AMHE Newsletter spring 2020 april 27 Haitian Medical Association Abroad Association Medicale Haïtienne à l'Étranger Newsletter # 276

AMHE NEWSLETTER Editor in Chief: Maxime J-M Coles, MD

Editorial Board: Rony Jean Mary, MD Reynald Altema, MD

Technical Adviser: Jacques Arpin

The Longevity of a Total Hip Replacement Maxime Coles MD

In this number - Words of the Editor, Maxime Coles,MD - You need to know the difference in symptoms: - La chronique de Rony Jean-Mary,M.D. - From The New York Times: - La chronique de Reynald Altéma,M.D. - Décès

- Chronicle of Slave rebellions in the . - And more... 2

In face of a patient presenting with a painful hip other causing stiffness and later pain and joint enabling him to ambulate and forcing the inability to bear weight and ambulate. use of external supports or a wheelchair, one 2- Autoimmune diseases like Rheumatoid can understand how daily living activities can arthritis in which the synovial membrane affect life. The hip become stiff and painful become diseased, inflamed or thickened, rendering any task requesting mobility, difficult. damaging the cartilage in allowing a loss The individual contemplating such procedure of joint surface. This kind of process often report difficulties in wearing socks represents a group of disorders called because of inability to cross their legs. Medications which have in the past relieved the inflammatory arthritis. symptoms, ceased to benefit the patient. A hip 3- Injuries to the hip joint following a replacement become the best option to restore traumatic event like a fracture dislocation, functionality. can damage the articular cartilage of the Anecdotally, the first total hip replacement was hip joint and lead to stiffness, pain and performed in the mid-20th century. This is a loss of motion. The blood supply to the successful procedure which over the years has femoral head can become deficient after allowed us to perfect the way of approaching the the dislocation limiting the blood supply joint to minimize the destruction of the anatomy to the femoral head and causing an and to restore the function. Improvements in the Avascular Necrosis. With time, the techniques and technology have greatly increase avascular portion of the femoral head the effectiveness of the hip joint. The Agency collapse resulting in arthritis. Many for Health Research and Quality reports more than 300,000 total hip reconstructions by total diseases like sickle cell and other hip replacement each year are performed in the hemoglobinopaties, like Gaucher’s United States of America. disease can present with the same lack of The hip joint is the largest joint of the human blood supply to the femoral head. We body. It consists in a ball-and-socket articulation have seen this complication in IV drug where the ball represents the head of the femur abusers and infections around the hip joint and the socket being a part of the pelvic bone as well. called acetabulum. An articulate cartilage 4- Many pathologies during infanthood or covered the joint surface allowing a smooth adolescence can also present with such motion. The joint is enveloped by a synovial problem. Kids with Developmental Hip membrane responsible for the lubrication of the Dysplasia called in the past Congenital joint eliminating any friction during motion. A hip dysplasia have shown a loss of massive musculature supported by ligaments is congruity at the hip joint leading to re-enforcing the capsule of the joint. The most common cause of pain and disability degenerative process. Slipped capital in a hip joint is degenerative arthritis. Many femoral epiphysis will also present with arthritic process due to osteoarthritis, Traumatic stiffness and loss of range of motion but arthritis or rheumatoid arthritis can involve this with time, osteoarthritis and chondrolysis joint and interfere with the range of motion: may set in. 1- Osteoarthritis is the becoming of all joint with time. It is aged-related and The Total Hip Replacement consists in the represents the “tear and wear” of the removal of damaged cartilage and bone joint. Any patient older than 50 years of including the femoral head with their age or older will manifest pain or replacement by prosthetic components. stiffness in relation to this type of They are replaced by a metallic stem inserted into the medullary canal of the arthritis. Some may develop the proximal femur. This stem can be degeneration earlier than others because cemented in people with poor bone stock of familial predispositions. The cushion or pressed fitted in younger individuals provided by the cartilage wears away with healthy bone. The orthopedic allowing the bones to rub against each surgeon will have also the choice to 3

