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   Table of Contents - Current issue
October-December 2019
Volume 2 | Issue 4
Page Nos. 243-336

Online since Monday, February 10, 2020

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Role of arginine and/or taurine in protection against gentamicin-induced nephrotoxicity in male and female rats p. 243
Wafaa M Ismaeil, Amal H Emara
Background As a highly effective antibiotic, gentamicin is used in the treatment of serious and life-threatening gram-negative infections. L-arginine (2-amino-5-guanidino-pentanoic acid) has a protective role on renal failure that induced by gentamicin administration and it may decrease the tubular reabsorption of another cationic substance, gentamicin due to its cationic structure. The aim of this study is to determine the influence of gender on nephroprotective effects of L-arginine (Arg) and/or taurine (Tau) on gentamicin (G) induced nephrotoxicity. Methods Adult Sprague-Dawley albino rats of both sexes (150-200 g, 48 male and 48 female), were bred from the animal unit of National Nutrition Institute, Cairo, Egypt. Male rats were divided randomly into 8 groups (n=6 per group) and the following treatments were given: Group 1 (negative control group): saline (2 ml/Kg/day, i.p); Group 2 (positive control group): was injected with G (100 mg/kg b.wt./day, i.p); Group 3 injected with G and treated with Arg (1.6 gm/kg b.wt /day, p.o); Group 4 injected with G and treated with Tau (0.75 gm/kg b.wt/day,i.p) and Group 5 injected with G and treated with combination of Arg and Tau at the same previously mentioned doses. The tested amino acids and their combination were also administrated to healthy rats (three groups) for ten consecutive days. Female rats were divided at random into eight groups and treated in the same fashion as above. Results Gentamicin administration resulted in nephrotoxicity as evidenced by significant elevation in serum creatinine (122% and 127%) and blood urea nitrogen (BUN) (18.3% and 117%), significant reduction in creatinine clearance (30% and 46.9%), proteinuria (250% and 372%), sharply elevated levels of urinary alkaline phosphatase (ALP) (267% and 415%) and potassium (244% and 376%) and decreased level of serum ALP (10.2% and 31.9%) in males and females, respectively. Gentamicin did not affect serum potassium in both males and females and on serum sodium in males; however, it increased serum sodium in females by 27%. Also, gentamicin injection enhanced lipid peroxidation as indicated by the elevated levels of renal malondialdehyde (MDA) (46.7% and 22.8%) and nitric oxide (NO) (48% and 72%) and the depressed level of reduced glutathione (GSH) in kidney (55% and 45%) and whole blood (5.7% and 8.8%) in male and female rats, respectively, as compared with normal rats. Also, the activity of erythrocyte Cu, Zn superoxide dismutase (SOD) was reduced (10.1%) in males but not in females as compared with normal rats. Supplementation with Arg and/or Tau attenuated G induced nephrotoxicity in male and female rats. These nephroprotective effects were more pronounced in females. Conclusion The results of the present study indicate that female Sprague-Dawley rats are more sensitive to the nephrotoxic effects of G. Treatment with Arg and/or Tau exerted a nephroprotective impact, which is gender specific.
