[Plant Traditional Treatment with Acalypha indica Inducing Haemolysis in Patients with G6PD Deficiency: A Frequent Circumstance in Mayotte?] / Phytothérapie traditionnelle par Acalypha indica induisant un accident hémolytique chez les patients porteurs d'un déficit en G6PD : une circonstance fréquente à Mayotte ?

A traditional treatment by plants with Acalypha indica L. can induce an intravascular haemolysis in patients with a glucose-6-phosphate-dehydrogenase (G6PD) deficiency. This information is poorly diffused in areas where the plant grows, where it is consumed for ethnomedicinal purpose and where G6PD deficiency prevalence is high; as a consequence, the probability of haemolytic accidents is presumably underestimated. It seems frequent in Mayotte according to local recent data reporting. Such accidents were previously only, and on a rare basis, reported in Sri Lanka. It seems necessary, at least in Mayotte, to inform patients, or the patients' relatives, about the potential risk in case of using traditional medicine by plants, in addition to all other circumstances able to induce haemolysis in G6PD deficiency.

Une phytothérapie traditionnelle par des remèdes contenant Acalypha indica L. est susceptible d'induire un accident hémolytique intravasculaire, potentiellement grave, chez les patients déficitaires en glucose-6-phosphate-déshydrogénase (G6PD). La toxicité potentielle de cette plante est connue, mais peu diffusée. Dans les régions où elle pousse et où coexistent un recours fréquent à la médecine traditionnelle et une prévalence élevée du déficit en G6PD, elle devrait être systématiquement recherchée. La situation semble fréquente à Mayotte, et n'avait jusqu'alors été signalée que rarement au Sri Lanka. Il semble indispensable que dans ces régions, les patients ou leurs parents soient systématiquement informés du risque potentiel en cas de recours à une médecine traditionnelle par les plantes, en plus des facteurs déclenchants habituellement recherchés.

[Severe poisoning by plants used for traditional medicine in Mayotte]. / Intoxications graves lors de traitements traditionnels par les plantes à Mayotte.

The authors describe three cases of severe accidental poisoning by plants used as part of a traditional treatment in Mayotte. The established, or suspected, toxicity of Thevetia peruviana (Yellow oleander), Cinchona pubescens (Red quinine-tree), Melia azaderach (Persian lilac, also called china berry) and Azadirachta indica (Neem), is discussed. The clinical presentation is cardiac (atrioventricular block) and well known for Thevetia and Cinchona intoxications. Neurological signs and multi-organ failure are found for Azadirachta and Melia. The identification of the plants is never easy, nor is the evidence of their accountability. In the three cases reported, no other cause than the traditional treatment has been found to explain the clinical presentation. The outcome was favorable in all cases. The authors emphasize the difficulties to investigate these accidents, the poor medical knowledge of these practices in tropical areas, and in Mayotte particularly. The need for cooperation with local botanists, familiar with traditional medicine, is also underlined.

Health situation and issues in the Seychelles in 2012.

Located off the coast of Kenya, the Republic of the Seychelles is an island archipelago nation whose citizens are mostly of African origin. The population, independent from the United Kingdom since 1976, has largely completed its demographic and epidemiological transitions. Major investments in infrastructure and social services have fostered a steady economic growth. Health services and education are free. The predominance of chronic non-communicable diseases and rapid aging of the population cause significant new challenges for public health and the health system. However, like the other small island states in the region, the Seychelles remains under the threat of outbreaks, particularly of arboviruses. Health indicators from 2012 are generally very good. There are concerns, however, about the future of health care in the country. Geographic isolation, the small and aging population and limited resources provide major challenges for maintaining and sustaining an effective workforce of health professionals, a constantly evolving technical platform and an increasing number of available medications. This is true particularly in view of the increasing burden of chronic diseases and the continued threat to the population of current or emerging infectious diseases. The purpose of this article is to provide a brief introduction to the geography, history, and political context of Seychelles to provide an account of the current situation regarding major diseases in the Seychelles and to review health priorities of the last few decades. To our knowledge, no comprehensive inventory of sporadic, endemic or epidemic events has been attempted before, except for a remarkable report from the 1950s [1]. Using health data from the past few decades, information from health personnel who live and practice in the Indian Ocean, we attempt to identify major current and future health challenges in the Seychelles.