replace the head with a metallic or the expected changes. In discussing with ceramic head over the tip of the his/her patient, expectation for daily component. The damaged cartilage of living activities should be raised. the acetabulum (socket) is also grounded - One has to understand that material used out and replaced with another metallic in the components are subject to wear. component which can be stabilized with So patient’s weight needs to be discussed cement, or screws alone. A spacer is then with exercises programs to minimize inserted into the socket to fit the femoral wear and loosening of the components. metallic head. This spacer can be of This can be manifested by a painful joint plastic, ceramic or metallic forming a replacement. Avoidance of high impact smooth gliding surface. activities such as jogging, jumping, hiking and even dancing is strongly When a surgical option is finally chosen suggested. by a patient to become a recipient of a Total Hip Replacement, it will require a - A dental evaluation to minimize cooperative effort between the patient bacteremia from any infection is and his family, the primary care recommended. If needed, the dental physician and the orthopedic surgeon. procedures should be carried prior to the Many factors will be analyzed during a planned replacement. Even routine consultation once a patient is ready for cleaning procedure should be delayed to the replacement: decrease any risk. - Urinary problems like an inflamed - Pain and disability rather than age prostate, should be resolved prior to any should be considered. We believe that 50 surgical treatment. Infections anywhere to 80 years of age-group have been in the body need to be treated. considered as typical ages for a hip replacement but recipient should be - Proper social planning with home chosen on an individual basis. Total joint therapy will be arranged at discharge arthroplasty has been performed from the hospital, after a short stay in successfully on teenagers and elderly hospital first and maybe also a stay in an who have demonstrated pain with every extended care facility providing help day activities, unrelieved by anti- with cooking, bathing, laundry etc. inflammatory medication. Often, Proper equipment will be also delivered stiffness and inability to ambulate after at home like high toilet seat, pillow, failed attempts at rehabilitation and dressing etc. ambulation with external support. Radiologic images may show extensive It is important also for the one who become a damage or deformity to the hip joint. recipient of a Total Hip Replacement to know Occasionally an MRI or a CT scan study about the possibility of failure of the component may be needed to determine the quality of the prosthetic device through different of the bone stock. processes like dislocation, infection, fracture, Other considerations for an evaluation prior mechanical failure with wear of polyethylene, to such procedure, should include: breakage or loosening in the cement fixation etc. Infections are seen in less than 2% of Total hip - The orthopedic consultant to decide replacements. Blood clots are common whether a hip replacement surgery is the complications especially in the pelvic veins and best method to relieve the pain and can be life-threatening. Prophylaxis with improve the mobility. He will need to anticoagulation therapy and sequential explain the potential risks and compressive devices or ankle pump will complications of such procedure in facilitate the vascular flow. Early mobilization is opening a true dialogue with the patient. always enforced with precautions when sitting, The more the patient know, the better bending and even sleeping. One has always to he/she will be able to accept and manage discuss those eventualities and the life 4 expectancy of such procedure. The conception that all hip replacements provide a normal pain- Failure in arthroplasty can be measured in free function for the remaining of their life many ways and patients who report failure in needs to be discouraged fully. A recipient one setting may also report success in another. should be also told about the possibility of a Revision surgery has an uncertain outcome leg-length discrepancy. seeing patients and clinicians deciding on the risks and benefits. We need to remember that Studies in the in 2014 have the goal for the revision surgery is as well to advertised Hip replacement were for people relieve pain. Studies have shown that less than with advanced degenerative arthritis and then a 20% of such patients in need of a revision revision was expected in the next 10 years. have not taken the choice. Women were found Nowadays, it is difficult to hear about the to have better construct survivorship at all ages longevity of a revised hip replacement’s than men. Data contributing to a 15-year surgery. The new hip replacement may activate survival are also available from the Australian metal detectors at the airports security stand and and Finnish Registries. a special identification card confirming the existence of an artificial hip, is generally To all who ask so often the pro’s and the cons provided. of a total hip replacement, we have to frankly state that there is not enough information When a recipient asks how long a hip available to predict how long a hip replacement will last, the physician has no other replacement based on searches from the choice than to rely on historical data. Some Arthroplasty Registry data from the USA, UK, registries have shown hip replacement lasting Finland, , Australia etc. 20 to 25 years or less but in fact they are limited These Registries contain almost ¾ of Hip by the quality of data presented and the lack of Replacement done in the last 20 years and follow up as well, then reflecting a bias. We more than ½ were done because of may rely on annual reports looking at age and Degenerative Arthritis. In conclusion, a sex distribution or implant design presented by proponent for a total hip replacement suffering different National Joint registries in , from degenerative arthritis should expect 15 to Wales or Sweden etc., to give a plausible 20 years from a replacement with all answer. Data on a series of 23000 hip precautions required for the well-being of the replacements have suggested a decrease in the prosthetic components revision rate. Maxime Coles MD

References: 1- NJR. 14th Annual report 2017: National Joint for England, Wales. Northern Ireland and Isle of Man 2016 2- Learmonth ID, Young C, Rorabeck, C: The operation of the century: Total Hip Replacement. Lancet 2007, 370: pp 1508-1519. 3- J Bone and Joint Surg. Am2018; 189:189-194. 4- NICE. Total Hip Replacement and Resurfacing arthroplasty for end stage arthritis of the hip: NICE technology appraisal guidance 304 London National Institute and Care Excellence 2014. 5- Philliport R, Farizon F, Camillien JP, et Al: Survival of Cement less dual morbidity socket with a mean17 years follow-up: Rev Chir Orthop Reparatrice Appr Mot 2008, 84; pp e23-27. 6- Sorensen EH, Newman L, Freund EG, Long term results after Charnley hip replacement Egeskr Laeger, 1996, 158 pp 7228-7232 (In Danish) 7- Rozhydal Z, Janicek P, Havlicek V, Pazoureck L Long-term results of use of the CLS stems in primary total hip replacement. Acta Chir Orhop Traumatology Cech 2998, 76:281-287 (In Czech) 8- National Joint Registry for England 5

Rony Jean-Mary, M.D. DANS LE LABYRINTHE DU COVID -19 : L’EVOLUTION DE LA MALADIE DE SON APPARITION A MAINTENANT.

Depuis l’apparition du COVID-19 voila déjà plus Pulmonaire. Les pathologistes de l’Amérique du de trois mois, des progrès sensibles ont été notés Nord, Canada et Etats unis y compris, ainsi que en ce qui a trait à la compréhension de la maladie. ceux pratiquant Outre Atlantic, sont de plus en Mais il faudra admettre que la route déjà longue plus convaincus de la présence d’une et sinueuse, de là où nous sommes, vers les coagulation intra vasculaire disséminée (DIC) sommets convoités , sera encore escarpée voire en qui serait à la base de cette embolie pulmonaire. dent de scie, avant que le mal finisse par ouvrir Cette coagulation intra vasculaire disséminée tous les secrets cachés dans son ventre. serait le résultat de processus inflammatoire aigu On croyait d’abord à une pneumonie virale au niveau de la paroi des veines déclenchant une accompagnée d’un processus inflammatoire mobilisation des Pl atelets avec la formation, en intense conduisant à une fibrose pulmonaire deuxième lieu, de caillots sanguins. . On a alors dont la mort du patient était le corollaire compris que les respirateurs artificiels, les inexorable. ventilateurs en général, n’étaient pas aussi utiles Mais on observa dans la suite que l’hypoxie était qu’on le croyait et l’on estimait même à un la toile de fond de la maladie et que, en dépit de certain moment que 80% des patient sous la présence d’une ventilation adéquate qui devait ventilateurs artificiels avait fini par mourir. assurer la présence d’une quantité suffisante Certains croyaient que la forte pression des d’oxygène au niveau des organes, ces derniers machines détruisait carrément les alvéolés au n’étaient toujours pas bien alimentés en oxygène. niveau des poumons et compromettait le On imputait alors ce miss-match entre la processus respiratoire. perfusion et la ventilation à une déficience des Devant cet imbroglio, cet embarras même auquel Globules rouges devenus incapables d’assurer le nous expose la maladie, on reste perplexe transport de l’oxygène vers les tissus. Et l’on aujourd’hui, et l’on se demande tout carrément : pensait à ce moment là, que c’était une Quelle théorie accepter ? Qui a raison et qui a pathologie Globulaire . Par la suite ,on s’est tort ? S’agit-il d’une maladie pulmonaire, d’une rendu compte que la maladie s’accompagnait de maladie globulaire ou d’une maladie douleur épigastrique intense, d’anxiété et de cardiovasculaire ? Il faut dire que la complexité détresse respiratoire, tous des signes cardinaux de la maladie n’aide pas vraiment à privilégier qui faisaient croire à une origine cardiovasculaire aucune théorie aux dépens des autres. de la pathologie. en l’occurrence à de l’embolie D’ABORD PEUT-IL S’AGIR D’UNE MALADIE PULMONAIRE ?. 6

