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Systemic therapy is a key management component of pancreatic ductal adenocarcinoma(PDAC). Racial disparities exist in PDAC, often linked to socioeconomic variables. We investigated the impact of race in PDAC patients who had undergone systemic therapy and surgical resection.A retrospective analysis was performed for all patients who underwent surgical resection for PDAC from 2010 to 2018.234 patients (78.2% White; 21.8% Black) were included. Black patients presented at a younger age with larger tumors. White patients benefited from systemic therapy with longer overall survival (35vs20 months, p = 0.002). This survival advantage was not present in Black patients (21vs15 months, p = 0.15). Black patients receiving systemic therapy had similar survival as White patients who did not (p = 0.81).Black PDAC patients present at younger ages and with larger initial tumors. In our population, White patients had a longer overall survival after both surgical and systemic therapy. These findings may indicate differences in tumor biology. Further prospective studies are needed.

Background: Physical therapy is playing an important role in enhancing and promoting health related quality of life in children with thalassemia and sickle cell disease by de-creasing the associated disease symptoms as pain, anxiety, depression and fatigue and enhancing the cardiopulmonary system, bone mass index, ferritin and serum levels by using different physical therapy modalities as exercise training, Yoga, Massage therapy, transcutaneous electrical nerve stim-ulation (TENS), spirometer and vibration therapy. Aim of Study: To identify the effectiveness of using physical therapy modalities in children with thalassemia and sickle cell disease. Subjects and Methods: This review included Children with thalassemia and sickle cell disease aged between 6 to 18 years, receive different physical therapy modalities. Design: A search of electronic databases that included, PubMed, Physical therapy Evidence Database, Google scholar, Science Direct and Cochrane was searched since ever till December 2019 using the following keywords: 'Physical therapy modalities', 'thalassemia', 'exercise training', 'sickle cell disease', 'breathing exercise', 'health related quality of life', 'transcutaneous electrical nerve stimulation' and 'children'. Results: Twelve articles that were retrieved met the inclusion criteria. Conclusion: From clinical point of view using physical therapy modalities can promote quality of life in children suffering from thalassemia and from sickle cell disease but furthermore studies are needed to help the researchers and the patients.

Tourniquet is a well-established model of hind limb ischemia–reperfusion (HLI/R) in rats. Nevertheless, measures should be taken to alleviate the expected injury from ischemia/ reperfusion (I/R). In the present study, 30 adult male Sprague-Dawley rats were randomly divided into 5 groups (n = 6): control, HLI/R, HLI/R given candesartan (1 mg/kg, P.O); HLI/R given Coenzyme Q10 (CoQ10) (10 mg/kg, P.O); HLI/R given candesartan (0.5 mg/kg) and CoQ10 (5 mg/kg). The drugs were administered for 7 days starting one hour after reperfusion. Candesartan and CoQ10 as well as their combination suppressed gastrocnemius content of angiotensin II while they raised angiotensin-converting enzyme 2 (ACE2) activity, angiotensin (1–7) expression, and Mas receptor mRNA level. Consequently, candesartan and/or CoQ10 reversed the oxidative stress and inflammatory changes that occurred following HLI/R as demonstrated by the rise of SOD activity and the decline of MDA, TNF-α, and IL-6 skeletal muscle content. Additionally, candesartan and/or CoQ10 diminished gastrocnemius active caspase-3 level and phospho-p38 MAPK protein expression. Our study proved that CoQ10 enhanced the beneficial effect of candesartan in a model of tourniquet-induced HLI/R by affecting classical and non-classical renin-angiotensin system (RAS) pathway. To our knowledge, this is the first study showing the impact of CoQ10 on skeletal muscle RAS in rats.

Cefepime belongs to the fourth generation cephalosporin family of antibiotics, it showed side effects such as nephrotoxicity and neurotoxicity. However little reports showed its hepatotoxic effects. The aim of the current study was to evaluate cefepime-induced hepatotoxicity and its associated histopathological changes in the liver. Also, it aimed to examine the effects of cefepime treatment on the proinflammatory cytokines as well as the protective and recovering roles of vitamin C against the cefepime-induced effects. . Blood samples were collected and the liver enzymes in serum ALT, AST and Total Bilirubin (T. Bil.) were estimated biochemically; liver tissues were collected and divided into two parts: the first part were fixed for histopathological examination by H&E staining whereas the other part was processed for RNA extraction and further for real time PCR examination of the mRNA expression of IL1β and TNFα. Cefepime could significantly increase the concentration of ALT, AST, T. Bil. as well as the mRNA expression of proinflammatory cytokines IL1β and TNFα; histopathological changes in the form of hepatic lobules distortion, marked degeneration, hepatocellular vacuolation and necrosis, nuclear pyknosis, scattered apoptosis, distortion of portal areas and marked fibrosis were observed after two weeks of cefepime administration; co- administration of vitamin C with cefepime or administration administering it for 7 days after cefepime could successfully improve the levels of ALT, AST, T. Bil., histopathological and mRNA expression of IL1β and TNFα. The current study suggested that cefepime has hepatotoxic effects shown as alternation of the liver enzymes, changing in the histopathological features as well as stimulating the inflammation in the liver tissue. Vitamin C can be used as a protective or recovering drug against cefepime-induced hepatotoxicity.

Background Postoperative hemorrhage is a potential complication of tonsillectomy, and early diagnosis and adequate management are mandatory to prevent hemorrhagic shock. The aim of this study was to assess the safety and efficacy of transcatheter embolization of recurrent post-tonsillectomy hemorrhage by using N-butyl 2-cyanoacrylate. Results We performed a retrospective analysis of the medical records, imaging findings, technical details, and clinical outcome of eight patients with delayed post-tonsillectomy hemorrhage who underwent endovascular embolization. All patients were followed up; technical and clinical successes of treatment were evaluated. All patients had arterial pseudoaneurysm as a source of bleeding. The injured artery was facial artery in four patients, lingual artery in three patients, and linguofacial trunk in one patient. All lesions were treated by endovascular embolization using NBCA glue. All patients were successfully embolized with no clinical complications. In one patient with pseudoaneurysm at the ostium of the facial artery, after filling the pseudoaneurysm with glue, inadvertently proximal reflux into the adjacent part of the external carotid artery (ECA) occurred leading to its occlusion with no related immediate or delayed complication. Conclusion Endovascular embolization is an effective and almost safe procedure in the management of recurrent post-tonsillectomy bleeding. In such cases, we can use NBCA glue with certain precautions as an effective appropriate embolizing agent.

