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The processes that restrict gene flow between populations are fundamental to speciation. Here, we develop a simple framework for studying whether divergence in morphology, climatic niche, time and space contribute to reduced gene flow among populations and species. We apply this framework to a model system involving a clade of spiny lizards (Sceloporus) occurring mostly in northeastern Mexico, which show striking variation in morphology and habitat among closely related species and populations. We developed a new time-calibrated phylogeny for the group using RADseq data from 152 individuals. This phylogeny identified 12 putative species-level clades, including at least two undescribed species. We then estimated levels of gene flow among 21 geographically adjacent pairs of species and populations. We also estimated divergence in morphological and climatic niche variables among these same pairs, along with divergence times and geographic distances. Using Bayesian generalised linear models, we found that gene flow between pairs of lineages is negatively related to divergence time and morphological divergence among them (which are uncorrelated), and not to geographic distance or climatic divergence. The framework used here can be applied to study speciation in many other organisms having genomic data but lacking direct data on reproductive isolation. We also found several other intriguing patterns in this system, including the parallel evolution of a strikingly similar montane blue-red morph from more dull-coloured desert ancestors within two different, nonsister species., (© 2024 The Author(s). Molecular Ecology published by John Wiley & Sons Ltd.)

Triatomines of the species Triatoma sherlocki are considered sylvatic; however, household invasion appears imminent, potentially carrying Trypanosoma cruzi, the causative agent of Chagas disease. The aim of this study was to report the first occurrence of a colony of T. sherlocki infected by T. cruzi in a subsistence pig farm. Triatomines collected underwent polymerase chain reaction (PCR) technique for T. cruzi detection and determination of blood meal source. The 19 triatomines collected in the pig farm were of the species T. sherlocki, comprising 26.3% nymphs (5/19), 52.6% males (10/19) and 21.1% females (4/19). PCR showed that 15.8% (3/19) of triatomines were infected by T. cruzi. The only detected blood meal source in triatomines (n = 11) was the domestic mammal Sus scrofa, commonly known as domestic pig, indicating that T. sherlocki is an opportunist, feeding on available vertebrates in the environment, including domestic animals such as pigs. These results highlight the possibility of domiciliation of the species T. sherlocki and its potential role in bridging the transmission of T. cruzi between sylvatic and domestic environments., (© 2024 Royal Entomological Society.)

The present study, carried out in the municipality of Gentio do Ouro, Bahia, Brazil aimed to evaluate which wild mammals may be involved in the transmission of T. cruzi and which are the blood sources for triatomines collected in the study area. PCR analysis of 31 wild mammals captured revealed T. cruzi infection in 6.4% (2/31): one specimen of the opossum Didelphis albiventris (1/3) and one of the rodent Kerodon rupestris (1/5); despite being more frequent in the area, no specimen of the rodent Thrichomys sp. (0/23) was infected. A total of 169 triatomines were captured. The conclusive detection of food sources was possible only for Triatoma sherlocki Papa et al., 2002 (n = 56), with evidence for: K. rupestris (35.7%), Gallus (17.9%), D. albiventris (14.3%), Homo sapiens (14.3%), Tropidurus hispidus (7.1%), Leopardus geoffroyi (5.3%), Conepatus semistriatus (1.8%), Thrichomys inermis (1.8%) and Rattus norvegicus (1.8%). Triatomines of the species T. sherlocki showed food eclecticism, including feeding on humans, with some of them being captured at dwellings. These facts make this triatomine a potential link for the transmission of T. cruzi between wild and anthropic environments, highlighting a latent risk of the reemergence of Chagas disease outbreaks., (© 2023 Royal Entomological Society.)

Objectives: Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not., Methods: We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures., Results: 672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI., Conclusion: Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI., Competing Interests: Conflict of interest We have no conflicts of interest to disclose., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Recently, Wolbachia infection has been described in leishmaniasis vector sandflies. This endosymbiont bacterium is present in 60% of insects, and has been suggested as a mechanism of biological control of vector insects, because it causes a series of changes in the invertebrate host. In addition, recent studies have shown that this bacterium can prevent the development of parasites in vector insects. In this context, the present study aims to molecularly characterize the circulating strain of this bacterium in sandflies in the State of Bahia, Brazil, as well as the natural infection rate of Leishmania sp., and to evaluate the coinfection between Wolbachia and Leishmania. Seven hundred and forty-five (745) specimens of sandflies were collected in nine municipalities of Bahia, belonging to two species, Lutzomyia longipalpis (Lutz and Neiva, 1912) and Nyssomyia whitmani (Antunes and Coutinho, 1939). The results confirm infection by the protozoan Leishmania infantum and Wolbachia in both species collected. The identified strain of Wolbachia in sandflies was wStv MI, known to lead to a phenotype of cytoplasmic incompatibility in vector insects., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: Cutaneous leishmaniasis (CL) is generally caused by Leishmania aethiopica in Ethiopia, and is relatively hard to treat. Sodium stibogluconate (SSG) is the only routinely and widely available antileishmanial treatment, and can be used systemically for severe lesions and locally for smaller lesions. There is limited data on the effectiveness of intralesional (IL) SSG for localized CL in Ethiopia and therefore good data is necessary to improve our understanding of the effectiveness of the treatment., Methodology/principal Findings: A pragmatic (before and after Quazi experimental) study was done to assess the effectiveness of intralesional SSG among localized CL patients at Boru Meda general hospital, Northeast Ethiopia. Patients who were assigned to intralesional SSG by the treating physician were eligible for this study. Study subjects were recruited between January and August 2021. Infiltration of intralesional SSG was given weekly to a maximum of six doses. However, when a patient's lesions were already cured before getting 6 doses, treatment was not conintued, and patient were only asked to come for lesion assessment. Skin slit smears (SSS) were taken each week until they became negative. Outcomes were assessed at day 90, with patients who had 100% reepithelization (for ulcerative lesions) and/or flattening (for indurated lesions) defined as cured. Multi-level logistic regression was done to assess factors associated with cure. A total of 83 patients were enrolled, and final outcomes were available for 72 (86.75%). From these 72, 43 (59.7%, 95% confidence interval 0.44-0.69) were cured at day 90. Adverse effects were common with 69/72 patients (95.8%) reporting injection site pain. Factors associated with cure were age (OR 1.07 95% CI: 1.07-1.27), being male (OR 1.79, 95% CI: 1.10-2.25), size of the lesion (OR 0.79, 95% CI: 0.078-0.94) and skin slit smear (SSS) result +1 grading (OR 1.53, 95% CI: 1.24-1.73) and +2 grading (OR 1.51, 95% CI: 1.41-3.89) compared to the SSS grade +6., Conclusion: Our findings revealed that intralesional sodium stibogluconate resulted in a cure rate of around 60%, with almost all patients experiencing injection site pain. This emphasizes the need for local treatment options which are more patient-friendly and have better cure rates., Competing Interests: The authors have declared that no competing interests exist.