En révisant les images radiographiques des d’un ventilateur mécanique forçant l’oxygène patients atteints du Covid-19, on a observé un dans les alvéoles. Dans des conditions normales aspect de verre dépoli au niveau des deux d’évolution, le jeu de bascule est maintenu entre poumons. Cela laisse croire à une origine le captage et la relâche de l’oxygène au moment systémique et centrale de la maladie. Il est de ses échanges avec les autres gaz..Mais comme expliqué que les macrophages du poumon aussi le fer ici n’assume pas tout à fait son rôle de appelés pneumocystose, qui sont censés protéger transporteur de l’oxygène, les radicaux libres et les les poumons contre l’accumulation de radicaux atomes de fer, s’accumulent dans les poumons toxiques, rôle qu’ils partagent d’ailleurs avec la causant ce qu’on appelle le stress oxydatif. Et fine membrane qui recouvre la paroi des Puisque l’hème de l’hémoglobine est affecté, on poumons, sont depassés par une affluence de fer peut dire qu’il s’agit bien là d’une maladie libre et de radicaux toxiques ; Ce qui conduit GLOBULAIRE.. directement à de la fibrose pulmonaire. Les Mais en plus des deux composantes sus-citées, on a poumons une fois fibrosés, perdent de leur aussi appris que le virus , en attaquant les élasticité et collapsent automatiquement. Ceci vaisseaux sanguins, déclenche un processus prouve que la pathologie est d’ordre d’inflammation et de coagulation qui, lorsqu’elles PULMONAIRE. sont intenses, et massives ,peuvent engendrer une coagulation intra vasculaire disséminée, suivie d’ MAIS D’Où VIENNENT LES RADICAUX embolie pulmonaire généralisée. La coagulation LIBRES , EN PARTICULIER LE FER intra vasculaire disséminée se rencontre dans près DONT NOUS PARLONS ICI ? de 75% des cas. Et conduit inéluctablement à la Une explication en bref de la physiologie mort : D’où l’origine cardiovasculaire de la respiratoire va nous permettre de mieux cerner la maladie. pathologie du Covid -19.Le sang est la gazoline Comme on peut voir, le problème est pulmonaire, du corps et le cœur en est le moteur. Il existe dans par la réaction de fibrose qui s’est observée le sang des cellules appelées Globules rouges qui bilatéralement. Il est globulaire, dû à l’incapacité contiennent dans leur matrice une substance des globules rouges à transporter l’oxygène. Et il appelée Hémoglobine. Cette substance complexe est enfin cardiovasculaire responsable d’une est faite d’ions ferreux et ferrique( 2+ ,3+) au embolie pulmonaire massive, à partir d’une nombre de 4 atomes par molécule, réaction inflammatoire causée par l’infection. d’hémoglobine, qui s’attachent sur le hème de l’hémoglobine, et servent à transporter certains L’EPIDEMIOLOGIE DU VIRUS ET LA gaz du corps dont le CO2, l’Azote (N)et THEORIE DES SOUCHES l’’Oxygène( O2). Si la pathologie du Covid -19 s’est révélée difficile Ces molécules de fer ont pour rôle de se dissocier à appréhender, son épidémiologie, en l’occurrence de l’hème au niveau des alvéoles pour attraper tout ce qui a à voir avec sa virulence , sa mutation, l’oxygène et relâcher en échange le CO2 qu’ils son mode de transmission et sa distribution emmènent avec eux depuis les différents organes géographique n’en sont pas moins complexes. du corps. L’oxygène de l’air une fois emmené à travers les conduits respiratoires et échangé contre D’après certaines études, il y aurait une souche A le CO2 ,l’azote et les autres gaz, est aussitôt capté qui apparaissait à Wuhan, en Chine , au mois de par les atomes de fer pour être transporté vers les Septembre de l’année dernière. Elle n’avait causé organes. Il appert que le virus attaque l’hème de aucun dommage sérieux dans la population. Cette L’hémoglobine, change sa configuration, et souche A s’est mutée en une souche B vers le mois empêche le fer d’y rester attaché : Ce qui rend le de décembre, puis en une souche C qui était encore globule rouge dysfonctionnel, donc incapable de beaucoup plus virulente que la souche B. transporter l’oxygène. Il en résulte alors de l’hypoxie au niveau du sang malgré la présence On avance que la souche A serait plus répandue 7

