Therapeutic follow-up of postoperative patients on tramadol in the intensive care unit a tertiary African hospital: a cohort study

Background: Tramadol, an analgesic, is a prodrug requiring bioactivation through cytochrome P450 enzymes (CYP450) to obtain O-desmethyltramadol (M1), its active metabolite. However, little is known on the African pharmacogenetic profile of tramadol metabolism. Hence, we aimed to study the biological efficacy of tramadol in an African population.Methods: This was a prospective cohort study over a 3-month period carried out at intensive care unit of a Cameroonian tertiary hospital. We enrolled patients with moderate-to-severe pain surgery, who had not been administered drugs metabolized by CYP450. Immediately after surgery, 2 mg/kg of tramadol was administered intravenously every 6 hours. Pain was assessed using the visual analog scale (VAS) within the first 24 hours. Vital signs and side effects were recorded. Plasma samples were collected at 3rd and 6th hours to assay tramadol and M1 using HPLC-UV.Results: We enrolled 30 patients with a mean age of 32 years operated for caesarean section, laparotomy and cancer surgery, under spinal and general anesthesia. Before administration of tramadol, the VAS was 6/10. The VAS decreased 4/10 to 1/10 between the 3rdand the 6th hour. There was a reduction of the respiratory rate of 3 breath cycles per minute as early as the 6th hour. Samples from 13 patients were analyzed. M1 was found in all patients; of which 4 had a slow metabolism and 3 had a faster metabolism.Conclusions: Overall there was good correlation between the clinical and biological analgesic efficacy of tramadol

Pyosalpinges after hysterosalpingography in a patient with lower genital tract infection and managed by laparoscopic surgery in a resource low tertiary hospital case report and literature review

Abstract Background Pyosalpinges (a complication of pelvic inflammatory disease) is infection of the fallopian tubes and the morbidity associated with it has major health implications. We are reporting a case of pyosalpinges diagnosed after hysterosalpingography and managed by laparoscopic surgery at the Douala General Hospital, Cameroon. Case presentation A 29-year-old single woman, an assistant nurse of the Douala tribe in Cameroon. She is G1P0010 and came to our attention because of secondary infertility of three years duration. She has a history consistent with four lifetime sexual partners, self-medication for chlamydia trachomatis infection and induced abortion by dilatation and aspiration. Furthermore, she is HIV positive and had an ultrasound scan suggestive of bilateral hydrosalpinges. After a hysterosalpingography examination she developed painless muco-purulent vaginal discharge and bilateral adnexal tenderness on bimanual examination suggestive of pyosalpinges. Vaginal and cervical cultures isolated Ureaplasma urealyticum and Gardnerella vaginalis sensitive to ofloxacin and metronidazole, respectively. At laparoscopy, bilateral pyosalpinges, pelvic adhesions and peri-hepatic adhesions were found. Bilateral salpingectomy with adhesiolysis including lysis of perihepatic adhesions and peritoneal toileting was done. She was discharged from hospital 72 h later and her hospital stay was uneventful. She was counseled for in-vitro fertilization and to register in the national HIV treatment programme. Her husband was prescribed ofloxacin empirically. Conclusion Antimicrobial prophylaxis should be given to patients prior to HSG, especially those with a history of chlamydia or evidence of hydrosalpinges. There should also be universal STI testing in high risk and HIV positive patients or the danger for suboptimal antibiotic usage in areas where self-medication is common. In resource-low tertiary hospitals where computed tomography or magnetic resonance imaging is not readily available and/or affordable, clinical examination and pelvic ultrasound remains the key diagnostic tool. Surgical treatment is the best option for pyosalpinges and when plausible, laparoscopic surgery is the treatment of choice. Laparotomy is the mainstay in most hospitals in Cameroon. The parent of the patient did not consent to histo-pathologic examination

Severe Viperidae envenomation complicated by a state of shock, acute kidney injury, and gangrene presenting late at the emergency department: a case report

Abstract Background Snake envenomation is an underestimated pathology in sub-Saharan Africa associated with severe emergencies, and even death in case of late presentation. We herein present a case of severe envenomation managed at the surgical emergency department of the Yaoundé Central Hospital. Case presentation We report a case of a 47-year-old female farmer with no relevant past history who sustained a snakebite by an Echis occellatus viper during an agricultural activity. Her initial management consisted in visiting a traditional healer who administered her some herbal remedies orally and applied a white balm on the affected limb. Due to progressive deterioration of her condition, she was rushed to our surgical department where she arrived 20 h after the snakebite incident. On admission she presented in a state of shock (suggestive of an anaphylactic shock), coagulopathy, renal impairment, and gangrene of the entire right upper limb. Emergency management consisted of fluid resuscitation, repeated boluses of adrenaline, a total of three vials of polyvalent anti-venom sera, promethazine, analgesics, corticosteroids, and administration of fresh frozen plasma. Within four hours of emergency department hospitalisation she developped signs of sepsis and persistent hypotension refractory to fluid resuscitation, suggestive of an associated septic shock. Management pursued with antiobiotherapy and administration of noradrenaline through an electric pump syringe to achieve a mean arterial blood pressure above 65 mmHg. The patient deceased at the 10th hour of hospitalisation in a state of circulatory collapse unresponsive to vasopressors, coagulopathy, renal failure, sepsis and gangrene of the right forearm. Conclusion The authors highlight this unusual presentation but equally pinpoint how late presentation to the emergency department, harmful tradition practices, poverty and cultural beliefs can adversely affect the prognosis of snakebite in our setting