Background: The eye-seeking fly Musca sorbens can act as a vector for ocular Chlamydia trachomatis , causing trachoma, yet there has been very little research on control measures. We investigated whether insect repellent products, specifically insecticide-treated clothing, could provide personal protection to the user from eye-seeking flies., Methods: We first conducted a series of phase I laboratory studies to inform our choice of field intervention. We then conducted a phase II randomised controlled trial testing the efficacy of permethrin-treated scarves (PTS) in reducing fly-face contact in Oromia, Ethiopia. Children aged 4-10 years in full health and with no known adverse reactions to permethrin or other insecticides were allocated to either arm using restricted randomisation. Intervention arm children wore Insect Shield® versatile wraps (as PTS) for 28 days. The primary outcomes, fly-eye, -nose and -mouth contact, were assessed on the first day (0/30/60/180 minutes), on day 7 and on day 28. All participants present per timepoint were included in analyses. This trial was registered with ClinicalTrials.gov (NCT03813069)., Findings: Participants were recruited to the field trial between 29/10/2019 and 01/11/2019, 58 were randomised to test or control arm. More fly (-eye, -nose and -mouth) contacts were observed in the PTS arm at baseline. After adjusting for baseline contact rates, across all timepoints there was a 35% decrease in fly-eye contacts in the PTS relative to control arm (rate ratio [RR] 0.65, 95% CI 0.52-0.83). Similar cross-timepoint reductions were seen for fly-nose and fly-mouth contacts (RR 0.69, 95% CI 0.51-0.92 and RR 0.79, 95% CI 0.62-1.01, respectively). All children were included on day 0. Two in the control arm were absent on day 7, one left the study and four were excluded from analysis at day 28. No adverse events occurred in the trial., Interpretation: Musca sorbens flies are sufficiently repelled by PTS to reduce fly-eye contacts for the wearer, thus possibly reducing the risk of trachoma transmission. Permethrin-treated scarves may therefore an alternative to insecticide space spraying for protection from these flies., Funding: Wellcome Trust., Competing Interests: The authors have nothing to disclose., (© 2022 The Authors.)

Introduction: The clinical and economic burden of clavicle fractures in England is not well documented. This study evaluated rates of surgical treatment, post-surgical complications, reoperations and costs in patients with clavicle fractures using the Clinical Practice Research Datalink (CPRD) database., Methods: CPRD data were linked to National Health Service Hospital Episode Statistics data. Patients with a diagnosis of clavicle fracture between 2010-2018 were selected in CPRD (date of fracture = index date). Of those, patients with surgical intervention within 180 days from index fracture were identified. Rates of post-surgical complications (i.e., infection, non-union, and mal-union), reoperations (for device removal or for postoperative complications), post-operative costs and median time to reoperations were evaluated up to 2 years after surgery., Results: 21,340 patients with clavicle fractures were identified (mean age 35.0 years(standard deviation (SD): 26.5), 66.7% male). Surgery was performed on 672 patients (3.2% of total cohort) at an average 17.1 (SD: 25.2) days post-fracture. Complications (i.e., infection, non-union, or malunion) affected 8.1% of surgically treated clavicle fracture patients; the rate of infection was 3.5% (95% CI, 1.7%- 5.2%), non-union 4.4% (95% CI, 2.4%-6.5%), and mal-union 0.3% (95% CI, 0%-0.7%). Adjusting for age, gender, comorbidities and time to surgery, the all-cause reoperation rate was 20.2% (13.2%-30.0%) and the adjusted rate of reoperation for implant removal was 17.0% (10.7%-25.9%)-84% of all-cause reoperations were thus performed for implant removal. Median time to implant removal was 254 days. The mean cost of reoperations for all causes was £5,000. The most expensive reoperations were for cases that involved infection (mean £6,156)., Conclusions: Complication rates following surgical clavicle fracture care averaged 8.1%. However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. Technologies to alleviate secondary device removal surgeries would address a significant clinical unmet need., (© 2022. The Author(s).)

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to governments implementing a variety of public health measures to control transmission and has affected health services. Leprosy is a communicable neglected tropical disease caused by Mycobacterium leprae and is an important health problem in low- and middle-income countries. The natural history of leprosy means that affected individuals need long-term follow-up. The measures recommended to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can create barriers to health services. We evaluated the impact of the COVID-19 epidemic response on leprosy services and disease management., Methods: We conducted a cross-sectional online survey with healthcare professionals in leprosy referral centres., Results: Eighty percent of leprosy diagnostic services were reduced. All respondents reported that multidrug therapy (MDT) was available but two reported a reduced stock. Clinicians used alternative strategies such as telephone consultations to maintain contact with patients. However, patients were not able to travel to the referral centres., Discussion: This study highlights the effects of the initial phase of the SARS-CoV-2 pandemic on leprosy services in a range of leprosy-endemic countries. Many services remained open, providing leprosy diagnosis, MDT and leprosy reaction medications. Centres developed innovative measures to counter the negative impacts of the COVID-19 pandemic., (© The Author(s) 2021. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: Minimally invasive plate osteosynthesis (MIPO) is one of the generally accepted surgical techniques for the treatment of humeral shaft fractures. However, despite the high bone union rate, a variety of complications are still prevailing. Moreover, the current literature lacks data comparing the anterolateral MIPO approach using dynamic compression plates accommodating different numbers of screws. The aim of this study was to analyze the biomechanical performance of comminuted humeral shaft fractures fixed with dynamic compression plates using either two or three screws per fragment., Methods: Six pairs of fresh-frozen human cadaveric humeri from donors aged 66.8 ± 5.2 years were randomized to two paired study groups for simulation of bridge-plated comminuted shaft fracture type AO/OTA 12-C1/2/3 without interfragmentary bony support, using a dynamic compression plate positioned on the anterolateral surface and fixed with two (group 1) or three (group 2) screws per fragment. All specimens underwent nondestructive quasistatic biomechanical testing under lateral bending, anterior bending, axial bending, and torsion in internal rotation, followed by progressively increasing cyclic torsional loading in internal rotation until failure., Results: Initial stiffness of the plated specimens in lateral bending, anterior bending, axial bending, and torsion was not significantly different between the groups ( P ≥ 0.22). However, cycles to 10°, 15°, and 20° torsional deformation and cycles to construct failure were significantly higher in group 2 compared with group 1 ( P ≤ 0.03)., Conclusions: From a biomechanical perspective, no significant superiority is identified in terms of primary stability when using two or three screws per fragment for bridge compression plating of comminuted humeral shaft fractures. However, three-screw configurations provide better secondary stability and maintain it with a higher resistance towards loss of reduction under dynamic loading. Therefore, the use of a third screw may be justified when such better secondary stability is required., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Guilherme Seva Gomes et al.)

