Circulating vaccine derived polio virus type 2 outbreak and response in Yemen, 2021-2022, a retrospective descriptive analysis.

BACKGROUND: The outbreaks of circulating Vaccine Derived Polio Viruses (cVDPVs) have emerged as a major challenge for the final stage of polio eradication. In Yemen, an explosive outbreak of cVDPV2 was reported from August 2021 to December 2022. This study aims to compare the patterns of cVDPV2 outbreak, response measures taken by health authorities, and impacts in southern and northern governorates. METHOD: A retrospective descriptive study of confirmed cases of VDPV2 was performed. The data related to cVDPV2 as well as stool specimens and environmental samples that were shipped to WHO-accredited labs were collected by staff of surveillance. Frequencies and percentages were used to characterize and compare the confirmed cases from the southern and northern governorates. The average delayed time as a difference in days between the date of sample collection and lab confirmation was calculated. RESULTS: The cVDPV2 was isolated from 227 AFP cases reported from 19/23 Yemeni governorates and from 83% (39/47) of environmental samples with an average of 7 months delayed from sample collection. However, the non-polio AFP (NPAFP) and adequate stool specimen rates in the north were 6.7 and 87% compared to 6.4 and 87% in the south, 86% (195) and 14%(32) out of the total 227 confirmed cases were detected from northern and southern governorates, respectively. The first and second cases of genetically linked isolates experienced paralysis onset on 30 August and 1st September 2021. They respectively were from Taiz and Marib governorates ruled by southern authorities that started vaccination campaigns as a response in February 2022. Thus, in contrast to 2021, the detected cases in 2022 from the total cases detected in the south were lower accounting for 22% (7 of 32) of compared to 79% (155 of 195) of the total cases the north. CONCLUSION: A new emerging cVDPV2 was confirmed in Yemen. The result of this study highlighted the impact of vaccination campaigns in containing the cVDPV2 outbreak. Maintaining a high level of immunization coverage and switching to nOPV2 instead of tOPV and mOPV2 in campaigns are recommended and environmental surveillance should be expanded in such a risky country.

Volume Changes in the Descending Aorta after Frozen Elephant Trunk and Conventional Hemi-Arch Repair after Acute Type A Aortic Dissection.

The aim of this study was to compare the mortality rates, re-intervention rates, and volumetric changes in aortas following surgery, in terms of the true lumen and false lumen changes, using conventional hemi-arch repair (CET) and frozen elephant trunk (FET) techniques. During the period from 2015 to 2018, 66 patients underwent surgical treatment for acute aortic dissection (Debakey type 1). Demographic and procedure-related data were evaluated. We measured volumetric change before surgical treatment, at discharge, and at 12- and 24-month time points based on computed tomography angiography. The study cohort was divided into two groups (FET vs. CET). The mean age of the patients was 56.9 ± 9.4 years in the FET group versus 63.6 ± 11 years in the CET group (p = 0.063). The mean follow-up time was 24 ± 6 and 25 ± 5 months for the FET and CET groups, respectively. There were no significant differences between the two groups in terms of the medical histories of the cohorts. The results showed a significant increase in true lumen volume after the FET procedure (within 24 months postoperatively; p = 0.005), and no significant changes in total (p = 0.392) or false lumen (p = 0.659) volumes were noted. After the CET procedure, there were significant increases in total and false lumen volumes (p = 0.013, p = 0.042), while no significant change in true lumen was observed (p = 0.219). The volume increase in true lumen after the FET procedure was higher compared to the CET group at all postoperative time points (at discharge, 12 months, and 24 months) without significant evidence (p = 0.416, p = 0.422, p = 0.268). At two years, the volume increase in false lumen was significantly higher among the CET group compared to the FET group (p = 0.02). The Kaplan-Meier curve analysis showed that patients who underwent the CET procedure underwent significantly more re-interventions due to false lumen expansion of the descending aorta (p = 0.047). Present study results indicate that the true and false lumen changes in the aorta following the FET and CET procedures were different. FET led to a significant increase in true lumen volume, while false lumen volume remained stable; however, after the CET procedure, significant false lumen enlargement was noted at mid-term follow-up time points. The re-intervention rate after CET was higher due to false lumen expansion.

Cost saving in primary versus tertiary level of reproductive health services in Sana'a, Yemen, 2013: a comparative cross-sectional study.

