Limb-salvage angioplasty in poor surgical chronic liver disease and diabetic patients

Critical limb ischemia [CLI] in high surgical risk patients with chronic liver diseases has a grave prognosis with a one-year mortality rate of 20% and a one- year amputation rate of 25% after the initial diagnosis. According to Trans-Atlantic Inter-Society Consensus [TASC]-II Guidelines, revascularization [surgical and endovascular] is the treatment of choice for patients with critical limb ischemia [CLI]. The primary goal of revascularization is to relieve ischemic rest pain, heal ulcers, prevent amputation, improve patient's quality of life [limb salvage] and secondary goal was the periprocedural complications. Endovascular techniques include balloon angioplasty, stents, stent-grafts, and plaque debulking procedures. Surgical options, identification of patients at risk of postoperative complications could have an impact on the indications for a procedure as well as permitting modifications of treatment to reduce the surgical risk. This study evaluated the treatment out comes after limb salvage angioplasty for patients who otherwise would be candidates for primary amputation due to poor co-morbid conditions as chronic liver disease and diabetes. The clinical evaluation, laboratory investigations and abdominal ultrasonography were performed to all patients to evaluate their liver status. Patients were classified according to Child-pugh classification into child A, B and C. All patients were subjected to either detailed arterial duplex or C.T. angiography to assess their arterial lesions from January 2008- January 2010. 95 patients with critical limb ischemia [Rutherford categories 4, 5, 6] were treated by primary percutaneous transluminal angioplasty [PTA]. No patient was excluded on the basis of the extent of arterial occlusive disease. The primary end points were immediate technical success, clinical improvement and limb salvages rates. Secondary end points were periprocedural complications and mortality. Most of the patients were male [54.7%] with mean age 62 [48-70 years]. Underlying cirrhosis due to HCV was [82.2%], HBV [5.4%], while mixed viral infections was [12.4%]. 54% were categorized as Child B, 32% as child A and 14% as child C. Associated diabetes mellitus was present in 96% of the cases, hypertension in 64.2%, ischemic heart disease in 74% and hyperlipedemia in 32%. Rest pain, tissue loss, or both, were the presenting symptoms in 83% while infection and ulcer were present in the other 17% of patients. The total numbers of interventions were 154; the treated lesions were 89 in the tibial arteries, 12 in the popliteal artery, 44 in the superficial femoral artery, 3 in the common femoral artery and 6 in the iliac arteries with initial technical success rate of 93.6% and periprocedural complications of 12.6%. All patients were in Rutherford clinical category 4, 5, 6 none of these patients had a previous bypass operation. Mean follow-up was 15 months. The limb-salvage rate was 87.4%. Eighty patients [84.2%] of toe amputation sites healed primarily, three patients with rest pain had resolution of their symptoms after angioplasty. All technical failures were due to inability to cross the lesions. Of the 6 technical failures, 4 required amputation, and 2 refused any further therapy

Serum OX40 ligand: a potential marker of atopic dermatitis disease severity in children

OX40 ligand [OX40L] and OX40 are members of the tumor necrosis factor [TNF] and TNF receptor [TNFR] super families respectively. Recent studies have indicated the critical involvement of OX40/OX40L nteraction in the pathogenesis of atopic dermatitis. To our knowledge, no data could be cited in literature concerning OX40L levels in serum or in other biological fluids of atopic dermatitis children. This study was done to explore the expression of OX40L in the serum of atopic dermatitis children with respect to disease activity and severity. This follow-up, case-control longitudinal study was conducted on 64 children as a stratified non-random sample; 34 with atopic dermatitis and 30 healthy children. Serum concentrations of OX40L were measured by and wich enzyme immunoassay. The severity of atopic dermatitis was assessed according to the Leicester Sign Score [LSS], Simple Scoring System [SSS], Scoring Atopic Dermatitis [SCORAD] index, and Objective SCORAD. Serum OX40L levels [pg/ml] in atopic dermatitis patients were significantly elevated as compared to controls [176.6 +/- 45.9] whether during flare [1007 +/- 241.5] or quiescence [699 +/- 198.5]. There were significant positive correlations between serum OX40L levels and each of the LSS, SSS and SCORAD indices of atopic dermatitis disease severity, while it was insignificant regarding the objective SCORAD. However, when atopic dermatitis children were classified according to the objective SCORAD index of severity into mild, moderate and severe, it was found that the mean serum level in the severe group was significantly higher than the corresponding values of the mild or the moderate group. OX40L levels did not correlate with serum total IgE or absolute eosinophils count. Serum total LDH levels correlated positively with each of the serum OX40L levels and the LSS and SCORAD indices of severity. Serum OX40L level is an objective reliable marker of atopic dermatitis severity in children. It may be useful for follow up and may help to improve research and management of this disease. Blockade of interactions between OX40 on Th2 cells and OX40L on activated dendritic cells using an OX40L-specific monoclonal antibody could represent a novel strategy for the treatment of atopic dermatitis