Introduction: Erythema nodosum leprosum (ENL) is an immunological complication of leprosy. ENL results in morbidity and disability and if it is not treated can lead to death. The current treatment consists of thalidomide or high doses of oral corticosteroids for prolonged periods. Thalidomide is not available in many leprosy endemic countries. The use of corticosteroids is associated with morbidity and mortality. Identifying treatment regimens that reduce the use of corticosteroids in ENL is essential. Methotrexate (MTX) is used to treat many inflammatory diseases and has been used successfully to treat patients with ENL not controlled by other drugs, including prednisolone and thalidomide. We present the protocol of the 'MTX and prednisolone study in ENL' (MaPs in ENL) a randomised controlled trial (RCT) designed to test the efficacy of MTX in the management of ENL., Methods and Analysis: MaPs in ENL is an international multicentre RCT, which will be conducted in leprosy referral centres in Bangladesh, Brazil, Ethiopia, India, Indonesia and Nepal. Patients diagnosed with ENL who consent to participate will be randomly allocated to receive 48 weeks of weekly oral MTX plus 20 weeks of prednisolone or 48 weeks of placebo plus 20 weeks of prednisolone. Participants will be stratified by type of ENL into those with acute ENL and those with chronic and recurrent ENL. The primary objective is to determine whether MTX reduces the requirement for additional prednisolone. Patients' reported outcome measures will be used to assess the efficacy of MTX. Participants will be closely monitored for adverse events., Ethics and Dissemination: Results will be submitted for publication in peer-reviewed journals. Ethical approval was obtained from the Observational/Interventions Research Ethics Committee of the London School of Hygiene & Tropical Medicine (15762); The Leprosy Mission International Bangladesh Institutional Research Board (in process); AHRI-ALERT Ethical Review Committee, Ethiopia; Ethics Committee of the Managing Committee of the Bombay Leprosy Project; and The Leprosy Mission Trust India Ethics Committee; the Nepal Health and Research Council and Health Research Ethics Committee Dr. Soetomo, Indonesia. This study is registered at www.clinicaltrials.gov. This is the first RCT of MTX for ENL and will contribute to the evidence for the management of ENL.Trial registration numberNCT 03775460., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Coracoid fractures have the potential to lead to inadequate shoulder function. Most coracoid base fractures occur with scapular fractures and the posterior approaches would be utilized for surgical treatment. We investigated the possibility of fixing the coracoid through the same approach without an additional anterior approach., Materials and Methods: Multi-slice CT scans of 30 shoulders were examined and the following measurements were performed by an independent specialized radiologist: posterior coracoid screw entry point measured form infraglenoid tubercle, screw trajectory in coronal plane in relation to scapular spine and lateral scapular border, screw trajectory in sagittal plane in relation to glenoid face bisector line and screw length. We used the results from the CT study to guide postero-anterior coracoid screw insertion under fluoroscopic guidance on two fresh frozen cadaveric specimens to assess the reproducibility of accurate screw placement based on these parameters. We also developed a novel fluoroscopic projection, the anteroposterior (AP) coracoid view, to guide screw placement in the para-coronal plane., Results: The mean distance between entry point and the infraglenoid tubercle was 10.8 mm (range: 9.2-13.9, SD 1.36). The mean screw length was 52 mm (range: 46.7-58.5, SD 3.3). The mean sagittal inclination angle between was 44.7 degrees (range: 25-59, SD 5.8). The mean angle between screw line and lateral scapular border was 47.9 degrees (range: 34-58, SD 4.3). The mean angle between screw line and scapular spine was 86.2 degrees (range: 75-95, SD 4.9). It was easy to reproduce the screw trajectory in the para-coronal plane; however, multiple attempts were needed to reach the correct angle in the parasagittal plane, requiring several C-arm corrections., Conclusion: This study facilitates posterior fixation of coracoid process fractures and will inform the "virtual visualization" of coracoid process orientation., (© The Authors, published by EDP Sciences, 2019.)

Introgression is now commonly reported in studies across the Tree of Life, aided by recent advancements in data collection and analysis. Nevertheless, researchers working with nonmodel species lacking reference genomes may be stymied by a mismatch between available resources and methodological demands. In this study, we demonstrate a fast and simple approach for inferring introgression using RADseq data, and apply it to a case study involving spiny lizards (Sceloporus) from northeastern México. First, we find evidence for recurrent mtDNA introgression between the two focal species based on patterns of mito-nuclear discordance. We then test for nuclear introgression by exhaustively applying the "five-taxon" D-statistic (D FOIL ) to all relevant individuals sampled for RADseq data. In our case, this exhaustive approach (dubbed "ExD FOIL ") entails testing up to ~250,000 unique four-taxon combinations of individuals across species. To facilitate use of this ExD FOIL approach, we provide scripts for many relevant tasks, including the selection of appropriate four-taxon combinations, execution of D FOIL tests in parallel and visualization of introgression results in phylogenetic and geographic space. Using ExD FOIL , we find evidence for ancient introgression between the focal species. Furthermore, we reveal geographic variation in patterns of introgression that is consistent with patterns of mito-nuclear discordance and with recurrent introgression. Overall, our study demonstrates that the combination of D FOIL and RADseq data can effectively detect introgression under a variety of sampling conditions (for individuals, populations and loci). Importantly, we also find evidence that batch-specific error and linkage in RADseq data may mislead inferences of introgression under certain conditions., (© 2018 John Wiley & Sons Ltd.)

Around the world, many species are confined to "Sky Islands," with different populations in isolated patches of montane habitat. How does this pattern arise? One scenario is that montane species were widespread in lowlands when climates were cooler, and were isolated by local extinction caused by warming conditions. This scenario implies that many montane species may be highly susceptible to anthropogenic warming. Here, we test this scenario in a montane lizard (Sceloporus jarrovii) from the Madrean Sky Islands of southeastern Arizona. We combined data from field surveys, climate, population genomics, and physiology. Overall, our results support the hypothesis that this species' current distribution is explained by local extinction caused by past climate change. However, our results for this species differ from simple expectations in several ways: (a) their absence at lower elevations is related to warm winter temperatures, not hot summer temperatures; (b) they appear to exclude a low-elevation congener from higher elevations, not the converse; (c) they are apparently absent from many climatically suitable but low mountain ranges, seemingly "pushed off the top" by climates even warmer than those today; (d) despite the potential for dispersal among ranges during recent glacial periods (~18,000 years ago), populations in different ranges diverged ~4.5-0.5 million years ago and remained largely distinct; and (e) body temperatures are inversely related to climatic temperatures among sites. These results may have implications for many other Sky Island systems. More broadly, we suggest that Sky Island species may be relevant for predicting responses to future warming., (© 2019 John Wiley & Sons Ltd.)

