Prevalence of hepatitis B virus serologic markers in pregnant patients in Antananarivo, Madagascar.

BACKGROUND AND OBJECTIVES: Hepatitis B virus (HBV) infection is a major public health problem in Madagascar. Its severity is related to the risk of chronicity, especially in case of neonatal contamination. Our objectives were to investigate the prevalence of HBV infection among pregnant patients at the Befelatanana obstetrics and gynecology teaching hospital department (BOGTH) by detecting HBsAg and to evaluate the risk of HBV mother to child transmission by screening for HBeAg. METHODS: We conducted a 6-month prospective study in the BTHOGD from February 2012 to July 2012. All pregnant patients consulting for antenatal care were screened for HBV serologic markers. RESULTS: The prevalence of HBsAg was 1.9% (20 out 1050 screened patients). The average age was 26.51 years (25-30 years). Most patients tested were unaware of their hepatitis B status and only 0.38% had been vaccinated before pregnancy. Only 1 (5%) of the 20 patients with HBsAg was positive for HBeAg. CONCLUSION: Hepatitis B is very frequent in pregnant patients in Madagascar and it is recommended that all pregnant patients be routinely screened for HBsAg. This screening of maternal infection would allow applying prophylactic measures to neonates to decrease the risk of disease chronicity.

Antileukemic and long-term effects of two regimens with or without TBI in allogeneic bone marrow transplantation for childhood acute lymphoblastic leukemia.

Between September 1986 and June 1997, 24 children with high-risk ALL in CR1 were allografted after TAM (fractionated TBI, high-dose Ara-C, and melphalan; n = 10) or BAM protocol (busulfan, high-dose Ara-C, and melphalan; n = 14). The EFS for transplants from sibling donors was 33% with TAM and 62% with BAM (P = 0.148). The probability of acute GvHD was 70% with TAM and 15% with BAM (P = 0.003). Four of 17 evaluable patients relapsed: one after TAM and three after BAM. In all, 46 other children transplanted in CR beyond CR1 were studied for sequelae. Long-term side effects were more frequent in TAM vs BAM. In children with ALL, busulfan may be a good alternative to TBI to improve the quality of life.

Trends of AIDS in Guadeloupe (French West Indies) a longitudinal survey from 1988 to 1997.

The study objective was to describe morbidity and mortality from HIV infection and the acquired immunodeficiency syndrome (AIDS) in Guadeloupe from 1988 to 1997 and to evaluate survival and prognostic factors. The HIV infected patients database of Guadeloupe included 1771 adult patients up to December 31, 1997. Annual incidence of AIDS defining illnesses was calculated and compared using Poisson regression. Survival analysis with log-rank test and multivariate analysis with Cox's model were performed for patients with AIDS. At the end of December 1997, 599 cases of AIDS (33.8%) and 367 deaths (20.7%) were reported. For 32.1% of the patients, AIDS was diagnosed before inclusion. Incidence of most AIDS-defining events decreased over time, especially after the introduction of protease inhibitor therapy. Before the introduction of protease inhibitors in September 1996, overall median survival after AIDS diagnosis was 11.8 months (95% Confidence Interval (CI), 95% CI 10.2-14.1). After this date median survival increased to 17.8 months (95% CI 18.6-22.5) and probability of survival was significantly higher for patients treated with protease inhibitor in combination regimen (mean 19.0 months, Standard deviation (SD) 1.3) compared to those who were not (mean 7.9 months, SD 0.6, p < 0.0001). Prognosis factors of death after AIDS were older age (Relative Hazard, RH: 1.17, 95% CI 1.07-1.28), occurrence of two or more AIDS-defining events at the beginning of the disease (RH: 1.70, 95% CI 1.32-2.19), and a CD4 cell count less than 50/mm3 (RH: 2.33, 95% CI 1.71-3.17). On the other hand, occurrence of AIDS during follow-up had a better prognosis (RH: 0.68, 95% CI 0.52-0.89) and protease inhibitor therapy was strongly associated with a longer survival (RH 0.26, 95% CI 0.13-0.53). We concluded that HIV infection in Guadeloupe was frequently diagnosed at the stage of AIDS. However, survival of patients and trends of major AIDS defining illnesses were more similar to the European pattern than to the Caribbean one, as a consequence of the availability of modern therapy.