The clinical link among diabetes, obesity, and thyroid dysfunction is of interest. Hence, medical records of 601 patients with diabetes, obesity, and thyroid dysfunctions at the Abha Specialist Center and Military Diabetic Endocrine Center we used in this analysis. Approximately 28% of diabetic patients had thyroid dysfunction, and 12.4% were vitamin D deficient. The patients with thyroid dysfunction had significantly elevated triglyceride levels compared to the patients without thyroid dysfunction (173.6 vs. 128. p=0.009). Vitamin D deficient obese patients were significantly younger (33.99±10.69 vs. 43.68±14.42; p

Background Serologic and anthropometric measures are commonly used as surrogate markers of nutritional status in clinical practice. In 2012, leading dietetic organizations published a standard definition of malnutrition based on clinical characteristics. We hypothesize that surrogate markers underrecognize clinical malnutrition and do not accurately identify patients at risk for adverse outcomes. Methods A single-institution cohort study of elective surgical inpatients from August 2015 to November 2017. Nutritional assessment was completed by trained registered dietitians using leading dietetic guidelines. Multivariable logistic regression was used to determine the association between malnutrition and perioperative outcomes. Results Among 953 elective surgical admissions, 456 underwent full clinical nutritional assessment. Of these, 202 (44.3%) met malnutrition criteria. In addition, 20.3% of patients with clinical malnutrition were underweight ( Conclusion In this cohort of elective surgical patients, traditional markers failed to identify malnutrition in a substantial portion of patients who met clinical malnutrition criteria. Clinical malnutrition assessment is effective in identifying patients who may be at risk for suboptimal outcomes. Surgeons should implement clinical nutritional assessment and factor that information into their preoperative evaluation and management of elective surgical patients.

Background Pelvic congestion syndrome (PCS) is a problematic cause of chronic pelvic pain in women. It is thought to result from venous insufficiency of either ovarian or pelvic veins. Patients also present a variety of symptoms including dysuria and dyspareunia as well as vulva and buttock varicosities. The aim of this study is to evaluate the efficacy of multi-detector CT (MDCT) in diagnosis of PCS. Two hundred patients were included in our study and underwent CT venography of the abdomen and pelvis. Results We performed a prospective comparative study conducted on 200 patients. Thirty patients (15%) were diagnosed as PCS. There were congestion of the ovarian venous plexus and uterine venous engorgement in all patients. Filling of the veins across the midline was noted in 10 patients and filling of the vulval and thigh varicosities was noted in 3 patients. Ten patients had right ovarian vein dilatation; 12 patients had left ovarian vein dilatation; while 8 patients had bilateral ovarian vein dilatation. The right ovarian vein mean diameter (± SD) = 7.1 ± 0.8 mm; while the left ovarian vein mean diameter (± SD) = 7.6 ± 1 mm. Left ovarian venous reflux was found in 6 cases while no pathological reflux depicted on right side. Conclusions CT venography is considered as one of the initial investigations for the diagnosis of PCS in female patients with chronic pelvic pain making the further assessment by ovarian venography is for interventional management of diagnosed cases.

Background and objectives The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries. We present a straightforward method using statistical process control to study the progression and efficacy of AIR. Methods This study represents a retrospective review of all anonymous incident reports and surgical critical events from 2012 to 2017 at a single-institution, 500-bed, university-based, metropolitan Veterans Affairs Administration Medical Center located in Texas. This work was approved by the Veterans Administration Quality Board and deemed to be an appropriate quality improvement project. This project did not require institutional review board approval. Results There was an exponential increase in AIRs in the first 15 months from 1 report per month to 168 reports in the ninth month (1425% increase). The results then plateaued over time (first year: 1017, second year: 1634, and third year: 1938-common-cause variation). A logarithmic regression was performed for progression of AIRs per month yielding the equation y = -7E-13ln(x) + 142.92, Pearson Correlation Coefficient = 0.55, where y represents number of reports and x time by month. The highest number of Critical Incident Tracking Notification System (CITNS) reports was observed early in the self-reporting process and decreased over time (first year: 5, second year: 2, third year: 1, fourth year: 1, and fifth year: 0). The numbers of AIR and CITNS reports were found to be inversely related with a Pearson correlation coefficient of -0.4. Conclusions Statistical process control can be applied to an institution's AIR program to study progression and situational awareness.

Background Vitiligo is a depigmentary skin disfigurement resulting from destruction of melanocytes caused by a possible malfunctioning immunity. This destruction could be linked to an aberrant T-cell-mediated immune response. Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and programmed death-1 (PD-1) are immune checkpoints capable of downregulating T-cell immune functions. Objectives To evaluate the pattern of expression of PD-1 and CTLA-4 in active vitiligo skin. Methods Thirty nonsegmental vitiligo (NSV) patients had been included in this pilot study. Marginal, lesional, and nonlesional skin biopsies were obtained. PD-1 and CTLA-4 immunohistochemistry expression in the mononuclear inflammatory infiltrates were evaluated using digital images. Results The marginal and lesional inflammatory infiltrates were significantly abundant when compared to nonlesional ones. The marginal infiltrates were significantly abundant when compared to the lesional ones. PD-1 and CTLA-4 were significantly expressed in the marginal and lesional infiltrates when compared to nonlesional skin. Moreover, the marginal expression of PD-1 was significantly higher than the lesional expression. However, no similar significant difference in CTLA-4 expression was found between the marginal and lesional infiltrates. Significant positive correlations were found between the expressions of PD-1 and CTLA-4 in marginal and lesional infiltrates. Conclusion Programmed death-1 and CTLA-4 are expressed within the inflammatory infiltrate of active NSV. Further studies are required to confirm their significance in the development or limitation of the disease.

Introduction Adapting Project Re-Engineered Discharge (Project RED), an intervention for reducing internal medicine hospital readmissions, is a promising option for reducing colorectal surgery readmissions. Methods We conducted a pilot study for the adaptation and implementation of Project RED with patients admitted for colectomy at a regional VA tertiary care center between July 2014 and January 2015. Implementation was evaluated using adherence to intervention components and results from the Survey of Healthcare Experiences of Patients. The adapted Project RED for Surgery has five components: surgical wound/ostomy-care education, scheduled follow-up appointments, medication reconciliation, an After Hospital Care Plan, and postdischarge phone calls. Results All (n = 21) participants received postoperative wound care education, and 77% of ostomy patients received education. Follow-up appointments were scheduled for 76% with surgery clinic and 67% with primary care. Half received pharmacist-led medication reconciliation. Seventy-five percent received a postdischarge phone call. Ninety five percent of participants reported positive or satisfactory care transitions versus less than 60% of a comparison group of surgery patients from the same institution. We summarized lessons learned from this intervention study to facilitate future dissemination efforts. Conclusion The lessons learned from this pilot can guide quality improvement teams seeking to implement the Re-Engineered Discharge for Surgery intervention within their existing workflows.

