Stroke care in 17 Sub-Saharan African countries: the FEBRUARY study (2016–2021) from African research network

Background

Stroke is one of the leading causes of morbidity and mortality worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability would occur in low- and middle-income countries. Between 2002 and 2020, estimation stroke mortality in Sub-Saharan Africa (SSA) was tripled. There is scarce data on management of stroke in SSA.

Purpose

To describe stroke care in cardiology departments in 17 SSA countries

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo (DCR), Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The FEBRUARY study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016. Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10)).

Results

Overall, 4360 patients were admitted to hospital over the 6 years of the study. Stroke was the third cause of hospitalization with 477 (11%) patients admitted. Proportions of patients admitted for stroke varied across countries from 0% in Ethiopia to 52% in DRC (p<0.01) (figure) and over the years from 11% in 2016 to 16.5% in 2021. Men represented 60.1% of stroke patients. Mean of age was 62.5±13.4 years. Overall, 300 patients (62.9%) were from low-income countries and 177 patients (37.1%) from middle-income countries. A majority of patients were living in urban areas (N=387; 82.9%) compared to rural areas (N=80; 17.1%). Individual wealth index was low, middle and high in 105 (23.2%), 152 (33.6%) and 196 (43.3%) patients respectively. Among stroke patients, 413 (89.8%) had a computed tomography. Ischemic stroke represented 71.8% of patients with stroke. Among CV risk factors, high blood pressure was identified in 81.9% of patients. In-hospital antithrombotic therapy was prescribed for 2 patients (0.42%). Anticoagulant therapy and antiplatelet therapy were prescribed for 26.4% and 53.5% of patients respectively. Proportions of patients treated with antiplatelet therapy varied across countries (p<0.05). At discharge, 8% and 44.4% of patients received anticoagulant therapy or antiplatelet therapy respectively. Mean of length of stay was 12.4±18.4 days. Stroke represent the second cause of mortality (18.7%) and did not vary significantly across countries.

Conclusion

Stroke was the third cause of admission with more than 1/10 patients and the second cause of mortality with almost 1/5 patients in cardiology departments in SSA.

Funding Acknowledgement

Type of funding sources: None.

Determinants of quality in home-based management of malaria by community health volunteers in rural Kenya

INTRODUCTION

Kenya adopted the World Health Organization's recommendation of community case management of malaria (CCMM) in 2012. Trained community health volunteers (CHVs) provide CCMM but information on quality of services is limited. This study aimed to establish determinants of quality of service of CCMM conducted by CHVs.

METHODOLOGY

A cross-sectional survey was conducted in November 2016 in Bungoma County, Kenya. Data were collected through observing CHVs perform routine CCMM and through interviews of CHVs using structured questionnaires. A ≥ 75% score was considered as quality provision. Descriptive statistics were performed to describe basic characteristics of the study, followed by Chi-Square test and binary logistic regression to examine the differences and associations between the categorical variables.

RESULTS

A total of 147 CHVs participated; 62% of CHVs offered quality services. There was a direct association between quality of services and stock-outs of artemether-lumefantrine (AL), stock-outs of malaria rapid diagnostic tests (RDT) and support supervision. CHVs who were supervised during the year preceding the assessment were four times more likely to perform better than those not supervised (uOR 4.2, 95% CI: 1.38-12.85). CHVs with reliable supplies of AL and RDT kits performed three times better than those who experienced stock outs (uOR = 3.2, 95% CI: 1.03-10.03 and 3.3, 95% CI: 1.63-6.59 respectively). Biosafety and documentation were the most poorly performed.

CONCLUSIONS

The majority of CHVs offered quality CCMM services despite safety gaps. Safety, continuous supplies of RDT, AL and supervision are essential for quality performance by CHV in delivering CCMM.

Cancer ecosystem assessment in West Africa: health systems gaps to prevent and control cancers in three countries: Ghana, Nigeria and Senegal

INTRODUCTION

Sub-Saharan Africa is experiencing a rapid epidemiological transition with the increasing incidence of Non-Communicable Diseases (NCD). Among these, cancer is one of the main causes of death in adults. This is a public health problem whose burden is unknown due to lack of statistical data. In addition, the already overburdened health systems are experiencing enormous constraints to address the problem with the double challenge of communicable and NCDs.

