Impatto della telepatologia sull’attività chirurgica in un ospedale rurale africano: rationale, problematiche e risultati

Introduzione. La telemedicina è una realtà nei paesi occidentali ma può avere una valida applicazione anche nei paesi a risorse limitate. La telepatologia in particolare può rappresentare una valida soluzione per migliorare la qualità dell’assistenza specialmente dove gli anatomopatologi sono pochi o mancano del tutto. Obiettivo: L’obiettivo generale di questa ricerca è stato quello di verificare la fattibilità e il reale impatto di un servizio di diagnostica istopatologica in telepatologia sul trattamento dei pazienti affetti da neoplasie ricoverati presso un ospedale rurale dell’Africa sub-sahariana. Obiettivi specifici : - valutare le risorse materiali ed umane utilizzate per il funzionamento del servizio di telepatologia ; - descrivere i risultati delle attività svolte dal servizio di telepatologia durante i primi due anni ; - proporre eventuali miglioramenti. Materiale e Metodi A seguito dell’elaborazione del progetto in collaborazione con i partner tecnici e finanziari nel 2015, la messa in opera del servizio di telepatologia è durata circa 12 mesi. Sono state prese in considerazione le problematiche relative agli aspetti finanziari, alla disponibilità delle risorse ed i risultati attesi. E’ stata eseguita una valutazione preliminare delle aspettative e delle eventuali perplessità del personale sanitario in merito all’adozione della telepatologia, provvedendo contestualmente a fornire opportune informazioni. Lo scanner acquisito è stato lo Hamamatsu NanoZoomer 2.0-RS C10730. Il personale locale è stato opportunamente formato ed è stato creato un registro in Excell dei pazienti esaminati. Sono stati quindi contattati e coinvolti dei patologi per la lettura dei vetrini a distanza attraverso una piattaforma informatica creata presso l’Hôpital de Zone Saint Jean de Dieu di Tanguiéta. Sono stati quindi valutati i risultati in termini di numero di esami istologici e tipologia delle patologie identificate. Risultati. Sono stati esaminati mediante telepatologia 1097 pazienti durante i primi due anni del progetto. 556 erano uomini e 541 donne, l’età media è stata di 41,5±19,9 anni (range 5 giorni- 88 anni). I prelievi istologici sono stati eseguiti praticamente a carico di tutti i tessuti ma in particolare nel 31,4% dei casi nel distretto uro-genitale, nel 14,2% a livello muscolo-cutaneo, nel 12,4% sulla mammella e nel 10,8% a carico dell’intestino. I tumori benigni hanno rappresentato il 38,6% delle diagnosi mentre le neoplasie maligne il 35,9%. L’intervallo di tempo tra l’invio delle immagini istologiche e la risposta del patologo è stato in media di 8±7 giorni. Per quanto riguarda la primitività delle neoplasie maligne, quelle a partenza dall’apparato urogenitale sono state le più frequenti (26,6%), seguite da quelle della mammella (20,1%) e del sistema linfo-splenico (13.7%). L’età media dei pazienti al momento della diagnosi del tumore maligno era di 42,5±20,1 anni. Per quanto riguarda le neoplasie della mammella, sono state identificate 136 neoformazioni. Di queste 79 (58.1%) erano neoplasie maligne e tutte le pazienti sono state sottoposte a trattamento chirurgico definitivo (quadrantectomia/mastectomia con linfoadenectomia). Queste pazienti rappresentano il 20.1% dei casi di cancro diagnosticati per mezzo della telepatologia a Tanguièta dal 2016 al 2018, quindi 1/5 di tutte le neoplasie. L’età media delle pazienti al momento della diagnosi era di 46.1± 13,5 anni con un range di 21-75. Conclusioni. La telepatologia è sicuramente una tecnologia con un impatto estremamente significativo sulla qualità dell’assistenza. I risultati ottenuti riguardano non solo il numero di esami istologici eseguiti ed eseguibili ma anche l’accuratezza delle diagnosi, la rapidità delle risposte e soprattutto la migliore definizione della strategia terapeutica da adottare in ogni singolo paziente. Riteniamo inoltre che la creazione di un servizio di telepatologia dovrebbe trovare maggiore diffusione nel contesto dei PVS, a livello Dipartimentale ma anche a livello nazionale. Requisito essenziale per la realizzazione di un servizio di telepatologia è la continuità assistenziale e funzionale della struttura ospedaliera che ne viene dotata, sia per quanto riguarda la formazione del personale dedicato sia per la necessità di costruire e garantire un network di patologi disponibili a collaborare

acute generalized peritonitis in a peripheral hospital centre in Benin. Can it be managed by a local general practitioner?

