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Background Limited data are available for Ceftazidime-avibactam (CAZ AVI) dosing in patients with chronic kidney diseases. High rate of treatment failure was found among patients with chronic kidney diseases for which renally adjusted doses has been used(1). In our institution, higher than labeled adjusted dosing regimens (HLAD) has been used for the treatment of severe infections. Doses were driven from ceftazidime adjusted dosing regimens in CKD patients. Therefore, we aimed to compare the efficacy and safety between labeled and HLAD regimens of CAZ-AVI in CKD patients. Methods A retrospective cohort study conducted between June 2018 and December 2020 in a tertiary hospital in Saudi Arabia, Jeddah. Patients ≥ 14 years old who received at least 48 hours of CAZ-AVI and have chronic kidney disease or on dialysis were included. The primary outcome was to assess the clinical cure of the HLAD group compared to labeled adjusted doses (LAD) group and defined as complete or partial resolution of fever and leukocytosis at the end of CAZ-AVI course. The secondary outcome was 30-day-mortality secondary to infections and recurrent of infections. Fisher's exact, chi-square test and contingency table analysis were used as appropriate. Results A total of 75 patients were included, 40 patients (46.7%) received HLAD. Fifty percent of the patients were on hemodialysis during CAZ-AVI course (n=38, 50%). The majority of our patients were in ICU (n=48, 64%). Clinical cure was relatively the same among the two groups with no statistical difference (57% with higher dose and 66%, 0.095 (-0.31-0.12), P=0.39). The number of 30-day mortality secondary to infection was higher (n=48, 64%) among the HLAD group compared to LAD group (74.2% and 55% respectively). Recurrence of infection were low in this study, which can be explained by the high rates of mortality, however, it was higher among patients who received LAD. Conclusion The efficacy and safety of both regimens of CAZ-AVI dosing were comparable and was not statistically significant in renally impaired patients. Larger studies are needed, however, to answer the study question on the use of higher than labeled adjusted dosing. Reference: Shields RK, Nguyen MH, Chen L, Press EG, Kreiswirth BN, Clancy CJ. Pneumonia and renal replacement therapy are risk factors for ceftazidime-avibactam treatment failures and resistance. Antimicrob Agents Chemother. 2018;62(5) Disclosures All Authors: No reported disclosures.

Background: Psoriasis is a chronic, inflammatory immune mediated skin disease characterized by dense infiltrates of immunocytes especially macrophages. Cross talk between immunocytes and keratinocytes is thought to mediate the disease. Hparanase 2 inhibits activity of Heparanase 1 which is involved in this cross talk by degradation of heparin sulphate chains in the basement membrane and extra cellular matrix (ECM). Objective: To assess the of Heparanase2 in psoriasis through its immunohistochemical expression in lesional and perilesional skin of psoriasis patients. Patients and Methods: This prospective case control study was carried out on a total number of 60 subjects, they included 30 patients with chronic plaque psoriasis and 30 age and gender matched apparently normal subjects as control group. Skin biopsies were taken for immunohistochemical evaluation of Heparanase 2 expression. Results: Our results showed significant difference between lesional, perilesional and control groups regarding the status of epidermal Heparanase 2 expression (P = 0.038). All lesional epidermal expression was negative while perilesional epidermal expression was negative in 24 (80%) cases and positive in 6 (20%) cases, control epidermal expression was negative in 27 (90%) cases and positive in 3 (10%) cases. There was no significant difference between the three studied groups regarding dermal Heparanase 2 expression (P = 0.318). Conclusion: Downregulation of Heparanase 2 could be incriminated in the pathogenesis of psoriasis. Heparanase 2 could have a protective role in skin.