METHODS

The purpose of this evaluation was to assess the capacity and needs of health systems to prevent and control cancer. A cross-sectional study, using both quantitative and qualitative methods, was conducted between April 2017 and February 2018 in target countries, through in-depth interviews with key actors, direct observations and documents review. The WHO framework for health system strengthening with the 6 pillars was used for the gaps analysis.

RESULTS

Little priority is given to the fight against cancer because of low political commitment. Programs´ resources are very limited and there is a poor coordination of the actions. Human resources are insufficient, and most of them are concentrated in the capital city. This limits access to care with a late consultation of patients. Diagnosis and treatment services are expensive and generally paid by households. Finally, the unavailability of reliable data at national level hinders the decision-based evidence.

CONCLUSION

There is an urgent need to create strong partnerships at national and regional levels to (i) Advocate for a strong political commitment; (ii) Strengthen the coordination of actions and create more synergy among stakeholders; (iii) Improve the quality and quantity of human resources; (iv) Extend universal health coverage to cancer and improve program funding; and (v) Set up cancer registries at national level.

P3459Research Network in Africa (RNA): gender differences in cardiovascular risk factors and complications in 12 African countries

Background

Cardiovascular diseases are rapidly growing epidemic in Sub-Saharan Africa. Unlike other regions of the world, death rates due to hypertension are greater for women than men in Africa. Scarce data were available on factors associated with gender in cardiovascular risk factors and complications in Sub-Saharan Africa.

Purpose

To assess gender differences in cardiovascular risk factors pattern in patients with hypertension in 12 Sub-Saharan countries.

Methods

We conducted a cross-sectional survey in urban clinics of twelve countries in Africa. Data were collected on demographics, treatment and standardized BP measures were made among the hypertensive patients attending the clinics. BP control was defined as BP<140/90 mmHg and hypertension grades were defined according to European Society of Cardiology guidelines. The separate association between women factors and BP control was investigated using Generalized Linear Mixed-Effects Models adjusted on age; A random effect on the country was added (generalized estimated equation models) to account for inter-country variability.

Results

The EIGHT study enrolled 2198 patients with hypertension in 12 sub-Saharan countries between January 2014 and November 2015. The proportion of women (60,2%) was higher than men and varied significantly according to countries (p<0.001), ranged from 33.7% (Guinea) to 71.9% (Gabon). Mean age was 57.7±12.0 years for women and 59.2±11.4 years for men (p<0.001).

Compared to men, women had a higher rate of family cardiovascular background (79% vs 70%, for women and men respectively) (p<0.0001), cardiovascular risk factors (74.3% vs 68.1) (p=0.008), such as obesity (25.8% vs 12.1%) (p<0.0001), sedentary behavior (42.1% vs 35.0%) (p=0,006). BP control didn't differ according to gender, the repartition of grades of hypertension was similar between women and men and proportion of uncontrolled BP was 77.2% in women and 77.8% in men (p=0.4), with same proportion of women and men receiving antihypertensive treatment (96 vs 97.5%) (NS).

However, African women had less cardiovascular complications than men (39% vs 52.4%) (p<0.0001) (OR: 0.50 [CI 95% 0.41–0.61]).

Conclusions

Our study highlighted gender differences in cardiovascular risk factors pattern in Sub-Saharan hypertensive patients. Tailoring medical (public health) programs to improve cardiovascular disease prevention that take into women characteristics may enhance their effectiveness.

[Appendiceal Duplication In A Patient Operated For Chilled Appendix Breastplate At Gao Regional Hospital]

Appendiceal duplication is the very rare malformation. It was first described by Picoli in 1892. It is a condition that is most often seen in the first years of life, sometimes some forms may remain asymptomatic and only occur in adulthood. We report the case of appendiceal duplication in a patient operated for chilled appendix breastplate at Gao Regional Hospital.

CONCLUSION

appendiceal duplication is a rare abnormal abnormality of intraoperative discovery in general. Each surgeon must think about it during an appendectomy.

