An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola.

BACKGROUND: The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014-2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country's maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP). METHODS: Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible. RESULTS: Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1-3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided. CONCLUSIONS: Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

A Simple Clinical Tool for Stratifying Risk of Clinically Significant CKD after Nephrectomy: Development and Multinational Validation.

BACKGROUND: Clinically significant CKD following surgery for kidney cancer is associated with increased morbidity and mortality, but identifying patients at increased CKD risk remains difficult. Simple methods to stratify risk of clinically significant CKD after nephrectomy are needed. METHODS: To develop a tool for stratifying patients' risk of CKD arising after surgery for kidney cancer, we tested models in a population-based cohort of 699 patients with kidney cancer in Queensland, Australia (2012-2013). We validated these models in a population-based cohort of 423 patients from Victoria, Australia, and in patient cohorts from single centers in Queensland, Scotland, and England. Eligible patients had two functioning kidneys and a preoperative eGFR ≥60 ml/min per 1.73 m2. The main outcome was incident eGFR <45 ml/min per 1.73 m2 at 12 months postnephrectomy. We used prespecified predictors-age ≥65 years old, diabetes mellitus, preoperative eGFR, and nephrectomy type (partial/radical)-to fit logistic regression models and grouped patients according to degree of risk of clinically significant CKD (negligible, low, moderate, or high risk). RESULTS: Absolute risks of stage 3b or higher CKD were <2%, 3% to 14%, 21% to 26%, and 46% to 69% across the four strata of negligible, low, moderate, and high risk, respectively. The negative predictive value of the negligible risk category was 98.9% for clinically significant CKD. The c statistic for this score ranged from 0.84 to 0.88 across derivation and validation cohorts. CONCLUSIONS: Our simple scoring system can reproducibly stratify postnephrectomy CKD risk on the basis of readily available parameters. This clinical tool's quantitative assessment of CKD risk may be weighed against other considerations when planning management of kidney tumors and help inform shared decision making between clinicians and patients.

Probing halogen-halogen interactions in solution.

Halogen-halogen interactions are a particularly interesting class of halogen bonds that are known to be essential design elements in crystal engineering. In solution, it is likely that halogen-halogen interactions also play a role, but the weakness of this interaction makes it difficult to characterize or even simply detect. We have designed a supramolecular balance that allows detecting BrBr interactions between CBr3 groups in solution and close to room temperature. The sensitivity and versatility of the chosen platform have allowed accumulating consistent data. In halogenoalkane solvents, we propose estimates for the free energy of these weak halogen bond interactions. In toluene solutions, we show that the interactions between Br atoms and the solvent aromatic groups dominate over the BrBr interactions.

Effect of changes in the nutritional status on the performances of growing Creole kids during an established nematode parasite infection.

In this study, we evaluated the effect of changes in the nutritional status on the performances of growing Creole kids during an established experimental gastrointestinal nematode (GIN) infection. Eighteen 6-month-old Creole kids were distributed in two main groups infected (I) and non-infected (NI) and were placed for a period of 4 weeks on each of three diets differing in their nutritional values: (1) fresh grass (FG, 6.7 MJ/kg dry matter (DM) and 7.9% crude protein (CP)) non-supplemented, (2) FG supplemented with a commercial concentrate (CC, 12.2 MJ/kg DM and 20.6% of CP), and (3) FG supplemented with dried banana (Ban, 11.1 MJ/kg DM and 4.3% CP). The experiment was designed as a split-plot with experimental infection (I and NI) as the main plot and the diets (FG, CC, and Ban) as the subplots with three replicates. We showed a significant effect of the diet changes on the fecal egg counts. A higher dry matter intake, digestibility, and growth rate were observed with the CC diet but together with a slight but significant increase of the intensity of the GIN infection. These data suggest that the improvement of the protein nutritional status during an establish GIN infection would improve the animal performance at the expense of the mechanism involved in the control of the infection.

Substitution of corn and soybean with green banana fruits and Gliricidia sepium forage in sheep fed hay-based diets: effects on intake, digestion and growth.

