[Role of Musca domestica in the transmission of multiresistant bacteria in the centres of intensive care setting in sub-Saharan Africa]. / Rôle de Musca domestica dans la transmission des bactéries multirésistantes dans un service de réanimation en Afrique subsaharienne.

OBJECTIVE: The houseflies (Musca domestica -MD) are involved in the transmission of the diseases of the faecal danger in subsaharan Africa. What is their role in the transmission of multiresistant bacteria in an intensive care setting in Dakar? TYPE OF STUDY: Descriptive, forward-looking. MATERIALS AND METHODS: The study was conducted from May 1 to September 30, 2003. During this period a flytrap was put above every patient carrier of BMR (methicillin resistant Staphylococcus, extended spectrum beta-lactamases-enterobacteria, ticarcillin resistant Pseudomonas). Caught MD were carried to the microbiology laboratory and incubated in heart-brain broth at 37 degrees C for 18 hours. Then selective gelose platers were used for identification of bacteria. Comparison of antibiotic sensitivities of bacteria isolated from MD and from the patients was made. RESULTS: Out of 441 hospitalized patients, 26 were colonised or infected by BMR. Human pathogenic microorganisms were obtained from 99 out of 120 flies. Seventeen of those flies were carried of BMR. Six among these 17 flies had BMR with sensitivity profile and phenotype of resistance identical to those of the patients under the trap with birdlime. More 3 MD carried BMR BLSE not found on our patients. CONCLUSION: This study shows that the MD can carry BMR. Their participation in the crossed transmission, between patients, of multiresistant bacteria in intensive care setting, must be discussed. The eradication of the MD in our Africa subsaharan services must be looked for.

[Hospital care of snakebites in Africa]. / Prise en charge hospitalière des morsures de serpent en Afrique.

Snakebites constitute a public health problem in Africa, with some 600,000 envenomations and 20,000 estimated deaths per year. Hospital care of cases guided by written protocols which take into account the epidemiological and physiopathological data, as well as the hospital situation, starts in the emergency room and is based on the diagnosis of envenomation, either by vipers or elapids. If this diagnosis is confirmed, intensive treatment must ensue. It includes a non-specific component, particularly the treatment of hypovolemia, consumptive coagulopathy tissue necrosis and respiratory failure and a specific component, immunotherapy the only ethiological treatment. The latter consists in giving an iv injection of polyvalent purified immunoglobulin fragments against the venom. This attention is included in a general public health policy which takes into account the organization and financing of the treatment.

[Abstract envenomation by the African puff adder (Bitis arietans): value of intracompartmental pressure measurement]. / Morsure par vipère Bitis arietans au Sénégal, intérêt de la mesure de pression intracompartimentale.

The purpose of this report is to describe a case of severe snake bite with envenomation by an African puff adder (Bitis arietans). Presenting symptoms warranted administration of antivenon upon admission. The patient's general condition improved. However bite-related trauma caused extensive phlyctenuar edema of the lower extremity with a high risk of compartimental syndrome due to hardening and compression. Due to the high risk for postoperative infection at our facility, aponevrotomy to relief pressure was not undertaken immediately. Instead management consisted in close surveillance with repeated measurement of peripheral pulses by Doppler ultrasound and of intracompartimental pressure. The outcome was favorable without need for aponevrotomy. This case demonstrates the value of intracompartimental pressure measurement in cases involving this type of envenomation in function of available technical facilities.

Morsure par vipere bitis arietans au Senegal; interet de la mesure de pression intracompartimentale

The purpose of this report is to describe a case of seve re snake bite with enve n o m ation by an A f rican puff adder(Bitis arietans). Presenting symptoms warranted administration of antivenon upon admission. The patient's ge n e ral condition improved. However bite-related trauma caused extensive phlyctenuar edema of the lower extremity with a high risk of compartimental syndrome due to hardening and compression. Due to the high risk for postoperative infection at our facility; apon ev ro t o my to relief pressure was not undert a ken immediately. Instead management consisted in close surveillance with rep e ated measurement of peripheral pulses by Doppler ultrasound and of intracompartimental pressure. The outcome was favo rabl e without need for aponevro t o my. This case demonstrates the value of intra c o m p a rtimental pressure measurement in cases invo lving this type of envenomation in function of available technical facilities

Sub-MAC concentrations of desflurane do not inhibit hypoxic pulmonary vasoconstriction in anesthetized piglets.

