Successful Management of Severe Unresponsive Snake Bite Envenomation Using Plasmapheresis and Corticosteroid at Egyptian National Environmental and Clinical Toxicology Research Center: A Case Report.

Snakebite is a significant public health issue in which venom-induced consumption coagulopathy is a common and serious complication that results from the activation of the coagulation pathway by snake toxins. We report a male patient, 56 y old, who was thought to have been bitten by a snake on his left foot. He was transported to a nearby hospital where he received analgesics and 3 snake polyvalent antivenom vials, and then he was transported to our hospital after 12 h. He presented with 2 small puncture wounds, pain, blistering, and edema of the left foot. On the 2nd day, the patient developed gingival bleeding and hematuria. Laboratory investigations upon admission revealed prothrombin time (PT) of more than 3 min, prothrombin concentration (PC) of less than 2.5%, and an international normalized ratio (INR) of 23.43. Further investigation of urine showed more than 100 RBCs. Despite receiving 16 packs of plasma and 40 snake polyvalent antivenom vials manufactured by VACSERA over 3 days, hemoglobin concentration and platelet count decreased with the appearance of jaundice, lactate dehydrogenase was 520, and reticulocytes were 3.5%. PT was more than 300 s, and INR was still over range. Plasmapheresis and corticosteroids were provided, which improved the patient's general condition, PT, PC, and INR, and the patient was discharged after 6 days of hospital stay. This case report indicated that plasmapheresis and corticosteroids were clinically efficient approaches in the management of snake envenomation unresponsive to antivenom.

Assessing neuropsychological disorders affecting pottery workers occupationally exposed to air pollutants.

OBJECTIVE: Pottery-related activities are characterized by the emission of multiple air pollutants in the form of particulate matter, gases, and organic compounds. These pollutants are associated with adverse neuropsychological effects. This study aimed at investigating the effect of occupational exposure to air pollutants on the neuropsychiatric health. METHODS: A total of 180 male workers (90 exposed workers and 90 administrative employees) were recruited from pottery-making activities in the Fawakher region located in old Cairo (Misr Al-Kadema); the administrative employees were the control group. Personal, medical, and family histories, general and neurological clinical examination, and neuropsychological assessments were recorded. Serum levels of 4-hydroxy-2-nonenal levels (4HNE) were measured by ELISA. Environmental measurement of workplace air pollutants was performed. RESULTS: Environmental monitoring of the workplace revealed that workers are exposed to high levels of SO2 and NO2 as these exceeded the national standard levels. Compared to the control group, the exposed workers' group demonstrated a significant decrease in digit forwards score, digit backward score, and symbol digit score and a significant higher Hamilton Depression Scale score, and Benton Visual Retention score. The level of 4HNE was significantly increased among the exposed workers' group compared to that of the control group. CONCLUSION: Occupational exposure to air pollutants is associated with impairment in neuropsychological functions, with a corresponding increase in the serum level of 4HNE, which is a biomarker for oxidative stress among Egyptian pottery workers.

Effect of occupational cadmium exposure on the thyroid gland and associated inflammatory markers among workers of the electroplating industry.

Cadmium (Cd) is widespread throughout the environment and is used in the electroplating industry. It has been found to have an effect on the endocrine system. However, its effects and their underlying mechanisms are still not clear. The aim of this study was to evaluate how cadmium exposure at work affected the levels of thyroid hormones and the associated inflammatory and oxidative markers. This study was conducted in an electroplating industry in Cairo, Egypt. Ninety male cadmium-exposed workers were matched with 90 male unexposed participants. A detailed questionnaire was designed and given to every participant in the study, and full clinical examinations were carried out. Blood samples were collected from all participants for determination of levels of serum cadmium, thyroid hormones, anti-thyroid peroxidase antibody (anti-TPO), interleukin-6 (IL-6), malondialdehyde (MDA), and tumor necrosis factor-alpha (TNF-α). Morning midstream urine samples were obtained to measure urine cadmium levels. Results showed that the total blood and urinary cadmium levels were significantly higher in the exposed group (2.38 ± 0.94 µg/L and 5.45 ± 1.92 µg/g creatinine, respectively) than in the unexposed group. The serum levels of anti-TPO antibody, TSH, MDA, IL-6, and TNF-α also were significantly higher in the cadmium-exposed group than in the unexposed group. Significant direct relationships were seen between the biological indices of cadmium exposure and anti-TPO antibodies, TSH, IL-6, TNF-α, and MDA. It was concluded that there is a link between occupational cadmium exposure and autoimmune hypothyroidism, inflammatory, and oxidative stress markers.