This study aimed to evaluate the substitution of imported corn and soybean by local feed resources from tropical production settings such as entire green banana and Gliricidia sepium forage as energy and protein sources, respectively, in sheep diets. Two experiments were conducted: first, a 'growth trial' and second, an in vivo digestion study. In the 'growth trial', 40 Martinik lambs [body weight (BW): 29.4 +/- 3.6 kg; 6 months old) were used and distributed into four groups of 10 lambs each according to treatment: HBGl (banana + gliricidia at low level; 1500 g/day; 119 g/kg BW(0.75)), HBGh (banana + gliricidia at high level; 3000 g/day; 238 g/kg BW(0.75)), HBS (banana + soybean cake) and Control (corn + soybean cake). In digestion trial, four Martinik rams (BW: 57.2 +/- 3.45 kg) fitted with ruminal and duodenal cannulae were used; treatments (HBG, HBS and Control) were similar but adjusted to metabolic body weight (MW) and just one level of gliricidia was used. Intake, average daily gain (ADG), feed intake to gain index (F:G), apparent total and ruminal digestibilities as well as nitrogen balance, microbial efficiency and volatile fatty acid (VFA) profile were monitored. Lambs fed HBGh had greater dry matter (DM) intake based on MW and ADG (173 g/day vs. 141 g/day; p < 0.001), whereas HBGl lambs showed the lowest ADG (71.5 g/day) and the worst F:G (14.4; p < 0.001). The DM, organic matter (OM), neutral detergent fibre and acid detergent fibre digestibilities were not influenced by treatment, whereas crude protein digestibility was higher (p = 0.024) in diets offered banana or corn + soybean cake (687 g/kg DM and 658 g/kg DM, respectively). Ruminal DM and OM digestibilities did not differ among treatments. Total or individual VFA concentrations were also not influenced by the diet. Higher (p = 0.006) ruminal fluid pH values were recorded for diets combining banana and gliricidia (6.54) or banana and soybean (6.39) until 3 h after a meal. As all animals on gliricidia- and banana-supplemented diets gained weight and maintained a positive N balance, it is concluded that green banana and gliricidia forage may be a viable alternative to replace conventional energy and protein supplements in sheep diets.

Influence of psychological factors on the response to clomipramine in hospitalized chronic low back pain patients. Preliminary data from a psychometric study.

BACKGROUND: Chronic low back pain is a complex condition produced by multiple factors. Psychological disturbances have been found in previous studies using a variety of psychological tests. The most widely used self-administered questionnaire was the Minnesota Multiphasic Personality Inventory (MMPI). OBJECTIVE: To assess the response to clomipramine in chronic low back pain patients according to baseline MMPI scores. PATIENTS AND METHODS: Thirty chronic low back pain patients were given clomipramine intravenously during a ten-day hospital stay, then orally for 20 days. The dose was gradually brought up to 150 mg/d. The MMPI was administered on the day before treatment initiation. MMPI scores were not looked at until the end of the study. The Saint Antoine Questionnaire, a visual analog scale for pain, Schöber's maneuver, and the global result as assessed by the patients (success or failure) were evaluated on days 0 (D0), 4 (D4), 10 (D10), and 30 (D30). RESULTS: The initial mean MMPI scores for hypochondria, depression, and hysteria were significantly lower in the 23 patients (76%) who considered their treatment successful on D30. Among the 13 patients with high hypochondria and hysteria scores, five improved during hospitalization then had a relapse after returning home. CONCLUSION: The response to treatment with clomipramine was better in nondepressive patients. The hypochondria and hysteria scores were the best predictors of the response to clomipramine. These results may provide a basis for selecting those chronic low back pain patients most likely to benefit from clomipramine therapy.

Surgery for lung tuberculosis and related lesions: change in clinical presentation as a consequence of migration of population.

In spite of better health care organization and improvement in medical treatment, the incidence of newly diagnosed cases of tuberculosis has not declined in our region as anticipated and a number of patients still require surgery for lung tuberculosis and related lesions. Thus 92 patients were operated in our institution during the 1972-1991 period. Indications for surgery were: medical treatment failures (13%), mass lesions of the lung (31%) and mediastinum (12%), complications of the disease (38%) or from previous operations (6%). The proportion of immigrants (47%) was significantly higher than expected from their relative number. They also had a tendency to have more advanced or complicated forms of disease (61% vs 49% in local natives). As a probable consequence of this, surgical resections were more aggressive in immigrants. The operative mortality was similar in both groups. This change of presentation of lung tuberculosis is a new challenge to our local strategy in treating this disease.

Thymoma: prognostic factors.