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Cardiovascular risk in patients with rheumatoid arthritis: the role of cholesterylester transfer protein p. 250
Taghreed F Mohammed Mostafa, Ali M Mursi, Sherry K Abdelrahman, Emad M Elshebiny, Sahar H Quashwa, Lobna Y Ebrahim
Aim To detect serum level of cholesterylester transfer protein (CETP) (the enzyme involved in reverse cholesterol transport) in patients with rheumatoid arthritis (RA) and to evaluate its relation to various clinical parameters of the disease, lipid profile, and carotid intima-media thickness (CIMT) as a marker of atherosclerosis and cardiovascular disease risk. Patients and methods This study involved a total of 80 participants, comprising 50 patients with RA and 30 age-matched and sex-matched healthy controls. Detailed medical history and thorough clinical examination (general and musculoskeletal) as well as laboratory investigations including lipid profile were performed for all patients with RA. Serum level of CETP was assessed by enzyme-linked immunosorbent assay technique. Carotid ultrasound scan was performed for all patients with RA to detect CIMT. Results Serum level of CETP was significantly lower in patients with RA than controls (4.11 ± 2.77 ng/ml in patients with RA and 5.30 ± 2.73 ng/ml in controls, P = 0.003). Regarding lipid profile values, high-density lipoprotein was lower in patients with RA relative to controls (63.02 ± 12.8 vs. 69.8 ± 6.7 mg/dl, P = 0.012), whereas total cholesterol (218.9 ± 39.5 vs. 206.9 ± 31.8 mg/dl, P = 0.073), triglycerides (144.2 ± 16.2 vs. 136.1 ± 16.6 mg/dl, P = 0.059), and low-density lipoprotein (118.5 ± 27.5 vs. 112.6 ± 38.5 mg/dl, P = 0.56) showed no significant differences between both groups. No correlation was found between serum level of CETP and the characteristics of patients with RA including demographic data, disease activity markers (28-joint disease activity score, erythrocyte sedimentation rate, and C-reactive protein), serological markers (rheumatoid factor and anti-cyclic citrullinated peptide antibodies titer), as well as lipid profile parameters. On the contrary, serum level of CETP was significantly negatively correlated with CIMT (r=−0.321, P = 0.023). Conclusion Finally, we concluded that CETP was found to be low in patients with RA when compared with controls and is inversely related to CIMT, suggesting its possible role in cardiovascular mortality risk in this disease.
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Glutamic acid decarboxylase auto-antibodies prevalence among patients with type 2 diabetes mellitus and their clinical characteristics in a sample of the Egyptian population p. 257
Ayat I Ghanem, Atef A Bassyounia, Ghada A Omar
Background Patients with latent autoimmune diabetes in adults may develop early loss of β-cell mass. They are often misdiagnosed as having type 2 diabetes mellitus (T2DM). This is because latent autoimmune diabetes in adults condition does share characteristics of both type 1 and T2DM. Aim To estimate the prevalence of unrecognized cases with glutamic acid decarboxylase auto-antibodies (GADA) among patients with T2DM in a sample of the Egyptian population, describing their clinical and laboratory features, and investigating the relationship with chronic complications of diabetes. Settings and design A total of 1515 Egyptian patients previously diagnosed as having T2DM were divided into two groups based on presence versus absence of GADA. Demographic and clinical characteristics were compared. Patients and methods Patients were selectively admitted according to clear criteria after informed consent and approval of the Ethics Committee. Patients underwent comprehensive history taking and examination. Laboratory investigations included blood chemistry, C-peptide, and GADA. Statistical analysis Data were analyzed using SPSS. Results Overall, 12.8% of patients with T2DM were GADA positive, showing lower C-peptide levels (P < 0.001). GADA-positive patients with T2DM demonstrated a positive correlation of GADA levels with central obesity (r = 0.175; P = 0.015) and systolic blood pressure (r = 0.171; P = 0.018). Moreover, a negative correlation with cardiovascular diseases (r=−0.0175; P = 0.015) was observed. Conclusion Prevalence of GADA among patients with T2DM in the analyzed sample was 12.8%, which agrees with the findings in other populations. These patients had lower C-peptide levels. GADA measurements are recommended in patients with T2DM with low C-peptide levels, especially in newly diagnosed patients, to help identify positive cases and initiate early insulin treatment to help preserve β-cell function and decrease the risk of long-term complications.
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Implementation of ventilator bundle for prevention of ventilator-associated pneumonia in pediatric intensive care unit p. 265
Mohamed F Alsoda, Mahmoud M Al-Shahat, Sherif M K. Reda, Ahmed Y Alsawah, Mohammad A M. Abboud, Abd-Elaleem Elgendy
Background Ventilator-associated pneumonia (VAP) is associated with increased morbidity and mortality in pediatric intensive care unit (PICU) patients. Objective The aim was to examine the effect of adherence to VAP prevention bundle on the incidence of VAP in PICU. Patients and methods A prospective comparative study was conducted in Al-Hussein University Hospital on all patients admitted and ventilated in PICU in a year from September 2017 until September 2018. They were divided into two groups: the first group included patients admitted to PICU after implementation of the study, comprising 43 patients as cases, and the second group included patients admitted to PICU before implementation of the study, comprising 22 patients as a control group. All included ventilated children were subjected to the following:
