A Comparative Study between Postoperative Analgesia of Fascia Iliaca Compartment Block and Anterior Quadratus Lumborum Block in Proximal Femur Fracture.

Elderly patients with various comorbidities are more likely to suffer from proximal femur fractures. It is also a painful fracture, and poor pain management can have serious physiological and psychological consequences, such as acute delirium. Purpose. The aim of this study is to compare the efficacy of ultrasound-guided transmuscular (anterior) quadratus lumborum block (QLB) versus infrainguinal fascia iliaca compartment block (FICB) in proximal femur fractures for postoperative analgesia. Patient-reported pain on the visual analogue scale (VAS), analgesic demand, and ambulation were the key factors. Patients and Methods. This prospective, randomised trial was done after receiving approval from the institute' study ethical committee. In this study, ultrasound-guided infrainguinal fascia iliaca compartment block was compared to ultrasound-guided anterior quadratus lumborum block using 50 ml of bupivacaine 0.25%, with a maximum dose of 2.5 mg/kg at the end of surgery after spinal anaesthesia in 128 patients (64 patients in each group). Nalbuphine was given as rescue analgesia if VAS >3. Our 1st outcome was the first rescue analgesia and total analgesic consumption in the 1st 24 hours; the 2nd outcome was the time patients started to ambulate. Results. Postoperative pain perception was substantially greater in the FICB group starting from 30 min (P value 0.022) till 24 hours (P value <0.001), and they received a considerably larger total narcotic dose (14.1 ± 3.5) than patients in the QLB group (7.9 ± 3.4), P value (<0.001 ∗ ). The time required to achieve first rescue analgesia was much less in the FICB group (8.5 ± 2.2) compared to the QLB group (14.1 ± 4.5), P value (<0.001 ∗ ), and they took much longer to ambulate (22.3 ± 4.8) when compared to the QLB group (20.1 ± 4.6), P value (0.011 ∗ ). Hypotension (1.6%) was detected mainly in the QLB group, whereas poor fascial separation (1.6%) was observed only in the FICB group. There were no significant differences in complications between both the FICB and QLB groups. Conclusion. Patients receiving postoperative anterior QL block for proximal femur fracture demonstrated delayed first rescue analgesia and lower total nalbuphine consumption with early ambulation than patients who received FICB.

Spatial Distribution of PCR-Identified Species of Anopheles gambiae senu lato (Diptera: Culicidae) Across Three Eco-Vegetational Zones in Cross River State, Nigeria.

Anopheles gambiae sensu lato complex (An. gambiae s.l.) describes a group of nine morphologically indistinguishable members that vary in their distribution, ability to transmit malaria, and susceptibility to pyrethroids. Here, we recorded the spatial patterns of PCR-identified An. gambiae s.l. complex species collected from four sites in Cross River State, Nigeria that represented three different ecological zones. Trapping was conducted between October 2015 and June 2016. Anopheles gambiae s.l. complex species identification was performed using species-specific primers followed by An. gambiae and An. coluzzii differentiation using the restriction fragment length polymorphism (RFLP) method. Bivariate and multivariate logistic regression models were used to identify ecological and seasonal variables closely associated with An. coluzzii and An. gambiae distribution. Out of 1,388 An. gambiae s.l. successfully amplified, 1,074 (77.4%) were An. coluzzii, 278 (20%) were An. gambiae, and 25 (1.8%) were hybrids (An. coluzzii/An. gambiae). A very small number of An. arabiensis (0.8%, n = 11) were also collected. Statistical analysis indicated that An. coluzzii is predominant in Guinea-savannah and tropical rainforest, and is highly associated with rainy seasons, while, An. gambiae is prevalent in mangrove swamp forest during dry seasons. Only 13 An. gambiae s.l. females were infected with Plasmodium falciparum (P. falciparum). The sporozoite infection rate was higher in mangrove swamp forest (53.8%, n = 7) than in rain forest (38.5%, n = 5) followed by Guinea-savannah (7.7%, n = 1) ecological zones. These results provide important insights for strategic planning of malaria control programs in Nigeria.

Crimean-Congo hemorrhagic fever virus in livestock ticks and animal handler seroprevalence at an abattoir in Ghana.

