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Background: Airway management has progressed since the first orotracheal intubation using a blind digital technique. The Macintosh laryngoscope has allowed tracheal intubation under direct vision. Objective: The present study was designed to compare the effect of fiberoptic intubation, bonfils intubation and direct laryngoscope on the hemodynamics, time taken for intubation, stress response hormones (glucose, cortisol and C-peptide) in difficult airway patients. Subjects and Methods: This Prospective, randomized, controlled study included a total of 90 adult patients aged 21-50 years with physical status (ASA) I or II of both sexes undergoing general anesthesia for elective surgical procedures. Patients were subjected to clinical examination and full investigations and assessment of the patients’ airway by El-Ganzori score. Patients were randomly allocated into three equal groups, 30 patients each: Group A: direct laryngoscope, Group B: fiberoptic bronchoscope and Group C: bonfils fiberoscope. Results: Fiberoptic has significant hemodynamic stability after one min of intubation than bonfils and direct laryngoscope. While bonfils has significant hemodynamic stability after five minute and ten minutes after intubation and had highly significant short time of intubation than fiberoptic and direct laryngoscope. As regard to number of attempts, most patients were successfully intubated on the first attempt in group B, while on the second attempt in groups A, and group C which was statistically non-significant between three groups. Conclusions: It could be concluded that bonfils has hemodynamic stability after five minute and ten minutes after intubation and also had the shortest time of intubation than fiberoptic and direct laryngoscope.

Early microbial recognition by the innate immune system is accomplished by Toll-like receptors (TLRs), with resultant initiation of a pro-inflammatory response against infecting organisms. In spite of presence of an abundance of Toll-like receptors on the surface of the liver, gut bacteria does not elicit an inflammatory reaction in healthy individuals due to tolerance to these TLRs, suggesting that the inflammatory responses seen in the liver are the result of breakdown of this tolerance. While orthotopic liver transplantation is often life saving in many instances, death following this procedure is most commonly due to infection that occurs in up to 80% of transplant recipients, most commonly due to microbial causes in up to 70% of cases and viral infections in 20%, while fungal infections affect only 8% of cases. The probability of acquiring infection following hepatic transplantation is heightened due to affection of the innate immune defense mechanisms of the host following this procedure. Single nucleotide polymorphisms of TLRs have been associated with increased likelihood of either development of post-transplant infection or eradication of infecting organism. However, conflicting reports from other studies reveal that prevalence of this single nucleotide polymorphism is not increased in infected patients.

Objective : Facial nerve injury is a primary complication of open surgical management of condylar fractures. A new modification of the retromandibular transparotid approach, the “biportal transparotid dissection” (BTD), was developed to reduce these injuries in accidental nerve exposure. Design : Prospective cohort study Setting : Tertiary referral center Methods : Patients managed by retromandibular transparotid approach for condylar fractures at Department of Otolaryngology – Head and Neck Surgery, Mansoura University were included between November 2015 and August 2019 with exclusion of cases managed endoscopically or by a closed approach. Three groups were identified; Group A included patients undergoing the BTD technique, which entails transparotid dissection above and below exposed nerve branches and minimal nerve retraction; Group B included patients undergoing traditional dissection and nerve retraction away from the surgical field; Group C included patients with unidentified facial nerve branches. The function of facial nerve branches was documented postoperatively. Results : Fifty-seven fractures were included in the study. Facial nerve branches’ injury occurred in thirteen cases (22.8%): two (of ten) in Group A (20%), seven (of ten) in Group B (70%) and four (of 37) in Group C (10.81%). Compared to patients with non-exposed branches, Group A and B were found to have 2.06 (p=0.447) and 19.25 (p=0.001) greater odds of nerve injury, respectively. Results showed significant faster nerve recovery in the BTD group compared to traditional dissection (mean 5 versus 9 weeks) (p=0.015). Conclusion and relevance : Although avoiding facial nerve exposure minimizes injury the most, BTD approach reduces exposed nerve injury compared to the traditional method.

Importance: Although conventional hump resections are a hallmark of rhinoplasty, there has been a rekindled interest in dorsal preservation (DP) techniques as a means for addressing the dorsal hump, with claims of superior functional and aesthetic results. As such, an understanding of DP, including technical considerations and outcomes, is imperative. Observations: DP allows for mobilization of the osseocartilaginous nasal vault as a single unit and thereby prevents disruption of the natural keystone area. The osseous nasal vault is managed with a transverse osteotomy and either a bilateral single lateral osteotomy (pushdown procedure) or bilateral bony wedge resections (letdown procedure) to allow for descent of the nasal dorsum. A variety of approaches to the septum exist, each differentiated by the location of cartilage resection: subdorsal, high-septal, midseptal, or inferior septum. These techniques result in pleasing dorsal aesthetic lines but may be limited by a higher rate of dorsal hump recurrence. Patency of the internal nasal valve (INV) is theoretically improved with DP. Robust series with patient-reported outcomes are lacking, although several reports and early experience at our center with a newly described high-septal resection technique do suggest positive functional and cosmetic outcomes with DP. Conclusions and Relevance: With the recent revitalized interest in DP, an understanding of the potential benefits, techniques, and challenges associated with this surgery is helpful. Maintenance of the dorsum as a single unit has implications for maintaining structural integrity at the nasal keystone, pleasing dorsal aesthetic lines, and the patency of the INV. As surgeons continue to develop and employ these techniques, critical assessment of patient-reported outcomes and objective nasal measurements, with an emphasis on comparison with standard hump takedown techniques, will be valuable.