Endothelial dysfunction, characterized by reduced bioavailability of nitric oxide and increased oxidative stress, is a hallmark characteristic in diabetes and diabetic nephropathy (DN). High levels of asymmetric dimethylarginine (ADMA) are observed in several diseases including DN and are a strong prognostic marker for cardiovascular events in patients with diabetes and end-stage renal disease. ADMA, an endogenous endothelial nitric oxide synthase (NOS3) inhibitor, is selectively metabolized by dimethylarginine dimethylaminohydrolase (DDAH). Low DDAH levels have been associated with cardiac and renal dysfunction, but its effects on DN are unknown. We hypothesized that enhanced renal DDAH-1 expression would improve DN by reducing ADMA and restoring NOS3 levels. DBA/2J mice injected with multiple low doses of vehicle or streptozotocin were subsequently injected intrarenally with adenovirus expressing DDAH-1 (Ad-h-DDAH-1) or vector control [Ad-green fluorescent protein (GFP)], and mice were followed for 6 wk. Diabetes was associated with increased kidney ADMA and reduced kidney DDAH activity and DDAH-1 expression but had no effect on kidney DDAH-2 expression. Ad-GFP-treated diabetic mice showed significant increases in albuminuria, histological changes, glomerular macrophage recruitment, inflammatory cytokine and fibrotic markers, kidney ADMA levels, and urinary thiobarbituric acid reactive substances excretion as an indicator of oxidative stress, along with a significant reduction in kidney DDAH activity and kidney NOS3 mRNA compared with normal mice. In contrast, Ad-h-DDAH-1 treatment of diabetic mice reversed these effects. These data indicate, for the first time, that DDAH-1 mediates renal tissue protection in DN via the ADMA-NOS3-interaction. Enhanced renal DDAH-1 activity could be a novel therapeutic tool for treating patients with diabetes.

Aim The aim of this study to assess the surgical presentation and outcome for bullous lung disease in Sudanese patients. Method A cross sectional hospital based descriptive retrospective study. Procedures were conducted at Al-Shaab Teaching Hospital Sudan during the period from November 2009 to September 2012. Results 11 patients had lung bullae in the given period. Smoking does not play an important role in the development of bullae in healthy young adults in our patients. Vanishing Lung syndrome (VLS) was seen in 18% of patients without history of smoking. The patients presenting in the fifth decade of life constituted (36.3%) of total number. symptoms of presentation were chest pain and SOB and half of them (45.5%) had exertional dyspnoea. The duration of symptoms before presentation was more than 2 months. Asthma was the only respiratory disease associated seen in 45%. HBV and HTN were the most associated diseases seen in 27% and 18% respectively without significant findings in the history. The diagnosis was made by highresolution CT. Chest in all patients. Bullectomy was done to majority of patients. Muscle sparing thoracotomy is the standard approach (Posterolateral Thoracotomy). improved regarding symptoms and signs (90.9%) and) and no death reported. Conclusions Bullous lung disease with bilateral lung involvement is common in our patients. However, there was no association between lung bullae and smoking in our population. lt's associated with other respiratory disease. The outcome was excellent, and no death was reported. To prevent the miss diagnosis we need sensitive and noninvasive investigation tools.

Introduction Non-alcoholic fatty liver disease (NAFLD) is becoming more prevalent. The investigations used to diagnose NAFLD include FIB-4 score, NAFLD score and AST/ALT ratio (AAR). Gold-standard for diagnosis is liver biopsy. Bariatric surgery reduces steatosis and fibrosis in NAFLD patients. However, in undiagnosed NAFLD, it can lead to worsening fibrosis and decompensation of cirrhosis, causing complications. The aim is to identify how well bariatric patients are being screened for NAFLD pre-operatively. Method Database analysis was conducted in the bariatric clinics at Royal Derby Hospital and analysed using SPSS. Results 392 patients’ data (Overall group) were analysed and compared with those who had an AAR>1 (Abnormal group). Abnormal group had a higher mean AAR, NAFLD and FIB-4 scores. Surprisingly, ALT and AST levels were higher in Overall group compared to Abnormal. Generally, patients were not pre-operatively checked sufficiently (81.9% LFTs, 62.2% ASTs). Conclusions A large number of patients could have undiagnosed NAFLD due to the lack of LFT/AST checks as ALT scores alone would miss fibrosis. Using AAR>1 and FIB-4 would allow clinicians to detect fibrosis earlier to carry out non-invasive diagnostic measures, avoiding unnecessary biopsies. Early diagnosis means patients undergoing bariatric surgery with possible cirrhosis will not experience decompensation and associated complications.

Background: The advantages of Unilateral Spinal An-esthesia (ULSA) over bilateral spinal anesthesia are less doses, cardiovascular side effects, and hospitalization. Femoral/Sciatic Nerve Block (FSNB) may decrease post-operative pain, nausea and vomiting, length of stay, surgical stress, morbidity and mortality and may improve mobilization and recovery of gastrointestinal function.Aim of Study: The aim of this study is to compare ULSA versus FSNB by Ultrasound (US) guided as anesthetic tech-nique for cases undergoing elective lower limb surgery.Material and Methods: This prospective randomized study was carried out on 60 adult educated patients, aged 18:60, of both sex, ASA I-II and scheduled for lower limb surgery at Tanta University Hospitals. Patients were randomized into 2 equal groups (30 patients in each); Group-I: ULSA and Group-II: US guided FSNB. Mean Arterial Blood Pressure (MAP) and Heart Rate (HR) were recorded before block and every 15min intraoperative and at 30, 60min, 2, 3, 4, 6 and 12h post-operative. Onset and duration of both sensory and motor block, the first time for need of rescue analgesia (morphine) and Visual Analogue Scale (VAS) at rest and with activity (at 0, 1, 2, 3, 4, 6 and 12hr) were recorded. Patient and surgeon satisfaction and any post-operative side effect were recorded.Results: Onset of sensory and motor block was signifi-cantly shorter in ULSA, but the duration of sensory and motor block was prolonged in FSNB with delayed first dose of analgesic. Intraoperative HR and MAP showed insignificant difference and post-operative significant increase in ULSA. VAS at activity showed earlier need for rescue analgesic in ULSA. There was no significant difference in surgeon and patient satisfaction with minimal side effects.Conclusion: Both ULSA with 2ml heavy bupivacaine 0.5% given slowly over one minute and US guided FSNB using combination of 0.25% bupivacaine and 1% lidocaine resulted in comparable adequate intraoperative anesthesia, stable hemodynamics and adequate surgeon and patient satis-faction with minimal side effects. US guided FSNB was superior to ULSA in post-operative analgesia.

