Stenting in the carotid artery: initial experience in 110 patients

PURPOSE

To evaluate the feasibility, safety, and efficacy of intravascular stents in the treatment of extracranial carotid artery occlusive disease.

METHODS

According to protocol, stent therapy was offered to symptomatic patients with > or = 70% arteriographically defined carotid stenoses or ulcerative lesions and, after September 1994, to asymptomatic patients with > or = 75% stenoses. From April 1993 to September 1995, 110 nonconsecutive patients (79 males; mean age 72 years, range 45 to 85) consented to participate in the study. The majority (79 [72%]) were asymptomatic. Lesions meeting the treatment criteria were in the proximal common (n = 3); mid common (n = 12); distal common (n = 8); internal (ICA) (n = 92); and external (n = 2) carotid arteries. Seven patients had bilateral ICA stenoses, and 17 patients were treated for postsurgical recurrent disease. The mean lesion length and diameter stenosis for all lesions were 12.4 +/- 9.2 mm and 86.5% +/- 10.6%, respectively. The procedures were performed either via direct percutaneous access to the cervical common carotid artery or through a retrograde femoral artery approach. Standard balloon dilation preceded deployment of balloon-expandable stents in most cases. No postprocedural anticoagulation was used (aspirin only).

RESULTS

In 110 patients (117 arteries) intended for treatment, 109 (99.0%) (116 arteries [99.1%]) were successfully treated with 129 stents (128 Palmaz, 1 Wallstent). One percutaneous procedure failed (0.9%) for technical reasons (stent could not be deployed) and was converted to carotid endarterectomy. Minor complications included 4 cases of spasm (successfully treated with papaverine); 1 flow-limiting dissection (stented); and 6 access-site problems. There were 7 strokes (2 major, 5 reversible) (6.4%) and 5 minor transient events (4.5%) that resolved within 24 hours. Three patients were converted to endarterectomy (2.7%) prior to discharge; 1 stroke patient expired (0.9%), and another patient died of an unrelated cardiac event in hospital. In the 30-day postprocedural period, 2 ICA stents occluded (patients asymptomatic). Clinical success at 30 days (no technical failure, death, endarterectomy, stroke, or occlusion) was 89.1% (98/110). Over a mean 7.6-month follow-up (range 2 to 31), no new neurological symptoms developed. Another stent occlusion at 2 months and one case of flow-limiting intimal hyperplasia at 7 months were detected on routine duplex scanning in asymptomatic patients. Life-table analysis shows an 89% cumulative primary patency rate.

CONCLUSIONS

Based on this early experience, carotid stenting appears feasible from a technical standpoint, with good midterm patency. However, the incidence of neurological sequelae is a serious problem. Technical enhancements and a more aggressive antiplatelet regimen may have a positive impact on these events.

Prevalence of epilepsy its treatment gap and knowledge, attitude and practice of its population in sub-urban Senegal an ILAE/IBE/WHO study

A door-to-door survey was used to determine the prevalence of epilepsy among 4500 people within the Pikine Health District (population 480,000) Senegal. Prevalence was 14.2/1000, and 23.4% of all people with epilepsy had never received appropriate treatment. Figures for the prevalence had increased since a previous survey in 1989. In parallel a study of knowledge attitude and practice was performed in the same district. Salient findings were that: two-thirds of interviewees had at some time witnessed a seizure, 51% agreed when asked if epilepsy is caused by evil spirits, 35% said epilepsy is contagious, only about 18% said that traditional therapy is best, 60% would not mind their child to play with a child with epilepsy but only 32% would agree if their child would want to marry a person with epilepsy.