Objective: There is a paucity of research devoted to understanding the communication restrictions encountered by facial paralysis patients. We aim to explore the relationship between patient-reported restrictions in communicative participation and objective facial paralysis severity using validated scales of facial movement. Methods: We performed a pilot retrospective study using a consecutive series of adult patients with a diagnosis of unilateral facial paralysis. In addition to baseline demographics, subjects were evaluated using the Communicative Item Participation Bank Short Form (CPIB), Electronic Facial Assessment by Computer Evaluation (eFACE), and Sunnybrook Facial Grading System (SFGS). Results: Twenty patients were included, 10 (50%) of whom were female with a mean age of 61 ± 13 years and mean duration of facial paralysis of 53 ± 82 months. The mean CPIB score was 14.6 ± 10.0 (range 0-29) and was comparable to scores of patients with conditions known to cause significant communicative disability. The mean eFACE scores were 67.4 ± 29.2, 44.2 ± 30.1, and 73.8 ± 30.0 for the static, dynamic, and synkinesis domains, respectively, with a composite smile score of 58.5 ± 16.9. After adjusting for age, gender, and duration of facial paralysis, significant moderate correlations were observed between the CPIB and the static eFACE domain ( r = –0.51, P = .03) and smile composite score ( r = 0.48, P = 0.0049), in addition to between the CPIB and SFGS synkinesis domain ( r = 0.48, P = 0.04). Conclusions: Patients with unilateral facial paralysis experience significant limitations in communicative participation. These restrictions demonstrate moderate to strong correlations with objective assessments of facial paralysis and quality of life measures. Communicative participation may be a helpful means of tracking response to treatment. Level of Evidence: IV

OBJECTIVES/HYPOTHESIS To describe a novel technique for tip plasty and determine its efficacy using validated patient-reported outcome measures and objective measures. STUDY DESIGN Retrospective cohort study. METHODS This study was carried out at a tertiary center. Patients undergoing tip plasty using the miniature lateral crural strut grafts (mini-LCSG) in cosmetic/combined rhinoplasty between January 2016 and August 2019 with available outcome measures were included. We used the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS), Nasal Obstruction Symptom Evaluation (NOSE) scores, visual analog scale: functional and cosmetic, and lateral wall insufficiency (LWI) grades. RESULTS Among 52 patients, 33 were included; 26 had cosmetic whereas seven had combined functional and cosmetic rhinoplasty, with a follow-up up to 3 years. Both cosmetic and combined subjects showed significant improvement in SCHNOS-Cosmesis (C) scores (-57.31 ± 1.79, P

This study evaluates the impact of different hump takedown techniques, namely the conventional hump resection with midvault reconstruction, the push-down (PD) and the let-down (LD) procedures, on the INV dimensions. In this cadaveric study, six heads were divided randomly into either the conventional hump resection technique (Group A; n = 6 sides) or DPR techniques (n = 6 sides). This latter group was subdivided such that initially a PD procedure was performed (Group B; n = 6 sides), followed by a LD procedure on the same heads (Group C; n = 6 sides). A validated radiological method was used to measure the INV angle and cross-sectional area (CSA) in a modified coronal plane both pre- and post-procedurally. Group A did not show significant reduction in the INV angle nor in CSA (p = 0.068 and p = 0.156, respectively). In the push-down group (B), we observed a mean change of 2.05° in the angles and 0.3 cm2 in the CSA (p = 0.0163 and p

The Sequoia Field, in West Delta Deep Marine concession, represents deep marine slope channels in Nile Delta of Egypt. The main hydrocarbon bearing formation is the Late Pliocene El Wastani Formati...

IntroductionChildhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.MethodsProspective cohort study in 109 institutions in 41 countries. Inclusion criteria: children ResultsAll-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3–11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); pConclusionsChildren with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.

Objective: The present study was design to determine the biochemical changes effect of thyme, ginger and BOL as growth on male New-Zealand rabbits. Methods: Twenty four white New-Zealand male rabbits were selected at the age from 6-8 weeks old with an average body weight of 0.600 - 0.750 kg were used in the experimental investigation of this study. The rabbits were fed on a basal feed diet throughout the course of the experiment in the form of concentrated feed diet composed. All rabbits were randomly assigned into four equal groups (6 animals per each group). The biochemical analysis estimated total protein, lipid profile include: cholesterol and triglyceride, albumin, creatinine, blood serum aspartate aminotransferase (AST), alkaline phosphatase (ALP), oxidative stress marker such as glutathione (GSH) concentration, cytokine (IL-6), testosterone level and growth hormone were determine by using biolabo commercial kits with spectrophotometer, ELISA and radioimmunoassay machine at the biochemistry laboratory. Results: After one month treatments, no significance difference was found between the rabbits groups in initial body weight in the 1st administration compared 2nd administration. There was increasing of ALP and AST with ginger and increase of ALP with thyme even their positive effect on the other concerned parameters in our study. Ginger increase level of serum IL-6 levels and GSH concentrations, while thyme decrease its level in serum. Although Thyme supplementation group improved the growth performance and feed efficiency of rabbits in comparison to ginger supplementation group and control group.

This research paper is meant to explore the use of melancholy as an explanatory model to understand the individual and the collective psyche in dealing with the historical and cultural dilemmas. It will further explore individual and collective melancholy and their effects, whether destructive or constructive within Orhan Pamuk’s novel The White Castle, belonging to the modern Turkish literature.