Background Postoperative bleeding complications are associated with less favorable outcomes in cardiac surgery and contribute to excessive overall healthcare costs. HEMOBLAST (Biom'up, Lyon, France) (HB) is a novel ready-to-use hemostatic powder that consists of porcine collagen, bovine chondroitin sulfate, and human pooled plasma thrombin that may help reduce surgical bleeding. Aims The aim of this study was to describe the techniques of application for this new combination powder-based hemostat, HB, and demonstrate its use employing photographs of application methods during cardiac procedures. Materials and methods The initial 24 procedures in which HB was used at our institution included: left ventricular assist device (LVAD) insertions, lung transplants, heart transplants, aortic valve replacements, coronary artery bypass grafting, and mitral valve repair. Results Hemostasis was achieved in all cases and there were no instances of mediastinitis, sternal infections, allergic reactions, or 30-day mortality. Discussion This report describes the best methods of application of HB including use for treatment of mediastinal bleeding in a re-operative procedure in a patient on antiplatelet agents and sternal bleeding during an LVAD insertion. Proper application can facilitate excellent hemostasis using this powder. Conclusion HB is a novel powder-based multiple component hemostatic agent that promotes focal or large area hemostasis. We have presented the techniques of use that are important to the successful application of HB to facilitate hemostasis.

BACKGROUND: Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature. PURPOSES: We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care. METHODS: This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models. RESULTS: The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care. CONCLUSIONS: Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09685-z) contains supplementary material, which is available to authorized users.

Recently we showed that homoarginine supplementation confers kidney protection in diabetic mouse models. In this study we tested whether the protective effect of homoarginine is nitric oxide synthase‐3 (NOS3)‐independent in diabetic nephropathy (DN). Experiments were conducted in NOS3 deficient (NOS3−/−) mice and their wild type littermate using multiple low doses of vehicle or streptozotocin and treated with homoarginine via drinking water for 24 weeks. Homoarginine supplementation for 24 weeks in diabetic NOS3−/− mice significantly attenuated albuminuria, increased blood urea nitrogen, histopathological changes and kidney fibrosis, kidney fibrotic markers, and kidney macrophage recruitment compared with vehicle‐treated diabetic NOS3−/− mice. Furthermore, homoarginine supplementation restored kidney mitochondrial function following diabetes. Importantly, there were no significant changes in kidney NOS1 or NOS2 mRNA expression between all groups. In addition, homoarginine supplementation improved cardiac function and reduced cardiac fibrosis following diabetes. These data demonstrate that the protective effect of homoarginine is independent of NOS3, which will ultimately change our understanding of the mechanism(s) by which homoarginine induce renal and cardiac protection in DN. Homoarginine protective effect in DN could be mediated via improving mitochondrial function., Our results indicate that homoarginine mediates renal and cardiac protection in diabetic NOS3‐/‐ mice which will ultimately change our understanding of the mechanism(s) by which homoarginine ameliorate diabetic kidney injury. Homoarginine protective effect in diabetic nephropathy could be mediated via improving mitochondrial function.

Background Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues’ experiences and published evidence. Methods In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

Modern cardiac surgery requires many devices for diagnostic and therapeutic uses. Temporary pacemakers are external artificial conduction systems that are used for diagnostic purposes, management of rhythm disturbances that may occur immediately after separation of cardiopulmonary bypass, or prophylaxis postoperatively. Cardiogenic shock in the perioperative period has high in-hospital mortality, and short-term mechanical circulatory support devices are valuable in the management of this life-threatening condition. Postcardiotomy low cardiac output syndrome is a form of cardiogenic shock that occurs after cardiac surgery. For the management of this syndrome, the intra-aortic balloon pump, which provides internal counter pulsation to augment diastolic pressure and increase coronary circulation, with reduction in myocardial work, is a valuable assist. Extracorporeal membrane oxygenation can provide respiratory or cardiac output support or both. Miniature axial flow ventricular assist devices are newer technologies used for circulatory support of the postcardiotomy failing heart.

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Narrowband-ultraviolet B (NB-UVB) is considered one of the main therapeutic tools in vitiligo, which is able to induce repigmentation and halt depigmentation. However, little remains known about the effect of NB-UVB on TYR gene family, the main pigmentary genes, in vitiligo patients. To assess the effect of NB-UVB on expression of some genes related to the pigmentary problem of vitiligo; tyrosinase (TYR), tyrosinase related protein 1 (TYRP1) and tyrosinase related protein 2 (TYRP2), mRNA levels of those genes were quantitatively evaluated by Real-Time quantitative Polymerase Chain Reaction (RT-qPCR) in skin biopsies obtained from 30 patients with nonsegmental vitiligo and five healthy controls. Vitiligo patients were classified into two groups; group 1, involving 12 untreated vitiligo patients and group 2, including 18 vitiligo patients treated by NB-UVB. The levels of TYR, TYRP-1, and TYRP-2 mRNAs in untreated group were significantly lower than in control subjects (P < .001). In NB-UVB treated group, the three genes were significantly higher than in group 1 (P < .001), however, they were still significantly lower than in the control subjects (P < .001). A significant positive correlation was detected between TYR and TYRP-2 genes in group 2 (P = .03). This study demonstrated that mRNA level of TYR, TYRP-1, and TYRP-2, which decreased in vitiligo, was significantly increased upon treatment with NB-UVB. Accordingly, the mechanism of depigmentation in vitiligo disease and repigmentation by NB-UVB treatment may be related to the changes in the expression of these genes.

New-onset DM or unmasking existing one, with or without metabolic complications, has been reported in SARS CoV-2 infection. New-onset DM in association with HHS alone or combination with DKA is uncommon but a possible manifestation of SARS CoV-2 infection that poses management challenges where the outcome may be worst.

The novel coronavirus disease (COVID-19) is a global public health emergency that has impacted medical professionals, infrastructures and the care of patients with gynecological malignancies The pandemic has also caused disruption to research and clinical trials worldwide We conducted a Survey within the Pan-arabian Region to evaluate the impact of the COVID-19 Pandemic on the management of patients with gynecological malignancies from the multidisciplinary physicians' perspective, with particular focus on clincial infrastructures, trial participation and maintenance therapy The survey is designed to capture the dynamic changes observed with the development of the pandemic in order to build robust emergency algorithms tailored to gynecological oncology patients globally in the future

Fibrosis is the final common pathway in the pathophysiology of most forms of chronic kidney disease (CKD). As treatment of renal fibrosis still remains largely supportive, a refined understanding of the cellular and molecular mechanisms of kidney fibrosis and the development of novel compounds are urgently needed. Whether arginases play a role in the development of fibrosis in CKD is unclear. We hypothesized that endothelial arginase-2 (Arg2) promotes the development of kidney fibrosis induced by unilateral ureteral obstruction (UUO). Arg2 expression and arginase activity significantly increased following renal fibrosis. Pharmacologic blockade or genetic deficiency of Arg2 conferred kidney protection following renal fibrosis, as reflected by a reduction in kidney interstitial fibrosis and fibrotic markers. Selective deletion of Arg2 in endothelial cells (Tie2Cre/Arg2fl/fl) reduced the level of fibrosis after UUO. In contrast, selective deletion of Arg2 specifically in proximal tubular cells (Ggt1Cre/Arg2fl/fl) failed to reduce renal fibrosis after UUO. Furthermore, arginase inhibition restored kidney nitric oxide (NO) levels, oxidative stress, and mitochondrial function following UUO. These findings indicate that endothelial Arg2 plays a major role in renal fibrosis via its action on NO and mitochondrial function. Blocking Arg2 activity or expression could be a novel therapeutic approach for prevention of CKD., Endothelial-arginase-2 plays a major role in renal fibrosis via its action on nitric oxide and mitochondrial function.

