Evaluation of the routine implementation of pulse oximeters into integrated management of childhood illness (IMCI) guidelines at primary health care level in West Africa: the AIRE mixed-methods research protocol

BACKGROUND

The AIRE operational project will evaluate the implementation of the routine Pulse Oximeter (PO) use in the integrated management of childhood illness (IMCI) strategy for children under-5 in primary health care centers (PHC) in West Africa. The introduction of PO should promote the accurate identification of hypoxemia (pulse blood oxygen saturation Sp02 < 90%) among all severe IMCI cases (respiratory and non-respiratory) to prompt their effective case management (oxygen, antibiotics and other required treatments) at hospital. We seek to understand how the routine use of PO integrated in IMCI outpatients works (or not), for whom, in what contexts and with what outcomes.

METHODS

The AIRE project is being implemented from 03/2020 to 12/2022 in 202 PHCs in four West African countries (Burkina Faso, Guinea, Mali, Niger) including 16 research PHCs (four per country). The research protocol will assess three complementary components using mixed quantitative and qualitative methods: a) context based on repeated cross-sectional surveys: baseline and aggregated monthly data from all PHCs on infrastructure, staffing, accessibility, equipment, PO use, severe cases and care; b) the process across PHCs by assessing acceptability, fidelity, implementation challenges and realistic evaluation, and c) individual outcomes in the research PHCs: all children under-5 attending IMCI clinics, eligible for PO use will be included with parental consent in a cross-sectional study. Among them, severe IMCI cases will be followed in a prospective cohort to assess their health status at 14 days. We will analyze pathways, patterns of care, and costs of care.

DISCUSSION

This research will identify challenges to the systematic implementation of PO in IMCI consultations, such as health workers practices, frequent turnover, quality of care, etc. Further research will be needed to fully address key questions such as the best time to introduce PO into the IMCI process, the best SpO2 threshold for deciding on hospital referral, and assessing the cost-effectiveness of PO use. The AIRE research will provide health policy makers in West Africa with sufficient evidence on the context, process and outcomes of using PO integrated into IMCI to promote scale-up in all PHCs.

TRIAL REGISTRATION

Trial registration number: PACTR202206525204526 retrospectively registered on 06/15/2022.

[Contribution of a virtual hysteroscopic simulator in the learning of hysteroscopic myoma resection]

OBJECTIVES

Uterine myomas are a frequent pathology affecting 20% of women of reproductive age. Myomas induce abnormal uterine bleeding, pelvic pain and increase the risk of infertility and obstetrical complications. Symptomatic sub-mucosal myomas are classically treated by hysteroscopic resection. Simulation is a method of education and training. It could improve quality and security of cares. The aim of this study is to assess the interest of a hysteroscopic simulator for the resection of myoma by novice surgeons.

METHODS

Twenty medical students were recruited, in a prospective study, in august 2014. The virtual-reality simulator VirtaMed HystSim™ (VirtaMed AG, Zurich, Switzerland) was used to perform the hysteroscopic training. All students received a short demonstration of myoma resection. The practice consists of a submucous myoma type 0 resection. The procedure and the evaluation were performed before and after a specific training in hysteroscopic resection of sixty minutes long. The main outcome criteria were time for the resection before and after training. The second criteria were fluid quantity used, number of contact between optic and uterine cavity and uterine perforation.

RESULTS

Twenty students aged from 22 to 24 years were included. The time for the procedure was significantly reduced after training (170s versus 335s, P<0.01). There is the same for fluid quantity used (335 mL versus 717mL, P<0.01) and the number of contact between optic and uterine cavity (0.2 contact versus 3, P=0.012). No perforation occurred in the simulation.

CONCLUSION

The results suggest that hysteroscopic simulator enhances and facilitates hysteroscopic resection for novice surgeons.

Interest of human papillomavirus DNA quantification and genotyping in paired cervical and urine samples to detect cervical lesions

BACKGROUND

Cervical cancer is caused by persistent infection with high-risk human papillomavirus (HR-HPV). Conventional human papillomavirus (HPV) testing requires cervical sampling. However, vaginal and urine self-sampling methods are more acceptable for patients and result in increased participation when they are available in screening programs. In this context, we have developed a non-invasive screening method via the detection of HPV DNA in urine samples.

