Mamadou Mourtalla Ka

Socio-demographic and clinical profile of chronic pain with neuropathic characteristics in sub-Saharan African elderly.

Data on characteristics of neuropathic pain (NP) in sub‐Saharan Africa are scarce, especially in the elderly. We conducted this study to appreciate the socio‐demographic and clinical profile of chronic pain (CP) with neuropathic characteristics in sub‐Saharan African elderly with musculoskeletal pain. From January to December 2011, we performed a cross‐sectional study in all Rheumatology outpatients over 60 years at the Center for Gerontology and Geriatrics, Dakar, Senegal. In this study, we included patients who experienced musculoskeletal pain for 3 months or longer (CP) and with a DN4 score ≥ 4 (NP). A complete clinical examination was performed to make the diagnosis of NP ‘definite’ or ‘probable’, and to identify the aetiologies of NP. During the study period, 698 outpatients were examined. There were 394 out of the 549 patients over 60 years who reported CP. Among them, 28 patients (7.1%) scored ≥4 on the DN4 questionnaire. Female patients, low educational attainment, manual professions, non‐workers and diabetes were associated with NP (p < 0.05). The symptoms described by patients with NP, often intricate, were lumboradiculalgia (n = 9), cervico‐brachial neuralgia (n = 3), polyneuropathy (n = 12) and mononeuropathy (n = 6). The presumed aetiologies in patients with NP were: chronic spine diseases (n = 14), painful diabetic peripheral neuropathy (n = 8), Sjögrens syndrome (n = 1), tarsal tunnel syndrome in rheumatoid arthritis (n = 1) and bone metastasis (n = 1). No aetiology was identified among three patients. Chronic spine diseases associated with radiculopathies and diabetic neuropathy are the main causes of NP, well detected by DN4 questionnaire and clinical examination in Senegalese sub‐Saharan African elderly.

Quantitative Ultrasound Measurements at the Calcaneus in a Population of Urban Senegalese Women: Least Significant Difference and T-Score

Background: Bone ultrasound measurements can be used to evaluate osteoporosis in clinical practice. As with DXA, ultrasonography shows marked variations across racial groups. In the USA, quantitative ultrasound measures were higher in African-American women than in Caucasian women. Few data are available on these measures in African women, and there are no normative data for Senegalese women. Our objectives were to evaluate the least significant difference (LSD) and to establish reference values of quantitative ultrasound measures at the calcaneus in Senegalese women. Methods: Reference values were obtained in 50 healthy women aged 25-35 years. A UBIS 5000 ultrasound sonometer was used to determine speed of sound (SOS), broadband ultrasound attenuation (BUA), and the Strength Index (STI) at both heels. Results: In the 50 healthy controls (mean age, 29.8 ± 3.7 years, mean height, 167.3 ± 5.8 cm, mean weight 68.1 ± 13.2 kg; 38 right-handed), BUA (mean of the two sides) was 72.24 ± 6.83 dB/MHz. BUA values were higher in women with regular sporting activities (n=10) and in those with higher body weight values, indicating an increase in bone mass associated with greater loads through the calcaneus. Conclusion: Quantitative ultrasound parameters measured at the calcaneus using a UBIS 5000 sonometer in Senegalese women showed similar reproducibility to that reported previously in Caucasian women examined using the same sonometer or a comparable sonometer. The mean BUA values in our reference population can be used to compute T-scores in individual female patients in Senegal. Our data support a link between greater mechanical loads and higher bone mass.

L’anémie de Biermer et ses présentations déroutantes : mise au point, avec un focus chez le sujet de race noire

La maladie de Biermer est une maladie auto-immune, caracterisee par la malabsorption de la vitamine B12 avec presence d’une gastropathie atrophique et de divers auto-anticorps dont des anticorps diriges contre le facteur intrinseque. Elle est surtout decrite chez les sujets caucasiens de la soixantaine. Toutefois, elle existe aussi chez le sujet noir africain, mais survient a un plus jeune âge. Les descriptions chez le sujet de race noire montrent une association frequente mais d’allure fortuite a des comorbidites, qui modifie le cours habituel de la maladie de Biermer. Il en resulte un retard diagnostique. La caracteristique la plus marquante des series africaines au sud du Sahara est la constance de la melanodermie acquise palmoplantaire qui disparait sous traitement. Toutefois, elle n’est pas consideree comme pathognomonique de cette affection auto-immune. Sur le plan biologique, l’anemie est frequemment profonde, avec un taux moyen d’hemoglobine a 6 g/dL.