This study describes the incidence of catheter-associated urinary tract infections in a large academic medical center and shows that even with prevention guideline adherence, catheter-associated urinary tract infections cannot truly be a never event.

Halo nevus (HN) is a rare dermatologic disorder characterized by typical whitish rim surrounding an existing melanocytic nevus resembling halo. It is a cosmetic problem that may be linked to vitiligo, and it is advised to remove these nevi in order to avoid development of vitiligo.The aim of the present study is to evaluate the cosmetic outcome after nevus removal and leukoderma dermabrasion with epithelial graft followed by narrow-band ultraviolet B (NB-UVB) phototherapy as management of resistant halo nevi and avoidance of development of vitiligo.Ten patients with persisting halo nevi were selected as candidates in this study. Superficial dermabrasion was carried out using proper diamond fraises on depigmented rim and then punch biopsy probes with suitable size were used to harvest the nevus. Thiersch graft was prepared and applied on the dermabraded depigmented area. After 1 week of the procedure, patients were exposed to NB-UVB twice weekly and were followed up for 3 months.Repigmentation was noticed in 2 weeks and was nearly fully accomplished in all 10 patients within the 3-month period. No other vitiligo lesions developed during this period in all patients except for one case.Excision of Sutton's nevus with combined dermabrasion and Thiersch grafting followed by phototherapy is a good aesthetic maneuver in treating halo nevi and helps in avoiding further vitiligo depigmentation.

Diabetes is the leading cause of end-stage renal disease, resulting in a significant health care burden and loss of economic productivity by affected individuals. Because current therapies for progression of diabetic nephropathy (DN) are only moderately successful, identification of underlying mechanisms of disease is essential to develop more effective therapies. We showed previously that inhibition of arginase using S-(2-boronoethyl)-l-cysteine (BEC) or genetic deficiency of the arginase-2 isozyme was protective against key features of nephropathy in diabetic mouse models. However, those studies did not determine whether all markers of DN were dependent only on arginase-2 expression. The objective of this study was to identify features of DN that are associated specifically with expression of arginase-1 or −2. Elevated urinary albumin excretion rate and plasma urea levels, increases in renal fibronectin mRNA levels, and decreased renal medullary blood flow were associated almost completely and specifically with arginase-2 expression, indicating that arginase-2 selectively mediates major aspects of diabetic renal injury. However, increases in renal macrophage infiltration and renal TNF-α mRNA levels occurred independent of arginase-2 expression but were almost entirely abolished by treatment with BEC, indicating a distinct role for arginase-1. We therefore generated mice with a macrophage-specific deletion of arginase-1 ( CD11bCre/ Arg1fl/fl). CD11bCre/ Arg1fl/fl mice had significantly reduced macrophage infiltration but had no effect on albuminuria compared with Arg1fl/fl mice after 12 wk of streptozotocin-induced diabetes. These results indicate that selective inhibition of arginase-2 would be effective in preventing or ameliorating major features of diabetic renal injury.

Novel therapeutic interventions for preventing or attenuating kidney injury following ischemia-reperfusion injury (IRI) remain a focus of significant interest. Currently, there are no definitive therapeutic or preventive approaches available for ischemic acute kidney injury (AKI). Our objective is to determine 1) whether renal arginase activity or expression is increased in renal IRI, and 2) whether arginase plays a role in development of renal IRI. The impact of arginase activity and expression on renal damage was evaluated in male C57BL/6J (wild type) and arginase-2 (ARG2)-deficient ( Arg2−/−) mice subjected to bilateral renal ischemia for 28 min, followed by reperfusion for 24 h. ARG2 expression and arginase activity significantly increased following renal IRI, paralleling the increase in kidney injury. Pharmacological blockade or genetic deficiency of Arg2 conferred kidney protection in renal IRI. Arg2−/−mice had significantly attenuated kidney injury and lower plasma creatinine and blood urea nitrogen levels after renal IRI. Blocking arginases using S-(2-boronoethyl)-l-cysteine (BEC) 18 h before ischemia mimicked arginase deficiency by reducing kidney injury, histopathological changes and kidney injury marker-1 expression, renal apoptosis, kidney inflammatory cell recruitment and inflammatory cytokines, and kidney oxidative stress; increasing kidney nitric oxide (NO) production and endothelial NO synthase (eNOS) phosphorylation, kidney peroxisome proliferator-activated receptor-γ coactivator-1α expression, and mitochondrial ATP; and preserving kidney mitochondrial ultrastructure compared with vehicle-treated IRI mice. Importantly, BEC-treated eNOS-knockout mice failed to reduce blood urea nitrogen and creatinine following renal IRI. These findings indicate that ARG2 plays a major role in renal IRI, via an eNOS-dependent mechanism, and that blocking ARG2 activity or expression could be a novel therapeutic approach for prevention of AKI.

Objective:To examine the extent to which multiple, sequential complications impacts variation in institutional postoperative mortality rates.Background:Failure to rescue (FTR) has been proposed as an underlying factor in hospital variation in surgical mortality. However, little is currently known ab

Inflammation is a central pathophysiologic mechanism that contributes to diabetes mellitus and diabetic nephropathy. Recently, we showed that macrophages directly contribute to diabetic renal injury and that pharmacological blockade or genetic deficiency of chemokine (C-C motif) receptor 2 (CCR2) confers kidney protection in diabetic nephropathy. However, the direct role of CCR2 in kidney-derived cells such as podocytes in diabetic nephropathy remains unclear. To study this, we developed a transgenic mouse model expressing CCR2 specifically in podocytes (Tg[ NPHS2-Ccr2 ]) on a nephropathy-prone (DBA/2J) and CCR2-deficient ( Ccr2 -/- ) background with heterozygous Ccr2 +/- littermate controls. Diabetes was induced by streptozotocin. As expected, absence of CCR2 conferred kidney protection after nine weeks of diabetes. In contrast, transgenic CCR2 overexpression in the podocytes of Ccr2 -/- mice resulted in significantly increased albuminuria, blood urea nitrogen, histopathologic changes, kidney fibronectin and type 1 collagen expression, podocyte loss, and glomerular apoptosis after nine weeks of streptozotocin-induced diabetes. Interestingly, there was no concurrent increase in kidney macrophage recruitment or inflammatory cytokine levels in the mice. These findings support a direct role for CCR2 expression in podocytes to mediate diabetic renal injury, independent of monocyte/macrophage recruitment. Thus, targeting the CCR2 signaling cascade in podocytes could be a novel therapeutic approach for treatment of diabetic nephropathy.

