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BACKGROUND Catheter-based endovascular neurointerventions require deep neuromuscular blocks during the procedure and rapid subsequent recovery of strength to facilitate neurological evaluation. We tested the primary hypothesis that sugammadex reverses deep neuromuscular blocks faster than neostigmine reverses moderate neuromuscular blocks. METHODS Patients having catheter-based cerebral neurointerventional procedures were randomized to: (1) deep rocuronium neuromuscular block with posttetanic count 1 to 2 and 4-mg/kg sugammadex as the reversal agent or (2) moderate rocuronium neuromuscular block with train-of-four (TOF) count 1 during the procedure and neuromuscular reversal with 0.07-mg/kg neostigmine to a maximum of 5 mg. Recovery of diaphragmatic function was assessed by ultrasound at baseline before the procedure and 90 minutes thereafter. The primary outcome-time to reach a TOF ratio ≥0.9 after administration of the designated reversal agent-was analyzed with a log-rank test. Secondary outcomes included time to successful tracheal extubation and the difference between postoperative and preoperative diaphragmatic contraction speed and distance. RESULTS Thirty-five patients were randomized to sugammadex and 33 to neostigmine. Baseline characteristics and surgical factors were well balanced. The median time to reach TOF ratio ≥0.9 was 3 minutes (95% confidence interval [CI], 2-3 minutes) in patients given sugammadex versus 8 minutes (95% CI, 6-10 minutes) in patients given neostigmine. Sugammadex was significantly faster by a median of 5 minutes (95% CI, 3-6 minutes; P < .001). However, times to tracheal extubation and diaphragmatic function at 90 minutes did not differ significantly. CONCLUSIONS Sugammadex reversed deep rocuronium neuromuscular blocks considerably faster than neostigmine reversed moderate neuromuscular blocks. However, times to extubation did not differ significantly, apparently because extubation was largely determined by the time required for awaking from general anesthesia and because clinicians were willing to extubate before full neuromuscular recovery. Sugammadex may nonetheless be preferable to procedures that require a deep neuromuscular block and rapid recovery.

Background: Common Variants in insulin-like binding protein 2 (IGF2BP2) gene to be associated with type 2 diabetes (T2DM) by several genome-wide association studies and replication analyses. This study aimed to determine the association of IGF2BP2 variants rs4402960 and rs1470579 with T2DM in Egyptian people.Methods: This study involved 50 T2DM patients and 50 control subjects. Genotyping of SNPs in (IGF2BP2) gene (rs1470579) and (rs4402960) variants using Real-time PCR.Results: In this study, using logistic regression of this additive model of SNP rs4402960, the presence of homozygous variant allele (TT) genotype carries a 3 fold risk of DM with an odds ratio (OR) of 3.28 (p = 0.095), and homozygous variant allele (CC) genotype of SNP rs1470579 carries a 5 fold risk of DM with OR of 5.44 (p = 0.011). Using the dominant model, the two IGF2BP2 variants carry a high risk of DM. Meanwhile, using the recessive model only SNP rs1470579 carries a risk near 3 fold risk of DM.Conclusions: This study shows that IGF2BP2 susceptibility variants rs4402960 and rs1470579 are associated with T2DM in Egypt.

Catheter ablation for atrial fibrillation (AF) has become an established treatment to control symptoms. AF ablation either by cryoballoon or radiofrequency using three-dimensional (3D) electroanatomical mapping exposes patients and medical staff to increased doses of radiation. To compare radiation exposure in patients during cryoballoon ablation compared to 3D electro-anatomic mapping catheter ablation in AF patients. A total of 30 patients referred for AF ablation underwent full history taking, 12-lead ECG, echocardiogram, and pulmonary vein isolation either by 3D mapping system or cryoballoon. Procedure duration and fluoroscopy time were collected and analyzed. Radiation exposure was measured using thermoluminescent dosimeters placed at different sites related to patients and medical staff. The procedural time was statistically significantly longer with 3D mapping compared to cryoballoon but showed no significant difference regarding fluoroscopy time. There was a significantly higher radiation skin dose at the right scapular area in the cryoballoon ablation group, in addition to higher peak skin dose compared to the 3D mapping ablation group. There was no statistically significant correlation between peak skin doses and fluoroscopy duration but a statistically significant correlation between peak skin dose and usage of high frame rate and the high dose area product. Cryoballoon ablation was found to be associated with higher peak skin radiation doses especially in the right scapular area. Knowing dose area product and peak skin dose is more important than fluoroscopy time alone.

Background: Terminal QRS distortion and fragmentation (fQRS) with elevated myeloperoxidase (MPO) were linked to poor cardiovascular outcomes in acute coronary syndrome. We aimed to investigate these parameters in early prediction of coronary artery disease severity based on SYNTAX score and in-hospital adverse events in STEMI patients. Methods: A total of 215 patients with first STEMI admitted for primary PCI were included in the study. They were divided according to the admission ECG into group I with QRS distortion or fQRS, group II with combined QRS distortion and fQRS, and group III without QRS distortion or fQRS. Myeloperoxidase and troponin I levels, ST resolution ratio, left ventricular EF%, and severity of coronary artery lesions using SYNTAX risk score were measured. Results: MPO level, SYNTAX score, and in-hospital mortality were higher in group I and II and were higher in group II compared to group I. By regression analysis, QRS distortion, fQRS, and MPO > 412 ng/ml were independent predictors of both CAD severity and in-hospital mortality. DM was an independent predictor of CAD severity (OR: 2.851, P 0.012) while high SYNTAX score was an independent predictor of in-hospital mortality (OR: 6.113, P 0.001). Adding MPO level to any QRS configuration pattern increased predictive value for the detection of CAD severity that was more evident in the combined QRS distortion and fragmentation. Conclusion: Terminal QRS distortion, fragmentation, or combined QRS distortion and fragmentation have a significant value in predicting in-hospital adverse events and CAD severity as assessed by SYNTAX score in association with plasma myeloperoxidase level in STEMI patients. Combined QRS distortion and fragmentation, in spite less common, could be more helpful for early risk stratification and management.