Sur la cotte ouest des Etats –Unis . Là , le contact avoir parlé au Professeur Montagnier pour être si plus étroit avec la Chine où débarquent près de péremptoire dans ses déclarations. Mais à peine 1000 ressortissants chinois journalier ment, avait Luc Montagnier a-t-il fini de parler que déjà des pu conférer une certaine immunité à la voies s’élèvent contre lui au Canada et dans le population..Par contre, quand la mutation de A à monde entier pour dire que le segment de HIV B s’est opérée en Décembre, la cotte Est des qu’il prétend voir est comparable à un simple Etats -Unis n’était pas aussi bien préparée pour mot d ‘un livre qui en apparaitrait dans plusieurs affronter le virus, d’où le nombre élevé de morts autres livres en même temps et qu’il n’en n’est dans les villes et états de New York et de New rien. Le professeur qui a déjà gagné un prix Jersey et de Massachussetts. Pour une raison non Nobel de médecine serait-t-il aussi naïf pour ne encore élucidée, il y avait une deuxième mutation pas pouvoir faire le distinguo entre ce qui est de B en C dont la forme a couvert l’Italie et ivraie et ce qui est du bon grain ? . l’Espagne en partie. D’où l’ampleur de la fatalité LES TESTS DE LABORATOIRE : Pour ceux dans ces deux derniers pays. Mais on a observé ou celles qui sont initiés à la science Médicale, il que dans une petite ile du , située entre ne fait pas de doute que certains tests vont L’Espagne et Portugal, le virus n’avait pas fait conduire sur une piste ou sur l’autre, dépendant trop de dégâts et l’on se réfère au pouvoir des résultats de laboratoire obtenus, et vont aider protecteur du BCG, un vaccin contre la à mieux comprendre la pathologie du Covid-19. tuberculose que les habitants du Portugal, du Par une RADIOGRAPHIE du thorax,par Brésil et du Japon aurait reçu dans le passé. Il exemple, on peut voir au niveau des poumons s’agirait ici d’un cas d’immunité croisée. Ce qui cet aspect de verre dépoli qui s’explique par serait une bonne nouvelle pour les Haïti l’accumulation de radicaux libres au niveau des considérant que beaucoup d’entre nous autres alvéoles. La GASOMETRIE va donner lieu à Haïtiens avaient été vaccinés contre la une alcalose respiratoire due à l’expulsion tuberculose dans le passé. massive de CO2 et à de l’hypoxémie, qui sont On en était déjà habitué à cette théorie des deux des caractéristiques de l’embolie souches lorsque le Docteur Luc Montagnier, pulmonaire. Le taux d’érythropoïétine va être prix Nobel de Médecine, très connu pour ses élevé .Quand le rein n’est pas bien oxygéné , il recherches sur le VIH, vint annoncer en début de accélère la production d’érythropoïétine qui semaine que le virus étudié était le résultat d’une stimule la moelle osseuse et entraine la recombinaison de deux virus différents dont un production de Globules rouges Une étude faite coronavirus avec en plus un segment du VIH. à WUHAN en Chine sur les 14 tests les plus Pour le professeur Luc Montagnier, c’est un virus usuellement recommandés, révèlent ce qui suit. : créé à partir d’un laboratoire dont la finalité a) PT OU PROTHROMBINE TIME est élevé. pourrait avoir été de développer un vaccin contre b) le taux de fibrinogène est réduit. le HIV et qui se serait échappé accidentellement c) la bilirubine totale est élevée des laboratoires Chinois. Le professeur d) Di-dimères est élevé. Montagnier affirme que des chercheurs Indiens e) les enzymes du foie sont toutes élevées: dont avaient fait la même découverte, mais qu’ils ont AST,ALT,LDH. du rentrer leurs trouvailles à cause de pressions f) Le taux de créatinine est élevé. diverses dont ils étaient l’objet. Il a bien dit que g) le cellules blanches dont WBC et neutrophiles le virus a un peu perdu de sa virulence et qu’il ne sont élevées . faut pas s’attendre à beaucoup de morts dans les h) les lymphocytes sont réduits ainsi que… prochains jours. Le professeur a aussi ajouté que i) le taux d’albumine est réduit contrairement aux chercheurs indiens, il n’a pas j)Le C-réactive protéine, marqueur de cet âge ou l’on peut le forcer à cacher la vérité. Le l’inflammation est élevé dans 90% des président Français Emmanuel Macaron lui-même cas..(CRP) K) le taux de procalcitonin peut être normal au a avoué que des choses se sont passées à Wuhan dont toute la vérité n’est pas bien connue. Il doit début mais s’il continue de monter au cours de la 8 maladie, cela peut être un mauvais pronostic.. Covid -19 parmi les personnes qui étaient déjà L) Le troponin cardiaque est élevé Due à la sous plaquenil.il aurait donc un effet préventif et fréquence élevée de la coagulation intra protecteur contre le COVID-19. On ne sait pas vasculaire disséminée, 75% des fois,il est si les autres anti inflammatoires connus tels recommande de procéder à des tests de l’acetaminophene, le cortisol , pourraient aussi coagulopathie en série pour détecter si un avoir un tel droit de cité. problème de coagulation va avoir lieu ou non. 2 ).-Apres le plaquenil, viennent directement les LE TRAIMENT : antibiotiques avec en tête de liste le zithromax la règle d’or consiste désormais à éviter d’utiliser que l’on associe généralement à un autre les ventilateurs et autres machines à pression antibiotique. Certains parlent en l’occurrence de élevée qui non seulement sont inutiles mais la tétracycline qui pourrait servir en lieu et peuvent causer des dommages aux alvéoles. Bien place de l’Azithromycin au cas où quelqu’un des protocoles ont été établis au cours des trois serait allergique à ce dernier. dernières semaines qui sont aiguillés vers un 3).-.La troisième classe de médicaments se traitement symptomatique de la maladie. Le débat retrouve parmi les anticoagulants dont qui revient sur le tapis est celui du milieu ambiant l’héparine en première loge. L’héparine est dans lequel le virus va évoluer. Beaucoup de gens utilisée pour son effet anticoagulant et pour ses meurent, dit-on, parce qu’ils n’avaient pas assez propriétés antivirales. L’héparine semble de force pour combattre le virus. C’est l’éternelle s’attacher aux récepteurs du virus empêchant à joute entre les adeptes de Louis Pasteur qui celui-ci d’attaquer les globules rouges sanguins. privilégient la théorie microbienne face aux En cas de résistance à l’héparine , il faudra adeptes d’Antoine Bechamp qui croient que la considérer le TPA. Mais il faudra tenir compte maladie évoluera négativement seulement si elle des exigences dont s’accompagne la prescription trouve un terrain propice à son évolution..On n’a d’un tel médicament. On parle enfin de jamais autant parlé de vitamine C , de Zn , de l’Aspirin qui doit être considérée dans les cas vitamine D, de Fish oïl et d’autres substances de pathologie cardiovasculaire. naturelles dans l’histoire de la médecine moderne : Toutes choses à même de renforcer ( On a fait bien des progrès depuis que la maladie booster) le système immunitaire de l’individu. a commencé à ravager la planète voila de cela Mais on a aussi pensé à un traitement direct de la quelques mois..Mais on est encore loin de cette condition avec des intrants pharmacologiques maitrise et de cette certitude absolue qui appropriés. permettraient à tout le monde de dormir 1).-D’abord et avant tout, c’est le plaquenil qui a tranquillement sans craindre d’être affecté soi- fait couler beaucoup d’encre. L’autre nom du même par la maladie et d’en tomber victime. De plaquenil est l’hydroxy chloroquine, un nouvelles données viennent chaque jour antipaludéen bien connu des milieux Haïtiens et bouleverser certaines notions que l’on Africains où la malaria est endémique.. Le Dr. considérait bien ancrées. On parle même de la Raoult Didier a parlé du succès monstre qu’il a possibilité qu’à l’hiver, nous soyons encore la connu avec l’utilisation de la drogue.. Cependant proie d’une nouvelle flambée de l’infection qui de plus en plus de gens rejettent le plaquenil à pourrait se révéler aussi meurtrière que la cause des effets secondaires désastreux dont presente. Les consignes doivent être maintenues l’utilisation est entachée.Beaucoup seraient morts et la prudence est encore de mise. Prions que les de toxicité cardiaque dit-on. On croit cependant gens cessent de mourir et que le monde soit un que l’effet du plaquenil serait du à ses propriétés jour vainqueur de ce mal qui nous terrasse tous. anti-inflammatoires qui préviennent le déclenchement du processus inflammatoire et Rony Jean-Mary, M.D. par ricochet, de la dissémination intra Coral Springs, FL vasculaire aigue( DIC).On a note dans certaines le 24 avril 2020. études avoir trouvé aucun malade souffrant de [email protected]. 9

