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• Self-healing properties of nanoalumina, nanosilica, and nanoclay were discussed. • Comparison of the nanomodified binders is made at varying dosages. • Changes in the molecular property and chemical composition due to nanomodifications were analyzed. Nanomaterials, due to their higher surface area, smaller particle size, and unique chemical characteristics, might be a potential additive to self-heal microcracks in asphalt pavement and extend pavement life. The goal of this study is to examine the self-healing potential of asphalt binder modified with nanosilica, nanoalumina, and nanoclay at three different dosages. First, factors affecting self-healing behavior (i.e., blending techniques, rest period, and damage level) were investigated following Performance grade, Surface Free Energy, Storage stability, and Fourier Transform Infrared Spectroscopy tests. 1% nanosilica exhibited the highest self-healing potential, while 3% nanoalumina also performed well at higher damage levels. [ABSTRACT FROM AUTHOR]

Pavements constructed on frost-susceptible subgrade layers are prone to deterioration from freezing in cold regions. A thermal insulation layer above the frost-susceptible subgrade layer in a pavement structure could effectively mitigate the deterioration due to frost action. The objective of study was to evaluate the thermal insulation performance of different insulating materials experimentally and numerically. Therefore, five large-scale pavement boxes, including one uninsulated pavement and four insulated pavements using different materials (i.e., XPS board, tire chips, foam glass aggregates (FGA), and foamed concrete), were constructed. The thermal insulation performance was studied under constant freezing condition and freeze-thaw cycles where the temperature profile of pavements was monitored. A finite element model was developed by considering the transient heat flow and the associated latent heat of fusion in the unbound granular layers. Correspondingly, the numerical simulation was conducted to extrapolate the temperature profile for pavement structures made by different insulating materials. The experimental results show that the XPS and FGA have the best overall insulation performance, followed by foamed concrete and tire chips. Results of the numerical simulation suggest that to achieve an equivalent level of insulation performance as a 5 cm thick XPS board under the same freezing conditions, insulating materials such as tire chips layer, FGA layer, foamed concrete layer, or recycled concrete aggregate should have insulation layer thicknesses of 40 cm, 25 cm, 30 cm, or 68 cm, respectively. In terms of cost-benefit analysis, the foamed concrete insulated pavement is the most expensive option, followed by uninsulated pavement, insulated pavements using FGA, tire chips, and XPS. This study highlights the critical role of the insulating material and the insulation layer thickness in cost-benefit thermal insulation for pavements in cold regions. • Insulation layer presents positive and negative effects on temperature profile. • XPS board has better thermal insulation than FGA, tire chip and foamed concrete. • For similar thermal performance, foamed concrete insulated pavement costs more. [ABSTRACT FROM AUTHOR]

Tranexamic acid (TXA) protects the vasculature endothelium after hemorrhage, resulting in a decreased capillary leak. These properties may protect patients receiving TXA from acute respiratory distress syndrome (ARDS), however, clinical studies have yet to examine this topic. We hypothesized that trauma patients receiving TXA would have lower incidence of ARDS. This was a retrospective review of adult (18+ y) patients who presented to a large Level I trauma center with an injury severity score ≥ 16 from admit years 2012-2020. Propensity matching was employed to examine how TXA administration is associated with ARDS. There were a total of 2751 patients meeting study criteria, with 162 (5.9%) received TXA. Of the 162 patients that received TXA, only 12 (7.4%) received pre-hospital TXA, while 4 (2.5%) received TXA both pre-hospital and in hospital. Of the 63 patients developing ARDS, 62 (98.4%) did not receive TXA. After propensity matching, 304 patients remained, with 152 in each cohort. The incidence of ARDS (P = 0.08), pneumonia (P = 0.68), any pulmonary complication (P = 0.33), and mortality (P = 0.37) were not different in patients receiving TXA on propensity matching. TXA did not protect trauma patients from pulmonary complications; however, nearly all patients developing ARDS did not receive TXA. Larger studies should examine this relationship to improve understanding of therapies that may prevent ARDS. [ABSTRACT FROM AUTHOR]

