Emergency admissions in sub Saharan Africa: example of the surgical emergency admissions unit at the Sylvanus Olympio Teaching Hospital of Lomé, Togo.

The management of patients in emergency departments is an important indicator of the quality of a healthcare system. In sub-Saharan Africa, emergency care is characterized by human and material difficulties. The purpose of this work was to assess the difficulties in managing emergencies at the surgical emergency admissions unit of Sylvanus Olympio teaching hospital of Lomé. This descriptive prospective study took place during the last 6 months of 2013. Epidemiological, clinical, and therapeutic data were collected. All admissions for acute conditions requiring urgent care were included. The study excluded patients who died at admission and patients receiving care in the medical emergency department. The study included 2880 patients, 60.3% men; the mean age was 46 years (range: 4 days to 92 years). Traffic accidents accounted for 519 cases (18%). Among patients with trauma, 23.7% had limb injuries and 17.2% head injury. Appendicitis accounted for 32.9% of the non-trauma emergencies, followed by peritonitis (27.3%), burns represented 1%. Laboratory tests were performed for 49.4% of patients, ultrasound for 14.2%, and computed tomography scans for 0.8%. Overall, 44.1% received venous catheterization, 40% volume replacement, 20% oxygen therapy, 16% blood products, 2% pressor amines, and 0.1% intubation. Analgesia was administered to 82%, antibiotic treatment (37%), and sedation to 1%. In all, 34.8% of patients underwent laparotomy, 26.6% trimming with sutures, 21.4% dressing of wounds, and 14.5% immobilization. Time to discharge was less than 24 hours for 82%, and 6.2% were transferred to intensive care. Eighteen patients died (0.6%). Management of surgical emergencies remains a major health problem in developing countries. Prevention measures and accessibility of the population to emergency care will reduce morbidity and mortality for these conditions.

Clinical profile of subdural hematomas: dangerousness of subdural subacute hematoma.

Subacute subdural hematomas are a poorly individualized nosological entity, often equated clinically to chronic subdural hematomas. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. We wanted to show this dangerousness by establishing the clinically evolving profile of the three types of subdural hematomas. This was a prospective and retrospective study of 63 subdural hematoma (18 acute, 13 subacute, and 32 chronic) patients admitted between 2012 and 2014 in the neurosurgery unit of Lomé University Hospital. Hematomas were classified according to the elapsed time after head injury and blood density on CT. The main parameter studied was the evolution of the Glasgow Coma Score (GCS) in the 3 months following the trauma, enabling to establish an evolving profile of each type of hematoma. The average age of patients was 58.1 years for chronic subdural hematomas and 47.6 years for subacute subdural hematomas. Disease duration before admission was 13.1 days for chronic against 36.6 h for subacute hematoma. The clinical profile shows acute worsening within hours during the second week for patients with subacute hematoma, while it is progressive for patients with chronic hematoma. We noted two deaths, all victims of a subacute hematoma (one operated, one patient waiting for surgery). Iso-density hematoma on CT, especially in a young person, must be considered as a predictive factor of rapid neurological aggravation suggesting an urgent care or increased monitoring by paramedics.

[Knowledge, attitudes, and practices relative to the risk of transmission of hepatitis B and C viruses in a hospital in Togo]. / Connaissances, attitudes et pratiques du personnel soignant sur le risque de transmission des hépatites virales B et C en milieu hospitalier au Togo.

OBJECTIVE: To assess the knowledge, the attitudes, and the practices of hospital nursing staff in relation to the infectious risks of the hepatitis B and C viruses. METHODS: Cross-sectional descriptive survey conducted at the Lome Campus Teaching Hospital among the nursing staff present during at least one of the 2 consecutive workdays of the survey. RESULTS: The total nursing staff included 190 people, 115 (60.5%) of whom participated in the investigation. Slightly more than three-fifths were men (61.7%). Their mean age was 37.9 ± 10.7 years. The contaminated materials encountered most often were blood (94.8%), needle-drawn fluids (77.4%), and biopsy samples (53.9%). Staff most often did not comply with protective measures: 75.5% did not use gloves regularly and 46.0% did not use bibs. More than one third of the nursing staff (34.8%) had had such a needle-stick or related accident, but only 8.8% had reported them: 74.2% because of the potential administrative difficulties and 25.8% because of ignorance (25.8%). Staff knowledge about the means of transmission of these viruses was good (98.3%). The vaccination coverage rate of the nurses questioned was 51.3%. CONCLUSION: Training and awareness campaigns about the occupational risks of HBV and HCV remain necessary.