High-speed railway (HSR) has demonstrated tremendous growth worldwide, and is currently attaining a maximum velocity of 575 km/h. Such a high speed makes mobile wireless communications extremely challenging for HSR since the handover (HO) rate increases with speed, resulting in a high call dropping probability. By employing a dedicated distributed antenna system (DAS) along with the two-hop network architecture, in this paper, we propose a frequency switch (FSW) scheme to mitigate the persistent HO issue in conventional HSR wireless communication systems. The proposed scheme significantly alleviates interruption time associated with the traditional HO process, providing an effective scheme when the train moves across small cells covered by remote antenna units (RAUs) belonging to the same central unit (CU). In order to further reduce the HO command failure probability, an enhanced fast predictive HO mechanism is proposed by starting the HO process in advance, when the train moves from one RAU to the next one controlled by the adjacent CU. Analytical results show that compared to the traditional HO scheme, the proposed schemes can improve the system performance substantially by delivering ultra-reliable low-latency communications with a reduced HO/FSW rate.

Supplemental Digital Content is Available in the Text. A 6-day ambulatory continuous peripheral nerve block reduces phantom limb pain and pain-induced physical and emotional dysfunction for at least 4 weeks after treatment., Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

Background Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed. Methods The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer’s disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed. Results The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001). Conclusions Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Both saline and lactated Ringer’s solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer’s solution than normal saline. Methods The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer’s solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. Results Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer’s solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer’s versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I–III versus 0, occurred in 6.6% of lactated Ringer’s patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. Conclusions In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer’s or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background : urethral stricture is one of the most difficult urological problems to cure adequately and is know to mankind since ages as it has been documented in ancient literature of Egyptians and Greeks. Aim of the work: the aim of our study is to evaluate and compare the outcomes of Ho:YAG laser urethrotomy with the conventional cold knife technique as regards treatment outcome, efficacy and complications Patients and methods: A total of 20 male patients presented to the urology department at El Maadi military hospital and Ain shams university hospitals diagnosed as urethral stricture requiring optical internal urethrotomy were included in this study. Patients were randomized into two groups : In group A (holmium group): 10 patients underwent internal urethrotomy with Holmium laser. In group B (cold knife group) 10 patients underwent internal urethrotomy with cold knife. Results: based upon uroflowmetry, assessment of treatment effectiveness and complications were made at 3 months follow-up. Post operative fall in the peak flow rate was noted during the follow up in both groups, but was highter fall in the holmium group than the cold knife group at the end of the third month.

Background Simultaneous retrograde and antegrade endoscopic combined intrarenal surgery in modified supine lithotomy positions offer significant progress in the endoscopic management of urolithiasis. The operative time has been significantly reduced. Aim of the Work To evaluate the Galdakao-modified Valdivia position in simultaneous handling of upper and lower urological pathologies in the same units. Patients and Methods The evaluation for the Galdakao-modified Valdivia position regarding the benefits in different upper and lower urological diseases was the aim of our prospective randomized clinical trial that will started on April 2017 and ended by April 2019. Results The study has included 60 patients comprising males and females. Conclusion We believe that GMSV provided a great versatility in the treatment for urolithiasis along the whole urinary tract, ante-retrograde access, treatment of uretero-ileal strictures in patients with urinary diversions or neobladders, missed double j stent, bilharizoma of the ureter and bladder mass involving the ureteric orifice. Also, the advantage provided by this approach to the surgeon, patient and anesthetist may lead to widespread adaptability of this technique in the management of complex urolithiasis.

BACKGROUND We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported. METHODS Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article. RESULTS Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance. CONCLUSIONS This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.

Internet of Things (IoT) has a huge attention recently due to its new emergence, benefits, and contribution to improving the quality of human lives. Securing IoT poses an open area of research, as it is the base of allowing people to use the technology and embrace this development in their daily activities. Authentication is one of the influencing security element of Information Assurance (IA), which includes confidentiality, integrity, and availability, non repudiation, and authentication. Therefore, there is a need to enhance security in the current authentication mechanisms. In this report, some of the authentication mechanisms proposed in recent years have been presented and reviewed. Specifically, the study focuses on enhancement of security in CoAP protocol due to its relevance to the characteristics of IoT devices and its need to enhance its security by using the symmetric key with biometric features in the authentication. This study will help in providing secure authentication technology for IoT data, device, and users.

Postoperative pain is common and promotes opioid use. Surgical wounds are hypoxic because normal perfusion is impaired. Local wound ischemia and acidosis promote incisional pain. Some evidence suggests that improving oxygen supply to surgical wounds might reduce pain. We therefore tested the hypothesis that supplemental (80% inspired) intraoperative oxygen reduces postoperative pain and opioid consumption.We conducted a post hoc analysis of a large, single-center alternating cohort trial allocating surgical patients having general anesthesia for colorectal surgery to either 30% or 80% intraoperative oxygen concentration in 2-week blocks for a total of 39 months. Irrespective of allocation, patients were given sufficient oxygen to maintain saturation ≥95%. Patients who had regional anesthesia or nerve blocks were excluded. The primary outcome was pain and opioid consumption during the initial 2 postoperative hours, analyzed jointly. The secondary outcome was pain and opioid consumption over the subsequent 24 postoperative hours. Subgroup analyses of the primary outcome were conducted for open versus laparoscopic procedures and for patients with versus without chronic pain.A total of 4702 cases were eligible for analysis: 2415 were assigned to 80% oxygen and 2287 to 30% oxygen. The groups were well balanced on potential confounding factors. Average pain scores and opioid consumption were similar between the groups (mean difference in pain scores, -0.01 [97.5% CI, -0.16 to 0.14; P = .45], median difference in opioid consumption, 0.0 [97.5% CI, 0 to 0] mg morphine equivalents; P = .82). There were also no significant differences in the secondary outcome or subgroup analyses.Supplemental intraoperative oxygen does not reduce acute postoperative pain or reduce opioid consumption.

