Image-Quality Assessment of 3D Intracranial Vessel Wall MRI Using DANTE or DANTE-CAIPI for Blood Suppression and Imaging Acceleration

BACKGROUND AND PURPOSE

3D intracranial vessel wall MRI techniques are time consuming and prone to artifacts, especially flow artifacts. Our aim was to compare the image quality of accelerated and flow-suppressed 3D intracranial vessel wall MR imaging techniques relative to conventional acquisitions.

MATERIALS AND METHODS

Consecutive patients undergoing MR imaging had conventional postcontrast 3D T1-sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE) and either postcontrast delay alternating with nutation for tailored excitation (DANTE) flow-suppressed or DANTE-controlled aliasing in parallel imaging results in higher acceleration (CAIPI) flow-suppressed and accelerated T1-SPACE sequences performed. The sequences were evaluated using 4- or 5-point Likert scales for overall image quality, SNR, extent/severity of artifacts, motion, blood suppression, sharpness, and lesion assessment. Quantitative assessment of lumen and wall-to-lumen contrast ratios was performed.

RESULTS

Eighty-nine patients were included. T1-DANTE-SPACE had significantly better qualitative ratings relative to T1-SPACE for image quality, SNR, artifact impact, arterial and venous suppression, and lesion assessment (P < .001 for each, respectively), with the exception of motion (P = .16). T1-DANTE-CAIPI-SPACE had significantly better image quality, lesion assessment, arterial and venous blood suppression, less artifact impact, and less motion compared with T1-SPACE (P < .001 for each, respectively). The SNR was higher with T1-SPACE compared with T1-DANTE-CAIPI-SPACE (P < .001). T1-DANTE-CAIPI-SPACE showed significantly worse lumen (P = .005) and wall-to-lumen contrast ratios (P = .001) compared with T1-SPACE, without a significant difference between T1-SPACE and T1-DANTE-SPACE. T1-DANTE-CAIPI-SPACE scan time was 5:11 minutes compared with 8:08 and 8:41 minutes for conventional T1-SPACE and T1-DANTE-SPACE, respectively.

CONCLUSIONS

Accelerated postcontrast T1-DANTE-CAIPI-SPACE had fewer image artifacts, less motion, improved blood suppression, and a shorter scan time, but lower qualitative and quantitative SNR ratings relative to conventional T1-SPACE intracranial vessel wall MR imaging. Postcontrast T1-DANTE-SPACE had superior SNR, blood suppression, higher image quality, and fewer image artifacts, but slightly longer scan times relative to T1-SPACE.

Short term outcomes of distal (ventricular) His bundle pacing: A single centre retrospective study

Funding Acknowledgements

Type of funding sources: None.

Introduction

Chronic right ventricular apical pacing can lead to pacing induced cardiomyopathy in a significant proportion of patients. Conduction system pacing may restore more physiological activation of the heart, and has recently been shown to have favourable outcomes in clinical trials. However there remains concern regarding the long-term outcomes due to lead displacement and high pacing thresholds. The most widely used technique in current practice is to pace the His bundle proximal to the tricuspid valve. Distal His bundle pacing has a number of advantages over proximal His pacing, including, lower capture thresholds, a more stable lead position, less far field atrial sensing and better spacing from the AV node in case ablation of this is required for AF rate control. Despite these, outcomes of distal His bundle pacing from the ventricular aspect are less well defined.

Methods

We performed a retrospective review of patients who underwent conduction system pacing between January 2020 and October 2021 at our centre. During this period all procedures were performed employing a distal His bundle pacing approach with the lead placed on the ventricular aspect of the tricuspid annulus. Data was collected at implant, follow-up at 1 month and then every 6 months.

Results

Out of 35 patients, 33 underwent successful His bundle pacing (acute success rate of 94%), 1 patient had left bundle branch pacing and another patient had an unsuccessful procedure. Mean age was 74 years, median LVEF 45% and median pre-implant QRS was 108ms. 80% of the cohort had a history of AF. The indications for pacing were as follows: AF - for pace & ablate (60%); high grade AV block with narrow QRS and mild LVSD (17%); failed LV lead (14%); and other 9%. Mean procedure duration and fluoroscopy time were 78 minutes and 12.05 minutes, respectively. Median threshold at implant was 1.00V (IQR 0.719V). Selective His bundle pacing was achieved in 60% and non-selective in 34%. Mean follow-up duration was 150 days with median threshold at last f/up of 0.75V (IQR 0.750V). There were no acute procedural complications. 1 patient had a significant rise in threshold at follow-up and therefore required upgrade to CRT-P.