Early Detection of Cartilage Degradation Among Heavy Manual Workers Using Serum Level of Collagen Type II Metabolite.

BACKGROUND: Work-related musculoskeletal disorders are common health problems in brick manufacturers, where mechanical load leads to degenerative joint diseases. Collagen type II metabolite (C2C) is a small peptide excreted in urine, and its serum concentration can directly reflect articular cartilage decomposition. OBJECTIVE: Early detection of musculoskeletal disorders among brick workers, using serum C2C as a biomarker of cartilage damage. METHODS: This study involved 88 male brick workers in Arab Abu Saed matched to 88 age- and sex-matched controls. Full history taking, pain assessment using the Standardized Nordic Questionnaire, and complete clinical examination were done for both groups. Serum C2C was measured using a competitive immunoassay method. RESULTS: Brick workers involved in the study were of a mean age 30.66 ± 7.90 years and mean work duration 14.80 ± 7.89 years, matched to 88 controls. The majority of the participants (77.3%) were of normal body mass index. An increase in pain/discomfort was found among the exposed group. Serum C2C had an increased mean among the exposed group compared with the control. Pearson correlation between serum C2C level, body mass index, age, and years of employment showed no correlation. CONCLUSIONS: Musculoskeletal disorders are prevalent among brick workers who adopt specific awkward postures, unhealthy working conditions, and nonexistent safety procedures, for prolonged periods. Detection of serum C2C level can be used as a predictive biomarker for the early detection of musculoskeletal disorders among brick workers.

Serum intracellular adhesion molecule-1 and interleukin-8 as predictors of pulmonary impairment among workers in secondary copper smelters.

OBJECTIVE: Copper smelter workers are exposed to harmful chemical agents in dust and fumes which contain harmful metals such as copper and arsenic. These substances are known to be respiratory irritants. METHODS: This study aimed at investigating the effect of occupational exposure to copper and arsenic on the respiratory system. A group of 75 male exposed workers, and 75 male administrative employees (control group) were recruited from a secondary copper smelting factory. Full history, complete clinical examination, ventilatory function parameters (FVC, FEV1, FVC/FEV1 and FEF), and chest X-ray were done for both groups. Serum levels of ICAM-1 and IL8 (as markers of epithelial injury) were measured by ELISA. Serum copper and arsenic were measured by atomic absorption spectrophotometer. RESULTS: The exposed group was associated with increased respiratory symptoms, higher serum copper, arsenic, and ICAM-1and Il-8 as compared to the control group. There was a significant decrease in ventilatory parameters among the exposed group: 58.7% of the exposed group had restrictive lung impairment, 40% had obstructive impairment. In the exposed group a positive correlation between serum copper, arsenic and serum ICAM and IL8 was found. While a negative correlation was observed between both serum ICAM, IL8 and ventilatory parameters among the exposed group. Moreover, 36% of the exposed group had radiological infiltrates on chest X.ray. CONCLUSION: Occupational exposure to copper and arsenic was associated with ventilatory and radiological impairment, with a corresponding increase in the serum level of ICAM-1 and IL8, which can be used as biomarkers for pulmonary impairment among copper smelter workers.

A spatial model for assessment of urban vulnerability in the light of the UN New Urban Agenda guidelines: case study of Assiut City, Egypt.