BACKGROUND Neuraxial anesthesia improves components of the Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) which are key pathogenic contributors to venous thrombosis in surgical patients. However, whether neuraxial anesthesia reduces the incidence of venous thromboembolism (VTE) remain unclear. We therefore tested the primary hypothesis that neuraxial anesthesia reduces the incidence of 30-day VTE in adults recovering from orthopedic surgery. Secondarily, we tested the hypotheses that neuraxial anesthesia reduces 30-day readmission, 30-day mortality, and the duration of postoperative hospitalization. METHODS Inpatient orthopedic surgeries from American College of Surgeons National Surgical Quality Improvement Program database (2011-2015) in adults lasting more than 1 hour with either neuraxial or general anesthesia were included. Groups were matched 1:1 by propensity score matching for appropriate confounders. Logistic regression model was used to assess the effect of neuraxial anesthesia on 30-day VTE, 30-day mortality, and readmission, while Cox proportional hazard regression model was used to assess its effect on length of stay. RESULTS Neuraxial anesthesia decreased odds of 30-day VTE (odds ratio 0.85, 95% confidence interval, 0.78-0.95; P = .002) corresponding to number-needed-to-treat of 500. Although there was no difference in 30-day mortality, neuraxial anesthesia reduced 30-day readmission (odds ratio 0.90, 98.3% confidence interval, 0.85-0.95; P < .001) corresponding to number-needed-to-treat of 250 and had a shortened hospitalization (2.87 vs 3.11; P < .001). CONCLUSIONS Neuraxial anesthesia appears to provide only weak VTE prophylaxis, but can be offered as an adjuvant to current thromboprophylaxis in high-risk patients.

To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards.A prediction study using data from two randomized controlled trials.Operating room, post-anesthesia care unit, and surgical ward.550 adult patients having abdominal surgery with ASA physical status I-IV.Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively.The primary predictors were minimum mean arterial pressure (60,65,70 and 80 mmHg) and minimum systolic blood pressure (70,75,80,85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure 70 mmHg or systolic pressure 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75.Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity.Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.

Background Current worldwide pandemic coronavirus disease 2019 (COVID-19) with high numbers of mortality rates and huge economic problems require an urgent demand for safe and effective vaccine development. Inactivated SARS-CoV2 vaccine with alum. Hydroxide can play an important role in reducing the impacts of the COVID-19 pandemic. In this study, vaccine efficacy was evaluated through the detection of the neutralizing antibodies that protect mice from challenge with SARS-CoV 2 3 weeks after the second dose. We conclude that the vaccine described here has safety and desirable properties, and our data support further development and plans for clinical trials. Methods Characterized SARS-COV-2 strain, severe acute respiratory syndrome coronavirus 2 isolates (SARS-CoV-2/human/EGY/Egy-SERVAC/2020) with accession numbers; MT981440; MT981439; MT981441; MT974071; MT974069; and MW250352 at GenBank were isolated from Egyptian patients SARS-CoV-2-positive. Development of inactivated vaccine was carried out in a BSL-3 facilities and the immunogenicity was determined in mice at two doses (55 and 100 μg per dose). Results The distinct cytopathic effect induced by SARS-COV-2 propagation on Vero cell monolayers and the viral particles were identified as Coronaviridae by transmission electron microscopy and RT-PCR on infected cells cultures. Immunogenicity of the developed vaccine indicated the high antigen-binding and neutralizing antibody titers, regardless of the dose concentration, with excellent safety profiles and no deaths or clinical symptoms in mice groups. The efficacy of the inactivated vaccine formulation was tested by the wild virus challenge of the vaccinated mice and viral replication detection in lung tissues. Conclusions Vaccinated mice recorded complete protection from challenge infection via inhibition of SARS-COV-2 replication in the lung tissues of mice following virus challenge, regardless of the level of serum neutralizing antibodies. This finding will support future trials for the evaluation of an applicable SARS-CoV-2 vaccine candidate.

Background Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. Methods Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. Results Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. Conclusions We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.

Background: LiveWell Initiative LWI is a self-funded nonprofit social enterprise that thrives on innovation.The organization has, for 5 years, supervised MPH and DrPH Practicums for the Harvard T. H. Chan School of Public Health, Harvard University, Boston USA. It also supervises the PhD thesis at the University of Helsinki, Finland. At the inception of COVID-19, LWI designed and compiled three (3) sets of study protocols in response to the COVID-19 response in Africa with a goal to arrive at a practical and affordable solution to the pandemic using 4-aminoquinolines. Method: A concurrent cohort/descriptive study of observation in patients exposed to HCQ/CQ prophylaxis and treatment with HCQ/CQ and quinine with categorization as specified as not critically ill, critically ill but not on a ventilator and critically ill on a ventilator. One hundred and twenty-three (123) subjects were categorized into shelter-in-place, self-quarantine and self-isolation (not critically ill, critically ill but not on a ventilator and critically ill on a ventilator). The 4-aminoquinolines were administered macrolide and zinc sulfate as appropriate for a defined duration and dose. Results: The preliminary study of the 123 subjects covering all categories listed above resulted in 100% positive outcomes: Nil death, Nil relapse in symptomatic persons and total recovery with no relapse after 6 weeks lockdown, and asymptomatic persons post-prophylaxis after 6 weeks lockdown. The results have been gathered principally from Clinician Reported Outcomes with a few Patient Reported Outcomes. Conclusion: These repurposed drugs with unique strengths—chloroquine and its analogue Hydroxychloroquine as well quinine—hold sway in the treatment of COVID-19.

