Explaining Heart Failure Hyper-mortality in Sub Saharan Africa: Global Genomic and Environmental Contribution Review.

The annual heart failure (HF) mortality rate in Africa is 34% according to the INTERHF study. This is twice the world average of 16.5% and 3.7 times that of South America, 9%. We review evidence-based explanations for the Hyper-mortality of HF, by comparison of North American, Caribbean, Afro-Brazilian with Sub-Saharan African (SSA) nations profiles, and suggest amelioration. 1 year HF mortality rates in SSA ranged from 29% to 58%, and intra-hospital mortality rate from 8 to 26% (n = 8). A clustering of adverse genetic single nucleotide polymorphisms (SNP) predisposing to hypertension and/or left ventricular hypertrophy (LVH) in the black diaspora may contribute. A higher prevalence of HF with reduced Ejection Fraction (HF r EF) phenotype, which is associated with greater mortality is more common in SSA nations. Additionally, a worse co-morbidity burden, especially valvular regurgitations causing LV remodeling (LVR), chronic kidney disease (CKD), anemia, lung disease, infections, late presentation in NYHA III/IV, right ventricular disease (RVD) were also common in SSA. Geographic variation in SSA, HF risk factors and co-morbidity was observed. There was sub-optimal use of guideline directed medical therapy (GDMT) and intracardiac device (ICD) unavailability. Gross Domestic Product -per purchasing power parity (GDP-PPP), which is low in SSA, was inversely correlated both to higher intra-hospital mortality rate % (r = -0.73, r 2 = 0.54 p = 0.038) and higher 1 year HF mortality rate % (r = -0.62, r 2 = 0.38, = 0.098). Localized primary prevention, early detection and prompt treatment of hypertension, diabetes, rheumatic fever, early cardiac valve repair and use of cardiovascular polypill, optimal use of GDMT, national health insurance scheme are advocated to stem the dismal mortality and cost burden of HF.

Effectiveness of postoperative analgesia in the management of acute pain in day-case surgeries.

Background: Surgery is the most common source of acute pain. Aim: To determine the intensity of acute pain following day case surgery and evaluate the effectiveness of the prescribed analgesics. Methods: A descriptive observational study carried out at the main operating and the Urology Outpatient theatre suites of the University College Hospital, Ibadan. Seventy consecutive adult patients presenting for day case surgeries between July and September 2013 were recruited. The procedures were stratified as follows: peripheral, groin/perineal, urologic/endoscopy or orthopedic/plastic surgeries. The prescribed postoperative oral analgesics were paracetamol alone or in combination with diclofenac, tramadol or both. Postoperative pain intensity was assessed on arrival in the recovery room and at 6, 12, 24, 48, & 72 hours using the Verbal Intensity Pain Scale (VIPS). The pain scores were presented as mean±SD at different time intervals for each stratified surgical procedures and analgesics using tables and frequency bar charts. A mean pain score of less than 2 for each category of surgical procedures or analgesics group was considered as satisfactory pain control and thus effective analgesia. Result: The overall prevalence of moderate to worst possible pain after surgery in this study was 54.3% on arrival in the recovery room. The mean pain score was greater than 2 at 6 hours postoperative in all surgical categories except in patients who had peripheral surgeries irrespective of single or combination analgesic therapy. Conclusion: A high proportion of patients arrived in the recovery room with a high pain score; measures to improve intraoperative analgesia should be employed.