Benzimidazole (BZ) resistance of Haemonchus contortus has been associated with single nucleotide polymorphisms (SNPs) in codons 200 (F200Y) and 167 (F167Y) and, to a lesser extent, in codon E198A, of the β-tubulin isotype 1 gene. The present study was undertaken to survey the status of BZ resistance in naturally infected goats in smallholder farms in southern Mozambique by real-time PCR (qPCR) using TaqMan® assays. H. contortus-infective larvae (L3; n = 432) from 12 populations were individually genotyped for F200Y and F167Y SNPs to detect BZ resistance. For the F200Y SNP, the results revealed an overall mean percentages of 18.8% homozygous resistant (RR), 47.8% homozygous susceptible (SS) and 33.4% heterozygous (RS) H. contortus. For the F167Y SNP, the overall mean percentages were 1.6% RR, 94.9% SS and 3.5% RS. The percentage of resistant alleles (%R) for the F200Y and F167Y SNPs was 35.7 and 3.4%, respectively. Genotype combinations of the two mutations indicate resistant percentages ranging from 0.0 to 52.9%. From the four herds with high RR individuals, three farms dewormed the animals monthly, while the fourth farm dewormed the animals every 3 months. In farms where animals were dewormed every 6 months, low percentages of RR individuals were found, whereas no RR individuals were discovered in herds where animals were dewormed annually. These results suggest that the F200Y SNP is more significant in BZ resistance development of the surveyed population compared with the F167Y SNP.

Background: Erythema nodosum leprosum (ENL) is a systemic inflammatory complication occurring mainly in patients with lepromatous leprosy (LL) and borderline lepromatous leprosy (BL). Prednisolone is widely used for treatment of ENL reactions. However, it has been reported that prolonged treatment with prednisolone increases the risk for prednisolone-induced complications such as osteoporosis, diabetes, cataract and arteriosclerosis. It has been speculated that perhaps these complications result from lipid profile alterations by prednisolone. The effects of extended prednisolone treatment on lipid profiles in ENL patients have not been studied in leprosy patients with ENL reactions. Therefore, in this study we conducted a case-control study to investigate the changes in lipid profiles and serological responses in Ethiopian patients with ENL reaction after prednisolone treatment., Methods: A prospective matched case-control study was employed to recruit 30 patients with ENL and 30 non-reactional LL patient controls at ALERT Hospital, Ethiopia. Blood samples were obtained from each patient with ENL reaction before and after prednisolone treatment as well as from LL controls. The serological host responses to PGL-1, LAM and Ag85 M. leprae antigens were measured by ELISA. Total cholesterol (TC), triglyceride (TG), high density lipoprotein (HDL) and low density lipoprotein (LDL) were measured by spectrophotometric method., Results: The host antibody response to M. leprae PGL-1, LAM and Ag85 antigens were significantly reduced in patients with ENL reactions compared to LL controls after treatment. Comparison between patients with acute and chronic ENL showed that host-response to PGL-1 was significantly reduced in chronic ENL after prednisolone treatment. Untreated patients with ENL reactions had low lipid concentration compared to LL controls. However, after treatment, both groups had comparable lipid profiles except for LDL, which was significantly higher in patients with ENL reaction. Comparison within the ENL group before and after treatment showed that prednisolone significantly increased LDL and HDL levels in ENL patients and this was more prominent in chronic ENL than in acute patients with ENL., Conclusion: The significantly increased prednisolone-induced LDL and TG levels, particularly in patients with chronic ENL reactions, is a concern in the use of prednisolone for extended periods in ENL patients. The findings highlight the importance of monitoring lipid profiles during treatment of patients to minimize the long-term risk of prednisolone-induced complications., Competing Interests: The authors have declared that no competing interests exist

We investigate the molecular phylogeny of Boophis, a group of arboreal frogs from the Malagasy-Comoroan family Mantellidae. Based on newly acquired DNA sequences of five mitochondrial and five nuclear markers (7444 base pairs), we infer a phylogeny of Boophis with complete species-level taxon sampling. We reconstruct the phylogeny using Bayesian inference and maximum likelihood and estimate divergence dates for the major clades of the genus. The phylogenetic analyses together support the monophyly of the two subgenera (Sahona and Boophis), and provide strong support for most previously identified species groups, except that the B. ulftunni group is nested within the B. majori group. We also erect a new species group related to the B. mandraka group, the B. blommersae group, composed of small-sized, brown stream-breeding frogs previously included within the B. majori group. Finally, we use the resulting phylogeny to illustrate striking examples of repeated evolution of coloration and ventral transparency and address the biogeographic history and broad pattern of species diversification in the genus. Ancestral area reconstructions provide evidence that Boophis diversified within the Eastern highland forests of Madagascar, and we suggest that adaptation to these highland areas was important in their diversification., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone.Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred.Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation.The metaphysis can be considered as a 'torus' or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion.The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical 'neck' fracture; a fracture line at the lower surface of the torus is the surgical 'neck' fracture. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180005., Competing Interests: ICMJE Conflict of interest statement: S. Lambert declares board membership of the Upper Extremity Expert Group, AO Foundation; consultancy for Mathys and Depuy; grants/grants pending from RCS England; payment for development of educational presentations from University College London; travel/accommodation/meeting expenses from AO Foundation, activities outside the submitted work.

Originally described in cattle, conglutinin belongs to the collectin family and is involved in innate immune defense. It is thought that conglutinin provides the first line of defense by maintaining a symbiotic relationship with the microbes in the rumen while inhibiting inflammatory reactions caused by antibodies leaking into the bloodstream. Due to the lack of information on the similar lectins and sequence detection in goats, we characterized the goat conglutinin gene using RACE and evaluated the differences in its gene expression profile, as well as in the gene expression profiles for surfactant protein A, galectins 14 and 11, interleukin 4 and interferon-gamma in goats. We used Saanen and Anglo Nubian F2 crossbred goats monitored over a period of four months and characterized them as resistant (R) or susceptible (S) based on the average values of EPG counts. Goat conglutinin was similar to bovine conglutinin, but its gene expression varied among different tissues. However, as with bovine conglutinin, it was most highly expressed in the liver. Variation in conglutinin (R=24.3±3.9; S=23.5±2.6, p=0.059), protein surfactant A (R=23.8±5.2, S=24.4±2.3, p=0.16), galectin 14 (R=15.9±3.5, S=14.7±6.2, p=0.49) and galectin l1 gene expression (R=25.4±2.6, S=25.8±3.7, p=0.53) was not significant between groups. However, there were weak correlations between interleukin 4 and the protein surfactant A gene (r=0.459, p=0.02) and between interleukin 4 and galectin 11 (r=0.498, p=0.01). Strong correlation between interferon-gamma and galectin 14 (r=0.744, p=0.00) was observed. Galectin 14 was negatively correlated with the number of nematodes in the goat (r=-0.416, p=0.04) as well as the EPG count (r=-0.408, p=0.04). This is the first study to date that identifies the gene expression of conglutinin, surfactant protein A and galectins 14 and 11 in the goat abomasum. In conclusion, we present evidence that lectin is involved in the immune response to gastrointestinal nematodes, which suggests that collectins and galectins are involved in the molecular recognition of helminths., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Deep prosthetic infection is a potentially devastating complication after total elbow arthroplasty, with an incidence of up to 12%. This study examined the demographics, microbiologic profile, and outcomes of infected total elbow arthroplasty treated with 2-stage revision in a tertiary referral unit., Methods: We identified 19 consecutive patients (mean age, 65 years) undergoing revision arthroplasty for deep prosthetic infection. All patients underwent a first-stage procedure with removal of implants, débridement, and insertion of an antibiotic-loaded cement spacer, followed by at least 6 weeks of intravenous antibiotics. Fourteen patients required a second-stage revision., Results: Five patients did not undergo a second-stage procedure because of patient choice (n = 2), medical or surgical risk factors (n = 2), and death from an unrelated cause (n = 1). Of the 19 patients undergoing a first-stage procedure, 16 (84%) remained infection free, and 11 of the 14 patients (79%) undergoing reimplantation of an elbow prosthesis remained infection free. Six patients required further surgery (3 for recurrent infection, 3 for noninfective indications). The commonest infecting organism was Staphylococcus aureus (47%). A degree of postoperative ulnar nerve dysfunction occurred in 37% of patients, but all resolved fully without further treatment., Conclusions: Management of prosthetic joint infection using 2-stage revision can result in high rates of eradication, although rates of reoperation and transient ulnar nerve dysfunction are high., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