BACKGROUND: Crimean-Congo Haemorrhagic Fever Virus (CCHFV) is a zoonotic virus transmitted by Ixodid ticks and causes Crimean-Congo hemorrhagic fever (CCHF) disease in humans with up to 50 % mortality rate. METHODS: Freshly slaughtered livestock at the Kumasi abattoir in the Ashanti Region of Ghana were examined for the presence of ticks once a month over a 6-month period from May to November 2011. The ticks were grouped into pools by species, sex, and animal source. CCHFV was detected in the ticks using reverse transcription PCR. Blood samples were collected from enrolled abattoir workers at initiation, and from those who reported fever in a preceding 30-day period during monthly visits 2-5 months after initiation. Six months after initiation, all participants who provided baseline samples were invited to provide blood samples. Serology was performed using enzyme linked immunosorbent assay (ELISA). Demographic and epidemiological data was also obtained from enrolled participants using a structured questionnaire. RESULTS: Of 428 freshly slaughtered animals comprising 130 sheep, 149 cattle, and 149 goats examined, 144 ticks belonging to the genera Ambylomma, Hyalomma and Boophilus were identified from 57 (13.3 %): 52 (34.9 %), 4 (3.1 %) and 1 (0.7 %) cattle, sheep and goat respectively. Of 97 tick pools tested, 5 pools comprising 1 pool of Hyalomma excavatum and 4 pools of Ambylomma variegatum, collected from cattle, were positive for CCHFV. Of 188 human serum samples collected from 108 abattoir workers, 7 (3.7 %) samples from 6 persons were anti-CCHF IgG positive with one of them also being CCHF IgM positive. The seroprevalence of CCHFV identified in this study was 5.7 %. CONCLUSIONS: This study detected human exposure to CCHF virus in slaughterhouse workers and also identified the CCHF virus in proven vectors (ticks) of Crimean Congo hemorrhagic fever in Ghana. The CCHFV was detected only in ticks collected from cattle, one of the livestock known to play a role in the amplification of the CCHF virus.

Pyrethroid Insecticide Resistance Mechanisms in the Adult Phlebotomus papatasi (Diptera: Psychodidae).

Phlebotomus papatasi is one of the most medically important sand fly species in the Old World, serving as a vector of Leishmania parasites and phleboviruses. Chemical control is still considered the most effective method for rapidly reducing populations of flying insects involved in vector-borne disease transmission, but is increasingly threatened by insecticide resistance in the target insect posing significant problems for entomologists responsible for control programs. This study was conducted to determine pyrethroid resistance mechanisms and the biological, physiological, and molecular impacts of resistance in Ph. papatasi, and to compare their resistance mechanisms against those reported for mosquitoes and other intensely studied dipterans. Field-collected Ph. papatasi from Aswan, Egypt, were subjected to sublethal doses of permethrin and reared as a resistant strain under laboratory conditions through 16 generations. Biological parameter observations of resistant Ph. papatasi revealed an association of resistance with productivity cost. Physiological analysis revealed that concentrations of oxidase and esterase enzymes increased in early generations of the resistant colony, and then subsided through the F16 generation to levels similar to those in a susceptible colony. The activity levels of acetylcholinesterase were higher in field-collected Ph. papatasi than in susceptible colony flies, but decreased significantly despite subsequent exposure to permethrin. The molecular search for gene mutations in the resistant strain of Ph. papatasi failed to identify any mutations common in pyrethroid-resistant mosquitoes. Our study revealed that the mechanism of pyrethroid resistance in sand flies is different than that in mosquitoes, at least at the genetic level.

The Seasonality and Ecology of the Anopheles gambiae complex (Dipetra: Culicidae) in Liberia Using Molecular Identification.

Members of the Anopheles gambiae sensu lato (Giles) complex define a group of seven morphologically indistinguishable species, including the principal malaria vectors in Sub-Saharan Africa. Members of this complex differ in behavior and ability to transmit malaria; hence, precise identification of member species is critical to monitoring and evaluating malaria threat levels. We collected mosquitoes from five counties in Liberia every other month from May 2011 until May 2012, using various trapping techniques. A. gambiae complex members were identified using molecular techniques based on differences in the ribosomal DNA (rDNA) region between species and the molecular forms (S and M) of A. gambiae sensu stricto (s.s) specimens. In total, 1,696 A. gambiae mosquitoes were collected and identified. DNA was extracted from legs of each specimen with species identification determined by multiplex polymerase chain reaction using specific primers. The molecular forms (M or S) of A. gambiae s.s were determined by restriction fragment length polymorphism. Bivariate and multivariate logistic regression models identified environmental variables associated with genomic differentiation. Our results indicate widespread occurrence of A. gambiae s.s., the principal malaria vector in the complex, although two Anopheles melas Theobald/A. merus Donitz mosquitoes were detected. We found 72.6, 25.5, and 1.9% of A. gambiae s.s specimens were S, M, and hybrid forms, respectively. Statistical analysis indicates that the S form was more likely to be found in rural areas during rainy seasons and indoor catchments. This information will enhance vector control efforts in Liberia.