Discussion

Our data shows that distal His bundle pacing is a safe and effective technique for conduction system pacing. Thresholds appear stable at follow-up and failure rate was found to be comparable to biventricular pacing. We noted an initial learning curve for both implanter and physiologists with relatively poorer outcomes for the earlier cases. Longer term follow-up is ongoing, including functional assessment and follow-up to assess for remodelling with echocardiography. Prospective randomised trials are needed to compare conduction system pacing vs RV pacing in AF patients with HFpEF or mild LVSD undergoing AVN ablation, and vs biventricular pacing in the severe LVSD population.

Short term outcome of distal (ventricular) His bundle pacing and atrioventricular node ablation in patients with symptomatic atrial fibrillation - Refining the concept

Funding Acknowledgements

Type of funding sources: None.

Introduction

Many patients with atrial fibrillation (AF) do not benefit from rhythm control due to failed catheter ablation, advanced left atrial disease and comorbidities. "Pace and AV node (AVN) ablation" strategy is often adopted for rate control but with a substantial risk of pacing-induced cardiomyopathy. His bundle pacing (HBP) enables physiological biventricular activation through the His Purkinje conduction system. However, the proximity of the HBP lead to the site of AV node ablation may potentially compromise lead integrity in patients who undergo conventional HBP and AVN ablation. Therefore, we have modified HBP by placing the HBP lead distally at the ventricular side of the His bundle (D-HBP) before AVN ablation in patients with symptomatic AF. All patients had a backup RV lead.

Method

Patients who had D-HBP as part of a "Pace and AVN ablation" strategy were retrospectively analysed. Implant and device clinic follow-up data were collected and analysed.

Result

Twenty-one patients who had "pace and AVN ablation strategy" with D-HBP between 26th February 2020 and 3rd November 2021 were included. They had a mean age of 75 ± 1.4 years (mean ± SEM), NYHA class of 2.1 ± 0.2, QRS duration of 106 ± 5.3ms and 50% had at least moderately impaired LV systolic function. Seventeen patients (81%) had narrow QRS duration. D-HBP was successful in twenty of twenty-one patients (95%). At D-HBP implant, the mean acute threshold of the HBP lead was 0.96 ± 0.12V at 0.5 ± 0.05ms and the mean HBP lead impedance was 548.1 ± 29.5Ω. Selective HBP pacing was observed in thirteen of twenty patients. The mean QRS duration of HBP paced beats was 104.5 ± 4.7ms. Failure to capture the His bundle was observed in one patient. AVN ablation was performed on the same day after D-HBP in eleven patients and as a subsequent procedure in nine patients. The mean duration of procedure and fluoroscopy for D-HBP were 77.4 ± 4.6 minutes and 11.9 ± 1.4 minutes respectively. There were no acute procedural complications with no lead damage, displacement or lead perforation observed. The median follow-up period was 207 days. The mean D-HBP lead threshold following AVN ablation was 1.1 ± 0.2 V at 0.6 ± 0.07 ms and the mean lead impedance was 433.8 ± 20.7Ω, which were similar to before AVN ablation. One patient was reprogrammed with RV pacing only for elevated HBP lead threshold after AVN ablation to 4.2 V at 1ms. The mean D-HBP percentage was 92.3 ± 6.6% and the mean estimated battery longevity of the pacemaker was 7.9 ± 0.6 years at the last follow up. There was improvement in heart failure symptoms in eight patients from previously symptomatic to NYHA class I following D-HBP and AVN ablation.

Conclusion

D-HBP appear to be safe with potentially more favourable lead parameters than conventional proximal HBP in patients with symptomatic AF offered "Pace and AVN ablation" strategy.