OBJECTIVES: To estimate the cost saving for utilisation of vaginal delivery (VD), antenatal care (ANC) and an intrauterine device (IUD) services at primary health level facilities (PHLF) instead of tertiary health level facilities (THLF) in Sana'a. DESIGN: A comparative cross-sectional study. SETTING: Eight PHLF in Sana'a governorate and three THLF in Sana'a city. PARTICIPANTS: A total of 180 women aged (15-45 years) were enrolled equally from PHLF and THLF. Sixty women attended for each reproductive health service (VD, ANC and IUD services). PRIMARY AND SECONDARY OUTCOME MEASURES: The direct and indirect costs of services at PHLF and THLF, and the cost saving for utilisation of PHLF instead of THLF. RESULTS: The median of direct medical cost (DMC) of VD, ANC and IUD services were US$43.86, US$14.77 and US$9.07 at THLF compared with US$19.54, US$0.93 and US$11.17 at PHLF, respectively. The DMC difference of VD, ANC and IUD services between THLF and PHLF was US$24.32, US$13.84 and US$-2.1, respectively. Regarding the direct non-medical costs (DNMC), the median of VD, ANC and IUD services were US$43.05, US$19.07 and US$17.27 at THLF compared with US$13.96, US$0.00 and US$0.00 at PHLF, respectively. The DNMC difference of VD, ANC and IUD service between THLF and PHLF was US$29.09, US$18.07 and US$16.27, respectively. Moreover, the median of indirect cost (INDC) for VD, ANC and IUD services were US$23.93, US$9.49 and US$10.44 at THLF compared with US$7.90, US$1.59 and US$1.06 at PHLF, respectively. The INDC difference of VD, ANC and IUD service between THLF and PHLF was US$16.03, US$7.90 and US$9.38, respectively. CONCLUSION: The study found the utilisation of VD, ANC and IUD services at PHLF instead of THLF is a considerable cost saving for families. Therefore, shifting the utilisation of services from THLF to PHLF reduces the financial burden affecting individuals, families and their productivity.

Effectiveness of probiotic lozenges and Chlorhexidine mouthwash on plaque index, salivary pH, and Streptococcus mutans count among school children in Makkah, Saudi Arabia.

PURPOSE: To compare the effect of the probiotic lozenges and chlorhexidine (CHX) mouthwash on plaque index (PI) , salivary pH and Streptococcus mutans (S. mutans) 3 count among groups of Saudi children. METHODS: A total of 54 participants aged 8-12 years were randomly allocated into three groups, 18 children in each group. Children in the probiotic group consumed one probiotic lozenge (Biogaia prodentis) daily, while children in the CHX group were instructed to use CHX mouthwash twice daily. The control group was only instructed to follow regular oral hygiene measures. Saliva samples were taken at baseline, 15th and 30th days. PI scores, salivary pH values and S. mutans count were evaluated. Data were statistically analyzed using the ANOVA and the Tukey post-hoc test. RESULTS: Probiotic lozenges and CHX mouthwash significantly reduced PI and S. mutans count and increased the salivary pH values. However, there were no statistical differences between the effect of probiotic lozenges and CHX mouthwash on PI (p-value= 800) and pH values (p-value= 0.927) on the 30th day. Conversely a significant difference was reported among their effects on S. mutans count (p-value=0.014) on the 30th day. Greater acceptance and compliance of children to probiotic lozenges were reported. CONCLUSIONS: Probiotic lozenges could be an alternative to CHX mouthwash and encouraged to be included with the daily oral hygiene measures.

Integrative assessment of CIP2A overexpression and mutational effects in human malignancies identifies possible deleterious variants.

