Gilles Guerrier

Bacteremic community-acquired infections due to Klebsiella pneumoniae: clinical and microbiological presentation in New Caledonia, 2008-2013

OBJECTIVES To provide data on severe bacteremic community-acquired infections due to Klebsiella pneumoniae in New Caledonia. METHODS All patients admitted with bacteremic community-acquired infections due to K. pneumoniae at the only tertiary medical center in New Caledonia, from 2008 to 2013, were included retrospectively in this study. Clinical and microbiological characteristics were analyzed, as well as risk factors for mortality. RESULTS The characteristics of 119 patients were analyzed. The most common clinical presentation was urinary tract infection (40 cases, 33%), followed by pneumonia (28 cases, 23%), deep abscesses (15 cases, 13%), liver abscess (12 cases, 9%), meningitis in (five cases, 4%), and endophthalmitis (two cases, 1%). Multiple localizations were reported in 18 cases (15%) and isolated bacteremia was reported in 22 cases (18%). The overall mortality rate was 22% (26/119) and the mortality rate in the intensive care unit was 33% (14/42). Renal impairment, chronic liver disease, pneumonia, and isolated bacteremia were independent risk factors for mortality. CONCLUSIONS K. pneumoniae is a dominant cause of severe community-acquired bacteremic infection in New Caledonia. Physicians should be aware of the poor prognosis of any patient with a bacteremic K. pneumoniae infection and should monitor patients presenting with risk factors closely.

Risk factors for intraoperative hypertension in patients undergoing cataract surgery under topical anaesthesia

PURPOSE Hypertension is the most common operative medical complication in patients undergoing cataract surgery under topical anaesthesia. Our objective was to identify risk factors for high blood pressure requiring anaesthetic interventions. METHODS All patients undergoing elective cataract operations were included in an observational prospective study preceded by a medical history description and physical examination. Intraoperative adverse medical events and type of management were recorded. RESULTS We studied 514 elective cataract operations. The overall rate of hypertension during surgery was 10.4% (n=54). Independent risk factors for developing intraoperative hypertension were female sex (OR=3.8 [1.4-10.3]; P=0.01), age>80years (OR=4.5 [1.5-13.8]; P=0.01) and anxiety (OR=10.5 [4.1-27.0]; P<0.001). The incidence of hypertension was not significantly reduced by premedication (OR=0.5 [0.04-6.0]; P=0.6). There was no significant difference between patients with or without hypertension history in the rates of hypertensive events (OR=3.2 [0.6-15.5]; P=0.15). Management of hypertension or anxiety was similar in patients regardless of their past medical history or ASA risk class. CONCLUSIONS A specific at-risk population may benefit from targeted preoperative interventions for reducing intraoperative anxiety and hypertension.

Teaching anthropology to medical students

As a longtime enthusiast of The Lancet, I have been irritated many times by the often-meaningless quotes on the front cover of the journal. I consider these a waste of precious space. The quote on the Nov 1 issue referring to the Culture and Health Commission by David Napier and colleagues, was especially unacceptable: “The systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest standard of health worldwide”. I wonder who can probably choose such an absurd and cynical statement. From my experience as a physician who has worked in many developing countries, it is the lack or unequal distribution of resources, rather than neglect of culture, that prevents progress in achievement of higher health-care standards. I highly recommend that The Lancet return to its old design, with content information on the front cover page to be seen at first glance. That way, the journal would save nearly one page for real medical information, and avoid printing meaningless nonsense.

Scientific journalism in Africa to help fight global health emergencies

The epidemic of the Ebola virus disease is not over yet because of persisting fear, mistrust, and opposition in Guinea, Liberia, and Sierra Leone. In view of the absence of an effective vaccine or treatment for this disease hitherto, outbreak control relies on isolation measures, monitoring contact cases, and disseminating preventive advice. However, despite the crucial importance of communication in outbreak contexts, there is no clear proposal from international agencies to improve the quality of broadcasted information in the wake of this epidemic. Media, such as radio and newspapers, can have a huge eff ect on individual and community opinion during outbreaks of communicable diseases—eg, exaggeration or reassurance from the media might exacerbate or temper people’s perceived risk of the Ebola virus disease. Along with sustaining and strengthening depleted health-care systems, enhanced communication through inexpensive methods is most needed, such as the media quickly delivering vital information to aff ected or at risk communities. However, journalists are not necessarily trained to provide adequate information about outbreaks. In 2015, in a review of Ebola-related articles published in epidemic countries, we noted that crucial intervention aspects (eg, contact cases lost to follow-up) were not mentioned, whereas a contextual analysis of opposing events (eg, dissimulation of dead bodies, non-compliance, or uncooperative contacts) was rarely completed. Almost none of the articles identifying opposing situations mentioned clear, comprehensive, accessible, and constructive public health messages. Similar results have been reported in the very few systematic reviews of newspapers done in aff ected and neighbouring African countries, including Guinea and Cameroon. Increasing journalists’ scientific knowledge could help them to broadcast the correct information about an associated risk of infection with potential epidemics and also could ease implementation of efficient public health measures. Journalists from high-income countries could share their knowledge and experience with their African counterparts during public health crises to help raise a community’s awareness. Some institutions are accustomed to participating in such capacity-building programmes (eg, Solthis) through existing media partnership cooperation networks. Dedicated financial support and policy initiatives are needed to create opportunities to raise awarness among journalists, both in epidemiology and medical anthropology, through workshops on epidemics. Mobilisation of journalists and their media would have indisputable benefi ts, including creating a critical group of journalists aware of pubic health and social sciences, and fortifying collaboration between the media and other health actors in outbreak contexts.

