Lovosice, Czech Republic

Comparative Factorial Study Design of Ultrasound Guided Wrist Block for Hand Surgery Comparing Effect of Bupivacane Alone and Bupivacane with Dexamethasone and Bupivacane with Dexametmiodine and Bupivacane with Dexamethasone and Dexametmiodine

Ultrasound guided wrist block comparing effect of bupivacane alone and bupivacane with dexamethasone and bupivacane with dexametmiodine and bupivacane with dexametmiodine and dexamethasone. Taking medical and surgical history from patients. Taking base line data as heart rate and blood pressure and spo2. Measure duration of analgesia for post operative pain using NRS for 24 hours abd recording NRS at time interval of 2 , 4,6,12,24 hours post operative. Any patient the NRS above 4 will receive 5 mg nalbufin . Recording patients satisfaction by a survey .

Comparative Analysis of Analgesic Efficacy and Maternal Satisfaction: by Single Shot Intrathecal Analgesia (SSSA) in Normal Labor

on arrival to the operating room, the demographic and baseline data will be collected, which include sections about age, height, weight, primigravida or multigravida, cervical dilation at the time of performing labor analgesia, fetus presentation, presence of rupture of membrane, baseline pain scores will be assessed using a 10-cm VAS (0 = no pain and 10 = worst imaginable pain) before SSSA. Intravenous access will be achieved in all patients loading will be undertaken using 500 ml Ringer's solution, baseline values of pulse rate (PR), respiratory rate (RR), hemoglobin oxygen saturation (SpO2), and arterial blood pressure (ABP) will be recorded. SSSA will be performed with the parturient in the sitting position under complete aseptic precautions at the L3-L4 level using a 25-gauge spinal needles. The correct positioning of the needle tip in the intrathecal space will be confirmed by the observation of a free flow of cerebrospinal fluid, and then the prefilled study drug will be injected intrathecally which is 2.5 mg bupivacaine plus 25 mic fentanyl or 5 mic dexmedetomidine or 0.5 ml saline according to different groups. parturient will then turn to the supine position, and a wedge will be placed under the right buttocks to prevent aortocaval compression. VAS will be evaluated every 5 min for the first 30 min, followed by every 20 min for 3 hours then every 30 min for next 3 hours. If VAS 8 or more the instigators will give the patient 50 mg intramuscular pethidine and the patient will be excluded. Maternal blood pressure, heart rate, respiratory rate, and oxygen saturation will be measured and recorded noninvasively every 5 min for the first half hour, followed by every 20 min for 3 hours, then every 1 h for next 3 hours. the investigators will give 5 mg ephedrine if there is hypotension ( decrease in ABP more than 25% of the baseline ABP) and .5 mg atropine if there is bradycardia (HR less than 50 beats per minute). Side effects such as hypotension, nausea, vomiting, bradycardia, shivering, pruritus, and tachycardia will be recorded. The first- and fifth-minute Apgar scores will also be recorded. The onset, duration of analgesia, and obstetric and neonatal outcomes will be compared. Maternal satisfaction questionnaire will be done after delivery to assess maternal satisfaction.