PURPOSE

To compare HPV viral loads and genotypes in paired cervical and urine samples, and to assess correlation between virological and cytological results in women seeking gynecological consultation.

METHODS

Paired urine and cervical specimens were collected and analyzed from 230 of 245 women participating in the previously described prospective PapU study. HPV DNA detection and quantification were performed using a real-time PCR method with short fragment PCR primers. Genotyping was carried out using the INNO-LiPA HPV genotyping assay.

RESULTS

The prevalence of HPV in the 230 paired urine and cervical smear samples was 42 and 49 %, respectively. Overall agreement for HPV positivity and negativity between the paired samples was 90 % (κ = 0.80). High HPV viral load in both cervical and urine samples was associated with cytological abnormalities. HPV-positive women were mostly infected with HR-HPV types. The agreement between high- and low-risk HPV (LR-HPV) detection in both samples was 97 % (κ = 0.95 for HR-HPV and κ = 0.97 for LR-HPV).

CONCLUSIONS

High concordance rates for HPV-DNA quantification and high/low-risk HPV genotyping in paired urine/cervical samples suggest that urinary HPV DNA testing could be useful for cervical lesion screening.

Assembly of molecular nanomagnets into nanogap electrodes by dielectrophoresis

We investigate the assembly of Prussian blue and Cs-Co-Cr Prussian blue analogue molecular nanomagnets into nano-patterned electrodes. Pd or Au gaps - 7-50 nm were fabricated on a SiO2/Si substrate using standard electron beam lithography and lift-off. Nanomagnets were positioned between the gaps via AC dielectrophoresis (DEP). At room temperature, the Cs-Co-Cr Prussian blue analogue nanoparticles exhibited negligible current whereas junction with Prussian blue nanoparticles exhibited - 30 pA at - 1 V.

[Laparoscopy for surgical treatment for uterine and ovarian cancer in France: a national practice survey]

AIM

The aim of this study was to describe the use of laparoscopy in gynecologic malignancies (cervical, endometrial and ovarian cancer, borderline included) in France during year 2005.

PATIENTS AND METHODS

We have carried out a retrospective national practice survey during 12 months. Each university hospital (45 centers) and each cancer center (20 centers) received a questionnaire to evaluate their practice in laparoscopy. Centers performing less than ten cases per year in this indication were excluded.

RESULTS

Among 65 centers, 31 answered and 19 were included. A total of 1397 surgical procedures for gynaecologic cancer was analysed. Laparoscopy was performed in 714 cases. In these cases, 51.1% (675 cases) of patients were treated by laparoscopy in France during year 2005. Seventy-four surgical procedures for cancer were performed each year per center and among them 38 by laparoscopy. The average cases number is 9.4 per surgeon.

CONCLUSION

We found that 51.1% of cases of gynaecologic cancer surgery were performed by laparoscopy in France during 2005, representing 38 cases per centers and 9.4 per surgeon per year. This suggests that access to training for surgeons and care for patients is difficult.

[Patient follow-up after treatment for breast cancer]

Patient follow-up after treatment for a breast cancer is based on the local recurrence risk. Annual mammography remains the main point of this follow-up and tumor markers detection has still no interest. Absence of benefit of an intensive clinical, biological and radiological surveillance has been proved for a long time but expert recommendations still are a subject of discussion although they knew no evolution for more than 10 years. Evolution of those follow-up modalities will depend on the future indications of MRI and PET. About distant recurrence, a better knowledge of the risk is now possible thanks to the tumor biological profile study. Nevertheless, intensification of follow-up for some kind of high-risk tumors will have interest only if we can propose a therapeutic alternative in metastatic situation.