l‐homoarginine is an endogenous, non‐proteinogenic amino acid that has emerged as a new player in health and disease. Specifically, low l‐homoarginine levels are associated with cardiovascular diseases, stroke, and reduced kidney function. However, the role of l‐homoarginine in the pathogenesis of diabetic nephropathy (DN) is not known. Experiments were conducted in 6‐week‐old Ins2Akita mice supplemented with l‐homoarginine via drinking water or mini osmotic pump for 12 weeks. Both plasma and kidney l‐homoarginine levels were significantly reduced in diabetic mice compared to nondiabetic controls. Untreated Ins2Akita mice showed significant increases in urinary albumin excretion, histological changes, glomerular macrophage recruitment, the inflammatory cytokine KC‐GRO/CXCL1, and urinary thiobarbituric acid reactive substances (TBARS) excretion as an indicator of oxidative stress, along with a significant reduction in kidney nitrate + nitrite levels compared to control mice at 18 weeks of age. In contrast, l‐homoarginine supplementation for 12 weeks in Ins2Akita mice, via either drinking water or mini osmotic pump, significantly reduced albuminuria, renal histological changes, glomerular macrophage recruitment, KC‐GRO/CXCL1 levels, urinary TBARS excretion, and largely restored kidney nitrate + nitrite levels. These data demonstrate that l‐homoarginine supplementation attenuates specific features of DN in mice and could be a potential new therapeutic tool for treating diabetic patients.

Background: Idiopathic nephrotic syndrome (INS) is a common pediatric disease. Minimal change disease (MCD) is the most common histopathological subtype and usually has good prognosis. However, in less common presentations, INS may have an unusual course that makes renal biopsy a necessity to identify its etiology. Immunoglobulin M (IgM) occasionally deposits in the mesangium and can be seen under immunofluorescence (IF). The role of IgM is controversial in MCD. It is likely associated with less favorable outcomes for MCD. This study aims to investigate the clinical significance of mesangial IgM deposits on the outcome of MCD in a pediatric population. Methods: In this retrospective cohort study, we obtained native kidney biopsy samples from 192 children who were diagnosed with MCD from 2003 to 2014. The samples were divided into groups according to the histopathological deposition of IgM in biopsies under IF. The group for which biopsies showed IgM was labeled as IgM + IF (n = 77), and the group for which biopsies were without IgM was labeled as IgM-IF (n = 115). We reviewed hypertension, hematuria, and estimated glomerular filtration rate (eGFR) at the time of presentation to our institute; response to steroid therapy (remission, dependence, frequent relapses, and resistance) and response after adjuvant immunosuppressive therapy (complete remission, partial remission, frequent relapses, and no response) when indicated; development of chronic kidney disease (CKD) and end-stage renal disease during the course of the disease (ESRD). Results: Our results showed that mesangial IgM deposition in MCD showed significant statistical association with hypertension at the time of presentation (P = .05). There was statistically significant association between the presence of IgM deposition and the development of steroid dependence (P = .05) and CKD during the course of the disease (P = .05). Conclusions: Our study showed that IgM deposition in MCD showed statistical association with hypertension by the time the patient presented to our institute, development of steroid dependence, and CKD. IgM may play a role in MCD. However, we recommend a prospective study to verify the role of IgM in MCD outcomes. Keywords: Nephrotic syndrome, Minimal change disease, IgM, IgM nephropathy

Introduction ― Our previous study cleared that both immunization with Egyptian Schistosoma mansoni schistosomula and therapy with praziquantel were able to induce significant levels of protection against re-infection as compared with immunization or treatment only. Aim ― The current study aimed to evaluate the immunostimulatory activity of schistosomula in naïve mice post injection with schistosomula either alone or with praziquantel to answer the question: can schistosomula be used as immunoadjuvant? Material and Methods ― Ten naïve mice were administered 3 doses of phosphate buffered saline. Ten mice injected with 500 schistosomula at day 0 and at 14th day. Ten mice were administered praziquantel (PZQ) (250 mg/kg body weight).Ten mice injected with schistosomula at day 0 and at 14th day and received PZQ. The levels of IgM and IgG against soluble egg antigen (SEA) and soluble worm antigen preparation (SWAP) were detected by ELISA. Immunophenotyping of mesenteric lymph nodes (MLN) lymphocytes and thymocytes were carried out. Results ― IgM and IgG levels were significantly elevated in sera from mice injected with schistosomula alone or with PZQ or PZQ only. The mean percentage of MLN CD4+, CD8+ T and B lymphocytes were increased but considered not significant. The MLN CD4+/CD8+ T ratios were >1. The mean % of CD4+ and CD8+ thymocytes were increased and the CD4+/CD8+ thymocytes ratios were >1. Conclusion ― Immunostimulatory activity schistosomula was detected by enhancing Igs titers, stimulating the mean % of CD4+, CD8+ T, B-MLN cells and thymocytes CD4+, CD8+ T. CD4+/CD8+ T cells ratios were >1 in MLN and thymus gland.

Severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) infection causes the disease known as coronavirus disease that started in Wuhan (China) in December 2019, leading to the current COVID-19 pandemic. The common presenting symptoms include fever, dry cough, shortness-of-breath, while sore throat, diarrhea, and abdominal and chest pain are the least. The atypical presentation of SARS CoV-2 infection poses a challenge for family physicians to screen and manage such patients for COVID-19 and specifically those at high risk with underlying disease such a sickle cell disease. Herein, we report a case of SARS CoV-2 infection in a known patient of sickle cell disease (SCD) with an atypical presentation, in whom the course of the disease was mild to moderate, uncomplicated, and the patient had an uneventful recovery. Primary care physicians should be vigilant to screen and manage such patients with established protocols, especially in the ongoing COVID-19 pandemic.

