[Onchocerciasis in the area of Lastourville, Gabon. Clinical and entomological aspects]

The African Programme for Onchocerciasis Control (APOC) has implemented a series of surveys aimed at evaluating the long-term impact of its activities. The region of Lastourville (Gabon) is one of the selected sites for this study. A total of 886 persons was examined for skin lesions, and 459 out of them participated in detailed ocular examinations. Blackflies were collected during one year and dissected. Although the focus was found to be hypoendemic (prevalence of nodules: 7.7%), the frequency of onchodermatitis was relatively high. The lesions of the anterior segment of the eye were rare, but the prevalence of optic nerve disease, and of choroido-retinal lesions reached 5.2 and 2.7%, respectively. The annual transmission potential (2,171 infective larvae per man) was high, when compared with the results recorded in the human population. This may be due to the presence of Onchocerca spp. of animal origin in the blackflies. These results indicate that in the area of Lastourville, though regarded as the main focus of onchocerciasis in Gabon, the disease is relatively mild.

[African Programme for Onchocerdasis Control (APOC): Onchocerca Simulium squamosum in two regions in the Republic of Cameroon]

In 1998, the African Programme for Onchocerciasis Control (APOC) decided to launch a long-term impact assessment of its operations. This paper reports the baseline entomological data collected throughout a whole year in two sites of Cameroon (Kahn and Bolo). The Simulium populations of the two study sites were characterized by parous rates of 7.2% and 33.5% respectively and infectivity by O. volvulus of 31 and 190 infective larvae per 1000 parous flies respectively The Annual Transmission Potentials (ATP) were respectively 523 and 9972 infective larvae per man and per year in Kahn and in Bolo. The Simulium populations studied in both sites, even though the ATP in Kahn is 19 times lower than that of Bolo, showed a pattern of an onchocerciasis hyperendemic zone in terms of vector capacities and entomological indices.

Biventricular Repair of Ebstein's Anomaly With Pulmonary Atresia in a Low Birth Weight Neonate

Cyanotic neonates with Ebstein's anomaly associated with pulmonary atresia are a subgroup with the high mortality rate in pediatric cardiac surgery. We report a case of a severely symptomatic low birth weight neonate with Ebstein's anomaly and pulmonary atresia. A biventricular repair with Danielson-type tricuspid valve repair was performed. The baby tolerated the procedure with adequate hemodynamics, but died of peritoneal hemorrhage on the second postoperative day. This report could be an addition to the recent literature regarding the feasibility of biventricular repair for symptomatic neonates with Ebstein's anomaly even in low birth weight neonates.

Programme africain de lutte contre l’onchocercose (APOC) : transmission d’Onchocerca volvulusparSimulium damnosumS. l. dans deux régions de la République Centrafricaine

Entomological baseline data were collected in the villages of Zinga and Boali-Falls in Central African Republic (CAR) in view of the long term impact assessment of community-directed treatment with ivermectin (CDTI). Morphological determinations revealed that flies caught in both sites belong to the sub-group Sou/Sq. In Boali, the nuisance was relatively high with biting rates averaging 243 bites/man/day, with a parous rate of 61.6% and a crude annual transmission potential (ATP) of 8,259 infective larvae/man/year; and the average number of infective larvae per 1,000 parous flies was 177. In Zinga, the mean biting rate was 191 bites/man/day, with a parous rate of 51.6%, a crude ATP of 3,422, and 86 infective larvae per 1,000 porous flies. In conclusion, the vectorial capacity and the entomological indices recorded are characteristic of high onchocerciasis transmission zones. However, some of the infective larvae found, maybe of animal origin, need identification to better determine the real level of endemicity.

Replacement of the common atrioventricular valve with floating annuloplasty in a patient with univentricular physiology

Significant common atrioventricular valve insufficiency is associated with increased mortality and morbidity in patients with univentricular physiology. Shortly after bidirectional cavopulmonary anastomosis and concomitant valvuloplasty, valve replacement was carried out using a floating annuloplasty technique reinforced by a Dacron strip in a patient with common atrioventricular valve insufficiency. The technique applied is described in detail.