Distraction osteogenesis maxillary expansion (DOME) is an emerging surgical concept for obstructive sleep apnea patients with a high-arched and narrow hard palate presenting with nasal obstruction. Herein we demonstrate the feasibility of DOME in the treatment of patients with persistent nasal obstruction after primary septoplasty.A total of 32 consecutive patients with persistent nasal obstruction after septoplasty who underwent DOME were enrolled in this study. The efficacy of DOME in treating persistent nasal obstruction in septoplasty failure patients was evaluated using the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Pre- and postoperative computed tomography (CT) scans were performed to measure the change of nasal floor width after surgery.NOSE score improved significantly from 13.62 ± 4.74 to 5.15 ± 3.50 (p 0.001) after DOME. The postoperative CT scan showed a significant increase of the nasal floor width from 22.4 ± 4.21 to 28.06 ± 4.52 (p 0.01). No patient had major complications such as wound infection, oronasal fistula, sinusitis, loss of incisor teeth, or malunion.We found that DOME appears to improve persistent nasal obstruction after septoplasty in patients with a narrow and high-arched hard palate.

Background The utility of penile suspensory ligament release (SLR) in the setting of penile prosthesis implantation (PPI) has received limited attention in the literature. Aim To assess the efficacy and safety of penile SLR release, pubic lipectomy (PL), and the utility of penopubic Z-plasty (ZP) during malleable PPI in improving sexual satisfaction compared to that achieved with the conventional method. Methods Between August 2018 and April 2020, 61 patients with refractory erectile dysfunction were prospectively randomized into 2 groups; group A included 31 patients who underwent PPI with SLR and PL via ZP, and group B included 30 patients who underwent conventional PPI via a penoscrotal incision. Outcomes Penile length was assessed at 3 months, and sexual satisfaction was assessed up to 1 year after PPI using both validated and non-validated tools. Results The median operative time was higher in group A than in group B (170 min; interquartile range [IQR] [160–190] vs 97.5 min; IQR [90–110] P < .001).The median pre- to postoperative differences in functional and visible penile lengths for group A were 1.5 cm; IQR [0–2] and 2.5 cm; IQR [1–3.5], respectively, while those in group B were both 0 cm; IQR [-1 to 0] P < .001). Group A patients reported higher scores in the International Index of Erectile Function satisfaction domains than the group B patients did (13; IQR [12–14] and 9; IQR [8–10] vs 11; IQR [9.5–12] and 8; IQR [6.5–8.5], respectively, P < .001). Moreover, the postoperative Erectile Dysfunction Inventory of Treatment Satisfaction score was higher in group A than that in group B (95.40; IQR [91–97.7] vs 85.20; IQR [72.7–91], respectively, P < .001). Common complications in group A were penile edema (77.4%), penile instability (9.7%) and glans numbness (9.7%). Clinical Implications The benefit in patient satisfaction following SLR and PL via ZP during PPI may outweigh the incremental increase in complications. Strength & Limitations To our knowledge, this is the first prospective randomized controlled study to evaluate the efficacy and safety of SLR, PL, and ZP during PPI. However, because an optimal tool for assessing sexual satisfaction after PPI is lacking at this time, we alternatively adopted the most used assessment tools. Further, our data applies only to malleable penile prosthesis. Conclusion SLR and PL via ZP during PPI resulted in a substantial improvement of the patients’ sexual satisfaction without serious complications.

Background Tissue perfusion and oxygenation monitoring is the fundamental of management to immediately identify and properly manage (impending) organ dysfunction in septic shock. This is a study of a prospective randomized trial that aims to comparing the prognostic value of lactate clearance versus base deficit correction as an indicator of tissue perfusion in septic shock, trying to prove the superiority of one over the other. Objective To assess the clinical utility of lactate clearance and arterial base deficit correction in predicting mortality in septic shock. Patients and Methods This is a Prospective randomized observational study that was conducted to assess the clinical utility of lactate clearance and arterial base deficit in predicting mortality in septic shock. This study included forty patients who were divided into two equal groups; each of twenty patients, group I (non-survivors), and group II (survivors). Results In this study, the base deficit values revealed statistically notable difference between the two groups at admission, 18 hours, 24 hours and 2 days of admission. The values revealed no notable difference at the 3rd. 4th, and 5th day of admission. At the 6th and 7th day of admission, the base deficit started to increase again in the non-survivor group with statistically notable increase in the values as compared to the survivor group. The cutoff point of base deficit to differentiate between nonsurvivors from survivors was > 11.43 with 62% sensitivity and 100% specificity. In this study, initial serum lactate levels at admission revealed higher accuracy in prediction of mortality as compared with initial base deficit. Conclusion Lactate clearance is a better predictor of mortality and morbidity than base deficit correction.

Upper airway surgery is a common therapeutic approach recommended for patients with obstructive sleep apnea (OSA) to decrease disease burden. We aimed to evaluate the effect of perioperative antibiotic prescription on complication rates.Retrospective cohort (national database).Tertiary referral center.This is a retrospective study of a large national health care insurance database (Truven MarketScan) from 2007 to 2015. Subjects diagnosed with OSA who had uvulopalatopharyngoplasty (UPPP) were included and stratified in single versus multilevel surgery. Other variables included smoking, age, sex, antibiotic prescription, and comorbidities based on the Elixhauser index. Evaluated outcomes were postoperative bleeding, intubation, pneumonia, superficial surgical site infection, tracheostomy, and hospital readmission. A multivariate regression model was created to assess each complication.A total of 5,798,528 subjects received a diagnosis of OSA, of which 39,916 were18 years old and underwent UPPP, either alone or with additional procedures. The mean age was 43 years, and 73.4% were male. Antibiotic prescription was associated with less bleeding in UPPP alone, UPPP with nasal surgery, and UPPP with nasal and tongue surgery (Although former studies recommended against the use of antibiotics after tonsillectomy, our results suggest that antibiotic prescription after UPPP for OSA was associated with less bleeding, surgical site infection, pneumonia, intubation, tracheostomy, and hospital readmission 30 days postoperatively.