RésuméContexte: La chirurgie est la source la plus fréquente de douleur aiguë. But: Déterminer l'intensité de la douleur aiguë après un cas de chirurgie de jour et évaluer l'efficacité des analgésiques prescrits. Méthodes: Une étude observationnelle descriptive réalisée à la salle principale d'opération et les suites de théâtre ambulatoire d'Urologie au Collège Hospitalier Universitaire, Ibadan. Soixante-dix patients adultes consécutifs se présentant pour des cas de chirurgies de jour entre juillet et septembre 2013 ont été recrutés. Les procédures ont été stratifiées comme suit: chirurgie périphérique, aine / périnéale, urologique / endoscopie ou chirurgie orthopédique / plastique. Les analgésiques oraux postopératoires prescrits étaient le paracétamol seul ou en combinaison avec le diclofénac, le tramadol ou les deux. L'intensité de la douleur postopératoire a été évaluée à l'arrivée dans la salle de récupération et à 6, 12, 24, 48 et 72 heures en utilisant l'échelle d'intensité verbale de l'intensité (VIPS). Les scores de douleur ont été présentés sous forme de moyenne ± écart-type à différents intervalles de temps pour chaque procédure chirurgicale stratifiée et analgésiques en utilisant des tableaux et des graphiques à barres de fréquence. Un score de douleur moyen inférieur à 2 pour chaque catégorie de procédures chirurgicales ou de groupe analgésique a été considéré comme un contrôle satisfaisant de la douleur et donc une analgésie efficace. Résultat: La prévalence globale de la douleur modérée à la pire possible après la chirurgie dans cette étude était de 54,3% à l'arrivée dans la salle de récupération. Le score moyen de la douleur était supérieur à 2 à 6 heures postopératoires dans toutes les catégories chirurgicales, sauf chez les patients ayant subi une intervention chirurgicale périphérique, quel que soit le traitement antalgique simple ou combiné. Conclusion: Une proportion élevée de patients est arrivée dans la salle de récupération avec un score de douleur élevé; des mesures visant à améliorer l'analgésie peropératoire devraient être utilisées.

Influencia de la edad sobre la frecuencia de conductos adicionales en primeros molares mandibulares / Influence of age upoon the frequency of additional Canals in first mandibular molars

Objetivo: en base a un trabajo previo in vitro, se realizó una experiencia clínica con el propósito de intentar instrumentar y obturar conductos adicionales (mesiales y distales medios) en primeros molares inferiores permanentes. Material y Métodos: las piezas dentarias fueron distribuidas en tres grupos etarios (adolescentes 14/18 años, jóvenes 19/23 años y adultos: 40/50 años), compuesto cada uno por 25 tratamientos. Resultados: el grupo de adolescentes mostró un 32% de conductos mesiales-medio y un 12% de distales-emdio; en el de jóvenes el porcentaje fue de 12% y sólo para conductos mesiales-medio, y no se detectaron conductos adicionales en adultos. Conclusiones: estos resultados evidencian la decisiva influencia que la edad tuvo sobre el número de conductos adicionales detectados. Su presencia se vincula a la amplitud del conducto o a la presencia de istmos que por inmadurez presentan los conductos en adolescentes y aun en jóvenes, lo que permitiría instrumentarlos en distintos puntos un único espacio. Por ese motivo, los conductos adicionales no deben ser vistos como rarezas sino, como situaciones normales de relativa frecuencia, ya que su existencia depende de la inmadurez del conducto, de que se los busque, instrumente y obture, aun cuando no sean entidades anatómicas definidas (AU)

Objective: based on a previous in vitro study, we performed a clinical study designed to instrument and obturate additional Canals (middle-mesial and middle-distal) in the mandibular first molars. Material and Methods: the dental specimens were divided in three age groups (adolescents: 14-18 years, young 19-23 years and adults: 40-50 years), with 25 treatments each. Results: the additional canals were present in 32% of the mesial and in 12% of the distal roots in adolescents, in 12% of the mesial roots in young adults and in none of the roots in adults. Conclusions: we may conclude that there is an association between age and the presence of addictional canals. The presence of additional canals would be associated to the ribbon-shape or the presence of isthmuses in the inmmature canals of molars in adolescents and even young adults. The shape and size of the canals would allow them to be accessed from different points. Thus, these canals, often considered virtual rather than real, should not be considered a rare finding (AU)

Presence of pores and vacuoles in set endodontic sealers.