TGF β 1 Expression Related Gene Polymorphism

The spectrum of clinical and histopathological manifestations reflects the immune response elicited by the microorganism in the host leprosy classified into polar groups: Lepromatous (LL) and Tuberculoid (TT); and borderline spectrum: Borderline Tuberculoid (BT), Borderline Borderline (BB) and Borderline Lepromatous (BL). This classification, proposed by Ridley and Jopling This classification widely used in clinical, immunological, microbiological, and histopathological aspects. While The World Health Organization classifies leprosy clinically as multibacillary and paucibacillary, according to the number of skin lesions and nerve involvement. In the tuberculoid form of leprosy (paucibacillary), the individual manifests an intense cell-mediated immune response that prevents proliferation of the bacillus, whereas the cell-mediated immune response is compromised in the lepromatous form (multibacillary) contributing to multiplication of the bacillus. In the intermediate forms,the patients exhibit characteristics that vary between the two types. Leprosy is measured the first disease to be categorized based on the host's immune response. The clinical symptoms of leprosy vary from one patient to another based on the spectrum of disease but more importantly on the type of host's immune response to the bacteria. Both innate and acquired immune responses have been associated with leprosy, but the disease is typically described by the side of a Th1/Th2 response. Patients with TT are decided by a relevant T-cell immune response, including interleukin-2 (IL-2), IL-4, IL-6, IL-10, interferon-γ (IFN-γ), tumor necrosis factor (TNF), and IL-17 and lymphotoxin, marked by some neural or cutaneous lesions with a few or no bacilli. Infected macrophages are activated by IFN- γ and clonal expansion of T cells is induced by IL-2 which, in turn, leads to an increase in IFN- γ production. Tumor necrosis factor alpha (TNF- α) also plays a role in the Th1 response. This cytokine contributes to the maintenance of this pattern and acts in synchronism with IFN- γ in the activation of infected macrphages, developing a significant mechanism for the maintenance of the cell-mediated immune response. In contrast, patients with LL show a superior humoral immune response, characterized by multiple lesions, elevated bacterial load, and reduced lymphocyte production develop a Th2 immune response characterized by intense production of transforming growth factor beta (TGF- β), IL-4, IL-5 and IL-10. These cytokines induce an incompetent immune response characterized by the high production of antibodies that apply no protective effect against the bacterium. IL-4 exerts an immunosuppressive effect that leads to an increase in bacterial proliferation and inhibits the proliferation of T cells and monocytes, the expression of CD14 on monocytes and the production of TNF- α, in addition to blocking the synthesis of nitric oxide which is essential for the destruction of intracellular microorganisms. In the 21st century, studies using modern genetic methods such as candidate gene association studies (CGASs) and genome wide association studies (GWASs) have gradually confirmed that the host genetic background play important role in the development of leprosy, and many leprosyassociated variants or genes have been reported. Most leprosy-associated genes are immune related, which is consistent with the finding that leprosy is caused by infection with pathogen. TGF β1 plays roles in the suppression of T cell responses, inhibiting both IFN γ and IL-2 expression, and has the ability to inhibit the lytic activity of macrophages by suppressing the production of intermediate oxygen-reactive and nitrogen-reactive factors, leading to the progression of infection. So, the production of TGF β1 by macrophages in LL and BL skin lesions, probably as part of the M. leprae evasion mechanism. Experimental studies on these pathogenic agents have demonstrated a role of TGF- β1 as a suppressor of macrophages. TGF-β1 production in lepromatous patients, which contributes to the anti-inflammatory situation and bacillary persistence observed

Evaluation The Effect of NB-UVB and Methotrexate on The Level of Serum Gelsolin in Psoriatic Patients

The protein expression of gelsolin- which is an actin scavenger controlling cytoskeletal remodeling, cell morphology, differentiation, movement, and apoptosis- has been found to be significantly decreased in several pathological conditions including neurodegenerative diseases, inflammatory disorders, and cancers. Gelsolin (GSN) is a member of the GSN protein family, the main function of it is to cut and seal actin filaments to regulate the cytoskeleton and participate in a variety of biological functions. Low serum gelsolin levels are linked to the severity of psoriasis, suggesting that gelsolin may help in assessing the severity of the disease and how it responds to treatment. Methotrexate (MTX) is the first-choice drug when phototherapy or retinoid treatment are not effective in psoriatic patients. It is a cytotoxic drug with powerful anti-proliferative and anti-inflammatory effects that has gained prominence in treating inflammatory diseases one of them is psoriasis. Narrowband (NB) UVB phototherapy is a common line of treatment in psoriasis. It was proven to be more effective than broadband UVB and safer and/or more practicable than psoralen_UVA in treatment of psoriasis

Validation of MRI Instead of CT to Follow-up Ross Procedure With Loose Jacket Technique