A case of Mayer-Rokitansky-Küster-Hauser syndrome in a low-resource tertiary hospital in Douala, Cameroon

The Mayer-Rokitansky-Küster-Hauser syndrome is the congenital absence or underdevelopment of the uterus and vagina even though the external genitalia, ovaries and ovarian function are normal. This condition is uncommon in Cameroon. A 23-year-old woman of the Fulbé tribe, a predominantly Islamic tribe of the northern part of Cameroon, complained of the absence of menstruation after age of puberty and lower abdominal pain occurring almost at the same period every month. She has been married polygamously for 10 years and has been having normal, satisfactory sexual intercourse. The sonographic and laparoscopic findings of this patient were consistent with Mayer-Rokitansky-Küster-Hauser syndrome. The patient was counseled for in vitro fertilization and surrogacy. Patients with Mayer-Rokitansky-Küster-Hauser syndrome typically present with primary amenorrhea during adolescence. With the existing medical technology in Cameroon, this condition is easily accessible in tertiary healthcare facilities. Patients with Mayer-Rokitansky-Küster-Hauser syndrome could become mothers through in vitro fertilization and surrogacy, but the cost is prohibitive in Cameroon

Urgences neurologiques au service de réanimation de l’Hôpital Gynéco-Obstétrique et Pédiatrique de Yaoundé : aspects clinique, étiologique, thérapeutique et pronostique

Objectif: Le but de notre étude était de déterminer la proportion et les étiologies des urgences neurologiques, de décrire leur prise en charge et d’évaluer leur pronostic dans une unité de réanimation.Méthodologie: Il s’agissait d’une étude cohorte prospective de 6 mois. Etaient inclus tous les patients de sexe féminin et d’âge supérieur ou égal à 18 ans, admis pour une urgence neurologique dans l’unité de réanimation de l’Hôpital Gynéco-Obstétrique et Pédiatrique de Yaoundé. Etaient exclues de l’étude les patientes ayant refusé de participer à l’étude, celles présentant une notion de traumatisme, les décès précoces (< 24 heures après l’admission). Les informations collectées concernaient les données cliniques, thérapeutiques, la durée de séjour et le devenir des patients. La comparaison des pourcentages entre les variables était faite avec le test de Khi carré, avec comme seuil de significativité p < 0,05.Résultats: Au total, 37 cas d’urgences neurologiques étaient enregistrés sur 499 patients admis soit une prévalence de 7,41% et seuls 35 patientes étaient inclus. L’âge moyen était de 38,2 ± 22,1 ans. Le délai moyen d’admission était de 16 heures. Les principaux antécédents étaient : la période post-partum (n=10, 27%), l’aménorrhée gravidique (n=7, 18,9%). Tous les patients présentaient une céphalée, une convulsion, un déficit neurologique focal et un syndrome méningé. Les principales étiologies étaient : l’éclampsie (n=17, 48,6%), les comas non traumatiques (n=8, 22,9%), les accidents vasculaires cérébraux (n=5, 14,3%), les méningo-encéphalites (n=5, 14,3%). Pour une durée moyenne de séjour de 6,5 ± 5,9 jours, la mortalité globale était de 37,1%, soit 13 décès. Les causes les plus fréquentes dans de décès étaient les méningo-encéphalites (n=4, 30,7%), le choc septique (n=3, 23,1%) et l’AVC (n=3, 23,1%). Les facteurs associés au décès étaient l’âge > 55 ans, l’infection au VIH, le score de Glasgow < 8, le délai d’admission > 6 heures, la mauvaise observance du traitement et la survenue de complications (p < 0,05).Conclusion: Près d’un patient sur 10 admis en réanimation présente une urgence neurologique. Un patient sur 3 avec urgence neurologique décédera. La prévention de l’éclampsie et la consultation à temps pourraient conduire à réduire cette mortalité.Mots clés: Urgence neurologique, Prise en charge, Réanimation, Pronostic, YaoundéEnglish Title: Neurological emergencies in the intensive care unit of the Yaounde Gynaeco- Obstetric and Paediatric Hospital: clinical presentation, treatment and outcomeEnglish AbstractObjective: The aim of our study was to describe the clinical, etiological, therapeutical and prognostical aspects of neurological emergencies in the intensive care unit.Materials and methods: We carried out a prospective cohort study over 6 months. We included female adult patients admitted for neurological emergencies into the intensive care unit of the Yaoundé Gynaeco- Obstetric and Pediatric Hospital. We studied the prevalence of neurological emergencies, the different emergencies encountered, treatment administered, and outcome.Results: The frequency of neurological emergencies was 7.4%. Eclampsia was recorded in 48.6% of patients. The management of eclampsia was based on the use of magnesium sulphate and antihypertensive bitherapy with nicardipine and alpha methyl-DOPA. All cases of neurological infection received empirical triple antibiotic therapy with short duration corticosteroid therapy. Management of non traumatic coma was mainly symptomatic. Management of strokes was oriented by the findings on the head CT scan. Non traumatic coma and neurological infections were the most deadly, responsible for 46.2% and 30.7% of deaths respectively. Factors associated to poor prognosis were age greater than 55 years, HIV immune deficiency, a Glasgow score less than or equal to 8, admission interval greater than 6 hours, poor adherence to treatment, and the development of complications.Conclusion: The management of neurological emergencies is not optimal. We can ameliorate our management by efficient health policies.Keywords: Neurological emergencies, Management, Intensive care unit, Prognosis, Yaound