Background Hepatitis C virus (HCV) infection is thought to be associated with immune dysfunction. We hypothesized that HCV status would be associated with increased infectious complications in the surgical intensive care unit (SICU). Methods All patients admitted to our SICU between 2008 and 2012 were included. We evaluated 90-day mortality and infectious complications in the SICU. Multivariate logistic regression was performed to identify predictors of infectious complications and 90-day mortality. Results A total of 1,941 patients were included. The HCV-positive group had a higher overall incidence of infectious complications (25% vs 18%), particularly ventilator-associated pneumonia (VAP) and bacteremia. The increased incidences of VAP and bacteremia persisted when cirrhotic patients were excluded. Prolonged intubation (Odds Ratio [OR] = 2.1), abdominal surgery (OR = 1.6), and model for end-stage liver disease ≥ 15 (OR = 1.4) were independent predictors of SICU infectious complications. Conclusions The HCV-positive group had an increased incidence of infectious complications in the SICU, particularly VAP and bacteremia. This effect persisted when cirrhotic patients were excluded.

Background: Stevioside has been used as a medication for reducing glucose levels in diabetic patients. The exact mode of action is still unclear. Therefore, the current study outlined the molecular and biological roles of stevioside in treatment of diabetes.Materials and Methods: Diabetic male Wistar rats were treated with stevioside and metformin as a medication for diabetes rats for 4 weeks. Biochemical, molecular and histopathological studies have been done to evaluate the therapeutic effect of stevioside on minimizing levels of glucose and its related gene expression in diabetic rats.Results: Stevioside administration normalized kidney and liver biomarkers, restored alterations in antioxidants activity and lipid profiles. Moreover, stevioside increased insulin and leptin secretion that are decreased in diabetic rats to the normal levels. For mRNA expression, stevioside up-regulated the expressions of PK and IRS-1 genes, which are down-regulated in diabetic rats, and was very effective in the down-regulation of CPT-1 mRNA expression. At the cellular levels; stevioside normalized the histopathological changes induced in pancreas.Conclusion: Stevioside has insulin like effects and is useful for diabetic patient’s therapy.Key words: Stevioside; Molecular effects; Insulin like activity, Diabetes.

Nonalcoholic steatohepatitis (NAFLD) is a progressive form of liver disease that leads to advanced fibrosis. The present study was designed to assess the hepatoprotective effect of thymoquinone (TQ) on liver functions, insulin resistance, and PPAR-γ expression in NAFLD. Rats were divided into two main groups: one fed with normal rat chow diet and the other with high-fat high-cholesterol diet group for 6 weeks. Every group was subdivided into three subgroups (n = 8): treated with saline, low dose TQ (10 mg/kg), high dose TQ (20 mg/kg). High fat high cholesterol diet caused marked liver damage as noted in histopathology and significant increase in liver index, liver enzymes. There was significant increase in the insulin resistance, serum cholesterol, triglyceride, PPAR-γ gene overexpression with significant decrease in HDL. Additionally, oxidative stress increased by measuring MDA associated with significant decrease in serum total antioxidant capacity. As markers of inflammation, hepatic TNF-α was significantly increased with decrease in IL10. Further, there was increase in BAX protein with decrease in Bcl as compared to control group. This model of 6 weeks high-fat high-cholesterol diet showed minimal fibrosis as noticed by increase MMP2 and Masson trichrome satin. Co-treatment with TQ improved all previous parameters. High dose was more effective, although mostly non-statistically significant. TQ may have a promising agent to improve hepatic steatosis, oxidative stress; inflammatory, apoptotic status, fibrosis and so prevent liver damage in patients with NAFLD. Although PPAR-γ was significantly under-expressed by TQ, insulin resistance was improved significantly suggesting a role of liver damage.

Background: Hyperprolactinemia may reflect neuroendocrine stress reaction against acute coronary syndromes. Aim: The aim of the present study was evaluation of the serum prolactin level in the acute myocardial infarction (MI) regarding the current pharmacotherapy in management of MI. Setting and Design: Cross-sectional clinical based study. Subjects and Methods: This cross-sectional clinical study involved all patients with acute MI in a coronary care unit, a total number of 44 patients (45% males and 55% females) with age ranged from 40 to 75 years. A full history for modifiable risk factors and current therapy with aspirin, clopidogrel and or metformin, all patients are nonsmokers. The anthropometric measurements; for estimations of body mass index (kg/m2), electrocardiography was obtained. Fasting blood samples were taken in the morning from all patients and the sera used for estimations of routine investigation and determination of ischemic cardiac biomarkers like cardiac troponin I (cTnI) and serum prolactin level. Results: This study shows a significant increase in the serum prolactin in acute MI as compared with the control. In acute MI serum cTnI elevation was correlated with serum prolactin increments. In metformin-treated group, there was a lowest prolactin serum level. Conclusions: Serum prolactin level increased in acute MI, and positively correlated with cardiac troponin level and reflects underlying cardiovascular complications.

Background Type 1 diabetes, previously known as juvenile diabetes or insulin-dependent diabetes, is a form of diabetes characterized by the body’s inability to produce insulin owing to the autoimmune destruction of the insulin-producing beta cells in the pancreas. Klotho (KL), known as an anti-aging protein, was discovered recently to have a multitude of biological effects. Major attention has been paid to the role of α-klotho (α-KL) in diabetes and its relation with diabetic nephropathy. The circulating form of α-KL, named as soluble KL, functions as an endocrine substance that exerts heterogeneous actions, including the modulation of renal function upon hyperglycemia, regulation of cell compensation, downregulation of inflammation and anti-oxidation effects. Aim The aim of this work is to study plasma KL and plasma copeptin in adolescents with type 1 diabetes and their relation to microvascular complications. Patients and methods This study was conducted in diabetes outpatient clinic in national institute of diabetes and endocrinology. The sample of 117 patients was divided into three groups: diabetes group, with 39 patients; diabetes with complication group, with 39 patients; and healthy controls, with 39 participants. Results Our study shows significant elevation of plasma copeptin level in type 1 diabetic adolescents, which was also significantly higher in the presence of microvascular complications particularly diabetic kidney disease (P=0.000). Although plasma KL is found to be significantly higher in type 1 diabetes without complications group, its level is dropped in the diabetes with complications group (P=0.005). Conclusion Plasma KL and plasma copeptin can be used as novel biomarkers for predicting early kidney injury in type 1 diabetic adolescents.