A polymerase chain reaction-based method was used to screen sandflies for infection with Wolbachia (Rickettsiales: Rickettsiaceae), an intracellular bacterial endosymbiont found in many arthropods and filarial hosts. Positive results were obtained in five of 200 field-collected sandflies and were confirmed by sequencing. All sandflies were Lutzomyia longipalpis (Diptera: Psychodidae) captured in a region endemic for visceral leishmaniasis in Brazil. This is the first study to identify Wolbachia infection in this Lutzomyia species, which is the main vector of leishmaniasis in the study area. The low infection rate found in this study (2.5%), together with the lack of detection of Wolbachia in previous studies and the diversity found in the sequences analysed, suggests horizontal transmission to these sandflies., (© 2017 The Royal Entomological Society.)

Background: The success of rotator cuff repair is primarily dependent on tendon-bone healing. Failure is common because weak scar tissue replaces the native enthesis, rendering it prone to reruptures. A demineralized bone matrix (DBM) consists of a network of collagen fibers that provide a sustained release of growth factors such as bone morphogenetic proteins. Previous studies have demonstrated that it can regenerate a fibrocartilaginous enthesis., Hypothesis: The use of a DBM and mesenchymal stem cells (MSCs) at the healing enthesis will result in a higher bone mineral density at the tendon insertion and will enhance the regeneration of a morphologically superior enthesis when compared with an acellular human dermal matrix., Study Design: Controlled laboratory study., Methods: Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 received augmentation of the repair with a cortical allogenic DBM (n = 6); group 2 received augmentation with a nonmeshed, ultrathick, acellular human dermal matrix (n = 6); and group 3 underwent tendon-bone repair without a scaffold (n = 6). All animals received 1 × 10 6 MSCs delivered in fibrin glue to the repair site. Specimens were retrieved at 6 weeks postoperatively for histological analysis and the evaluation of bone mineral density., Results: All groups demonstrated closure of the tendon-bone gap with a fibrocartilaginous enthesis. Although there were no significant differences in the enthesis maturation and modified Movin scores, repair augmented with a dermal matrix + MSCs exhibited a disorganized enthesis, abnormal collagen fiber arrangement, and greater cellularity compared with other MSC groups. Only repairs augmented with a DBM + MSCs reached a bone mineral density not significantly lower than nonoperated controls., Conclusion: A DBM enhanced with MSCs can augment rotator cuff healing at 6 weeks and restore bone mineral density at the enthesis to its preinjury levels., Clinical Relevance: Biological augmentation of rotator cuff repair with a DBM and MSCs may reduce the incidence of retears, although further studies are required to determine its effectiveness.

The Tropical Andes make up Earth's most species-rich biodiversity hotspot for both animals and plants. Nevertheless, the ecological and evolutionary processes underlying this extraordinary richness remain uncertain. Here, we examine the processes that generate high richness in the Tropical Andes relative to other regions in South America and across different elevations within the Andes, using frogs as a model system. We combine distributional data, a newly generated time-calibrated phylogeny for 2,318 frog species, and phylogenetic comparative methods to test the relative importance of diversification rates and colonization times for explaining Andean diversity at different scales. At larger scales (among regions and families), we find that faster diversification rates in Andean clades most likely explain high Andean richness. In contrast, at smaller temporal and spatial scales (within family-level clades within the Andes), diversification rates rarely explain richness patterns. Instead, we show that colonization times are important for shaping elevational richness patterns within the Andes, with more species found in habitats colonized earlier. We suggest that these scale-dependent patterns might apply to many other richness gradients. Recognition of this scale dependence may help to reconcile conflicting results among studies of richness patterns across habitats, regions, and organisms.

Background: Leprosy reactions are a significant cause of morbidity in leprosy population. Erythema nodosum leprosum (ENL) is an immunological complication affecting approximately 50% of patients with lepromatous leprosy (LL) and 10% of borderline lepromatous (BL) leprosy. ENL is associated with clinical features such as skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. ENL is treated mainly with corticosteroids and corticosteroids are often required for extended periods of time which may lead to serious adverse effects. High mortality rate and increased morbidity associated with corticosteroid treatment of ENL has been reported. For improved and evidence-based treatment of ENL, documenting the systems affected by ENL is important. We report here the clinical features of ENL in a cohort of patients with acute ENL who were recruited for a clinico-pathological study before and after prednisolone treatment., Materials and Methods: A case-control study was performed at ALERT hospital, Ethiopia. Forty-six LL patients with ENL and 31 non-reactional LL matched controls were enrolled to the study and followed for 28 weeks. Clinical features were systematically documented at three visits (before, during and after predinsolone treatment of ENL cases) using a specifically designed form. Skin biopsy samples were obtained from each patient before and after treatment and used for histopathological investigations to supplement the clinical data., Results: Pain was the most common symptom reported (98%) by patients with ENL. Eighty percent of them had reported skin pain and more than 70% had nerve and joint pain at enrolment. About 40% of the patients developed chronic ENL. Most individuals 95.7% had nodular skin lesions. Over half of patients with ENL had old nerve function impairment (NFI) while 13% had new NFI at enrolment. Facial and limb oedema were present in 60% patients. Regarding pathological findings before treatment, dermal neutrophilic infiltration was noted in 58.8% of patients with ENL compared to 14.3% in LL controls. Only 14.7% patients with ENL had evidence of vasculitis at enrolment., Conclusion: In our study, painful nodular skin lesions were present in all ENL patients. Only 58% patients had dermal polymorphonuclear cell infiltration showing that not all clinically confirmed ENL cases have neutrophilic infiltration in lesions. Very few patients had histological evidence of vasculitis. Many patients developed chronic ENL and these patients require inpatient corticosteroid treatment for extended periods which challenges the health service facility in resource poor settings, as well as the patient's quality of life.