Insights into Early Pregnancy Demise following Intracytoplasmic Sperm Injection in Women with Unexplained Infertility

OBJECTIVE

To investigate the effects of some potential risk factors on early pregnancy loss -EPL - in a cohort of pregnant women treated by assisted reproductive technology - ART.

METHODS

This is a retrospective cohort of 195 pregnancies, defined as serum human chorionic gonadotrophins ≥ 10 IU/l on day 14 - 17 after embryo transfer, recruited from an assisted reproductive technology unit, Ain Shams & Al-Azhar Maternity hospital, Cairo, Egypt, during the period from January 1st, 2016 to December 31, 2020. Risk factors investigated were maternal age, body mass index, status, baseline hormonal profiles, treatment protocol, quality and number of embryos.

RESULTS

Overall early pregnancy loss among the studied 195 pregnant women was 29 cases (15%). The risk of early pregnancy loss was associated with older age and fewer number of embryos transferred. Women > 35 years were found to have two and half times of early pregnancy loss compared with younger age group < 25 years, this was not significant after adjusting for other factors. The risk in both lean (BMI < 25 kg/m2) and very obese (BMI > 35 kg/m2) women was also not significantly higher in unadjusted analysis. Transfer of two or more embryos was associated with a non-significant reduced risk of early pregnancy loss, and after adjusting for other factors, the reduction was about 70%.

CONCLUSIONS

Early pregnancy loss represents a considerable drawback of intracytoplasmic sperm injection treated women with old age to increase the risk of early pregnancy loss and transferring more than one embryo to reduce the risk by about 70%. Obesity and other factors appeared to play a minor role.

Evaluation of the ex-vivo porcine simulator on EUS-guided cystogastrostomy using lumen-apposing metal stent training

Bckground and Objectives

EUS-guided cystogastrostomy is a well-established advanced endoscopic technique with a steep-learning curve which necessitates an ex-vivo simulator that would allow for adequate training. The aim of this study is to evaluate the feasibility of the model in allowing training for EUS-guided cystogastrostomy using lumen-apposing metal stent (LAMS).

Subjects and Methods

The model was created by ROEYA Training Center, Egypt, using native porcine tissue to create fluid collections simulating both cystic and solid lesions. It was designed and tested in advance while the hydrogel was added on-site. The simulator was evaluated prospectively in five training sessions involving 17 international experts. The task was to successfully deploy the LAMS to drain the created cyst. After using the simulator, the experts were asked to fill a questionnaire to assess their experience. The primary endpoint was overall satisfaction with the model as a training tool.

Results

All of the experts were satisfied with the model as a tool to train endoscopists for the technique. 76.5% (n = 11) of the experts thought the model to be moderately realistic. Proper visualization was reported by 94.1% of the experts. All experts believed the lesions to be either slightly like or very similar to real lesions. The model was graded "easy" in difficulty by 11 of the experts.

Conclusions

In all parameters assessed, the experts thought the model to be a useful tool for future training. This preliminary study suggests that the aforementioned simulator can be used to train endoscopists on using LAMS in a risk-free environment.

Prevalence and Predictors of Metabolic Syndrome among Adults in North-Central, Nigeria

BACKGROUND

Metabolic syndrome contributes to the burden of non-communicable diseases and is a growing public health problem in both developed and developing countries. We determined the prevalence and predictors of metabolic syndrome among adults in Benue State, North-Central, Nigeria to guide targeted interventions.

METHODS

We conducted a community-based cross-sectional study in Benue State, North-Central, Nigeria. Multistage sampling technique was used to recruit 823 respondents. We defined metabolic syndrome using the National Cholesterol Education Programme Adult Treatment Panel III guideline and adapted a component of the WHO Stepwise questionnaire for data collection. Prevalence of metabolic syndrome and the associated risk factors were estimated using Chi square test and logistic regression at 5% level of significance. Statistical analysis was done using SPSS version 23.0.

RESULTS

The mean age of the respondents was 40.1± 15.7 years. Most of the respondents were literate (86.8%) and married (67.0%). The prevalence of metabolic syndrome was 19.4%. One in every four of the respondents had pre-metabolic syndrome (25.6%) and this was more in females (28.2%) compared to males (22.9%). Thirty-four percent of the respondents had only one whereas 20.7% did not have any of the risk factors for metabolic syndrome. Age [aOR:10.3; 95%CI: 4.8-22.2], sex [aOR:2.4; 95% CI: 1.7-3.5] and education [aOR:2.9; 95%CI: 1.4-6.1] were significantly associated with metabolic syndrome among the respondents.