• Fiber dosage rate impacted the optimum binder content of asphalt mixtures when using a Superpave mix design procedure. • Air void contents of asphalt mixtures increased with increases in fiber dosages. • Carbon fibers showed the greatest improvement in CT index , particularly at 0.3% dosage rate (by asphalt mixture weight). • Fibers did not statistically improve the rutting performance of the asphalt mixture. The purpose of this study was to evaluate the impact of fiber types, binder content, and their dosage rates on the volumetric properties and laboratory performance of asphalt mixtures. One asphalt mixture (control) and three fiber types (Basalt, Fiberglass, and Carbon) were used. Two different fiber dosage rates were considered 0.15% (recommended dosage rate) and 0.30% by total mixture weight. Furthermore, a novel experimental methodology was developed and implemented consisting of a volumetric mixture design and performance testing—Indirect Tensile Asphalt Cracking Test (IDEAL-CT) and Asphalt Pavement Analyzer (APA)—to isolate the effects of fiber types and dosage rates from the effect of binder content. Statistical analysis was also used to further evaluate the impact of fibers on mixture performance. Results showed that 0.15% dosage rate had little to no impact on optimum binder content, whereas 0.30% dosage rate required an increase in binder content of 0.6%, 0.6%, and 0.8% for basalt, fiberglass, and carbon fibers, respectively, to meet the volumetric requirements. This study showed that the need for additional binder content at 0.30% dosage rate could be due to an increase in specimen volume (referred to as rebounding height) that occurred after 24 h of specimen cooling at room temperature. Performance testing showed that 0.15% (regardless of fiber type) had no impact on cracking and rutting performance. At 0.30% dosage rate, only carbon fiber improved cracking performance without the use of additional binder. Overall, the study highlighted laboratory performance benefits and challenges of using fiber-reinforced reinforced asphalt mixtures. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic inguinal hernia repair is widely adopted and well accepted in many centers. Objective: We aimed with this study to evaluate the technique regarding its advantages and disadvantages in Sohag University Hospital. Patients and Methods: This was a prospective observational study included 50 patients suffering from inguinal hernia admitted electively to Sohag University Hospital between September 2019 and April 2020. Patients were enrolled for laparoscopic Trans Abdominal Pre Peritoneal (TAPP) repair. Patients were evaluated regarding demographic criteria, clinical picture, operative, and postoperative course after an outpatient follow-up period of 6 months. Results: The mean operative time in minutes ±SD was (125±12.5) for the early 10 patients while it was (69.8± 24) for the last 25 patients. Intraoperative complications were encountered in two cases of visceral injury and one case of bleeding arising from the inferior epigastric artery that was managed laparoscopically without surgical sequelae. The duration of hospital stay ranged from 24-48 hours. Postoperative complications were encountered in 3 patients whom had surgical emphysema which resolved conservatively. Patients returned to full activities in 7.14 ± 0.96 days and returned to their work in 14 ±2.5 days. On follow-up, recurrence was not encountered allover the period of 6 months postoperatively. Conclusion: TAPP repair for inguinal hernias is justified as a feasible, reproducible, and safe technique with rapid recovery and early return to work as well as comparable morbidities to other techniques. It is recommended as the procedure of choice in elective groin hernia repair especially in bilateral cases, with short learning curve requiring little facilities in the center. [ABSTRACT FROM AUTHOR]

Abstract: New Ni x Mg1−x Al2O4 nanosized in different composition (0.1≤ x ≤0.8) powders have been synthesized successively for first time by using low temperature combustion reaction (LTCR) of corresponding metal chlorides, carbonates and nitrates as salts with 3-methylpyrozole-5-one (3MP5O) as fuel at 300°C in open air furnace. Magnesium aluminate spinel (MgAl2O4) was used as crystalline host network for the synthesis of nickel-based nano ceramic pigments. The structure of prepared samples was characterized by using different techniques such as thermal analysis (TG–DTG/DTA), X-ray powder diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR) and transmission electron microscopy (TEM). UV/Visible and Diffuse reflectance spectroscopy (DRS) using CIE-L*a*b* parameters methods have been used for color measurements. The obtained results reveal that Ni x Mg1−x Al2O4 powder of samples is formed in the single crystalline and pure phase with average particle size of 6.35–33.11nm in the temperature range 500–1200°C. The density, particle size, shape and color are determined for all prepared samples with different calcination time and temperature. [Copyright &y& Elsevier]

• Evaluating the potential for improving the cracking resistance of microsurfacing mixtures using polymer and fiber additions. • Performance testing of microsurfacing mixtures using the Overlay Tester (OT) and the Semi-Circular Bend (SCB) tests. • General procedure for fabricating microsurfacing mixtures' samples in laboratory settings. • Impact of fiber reinforcement on cracking resistance of microsurfacing mixtures. This study evaluated the potential for improving the cracking resistance of microsurfacing mixtures using polymer and fiber additions. Three mixtures were evaluated in this study: a fiber reinforced mixture using 1/4″ glass fibers, a polymer (SBR) enhanced emulsion, and a mixture using a combination of polymer and fibers. The polymer enhanced samples and the combination samples showed improvements for the Texas Overlay Tester and the Semi-Circular Bend Test. The greatest improvements in performance for the Texas Overlay Tester were obtained from the polymer enhanced sample, whereas the greatest improvements in the Semi-Circular Bend Test were obtained from the combination samples. [ABSTRACT FROM AUTHOR]

• Fresh hot mix asphalts (HMA) and reclaimed asphalt pavements (RAP) were assessed. • Water extractable element concentrations were below MCLs except lead (Pb). • Few potential pollutants released from RAPs were largely attenuated by soils. • RAPs can be used as unbound materials in non-acidic environments (pH ≥ 5). To investigate the environmental impacts of reclaimed asphalt pavement (RAP) while it was freshly processed (i.e. hot mixed asphalt or HMA) and after being subjected to weathering, three RAP materials, namely north-RAP, central-RAP, south-RAP, from three plants and one fresh HMA loose mix sample (Fresh-HMA) throughout New Jersey, USA underwent four different weathering processes including: Ultraviolet (UV) and precipitation weathering on unbounded RAP, UV and precipitation weathering on compacted RAP, weathering by heat and moisture cycles, and groundwater flow-through leaching. Batch experiments were conducted to mimic releasing of trace elements in weak acidic leachate from landfills. North-RAP and central-RAP released levels of Pb greater than the United States Environmental Protection Agency (USEPA) primary drinking water maximum contaminant level (MCL) of 15 µg/L. Novel two-column experiments (a RAP column followed by a soil column) were conducted to investigate the release of trace elements from RAP and the attenuation effect of soil on potential pollutants. The results of these experiments showed that pollutants released from RAPs such as Mn and Ni were largely attenuated in the soil. The results suggest that RAP can be used as an unbound material in environments except those acidic (i.e., pH < 5 as in mines with sulfur-containing minerals and landfills with acidic environment). [ABSTRACT FROM AUTHOR]