Background: Coronary artery ectasia (CAE), known as a dilatation of coronary segment to at least 150% of the diameter of adjacent healthy segment. Despite the fact that coronary ectasia is under-treated angiographic finding, it has a tremendous impact on patients mortality and morbidity. The hypothesis that isolated CAE is a cause of subtle left ventricle (LV) systolic dysfunction needs intense and thorough research. Objective: To assess longitudinal LV functions in patients with isolated coronary ectasia using 2 dimensional (2D) speckle tracking echocardiography. Patients and Methods: This study is a case control study conducted on two groups of patients referred to our tertiary centre for elective coronary angiography. The first group included 30 consecutive symptomatic patients proved to have CAE without obstructive coronary artery disease. The second group included 30 patients with normal coronary angiography serving as a control group. Patients with any form of structural heart disease affecting LV systolic functions were excluded, echocardiographic evaluation was held for every patient targeting 2D assessment of systolic and diastolic functions, tissue Doppler measurements and finally offline 2D speckle tracking for assessment of global LV longitudinal strain. Results: Males were more dominant in CAE group. Hypertension and dyslipidemia were more prevalent in CAE group unlike diabetes that was more common among control subjects. LV volumes, dimensions, mass index, left atrium (LA) volume index and aortic root diameter were significantly higher among CAE group. Mean global longitudinal strain was significantly lower in CAE group with value of (-16.5%) versus (-19.5%) in control group. Conclusions: Global longitudinal strain is significantly reduced in patients with CAE even in the absence of obstructive coronary artery disease denoting subclinical LV systolic dysfunction

Background Nicorandil is a nicotinamide ester commonly prescribed for treatment of patients with chronic coronary syndrome, there is an ongoing controversy about its effectiveness in prevention of contrast induced acute kidney injury. Aim of the Work The aim of this work is to evaluate the effect of pretreatment with oral nicorandil 40 mg/day on the incidence of contrast-induced acute kidney injury in type II diabetic patients with renal dysfunction (mild- moderate CKD) undergoing elective percutaneous coronary intervention. Patients and Methods This prospective, randomized, controlled study included 100 consecutive diabetic patients, carrying the diagnosis of chronic coronary syndrome and suffering from mild or moderate CKD, their age ranged between 39 and 81 years. They were referred to the catheterization laboratory for planned PCI in the period between January 2018 and August 2018. Mild-to-moderate CKD was defined by means of estimated glomerular filtration rate (e GFR) of 30 to Conclusion Nicorandil dose of 40 mg per day for 7 days before PCI, And for 48 hours after PCI is associated with decreased incidence of CI- AKI in diabetic patients with chronic kidney disease compared to the conventional treatment. Abbreviations CI-AKI: contrast induced acute idney injury; PCI: percutaneous coronary angiography; CKD: chronic kidney disease; GFR: glomerular filtration rate; CAD: Coronary artery disease.

Background Cyclophosphamide (CYP) is considered one of the most successful chemotherapeutic drugs involved in anticancer regimens. However, it has multiple side effects. Mesna has an antiinflammatory effect and usually used in the treatment of cystitis. Vitamin C is a water-soluble vitamin which has a potent anti –oxidant effect that might protect cells against the oxidative damage caused by cyclophosphamide. Aim of the study The aim of the present study was comparing between the possible protective effect of vitamin C versus mesna and their combined therapy against the histological and immunohistochemical changes induced by cyclophosphamide on the urinary bladder of adult male albino rats. Material and methods Thirty adult male albino rats were divided into 5 groups, 6 rats each; (control(?), CYP-treated group (Пa), recovery group(Пb), mesna-treated group(???), vitamin C- treated group(?V) and the combined group (V). Histological examination of the H&Eand toluidine blue stained sections was done by light microscopy to assess the changes in the architecture of the urinary bladder. Avidin Biotin staining was performed for demonstration of iNOS immunoreactivity and histomorphometric analysis was done. Results Examination of H&E stained sections of cyclophosphamide- treated group (Пa) showed variable degrees of urothelial affection. Wide areas of urothelial cell degeneration with evident basal cytoplasmic vacoulatins, surface erosions and sloughed urothelial debris. Other Areas showed surface ulceration, completely denuded urothelium or the presence of multiple cysts replacing the urothelium and resting on the basement membrane. Semithin sections showed that the cytoplasmic microvesicles of umbrella cells were hardly detected. The Avidin Bioton stained sections showed intense positive immune reaction to iNOS in all layers of the urothelium. Scanning electron microscopy showed loss of the normal polygonal shape of the superficial epithelial cells, erosions, or deep ulcerations. Moreover, examination of the lamina propria by light microscopy showed multiple mononuclear inflammatory cells were detected, mast cells were seen in the lamina propria and some of them were invading the basement membrane of the urothelium. Dilated blood vessels and wide areas of extravasted blood (hemorrhage) were also observed. In addition, multiple epithelial cell nests of irregular shapes and sizes were deeply located in the lamina propria and exhibited pale esinophilic colloid discharge in their lumen. Scanning electron microscopy showed dense deposition of collagen fibers in both superficial and deep fibers of the lamina propria. Minimal improvement was observed in the recovery group (subgroup Пb). Mild to moderate improvement of the previous findings of CYP treated group was observed with each of mesna and vitamin C. Combined treatment of CYP with both of mesna and vitamin C induced apparent restoration of almost of the normal architecture of the urinary bladder. Conclusion CYP consumption developed morphologic and morphometric changes in the urinary bladder. The recovery group showed minimal improvement of the bladder architecture and increasing the period of recovery might produce better results. Each of vitamin C and mesna- treated groups induced mild to moderate improvement on the bladder architecture but treatment with combination of both of them offered remarkable improvement. Combined mesna and vitamin C induced significant protection via their combined anti-inflammatory and anti-oxidant proprieties.