Fractional Erbium YAG Laser vs Intradermal and Systemic Tranexamic Acid

Melasma is more common in people with dark complexions and Fitzpatrick skin types III IV.Depending on ethnicity and region, melasma prevalence might vary from 8.8% to 40%. The cause of melasma is still unknown in the meantime. Numerous elements, including genetics, sunshine, endocrine stimulation, oxidative conditions,pregnancy, exogenous hormons,and morphofunctional changes, may have a role in the development of the disease. Since melasma is a common skin condition affecting mostly pregnant women and those on hormonal birth control, it is known as the "mask of pregnancy, Treatment for melasma remains a challenge, with substantial psychosocial ramifications. Many factors, including variability in clinical presentation and responsiveness to treatment between genders, skin phototypes, and ethnicities, can affect treatment efficacy. None of variety methods have been sufficiently effective to be considered the gold standard. Hydroquinone (HQ) has historically been the most studied topical agent in the treatment of melasma. HQ is a hydroxyphenolic compound that inhibits the conversion of dopa to melanin by the inhibition of tyrosinase; it also inhibits RNA and DNA synthesis of melanocytes and degrades melanosomes. Tranexamic acid (TXA) is an antifibrinolytic drug that has been used off-label for the treatment of melasma, as an oral or intradermal injection. TXA is a lysine-derived amino acid with anti-inflammatory effects that prevents ultraviolet (UV)-induced skin pigmentation by inhibiting attachment of plasminogen to keratinocytes and activation of plasmin. Plasmin stimulates melanogenesis by conversionof arachidonic acid to prostaglandin and leukotriene. On the other hand, plasmin increases the level of melanogenic factors. Laser therapy is a unique ablative modality that might potentially increase the penetration of medications applied topically by destroying the SC, epidermal, and dermal layers of the skin in a predictable and controlled manner. The Fractional erbiumdoped yttrium aluminum garnet (Er: YAG) laser has a wavelength of 2,940 nm and is strongly absorbed by water in the epidermis. It exerts its ablation effect with minimal penetration depth and minimal heat generation and therefore minimal thermal damage.

Impact of Education Level on Clinical Outcomes in Self-INR Managed Patients

Study Methods - Population of study: Patients who have a clinical indication for long term VKA. - Study location: Aswan Heart Center. - Inclusion criteria: Adult patients above 18 years who are indicated for long term VKA and has been on VKA for more than 6 months. - Exclusion criteria: 1. Refusal to join the study. 2. History of life-threatening bleeding or thrombo-embolic events. 3. Illiterate patients with no caregivers living at the same home. - Patient informed consent: Individual informed consent will be taken from every candidate for the study. The candidates will have the right to withdraw from the study at any time without any changes in the clinical service provided to them. - Methodology in details: A-Medical history including: Age, gender, indication of VKA. Data about valve surgery including date, location and type of valve. Past history of any chronic medical conditions, thrombo-embolic or bleeding events. Past history of blood transfusion. B-Social history including: Marital status, occupation, level of education and self-care capability. C- Clinical examination including: Assessment of body weight, height and body mass index calculation. Vital signs including blood pressure measurement using standard technique, assessment of the pulse, respiratory rate and temperature. C- Blood sample and chemistry: Blood tests will be done for all participants initially and at the end of the study. Laboratory workup will include complete blood count, liver, kidney function tests and electrolytes. F- Electrocardiography (ECG): 12-lead ECG will be done for all participants initially and the end of the study to confirm rhythm. H- Echocardiography: - Trans-thoracic echocardiography will be done for all patients to assess valve function, leaflet excursion, peak and mean pressure gradients across the valve. - In case of abnormally elevated pressure gradients, abnormal leaflet motion or suspected prosthesis-related mass, trans-oesophageal echocardiography will be done to confirm or exclude MVP malfunction. I. Randomization: - Patients will be randomized with the ratio of 1:1 to undergo self-management of INR versus standard management in the anticoagulation clinic using a randomization table. - Self-management arm: • All participants will receive full education class of minimum one-hour time and training about how to interpret INR levels and adjust their medication dose according to a pre-determined dose-INR schedule. • A registered nurse will be responsible for education and training. Another registered nurse would be responsible to check the participant feedback and well-understanding. • The participant will receive a chart to record INR results, test dates and dose modifications for the upcoming 6 months. • The participant will be educated about bleeding events, how to grade and when to seek medical attention immediately. • The participant will be educated about early manifestations of thrombo-embolism including shortness of breath, focal neurological deficits or lower limb pain. • If INR exceeds 8 at any time, the participant will be instructed to urgently contact the center and seek medical advice, he/she will be withdrawn from the trial and switched to the standard monitoring care. • If major bleeding or thrombotic event occurred, the participant will be instructed to contact us urgently and will be withdrawn from the trial and switched to the standard monitoring care. - Standard monitoring arm: - This group will be managed according to the local protocol of INR monitoring in a dedicated anticoagulation clinic. A registered nurse (supervised by a physician) would be responsible for medication dose adjustment, scheduling tests and recording any thrombo-embolic or bleeding events. K. Follow-up: Standard monitoring group will be reviewed on monthly basis or less according to INR test results. Self-management group will be reviewed 6 months after randomization, with the following data to be obtained: 1. All-cause death. 2. Bleeding events will be graded according to BARC classification - Minor bleeding Type 1: self-controlled bleeding that doesn't need seeking medical advice. - Major bleeding Type 2: Overt bleeding that requires medical intervention or hospitalization. Type 3a: Bleeding with Hb drop (3-5 gm/dL), or requiring blood transfusion. Type 3b: Bleeding with Hb drop 5 gm/dL or more, or requiring surgical intervention. Type 4: Coronary artery bypass graft-related bleeding. Type 5: Fatal bleeding. 4. Thrombo-embolic event: defined as mechanical valve thrombosis confirmed by trans-oesophageal echocardiography (prosthesis-related mass, elevated gradients, stuck leaflet motion), cerebrovascular stroke, peripheral embolism causing acute limb ischemia. 5. Time and proportion of tests in therapeutic range will be calculated using Rosendaal method. 6. Frequency of tests will be recorded. In case of mortality, data will be collected about the date and cause of mortality, and any reported clinical events before mortality. Data will be presented and used without inference to the name or personal data of the patients. All patient records will be handled in accordance to hospital and national confidentiality protocols.

