Ischemic stroke in Morocco: Prehospital delay and associated factors.

OBJECTIVES: This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco. PATIENTS AND METHODS: An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department. RESULTS: A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke. CONCLUSION: Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.

Schistocytes in disseminated intravascular coagulation.

INTRODUCTION: The presence of schistocytes on the peripheral blood film during disseminated intravascular coagulation (DIC) remains controversial. METHODS: We examined schistocytes count on blood films from 35 DIC patients and checked morphological anomalies of all RBCs. RESULTS: Thirty of 35 patients presented with schistocytes and 22 with acanthocytes, which was the commonest shape anomaly. Mean percentage ± standard deviation was 0.33 ± 0.38%, median value was 0.1%, and range was 0-1.4%. The patients with schistocytes ≥ 1% had circumstances frequently associated with increased schistocytes count (promyelocytic leukaemia, pregnancy, severe infection). DISCUSSION: Schistocytes were thus frequently observed in DIC patients, usually with low percentage, within or close to the reference range (<0.5%). Schistocytes measurement is not a clue test for the initial diagnosis of DIC, but might be of clinical value to suggest an associated or underlying thrombotic microangiopathy if ≥ 1%.

[Evaluation of four immunoenzymatic tests for detecting Clostridium difficile toxins A and B]. / Evaluation de quatre réactifs immunoenzymatiques pour la recherche des toxines A et B de Clostridium difficile.

Four immunoenzymatic tests for detecting Clostridium difficile toxins A and B were studied: two rapid tests (Tox A/B QUIK CHEK-Techlab and NoviView Toxine-A-Hiss diagnostics) and two Elisa tests (C. difficile TOX A/B II -Techlab and Toxin A+B Elisa Test, Novitec-Hiss diagnostics). The results were compared to those obtained with ImmunoCard Tox A+B -ICTAB (Meridian), C. difficile Toxine A (Oxoid) for rapid test and Elisa Premier A+B Meridian for Elisa. A total of 41 stools and 16 isolates were studied with rapid tests. On stools, the sensitivity and specificity of QUIK CHEK test was 94.1% and 100% respectively compared to the test ICTAB. On the isolates, sensitivity and specificity was 100%. With the Noviview test, the sensitivity on stools and isolates was respectively 88.2 and 85.7% and the specificity was 100% compared to Oxoid. A total of 38 stools were studied with Elisa tests. With Techlab test compared to the test Premier, sensitivity and specificity was 100%. The Novitec test gave five false negative reactions with consequently a sensitivity of 70.6%.

[Bilateral breast cancer. Incidence and risk factors]. / Cancer du sein bilatéral. Incidence et facteurs de risque.

OBJECTIVE: To clarify, thanks to a retrospective study of 24 bilateral breast cancer cases, the frequency, the risk factors and the prognosis of bilateral breast cancers. PATIENTS AND METHOD: Between 1984 and 1999, out of 506 patients treated for unilateral non-metastatic breast cancer at Gynecologic and Obstetric ward, at Maternity Souissi of Rabat, 24 cases of bilateral breast cancers were diagnosed. Our results were compared to those of the literature. RESULTS: The frequency of bilateral breast cancers was 4.7% (24/506). In 87.5% of cases, these were metachronous cancers with a mean interval of 45 months (12-144 months). Patients under 40 at first cancer ran a fivefold superior risk than women more than 40 (P < 0.05). In cases of T3 or T4 tumors, the risk was 10-fold superior to that in smaller ones (P < 0.05). DISCUSSION AND CONCLUSION: Significantly more first metachronous tumors were invasive adenocarcinoma cancers. Histologic type of first and second tumor was the same in all cases. The prognosis depends at once on the first and second cancer staging and the treatment must be done according to the same rules as in the first cancer.

[Primary malignant melanoma of the cervix]. / Mélanome malin primitif du col utérin.

INTRODUCTION: Primary malignant melanoma of the cervix is an extremely rare histological variety of cervical tumor, with only 54 cases reported. OBSERVATION: A 70 year-old woman consulted for metrorrhagia and pelvic pain. Clinical examination revealed a tumefaction on the anterior labium of the cervix. The anatomo-pathological examination of the biopsy led to diagnosis of a malignant melanoma of the cervix. Despite enlarged Wertheim-type colpohysterectomy associated with pelvic lymphadenectomy, pulmonary metastases developed and the patient died six months later. COMMENT: This is a typical case of malignant melanoma of the cervix. All the authors underline the poor prognosis when visceral metastases occur early, as was the case in our patient.

[Breast tuberculosis]. / Tuberculose mammaire.