BACKGROUNDS Rhinoplasty necessarily concerns functional and cosmetic aspects, and outcomes of both should be assessed in each patient. There has been a lack in the literature in Italian for a comprehensive tool for assessing both aspects of rhinoplasty. The objective is to translate and validate the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) into Italian. METHODS Forward and back-translation was used. Content validity was evaluated by experts and by patient interviews. Internal consistency was assessed by a Cronbach's alpha. The structure validity was assessed by an exploratory factor analysis. RESULTS Cognitive interviews of 10 rhinoplasty patients resulted in a good overall comprehension of the SCHNOS. Of the 411 respondents, 281 (32%) were women, and the average age was 33.6 (11.3) years. The alpha was excellent for both the obstruction domain (SCHNOS-O) (0.90) and the cosmetic domain (SCHNOS-C) (0.94). All the correlations between repeated measures were moderate to very strong. The exploratory factor analysis demonstrated unidimensionality of both the SCHNOS-O and the SCHNOS-C scores. CONCLUSIONS The SCHNOS was successfully translated and validated in Italian and can be recommended for a clinical use among rhinoplasty patients. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Novel substituted [1,2,3]triazolo[4,5-d]pyrimidine-7-one derivatives were synthesized using 1,2,3-triazolo-4-carboxamide derivative (2) by the reaction with carbon disulfide, triethoxymethane, 4-fluorobenzaldehyde and ethyl benzoate respectively. The S-glucoside, N-glycoside derivatives and acyclic sugar analogs of new synthesized [1,2,3]triazolo[4,5-d]pyrimidines were also synthesized. The synthesized compounds were tested for cytotoxicity and in vitro anticancer activity versus human lung (A549), colon (HCT116) and breast (MCF-7) cancer cell lines. The results disclosed that the synthesized compounds apply their activities in A549 and MCF-7. MCF-7 cells are more sensitive to the tested compounds than the other cell lines. Compounds 2, 3, 9 and 10 exposed promising anticancer activities compared to the action of the ordinarily used anticancer drug, doxorubicin in both A549 and MCF-7 cell lines. A good binding affinities for compounds 2, 3, 6, 10 and 11 were noted in docking studies. Results showed a clear effect of N3-substitution in pyrimidine ring on the activities of the synthesized compounds

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Obje...

This study evaluated the effect of spraying incubated quail eggs with betaine on chick development, hatchability and some physiological estimates of Japanese quails during early embryogenesis. A total of 750 eggs were equally divided into two groups (2 groups × 5 treatments × 5 replicates × 15 eggs). Eggs in the 1st group were incubated at normal incubation temperature (37.5°C/NIT), while those in the 2nd group were incubated at chronic incubation temperature (39.5 °C/CIT) for 3 hours daily from the 4th up to and 6th day of incubation. Eggs in NIT and CIT groups were subjected to five treatments, T1 (negative control), T2 sprayed distilled water (positive control), while T3, T4, T5 groups sprayed distilled water supplemented with 500, 1000 and 2000mg betaine/L respectively. The chick weight at hatch and slaughter weight and first egg weight was significantly impaired by CIT treatment. CIT group revealed a significant increase in the H/L ratio and a significant decrease in T3 hormone and blood protein levels than the NIT group. Regarding betaine effects, the embryonic mortality rates, hatchability, hatched chick weight, and slaughter weight were significantly improved compared with the control. Also, betaine significantly increased blood protein and T3 hormone levels and significantly decrease the liver enzymes levels and total feed consumption compared with untreated group. The RV/TV ratio of quails in CIT group was significantly increased, while betaine treatment significantly decreased this ratio. Considering these results, it’s strongly suggested that spraying of betaine on eggs at 1000 or 2000 mg//L optimizes Japanese quails performance.

As appraisals are considered one of the most problematic and challenging modules of human resource management in hotels, This study discusses the evaluation of staff performance at the food and beverage department, and compare between the hotel of Egyptian company of tourism and hotels (EGOTH) and Accor hotel chain. Primary data was collected using a questionnaire survey of managers and supervisors in the hotel of Egyptian company of tourism and hotels (EGOTH) and Accor hotel chain. Finally, the correlation test was conducted to identify the relationship between the challenges of the performance appraisal process and the employees' performance appraisal in the hotels under study. The results indicated that there is a significant and negative relationship between challenges of the performance appraisal process and employees’ performance appraisal in the food and beverages department in both E.G.O.T.H. and Accor hotels. Finally, this study recommended that these hotels should Set clear criteria for employees' performance appraisal, characterized by fairness, accuracy, and objectivity, and emphasizing that the performance appraisal process aims to develop and improve their performance and address the shortcomings of performance rather than punishment.

To assess the effect of distraction osteogenesis maxillary expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes.Retrospective cohort study.Tertiary referral center.After Institutional Review Board approval, included subjects were those with obstructive sleep apnea, had undergone DOME from September 2014 to April 2018, and had cone beam computed tomography scans available before and after expansion. Measurement of the internal nasal valve parameters was performed with Invivo6 Software (version 6.0.3). Interrater reliability of all pre- and postexpansion parameters was measured. Patient-reported outcome measures included the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) and Epworth Sleepiness Scale scores, and correlation between objective and subjective outcomes were evaluated by Spearman correlation analysis.Thirty-two subjects met inclusion criteria. All showed significant improvement in their subjective outcomes as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in postexpansion NOSE score (right angle,DOME widens the internal nasal valve objectively (dimensions), which correlates significantly with subjective improvement (NOSE scores).