Background Chronic obstructive pulmonary disease (COPD) is a well-known respiratory system disorder impacting patient’s morbidity and mortality. Many COPD patients die from cardiovascular diseases. Criteria of arterial stiffness might be the early clue for cardiovascular affection in COPD patients. This study aimed to evaluate the occurrence of arterial stiffness as an early subclinical change in stable mild to moderate COPD patients. Results This cross-sectional study included 80 mild-to-moderate COPD patients and another 80 healthy controls. The carotid-femoral pulse wave velocity (cf-PWV) and the heart rate adjusted augmentation index (AIx75) were statistically significantly higher (13.8 ± 2.6 and 23.9 ± 10.8, respectively) among studied mild-to-moderate COPD patients when compared to healthy controls (10.7 ± 1.1 and 18.1 ± 8.9, respectively) (p < 0.001). FEV1 (forced expiratory volume in 1 s) % of predicted correlated negatively with both AIx75 (r = − 0.84, p < 0.001) and cf-PWV (r = − 0.85, p < 0.001), while BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index correlated positively with both AIx75 (r = 0.58, p < 0.001) and cf-PWV (r = 0.52, p < 0.001) in patients with mild-to-moderate COPD. Conclusions Pulse wave velocity and augmentation index correlated with FEV1% of predicted and BODE index in patients with mild-to-moderate COPD.

Background: Biomarkers are the corner stone for diagnosis of myocardial infarction (MI). MicroRNA-208a (miR-208a) is known to be heart specific. So, this study was designed to explore its role as a marker for diagnosis of MI as well as a predictor of outcome of primary percutaneuos coronary angiography especially no-reflow phenomenon. Methods: This study was carried out between January 2018 and August 2019 in Cardiology Department, Zagazig University Hospitals, Egypt. Approval was obtained from institutional review board adhering to the guidelines of the Declaration of Helsinki. Patients (n=75) presented by chest pain were recruited into two groups. Group 1 (n=40) had STEMI and underwent primary PCI: 21 patients with sufficient reperfusion and 19 with no-reflow. Group 2 (n= 35) had negative troponin T (cTnT). Plasma miR-208a expression was assessed using quantitative polymerase chain reaction and patients were followed for occurrence of in-hospital (3 days average) major adverse cardiac events (MACE). Results: Analysis of relative expression values shows that miR-208a has reasonable sensitivity and specificity for MI diagnosis (AUC= 0.92, sensitivity = 92.5, Specificity = 80) which is comparable to the routine cardiac biomarkers; creatine kinase-MB (CK-MB) (area difference 0.0439, P= 0.235) and cTnT (area difference 0.0614, P= 0.06). The no-reflow group (b) had higher expression compared to subgroup (a). ROC analysis shows it to be a good predictor of no-reflow (AUC= 0.88, sensitivity = 73.7, Specificity = 95.2) which is significantly superior to cTnT (AUC difference of 0.231, P= 0.0233). As well, it was superior to cTnT as a predictor of in-hospital MACE (AUC difference of 0.367, P= 0.0053). Conclusion: This study highlights the value of miR-208a as a diagnostic and prognostic marker in STEMI context. To the best of our knowledge, this is the first study to investigate the value of miR-208a in no-reflow and almost the second to investigate the role of any known miRNA in no-reflow. Although still far from clinical application due to long time needed for the assay, the future introduction of new fast nucleic acids assays could support its clinical application. The study points to a possible mechanism for no-reflow development that needs to be thoroughly investigated.

Background Uncontrolled pain after noncardiac surgery activates the sympathetic nervous system, which causes tachycardia, hypertension, and increased cardiac contractility-all of which may increase myocardial oxygen demand. We therefore determined whether time-weighted average pain scores over the initial 72 postoperative hours are associated with myocardial injury after noncardiac surgery (MINS). Methods We conducted a retrospective cohort analysis of adults with routine postoperative troponin monitoring after noncardiac surgery under general, regional, or combined anesthesia at tertiary level centers in Cleveland from January 2012 to December 2015. Time-weighted average pain scores were calculated from all the available pain scores, typically at 4-hour intervals, until a troponin elevation was detected. MINS was defined as peak troponin T concentrations exceeding 0.03 ng/mL within 72 hours after surgery. We used a generalized linear mixed model to assess the association between pain and MINS with 3 hospitals as clusters, adjusting for potential confounders. Results Among 2892 eligible patients, 4.5% had myocardial injury within 72 hours after surgery. Higher time-weighted average pain scores were associated with increased hazard of myocardial injury. The estimated hazard ratio for a 1-unit increase in pain score was 1.12 (95% confidence interval [CI], 1.02-1.22; P = .013), adjusting for confounding variables. Conclusions Among patients undergoing noncardiac surgery, time-weighted average pain scores within 72 hours after surgery were significantly associated with myocardial injury.

This research presents an experimental investigation of the space heating/cooling and ventilation system of the poultry houses in Egypt. High temperature and lack of proper environment, poultry production faced heat stress that reduced feed consumption, weight gain, and egg yield. This will lead to reducing production and consequently increased the price of poultry in the local market. The present work provided an experimental study to signify the effectiveness of the evaporative cooling system using several pads that made from low cost, and locally available materials. Designing a proper ventilation system is also introduced. The energy needed for heating and cooling purposes are provided by solar energy equipment. It can provide the system with the required electrical and thermal energy that derive the cooling/heating systems throughout the year. It was found that the system performance is affected by several parameters like type and thickness of pad materials, air temperature distribution inside the poultry house, meteorological conditions, temperatures of the hot water and cooling water. It was found that the highest ambient air temperature reduction is achieved by using pad materials of carton, linen, canvas, and rice straw respectively.

