The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Tietze syndrome is a rare form of chest wall costochondritis with joint swelling which can cause significant chest pain and decline in ability of daily activities. There is no standardized treatment protocol. The aim of this study was to assess the efficacy of adding oral steroids in addition to other non- steroidal treatment in improvement of pain and quality of life (QOL) in patients with Tietze syndrome. METHODS: Forty patients with Tietze syndrome were randomly divided into two treatment groups: (1) One week of prednisolone 40 mg daily followed by 1 week of prednisolone 20 mg daily followed by 1 week of 10 mg with 3 weeks of non-steroidal anti-inflammatory drug (NSAID) treatment (n = 20); (2) three weeks of NSAID treatment only (n = 20). A symptom questionnaire was used to rate the major symptoms of Tietze syndrome and costochondritis: Numeric rating scale (NRS) for pain on a scale of 0 (no pain) to 10 (severest pain); the resulting global symptom score was used to evaluate the efficacy of treatment with assessment of joint swelling resolution. The EQ-5D-5L instrument for measurement of QOL was used. Assessments were made on intention to treat basis at baseline and at 1, 2 and 3 weeks followed by a medium term follow period after treatment cessation. The trial was registered at www.isrctn.com ISRCTN11877533. RESULTS AND DISCUSSION: There was a significant drop in mean NRS pain scores between the groups at 1, 2 and 3 weeks in favour of the steroid group (46.8% vs. 17.7%; p < 0.001, 56.3% vs. 35.8% p < 0.001 and 65.4% vs. 46.7% p < 0.001 respectively). There was a 25.8% (95% CI 13.2-38.8) difference in mean NRS score drop at a median of 6.5 months after treatment cessation in favour of the steroid group over the NSAID only group. Only three cases of mild GIT upset in the steroid group and two cases of mild nausea were reported in the NSAID group. There was an improvement in QOL using the median EQ-5D-5L scoring at 3 weeks in favour of the steroid group 7 (7, 8) versus 10 (8.5-11), (p < 0.001). The improvement in pain scoring and QOL did not correlate with improvement in joint swelling at 3 weeks after treatment with 2/20 (10%) in the steroid arm versus 1/20 (5%) in NSAID arm having an obvious improvement (p = 0.393). WHAT IS NEW AND CONCLUSION: In this study, addition of short-term oral corticosteroids showed a clear benefit for use at 1, 2 and 3 weeks in improvement of pain and QOL in patients with Tietze syndrome. This difference was maintained at mid-term follow up after treatment cessation. This facilitates the advantage of using steroids as well as excluding their side effects for an accepted timeframe.

Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective.

Background: Despite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt. Methods: A prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider's perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually. Results: The study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9-100%] vs. 73.1% (52.7-95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of -72.5796 for the intervention group. Conclusion: The PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT04409613].

A variable-trust threshold-based approach for DDOS attack mitigation in software defined networks.

Software-defined networks offer a new approach that attracts the attention of most academic and industrial circles due to the features it contains. However, some loopholes make such modern networks vulnerable to many types of attacks. Among the most important types of these attacks is the Distributed Denial of Service (DDoS) attack, which in turn affects the network's performance and delays many real user requests. As one of the main features of SDN is the centralization of all the control plane in the SDN controller, it becomes a central point of attack that may compromise the whole network. Hence, in our proposed approach, we aim to mitigate the DDoS attack that maybe launched to compromise the SDN controller, flood the control plane and cripple the entire network. Many DDoS mitigation scheme have been proposed, however, determining the threshold between legitimate requests and malicious requests is still a challenging task. Our proposed approach relies on a two-phases algorithm that assigns a variable trust value for every user. This trust value is compared with schemes relying on a threshold value that changes dynamically and assists in detecting the DDoS attack. The first phase of our two-phases algorithm is Header fields extraction, and the second phase is calculating the trust value based on header fields information. Our proposed approach shows better performance than related detection schemes in terms of accuracy, detection rate, and false-positive rate. Where the accuracy of the system reaches up to 98.83% which is high compared to other traditional methods.

Mitral valve repair versus replacement in severe ischemic mitral regurgitation systematic review and meta-analysis.