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport. Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression. Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients. Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Burns can cause long-term complications including pain and poor physical function. While neighborhood disadvantage is associated with burn severity, its effect on long-term complications has not been investigated. We hypothesized that patients from areas of higher area of deprivation index (ADI) will report poorer long-term outcomes., Methods: We linked patient data from the Burn Model System with ADI state decile (1 = least, 10 = most disadvantaged) using year and residence at time of injury. We performed bivariate analyses to identify associations between ADI and patient and burn characteristics and multivariate regressions to determine whether ADI was associated with PROMIS-29 pain and physical function 6- and 24-months post-burn., Results: We included 780 patients; 69 % male, median age = 46 years, median ADI = 6, and median TBSA = 8 %. Multivariate regressions adjusting for TBSA, race, age, sex, anxiety, depression, and pain interference demonstrated that higher ADI was a significant predictor of higher pain intensity 6- (p = 0.001) and 24-months (p = 0.037) post-burn but not worse physical function 24-months post-burn (p = 0.089)., Conclusions: Higher neighborhood disadvantage was associated with higher long-term pain intensity post-burn. This study highlights the importance of socioeconomic factors that may impact long-term outcomes and the use of aggregate markers to identify patients at risk for worse outcomes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 Elsevier Ltd and International Society of Burns Injuries. All rights reserved.)

Introduction: Turner syndrome (TS) is the most common sex chromosome abnormality in women, caused by a complete or partial absence of the second sex chromosome. The karyotype 46, X,i(Xq) is the underlying cause in about 10% of the cases of TS. Hepatic abnormalities are frequent in TS. Granulomas are relatively common in liver samples but are very rarely reported in TS., Case Presentation: A 15-year-old female with TS attended a consultation for evaluation of elevated liver enzymes. Her chromosomal analysis showed mosaicism 46, X (iso xq)100%. There were no stigmata of chronic liver disease. A liver biopsy showed granulomatous hepatitis. Other causes of hepatic granulomas have been excluded. Ursodeoxycholic acid (UDCA) therapy leads to the normalization of transaminases., Clinical Discussion: Although Hepatic involvement is common and mostly asymptomatic in TS, the mechanism of liver injury is not well understood. The hepatic histological changes in these cases are variable and range from minimal abnormalities to nonalcoholic steatohepatitis (NASH), liver architectural changes, and biliary lesions. Hepatic granulomas are associated with a wide range of systemic disorders but are very rarely reported in tuner syndrome. Normalization of liver enzymes after treatment with UDCA was previously reported, but the importance of this approach is to be determined., Conclusion: Granulomatous hepatitis may be associated with TS and may be added to the histological patterns encountered in this disorder., Competing Interests: The authors declared no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article, (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Despite the availability of international recommendations for the management of Infantile Epileptic Spasms Syndrome (IESS), there is a lack of recommendations adapted to the local context of clinical practice of pediatric neurology in the Gulf Cooperation Council (GCC) countries. By an initiative from the Saudi Pediatric Neurology Society (SPNS), a literature review was performed and an expert panel comprised of 13 pediatric neurologists from all GCC countries (Saudi Arabia, Kuwait, Bahrain, Oman, Qatar, and the United Arab Emirates) was subsequently convened to discuss all issues related to the management and diagnosis practices of IESS in the GCC. The overall aim of this consensus document was to develop practical recommendations to support the care of patients with IESS in the GCC and to reflect on how clinical management approaches compare with those adopted internationally., (Copyright © 2024. Published by Elsevier Ltd.)