Background: Flail shoulder can occur following a brachial plexus injury and is characterized by painful subluxation of the glenohumeral joint and the inability to independently position the hand in space. The present study aimed to report the clinical outcomes following glenohumeral arthrodesis for late reconstruction of flail shoulder in patients with traumatic supraclavicular brachial plexus palsy., Methods: Seven patients were included in the present study and were followed-up for a mean of 98 months (range 27 months to 197 months). The mean age at the time of surgery was 48 years (range 28 years to 80 years) and the mean time to surgery from injury was 5 years (range 2.5 years to 8 years)., Results: Six patients achieved bony union with a mean time to fusion of 4.7 months (range 2 months to 8 months). Non-union occurred in one case. The mean Oxford Shoulder Score improved from 11 pre-operatively (range 4 to 16) to 27 postoperatively (range 16 to 40) ( p  = 0.016), and the mean Subjective Shoulder Value improved from 7 (range 0 to 15) pre-operatively to 45 (range 15 to 100) postoperatively ( p  = 0.029)., Conclusions: In our series, glenohumeral arthrodesis was associated with few complications, and effectively reduced pain and improved functional outcome in this selected patient population.

Background: The prevalence of skin disease in low and middle income countries is high and communicable skin diseases are a significant public health problem. Tungiasis is an ectoparasite infestation caused by the flea Tunga penetrans, which has a widespread geographical distribution. Tungiasis causes painful skin lesions and may affect activities of daily living., Objective: We wished to determine the prevalence and impact of tungiasis and scabies in schoolchildren in southern Ethiopia., Methods: A cross-sectional study was performed in which students were examined by dermatologists and the skin disorders recorded. Individuals with pyogenic skin infections, scabies and tungiasis were also invited to complete the Children's Dermatology Life Quality Index., Results: There was a high burden of skin disease amongst this cohort with more than 40% having an ectodermal parasitic skin disease. The majority of these were due to tungiasis. Tungiasis was evident in more than a third of children and was associated with onychodystophy. There was a significant association between wearing "closed" footwear and a greater number of tungiasis lesions but not tungiasis per se. Dermatophyte infections, acne and plantar maceration secondary to occlusive footwear were also common. Scabies and tungiasis appeared to have a significant negative effect on quality of life., Conclusion: Tungiasis is highly prevalent in schoolchildren in the part of Ethiopia where the study was conducted and is associated with a deleterious effect on quality of life. The role of footwear in both preventing and possibly exacerbating cutaneous ailments in this setting requires further study.

Objectives: We wished to validate our recently devised 16-item ENLIST ENL Severity Scale, a clinical tool for measuring the severity of the serious leprosy associated complication of erythema nodosum leprosum (ENL). We also wished to assess the responsiveness of the ENLIST ENL Severity Scale in detecting clinical change in patients with ENL., Methods: Participants, recruited from seven centres in six leprosy endemic countries, were assessed using the ENLIST ENL Severity Scale by two researchers, one of whom categorised the severity of ENL. At a subsequent visit a further assessment using the scale was made and both participant and physician rated the change in ENL using the subjective categories of "Much better", "somewhat better", "somewhat worse" and "much worse" compared with "No change" or "about the same"., Results: 447 participants were assessed with the ENLIST ENL Severity Scale. The Cronbach alpha of the scale and each item was calculated to determine the internal consistency of the scale. The ENLIST ENL Severity Scale had good internal consistency and this improved following removal of six items to give a Cronbach's alpha of 0.77. The cut off between mild ENL and more severe disease was 9 determined using ROC curves. The minimal important difference of the scale was determined to be 5 using both participant and physician ratings of change., Conclusions: The 10-item ENLIST ENL Severity Scale is the first valid, reliable and responsive measure of ENL severity and improves our ability to assess and compare patients and their treatments in this severe and difficult to manage complication of leprosy. The ENLIST ENL Severity Scale will assist physicians in the monitoring and treatment of patients with ENL. The ENLIST ENL Severity Scale is easy to apply and will be useful as an outcome measure in treatment studies and enable the standardisation of other clinical and laboratory ENL research.

Background: To evaluate biological strategies that enhance tendon-bone healing in humans, it is imperative that suitable animal models accurately reproduce the pathological changes observed in the clinical setting following a tear. The purpose of the present study was to investigate rotator cuff degeneration in a rat, as well as assess the development of osteopenia at the enthesis following tendon detachment., Methods: Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Specimens were retrieved at 4 weeks ( n  = 6), 6 weeks ( n  = 6) and 9 weeks ( n  = 6) postoperatively for histological analysis and peripheral quantitative computer tomography., Results: Three weeks following tendon detachment, there was a significant increase in the modified Movin score, characterized by a loss of muscle mass, fatty infiltration, an increase in musculotendinous cellularity, loss of normal collagen fibre structure/arrangement, rounded tenocyte nuclei and an increase in the number of vascular bundles. This was accompanied by a reduction in bone mineral density at the tendon insertion site. After 3 weeks however, these changes were less prominent., Conclusions: The rotator cuff tendon-muscle-bone unit in a rat model 3 weeks after detachment of supraspinatus represents a valid model for investigating rotator cuff degeneration.

Purpose: Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy., Methods: A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures., Results: Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively (range, 7-22) to 26 post-operatively (range, 12-45) ( p = 0.031). This was accompanied by an increase in the mean Subjective Shoulder Value, which improved from 29 (range, 10-80) pre-operatively to 53 (range, 15-90) post-operatively ( p=0.042)., Conclusions: Anatomical shoulder arthroplasty may offer a solution for the treatment of instability arthropathy in patients with epilepsy and persistent seizures.