AIM: To assess qualitatively the presence of pores and vacuoles in the structure of various endodontic sealers when set. METHODOLOGY: Eight specimens were prepared in keeping with Instituto Argentino de Racionalización de Materiales (IRAM) and ISO regulations for each of the 10 sealers assessed. Four specimens per sealer were examined to identify the presence of structural defects, termed pores, on the external surface. The remaining four specimens were used to examine the presence of defects on the surface exposed by cross-sectional fracture; these were termed vacuoles. The largest and smallest diameters of the pores and vacuoles were measured by scanning electron microscope on both surfaces. The structural defects were classified according to their frequency as abundant, frequent, scarce or exceptional. RESULTS: Pores and vacuoles were consistently found in every specimen of each sealer. However, their frequency and dimensions were greater in zinc-eugenol-based sealers than in epoxy-resins and glass-ionomer sealers; they increased if the sealer contained calcium hydroxide. The diameter of the pores ranged from 5 to 320 microm and the diameter of the vacuoles ranged from 80 to 500 microm. The diameter of the vacuoles always exceeded that of the pores. CONCLUSIONS: Pores and vacuoles were a consistent finding in set sealers. Their frequency and size depended on the density of the sealer and increased when the sealers contained calcium hydroxide.

A prospective study of hemodialysis access-related bacterial infections.

The objective of this study was to describe hemodialysis vascular-access related infections that occurred in hemodialysis patients over an 18-month period. The study is a prospective descriptive analysis of incidence infection rates in a hemodialysis unit in a tertiary-care medical center. Prospective surveillance for hemodialysis vascular access-related infection was performed for all patients undergoing hemodialysis from November 1999 through April 2001 at King Fahd Hospital of King Faisal University, Al-Khobar, Saudi Arabia. The total number of dialysis sessions was calculated. The type of vascular access was noted. Cultures were obtained and all infections were recorded and infection rates were calculated. There were 9627 hemodialysis sessions (5437 via permanent fistulae or grafts, 2409 via temporary central catheters, and 1781 via permanent tunneled catheters) during the 18-month study period. We identified a total of 109 infections, for a rate of 11.32/1000 dialysis sessions (ds). Of the 109, 23 involved permanent fistulae or grafts (4.23/1000 ds); 18 involved permanent-tunneled central catheter infections (10.1/1000 ds); and 68 involved temporary-catheter infections (28.23/1000 ds). There were 38 bloodstream infections (3.95/1000 ds) and 34 episodes of clinical sepsis (3.53/1000 ds). Seventy-one vascular access infections without bacteremia were identified (7.38/1000 ds), including 16 permanent-fistulae or graft infections (2.94/1000 ds), 7 permanent-tunneled central catheter infections (3.93/1000 ds), and 48 temporary-catheter infections (19.92/1000 ds). Staphylococcal organisms were responsible for 77% of the infections, with Staphylococcus epidermidis being the strain most commonly implicated. Gram-negative organisms were responsible for 23% of the infections. In conclusion, infection rates were highest in hemodialysis patients with temporary vascular access, compared with rates in those with permanent arteriovenous fistulae and synthetic grafts. Most of the bacterial organisms isolated from the vascular access sites were gram-positive cocci, with S. epidermidis accounting for 50% of the organisms. The rate of infection with gram-negative bacilli was higher than in other reports. Our greater dependence on central venous catheters, due to local factors, coupled with the immune-compromising comorbid conditions of our patients, may be contributory to the pattern of infection reported. Delays in the creation of vascular grafts for hemodialysis access should be avoided.

Quality of apical seal in curved canals using three types of spreaders.

The aim of the present study was to evaluate the influence of spreader shape on the quality of obturation. Forty-five single canal teeth with varying degrees of apical curvature were used throughout. The canals were prepared using the step-back technique and obturated with lateral condensation. The teeth were classified into three groups (A, B, and C) and treated as follows. Group A was treated with markedly conical, flat-ended spreaders (A to D; Dentsply-Maillefer, Ballaigues, Switzerland). Group B was treated with slightly conical (15 to 40) sharp-pointed CC-cord spreaders. Group C was treated with CC-cord, slightly conical but flat-ended spreaders. The obturated teeth were decalcified in 7.5% nitric acid to obtain four cross-sections: the first at 2 mm from the apex and then the following three sections at 1-mm intervals. Section thickness was approximately 1 mm. Each section was photographed under a stereoscopic microscope. The following areas were measured on each of the microphotographs using a planimeter: (a) gutta-percha mass, (b) mass of sealer, (c) foreign bodies, and (d) empty spaces. These four areas were added to determine total cross-sectional canal area and then the percent of that area attributable to a and to b + c + d was calculated. The statistical analysis of the data (parametric Student's t test for independent groups) revealed that only in group B was the area occupied by a, the gutta-percha mass, significantly greater at all levels than the area occupied by b + c + d. Next in obturation effectiveness was group C, followed by group A.