The relative importance of factors influencing prognosis and survival in the treatment of thymoma is still controversial. Fifty-three patients operated on for thymoma from 1966 to 1990 were evaluated, 14 with myasthenia gravis and 39 without. Survival was analyzed as it related to associated disease, gross invasion by the tumor and the predominant cell type. Follow-up information was obtained in all cases (mean observation time: 11.2 years). A high proportion (51%) of our patients had invasive forms (stages III and IV). The overall 5-, 10- and 20-year survival rates were 52%, 46% and 21%, respectively. Factors indicating a poor prognosis included local invasion (P < 0.0001), predominantly, epithelial histologic features (P = 0.002), tumor-related symptoms and the type of surgical procedure. Myasthenia gravis was not an adverse factor for survival. The degree of tumor invasion was the main prognostic factor and treatment should be planned accordingly.

[Bronchiectasis: indication and timing for surgery]. / Les bronchectasies: indication et moment de la chirurgie.

Despite continuous improvement in the medical treatment of bronchiectasis, a number of patients will eventually require surgery. The optimal timing of surgical resection and the efficacy of surgery need to be reassessed in this context. The records of 85 patients operated for bronchiectasis during the period 1971-1991 were reviewed. Six patients underwent repeated surgical resections. Long term results could be assessed in 73 patients (86%) by means of questionnaire or subsequent medical evaluation. Indications for surgery were: persistent symptoms under medical treatment in 43 cases (51%), local complications such as fungal superinfection or severe bleeding in 17 (20%) and 11 (13%) respectively, pulmonary mass lesions in 14 (16%). Limited resections such as segmentectomies or lobectomies were carried out in 79 cases (93%). In patients with localized disease (N = 49), surgery led to significant improvement in 91% of cases. In patients with extensive or complicated disease (N = 36), long term results of surgery were satisfactory in 62% and poor in 38%; surgery was often more aggressive in this group of patients (5 pneumonectomies), and 4 postoperative deaths occurred (in debilitated patients). Patients with localized disease and recurrent symptoms despite medical treatment should be operated before the development of complications. At this stage, surgical resection can be limited and has the potential to cure or significantly improve their condition. In contrast, patients with extensive disease are often debilitated and surgical treatment is less rewarding and sometimes poorly tolerated.

[Impact of organ shortage on the transplantation program]. / Impact de la pénurie d'organes sur un programme de transplantation.

The purpose of the study was to evaluate the consequences of a recent progressive shortage of donor organs on our different transplant programs. Although the waiting time before transplantation remained in general relatively short (4.6 [mean], 0-3, 0-10 months for renal, liver and heart transplantation, respectively), patients started to accumulate on our waiting list during the last year (1990) of the study (kidney transplantation). Furthermore some patients clearly deteriorated, other died awaiting transplantation (18% and 15% of the patients listed for liver and heart transplantation, respectively). In emergency, organs were provided most often by neighbouring foreign centers. Given these facts adhesion to supranational donor networks should be considered.

[Kidney retransplantation: results and prognostic factors]. / Retransplantation rénale: résultats et facteurs de pronostic.

48 non primary renal transplants were performed in 40 recipients during the 1973-1990 period in our institution (40 second grafts, 6 third grafts and 1 four and fifth grafts). Despite poor HLA matching our second graft survival rates compare favorably with others (80% and 70%, 1 and 5 year graft survival rates). The type of immunosuppression (including ciclosporine A or not) and the duration of the first graft had an influence on the outcome of second grafts. Our experience with repeated retransplantation is limited, but graft survival appears to be poor: most of the grafts were rejected within 2 years (or less). However patient survival was not affected by overimmunosuppression following multiple grafts.

[Asymptomatic mediastinal masses: prognosis, attitude and impact of thoracic radiography]. / Les masses médiastinales asymptomatiques: pronostic, attitude et impact de la radiographie du thorax.

Mediastinal masses remain an interesting diagnostic and therapeutic problem for the clinician. Recent advances in imaging techniques and the increased use of chest roentgenograms in medical practice contribute to early screening of asymptomatic mediastinal masses. From 1965 to 1990, 290 patients with a primary mediastinal cyst or neoplasm were operated and treated in our institution. Among those, 80 patients presented with asymptomatic mediastinal masses. The prognosis of these asymptomatic lesions was evaluated and compared to that of symptomatic ones. Overall, two third of patients who were asymptomatic at diagnosis had a neoplasm, which proved to be malignant in half of the cases. A significantly greater number of patients with malignant neoplasms were asymptomatic at the time of diagnosis during the recent period. The prognosis of these asymptomatic lesions appeared to be better in selected tumoral types (e.g. thymomas, lymphomas) although it was difficult to completely avoid statistical bias. Early radiological detection of mediastinal tumors could improve their prognosis in selected cases. Incidental diagnosis of mediastinal masses by radiological examination should lead to early aggressive diagnostic procedure and treatment.