BACKGROUND AND AIM: Ischemic mitral regurgitation (IMR) is a serious consequence of coronary artery disease. The choice of the optimal surgical strategy remains debatable. The aim of the present meta-analysis is to compare the outcomes of mitral valve repair (RPR) versus replacement (RPL) regarding perioperative mortality, overall mortality, reoperation, recurrence of MR, and reverse remodeling after surgery. METHODS: Electronic searches were performed using the searchable databases of Google Scholar, Pubmed, and Embase, and the search terms mitral valve, IMR, RPR, RPL, and coronary artery bypass grafting. The main outcomes of interest are perioperative mortality, overall mortality, reoperation, recurrence of MR, and reverse remodeling after surgery. Perioperative mortality was defined as death during the surgery or within 30 days after the operation. RESULTS: There was a trend towards better perioperative survival in the RPR arm. However, the difference fell short of statistical significance [odds ratio (OR) (95% confidence interval [CI]): 0.66 (0.41-1.07), p = 0.09]. Patients submitted to RPR experienced a significantly higher MR recurrence rate when compared with their counterparts submitted to RPL [OR (95% CI): 16.8 (5.07-55.7, p = 0.00001)]. CONCLUSION: There is a trend towards lower perioperative mortality in RPR in comparison to RPL. On the other hand, RPL was associated with significantly lower recurrence rates.

Intravenous iron supplementation treats anemia and reduces blood transfusion requirements in patients undergoing coronary artery bypass grafting-A prospective randomized trial.

Study Objective: Preoperative anemia results in two- to sixfold increased incidence of perioperative blood transfusion requirements and reduced postoperative hemoglobin (Hb) level. This prospective study was designed to investigate the effect of preoperative intravenous infusion of iron on Hb levels, blood transfusion requirements, and incidence of postoperative adverse events in patients undergoing coronary artery bypass grafting. Design: Prospective randomized trial. Setting: Academic university hospital. Patients: Eighty patients (52-67 years old) underwent coronary artery bypass grafting and received either iron therapy or saline infusion preoperatively. Interventions: Patients were randomly allocated to iron or placebo groups. In the iron group, patients received a single intravenous dose of ferric carboxymaltose (1000 mg in 100 mL saline) infused slowly over 15 min 7 days before surgery. In placebo group, patients received a single intravenous dose of saline (100 mL saline) infused slowly over 15 min 7 days before surgery. Measurements: Patients were followed up with regards to incidence of anemia, Hb level on admission, preoperatively, postoperatively, 1 week and 4 weeks after discharge, aortic cross-clamp time, the number of packed red blood cells (pRBCs) units, the percentage of reticulocytes pre-postoperatively and 1 week later, hospital stay and intensive care unit (ICU) stay length, and the incidence of postoperative complications. Main Results: Iron therapy was associated with lower incidence of anemia 4 weeks after discharge (P < 0.001). Hb level was significantly higher in the iron group compared to the placebo group preoperatively and postoperatively, and 4 weeks after discharge (P < 0.001). Iron therapy resulted in shorter hospital and ICU stay (P < 0.001) and shorter aortic cross-clamp time, reduced pRBCs requirements postoperatively. Percentage of reticulocytes was significantly higher in placebo group than in iron group postoperatively and 1 week after discharge and the incidence of postoperative complications was similar to the placebo group. Conclusions: Preoperative IV iron infusion is a safe and feasible way to manage preoperative anemia. Preoperative administration of IV iron is associated with a higher postoperative Hb level, shorter hospital and ICU stay, and reduced perioperative red blood cell transfusion requirements with insignificant difference in incidence of postoperative complications.

Evaluation of the Analgesic Efficacy of Bilateral Ultrasound-Guided Transversus Thoracic Muscle Plane Block on Post-Sternotomy Pain: A Randomized Controlled Trial.

PURPOSE: Transverse thoracic block is a new perioperative analgesic method for post-sternotomy discomfort. This study discusses the efficacy of an ultrasound-guided transversus thoracic muscle plane block (TTPB) in patients undergoing heart surgery, including sternotomy. PATIENTS AND METHODS: In this prospective trial, 60 patients were randomly assigned to two groups: transversus (T) or general anesthesia (GA). Patients in the T group received TTPB with GA and 15 mL of 0.25% bupivacaine was administered on either side. Patients in the GA group received TTPB along with GA, but 15 mL saline was injected on either side instead. The patients were followed up postoperatively. The percentage of patients receiving additional opioids, extubation time, intensive care unit (ICU) length, postoperative morphine dose, and adverse events were documented. RESULTS: The percentage of patients requiring additional morphine was significantly lower in the T group (p<0.015). Pain scores were comparable between the groups at extubation time and 18 h postoperatively. At 8, 12, and 24 h after surgery, pain scores in the T group were significantly lower (P<0.001). The total amount of morphine required after surgery was much lower in the T group (8±0.74 mg), and the duration to initial analgesic necessity was significantly greater in the GA group (P<0.001). Patients in the GA group had a considerably longer ventilation time (11.07±0.64) (P<0.001). The ICU stay in the T group was substantially shorter (P<0.001), and postoperative complications were comparable. CONCLUSION: For patients undergoing heart surgery, TTPB offers sufficient postoperative pain control, resulting in lower pain scores, lower postoperative analgesic doses, shorter extubation times, and shorter ICU stay lengths.