Benzimidazoles are the most common anthelminthic used for control of gastrointestinal nematodes of goats in the Brazilian semi-arid region. Resistance to these compounds in the nematode Haemonchus contortus has been associated with single nucleotide polymorphisms (SNP) in codons 167 (F167Y) and 200 (F200Y) on the β-tubulin isotype 1 gene. To determine the resistance profile to benzimidazoles of populations of H. contortus of goats of Brazilian semi-arid region, larvae of 29 populations of these nematodes were individually genotyped by real time PCR using a Taqman assay. The percentage of larvae homozygous (RR) for SNP F200Y was relatively low (18.9%), particularly when compared to SNP F167Y (32.7%), indicating that the latter has more relevance in this region. However, the associations between these two SNP demonstrate percentages of resistance ranging from 34.7% to 100% between populations, being the highest percentages for homozygous individuals resistant for the mutation 167 and susceptible to mutation 200 (RR-F167Y/F200Y-SS: 26.7%), followed by combination of heterozygous for both mutations (F167Y-SR/F200Y-SR: 22.8%). These results indicate high levels of resistance in populations of H. contortus of goats in the Brazilian semi-arid region, and thus ineffective antiparasitic control with the use of benzimidazoles in the region., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: This study reports the clinical outcome after glenohumeral arthrodesis for recurrent type II (atraumatic structural) and type III (muscle patterning nonstructural disorder) shoulder instability., Methods: A retrospective review was conducted at a single facility. Eight consecutive patients (7 women and 1 man) with recurrent shoulder instability underwent arthrodesis and were monitored for a mean of 57 months (range, 24-123 months). Mean age at the time of surgery was 47 years (range, 21-73 years)., Results: Bony union was achieved in all patients at a mean time to fusion of 3 months (range, 1-11 months). No complications, such as routine removal of the metalwork or loosening, were noted. No residual perceived glenohumeral instability was reported, and no patient developed scapulothoracic instability or painful scapular dyskinesis. The mean Oxford Shoulder Instability Score improved from 8 preoperatively (range, 0-19) to 32 postoperatively (range, 16-41; P = .001). This was accompanied by an increase in the mean subjective shoulder value, which improved from 22 (range, 0-50) preoperatively to 73 (range, 50-100) postoperatively (P = .004)., Conclusion: In our series, glenohumeral arthrodesis was associated with no complications and was able to reduce pain, eliminate instability, and improve functional outcome. It should therefore be considered in this patient population., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to assess the effect of demineralized bone matrix (DBM) on rotator cuff tendon-bone healing. The hypothesis was that compared with a commercially available dermal matrix scaffold, DBM would result in a higher bone mineral density and regenerate a morphologically superior enthesis in a rat model of chronic rotator cuff degeneration., Methods: Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 animals were repaired with DBM (n = 6); group 2 received augmentation with the dermal scaffold (n = 6); and group 3 (controls) underwent nonaugmented tendon-bone repair (n = 6). Specimens were retrieved at 6 weeks postoperatively for histologic analysis and evaluation of bone mineral density., Results: No failures of tendon-bone healing were noted throughout the study. All groups demonstrated closure of the tendon-bone gap with a fibrocartilaginous interface. Dermal collagen specimens exhibited a disorganized structure with significantly more abnormal collagen fiber arrangement and cellularity than in the DBM-based repairs. Nonaugmented repairs exhibited a significantly higher bone mineral density than in DBM and the dermal collagen specimens and were not significantly different from control limbs that were not operated on., Conclusion: The application of DBM to a rat model of chronic rotator cuff degeneration did not improve the composition of the healing enthesis compared with nonaugmented controls and a commercially available scaffold. However, perhaps the most important finding of this study was that the control group demonstrated a similar outcome to augmented repairs., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The Pediatric Anesthesia Neuro Development Assessment (PANDA) team at the Anesthesiology Department at Columbia University Medical Center held its fifth biennial symposium to discuss issues regarding potential neurotoxicity of anesthetic agents in pediatric patients. Overall optimal surgical timing as well as a "critical window" for surgery on a specialty specific basis are areas of focus for the American Academy of Pediatrics Surgical Advisory Panel. An ad hoc panel of pediatric surgical experts representing general surgery, urology, neurosurgery, and ophthalmology was assembled for this meeting and provided a dialogue focused on the benefits of early intervention versus potential anesthetic risk, addressing parental concerns, and the need for continued interdisciplinary collaboration in this area.

Introduction: Robotic technology has been increasingly utilized for complicated reconstructive surgeries in pediatric urology, such as ureteroureterostomy (UU). The literature is limited regarding the performance of minimally invasive UU in children, and the existing published series utilize indwelling ureteral stents. We sought to report on our pediatric experience with robot-assisted laparoscopic (RAL)-UU using a temporary ureteral catheter in duplex systems with ureteral ectopia., Methods: A retrospective chart review was performed of all pediatric patients who underwent RAL-UU at a single institution over a 2-year period. An externalized ureteral catheter was kept overnight and removed with the indwelling catheter on postoperative day 1. Intraoperative as well as postoperative complications, length of stay (LOS), and analgesia were recorded. Follow-up renal ultrasound (US) and evaluation for symptom resolution were completed 3 months postoperatively., Results: Twelve patients (four male, eight female) underwent RAL-UU at a mean age of 19.4 months (range 9-48 months) during the study period. The majority of patients (83.3%) presented with hydronephrosis, and all were found to have duplicated systems with ureteral ectopia. No child had ipsilateral vesicoureteral reflux. Two children had bilateral duplicated systems, one of which required bilateral surgery. Median operative time was 138 minutes (IQR 119-180 minutes), and mean estimated blood loss was 1.5 mL. There were no intraoperative complications, and no case required open conversion. Median hospital LOS was 31 hours (IQR 30-39 hours). Median follow-up time was 11 months (range 3-22 months). One patient developed a postoperative febrile upper respiratory infection. All patients had improved hydroureteronephrosis on US at 3 months postoperatively. One patient with preoperative urinary incontinence was dry postoperatively. Therefore, the overall success rate was 100%., Conclusion: Our institutional results demonstrate that RAL-UU utilizing a temporary ureteral catheter is a safe and effective technique for managing duplicated, ectopic ureters in children and infants.

We report a new chameleon-like Anolis species from Hispaniola that is ecomorphologically similar to congeners found only on Cuba. Lizards from both clades possess short limbs and a short tail and utilize relatively narrow perches, leading us to recognize a novel example of ecomorphological matching among islands in the well-known Greater Antillean anole radiation. This discovery supports the hypothesis that the assembly of island faunas can be substantially deterministic and highlights the continued potential for basic discovery to reveal new insights in well-studied groups. Restricted to a threatened band of midelevation transitional forest near the border of the Dominican Republic and Haiti, this new species appears to be highly endangered.

Epileptic seizures can cause dislocation of the shoulder. Recurrent instability is common and occurs soon after the first dislocation. Significant bone loss from the humeral head and glenoid is thought to be responsible for this, and therefore the majority of surgical approaches focus on bone augmentation of the glenohumeral joint. Understanding of the current management strategies and the anatomic lesions associated with seizure-related shoulder instability will guide clinical decision-making. The purpose of this article was to review the pathoanatomy, treatment options, and clinical outcomes of seizure-related shoulder instability., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aim: To report the results of fixed-fulcrum fully constrained reverse shoulder arthroplasty for the treatment of recurrent shoulder instability in patients with epilepsy., Methods: A retrospective review was conducted at a single facility. Cases were identified using a computerized database and all clinic notes and operative reports were reviewed. All patients with epilepsy and recurrent shoulder instability were included for study. Between July 2003 and August 2011 five shoulders in five consecutive patients with epilepsy underwent fixed-fulcrum fully constrained reverse shoulder arthroplasty for recurrent anterior shoulder instability. The mean duration of epilepsy in the cohort was 21 years (range, 5-51) and all patients suffered from grand mal seizures., Results: Mean age at the time of surgery was 47 years (range, 32-64). The cohort consisted of four males and one female. Mean follow-up was 4.7 years (range, 4.3-5 years). There were no further episodes of instability, and no further stabilisation or revision procedures were performed. The mean Oxford shoulder instability score improved from 8 preoperatively (range, 5-15) to 30 postoperatively (range, 16-37) (P = 0.015) and the mean subjective shoulder value improved from 20 (range, 0-50) preoperatively to 60 (range, 50-70) postoperatively (P = 0.016). Mean active forward elevation improved from 71° preoperatively (range, 45°-130°) to 100° postoperatively (range, 80°-90°) and mean active external rotation improved from 15° preoperatively (range, 0°-30°) to 40° (20°-70°) postoperatively. No cases of scapular notching or loosening were noted., Conclusion: Fixed-fulcrum fully constrained reverse shoulder arthroplasty should be considered for the treatment of recurrent shoulder instability in patients with epilepsy.