IMPORTANCE: Identifying factors affecting forehead flap neovascularization during nasal reconstruction surgical procedures using quantitative dynamics of fluorescence from indocyanine green angiography may be associated with reduced vascular complications. OBJECTIVES: To identify quantifiable forehead flap perfusion measures using indocyanine green angiography during nasal reconstruction procedures and to evaluate clinical factors associated with neovascularization. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 71 patients at a tertiary referral center of Stanford University, Stanford, California, between January 1, 2010, and March 31, 2018, undergoing forehead flap nasal reconstruction surgery with flap perfusion assessed by indocyanine green angiography. EXPOSURES: Indocyanine green angiography was performed intraoperatively to record forehead flap neovascularization during the second stage of nasal reconstruction surgery after temporary clamping of the pedicle. MAIN OUTCOMES AND MEASURES: With use of quantifiable data of fluorescence dynamics, flap perfusion in association with a reference point in the cheek after pedicle clamping was assessed by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio and (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of indocyanine green flap inflow, maximum fluorescence [peak], and midpoint of indocyanine green flap outflow) and their calculated mean. Association of the perfusion measures with patient and procedural factors was performed using linear regression models. RESULTS: Of the 71 patients included in the study, 43 (61%) were men; the mean (SD) age was 71.1 (11.0) years. The mean (SD) flap-to-cheek inflow ratio was 0.48 (0.40), peak fluorescence ratio was 0.59 (0.34), and outflow ratio was 0.88 (0.42). The calculated mean (SD) flap-to-cheek perfusion ratio of these measures was 0.65 (0.35). The mean (SD) flap-to-cheek ingress ratio was 0.54 (0.36) and egress ratio was 0.65 (0.98). With use of a multivariable regression model, the time between stages was positively associated with flap-to-cheek ingress ratio (β, 0.015; 95% CI, 0.001 to 0.030), and cartilage grafting was negatively associated with flap-to-cheek outflow ratio (β, –0.240; 95% CI, –0.472 to –0.008). CONCLUSIONS AND RELEVANCE: The findings suggest that indocyanine green angiography is an effective method to quantify relative neovascularization perfusion of forehead flaps. Future applications may include the use of this technology to aid in early flap division and ensure adequate perfusion among high-risk patients. LEVEL OF EVIDENCE: NA.

IMPORTANCE: Assessment of melolabial flap perfusion using indocyanine green (ICG) angiography for nasal reconstruction has not been previously described. OBJECTIVE: To assess melolabial flap relative perfusion using ICG angiography in nasal reconstruction and highlight its clinical relevance. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective case series at a tertiary referral center, 10 patients undergoing melolabial flap reconstruction of nasal defects between January 2015 to April 2018 with flap perfusion were assessed by ICG angiography. EXPOSURES: Indocyanine green angiography was performed to assess melolabial flap perfusion at second stage surgery after temporary clamping of the pedicle and after pedicle division and flap inset. MAIN OUTCOMES AND MEASURES: Flap perfusion in relation to a reference point on the cheek was calculated after both pedicle clamping and division by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio; (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of ICG flap inflow, maximum [peak] fluorescence, and midpoint of ICG outflow), and their calculated mean. Correlations of perfusion with time between stages, and patient factors were performed; perfusion parameters after temporary pedicle clamping and after division and flap inset were compared. RESULTS: Ten patients (mean [SD] age, 66 [7.5] years) were enrolled with a mean (SD) interval of 23 (4) days between first and second surgery. No correlation existed between perfusion parameters and time interval between first and second stage, or any other patient factors. Of the different perfusion parameters, a statistically significant difference was observed when comparing temporary clamping and postdivision mean (SD) flap-to-cheek perfusion ratio (0.89 [0.22] and 0.80 [0.19]; 95% CI, 4.1-12.6; P = .001), as well as mean (SD) peak perfusion ratio (0.81 [0.2] and 0.77 [0.2]; 95% CI, 0.005-0.080; P = .02) only. No partial or complete flap necrosis was reported after pedicle division. CONCLUSIONS AND RELEVANCE: Indocyanine green angiography is an effective method to determine neovascularization perfusion of melolabial flaps, with a mean perfusion of 89% after pedicle clamping. Future applications of this technology include use in patients at high risk for flap necrosis, or those who may benefit from early flap division to ensure adequate perfusion and minimize the time interval between staged procedures. LEVEL OF EVIDENCE: NA.

To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis.Retrospective cohort.Tertiary referral center.Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability.Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations (The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

Iatrogenic intra operative acute coronary artery obstruction is a rare and potentially fatal complication of valve surgery [1]. Sudden coronary spasm, embolization of calcium plaque, and surgical factors can induce acute coronary obstruction after AVR [2]. Initially described in 1967, following aortic valve surgery, it is now recognized that patients who develop myocardial ischemia postoperatively following valve surgery, should be investigated deeply to exclude this rare phenomenon as the cause of myocardial dysfunction [3]. Although most reports highlight the potential for coronary artery stenosis in the months following valve surgery there are few documented cases of intraoperative coronary embolism causing circulatory collapse and requiring prompt treatment [5]. After Ethical Committee approval and after written consent taken from the patient family for publication, we present a case of acute intra operative left main coronary artery obstruction after Aortic Valve Replacement (AVR) and its immediate management.

