[Nosocomial ventilator-associated pneumonia in a tropical intensive care unit]. / Pneumopathies nosocomialesacquises sous ventilation mécanique dans un service de réanimation en milieu tropical.

INTRODUCTION: Nosocomial ventilator-associated pneumonia (VAP) occupy an important place among nosocomial infections and are responsible for a very high mortality. The objective of this work was to study epidemiologic, diagnostic and therapeutic aspects of ventilator-associated pneumonia in a tropical Intensive Care Unit and to release an adapted strategy of antimicrobial treatment. PATIENTS AND METHODS: It is a prospective descriptive study carried out from January to December 2002 in the polyvalent intensive care unit, in collaboration with the laboratory of bacteriology-virology of the CHU Dantec of Dakar. We included all the patients admitted and who presented radiological pulmonary infiltrates appearing after 48 hours of mechanical ventilation, associated to at least 2 clinic or biologic criteria and to a positive tracheal aspirate with a cut off value of 10(4) CFU/ml. RESULTS: Thirty two cases of VAP have been diagnosed among 446 patients admitted in our ICU. The incidence was 7.16 per 100 admitted patients and 50 per 100 ventilated patients. The reasons for ICU admission were dominated by trauma (44%). Microorganisms responsible of VAP were essentially Gram negative bacilli (GNB), 68% with in head the Pseudomonas. Acinetobacter strains were practically resistant to all usually used antibiotics. The more used antibiotics were gentamicine, 3rd generation cephalosporins and fluoroquinolones. Antibiotic treatment was appropriate in only 13 cases in 26 patients at whom intrinsic antibacterial activities of antimicrobial agents were examined. The mortality rate was of 81%. CONCLUSION: The improvement of the prognosis of these VAP require preventive measures with protocols of care, a qualified staff, diagnostic means and active antibiotics on the responsible pathogens.

In vitro production of immunoglobulins of various classes and subclasses by cord blood B cells in African neonates: modeling and assessment of determination.

Cord blood B cells obtained from neonates of healthy Senegalese mothers were assayed in vitro for their capacity to fully differentiate and secrete immunoglobulins (Ig) of various classes and subclasses. Stimulation of mononuclear cells with SAC particles or anti-micro antibodies in the presence of IL-4, or with IL-2 and IL-10 induced a strong production of IgG, provided that an additional CD40/CD40L signal was present, in contrast to adult cell cultures. Cord blood mononuclear cells differentially stimulated with various cytokines in order to lead to Ig heavy chain switching and production of the various classes/subclasses consistently produced IgG1, IgG3, IgG4, IgE and IgA. This system has been applied to immune cells from African neonates that have not been extensively studied previously. Estimation of Ig production as OD ratios could be applied to cultures where cord blood B cells are stimulated with defined antigens of human pathogens to which the fetus immune system was primed in utero.

[Intensive care management of 28 patients with severe eclampsia in a tropical African setting]. / Prise en charge de l'éclampsie grave en réanimation en milieu tropical africain. A propos de 28 cas.

OBJECTIVE: To study the specific management problems of severe eclampsia under tropical latitudes. STUDY DESIGN: A two years retrospective study in a University hospital in the tropics. PATIENTS AND METHODS: In all patients admitted for eclampsia between January 1997 et December 1999, the following parameters were studied: age, parity, interval between disease et admission, post-eclampsia Glasgow Coma Scale (GCS), time of occurrence of eclampsia during pregnancy, delivery route, blood pressure data at admission, the occurrence of complications at admission or during hospital stay. RESULTS: Twenty-eight mainly primiparous patients (mean age: 26 +/- 6) were admitted with an average delay of 8.5 +/- 10.2 hours after the first symptoms. The time of occurrence was prepartum in 6, perpartum in 14 and postpartum in 8 cases. All patients were hypertensive and comatose with an average GCS of 8 +/- 2.2. Twenty patients had been previously intubated and ventilated. Delivery was natural in 22 and by caesarean section in 6 patients. The following complications were found: acute oliguric renal failure (9), HELLP-syndrome (4), cerebral haemorrhage (4), acute lung oedema (3) and acute respiratory distress syndrome (1). Maternal and child mortality were 35 and 42.8% respectively. CONCLUSION: Eclampsia is a major cause of both maternal and infantile mortality in developing countries. The authors insist that prevention and management require speedy transfers to adapted specialized obstetrical intensive care structures.