Stellate Ganglion Block for Preserving Arteriovenous Fistula in Hemodialysis Patients Undergoing Major Lower Limb Orthopedic Surgery

The best way for dialysis in chronic renal failure (CRF) patients with consideration of feasibility, rate of infection, and patency is hemodialysis by using native access by using arteriovenous fistula (AVF). Altered calcium and phosphor metabolism in CRF patients would also increase vascular reactivity. Stellate ganglion blockade (SGB) has been used for several years for both diagnosis and treatment of circulatory problems in upper extremity. Recently preemptive SGB has been used in prevention of radial artery spasm in coronary artery patients. SGB increases blood flow and decrease vascular resistance in the arm. SGB prevents or ameliorates the reactivity of the muscular layer of the RA in response to both surgical manipulation during harvesting the artery and to the potent vasoconstrictor mediators released during surgery

Renal Resistive Index As a Predictor of Acute Renal Impairment in High-risk Patients

Acute kidney injury (AKI) is a common clinical problem encountered in critically ill patients, frequently in the setting of multiple organ failure, and is an independent risk factor for increase hospital stay and mortality risk. Early-stage acute kidney injury was first assessed based on the risk, injury, failure, loss and end-stage (RIFLE) criteria in 2004, and then by the Acute Kidney Injury Network (AKIN) criteria in 2007. The Kidney Disease: Improving Global Outcomes (KDIGO) classification, based on both the AKIN and RIFLE criteria, was introduced in 2012, offering an assessment based on baseline creatinine and urine output. The best strategy in clinical practice is to identify AKI as early as possible, reverse its cause, and even improve the sequelae. In the past decades, several serum creatinine (SCr)-based classification systems have been proposed to define AKI. The limitations of SCr is that the determinants of SCr (rate of production, apparent volume of distribution, and rate of elimination) are variable. Therefore, there is an unmet need for other objective measures to help detect AKI in a timely manner. The role of several biomarkers in the early prediction or risk assessment of AKI has been proposed, including kidney tubular damage markers (e.g., neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM- 1), liver-type fatty acid-binding protein (L-FABP) and cystatin C). Cystatin C is a protein from the family of cysteine proteinase inhibitors and is of interest as an early marker of decreased renal function. It is a protein that is synthesized at a constant rate by all cells containing nuclei, secreted into biological fluids: plasma, pleural, ascitic, cerebrospinal fluid, freely filtered through the glomerular membrane (due to its low molecular weight), fully metabolized in the kidneys, not secreted by the proximal renal tubules. Renal resistive index (RRI) is a noninvasive instrument to evaluate kidney hemodynamics, and it is obtained by analysis of intrarenal arterial waves using Doppler ultrasound.

