Hormonal and metabolic adaptation in professional cyclists during training.

The aim of this study was to examine hormonal and metabolic changes in a group of 18 professional male cyclists ((.)VO(2)max 69.9 [95 % CI 64.9 to 74.9] mL x kg(-1) x min(-1) ) during two successive periods of adapted intensive training. The second training period included 4 days of cycling competition. Intensity was increased while volume was decreased in the second training. Anthropometric data were collected before and at the end of the two training periods. Venous blood samples were taken in a basal state before the two training sessions and after each training session. Serum concentrations of cortisol (C), testosterone (T), dehydroepiandrosterone sulfate (DHEAs), and catecholamines were determined as well as branched-chain amino acids (valine, leucine, isoleucine) (BCAA) and free fatty acids (FFAs). At the end of the two training periods, the subjects lost fat mass whereas mean body mass was unchanged. The T/C ratio was reduced transiently after the first training session (45.90 %), while DHEAs/C remained unchanged. T/C and DHEAs/C were significantly increased after the second training session compared to the first (48.40 and 97.18 %, respectively). Catecholamines and FFAs were unchanged. The significant increase in BCAA levels after the second training session was of note as it might constitute a "store shape" of amino acids in anticipation of future intense training loads. Based on the responses of testosterone, DHEAs, and cortisol, and on the training-induced increase in BCAA, there appeared to be hormonal and metabolic adaptation despite the inherent psychological stress of competition.     

Molecular markers of Plasmodium falciparum drug resistance in southern highland Rwanda

In Rwanda, frequent mutations in the pfdhfr and pfdhps genes of Plasmodium falciparum have suggested intense sulfadoxine-pyrimethamine resistance. However, data on pfmdr1 are not available but might be important in the context of the first-line treatment with artemether-lumefantrine. During a survey among 749 children under five years of age in southern highland Rwanda, 104 P. falciparum isolates were obtained. Parasite polymorphisms associated with drug sensitivity were typed including the genes pfdhfr, pfdhps, pfmdr1, and pfcrt. Plasma concentrations of chloroquine and pyrimethamine were measured by ELISA. Treatment with artemether-lumefantrine within the preceding two weeks was stated by 12.5% of the respondents; chloroquine in plasma was detected in 17.6%, pyrimethamine in none. Isolates with pfdhfr triple and pfdhps double/triple mutations occurred in 75% and 93%, respectively; 69% of the isolates comprised pfdhfr/pfdhps quintuple or sextuple mutations associated with high-grade sulfadoxine-pyrimethamine resistance. Pfdhfr L164 was absent. The pfmdr1 pattern revealed more than 50% of the F184 polymorphism and almost 40% of the N86-F184-D1246 allele combination known to be selected in infections reappearing following artemether-lumefantrine treatment. Molecular markers demonstrate intense antifolate drug resistance of P. falciparum in southern Rwanda. The present, first-time data on pfmdr1 alleles from Rwanda reveal a pattern which might reflect a predominance of wild types for some alleles or, alternatively, substantial artemether-lumefantrine pressure on the local parasite population.     