Most cities in developing countries suffer environmental degradation caused by the growth of unplanned areas that sprawl in the cities. In the current paper, we attempted to integrate a set of selected UN-based urban indicators based on the New Urban Agenda (NUA) within a GIS framework to observe and assess some aspects of urban vulnerability among city districts based on deprivation. The vulnerability map for the districts in Assiut City was created through a spatial multicriteria evaluation model. Thirteen sub-indicators related to shelter, social environmental and economic situations have been assessed in the model using standardization, weighting and aggregation methods. Results revealed that: districts, namely, El Thaltha, El Owla, El Thania, and El Rabaa are most vulnerable in most scenarios, while districts, namely, El Sheyakha El Sabaa, and El Sadsa, El-Walidya El Qiblia and El-Hamra El Thania are among the least vulnerable zones. Results also revealed that vulnerable districts encompass the highest percentage of slums, highest density of population, highest rates for urban growth and poor connection to services. Eventually, we assume that the most vulnerable zones in the city are under the highest risk of airborne diseases including COVID-19 epidemic. Eventually, a subset of selected urban vulnerability indicators that could be triggering the spread of the pandemic was chosen for another spatial multcriteria model to delineate city zones under risk. The result revealed that expected high-risk areas exist in the south-west of the city and include El Thaltha, El Owla, El Thania and El Rabaa districts, while the least risk district is El-Walydia El-Qeblia. The applied methodology and its outputs could support decision makers in reviewing priorities, setting contingency plans, allocation of funds and raising resilience among the city districts.

Predictive value of novel biomarkers for chronic kidney disease among workers occupationally exposed to silica.

There is a pressing need to find reliable biomarkers for the early diagnosis of silica-induced nephropathy. Abundant genes are upregulated in damaged kidneys with subsequent protein products appearing in the urine. Liver-type fatty acid-binding protein (L-FABP) and kidney injury molecule-1 (KIM-1) are among the most promising. Our objective was to study the importance of L-FABP and KIM-1 genes and their urinary proteins in the early detection of silica-induced renal injury, as compared with other conventional biomarkers. A cross-sectional study was conducted among 90 pottery workers occupationally exposed to silica, as compared to 90 controls. A full history taking and complete clinical examination were performed. Levels of serum creatinine, liver enzymes, urinary silicon, KIM-1, and L-FABP gene expression and protein products were measured. Estimated glomerular filtration rate (eGFR) was calculated, and abdominal ultrasound was performed. The results showed that the silica-exposed group had a statistically significant increase in serum creatinine and urinary silica, as well as a significant decrease in eGFR. Additionally, a significant increase in KIM-1 and L-FABP gene expression, associated with a significant increase in their urinary protein, was found among the exposed group. A positive correlation between urinary silica level and L-FABP gene expression was also found. A receiver operating characteristic curve analysis for L-FABP and KIM-1 gene as predictors for silica-induced nephropathy showed that L-FABP gene and protein specificity were greater than the KIM-1 gene and protein. Taken together, these findings suggest that the L-FABP gene and its protein product may be used as early indicators for renal injury among silica exposed workers.

Some health effects of work-related stress among nurses working in critical care units.

Occupational stress is a major health problem among nurses. Critical care nurses appear to experience more stress at work compared to others. Stress is associated with multiple system disorders, hormonal, and immunological disturbances, and genetic effects. The aim of our study was the detection of health effects of work-related stress and to investigate the link between stress and immune response, alterations of hormones, and expression of micro-RNA (miRNA) among critical care nurses. An exposed 80 critical care nurses matched to 80 controls were involved in our study. Full history, psychological assessment using the General Health Questionnaire (GHQ12) and a complete clinical examination were done for both groups. Serum interleukin (IL)-6, IL-10, luteinizing hormone (LH), follicle-stimulating hormone, thyroid-stimulating hormone (TSH), free triiodothyronine, and free thyroxine (FT4) were measured by enzyme-linked immunosorbent assay, micro-RNA26, and 142 extractions. The exposed group had a mean age of 41 ± 10 years old and mean work duration of 22 ± 9.7 years, matched to 80 controls. The exposed group (32.5%) was associated with severe psychological distress (GHQ scores > 20) compared to only 5% among controls. In addition, the exposed group had a significantly higher level of miRNA 26, miRNA 142, TSH, LH, and IL-6 when compared to the control group. However, there a significantly lower level of FT4 among the exposed group compared to the control group, there were no statistically significant differences between the studied participants regarging FT3,FSH and IL-10 levels. Stress is prevalent among critical care nurses and is reflected on their psychological health with an increase in inflammatory cytokines and disturbances in endocrine functions.