[Sentinel node detection applied to breast cancer: 2007 update]

The technique of detection and resection of the sentinel lymph node applied to early breast cancer management aims to spare the patient with a low risk of lymph node involvement an unnecessary axillary lymphadenectomy. This innovating technique lies on the double hypothesis of an accuracy to predict non sentinel lymph node status and to induce a lower morbidity when compared with axillary lymphadenectomy. This multidisciplinary technique depends on surgeons, nuclear physicians and pathologists. In practice sentinel lymph nodes are detected thanks to two types of tracers, the Blue and the colloids marked with technetium, harvested by the surgeon guided by the blue lymphatic channel and the use of a gamma probe detection, analyzed by the pathologist according to a particular procedure with the concept of serial slices, and possibly immuno histo chemistry. The objectives of this review are to specify the state of knowledge concerning the different steps: detection, surgical resection and the pathological analysis of the sentinels lymph nodes and to focus on validated and controversial indications, and on the main ongoing trials.

Rupture utérine obstétricale après hystéroscopie opératoire

The aim of this study was to attempt to identify factors predictive of uterine rupture following operative hysteroscopy. A MEDLINE and EMBASE search (1980 to April 2006) using the keywords "hysteroscopy", "uterine rupture" and "pregnancy" was performed with no limitations of languages. 18 cases of uterine rupture following operative hysteroscopy were retrieved. Hysteroscopic metroplasty (uterine septa and synechiae) was involved in 16 (89%) cases. Hysteroscopic resection was performed with monopolar current cutting, rigid scissors and laser in respectively 14 (78%), 3 (16.5%) and 1 (5.5%) cases. Uterine perforation occurred in 10 (55.5%) cases. The interval between hysteroscopy and subsequent pregnancies varied from 1 month to 5 years with an average delay of 16 months. Uterine rupture occurred between 19 and 41 weeks, with no labour in 12 (66.5%) cases. Four fetal and one maternal deaths followed uterine rupture. Hysteroscopic metroplasty may expose patients to an increased risk of uterine rupture in subsequent pregnancy. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome. Considering hysteroscopic metroplasty, the use of coaxial bipolar electrode should be preferred.

Hyperplasies atypiques et carcinomes de l'endomètre de stade I chez la femme jeune désirant une grossesse : le traitement conservateur est-il envisageable ? Résultats d'une étude multicentrique française

OBJECTIVES

To analyse the carcinological and obstetrical results of young women with atypical endometrial hyperplasia or endometrial adenocarcinoma, treated in a conservative way to allow pregnancy.

PATIENTS AND METHODS

A retrospective analysis of 13 cases (5 adenocarcinomas and 8 atypical hyperplasias) followed in 8 French centers between 1997 and 2004.

RESULTS

After 4.6 months of conservative treatment, there were no residual lesions in 61.5% of the cases. Progestatives seem to be the most effective treatment. Tumoral regression makes it possible to plan a pregnancy, with childbirth in 25% of the cases. In these frequently infertile patients, all the techniques of assisted reproduction can be used. Recurrences are not rare after hormonal treatment (37.5%), so, total hysterectomy is justified after delivery.

DISCUSSION AND CONCLUSION

Conservative treatment for young women with atypical endometrial hyperplasia or endometrial adenocarcinoma stage I can be considered in some cases to enable pregnancy.

[Malignant tumors arising in extra-ovarian endometriosis: a case report]

We report a case of degenerative extra-ovarian endometriosis. This is a rare complication of endometriosis, the frequency of which is estimated at 0.9%. In more than 50% of the cases, the diagnosis is made following investigation for abdominal pain. If the degeneration is of the same histological type as the endometriosis, it can be said to have arisen from the endometriosis. First-line treatment is surgery, removing as much endometriosis as possible, staging at this point is also necessary. Second-line treatment, with chemotherapy, radiotherapy and even hormonotherapy may be needed. Prognosis for this tumor is variable, from 10 to 100% five-year survival, depending on histological type and localization of the disease.