Background Coronary artery ectasia (CAE) is one of the uncommon cardiovascular disorders. CAE is one of the known risk factors for acute coronary syndrome, its incidence ranges from 1.5%-5% of patients undergoing coronary angiography, with predominance in males. Coronary artery ectasia (CAE) is defined as dilatation of an arterial segment to a diameter at least 1.5 times that of an adjacent normal artery and involves at least one third of the affected artery (1)(1). The exact pathogenesis of CAE is not well established; however, Coronary atherosclerosis is detected in more than 50% of the patients. Objective To evaluate global left ventricle longitudinal strain by 2D speckle tracking echocardiography in patients with coronary artery ectasia and without significant (>50%) coronary artery stenosis. Patients and Methods This study carried on sixty patients referred to cath lab of Ain Shams university hospital for elective coronary angiography during period between January 2018 and Augest 2019. The patients were divided in to two groups (Group A) included thirty patients with ectasia in one or more of the coronary arteries without any significant coronary artery stenosis and (Group B) included thirty patients with normal coronary angiographic findings serving as control group. Results The present study showed a statistically significant decrease in EF comparing CAE group to control group .As regards other echocardiography parameters, there was a highly significant difference of LVEDD, LVEDD index, LVESD,, LVESD index, LV mass, LV mass index, LA volume and LA volume index between the two groups. Global peak longitudinal strain showed highly significant difference between two groups as its mean value was significantly lower in the CAE group. Conclusion In our study, we have concluded that global peak longitudinal strain was significantly impaired in patients with coronary artery ectasia without significant coronary artery lesion denoting subclinical LV systolic dysfunction .LV diastolic dysfunction was more prevalent in coronary artery ectasia patients compared to control subjects.

T he present study aimed at investigating the effect of using Interactive white board activities based program (IWB) on improving primary stage pupils' writing skills and their motivation. The targeted writing sub- skills were (Content– vocabulary – grammar- organization – Mechanics of writing). The study adopted the quasi-experimental design using sixty sixth year primary stage pupils to be the study participants who were divided into two groups: an Experimental group received the IWB treatment and a Control group received the traditional method. Instruments designed and used in the study were a writing skills questionnaire, a pre-post writing test, an interactive whiteboard activities check list, and a writing motivation scale. The Experimental treatment was conducted during the second semester in the academic year 2016/2017. Results showed that there were statistically significant differences between the Experimental and control groups on both instruments (EFL writing test and motivation scale) in favor of the Experimental group. In addition, there were statistically significant differences between pre- and post-levels of the Experimental group on both instruments in favor of the post level. These results indicated that the IWB led to developing pupils' EFL writing skills and motivation in English language.

