Cytomegalovirus-associated esophageal stricture as a manifestation of the immune reconstitution inflammatory syndrome.

Cytomegalovirus (CMV) esophagitis is well described in immunocompromised individuals, however, esophageal stricture due to CMV is rare. CMV disease in the setting of the immune reconstitution inflammatory syndrome (IRIS) usually takes the form of an immune-recovery uveitis or retinitis. We describe a young female patient with HIV who developed an esophageal stricture due to CMV within 6 months of starting antiretroviral therapy (ART). The patient responded well to treatment which involved 14 days of intravenous ganciclovir and esophageal dilatation. This is the first description of a patient developing gastrointestinal cytomegalovirus disease as a manifestation of IRIS.

Adaptation and implementation of local maternity dashboards in a Zimbabwean hospital to drive clinical improvement.

PROBLEM: The Commission on Information and Accountability for Women's and Children's Health of the World Health Organization (WHO) reported that national health outcome data were often of questionable quality and "not timely enough for practical use by health planners and administrators". Delayed reporting of poor-quality data limits the ability of front-line staff to identify problems rapidly and make improvements. APPROACH: Clinical "dashboards" based on locally available data offer a way of providing accurate and timely information. A dashboard is a simple computerized tool that presents a health facility's clinical data graphically using a traffic-light coding system to alert front-line staff about changes in the frequency of clinical outcomes. It provides rapid feedback on local outcomes in an accessible form and enables problems to be detected early. Until now, dashboards have been used only in high-resource settings. LOCAL SETTING: An overview maternity dashboard and a maternal mortality dashboard were designed for, and introduced at, a public hospital in Zimbabwe. A midwife at the hospital was trained to collect and input data monthly. RELEVANT CHANGES: Implementation of the maternity dashboards was feasible and 28 months of clinical outcome data were summarized using common computer software. Presentation of these data to staff led to the rapid identification of adverse trends in outcomes and to suggestions for actions to improve health-care quality. LESSONS LEARNT: Implementation of maternity dashboards was feasible in a low-resource setting and resulted in actions that improved health-care quality locally. Active participation of hospital management and midwifery staff was crucial to their success.

A 'one-stop shop' approach in antenatal care: does this improve antiretroviral treatment uptake in Zimbabwe?

SETTING: Prevention of mother-to-child transmission (PMTCT) programme, Mpilo Hospital antenatal clinic, Zimbabwe. OBJECTIVE: Before and after the introduction of a one-stop shop approach and task-shifting of antiretroviral treatment (ART) to midwives in the PMTCT programme, 1) to compare ART uptake and 2) to determine socio-demographic and other characteristics associated with non-initiation of ART post integration. DESIGN: Before and after cohort study. RESULTS: A total of 285 women were eligible for ART before the introduction of the one-stop approach and 280 after. Of the 285, 163 (57%) initiated ART before integration; this increased to 244/280 (87%) after integration (RR 1.5, 95% CI 1.4-1.7, P < 0.001). A total of 36 (13%) women did not initiate ART after integration; this was significantly associated with cotrimoxazole uptake (P = 0.03). CONCLUSION: Integrating ART into antenatal care along with task-shifting to midwives considerably increased the uptake of ART. This provides further evidence for scaling up integration rapidly to other facilities in Zimbabwe, and is in line with the vision of a world where no child will be born with the human immunodeficiency virus by 2015.

[Cardiac surgery in Cameroon. Results at one year of the pilot phase]. / Chirurgie cardiaque au Cameroun. Résultats à un an de la phase pilote.

In the framework of implementation of his national program for control and prevention of cardiovascular diseases, Cameroonian government has set up a cardiac surgery project. We report in this manuscript results of one year follow up of the patients operated during the pilot phase. From September 22 till 26, 2008, 11 patients have been operated in Cameroun. Surgical procedures were 5 mitral mechanic valve replacement, 2 aortic mechanic valve replacement, 1 atrial septal defect closure, 2 pace maker implantation. No intrahospital death was observed. One patient died at 11th month after the operation due to mitral valve thrombosis and attributed to lack of compliance. One patient presented low cardiac output, pneumonia and a pleural effusion. 2 patients presented 2 minor complications consisting of pericarditis and superficial wound infection. The results of the pilot phase of cardiac surgery in Cameroon are effective. However, the sustainability of the program require human, material capacity building, and funding mechanism as well.

[Diagnosis of pheochromocytoma in Yaoundé (Cameroon): a study of nine cases]. / Phéochromocytomes au Cameroun: neuf observations.