Trends of AIDS in Guadeloupe (French West Indies): a longitudinal survey from 1998 to 1997

The study objective was to describe morbidity and mortality from HIV infection and the acquired immunodeficiency syndrome (AIDS) in Guadeloupe from 1998 to 1997 and to evaluate survival and prognostic factors. The HIV infected patients database of Guadeloupe included 1771 adult patients up to December 31, 1997. Annual incidence of AIDS defining illnesses were calculated and compared using Poisson regression. Survival analysis with log-rank test and multivariate analysis with Cox's model were performed for patients with AIDS. At the end of December 1997, 599 cases of AIDS (33.8 percent) and 367 deaths (20.7 percent) were reported. For 32.1 percent of the patients, AIDS was diagnosed before inclusion. Incidence of most AIDS-defining events decreased over time, especially after the introduction of protease inhibitor therapy. Before the introduction of protease inhibitors in September 1996, overall median survival after AIDS was 11.8 months (95 percent Confidence Interval (CI), 95 percent CI 10.2 - 14.1.) After this date median survival increased to 17.8 months (95 percent CI 18.6 - 22.5 ) and probability of survival was significantly higher for patients treated with protease inhibitor in combination regimen (mean 19.0 months. Standard deviation (SD) 1.3) compared to those who were not (mean 7.9 months, SD 0.6, p<0.0001). Prognosis factors of death after AIDS were older age (Relative Hazard, RH : 1.17, 95 percent CI 1.07 - 1.28), occurrence of two or more AIDS-defining events at the beginning of the disease (RH: 1.70, 95 percent CI 1.32 - 2.19), and a CD4 cell count less than 50/mm3 (RH: 2.33, 95 percent CI 1.71- 3.17). On the other hand, occurrence of AIDS during follow-up had a better prognosis (RH : 0.68, 95 percent CI 0.52 - 0.89) and protease inhibitor therapy was strongly associated with a longer survival (RH 0.26, 95 percent CI 0.13 - 0.53). We concluded that HIV infection in Guadeloupe was frequently diagnosed at the stage of AIDS. However, survival of patients and trends of major AIDS defining illnesses were more similar to the European pattern than to the Caribbean one, as a consequence of the availability of modern therapy.

Assessment of acyclovir intraindividual pharmacokinetic variability during continuous hemofiltration, continuous hemodiafiltration, and continuous hemodialysis.

The use of intravenous acyclovir can be particularly complicated in pediatric patients with evolving renal impairment, because of intraindividual pharmacokinetic variability linked to the patient's clinical condition. The objective of this study was to use therapeutic drug monitoring data to assess acyclovir intraindividual pharmacokinetic variability during several types of renal replacement therapy. Bayesian adaptive control of acyclovir dosage regimen was performed in a pediatric patient with bone marrow transplant who developed severe renal impairment. Acyclovir pharmacokinetic parameter values corresponding to the different techniques and periods of renal replacement therapy were estimated using USCPACK PC Clinical Programs and therapeutic drug monitoring data. Results showed a wide intraindividual pharmacokinetic variability during CAVH, CAVHDF, and CVVHD, reflecting not only the performance of each dialysis technique but also the difficulty in making use of each one. The acyclovir elimination rate constant was higher during CVVHD compared to CAVH or CAVHDF. Bayesian method appears to be valuable in assessing intraindividual pharmacokinetic variability, as it allows the clinician to deal with sparse routine patient data.

[Dengue fever with neurologic expression. Three cases in adults]. / Fièvre dengue à expression neurologique. Trois observations chez l'adulte.