Control of erythropoiesis after high altitude acclimatization

Erythropoiesis was studied in 11 subjects submitted to a 4-h hypoxia (HH) in a hypobaric chamber (4,500 m, barometric pressure 58.9 kPa) both before and after a 3-week sojourn in the Andes. On return to sea level, increased red blood cells (+3.27%), packed cell volume (+4.76%), haemoglobin (+6.55%) (P<0.05), and increased arterial partial pressure of oxygen (+8.56%), arterial oxygen saturation (+7.40%) and arterial oxygen blood content (C_aO₂) (+12.93%) at the end of HH (P<0.05) attested high altitude acclimatization. Reticulocytes increased during HH after the sojourn only (+36.8% vs +17.9%, P<0.01) indicating a probable higher reticulocyte release and/or production despite decreased serum erythropoietin (EPO) concentrations (–46%, P<0.01). Hormones (thyroid, catecholamines and cortisol), iron status (serum iron, ferritin, transferrin and haptoglobin) and renal function (creatinine, renal, osmolar and free-water clearances) did not significantly vary (except for lower thyroid stimulating hormone at sea level, P<0.01). Levels of 2,3-diphosphoglycerate (2,3-DPG) increased throughout HH on return (+14.7%, P<0.05) and an inverse linear relationship was found between 2,3-DPG and EPO at the end of HH after the sojourn only (r=–0.66, P<0.03). Inverse linear relationships were also found between C_aO₂ and EPO at the end of HH before (r=–0.63, P<0.05) and after the sojourn (r=–0.60, P=0.05) with identical slopes but different ordinates at the origin, suggesting that the sensitivity but not the gain of the EPO response to hypoxia was modified by altitude acclimatization. Higher 2,3-DPG levels could partly explain this decreased sensitivity of the EPO response to hypoxia. In conclusion, we show that altitude acclimatization modifies the control of erythropoiesis not only at sea level, but also during a subsequent hypoxia.     

Le bloc coracoïdien : mise en évidence ďune voie ďabord simple utilisant le petit pectoral

OBJECTIVE: Despite their recognized advantages, infraclavicular blocks, especially with the pericoracoid approach, are underutilized because the lack of simple anatomical landmarks. The goal of this study is to determine a simple, reliable and reproducible reference point by means of magnetic resonance imaging (MRI), using the anterior extremity of the coracoid process, and the pectoralis minor as a tactile reference point. METHOD: Sagittal and para-sagittal MRI sections at the coracoid process were performed on 11 patients. The relationships between the coracoid process, the nerve-vessel bundle, the pectoralis minor and the skin were measured. RESULTS: The optimal puncture point for a needle introduced strictly in an anterio-posterior direction in a supine, alert patient is located 2 cm within and 2.5 cm below the coracoid process. The injection point, defined as the distance between the skin and the tip of the needle lying in the centre of the visualized nerve-vessel bundle, is located an average of 5 cm from the skin (mean 5.02 cm, with a standard deviation of 1.03 and a confidence interval of 0.91). This injection point goes from 0.4 cm (at the most anterior part of the bundle) and 1.75 cm (at the most posterior part), with an average 1 cm from the posterior surface of the pectoralis minor (tactile reference point). Neither body mass index nor sex influence significantly the variables measured. CONCLUSIONS: The reference points defined here could allow easy and reproducible performance of this relatively simple block and make it more effective.     

Normo or hypobaric hypoxic tests: propositions for the determination of the individual susceptibility to altitude illnesses

Assessment of individual susceptibility to altitude illnesses and more particularly to acute mountain sickness (AMS) by means of tests performed in normobaric hypoxia (NH) or in hypobaric hypoxia (HH) is still debated. Eighteen subjects were submitted to HH and NH tests (PIO₂=120 hPa, 30 min) before an expedition. Maximal and mean acute mountain sickness scores (AMSmax and mean) were determined using the self-report Lake Louise questionnaire scored daily. Cardio-ventilatory (f, V_T, PetO₂ and PetCO₂, HR and finger pulse oxymetry SpO₂) were measured at times 5 and 30 min of the tests. Arterial (PaO₂, PaCO₂, pH, SaO₂) and capillary haemoglobin (Hb) measurements were performed at times 30 min. Hypoxic ventilatory (HVR) and cardiac (HCR) responses, peripheral O₂ blood content (CpO₂) were calculated. A significant time effect is found for ΔSpO₂ (P = 0.04). Lower PaCO₂ (P = 0.005), SaO₂ (P = 0.07) and higher pH (P = 0.02) are observed in HH compared to NH. AMSmax varied from 3 to12 and AMSmean between 0.6 and 3.5. In NH at 30 min, AMSmax is related to PetO₂ (R = 0.61, P = 0.03), CpO₂ (R = −0.53, P = 0.02) and in HH to CpO₂ (R = −0.57, P = 0.01). In NH, AMSmean is related to Δf (R = 0.46, P = 0.05), HCR (R = 0.49, P = 0.04), CpO₂ (R = −0.51, P = 0.03) and, in HH at 30 min, to V_T (R = 0.69, P = 0.01) and a tendency for CpO₂ (R = −0.43, P = 0.07). We conclude that HH and NH tests are physiologically different and they must last 30 min. CpO₂ is an important variable to predict AMS. For practical considerations, NH test is proposed to quantify AMS individual susceptibility using the formulas: AMSmax = 9.47 + 0.104PetO₂(hPa)–0.68CpO₂ (%), (R = 0.77, P = 0.001); and AMSmean = 3.91 + 0.059Δf + 0.438HCR–0.135CpO₂ (R = 0.71, P = 0.017).     