Grossesse isthmique localisée au niveau d'une cicatrice d'hystérotomie traitée par méthotrexate. À propos d'un cas

We report a case of a patient who presented an isthmic pregnancy successfully treated with an intramuscular injection of methotrexate. The diagnosis of isthmic pregnancy was made clinically (cervical colour was normal, inferior segment soft and enlarged) and echographically (long cervix, foetal sack situated in the isthmus and the uterine body was empty). An isthmic full term pregnancy is possible but would carry major haemorrhagic risk. There are several therapeutic options if the pregnancy is interrupted: medical treatment of methotrexate, curettage, curettage with embolisation of the uterine arteries and as a last resort, hysterectomy. The success of conservative treatment seems to be related to the criteria known for the cervical pregnancy, which are cardiac activity, the level of HCG, gestational age and cranial-caudal length.

Conséquences de l’obésité maternelle sur le déroulement du travail et l’accouchement

AIMS

The aim of this survey was to analyze the effects on labor, delivery, afterbirth, and neonatal status of maternal obesity, independently of other diseases that might modify obstetrical management.

POPULATION AND METHODS

Cross-sectional survey of cases during one year in the obstetrics department of a university hospital center. The inclusion criterion was obesity, defined as BMI > 30. The exclusion criteria were hypertension, pregnancy-related hypoxemia, diabetes (pre-existing or pregnancy-related), maternal cardio-pulmonary disease, uterine scar, multiple pregnancy, and non-cephalic presentation. Two groups, one obese and the other not, were matched for age and parity.

RESULTS

The rate of post-term deliveries was higher among obese women (p = 0.04), induction of labor more frequent (p = 0.05), and the duration of its first phase longer (p = 0.003); the cesarean rate was seven times higher (14.6% versus 2.1%) and the mean weight of the newborns significantly higher (p = 0.01). Multivariate analysis found the following factors to be significantly associated with maternal obesity: longer duration of the first phase of labor, less frequent spontaneous vaginal delivery, higher cesarean rate, and higher rate of lack of progress in dilatation.

CONCLUSION

This study shows that maternal obesity is a risk factor for complications during pregnancy, independently of its standard complications--pregnancy-related diabetes and hypertension. It compromises the smooth progression of labor and delivery. Pregnancy in obese women must be considered to be "at risk", regardless of any complications of obesity. It is thus important to help obese women become more aware of the importance of a balanced diet for themselves and their children. The presence of an obese adult in the household quadruples the risk of obesity in children.

Sarcome du chorion cytogène de bas grade

Endometrial stromal sarcoma is a rare malignant uterine tumor. We report 4 cases of low-grade endometrial stromal sarcoma, corresponding to the form with a mitotic index at less than 10 mitoses per 10 high power fields (HPF), from which we carried out a review of the literature and defined the potential interest of hormone therapy and chemotherapy by etoposide. Generally diagnosed in pre-menopause, the main clinical signs, which are not very specific, are metrorrhagia and pelvic pain. The etiologic diagnosis is established from the pathology analysis. Intravascular extension, which is observed in nearly 50% of patients, should evoke the disease. The initial treatment is mainly based open surgery, generally total hysterectomy with annexectomy. There is no effective adjuvant treatment. The potential of reccurences remains around 50% with a 34-month median. Several therapeutic options are possible after recurrence but no standard treatment has been established. We are mainly interested in three medical options but the surgery remains an alternative of choice. Chemotherapy by oral etoposide offers easy administration, good compliance and acceptable toxicity with median 20-month remission in 3 patients before progression. Hormone therapy with progestogens (hormone receptor expression of the tumor is 71% for estrogens and 95% for progesterone) is widely studied in the literature with a 46% response rate and 46% rate of disease stabilization. Hormone therapy with an anti-aromatase appears to be a promising treatment according to the bibliographic references on this subject. Overall, prognosis of low-grade endometrial sarcoma is relatively good with 100% survival at 5 years. The progression pattern is slow, requiring regular and prolonged surveillance.