A girl in early adolescence with autism presented with 3 months of abdominal pain and 36 hours of anuria. She had recently received treatment for urinary tract infections, anxiety and menorrhagia (she had undergone menarche a few months earlier). Due to the pain, she had pulled out an incisor. Bladder scan showed 923 mL, creatinine was 829 mmol/L but urethral catheter insertion did not drain urine. An unenhanced CT scan revealed an absent left kidney, didelphys uterus and right-sided hydroureteronephrosis caused by haematocolpos in keeping with a diagnosis of OHVIRA syndrome and ureteric obstruction of a single kidney causing acute renal failure. She underwent vaginal septoplasty, drainage of the haematocolpos and right ureteric stent., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Giant Cell Arteritis (GCA) is the commonest form of systemic vasculitis in people over the age of 50. Published research highlighted the lack of a disease-specific patient reported outcomes (PROMs) for GCA., Objectives: To assess the validity, reliability and responsiveness to change of a devised disease specific patient self-reported outcome measures questionnaire for Giant Cell Arteritis (GCA)., Methods: The GCA-PROMs was conceptualized based on frameworks outlined in the OMERACT developed core set of Outcome Measures for Large-Vessel Vasculitis and the guiding principles of the FDA guidance. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction was achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented., Results: A total of 54 GCA patients completed the questionnaire. The GCA-PROMs questionnaire was reliable as demonstrated by a high standardized alpha (0.878-0.983). Content construct assessment of the GCA-PROMs functional disability and QoL revealed significant correlation (p< 0.01) with both HAQ and EQ-5D. Changes in functional disability, QoL showed significant (p< 0.01) variation with diseases activity status in response to therapy., Conclusions: The developed GCA-PROMs questionnaire is a reliable and valid instrument for assessment of GCA patients. A stratified treatment regimen depending on the individual patient's risk factors as well as preferences and associated comorbidities is the best approach to tailored patient management., Competing Interests: Declaration of Competing Interest Authors declare no conflicts of interest., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Food security (FS) is defined as access to sufficient and nutritious food. Children, especially those in low- and middle- income countries (LMICs), are disproportionately affected by low FS. We hypothesized high FS would be predictive of decreased pediatric postburn mortality in LMICs. Publicly-available, deidentified datasets were obtained from the World Health Organization's Global Burn Registry (GBR) and Economist Intelligence Unit's Global FS Index (GFSI). The GFSI calculates FS scores annually from intergovernmental organization data reviewed by a panel of experts. FS scores are reported on a 0 to 100 scale with 100 indicating the highest FS. Patients aged 0 to 19 yr were included; after linking GBR and GFSI datasets, countries with <100 burn patients were excluded. Data were analyzed with descriptive statistics and bivariate analyses. Multiple logistic regression controlling for confounders was used to quantify associations between mortality and FS score. Significance was set at P < 0.05. From 2016 to 2020, there were 2,246 cases including 259 deaths (11.5%) over nine countries. Those who died had a higher median age (7 [IQR 2, 15] vs 3 [2, 6] years, P < 0.001), higher proportion of females (48.6% vs 42.0%, P =0.048), and lower median FS score (55.7 [IQR 45.3, 58.2] vs 59.8 [IQR 46.7, 65.7], P < 0.001). Increasing FS score was associated with decreased odds of postburn mortality [multivariable odds ratio 0.78 (95% confidence interval 0.73 to 0.83), P < 0.001]. With the association between FS and mortality, international efforts to increase FS in LMICs may help improve pediatric burn patient survival., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: The root cause of mass shooting events (MSEs) and the populations most affected by them are poorly understood., Objective: To examine the association between structural racism and mass shootings in major metropolitan cities in the United States., Design, Setting, and Participants: This cross-sectional study of MSEs in the 51 largest metropolitan statistical areas (MSAs) in the United States analyzes population-based data from 2015 to 2019 and the Gun Violence Archive. The data analysis was performed from February 2021 to January 2022., Exposure: Shooting event where 4 or more people not including the shooter were injured or killed., Main Outcome and Measures: MSE incidence and markers of structural racism from demographic data, Gini income coefficient, Black-White segregation index, and violent crime rate., Results: There were 865 MSEs across all 51 MSAs from 2015 to 2019 with a total of 3968 injuries and 828 fatalities. Higher segregation index (ρ = 0.46, P = .003) was associated with MSE incidence (adjusted per 100 000 population) using Spearman ρ analysis. Percentage of the MSA population comprising Black individuals (ρ = 0.76, P < .001), children in a single-parent household (ρ = 0.44, P < .001), and violent crime rate (ρ = 0.34, P = .03) were other variables associated with MSEs. On linear regression, structural racism, as measured by percentage of the MSA population comprising Black individuals, was associated with MSEs (β = 0.10; 95% CI, 0.05 to 0.14; P < .001). Segregation index (β = 0.02, 95% CI, -0.03 to 0.06; P = .53), children in a single-parent household (β = -0.04, 95% CI, -0.11 to 0.04; P = .28), and Gini income coefficient (β = -1.02; 95% CI, -11.97 to 9.93; P = .93) were not associated with MSEs on linear regression., Conclusions and Relevance: This study found that major US cities with higher populations of Black individuals are more likely to be affected by MSEs, suggesting that structural racism may have a role in their incidence. Public health initiatives aiming to prevent MSEs should target factors associated with structural racism to address gun violence.

Background: To compare the efficacy and safety of standard percutaneous nephrolithotomy (PCNL) with mini- PCNL for kidney stones 2-4 cm., Methods: Eighty patients were enrolled in a comparative study, they were randomly divided into mini-PCNL group (n = 40) and standard-PCNL (n = 40). Demographic characteristics, perioperative events, complications, stone free rate (SFR) were reported., Results: Both groups showed no significant difference in clinical data about age, stone location, back pressure changes, and body mass index. The mean operative time was (95 ± 17.9 min) in mini-PCNL, and (72.1 ± 14.9 min). Stone free rate were 80% and 85% in mini-PCNL and standard-PCNL respectively. Intra-operative complications, post-operative need for analgesia, hospital stay were significantly higher in standard-PCNL compared to mini-PCNL (85% vs. 80%). The study followed CONSORT 2010 guidelines for reporting parallel group randomization., Conclusion: Mini-PCNL is an effective and safe treatment of kidney stones 2-4 cm, it has the advantage over standard-PCNL being has less intra-operative events, less post-operative analgesia, shorter hospital stay, while operative time and stone free rate are comparable when considering multiplicity, hardness, and site of stones., (© 2023. The Author(s).)

