Danger signs and management of suspected severe malaria cases at community level and in referral health facilities: an operational study in the Democratic Republic of the Congo

BackgroundEvidence from one trial in Africa suggests that pre-referral Rectal Artesunate (RAS) can be a life-saving intervention for severe malaria in remote settings, where parenteral treatment is not available. Recognition of danger signs indicative of severe malaria is critical for prompt and appropriate case management.MethodsAn observational study was conducted in the Democratic Republic of the Congo (DRC) in the frame of the multi-country CARAMAL project, to assess the effectiveness of RAS under real-world conditions. Severely ill feverish children <5 years seeking care from a community-based healthcare provider were recruited in three rural health zones into a patient surveillance system. They were subsequently followed within the healthcare system and at home after 28 days to determine care seeking, antimalarial treatment provision and health outcomes.ResultsOverall, 66.4% of patients had iCCM general danger signs, as well as more specific danger signs. Children aged 2-5 years (aOR=1.58, 95% CI 1.20–2.08) and those presenting iCCM general danger signs were more likely to receive RAS (aOR = 2.77, 95% CI 2.04–3.77). Injectable treatment was less likely with RAS pre-referral treatment (aOR=0.21, 95% 0.13– 0.33). In the post-RAS phase, the case fatality ratio was 7.1%. Children not receiving RAS had a higher risk of dying, but this was not statistically significant (aOR = 1.50, 95% CI 0.86– 2.60). The odds of dying were reduced in patients without iCCM general danger signs, but just not statistically so (aOR = 0.64, 95% CI 0.38–1.06). Full oral therapy at a RHF was highly protective (aOR = 0.13, 95% CI 0.07-0.26), while a full treatment of severe malaria (injectable + oral) was shown to also decrease massively the odds of dying (aOR = 0.26, 95% CI 0.09– 0.79) compared to injectable treatment alone.ConclusionsBetter understanding the determinants of successful case management, and targeted improvements of the health system (especially the provision of a full course of an oral antimalarial) are crucial for improving health oucomes of children with suspected severe malaria.

Patient Characteristics and Preferences Regarding Anticoagulant Treatment in Venous Thromboembolic Disease

Background: Anticoagulants are the recommended treatment for venous thromboembolic disease (VTE). The mode of anticoagulant administration may influence compliance, and therefore the effectiveness of the treatment. Unlike in atrial fibrillation or cancer-associated thrombosis, there is only limited data on patient preferences regarding the choice of anticoagulation in VTE. This study aims to evaluate patient preferences regarding anticoagulants in terms of administration: types (oral or injectable treatment) and number of doses or injections per day.Patients and Methods: This is a national survey through a questionnaire sent by e-mail to 1936 French vascular physicians between February and April 2019. They recorded the responses for each patient admitted for VTE.Results: Three hundred and eleven (response rate of 16%) of the 1936 contacted physicians responded for 364 patients. Among these, there were 167 fully completed questionnaires. Most patients (63%) express concerns about VTE and prefer oral treatment (81.5%), justified by the ease of administration (74%) and a fear of the injections (22%). When patients were taking more than three oral treatments they statistically chose injectable treatment more often (54%) than oral treatment (25%, p = 0.002). Patients who chose injectable treatment were also older (70 ± 16 vs. 58 ± 17 years old, p = 0.001). There was no statistically difference in anticoagulation preference according to gender or to the expected duration of treatment (6 weeks, 3 months, 6 months or unlimited). When oral treatment was preferred (81%), most chose oral treatment without dose adjustment and biomonitoring (74.3%). Among them, very few (5.8%) preferred a twice-daily intake.Conclusion: Patient preference in terms of anticoagulant treatment in VTE disease is in favor of oral treatment without adjustment or biomonitoring and with once-daily intake. When an injectable treatment is chosen, a prolonged duration of treatment does not seem to be a constraint for the patient.Clinical Trial Registration:ClinicalTrials.gov, identifier [NCT03889457].