Field responses of Anopheles gambiae complex (Diptera: Culicidae) in Liberia using yeast-generated carbon dioxide and synthetic lure-baited light traps.

Malaria infection is a serious public health problem throughout Liberia, but vector surveillance is limited or nonexistent in remote regions of the country. To better understand the spatial and temporal distribution of malaria vectors in Liberia and to support vector and malaria activities of the Liberian Ministry of Health, a study was conducted to determine the efficacy of light traps baited with a synthetic lure and CO2 for capturing Anopheles gambiae sensu lato (Giles). Traps with a ultraviolet, light-emitting diode, and incandescent lights baited with a synthetic skin lure and CO2 combinations were evaluated at four field sites in three counties of Liberia for five consecutive nights every 8 wk during 2011. In total, 4,788 mosquitoes representing 56 species from nine genera were collected throughout the 30-wk study; An. gambiae s. l. comprised 32% and of the148 An. gambiae s. s. collected, 85% were of the S form. A greater percentage of An. gambiae s. l. were collected in ultraviolet traps baited with a synthetic lure and CO2 compared with any other trap configuration. The influence of trap configuration on conclusions from surveillance efforts, specifically with regards to An. gambiae is discussed.

Outcome of surgical treatment of patients with upper versus lower urinary tract urothelial carcinoma: stage-by-stage comparison.

OBJECTIVES: It remains controversial whether we can apply similar principles in the management of upper urinary tract urothelial carcinoma (UUT-UC) based on the behavior of bladder urothelial carcinoma (B-UC). We sought to assess whether UUT-UC and B-UC have similar biology and performed a stage-by-stage comparative analysis of outcome between the 2 groups. METHODS: A retrospective review was performed on patients who underwent nephroureterectomy for UUT-UC and radical cystectomy for B-UC from 1991 to 2006. Standard variables were collected and recurrence-free and overall survival (OS) rates were calculated. RESULTS: 280 patients with a median age of 69 years were included (99 UUT-UC treated via nephroureterectomy and 181 B-UC treated via radical cystectomy). Median follow-up was 29 months. None received neoadjuvant chemotherapy. Patients with UUT-UC presented less commonly with invasive disease compared to those with B-UC (44 vs. 77% were >pT2). Overall, 5-year OS for the B-UC group was significantly lower than for the UUT-UC group (60.8 vs. 74.5%, p = 0.02). However, when patients were stratified by stage (>pT2), patients with B-UC had similar OS compared to those with UUT-UC (54.6 vs. 60.8%, p = 0.74). CONCLUSION: Invasive UUT-UC appears to have similar tumor biology compared to B-UC. Whether we can safely extrapolate on the benefit of neoadjuvant and adjuvant strategies to patients with UUT-UC requires further investigation.

Familial trends of inheritance in gastro esophageal reflux disease, Barrett's esophagus and Barrett's adenocarcinoma: 20 families.

We reported four families with familial Barrett's esophagus (FBE) in 1993. This follow-up study includes an additional 16 families with FBE, gastroesophageal reflux disease (GERD) and BE-related adenocarcinoma (BEAC) highlighting the familial trends of inheritance. A retrospective survey of endoscopic and histopathological reports on 95 confirmed cases of BE from 1975 to 2005 was performed and a detailed family history was obtained. Five representative pedigrees from a total of 20 are discussed here. These 20 families represent one of the largest cohorts studied over three decades from a single institution. Familial BE is more common than previously thought and the prevalence of GERD, BE and BEAC in these families is distinctly higher than with sporadic cases. The conditions appear to be inherited in an autosomal dominant fashion with incomplete penetrance. Hence diligence in taking family history with BE patients is critical since the endoscopic screening of relatives is warranted in FBE. Earlier diagnosis and surveillance of FBE should hopefully improve outcomes.

Patterns of dystrophin gene deletion in Egyptian Duchenne/Becker muscular dystrophy patients.