Background. Acute generalized peritonitis in resource-poor countries is still a health challenge due to late diagnosis, surgical delay, and specialists’ unavailability. %ese are the foremost determinants of surgical morbidity and mortality. We report the experience of a peripheral hospital in Benin not equipped with specialized surgeons. Methods. %is is an observational, retrospective, and descriptive study including patients operated for acute generalized peritonitis at the Atacora Departmental Hospital Centre, Benin, where unfortunately CTscan and intensive care unit are still not available. Most of surgical activities were performed by a general practitioner with previous surgical training (but no surgical specialization). Age, gender, cause of peritonitis, surgical procedures, and postoperative outcome were evaluated. Results. Sixty-three patients were included. %e mean age was 23.2 years and sex ratio M/F 1.5. %e mean surgical delay was 26 hours (range: 6–92 hours). An ileal typhoid perforation was found in 40 patients (63.5%), and 35 of them (87.5%) underwent a primary perforation repair without bowel resection. 73% of surgical procedures were performed by the general practitioner. Morbidity was 34.9% and mortality was 14.3%. %e average postoperative hospital stay was 12 days (range: 11–82 days). %ese results were comparable to those observed in the subgroup of patients (17 cases) operated by the general surgeons (morbidity 32.6%, mortality 13.0%, and average postoperative hospital stay 11 days, range: 1–58 days). Conclusion. Acute generalized peritonitis requires urgent management, and it can be effectively carried out, in a context of limited resources, by a general practitioner with surgical skills

Epidemiological aspects of surgical site infections in an income country. The case of regional hospital center, Borgou (Benin)

ABSTRACT Background: Surgical site infection is frustrating for the care team and depressing for the patient. Objective: To determine the epidemiological aspects of surgical site infections in regional hospital, Borgou. Methods: The study was crossed with prospective data collection. Recruitment was done for six months (from February 2013 to July 2013), each patient operated in both surgical services (general surgery and maternity) consents to be followed for one month or year. The surgical site infection was defined according to the CDC/NHSN 2009. Results: The frequency of surgical site infections was 7.3% (44/603). The mean age was 30.7 ± 15.8 years with minimum and maximum of 5 months and 70 years, respectively. They were significantly (p<0.05) more common in general surgery than that of maternity and visceral surgery and obstetrics were more concerned (14/44 each); the median time to SSI onset was 7.8 ± 3.8 days. The deep incisional infection was the most frequent (34/44). The most encountered organism was Escherichia coli (64.7%); multidrug resistance was 41.2%. The healing time averaged 30.5 ± 13.8 days with minimum and maximum of 20 and 92 days. Conclusion: Monitoring measures must be taken to reduce surgical site infection at the Regional Hospital Centre of Borgou.Background: Surgical site infection is frustrating for the care team and depressing for the patient. Objective: To determine the epidemiological aspects of surgical site infections in regional hospital, Borgou. Methods: The study was crossed with prospective data collection. Recruitment was done for six months (from February 2013 to July 2013), each patient operated in both surgical services (general surgery and maternity) consents to be followed for one month or year. The surgical site infection was defined according to the CDC/NHSN 2009. Results: The frequency of surgical site infections was 7.3% (44/603). The mean age was 30.7 ± 15.8 years with minimum and maximum of 5 months and 70 years, respectively. They were significantly (p<0.05) more common in general surgery than that of maternity and visceral surgery and obstetrics were more concerned (14/44 each); the median time to SSI onset was 7.8 ± 3.8 days. The deep incisional infection was the most frequent (34/44). The most encountered organism was Escherichia coli (64.7%); multidrug resistance was 41.2%. The healing time averaged 30.5 ± 13.8 days with minimum and maximum of 20 and 92 days. Conclusion: Monitoring measures must be taken to reduce surgical site infection at the Regional Hospital Centre of Borgou

Mannheim Peritonitis Index: usefulness in a context with limited resources: Prognosis of acute peritonitis.