Endodontic anatomy of the root canals of lower incisors.

Ninety lower incisors of known age (18 to 20 yr, 30 to 40 yr and over 50 yr) were grouped into 2 sets of 45 pieces each. Cross sections of the root at 4 levels (coronal, middle and apical thirds and 2 mm from the apex) were employed to study: 1. The shape of the canals 2. The changes in diameter induced by age 3. The correlation at the apex of the maximum diameter of the root canal with the Dzero diameter of endodontic instrument. The results showed that the canal anatomy of lower incisors is not as simple as it appears to be and that it is characterized by the predominance of flat shapes even in the vicinity of the foramen. The statistical analysis showed that the dentin deposits, typically age-associated, are influenced by the morphological changes that take place. A true compensation occurs between the different buccolingual and mesiodistal diameters, particularly in the vicinity of the apex, to guarantee irrigation in old age and avoid calcification fo the canal. The correlation between the maximum diameter of the canal at 2 mm from the apex and the Dzero diameter of the instruments evidenced the difficulties involved in adequate apical preparation of these teeth, regardless of age.

Endodontic anatomy of the root canals of lower incisors

Ninety lower incisors of known age (18 to 20 yr, 30 to 40 yr and over 50 yr) were grouped into 2 sets of 45 pieces each. Cross sections of the root at 4 levels (coronal, middle and apical thirds and 2 mm from the apex) were employed to study: 1. The shape of the canals 2. The changes in diameter induced by age 3. The correlation at the apex of the maximum diameter of the root canal with the Dzero diameter of endodontic instrument. The results showed that the canal anatomy of lower incisors is not as simple as it appears to be and that it is characterized by the predominance of flat shapes even in the vicinity of the foramen. The statistical analysis showed that the dentin deposits, typically age-associated, are influenced by the morphological changes that take place. A true compensation occurs between the different buccolingual and mesiodistal diameters, particularly in the vicinity of the apex, to guarantee irrigation in old age and avoid calcification fo the canal. The correlation between the maximum diameter of the canal at 2 mm from the apex and the Dzero diameter of the instruments evidenced the difficulties involved in adequate apical preparation of these teeth, regardless of age.

Endodontic anatomy of the root canals of lower incisors.

Ninety lower incisors of known age (18 to 20 yr, 30 to 40 yr and over 50 yr) were grouped into 2 sets of 45 pieces each. Cross sections of the root at 4 levels (coronal, middle and apical thirds and 2 mm from the apex) were employed to study: 1. The shape of the canals 2. The changes in diameter induced by age 3. The correlation at the apex of the maximum diameter of the root canal with the Dzero diameter of endodontic instrument. The results showed that the canal anatomy of lower incisors is not as simple as it appears to be and that it is characterized by the predominance of flat shapes even in the vicinity of the foramen. The statistical analysis showed that the dentin deposits, typically age-associated, are influenced by the morphological changes that take place. A true compensation occurs between the different buccolingual and mesiodistal diameters, particularly in the vicinity of the apex, to guarantee irrigation in old age and avoid calcification fo the canal. The correlation between the maximum diameter of the canal at 2 mm from the apex and the Dzero diameter of the instruments evidenced the difficulties involved in adequate apical preparation of these teeth, regardless of age.

Pseudomesotheliomatous carcinoma involving pleura and peritoneum: A clinicopathologic and immunohistochemical study of three cases.