  1. Diagnosis on admission and indication of mechanical ventilation.
  2. Full physical examination including the assessment of the following:
    1. Anthropometric measures that were plotted on percentiles.
    2. Vital signs: oxygen saturation and heart rate were continuously recorded.
    3. Systemic examination and clinical evidence of sepsis and pneumonia.
  3. Ventilation mode and duration.
  4. Type of feeding whether Total parenteral nutrition (TPN) or enteral feeding.
  5. Laboratory investigations, including the following:
    1. Complete blood count.
    2. Quantitative C-reactive protein.
    3. Blood chemistry and renal functions.
    4. Arterial blood gases.
  6. Chest radiographs.
  7. Microbiological studies.
Results The VAP rate decreased with compliance with the ventilator bundle from 50 to 14% (P = 0.002). Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP. VAP bundle is effective in VAP reduction when compliance is maintained. Conclusion VAP is one of the severe complications of mechanical ventilation that significantly increases the length of PICU stay and mortality. Bundle implementation was found effective in decreasing the VAP rate in the PICU patients.
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Recent conservative management trends in dealing with uterine adnexal torsion will preserve fertility in childbearing women: a review of literature and case series p. 273
Hossam H Soliman
Introduction Uterine adnexal torsion is a rare gynecologic emergency, representing 2.5–7% of all the acute gynecologic surgical conditions. It could lead to adnexal ischemia and necrosis, putting a woman at the risk of a radical surgery, which leads her to lose a uterine adnexa, plummeting her future fertility, and possibility inducing a negative effect of her future marital and family life. Adnexal detorsion associated with cystectomy is a simple maneuver that could spare the woman of losing her ovary; this technique could successfully work even with an apparently necrosed ovary. Aim A review of literature, in addition to a retrospective observational study was done, the aim of this study was to assess the potential of saving a torsed, devitalized adnexa, through the less radical detorsion technique and simple cystectomy. Results Several studies have favored ovarian detorsion, cystectomy, and ovariopexy, as combined techniques, if done altogether could spare an ovary being removed for being necrosed. The present retrospective study of 12 cases with ovarian torsion revealed complying findings, where two of five patients with suspected adnexal necrosis were treated conservatively by combined detorsion and cystectomy, with the ovaries resuming normal activity soon within a few weeks. Conclusion Many apparently necrosed ovaries could be spared unnecessary excision, through implying a more conservative techniques, such as ovarian detorsion and cystectomy, with no marked detrimental consequences.
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The use of gonadotropin-releasing hormone antagonist in women undergoing intrauterine insemination p. 281
M Yousef Elsemary, Bassem Sobhy
Background Intrauterine insemination (IUI) is considered to be a very popular treatment procedure that is used for many infertile women worldwide. Aim The aim was to evaluate whether the addition of gonadotropin-releasing hormone antagonist would improve the clinical pregnancy rate in women undergoing IUI. Materials and methods A prospective study was performed at El-Galaa Maternity Teaching Hospital where 124 women with primary or secondary infertility were subjected to controlled ovarian stimulation with human menopausal gonadotropin (74–150 IU/day) only (control group, n=62) or to human menopausal gonadotropin (75–150 IU/day) plus Cetrorelix (0.25 mg/day, starting when the leading follicle was ≥16 mm; n=62). A single insemination was performed 36 h after hCG was given (5,000 IU, intramuscularly) in both groups. Main outcome measure(s) Clinical pregnancy rate, premature luteinization (PL), and follicular development were measured. Results Clinical pregnancy rates (20 vs10.9%) and the number of mature follicles (2.2±1.1 vs 1.4±0.96) were statistically significantly higher in the antagonist group compared with the control group. The PL rate was significantly lower in the antagonist group (0.91 vs 4.61%). Conclusion The addition of a gonadotropin-releasing hormone antagonist to controlled ovarian stimulation and IUI was significantly associated with an increase in pregnancy rates in multifollicular cycles and a reduction in the incidence of PL.