First evidence of natural vertical transmission of yellow fever virus in Aedes aegypti, its epidemic vector

Entomological investigations were conducted in 1995 in Senegal, following a yellow fever (YF) outbreak. A total of 1125 mosquitoes collected in the field, including males, females and 12-48 h old newly emerged adults reared from wild-caught larvae, were tested for YF virus. Among the 22 species captured, Aedes aegypti was the most common. 'Wild' vectors of YF were also captured, including A. furcifer, A. metallicus and A. luteocephalus. In all, 28 YF virus isolations were made: 19 from A. aegypti females, including 2 from newly emerged specimens; 5 were obtained from A. aegypti males, including one from a pool of newly emerged specimens, 2 from A. furcifer females, and one each from a female A. metallicus and a female A. luteocephalus. The true infection rates (TIRs) were much higher in adult A. aegypti than in specimens reared from larvae--8.2% and 31.4% for female and male A. aegypti captured on human volunteers, respectively (P < 0.0001). The TIRs for A. aegypti reared from larvae were 1.4% and 0.5% for females and males, respectively (P > 0.05). This outbreak was an intermediate YF epidemic, involving 4 vector species. Our data provide the first evidence of vertical transmission of YF virus in nature by A. aegypti, its main vector to humans, and strongly suggest that vertical transmission played a major role in the spread of the epidemic.

Treatment of severe tetanus by intrathecal injections of baclofen without artificial ventilation

A study was conducted to evaluate repeated intrathecal injections of baclofen, without artificial ventilation, in the treatment of severe tetanus. Ten patients, 5 men and 5 women, with a mean age of 34 +/- 7 years, were included in the study. The dose of baclofen injected was 1000 micrograms between the ages of 16 and 55 years, 800 micrograms over the age of 55 years and 500 micrograms under the age of 16 years. The efficacy was assessed on the basis of the resolution of contractures and paroxysms and the initial dose was reinjected prior to the reappearance of these symptoms. Treatment was discontinued in the case of central nervous system depression or inefficacy. The first injection was effective in 9 cases for 24-48 h. The haemodynamic safety was always good. Five patients developed central depression with coma and respiratory depression, requiring artificial ventilation in 3 cases and reversed by flumazenil in 2 cases. Five patients were treated exclusively with baclofen with 4 cures. Five patients had to be ventilated with only one cure. This study confirms earlier studies concerning the efficacy of intrathecal baclofen in tetanus. However, the frequency of episodes of respiratory depression prevents the recommendation of repeated injections when respiratory intensive care facilities are not available.

Single-tube and nested reverse transcriptase-polymerase chain reaction for detection of Rift Valley fever virus in human and animal sera

Rift Valley fever (RVF) is an anthropozoonosis caused by a Phlebovirus (Bunyaviridae family) that has re-emerged recently in East and West Africa in 1997-1998. This emphasizes the need for early and rapid detection of the virus and an efficient surveillance system. To this goal, a single tube or a nested reverse transcriptase-polymerase chain reaction (RT-PCR) method focusing on the NSs coding region of the S segment was developed and used to detect the RVF virus (RVFV) genome, resulting respectively in the synthesis of 810 and 662 bp DNA amplimers. The assay was specific for RVFV and did not amplify any other phleboviruses known to circulate in sub-Saharan Africa. When serial dilutions of RVFV were artificially mixed with human normal serum, the minimal detection limits were 50 and 0.5 plaque forming units respectively using the simple and the nested RT-PCR. The RT-PCR method was efficient for the detection of RVFV RNA in the blood from experimentally RVFV-infected mice and lamb and the nested RT-PCR was found more sensitive than the virus isolation method. Additionally, this detection method was applied successfully for the diagnosis of human cases during the 1998 Mauritanian outbreak.