Capacity and readiness of civil society organisations to implement community case management of malaria in Kenya

INTRODUCTION

Civil Society Organizations (CSOs) contribute to achieving development goals through advocacy, social mobilisation and provision of health services. CSO programming is a key component of Global Fund (GF) grants; however, CSOs face technical and governance capacity challenges in grant utilisation leading to missed opportunities for improving health at community level. Amref Health Africa was appointed Principal Recipient of a GF grant aimed at scaling up community case management of malaria through CSOs as sub-recipients in western Kenya. To identify potential risks and strengthen grant management, Amref Health Africa and the Ministry of Health conducted a capacity needs assessment to determine the capacity of CSOs to effectively utilise grants.

METHODS

26 selected CSOs participated in this study. Document reviews and on-site assessments and observations were conducted using structured tool. The five main assessment areas were: governance and risk management; strategic and operational planning; monitoring and evaluation; programme management; and financial management. Overall performance was grouped into four categories: 3.0-2.5 (excellent), 2.0-2.4 (good), 1.5-1.9 (fair), and 1.0-1.4 (poor). Data were collected and analysed using Excel software.

RESULTS

Twenty five out of 26 CSOs were legally compliant. 14(54%) CSOs were categorized as good; 7(27%) as excellent; 3(12%) as poor and 2(8%) as fair. Most CSOs had good programme management capacity but monitoring and evaluation presented the most capacity gaps.

CONCLUSION

More than 75% of the CSOs were rated as excellent or good. A capacity building plan, programme risk management plan and oversight mechanisms were important for successful grant implementation.

Challenges in controlling the Ebola outbreak in two prefectures in Guinea: why did communities continue to resist?

Introduction

The Ebola outbreak emerged in a remote corner of Guinea in December 2013, and spread into Liberia and Sierra Leone in the context of weak health systems. In this paper, we report on the main challenges faced by frontline health services and by communities including their perceptions and views on the current Ebola response in the Prefectures of Coyah and Forecariah in Guinea.

Methods

A cross-sectional study was conducted in December 2014 using mixed approaches: (i) Desk review; (ii) Interviews; and (iii) Direct observation.

Results

Almost one year after the beginning of the Ebola virus disease outbreak in West Africa, the perceptions of stakeholders and the observed reality were that the level of preparedness in the two health districts was low. The study identified poor coordination mechanisms, inadequate training of human resources and lack of equipment and supplies to field teams and health facilities as key elements that affected the response. The situation was worsened by the inadequate communication strategy, misconceptions around the disease, ignorance of local culture and customs and lack of involvement of local communities in the control strategies, within the context of poor socioeconomic development. As a result distrust developed between communities and those seeking to control the epidemic and largely contributed to the reluctance of the communities to participate and contribute to the effort.

Conclusion

There is a need to rethink the way disease control interventions in the context of an emergency such as Ebola virus disease are designed, planned and implemented in low income countries.

[Interest of laparoscopic surgery in the management of chronic abdominal pains in the surgery "A" department of the of the Point G University Hospital]

AIM

to evaluate the contribution of laparoscopic surgery in the management of chronic abdominal pains of unspecified etiology.

METHODS

A retrospective descriptive study was conducted over a period of 49 months (March 2008 to March 2012), in the surgery A service of the Point G university hospital.

RESULTS

52 patients suffering from chronic abdominal pain for 3 months have been listed. There were 36 women and 16 men, with a sex-ratio of 2.25. The pathologies found in laparoscopy were: 16 cases of adherences, 16 cases of gynaecological diseases, 6 cases of chronic appendicitis, 5 cases of chronic cholecystitis, 6 cases of abdominal tumors and 3 cases of intrauterine contraceptives in abdomen. Conversion to laparotomy was not made and mortality was null. No lesion was found in 11.54% of cases. The mean duration of hospitalization was 2 days. The duration of follow-up of the patients was 18 months with a minimum of 6 months and a maximum of 24 months. No painful symptomatology was found in 6 months in 88.46% of the cases. Persistent stomach pains were found in 3% of the cases. 8.54% of the patients had an improvement of symptomatology.

CONCLUSION

Chronic abdominal pains put a diagnosis problem in surgery. Laparoscopy is a reference technique to diagnose this pain and to discuss them.

