Lymphatic obstruction by Wuchereria bancrofti is thought to be the mechanism for development of tropical hydrocele in men and for elephantiasis, mostly in women. Hydrocele prevalence is used to determine the effectiveness of para site eradication programs. METHODS:

We maintained a prospective log of operations performed at 1 Canadian Field Hospital during its relief mission to Léogâne, Haiti. Information regarding duration of symptoms, type of previous surgery (if any), surgical approach, associated inguinal hernia and volume and appearance of hydrocele fluid in patients with tropical hydroceles were recorded. RESULTS:

From January to March 2010, 4922 patients were seen, none of whom had elephantiasis. Of the 64 patients who collectively underwent 69 inguino-scrotal procedures, 5 patients had inguinal hernia repair several years after hydrocele excision via the scrotum, 19 patients with bilateral hydroceles underwent a scrotum-only approach, and 45 patients had an inguinal approach (33 unilateral and 12 bilateral) to repair 57 hydroceles. A patent processus vaginalis was present in 50 of 57 (88%) hydroceles where the groin was explored. CONCLUSION:

Hydroceles remain common in Léogâne despite successful eradication of filariasis with mass drug administration using diethylcarbamazine-fortified cooking salt. Persistent patent processus vaginalis is a more likely cause than persistent filariasis. There is probably little difference between hydrocele in developed countries and tropical hydrocele other than neglect. Hydrocele prevalence is not a measure of the effectiveness of parasite eradication programs.

CONTEXTE:

On croit qu’une obstruction lymphatique par Wuchereria bancrofti serait le mécanisme à l’origine de l’hydrocèle tropicale chez les hommes et de l’éléphantiasis, surtout chez les femmes. La prévalence de l’hydrocèle est utilisée pour déterminer l’efficacité des programmes d’éradication parasitaire. MÉTHODES:

Nous avons tenu un registre prospectif des interventions effectuées au 1er Hôpital de campagne du Canada durant une mission humanitaire à Léogâne, en Haïti. Nous avons noté la durée des symptômes, les antécédents chirurgicaux (le cas échéant), l’approche chirurgicale, l’hernie inguinale associée, de même que le volume et l’aspect du liquide présent dans l’hydrocèle de patients atteints d’une hydrocèle tropicale. RÉSULTANTS:

De janvier à mars 2010, 4922 patients ont été vus et aucun ne souffrait d’éléphantiasis. Sur les 64 patients qui ont subi en tout 69 interventions inguinoscrotales, 5 ont subi une réparation d’hernie inguinale plusieurs années après l’exérèse d’une hydrocèle par voie scrotale, 19 patients porteurs d’hydrocèles bilatérales ont subi l’intervention exclusivement par approche scrotale et 45 patients, par approche inguinale (33 unilatérales et 12 bilatérales) pour la réparation de 57 hydrocèles. Une ouverture du processus vaginal a été observée dans 50 cas d’hydrocèle sur 57 (88 %) où on a procédé à un examen inguinal. CONCLUSIONS:

L’hydrocèle demeure fréquente à Léogâne, malgré l’éradication efficace de la filariose, grâce à un traitement médicamenteux de masse par le biais de sel pour la cuisson additionné de diéthylcarbamazine. La persistance de l’ouverture du processus vaginal est une cause plus probable de filariose persistante. Il y a probablement peu de différences entre les cas d’hydrocèle recensés dans les pays industrialisés et les hydrocèles tropicales, à part la négligence. La prévalence de l’hydrocèle ne permet pas d’évaluer l’efficacité des programmes d’éradication parasitaire.

“These efforts are essential for the training of Afghan physicians in medical and surgical specialties, to ensure a healthy future for the people of Afghanistan,” says Major Vivian McAlister, MD, FRCSC, member of Royal College Council and NTM-A participant.

The capacity-building initiative is supported on the ground by the NTM-A team, which includes numerous Fellows of the Royal College, who advise their Afghan counterparts on ways they can lead advances in the country’s health care system.

As part of these efforts, Dr. Emal Wardak, an orthopedic surgeon from the Wazir Akbar Khan Hospital in Kabul, was presented with a special Royal College speaker certificate during the Orthopaedic Society of Afghanistan 2012 trauma symposium, for his lecture on the evolution of fracture management.

This goodwill gesture was to officially recognize and promote leveraging local knowledge as the rebuilding process progresses.

“In any international endeavor, it is important to recognize that one-size does not fit all and that collaboration is key. I am proud to say that we have been collaborating in every sense with our colleagues in Kabul to map out a resident training system that is appropriate to their needs and that makes use of their expertise,” adds Dr. McAlister.