Reynald Altéma, MD MODULATION OF IMMUNE SYSTEM TO PROTECT AGAINST COVID-19 It has become a dangerously new normal on a daily basis that we exchange news about the fallen: a colleague, coworker, acquaintances, a luminary and so on. The stats are very telling however: in urban areas, neighborhood with high concentration of Blacks are disproportionately affected and idem for mortality rate, more males than females regardless of ethnic group, more complications among those with preexisting cardiovascular conditions. Although old age is a risk factor, there have been enough casualties among the not so young to make this tiny RNA particle protected by a fatty but spikes-protected carapace to cause havoc to all comers. No one has publicly stated the obvious but the policy in place is an undeniable departure of the binary approach of high tech versus low tech but rather a dual intervention emphasizing prevention on one hand and reliance on the big guns as needed. In fact, the dearth of protective devices in a society accustomed to disposable supplies in huge quantity has led to a recalibration of assumptions, practices and has even led to the mushrooming of a cottage industry of home-made face masks, reuse of once-before-quickly-discarded N95 masks. Along the way, we are discovering that the rush to intubate may not be so wise1. Simpler methods like keeping a patient in the prone or lateral decubitus position may make all the difference, even among intubated patients. Basic but time-tested methods like hand washing is being promulgated with the zeal of a convert with a new discovery. Analysis of the stats leads one to ask several questions: why the gender discrepancy? Why the racial difference? Last but not least, what else can one add to the list of preventive behavior such as social distancing, confinement, frequent hand washing and wearing a mask when going outside? There are fortunately some good ideas to explain the above questions. In a book published at the beginning of this month, The better half: on the genetic superiority of women, the author, Dr. Moalem2 makes the case of the better genetic predisposition of genetic females (XX) to deal with diseases by possessing 1000 genes per X chromosome and the genetic male (XY) having only 70 genes on the Y chromosome. This, he claims, explains genetic females’ tendency to outlive genetic males, to better handle pathologic stresses and have a better outcome to serious illnesses, including infections. This is an interesting concept and reading of this book is highly recommended to help us become better clinicians and find out about gender-specific disease profiles. Just in passing the price that genetic females pay for a stronger immune system is a disproportionate rate of autoimmune maladies. The gender disparity is not cast in stone in the mortality rate of Covid-19. In some other countries, the difference is far less striking and like so many instances of genetic predisposition and disease manifestation, the concept of nature versus nurture tells us that epigenetic factors, aka behavior or lifestyle, can make a difference. Hence cigarette smoking, alcohol use, lack of exercise, unhealthy diet, obesity are all additional 10 factors that can accelerate, worsen disease manifestation and predispose to complications. Timing of seeking medical care is always a determining factor and genetic males tend to lag behind genetic females and this adds another layer to the data. It follows from the above that minority populations in this country that have always suffered disproportionately from cardiovascular complications will be at higher risk of complications when afflicted by Covid-19. Along the line of a dual approach to counter this pandemic, is there anything one can do in addition to, not instead of, the basic measures being touted daily or in addition to classic therapeutic interventions? The answer is yes with the understanding that there is no panacea. The best and most one can do is to take measures to minimize risk; we can’t eliminate risk at 100%. The pathogenesis of the disease tells us that the virus is sneaky. It penetrates our cells and imposes its will so it uses our replication process for its own’s, while devising all clever ways to evade our immune system. So long as it remains undetected, it replicates as it deems fit in an exponential fashion. By the time it reaches a sizable number and our immune system reacts, it goes into overdrive and this is what creates the major problems with dead cells accumulating in the airways and interfering with normal gas exchange; this opens a domino effect and other major organs begin to fail. By the time this happens, we are in serious danger zone and the best that can be done is damage control. Being in the danger zone as we well know is associated with high morbidity and mortality. Obviously and fortunately only about 5 to 10% at the most of infected persons reach the danger zone. The vast majority either have no symptoms or mild illness. It would seem then that to the extent the immune system is able to prevent significant replication of the virus, then the likelihood of disease is low. We need to always remember that unfortunately not being symptomatic is a double-edged sword as it allows propagation of the virus from the vector to others. This is the reason why wearing a mask and practicing the basic measures becomes so important. The low hanging fruit seems to point toward having a solid immune system. So, what are some means of improving one’s immune system? • First and foremost is good gut health. The microbiome of the gut determines our overall health status3. The use of high fiber is a sine qua non. Prebiotics (leeks, onions, honey, to name a few), probiotics (yogurt, kefir, cottage cheese, etc..) are a good starting point. Antioxidants are also very good. Obviously, some are already high in fiber such as fruits like berries, beans, vegetables; dark chocolate (pleasure and health such a combination!), nuts and so on. A simple amino acid, L- glutamine is preferentially used by the enterocytes, colonocytes and even lymphocytes as respiratory fuel. [After a bout of diarrhea, it’s a good idea to take prebiotics, probiotics to replenish the balance of the gut microflora and also take L-glutamine for a period of up to 3 weeks]4,5.