Impact of Video Technology for Improving Success of Medial Canthus Episcleral Anesthesia in Ophthalmology

Background and Objectives Efficient learning of regional anesthesia in ophthalmology remains challenging because trainees are afforded limited opportunity to practice ocular anesthesia. The aim of this prospective, randomized, blinded study was to determine whether teaching with video improves regional anesthesia skills of residents in ophthalmology. Methods From January to October 2016, 32 novice anesthesiology residents were evaluated while performing medial canthus episcleral procedures during a 5-day rotation. Residents were randomly assigned to either receive or not receive a video review of their performance at day 3. The primary outcome was a comparison of akinesia using a 12-point scale before incision assessed by the blinded surgeon. Results A total of 288 blocks were performed by 32 residents and were assessed by 3 surgeons before the intervention (144 blocks) and after the intervention (144 blocks). Residents in the review group improved to a greater degree compared with residents in the no-review group. The median overall akinesia scores for the review and no-review groups were similarly low (6; interquartile range [IQR], 2–11; and 6 [IQR, 2–9], respectively) on day 1 of the rotation, whereas anesthesia performed by residents in the video group provided a better akinesia score (12 [IQR, 10–12] vs 8 [IQR, 6–10]; P < 0.001) on day 5 of the rotation. Conclusions Video-assisted teaching significantly improves performance of medial canthus episcleral anesthesia performed by novice trainees.

Comparison of a Supraglottic Gel Device and an Endotracheal Tube in Keratoplasty Performed Under General Anesthesia: A Randomized Clinical Trial.

Purpose: To assess the safety of a laryngeal mask (i-gel) in keratoplasty performed under general anesthesia. Methods: Patients with indications for keratoplasty (n = 110) were enrolled in a prospective study and randomly assigned to the i-gel (n = 55; 30 lamellar keratoplasty and 25 penetrating keratoplasty) or tracheal tube group (n = 55; 29 lamellar keratoplasty and 26 penetrating keratoplasty). Perioperative complications and the recovery time were compared between the 2 groups using the t test or &khgr;2 test. Contraindications to elective use of the laryngeal mask airway (esophageal reflux, extreme obesity, oropharyngeal pathology, or expected difficult intubation) and expected difficult intubation were excluded. Results: No surgical perioperative complications were reported in either group. There was a significantly greater incidence of coughing at extubation and/or after extubation in the tracheal group (40/55; 73%) than in the laryngeal mask group (3/55; 5%) (P < 0.001). The recovery time was shorter in the i-gel group (80 minutes; 95% confidence interval, 75–86) compared with that in the tracheal tube group (88 minutes; 95% confidence interval, 82–95) (P = 0.03). There were no significant differences in the incidence of sore throat and hoarseness between both devices. Conclusions: The use of i-gel for keratoplasty under general anesthesia appears to be safe, reduces the risk of potential ocular hypertension during recovery, and saves recovery time.

High syphilis but low HIV prevalence rates among pregnant women in New Caledonia.

Sexually transmitted infections have been described as one of the major health problems in several countries of the Pacific Region. The objective of the study was to estimate the prevalence of pregnant women infected with HIV and/or syphilis in New Caledonia. HIV and syphilis test results were obtained from women attending antenatal clinics. From 2008 to 2011, 3353 pregnant women were tested with a mean prevalence of active syphilis found at 5.6/100,000. No pregnant women tested positive for HIV. Despite available resources and public health strategies similar to those existing in France, active syphilis prevalence is high in New Caledonia. Surprisingly, HIV seroprevalence remains far below the figures reported in mainland countries. However, social and economic changes as well as the looming referendum on independence scheduled in 2014 may have a potential negative impact on public health resources. The need for action to control syphilis and other curable sexually transmitted infections is pressing in order to prevent further spread of HIV in New Caledonia.