[Health situation and issues in the Seychelles in 2012]. / Situation et enjeux sanitaires aux Seychelles en 2012.

Off the coast of Kenya, the Seychelles, home to 87,400 inhabitants mostly of African origin, have largely completed their demographic and epidemiologic transitions. Major investments in infrastructure and social services have fostered steady economic growth. Health care and education are free. The predominance of chronic non-communicable diseases and rapid aging of the population nonetheless present significant challenges for public health and the health system. Like the other small island states in the region, the Seychelles continue to be threatened by arbovirus outbreaks. Health indicators are good, but the geographic isolation, the small and aging population, and limited resources make a major challenge maintaining and sustaining an effective workforce of health professionals, a constantly evolving technical platform, and increasing amount of medications particularly in view of the increasing burden of chronic diseases.

[Should mechanical ventilation be used in ICU patients in developing countries?]. / Faut-il ventiler les patients de réanimation dans les pays en développement?

The purpose of this monocentric prospective cohort study was to assess mortality in intensive care unit (ICU) patients requiring more than 6 hours of mechanical ventilation (MV) in a developing country. The study setting was a 10-bed polyvalent ICU at the Centre Hospitalier Régiona1 in El Maarouf, Comoros Islands. The study population included a total of 106 patients requiring MV out of 633 consecutive patients admitted to the ICU over a 10-month period. Study parameters included demographic data, simplified acute physiology score version 2 (SAPS II), reason for admission, urgency of MV, duration of MV, complications of MV need for sedation and mortality in hospital and at one year. In-hospital mortality was 59%. Mortality was significantly higher in patients presenting elevated SAPS II and requiring myorelaxant drugs. Age, gender, reason of admission, emergency, sedation, complications of MV, duration of MV were not correlated with mortality. The best prognosis was associated with the following indications: severe malaria, meningitis, eclampsia and poisoning. All patients who left the ICU (41) were alive at one year. Mortality associated with use of MV for resuscitation in a developing country was similar to that observed in developed countries. The young age of patients, acute nature of manifestations and reversibility of diseases encountered may explain the favorable outcome observed in this study. The initial diagnosis and associated risk factors (using a severity score if necessary) must be taken into account in deciding the indication for starting and stopping MV. The results of this study show that MV is feasible and effective in a developing country, but requires experience, inventiveness and realism.

[Off-pump coronary artery bypass: analysis of 1080 patients]. / Le pontage coronaire à coeur battant: à propos de 1080 patients.

A consecutive cohort including 1080 patients undergoing "off-pump" myocardial revascularization was reviewed. An average of 2.22 bypass/patients was performed. The death-rate during the first 30 days after surgery was 0.65%. Four cases needed cross-over to on-pump. The postoperative events were: need of inotropic drugs (2.7%), atrial fibrillation (12.4%), myocardial infarction (6.6%). The extubation was performed before the first postoperative 24 h in 91.9% of cases. The majority of patients was discharged from hospital before 8 days after surgery. Off pump coronary artery bypass surgery exhibit good results for most of the patients even if they present multiple vessel disease and high operating risk.

[Practice of spinal anesthesia in a developing country: usefulness of vascular preloading with a 7.5% hypertonic saline solution]. / Pratique de la rachianesthésie dans un pays en voie de développement: intérêt du remplissage vasculaire par un soluté salé hypertonique à 7,5%.

OBJECTIVE: To assess the efficacy of hypertonic saline for prevention of arterial hypotension in patients undergoing spinal anaesthesia in Niger. STUDY DESIGN: Prospective, randomized, double-blinded study. PATIENTS: Fifty adults undergoing scheduled surgery under spinal anaesthesia, allocated either to a hypertonic saline group (HSG) or a isotonic saline group (ISG). METHODS: Over the 15 min prior to anaesthesia, 100 mL of 7.5% saline were infused in patients of HSG, and 100 mL of 0.9% saline in those of ISG respectively. Spinal anaesthesia was performed at the L3-L4 or L4-L5 interspace using either lidocaine 5%, or bupivacaine 0.5% or a mixture of both supplemented with fentanyl. Arterial pressure (AP) and heart rate (HR) were measured the day before surgery, prior to and after spinal anaesthesia, thereafter every 5 min over 30 min and every 10 min thereafter until completion of surgery. Hypotension (30% decrease of systolic AP control value was treated with 500 mL of Ringer lactate solution and in case of failure with ephedrine (5-30 mg i.v.). An isolated bradycardia (HR < 60 b.min-1) was treated with atropine (0.5-1 mg i.v.). RESULTS: Hypotension occurred in two out of 24 patients of the HSG and eight out of 24 of the ISG (P < 0.05). The mean infused volumes of Ringer lactate solution were 387 +/- 218 mL vs 623 +/- 318 mL respectively (P < 0.05). Ephedrine and/or atropine were not required in HSG, however in 7 out of the 24 patients of the ISG. Adverse clinical effects did not occur. CONCLUSION: Hypertonic saline prevents efficiently the occurrence of hypotension during spinal anaesthesia. Considering its ease of preparation, the lack of adverse effects, in patients not suffering arterial hypertension or congestive heart failure, and low cost, hypertonic saline is well adapted for use in a developing country, if isotonic solutions are not available.