Lupus et ischémie intestinale : une association de mauvais pronostic

Lelupus erythemateux systemique (LES) est une affection auto-immune non specifique d’organe dont les presentations cliniques peuvent etre multiples et variees. Parmi elles, des douleurs abdominales peu specifiques sont trouvees chez pres de 80 % des malades et peuvent etre la seule expression d’une ischemie mesenterique. De par leur manque de specificite, la frequence d’une atteinte lupique digestive est probablement sous-estimee, certaines series autopsiques rapportant jusqu’a 70 % d’atteintes peritoneales dont 10 % etaient pauci-symptomatiques. La morbidite et la mortalite de la maladie lupique sont correlees aux lesions de l’intestin grele ou du colon qui sont souvent liees a une vascularite mesenterique lupique evoluant vers l’ischemie intestinale aigue ou chronique. Ainsi, la vascularite mesenterique lupique constitue la principale cause a considerer precocement devant une douleur abdominale inhabituelle, prolongee ou intense, dans le but de reduire l’evolution vers l’infarctus mesenterique et ses complications telles que la perforation. Le pronostic depend donc d’un diagnostic precoce passant par la prise en compte de tout symptome digestif chez un patient atteint de lupus. La gravite potentielle de ces complications doit guider l’indication, au mieux d’une tomodensitometrie, ou a defaut d’une echographie abdominopelvienne en urgence en vue d’une prise en charge precoce et intensive. Au stade precoce, le traitement sera d’abord medical avec une place de choix pour la corticotherapie intraveineuse suivie d’un relai par voie orale voire ulterieurement par la prescription d’immunosuppresseurs. Toutefois, la chirurgie peut etre necessaire si le patient est vu au stade de complication.Cette mini-revue a pour objectif de rappeler l’importance qu’il faut accorder (« surveillance armee ») a tout symptome digestif survenant chez un patient lupique.

Authors' reply to the comment by Pazzaglia et al

Since the aetiologies of neuropathic pain are most often degenerative or age related, it is not surprising that these conditions are more common in the elderly (Ahmad and Goucke, 2002; Pickering and Capriz-Ribière, 2008). Neuropathic pain occurs and persists in a heterogeneous group of aetiologically different diseases, with various physio-pathological mechanisms (Cruccu and Truini, 2009; Baron et al., 2012). Patients with neuropathic pain present with various pain-related sensory abnormalities (Baron et al., 2012). Subgrouping patients with neuropathic pain on the basis of individual sensory profiles could guide the choice of pharmacological agents to be proposed to each patient (Bouhassira et al., 2004; Cruccu and Truini, 2009; Baron et al., 2012). We appreciate Pazzaglia et al.’s interest in our study on the characteristics of neuropathic pain in a population of sub-Saharan African elderly, followed for chronic pain of musculoskeletal origin (Lekpa et al., 2012). In this study, we choose to use the neuropathic pain diagnostic questionnaire DN4 (Bouhassira et al., 2005) instead of other validated instruments. Apart from its good discriminative properties for the identification of neuropathic pain, the DN4 questionnaire was easy to use, especially in our sample of elderly patients with a low level of education. Thus, we were able to show through this study that: (1) neuropathic pain existed in African elderly; (2) female gender, low educational status, manual professions, unemployment and diabetes mellitus were significantly associated with the presence of neuropathic pain; (3) chronic spine diseases and painful diabetic peripheral neuropathy are the main causes of neuropathic pain in our sample; and (4) neuropathic pain were neglected by physicians with a low rate of prescription drugs directed against neuropathic pain (Lekpa et al., 2012). In his comments, Pazzaglia et al. presented the methodology and results of a multicentre study they conducted among Italian elderly over 65 years, with peripheral neuropathy (Pazzaglia et al., 2013). The methodology used in our study was different from that used by these authors (musculoskeletal pain vs. peripheral neuropathy). Despite this difference, the results are broadly comparable. Indeed, these authors showed that (Pazzaglia et al., 2013): (1) neuropathic pain are also common in elderly; (2) the aetiologies are numerous; (3) the clinical profile or sensory profile, assessed with the Neuropathic Pain Symptom Inventory (NPSI) (Bouhassira et al., 2004), varies depending on the aetiology; and (4) also the low rate of prescription drugs targeting neuropathic pain. The use of NPSI (Bouhassira et al., 2004) would not have changed the results obtained in our study. However, it would have provided important additional information. We could have had a more accurate assessment of the clinical profile of our patients, differentiating subtypes of neuropathic pain. Indeed, the NPSI was developed and validated for the assessment of different symptoms of neuropathic pain. It is also a simple and easy-to-use instrument for daily practice and clinical studies. The NPSI allows discrimination and quantification of five distinct clinically relevant dimensions of neuropathic pain: burning (superficial) spontaneous pain, pressing (deep) spontaneous pain, paroxysmal pain, evoked pain and paraesthesia/ dysaesthesia. One important feature of the NPSI is its sensitivity to treatment effects (Bouhassira et al., 2004). Subgrouping neuropathic pain in our study might have permitted us to make assumptions about the appropriate type of drug to offer to each of our patients, according to the sensory profile of the neuropathic pain presented by each patient, as suggested by Bouhassira et al. (2004), but it remains to be confirmed in controlled studies. Until then, it seems important to recommend the use of the NPSI or other neuropathic pain classification instruments (and the DN4 questionnaire) for the diagnosis and clinical assessment of neuropathic pain, both in daily practice and in further clinical studies.