Tuberculosis rarely affects the breast. The authors report the case of a 50 years-old woman with breast tuberculosis. The main purpose of this case report is to remind clinicians of the unusual presentations of extrapulmonary tuberculosis that can easily be forgotten. Mammary tuberculosis presents a number of diagnostic pitfalls. Diagnosis is based on identification of the tubercle bacillus in cultures or demonstration of typical histological lesions. Antibacillary drugs are the mainstay of therapy. Surgery is used only is cases that fail to respond to medical treatment and/or involve extensive tissue damage. Although rare, tuberculosis of the breast should be considered as a possible diagnosis, particularly in countries where tuberculosis is endemic.

[Gestational trophoblastic diseases. Apropos of 105 cases]. / Les maladies gestationnelles trophoblastiques. A propos de 105 cas.

The authors report a retrospective study of 105 observations of gestational trophoblastic diseases managed at the university clinic of obstetric gynecology I (Pr Chaoui). Of this study, one listed 72 cases of complete mole hydatiforme with 5 cases of sacrofetal pregnancy. The invasive mole is found in 4 cases and the choriocarcinoma in 24 cases. The general frequency of this pathology is of 1/770 pregnancies. The age of our patients varies from 15 to 52 years with an average age 27 years and the multiparity is found in 50% of the cases. 103 patients (95.5%) consulted for metrorrhagia associated pelvic pains in 31 cases (30%). The toxic syndrome was present in 20 patients (12%) with a preeclampsy in 6 cases (5.71%). The physical examination showed a very increased uterus of size in 92 cases (87.5%) associated adnexal mass in 37 cases (35.2%). The diagnosis was especially echographic in the totality of the cases associated or not with a proportioning of plasmatic beta HCG or prolans urinary. The treatment of the trophoblastic disease varies simple endo-uterine aspiration (85%) until the chemotherapy treatment (32.4%), the hysterectomy was indicated in a third of the cases. The evolution of the non complicated mole hydatiforme was good in 100% of the cases, it quasi totality of the invasive moles presented a complete remission. Among the 24 choriocarcinoma, we deplore 4 deaths in a table of pulmonary, hepatic and cerebral metastases. In order to improve the forecast of these diseases, the diagnosis must be early with an adequate treatment and a rigorous monitoring.

[Angiosarcoma of the breast: a case report]. / L'angiosarcome du sein: à propos d'un cas.

We report a breast's angiosarcoma case admitted at the maternity hospital Souissi of Rabat in 1997. We discussed epidemiologic, diagnostic and therapeutic aspects of this type of tumor insisting on the difficulties of diagnosis.

[Congenital cystic adenomatoid malformation of the lung. Prenatal diagnosis in a case]. / Malformation adénomatoïde kystique congénitale du poumon. Diagnostic anténatal à propos d'un cas.

We report a case of congenital cystic adenomatoid lung malformation, type I in the Stocker classification, diagnosed at ultrasonography at 27 weeks gestation. The lesion stabilized as was the hydramnios. Vaginal delivery was uneventful. Early surgery with lobectomy led to a favorable outcome at 8 months follow-up. Congenital adenomatoid lung malformation is a rare finding. Prenatal ultrasound diagnosis has enabled early treatment and improved prognosis.

[Malignant schwannoma of the breast. A case report]. / Schwannome malin du sein. A propos d'un cas.

Malignant schwannoma is a very rare sarcomatous tumor of unknown etiology. Primary mammary localization is exceptional. Clinically, the tumor manifests as an isolated painless nodule visualized as a benign nodule on standard radiogram. Positive diagnosis is provided by pathology. Treatment is surgical. The risk of local recurrence imposes a radical treatment. We report one case and review the literature, underlining the difficulties encountered in diagnosis and emphasizing the recurrent nature of this tumor after conservative treatment.

[Struma ovarii. A case report]. / Goitre ovarien. A propos d'un cas.

Struma ovarii is a rare ovarian tumor composed entirely or in part of thyroid tissue. Pathogenesis is unclear. Diagnosis rests on the histologic study. A case is reported. Specific features of struma ovarii are discussed based on a review of the literature. The treatment is surgical and the outcome generally favorable.

[Krukenberg's tumors. 9 cases. Review of the literature]. / Tumeurs de Krukenberg. A propos de 9 observations. Revue de la littérature.