Healthy eating, exercise are good habits to develop and maintain

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• Vitamin D. More of a hormone than a vitamin, the level of vitamin D does matter for the immune system. Studies have shown an increased risk of URI (Upper Respiratory Infection), including the flu, with low level of vitamin D. The prevalence of low level of vitamin D is significantly high among darker-skinned individuals. Although the controversy about the value of Vitamin D in good health has somewhat abated, unfortunately not many of afflicted patients and physicians among our midst heed to the evidence. A simple search on the website of Harvard Chan School of Public Health6 can be useful to delve into this matter. The use of vitamin D as adjuvant during an episode of Covid-19 especially among groups known to have a high prevalence of deficiency or anybody deficient for that matter is basically part of standard practice7. The dose used during an infection can be increased over maintenance dose to increase blood level. One can safely use 5000-10,000 IU/day for a few weeks and then obtain a blood level. • Vitamin C. No other vitamin has been the scorn of scientists more than vitamin C. It all started when Linus Pauling of double Nobel Prize fame in the early seventies fawned over it and promoted a daily megadose8. Intentional or not it took the allure of promotion of a panacea. This issue was elegantly litigated elsewhere and there is no need to rehash it9. Nonetheless, history will retain that he did take it daily and lived to the golden age of 93 but died of prostate cancer. It’s universally agreed that no panacea exists and vitamin C is no exception, but painstakingly completed studies over the years have proven that it has a great role to play in inflammatory illnesses (pancreatitis, wound healing), and especially in infectious diseases6,9,10,11. I gave several references in the previous issue of the AMHE Bulletin about the therapeutic role it plays in patients with URI, and in Covid-19. The basic science behind the role of vitamin C resides in the fact that it acts as a modulator of white cells, especially neutrophils, lymphocytes, phagocytes12. In summary, during an infection, the serum level of vitamin C drops as the above cells quickly accumulate vitamin C as protection against oxidative damage while at the same time releasing reactive oxygen species to kill the pathogens and cells containing them, like snuffing them out in the bud. The dose needed in an acute infection is not standardized in the literature. Suffice it to say that one can take up to 9 grams/day orally so long as it doesn’t cause diarrhea. To enhance the absorption of vitamin C from the gut, a clever delivery is used. There’s now the liposomal form that results in higher serum level through enhanced bioavailability. Liposomal vitamin C comes in concentration of 1gm-3 gm; because of a rush on it, lately its availability has been spotty at times. Based on available scientific evidence, it behooves one to take vitamin C during an acute episode of Covid-19 or for that matter in any URI including bacterial pneumonia. The IV form for hospitalized patients can be used but the liposomal form is next best. The dose of the IV is also not yet standardized. It ranges from 1.5gm TID to as much as 50 gm/per day (this much higher dose is primarily used in China). A caution: for patients known to have G6PD deficiency or renal insufficiency, one should use the lower dose; diarrhea is a limiting factor (when caused by vitamin C). • Zinc. It’s normally found in legumes, nuts, whole grains. It does help the immune system prevent replication of coronavirus in vitro13. It had gained its fame initially against the common cold. It’s now one more an option in the face of Covid-19. It should be noted that zinc deficiency is associated with dysgeusia and hypo or anosmia. Interestingly these two complaints are being found in Covid-19 patients. It’s not, to my knowledge, known if such patients are deficient in zinc but it would be curious to check their level and find this out. A typical dose is 220mg daily or BID during the period of treatment. One caveat: don’t take the nasal formulation as it can temporarily or permanently impair sense of taste.3,6 12

• Selenium. It’s readily found in nuts, grains, seafood. It plays an important role in the immune response and optimal function of both B and T cells. As such it’s used as adjunctive therapy in HIV cases because of its known antiretroviral activity. It also helps to regenerate vitamin C from its oxidized form and in helping in antioxidant protection. Caution: some people can’t tolerate exogenous selenium pills because of insomnia. Dose ranges from 25 to 100 micrograms, as tolerated14,15,16.

We are learning as we go along with this pandemic. Trying to stay healthy is a daily commitment. Even when we do everything that we are supposed to do, there’s still no guarantee of the outcome. However, enhancing the immune system is another layer of security that we can count on as we are trying to stay safe.

References: 1. https://www.nytimes.com/2020/04/20/opinion/coronavirus-testing- pneumonia.html?referringSource=articleShare 2. Moalem, Sharon, MD, PhD, The better half. On the genetic superiority of women. Farrar, Strauss, Giroux. NY, 2020. 3. http://webmd.com 4. Kim MH, Kim H. The Roles of Glutamine in the Intestine and Its Implication in Intestinal Diseases. Int J Mol Sci. 2017;18(5):1051. Published 2017 May 12. 5. Perna S, Alalwan TA, Alaali Z, et al. The Role of Glutamine in the Complex Interaction between Gut Microbiota and Health: A Narrative Review. Int J Mol Sci. 2019;20(20):5232. Published 2019 Oct 22. doi:10.3390/ijms20205232 6. http://www.hsph.harvard.edu 7. Ginde, AA,. Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey. Archives of Internal Medicine. 2009 Feb 23;169(4):384-90. 8. Pauling L. The significance of the evidence about ascorbic acid and the common cold. ProcNatAcadSci, Vol 68, 11, 2678-2681, November1997. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=4941984 9. Hemilä, H. Vitamin c and the common cold. Br J Nutr. 1992 Jan;67(1):3-16. 10. Scott, P. et al. Vitamin C status in patients with acute pancreatitis. BJS, Vol 80, 6, June 1993. 11. Hemilä, H. Vitamin C and Infections. Nutrients. 2017;9(4):339. Published 2017 Mar 29. 12. Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5–13. doi:10.1002/biof.7 13. te Velthuis AJW, et al. (2010) Zn2+ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture. PLoS Pathog 6(11): e1001176. doi:10.1371/journal.ppat.1001176 14. http://www.lpi.oregonstate.edu 15. Huang Z, Rose AH, Hoffmann PR. The role of selenium in inflammation and immunity: from molecular mechanisms to therapeutic opportunities. Antioxid Redox Signal. 2012;16(7):705-743. 16. Mattmiller SA, Carlson BA, Sordillo LM. Regulation of inflammation by selenium and selenoproteins: impact on eicosanoid biosynthesis. J Nutr Sci. 2013;2:e28

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Chronicle of Slave rebellions in the Americas. Maxime Coles MD

All societies practicing will have to deal with slave revolts because there is that desire for Freedom in any human being. One can express it in their songs or their story-telling nights. It becomes part of their culture and an art in knowing how to implant it on others with the same background.