The aim of this study was to describe methods used for diagnosis of pheochromocytoma inYaoundé, Cameroon. This retrospective study was based on analysis of the charts of patients treated in the surgical department of the Yaoundé University Teaching Hospital from 1985 to 2009. Nine patients with histologically confirmed pheochromocytoma were identified. There were 8 women and 1 man with a mean age of 39.5 years (range, 12 and 66). Pheochromocytoma was associated with hypertension in 6 cases. In two women with hypertension, diagnosis was based on palpation of an abdominal tumor after caesarean section following pregnancy associated with arterial hypertension. In another woman, diagnosis was made during laparotomy for a left hypochondrial tumor. In 7 patients, diagnosis was based on laboratory findings showing high urinary levels of vanyl mandelic acid (VMA). In six patients, ultrasound examination allowed topographic diagnosis that was confirmed by CT-scan in 3 cases. Two patients presented extra-renal pheochromocytomas in the abdomen. In three patients, i.e., one third of cases, histology showed malignant features. The findings of this study indicated that diagnosis of pheochromocytoma in Yaoundé be improved with the introduction MRI, scintigraphy, and modern techniques for assaying urinary methoxyderivates.

[Results of the first three years of operation of the emergency medical assistance service (SAMU) in Yaounde, Cameroon]. / Bilan des trois premieres années d'activités du SAMU de Yaoundé (Cameroun).

PURPOSE: The purpose of this article is to present the results of a descriptive and retrospective study of the operations of the emergency medical assistance service (SAMU) in Yaounde, Cameroon. METHODS: Medical regulation and intervention records and monthly statistics forms were analysed for the period going from the creation of the SAMU in 2004 to March 2007. Study was limited to call reception, medical regulation, and extra-hospital and training activities. Study focused on operations and services. RESULTS: The SAMU in Cameroon is managed by a pilot committee presided by the Minister of Public Health and headed by a technical executive secretary. The single phone number to contact SAMU Yaoundé is 19 (119). When a call comes, the personnel on duty in the regulation room identifies the caller and either gives a non-medical response or transfers the call to an on-call emergency doctor who decides whether or not on-site intervention is required. In the 3-year study period, the SAMU received 50,822 calls per year (mean, 1694 +/- 2195). There were 1 596 prank calls (3.14%), 31 044 (61.08%) calls requesting non-medical information, and 2054 (4.04%) calls requiring on-site intervention. The number of calls decreased by 23% from the first to third year of operation. The number of on site-interventions carried out by Yaoundé SAMU was 578 in the first year, 651 in the second and 825 in the third year. A total of 1555 interventions were carried out including 142 that ended in no action and 107 that ended in late arrival. Road traffic accidents were the main reason for intervention. Only one training session was organised for the personnel during the first year of operations. CONCLUSION: The SAMU Yaoundé is based on the French model (on-site care). The number of calls has dropped from the first to third year but the number of prank calls has also decreased. Road traffic accidents accounted for most of the on-site interventions. Further work is needed to increase public awareness of the importance of the SAMU and to provide training for SAMU personnel.

[Historical cohort study of delivery in women of forty years of age and older]. / Etude cohorte historique de l'accouchement a 40 ans et plus a Yaoundé-Cameroun.

In a recent study at the Yaounde-Cameroon University Teaching Hospital, we found that delivery at extreme ages of reproductive health was associated with increased foetal and maternal risks. However we were not able to evaluate the impact of advanced age on exposure do different risks observed. The purpose of this study was to test the hypothesis that deliveries of women aged 40 years and above were associated with increased risk. Data collection was retrospective from delivery room registers at the Yaoundé University Teaching Hospital Between 01/01/1991 - 31/12/2000. The deliveries of 180 women in their forties were compared with those of 532 women in their twenties. The software EPI Info 6 and SPSS were used in analysis. At unvaried analysis, the risk of delivery by caesarean section for women in their forties (16.1%) was significantly high compared to women in their twenties (10.0%), (HR: 1.7; 95% CI: 1.1-2.8; p = 0.027). After adjustment for different factors associated with the occurrence of delivery by caesarean section, its risk for women aged 40 and above remained significantly increased (HR: 1.7; 95% CI: 1.0-2.9; p = 0.039). Similar observation was found for stillbirth with 11.7% by women aged 40 and above compared to 5.8% by women in their twenties (HR: 2.1; 95% CI: 1.1-3.9; p = 0.011). After adjustment for different factors associated with mortinatality, its occurrence remained significantly increased at age 40 and above (HR: 1.9; 95% CI: 1.1-3.6; p = 0.032). Women aged 40 years and above had an increased risk of stillbirth and delivery by caesarean section than those in their twenties. Studies are needed to establish the exact causes of these risks and evaluate management options in these women.

Post Caesarean section infective morbidity in HIV-positive women at a tertiary training hospital in Zimbabwe.