Background: This case report describes a cystic fibrosis case after 7 years of a presumed diagnosis of celiac disease without confirming laboratory tests and biopsies. Both cystic fibrosis and celiac disease cause malnutrition, malabsorption, and failure to thrive. Also, the occurrence of cystic fibrosis in celiac disease patients is higher than in the normal population. Therefore, the differentiation between the two diseases might be challenging. This article highlights the reason for the confusion between cystic fibrosis and celiac disease and emphasizes the importance of not skipping the necessary investigations no matter how difficult it is to perform them., Case Presentation: This report details the case history of a patient presumed to have celiac disease for 7 years without confirming investigations. He developed multiple respiratory infections and weight loss throughout the 7 years but was only diagnosed with cystic fibrosis after hospitalization for gradual abdominal distension and productive cough. Chest CT showed atelectasis in the right upper lobe, tree-in-bud sign on both sides, and right periumbilical mass with several enlargements in the mediastinal nodes. Ascites paracentesis revealed a high SAAG gradient and low-protein fluid. The sweat chloride test resulted in a chloride level of 90 mEq/L, which confirmed the cystic fibrosis diagnosis. Subsequent genetic testing revealed the rare G85E mutation., Conclusion: This report highlights the potential for diagnostic confusion between cystic fibrosis and celiac disease. Also, it reminds physicians about the importance of taking a detailed medical history and performing the essential investigations no matter how difficult it is to do them. Finally, it emphasizes the need to verify the patient's previous medical history in case there is no official documentation of his case. This should be considered particularly in rural areas in low-income countries where the possibility of medical malpractice should not be forgotten., (© 2023. The Author(s).)

Objectives: To describe the clinical phenotype of eight children diagnosed with CD59 deficiency and their ultimate neurological outcome., Methods: The data of our cases were extensively reviewed both clinical and ancillary tests; investigations included: neuroimaging, neurophysiological studies, and laboratory tests., Results: All patients presented during early infancy with Guillain-Barre syndrome later they suffered repeated relapses leading to the diagnosis of chronic axonal neuropathy. Recurrent stroke and acute necrotizing encephalopathy were described, 2 patients in each group. One girl developed acute disseminated encephalomyelitis while one boy developed acute transverse myelitis. Overt hemolytic anemia requiring blood transfusion reported in six patients., Conclusion: Inherited CD59 deficiency is an autosomal recessive disorder which can have devastating neurological consequences. First line immunotherapy including intravenous immunoglobin, corticosteroids, and plasma exchange may have transient beneficial effect. Reports of targeted therapy with eculizumab might be lifesaving. Genetic counseling is crucial., (Copyright: © Neurosciences.)

Introduction: Trauma represents the leading cause of nonobstetrical maternal death. How in-hospital outcomes of acutely injured pregnant patients (PP) compares to that of similarly aged nonpregnant control groups (CGs) has not been described. We hypothesized that PPs suffering acute traumatic injuries would have worse outcomes compared to a matched CG., Materials and Methods: The American College of Surgeons Trauma Quality Improvement Program (TQIP) was used to identify traumatically injured females between 2017 and 2019. Propensity score matching on age, race, injury severity score , and type of trauma (blunt, penetrating, or other) was used to compare PPs and the CG. Primary outcomes were mortality, disposition, length of stay (LOS), and complications., Results: A total of 1078 traumatically injured pregnant females were identified. Propensity score matching resulted in 990 patients in the PP and CG cohorts. After matching, PPs were more likely to be assault victims (11% versus 6%, P < 0.001), had longer length of stay (LOS) (5 versus 3 d, P < 0.001), and were more likely to require mechanical ventilation (26% versus 16%, P < 0.001) or intensive care unit (ICU) admission (44% versus 32%, P < 0.001). PPs were more likely to proceed directly to the operating room (OR)(34% versus 15%, P < 0.001) and less likely to be discharged home from the emergency department (ED) (1% versus 12%, P < 0.001). Complications and mortality rates were similar among PPs., Conclusions: After acute trauma, PPs did not have increased mortality or complications when compared to matched controls, although they were more likely to be victims of assault, directly proceed to the OR, require mechanical ventilation or ICU admission, and have longer LOSs., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Abstract: Introduction: Time is an essential element in outcomes of trauma patients. The relationship of time to treatment in management of noncompressible torso hemorrhage (NCTH) with resuscitative endovascular balloon occlusion of the aorta (REBOA) or resuscitative thoracotomy (RT) has not been previously described. We hypothesized that shorter times to intervention would reduce mortality. Methods: A review of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery registry from 2013 to 2022 was performed to identify patients who underwent emergency department aortic occlusion (AO). Multivariate logistic regression was used to examine the impact of time to treatment on mortality. Results: A total of 1,853 patients (1,245 [67%] RT, 608 [33%] REBOA) were included. Most patients were male (82%) with a median age of 34 years (interquartile range, 30). Median time from injury to admission and admission to successful AO were 31 versus 11 minutes, respectively. Patients who died had shorter median times from injury to successful AO (44 vs. 72 minutes, P &lt; 0.001) and admission to successful AO (10 vs. 22 minutes, P &lt; 0.001). Multivariate logistic regression demonstrated that receiving RT was the strongest predictor of mortality (odds ratio [OR], 6.6; 95% confidence interval [CI], 4.4-9.9; P &lt; 0.001). Time from injury to admission and admission to successful AO were not significant. This finding was consistent in subgroup analysis of RT-only and REBOA-only populations. Conclusions: Despite expedited interventions, time to aortic occlusion did not significantly impact mortality. This may suggest that rapid in-hospital intervention was often insufficient to compensate for severe exsanguination and hypovolemia that had already occurred before emergency department presentation. Selective prehospital advanced resuscitative care closer to the point of injury with "scoop and control" efforts including hemostatic resuscitation warrants special consideration., Competing Interests: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no conflicts of interest., (Copyright © 2022 by the Shock Society.)