[Pediculated labial ureteroplasty: an original treatment procedure for ureteral lesions of obstetric origin]. / Urétroplastie labiale pédiculée: un procédé original de traitement des lésions urétrales étendues d'origine obstétricale.

Destruction of the urethra is the most severe complication of pregnancy-related vesicovaginal fistula. Although uncommon in Europe, pregnancy-related urethral destruction is still observed in Africa. In this study we describe our experience with a new reconstruction technique using a pedunculated skin flap raised from the labia majora. Between January 1992 and June 1996 we treated 35 patients in the Urology Department of Niamey Hospital in Niger. All patients were black. Mean age was 18 years and mean follow-up was 19 months. Two plasty techniques were used, i.e. extension (16 cases) and tubulisation (19 cases). Urinary incontinence was treated using a suburethral loop system created using a fatty flap taken from the labia majora (Martius method). Urethrocervico-suspension of the vagina was necessary in 6 cases. Normal micturition with no leakage was obtained in 24 patients (68.6%) and functional improvement in 6 cases (17.1%) Treatment failed in 5 cases (4.2%). In comparison with previously reported techniques, urethral reconstruction using a pedunculated labial flap and suburethral looping system allows successful treatment of pregnancy-related urethral destruction in 70% of cases. This technique is particularly well suited for use in developing countries where occurrence of this complication is most frequent. However even with the greatest skill, creation of a physiologically perfect closure system is currently impossible.

Modifications of platelet shape change and ATP release during cardiopulmonary bypass.

Platelet activation is accompanied by characteristic morphological changes: smooth-disc platelets become more spherical in shape and develop psudopods. The purpose of this study is to investigate whether platelets change after extracorporeal bypass. Twenty-two patients undergoing cardiopulmonary bypass (CPB) were studied prior to anesthesia and immediately after the operation. Platelets activated by different agonists were monitored simultaneously for morphological changes, ATP release and aggregation. While shape change measured before surgery was large, it was significantly reduced after bypass surgery (p < 0.01); morphological changes were quicker postoperatively. Several other parameters also changed: the time lapse between administration of the agonist and the start of ATP secretion decrease significantly (p < 0.01). After activation with high concentrations of ADP, ATP release was significantly increased (p < 0.01). On the other hand, less ATP was released after platelet activation with collagen and arachidonic acid, suggesting a change in platelet adhesion or a downregulation of endoperoxide synthesis. In our study, the importance of preactivation change in shape, estimated quantitatively by percent loss in ability of changing shape, can be compared using various agonists, with proportional defects in release and aggregation. These data provide evidence for different intrinsic levels in platelet defects after CPB.

[Perioperative ischemia in coronary surgery caused by coronary spasm of an angiographically normal coronary artery]. / Ischémie périopératoire en chirurgie coronaire par spasme coronaire sur artère radiologiquement normale.

Spasm of healthy native coronary arteries is rare but a serious cause of perioperative ischaemia after coronary bypass surgery. The authors report five characteristic cases. In each case, the spasm presented with giant ST elevation and haemodynamic changes. In one case, further coronary bypass surgery was required. In three cases, symptomatic treatment of the hypotension associated with diltiazem completely cured the problem. One case was complicated by a small myocardial infarction. There were no fatalities. Previously reported cases often describe very heavy therapeutic protocols, justified by the high risks of this condition. Due to the fact that it is not possible to identify a target-population, simple prophylactic treatment with diltiazem seems to be justified in patients undergoing coronary artery bypass surgery.