Background: The objective of this study is to evaluate the Mannheim Peritonitis Index (MPI) usefulness for acute generalized peritonitis management in a clinical limited resources context. Methods: This is a prospective study from 1 January to 31 October 2019 including patients admitted to a sub-saharan hospital for acute generalized peritonitis. Perioperative variables and outcomes were considered. Results:&nbsp; 70 patients were included. Mean age was 32.6 ± 14.6 years with a sex ratio of 1.33. The mean time to patients’ hospital admission was 3.9 ± 2.1 days. Most patients had ileal and gastric perforations (27.1% and 18.6%). Twenty six patients (37.1%) developed complications and thirty-day mortality rate was 14.3%. Positive predictive value of MPI was 63.6% and negative predictive value was 83, 8%. Sensitivity of MPI ≥ 26 was 77.8%; Specificity of MPI &lt; 25 was 72.1%. Conclusion This experience shows that MPI is a good predictor of morbidity and mortality for patients with&nbsp;acute peritonitis even in a difficult context with few resources and many patients. Identifying the most critical patients, a more careful surgical staff involvement may improve patients outcome

Usefulness of a clinico-biological Francois’ score in the diagnosis of acute appendicitis. Experience of the University Hospital Center of Parakou, Benin

Introduction: Diagnostic wanderings of acute appendicitis are responsible for serious complications or abusive appendectomies. Existing Clinico-biological scores are efficient. Objective: To determine the diagnostic efficiency of François’ score in acute appendicitis. Methodology: over 10 months, all the patients admitted in the CHUD-Parakou Emergency Department for pain in the right iliac fossa had been examined by resident students who calculated François’ score. After verification by the surgeon, patients were put into three categories: category 1 score ≥ 2; category 2, score between -6 and 2; category 3, score below -6. Sensitivity and specificity were calculated. Results: out of 54 patients selected (29 men and 25 women), 29 were classified as group 1; 19 as group 2 and 6 as group 3. An ultrasound was performed in all patients in group 2, and signs in favor of appendicitis were found in 12 patients. Of the 41 appendicectomies performed, the histologic analysis of 33 operative specimens found a pathological appendix. Sensitivity, specificity and negative predictive value per group were 100%. It has prevented almost in one every four patients (24.07%) an abusive appendectomy. Conclusion: This score would reduce diagnostic wanderings and target patient groups for imaging studies

Acute Generalized Peritonitis in a Peripheral Hospital Centre in Benin: Can It Be Managed by a Local General Practitioner?

Background. Acute generalized peritonitis in resource-poor countries is still a health challenge due to late diagnosis, surgical delay, and specialists’ unavailability. These are the foremost determinants of surgical morbidity and mortality. We report the experience of a peripheral hospital in Benin not equipped with specialized surgeons. Methods. This is an observational, retrospective, and descriptive study including patients operated for acute generalized peritonitis at the Atacora Departmental Hospital Centre, Benin, where unfortunately CT scan and intensive care unit are still not available. Most of surgical activities were performed by a general practitioner with previous surgical training (but no surgical specialization). Age, gender, cause of peritonitis, surgical procedures, and postoperative outcome were evaluated. Results. Sixty-three patients were included. The mean age was 23.2 years and sex ratio M/F 1.5. The mean surgical delay was 26 hours (range: 6–92 hours). An ileal typhoid perforation was found in 40 patients (63.5%), and 35 of them (87.5%) underwent a primary perforation repair without bowel resection. 73% of surgical procedures were performed by the general practitioner. Morbidity was 34.9% and mortality was 14.3%. The average postoperative hospital stay was 12 days (range: 11–82 days). These results were comparable to those observed in the subgroup of patients (17 cases) operated by the general surgeons (morbidity 32.6%, mortality 13.0%, and average postoperative hospital stay 11 days, range: 1–58 days). Conclusion. Acute generalized peritonitis requires urgent management, and it can be effectively carried out, in a context of limited resources, by a general practitioner with surgical skills

Amputations de membres dans un hopital de zone du Nord-Bènin: A' propos de 122 cas