High-Resolution Cervical Auscultation Signal Features Reflect Vertical and Horizontal Displacements of the Hyoid Bone During Swallowing.

Millions of people across the globe suffer from swallowing difficulties, known as dysphagia, which can lead to malnutrition, pneumonia, and even death. Swallowing cervical auscultation, which has been suggested as a noninvasive screening method for dysphagia, has not been associated yet with any physical events. In this paper, we have compared the hyoid bone displacement extracted from the videofluoroscopy images of 31 swallows to the signal features extracted from the cervical auscultation recordings captured with a tri-axial accelerometer and a microphone. First, the vertical displacement of the anterior part of the hyoid bone is related to the entropy rate of the superior-inferior swallowing vibrations and to the kurtosis of the swallowing sounds. Second, the vertical displacement of the posterior part of the hyoid bone is related to the bandwidth of the medial-lateral swallowing vibrations. Third, the horizontal displacements of the posterior and anterior parts of the hyoid bone are related to the spectral centroid of the superior-inferior swallowing vibrations and to the peak frequency of the medial-lateral swallowing vibrations, respectively. At last, the airway protection scores and the command characteristics were associated with the vertical and horizontal displacements, respectively, of the posterior part of the hyoid bone. Additional associations between the patients' characteristics and auscultations' signals were also observed. The hyoid bone maximal displacement is a cause of swallowing vibrations and sounds. High-resolution cervical auscultation may offer a noninvasive alternative for dysphagia screening and additional diagnostic information.

Impact of elevated glycosylated hemoglobin on hospital outcome and 1 year survival of primary isolated coronary artery bypass grafting patients.

OBJECTIVE: It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. METHODS: From December 2013 to November 2015, 80 consecutive patients underwent primary isolated CABG surgery at national heart institute, their data were prospectively collected and they were classified according to their HbA1c level into two groups, Group (A): Forty patients with fair glycemic control (HbA1c below or equal to 7%), Group (B): Forty patients with poor glycemic control (HbA1c above 7%). Hospital morbidity, mortality and one year survival were examined in both groups. Telephone conversation was used to call patients or their relatives to determine the one year survival and it was 100% complete. This study had gained the ethical approval from national heart institute ethical committee. RESULTS: In-hospital mortality for group A was 2.5% (one patient) and 7.5% (3 patients) for group B with no statistical significance. One year mortality was (5.13%) (2 patients for group A) and (8.11%) (3 patients) for group B with no statistical significance. As regard the morbidity there was no statistical significance between the two groups in the incidence of neurological complications whether stroke or coma, atrial fibrillation, postoperative myocardial infarction, low cardiac output syndrome, heart failure, renal failure, need for dialysis, deep sternal wound infection, and readmission. However, group B had lengthy hospital stay, lengthy ventilation hours, more respiratory complications, and more superficial wound infection with a statistical significance when compared to group A, P values were 0.003, 0.003, 0.038, 0.044 respectively. CONCLUSIONS: This study showed that HbA1c is a good predictor of in-hospital morbidity. It worth devoting time and effort to decrease HbA1c level below 7% to decrease possible postoperative complications.

Tricuspid valve repair with Dacron band versus DeVega or segmental annuloplasty. Hospital outcome and short term results.