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Determinants of infarction patterns in posterior cerebral circulation p. 286
Taha K Alloush, Ramez R Moustafa, Mohamed M Fouad, Ahmed H. T Badr Ahmed
Background Ischemic stroke is defined as focal or global neurological dysfunction lasting longer than 24 h or leading to death that is caused by vascular insult, either stricture or occlusion of a specific vascular territory. Aim of the study This study aimed to determine the relationship between different risk factors and different infarction patterns in posterior circulation such single small lacunar lesion, single large lesion, and multiple scattered lesions. Patients and methods This study included 60 patients recruited from the stroke unit of Ain Shams University and El Sahel Teaching Hospitals during the period from April to October 2018 with the diagnosis of posterior circulation ischemic stroke. The study population was divided into three groups according to the infarction pattern. Infarction patterns were categorized into a single small lacunar lesion (20 patients) (group I), a single large lesion (20 patients) (group II), and multiple scattered lesions (20 patients) (group III). Results There was no significant difference between the three groups in the presence of vascular risk factors such as hypertension (P = 0.153), diabetes (P = 0.317), dyslipidemia (P = 0.420), presence of cardiac diseases (P = 0.180), and smoking (P = 0.931). The only significant difference in terms of vascular risk factors was atrial fibrillation (AF). AF was present in six patients in group II and six patients in group III, and not present in group I patients (P = 0.024). Conclusion Different vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking are present in all infarction patterns of posterior cerebral circulation, either single or multiple infarctions, and there were no significant differences in the presence of these vascular risk factors in relation to the type of the vascular lesion. AF and significant vertebrobasilar stenosis were mostly associated with large and multiple infarct lesion patterns. Small-vessel disease was the most common stroke etiology for a single small lacunar lesion, whereas large artery atherosclerosis was mostly present in a single large lesion and multiple lesions. Strict control of vascular risk factors is highly recommended in all infarction patterns of posterior circulation.
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Additive value of intraoperative hemodynamic monitoring to epicardial echocardiography during surgical repair of children with congenital heart disease p. 297
Rania D. Eldin Abou Shokka, Ahmed A Algebaly, Hanan Mohammed Hassan
Aim The aim was to evaluate the additive value of intraoperative hemodynamic monitoring to epicardial echocardiography on the surgical outcome in children undergoing surgical correction of congenial heart disease. Patients and methods This study was conducted on 238 children with congenital heart disease who were enrolled for surgical correction. They were arranged in two groups: group A included 159 children in whom e-echo was used to detect intraoperative residual lesions while group B included 79 patients in whom e-echo and intraoperative hemodynamic monitoring using oxygen saturation step-up and intracardiac pressures after disconnection of cardiopulmonary bypass to detect residual shunt flow and outflow tract obstruction were used; revision of bypass was done when significant lesions were detected for repair. The follow-up echocardiography showed no significant residual lesions and complications in the subgroup of patients who had both epicardial monitoring and hemodynamic studies, in contrast to other groups of patients in whom19 patients had residual lesions and complications. Conclusions Routine use of intraoperative epicardial echocardiography allows detection of majority of residual defects after bypass; however, addition of other intraoperative monitoring tools like hemodynamic pressure measurement and oxygen saturation step-up can result in the detection of more residual lesions with revision of bypass, thus saving these patients from reoperation and postoperative complications.