Background: Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence., Methods: Firearm injury data was collected from 2016 to 2020 (n = 3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data were linked with Map the Meal Gap data, a publicly available data set, which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. Food insecurity by county of patient residence was categorized by rates less than the national average of 11.5% (low), between the national and state average (16.5%) (moderate), and greater than the state average (high). Out of state residents were excluded from the analyses., Results: Of the 3,115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a Level I trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. Food insecurity was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval, 54-59) and increased odds of the injury classified as assault (odds ratio, 1.13; 95% confidence interval, 1.07-1.19)., Conclusion: Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism., Level of Evidence: Prognostic and Epidemiologic; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome., Methods: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs., Results: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome., Conclusion: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Pediatric pelvic fractures are a significant source of morbidity for children in the United States. In the era of specialized care, the relationship between trauma center designation and outcomes remains unknown. We hypothesized that there would be no difference in patient outcomes when treated at adult trauma centers (ATCs), pediatric trauma centers (PTCs), or dual trauma centers (DTCs)., Materials and Methods: We used the National Trauma Data Bank to identify pediatric (≤14 y) patients suffering pelvic fractures in 2013-2015. DTCs were defined as centers with level I or II trauma designation for both pediatric and adult care. Primary outcomes included mortality, complications, and computed tomography (CT) utilization., Results: There were 4260 patients who met study criteria. Of these, 1290 (22%) were treated at ATCs, 1332 (30%) at PTCs, and 2120 (48%) at DTCs. Pediatric patients treated at ATCs were more likely to suffer a complication or receive a CT scan. On multivariate analysis, patients treated at PTCs and DTCs were significantly less likely to have a recorded complication or receive head, thoracic, or whole-body CT scans compared with ATCs. DTCs, but not PTCs, used fewer abdominal CT scans. Mortality rates were not predicted by center designation., Conclusions: For pediatric pelvic fractures, centers with pediatric trauma designation (PTCs and DTCs) appear to have better outcomes despite significantly less use of CT scans. Further studies are needed to determine optimal management of pediatric pelvic fractures while minimizing exposure to ionizing radiation., Level of Evidence: Level III Retrospective., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background & Aims: Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients., Methods: We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY)., Results: In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY)., Conclusions: Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care., Background: Diagnosis of thyroid cancer in the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors., Methods: We created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events., Results: In our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS., Conclusions: The ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.

Background: Intrapartum-related hypoxic events are a major cause of morbidity and mortality in low resource countries. Neonates who receive proper resuscitation may go on to live otherwise healthy lives. However, even when a birth attendant is present, these babies frequently receive suboptimal ventilation with poor outcomes. The Augmented Infant Resuscitator (AIR) is a low-cost, reusable device designed to provide birth attendants real-time objective feedback on measures of ventilation quality during resuscitations and is intended for use in training and at the point of care. The goal of our study was to determine the impact and cost-effectiveness of AIR deployment in conjunction with existing resuscitation training programs in low resource settings., Methods: We developed a simulation model of the natural history of intrapartum-related neonatal hypoxia and resuscitation deriving parameters from published literature and model calibration. Simulations estimated the number of disability-adjusted life years (DALYs) averted with use of the AIR by birth attendants if deployed at the point of care. Potential decreases in neonatal mortality and long-term subsequent morbidity from disability were modeled over a lifetime horizon. The primary outcome for the analysis was the cost per DALY averted. Model parameters were specific to the Mbeya region of Tanzania., Results: Implementation of the AIR strategy resulted in an additional cost of $24.44 (4.80, 73.62) per DALY averted on top of the cost of existing, validated resuscitation programs. Per hospital, this adds an extra $656 to initial training costs and averts approximately 26.84 years of disability in the cohort of children born in the first year, when projected over a lifetime. The findings were robust to sensitivity analyses. Total roll-out costs for AIR are estimated at $422,688 for the Mbeya region, averting approximately 9018 DALYs on top of existing resuscitation programs, which are estimated to cost $202,240 without AIR., Conclusion: Our modeling analysis finds that use of the AIR device may be both an effective and cost-effective tool when used as a supplement to existing resuscitation training programs. Implementation of this strategy in multiple settings will provide data to improve our model parameters and potentially confirm our findings.