PURPOSE: In vitro, halogenated agents reduce the pulmonary vasoconstrictor response to alveolar hypoxia in isolated perfused lungs. However, studies in intact animals have been less convincing. The aim of the present study was to assess the effect of sub-MAC concentrations of desflurane on hypoxic pulmonary vasoconstriction (HPV) in anesthetized piglets using the pressure/cardiac output relationship (P/Q). METHODS: Eleven large white piglets were anesthetized and ventilated mechanically, alternatively in hyperoxia (FIO2=0.4) and in hypoxia (FIO2=0.12). Multipoint plots of pulmonary arterial pressure (PAP), or differences between PAP and left atrial pressure (LAP) against Q were generated by gradual inflation of a balloon advanced into the inferior vena cava. P/Q relationships were established in hyperoxia and in hypoxia at baseline, and then with gradual concentrations of desflurane. RESULTS: In hypoxia, pressure gradients (PAP-LAP) increased significantly at every level of Q, demonstrating active pulmonary vasoconstriction. Desflurane did not affect these P/Q relationships either in hyperoxia, or in hypoxia, when compared with baseline. CONCLUSION: Desflurane at a clinically relevant dose has no significant effect on HPV in anesthetized piglets.

Elevated parathyroid hormone 44-68 and osteoarticular changes in patients with genetic hemochromatosis.

OBJECTIVE: To determine whether the osteoarticular changes associated with genetic hemochromatosis could be explained by metabolic parathyroid hormone (PTH) disorders. METHODS: The study involved 210 patients with liver iron overload syndromes. Osteoarticular changes were numerically scored as the number of damaged joints. PTH 1-84 and 44-68 were assayed. RESULTS: An increase in serum PTH 44-68 levels was found in one-third of untreated patients who had no calcium or PTH 1-84 abnormalities. Serum PTH 44-68 levels correlated positively with serum ferritin levels. In multivariate analyses, the number of affected joints correlated positively with age, serum PTH 44-68 levels, and serum ferritin levels. CONCLUSION: Liver iron overload syndromes, especially genetic hemochromatosis, are associated with elevated circulating levels of PTH fragments containing the 44-68 region, which appears to play a role in osteoarticular changes. This increase seems to be a consequence of iron overload.

Influence of severity of chronic inflammatory joint disease on the pharmacokinetics of indomethacin and etodolac.

The goal of this study was to look for correlations between the severity of chronic inflammatory joint disease and pharmacokinetic parameters of nonsteroidal antiinflammatory drugs. Disease severity data (pain severity and magnitude of abnormalities in laboratory tests for inflammation) and pharmacokinetic data (area under the curve in the morning (AUCm) and maximum plasma concentration (Cmax) were collected during a prospective, randomized, double-blind, parallel-group study. Two groups of nine and 11 patients, respectively, were given 300 mg etodolac b.i.d or 50 mg indomethacin b.i.d. by the oral route, for three days, after a 36-hour placebo washout. Univariate analyses demonstrated statistically significant negative correlations between pharmacokinetic parameters of both study drugs and a number of disease severity parameters. In the multivariate analysis of data for etodolac, the sigma erythrocyte sedimentation rate contributed significantly to variations in all pharmacokinetic parameters and explained 100% of the variations in free S-enantiomer AUCm and in total and free S-enantiomer Cmax. For indomethacin, pain contributed to variations in Cmax values of the total and free forms; the sigma erythrocyte sedimentation rate was also a factor in variations in total indomethacin. These negative correlations suggest that severity of chronic inflammatory joint disease may influence the pharmacokinetics of nonsteroidal antiinflammatory drugs.

The role of HLA-DR-DR and HLA-DR-DP interactions in genetic susceptibility to rheumatoid arthritis.

In order to analyze the relationships between the DR and DP loci in the genetic susceptibility to RA, HLA-DRB1 and -DPB1 polymorphism was studied in 155 RA patients compared to 150 controls, using a reverse dot-blot analysis. Our data were consistent with the involvement of the amino acid in position 71 of the third hypervariable region of the DR beta 1 chain in susceptibility to the disease. The higher risk for RA was observed in patients who carried the association of a lysine (K), characterizing the DRB1* 0401 susceptibility allele, with an arginine (R), observed in all the other DRB1* susceptibility alleles (21.9% vs 0.6%, p(c) < 10(-6), OR = 42) In the absence of arginine, the presence of lysine was still associated with the disease (33% vs 19%, p(c) < 0.03, OR = 2). In contrast, in the absence of lysine, the frequency of arginine in position 71 was similar in patients and controls (30% vs 26%, p = NS). On another hand, the analysis of the HLA-DPB1 locus showed that the DPB1 *0401 allele frequency was significantly increased in the RA patient group (n = 47) who expressed only arginine at the position 71 of the beta 1 chain (82% vs 56% in controls, p < 0.008), with role of HLA-DR--DR and -DR-DP interactions in the genetic susceptibility to RA.

