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.

Sequential determinations of urinary cytology and plasma and urinary lymphokines in the management of renal allograft recipients.

Urine cytology, plasma (P), and urinary (U) interleukin-2 (IL-2)* and IL-2 receptor (IL-2R) levels were evaluated as immunological monitoring techniques in 65 renal allograft recipients. Normal individuals showed normal urine cytology, IL-2(U) = 0, IL-2(P) = 0.4 +/- 0.1 ng/ml (mean +/- SEM) and IL-2R(P) = 318 +/- 26 U/ml. Stable transplants also showed normal urine cytology, no IL-2(U), IL-2(P) = 0.8 +/- 0.2 ng/ml, and IL-2R(P) = 326 +/- 29 U/ml. Rejection episodes (n = 21) were accompanied by cytologic changes, including lymphocyturia, exfoliation of immature tubular cells, platelet aggregates, and fibrin deposits. The corresponding lymphokine changes were IL-2(U) = 39.6 +/- 1.4 ng/ml, IL-2(P) = 79 +/- 21 ng/ml, and IL-2R = 1884 +/- 202 U/ml, all markedly increased. Successful treatment was associated with return of all parameters to normal; treatment failure was associated with continued abnormalities. Fourteen rejections unresponsive to Solumedrol (500 mg x 5 days) required OKT3 rescue (5 mg x 14 days). In the 11 that were reversed, onset of OKT3 therapy was characterized by markedly increased exfoliation of necrotic cellular debris, lymphocytes, and collecting duct cells. Interestingly, serum creatinine increases of 57.2 +/- 18.9% (range 25-90%) over pre-OKT3 levels were noted. Maximal changes occurred 48-72 hr after the first dose, followed by gradual return to normal. Rejections unresponsive to OKT3 (n = 3) showed no cytologic changes from the pretreatment mean creatinine increase of 13.2 +/- 2.7% (range 9-15%), and maximum change occurred 24 hr after the first dose. Rejections responsive to Solumedrol only (n = 4) showed gradual improvement of all parameters. Rejections treated with Solumedrol following failed OKT3 prophylaxis (n = 3) did not reverse and continued to show rejection associated cytologic changes and abnormal creatinines. Patients experiencing CsA toxicity (n = 12) showed mild creatinine elevations, normal or negative IL-2(P) and IL-2R(P) levels, and no IL-2(U). They showed distinctive cytologic changes consisting of swollen convoluted tubular cells with nuclear pyknosis and cytoplasmic vacuoles. Pretransplant IL-2(P) levels of patients who subsequently rejected were elevated, with 19/21 patients with preoperative IL-2 levels greater than 15 ng/ml having subsequent rejections. In contrast, pretransplant creatinine, urine cytology, and IL-2(U) levels showed no correlation to subsequent clinical course.(ABSTRACT TRUNCATED AT 400 WORDS)

Procurement of a whole pancreas and liver from the same cadaveric donor.

Analogous arterial and portal circulation to the liver and pancreas has heretofore represented an impediment to the simultaneous procurement of a liver and pancreas from the same cadaveric donor. A surgical approach that allows for the retention of sufficient arterial and portal supply to both allografts is described. Variant hepatic arterial anatomy may be technically managed by the use of a donor iliac artery interposition graft.

The myotropic and plasma-calcium modulating effects of calcitonin gene-related peptide (CGRP).

Human and rat calcitonin gene-related peptides cause a dose-related contraction of guinea pig ileum, which is antagonised by an anti-histamine, mepyramine, and an anticholinergic compound, hyoscine. Both peptides also cause a positive inotropic and a positive chronotropic effect in the rat isolated auricle and these responses are antagonised by propranolol, a B adrenoceptor blocker. Further, the peptides lower plasma calcium levels in both rats and rabbits in a dose-related manner resembling calcitonin; in the rabbit, but not in the rat, the initial calcium lowering effect is succeeded by hypercalcaemia at higher doses, while in the chick, only the parathyroid hormone-like calcium-raising effect is seen.

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.

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.

[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.

[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.

[Dexamethasone suppression in the depressed patient. Reflections apropos of an experience]. / Epreuve de freination à la dexaméthasone chez le déprimé. Réflexions à propos d'une expérience.

This work, based on the dexamethasone suppression test (DST) for 28 patients classified according to the Research Diagnostic Criteria (RDC), tries, by examining the literature, to point out the acquired knowledge through this new biological psychiatric instrument. The results confirm those of previous works. The discussion is directed towards a better delimitation between the different categories of primary affective disorder and the possible extensions of DST to other fields not yet enough studied.

[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.

[Electrogastroenterographic study of the digestive motor effects of prolonged psychotropic treatment]. / Etude électrogastro-entérographique des effets moteurs digestifs des traitements psychotropes prolongés

Functional digestive complaints are frequent in psychiatri patients: simple constipation, which cannot be explained solely by the loss of the sensation of rectal fullness; occlusions, occasionally hemorragies; the late complication of dolichomegacolon (Bourgeois, 1973). In 160 subjects, an attempt to understand the physio-pathology were made by recording diurnal digestive motor activity using skin electrodes placed on the abdomen and extremities (electrogastroenterography or E.G.E.G.). A hypoactive E.G.E.G. was observed in 2/3 of 18 psychotic depressive patients, in 3/4 of 36 schizophrenies. The nocive effect of giving sedative phenothiazine and antiparkinsonian drugs (trihexyphenidyl or ethybenzatropine) during long periods is clear. Whereas non sedative phenothiazine and clotiapine gicen in small doses, do not have an undesirable effect. Sulpiride has been used in gastroduodenal dyskinesia. The dyskinesia noted by the E.G.E.G., sometimes found in the large intestin, were found in 55% of 30 patients with caracter disorders; they coincide with the high frequency of electro-encephalogram dysrythmies. Finally, in hysterical patients, one usually observes normal E.G.E.G., tracings which confirms the clinical observation that hysterical and psychosomatic symptoms, may succeed each other, but do not appear at the same time. In the same categories of patients, no longer treated in a classical psychiatric environment but in a group with institutional objectives, the same clinic results were obtained with fewer digestive disturbances. This tends to show the inutility and nocivity of excessive doses of psychotropic drugs given alone or in complexe association.

[Elaboration of an ethogram for the diagnosis of Pattern "A"]. / Elaboration d'un éthogramme pour le diagnostic du Pattern "A".

In order to develop a technique which allows the detection of Pattern A (P.A.) we present in this paper a series of steps for constructing an observation grill (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 P.A. These observations also confirm that the P.A. 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 P.A. corresponds to a particular behavioral pattern which is dependent on the work environment.