Anatomic cementless total hip arthroplasty with ceramic bearings and modular necks: 3 to 5 years follow-up.

Reported here are the results obtained for 216 prosthetic implants in which cementless arthroplasty and a modular neck were used. The advantages to using this method are related to the fact that it may be adapted to a variety of anatomical conditions.

Is it possible to define a better ASCUS class in cervicovaginal screening? A review of 187 cases.

OBJECTIVE: To try to better define the cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) in a cervical screening protocol. STUDY DESIGN: Smears from 187 patients with cytologic diagnoses of ASCUS and histologic or two years' cytologic/colposcopic follow-up were reviewed. When an ASCUS diagnosis was confirmed, it was done strictly on the basis of the morphologic criteria recommended by the Regione Emilia Romagna Screening Protocol in 1997, trying also to subclassify ASCUS into favor reactive or favor neoplasia. RESULTS: Seventy ASCUS cases were negative (37.4%). Three cases (1.6%) were low grade squamous intraepithelial lesion, and seven (3.8%) were high grade squamous intraepithelial lesion. One hundred seven ASCUS cases (57.2%) were confirmed. Among the 70 negative cases, 36 (51.4%) had reactive changes on biopsy, 30 (42.9%) koilocytosis, 3 cervical intraepithelial neoplasia (CIN 1) and one CIN not otherwise specified (5.7% total). CONCLUSION: Reclassification of ASCUS cases using tighter criteria reduced them to a rate of 57.2% but missed 30 patients with histologic diagnoses of koilocytosis and 4 with histologic diagnoses of CIN.

External quality assurance in cervical/vaginal cytology: Interlaboratory agreement in the Emilia-Romagna region of Italy.

OBJECTIVE: To evaluate the diagnostic agreement between seven cervical/vaginal cytology laboratories participating in the first external quality assurance (EQA) scheme developed in Italy. STUDY DESIGN: Between 1991 and 1993, 110 cytologic smears were selected and classified by a committee and circulated and reported on by the laboratories according to the 1988 Bethesda System. Agreement was evaluated with the kappa statistic. Systematic disagreement was assessed by means of the Wilcoxon signed rank test. RESULTS: Interlaboratory kappa values varied between .01 and .29 (group score, .11) for sample adequacy and between .53 and .78 (group score, .67) for epithelial abnormalities. The lowest specific kappa values were observed for the three classes of sample adequacy (unsatisfactory, .07; less than optimal [LTO], .10; satisfactory [SAT], .14) and for the class of atypical cells of undetermined significance (ACUS), (.29). As compared with the study committee, 5/7 laboratories showed a systematic (P<.01) tendency to undercall sample adequacy. Agreement on epithelial abnormalities was also analyzed according to the pattern of adequacy reported by paired laboratories (LTO/LTO, LTO/SAT, SAT/SAT). As compared with smears designated SAT/SAT, those classified as LTO/SAT were associated with lower specific kappa values for agreement on the presence of carcinoma and ACUS and with equal or greater values for agreement on the other classes, suggesting an arbitrary use of notations of LTO inversely related to the severity of epithelial lesions. CONCLUSION: EQA schemes, as applied to cervical/vaginal cytology, can shed light on major deficiencies in specific diagnostic areas.

Intralaboratory reproducibility of cervical cytology diagnoses in the external quality assurance scheme of the Emilia-Romagna region of Italy.

In an external quality assurance (EQA) scheme, 110 selected cervical smears were independently reported by seven cytology laboratories using the 1988 Bethesda System. In one of these, a random sample of 60 study smears was independently classified by five cytologists before undergoing joint examination according to EQA protocol. Internal agreement (i.e., among these cytologists) was compared with external agreement (between these cytologists and the other six laboratories) and with interlaboratory agreement (among these laboratories). The kappa value for internal agreement on sample adequacy (0.57) was considerably greater than those for external (0.16) and interlaboratory agreement (0.10). For interpretation of epithelial abnormalities, internal kappa was excellent (0.80) but not substantially greater compared with external kappa (0.66) and interlaboratory kappa (0.70). Calculation of class-specific kappa values revealed (a) that superiority of internal agreement on sample adequacy was restricted to the notations of "less than optimal" and of "satisfactory," and (b) that internal increase in agreement on cytologic abnormalities was substantial for the diagnosis of "atypical cells of undetermined significance."

[High risk pregnancies and family planning]. / Grossesses a haut risque et planning familial.