MicroRNA-208a is a cardiac specific oligo-nucleotide. We aimed at investigating the ability of microRNA-208a to diagnose myocardial infarction and predict the outcome of primary percutaneuos coronary angiography (PCI). Patients (n = 75) presented by chest pain were recruited into two groups. Group 1 (n = 40) had ST elevation myocardial infarction (STEMI) and underwent primary PCI: 21 patients had sufficient reperfusion and 19 had no-reflow. Group 2 (n = 35) had negative cardiac troponins (cTns). Plasma microRNA-208a expression was assessed using quantitative polymerase chain reaction and patients were followed for occurrence of in-hospital major adverse cardiac events (MACE). MicroRNA-208a could diagnose of MI (AUC of 0.926). After primary PCI, it was superior to cTnT in prediction of no-reflow (AUC difference of 0.231, P = 0.0233) and MACE (AUC difference of 0.367, P = 0.0053). Accordingly, circulating levels of miR-208a can be used as a diagnostic marker of MI and a predictor of no-reflow and in-hospital MACE. Graphical abstract Receiver operating curve analysis of no-reflow prediction of miRNA208a, CK-MB and hs-Troponin T. MicroRNA-208a shows significantly higher prediction of no-reflow as compared to routine cardiac biomarkers.

Background Contrast induced nephropathy (CIN) which is following the administration of radiographic contrast media in coronary intervention results in increased morbidity and mortality. Several prophylactic methods were done to prevent CIN post coronary intervention. Aim of the work To evaluate contrast media volume to creatinine clearance (V/CrCl) ratio for predicting (CIN) and to determine a safe contrast media volume to prevent CIN post Coronary interventions in catheterization unit. Patients and methods This study was carried out in ----- Cardiac Catheterization Unit and included 315 patients who underwent coronary intervention. Inclusion criteria: Coronary angiography, PCI,. Exclusion criteria: Acute renal failure, Dialysis- dependant chronic renal failure. Blood urea, serum creatinine and Creatinine clearance were measured and calculated for all patients in the day before coronary angiography and then daily after the procedure for three days after the procedure. Results The patients were divided into four groups; Group I: 77 patients who have V/Cr.Cl 3.31. The optimal cut off level for the V/CrCl ratio for predicting CIN was >2.8593 (85.3% sensitivity & 79.6% specificity) and is an independent risk factor of CIN. Conclusion a reduction in the contrast media volume to a V/CrCl ratio

Objectives Patients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. There is no appropriate score for early-risk stratification at the time of the first medical contact with ACS patients. Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) is a new risk score for early prognostication in acute coronary syndromes. The aim of our study is to evaluate the accuracy and validity of Canadian-ACS risk score as a prognostic score for in-hospital risk stratification of patients with ACS, as compared to TIMI AND GRACE risk scores in the Egyptian patients. Methods Our study included 79 patients having acute coronary syndrome admitted to CCU. Calculations of The Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of: age ≥75 years, Killip class >1, systolic blood pressure 100 beats/min. Results In our study, there is a strong association between Canadian-ACS and TIMI risk score with sensitivity 85.7% and specificity 100.0% and Grace risk score with sensitivity 78.1%% and specificity 85.1%. The negative predictive value of a Canadian-ACS score ≥1 is ≥84.4% for short-term in hospital morbidity and mortality, and for score ≥2 at ≥98%. Conclusion the Canadian-ACS is a valid accurate and simple prognostic risk score for short-term risk stratification in patients with ACS independent of hypertension, diabetes, smoking and troponin level.

Background To evaluate the relationship between surgical timing and 1-year mortality in patients requiring hip fracture repair. Methods We analyzed all 720 patients (>65 years) who had hip fracture surgery between March 2005 and February 2015, identifying patients by ICD-9 diagnosis and procedure codes using electronic data query. Mortality data were obtained from the institutional database, state and Social Security Death Indices. The relationship between surgical timing (defined as the interval from admission to the start of surgery) and 1-year mortality was assessed using a multivariable logistic regression, adjusting for baseline clinical status and surgical factors. Results Among the 720 patients, 159 patients (22%) died within 1 year. The median time from admission to surgery was 30 hours. A linear relationship between the surgical timing and 1-year mortality was demonstrated. Delaying surgery was significantly associated with increased 1-year mortality, odds ratio 1.05 (95% CI: 1.02-1.08) per 10-hour delay (P = 0.001). Conclusions A linear relationship was observed between surgical timing and 1-year mortality. Each 10-hour delay from admission to surgery was associated with an estimated 5% higher odds of 1-year mortality. Therefore, we suggest that hip fractures should be treated urgently similar to other time-sensitive pathology such as stroke and myocardial ischemia. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Hypertension increases the risk of atrial fibrillation by about twofold. Micro-albuminuria is an independent predictor of cardiovascular morbidity and mortality in patients with atrial fibrillation. Aim of the work The aim of this work was to investigate the relationship between micro-albuminuria 1 (MAU) and occurrence of atrial fibrillation in patients with arterial hypertension. Patients and methods Our study was conducted in Cardiology Department, Zagazig University. We recruited 300 consecutive patients with newly diagnosed hypertension from outpatient clinics. In this prospective study, we checked for micro-albuminuria (MAU) 1 at presentation. Then a follow up for 6 months to all cases to elicit any documented attack(s) of paroxysmal or persistent atrial fibrillation. Then patients were classified according to development of AF into Group I (patients who did not develop AF during 6 months after diagnosis of hypertension) (230 patients) and Group II (patients who developed AF during 6 months after diagnosis of hypertension) (70 patients). Results The micro-albuminuria was the strongest predictor to develop AF in our cases as the upper and lower “confidence interval” CI was (0.138–0.014) with high significant difference ( p p Conclusion Micro-albuminuria was the strongest predictor of AF in hypertensive patients. Recommendation and clinical implications The early detection and treatment of micro-albuminuria is accompanied by an improved cardiovascular prognosis in hypertensive patients and prevent new onset of atrial fibrillation.