Background: To determine the prevalence of dry eye disease (DED) at Jalan Hospital Eye Care, International Islamic University Malaysia (IIUM), Kuantan, Malaysia. Methods: The dry eye symptoms and tear breakup time test (TBUT) values retrieved from the medical records of 643 patients were retrospectively analysed. Dry eye cases with one or more symptom were included. ‘Yes’ or ‘no’ responses were used in discriminant analysis of tear abnormality (TBUT < 5 seconds). Results: The crude prevalence of DED was 48.5%, the age-adjusted prevalence was 43% in women

Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization.A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014. Since 2014, we have implemented strategies to reduce post-operative wound complications, including: (1) Decreasing the use of incisional skin staples, (2) increasing the use of negative pressure wound therapy (NPWT) dressings, and (3) implementing an outpatient elective decontamination protocol for methicillin-resistant Staphylococcus aureus. "Pre-era" is defined as the period between January 2012 and December 2013, before the implementation of infection control strategies; "Post-era" is between January 2015 and August 2016, after implementation. The primary outcome of interest is 30-day wound complications (infection or dehiscence). Multi-variable logistic regression analysis was used to identify significant predictors of wound-related complications between the two cohorts. Propensity score adjustment controlled for baseline patient characteristics, peri-operative variables, and surgeon experience.A total of 338 open infra-inguinal procedures were performed: 175 in the pre-era and 163 in the post-era. Chlorhexidine skin preparation was used in the majority (321 [95%]) of cases. Comparing the periods, the post-era is characterized by a significant decrease in the use of groin staples (118 [67%] vs. 51 [31%], p 0.001), and an increased application of NPWT dressings (6 [4%] vs. 66 [43%], p 0.001). Thirty-five (37%) outpatient elective cases received the pre-operative decontamination protocol in the post-era. Compared with the pre-era, there was a decrease in the 30-day rate of wound complications (68 [39%] to 42 [26%], p = 0.011), and infection-related re-admissions (31 [17.7%] to 21 [12.9%], p = 0.220). When adjusting for patient characteristics, operative variables, and surgeon experience, post-era had significantly lower wound complications (odds ratio [OR] 0.33, p = 0.002) and re-operations (OR 0.16, p = 0.007). Among outpatient elective cases, the decontamination protocol was also independently associated with these two outcomes (wound complications: OR 0.05, p = 0.006; re-operations: 0.06, p = 0.002). The use of groin staples was an independent predictor of deep groin infections (OR 248, p 0.001) and re-operations (OR 8.16, p = 0.032).Wound complications after open infra-inguinal re-vascularization have decreased significantly after the implementation of several infection-control strategies. Findings suggest that skin staples should be avoided in groin wounds, and anti-staphylococcal decontamination protocols decrease wound complications and prevent re-operations.

Renovascular hypertension is an unusual but treatable cause of refractory hypertension that is infrequently caused by external compression of the renal vasculature by a giant hydatid cyst, a parasitic infection, caused by Echinococcus granulosus in its larval stage which is endemic in many parts of the world including Saudi Arabia. The disease can produce a cyst in almost every part of the body with the liver and lungs being the most frequently targeted organs producing a variety of symptoms depending upon the site and size of the cyst. We report a case of giant hepatic hydatid cyst with the possibility of renovascular hypertension due to mass effect as evident by dramatic drop of the blood pressure to its normotensive state postoperatively.

Background With the increasing use of the robotic platform in general surgery, whether 8-mm ports should be closed comes into question. We sought to characterize the incidence of port-site hernias (PSHs) among patients undergoing robotic-assisted general surgery. Methods A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general surgery from July 2010 to December 2016. For each patient, the number, type, location, and size of all ports were collected. Twelve-millimeter port sites were routinely closed, whereas 5-mm and 8-mm port sites were not. PSH was detected on review of documented physical examination and of postoperative cross-sectional imaging, when available, in which case it was defined as a disruption of the fascia with or without eventration of tissue at a site of prior port placement. Results One hundred and seventy-eight patients underwent robotic-assisted general surgery, with 725 total ports: 433 8-mm working ports, 72 12-mm working ports, 178 12-mm camera ports, and 42 5-mm assistant ports. Ninety-four percent of the patients were men, the mean age was 63 ± 12, body mass index was 29 ± 7 kg/m2, and the median American Society of Anesthesiologists score was 3. Types of cases included 68 rectal (38.2%), 36 colon (20.2%), 25 hepatopancreatobiliary (14.0%), 21 inguinal hernia (11.8%), and 28 “other” (15.7%) operations. At a median follow-up of 193 d, there were three PSHs through 8-mm port sites (0.7%), two PSHs through 12-mm port sites (0.8%), and no PSH through 5-mm port sites. Two of the three 8-mm PSHs occurred in the early postoperative period and required emergent repair due to small bowel incarceration. Conclusions PSHs through 8-mm robotic port sites occur infrequently but can cause significant morbidity. Further investigation with longer follow-up is warranted to better understand the true incidence of robotic PSH.

Background The new Model for End-Stage Liver Disease includes serum sodium (MELD-Na). To evaluate its predictive power in non-transplant surgery, we analyzed emergency surgery outcomes of cirrhotic patients, hypothesizing that negative outcomes could be associated with discrete MELD-Na score thresholds. Methods Retrospective chart review was conducted of patients with cirrhosis undergoing emergency surgery at our institution from 2001 to 2013 (n = 85). Risk thresholds and predictors of peri-operative outcomes were identified using univariate and multivariate regression. Results MELD-Na scores of 19, 17, and 12 were identified as predictors of 30-day mortality (OR = 3.44), post-operative complications (OR = 3.08), and discharge to home (inverse relationship, OR = 0.31). Post-operative complications were independent negative predictors of discharge to home (OR = 0.21). Conclusion Although emergency surgery in patients with cirrhosis can be life-saving, knowledge of the significant peri-operative risk should drive decision-making, informed by the increased risk associated with these score thresholds. Further study is needed to establish definitive MELD-Na thresholds.

Our previous publication showed that inhibition of arginase prevents the development of diabetic nephropathy (DN). However, identification of targets that retard the progression of established DN–which is more clinically relevant–is lacking. Therefore, we tested the hypothesis that arginase inhibition would prevent the progression of established DN. Effects of arginase inhibition were compared with treatment with the angiotensin-converting enzyme inhibitor captopril, a current standard of care in DN. Experiments were conducted in Ins2Akitamice treated with the arginase inhibitor S-(2-boronoethyl)-l-cysteine (BEC) or captopril starting at 6 wk of age for 12 wk (early treatment) or starting at 12 wk of age for 6 wk (late treatment). Early and late treatment with BEC resulted in protection from DN as indicated by reduced albuminuria, histological changes, kidney macrophage infiltration, urinary thiobarbituric acid-reactive substances, and restored nephrin expression, kidney nitrate/nitrite, kidney endothelial nitric oxide synthase phosphorylation, and renal medullary blood flow compared with vehicle-treated Ins2Akitamice at 18 wk of age. Interestingly, early treatment with captopril reduced albuminuria, histological changes, and kidney macrophage infiltration without affecting the other parameters, but late treatment with captopril was ineffective. These findings highlight the importance of arginase inhibition as a new potential therapeutic intervention in both early and late stages of diabetic renal injury.