PIP: Each year as a consequence of pregnancy and delivery at least 500,000 women die, 99% of them in developing countries. Most maternal deaths are avoidable. For each death, 10-15 other women suffer serious health effects which may lead to chronic pain or even social isolation. Childbirth is riskier for women who are too young or too old, who have many children, or whose births are too closely spaced. Limiting family size reduces both maternal and child deaths. In developed countries, 5-30 women die per 100,000 births, compared to 50-800 in developing countries. Maternal mortality rates at 2 hospitals in Yaounde, Cameroon, have declined significantly in recent years, probably due to establishment of high risk pregnancy clinics, improved monitoring during labor, and child spacing clinics. Improved obstetric services and child spacing could reduce maternal mortality in developing countries as they have in the developed world. The use of contraception has been a controversial topic in traditional African societies, but by now the majority of governments of developing countries include family planning programs in their development plans for their health as well as their economic benefits. Despite gradual increases, fewer than 5% of women in most African countries use modern contraception. African men play an insignificant role in family planning. The continuing practices of prolonged lactation and postpartum abstinence in rural areas have compensated to some extent for the absence of modern contraception. Oral contraceptives are the most widely used reversible method. They may protect against vaginal infection, iron deficiency anemia, ectopic pregnancy, benign breast disease, ovarian and endometrial cancer, dysmenorrhea, endometriosis, and rheumatoid arthritis. There is evidence that some steroid hormones have a beneficial effect in stabilizing the cellular membranes of red blood cells in women with sickle cell anemia. The danger of infection with the IUD is largely limited to the 1st 4 months of use and to women with sexually transmitted diseases. Careful selection of candidates, aseptic insertion, and regular follow-up are needed to ensure IUD safety. The IUD is contraindicated for nulliparas. Barrier methods provide contraception as well as some protection against sexually transmitted diseases. Condoms have a significant protective effect against HIV infection. Diaphragms, cervical caps, and vaginal sponges provide some protection against infections like gonorrhea and chlamydiae that invade the cervical cells. Many adolescents resist condoms because they diminish sensation. But condoms provide protection against sexually transmitted diseases and are appropriate for individuals with sporadic sex lives. Oral contraceptives are more effective but adolescents are at risk of forgetting pills. IUDs are the least attractive option for adolescents because of the danger of infection and subsequent infertility.^ieng

[Cytomegalovirus transmission following a blood transfusion]. / Trasmissione di citomegalovirus in seguito ad emotrasfusione.

In order to assess the incidence of anti-CMV antibodies in blood donors and the possible transmission of infection in blood transfusions, 900 donors, 60 patients serum negative or positive patients given serum positive blood and 5 immature serum negative patients given serum negative blood were examined. At 67.11% the incidence of anti-CMV antibodies in the donors was in line with reports in the literature. It was also noted that reinfection arose when serum positive blood was given (36.36% of the serum negative patients and 10.52% of the serum positive ones developed anti-CMV antibodies indicating infection or reinfection; none of the 5 immature patients revealed anti-CMV antibodies). It is concluded that the routine search for anti-CMV antibodies is impracticable given the high incidence of serum-positive donors and that the technique should be reserved for particular cases: the young, the pregnant, transplant patients, immunodepressed subjects. However the best way to prevent the transmission of disease remains the avoidance of unnecessary transfusions.

[Use of monoclonal antibodies in the immunohematological diagnosis]. / L'impiego degli anticorpi monoclonali nella diagnostica immunoematologica.

A review of the data in the literature suggests that monoclonal antibodies will become the standard reagents given their high specificity and constant quality. It is hypothesised that their primary use will be in immunopharmacology or immunoradiotherapy.

[The use of anti-A, anti-B and anti-AB monoclonal antibodies in a blood transfusion center. Preliminary results]. / Utilizzazione di anticorpi monoclonali anti-A, anti-B e anti-AB nel centro trasfusionale. Risultati preliminari.

The properties of the anti-A, anti-B and anti-AB monoclonal antibodies were investigated by comparing these with 3 polyclonal antibodies with particular emphasis on specificity, titre and take-up. The results obtained suggest that monoclonal antibodies are highly specific and possess a similar titre but a superior take-up capacity to the polyclonal antibodies. It is concluded that they will be extremely valuable in immunohaematology laboratories.

[Evaluation of the immune function of patients undergoing radiotherapy: results after 18 months]. / Valutazione dell'assetto immunitario di pazienti sottoposti a radioterapia: risultati a 18 mesi.

The effects of radiotherapy on subset lymphocyte populations of 15 neoplastic patients were studied. The initial impairment of lymphocyte functions, was restored after eighteen months to 78% of initial values. The numerical equilibrium of T and B subpopulations was completely reinstated.