The dermatomal level of analgesia achieved with quadratus lumborum blocks varies according to the location of injection. The most commonly used approaches are either at the postero-lateral aspect or anterior to the quadratus lumborum muscle.To determine whether the site of injection of contrast dye around the quadratus lumborum muscle of cadavers affects the extent and mechanism of dye spread.Observational human cadaver study.Cleveland Clinic cadaveric laboratory.Six fresh human cadavers.The cadavers received either a posterior quadratus lumborum block or an anterior subcostal quadratus lumborum block on each side.Cadavers were dissected to determine the extent of dye spread.The posterior quadratus lumborum block approach revealed consistently deep staining of the iliohypogastric, ilioinguinal, subcostal nerve, T11 to 12 and L1 nerve roots. In addition, staining of the middle thoracolumbar fascia was seen in all specimens but only variable staining of T10 nerve roots. The anterior subcostal quadratus lumborum block approach in all specimens demonstrated predictable deep staining of the iliohypogastric and ilioinguinal nerves, subcostal nerves, T11 to 12 and L1 nerve roots, and in addition traversing the arcuate ligaments to involve T9 to 12 nerve roots with variable staining of higher thoracic nerve roots.Our cadaveric study demonstrates that injection of dye on the posterior aspect of quadratus lumborum muscle led to injectate spread through the lateral and posterior abdominal wall but with limited cranial spread, whereas the anterior approach produced broader coverage of the lower to mid-thoracic region. Clinical translation of these findings to determine the practical significance is warranted.

A structural graft is often used to maintain correction and achieve union after anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot. Autograft, the current gold standard, is limited in availability and configuration and is associated with donor site morbidity in as much as 48%, whereas the alternative allograft carries risks of disease transmission and collapse. Polyaryletherketone cage, with a healing rate similar to that of autograft, high stability, and no donor-site morbidity, has been used in spine surgery. However, its use has not been documented in foot and ankle surgery. We reviewed 15 patients with painful flatfeet after failure of conservative treatment who were treated by anterior calcaneal lengthening osteotomy using polyaryletherketone cage instead of bone graft. Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). The male-female ratio was 1:1.5 (six males, nine females). Mean age at time of surgery was 10.8 +/- 1.7 years (range, 8-13.5 years). Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). Nine patients had a unilateral procedure and three had a simultaneous bilateral procedure, for a total of 15 operated feet (seven right and eight left). The paired t-test result was statistically significant in comparison of radiographic measurements at presurgery and postsurgery with P value

Textiles represent promising support materials for enzymes. The goal of the present work was to investigate the immobilization of commercial peroxidase on a polyester needle felt and the repeated use in the gentle degradation of norbixin in whey from dairy cheese as a practical application. High enzyme loads were obtained by a 2-step immobilization procedure. First, the number of functional groups on the textile surface was increased by a modification with amino-functional polyvinylamine. Second, the enzyme was immobilized by using 2 types of crosslinking agents. Due to the iron content of peroxidase, inductively coupled plasma–optical emission spectrometry was used for the quantitative determination of the enzyme load on the textile. The enzyme activity was evaluated using common 2,2'-azino-di-(3-ethylbenzthiazoline-6-sulfonic acid) assay for peroxidases. By the variation of enzyme input and crosslinker concentration, a maximal enzyme load of 80 mg/g of textile was achieved, and a maximum specific activity of 57 U/g of textile. For the visualization of the enzyme on the fiber surface, fluorescence microscopy as well as scanning probe microscopy were used. The immobilized peroxidase showed significant activity, even after 50 reuse cycles. In addition, the potential of the new support and enzyme combination in commercial whey bleaching was demonstrated successfully on a 10-L scale.

IMPORTANCE: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. OBJECTIVE: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. DESIGN, SETTING, AND PARTICIPANTS: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. INTERVENTIONS: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. MAIN OUTCOMES AND MEASURES: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo(2)]

The quadratus lumborum (QL) block provides analgesia to the abdominal wall while sparing the side effects of neuraxial blocks. We describe a case series of eight patients treated with a continuous infusion of local anesthetic via bilateral posterior QL catheters infusion block for analgesia after abdominal surgeries. We found that the median duration of the procedure was 26 min and the median opioid consumption over the first postoperative 72 h was 110 mg of morphine equivalents. The bilateral continuous posterior QL block is a feasible analgesic intervention and can be considered as a component of multimodal analgesic pathways.

Author(s): Elsharkawy, Hesham; Barnes, Theresa; Babazade, Rovnat; Huarte, Maria; Ali Sakr Esa, Wael; Ilfeld, Brian M | Abstract: BACKGROUND:Various methods for peripheral nerve and epidural catheter location assessment exist, with varying degrees of ease of use, utility, and accuracy. Pulsed wave Doppler (PWD) evaluates the presence of fluid flow and is possible modality to assess the location of a percutaneously inserted perineural catheter. METHODS:A retrospective chart review was conducted in which PWD ultrasonography was used to confirm the position of nerve catheters for regional anesthesia. Data was collected to assess 24-hour postoperative pain scores, opioid consumption, complications, and the incidence of catheter replacement. RESULTS:Eighty-six patients were included; average age was 58 years and a 27% incidence of chronic pain. These catheters were left in place based on the PWD images. Three catheters failed and a total of 16 catheters were repositioned. In the first 24 hours average pain scores ranges between 3.5 to 5.9 and median postoperative opioid consumption range was 11.3 mg to 60.8 mg. For epidural catheters, PWD changes were more obvious with air injection and there was only one episode of hemodynamic instability. CONCLUSIONS:Our preliminary experience with PWD ultrasonography suggests that they may offer the ability to selectively assess flow at different locations to identify the proper location of epidural and perineural catheters. Future randomized, controlled investigations are warranted to further evaluate the effectiveness and safety of this modality.