Selection of glutamate-rich protein long synthetic peptides for vaccine development: antigenicity and relationship with clinical protection and immunogenicity

Antibodies against three long synthetic peptides (LSPs) derived from the glutamate-rich protein (GLURP) of Plasmodium falciparum were analyzed in three cohorts from Liberia, Ghana, and Senegal. Two overlapping LSPs, LR67 and LR68, are derived from the relatively conserved N-terminal nonrepeat region (R0), and the third, LR70, is derived from the R2 repeat region. A high prevalence of antibody responses to each LSP was observed in all three areas of endemic infection. Levels of cytophilic immunoglobulin G (IgG) antibodies against both GLURP regions were significantly correlated with protection from clinical P. falciparum malaria. Protected children from the Ghana cohort possessed predominantly IgG1 antibodies against the nonrepeat epitope and IgG3 antibodies against the repeat epitope. T-cell proliferation responses, studied in the cohort from Senegal, revealed that T-helper-cell epitopes were confined to the nonrepeat region. When used as immunogens, the LR67 and LR68 peptides elicited strong IgG responses in outbred mice and LR67 also induced antibodies in mice of different H-2 haplotypes, confirming the presence of T-helper-cell epitopes in these constructs. Mouse antipeptide antisera recognized parasite proteins as determined by immunofluorescence and immunoblotting. This indicates that synthetic peptides derived from relatively conserved epitopes of GLURP might serve as useful immunogens for vaccination against P. falciparum malaria.

Therapeutic trial of diazepam versus placebo in acute chloroquine intoxications of moderate gravity

OBJECTIVE

Acute chloroquine intoxication is responsible for a membrane-stabilising effect which results in electrocardiographic (ECG) and hemodynamic disturbances. Diazepam is used in acute chloroquine intoxication on the basis of clinical and experimental observations, but its utility alone, in man, remains unproven. The goal of this study was to verify whether diazepam alone has an effect on the membrane-stabilising effect observed in moderately severe chloroquine intoxications.

DESIGN

Prospective, multi-center, double-blind, placebo-controlled study.

SETTING

Prehospital mobile intensive care units (Paris) and hospital intensive care units (paris and Dakar).

PATIENTS AND PARTICIPANTS

Adults with moderately severe intoxication defined as: a suspected ingested dose of 2 or more but less than 4 g, systolic blood pressure (SBP) higher than 80 mmHg, QRS duration less than 0.12 s and the absence of dysrhythmia at inclusion.

INTERVENTIONS

Patients received either a loading dose of 0.5 mg/kg diazepam followed by an infusion of 1 mg/kg over 24 h or an equivalent volume of placebo.

MEASUREMENTS AND RESULTS

Outcome was measured by serial assessments of SBP, ECG (QRS and QT segments) and clinical deterioration. There were no significant differences observed in the initial or serial ECG or SBP measurements. There were no deaths and no patient had to be removed from the study due to clinical deterioration.

CONCLUSIONS

Diazepam, at the dose studied, does not appear to reverse the chloroquine-induced membrane-stabilising effect in acute moderately severe chloroquine intoxication. Supportive intensive care of these intoxications appears to be all that is necessary.

[Treatment of status epilepticus in a developing country]

Status epilepticus (SE) is a condition requiring emergency care, which is often poorly managed in developing countries due to the lack of personnel, drugs, and insufficient technical and medical means. This study aims at determining the epidemiologic and etiologic characteristics and the difficulty in treating SE under the existing medical practice conditions in a developing country such as Senegal. A retrospective study was therefore carried out based on SE medical files at the University Hospital of Dakar over the period January 1988 to December 1998, and included several hospital departments, i.e., paediatrics, infectious diseases and neurology. Over an 11-year period 697 cases were recorded; of these, 48.2% of patients were under 5 years of age. The seizures were generalized in 58.2% of cases, partial in 21.2%, partial secondarily generalized, or with an association of both clinical presentations in 20.6% of cases. The etiology was as follows: mainly infectious (67%), followed by resistant and/or unbalanced epilepsy (9.9%), epilepsy of vascular origin (8%), and various other causes. The overall mortality rate was 24.8%. A long period between the onset of clinical symptoms and hospital treatment was noted, with an average time lapse of 16.6 h before treatment. The drugs utilized were diazepam and phenobarbitol, administered by injection. The overall outcome could be improved by better management, i.e., better prevention and an efficient treatment of infectious diseases, a reduction in the time before treatment, and improved means of intensive care.