Large variations in the proportion of intragenic deletion in the dystrophin gene have been observed in different populations. Although dystrophin gene deletion was extensively studied all over the world, only few studies were done on Egyptian population and there was no account on the dystrophin gene duplication. In this study, we present our results on the pattern of deletion of the dystrophin gene together with the usage of quantitative polymerase chain reaction (PCR) as a method for duplication analysis within the dystrophin gene in Egyptian patients. Forty one Duchene/Becker muscular dystrophy patients were included in this study. The diagnosis was based on detailed clinical assessment, serum creatine kinase (CK) level, neurophysiologic study and muscle biopsy for histopathological analysis. DNA was extracted from ten milliliter peripheral blood according to basic protocol, and multiplex polymerase chain reaction for dystrophin gene using both Chamberlin and Beggs sets of primers amplifying eighteen exons covering the two main dystrophin gene hot spots. In addition primers from Abbs set were used when it was necessary to check the exon borders. DNA from cases with no detectable deletion was analyzed for dystrophin gene duplication using quantitative PCR technique. We had a percentage of 61.1% deletion which is higher than data from previous Egyptian studies and most of the deletion was localized in the major hotspot region between exons 44 and 52 and we had 5% of the cases with duplication. Our results were compared with previous studies from Egypt and with studies from different populations especially with data recorded in the Middle East and North Africa.

The S-Quattro in the management of sports injuries of the fingers.

Intra-articular phalangeal fractures of the small joints of the hand are difficult sports injuries to manage. The Stockport Serpentine Spring System, abbreviated to S-Quattro was developed by the senior author as an external fixator to treat these fractures. We present the largest series of patients with sports injuries treated with the S-Quattro. Twenty patients with these fractures were treated over a three-year period. The injured joint was distracted after inserting two pins percutaneously into normal phalangeal bone. Two serpentine springs were then inserted between the pins applying distraction to the fracture site. The fixation devices were removed in clinic between 4 and 6 weeks. Objective analysis revealed an average arc of movement of the affected joint of 94 degrees at an average follow-up of 14 months. The mean DASH score was 5 indicating mild impairment. All of the patients were satisfied with the results and the radiographic appearances were satisfactory. The S-Quattro is a versatile system that permits some movement of the injured joint while maintaining reduction. It is relatively free of complications with good results. We advocate the routine use of the S-Quattro in view of its inherent simplicity and the good results it produces with these difficult sports injuries.

The S-Quattro in the management of acute intraarticular phalangeal fractures of the hand.

Intraarticular phalangeal fractures of the hand are difficult and challenging to manage. Dynamic external fixation devices offer the advantages of allowing distraction of the impacted fracture and early joint mobilization. We present our study of 100 patients with a variety of fractures who were treated with the S-Quattro technique over a 6-year period, with an average follow-up of 10.5 months. The mean active range of motion regained was 92 degrees for proximal interphalangeal joints (81 fractures), 82 degrees for distal interphalangeal joints (10 fractures), 91 degrees for metacarpophalangeal joints (6 fractures) and 80 degrees for interphalangeal joints of the thumb (3 fractures). Only nine patients complained of mild or moderate pain. Postoperative radiographic appearances were satisfactory in all but five out of the 100 patients. This device is a simple and effective technique for the management of these difficult fractures. It offers advantages in terms of versatility, ease of application, good tolerance by patients, few complications and good outcome.

A conservative approach for proximal interphalangeal joint arthroplasty.

Access to the proximal interphalangeal joint of the finger for arthroplasty is difficult without detaching its stabilizers or dividing the tendons that cross it, which then require repair and slow rehabilitation. We describe a method that conserves both, so facilitating post-operative rehabilitation.A C-shaped incision is made on the dorsum of the finger. The lateral bands of the extensor expansion are separated from the central slip proximally to the extensor hood. They are then retracted to expose the condyles of the proximal phalanx, which are excised. The PIP joint is then dislocated between the central slip and a lateral band allowing the remainder of the head to be excised. The middle and proximal phalanges are then prepared to accept the prosthesis. The prosthesis is then inserted and the joint is reduced. The lateral bands of the extensor mechanism are sutured back to the central slip before the skin is closed.

Severe Dupuytren's contracture of the proximal interphalangeal joint: treatment by two-stage technique.

Thirty-four patients with a Dupuytren's contracture in excess of 70 degrees of the proximal interphalangeal (PIP) joint were treated by preliminary palmar fasciotomy, release of the accessory collateral ligaments and PIP joint distraction using the S-Quattro for 6 weeks. A formal fasciectomy with full thickness skin graft was then performed 2 weeks after removal of the fixator. There was a mean residual flexion deformity of the PIP joint of 22 degrees (mean correction of 67 degrees) at an average follow-up of 30 months. There were no infections or amputations. We recommend this technique for the management of severe Dupuytren's contracture of the PIP joint.

The "S" Quattro Turbo in the management of neglected dorsal interphalangeal dislocations.