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Surgical outcomes of obstructive mechanical valve thrombosis, risk factors, and comorbidity analysis p. 303
Ahmed Shafeek Ali
Background Obstructive mechanical valves thrombosis is a life-threatening complication associated with high morbidity and mortality. Although thrombolytic therapy has gained a lot of popularity in recent years, yet the treatment of choice is still controversial. Objective The aim of this study was to evaluate the outcomes of patients who underwent redo valve surgery for obstructive mechanical valve thrombosis. Patients and methods Outcomes of 380 patients who underwent emergency redo surgery for obstructive mechanical valve thrombosis at our institute during a 5-year period (January 2012 to December 2017) were reviewed retrospectively. Clinical symptoms and transthoracic echocardiography were the mainstay in diagnosis. Fluoroscopy was used in the presence of dilemma regarding diagnosis. All patients were treated on an emergency basis. Postoperative outcomes were analyzed to determine risk factors and comorbidities affecting mortality rates in this high-risk group of patients. Results Number of patients was 380, with prevalence of female sex being 268 (70.52%). Mean age was 32.65 ± 10.70 years. Associated comorbidities were hypertension in 96 (25.26%), diabetes mellitus in 32 (8.42%), elevated liver enzymes in 32 (8.42%), elevated creatinine in 44 (11.57%), and preoperative cardiac arrest in eight (2.10%). Overall mortality was seen in 52 (13.68%) patients. Risk factors influencing mortality rates were preoperative hemodynamic instability, increased NYHA class, renal dysfunction, low left ventricular ejection fraction, and right ventricle dysfunction. Moreover, mortality was significantly affected by repetition of redo surgery, long bypass and cross-clamp time, high postoperative cardiac support, duration of mechanical ventilation, and ICU stay. Conclusion Prosthetic valve thrombosis is a life-threatening situation associated with substantial risk regardless of treatment modality. Late presentation with hemodynamic instability, increased NYHA class, low left ventricular ejection fraction, and severe right ventricle dysfunction carry worst prognosis in surgically treated patients.
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A comparison between monopolar radiofrequency ablation and electrocautery (Diathermy) ablations in left modified MAZE (short-term results) p. 311
Waleed El-Awady
Introduction Atrial fibrillation is the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The classic cut-and-sew maze procedure is successful in 85–95% of patients. However, it is technically challenging and requires prolonged cardiopulmonary bypass. The left modified maze procedure is successful in 65–85% of patients. The aim of this study was to compare the success of two different ablation sources in the left modified MAZE. Patients and methods Between June 2010 and December 2016, 40 patients underwent left modified MAZE (Cox III) procedure: 20 patients were done with monopolar radiofrequency ablation (group A) and the other 20 patients were done with diathermy as electrocautery ablation (group B). All patients had left maze plus a concomitant operation. Results The patients' mean age was 38.2 ± 12.7 years; there was no mortality or stroke or any thromboembolic events in both groups. There were 14 (35%) males and 26 (65%) females. The mean left atrial size ranged from 62.6 to 27.4 mm. The mean cardiopulmonary bypass (CPB) time was 115.1 ± 84.9 min. The mean cross-clamp time was 86 ± 64 min. The incidence of freedom from atrial fibrillation was 45% at the end of the operation (40% of patients with normal sinus rhythm with group A and 50% with group B), and after 1-year follow-up, this incidence increased to 67.5%, with 70% in group A and 65% in group B; only one patient required permanent pacemaker. Conclusion Although monopolar radiofrequency ablation is slightly superior to electrocautery, diathermy is definitely a cheaper option and can be used with satisfactory considerable short-term results in left modified Maze procedure in case of absence of standard devices of ablation.
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Omental flap harvested through transdiaphragmatic approach at the same sternotomy incision for poststernotomy mediastinitis: a new approach p. 319
Waleed El-Awady
Background The surgical treatment of poststernotomy mediastinitis is still a challenge and associated with high mortality. Conservative treatment and various surgical procedures are sometimes inadequate and need more aggressive treatment. Omental flap improves control of infection and prognosis, but harvesting is an additional procedure with its associated morbidity and trauma. Patients and methods A total of 14 patients had omental flap, which was harvested through a diaphragmatic opening at the lower part of the same sternotomy incision, without additional laparotomy incision or extension of sternotomy incision into the upper abdomen or even laparoscopically. The mean age of the patients was 59.5 ± 15.5 years. There were nine females and five males. Coronary artery bypass grafting was done in 12 patients and two patients had mitral valve replacement. Results There were no complications related to the omentoplasty. No herniation of abdominal organ occurred. Reoperation was performed at an interval of 15 days (7–23 days). Wound debridement was done in four patients, and wound was opened in five patients. Two patients had vacuum suction. Tissue cultures revealed staphylococci in eight patients. Omental flap was performed alone in 10 and combined with pectoralis flap in four patients. The operative mortality was one patient. Prolonged ICU stay (±pneumonia) was seen in four patients and prolonged ventilation in four patients. Septicemia was seen in two patients, and one of them died with septic shock. No early or late flap failure occurred. Incisional hernia occurred in one patient and lymphorrhea in one patient. Conclusion Transdiaphragmatic approach which allows harvesting of omental flap safely through the same sternotomy incision is a new era of minimally invasive surgery without the need of additional laparotomy or extension of the sternotomy incision to the upper abdomen or even laparoscopic surgery and provides excellent results for the treatment of poststernotomy mediastinitis through the same sternal incision.