Pronostic fonctionnel des accidents vasculaires cérébraux dans les pays en voie de développement : Sénégal

OBJECTIVE

To evaluate the functional outcome in patients followed in the department of neurology of Dakar for stroke.

MATERIALS AND METHOD

Prospective longitudinal observational study from August 2003 to May 2005 included inpatients or outpatients with stroke one month or less from entry confirmed by computed tomography scan. Patients were followed monthly for 12 months. At each visit, data on functional autonomy measured by the Barthel index and the treatments received were collected.

RESULTS

One hundred and seventy patients aged 25 to 90 years (mean 61+/-13 years) were evaluated. The sex ratio was 0.68. A total of 64.7% of strokes involved ischemic cerebral vascular accidents and 35.3% hemorrhagic vascular accidents. Right hemiplegia was present in 55.9%, left hemiplegia in 42.9% and bilateral paresis in 1.2% of patients. A total of 28.8% of patients died between d0 and d30, 50.6% within one year. At entry, the Barthel score was greater than 60 in only 4.7% of patients. After one-year follow-up, 58.3% of the patients had a Barthel score greater than 60, 19.1% had a score between 20 and 40 and 22.6% a score between 40 and 60. Only 53.5% received rehabilitation care. The parameters significantly associated with a functional recovery were age less than 55 years (P<0.05), hemorrhagic vascular accident as opposed to ischemic vascular accident (P<0.05), and earlier rehabilitation care under qualified personnel (P<0.01).

DISCUSSION

Our study shows an important rate of mortality during the first year following stroke and the rather young age of our population. The parameters associated with a better functional recovery are comparable to most of the data in the literature. The results of our study suggest that it is possible to improve functional prognosis after stroke by setting measures of prevention of the risk factors and rehabilitation in the early management of hemiplegia.

Enquête sur l’épilepsie chez des enseignants d’un pays en développement : exemple du Sénégal

Epilepsy is one of the most common disorders encountered in children of developing countries. In Senegal, as in many other African countries, the disease is enrobed in superstition, discrimination, and stigma. There is a clear-cut lack of information programs in the developing world about seizures and epilepsy. Academic achievement of children with epilepsy is hampered by social barriers in addition to the burden of the disease and its treatment. The aim of this study was to evaluate teachers'knowledge, awareness, and current attitudes about epilepsy in order to obtain baseline data for the development of a school health education program on epilepsy. The study was carried out in Dakar. It was conducted by sending self-administered and anonymous questionnaires to 400 elementary school teachers; the data were randomly mapped, stratified, and chosen to produce a statistically representative sample of the teacher population of Dakar. The questionnaires contained 22 items related to knowledge of epilepsy, the attitude of teachers towards epilepsy, and their ability to provide first aid in case of seizures. A total of 373 teachers (93p.cent) completed the questionnaires. For 69p.cent, epilepsy arises in the brain, for 28.7p.cent it is a subnatural affliction. Epilepsy was considered to be contagious for 24p.cent and could be cured for 73p.cent. Although 66p.cent would help an epileptic pupil during a seizure, 53p.cent mentioned harmful measures. Eighty-four percent noticed that an epileptic child could go to a normal classroom, while 62.5p.cent would prefer a special school. Eighty-four percent said their knowledge on epilepsy was not sufficient and the majority (99p.cent) desired training on epilepsy. For 25.7p.cent, better collaboration between parents, doctors, and teachers would b helpful to achieve better management of epileptic children. This study demonstrated encouraging knowledge of teachers about epilepsy. However, some of their wrong attitudes may be attributed to superstitions and could be improved by informative actions and better training about epilepsy. Such education might be provided by local health professionals with the collaboration of parents, teachers, and non-governmental organizations.