Interlocking Multi-Twisted Wires Versus Interrupted Simple Sternal Wires for Closure of Median Sternotomy.

BACKGROUND: Although closure of a sternotomy incision is usually a simple procedure, failure to do so (sternal dehiscence) is a serious complication and is an independent factor that poses a high degree of morbidity or mortality after open heart surgery. Instability of the bone fragments can lead to complete sternal breakdown, sternal wound infection, and mediastinitis. The stainless-steel encircling wire used as either interrupted simple sutures or as figure of eight sutures is the current standard method of median sternotomy closure. Interlocking multi-twisted sternal wire closure is an alternative that provides rigid sternal fixation. We aim to identify the best method of sternal closure in order to implement it as a standardised protocol for our department. METHODS: Two-hundred patients aged 18-70 years were undergoing cardiac surgeries at Ain Shams University hospitals. They were divided into two groups: Group I included 100 patients with sternal closure using simple wire, and group II included 100 patients with sternal closure using interlocking multi-twisted wires. The day 7, 1 month, and 3 months sternal instability, superficial wound infection, ventilation time, cross-clamp time, length of ICU stay, and length of hospital stay were analyzed. RESULTS: The incidence of sternal instability on the 7th day, 1 month, and 3 months was significantly higher in the simple wire closure group (P < 0.05). However, incidence of superficial wound infection, length of ICU stay, and duration of mechanical ventilation were comparable between the two groups. CONCLUSION: The interlocking multi-twist is a safe, effective, and easily reproducible method for preventing sternal dehiscence.

Efficacy of Histidine-Tryptophan-Ketoglutarate Solution Versus Blood Cardioplegia in Cardiac Surgical Procedures: A Randomized Controlled | Parallel Group Study.

BACKGROUND: In cardiac surgery, myocardial protection is required during cross-clamping followed by reperfusion. The use of cardioplegic solutions helps preserve myocardial energy stores, hindering electrolyte disturbances and acidosis during periods of myocardial ischaemia. This study aimed to compare the efficacy and safety between the histidine-tryptophan-ketoglutarate (HTK) solution and blood cardioplegia in various cardiac surgeries. METHODS: Three-hundred-twenty patients aged 30-70 years old undergoing various cardiac surgeries were randomized into the HTK group and the blood cardioplegia group. The ventilation time, total bypass time, cross-clamp time, length of intensive care unit (ICU) or hospital stay, and postoperative complications were analyzed. RESULTS: The total bypass time and cross-clamp time were significantly shorter in the HTK group than in the blood cardioplegia group (P < 0.001). Segmental wall motion abnormalities (SWMA) at postoperative echocardiography were significantly higher in in the blood cardioplegia group (P = 0.008). The number of patients requiring DC Shock was significantly higher in the HTK group (P < 0.001). The number of patients requiring inotropic support was significantly higher in the blood cardioplegia group (P < 0.001). The length of ICU, hospital stay, and ventilation time were significantly longer in the blood cardioplegia group than in the HTK group (P = 0.004, P < 0.001, P < 0.001, respectively). The number of patients requiring prolonged ventilation was significantly higher in the blood cardioplegia group compared with the HTK group (P = 0.022). There was no significant difference between the study groups regarding electrocardiographic changes, 30-day mortality, and 30-day readmission. CONCLUSION: The use of HTK cardioplegia was associated with significantly shorter cross-clamp time, bypass time, duration of mechanical ventilation, length of ICU stay, and length of hospital stay. It is associated with less incidence of postoperative segmental wall abnormalities and less need for inotropic support than blood cardioplegia. Custodiol cardioplegia is a safe and feasible option that can be used as an effective substitute for blood cardioplegia to enhance myocardial protection.