[Benzodiazepine poisoning in a neonate: clinical and toxicokinetic evaluation following enterodialysis with activated charcoal]

CASE REPORT

A pregnant woman who was a regular user of anxiolytics was admitted to the maternity ward at 38 weeks and 4 days amenorrhea after a massive overdose of clorazepate dipotassium, a benzodiazepine. The exact quantity ingested was undetermined. The infant, born at 39 weeks, presented no spontaneous breathing and tracheal intubation was necessary in the delivery room. The neonatal blood concentrations of the clorazepate metabolites were very high at delivery (26 mg/l nordiazepam and 3.5 mg/l oxazepam) and showed little change over the next 5 days (16 mg/l nordiazepam and 2.1 mg/l oxazepam, with an apparent half-life of 168 h for nordiazepam and 160 h for oxazepam). By day 6, the infant was still dependent on ventilator support and enterodialysis was begun with repeated doses of activated charcoal (1 g/kg every 6 h by gastric tube). Treatment was continued for 5 days and a spectacular diminution in the serum concentrations of the two metabolites was noted on day 11: 1.5 mg/l nordiazepam and less than 0.1 mg/l oxazepam. The nordiazepam and oxazepam half-lifes were reduced to 42 h and 30 h respectively. The concomitant clinical improvement authorized the weaning from ventilation on day 12.

CONCLUSION

This is the first report of the use of enterodialysis to treat severe benzodiazepine poisoning in a neonate. Depuration of the toxin was accelerated and the duration of intensive care was shortened thanks to this technique.

Towards a better understanding of the magnetic interactions within m-phenylene alpha-nitronyl imino nitroxide based biradicals

An extensive investigation of the magnetic properties of three series of biradicals (bis-nitronyl nitroxides diNN-R, bis-imino nitroxides diIN-R and mixed INNN-R, where R is either hydrogen, a triple bond or trimethylsilylacetylenic group) has been carried out to give clear values of the intramolecular interactions through the m-phenylene coupling unit with alpha-nitronyl nitroxides (NN) or alpha-imino nitroxides (IN). An EPR study of the molecules in the isolated state is validated by ab initio calculations, which show the respective influence of spin polarisation and molecular conformation on the singlet-triplet gaps. All these results indicate that the triplet state is the ground state for such biradicals, except when the imidazolyl cycles are orthogonal to the phenyl ring. The magnetic properties of the biradicals in the solid state can be rationalised by examination of the short contacts produced between the ONCNO and ONCN groups. EPR studies on single crystals of the H-substituted series have confirmed the presence of a structural distortion for diNN-H whereas diIN-H and INNN-H do not exhibit such a peculiarity. The magnetic behaviour of diIN-H is described well by a four-spins model, with a strong intermolecular antiferromagnetic interaction of -90 K, whereas in the case of the two other compounds, a supplementary contact involves more complex interactions between the dimers. The compound diNN-tmsa exhibits a ferromagnetic intermolecular interaction of +11 K within the dimers, and this could be attributed to the relative disposition of the imidazolyl rings. Compound diNN-tr reveals a chain-like behaviour, whereas diIN-tr shows a predominant antiferromagnetic interaction within the dimers. The values for the intramolecular interactions in the solid state are in good agreement with those found for the isolated molecules.

[Gravely ill newborns (excluding greatly premature) in 1986 and 1995 in three deparments of Pays de la Loire]

AIM

Evaluation of the progress in the treatment of seriously ill newborn infants under hospital care over the nine-year period from 1986 to 1995 in three departments of the Pays de la Loire region in France.

POPULATION AND METHODS

The category of seriously ill newborn infants included only infants born after at least 32 weeks of gestation and having a Cullen severity score higher than 2. The two groups of seriously ill newborn infants at risk in 1986 and 1995 were first compared to a control group of healthy newborn babies delivered during the same years. The two groups were then compared with each other.

RESULTS

In 1986 and 1995, the numbers of births were respectively 32,876 and 29,446, and the numbers of seriously ill newborn infants under hospital care were respectively 307 and 245. However, between 1986 and 1995 the risk factors as well as the causes of morbidity had changed. The average period of hospitalization decreased by five days. The mortality rate dropped from 0.16% to 0.09% (P < 0.05) and the number of serious complications decreased from 0.07% to 0.03% (P < 0.05).

CONCLUSION

The improvement in the care of seriously ill newborn infants between the two reference periods, 1986 and 1995, may be attributed not only to technical progress but also to a better organization of the perinatal care in our region.