Integration of non-communicable diseases in health care: tackling the double burden of disease in African settings

Sub-Saharan African countries now face the double burden of Non Communicable and Communicable Diseases. This situation represents a major threat to fragile health systems and emphasises the need for innovative integrative approaches to health care delivery. Health services need to be reorganised to address populations' needs holistically and effectively leverage resources in already resource-limited settings. Access and delivery of quality health care should be reinforced and implemented at primary health care level within the framework of health system strengthening. Competencies need to be developed around services provided rather than specific diseases. New models of integration within the health sector and other sectors should be explored and further evidence generated to inform policy and practice to combat the double burden.

Acceptance of a malaria vaccine by caregivers of sick children in Kenya

BACKGROUND

Several malaria vaccines are currently in clinical trials and are expected to provide an improved strategy for malaria control. Prior to introduction of a new vaccine, policymakers must consider the socio cultural environment of the region to ensure widespread community approval. This study investigated the acceptance of a malaria vaccine by child caregivers and analysed factors that influence these.

METHODS

Interviews from a standard questionnaire were conducted with 2,003 caregivers at 695 randomly selected health facilities across Kenya during the Kenya Service Provision Assessment Survey 2010. Multinomial regression of quantitative data was conducted using STATA to analyse determinants of caregivers accepting malaria vaccination of their child.

RESULTS

Mothers represented 90% of caregivers interviewed who brought their child to the health facility, and 77% of caregivers were 20-34 years old. Overall, 88% of respondents indicated that they would accept a malaria vaccine, both for a child in their community and their own child. Approval for a vaccine was highest in malaria-endemic Nyanza Province at 98.9%, and lowest in the seasonal transmission area of North Eastern Province at 23%. Although 94% of respondents who had attended at least some school reported they would accept the vaccine for a child, only 56% of those who had never attended school would do so. The likelihood of accepting one's own child to be immunized was correlated with province, satisfaction with health care services in the facility attended, age of the caregiver, and level of education.

CONCLUSIONS

Results from this study indicate a need for targeted messages and education on a malaria vaccine, particularly for residents of regions where acceptance is low, older caregivers, and those with low literacy and school-attendance levels. This study provides critical evidence to inform policy for a new malaria vaccine that will support its timely and comprehensive uptake in Kenya.

Why are IPTp coverage targets so elusive in sub-Saharan Africa? A systematic review of health system barriers

BACKGROUND

Use of intermittent preventive treatment (IPTp) is a proven cost-effective intervention for preventing malaria in pregnancy. However, despite the roll-out of IPTp policies across Africa more than ten years ago, utilization levels remain low. This review sought to consolidate scattered evidence as to the health system barriers for IPTp coverage in the continent.

METHODS AND FINDINGS

Relevant literature from Africa was systematically searched, reviewed and synthesized. Only studies containing primary data were considered. Studies reveal that: (i) poor leadership and governance contribute to slow decentralization of programme management, lack of harmonized guidelines, poor accountability mechanisms, such as robust monitoring and evaluation systems; (ii) low budgetary allocation towards policy implementation slows scale-up, while out-of-pocket expenditure deters women from seeking antenatal services that include IPTp; (iii) there are rampant human resource challenges including low staff motivation levels attributed to such factors as incorrect knowledge of IPTp recommendations and inadequate staffing; (iv) implementation of IPTp policies is hampered by prevailing service delivery barriers, such as long waiting time, long distances to health facilities and poor service provider/client relations; and (v) drug stock-outs and poor management of information and supply chains impair sustained availability of drugs for IPTp.

CONCLUSIONS

For successful IPTp policy implementation, it is imperative that malaria control programmes target health system barriers that result in low coverage and hence programme ineffectiveness.

Safety monitoring of artemisinin combination therapy through a national pharmacovigilance system in an endemic malaria setting

Background

The National Malaria Control Programme in Senegal, introduced since 2006, artemisinin-based combination therapy (ACT administration) for the treatment of uncomplicated malaria cases. In this framework, an anti-malarial pharmacovigilance plan was developed and implemented in all public health services. This study investigated the occurrence of Adverse Drug Events (ADEs) after ACT.

Methods

The study was conducted between January 2007 and December 2009. It was based on spontaneous reports of ADEs in public health facilities. Data on patient demographic characteristics, dispensing facility, adverse signs and symptoms and causality were collected from a total of 123 patients.