The renin angiotensin system (RAS) is thought to be the body's main vasoconstrictor system, with physiological effects mediated via the interaction of angiotensin II with angiotensin I receptors (the "classic" RAS model). However, since the discovery of the heptapeptide angiotensin 1-7 and the development of the concept of the "alternate" RAS system, with its ability to reduce arterial blood pressure, our understanding of this physiologic system has changed dramatically. In this review, we focus on the newly discovered functions of the RAS, particularly the potential clinical significance of these developments, especially in the realm of new pharmacologic interventions for treating cardiovascular disease.

High-speed train (HST) has drawn considerable attention and become one of the most preferable conveyance mechanisms. Every year the manufacture corporations achieve a higher speed record and expect to attain 1000 km/h by 2021 using hyperloop one technology. Moving at such a high speed results in a high handover rate which makes it challenging for high speed railway (HSR) mobile wireless communication to preserve steady link performance. Employing distributed antenna systems (DASs) along with the two-hop architecture, this paper proposes a fast predictive handover algorithm. In this strategy, the serving cell starts the handover preparation phase in advance by inferring the train's current location. Issuing the handover preparation phase in advance reduces the handover latency and handover command failure probability as well. Lower handover command failure probability means lower handover failure probability which could greatly improve the end-users' quality of services (QoS). The analytical results show that the proposed scheme outperforms the conventional handover scheme.

Designing of Wireless Multimedia Sensor Network (WMSN) routing protocols limited by conventional sensor network protocols. They have been designed for scalar data such as sensor data; which is small in size compared to multimedia data. The addressed challenges were the motivation to design mobile reliable routing protocol based on greedy routing structure. In this paper, we propose a new routing protocol for greedy forwarding based on throughput energy aware multi-path routing protocol(GFTEM), which is based on selection of next hop node that has the highest throughput and closer to destination node. GFTEM performance is seen and compared against Ad hoc on-demand distance vector routing protocol (AODV), Dynamic MANET on-demand routing protocol(DYMO) and greedy perimeter stateless routing for wireless networks (GPSR). The OMNET++ simulator has been used to study the behavior of the protocols in terms of end-to-end delay, packet error rate and residual energy. The protocols has been tested under various sensor node speed and the simulations demonstrate that GFTEM has better end-to-end delay, packet loss ratio, with good energy efficiency compared to GPSR, AODV, DYMO routing protocols.

High-speed trains have become one of the most leading transportation means, where each year the manufacture companies reach a new speed record. This progressive speed records increase the handover (HO) rate which makes it very difficult for high speed railway (HSR) mobile communication to sustain a reliable communication link. Utilizing distributed antenna systems (DASs) along with the two-hop architecture, this paper analyzes the conventional handover scheme based on this architecture and proposes a faster HO strategy. The proposed scheme reduces the HO latency and failure probability which could greatly improve the end-users quality of services (QoS). The analytical results show that the proposed scheme performs better than the conventional HO scheme.

High-speed railway (HSR) has witnessed a huge growth globally, and now is reaching a maximum speed of 575 km/h. This record of speed makes mobile communications difficult for HSR since the handover (HO) frequency increases which results in a high loss of connectivity. Based on distributed antenna systems (DASs), this paper utilizes the two-hop network architecture for HSR broadband wireless communication systems. With the target of achieving high system capacity, superior transmission reliability, and consequently high-quality broadband wireless communication service for passengers in HSR. Moreover, a Frequency Switch (FSW) scheme is proposed for the two-hop network architecture to alleviate the frequent HO issue in traditional HSR wireless communication systems where HO generally happens between the successive remote antenna units (RAUs) connecting to the same central unit (CU) control. The FSW scheme provides mobility robustness signalling process that guarantees a successful frequency switching instead of HO, and reduces the probability of radio link failure (RLF) compared to HO process in traditional HSR systems, where the HO failure (HOF) rate is about 21%. The analytical results show that the proposed scheme outperforms traditional HO schemes.

Background: Ultrasound guidance for continuous femoral perineural catheters may be supplemented by electrical stimulation through a needle or through a stimulating catheter. The authors tested the primary hypothesis that ultrasound guidance alone is noninferior on both postoperative pain scores and opioid requirement and superior on at least one of the two. Second, the authors compared all interventions on insertion time and incremental cost. Methods: Patients having knee arthroplasty with femoral nerve catheters were randomly assigned to catheter insertion guided by: (1) ultrasound alone (n = 147); (2) ultrasound and electrical stimulation through the needle (n = 152); or (3) ultrasound and electrical stimulation through both the needle and catheter (n = 138). Noninferiority between any two interventions was defined for pain as not more than 0.5 points worse on a 0 to 10 verbal response scale and for opioid consumption as not more than 25% greater than the mean. Results: The stimulating needle group was significantly noninferior to the stimulating catheter group (difference [95% CI] in mean verbal response scale pain score [stimulating needle vs. stimulating catheter] of −0.16 [−0.61 to 0.29], P < 0.001; percentage difference in mean IV morphine equivalent dose of −5% [−25 to 21%], P = 0.002) and to ultrasound-only group (difference in mean verbal response scale pain score of −0.28 [−0.72 to 0.16], P < 0.001; percentage difference in mean IV morphine equivalent dose of −2% [−22 to 25%], P = 0.006). In addition, the use of ultrasound alone for femoral nerve catheter insertion was faster and cheaper than the other two methods. Conclusion: Ultrasound guidance alone without adding either stimulating needle or needle/catheter combination thus seems to be the best approach to femoral perineural catheters.