Assessment of carotid artery stenosis and lower limb peripheral ischemia before coronary artery bypass grafting operations: a non-randomized clinical trial.

BACKGROUND: Atherosclerosis is a systemic disease affecting the coronary, carotid, and lower limb arteries. Cerebrovascular accidents and lower limb ischemia are devastating postoperative complications. We aimed to evaluate the role of non-selective routine arterial duplex scanning in patients undergoing coronary artery bypass grafting (CABG). METHODS: This non-randomized clinical trial included 360 patients scheduled for elective isolated CABG who were divided into two groups: low-risk (n = 180) and high-risk (n = 180). Both groups underwent preoperative carotid and lower limb ultrasound screening for associated arteriopathy. RESULTS: 16 (8.9%) patients and 22 (12.2%) patients showed ≥70% carotid artery stenosis while 11 patients (6.1%) and 20 patients (11.1%) showed ≥50% lower limb arterial stenosis in the low-risk group and the high-risk group, respectively; though the difference was not statistically significant in both the cases (p > 0.1). CONCLUSION: Routine preoperative peripheral arterial screening by sonography is a feasible and effective strategy to avoid unnecessary post CABG complications. TRIAL REGISTRATION: NCT03516929 , Registered in 24 th of April 2018.

Left atrial cardiac Tamponade complicating radical nephrectomy - case report.

BACKGROUND: We present an unusual case of pericardial tamponade occurring subsequent to a radical right nephrectomy performed entirely through a laparotomy. CASE PRESENTATION: A 43 year old gentleman who presented with large loculated posterior pericardial effusion compressing the left atrium, following a radical nephrectomy performed entirely through a laparotomy. He required an emergency sternotomy, pericardial and pleural drainage. CONCLUSION: Cardiac tamponade is an extremely rare complication of radical nephrectomy. However, any procedure that involves opening of the pericardium does carry a risk of bleeding and therefore cardiac tamponade, particularly in the context of post-operative full anticoagulation.

A randomized control trial comparing prophylactic dexmedetomidine versus clonidine on rates and duration of delirium in older adult patients undergoing coronary artery bypass grafting.

STUDY OBJECTIVE: Postoperative delirium occurs in 20-50% of elderly patients undergoing cardiac surgery and increases morbidity and mortality. We investigated whether prophylactic dexmedetomidine could reduce delirium incidence in elderly patients after coronary artery bypass grafting (CABG), compared with clonidine. DESIGN: Prospective observational trial. SETTING: Academic university hospital. PARTICIPANTS: Patients (60-70 years old) who underwent CABG and received either dexmedetomidine or clonidine infusion postoperatively. INTERVENTIONS: Patients were randomly allocated to dexmedetomidine or clonidine groups. In the dexmedetomidine group, patients received an initial infusion of 0.7-1.2 µg/kg/h; sedation and analgesia were evaluated after 45-60 min. If the Richmond assessment sedation score (RASS) increased from +1 to +4, the infusion rate was increased by 0.1-0.2 µg/kg/h every 30 min, up to 1-1.4 µg/kg body-weight/h. Dexmedetomidine infusion was not discontinued pre-extubation; thereafter, infusion was reduced by 0.1 µg/kg/h until 0.2 µg/kg/h. The maximum infusion duration was 72 h. In the clonidine group, patients received an initial infusion of 0.5 µg/kg, followed by 1-2 µg/kg/h, if the RASS changed from +1 to +4. This was continued throughout mechanical ventilation. MEASUREMENTS: Patients were followed up to 5 days post-surgery. Delirium incidence, extubation time, lengths of intensive care unit (ICU) and hospital stay, need for inotropic support or vasopressors, mean arterial blood pressure and heart rate, hospital mortality rate, total postoperative morphine dose, number of patients receiving haloperidol, and adverse events were recorded. MAIN RESULTS: Two-hundred-and-eighty-six patients (dexmedetomidine, 144; clonidine, 142) were studied. Dexmedetomidine was associated with lower risk and duration of delirium, shorter mechanical ventilation duration and ICU stay, lower mortality rate, and lower morphine consumption than the clonidine group. Dexmedetomidine significantly decreased heart rates after ICU admission. CONCLUSIONS: Postoperative infusion of dexmedetomidine provides a feasible option for postoperative control of delirium after CABG in adult patients.