Pseudomesotheliomatous carcinoma is a rare variant of peripheral adenocarcinoma of the lung that can manifest clinical, radiologic, and pathologic features similar to malignant mesothelioma. We present three patients with pseudomesotheliomatous carcinoma of the lung. In one patient the carcinoma extended beyond the thorax and extensively involved the peritoneum, mesentery, omentum, and intestines. All patients experienced weight loss and chest pain. All were white men aged 63, 65, and 67 years. Two were smokers and had shortness of breath, cough, and pleural effusion. One had a history of asbestos exposure. No patient developed dyspnea or hemoptysis. One was successfully treated for prostatic carcinoma 18 months earlier. Radiographically, all tumors were pleura-based. Grossly, the tumors spread extensively over pleural (and in one case peritoneal) surfaces and mimicked malignant mesothelioma. Histologically, all tumors were poorly differentiated and necrotic; two tumors exhibited spindle-cell components and desmoplasia. Mucin production was detectable in none, 10%, and 50% of tumor cells. The percentages of tumor cells immunoreactive for Ber-EP4 were 70%, 100%, and 80%; for Leu MI 0%, 90%, and 50%; for epithelial membrane antigen 80%, 80%, and 100%; for B 72.3%, 0%, 90%, and 20%; for polyclonal carcinoembryonic antigen 0%, 10%, and 10%; and for monoclonal 5%, 0%, and 0%. Of these, Ber-EP4 and B 72.3 rendered the most reliable diagnostic results. The clinical, radiologic, and gross and routine histologic findings were similar to those of a malignant mesothelioma; the final diagnosis could be made based mainly on immunocytochemical results. We have reviewed the English and German literature regarding 65 such tumors and present our experience with three additional cases. We emphasize the application of immunocytochemical studies on pleura-based poorly or undifferentiated malignant tumors of unknown origin.

Apical canal diameter in the first upper molar at various ages.

The shape of root canals cross-sectioned through their roots at 2 mm from their apices and its correlation with the D0 diameter of endodontic instruments was evaluated in 40 first upper molars. The molars were grouped according to age: under 13 yr (children), 18 to 20 yr (adolescents), 30 to 40 yr (adults), and over 50 yr. Evaluation of the root canal diameters revealed that the shapes were predominantly circular in the palatal canal, mostly flat in the mesiobuccal canal, and circular or flat in equal proportions in the distobuccal root. Age does not seem to affect the shape of the canals. Narrowing with age was statistically significant (p < 0.05) for palatal and mesiobuccal canals only. Correlation between the maximum diameter of the canals and the instruments was varied. Even in old age, diameters were observed that would require instruments of a size that would be impossible to use, because one internal diameter would exceed the root's external diameter in a different direction (i.e. intimal buccolingual diameter of #80 and external mesiodistal diameter of #70).

Papillary serous carcinoma of the peritoneum in a man: a case report.

BACKGROUND: Papillary serous carcinoma of the peritoneum (PSCP) is a rare primary peritoneal tumor, described exclusively in women. It is believed to arise from the secondary müllerian system, which is comprised of the pelvic and lower abdominal mesothelial lining and subjacent (subcoelomic) mesenchyme in women. Both mesotheliomas and PSCP arise from the coelomic epithelium, but are clinicopathologically and biologically distinct entities. METHODS: The authors report clinicopathologic findings in a man, age 74 years, who died 3 months after the diagnosis of an extensive malignant abdominal disease. RESULTS: The routine histologic and immunocytochemical studies of tumor tissue, obtained during the patient's lifetime and at autopsy, validated the unique occurrence of PSCP in a man. CONCLUSIONS: This case illustrates that PSCP can occur in a man and that this diagnosis may be considered in the differential diagnosis of papillary serous tumors of the peritoneum in male patients. Although rare, PSCP is a diagnostically distinct entity the treatment of which is similar to ovarian serous tumors rather than mesotheliomas.

Clinical prediction rule for pulmonary infiltrates.

Full text is available as a scanned copy of the original print version.

Malignant thymic carcinoid in multiple endocrine neoplasia type I syndrome: case report and literature review.