CONCLUSION

The prevalence of metabolic syndrome was high. The associated risk factors were age, gender and educational status. Therefore, interventions should be targeted at young adults to reduce the long-term impact of the disease.

Mental health crisis in Somalia: a review and a way forward

Background

Somalia has been without an effective government since the collapse of the military regime in 1991. Years of conflict, disasters, and insecurity have all contributed to very low scores for most health indicators due to poor governance, protracted conflict, underdevelopment, economic decline, poverty, social and gender inequality, and environmental degradation. The three-decade long protracted conflict has led to widespread psychosocial trauma, social deprivation and substance abuse with devastating consequences on mental health. A WHO study showed Somalia has one of the highest rates of mental illness in the world. The main aim of this study is to assist policy makers in setting priorities for the design and delivery of interventions to promote mental health and psychosocial wellbeing in Somalia.

Methods

The study uses a systematic mapping technique (from January 1991 to May 2020) and data collected from public domain, to collect, collate, and present mental health data mainly from WHO’s Global Health Observatory. Since there is no primary database for Somalia’s public health research, the bibliographic databases used for mental health in this study included Medline, PubMed, CINAHL, PsycINFO, and Google Scholar. Data were extracted using techniques for web data mining for public health.

Results

Systematic mapping of mental health-related issues in Somalia showed that policy-related determinants and mental health services dominated (74.4%), followed by the disaster-related determinants and women’s health consequences (39.3%). The ratio of the number of beds for mental health in general hospitals (per 100,000 population) in Somalia in 2017 is 0.5 compared to the Eastern Mediterranean region (EMR) at 6.4 and globally at 24. One of the biggest casualties of the civil war was loss of essential human resources in healthcare as most either fled the country or were part of the victims of the war.

Conclusions

The vast scale of the mental health problems in Somalia and the priority setting guidelines for interventions to address the issues outlined in this paper, prompt a dire need that the Somali government and its national/international partners should prioritize and emphasize the need to invest in the prevention and the treatment of mental illness across the country.

Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient

BACKGROUND

Failure to rescue (FTR) denotes mortality from post-operative complications after surgery with curative intent. High-volume, low-mortality units have similar complication rates to others, but have lower FTR rates. Effective response to the deteriorating post-operative patient is therefore critical to reducing surgical mortality. Resilience Engineering might afford a useful perspective for studying how the management of deterioration usually succeeds and how resilience can be strengthened.

METHODS

We studied the response to the deteriorating patient following emergency abdominal surgery in a large surgical emergency unit, using the Functional Resonance Analysis Method (FRAM). FRAM focuses on the conflicts and trade-offs inherent in the process of response, and how staff adapt to them, rather than on identifying and eliminating error. 31 semi-structured interviews and two workshops were used to construct a model of the response system from which conclusions could be drawn about possible ways to strengthen system resilience.

RESULTS

The model identified 23 functions, grouped into five clusters, and their respective variability. The FRAM analysis highlighted trade-offs and conflicts which affected decisions over timing, as well as strategies used by staff to cope with these underlying tensions. Suggestions for improving system resilience centred on improving team communication, organisational learning and relationships, rather than identifying and fixing specific system faults.

CONCLUSION

FRAM can be used for analysing surgical work systems in order to identify recommendations focused on strengthening organisational resilience. Its potential value should be explored by empirical evaluation of its use in systems improvement.