[The para-umbilical block in children: 75 cases report]. / Le bloc para-ombilical chez l'enfant: a propos de 75 cas.

The objective of this study is to assess both intra and post operative analgesia in infants undergoing umbilical hernia repair under general anaesthesia with neither opioid nor muscle relaxant, associated with a para umbilical block. It's a prospective study covering a 15 months period. The study included 75 infants (age = 5 months - 13 years; body weith = 6 kg - 35 kg). General anaesthesia was induced with either thiopentone or halothane and, maintained with halothane in a N2O - O2 50 VOL % mixture. Para-umbilical block was obtained using 1 ml/kg of 0.25% marcaïne. Pain was assessed using time course of respiratory rate, heart rate and mean arterial pressure. A change of more than 20% in one of these variables was considered criterion of poor analgesia. Intraoperative analgesia was adequate in all patients but four, 5 minutes after incision. Surgical conditions were considered as being godd or satisfactory in 90.6% and 9.4% of cases, respectively. Post operative analgesia, assessed 1 and 6 hours after completion of surgery was convenient in 93.3% of infants. The block appears as simple, most after efficient and safe in umbilical surgery.

[Assessment of the management of polytrauma patients at Le Dantec Hospital, Dakar]. / Evaluation de la prise en charge des polytraumatisés au CHU Le Dantec de Dakar.

Traumatisms represent the first reason of death in people less than 40 years in the developed countries. In Senegal, with the growth of urbanization, road accidents are more and more frequent and mortality by polytrauma is raised. The aim of this study was to evaluate the management of polytrauma patients in our hospital and to determine factors of mortality. This prospective study was carried out from January to June 2000 at the surgical emergencies department and the intensive care unit in Le Dantec Teaching Hospital of Dakar. One hundred and six polytrauma patients were taken care of during the study period. The mean age of patients was 30 years. There were 85 men and 21 women. Circumstances of trauma were dominated by road accidents (74.5%) and in 77.4% of cases patients were evacuated without prehospital care. The mean delay from the accident to the arrival at emergencies was 8 hours. Half of the patients presented to the admission a clinical picture of circulatory failure; respiratory distress was also present among 50% of patients and 53.8% of patients had a serious head injury with a Glasgow coma scale lower than 8. The global mortality was 69.8% and 80.6% of these deaths were attributable to serious head injury. Management of trauma patients in Dakar could be improved by setting up a medical transport system and by the improvement of the technical means in the hospitals. These measures, in combination with the prevention of road accidents, will surely allow to reduce the number of accidents, polytrauma and deaths.

[Anesthesia in the surgery of hyperthyroidism at Le Dantec Teaching Hospital]. / Anesthésie dans la chirurgie de l'hyperthyroïdie au CHU Le Dantec.

Authors report a study of 66 patients admitted to the clinic ORL of CHU Le Dantec between 1991 and 2000 for goiter and hyperthyroidism. They evaluate the perioperative management and underline the importance of the medical preparation. The age of patients varied between 15 and 74 years. There were 62 women and 4 men. Fifty three patients presented clinical and biological hyperthyroidism. Thirteen patients had functional hyperthyroidism without clinical signs of thyrotoxicosis. Exophthalmia was present in 20 patients. Twenty one patients have been addressed to the Internal Medicine service for preoperative management of hyperthyroidism. Forty five patients have been operated under general anaesthesia. The medical preparation comprised antithyroid drugs and beta-blockers. We found as complications 3 cases of difficult intubation, 7 cases of peroperative haemorrhage and 1 case of acute thyroid crisis. The anaesthesia for surgery of hyperthyroidism is currently well codified and operative outcome became simple. The medical preparation in case of hyperthyroidism allows to return the patient in euthyroidism and reduces considerably the acute thyroid crisis risk, the most fearsome complication and the most feared of the hyperthyroidism.

Assessment of an uncalibrated pressure waveform device's ability to track cardiac output changes due to norepinephrine dose adjustments in patients with septic shock: a comparison with Doppler echocardiography.