Stroke in women: When gender matters

Stroke in women may be considered as a distinct entity due to numerous differences compared with men, including specific epidemiological, etiological, and outcome features along with unique pathophysiological mechanisms. Stroke is the second cause of death in women worldwide with sex-specific causes of stroke in youger women such as pregnancy, post-partum period, oral contraception and migraine. Substitutive hormone treatment in older women is no more recommended in regard of the increased thromboembolic risk it generates. Venous thrombolysis with rtPA and mechanical thrombectomy are now proven to be as efficacious in women as in men. After a stroke, women present poorer quality of life than men attributable to age, more severe stroke, pre-stroke dependency and depression. Recent data concerning the latest epidemiological surveys reveal a shift in trends with the rise of incidence of strokes in young women (≤55 years and 64 years) contrasting with the stability of incidence rates in older women. As science is unvealing sex-related differences in cardiovascular disorders, health policies need to be adapted accordingly to improve stroke prevention and pre-stroke health in women. In the meantime, therapeutical trials should include more women in order to be able to formulate adequate management.

[Homozygous sickle cell disease in patients above 20 years of age: follow-up of 108 patients in Dakar]

CONTEXT

The progress realized in the treatment of sickle cell anemia has resulted to a better and longer life for these patients in developed countries. Ongoing challenge are to manage complication and social living for these patients. The purpose of this study was to determine morbidity, mortality and socioprofessional insertion of homozygous sickle cell patients, followed up in Dakar university hospital.

PATIENTS AND METHODS

We performed a longitudinal and prospective study including 108 homozygous sickle cell anemia patients, whose age were above 20 years, followed in a regular basis (at least 3 times per year), during 5 years on average (3 to 12 years). All patients had a quarterly hematological check-up and a annual statement to detect chronic complications. Clinic and paraclinical data, as information in socioprofessional insertion were noted in medical records for analysis.

RESULTS

Mean age was 27 years (20-51 years). The age between 20-29 years was represented by 67.5%, 26.9% aged 30-39 years and 5.6% were above 40 years of age. Men were slightly predominant with a sex-ratio of 1.25. Concerning morbidity, 96.3% of patients had at least 1 vaso-occlusive crisis per year, 26.9% were transfused and 64.8% had been hospitalized during the follow-up. A chronic complication was found in 49% of patients (53/108). The more frequent of these complications were gall stone (10%), femoral head necrosis (9.2%), priapism (11.6% of men), chronic leg ulceration (4.6%), ophthalmic involvement (3.7%), renal and cardiac complications (2.7% for each one). The presence of complications was not significantly influenced by patient's sex. Five patients died during a mean follow-up of 5 years. Concerning school attendance, 13% reach university level whereas 47% stop their education on the secondary level and 40% on primary level. Professionally, 36.2% of patients had no exercise any activity.

CONCLUSION

Our results emphasize that life expectancy can be prolonged in sickle cell anemia patients in Africa, when they have a benefit of a regular follow-up. We show also the respective frequency of chronic complications and then, the necessity of multidisciplinary teams to optimize the take care of sickle cell anemia patients in Africa.

Genomic analysis of three African strains of Bacillus anthracis demonstrates that they are part of the clonal expansion of an exclusively pathogenic bacterium

Bacillus anthracis is the causative agent of anthrax and is classified as a ‘Category A’ biological weapon. Six complete genomes of B. anthracis (A0248, Ames, Ames Ancestor, CDC684, H0491, and Sterne) are currently available. In this report, we add three African strain genomes: Sen2Col2, Sen3 and Gmb1. To study the pan-genome of B. anthracis, we used bioinformatics tools, such as Cluster of Orthologous Groups, and performed phylogenetic analysis. We found that the three African strains contained the pX01 and pX02 plasmids, the nonsense mutation in the plcR gene and the four known prophages. These strains are most similar to the CDC684 strain and belong to the A cluster. We estimated that the B. anthracis pan-genome has 2893 core genes (99% of the genome size) and 85 accessory genes. We validated the hypothesis that B. anthracis has a closed pan-genome and found that the three African strains carry the two plasmids associated with bacterial virulence. The pan-genome nature of B. anthracis confirms its lack of exchange (similar to Clostridium tetani) and supports its exclusively pathogenic role, despite its survival in the environment. Moreover, thanks to the study of the core content single nucleotide polymorphisms, we can see that our three African strains diverged very recently from the other B. anthracis strains.