KIAA1524 is the gene encoding the human cancerous inhibitor of PP2A (CIP2A) protein which is regarded as a novel target for cancer therapy. It is overexpressed in 65%-90% of tissues in almost all studied human cancers. CIP2A expression correlates with cancer progression, disease aggressivity in lung cancer besides poor survival and resistance to chemotherapy in breast cancer. Herein, a pan-cancer analysis of public gene expression datasets was conducted showing significant upregulation of CIP2A in cancerous and metastatic tissues. CIP2A overexpression also correlated with poor survival of cancer patients. To determine the non-coding variants associated with CIP2A overexpression, 5'UTR and 3'UTR variants were annotated and scored using RegulomeDB and Enformer deep learning model. The 5'UTR variants rs1239349555, rs1576326380, and rs1231839144 were predicted to be potential regulators of CIP2A overexpression scoring best on RegulomeDB annotations with a high "2a" rank of supporting experimental data. These variants also scored the highest on Enformer predictions. Analysis of the 3'UTR variants of CIP2A predicted rs56255137 and rs58758610 to alter binding sites of hsa-miR-500a-5 and (hsa-miR-3671, hsa-miR-5692a) respectively. Both variants were also found in linkage disequilibrium with rs11709183 and rs147863209 respectively at r2 ≥ 0.8. The aforementioned variants were found to be eQTL hits significantly associated with CIP2A overexpression. Further, analysis of rs11709183 and rs147863209 revealed a high "2b" rank on RegulomeDB annotations indicating a probable effect on DNAse transcription factors binding. The MuTarget analysis indicated that somatic mutations in TP53 are significantly associated with upregulated CIP2A in human cancers. Analysis of missense SNPs on CIP2A solved structure predicted seven deleterious effects. Four of these variants were also predicted as structurally and functionally destabilizing to CIP2A including; rs375108755, rs147942716, rs368722879, and rs367941403. Variant rs1193091427 was predicted as a potential intronic splicing mutation that might be responsible for the novel CIP2A variant (NOCIVA) in multiple myeloma. Finally, Enrichment of the Wnt/ß-catenin pathway within the CIP2A regulatory gene network suggested potential of therapeutic combinations between FTY720 with Wnt/ß-catenin, Plk1 and/or HDAC inhibitors to downregulate CIP2A which has been shown to be essential for the survival of different cancer cell lines.

Effects of the Grafting of Lanthanum Complexes on a Silica Surface on the Reactivity: Influence on Ethylene, Propylene, and 1,3-Butadiene Homopolymerization.

In this contribution, we report full details of the ethylene, 1,3-butadiene, and propylene homopolymerization processes mediated by alkylated bis(trimethyl)silylamide lanthanide-grafted complexes using a density functional theory (DFT) study of the initiation and first propagation steps. These systems allows us (i) to examine the role of the grafting mode on the kinetics and thermodynamics of the three processes considered, (ii) to confirm the catalytic behavior of these grafted complexes in ethylene polymerization, (iii) to rationalize the experimental preference for 1,4-cis polymerization of 1,3-butadiene, and (iv) to provide unprecedented information on the catalytic activity of the lanthanide-grafted complex as a propylene hompolymerization catalyst.

Preoperative endoscopic third ventriculostomy in children with posterior fossa tumors: an institution experience.

AIM: To assess the effectiveness and safety of pre-resection endoscopic third ventriculostomy (ETV) in permanently relieving hydrocephalus in children with posterior fossa tumors. MATERIAL AND METHODS: 17 pediatric patients with posterior fossa tumors and associated triventricular obstructive hydrocephalus underwent ETV before definitive tumor resection, and ETV was repeated after tumor resection if hydrocephalus with increased intracranial pressure persisted or recurred. The medical records, operative notes and imaging studies were retrospectively reviewed. RESULTS: 18 ETV procedures were performed in 17 patients, consisting of 11 males and 6 females, age range (1.5 to 13 years; mean 6±3.86). Follow-up periods ranged from 6 to 23 months (mean follow-up 13.9±5.4 months). ETV was successful in relieving hydrocephalus during the follow-up period in 15 out of 17 patients (88.2%). Prior to surgical excision of the posterior fossa tumors, no failures of ETV were detected and all of the 17 patients showed marked clinical improvement and radiological disappearance of signs of active hydrocephalus. CONCLUSION: Preoperative ETV is a highly effective long-term CSF diversion procedure for treatment of hydrocephalus associated with posterior fossa tumors in children. In experienced hands, ETV has a very low complication rate.

Oxo-functionalization and reduction of the uranyl ion through lanthanide-element bond homolysis: synthetic, structural, and bonding analysis of a series of singly reduced uranyl-rare earth 5f1-4f(n) complexes.