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Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects using amplatzer vascular plug II p. 324
Rania Diaa Abou Shokka, Ahmed A Al Gebaly, Wael M Hossam
Introduction Retrograde transcatheter closure of perimembranous aneurysmal ventricular septal defects (pmVSD) can be a better option for transcatheter closure of ventricular septal defect with device placement into ventricular septal aneurysm with fewer complications. Also, a retrograde approach might decrease procedure time and radiation exposure time. Aim The purpose of this study was to report off-label experience using Amplatzer Vascular Plug II (AVPII) for the trans catheter closure of perimembranous aneurysmal VSD. Comparison of haemodynamic effects of ketamine and sevofluorane as in induction of anesthesia. Materials and methods Our series consists of a fifteen child with pmVSD. The mean age was 4.9 years (range: 1.2–10 years), mean left ventricular end-diastolic dimension 38.3 mm. Maximum and minimum defect sizes were 4 and 8 mm by transthoracic echocardiography (mean defect size: 5.2 mm). The procedure was performed under general anesthesia with left heart catheterization for retrograde closure of the defect. The study was done on 15 children from 2016 to 2018 for retrograde transcatheter closure of aneurysmal perimembrance VSDs using an Amplatzer vascular plug II Baseline characteristics of the study patients are set in Table I. All the children who had aneurysmal perimembrance outlet ventricular septal defect with left to right shunt were included for assessment of closure. The children eligiable underwent clinical evaluation that also included electrocardiogram (ECG), and standard echocardiography assessment. Results All participants who met the inclusion criteria were sent to the catheterization laboratory. Following left ventricular angiogram, three patients were excluded as technically nonfeasible. Failure to cannulate the defect in one patient and deficient aneurysmal tissue during left ventricular angiography in two cases. The device was successfully deployed in 12 children with the retrograde technique. In two patients antegrade approach was used using the ADO I device due to deficient aneurysmal tissue. The complete VSD closure rate was 84% immediately, 92% at 24 h, and 92% at the last follow-up. Atrioventricular conduction system was not affected by the procedure in any patients. Arterial complication developed in two patients. There was no device embolization; no aortic regurge developed in any patient. According to children had ketamine in induction of anesthesia HR recorded (122±16) beats /min but the children had sevofuran in indnction of anestherin re corded (108±12) beats/min but not significant different howevere the (MBP) inth children had ketamin had (68±14) mm Hg but the children had sevofluran in induction (60±8) mm Hg but not significant different. Conclusions Retrograde transcatheter closure of pmVSDs using AVPII is a safe and effective alternative method which allow closure of a wider range of VSDs due to availability of wide ranges of AVPII sizes of up to 22 mm in diameter. The retrograde approach can also simply the procedure with less fluoroscopy time and anesthesia time.
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One-year angiographic results of left anterior descending bypass using internal mammary artery: a series of 48 consecutive patients p. 330
Ahmed S Mahlab
The left internal mammary artery (LIMA) has been used as a conduit for coronary artery revascularization since 1968. Here we are reporting A total of 48 consecutive patients were operated upon using double mammary arteries. All of them received a mammary graft to the left anterior descending artery (LAD). All 48 of them were controlled angiographically at 1 year postoperative to ensure satisfactory well-functioning grafts.
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Ruptured inferior mesenteric artery aneurysm: a case report p. 334
Assem Mohamed Herzallah
Among visceral artery aneurysms, inferior mesenteric artery aneurysm is the rarest. Although most cases are of degenerative etiology, a small fraction of these cases are caused by autoimmune diseases. We report a case of spontaneous retroperitoneal hemorrhage from a ruptured inferior mesenteric artery aneurysm in a 30-year-old patient with systemic lupus erythematosus, treated by ligation.
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