Objectives: Serous ovarian carcinoma (SOC) is the commonest ovarian carcinoma type with poor prognosis due to early metastasis and first presentation with advanced stage. In this work, we investigated serum level of Galactin-1 (Gal-1) and its tissue immunohistochemical expression in SOC patients at different stages trying to find out its significance as a diagnostic and prognostic marker. Patients and methods: The study included 95 females I-Control group: Twenty five healthy females; II-Patients group: Seventy females diagnosed as SOC at different stages; Stage I: 8 cases, Stage II: 12 cases, Stage III: 32 cases and Stage VI:18 cases. Serum Galectin-1 and CA-125 were measured by ELIZA and tissue Galectin-1 was assessed by immunohistochemistry. All patients were followed for up to 3 years after surgery. Results: Serum Gal-1 and CA-125 levels were significantly higehr in SOC patients compared to controls (p 135 ng/ml was superior to CA-125 a cut off value > 49 u/ml with sensitivity, specificity of 100%, vs 88.57, 96% for CA-125. Serum Gal-1 was significantly associated with tumor stage (p < 0.001). Immunohistochemistry showed that patients with strong Gal-1 expression had higher serum level (p = 0.002). Stromal and tumor Gal-1 expression were significantly correlated with tumor grade (p < 0.001) and stage (p = 0.001). Serum Gal-1, CA-125 and IHC Gal-1 expression were associated with poor survival (p < 0.001, p = 0.009 and p = 0.002) respectively. Conclusion: Serum Gal-1 and its tissue IHC expression are useful diagnostic and prognostic markers for SOC patients.

Background: Obesity is a major risk factor for endometrial carcinoma, and we aim to assess markers of carcinogenesis including PTEN and Ki-67 and hormone receptors profile including ER, PR and AR before and after bariatric surgery to find out its effects in reducing endometrial carcinoma risk in morbid obese females. Patients and methods: The study included 80 females with morbid obesity (BMI > 40 Kg/m2) who underwent bariatric surgery. All were sampled by Pipelle biopsy at baseline and 12 months after operation and examined histopathologically and immunohistochemically for Ki-67, PTEN, ER, PR and AR. Results: Sixty two out of 80 (62/80) females showed no pathological abnormalities; 4 had polyps; 7 had simple endometrial hyperplasia; 4 had atypical endometrial hyperplasia and 3 had endometrial carcinoma. In total, 34 females underwent gastric bypass operation (42.5%) and 46 underwent a sleeve gastrectomy operation (57.5%). There was a statistically significant difference between baseline weight and BMI before and after surgery (p Conclusion: Females with morbid obesity have a higher risk of harboring endometrial abnormalities even if asymptomatic. However, the endometrial pathology and the high ER and PR expression can be normalized within one year without medical treatment, signifying the role of bariatric surgery-induced weight loss in reducing the risk of endometrial neoplasia development. Also, the marked weight loss occurring after bariatric surgery induces highly significant endometrial change as resolution of atypical hyperplasia, and molecular changes as reduction of Ki-67 and restoration of PTEN that are associated with transition of endometrium from high to low risk.

This study proposes a way of designing a reliable voltage controller for buck DC/DC converter in which the terminal attractor approach is combined with an enhanced reaching law-based Fast Terminal Synergetic Controller (FTSC). The proposed scheme will overcome the chattering phenomena constraint of existing Sliding Mode Controllers (SMCs) and the issue related to the indefinite time convergence of traditional Synergetic Controllers (SCs). In this approach, the FTSC algorithm will ensure the proper tracking of the voltage while the enhanced reaching law will guarantee finite-time convergence. A Fuzzy Neural Network (FNN) structure is exploited here to approximate the unknown converter nonlinear dynamics due to changes in the input voltage and loads. The Fuzzy Neural Network (FNN) weights are adjusted according to the adaptive law in real-time to respond to changes in system uncertainties, enhancing the increasing the system’s robustness. The applicability of the proposed controller, i.e., the Adaptive Fuzzy-Neural Fast Terminal Synergetic Controller (AFN-FTSC), is evaluated through comprehensive analyses in real-time platforms, along with rigorous comparative studies with an existing FTSC. A dSPACE ds1103 platform is used for the implementation of the proposed scheme. All results confirm fast reference tracking capability with low overshoots and robustness against disturbances while comparing with the FTSC.

Putting a new concerning to each of the Eastern Mediterranean, offshore plays, gas detection using the most advanced tools, and the zones between gas zones which may not be easily recognized. This was done by adding the total combinable magnetic resonance (TCMR), to density porosity (PHIT-D), and density magnetic resonance porosity (DMRP). X-gas reservoir in the offshore Eastern Mediterranean used as case study. PHIT-D highest result values exist against gas bearing zones with about 29% in X-D5 and lowers at zones not bearing gas with about 6% in X-D3. TCMR highest result values exist against zones not bearing gas with about 49% in X-D5 and lower value zones bearing gas with about 32% in X-1. DMRP in the gas bearing zones does not increase like PHIT-D or decrease like TCMR so it is considered the best gas detector against gas bearing reservoirs and that is very useful. By comparing PHIT-D with DMRP, the gas zones are best detected, but in between zones, some gas zones not detected. By adding TCMR to the comparison, some new gas zones are detected which are lying in-between normal detected gas zones; so, this is a new solution. Interpretation is that PHIT-D is a tool, but DMRP is not a tool and is just integration between two tools: density and NMR. This makes a blind zone between density and DMRP which could be cleared by adding TCMR tools at the same time. The new method will change the producibility from gas reservoirs for the future operations in Eastern Mediterranean plus the previous reservoir production. Also, still applicable to any other gas reservoir.