The heterobimetallic complexes [{UO2Ln(py)2(L)}2], combining a singly reduced uranyl cation and a rare-earth trication in a binucleating polypyrrole Schiff-base macrocycle (Pacman) and bridged through a uranyl oxo-group, have been prepared for Ln = Sc, Y, Ce, Sm, Eu, Gd, Dy, Er, Yb, and Lu. These compounds are formed by the single-electron reduction of the Pacman uranyl complex [UO2(py)(H2L)] by the rare-earth complexes Ln(III)(A)3 (A = N(SiMe3)2, OC6H3Bu(t)2-2,6) via homolysis of a Ln-A bond. The complexes are dimeric through mutual uranyl exo-oxo coordination but can be cleaved to form the trimetallic, monouranyl "ate" complexes [(py)3LiOUO(µ-X)Ln(py)(L)] by the addition of lithium halides. X-ray crystallographic structural characterization of many examples reveals very similar features for monomeric and dimeric series, the dimers containing an asymmetric U2O2 diamond core with shorter uranyl U═O distances than in the monomeric complexes. The synthesis by Ln(III)-A homolysis allows [5f(1)-4f(n)]2 and Li[5f(1)-4f(n)] complexes with oxo-bridged metal cations to be made for all possible 4f(n) configurations. Variable-temperature SQUID magnetometry and IR, NIR, and EPR spectroscopies on the complexes are utilized to provide a basis for the better understanding of the electronic structure of f-block complexes and their f-electron exchange interactions. Furthermore, the structures, calculated by restricted-core or all-electron methods, are compared along with the proposed mechanism of formation of the complexes. A strong antiferromagnetic coupling between the metal centers, mediated by the oxo groups, exists in the U(V)Sm(III) monomer, whereas the dimeric U(V)Dy(III) complex was found to show magnetic bistability at 3 K, a property required for the development of single-molecule magnets.

Uranyl oxo activation and functionalization by metal cation coordination.

The oxo groups in the uranyl ion [UO(2)](2+)-one of many oxo cations formed by metals from across the periodic table-are particularly inert, which explains the dominance of this ion in the laboratory and its persistence as an environmental contaminant. In contrast, transition metal oxo (M=O) compounds can be highly reactive and carry out difficult reactions such as the oxygenation of hydrocarbons. Here we show how the sequential addition of a lithium metal base to the uranyl ion constrained in a 'Pacman' environment results in lithium coordination to the U=O bonds and single-electron reduction. This reaction depends on the nature and stoichiometry of the lithium reagent and suggests that competing reduction and C-H bond activation reactions are occurring.

A DFT study of the reactivity of actinidocenes (U, Np and Pu) with pyridine and pyridine N-oxide derivatives.

The ortho C-H bond activation of several pyridine and pyridine N-oxide derivatives mediated by Cp(2)An(IV)(CH(3))(2) and Cp(2)An(III)(CH(3)) (Cp = C(5)H(5) and An = U, Np, Pu) have been investigated at the DFT level. For uranium(IV) complex, an excellent agreement with experimental observations is found, and particularly in the case of 2-picoline where only ortho sp(2) C-H activation is observed without any sp(3) C-H activation. These differences of reactivity can be explained by the charges distribution at the metathesis transition state level. A predictive study of the reactivity of neptunium and plutonium complexes with pyridine and pyridine N-oxide is reported. This study shows that neptunium and plutonium have almost the same reactivity. The C-H activation mediated by actinide (III) complexes have found to be more kinetically and thermodynamically favorable than for actinide (IV) complexes. The influence of 5f electrons on organoactinide reactivity is found to be small by comparing implicit and explicit treatment of 5f electrons.

The effect of the equatorial environment on oxo-group silylation of the uranyl dication: a computational study.

A theoretical investigation of the reductive oxo-group silylation reaction of the uranyl dication held in a Pacman macrocylic environment has been carried out. The effect of the modeling of the Pacman ligand on the reaction profiles is found to be important, with the dipotassiation of a single oxo group identified as a key component in promoting the reaction between the Si-X and uranium-oxo bonds. This reductive silylation reaction is also proposed to occur in an aqueous environment but was found not to operate on bare ions; in this latter case, substitution of a ligand in the equatorial plane was the most likely reaction. These results demonstrate the importance of the presence but not the identity of the equatorial ligands upon the silylation of the uranyl U-O bond.

A DFT study of the single electron reduction and silylation of the U-O bond of the uranyl dication in a macrocyclic environment.