Background Obesity is associated with significant cardiovascular morbidity and mortality effects. Cardiac rehabilitation programs cause a significant reduction in cardiovascular mortality and a reduction in all cardiovascular risk factors. Up to 80% of patients referred to cardiac rehabilitation programs are either overweight or obese. This study aimed to compare the effects of a phase 2 cardiac rehabilitation program on obese and non-obese patients with stable coronary artery disease following total revascularization by coronary angioplasty. Results This was a prospective study including 120 patients with stable coronary artery disease. Patients were enrolled in a 12-week phase 2 cardiac rehabilitation program. Patients were classified into two groups based on their body mass index (BMI): those with a BMI < 30 kg/m2 were considered non-obese (n = 58) while those with a BMI ≥ 30 kg/m2 were considered obese (n = 62). At baseline, BMI and blood pressure (BP) were recorded; fasting blood sugar, triglyceride levels, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) levels were assessed; and echocardiography was used to measure left ventricular ejection fraction (LVEF). These were re-assessed after completion of the program. At baseline, there were more females in the obese group 20 (32.25%) vs 6 (10.13%) (p = 0.04), more hypertensives (p = 0.023), and less smokers 32 (51%) vs 46 (79%) (p = 0.025). Obese patients achieved fewer metabolic equivalent of tasks (METs) 7.97 ± 2.4 vs 9.74 ± 2.47 (p = 0.007) and had higher LDL-C levels 121.63 ± 36.52 mg/dl vs 95.73 ± 31.51 mg/dl (p = 0.005). At the end of the program, obese patients showed more reduction in BMI − 1.78 ± 1.46 kg/m2 vs − 0. 60 ± 0.70 kg/m2 (p < 0.001) and systolic and diastolic BP (p = 0.016 and 0.038, respectively). LDL-C level was more reduced in the obese group − 25.76 ± 14.19 mg/dl vs − 17.37 ± 13.28 mg/dl (p = 0.022). Non-obese patients had more increase in LVEF (p = 0.024). There was no difference between obese and non-obese patients in the magnitude of increase in METs achieved (p = 0.21). Conclusion Cardiac rehabilitation programs lead to an improvement in cardiovascular disease risk factors with more reduction in BMI, BP, and LDL-C levels in obese patients compared to non-obese ones. LVEF was more increased in non-obese individuals. Exercise capacity in the form of METs achieved was equally improved in both groups.

Introduction: COVID-19 is a newly emerging pandemic viral disease. Multiple management guidelines were introduced; nevertheless, their efficacy is still under debate. Thus, the presences of prognostic factors are essential for predicting which patients will need more invasive treatments. Objective: The study aims to investigate the prognostic accuracy of neutrophil-lymphocyte ratio in COVID-19 infection. Methods: This is a prospective study done in Al-Ain Hospital in the United Arab Emirates. All the Covid-19 patients presenting to the hospital were enrolled over 1 month from 20/3 to 20/4/2020. We gathered information about their age, sex, mode of transmission, and calculated their Neutrophils/Lymphocytes ratio (NLR) from the first complete blood picture on admission. We divided the patients into two groups: those whose age was 50 years and above and the those aged less than 50 years. We chose the best NLR cut-off value based on the Youden index and receiver operating characteristic (ROC) curve analysis and the target endpoint was presence or absence of intensive care unit (ICU) admission. Results: The study revealed that 48 patients (14%) needed ICU admission, while 296 patients (86%) were admitted to a ward or quarantine facilities. When the patient's age was > 50, and NLR was ≥ 3.10, it showed a sensitivity of 95.24% and a specificity of 92.86% for predicting the need for ICU admission. When NLR was ≥ 4.21, and the patient's age was < 50, the sensitivity and specificity were 70.3% and 93.7%, respectively. Conclusions: NLR proved to be highly specific and sensitive in helping to identify patients who need more invasive care among people over 50 years of age with COVID-19.