Does Surgeon Gender Matter for Aesthetic Patients?

Background Plastic surgery patients have expectations for an ideal practice to visit. However, patients’ preferences in their plastic surgeon are still being described. Objectives This study investigates if elective cosmetic plastic surgery patients exhibit gender preference in their plastic surgeon for online inquiries at a private practice located in Houston, TX. The surgeons are a married couple, one female and one male, with identical training, age, and experience out of residency. Methods A retrospective, single-practice review of all online inquiries for elective plastic surgery and nonsurgical injectable treatment from June 2019 to June 2020 was performed. Patients submitted an online inquiry for their procedure of interest and surgeon preference via the practice website. Results The private practice had 873 online inquiries during the year-long study period. The majority of patients were female, 855 (97.9%), and 18 (2.1%) of those patients were male. 476 (55.7%) female patients prefer a female surgeon and 138 (16.1%) female patients prefer a male surgeon. 241 (28.2%) female patients made no surgeon preference. Regardless of surgeon preference, the majority of procedures inquired about were breast and body contouring. Conclusions This cohort of female patients prefers the female surgeon for breast procedures or multiple procedures involving breast, and the male surgeon for injectable procedures and facial procedures. There is no favor towards the male or female surgeon in body procedures. In conclusion, female plastic surgery patients may be influenced by surgeon gender in choosing their surgeon, depending on their surgery of interest.

Case Report: Use of Subcutaneous Midazolam During an Episode of Catatonia

Midazolam is a benzodiazepine (BZD) mainly used in anesthetic induction due to its pharmacokinetic features. Its place in the therapeutic management of catatonia remains to be determined. Here we present the case of a 65-year-old man who presented with a first episode of catatonia with opposition to any form of oral treatment, where a single dose of 1 mg of subcutaneous (SC) Midazolam permitted clinical improvement allowing oral treatment to be given. The patient's history notably included a renal transplant linked to Polycystic Kidney Disease (PKD) and no history of psychiatric illness nor of any use of psychotropic drugs. As the patient refused to drink or eat and ceased answering basic questions, a psychiatric assessment was required. A diagnosis of Catatonic disorder due to a general medical condition [DSM 5–293.89/ ICD10 [F06.1]] was made. A Bush-Francis Catatonia Rating Scale (BFCRS) analysis returned a score of 15 out of 62, with stupor, mutism, negativism, staring, withdrawal, rigidity, and stereotypy. As the negativism prevented the patient from taking any form of oral treatment, after a brief discussion with the unit's physician, it was decided to administer 1 mg of SC Midazolam. One hour later, the patient was more responsive and compliant, and agreed to drink, eat, and take medication. Thus, the catatonic signs of mutism, negativism, staring, and withdrawal were resolved, but waxy flexibility and catalepsy appeared, leading to a new BFCRS score of 10 out of 62. Oral treatment with 2.5 mg Lorazepam, 4 times a day, was then initiated. Midazolam could be a safer choice compared with the other options available, such as other SC BZD, considering the complex safety profile of this patient with renal insufficiency. This situation represents the first report of using SC Midazolam as an injectable treatment for catatonia. More studies are needed to assess the clinical pertinence of SC Midazolam in the treatment of catatonia.

The Efficiency of Conservative Methods of the Treatment at Early Stages of Osteoarthritis

Osteoarthritis (OA) is one of the leading causes of disability in the elder population. OA is a chronic disorder characterized by joint pain and inflammation, increasing physical disability and continuous cartilage degeneration.The changes of lubricating properties of synovial fluid lead to significant pain and loss of function. One of the strategies uses the high molecular weight molecule hyaluronic acid as either an injectable treatment. The injection of hyaluronic acid in the joints, improves the biochemical properties of synovial fluid into osteoarthritis of knee joints. The clinical effect is pain relief and disease modifying activity. Hyaluronic acid is a relatively new treatment that has shown varied results through several clinical trials. It can be used as a scaffold for engineering new treatments and several new preparations have been just added to the markets.