Background: Functional MR urography (fMRU) provides comprehensive functional data that can be subject to variability. To interpret the results of fMRU, it is essential to know the intra- and inter-observer variability of the measured parameters., Objective: To define the range of variability in fMRU, particularly that of the differential renal function based on volume (volumetric differential renal function) and Patlak differential renal function measurements in children., Materials and Methods: We included 15 fMRU studies, 10 of non-duplicated and 5 of unilateral duplex kidneys. We recruited six observers with a range of fMRU experience, including two MRI technologists, one resident, one fellow, one pediatric radiologist and one pediatric urologist. The observers underwent intensive training in using the Children's Hospital of Philadelphia (CHOP)-fMRU freeware for analysis. They conducted the fMRU analysis on each case twice, at least 1 week apart. Mean and standard deviation were calculated for each set of absolute volume, absolute Patlak, volumetric differential renal function and Patlak differential renal function. We calculated the statistical significance of these deviations using the student's t-test. We also calculated interclass correlations for intra-observer and inter-observer agreement of both volume and Patlak measurements using SPSS software., Results: Intra- and inter-observer variability did not differ significantly, measuring 6% and 4% for relative volume (volumetric differential renal function: P > 0.05) and 5% and 3% for relative function (Patlak differential renal function: P > 0.05). Absolute values of parameters showed more variability than the relative values. Intra- and inter-observer agreement was well above 0.90 (P < 0.001) for all volume measures except for duplex upper pole intra-observer measurements (0.80, P < 0.01). Intra- and inter-observer agreement for Patlak values were also above 0.90 (P < 0.001) except for duplex upper pole measurements, which were 0.54 (P = 0.13) and 0.81 (P < 0.01), respectively., Conclusion: Functional MRU analysis using CHOP-fMRU software is reproducible, with overall intra- and inter-observer variability rates of 5% for volumetric differential renal function and 4% for Patlak differential renal function. There was higher variability in volume and function measurements between upper and lower pole moieties of duplicated kidneys and for absolute volume and function values overall. A range of 45-55% for relative values of volumetric differential renal function and Patlak differential renal function could serve as the normal range.

Background: Leprosy Type 1 (T1R) reactions are immune-mediated events leading to nerve damage and preventable disability affecting hands, feet and eyes. Type 1 Reactions are treated with oral corticosteroids. There is little evidence on alternative treatments for patients who do not respond to steroids or experience steroid adverse effects. We report the results of a randomized controlled trial testing the efficacy and adverse effect profile of ciclosporin and prednisolone (CnP) in comparison to prednisolone only (P) in patients with new T1R in Ethiopia. Ciclosporin is a potent immunosuppressant. Outcomes were measured using a clinical severity score, recurrence rate, adverse events and quality of life., Results: Seventy three patients with new T1R were randomized to receive CnP or P for 20 weeks. Recovery rates in skin signs was similar in both groups (91% vs 88%). Improvements in nerve function both, new and old, sensory (66% vs 49%) and motor (75% vs 74%) loss were higher (but not significantly so) in the patients on CnP. Recurrences rates of T1R (85%) were high in both groups, and recurrences occurred significantly earlier (8 weeks) in patients CnP, who needed 10% more additional prednisolone. Serious major and minor adverse events rates were similar in patients in the two treatment arms of the study. Both groups had a significant improvement in their quality of life after the study, measured by the SF-36., Conclusions: This is the first double-blind RCT assessing ciclosporin, in the management of T1R in Africa. Ciclosporin could be a safe alternative second-line drug for patients with T1R who are not improving with prednisolone or are experiencing adverse events related to prednisolone. This study illustrates the difficulty in switching off leprosy inflammation. Better treatment agents for leprosy patients with reactions and nerve damage are needed.

Background: Erythema Nodosum Leprosum (ENL) is a serious complication of leprosy. It is normally treated with high dose steroids, but its recurrent nature leads to prolonged steroid usage and associated side effects. There is little evidence on the efficacy of alternative treatments for ENL, especially for patients who have become steroid resistant or have steroid side effects. These two pilot studies compare the efficacy and side effect profile of ciclosporin plus prednisolone against prednisolone alone in the treatment of patients with either new ENL or chronic and recurrent ENL., Methods and Results: Thirteen patients with new ENL and twenty patients with chronic ENL were recruited into two double-blinded randomised controlled trials. Patients were randomised to receive ciclosporin and prednisolone or prednisolone treatment only. Patients with acute ENL had a delay of 16 weeks in the occurrence of ENL flare-up episode, with less severe flare-ups and decreased requirements for additional prednisolone. Patients with chronic ENL on ciclosporin had the first episode of ENL flare-up 4 weeks earlier than those on prednisolone, as well as more severe ENL flare-ups requiring 2.5 times more additional prednisolone. Adverse events attributable to prednisolone were more common that those attributable to ciclosporin., Conclusions: This is the first clinical trial on ENL management set in the African context, and also the first trial in leprosy to use patients' assessment of outcomes. Patients on ciclosporin showed promising results in the management of acute ENL in this small pilot study. But ciclosporin, did not appear to have a significant steroid-sparing effects in patients with chronic ENL, which may have been due to the prolonged use of steroids in these patients in combination with a too rapid decrease of steroids in patients given ciclosporin. Further research is needed to determine whether the promising results of ciclosporin in acute ENL can be reproduced on a larger scale.

We describe a new species of Boophis treefrog from Ranomafana National Park in the southern central east of Madagascar. This region has remarkably high anuran diversity, and along with neighbouring sites, hosts more than 35 Boophis species. Boophis boppa sp. nov. is part of the B. ankaratra sub-clade (herein named the B. ankaratra complex), previously identified within the monophyletic B. albipunctatus species group. It occurs sympatrically with two other species of the complex (B. ankaratra and B. schuboeae). Morphological differentiation of species within the B. ankaratra clade remains elusive, but species are well characterized by distinct advertisement calls, with B. boppa having the longest note duration and inter-note intervals when compared to closely related species. Furthermore, it has moderate differentiation in mitochondrial DNA, with pairwise distances of 1.9-3.7% to all other species in sequences of the mitochondrial 16S rRNA marker. Additional evidence is given by the lack of haplotype sharing with related species for the nuclear exon DNAH-3. All examples of syntopic occurrence in this complex involve species with strongly different advertisement calls, while allopatric species have more similar calls. Such a pattern might result from adaptive call co-evolution but could also be the result of non-adaptive processes. Thorough clarification of the systematics of the B. ankaratra sub-clade is required, and we outline future directions for both bioacoustic and genetic research.