A pitfall in ligation of intrahepatic shunting after Fontan type operation

An 8-year-old boy experienced progressive cyanosis after a Fontan type operation. Under the guidance of intraoperative color Doppler we performed a transabdominal ligation of the accessory hepatic veins which drained into a common atrium. Reoperation was needed through a median sternotomy to eliminate residual shunting. Although intraoperative Doppler is useful to aid in the ligation of accessory veins while portal hypertension is monitored, intraoperative angiogram serves better to ensure the elimination of intrahepatic shunting in a transabdominal approach.

Intracardiac lead fracture in an implantable cardioverter-defibrillator

A patient with an implantable cardioverter-defibrillator (ICD) experienced inappropriate shocks. X-rays revealed that the ventricular lead was fractured at a point, which seemed to be in a mechanical stress-free space in the heart. Multiple leads were entwined making a short flexible section sandwiched between the entwined area and the stiff coil susceptible to the stress from heart beats. The present case shows that indirect concentrated stress caused by restriction of lead flexibility can result in lead fracture. Upon implanting multiple endocardial leads, attention should be given to the relative position of each lead.

[Cor triatriatum diagnosed in adulthood; report of a case]

Cor triatriatum is a rare congenital cardiac anomaly especially in adulthood. A 68-year-old female was diagnosed as a cor triatriatum classified to Lucas-Schmidt IA, severe degree of mitral regurgitation and atrial fibrillation. Resection of the abnormal diaphragm in the left atrium and miral valve replacement were performed. Although the reason of sudden death of this patient after discharge is unknown, surgical intervention for atrial fibrillation should have performed to prevent a thromboembolism in such cases.

[Delayed onset malignant hyperthermia after a closure of ventricular septal defect]

An 18 month-old girl was diagnosed as ventricular septal defect (VSD) with mild aortic valve prolapse. She underwent a closure of VSD. Intra-and early postoperative course was uneventful. However, 20 hours after surgery, sudden bradycardia led to cardiac arrest and strong muscle rigidity was seen. Hyperkalemia and metabolic acidosis rapidly progressed and resuscitation was failed. Extracorporeal life support and continuous hemodialysis were initiated, but the patient died with multiple organ failure on 5th postoperative day. Her clinical course supported the diagnosis of delayed onset malignant hyperthermia. Histopathological findings of muscle biopsy were consistent with rhabdomyolysis, and immunopathological stains demonstrated changes as in a Duchenne type muscular dystrophy carrier. Delayed onset malignant hyperthermia is an extremely rare complication of general anesthesia. We should be aware of this lethal condition, which occurs with a certain time lag after surgery, especially when the patient has possible background of myopathy.

[Asplenia syndrome with total anomalous pulmonary venous connection]

Three patients of asplenia syndrome with total anomalous pulmonary venous connection (TAPVC) were reported. Case 1 with exceeding pulmonary blood flow, underwent TAPVC repair and pulmonary artery banding as a first palliation before bi-directional Glenn shunt. Case 2 did not require any surgery to control the pulmonary blood flow before the simultaneous procedure of TAPVC repair and bi-directional Glenn shunt. Case 3 with decreased pulmonary blood flow underwent a complicated course with 3 times of Blalock-Taussig shunts and the repair of TAPVC to prepare for bi-directional Glenn shunt. Simultaneous repair of TAPVC with the procedure which aimed to control the pulmonary blood flow at the first palliation surgery will simplify the control of pulmonary blood flow and prepare good condition of the lung for the Fontan operation in the future.

High-frequency QRS potentials as a marker of myocardial dysfunction after cardiac surgery

BACKGROUND

High-frequency QRS potentials are sensitive to myocardial ischemia. The aim of this study was to evaluate the usefulness of high-frequency QRS potentials as a marker of myocardial dysfunction after cardiac surgery.

METHODS

Seventy patients undergoing coronary artery bypass grafting or heart valve surgery were involved. High-frequency QRS potentials were measured by signal-averaged electrocardiogram, and calculated as the root-mean-square voltage of the total QRS duration (RMST). The postoperative RMST was expressed as a percentage of the preoperative RMST. The mean RMST at 1 to 2 hours after removing the aortic cross-clamp was compared with the cardiac index, inotropic agents, and aortic cross-clamping time. The occurrence of ventricular tachycardia within 24 hours and the RMST at 2 postoperative days were also evaluated. Patients were divided into quartile groups from highest to lowest at postoperative RMST (groups 1, 2, 3, and 4, respectively, from maximum to minimum).