Although most pediatric proximal humeral fractures can be successfully treated conservatively with satisfactory results, many operative techniques have been described for the treatment of displaced proximal humeral fractures. The aim of this study is to evaluate the efficacy of percutaneous fixation using a modified palm tree technique for proximal humerus fractures in children. Between March 2011 and May 2013, the modified palm tree technique was used for the management of 30 children (20 boys and 10 girls) with displaced proximal humeral fractures. The average age of the patients was 11.5 years (age range from 8 to 15 years). They were evaluated clinically by the Constant-Murley score and by radiological analysis. The average follow-up duration was 18 months. The average time of fracture union was 6 weeks (range from 4 to 8 weeks). The average Constant score of the patients was 92 (range from 87 to 95), with excellent results in 27 (90%) cases, good results in three (10%) cases, and no fair or poor results (0%). The reported complications were superficial pin-tract infection in five cases, treated by daily dressing and local antibiotics, and malunion with a varus deformity in two cases (about 15°), with no recorded cases with deep infection. None of the cases required open reduction. No cases were complicated by avascular necrosis of the head humerus or loss of fixation. Kirschner wires were removed after an average period of 7 weeks. The modified palm tree technique represents an efficient method for the treatment of proximal humerus fractures in children. It produces a good grip in both the proximal and distal fragments. It allows for early joint movements.

The aim of this study was to compare the results of treatment of segmental tibial defects in the pediatric age group using an Ilizarov external fixator versus a nonvascularized fibular bone graft. This study included 24 patients (age range from 5.5 to 15 years) with tibial bone defects: 13 patients were treated with bone transport (BT) and 11 patients were treated with a nonvascularized fibular graft (FG). The outcome parameters were bone results (union, deformity, infection, leg-length discrepancy) and functional results: external fixation index and external fixation time. In group A (BT), one patient developed refracture at the regenerate site, whereas, in group B (FG), after removal of the external fixator, one of the FGs developed a stress fracture. The external fixator time in group A was 10.7 months (range 8-14.5) versus 7.8 months (range 4-11.5 months) in group B (FG). In group A (BT), one patient had a limb-length discrepancy (LLD), whereas, in group B (FG), three patients had LLD. The functional and bone results of the Ilizarov BT technique were excellent in 23.1 and 30.8%, good in 38.5 and 46.2, fair in 30.8 and 15.4, and poor in 7.6 and 7.6%, respectively. The poor functional result was related to the poor bone result because of prolonged external fixator time resulting in significant pain, limited ankle motion, whereas the functional and bone results of fibular grafting were excellent in 9.1 and 18.2%, good in 63.6 and 45.5%, fair in 18.2 and 27.2%, and poor in 9.1 and 9.1%, respectively. Segmental tibial defects can be effectively treated with both methods. The FG method provides satisfactory results, with early removal of the external fixator. However, it had a limitation in patients with severe infection and those with LLD. Also, it requires a long duration of limb bracing until adequate hypertrophy of the graft. The Ilizarov method has the advantages of early weight bearing, treatment of postinfection bone defect in a one-stage surgery, and the possibility to treat the associated LLD. However, it has a long external fixation time.

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Twenty patients (11 males and nine females) with cubitus varus deformity were treated with corrective dome osteotomy through the paratricipital approach. Patients presented after an average 3 years of appearance of the deformity. The average age of the patients was 8.5 years (range 6-14 years). All patients had a previous history of supracondylar fracture. Preoperatively, carrying angle, lateral condylar prominent index, and range of motion were recorded. There were no intraoperative complications. Postoperatively, three patients developed a superficial skin infection. No patient had unsightly scarring or a prominent lateral condyle. No patient reported pain, motor weakness, or atrophy of the arm musculature. There was no fixation failure or loss of correction during the healing stage and no revision surgery was needed. The results were graded according to the preoperative and postoperative carrying angle, movement of flexion and extension, and lateral condylar prominence index and they were evaluated statistically. Preoperative and postoperative extension, carrying angle, and lateral condylar prominence index were statistically significant. Corrective dome osteotomy using the paratricipital approach seems to be a reliable technique for correction of cubitus varus in children. The procedure is relatively simple and enables correction of the deformity without inducing lateral condylar prominence.

Intertrochanteric fractures of the femur were treated with an external fixator in 38 elderly high-risk patients between November 2005 and February 2007. The mean operation time was 25 min (range: 20 to 32 min), the mean fluoroscopy time was 15 sec (range: 10 to 18 sec), and the mean hospital stay was four days (range: 3 to 7 days). The average time to union was 9.5 weeks. No deep pin track infections occurred; superficial skin inflammation was seen in 30%. Implant failure or knee stiffness were noted in no instance. At the latest follow-up, the mean femoral shaft-neck angle was 130 degrees (range: 116 degrees to 138 degrees), the average Harris hip score was 64 (range: 50-80). Mortality rate was 8% at 6 months from causes unrelated to the operation. The use of a multiplanar external fixator in these patients provided a satisfactory stability, reduced their time in hospital and facilitated their postoperative rehabilitation.