History is full of examples of such revolts. When a Roman slave named Spartacus (73-71 BC) rose against abuses committed by the Roman Empire or a Scandinavian Slave Tunni, in the 9th century, revolted against the Swedish Monarchy, you can also understand well how the slaves of Santo Domingo, Bookman, Dessalines and others may have felt in the 18th century (1791) against the French Imperialism of Napoleon Bonaparte. The French revolution indeed bought to us the words of Liberty and Equality for all.

Muhammed led the east African slaves in the Zani Rebellion in Iraq to revolt against the Abbasid Caliphate. Nanny of the Maroons revolted against the British in Jamaica. In continental United States, Denmark Vesey rebelled in South Carolina.

Ancient Sparta had serfs called helots who rebelled against the Spartans as reported by Herodotus. English peasants revolted in 1381 to obtain reform in the feudalism system in England and increase the right of the serfs and Richard II agreed to their requests. In , the slaves were called Kholops and slavery remained an institution until 1723 when Peter the Great converted the slaves into serfs. They became outlaws called “Cossacks” living in the southern steppes. Numerous rebellions and Cossacks uprisings with Ivan Bolotnikov (1606), Stenka Razin (1667), Kondraty Butavin (1707) are some of the many hundred outbreaks across Russia.

Numerous African slave revolts took place in America during the 17th, 18th and 19th centuries. More than 250 uprising have been documented. Slaves like Gabriel Prosser (Richmond, VA 1800), Denmark Vesey (Charleston SC 1822) Nat Turner (South Hampton County VA 1831) merit their named to be mentioned and this is the story of the most striking revolts that I want to bring to light.

I have taken solemnly that task to bring to light the most distinctive slave revolutions in the Americas and chose to review some of the most epic African slave revolts which have marked forever the new world in this “Chronicle of African Slave revolts in the Americas”. I am sure you will find time to appreciate what our ancestors have done to make Haiti a free Nation for the Haitians.

This month, we will talk about the 1712 New-York revolt in the British province of New York.

1712 New York slave revolt British province of New York

The NY Slave Revolt in 1712 Maxime Coles MD

A revolt of 23 African slaves in New York city, in the province of New York was formatted during the year 1712. They killed 9 whites before they were stopped in their efforts. In 70 blacks arrested and jailed, 21 were convicted.

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New York city was known to have the largest slave population in the New England There were no large plantations while slaves worked as “house slaves” like servants, artisans, dock workers etc. New York city differed from any southern cities. More they worked also among free blacks. Slaves were able to communicate and planned conspiracy easily.

When the English took over the colony New Amsterdam in 1664 from the Dutch, they imposed different rules and restricted the free slaves from marrying or possessing any land. A was built in the area of what we call now “Wall Street” to facilitate the sale of slaves imported by the Royal African Company. B the beginning of 1700’s around 20% of the population were enslaved black people. Measures require blacks to carry a pass to travel more than a mile from home. Gatherings of more than 3 people, were prohibited.

On the night of April 6. 1712 a group of 20 black slaves set up fire to a building (Maiden Lane) near Broadway. They were armed with guns, hatchets and swords to attack the whites. Colonial forces arrested seventy blacks. Among the one arrested six committed suicide and 21 were convicted and sentenced to death including one woman and a child. 20 blacks were burned to death and one was execute on a breaking wheel (“Supplice de la Roue”). I can add that the Supplice of the Wheel was popular with the French colonialist in the Caribbean and one has to remember after the French revolution in 1789 the way Vincent Oge perished on the place of Cap- Haiti.

More restrictive laws were passed in the colony affecting Blacks and Indians slaves. As we already described earlier, they were not permitted to stay in group of more than three (3), nor they will be able to carry firearms or gambling. Rape, Conspiracy or propriety damage were punished by the death penalty. Free blacks were still allowed to own land. Anthony Portuguese, owned land which represent the present-day Washington Square Park and his daughters and grand-children still remained present owners.

To free a slave, a tax of 200 pounds was needed and it was debated in 1715 before the Lords of in London by the Governor Hunter, that a slave might inherit part of a master wealth and share his lifetime fortune.

References:

1- Diehl, Lorraine B (October 5, 1992) “Skeletons in the Closet”. New York Magazine: New York Media LLC pp 78-86. 2- New York Slave Revolt 1712. In O’Callaghan, E.B. (ed.) Documents relative to the Colonial History of the State of New York procured in Holland, England and . Albany, New York: Weeds, Parson (2016-06-14) 3- “New York’s Revolt of 1712”. Africans in America (January 5, 2008). 4- “The Freedmen of New Amsterdam”. In McClure Zeller, Nancy Anne (ed). A Beautiful and Fruitful Place: New Netherland Institute (April 4, 2018). selected. 5- Geismer, Joan H. (April 2004). The Reconstruction of Washington Square Arch and Adjacent Site Work”. New York City Department of Park and Recreation, P 10 (April4, 2018). 6- Johnson, Mat (2007), The Great Negro Plot, New York: Bloomsbury. 7- Horton, James & Horton, Lois (2005), Slavery and the Making of America, New York: Oxford University Press,

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Ma solitude Maxime Coles MD

Du coin de l’oeil, j’ observe attentivement Ce regard divin, et ce sourire angelique. Qui fleurissent mon coeur d’allegresse Dans une solitude maladive.

Comment pourais-je chanter tes louanges Sur ce quai, abandonne dans la cohue? Que deviendra mon etre qui pavanne, Assoiffe de ton nectar?

Que dirais-je ce soir-la, muse de mes reves Dans cette multitude de regards Alors que le parfum que tu emanes M’ennivre encore d’un Bonheur soutenu.

La candeur de ta chaire spirituelle Encourage mes instincts Alors que mon ame arbore ses secrets Sur le chemin de ma Destinee.