Prevalence of cutaneous leishmaniasis in the largest populated city Karachi, Pakistan

The study was undertaken from September 2018 to April 2019 to determine the prevalence of cutaneous leishmaniasis in human beings living in six districts of Karachi. Suspected persons were screened for the disease and positive cases were identified on the basis of skin lesions and blood samples. Samples were observed by mounting their smear. A total of 207 subjects of different ages and sex groups were investigated, however, only 192 (92%) of the suspected cases were found to have the disease 64% of cases were male which were significantly high (p 0.05), than female 36%. The lesion was more frequently detected among the youth ages of 21-30 years (31%) as compared to other groups. In both sexes, legs were found to be more infected (25% male + 20% female) followed by arms (20% male + 0% female) and face (15% male +11% female). The mixed body parts had shown the lowest infections such as (4% in males + 5%) in females. In conclusion, the highest and lowest leishmaniasis infections were observed in District West (23% male + 9% female) followed by District East (15% male + 7% female), District Malir (11% male+ 4% female), District Central (7% male + 5% female), District Korangi (4% male + 7% female) and District South (4% male + 4% female) respectively.

Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis

OBJECTIVES

Endoscopy is the mainstay treatment option for acute variceal bleeding (AVB) in liver cirrhosis. However, the optimal timing of endoscopy in such patients remains unclear.

METHODS

PubMed, EMBASE and Cochrane Library databases were searched. We compared the mortality, incidence of rebleeding, length of stay, endoscopic hemostasis, need for salvage and units of transfusion between cirrhotic patients with AVB who underwent early and delayed endoscopy. Meta-analyses were performed by using a random-effect model. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analysis was performed in studies where early endoscopy was defined as <12 h.

RESULTS

Nine retrospective studies involving 2824 patients were included. The early endoscopy group had a significantly lower overall mortality than the delayed endoscopy group in overall analysis (OR = 0.56, 95% CI, 0.33-0.95, P = 0.03), but the difference between them was NS in subgroup analysis (OR = 0.72, 95% CI, 0.38-1.38, P = 0.33). In-hospital (OR = 0.77, 95% CI, 0.26-2.32, P = 0.65) and 6-week (OR = 0.78, 95% CI, 0.42-1.47, P = 0.45) mortality were not significantly different between them. Overall rebleeding was not significantly different between early and delayed endoscopy groups in both overall (OR = 0.88, 95% CI, 0.51-1.51, P = 0.63) and subgroup (OR = 1.04, 95% CI, 0.55-1.95, P = 0.90) analyses. In-hospital (OR = 1.41, 95% CI, 0.67-2.96, P = 0.37) and 6-week (OR = 0.93, 95% CI, 0.40-2.17, P = 0.86) rebleeding remained not significantly different between them. Additionally, the length of stay, endoscopic hemostasis, need for salvage and units of transfusion were not significantly different between them.

CONCLUSIONS

Early endoscopy may improve the survival of cirrhotic patients with AVB, but has no remarkable benefit on the prevention of rebleeding. These findings should be further validated by high-quality studies.

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Background

Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE).

Case Description

We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused.

Discussion

The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Background

Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE).

Case Description

We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused.

Discussion

The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

Antibacterial and antifungal activity of methanolic extracts of Salix alba L. against various disease causing pathogens

The present study was aimed to manifest the antibacterial and antifungal activity of methanolic extracts of Salix alba L. against seven Gram-positive and Gram-negative bacterial pathogens e.g. Streptococcus pyogenes, Staphylococcus aureus (1), S. aureus (2), Shigella sonnei, Escherichia coli (1), E. coli (2) and Neisseria gonorrhoeae and three fungal isolates from the air such as Aspergillus terreus, A. ornatus, and Rhizopus stolonifer. Two different serotypes of S. aureus and E. coli were used. The agar well-diffusion method results showed the dose-dependent response of plant extracts against bacterial and fungal strains while some organisms were found resistant e.g. E. coli (1), S. sonnei, A. terreus and R. stolonifer. The highest antibacterial activity was recorded at 17.000±1.732 mm from 100 mg/mL of leaves methanolic extracts against S. pyogenes while the activity of most of the pathogens decreased after 24 h of incubation. The highest antifungal activity was reported at 11.833±1.0 mm against A. ornatus at 50 mg/mL after 48 h of the incubation period. These experimental findings endorse the use of S. alba in ethnopharmacological formulations and suggest the use of methanolic extracts of the said plant to develop drugs to control the proliferation of resistant disease causing pathogenic microbes.

