Search

Safwat Eldaabossi,1,2 Yasser Al-Ghoneimy,3 Ayman Ghoneim,3,4 Amgad Awad,5,6 Waheed Mahdi,2– 7 Abdallah Farouk,8,9 Hesham Soliman,10 Hatem Kanany,11 Ahmad Antar,12 Yasser Gaber,13,14 Ahmed Shaarawy,1 Osama Nabawy,1 Moaz Atef,1 Sameh O Nour,1 Ahmed Kabil1 1Department of Chest Diseases, Al-Azhar University, Cairo, Egypt; 2Pulmonology Department, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 3Cardiothoracic Surgery Department, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 4Department of Cardiothoracic Surgery, Al-Azhar University, Cairo, Egypt; 5Nephrology Department, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 6Department of Internal Medicine, Al-Azhar University, Cairo, Egypt; 7Department of Chest Diseases, Banha Faculty of Medicine, Banha, Egypt; 8Critical Care Consultant, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 9Department of Critical Care, Alexandria Faculty of Medicine, Alexandria, Egypt; 10Consultant and Chief of Anesthesia, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 11Department of Critical Care and Anesthesia, Al-Azhar University, Cairo, Egypt; 12Department of Internal Medicine, Hematology-Oncology Section, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 13Radiology Department, Almoosa Specialist Hospital, Al Ahsa, Saudi Arabia; 14Department of Radiology, Al-Azhar University, Cairo, EgyptCorrespondence: Ahmed Kabil, Department of Chest Diseases, Al-Azhar University, Cairo, Egypt, Tel +201006396601, Email a_ka_81@hotmail.comBackground: Pulmonary complications after thoracic surgery are common and are associated with prolonged hospital stay, higher costs, and increased mortality. This study aimed to evaluate the value of The Assess Respiratory risk in Surgical Patients in Catalonia (ARISCAT) risk index in predicting pulmonary complications after thoracic surgery.Methods: This retrospective study was conducted at Almoosa Specialist Hospital, Saudi Arabia, from August 2016 to August 2019 and included 108 patients who underwent thoracic surgery during the study period. Demographic data, ARISCAT risk index score, length of hospital stay, time of chest tube removal, postoperative complications, and time of discharge were recorded.Results: The study involved 108 patients who met the inclusion criteria. Their mean age was 42.5 ± 18.9 years, and most of them were men (67.6%). Comorbid diseases were present in 53.7%, including mainly type 2 diabetes mellitus and hypertension. FEV1% was measured in 58 patients, with a mean of 71.1 ± 7.3%. The mean ARISCAT score was 39.3 ± 12.4 and ranged from 24 to 76, with more than one-third (35.2%) having a high score grade. The most common surgical procedures were thoracotomy in 47.2%, video-assisted thoracoscopic surgery (VATS) in 28.7%, and mediastinoscopy in 17.6%. Postoperative pulmonary complications (PPCs) occurred in 22 patients (20.4%), mainly pneumonia and atelectasis (9.2%). PPCs occurred most frequently during thoracotomy (68.2%), followed by VATS (13.6%), and mediastinoscopy (9.1%). Multinomial logistic regression of significant risk factors showed that lower FEV1% (OR = 0.88 [0.79– 0.98]; p=0.017), longer ICU length of stay (OR = 1.53 [1.04– 2.25]; p=0.033), a higher ARISCAT score (OR = 1.22 [1.02– 1.47]; p=0.040), and a high ARISCAT grade (OR = 2.77 [1.06– 7.21]; p=0.037) were significant predictors of the occurrence of postoperative complications.Conclusion: ARISCAT scoring system, lower FEV1% score, and longer ICU stay were significant predictors of postoperative complications. In addition, thoracotomy was also found to be associated with PPCs.Keywords: thoracic surgery, postoperative complications, pulmonary complications, ARISCAT score, atelectasis, pneumonia