10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa

Nurse-led delivery care models have the potential to address the significant burden of heart failure in sub-Saharan Africa. Starting in 2006, the Rwandan Ministry of Health, supported by Inshuti Mu Buzima (Partners In Health–Rwanda), decentralized heart failure diagnosis and care delivery in the context of advanced nurse-led integrated noncommunicable clinics at rural district hospitals. Here, the authors describe the first medium-term survival outcomes from the district level in rural sub-Saharan Africa based on their 10-year experience providing care in rural Rwanda. Kaplan-Meier methods were used to determine median time to event for: 1) composite event of known death from any cause, lost to follow-up, or transfer to estimate worst-case mortality; and 2) known death only. Five-year event-free rates were 41.7% for the composite outcome and 64.3% for known death. While death rates are encouraging, efforts to reduce loss to follow-up are needed.     

Emergency general surgery in Rwandan district hospitals: a cross-sectional study of spectrum,management, and patient outcomes

Background

Management of emergency general surgical conditions remains a challenge in rural sub-Saharan Africa due to issues such as insufficient human capacity and infrastructure. This study describes the burden of emergency general surgical conditions and the ability to provide care for these conditions at three rural district hospitals in Rwanda.

Methods

This retrospective cross-sectional study included all patients presenting to Butaro, Kirehe and Rwinkwavu District Hospitals between January 1st 2015 and December 31st 2015 with emergency general surgical conditions, defined as non-traumatic, non-obstetric acute care surgical conditions. We describe patient demographics, clinical characteristics, management and outcomes.

Results

In 2015, 356 patients presented with emergency general surgical conditions. The majority were male (57.2%) and adults aged 15–60 years (54.5%). The most common diagnostic group was soft tissue infections (71.6%), followed by acute abdominal conditions (14.3%). The median length of symptoms prior to diagnosis differed significantly by diagnosis type (p?<?0.001), with the shortest being urological emergencies at 1.5 days (interquartile range (IQR):1, 6) and the longest being complicated hernia at 17.5 days (IQR: 1, 208). Of all patients, 54% were operated on at the district hospital, either by a general surgeon or general practitioner. Patients were more likely to receive surgery if they presented to a hospital with a general surgeon compared to a hospital with only general practitioners (75% vs 43%, p?<?0.001). In addition, the general surgeon was more likely to treat patients with complex diagnoses such as acute abdominal conditions (33.3% vs 4.1%, p?<?0.001) compared to general practitioners. For patients who received surgery, 73.3% had no postoperative complications and 3.2% died.

Conclusion

While acute abdominal conditions are often considered the most common emergency general surgical condition in sub-Saharan Africa, soft tissue infections were the most common in our setting. This could represent a true difference in epidemiology in rural settings compared to referral facilities in urban settings. Patients were more likely to receive an operation in a hospital with a general surgeon as opposed to a general practitioner. This provides evidence to support increasing the surgical workforce in district hospitals in order to increase surgical availability for patients.