Forklift-related lower limb injuries: a retrospective case series study with patient-reported outcome measures (PROMs)

AIM

Forklift trucks can cause serious lower limb trauma with long-lasting sequelae to patients. The aim of this study was to analyse a case series of patients with forklift-related injuries over 7 years at a level 1 major trauma centre in the UK and present their patient-reported outcome measures (PROMs) with long-term follow-up. To the best of the authors' knowledge, this is the largest case series study in the UK describing forklift injuries.

METHODS

Retrospective case note analysis of 19 patients over 7 years. Data including demographics, injury mechanism, pattern of injury, management, length of hospital stay, number of operations and complications were extracted from the notes. We used 'Enneking score' as a validated tool for PROMs.

RESULTS

Seventeen men and two women with mean age of 47 years; 20% had bilateral injuries and 34% had multi-level fractures. The mean number of theatre sessions was 5.21, while the mean length of hospital stay was 30.10 days. There was one mortality. Twelve patients (63%) required reconstruction with free tissue transfer, with one flap failure. The mean long-term Enneking percentage score was 57.33%. The mean Enneking score for patients in this study is lower than our institute's score for Gustilo 3B, highlighting the gravity of these injuries.

CONCLUSION

Forklifts can cause grave injuries with massive energy transfer. This study highlights the seriousness of those injuries, thus guiding patient counselling and optimising planning of management.

Methylene blue versus vasopressin analog for refractory septic shock in the preterm neonate: A randomized controlled trial

BACKGROUND

Refractory septic shock in neonates is still associated with high mortality, necessitating an alternative therapy, despite all currently available treatments. This study aims to assess the vasopressor effect of methylene blue (MB) in comparison to terlipressin (TP) as adjuvant therapy for refractory septic shock in the preterm neonate.

METHODS

A double-blinded randomized controlled trial was conducted in the Neonatal Intensive Care Units at Ain Shams University, Egypt. Thirty preterm neonates with refractory septic shock were randomized to receive either MB or TP as an adjuvant to conventional therapy. Both MB and TP were administered as an intravenous loading dose followed by continuous intravenous infusion. The hemodynamic variables, functional echocardiographic variables, and oxidant stress marker were assessed over a 24 h period together with the side effects of MB.

RESULTS

MB causes significant improvement in mean arterial blood pressure with a significant decrease of the norepinephrine requirements (1.15±0.21μm/kg/min at baseline vs. 0.55±0.15μm/kg/min at 24 h). MB infusion causes an increase of the pulmonary pressure (44.73±8.53 mmHg at baseline vs. 47.27±7.91 mmHg after 24 h) without affecting the cardiac output. Serum malonaldehyde decreased from 5.45±1.30 nmol/mL at baseline to 4.40±0.90 nmol/mL at 24 h in the MB group.

CONCLUSION

Administration of MB to preterm infants with refractory septic shock showed rapid increases in systemic vascular resistance and arterial blood pressure with minimal side effects.

90 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management

Aim

to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient’s candidates for non-operative management.

Method

In this comparative study 40 abdominal stab victims (admitted to Emergency Department of Alexandria Main University Hospital) were selected during 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome.

Results

In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications.

Conclusions

Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.

Serum Amyloid A Level in Women with Unexplained Infertility

Background

By various molecular and cellular research efforts it was displayed that folliculogenesis, ovulation, and corpus luteum formation is considered as an inflammatory processes that hav raised the research interest to investigate that serum amyloid A as an inflammatory mediator to reveal its possible role in infertility.

Objective

This study aims to assess the association between SAA and unexplained infertility in women.

Methods

The current research study have been conducted at Ain Shams University Maternity Hospital during the period from September 2018 to April 2019. Women approached were recruited from outpatient clinic of Ain Shams University Maternity Hospital. The recruited 90 research study subjects have been divided into two research groups

Results

Serum amyloid A was statistically significantly higher among the unexplained research group versus control group (SAA had excellent discriminative value with an area under the ROC curve (AUC) of 0.992 (95% CI = 0.945 to 1.000, Pvalue &lt;0.0001). A best cutoff criterion is SAA of 28.7 mg/l (sensitivity = 98%, specificity = 96%, J-index = 0.93)) denoting that amyloid A as an acute phase inflammatory modulator is higher among the unexplained research group reflecting a form of chronic inflammatory process in those category of cases. Analytical research results of multivariable binary logistic regression analysis as regards the correlation between SAA and unexplained infertility after adjustment for age and BMI, it was revealed that serum amyloid A an independent predictor for unexplained infertility.