HIV care in Cameroon: a missed opportunity to screen for high blood pressure among adults living with HIV/AIDS?

Background: Two third of the thirty-seven million people living with HIV/AIDS (PLWHA) globally live in Africa. With the advent of antiretroviral drugs, African PLWHA are living longer and are at increased risk of cardiovascular diseases including high blood pressure (HBP). In this preliminary study, we assessed how often blood pressure (BP) was measured and recorded and the prevalence of HBP in PLWHA followed at three hospitals in Cameroon.Methods: We retrospectively analysed the blood pressure measurement frequency and data of patients enrolled in the HIV care at the Limbe Regional hospital, Bamenda Regional hospital and the Jamot hospital in Yaounde from 2014 to 2017. Files of all PLWHA aged ≥21years were reviewed. Sociodemographic, laboratory and clinical data were captured. HBP was defined as systolic (and/or diastolic) blood pressure (BP)≥ 140 (90) mm Hg, or ongoing BP- lowering medications. Analysis were done using Epi info version 2.0. Statistical significance was set at p-value<0.05 at 95% confidence interval.Results: Of 991 medical files examined, 875 files (88.3%) had BP recorded at least once during the study period among which only 418 (47.8%) participants at enrolment in care. 281 (67.2%) were women, mean age was 42.6±10.6 years. The prevalence of HBP was 24.2% in 2014, dropped to 20.2% in 2015, rose to 26.3% in 2016, then dropped again to 18.9% in 2017. Compared with females, this prevalence was consistently higher among males each year.Conclusion: Less than half of PLWHA had their BP recorded at enrolment in HIV care but almost 1 of every 5 of these patients had HBP. The trend of HBP prevalence over the study period was inconsistent due to poor recording. These results warrant awareness raising for HBP screening in HIV treatment centres and further studies in larger sample with a longer follow-up period to better understand the occurrence of HBP in PLWH.Keywords: HIV/AIDS, High Blood Pressure, opportunity, trend, prevalence, Cameroo

Clinical outcome of patients with venous thromboembolism on Rivaroxaban versus vitamin K antagonists : A preliminary report from Douala, Cameroon

Background: Direct Oral Anticoagulants (DOACs) which are increasingly used for the management of Venous Thromboembolism (VTE) have demonstrated efficacy and safety in clinical trials. However, little is known on outcomes in those managed with DOACs compared to Vitamin K Antagonists (VKAs) in routine clinical practice in Africa. In this preliminary study, we sought to compare the non-fatal clinical outcomes in VTE patients managed with Rivaroxaban versus VKAs in Douala. Materials and Methods: This preliminary study analyzed medical records of VTE patients managed with oral anticoagulants over a 3-year retrospective period in Douala General Hospital and Douala Cardiovascular Center. Outcomes of interest included bleeding, recurrent VTE and post-thrombotic syndrome. Data was analyzed using SPSS version 23. Results: Eighty-seven medical records were identified; Deep venous thrombosis (DVT) was diagnosed in 36.8% and 13.8% had both DVT and pulmonary embolism. Rivaroxaban was prescribed in 77% of cases. We included 82 medical records for the outcome analysis. Adverse clinical outcomes were recorded in 19 (23.2%) medical records amongst which 15 (78.9%) in the Rivaroxaban group. All (4 patients) who bled, 6 (66.7%) patients who had VTE recurrence and 5 (71.4%) patients with post-thrombotic syndrome were managed with Rivaroxaban, however, these were not statistically significantly different from those managed with VKAs. No predictor of clinical outcome was identified. Though more outcomes occurred within 30 days of oral anticoagulation, this was not statistically significant. Conclusion: Three-quarters of VTE patients were managed with Rivaroxaban. Although more bleeding was observed with rivaroxaban group, clinical outcomes were similar with VKA group. This seeds the idea of a prospective study in real life with a larger sample size in Africa. Keywords: Outcomes, Deep vein thrombosis, pulmonary embolism, Venous thromboembolism, Oral anticoagulation, Cameroo