Results

The age range of these patients was six months to 93 years with a mean of 25.9 years. Of the reported symptoms, 46.7% were related to the abdomen and the digestive system. Symptoms related to the nervous system, skin and subcutaneous tissue, circulatory and respiratory systems and general symptoms and signs were 7%, 9.7%, 3.5% and 31.3%, respectively. Causality results linked 14.3% of symptoms to Falcimon® (Artesunate-Amodiaquine) with certainty. Effects were classified as mild and severe in 69.1% and 7.3% of cases respectively while 23.6% were serious. All patients with serious ADEs were hospitalized. One death was reported in a patient who had taken 24 pills at once.

Conclusion

These results confirm the need to develop and implement pharmacovigilance systems in malaria endemic countries in order to monitor the safety of anti-malarial treatments.

Scale-up of home-based management of malaria based on rapid diagnostic tests and artemisinin-based combination therapy in a resource-poor country: results in Senegal

Background

Effective case management of malaria requires prompt diagnosis and treatment within 24 hours. Home-based management of malaria (HMM) improves access to treatment for populations with limited access to health facilities. In Senegal, an HMM pilot study in 2008 demonstrated the feasibility of integrated use of RDTs and ACT in remote villages by volunteer Home Care Providers (HCP). Scale-up of the strategy began in 2009, reaching 408 villages in 2009 and 861 villages in 2010. This paper reports the results of the scale-up in the targeted communities and the impact of the strategy on malaria in the formal health sector.

Methods

Data reported by the HCPs were used to assess their performance in 2009 and 2010, while routine malaria morbidity and mortality data were used to assess the impact of the HMM programme. Two high transmission regions where HMM was not implemented until 2010 were used as a comparison.

Results and discussion

From July 2009 through May 2010, 12582 suspected cases were managed by HCPs, 93% (11672) of whom were tested with an RDT. Among those tested, 37% (4270) had a positive RDT, 97% (4126) of whom were reported treated and cured. Home care providers referred 6871 patients to health posts for management: 6486 with a negative RDT, 119 infants < 2 months, 105 pregnant women, and 161 severe cases. There were no deaths among these patients. In 2009 compared to 2008, incidence of suspected and confirmed malaria cases, all hospitalizations and malaria-related hospitalizations decreased in both intervention and comparison regions. Incidence of in-hospital deaths due to malaria decreased by 62.5% (95% CI 43.8-81.2) in the intervention regions, while the decrease in comparison regions was smaller and not statistically significant.

Conclusion

Home-based management of malaria including diagnosis with RDT and treatment based on test results is a promising strategy to improve the access of remote populations to prompt and effective management of uncomplicated malaria and to decrease mortality due to malaria. When scaled-up to serve remote village communities in the regions of Senegal with the highest malaria prevalence, home care providers demonstrated excellent adherence to guidelines, potentially contributing to a decrease in hospital deaths attributed to malaria.

Major reduction in anti-malarial drug consumption in Senegal after nation-wide introduction of malaria rapid diagnostic tests

BACKGROUND

While WHO recently recommended universal parasitological confirmation of suspected malaria prior to treatment, debate has continued as to whether wide-scale use of rapid diagnostic tests (RDTs) can achieve this goal. Adherence of health service personnel to RDT results has been poor in some settings, with little impact on anti-malarial drug consumption. The Senegal national malaria control programme introduced universal parasite-based diagnosis using malaria RDTs from late 2007 in all public health facilities. This paper assesses the impact of this programme on anti-malarial drug consumption and disease reporting.

METHODS AND FINDINGS

Nationally-collated programme data from 2007 to 2009 including malaria diagnostic outcomes, prescription of artemisinin-based combination therapy (ACT) and consumption of RDTs in public health facilities, were reviewed and compared. Against a marked seasonal variation in all-cause out-patient visits, non-malarial fever and confirmed malaria, parasite-based diagnosis increased nationally from 3.9% of reported malaria-like febrile illness to 86.0% over a 3 year period. The prescription of ACT dropped throughout this period from 72.9% of malaria-like febrile illness to 31.5%, reaching close equivalence to confirmed malaria (29.9% of 584,873 suspect fever cases). An estimated 516,576 courses of inappropriate ACT prescription were averted.