A DFT study of the reduction and silylation of the uranyl U-O bond in a macrocyclic complex shows the importance of the initial dipotassiation in THF solution, and a slightly downhill reaction pathway for the oxo group functionalisation.

Cationic methyl complexes of the rare-earth metals: an experimental and computational study on synthesis, structure, and reactivity.

Synthesis, structure, and reactivity of two families of rare-earth metal complexes containing discrete methyl cations [LnMe(2-x)(thf)n]((1+x)+) (x = 0, 1; thf = tetrahydrofuran) have been studied. As a synthetic equivalent for the elusive trimethyl complex [LnMe3], lithium methylates of the approximate composition [Li3LnMe6(thf)n] were prepared by treating rare-earth metal trichlorides [LnCl3(thf)n] with 6 equiv of methyllithium in diethyl ether. Heteronuclear complexes of the formula [Li3Ln2Me9L(n)] (Ln = Sc, Y, Tb; L = Et2O, thf) were isolated by crystallization from diethyl ether. Single crystal X-ray diffraction studies revealed a heterometallic aggregate of composition [Li3Ln2Me9(thf)n(Et2O)m] with a [LiLn2Me9](2-) core (Ln = Sc, Y, Tb). When tris(tetramethylaluminate) [Ln(AlMe4)3] (Ln = Y, Lu) was reacted with less than 1 equiv of [NR3H][BPh4], the dimethyl cations [LnMe2(thf)n][BPh4] were obtained. The coordination number as well as cis/trans isomer preference was studied by crystallographic and computational methods. Dicationic methyl complexes of the rare-earth metals of the formula [LnMe(thf)n][BAr4]2 (Ln = Sc, Y, La-Nd, Sm, Gd-Lu; Ar = Ph, C6H4F-4) were synthesized, by protonolysis of either the ate complex [Li3LnMe6(thf)n] (Ln = Sc, Y, Gd-Lu) or the tris(tetramethylaluminate) [Ln(AlMe4)3] (Ln = La-Nd, Sm, Dy, Gd) with ammonium borates [NR3H][BAr4] in thf. The number of coordinated thf ligands varied from n = 5 (Ln = Sc, Tm) to n = 6 (Ln = La, Y, Sm, Dy, Ho). The configuration of representative examples was determined by X-ray diffraction studies and confirmed by density-functional theory calculations. The highly polarized bonding between the methyl group and the rare-earth metal center results in the reactivity pattern dominated by the carbanionic character and the pronounced Lewis acidity: The dicationic methyl complex [YMe(thf)6](2+) inserted benzophenone as an electrophile to give the alkoxy complex [Y(OCMePh2)(thf)5](2+). Nucleophilic addition of the soft anion X(-) (X(-) = I(-), BH4(-)) led to the monocationic methyl complexes [YMe(X)(thf)5](+).

Prevalence of coronary risk factors, clinical presentation, and complications in acute coronary syndrome patients living at high vs low altitudes in Yemen.

BACKGROUND: A comparative retrospective study was performed to compare the distribution of risk factors and complications in patients with acute coronary syndrome (ACS) at high-altitude vs low-altitude areas in Yemen. METHODS: The records of 768 patients from Sana'a (high altitude) and Aden (low altitude) were reviewed. Risk factors assessed were age, hypertension, diabetes mellitus, hyperlipidemia, cigarette smoking, and reported history and family history of coronary artery disease (CAD). Complications of ACS of interest were heart failure, arrhythmias, cerebrovascular accident (CVA), and death. RESULTS: The mean age of ACS patients at high altitude was significantly lower than those at low altitude (55.3 years [SD = 8.2] vs 56.8 years [SD = 7.1]; P = .007). History of hyperlipidemia was significantly higher in high-altitude patients than in low-altitude patients (49.2% vs 38.3%; odds ratio [OR] = 1.563; P = .002). Reported history of CAD was also significantly higher at higher altitudes (16.7% vs 9.4%; OR = 1.933; P = .003). Previous history of diabetes mellitus and tobacco smoking was slightly higher with borderline significance. Hypertension and reported family history of CAD were comparable among high- and low-altitude patients. In terms of in-hospital complications, CVAs were significantly higher in high-altitude patients than in low-altitude patients (7.8% vs 4.4%; P = .0001). Heart failure, arrhythmias, and death rates were comparable in both groups of patients. Wall motion abnormalities were comparable, whereas the ejection fraction was lower in the high-altitude patients (49.8% [SD = 16.08] vs 54.8% [SD = 16.23]; P = .0001). CONCLUSIONS: ACS occurs at a younger age at high altitudes. Patients who live in high-altitude regions are also more likely to have hyperlipidemia and a previous history of CAD. Stroke and reduced left ventricular ejection fraction (LVEF) occur more commonly in high-altitude ACS patients. High altitude may generally be a risk factor for ACS.