BACKGROUND: The purpose of this study was to compare the hospital outcome and short term results of tricuspid valve (TV) repair with three repair techniques for functional tricuspid regurgitation (TR), namely, flexible Dacron band, DeVega and segmental annuloplasty. METHODS: A total of 60 patients underwent TV repair at National Heart Institute from January 2013 to November 2014, of which 20 had DeVega procedure (DV), 20 had a segmental annuloplasty (SA) procedure and 20 had a Dacron band (DB) procedure. Concomitant procedures done for rheumatic left sided valve pathology consisted of mitral valve replacement in 70% of patients, and double valve replacement in 30% of patients. Clinical and echocardiographic follow-up data were obtained. Follow-up was 100% complete and was concluded after one year. RESULTS: All demographic criteria and preoperative characteristics of the three studied groups were comparable except for preoperative right ventricular (RVEDD) size that was significantly bigger in Dacron band group as compared to the other two groups (3.18 ± 0.43 cm compared to 3.00 ± 0.33 cm (DV) and to 2.88 ± 0.35 cm (SA), p value of (0.045)). Similarly, all operative and postoperative criteria were comparable among the study groups. Noticeably, (RVEDD) size remodeled better postoperatively in (DB) group as compared to the other two groups, (2.54 ± 0.26 cm compared to 2.83 ± 0.311 cm (DV) and to 2.72 ± 0.29 cm (SA), mean difference values were group (0.64 ± 0.47 cm) for (DB) compared to (0.18 ± 0.29 cm) for (DV) or to (0.16 ± 0.45 cm) for (SA) with p value of 0.000. The majority of patients in each group did not have tricuspid regurgitation (TR) or mild degree (+1) of (TR) on discharge. After one year of follow-up, most of the patient had either no regurgitation or grade (+1 TR). Two patients (10%) in DV group and one patient (5%) in SA group had (+3 TR). There was no statistical significance in the incidence of hospital mortality, only one patient died in DB and one in DV group (5%) and no death happened after hospital mortality for the three groups after one year. CONCLUSIONS: The three techniques are options to repair the tricuspid valve, however, placement of Dacron band in patients undergoing tricuspid valve repair is associated with better RV remodelling, and hence, a probable better right ventricular performance and better outcome of repair is expected. A higher number of patients are needed with longer follow up period to appreciate the effect on survival and rate of freedom from tricuspid regurgitation and re-intervention.

Noncomplicated Excision of a Mobile Pedunculated Septal Hemangioma of the Left Ventricle.

BACKGROUND Cardiac tumors are quite rare, and differential diagnosis of them is challenging. CASE REPORT A young lady with a history of palpitations, dyspnea, and fatigue was proven by transthoracic echocardiography and cardiac magnetic resonance imaging to have a mobile left ventricular mass with rounded contour attached to the mid-part of the interventricular septum. The mass was approached via a posterior inter-atrial approach to avoid left ventriculotomy and provide adequate exposure to completely excise the tumor and control its pedicle with minimal cardiac trauma. Histological examination of the mass was diagnostic of capillary and sinusoidal hemangioma. CONCLUSIONS Complete excision of cardiac hemangioma is recommended once it is diagnosed, for histopathologic diagnosis and because of the possibility of serious complications.

Immunotoxicity and pulmonary toxicity induced by paints in Egyptian painters.

Associations between painting, sensitization, and respiratory disease have received little attention, despite the extensive use of paint and paint removal products. The objectives of this study were to investigate the possible immunotoxicity and pulmonary toxicity induced by paints in Egyptian painter workers. This study was carried out on 60 adult males. Subjects were designated as controls (n = 30 healthy persons) or paint-exposed workers (n = 30). The controls and workers were then divided into four equal groups (15 individuals/group): Group I, Control group-never smoked; Group II, Smoker controls; Groups III, paint-exposed non-smoking workers; and Group IV, paint-exposed smoker workers. A complete physical examination, chest radiograph, and pulmonary function test (PFT) were performed with each subject. Serum levels of immunoglobulin (Ig) E and interleukin (IL)-4, -6, and -10, WBC sub-set counts, total numbers of WBC, and leukocyte differentials were also assessed. The pulmonary toxicity due to the paint exposures appeared in the form of allergic manifestations in the respiratory tract, significant reductions in FVC, FEV1, FEV1/FVC ratio and PEF parameters, and a reticular pattern in both lung fields. Immunotoxicity was evidenced by increases in total leukocyte levels, total lymphocytes, CD8(+) T-lymphocytes, B (CD19(+))-lymphocytes, NK (CD3(+)CD16(+)CD56(+)) cells, and eosinophils, as well as a significant decrease in CD4+ T-lymphocyte; there were also significant elevations in serum IgE, IL-4, and IL-6, and a significant reduction in IL-10, levels in these hosts. Based on these results, we assert that repeated paint exposure is associated with pulmonary and immune system toxicities that may lead to an augmentation of allergic diseases.