La nuit reflete ma solitude Et comme berce par une pleine lune, Mes pensees s’envolent eparlillees Vers ce firmament etoile.

Dans ce confinement, je pense A nos amis disparus sur le front, Comme des voyageurs du temps Qui surement nous preparent le chemin.

Je dedie ce poeme a tous nos compagnons qui ont sacrifie leur vie dans cette pandemie. Puissent ce Dieu de Misericorde les recevoir dans son royaume, a bras ouverts.

Maxime Coles MD (4-21-2020)

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COVID-19 continue a devaster Notre communaute medicale.et recemment Louis Edouard Fontaine MD, un de nos jeunes et fougeux de la promotion 1996, EST passe de vie a trepas, combattant cette pandemie, a Brooklyn NY. Sinceres condoleances a ses parents et allies affectes par ce deuil. Paix a son ame et que la Terre lui soit legere. Maxime Coles MD. 4-19-2020.

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COVID-19 a coûté la vie à un autre médecin parmi nous à l'AMHE. Bredy Pierre-Louis MD nous a quitté pour rejoindre son Créateur, combattant la pandémie en première ligne. Sincères condoléances à sa femme Maggie, ses enfants, sa famille et ses amis. Que tu reposes en paix, Bredy. Maxime Coles MD

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ICS US Section Past President, Prof. Kazem Fathie MD of Las Vegas, was a friend of mine and we worked closely for the last 33 years to make the International College of Surgeons and the American Academy of Orthopedical and Neurological Surgeryrespected organizations in the USA. He was awarded a Presidential Recognition Award during the 2010 Annual Convention in Denver, acknowledging the tremendous contributions he has made to both academies. He was chairman, at the AANOS and become President of the US ICS Section in 2001. He was a scientist, a poet, and a friend we found time to appreciate over the years. We will miss him dearly. Rest in Peace Kazem. Maxime Coles MD. ***

Marie Camel Pierre-Louis MD n"est plus de ce monde. Elle nous a quitte le 3 Avril 2020, combattant cette pandemie a NY. Elle a dedie sa vie a prendre soin des plus faibles et des opprimes. Je l'ai bien connu sur les bancs de la faculte alors que nous oeuvrons a la faculte de Medecine. Nous sommes de la promotion 1976 (Price Mars) et comme plusieurs d'entre nous. elle s'est rendue aux USA pour parfaire ses etudes. Elle a travaille d'arache-pied en maladies infectueuses et s'est specialisee dans le SIDA. Elle laissera un vide parmi nous, difficile a combler. Bon voyage Marie Carmelle et que la terre te soit legere, La AMHE presente ses sinceres concoleances a la famille et aux amis affectes par ce deuil. Maxime Coles MD *** CLOVID-19 claimed another life in the AMHE Medical community on Sunday 19 April 2020. Jean Marie Claude Desrosiers graduated in 1982 and came to the state to specialize in Geriatric Medicine. He practiced for years in the New York area and become a Geriatric specialist The AMHE is sending it sincere condolences to his family and friends affected by this loss. Maxime Coles MD

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Leslie Augustin (TI-Jo) n'est plus de ce monde. Il a ete rejoindre son createur. Leslie EST Le jeune frere de Ducarmel Augustin MD and a note from Henriot St Gerard MD nous raconte un peu de son passage sur Terre. Sinceres condoleance de la AMHE a Ducarmeta la famille Augustin et aux amis affectes par cette perte. Maxime Coles MD

Henriot St Gerard MD dixit:

A Tous: Je veux par la présente vous annoncer Le décès de Leslie Augustinjeune frère de Notre confrère Ducarmel. Leslie vivait en Haïti et EST décédé Des suites d’une rupture d’anévrysme cérébral. La situation qui prévaut à cause de la pandémie du coronavirus rend les circonstances plus difficiles. Nous vous encourageons à entourer Le confrère de tout Le support possible.

Nous présentons nos condoléances à toute la famille et nous les assurons de nos pensées et prières pour les accompagner au cours de cette épreuve.

Les coordonnées de Ducarmel:Augustin MD peuvent etre retrouvee at AMHE.org

Sincèrement Henriot St Gerard MD 18

Maxime Coles MD Dixit: You need to know the difference in symptoms:

1) Common Cold: 3) Influenza: -Sneezing -Fever or/and Chills -Stuffy nose -Cough -Sore throat -Muscle and body aches -Coughing -Headaches -Mild body aches -Fatigue -Sore Throat 2) Seasonal Allergies -Runny and Stuffy nose -Stuffy and runny nose -Sneezing 4) COVID-19 Infection -Itchy eyes, mouth, and skin -Dry Cough -Wheezing -Fever - Shortness of Breath - Fatigue -Nasal Congestion - Aches and Pains

From The New York Times:

Covid-19 Trickles Into Haiti: ‘This Monster Is Coming Our Way’

The virus has been slow to hit the country. But as laid-off Haitians return from hard- hit areas, doctors are preparing furiously for an outbreak they fear will strain the nation’s threadbare health care system. https://www.nytimes.com/2020/04/22/world/americas/coronavirus-haiti.html?smid=em-share

Le Newsletter est publié toutes les 3 semaines. Prochaine parution: 18 mai 2020

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Published on the AMHE Facebook page last two weeks Articles parus sur la page Facebook de l'AMHE durant la dernière semaine

Coronavirus en Haïti: les experts craignent plus de 20000 morts - Because farmers can't sell to restaurants and markets, the vegetables are left to waste. MC - Thank you, Daniel.Laroche, MD/ MC - DES CONSEILS APPROPRIÉS, COMPLETS ET PRÉCIS. - Les noirs ne sont pas bien traites en Chine et ils souffrent de la pandemie. MC - Monument National qui a ete temoin des noces du Roi Henry Christophe, datant de 1810, - Surveillance COVID-19, Haiti, 2020 - Karl Latortue MD, president du chapitre AMHE-NY avec Ricot Dupuis de Radio Soleil (New York). Maxime Coles MD - Can you name the capital of any African Country? MC - Un rappel historique et une revue des bienfaits de la Chloroquine (Quinine) - Pouvez-vous deviner qui vient dîner le dimanche de Pâques. Maxime Coles MD - Le pays de mes ancetres!. And more…