Monocyte chemotactic protein-4 [MCP-4/CCL-13] and CC chemokine receptor 3 [CCR3] in the sputum of asthmatic children

Monocyte chemotactic protein-4 [MCP-4/CCL-13] is a potent chemoattractant to eosinophils, monocytes and lymphocytes. We aimed to investigate MCP-4 and its CC chemokine receptor 3 [CCR3] expression on cells of induced sputum during acute asthma exacerbation. Immunohistochemistry was used to assess MCP-4 and CCR3 expression on induced sputum cells of 30 children during asthma exacerbation and 20 healthy matched controls. Patients were divided into three groups according to exacerbation severity; mild, moderate and severe [n = 10 for each]. Patients were followed until quiescence, when sputum was re-examined. MCP-4 and CCR3 were expressed on eosinophils and monocytes. Lymphocytes expressed only MCP-4. The percentages of sputum total cells, eosinophils and lymphocytes expressing MCP-4 and/or CCR3 were significantly higher during asthma exacerbation than in controls and negatively correlated with peak expiratory flow rate, whereas that of monocytes was not. The percentages of sputum total cells, eosinophils, monocytes and lymphocytes expressing MCP-4; and total cells and eosinophils expressing CCR3 were significantly higher in patients with severe than those with mild and moderate exacerbations. When patients were followed till remission, the percentages of sputum cells expressing MCP-4 and CCR3 decreased. Sputum eosinophil percentage correlated positively with the percentage of eosinophils expressing MCP-4 and CCR3 [r = 0.69, p < 0.0001; r = 0.62, p < 0.001, respectively]. The percentage of sputum eosinophils expressing MCP-4 correlated positively with that of cells expressing CCR3 [r = 0.95, p < 0.0001]. The expression of MCP-4 and CCR3 on sputum cells increases during acute asthma exacerbation and this increase correlates with exacerbation severity, and it decreases during remission. Modification of their expression could be a potential target for asthma therapy

influence of HLA-DRB1 alleles on polyarticular onset juvenile rheumatoid arthritis susceptibility, severity, and prognosis