The main purpose of this paper to compare and analyze three types of controllers in the three phases DC–AC inverters in hybrid renewable energy source (HRES) systems. To achieve this, two modern controllers are developed and compared based on sliding mode control (SMC) and artificial neural network techniques. The HRESs comprise photovoltaic (PV), wind turbines, battery storage systems, and transmission lines connected to infinite bus bars via a step-up transformer. The developed controllers at the inverter side utilize both voltage control and current regulation. A DC–DC boost converter is employed to set up a voltage demand at the point of common coupling (PCC). Then, the formulation of an HRES with the developed controllers is presented. The developed controllers are considered to operate under various solar radiations, temperatures, and wind speed loading conditions. The HRESs with the developed controllers are simulated via MATLAB/Simulink to verify the effectiveness of the developed controllers. The obtained results demonstrate that adaptive SMC and artificial ANN control techniques give better results in terms of input power, output power, current, and voltage when compared to classic PI control.

The site investigations in the new urban areas are aim to map the shallow clay soils and their geotechnical properties which are considered the main reason for most engineering and environmental problems. The present study is conceded for assessing the soil characterization of Quaternary alluvial deposits which are covered sites of the new urban projects amidst desert fringes of East Nile Delta, Egypt (e;g. Tenth of Ramadan city, Cairo-Ismailia desert road). The site investigations were carried out on distributed and undistributed samples collected from 10 drilled boreholes with maximum depth of 10 m. Several field and lab tests were carried out to determine the physical and geotechnical site characterizations including free swelling, Self-penetration test (SPT), Uniaxial Compressive Strength (UCS), Water-content (WC) and others. The obtained results indicate that, the soil properties in the site are variable within a short distance and, consequently, difficult to be predicted. Surficial soils have medium plastic values, low compressive strength, saturated and moderate swelling potentiality. Accordingly, clayey soils were generally rated as poor material for backfill or embankments. Furthermore, gravelly sand soils are classified as a good foundation material for sup-porting structures, roads and embankment and can be used for backfill material for retaining walls. Based on the inferred geotechnical and physical properties, foundation and environmental problems in the suggested site or other related regions could be evaluated.

Metallorganische Gerüste (MOFs) sind poröse Hybridmaterialien, die aus einem Metallzentrum bestehen, verbunden über Koordinationsbindungen mit einem organischen Linker. Nahezu unendliche Möglichkeiten der Metall-Linker-Kombination haben bisher zu einer großen Anzahl von MOF-Strukturen (>100.000) mit unterschiedlichen Strukturtopologien geführt. Die Eigenschaften von MOFs können durch eine durchdachte Auswahl der Metallzentren und organischen Linker abgestimmt werden, um MOFs spezifisch für bedarfsgerechte Anwendungen zu entwickeln. Bezugnehmend auf die weit fortgeschrittenen Anwendungen, ist die Herstellung von Festkörper-MOFs mittels der herkömmlichen Solvothermal-Methode nicht immer zielführend. Heterogene Morphologie, schwächere Anbindung an das Substrat und eine hohe Fehlstellendichte , wie in Festkörper-MOFs vorhanden, beeinflussen stark die Struktur-Eigenschafts Korrelation. Ein Ansatz zur Herstellung monolithischer kristalliner MOFs mit gut kontrollierten Dicke ist das Schicht-für-Schicht (LbL – layer-by-layer) -Verfahren über das Flüssigphasen-Epitaxie-Technik. In dieser Arbeit habe ich diese Technik verwendet, um hochkristalline, monolithische und orientierte SURMOF Strukturen aufzubauen. Eine hier verwendete Art von organischem Linker nennt sich photoaktive Verbindungen. Die räumliche Anordnung dieser photoaktiven Moleküle in der SURMOF-Plattform lieferte also hervorragende photophysikalische Eigenschaften. In der vorliegenden Arbeit habe ich ein Bianthrylchromophor untersucht, das mit metallkoordinierenden Gruppen ausgestattet ist, um einen photolumineszierenden oberflächenverankerten MOF -Dünnfilm (SURMOF) auf Zn-bianthrylbasis zu konstruieren. Die Zn-bianthryl-SURMOF haben eine gestapelte 2D-Schichtstruktur, die bei Anregung mit ultraviolettem (UV) Licht eine Cyan-Lumineszenz zeigt. In Reaktion auf die verlängerte UV-Bestrahlung in der Umgebungsbedingungen, zeigte der SURMOF auf Zn-bianthrylbasis jedoch eine deutliche Änderung der optischen Eigenschaften des Grund- und des angeregten Zustands, ohne seine Kristallstruktur zu verlieren. Eine detaillierte spektroskopische Untersuchung unter Verwendung von UV-Vis, FTIR, Raman, EPR und NEXAFS zeigte die Bildung der stabilen oxidierten Produkte von Bianthryl (Endoperoxid-Bianthryl) im SURMOF. Die vorliegende Studie identifiziert die Schlüsselfaktoren des Bianthryloxidationsprozesses, die einen selbstsensibilisierten photochemischen Weg beinhalten. Auch redoxaktive metallorganische Gerüste (MOFs) auf Viologenbasis haben in den letzten Jahren unter dem Gesichtspunkt intelligenter optisch aktiver Materialien großes Interesse gefunden. Hier wird ein Dicarboxylat-funktionalisiertes Viologen, 1,1‵-Bis (4- (carbonsäure) phenyl) - [4,4‵-bipyridin] -1,1‵-diiumdichlorid (viologen), als Linker zum Aufbau von SURMOF-Dünnfilmen unter Verwendung eines Schicht-für-Schicht-Flüssigphasen-Epitaxie-Verfahrens hergestellt. Diese Technik erzeugt ein hochkristallines, orientiertes SURMOF-2 auf Viologenbasis. Der orientierte, monolithische, kristalline SURMOF-Dünnfilm zeigt im Vergleich zu den zuvor beschriebenen Pulver-MOFs auf Viologenbasis eine schnell reversible Photochromie. Die Photochromie im SURMOF wird mittels UV-Vis, EPR und XPS untersucht.