RESULTS

In postoperative states, cardiac index significantly decreased in accordance with the RMST decrease in a stepwise manner, although there were no differences in cardiac index among the four groups preoperatively. Inotropic agents and aortic cross-clamping time increased as RMST decreased. A high rate of ventricular tachycardia within 24 hours and delayed RMST recovery at 2 postoperative days were seen in group 4. The curve of sensitivity and specificity showed that severe reduction (threshold, 35%) of RMST indicated low-output syndrome.

CONCLUSIONS

The severe reduction of filtered high-frequency QRS potentials was related to myocardial dysfunction. Measurement of filtered high-frequency QRS potentials could become a useful, noninvasive, real-time monitor of myocardial dysfunction after surgery.

[Leaflet extension technique in a congenital aortic valve regurgitation]

A 17-year-old boy who was diagnosed as congenital aortic valve regurgitation underwent the leaflet extension technique in 3 aortic leaflets using glutaraldehyde-preserved autologous pericardium. Intraoperative transesophageal echocardiography and postoperative cardiac catheter revealed grade I regurgitation and the patient has been doing well for more than 4 months after the surgery. The leaflet extension technique is considered to be an acceptable surgical treatment for aortic valve disease especially in young patients to whom valve replacement or Ross procedure might not be suitable. A careful long-term follow-up will be necessary to evaluate the durability of the leaflet extension technique with autologous pericardium.

[Right-sided infective endocarditis with a large size vegetation]

A 2-year-old boy with ventricular septal defect(VSD) had suffered from right-sided infective endocarditis with a vegetation 1.0 cm in size, involving pulmonary valve. Resection of the vegetation and partial resection of the pulmonary valve and patch closure of the VSD was performed after 3 weeks intravenous antibiotic therapy. In right-sided infective endocarditis, it is still unclear, however, which factors may be useful in predicting outcome or determining the need of surgical intervention. We recognize that following factors are the risk for need of surgical intervention. 1. persistent infection, 2. sever right-sided heart failure, 3. multiple embolic episodes, 4. infected by Staphylococcus aureus, 5. infection involving the annulus of the valve, 6. infection of prosthetic valve, 7. vegetation which is floppy and greater than 1.0 cm in size.

Palliative open heart surgery in an infant with factor VII deficiency

An infant with factor VII deficiency underwent palliative open heart surgery for pulmonary atresia with an intact ventricular septum. No references had been found on the management of this rare coagulation disorder in infantile cardiac surgery. We describe the peri- and postoperative management with a replacement therapy including a recombinant factor VIIa concentrate. We conclude that an appropriate replacement therapy is needed to control bleeding during open heart surgery with factor VII deficiency.

[Management of mediastinitis after pediatric cardiac surgery with continuous closed irrigation method]

Two cases are presented as a successful management for mediastinitis with the continuous closed irrigation method after pediatric cardiac surgery. The continuous closed irrigation method has significant advantages over conventional open irrigation method or muscle flap in pediatric cases, because the system is simple to handle and easy to wash out any infectious tissue debris without additional invasive intervention. However, adequate duration of the irrigation and subsequent antibiotic regimen is still unclear. We conclude that the continuous closed irrigation method is an effective management which is applicable to most of mediastinitis cases after pediatric cardiac surgery.

Mortality of pulmonary artery banding in the current era: recent mortality of PA banding

BACKGROUND

The mortality of pulmonary artery banding improved significantly in the 1980s. However, we lack information on this procedure in the current era.

METHODS

The results of pulmonary artery banding in 365 patients who had operations between 1966 and 2001 were reviewed. The patients were divided into three groups: (1) group 1 patients who had operations between 1966 and 1979, (2) group 2 patients who had operations between 1980 and 1989, and (3) group 3 patients who had operations between 1990 and 2001.

RESULTS

Significantly younger and smaller patients have been operated on recently (mean age: group 1, 169.0 +/- 40 days; group 2, 101.8 +/- 11 days; and group 3, 69.7 +/- 8.9 days; and mean weight: 4.6 +/- 0.1, 4.1 +/- 0.1, and 3.2 +/- 0.1 kg, respectively). A decrease was found in the number of simple cardiac anomalies, such as isolated ventricular septal defects. The early mortality in the three groups was 38.3% for group 1 (65 of 187), 13.5% for group 2 (15 of 111), and 13.8% for group 3 (12 of 87). Although the mortality did not vary significantly between groups 2 and 3, it improved over time in patients weighing less than 3 kg. Multivariate analysis of group 3 demonstrated that no isolated variable, including sex, weight, and diagnosis was a significant risk factor.