A two-day medical scientific conference was held by the Armed Forces Academy of Medical Sciences (AFAMS) on 30 – 31 December 2012 in Kabul. With almost 300 attendees, the theme of the conference was efficient delivery of healthcare in Afghanistan.

The conference was planned and run by an Afghan faculty, while members of the Canadian Forces provided advice. All of the presentations were made by Afghan physicians with the exception of one talk given by Major Dennis Marion of the Canadian Forces Health Services. Major Marion, a specialist in Internal Medicine, is currently posted to Edmonton, Alberta.

Major Vivian McAlister, a member of Graduate Medical Education (GME) advisory team who is also a councilor of the Royal College of Physicians and Surgeons of Canada, spoke at the end of the conference to congratulate AFAMS on the high standard of the meeting. Dr McAlister reminded specialists attending the meeting to apply for CME credits to their colleges. He then presented the Royal College speaker certificate to Dr Zabiullah Azizi of Kabul for his presentation on sepsis.

Major Marion spoke on the topic of applying evidence-based medicine techniques to clinical examination. While the principles of rational clinical examination were new to many in the audience, the presentation was welcomed as the way of the future for Afghan medicine.

The Canadian contribution to the NATO Training Mission – Afghanistan has been advising the Afghan National Army during the current phase of its reconstruction. The GME Advisory Team has assisted Afghan medical faculty during the process of developing curricula for training specialist physicians and surgeons in Afghanistan.

The success of medical conferences such as this one held in AFAMS, bodes well for the future of academic medicine in Afghanistan. The contribution of Canada to this process was recognized by Surgeon General Mohammed Musa Wardak during his closing remarks to the conference.

When not engaged in military duties, Major McAlister works at Western University in London, Ontario as a Professor of Surgery. He is also a member of the Council of the Royal College of Physicians and Surgeons of Canada.

"Major McAlister’s appointment as co-editor of the Canadian Journal of Surgery illustrates the very high quality of health professionals within the Canadian Armed Forces," said the Honourable Peter MacKay, Minister of National Defence."The health of Canadian Armed Forces personnel is a top priority for this government and medical officers such as Major McAlister represent the finest doctors in our country and abroad. I congratulate him on behalf of the Government of Canada."

The mission of the Canadian Journal of Surgery, a publication of the Canadian Medical Association, is to contribute to the effective continuing medical education of Canadian surgical specialists, using innovative techniques when feasible, and to provide surgeons with an effective vehicle for the dissemination of observations in the areas of clinical and basic science research.

"As a professor of surgery who has completed six tours in combat, mentorship, and humanitarian assistance operations in Afghanistan and Haiti, Major McAlister brings a superb international reputation and an extraordinary wealth of experience to the Canadian Journal of Surgery," said Brigadier-General Jean-Robert Bernier, the Surgeon General. "His contributions to the journal’s educational mission, his work at Western University, and his service on the Royal College’s council all exemplify the close collaboration and mutual support between the civilian and military medical communities. This close relationship has existed since before Confederation and benefits all Canadians."

Contact: Joanna.Labonte@forces.gc.ca

Notes to editor / news director: For more information on Canadian Forces Health Services please visit: http://www.forces.gc.ca/health-sante/default-eng.asp.

• Comprehensive trauma care system: guidelines,

registry, review

• Protocols for care: damage control; massive

blood transfusion policy; mass casualty care

• Techniques: resuscitative thoracotomy;

decompressive craniectomy; pelvic-gluteal

hemorrhage control

• Rehabilitation: Mild traumatic brain injury

• Delegated medical acts: medics / PAs

An updated definition of early allograft dysfunction (EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients. This analysis did not differentiate between donation after brain death (DBD) and donation after cardiac death (DCD) allograft recipients.

METHODS:

We reviewed our prospectively entered database for all DBD (n=377) and DCD (n=38) liver transplantations between January 1, 2006 and October 30, 2011. The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups.

RESULTS:

EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients, but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD (11.5%) compared with those without EAD (16.7%) (P=0.664) or in the rate of death in recipients with EAD (3.8%) compared with those without EAD (8.3%) (P=0.565). The graft failure rate in the first 6 months in those with international normalized ratio ≥1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio <1.6 on day 7 (P=0.022).

CONCLUSIONS:

The recently validated definition of EAD is a valid predictor of patient and graft survival in recipients of DBD allografts. On initial assessment, it does not appear to be a useful predictor of patient and graft survival in recipients of DCD allografts, however a study with a larger sample size of DCD allografts is needed to confirm these findings. The high ALT/AST levels in most recipients of DCD livers as well as the predisposition to biliary complications and early cholestasis make these parameters as poor predictors of graft failure. An alternative definition of EAD that gives greater weight to the INR on day 7 may be more relevant in this population.