The common causes of stridor in adults are abscesses or swelling of the upper airway, tumors, paralysis, or malfunction of vocal cords. Tracheitis due to immunoglobulin deficiency may be a rare explanation for stridor in adults, although occasionally reported in children. We report an adult man having stridor secondary to isolated immunoglobulin A deficiency. We did an in-depth review of the literature to seek out no reported cases of stridor thanks to immunoglobulin deficiency in adults. This case underlines the very fact that a standard symptom like stridor rarely occurs thanks to uncommon causes. This case is exclusive because it reports the presence of stridor associated with isolated immunoglobulin A deficiency in an adult patient. The explanation for the stridor was an intraluminal narrowing of the upper part of the extrathoracic trachea.

Background Modified pectoral nerves (PECSII) and serratus blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This prospective randomized, controlled study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus blocks in patients undergoing modified radical mastectomy (MRM) for breast cancer. Patients and Methods One-hundred and eighty adult females scheduled for MRM were randomly allocated to three groups. PECS group patients received a PECSII block with 30mL of bupivacaine 0.25%, whereas SAPB group received a serratus anterior plane block (SAPB) using the same volume of bupivacaine 0.25% before induction of anesthesia. The control group received general anesthesia alone. Outcomes included 24 hours morphine consumption, intraoperative fentanyl requirements, visual analogue scale (VAS) scores for pain at rest and during movement, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and sedation scores. Results Both PECSII and serratus blocks were associated with reduced postoperative morphine consumption compared to the control group (p

Abstract New corona virus disease COVID-19 is a pandemic outbreak viral infection that is highly contagious. The disease can affect any age groups. Majority of patients show mild or no symptoms. Immunocompromised patients and patients with co-morbidities are more vulnerable to have more aggressive affection with higher rate of complications. Thus, cancer patients carry a higher risk of infection. Diseased patient can transmit infection throughout the disease course starting from the incubation period to clinical recovery. All healthcare workers contacting COVID-19-positive patients are at great risk of infection, especially the anesthesiologists who can be exposed to high viral load during airway manipulation. In the National Cancer Institute of Egypt, we apply a protocol to prioritize cases where elective cancer surgeries that would not affect patient prognosis and outcome are postponed during the early phase and peak of the pandemic till reaching a plateau. However, emergency and urgent surgeries that can compromise cancer patient’s life and prognosis take place after the proper assessment of the patient’s condition. Aim This review aims to spot the management of cancer patients undergoing surgery during the COVID-19 pandemic in the National Cancer Institute, Egypt.

The “iterated prisoner's dilemma” (IPD) game is considered to be a well-known model for studying the evolution of cooperative manner among rational individuals over the long term. Analytical studies in IPD mostly focus on the two-player IPD game since the game's relations and dynamics become more complicated when increasing players' numbers. Here, we extend investigating the “Zero-Determinant” (ZD) strategies to the symmetric infinitely repeated IPD game involving three players with two actions for each player. We propose two simultaneous models of the IPD game with three players to investigate ZD strategies. Further, we analytically extract the boundaries of the equalizer and extortion ZD strategies in both proposed models and provide numerical examples demonstrating such boundaries.

Evolutionary games have been extensively used to model and understand various complex real world situations, especially when investigating how cooperation evolve among self-interested players involved in strategic interactions. Many situations exhibit iterated interactions where players use past experiences (game history) to decide on their next actions. Cooperation evolves when a player trades the short-term benefits of being selfish with the long-term benefits of being cooperative, and this is only feasible if future interactions have sufficiently large discount factor (i.e., direct reciprocity settings). How do players decide on the discount factor is an interesting research question, it may depend on the player's personal experience or on public knowledge. In this study, we present novel models and investigate the cooperation levels in a coevolutionary environment of stochastic strategies. We extend the stochastic strategies' representation to allow players to evolve probabilities to terminate future interactions, and we show that this significantly decrease the levels of cooperation. We then show that the previous conclusion still holds when using global statistics as global (population-level) termination probabilities. We illustrate that enhancing the probability to cooperate in the game's initial round increases the levels of cooperation when termination probabilities are used by players.