Abstract Limb amputation at a zone hospital in Northern Benin area: about 122 cases Aim: To study limb amputations at the Zone Hospital of Saint Jean de Dieu of Tanguiéta (ZHSJDT) in Benin. Materiel and methods: This was a descriptive study with retrospective data collection over a 5 yearperiod from January 1th 2009 to December 31th 2013. Different registers have been consulted. Data analysis was conducted by informatics and statistical significance was set at the .05 level. Results: One hundred and twenty-two (122) amputations in 118 patients were carried out. The mean age was 37.4 years, ranging from 1 to 80 years and 71.2% of the amputations occurred in manual workers respect to other professional activities (p = 0.041). Seventy (70) amputations (57.4 %) were performed on the left body side and 52 (42.6%) on the right side. Lower limbs were involved in 73.8% of cases and upper extremities in 26.2%. Major amputations accounted for 86.1% and minor amputations for 13.9% (p = 0.002). The causes of amputations were road injuries in 41.0% of cases and post-traumatic gangrene in 58.0%. Postoperative complications occurred in 37.7% of patients with 22.1% of surgical site infections and 10.2% of psychiatric manifestations. Mortality was 1.7%. Only 9.0% of cases had a prosthetic device after amputations. Conclusion: The young and active population are the most affected by limb amputations in ZHSJDT.Résumé Objectif : Etudier les amputations de membres à l’Hôpital de Zone Saint Jean de Dieu de Tanguiéta (HZSJDT) au Bénin. Matériel et méthodes : Il s’agissait d’une étude descriptive avec recueil rétrospectif des données sur une période de 5 ans allant du 1er janvier 2009 au 31 décembre 2013. Différents registres ont été consultés. Le traitement et l’analyse des données ont été informatiques. Les résultats ont été considérés significatifs pour un seuil alpha de 5%. Résultats : Au total, 122 amputations ont été réalisées chez 118 patients. L’âge moyen était de 37.4 ± 21.2 ans avec des extrêmes de 1 et 80 ans et un sex-ratio de 3.7. Les travailleurs manuels ont représenté 71.2% des amputés (p = 0.041). Soixante-dix amputations (57.4%) ont été réalisées du côté gauche et 52 (42.6%) du côté droit. Le membre pelvien était concerné dans 73.8% et le membre thoracique dans 26.2%. Les amputations majeures ont représenté 86.1%, les mineures 13.9% avec p = 0.002. Les traumatismes ont constitué 41% des causes avec 58% de gangrènes post-traumatiques. Des complications post-opératoires sont survenues dans 37.7% avec 22.1% d’infection du site opératoire et 10.2% de manifestations psychiatriques. La mortalité a été de 1.7%. Le taux d’appareillages a été de 9%. Conclusion : La population jeune et active est la plus concernée par les amputations de membre à l’HZSJDT

Surveillance of surgical site infections. An emergency in Saint John of God Regional Hospital of Northem in Republic of Benin

Surveillance of surgical site infections: an emergency in Saint John of God regional hospital of Northern in Republic of BeninIntroduction: The patient’s endogenous source is mostly involved in the occurrence of surgical site infections1 (SSI). Exogenous contamination is less frequent. Objectives: - Determine the incidence of SSI in Caesarean parturient - Identify the causative germs. Methods: This is a prospective cohort study with real-time data collection, including Caesarean parturients from 01 February to 30 May 2014 and 2015. The follow-up with phone calls was provided up to +30 days. In case of suspicion of an SSI, samples for cytobacteriological examination of the liquid coming from the superficial or deep part of the incision have been realized. The data was entered and evaluated using Epi info6 software. Results: The incidence rate in 2014 is 16.72% (52/311) and 4.7% (14/ 300) in 2015. Third generation cephalosporins were used in 87.2% (472/541) for antibiotic prophylaxis. The SSI occurred after the exit of the parturients in 72.7% of the cases, 42 (63.6%) cases benefited cytobacteriological analysis from purulent secretions. The examination returned positive in 43% (18/42) of the cases, 57% (24/42) were decapitated (sampling after an average delay of antibiotic therapy of 6.9 ± 2.8 days). 20 germs were isolated, predominantly monomicrobial (88.9%), 65% were Gram-positive cocci: staphylococcus aureus accounted for 45% of the isolated germs including MRSA followed by Streptococcus agalactiae in 20%, no strain of staphylococcal coagulase has been found. Gram-negative bacilli represent 35%: 71.4% are enterobacteriaceae, 40% of which are extended-spectrum beta-lactamase (ESBL), Escherichia coli was isolated in 10%, the same for pseudomonas aeruginosa (without any resistance). Conclusion: The endogenous flora is responsible for the majority of documented SSI, whether through poor skin preparation or aseptic error, but the emergence of ESBL is linked to the use of broadspectrum antibiotics. This requires clinical, microbiological and therapeutic vigilance in view of their specific resistance profile to antibiotics