[Disease-modifying treatment for inflammatory rheumatism in sub-Saharan Africa: outcome at 6 months of 205 Senegalese patients with rheumatoid arthritis].

RATIONALE Few data are available on the treatment of rheumatoid arthritis (RA) in sub-Saharan Africa, where the diagnosis is often substantially delayed. Disease-modifying antirheumatic drugs (DMARDs) are more effective when started early. Biotherapies are not available. Given the socioeconomic constraints in sub-Saharan Africa, treatments must be selected based on locally available resources. The objective of this study was to evaluate outcomes 6 months after initiation of conventional DMARDs in Senegalese patients with RA. METHODS We retrospectively studied consecutive RA patients seen at the rheumatology outpatient clinic of the Le Dantec Teaching Hospital, Dakar, Senegal, from January 2005 through June 2009. All patients met the ACR criteria for RA. ACR and EULAR response criteria were evaluated 6 months after treatment initiation. RESULTS The study included 205 patients. Corticosteroids were used in 205 patients, hydroxychloroquine in 190, methotrexate in 137, and sulfasalazine in 11. Combined corticosteroid, methotrexate, and hydroxychloroquine therapy was used in 122 patients and combined corticosteroid and hydroxychloroquine therapy in 63. DMARD treatment was interrupted for at least 5 days per month for 26% of the patients, either because the drugs were out of stock at the local pharmacies and/or because the patients could not afford to purchase them. During the first 6 months of treatment, patients had a mean of 4 clinic visits, and 48% of patients missed at least one scheduled visit. After 6 months, all clinical variables had improved significantly, except the swollen joint count. The ACR20, 50, and 70 response criteria were met in 50%, 31%, and 6.9% of patients, respectively. The EULAR response was good in 53.9% of patients, moderate in 12.7%, and poor in 23.1%. DMARD therapy failed in 10.3% of patients. Half the patients had their treatment modified during the 6-month study period. DMARD therapy was discontinued in 10 patients for the following reasons: plans to become pregnant, n = 5; pregnancy during treatment, n = 2; and tuberculosis, n = 3. CONCLUSION In Senegal, the treatment of RA relies chiefly on variable combinations of methotrexate, hydroxychloroquine, and corticosteroids. The six-month outcomes are satisfactory. Biotherapy is required in 7% to 10% of patients, a rate that could be decreased by optimizing patient follow-up. The management of chronic inflammatory joint disease couple be improved despite the limited financial resources in sub-Saharan Africa with better physician training and the incorporation of osteoarticular diseases within a vast information and education program for the general population.

Hematologic and immunologic signs of the lupus disease: the experience of the Dakar's hospital

INTRODUCTION The systemic erythematosus lupus (SEL) or lupic disease is a systemic auto-immune pathology, characterized primarily by the presence of antibodies directed against native antibodies anti-DNA. The circumstances of discovery are variable and polymorphic. The hematologic signs and the immunological disorders constitute criteria of diagnosis of lupic disease. METHODOLOGY It is a multicentric retrospective study from January 1, 1997 to September 30, 2006. Patients were followed up in Internal medicine of Dakar. We appreciate the hematologic and immunological aspects appreciate their prognosis prevalence and their implications with the course the lupic disease. RESULTS 142 lupic patients were included with 125 women and 17 men; the sex ratio is 0.13. The average age was 34 years with extremes of 6 and 72 years. Our patients had hematologic manifestations average in 32,4 % of the cases and immunological in 76,8 % of the cases. The immunological tests showed the presence, of antinuclear antibodies in 97,9 % of the cases, of native antibody anti-DNA in 45,7 % of the cases, the anti-ECT in 86,95 % (with the anti-RNP in 78,3 % of the cases, anti-Sm in 56,5 % and of anti-SSA in 87 % of the cases). Antibodies anti-DNA and anti-ECT were associated with the hematologic demonstrations respectively in 92,0 % and 95 % of the cases (p = 0,08). Total survival in 96 % of the cases is estimated to 7 years. CONCLUSION The circumstances of discovery of the lupic disease are variable. The hematologic signs constitute criteria diagnosis of lupic disease. The accessibility of the hematologic and immunological assessment is necessary for an early diagnosis and an early treatment.