CONCLUSIONS

The data indicate high adherence of anti-malarial prescribing practice to RDT results after an initial run-in period. The large reduction in ACT consumption enabled by the move from symptom-based to parasite-based diagnosis demonstrates that effective roll-out and use of malaria RDTs is achievable on a national scale through well planned and structured implementation. While more detailed information on management of parasite-negative cases is required at point of care level to assess overall cost-benefits to the health sector, considerable cost-savings were achieved in ACT procurement. Programmes need to be allowed flexibility in management of these funds to address increases in other programmatic costs that may accrue from improved diagnosis of febrile disease.

Identifying barriers to effective tuberculosis control in Senegal: an anthropological approach

SETTING

Low tuberculosis (TB) cure rates (average 53%) and high treatment default rates (average 28%) were reported in Senegal between 1999 and 2001.

OBJECTIVE

To qualitatively evaluate the ability of TB patients to access and complete treatment in Senegal, with a view to helping to develop suitable strategies to improve TB control.

METHODS

Anthropological study conducted in a series of public and private, urban and rural health facilities in 2001 and 2002. The qualitative methods used included semi-structured and in-depth interviews of health staff, patients and relatives, focus group discussions, and observations carried in health facilities.

RESULTS

Problems were identified at several levels of health care. The main impediments to successful patient outcomes identified were: limited access to TB diagnosis and treatment facilities, poor communication between health personnel and patients, poor quality information provided to patients, poorly applied directly observed treatment, lack of a strategy to trace defaulting patients and limited supervision of the treatment units by the district leadership team.

CONCLUSION

The anthropological analysis of patient care is an appropriate means of addressing complex public health problems in disease control and identifying solutions that are acceptable, sustainable and adapted to the local context.

Effectiveness of a strategy to improve adherence to tuberculosis treatment in a resource-poor setting: a cluster randomized controlled trial

CONTEXT

Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed.

OBJECTIVES

To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection.

DESIGN, SETTING, AND PATIENTS

A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear-positive pulmonary TB were randomly assigned to the intervention or control group.

INTERVENTION

The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged.

MAIN OUTCOME MEASURE

Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment.

RESULTS

A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89).

CONCLUSION

The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00412009.

[Tuberculosis control in Senegal: update on care services and recommendations for improvement]

The goal of this study was to evaluate tuberculosis control in Senegal especially with regard to organization, quality, and availability of care services. Study was carried out from January to October 2002 within the framework of the National Turberculosis Control Program (NTCP) in 10 public hospitals and 8 private facilities including 4 doctors' offices, 2 company medical dispensaries, and 2 medical laboratories. Case observations were collected at the same time as surveying of diagnostic and therapeutic departments. In addition NTCP records for the period from 2000 to 2001 were searched. The reporting rate of new cases confirmed by positive smears is still low in Senegal, (62/100 000 inhabitants). Reporting is particularly low in rural areas where a clear-cut male predominance was observed. The cure rate also remains low (mean, 62%) mainly due to failure to complete treatment (28%). This situation contrasts with the extensive resources that have been devoted to diagnosis and treatment including field units for diagnosis (76 laboratories) and treatment (68 centers). These facilities are well integrated into the healthcare system and distributed nation-wide and provide effective care free of charge. The findings of this study demonstrate that there are serious impediments to control of tuberculosis in Senegal. Recommendations are made at various levels based on the results of problem analysis and are used to develop new management strategies aimed at improving NTCP performance indicators in Senegal.