Background The aim of this prospective, comparative, randomized study was to compare the inhalational anesthetics isoflurane, sevoflurane, and desflurane in pediatric patients undergoing craniotomy for excision of supratentorial tumors. We assessed early postoperative recovery outcome, intraoperative hemodynamics, and degree of brain swelling, as well as postoperative vomiting and shivering. Methods Sixty patients scheduled for supratentorial brain tumor excision, were randomly allocated into 1 of 3 groups (20 patients each); isoflurane, sevoflurane, and desflurane group. After IV induction of anesthesia, maintenance was achieved using the inhalational anesthetic according to the allocated group. Tracheal extubation time was the primary endpoint. The secondary endpoints included: emergence time and the interval time needed to reach Aldrete score ≥9, intraoperative degree of brain swelling, intraoperative heart rate and mean arterial blood pressure, as well as postoperative vomiting and shivering. Results The mean emergence time, extubation time, and the interval required to reach Aldrete score 9 were significantly shorter in the desflurane and sevoflurane groups than the isoflurane group. No statistically significant changes in the 3 groups regarding intraoperative brain swelling, hemodynamics, and postoperative shivering or vomiting were noted. Conclusions Desflurane and sevoflurane can be used to facilitate early emergence from anesthesia in neurosurgical pediatric patients. Emergence times are shorter with desflurane or sevoflurane than with isoflurane. The patients who received desflurane or sevoflurane have similar intraoperative and postoperative incidence of adverse effects compared with those who received isoflurane. Thus, desflurane and sevoflurane can be considered as suitable for emergence in pediatric neurosurgical anesthesia.

Background Recently a concept of target controlled inhalational anesthesia (TCA) is introduced in which the fresh gas flow and its composition are automatically delivered to the patients with the least possible flow. The aim of this study is to compare safety, consumption and cost of both sevoflurane and desflurane when delivered by target controlled anesthesia (TCA) using fully closed circuit conditions. Patient and method After approval of the hospital review board and obtaining parental informed consent, 60 pediatric patients aged 2–12 were selected. The patients were classified into two groups according to the anesthetic used S Group ( n = 30) in which sevoflurane D Group ( n = 30): in which desflurane was used. Both were delivered by auto control mode of Zeus machine. Anesthetic agent and O 2 consumption, cost and number of adjustments were assessed. Blood samples were obtained preoperatively and at 24, 48 and 72 h after the end of surgery for measuring serum creatinine, BUN, AST and ALT. Twenty-four hour urine samples were collected for 3 consecutive days to measure glucose, microprotein and creatinine for the estimation of creatinine clearance. Results This study revealed that sevoflurane group had a lower O 2 , anesthetic consumption and cost than desflurane group. Also both groups had higher levels of serum urea and creatinine together with urinary microproteins and glucose in the first three post-operative days compared to preoperative values which indicates minor tubular insult. However there was no statistically significant difference between the two groups. Conclusion Sevoflurane is as safe as desflurane when delivered by auto control mode of Zeus machine with decreased anesthetic consumption and cost.

Objective The laryngeal mask airway (LMA) is an established way for airway control during spontaneous ventilation. Its ability to deliver positive pressure ventilation without leakage especially in low flow states is still controversy. The aim of this study is to test the possibility of using LMA in pediatric closed circuit controlled ventilation, and to find out the optimum cuff volume to perform closed system ventilation.

Objective After the pregabalin has been approved for the treatment of neuropathic pain, preliminary clinical studies suggested a possible role in the perioperative period. To our knowledge, It has never been studied the perioperative analgesic effect of pregabalin in patients with cancer bladder. In this study, we hypothesized that cancer bladder patients undergoing radical cystectomy and received oral pregabalin 75 mg twice daily for ten days preoperatively would get their postoperative pain reduced.