The genetic background of juvenile rheumatoid arthritis [JRA] in Egyptian children is understudied. The association between class II human leukocyte antigen [HLA] and RA in adults had been reported in different ethnic populations. To detect the frequency prevalence of HLA-DRB1 genes, and to study the influence of such alleles on JRA susceptibility or protection among a group of Egyptian children having polyarticular onset JRA. Also, to clarify the genetic contribution of the shared epitope [SE] positive alleles in relation to JRA severity and progression. Genotyping of HLA-DRB1 alleles were analyzed by polymerase chain reaction- sequence-specific primer amplification and allele specific probing technique in 60 JRA Egyptian children and 50 healthy children serving as controls. Measurement of bone mineral density [BMD using single energy quantitative computed tomography [SEOCT] was done to all patients and controls. The strength of the association of these alleles with JRA susceptibility, severity [clinical and radiological], and progression was expressed as relative risk estimated by odd ratio [OR]. The most frequent DRB1 specificities among JRA were *04 [allele frequency = 25.2%], *14 [20.7%], and *01[10.8%] compared to *08 [25.6%] and *04 [16.9%] among controls. In a logistic regression model, both DRB1 *04, and *14 alleles were significantly associated with JRA susceptibility while *08 allele was protective. Among JRA, the most common SE-containing DRB1 haplotypes were *1001 [5.4%], *0101 *0401, *0404, and *1402 [4.5% for each]. SE sequences were present in 40% of patients compared to 10% of controls [P=0.0001]. SE was present in homozygous state in 22% of patients. Furthermore, in a logistic regression model, the likelihood of having JRA was 29.6-fold higher among homozygote SE [P=0.002], compared to 1.94-fold higher among heterozygote SE [P=0.06]. The SE sequence [QKRAA, QRRAA and RRRAA] was found in [10%, 41.6%, and 10% respectively in JRA versus 2%, 8%, and 2% respectively in controls]. The carriage of [SE+/+] alleles encoding glutamine [0] at beta 70 [Q70 + or high risk SE] were associated with the greatest risk of JRA, while possession of alleles encoding aspartic [D] at beta 70 [D70 + or low risk SE] were associated with the lowest risk [OR 0.46 and 0.64, respectively] There were significant associations between disease clinical severity, radiological progression, and reduced BMD and the presence of [*04] and [*01] alleles. Our findings confirm the association of DRB1 *04 and *14 alleles with JRA susceptibility, and DRB1*08 with protection. A double allelic dose of SE particularly *04 and *01 alleles may contribute to the risk of developing severe forms of JRA, and are strong determinant of disease progression and aggressiveness. We recommended that DRB1 genotyping is one of the parameters to be taken into account to predict the course and prognosis of JRA and to aid in selecting children who deserve early aggressive therapy, thereby helping to prevent some of the associated morbidity and mortality. Further wide scale prospective hospital-based controlled studies are warranted to verify this conclusion and extend preliminary results

Role of E- selectin in coronary artery disease

Our present study was designed to evaluate the role of circulating E-selectin as a marker of endothelial dysfunction in coronary artery disease [CAD] and to answer the question [Is E-selectin considered one of the acute phase reactants in acute coronary syndrome or not?]. Fifty-six patients with CAD [thirteen cases had stable angina pectoris [SAP]; twenty-two cases had unstable angina [UA] and twenty one cases had acute myocardial infarction [AMI] were included in this study compared with ten healthy normal persons as control groups [NC]. All patients and control group were subjected to the following: [full medical history, clinical examination; resting [ECG]; two dimensional echo-cardiographic Doppler examination and coronary angiography [where CAD was considered when one or more of epicardial coronary vessels was stenosed >/= 50% E-selectin was evaluated once for all patients except for those of AMI the evaluation of E-selectin was done twice [at admission and after 24 hours of admission]. Total serum cholesterol [TC], serum triglyceride [TG], LDL-cholesterol, HDL-cholesterol, and random blood sugar [RBS] were evaluated for all patients. A highly significant levels of E-selectin were obtained when E-selectin level in AMI group was compared to NC group [P<0.01]. UA group showed a significant comparative results with NC group [P<0.05]; while no significant results when E-selectin in SAP group was compared to NC group. E-selectin show significant statistical difference when comparison was done between AMI group and UA [P<0.05], and between AMI and SAP [P<0.01] and between UA and SAP [P<0.05]. E-selectin did not show a statistical difference when comparison was made in AMI group at admission and 24 hs later.No direct relation between E-selectine and other risk factors TC, TG, HDL-C, LDL-C, RBS, but there is parallel relation between E-selectin and TC, TG, HDL-C. E-selectin is significantly elevated in AMI and UA [compared to SAP group and NC group]; so it is suggested to be used in the future as a useful marker for the diagnosis of AMI and UA but not for SAP [i.e. as acute phase reactant in acute coronary syndrome]. E-selectin may be used as a diagnostic tool to differentiate between UA and SAP

Evaluation of subthreshold stimulation the predicting the site of successful radiofrequency ablation in supra-ventmcular tachycardia