Conclusion

s: Serum amyloid A as a biomarker for could be implemented as a predictability tool for unexplained infertility since it is a reflector of an chronic inflammatory process that is ongoing that could affect the process of implantation and ovulation however the clear molecular and cellular processes linked to the pathophysiological process that reflects the fertility hindering process should be implemented in future research efforts taking in consideration to have multicentric fashion of research with larger sample sizes to verify the value of serum amyloid A as biomarker that reflects the fertility potential besides the routine infertility work up.

Early Detection of Acute Kidney Injury by Neutrophil Gelatinase Associated Lipocalin in Patients Undergoing Coronary Artery Bypass Grafting with Cardiopulmonary Bypass

Neutrophil Gelatinase-Associated Lipocalin (NGAL) is rapidly released by renal tubules after injury, potentially allowing early identification of acute kidney injury (AKI) after cardiac surgery. However, the diagnostic performance of NGAL has varied widely in clinical studies and it remains unknown what factors modify the relationship between NGAL and AKI. The main objective of the study was to determine the efficacy of NGAL in early detection of AKI among the CABG patients undergoing cardiopulmonary bypass (CPB). This prospective observational study was conducted in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh in collaboration with the Department of Biochemistry, BSMMU among 42 patients admitted into the Department of Cardiac Surgery, Ibrahim Cardiac Hospital and Research Institute, Dhaka Bangladesh from July 2014 to June 2015. For the measurement of NGAL, urine samples were obtained before surgery and 6 hours after commencement of CPB. Serum creatinine was measured preoperatively and 6, 24 and 48 hours postoperatively. Increase in the serum creatinine level at 6, 24 and 48 hours after surgery was used to analyze the diagnostic value of urinary NGAL. In this study 42 CABG patients with no known renal insufficiency planned to have CPB were included. Receiver-operator characteristic (ROC) was constructed by using NGAL, which gave a cut off value of ≥185.90ng/ml. Eight patients were AKI positive among them 6(75.0%) patients were NGAL positive and 2(25.0%) were NGAL negative. Diagnosis of AKI was delayed by 24-48 hours by serum creatinine measurement. This study has demonstrated that level of urinary NGAL concentration at 6 hours post CPB increased before the increase of serum creatinine level and NGAL is an early predictor of AKI in adult cardiac surgical patients. The early detection of renal injury by NGAL may allow earlier intervention in patients with high risk for AKI.

Endoscopic treatment for gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) is one of the uncommon causes of upper gastrointestinal bleeding. Major treatment of GAVE includes pharmacotherapy, endoscopy, and surgery. The efficacy and safety of pharmacotherapy have not been sufficiently confirmed; and surgery is just considered when conservative treatment is ineffective. By comparison, endoscopy is a common treatment option for GAVE. This paper reviews the currently used endoscopic approaches for GAVE, mainly including argon plasma coagulation (APC), radiofrequency ablation (RFA), and endoscopic band ligation (EBL). It also summarizes their efficacy and procedure-related adverse events. The endoscopic success rate of APC is 40-100%; however, APC needs several treatment sessions, with a high recurrence rate of 10-78.9%. The endoscopic success rates of RFA and EBL are 90-100% and 77.8-100%, respectively; and their recurrence rates are 21.4-33.3% and 8.3-48.1%, respectively. Hyperplastic gastric polyps and sepsis are major adverse events of APC and RFA; and Mallory-Weiss syndrome is occasionally observed after APC. Adverse events of EBL are rare and mild, such as nausea, vomiting, esophageal or abdominal pain, and hyperplastic polyps. APC is often considered as the first-line choice of endoscopic treatment for GAVE. RFA and EBL have been increasingly used as alternatives in patients with refractory GAVE. A high recurrence of GAVE after endoscopic treatment should be fully recognized and cautiously managed by follow-up endoscopy. In future, a head-to-head comparison of different endoscopic approaches for GAVE is warranted.