Fentanyl Versus Dexmedetomidine As an Adjuvant to Bupivacaine in Spinal Anesthesia ; Peritoneal Symptomatic Effects

Acute appendicitis is among the most common causes of lower abdominal pain leading patients to attend the emergency department and the most common diagnosis made in young patients admitted to the hospital with an acute abdomen . In intracavitary abdominal surgery (e.g. Appendectomy),general anesthesia is conventionally chosen as it provides a higher safety profile with respect to the risk of aspiration, abdominal discomfort, and better exposure secondary to muscle relaxation however, at present it is considered safe to do spinal anesthesia in various abdominal procedures, even where significant muscle relaxation is required in certain complex cases such as peritonitis many patients with complicated conditions were operated under spinal anesthesia, which did not significantly interfere with surgical technique or exposure. Additional advantages of spinal anesthesia include faster recovery, better oral tolerance, and shorter hospital stay compared to general anesthesia. The Covid-19 pandemic currently affects almost every aspect of healthcare. The risk to the operating room team from the contaminated aerosols produced by intubation and positive pressure ventilation may be reduced by performing suitable open operations with neuraxial anaesthesia instead of General anesthesia . Neuroaxial anesthesia is commonly preferred for surgeries of lower abdomen, perineal and lower limb. It is easy to administer and very economical but needs skills. Intrathecal local anesthetics are limited by short duration of action and needs early use of rescue analgesia postoperatively. Adjuvants are added to improve quality and duration, provide better postoperative analgesia and patient comfort. A common problem during abdominal surgeries under spinal anesthesia is peritoneal related symptoms as visceral pain, nausea, vomiting, vagal symptoms like bradycardia and hypotension. Many adjuvants like fentanyl, morphine, ketamine, neostigmine, and clonidine are being used to prolong the analgesic effects of local anaesthetic for many years. These drugs including opioids are usually results in several side effects include itching, decrease respiratory rate, difficulty in urination, postoperative gastrointestinal disturbance which can be overcome by preferring them as adjuvant with other analgesics. Intraoperative peritoneal related symptoms as visceral pain, nausea, vomiting, vagal symptoms like bradycardia and hypotension are a common problem and there are some intrathecal adjuvants can solve these symptoms. Fentanyl is µ receptor agonist 80 times more potent than morphine as an analgesic added to spinal 0.5% heavy bupivacaine improves quality of spinal analgesia, reduces visceral and somatic pain. However, their addition may have side effects like pruritus, respiratory depression, urinary retention, postoperative nausea and vomiting which limits their use. Dexmedetomidine is highly selective α2-agonist, S-enantiomer of veterinary sedative medetomidine. Food and Drug Administration has approved its use for short-term ICU sedation, it is reported to provide sedation that parallels natural sleep, anxiolysis, analgesia, sympatholytic, and anaesthetic-sparing effect with minimal respiratory depression. α2- agonists produce clinical effects. It was reported in a previous study that intraoperative dexmedetomidine can reduce the incidence of postoperative nausea and vomiting (PONV)in patients undergoing thoracic surgery and a dose-response relationship between intraoperative dexmedetomidine and PONV was Observed; and the optimal dose range for antiemetic effects of PONV is 50-100 μg. Previous small Some meta-analyses demonstrated that intraoperative dexmedetomidine significantly lowered post-operative pain scores and opioid consumption, which could lead to a reduced opioid-related adverse events, including PONV. Dexmedetomidine prevents and reduces peritoneal related symptoms Intraoperative, and it can significantly lower the demand for opioids and inhalation anesthesia during and after operation, which could help to reduce opioid-related adverse events, including PONV.