OBJECTIVES: The FloTrac Vigileo (FTV) estimates cardiac output (CO) on the basis of an uncalibrated arterial pressure waveform. To assess the ability of the third-generation of FTV (v.3.02) to track changes in CO following norepinephrine dose adjustment in patients with septic shock, we performed a comparative study using Doppler echocardiography (DE). STUDY DESIGN: Prospective observational study. PATIENTS: We prospectively included 20 mechanically ventilated patients receiving norepinephrine and monitored with the FTV. Five minutes after each change in norepinephrine dose (decided by the attending physician), CO was measured simultaneously with the FTV (CO(FTV)) and DE (CO(DE)). The changes in CO were compared. ROC curves were built to assess the ability of FTV to detect significant changes in CO(DE) of at least 15%. RESULTS: Ninety pairs of CO variations measurements were made. The intertechnique correlation coefficient for changes in CO of at least 15% was r=0.59; P=0.0009. The AUC of a ROC curve built to test the FTV's ability to detect a CO(DE) increase of 15% or more was 0.783 (±0.083) (P=0.005). A CO(FTV) threshold value of 15% had a sensitivity of 54% (25-81) and a specificity of 87% (77-94). For a CO(DE) decrease of 15% or more, the ROC curve had an AUC of 0.616 (±0.075) (P=0.12) and a CO(FTV) threshold value of 13% yielded a sensitivity of 53% (27-79) and a specificity of 72% (60-82). CONCLUSIONS: The FTV was unable to accurately track changes in CO following norepinephrine dose adjustments in critically ill patients with septic shock.

Anthropological and perceptual predictors affecting the ranking in arm wrestling competition / Predictores antropológicos y perceptuales que afectan la clasificación en la competencia de fuerza

The purpose of this study was to investigate the predictors contributing to be in the first three places with right and left arm in armwrestling. Seventy-three male senior armwrestlers competed in Turkish National Championship voluntarily participated in this study. Some participants competed with both arms. Two samples were composed of according to the participant competition category, for right (69 participants) and left arm (65 participants). The data were collected from eight different weight classes. Handgrip strength, auditory reaction time, forearm length, and forearm circumference were determined as the predictors. All the measurements were taken after weigh-ins had been done and before the first day of national championship competition. Logistic regression analysis was conducted to predict whether a competitor in armwrestling would be in the first three places either with right or left arm, to be a winner or non-winner. Relative handgrip strength was found a significant predictor for both right and left arm ranking (p < 0.05). Auditory reaction time was found a significant predictor only for right arm ranking (p < 0.05) and forearm circumference was found a significant predictor only for left arm ranking (p < 0.05). These results suggest that strength can be viewed as the main predictor in left arm ranking; however, auditory reaction time is also an important factor to be in the first three places in right arm ranking. Thus, competitors should also focus to improve this perceptual skill.

El objetivo de este estudio fue investigar los predictores que contribuyen a clasificar en los tres primeros lugares en la lucha de fuerza de brazos (vencidas o pulsadas) con el brazo derecho e izquierdo. Setenta y tres hombres luchadores senior compitieron en el Campeonato Nacional de Turquía y participaron voluntariamente en este estudio. Algunos participantes compitieron con ambos brazos. Dos muestras fueron conformadas de acuerdo con la categoría de competencia del participante, para el brazo derecho (69 participantes) y el brazo izquierdo (65 participantes). Los datos se obtuvieron para 8 categorías de peso. La fuerza de prensión, tiempo de reacción auditiva, largo del brazo y circunferencia del antebrazo se determinaron como predictores. Todas las medidas fueron tomadas después de pesaje clasificatorio y antes del primer día de competición. Un análisis de regresión logística se realizó para predecir si un competidor en lucha de fuerza estaría en los tres primeros lugares ya sea con el brazo derecho o izquierdo, para ser un ganador o no ganador. La fuerza de prensión relativa resultó un predictor significativo para la clasificación tanto en el brazo derecho e izquierdo (p <0,05). El tiempo de reacción auditiva se encontró un predictor significativo sólo para la clasificación del brazo derecho (p <0,05) y la circunferencia del antebrazo un predictor significativo sólo para el brazo izquierdo (p <0,05). Estos resultados sugieren que la fuerza puede ser vista como el principal predictor en la clasificación para el brazo izquierdo, sin embargo, el tiempo de reacción auditiva es también un factor importante para estar en los tres primeros lugares de la clasificación para el brazo derecho. Por lo tanto, los competidores también deben centrarse en mejorar esta habilidad perceptual.