CONCLUSIONS

Despite the advances in perioperative management, we found no improvement in the early mortality of pulmonary artery banding during the last decade. These results will support the preference for primary repair of intracardiac anomalies in small infants. However, this operation can now be performed with the same risk even in smaller patients. We believe that pulmonary artery banding has a role in the treatment of congenital cardiac anomalies.

Gender issues in the community-directed treatment with ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC)

This paper reviews the issues relating to compliance and participation among the men and women of three countries within the remit of the African Programme for the Control of Onchocerciasis (APOC): Cameroon, Nigeria and Tanzania. Project-monitoring data from 109 focus-group discussions, 6069 household-survey respondents and 89 interviews with ivermectin distributors were analysed to gain an insight into the attitudes and behaviours of men and women in relation to ivermectin treatment and their participation in the programme. Although there are no statistically significant gender differences in coverages for ivermectin treatment, culturally prescribed gender relationships influence the ways in which men and women express and experience treatment-related behaviours. Gender roles also affect participation in the programme. Decision-making in communities on the selection of distributors tends to follow socio-cultural hierarchies based upon patriarchy and gerontocracy. Relatively few ivermectin distributors (21%) are women. Although they receive less support than their male counterparts, the female distributors are just as willing to continue ivermectin distribution in the community, and they perform as well or better than men in this regard. The terms 'community-directed', 'community participation' and even 'compliance' obfuscate important gender differences that are inherent in the implementation of onchocerciasis control. Development of strategies that recognize these gender differences will have important implications for long-term adherence to treatment and for the overall quality and sustainability of the programme.

APOC's strategy of community-directed treatment with ivermectin (CDTI) and its potential for providing additional health services to the poorest populations. African Programme for Onchocerciasis Control

Since its inauguration in 1995, the African Programme for Onchocerciasis Control (APOC) has made significant progress towards achieving its main objective: to establish sustainable community-directed treatment with ivermectin (CDTI) in onchocerciasis-endemic areas outside of the remit of the Onchocerciasis Control Programme in West Africa (OCP). In the year 2000, the programme, in partnership with governments, non-governmental organizations and the endemic communities themselves, succeeded in treating 20,298,138 individuals in 49,654 communities in 63 projects in 14 countries. Besides the distribution of ivermectin, the programme has strengthened primary healthcare (PHC) through capacity-building, mobilization of resources and empowerment of communities. The community-directed-treatment approach is a model that can be adopted in developing other community-based health programmes. The approach has also made it possible to bring to the poor some measure of intervention in some other healthcare programmes, such as those for malaria control, eye care, maternal and child health, nutrition and immunization. CDTI presents, at all stages of its implementation, a unique window of opportunity for promoting the functional integration of healthcare activities. For this to be done successfully and in a co-ordinated manner, adequate funding of CDTI within PHC is as important as an effective sensitization of the relevant policy-makers, healthworkers and communities on the value of integration (accompanied by appropriate training at all levels). Evaluation of the experiences in integration of health services, particularly at community level, is crucial to the success of the integration.

The challenges of community-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC)

The principal strategy adopted by the African Programme for Onchocerciasis Control (APOC), for the control of onchocerciasis in the 19 countries of Africa that now fall within the programme's remit, is that of community-directed treatment with ivermectin (CDTI). Halfway through its 12-year mandate, APOC has gathered enough information on the main challenges to guide its activities in Phase 2. An analysis of reports and other documents, emanating from consultants, scientists, monitors and national and project-level implementers, indicates that there are three broad categories of challenge: managerial; technical; and socio-political. Under these three categories, this review identifies the most pertinent concerns that APOC must address, during Phase 2, to enhance the prospects of establishing sustainable systems for ivermectin distribution. The major challenges include: (1) maintaining timely drug-collection mechanisms; (2) integrating CDTI with existing primary-healthcare services; (3) strengthening local health infrastructure; (4) achieving and maintaining an optimal treatment coverage; (5) establishing and up-scaling community self-monitoring; (6) designing and implementing operations research locally; (7) ensuring the adequacy of community-directed distributors; (8) increasing the involvement of local non-govemmental develop organizations in the programme; (9) achieving financial sustainability; (10) implementing equitable cost-recovery systems; and (11) engaging in effective advocacy. The implications of the challenges and suggestions about how they are being (or could be) addressed are also highlighted in this brief review, which should be of value to other programmes and agencies that may be contemplating the adoption of this unique strategy.

Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control (APOC)

One of the fundamental challenges that the African Programme for Onchocerciasis Control (APOC) has had to face is how to identify the endemic communities where its mass ivermectin-treatment operations are to be carried out in conformity with its stated objective of targetting the most highly endemic, affected and at-risk populations. This it has done by adopting a technique, known as the rapid epidemiological mapping of onchocerciasis (REMO), that provides data on the distribution and prevalence of onchocerciasis. Integration of the REMO data into a geographical information system (GIS) enables delineation of zones of various levels of endemicity, and this is an important step in the planning process for onchocerciasis control. Zones are included in (or excluded from) the APOC-funded programme of community-directed treatment with ivermectin (CDTI), depending on whether or not their levels of onchocercal endemicity reach the threshold set by APOC. This review describes the application of the REMO/GIS technique by APOC in its operations, and identifies the remaining related challenges.

Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC)

Community-directed treatment is a relatively new strategy that was adopted in 1997 by the African Programme for Onchocerciasis Control (APOC), for large-scale distribution of ivermectin (Mectizan). Participatory monitoring of 39 of the control projects based on community-directed treatment with ivermectin (CDTI) was undertaken from 1998-2000, with a focus on process implementation of the strategy and the predictors of sustainability. Data from 14,925 household interviews in 2314 villages, 183 complete treatment records, 382 focus-group discussions, and the results of interviews with 669 community leaders, 757 trained community-directed drug distributors (CDD) and 146 health personnel (in 26 projects in four countries) were analysed. The data show that CDD dispensed ivermectin to 65.4% of the total population (71.2% of the eligible population), with no significant gender differences in coverage (P > 0.05). Treatment coverage ranged from 60.2% of the eligible subjects in Cameroon to 76.9% in Uganda. There was no significant relationship between the provision of incentives to CDD and treatment coverage (P > 0.05). The frequency of treatment refusal was highest in Cameroon (29.2%). Although most (72.1%) of the communities investigated selected their CDD on the basis of a community decision at a village meeting, only 37.9% chose their distribution period in the same way. There is clearly a need to improve communication strategies, to address the issues of absentees and refusals, to emphasise community ownership and to de-emphasise incentives for CDD. The investigation of the 'predictor indicators' of sustainability should enable APOC to understand the determinants of project performance and to initiate any appropriate changes in the programme.

The achievements and challenges of the African Programme for Onchocerciasis Control (APOC)

The main strategy of APOC, of community-directed treatment with ivermectin (CDTI), has enabled the programme to reach, empower and bring relief to remote and under-served, onchocerciasis-endemic communities. With CDTI, geographical and therapeutic coverages have increased substantially, in most areas, to the levels required to eliminate onchocerciasis as a public-health problem. Over 20 million people received treatment in 2000. APOC has also made effective use of the combination of the rapid epidemiological mapping of onchocerciasis (REMO) and geographical information systems (GIS), to provide information on the geographical distribution and prevalence of the disease. This has led to improvements in the identification of CDTI-priority areas, and in the estimates of the numbers of people to be treated. A unique public-private-sector partnership has been at the heart of APOC's relative success. Through efficient capacity-building, the programme's operations have positively influenced and strengthened the health services of participating countries. These laudable achievements notwithstanding, APOC faces many challenges during the second phase of its operations, when the full impact of the programme is expected to be felt. Notable among these challenges are the sustainability of CDTI, the strategy's effective integration into the healthcare system, and the full exploitation of its potential as an entry point for other health programmes. The channels created for CDTI, could, for example, help efforts to eliminate lymphatic filariasis (which will feature on the agenda of many participating countries during APOC's Phase 2). However, these other programmes need to be executed without compromising the onchocerciasis-control programme itself. Success in meeting these challenges will depend on the continued, wholehearted commitment of all the partners involved, particularly that of the governments of the participating countries.