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Introduction: Echinacea purpurea is a flowering plant commonly used as an herbal medicine despite insufficient scientific bases to validate its usage. The present study aimed to examine in vitro and in vivo hepatoprotective effects of aqueous and alcoholic extracts of E. purpurea flowers. Methods: In vitro protection against hepato-cytotoxicity was carried out on human HepG-2 cells using colorimetric tetrazolium (MTT) assay, while the in vivo hepatoprotective activity was studied against carbon-tetrachloride (CCl4) induced acute hepatotoxicity in rats. Results: The results revealed that the extracts of E. purpurea induced discernable in vitro protection on HepG-2 cells and in vivo against CCl4 induced hepatotoxicity. Both extracts were significantly able to restore the serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), total bilirubin, total protein, and albumin to normal levels compared to the CCl4 intoxicated group. In addition, the extracts markedly mitigated the oxidative stress by decreasing Malondialdehyde (MDA) and increasing superoxide dismutase (SOD) and glutathione (GSH) markers compared to the CCl4 intoxicated group. It was also associated with the down-regulation of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels in liver tissues. Histopathological examination revealed a decrease in hepatocytes’ degenerative changes and noticeable improvement of the liver damage by extracts of E. purpurea. Conclusion: These findings have proven that aqueous and alcoholic extracts of E. purpurea flowers have a significant hepatoprotective effect, probably owing to antioxidant, anti-inflammatory activities, and regulating apoptotic-related genes. This confirms the ethnomedicinal uses of E. purpurea in patients suffering from liver diseases.

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups. MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.

Introduction: There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ATS, Bicarbon, and On-X mechanical valves. Methods: We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months. Results: Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P

Background: The choices of premedication and anesthetic techniques are able to influence the neurohormonal stress response by modulating the pathophysiological pathways. Various pharmacological agents like nitroglycerine, beta blocker, and opioids were used to decrease surgical stress of laparoscopic procedures to improve outcome, with their own limitations. Objective: It was to compare the effect of opioid-free (using dexmedetomidine and propofol) and opioid-based (using fentanyl and propofol) TIVA techniques on hemodynamic stability, sedation postoperative pain intensity and the incidence of side effects in patients scheduled for LC. Patients and Methods: Eighty patients who were scheduled for elective laparoscopic cholecystectomy were included in this study. Before induction of anesthesia, patients were randomly divided into two equal groups: (40 each). Dexmedetomidine group(Non-opioid group) received dexmedetomidine (1 µg/kg) over 10 minutes before induction of anesthesia followed by continuous infusion of 0.5 µg/kg/hr. till the end of surgery and Fentanyl group (Opioid group) received fentanyl (1.0 µg/kg) over 10 minutes before induction of anesthesia followed by continuous infusion of 0.4 µg/kg/hr. till the end of surgery. Results: The results of the present study showed that there were no significant differences between the two groups regarding HR and MAP except after loading dose of the studied drugs, after intubation, after pneumoperitoneum, 15 min, 30 min, 45 min, and 60 min after induction where it was lower in dexmedetomidine group than fentanyl group. There were no significant differences between two groups regarding intraoperative SPO2, postoperative SPO2 and blood glucose level (mg/dl). Conclusion: This study concluded that dexmedetomidine is better than fentanyl for patients who undergo elective laparoscopic cholecystectomy due to perioperative maintaining of hemodynamic stability, decrease dosages of postoperative analgesics, prolong the duration of postoperative analgesia and decrease postoperative nausea and vomiting.

Background and objectives: Awake fiber optic intubation (AFOI) is recommended technique in securing the airway in predicted difficult airway patients with sedation. However, it is not easy to achieve a comfortable sedation so conscious sedation is the key for a successful AFOI. The goal of the study to compare different conscious sedation strategies aimed to improve comfort and safety in patients prepared for elective surgeries. Subjects and Methods: Case control, randomized controlled study in predicted difficult airway patients scheduled for elective surgery under GA carried out at AL-Azhar University Hospitals after approval by the local ethical committee. 120 patients of age group 18-60 years old with ASA I and II prepared for nasal (AFOI) under conscious sedation after giving their informed written consent to participate in our study. The patients were randomly assigned into 4 groups: Group dexmedetomidine (DEX), group ketofol, group magnesium sulfate and group midazolam. HR, MAP, Oxygen saturation and end tidal CO2 were monitored. Sedation score, patient tolerance, patient satisfaction and intubation score (vocal cord movement and coughing) were assessed. Results: All patients were successfully intubated by fiber optic and none of them developed bradycardia or reduced MAP more than 20% from the base line during intubation. Group DEX mild decrease in MAP and HR ( 0.05). Group ketofol and midazolam patients were sedated deeper after the start of the study drugs than group DEX and none of the patients were sedated to a score of < 2 (modified OAA/S score) in either of the groups. Group magnesium showed lighter sedation level significantly different with other groups. Conclusion: Study showed DEX provides optimum sedation without compromising airway or hemodynamic stability with favorable intubation time and less intubation attempts during AFOI in comparison to magnesium sulphate, ketofol and midazolam patients with better patient tolerance and satisfaction.