We have used the "S" Quattro Turbo to treat four neglected dorsal interphalangeal joint dislocations. At an average follow up period of 45 months, there was a mean increase in the range of movement of the PIP joints by 74 degrees and of the IP joint of the thumb or DIP joints by 45 degrees. We recommend this technique for treating dorsal dislocations of the interphalangeal joints of more than 3 weeks duration.

Early active mobilisation of volar plate avulsion fractures.

This is a prospective follow up of 190 consecutive cases of volar plate avulsion fractures. A standard management regimen of immediate, active movement was followed in all cases and physiotherapy was rarely required. Of the 190 patients, 162 were followed up for at least one year. An excellent or good outcome was achieved in 98 per cent. Patients presenting more than three weeks from injury had a worse outcome. The size and displacement of the avulsed fragment did not affect the outcome. For the stable joint, early active mobilisation with minimal or no splintage provides a good result.

Postoperative acute pulmonary edema: a rare presentation of pheochromocytoma.

A 39-year-old white female underwent an uneventful vaginal hysterectomy for dysfunctional bleeding. Evaluating a mild aortic insufficiency murmur preoperatively an echocardiogram revealed normal left ventricular wall motion and function. Postoperatively the patient developed severe abdominal pain, acute hypertension (200/100 mmHg), and sinus tachycardia. Within minutes she decompensated into acute pulmonary edema. ECG demonstrated acute ST segment elevation in the precordial leads consistent with acute infarction. Emergency left heart catheterization showed normal coronary vessels with severe left ventricular dysfunction. An abdominal ultrasound was obtained, revealing a right adrenal mass. Plasma epinephrine was 334, norepinephrine 34,543 pg/ml; urine epinephrine 45, urine norepinephrine 2,137 micrograms/24 hours. She was started on prazosin and nifedipine sustained release with good blood pressure control. Four days later, an echocardiogram demonstrated the left ventricular wall motion reverting to normal. The adrenal tumor was subsequently resected successfully. Acute pulmonary edema causing dilated cardiomyopathy is a rare complication of pheochromocytoma that has been seldomly reported. A progressive fatal course is common: reversibility and survival depend on identifying and removing the pheochromocytoma.

Chronic fracture dislocations of the proximal interphalangeal joint. Treatment by the "S" Quattro.

The "S" Quattro has proved its value in the treatment of acute displaced comminuted intraarticular phalangeal fracture dislocations. We have used the system to treat five cases of chronic fracture-dislocation or subluxation of the PIP joint. At an average follow-up period of 16.4 months, there was a mean increase in the range of movement of the injured joint by 75 degrees. We recommend this technique for selected cases.

Calcium mobilization is a prerequisite for the expression of phorbol ester-stimulated luteinizing hormone secretion from pituitaries of male and acutely ovariectomized rats.

Ionomycin, which mobilizes Ca2+, and phorbol 12-myristate 13-acetate (PMA), which activates protein kinase C (PKC), were used to compare the effects/interactions of Ca2+ and PKC on luteinizing hormone (LH) secretion from pituitaries of intact male and acutely ovariectomized (72 h) rats. Quartered pituitaries from donor animals were perifused at 0.25 ml/min and sequential effluent fractions were collected every 10 min. Continuous administration (4 h) of 1 nmol of gonadotropin-releasing hormone (GnRH) resulted in an increase in LH secretion. Cycloheximide (5 mumol) dissociated the GnRH-stimulated LH responses into protein synthesis-independent and -dependent components. While ionomycin (10 mumol) stimulated LH secretion from pituitaries of both sexes by protein synthesis-independent mechanisms, PMA (1 mumol) and the inactive phorbol ester, 4 alpha-phorbol 12,13-didecanoate (PDD), were ineffective secretagogues. However, PMA (but not PDD) interacted synergistically with ionomycin and GnRH to augment LH secretion by protein synthesis-dependent mechanisms. These results suggest a similarity in the effects/interactions of Ca2+ and PKC in gonadotropes from male and ovariectomized rats. If the effects of PMA can be attributed to PKC activation, then it also appears that Ca2+ mobilization is necessary for the manifestation of PKC as a mediator of LH secretion from these gonadotropes. While PKC activity can be divorced from the protein synthesis-independent component of LH release (this component appears to be mediated by Ca2+ mobilization), the enzyme might be involved in amplifying the response to Ca2+ mobilization through synergistic protein synthesis-dependent mechanisms.

The 'S' Quattro--results of treatment in 11 cases of sports injury.

The 'S' Quattro is a dynamic external fixator which has been designed to treat displaced comminuted intraarticular fractures of the phalanges. This type of fracture is commonly the result of a sports injury. We present a follow-up study of 11 cases.