[Assessment of a therapeutic protocol for the management of snakebite envenomations in Benin]. / Évaluation d'un protocole de traitement des envenimations ophidiennes au Bénin.

Introduction: Snakebite envenomation is a major public health issue in Sub-Saharan Africa (SSA). Antivenoms are the only etiological treatment. However, the dose recommended by the manufacturer (2 vials renewed every 2 hours in case of persistent bleeding) is usually not applied due to the high cost which is borne only by the patient. Based on clinical presentation, we evaluated the administration of a single vial on admission (instead of 2 vials), which corresponds to the therapeutic protocol used in current practice in most health centers in Benin and beyond in SSA. Renewal of antivenom followed manufacturer's recommendation. Material and method: The study took place in a first referral hospital in Tanguiéta, North Benin. All envenomed patients received a slow intravenous vial of Inoserp® Pan-Africa (IPA) upon arrival. A clinical assessment identical to that of inclusion was carried out 2, 4, 6, 12 and 24 hours later to assess the tolerance and efficacy of the IPA, as well as the need to readminister the antivenom. The occurrence, persistence or worsening of clinical hemorrhages or neurological disorders, the latter reflecting envenomation by elapids, systematically led to the injection of 2 or 4 vials of IPA, respectively. Signs of intolerance were sought before and after each administration of antivenom, then 2 weeks to 1 month after treatment, in order to estimate the incidence of adverse effects attributable to the antivenom. Efficacy of IPA was assessed by cessation of bleeding and/or normalization of whole blood coagulation test (WBCT) within 24 hours of initial administration. Results: The study took place from July 31 to October 31, 2019. We received 53 cases of snakebites of which 43 were included. The median age was 21 [IQR: 18-31] years and the sex ratio (M/F) was 1.5. Farmers were the majority (48%). The median time to admission was 1 [IQR: 0-2] day. On admission, 32 patients (74%) presented hemostasis disorders marked by bleeding and/or abnormal WBCT. None of the patients showed neurological symptoms. The median time to normalization of WBCT was 24 [IQR: 4-72] hours. The median time to stop bleeding was 6 [IQR: 4-12] hours. In 3 of the 11 patients whose bleeding had stopped at H2, a recurrence occurred within the following 24 hours. In addition, 3 patients presented with late bleeding 24 hours after admission. Two patients (5%) died as a result of envenomation. Discussion/conclusion: The simplified protocol represents a significant saving in the number of vials used, i.e. 1.8±0.4 vials per patient instead of the 2.4±0.2 which would have been necessary in these same patients treated according to the standard protocol (p = 2.6·10-4). However, in comparison with the results obtained during the previous clinical study, the cessation of bleeding is delayed, as is the normalization of the WBCT at the different follow-up times. In addition, the number of re-administrations of antivenom after H2 is higher in the light protocol than in the standard one, respectively 13 patients out of 43 treated versus 4 patients out of 59 (p = 0.006). There was no significant difference between the incidence of signs of early antivenom intolerance in this study compared to the previous one (16% and 11%, respectively; p = 0.79). This delay can put up to a third of patients at risk of complications. Despite its effectiveness and the antivenom savings made, it does not seem reasonable to recommend it.

Surgical management of rickets-like bone deformities (knock-knee and bow-leg) in children in sub-Saharan Africa.

Rickets-like deformities of the lower limb (knock- knee or bow-leg) are very frequent in sub-Saharan Africa. A prospective study was carried out over a period of 5 years. Forty-eight children were treated surgically for rickets-like deformities. The surgical technique was guided growth using a tension-band plate (eight plate). One patient was lost to follow- up. The technique failed in two cases (absence of correction in one case and hypercorrection in one case). Five patients are still under follow-up with progressive correction and were excluded from the study. A full correction was achieved in 40 patients (73 knees). There were 33 bilateral and 7 unilateral deformities. The deformities were knock-knees in 20 cases, bowlegs in 18 cases and there were 2 windswept deformities Good correction was obtained after a mean time of 11.4 months for genu varum and after a mean time of 12.4 months. The two windswept deformities were corrected after 8 and 9 months respectively. The guided growth technique using eight plate is effective as well in Africa. The needed material is not expensive if a two-hole tubular plate is used with two 3.5 screws.

Treatment of large diaphyseal bone defect of the tibia by the "fibula pro tibia" technique: application in developing countries.

Large segmental bone defects of the tibia may be due to infections, high-energy fractures, congenital diseases or tumors and represent a challenge for both the physician and the patient. In developing countries, the use of expansive techniques is not possible so that amputation is sometimes proposed. However, an alternative technique for limb salvage, applicable in developing countries consists of tibialization of the ipsilateral fibula. This technique is also called "Fibula pro Tibia", fibular transfer to the tibia or fibular centralization. We report this transfer in 4 patients with an average defect length of 11.8 cm. Union between the transferred fibula and the tibia was obtained in all patients, for both proximal and distal junctions, after an average time of 8.5 months (range, 4 to 18 months). Three patients returned to a normal walking function while one was still limping, but was able to walk independently without need of crutches.

Comparative analysis of primary repair vs resection and anastomosis, with laparostomy, in management of typhoid intestinal perforation: results of a rural hospital in northwestern Benin.

BACKGROUND: The objective is to compare primary repair vs intestinal resection in cases of intestinal typhoid perforations. In addition, we hypothesised the usefulness of laparostomy for the early diagnosis and treatment of complications. METHODS: 111 patients with acute peritonitis underwent emergency laparotomy: number of perforations, distance of perforations from the ileocaecal valve, and type of surgery performed were recorded. A laparostomy was then created and explored every 48 to 72 hours. The patients were then divided into two groups according to the surgical technique adopted at the initial laparotomy: primary repair (Group A) or intestinal resection with anastomosis (Group B). Clinical data, intraoperative findings, complications and mortality were evaluated and compared for each group. RESULTS: In 104/111 patients we found intestinal perforations, multiple in 47.1% of patients. 75 had primary repair (Group A) and 26 had intestinal resection with anastomosis (Group B). Group B patients had more perforations than patients in Group A (p = 0.0001). At laparostomy revision, the incidence of anastomotic dehiscence was greater than that of primary repair dehiscence (p = 0.032). The incidence of new perforations was greater in Group B than in Group A (p = 0.01). Group B correlates with a higher morbility and with a higher number of laparostomy revisions than Group A (p = 0.005). CONCLUSIONS: Resection and anastomosis shows greater morbidity than primary repair. Laparostomy revision makes it possible to rapidly identify new perforations and anastomotic or primary repair dehiscences; although this approach may seem aggressive, the number of operations was greater in patients who had a favourable outcome, and does not correlate with mortality.