Renal retransplantation in Switzerland: poor HLA matching of first and subsequent allografts does not appear to affect overall graft survival.

In Switzerland graft survival after primary renal transplantation can be considered as satisfactory, although our current policy does not favour HLA compatibility except for acute rejectors or sensitized patients. This low level of HLA matching could result in increased sensitization and affect subsequent graft survival. A total of 318 non-primary renal transplants were performed in 293 recipients during the period 1981-1990. Of these, 271 were second transplants, 40 were third transplants and seven were fourth or fifth transplants. Survival rates at 1, 2 and 5 years were 75%, 68% and 60% for second grafts, and 72%, 60% and 54% for third grafts, respectively. Results after multiple grafts were poor, but our experience was limited. The number of sensitized patients (peak PRA > 50%) awaiting retransplantation slightly increased (51 to 69), but decreased as a proportion (72% to 66%). Our policy of relying only marginally on HLA compatibility does not appear to have affected our results adversely.

[Study of residual levels of delayed-action neuroleptics]. / Etude des taux résiduels de neuroleptiques à action prolongée.

Pharmacokinetics of the depot antipsychotics are unclear and mainly depend on releasing from the depot site (according to a "flip-flop" model). Few data are available on residual plasma concentrations of those drugs. We have practiced 38 blood determinations among 15 patients treated by long-acting neuroleptics (10 by fluphenazine decanoate, 4 by flupentixol decanoate and 1 by pipotiazine palmitate). Radio Receptor Assay method was used (based on competition for dopamine receptors binding), with results expressed as chlorpromazine equivalents. They showed; a wide interindividual variability; considering each subject, intraindividual variability is attenuated; blood measurements are mainly higher than therapeutic ranges (especially for patients on fluphenazine decanoate). Those results might involve that some patients are overdosed, but other studies are needed in this way.

[Incidence of primary mediastinal lesions: change in the profile and therapeutic implications]. / Incidence des lésions médiastinales primaires: changement de profil et implications thérapeutiques.

The pattern of occurrence of mediastinal masses has to be taken into account when treating and approaching these lesions. In most reported series tumors of neural or germinal origin and thymomas are predominant. We reviewed the records of 277 patients operated for primary mediastinal lesions over the last 25 years (1965-1989) in our center. Surprisingly (Hodgkin's and non-Hodgkin's) lymphomas (24-25%) were found to emerge as the most common tumors in our series, whereas tumor of neural (11%) and germinal (65%) origins were relatively rare and decreasing in incidence. Thymomas (17%) and mediastinal cysts (14%) occurred as predicted in the literature. Consequently the malignancy rate was high (53%) even in asymptomatic patients (18%). Similar findings have been described recently by others. Factors responsible for this new distribution are difficult to identify. The therapeutic implications of the changes are discussed.

[Pulmonary aspergilloma]. / Les aspergillomes pulmonaires.

Pulmonary aspergillomas usually arise from colonization of Aspergillus in preexisting lung cavities. Between 1972 and 1988, 18 patients underwent thoracotomy for treatment of pulmonary aspergilloma in our institution. Eight patients had simple aspergilloma and ten had complex aspergilloma. Hemoptysis was the most frequent complication. Tuberculosis was the most common underlying lung disease. Patients presenting with complex aspergilloma usually had associated factors potentially reducing their immune competence. Patients with simple aspergilloma tolerated surgery quite well and the outcome was satisfactory. By contrast operative mortality was 30% (3 deaths) in patients with complex aspergilloma and complications occurred in 8 patients (80%). Treatment of pulmonary aspergilloma must be individualized to take into account the patient's overall health and the risks attendant with each treatment modality.

[Elaboration of an ethogram for the diagnosis of the A Pattern in coronary pathology]. / Elaboration d'un éthogramme pour le diagnostic du Pattern "A" en pathologie coronaire.

In order to develop a technique which allows the detection of Pattern A (PA) we present in this paper a series of steps for constructing an observation gril (ethogram) which allows for the quantification of behavior in situation of structured interview. The behavioral units making up the final ethogram are derived from inter-item correlations taken from a population of 48 subjects who had suffered heart attacks. The observations on this population permit an inclusion score in the PA. These observations also confirm that the PA present a risk factor which is independent of classical risk factors. A significative positive correlation with work stress has been found showing, in accordance with the view of Friedman and Rosenman that the PA corresponds to a particular behavioral pattern which is dependent on the work environment.