aware that the effects of trandermal treatments do not disappear immediately when removed, due to their pharmacokinetics properties.

Morbi-mortalite des accidents vasculaires cerebraux hemorragiques apres prise en charge en reanimation a Djibouti

Les donnees prospectives sur la prise en charge et l'evolution des accidents vasculaires cerebraux (AVC) en Afrique sont pauvres. Le but de ce travail etait de decrire les aspects epidemiologiques; cliniques et e volutifs d'une serie d'AVC hemorragiques a Djibouti. Une etude prospective descriptive a ete realisee pendant 18 mois de tous les patients admis dans le service de reanimation du Groupement Medico-Chirurgical Bouffard pour hemorragie cerebrale diagnostiquee par scanner cerebral. Dix-huit patients dont seize hommes ont ete inclus. L'agemedian etait de 51;5 ans [20-72]. La duree mediane de sejour en reanimation etait de 3 jours [1-38]. Le score de Glasgow moyen a l'entree etait de 9 [3-14]. Cinq patients ont beeeficie d'unee evacuation sanitaire aerienne. Les principaux facteurs de risque retrouvse etaient l'hypertension arterielle (HTA); le tabagisme et la consommation reguliere de Khat. Dix patients (55;5) ont beneficie de ventilation artificielle avec une survie de 40. La mortalite en reanimation etait de 33; la mortalite hospitaliere a 1mois de 39et la mortalite a 6 mois et 1 an de 44;4. La survie a un an des patients ayant un Glasgow . 7 a l'entree etait de 33. L'hypertension arterielle; le khat; et le tabagisme apparaissent comme des facteurs de risque importants pour les hommes djiboutiens. Les mesures medicales de neuroreanimation permettent d'obtenir des taux de mortalite hospitaliere proches de ceux des pays occidentaux. Le pronostic fonctionnel apparait bon pour les survivants autochtones malgre l'absence de reeducation fonctionnelle. Ces donnees plaident contre la passivite et le fatalisme dans la prise en charge en reanimation des hemorragies cerebrales; et pour la prevention primaire en luttant contre les facteurs de risque cardio-vasculaires

[Celiac disease: special features in Africa. Description of 8 cases in Djibouti (horn of Africa)]. / Maladie coeliaque: particularités africaines. A propos de 8 cas à Djibouti.

Celiac disease is poorly documented in intertropical Africa. The purpose of this retrospective report was to describe 8 cases observed at the Groupement Medico-Chirurgical of Bouffard Hospital in Djibouti (Horn of Africa) between January 2003 and January 2006. There were 5 females and 3 males ranging in age from 9 months to 17 years old (mean age: 48 months). Six patients were of Somali ethnic origin and two of Yemenite ethnic origin. Six were classified as middle class and 2 as lower class. All forms were symptomatic associating constant loss of weight with digestive manifestations (diarrhoea and vomiting). Diagnosis of celiac disease was based on the presence of anti-gliadin antibodies IgA and IgG associated with anti-endomysium or anti-transglutaminase antibodies that were measured in six and two cases respectively. Gastroduodenal endoscopy performed in three cases including two with duodenal biopsy demonstrated villous atrophy associated with gross of intra-epithelial lymphocytosis. A gluten-free diet initiated in five patients led to clinical improvement in four cases with a follow-up of 8.25 months. The findings of this study in Djibouti show that celiac disease exists in intertropical Africa. Its presentation is quite similar to elsewhere but diagnosis is more difficult due to poor knowledge about the disease and limited diagnostic facilities. Favourable response to presumptive treatment by a gluten-free diet is an alternative for diagnosis especially in Djibouti where eating habits differ from those in industrialized countries and this type of diet is easier to follow.

Maladie coeliaque : particularites africaines. A propos de 8 cas a Djibouti

La maladie coeliaque est meconnue en Afrique intertropicale. Nous en rapportons 8 observations colligees de facon retrospective entre janvier 2003 et janvier 2006; au Groupement Medico-Chirurgical Bouffard a Djibouti. Elles ont concerne 5 filles et 3 garcons dont l'age varie de 9 mois a 17 ans (age moyen : 48 mois); d'ethnie Somali 6 fois et Yemenite 2 fois; issus des classes moyennes de la population 6 fois et des classes les plus defavorisees 2 fois. Il s'agissait toujours de formes symptomatiques : alteration de l'etat general constante associee a des troubles digestifs (diarrhee ou vomissements). Le diagnostic a ete retenu dans ce contexte sur la presence d'anticorps anti-gliadine de type IgA et IgG; associes a des anticorps anti-endomysium ou anti-transglutaminase respectivement realises dans 75et 25des cas. Une endoscopie gastroduodenale realisee 3 fois avec biopsies duodenales a montre deux fois une atrophie villositaire totale associee a une augmentation de la lymphocytose intra epitheliale. Un regime sans gluten; instaure chez 5 malades; a entraine une reponse clinique favorable dans 4 cas avec un recul de 8;25 mois. La maladie coeliaque existe en Afrique intertropicale dans la region de la Corne de l'Afrique ou elle ne presente pas de particularite; en dehors de difficultes diagnostiques liees a une meconnaissance de l'affection et des moyens diagnostiques souvent insuffisants. La reponse favorable au regime sans gluten d'epreuve peut constituer une alternative diagnostique d'autant que ce regime parait moins astreignant a suivre a Djibouti qu'en occident en raison d'habitudes alimentaires differentes