Context: Four-dimensional speckle-tracking echocardiography (4D-STE) is ideal to accurately assess myocardial deformation. The novel 4D global area strain (GAS) uses global longitudinal and global circumferential strains (GCSs) to detect subtle changes in myocardium. Aims: The aim of this study was to determine the predictive value of 4D strain echocardiography for major adverse cardiovascular events (MACEs) in ST-elevation acute myocardial infarction (STEMI) patients after successful reperfusion by primary percutaneous coronary intervention (PCI). Settings and Design: This was a longitudinal study at a single center. Patients and Methods: We enrolled 170 patients who underwent successful primary PCI. Each patient was evaluated with 2D echocardiography and 4D echocardiography with 4D strain parameters and followed up over a year for the occurrence of MACE. Statistical Analysis Used: Chi-square test, independent t-tests, and multivariate logistic regression analysis were used. Results: Over 1 year of follow-up, 32 MACE were recorded. Patients with MACE were more likely to have had percutaneous transluminal coronary angioplasty done during the index primary PCI intervention, multivessel coronary artery disease, higher left ventricular end-diastolic and end-systolic dimensions (left ventricle end diastolic dimension (LVEDD) and left ventricle end systolic dimension (LVESD), respectively), lower 2D left ventricular ejection fraction (LVEF), higher wall motion score index, higher baseline heart rate, higher end-diastolic and end-systolic volumes, lower 3D-LVEF, higher 4D global longitudinal strain, 4D-GCS, 4D-GAS, and lower 4D global radial strain (4D-GRS) (P < 0.005 for all parameters). The most powerful predictor for MACE among our study population is 4D-GAS, with the best cutoff value of 4D-GAS >−17 (P = 0.008; odds ratio = 20.668; confidence interval = 2.227–191.827). Conclusions: The novel 4D-GAS echocardiography predicts adverse clinical events in STEMI patients managed by successful primary PCI.

Objective: Some patients who had chronic coronary syndrome (CCS) and were recognized as low risk, however, developed cardiovascular events, whereas others who were categorized as high risk did not develop any cardiovascular events. Invasive coronary angiography is the gold standard tool for the assessment of coronary artery disease (CAD) severity. The SYNTAX score (SS) was recently recognized as an invasive angiographic-guided scoring system used in risk stratification of patients who have more than one-vessel CAD and undergoing revascularization with percutaneous cardiovascular intervention. It has a good predictive value of adverse cardiovascular events. Exploration for unique noninvasive modalities that may help in a better way for risk stratification of CCS patients by predicting the severity of CAD (as reflected by SS) would be of a paramount value. Tei index is a promising modality for that objective, which is a Doppler-derived time interval index that combines both systolic and diastolic cardiac performance. Methods: We examined the relationship between the severity of CAD as assessed by the SS and Tei index in 100 patients with CCS and normal left ventricular systolic function. Results: All the studied 100 patients had a normal ejection fraction with mean = 58.92 ± 7.88; the mean value of Tei index was 0.84 ± 0.26. There was a statistically significant positive association between Tei index and SS (P = 0.0001); moreover, there was a correlation between left anterior descending (LAD) affection and Tei index (P = 0.0001).The cutoff point of Tei index to detect SS above 22 was >0.93 (with specificity of 86.5% and sensitivity of 42.4%). Conclusion: Tei index significantly correlates with SS and LAD affection. Moreover, it is a cheap, radiation-free, noninvasive technique and may be used as a further risk stratification modality beyond others.

Objectives Validation of a mitral annular plane systolic excursion (MAPSE)–derived formula to calculate the ejection fraction where EF = 4.8 × MAPSE (mm) + 5.8 in adult males with left ventricular (LV) dysfunction. Background Echocardiographic assessment of LV function generally requires expert echocardiographer and is somewhat subjective and prone to reader discordance. MAPSE has been suggested as a surrogate measurement for LV function. Methods Prospective analysis of 170 male patients with systolic dysfunction by two-dimensional transthoracic echocardiography was carried out. MAPSE and ejection fraction measured by qualitative visual inspection, M-mode, and biplane modified Simpson's rule were measured. MAPSE-derived EF was compared against other conventional methods to measure EF using Bland–Altman analysis and independent t-test. Results There was a significant positive correlation between average MAPSE and EF measured by M-mode (r = 0.554, P

BACKGROUND: Identification of viable myocardium after myocardial infarction has gained paramount importance with the current progress in coronary revascularization. OBJECTIVE: To explore the prognostic power of certain patient characteristics to predict myocardial contractile recovery after revascularization in patients presenting with acute anterior ST elevation myocardial infarction (STEMI) who received thrombolytic therapy. METHODS: Seventy-three consecutive patients presenting with first acute anterior STEMI who had received thrombolytic therapy and had significant coronary stenosis or occlusion of the infarctrelated artery amenable for revascularization were enrolled. All patients underwent echocardiographic assessment of regional wall motion and left ventricular ejection fraction. Patients underwent coronary revascularization by either percutaneous angioplasty or surgical bypass. Echocardiography was repeated two to three months following revascularization. Patients were classified into two groups: group 1 had evidence of contractile recovery after revascularization at follow-up echocardiography and group 2 had no such evidence of recovery. RESULTS: Predictors of contractile recovery after revascularization included a shorter time from symptom onset to the institution of thrombolytic therapy, a lower baseline wall motion score index, the presence of grade 3 collaterals to the infarct-related artery and the use of beta-blockers. Instead, the presence of diabetes mellitus and a totally occluded infarct-related artery predicted poor contractile recovery. CONCLUSIONS: Myocardial contractile recovery after revascularization in patients presenting with first acute anterior STEMI may be predicted by the absence of diabetes, a shorter time from symptom onset to thrombolytic therapy, the use of beta-blockers, a lower initial wall motion index score and the presence of collaterals to the infarctrelated artery.