[Hyperammonemia encephalopathy after ureterosigmoidostomy]. / Encéphalopathie hyperammoniémique après urétérosigmoïdostomie.

Ureterosigmoidostomy (USS) for bladder cancer is an attractive surgical technique for the improved quality of life provided to the patient, notably from a preserved body image. Complications, however, can jeopardize this result. We report the case of a woman who developed an hyperammonemic encephalopathy after USS "Mainz pouch II". We discuss the indication of a liver needle biopsy before USS when hepatic functions are abnormal and we stress the importance of regular "rectal exonerations" during the day.

[Combination of propofol-ketamine-vecuronium for total intravenous anesthesia under hazardous conditions]. / Association propofol-kétamine-vécuronium pour l'anesthésie totalement intraveineuse en situation difficile.

A total intravenous technique using propofol, ketamine and vecuronium was successfully used on 29 patients treated for elective surgery at the UNPROFOR French Medical Group (Sarajevo, Bosnia Herzegovina). Operative conditions were satisfactory for the surgeons. Recovery was fast and emergence reactions very limited. No hypoxaemia was observed during the immediate postoperative period. The use of a propofol/ketamine/vecuronium combination is possible in field anaesthesia especially when opiates and inhalational agents are not available.

Adult-onset Klippel-Feil syndrome with inaugural neurologic symptoms: two case reports.

Two cases of adult-onset Klippel-Feil syndrome with inaugural neurologic manifestations are reported. Increased awareness of this infrequent syndrome would improve the early diagnosis of the potentially fatal or disabling congenital defects associated with Klippel-Feil syndrome.

Sciatica as the first manifestation of synovial sarcoma. Contribution of magnetic resonance imaging to the diagnosis.

A 38-year-old man presented with paralyzing sciatica as the first manifestation of synovial sarcoma of his right leg. Although neurologic symptoms sometimes occur as manifestations of synovial sarcoma, they are exceptionally inaugural. Magnetic resonance imaging is a valuable tool in patients with synovial tumors, both for establishing the diagnosis and for evaluating the extent of the lesion.

[Propofol and ketamine for dressing in burnt patients]. / Propofol et kétamine pour la réalisation de pansement de brûlés.

General anaesthesia is often required for burns dressing. Ketamine was the most common agent for carrying out removal of adherent dressings. Disadvantages are delirium on emergence from anaesthesia and prolonged recovery. We have studied an intravenous combination of propofol and ketamine in 29 burned patients for 39 dressings. After induction with 1 mg.kg-1 of propofol and 0.75 mg.kg-1 of ketamine, the maintenance rate was 2.5 mg.kg-1.h-1 of each agent. Satisfactory intraoperative conditions were obtained in all cases. Mean time of recovery was less than 15 min. Unpleasant dreaming occurred in 3 patients only, without agitation. The technique proved to be simple, effective and should revive interest for ketamine in the management of burned patients.

[Lung contusion in the multiple trauma patient]. / Contusion pulmonaire chez le polytraumatisé.

The main management's characteristics of the pulmonary contusion in the trauma patients are explained. From possible alveolocapillary membrane's injuries, with consideration of worsening evolution (ARDS, nosocomial infection, MOF), main points of discussion are circulation and mechanical ventilation. For the most severely injured, invasive monitoring is necessary, including the oxygenation parameters we now can dispose of. Quantification of extravascular lung water is an original and valuable tool to determine the time course and amount of pulmonary oedema. There is no ideal mode of ventilation but the basic ventilatory patterns must be adjusted; a target is the reduction of time requirement for ventilatory support.

[Aspects and value of MRI in the diagnosis and follow-up of common microbes infectious spondylodiscitis. Apropos of 25 clinically and biologically suspected patients]. / Aspects et intérêt de l'IRM dans le diagnostic et le suivi des spondylodiscites infectieuses à germes banals. A propos de 25 patients suspects cliniquement et biologiquement.

This work is about 25 patients clinically and biologically suspected of spondylodiscitis (27 levels). All of them had a MRI exam before disco-vertebral needle biopsy and treatment. The results are compared to those of literature. Each infectious spondylitis case (19 cases) had a new MRI exam each three months. This study conclude to the great sensibility of MRI (89%) in the diagnosis of infectious spondylitis and to the limited interest of it in the follow-up of spondylodiscitis.