This study is aimed to determine the incidence of terminating the supra-ventricular tachycardia [SVT, [AVNRT and AVRT]] by Subthreshold stimulation [STS] and to evaluate the ultrarapid STS in predicting the site of successful radiofrequency ablation in these arrhythmias. Thirty patients were selected during routine EPS; for this study; fifteen have had AVNRT and fifteen have had AVRT, [patients with other arrhythnhias were excluded]. All patients were well prepared for EPS and subjected to the following: Pacing protocol: in all cases pacing of the RV was followed to avoid early atrial stimulation that would potentially throw the patients into AF 1- Ventricular stimulation protocol: to initiate orthodromic tachycardia and localization the site; and to detect the site of earliest retrograde atrial activation. 2- Atrial stimulation protocol: to initiate antidromic wide QRS tachycardia and discover presence or absence of AH jump suggesting dual AVNodal pathway. Subthreshold stimulation [STS] method. Once patient developed AVNRT or AVRT we put ablation catheter near to expect site of ablation either slow pathway in case of AVNRT or accessory pathway in case of AVRT. We started pacing from ablation catheter aiming to terminate the re-entry circuit by STS and not to capture the whole myocardium. STS by threshold ranging between 2-5 mA and cycle length [CL] shorter than that of tachycardia by 50 msec., then decreasing CL every step by 50 msec., until reach CL 200 msec., for aduration of 3-5 sec. continuous pacing each step. If AVNRT or AVRT was terminated in certain site we started ablation in this site and if AVNRT lead to slow Junctional rhythm or AVRT terminated tachycardia with or without VA dissociation this would be considered. a positive result. If AVNRT or AVRT was not terminated in certain site we started ablation in this site and if slow functional rhythm in AVNRT or termination of AVRT with or without AV dissociation in AVRT this would be considered negative result. If AVNRT or AVRT did not terminated by STS as well as by ablation we tried STS and ablation in another site and so on. We achieved [53%] positive results in cases of AVRT and negative results in [47%] of cases; while in AVRT the positive results was [66%] of cases and the negative results was [34%] of cases. STS-guided mapping is a novel tool for the detection of target sites of slow pathway [SP] and accessory pathway [AP] ablation in patients with reproducible inducible and sustained AVNRT and AVRT. This technique helps to reduce the number of RFC pulses required for SF and AP ablation without an increase of fluoroscopy time or procedure duration

Plasma homocysteine level in patients of coronary artery disease and its relation to vitamin B[12], folic ACID and other lipid risk factors

This study was planned to clarify the role of Homocysteine level in patients with coronary artery disease [CAD] in relation to folic acid and vitamin B[12], deficiency. The study included 90 persons; 20 healthy control, and 70 patients with [CAD], whom classified into [subgroup-1] included 25 cases of AMI, [subgroup-2] included 25 patients of unstable angina, and [subgroup-3] included 20 cases of stable angina. All cases in different groups and subgroups were underwent to coronary angiography at cardiology department of Al-Hussein university Hospital. Blood samples from all patients and control groups were analyzed at clinical pathology department at the same hospital for: 1 - Serum total Homocysteine. 2-Serum vitamin B[12] and folic acid- 3-Serum total cholesterol, Triglyceride, LDL, HDL, CK, CK-MB and LDH. The study revealed that there was high significance difference between control group and each subgroup as regard elevation of homocysteine and reduction of folic acid and vitamin B[12]; P-value <0.0001. There was correlation between elevation of homocysteine and folic acid deficiency in all subgroups, p-value<0.05- Also, there was correlation between elevation of homocysteine and vitamin B[12] deficiency in all subgroups, P-value<0.05. There is direct relation between hyper-homocysteinemia, folic acid, vitamin B[12] deficiency and coronary artery disease. We advice administration combined therapy with folic acid and vitamin B[12] to high risk individual of CAD

Intraoperative epidural nalbuphine bupivacaine analgesia: a comparative study

Epidural analgesia and anesthesia proved to be an excellent method of anesthesia in patients undergoing lower abdominal operations. Smaller doses of drugs are needed to achieve adequate analgesia and minimal side effects when given intrathecally or epidurally. The study was designed to compare the analgesic effect of epidural nalbuphine-bupivacaine to that of epidural bupivacaine alone. Nalbuphine-bupivacaine was also compared to other epidural opioids' analgesic effects. It was conducted on 100 patients scheduled for lower abdominal surgery. They were divided into five groups receiving bupivacaine [I], nalbuphine [II], morphine [III], fentanyl [IV] and pethidine [V] as an adjuvant to bupivacaine. The onset, duration of action of each drug, effects on pain scores, hemodynamics, respiratory rate, oxygen saturation, blood gases, and side effects were recorded after drug administration and over the next 12 h. Nalbuphine produced rapid onset analgesia 8-15 min, with a duration of 3-6 hours, perfect hemodynamic stability, minimal side effects [drowsiness and dysphoria] compared to other narcotics. Morphine with local anesthetic produced excellent analgesia 15-30 min of onset and duration of 6-12 hours but with liability to delayed respiratory depression and other side effects. Fentanyl has rapid onset of action and very effective analgesia for 1-3 hours with higher risk of respiratory depression than morphine. Pethedine given epidurally produced excellent analgesia of same onset as morphine, duration of 4-6 hours and may precipitate early respiratory depression