OBJECTIVE: To describe a case of thymic carcinoid tumor in association with multiple endocrine neoplasia type I (MEN I) and discuss the various manifestations of this syndrome. METHODS: We present the clinical and laboratory data, including histopathologic and immunocytochemical findings, for our current patient and also review the literature on MEN I syndromes. RESULTS: In a 46-year-old Caucasian man with no family history of multiple endocrine neoplasia, numerous MEN I lesions developed over time. The patient had gastrinoma of the duodenum, Zollinger-Ellison syndrome, hyperparathyroidism, a nonfunctioning adrenal mass, and foregut carcinoid tumors, including gastric and malignant thymic carcinoids. He sequentially underwent partial gastrectomy in conjunction with Billroth II anastomosis, a four-gland parathyroidectomy, and palliative radiotherapy for malignant carcinoid tumor, as well as endoscopic excision of accessible tumors. CONCLUSION: The involvement in MEN I can be clinically complex. Early detection of MEN I lesions will facilitate timely implementation of treatment and help minimize complications.

Comparative immunoreactivity of CD-68 and HMB-45 in malignant melanoma, neural tumors and nevi.

The monoclonal antibody CD 68 (KP 1) reacts with fibrohistiocytic and some epithelial neoplasms; its reactivity compared with that of HMB 45 in malignant melanoma (MM) and neural tumors needs further elucidation. Using a streptavidin-biotin-immunoperoxidase procedure, we examined the reactivity of 65 MM (46 conventional, 1 polypoid, 6 desmoplastic [DMM], and 12 metastatic), 21 neurofibromas, 1 neurofibrosarcoma, 10 schwannomas, 1 perineurioma, 2 neurothekeomas, and 14 blue and 26 other nevi for CD-68, HMB-45-defined antigen, S 100 and neurofilament protein. A positive staining for CD 68 was observed in 38 of 42 primary, 5 of 6 DMM, and 11 of 12 metastatic melanomas; 6 of 10 schwannomas; 5 of 10 nevi with junctional component and all 14 blue nevi. All 21 neurofibromas, 1 each neurofibrosarcoma and perineurioma, both neurothekeomas, and all 12 nevi with dermal component were CD 68-negative. HBM 45 was expressed by all 44 primary, none of 6 DMM, and 7 of 12 metastatic melanomas; by none of 10 schwannomas, 6 neurofibromas, 1 neurofibrosarcoma, 1 perineurioma and 2 neurothekeomas. Both junctional nevi, 8 of 10 nevi with junctional components, 1 of 10 dermal components of junctional nevi, and 11 of 13 blue nevi were also HMB 45 positive. Except for 1 perineurioma, S 100 decorated all tumors examined. NF was immunoreactive in 1 of 45 conventional melanomas, 2 of 21 neurofibromas, 2 of 10 schwannomas, and 3 of 10 blue nevi; it was non-reactive in all polypoid, desmoplastic and metastatic melanomas; neurofibrosarcoma, perineurioma, neurothekeoma and other nevi. We conclude that the CD-68-reactivity in primary melanomas, neurofibromas, neurofibrosarcomas, perineuriomas, and nevi was similar to that of HMB 45. The significantly higher CD 68-positivity than of HMB 45 in metastatic and desmoplastic melanomas and schwannomas may be of diagnostic value.

[Dentinopulpar organ: biological basis of clinical response to Ca(OH)2 application]. / Organo dentino pulpar: fundamentos biológicos acerca de la respuesta clínica por aplicación de Ca(OH)2.

We have studied the changes presented by mediate and immediate roentgenographic images of indirect pulp capping and pulpotomies. In the cases of indirect pulp capping it was observed an increase of radiolucidity in the places occupied by Ca(OH)2, and sclerotic dentin was present. In pulpotomies, it was found the dentin bridge, which thickness increases with time. The radiolucidity of pulp chamber occupied by Ca(OH)2 was greater in the long time treatment. The radiopacity of non-vital dentin of walls and floor chamber was increased too. It has suggested that Ca++ ion would have migrated from its place and probably would take part in the synthesis of sclerotic dentin, independently of the vitality of the tissue.