Background: Terminal QRS complex distortion on admission electrocardiography (ECG) has been used to estimate the final infarct size and the prognosis after acute coronary syndrome (ACS); however, it is not sure whether the QRS distortion is more reliable for predicting the severity of coronary artery lesions or not. The Aim of the Work: The aim is to analyze the admission ECG in ACS based on abnormality observed in the terminal QRS complex distortion and ST-segment and its relation to coronary artery lesion severity. Patients and Methods: We included 150 patients presented with ACS. Patients were divided according to the presenting ECG in two major groups, 120 patients presented with ST-segment elevation myocardial infarction (STEMI) who were classified into two groups according the presence or absence of the QRS distortion: 42 patients with +ve QRS distortion (Group I) and 78 patients with −ve QRS distortion (Group II), and 30 patients presented with non-ST-segment elevation (NSTE)-ACS who were also further classified according the magnitude of ST shift by millimeter into three groups. All patients underwent primary percutaneous coronary intervention, and Gensini score defined the severity of coronary artery lesions. Results: In this study, in STEMI patients groups, we observed that QRS distortion on admission, ECG has a significant relationship with high Gensini score values, whereas in NSTE-ACS patients, we demonstrated no significant difference between the extents of ST-segment shift and Gensini score values. Conclusion: QRS distortion has a significant value in predicting severe coronary artery lesions in STEMI patients while the extent of ST-segment shift has no benefits in predicting the severity of coronary artery lesion in NSTE-ACS patients.

Objectives: Contrast-induced nephropathy is one of the most common adverse side effects in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Serum cystatin C level is a biomarker of the renal function test. We aimed to compare the degree of renal dysfunction in transradial primary PCI versus transfemoral primary PCI and to use of serum cystatin C as a predictor of contrast-induced nephropathy. Methods: This study included 90 patients who were admitted to the hospital with STEMI and who underwent a primary PCI and they were divided into Group I (45 patients): a primary PCI via femoral approach and Group II (45 patients): a primary PCI via radial approach. We estimated both serum cystatin C and serum creatinine after 72 h of primary PCI. Results: Serum cystatin C level post-PCI had high sensitivity results in correlation with CIN and non-CIN groups. Further, the significant effects were found in all patients in association with serum cystatin C before and after PCI. The cutoff value of serum cystatin C with receiver operating characteristic curve analysis before PCI was 1.1 mg/dL and after PCI was 1.3 mg/dL. Conclusion: The transradial approach for a primary PCI is an effective and safe approach alternative to the femoral approach. Serum cystatin C is a biomarker and a predictor of the occurrence of contrast-induced nephropathy in STEMI patients who underwent a primary PCI and is one of the most sensitive renal markers regarding CIN in comparison to serum creatinine level.

BACKGROUND Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN A randomised, controlled trial. SETTING Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall α of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P

Background and Aims: Early discovery of diabetic heart disease is a dignified mission. Classic echocardiographic method is not sensitive to detect subclinical early LV systolic dysfunction. Early deleterious effects of DM on LV systolic function appeared longitudinally by speckle tracking. We aimed to uncover the determinants of deleterious effects of DM on the myocardium using echocardiographic indices, considering the duration of DM as well as the state of DM control. Methods and Results: 52 diabetic patients were enrolled in two groups (Group I; uncontrolled DM with HbA1c ≥ 6.5%) and group II; controlled DM with HbA1c5 years or 5 years (-15.7i‚±2.8%). (t=8.9, p=0.05). Conclusion: The duration of DM is strongly correlated with reduction of GLS and elevation of LV filling pressure. Poor glycemic control (HbA1c>6.5%), leads to reduction in LV GLS, which is associated with preclinical LV dysfunction and elevated LV filling pressure.

A more posterior approach for abdominal wall blocks was described by Dr. Blanco as Quadratus Lumborum (QL) block. We performed the first reported transmuscular QL block using liposomal bupivacaine. We are describing the technique we used as well as other approaches used for QL block. This case report showed that QL block using a single dose of Liposomal Bupivacaine provided a sensory level and analgesia for 2 days. Our limited experience shows that this new type of block can prolong the analgesia along mid and lower thoracic dermatomes. to quadratus lumborum (QL) muscle has been sought for to potentially provide the patients with more visceral blockade and thus better analgesia [2,3]. Moreover, the effective period of this block can be prolonged by using liposomal bupivacaine [4]. This is the first report demonstrating injection of liposomal bupivacaine for a QL block. Description of the Case Institutional Review board of Cleveland Clinic waived written consent since there was no patient identifying information. The patient was a 32-year-old male with body mass index of 21.07 kg/m2 who was scheduled for a subtotal colectomy in the setting of ulcerative colitis. The surgery was scheduled to be performed through a midline incision extending from above the umbilicus to pubic symphysis. Preoperatively, our acute pain management service was consulted. The patient was initially offered an epidural catheter, which he refused due to previous ineffective analgesia. Thereafter, TAP and QL blocks were offered to the patient and the risks and benefits were explained. It was also explained to the patient that QL blocks and Liposomal bupivacaine use are not investigated thoroughly yet. The patient expressed understanding and agreed to proceed with the proposed set of blocks. The patient subsequently received a left QL (trans-muscular approach, type 3) and a right TAP single shot block for postoperative pain control to allow the right side to serve as a “control”. The blocks were performed in the induction room, with routine monitoring and midazolam (2 mg IV) sedation. The patient was initially placed in right lateral decubitus position. After sterile prepping and draping, a low frequency (2-5 MHz) curved array ultrasound transducer (Mindray, Nanshan, Shenzhen, China) covered in sterile plastic sheath was placed in the anterior axillary line between the subcostal margin and the

Fluid management is a crucial issue for patients undergoing major orthopedic surgery, in which large blood loss, transfusions, fluid shifts, and high incidence of postoperative complications are important concerns. Fluid balance is a major contributing factor to postoperative morbidity and mortality. Persistent hypovolemia is associated with organ hypoperfusion, systemic inflammatory response syndrome, sepsis, and multiple organ failure. Fluid overload, on the other hand, is associated with edema, ileus, postoperative nausea and vomiting, pulmonary complications, and increased cardiac demands