possible role of helicobacter like species in the aetiology of chronic cholecystitis in patients with positive gastric helicobacter infection

The aim of this study was to correlate between the helicobacter species identified in gall bladder specimens and those in upper GI biopsies. In this study, out of 60 gastric biopsies, 32 were +ve for H. pylori. The H. pylori like organisms were detected in 5 gall bladder specimens. The 5 positive gall bladder specimens were only found among the 32 cases with gastric biopsies +ve for H. pylori. This study suggested that there was no apparent association between colonization of the gall bladder with Hp in relation to chronic calcular cholecystitis. However, wider scale studies with multicentre-controlled investigations may help to establish a more consistent role of helicobacter species in the aetiology of cholecystitis

Antibody mediated immune response in sickle disease variants

Sickle cell anemia, a hemoglobinopathy with serious impacts, represents a health challenge in the developing world. Patients are particularly susceptible to repeated infection that may endanger their lives. In this study, 83 adults and 30 children were included. Cross-sectionally, serum immunoglobulins [IgG, IgA, IgM] and complement factors [C3 and C4] were assessed. All subjects prospectively were immunized by hepatitis B vaccine [recombinant hepatitis B virus surface antigen]. The immune response was evaluated and followed up by antibodies to the selected antigen. IgA was significantly elevated in sickle disease patients and serum IgM was significantly lower in sickle disease children, while C3 and C4 did not show significant differences between groups. The immune response to immunization did no show difference in rate of response between various age matched groups, responders were over 80% in all groups after seven months from the first dose of vaccination in those who completed the study. However, the results denoted a quantitative difference in the level of hepatitis B surface antibody. Further studies to delineate the implicated mechanisms in the immunodeficiency are suggested. Meanwhile, chemoprophylaxis and immunoprophylaxis are recommended in sickle cell anemia

Childhood pleural diseases: diagnostic correlations

This study was done on 25 patients with pleural effusion. They were 18 males and 7 females, their ages ranged from 4 months to 12 years. 80% of the patients were below five years. All patients were examined carefully and fully investigated. Thoracocentesis with cytological and biochemical studies of pleural aspirate were made to every patient. Culture and sensitivity of pleural aspirate were also done. Radiological examination showed that the effusion was right sided in 40%, left sided in 32% and bilateral in 28% of patients. On the basis of cytological and biochemical examination of the pleural aspirate, it was empyema in 68% complicating pneumonia in most of the cases, lung abscess and immunodeficiency as well. 12% of the patients were suffering from hydrothorax as a part of generalized edema. Hemothorax was present in 8% of the cases as a result of metastatic tumor. Tuberculosis and systemic lupus erythematosus were the causes of inflammatory exudate in two patients. Chylothorax was present in one case as a result of injury of the thoracic duct during cardiac surgery. The causes of pleural effusion could be minimized by proper management of pneumonia as it is the leading cause of pleurisy in the pediatric age group. Thoracocentesis should be done to every case with pleural effusion for diagnostic and therapeutic purposes

Analysis of the relationship between learner's characteristics, and traditional teaching methods vs performance of observational nursing tasks

The aim of the current study was to analyze each selected learner's characteristic and traditional teaching methods vs achievement of learning objectives related to observation. A group of 45 newly enrolled university nursing students was included in this study. The study recommended that the assessment check list be used as mental organizers and scored for feedback. Also, presenting theoretical knowledge after clinical training for lower aptitude students and replication of the study using a control group to test the effect of different teaching strategies as regard observation