Twenty five intra-articular fractures of the calcaneus in 25 patients were reduced through a minimal incision and fixed with an Ilizarov external fixator. The average age of patients was 38.6 years (range: 17 to 62 years). According to the Sanders CT classification, 10 (40%) were type II, 9 (36%) type III, and 6 (24%) type IV. The average follow-up was 30 months (range: 24-40 months). According to the AOFAS scale for ankle and hind foot there were 6 (24%) excellent, 11 (44%) good, 6 (24%) fair, and two (8%) poor results. The average score was 68 with a range of 48 to 92. The average length of the treatment period with the fixator was 9.7 weeks (range, 8 to 12 weeks). Radiological assessment revealed reduction malalignment < 5 degrees in 22 cases and > 10 degrees in 3 cases. The calcaneal width averaged 112% of the contralateral side. The calcaneal height was restored to 92% of the normal side, the mean (+/- SD) Böhler angle was changed from 11 degrees +/- 9 degrees preoperatively to 24 degrees +/- 5 degrees postoperatively. The most common complication was superficial skin infection at wire insertion sites. The results with this technique in a small number of non randomised cases with an average follow-up of 2.5 years seem to indicate that it could be a good alternative to traditional methods for management of intraarticular calcaneus fractures, with fewer secondary problems.

Twenty two patients with intra-articular fractures of the distal humerus were operatively treated using the extensor mechanism-sparing paratricipital approach as described by Schildhauer et al. All fractures were AO type C (six AO type C1, 11 C2 and five C3). There were 16 males and six females with a mean age of 32.5 years. Internal fixation was achieved with bilateral plates and screws. The results were evaluated after a mean follow-up period of 30 months using Mayo Elbow Score. The results were graded as excellent in 13 patients (59.2%), good in six (27.3%), fair in two patients (9%) and poor in one (4.5%). The average range of flexion was 120 degrees +/- 8 degrees (range: 100 to 140), extension 6 degrees (range: 0 to 15). Eighty-two percent of patients had normal muscle strength in comparison to the contralateral side and 18% had good muscle strength. The average time to union was 2.4 +/- 1.6 months (range: 2 to 4). No implant failure, neurovascular deficit or nonunion was noted. There was one deep infection. The extensor mechanism-sparing paratricipital approach is an invaluable approach for fixation of intercondylar fractures of the humerus without negative effects on triceps strength; however it is not recommended for multifragmentary type C3 fractures.

Corticotomy and periosteal elevation as a surgical procedure for management of chronic critical limb ischaemia is a relatively new technique. The current study aimed at assessing its safety, efficiency and cost/benefit ratio. The procedure was performed in 36patients. Preoperative documentation for age, sex, co-morbidities, ankle systolic pressure, and magnetic resonance contrast angiography was obtained. Early results included evaluation of skin perfusion. Late results involved assessment of wound healing, which was documented with photographs and was graded (healed, healing, resistant, recurrent), pain (intermittent claudication and pain at rest), Kelkar score, procedure morbidity, patient satisfaction and quality of life. Mean age was 68.03 +/- 5.5 years; 23 patients were males (63.9%) and 13 females (36.1%). Twenty (55.6%) patients had ankle systolic pressure < 50 mmHg and 29 (80.5%) had infra-inguinal vascular disease. Skin perfusion improved in 33/36 patients (91.7%). At final follow-up, 34 patients (94.1%) achieved complete wound healing. Relief from ischaemic rest pain and intermittent claudication was achieved in 86.1% and 55.6% respectively, with 20 (55.6%) patients having an excellent Kelkar score. Only one patient required a major amputation. Morbidity was noted in 17.7% of cases. Patient satisfaction scores at 12 months and at final follow-up were 7.1 +/- 1.3, and 8.7 +/- 1.7 respectively, on a scale from 0 to 10. Quality of life was markedly improved as compared to the preoperative status (overall score: p = 0.05, mental health scale: p <0.05 and pain/anxiety domain: p < 0.001). The procedure appears to represent an interesting tool, which should be evaluated in randomised studies. Our findings support the postulated angiogenic effect of the fracture haematoma.

This study comprised 42 patients with cancer bladder, who underwent radical cystectomy. The aim of work is to determine if HLA-G is expressed on tumor cells, derived from cancer bladder. We studied HLA-G-mRNA expression using RT-PCR and HLA-G cell surface expression by immunohistochemistry (IHC) staining technique. HLA-G was expressed in 28.6 % of cancer cases as determined by PCR and on 16.7% of cases determined by IHC staining. The sensitivity, specificity and accuracy of IHC were 58.3%, 96% and 81.7% respectively as compared to PCR results. There was a highly significant increase in the expression of HLA-G on cancer bladder cases with metastatic prostate infiltration (P= 0.021). It is concluded that HLA-G is ectopically expressed on cancer bladder malignant cells both at molecular and protein levels. However, it is not significantly associated with histologic type, tumor grade, stage, T category, schistosomiasis and lymph node involvement.

Angelman syndrome is characterized by severe mental retardation, absence of speech, bursts of laughter, ataxia, seizure disorder and facial dysmorphism. This report describes the first 3 children with Angelman syndrome from Bahrain. The diagnosis was based on clinical features and confirmed by the presence of microdeletion of 15q11q13 using fluorescence in situ hybridization.