OBJECTIVE: To investigate the infective morbidity in HIV-positive and HIV-negative women whose babies were delivered by Caesarean section. DESIGN: A hospital based, prospective study: part of a larger operational research project. SETTING: Harare Maternity Hospital, a tertiary referral teaching hospital in Harare, Zimbabwe. SUBJECT: 164 HIV-positive and 382 HIV-negative women who were delivered of their babies by Caesarean sections. MAIN OUTCOME MEASURES: Minor and major infective complications. RESULTS: The results compare HIV-positive and HIV-negative women, 18/164 (10.9%) HIV-positive women developed anaemia requiring blood transfusion compared with 15/382 (3.9%) HIV-negative women. The difference was statistically significant (RR 3.05). HIV-positive women had a statistically significant increase in the incidence of post operative fever (RR 1.3) and wound sepsis/sinus (p = 0.002). CONCLUSION: Our study indicates that HIV-positive women who were given prophylactic pre-operative antibiotics were at an increased risk of minor infective complications and blood transfusion post Caesarean section. The risk of blood transfusion was higher in women who had a pre-operative haemoglobin of 10.5 grams/dl. Post operative fever, wound sepsis and wound sinus was commoner in HIV-positive when compared to HIV-negative women.

Outcome of twin deliveries at the University Teaching Hospital, Yaoundé, Cameroon-a 15-year experience.

From 1982 to 1996, a total of 16 181 deliveries was registered at the obstetric unit of the Yaoundé University, Cameroon, out of which 291 were twins (1.8%). For the latter, the average gestational age was 37 +/- 2.9 weeks. In 45.0% of cases both fetuses presented cephalic, in 42.6% one presented cephalic and the other breech, while both fetuses presented as breech in 9.9% of cases. The frequency of the combination cephalic-transverse was 0.05%. Spontaneous delivery of both babies was observed in 90.2% of the patients, while in 9.7% delivery of both babies was by caesarian section. The caesarian section rate for a retained second twin was 1%. The perinatal mortality rate was 65 per 1000 (38 deaths in the first week of life), out of which the fetal loss was 4.4% for the first twin compared with 7.9% for the second. The perinatal mortality for the second twin was significantly associated with the type of fetal presentation at the time of delivery, as well as the time gap between the delivery of the twins. Sixteen deaths were observed amongst second twins after podalic presentation out of a total of 23 deaths recorded in the group. In addition, the mortality rate among second twins born more than 20 minutes after expulsion of the first was four times higher than in those delivered within 20 minutes time interval (16.0%5 versus 4.3%). The main cause of twin deaths in our study was found to be prematurity which complicated 30 cases of the registered deaths (78.9%).

[Use of tubal sterilization by minilaparotomy after vaginal delivery in a developing country. A retrospective analysis of 347 cases at the Yaoundé University Gynecologic Clinic (Cameroon)]. / Wertigkeit der Tubensterilisation durch Minilaparotomie nach vaginaler Entbindung in einem Entwicklungsland. Eine retrospektive Analyse von 347 Fällen an der Universitätsfrauenklinik Yaoundé (Kamerun).

The authors report the results of a retrospective study of 347 cases of tubal ligation collected between January 1985 and December 1991 in the maternity unit of the Yaoundé teaching hospital group. The tubal ligations were performed through minilaparotomy with local anesthesia using the method of Pomeroy. The frequency of tubal ligation evaluated by 3.8 per cent did not change during the period of this study. The authors note that the majority of patients in this study asked for a tubal ligation only when they had 5 or more surviving children. The authors conclude that because of poorly equiped medical infrastructures in the context of developing countries tubal ligation through minilaparotomy should be promoted by the contraceptive methods in family planning programs.

Regression spontanee de grossesse ectopique et fertilite: A propos d'un cas observe au cours d'une cystectomie

Les auteurs rapportent un cas de grossesse ectopique d'evolution regressive decouverte au cours d'une cystectomie par laparotomie. L'interrogation detaillee de la patiente montre les difficultes de diagnostic de grossesse ectopique dans le contexte d' un pays en developpement ou les infrastructures medicales sont encore peu developpees. En se referant a la litterature; les auteurs indiquent la possibilite de regression de certains cas de grossesse ectopique. Ils insistent sur l'amelioration des infrastructures medicales au Cameroun; ce qui devrait permettre d'integrer l'echographie endovaginale et le dosage de Beta HCG dans le diagnostic precoce de la grossesse ectopique

[Minilaparotomy tubal ligation in the immediate post-partum after vaginal delivery. A retrospective analysis of 253 cases in the maternity service of the Yaounde University Hospital Center (Cameroon)]. / Ligature des trompes par minilaparotomie dans le post-partum immediat apres l'accouchement par voie basse. Une analyse retrospective de 253 cas a la maternite du CHU de Yaounde (Cameroun).