Elemental analysis of soft plaque and calcified plaque deposits from human coronary arteries and aorta

Twenty-five samples of soft plaque and calcified plaque deposits from human hearts or aorta were analyzed using inductively coupled plasma-mass spectrometry (ICP-MS). The determined elements were Ca, P, Na, K, Mg, Zn, Cu, Ba, Pb, Fe, Al, Si, and S. Results showed that the concentration of all elements in the soft plaque was at the micromolar level. In the calcified deposits, the concentrations of Ca and P were at least an order of magnitude higher than the soft plaque, but the other elements were at the same order of magnitude. In the calcified plaque the molar ratios of Ca/P suggested that a significant portion existed as hydroxyapatite Ca10(PO4)6(OH)3. However, their absolute concentrations indicated that this compound was not a major component of the plaque although it may play a major role in determining the crystal structure of the deposit. In some samples the Ca/P ratio was too high to conform to hydroxyapatite. In others it was too low. This indicated that both the calcium and phosphorus existed in other chemical forms which varied from sample to sample. In the soft tissue the P level was high indicating it existed primarily in chemical forms other than hydroxyapatite. The presence of homocysteine is often associated with heart disease. However, the low levels of sulfur indicate that although it may be present, it is not a major component of the plaque, but may nevertheless play an important role in its formation.

Elution behavior of unsaponifiable lipids with various capillary electrochromatographic stationary phases

Capillary electrochromatographic (CEC) separations of unsaponifiable lipids, tocopherols (T), tocotrienols (T3), and plant sterols were studied under various conditions. Investigated stationary phases include pentafluorophenylsilica (PFPS), triacontylsilica (TCS), and octadecylsilica (ODS) phases. A baseline separation of four sterols (ergosterol, lanosterol, sitosterol and stigmasterol) on ODS was achieved and their elution order was found to be dictated by side-chain structures. CEC of the tocol-derived compounds on PFPS in aqueous methanol yielded the most satisfactory results with complete resolution of all components eluting in the order deltaT3>beta3>gammaT3>epsilonP>alphaT3>deltaT>zeta2T>betaT>gammaT>alphaT, while a reversal in elution of the epsilonT-alphaT3 pair was observed in aqueous acetonitrile. CEC with a TCS phase in non-aqueous methanol led to a different elution pattern deltaT3>gammaT3>betaT3>alphaT3epsilonT>deltaT>(zeta2+gamma)T>betaT>alphaT, despite favorable resolution of the (gamma-zeta2)T pair along with the observation of inseparable(beta-gamma)T and (beta-gamma)T3 pairs in non-aqueous dimethylformamide. Non-aqueous acetonitrile mobile phases provided unique selectivity for the (gamma-zeta2)T pair and isomer separations on TCS. Variations in separation and retention factors of relevant antioxidant species with CEC variables were evaluated. Examples of CEC quantification of unsaponifiable fractions of rice bran oils and soybean oils are presented.

Capillary electrochromatography of cholesterol and its ester derivatives

Separation of cholesterol and its ester derivatives using micellar electrokinetic chromatography is a challenge due to the extreme hydrophobicity of these compounds. In this work, an isocratic capillary electrochromatography (CEC) method has been developed to separate a complex mixture of cholesterol and its 12-ester derivatives. The proportions of mobile phase (tetrahydrofuran, acetonitrile, water), as well as the effects of acid modifiers, buffer concentrations, voltage, and temperature on the separation of cholesterol derivatives were investigated. Addition of a polymeric surfactant, poly(sodium N-undecanoyl-L-glycinate), to the mobile phase reduced migration time and improved resolution of the analytes. The CEC method developed allows baseline separation of a complex mixture of cholesterol and 12 ester derivatives in less than 40 min. Finally, the method is applied to the characterization of cholesterol, cholesterol linoleate, and cholesterol oleate extracted from atherosclerotic plaque deposits in the arterial walls of a human aorta.

[Left ventricular aneurysm in human immunodeficiency virus infection: a case report]

The authors report the case of a 30 year old man with a left ventricular aneurysm who was seropositive to HIV 1 and HIV 2. The patient was stage IVC 1 (AIDS related complex) by the "Center for Disease Control" classification. The clinical presentation was pyrexia, loss of weight, micropolyadenopathy and cardiac failure. The electrocardiogramme showed low voltage in the peripheral leads with a QS morphology in S2, S3 and aVF and abrasion, of the R wave in the precordial leads. Doppler echocardiography demonstrated a large left ventricular aneurysm with a wide neck. Despite treatment with a diuretic, angiotensin converting enzyme inhibitor and anticoagulants, the patient died suddenly. Autopsy confirmed the wide necked left ventricular aneurysm. This would appear to be the first report of this form of cardiac disease during HIV infection. However, a simple coincidence of the two pathologies cannot be excluded.