Overweight and obesity among schoolchildren in Sana'a City, Yemen.

AIM: To estimate the prevalence of overweight and obesity among schoolchildren in Sana'a City (Yemen) and to examine the association with lifestyle and some socioeconomic factors. METHODS: A cross-sectional study was done in public and private schools in Sana'a City during 2002-2003. We selected 1,253 students by the multistage random sampling technique. Weights and heights were measured to calculate body mass index (BMI = weight/height2). Data about age, sex, education level of the parents, food consumption and lifestyle was also collected. RESULTS: The mean age of the children was 12.6 +/- 2 years. Overweight was 6.2% and obesity was 1.8%. The prevalence of overweight and obesity was higher among private schoolchildren (p<000), females (p = 0.002), children with a sedentary lifestyle (p = 0.001) and children with a family history of obesity (p = 0.013). Also there is a positive association of overweight/obesity with the education level of the parents (p = 0.013 for the father and p = 0.19 for the mother) and consumption of unhealthy foods. CONCLUSION: Prevalence of overweight and obesity is low and positively associated with the education level of the father, private schooling, sedentary lifestyle, and with students who took unhealthy meals.

Frequency and treatment of urinary tract infection in children subjected to urine culture, in Sana'a, Yemen.

BACKGROUND: This study was carried out to estimate the frequency of urinary tract infection among children subjected to urine culture presenting to Sam Hospital, Sana'a city, Yemen and to determine the susceptibility of the isolated bacteria to the antibiotics. METHODS: Record-based study was done in Sam hospital in Sana'a city Yemen during three years 1/1/1999-31/12/2001. Out of 70,500 patients seen for different causes through that period 820 (1.16%) having urinary symptoms (fever, rigor, vomiting, frequency or screams during the act of urination) were subjected to urine culture. Data about age and sex were also collected. RESULTS: Frequency of urinary tract infections among children examined by urine culture was 36.8% (n=302), with mean age of 7.6 years. 272 (90.1%) of them were females, and 30 (9.9%) were males. More than half 154 (51%) of infected patients were less than three years old. The isolated bacteria was Escherichia coli 201 (66.3%) followed by Staphylococcus suprofyticus 45 (14.9%), Proteus spp 15 (4.9%), Klebsiella 12 (3.9%) then Enterococcus spp 12 (3.9%). Sensitivity of E. coli to Nalidexic acid was 70%, to Amoxicillin/Clavulanic acid was 29.9%, to Co-trimoxasole was 16.4%, and to Nitrofurantoin was 15.9%. CONCLUSION: The majority of the infected patients were females and the highest frequency of the disease was in the first three years of age. The most common isolated microorganism was E. coli followed by Staphylococcus suprofyticus, Proteus spp, then Enterococcus spp. The highly active antibiotic for most organisms isolated was Nalidexic acid, then amoxicillin/clavulanic acid. Nalidexic acid can be used as a first line empiric treatment and/or prophylaxis of UTI in children.

Effect of gentamicin on serum digoxin level in patients with congestive heart failure.

OBJECTIVE: Gentamicin is frequently used to treat infectious diseases in patients receiving digitalis therapy. The aim of this study is to evaluate the effect of gentamicin on serum digoxin level. METHOD: Twenty-four diabetic patients and patients with congestive heart failure and twelve normal healthy volunteers were enrolled in this study. The patients received digoxin treatment 0.25 mg/day. Gentamicin in a dose of 80 mg i.m. twice a day for 7 days was prescribed for these patients to treat chest infection. Serum digoxin and creatinine levels were determined before and after gentamicin administration. RESULTS: Gentamicin induced a significant increase in serum digoxin level of diabetic patients and patients with congestive heart failure. Serum creatinine level increased significantly before and after i.m. injection of gentamicin. CONCLUSION: The present study indicated that increase serum digoxin level when combined with gentamicin should be considered a risk factor for digitalis toxicity.