The authors report a series of nine cases of Krukenberg's tumor, operated at the university clinic of obstetric gynecology (Professor Chaoui) during a period from 1977 to 1990. They underline the metastatic character of this tumor, whose primitive lesion is very often digestive. In most cases, the diagnosis is set late by histological study of the operatory piece, showing the revealing character of this tumor. All the authors agree upon the very dark prognostic of this tumor. The only hope of improvement lies in an extraction as soon as possible of the primitive tumor, followed by a radical treatment of the ovarian tumor. The contribution of complementary treatment is questionable; however, adjuvant chemotherapy keeps a positive efficacy, according to certain authors. The authors deplore one death in keeping with a late diagnosis.

[Ovarian pregnancy. Four cases with review of the literature]. / La grossesse ovarienne. A propos de 4 observations avec revue de la littérature.

The authors report four cases of ovarian pregnancies operated in Central Maternity of Rabat (Pr Chaoui) during a period from 1979 to 1989. In the light of literature data, they have tried to trace out the particularities of this form of extra-uterine pregnancy. Clinical symptomatology of ovarian pregnancy very often remains similar to that of tubary GEU as well as the data of complementary exams with the exception sometimes of coelioscopy. The treatment, because of diagnostic delay, is annexectomy in all cases. But it is desirable to carry out a conservative treatment in the form of partial ovariectomy. Only pathological anatomy can give the diagnosis a sense of certainty.

[Malignant non-Hodgkin's lymphoma of primary mammary localization. Two cases]. / Lymphomes malins non hodgkiniens à localisation mammaire primitive. A propos de deux cas.

The authors report two cases of non-hodgkinian malignant lymphoma (NHML) of primitive mammary localization. Surveying the data of world literature, they have tried to trace the main characteristics of this breast cancer. The NHML are met at all ages, of female predominance and whose clinical aspect is summarized in two great tables: a module radiologically benign, isolated, quite limited, or a tumor of inflammatory aspect. Anatomopathological exam and the extension check-up constitute a fundamental step to establish the diagnosis, to confirm the initial localization and evaluate the prognosis which depends on two main factors: anatomical stage and histological type. Chimiotherapy is indicated initially, often related to a conservative surgery (tumorectomy), rarely to a radiotherapy.

[Hypertrophic tuberculosis of the cervix. Three cases]. / La tuberculose hypertrophique du col. A propos de trois cas.

Tuberculosis of the cervix of the uterus is a rare form of genital tuberculosis. The epidemiology does not have any particular specific feature; but the macroscopic appearance gives a first impression of a cancer. Only by carrying out a biopsy of the cervix, followed by study of the histology can the problem be solved so that longterm anti-tuberculous treatment can be started. There is rarely any need for surgery, that only in cases resistant to medical treatment. The authors report three cases of tuberculosis of uterine cervix, found in the university clinic of obstetrics and gynaecology I (Professor Chaoui) during the years 1986-90. The incidence of this condition is 8.5% of genital tuberculosis. The outlook is good with full healing if the treatment is carried out properly.

[Pregnancy and delivery in grand multiparas in Morocco]. / La grossesse et l'accouchement chez la grande multipare au Maroc.

The authors analysed 602 case histories of patients who had had 6 deliveries or more in order to evaluate the prognosis of grand multiparity and its repercussions on the mother and infant. The authors point out that all the complications of pregnancy and the puerperium can occur but with an increased frequency. In particular toxaemia of pregnancy, abruptio placentae and dystocic labours, as well as uterine rupture, occur. The prognosis for the fetus is also made worse because they are threatened with prematurity and death. The authors conclude that only making antenatal care obligatory and a better acceptance of family planning could one day bring success to the fight against the rapid advance to grand multiparity which is not controlled and to avoid the risks of the condition.

[Multiple cancers. Apropos of a quadruple cancer]. / Les cancers multiples. A propos d'un cancer quadruple.

A woman of 48 years of age presented over a period of twelve years with, successively, a cancer of the rectum, a cancer of the breast, cancer of the scalp and finally of the endometrium without metastases. Her general condition stayed good. We have looked into the nosological, statistical, pathogenic and prognostic features of multiple cancers. It does seem that the hormone state may be the trigger for this polycancerous condition (hyperoestrogenaemia). This was linked to an alimentary factor (obesity) and to a family history of a predisposition to cancer, as our patient was the tissue of a blood-related marriage and a member of a family where the incidence of cancer was 40%. Multiple cancers are 2.42% of all cancers but are mainly double or triple cancers. There are only 20 cases of quadruple cancers in the literature. One can divide these into: Cancers with a short interval between each appearance of simultaneous appearances, which usually occur at an advanced age, due to simple chance and often with a bad prognosis. Cancers that occur at longer intervals in younger people, which are rarer and show a family predisposition or endogenous factors. Their prognosis is as a whole better.