Dengue fever, unlike most other arboviral diseases, does not usually cause encephalitis. However, neurologic symptoms with poor prognosis have been regularly reported, mostly in Asian children affected by the severe dengue hemorrhagic fever/dengue shock syndrome, and attributed to a non specific, anoxic or metabolic encephalopathy. Recently, first isolations of dengue viruses from CSF or brain tissue, have renewed this concept. We report 3 dengue fever cases with neurologic manifestations and favorable outcome. Occurrence in adult age, during classic (benign) dengue fever (2 cases), and neurologic sequellae (1 case) were the three outstanding features. We point out the proteiform expression of these neurologic changes and their low incidence rate (< 3% in our series of adult dengue fever). Although their pathogenesis is poorly understood, different mechanisms are suggested: encephalopathy (case n. 1), acute specific encephalitis (questionable in case n(o) 2), or post-infective encephalitis (case n(o) 3).

[Tetraparesis in an infant after prolonged administration of pancuronium]. / Tétraparésie chez un nourrisson après administration prolongée de pancuronium.

Long-term administration of pancuronium for ventilatory support of adults with ARDS may result in severe tetraparesis, with areflexia and atrophy of distal muscles. This adverse effect occurs rarely in paediatric intensive care units. We describe a case of tetraparesis after prolonged pancuronium infusion in a 9-month-old girl who experienced a severe bronchopneumonia caused by para-influenza virus, requiring endotracheal intubation and mechanical ventilation. To decrease chest wall rigidity, pancuronium was administered over 11 days, with a total dose of approximately 120 mg of pancuronium bromide. The day after discontinuation of the muscle relaxant she had a severe tetraplegia with areflexia, but normal head movements. Electromyography showed a normal neuromuscular transmission. She recovered from tetraplegia three months later. Other causes of peripheral neuropathy were eliminated. Electroencephalograms and head CT-scans were normal. The recovery pattern observed in our patient corresponded to the process of regeneration seen after axonal degeneration. It is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment, associated with corticosteroid and aminoglycoside administration.

[3 pediatric cases of leptospirosis]. / Trois observations pédiatriques de leptospirose.

Three children presented with an association of pains, infectious syndrome, acute renal failure, hepatitis and meningitis, that lead to the diagnosis of leptospirosis. The clinical spectrum of this rare disease are recalled.

[Primary hyperparathyroidism in 2 adolescents]. / Hyperparathyroïdie primitive chez deux adolescents.

The authors report on two cases of primary hyperparathyroidism (PHP) in adolescents. In a 15-year-old boy, the clinical picture included skeletal, dental, renal and psychological manifestations. In the second case, the first symptom was urolithiasis at age 12; following a period without any important clinical event, the diagnosis was established when the patient was 18. In both cases, increased calcium and low phosphorus plasma levels associated to moderately elevated plasma parathyroid hormone levels were noted. CT scan and ultrasounds were normal but MRI showed an enlarged gland in the second case. The surgical exploration of the neck revealed an adenoma in the first case and a hyperplastic gland in the second one. Surgery was followed by an immediate improvement of both clinical and laboratory findings. These observations bring us to examine the spectrum of PHP in childhood, the difficulties in biological diagnosis and localizing techniques, and the recent results of surgical treatment.

[Cerebrovascular accidents and sickle cell disease]. / Accidents vasculaires cérébraux et drépanocytose.

A 7 year-old girl, with homozygous sickle cell disease experienced two cerebrovascular strokes over an 8-month period. The diagnostic investigations were performed with highly sensitive imaging methods (MRI, angiography). Such a complication raises problems in curative and prophylactic treatment. New diagnostic methods are being evaluated.

[The autopsy]. / L'autopsie.

In France, Caillavet's law sets the conditions required for autopsy and organ removal. Despite the liberal conditions of this law, the autopsy rate is becoming rare. Other obstacles exist, in particular, religious beliefs in the case of islamic and jewish people. The final decision rests with the family although this decision may be influenced by the physician, if the family can be convinced of the importance of such an examination.