Objective Caudal epidural analgesia has become very common analgesic technique in paediatric surgery. Adding tramadol to bupivacaine for caudal injection prolongs duration of analgesia with minimal side effects. The aim of the study was to investigate the different effects of caudal bupivacaine versus bupivacaine with thamadol for postoperative analgesia in paediatric cancer patients.

Background: Postoperative recurarization remains a risk following the use of the conventional neuromuscular blocking agents. In addition, none of the commonly used reversal agents, such as neostigmine or edrophonium are capable of reliably reversing profound blockade. The present comparative and randomized study investigated the use of sugammadex for reversing profound neuromuscular blockade (NMB) in pediatric neurosurgical patients undergone posterior fossa tumor excision. Patients and Methods: Forty pediatric patients undergoing elective craniotomy for posterior fossa tumor excision were randomly divided into either of neostigmine or sugammadex group in which muscle relaxant was reversed at the end of anesthesia either with neostigmine 0.04 mg/kg added to atropine 0.02 mg/kg or sugammadex 4 mg/kg alone, respectively. The primary endpoint was the time from the administration of sugammadex or neostigmine to recovery of the train of four (TOF) ratio to 90% after rocuronium-induced neuromuscular block. Unpaired t-test was used to compare continuous variables between groups. Meanwhile, repeated ANOVA was used to detect intragroup differences. Results: Patients in sugammadex group attained a TOF ratio 90% in statistically shorter time (1.4 ± 1.2 min) than those in neostigmine group (25.16 ± 6.49 min) for reversal of the rocuronium. Mean arterial pressure and heart rate were significantly higher in neostigmine group at 2, 5 and 10 min after administration of the reversal agents and returned nonsignificantly different after that. With no recurarization in any patient throughout the study period. Conclusion: Sugammadex rapidly and effectively reverses rocuronium-induced NMB in pediatric patients undergoing neurosurgery when administered at reappearance of T2 of TOF at dose 4 mg/kg.

Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can be fatal. We present three case reports that describe the management of splenic abscesses in patients initially diagnosed with infective endocarditis. In all cases, the diagnosis was based on the findings of abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI). In two of the cases, splenectomy was performed before valve surgery; while in the third case, the spleen was removed after cardiac surgery. All three patients recovered fully, with satisfactory follow-up as outpatients. Immediate splenectomy, combined with appropriate antibiotics and valve replacement surgery alongside multi-disciplinary team work could be the treatment of choice in this clinical scenario.

A Stanford Type A aortic dissection is a life-threatening surgical emergency that requires emergent surgery. The mortality after repair is high especially if the aortic dissection is complicated by visceral or peripheral malperfusion. We describe a case of a male patient who presented with an aortic dissection involving the ascending aorta, aortic arch, descending thoracic aorta, and the abdominal aorta down to the iliac bifurcation. The dissection also involved the visceral and renal arteries with evidence of superior mesenteric artery (SMA) occlusion. Successful outcome was achieved by endovascular stenting of the patient's SMA, followed by a Bentall procedure. To the best of our knowledge this is the first case report in the English literature of SMA stenting followed by a Bentall procedure to treat acute Type A aortic dissection complicated by SMA occlusion.

Evolutionary games are used to model and understand some complex real world situations in economics, defence, and industry. However, different games are usually studied independently and in isolation of each other. Notwithstanding, in real world situations, an agent is involved in multiple games simultaneously and her action in one game influences her utility in the others. This situation is far more complex when the utility functions for the different games are in conflict with each other. In this paper, we propose for the first time an analysis for the interaction between the iterated prisoner's dilemma and the minority games. We empirically explore the relationship and clarify the mathematical conditions under which the Minority game won't change the dynamics of the iterated prisoner's dilemma game.