Background: decisions regarding fluid therapy, whether in the operating theatre, intensive care unit, emergency department, are among the most challenging and important tasks that clinicians face on a daily basis. Specifically, almost all clinicians would agree that both hypovolaemia and volume overload increase the morbidity and mortality of patients. The therapeutic goal of fluid administration is to increase preload, or the stressed venous volume, leading to an in­creased stroke volume and cardiac output. However, studies of patients with acute illness or hypotensive patients in the intensive care unit consistently demonstrate that approximately 50% of fluid boluses fail to achieve the intended effect of increasing car­diac output. Aim of the Work: this study was done to evaluate the correlation between central venous pressure (CVP) measurements and ultrasound measurements of the inferior vena cava diameter, and collapsibility index. The secondary aim was to evaluate the value of ultrasound as a noninvasive tool in assessment of intravascular volume status and fluid responsiveness in critically ill intensive care unit patients. Patients and Methods: after obtaining the approval of the Al-Azhar University Ethical Committee and written informed consent, 50 patients aged 30-60 years of either sex, ASA I-III admitted in the ICU of Al-Azhar teaching hospitals who had a functioning central venous catheter inserted for any clinical indication, were involved in this single blinded correlational study. Hemodynamic parameters were monitored continuously including heart rate and non-invasive mean arterial blood pressure. CVP measurements were taken with the patient in the supine position. Clinical assessment was done for signs of hypovolemia like hypotension, tachycardia, prolongation of capillary refill: >3 seconds, acidosis, increased serum lactate more than 2 mmol/L or loss of skin turgor. Results: in our study, there was a significant correlation between CVP and the two studied ultrasound parameters, IVC CI and IVCdmax. Analysis of the receiver operating characteristic curve ROC showed that inferior vena cava collapsibility index (IVC CI) had the most favorable performance of the two ultrasound parameters in predicting CVP < 10 cm H2O. As regards prediction of fluid responsiveness, analysis of the ROC showed a better diagnostic accuracy of IVC collapsibility index and IVC diameter for predicting fluid responsiveness. Conclusion: ultrasound of the inferior vena cava may be used as a feasible non-invasive, rapid and simple adjuvant method to assess the intravascular volume and guide fluid responsiveness in critically ill intensive care unit patients, inferior vena cava collapsibility index may be used to predict low central venous pressure and predict fluid responsiveness.

Lung tissue exposure to ionizing irradiation can invariably occur during the treatment of a variety of cancers leading to increased risk of radiation-induced lung disease (RILD). Mesenchymal stem cells (MSCs) possess the potential to differentiate into epithelial cells. However, cell culture methods of primary type II pneumocytes are slow and cannot provide a sufficient number of cells to regenerate damaged lungs. Moreover, effects of ablative radiation doses on the ability of MSCs to differentiate in vitro into lung cells have not been investigated yet. Therefore, an in vitro coculture system was used, where MSCs were physically separated from dissociated lung tissue obtained from either healthy or high ablative doses of 16 or 20 Gy whole thorax irradiated rats. Around 10±5% and 20±3% of cocultured MSCs demonstrated a change into lung-specific Clara and type II pneumocyte cells when MSCs were cocultured with healthy lung tissue. Interestingly, in cocultures with irradiated lung biopsies, the percentage of MSCs changed into Clara and type II pneumocytes cells increased to 40±7% and 50±6% at 16 Gy irradiation dose and 30±5% and 40±8% at 20 Gy irradiation dose, respectively. These data suggest that MSCs to lung cell differentiation is possible without cell fusion. In addition, 16 and 20 Gy whole thorax irradiation doses that can cause varying levels of RILD, induced different percentages of MSCs to adopt lung cell phenotype compared with healthy lung tissue, providing encouraging outlook for RILD therapeutic intervention for ablative radiotherapy prescriptions.

Introduction: Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population. Methods: We reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4mg/kg IM, following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine. Results: Review of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off. Conclusion: Ketamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access. [West J Emerg Med. 2014;15(7):–0.]