Undernutrition and vitamin A deficiency in the Department of Linguère, Louga Region of Sénégal

Anthropometric measurements were taken on 281 toddlers (24-48 mo old) in Linguère, Sénégal, to determine the prevalence of undernutrition. Blood samples collected from 271 of the toddlers were analyzed for retinol and carotenoids by HPLC. According to the National Center for Health Statistics reference values 30.2% of the population was undernourished. Serum retinol values were below the lower limit of the normal range in 71.5% of the children; 7.4% of this group had concentrations < 0.35 mumol/L, placing them at risk for xerophthalmia. Only 3% of the population had serum retinol values > or = 1.0 mumol/L. Serum carotenoids were low (< 0.70 mumol/L) in 55% of the children. Retinol-binding protein values were low and measurable concentrations of retinyl palmitate were detectable in only 17% of the children. Undernutrition and poor vitamin A status were found to exist at a concentration that would endanger health.

[Disseminated histoplasmosis due to Histoplasma capsulatum var. duboisii in Senegal. A case in HIV-infected patient]

INTRODUCTION

Histoplasmosis, a disease due to Histoplasma capsulatum, is an invasive opportunistic fungal infection, endemic in Africa. So, the occurrence of african histoplasmosis associated with HIV infection has been rarely reported despite the high prevalence of both pathogens in this area. We report the first case of disseminated african histoplasmosis in an HIV-infected Senegalese patient.

OBSERVATION

A patient, 50-year-old has been admitted for umbilicate, necrotic and disseminated papulonodular lesions with oral infection, fever and reduction of total body mass. HIV1 test was positive, and CD4 count was 4/mm(3). Direct examination of ulcerated lesions shown extracellular, large, doubly contoured yeasts. After culture, we obtain brownish colonies, septate hyphae, echinulated chlamydospores characteristic of Histoplasma. Cutaneous biopsy revealed polymorphous granulomatous infiltrate, giant cells containing numerous large, doubly contoured, thick-wall yeast-bodies characteristic of H. capsulatum var. duboisii.

DISCUSSION

The association AIDS and histoplasmosis frequency is probably underestimated because the difficult diagnosis and the ignorance of the medical staff.

MALDI-TOF MS identification of Malassezia species isolated from patients with pityriasis versicolor at the seafarers' medical service in Dakar, Senegal

Pityriasis versicolor (PV) is a superficial mycosis caused by yeast of the genus Malassezia. The most common isolated Malassezia species in PV lesions differ among M. furfur, M. globosa and M. sympodialis. We purpose to determine the distribution of Malassezia species in PV patients at the seafarers' medical service in Dakar, Senegal and to examine whether any association between identified Malassezia species and patients' profile. From May 2017 to August 2017, first a questionnaire was filled to get informative data before collection of skin scrapings taken from most scaly site using sterile scalpel blade and application of scotch^® for direct examination (DE). At the laboratory, DE, culture and identification by MALDI-TOF MS were done. One hundred patients with PV - all men - were included with a mean age of 34 years. Among seafarers, 81% were sailors. Clinical prevalence of PV was highest in aged adults patients with ages of 31 to 60 years (56%). Seafarers with high level of education were less representative with only 2%. The mean duration of the PV was 26.83 months. 20% of subjects suffered lesions in more than one location. The chest was the most affected anatomical site. Furthermore, possible predisposing factors associated with PV were also detected. DE was positive in 95% but culture growth only in 46%. MALDI-TOF MS analysis of the positive cultures could be performed in 84.8% (39/46). Only M. furfur was identified in 100% (39/39). In definitive, M. furfur is the only causative agent of PV in Dakar.