Background: Assessment of viability could be of significance in ischemic and heart failure patients before deciding for revascularization. The use of Dobutamine stress echocardiography has the disadvantage of subjective visual evaluation of regional wall motion, so, new technologies have been modified; one of these is to assess mitral annular velocity using tissue Doppler imaging. Aim: The aim of this study was to evaluate the value of Pulsed wave tissue Doppler mitral annulus velocity with dobutamine echocardiography in assessment of myocardial viability and prediction of functional recovery of wall motion abnormalities after revasularization in patients with coronary artery disease. Patients and methods: The study group included 40 patients, selected consecutively from patients presented to Ain Shams university Hospitals with coronary artery disease as proved by diagnostic coronary angiography and recommended for potential coronary revascularization. Each patient underwent baseline transthoracic echocardiography, in addition to low dose dobutamine echocardiography using TDI at mitral annulus in 6 different walls. All patients were subjected to revascularization (30 by PCI and 10 by CABG) then followed up after 6 months by transthoracic echocardiography to assess improvement in EF and SWMA. Results: Using the 16 segment method, a total of 640 segments were studied: 250 Segments were considered nondysfunctional (39%), 390 Segments were dysfunctional: of which, severely hypokinetc (216, 55.4 % of abnormal), 158 segments akinetic (40.5% of abnormal), and 16 Segments were dyskinetic (4.1% of abnormal). The mean SWM index at rest was 1.9 (0.39).Using low dose dobutamine echocardiography, 220 segments were detected to be viable (56.4%), while 170 were non-viable (43.6%). In order to relate the results of TDI, The 16 segments were reevaluated into 6 walls per patient. Using this method, 240 walls were studied. 19 walls were excluded due to technical difficulties in assessment of TDI. Pulsed wave TDI demonstrated that dysfunctional areas had lower systolic velocities compared to areas considered as normal. Similarly, the increase from baseline to DSE (ΔTDI) was higher in nondysfunctional areas vs. dysfunctional areas. However, there was no significant difference in the mean TDI at rest for viable and non-viable walls as detected by dobutamine stress echocardiography. But the increase in TDI velocity with peak dobutamine was significantly more in viable (1.97±0.44) vs. nonviable (1.14±0.54) walls, with p

Background: Six-minute walk test (6MWT) constitutes a suitable alternative for Cardio-pulmonary exercise testing to assess functional capacity in patients with heart failure (HF). Echocardiography has always been considered as the most useful easy test for evaluation of these patients. Purpose: To determine the echocardiographic predictors of six-minute walk distance (6MWD) in patients with chronic systolic heart failure as an objective assessment of functional capacity. Patients: This study included 40 patients with HF (EF

Use of Strain Imaging to Predict Myocardial Function Recovery after Percutaneous Revascularization of Infarct Related Artery Background: Speckle tracking echocardiography is integrated into echocardiographic systems for automated evaluation of left ventricular (LV) function by means of Automated Function Imaging (AFI). This study aimed at evaluating role of strain imaging [AFI & Tissue Velocity Imaging (TVI)] in predicting post-percutaneous coronary intervention (PCI) LV function recovery. Methods: Fifty patients with anterior wall myocardial infarction & impaired LV ejection fraction (LVEF≤45%), were prospectively enrolled. All patients showed positive viability results concerning left anterior descending (LAD) artery territory using low-dose dobutamine stress echocardiography (LDSE) & significant LAD disease for PCI. All patients underwent strain maging using AFI & TVI; at rest, at peak dose of LDSE and 3 months after PCI.