Background: The effect of moral distress among healthcare providers is significant on disease morbidity, especially within the intensive care unit (ICU). In this systematic review and meta-analysis, we aimed to gather all evidence regarding moral distress frequency and severity/intensity among ICU health care providers. Methods: We conducted a systematic search to gather all relevant studies from six databases, followed by a manual search of references. Fourteen studies consisting of 5905 participants were included in the final moral distress scale analyses. Results: Overall, there was moderate moral distress severity/intensity among all participants (Mean = 27.79; 95% confidence interval (CI) = 7.40–64.18). On further stratification of the results according to countries, Canada (Mean = 91.99; 95% CI = 80.10–105.65) and USA (Mean = 52.54; 95% CI = 44.78–61.64) showed the highest distress scores, followed by Iran (Mean = 21.20; 95% CI = 7.21–62.30) and Italy (Mean = 3.42; 95% CI = 3.15–3.72). Studies conducted in high income-earning countries reported more severity/intensity (Mean = 22.65; 95% CI = 6.58–78.02) compared to those in the upper-middle income-earning ones (Mean = 18.89; 95% CI = 2.80–127.34). There was significant heterogeneity among the included studies, which could not be explained by the difference in scales, country of the participants, or the female proportion. Moreover, there was a moderate frequency of moral distress (Mean = 46.83; 95% CI = 8.34–262.87), which was found to be much higher (Mean = 87.94; 95% CI = 83.55–92.57), in performing analysis. Conclusion: Moral distress is a major problem in the ICU setting, in terms of both severity/intensity and frequency. Future large-scale studies are required, through a unified framework, to develop appropriate interventions to address ICU-related moral distress.

Introduction Anatomic characterization of the upper airway remains important in directing and monitoring care of patients with obstructive sleep apnea (OSA). Nasopharyngoscopy is routine in clinical practice, but it is invasive, non-reproducible, and only allows subjective assessment. We used machine-learning enabled ultrasonography to correlate upper airway tissue characteristics with OSA severity. Methods Sixty-three subjects (14 female) with a mean age of 39.4±12.6 years, BMI of 26.4±4.6 kg/m2, and AHI of 19.0±16.1 were consented from Stanford Sleep Surgery (July 2020 to May 2021). Standardized ultrasound protocol was used to image the soft palate, oropharynx, and tongue-base. Via machine learning, an FDA-cleared backscattered ultrasound imaging (BUI) of the upper airway was performed. Combined with B-mode measurements of airway muscular cross-sections, a logistic regression model was built to correlate with OSA severity. Results BUI of subjects with mild OSA was different from moderate-severe (AHI≥15) OSA at the soft palate (p=0.0007). The axial-to-lateral ratio of upper airway length was reduced in the lower soft palate of the moderate-severe group (p =0.0207). The logistic regression model with BUI, axial-to-lateral ratio at the soft palate, and BMI showed an Area Under the Receiver Operating Characteristic (AUROC) curve of 0.84 (95% CI 0.726 to 0.920) in moderate-severe OSA. Conclusion A non-invasive yet replicable technique to visualize and phenotype the upper airway is critical in the management of patients with sleep-disordered breathing. Sonographic BUI combined with B-mode airway measurements analyzed by machine learning show promise in characterizing the upper airway in patients with moderate-severe OSA. Support (If Any)

In this paper, the dynamic combined economic environmental dispatch problems (DCEED) with variable real transmission losses are tackled using four metaheuristics techniques. Due to the consideration of the valve-point loading effects (VPE), DCEED have become a non-smooth and more complex optimization problem. The seagull optimization algorithm (SOA), crow search algorithm (CSA), tunicate swarm algorithm (TSA), and firefly algorithm (FFA), as both nature and biologic phenomena-based algorithms, are investigated to solve DCEED problems. Our proposed algorithms, SOA, TSA, and FFA, were evaluated and applied on the IEEE five-unit test system, and the effectiveness of the proposed CSA approach was applied on two-unit, five-unit, and ten-unit systems by considering VPE. We defined CSA for different objective functions, such as cost of production, emission, and CEED, by considering VPE. The obtained results reveal the efficiency and robustness of the CSA compared to SOA, TSA, FFA, and to other optimization algorithms reported recently in the literature. In addition, Matlab simulation results show the advantages of the proposed approaches for solving DCEED problems.

Preservation rhinoplasty may refer to preserving several anatomic components including: the nasal bones, upper lateral cartilages, the keystone area and/or ligaments of the nose. Preserving the osseocartilaginous framework or "dorsal preservation" minimizes or completely avoids violation of the dorsal aesthetic lines' architecture. Conventional hump reduction in open rhinoplasty disrupts these lines; however, it also provides versatility to reshape the entire dorsum. Surgical success with either technique requires a thorough understanding of the underlying nasal anatomy.