The authors report the results of a retrospective study of 253 cases of tubal ligation collected between January 1985 and December 1989 in the maternity unit of the Yaounde Teaching hospital. The tubal ligations were done through minilaparotomy with local anesthesia using the technique of Pomeroy. The frequency of tubal ligation evaluated at 3,8 per cent did not change during the period of this study. The authors note that the majority of patients in this study wished a tubal ligation only when they have 5 or more surviving children. We had no post-operative death, but our complication rate of 1,6 % can be improved upon by paying more attention to operative details. The authors conclude that because of poorly equipped medical infrastructures in the context of developing countries tubal ligation through minilaparotomy should be promoted as a contraceptive method in family planning programs.

[Disseminated intravascular coagulations]. / Les coagulations intra-vasculaires disséminées.

Disseminated intravascular coagulation (DIC) syndromes can be defined as the formation of fibrin deposits within the microcirculation, occurring in definite clinical situations. Their biological counterpart is a consumption coagulopathy. The clinical profiles of DIC have been well known for decades, are multiform and range from latency to overwhelming haemorrhagic diatheses, including also characteristic but rare situations, such as purpura fulminans, acral cyanosis and pictures resembling thrombotic thrombocytopenic purpura or haemolytic-uraemic syndrome. Biological tests of DIC show a consumption coagulopathy, displayed on the standard haemostasis sheet; along with signs of paracoagulation and/or of secondary fibrinolysis (FDP). New tests have recently been introduced: D-dimers are specific and sensible; Antithrombin-III, protein C and alpha 2-antiplasmin also can sometimes be useful. The knowledge of the pathophysiology of DIC has made advances with passing years. Fibrin deposits may be non-occlusive, and indeed they are swiftly removed by a secondary fibrinolysis. Except in very rare situations, such as those leading to a cortical renal necrosis, and perhaps in some ARDS, there is little evidence relating DIC to organ failure syndromes. Moreover, there is no clear relationship between the severity of the consumption coagulopathy and the prognosis. For instance, the mortality is much lower in abruptio placentae, where the coagulopathy is very severe, than in septic shock, where it is usually moderate. In septic shock, the disorders of haemostasis were related initially to a platelet activation, then to an activation of the contact system (releasing kinins and triggering complement cascade), and nowadays to the activation of the extrinsic coagulation system. The treatment of DIC is mainly the treatment of its cause. Indications for heparin therapy should be strictly limited to a few exceptional circumstances. When haemorrhagic diathesis threatens, FPC and/or platelet transfusion may be indicated. Aprotinin can be useful in rare cases of overwhelming secondary fibrinolysis. Trials with antithrombin-III or C1-esterase inhibitors are in progress.

[Treatment of ectopic pregnancies by laparotomy in under-equipped countries. A series of 144 cases at the Yaounde University Hospital Center (Cameroon)]. / Traitement des grossesses extra-utérines par laparotomie en pays sous-équipé. A propos d'une série de 144 cas au CHU de Yaoundé (Cameroun).

We report in the context of a developing country the results of ectopic pregnancies treated by laparotomy in the last ten years (1984-1993) in the maternity unit of the Teaching Hospital Yaounde (Cameroons). There were 144 cases of ectopic pregnancies from a total of 12,507 deliveries; this corresponds to 11 cases of ectopic pregnancies for 1,000 deliveries. In 75 cases (52%) the patients were operated in emergency situations with clinical signs of ruptured ectopic pregnancy which were later confirmed at laparotomy. In 69 cases (47.9%) the patients were retained in hospital for definitive diagnosis and in the follow-up, the diagnosis was confirmed by laparoscopy in 37 cases (53.6%) and by ultrasonography in 22 cases (31.9%). In this study the frequency of ectopic pregnancy was most common among primiparous women (36 cases) and second parity (37 cases). The highest frequency of ectopic pregnancies was found in women in the age range between 25 and 30 years. Radical treatment of ectopic pregnancy was performed in 62 cases (43.0%) and conservative treatment in 82 cases (56.9%). The main complication during the operation was represented by severe hemorrhage in 65 cases (45.1%); blood transfusion was required in 25 cases. Among the patients who were followed up in the prenatal clinic (98 cases) 16 patients (16.3%) presented an intra-uterine pregnancy and 12 patients (12.2%) a recurrence of ectopic pregnancy. Ectopic pregnancy is a frequent pathology in Cameroon. In the absence of methods for early diagnosis of ectopic pregnancy such as endovaginal ultrasonography and the measurement of beta human chorionic gonadotropin (beta hCG), primary use of laparotomy is necessary when clinical signs of ectopic pregnancy exist. This procedure permits the avoidance of severe complications such as hemorrhage and maternal death. It can be said that laparotomy still has its place in the treatment of ectopic pregnancy in developing countries.