Objective The aim of this study was to compare chest ultrasonography with chest radiography (CXR) in the diagnosis of children with pneumonia. Background In Egypt, pneumonia and other acute respiratory infections were the causes of death in ∼19% of children younger than 5 years. According to current guidelines, pneumonia is diagnosed by clinical history, respiratory rate, fever, respiratory signs, and symptoms. Patients and methods A cross-sectional study was conducted on 60 patients with fever and signs of respiratory distress, and they were divided in two groups: group I with pneumonia, which included 45 patients who were finally diagnosed as having clinically evident pneumonia, and group II without pneumonia, which included 15 patients who did not have pneumonia. Full history taken, clinical examination, laboratory investigations, CXR, and chest ultrasonography were done. Results There was no statistically significant difference between the two groups regarding age, birth order, weight, residence, parent's education, and employment. C-reactive protein level was higher in pneumonia group than nonpneumonia group (P < 0.001). Lung ultrasonography could detect consolidation in more than one lobe than CXR, which was statistically significant (P = 0.048). Conclusion Chest ultrasonography offers an important contribution to the diagnostic procedures of pleuropulmonary disorders in children, such as pneumonia and pleural effusion, with higher sensitivity, specificity, and positive predictive index compared with CXR.

OBJECTIVES: The purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS). BACKGROUND: Patent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging. METHODS: Thirty-eight consecutive patients who were undergoing PFO closure had simultaneous transcranial Doppler and intracardiac echocardiography performed. Agitated saline injections were performed at rest, with Valsalva maneuver, and with forced expiration into a manometer to 40 mm Hg before and after closure, as well as 3 or more months after closure. Right atrial pressures were measured in the periprocedural period, and RLS were graded according to standard methods during these maneuvers. RESULTS: Right atrial pressures were significantly higher with Valsalva maneuver compared with rest (before closure 21.6 +/- 11.9 mm Hg vs. 6.6 +/- 2.6 mm Hg, p < 0.001; after closure 28.4 +/- 13.9 mm Hg vs. 6.8 +/- 2.6 mm Hg, p < 0.001) and with manometer compared with Valsalva maneuver (before closure 38.7 +/- 6.6 mm Hg vs. 21.6 +/- 11.9 mm Hg, p < 0.001; after closure 44.0 +/- 9.5 mm Hg vs. 28.4 +/- 13.9 mm Hg, p < 0.001). Intracardiac echocardiography underestimated shunting in 34% of patients with Valsalva maneuver or manometer after closure compared with TCD. CONCLUSIONS: Transcranial Doppler with immediate feedback provided by forced expiration against a manometer to 40 mm Hg is more sensitive than echocardiographic imaging for the detection of RLS. These observations have significant implications for determining the incidence of RLS in patients with stroke or migraine.

Introduction: Ketorolac tromethamine is a potent injectable non-steroidal anti- inflammatory drug (NSAID). Ketorolac provides successful analgesia after intrathecal or epidural injection. It is frequently used to manage post-operative pain, cancer pain, and arthritis either intrathecally, or intramuscular. However, its long term administration could induce renal toxicity and/or gastro-intestinal ulceration. Aim of the study: The aim of this study was to assess the analgesic potency of ketorolac after intrathecal injection. Also, we aimed to study the histological effect of ketorolac on the spinal cord and the duodenum after treatment in an animal model. Methods: 40 adult male albino rats, weighing 250-350 gm, were used and divided into 4 groups, 10 rats each. Group S (control) received 10μl normal saline intrathecally, group K50 received 50μg ketorolac intrathecally, group K50 + omeprazole (proton pump inhibitor) received 50μg ketorolac intrathecally plus 0.2 mg omeprazole orally, and finally, group K100 received 100μg ketorolac intrathecally. All animals were treated for four successive days. Result: The rat tail flick latency was longer in K50, K50 + omeprazole, and K100 groups when compared to normal control (P = 0.002). Also, the hind-paw withdrawal latency was longer in treated groups when compared to those of the control group (P = 0.0001). Moreover, K50 group showed decreased phase II response by 61%, K50 + omeprazole group showed decreased phase II by 62%, while K100 group showed decreased it by 76%. Histological examination revealed no changes in the spinal cord of all treated animals. Also, examination of the duodenum showed normal duodenal mucosa in group K50 and those of group K50 + omeprazole. On the other hand, cellular infiltration as well as destruction of the mucous acini have been noticed in the duodenum of K100 group. Conclusion: Ketorolac could be a good alternative drug used intrathecally to manage pain.