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Objective: The objective of this systematic review was to state and analyze all the case reports published on extraskeletal extradural Ewing’s Sarcoma to date. Material and Methods: We searched PubMed, MEDLINE, EMBASE, and Google Scholar using the following search term, including Boolean operators AND and OR. We only included published case reports and series about Ewing's Sarcoma that were Extra-skeletal and Extradural. We excluded the intradural EWS cases and those that did not have both components, i.e. extraskeletal and extradural. Conference articles, commentaries, and unpublished articles were also not included. A PRISMA flowchart was also formed. Results: After the first case of EES in 1969, around 40 case reports and series have been reported, which sheds light on the rarity of this disease. Age of presentation varies from as early as two months, with the oldest report being 49 years of age, and most cases presenting in adolescents and young adults. Spinal Epidural extraskeletal Ewing's sarcoma has been more frequently reported in males. The level of occurrence of the tumor also varies among cases, with cervical, thoracic and lumbar regions being more frequently affected than sacral regions. Conclusion: Extraskeletal extradural ES is an exceedingly rare anomaly. Multicentric collaborative work is the need of the hour for such orphan illnesses, to optimize treatment paradigms as a single-center is exceedingly unlikely to amass cases.

Background Refractive error is an important preventable cause of visual impairment and blindness worldwide. In adult life, reduced vision can potentially affect the academic performance, choice of occupation and socio-economic status. This study aimed to assess the prevalence of refractive errors and related visual impairment among undergraduate male students in Prince Sattam bin Abdulaziz University in Al-Kharj, Saudi Arabia. Methods A descriptive cross-sectional study was employed in the current work. After obtaining an informed consent; each eligible student was asked to fill a self-constructed survey and have screened in the college premises for visual acuity and refractive error. Candidates detected with defective vision have been referred for further examination at well-equipped ophthalmology clinic in the University Hospital. Results A total of 420 undergraduate students, with age ranged from 18 to 30 years, have participated in the current study. About 25.0% of the participants have used spectacles at the time of examination. Positive family history of spectacles use was found in 71.4%. Our study showed that visual acuity in the better eye was low in 34.76% of the participants. Seventy-eight students (18.6%) of the total participants reported defective vision and have fulfilled refractometric examination. Of the examined students 83.3% were found to have refractive errors. Astigmatism, 52.6%, was the most frequently encountered refractive error among the participants; followed by myopia, 26.9%; and hypermetropia 2.6%. Conclusion The current study confirms that refractive error is an important preventable cause of visual impairment. Significant portion of the examined participants were found to have refractive errors recommending further work to improve visual status in undergraduate students.

Background: As part of the ‘small round-cell tumor’ family, Ewing’s sarcoma (ES) is a malignant mesenchymal tumor classified as a primitive neuroectodermal tumor (PNET). Within the PNETs, spinal extraosseous extradural lesions are exceedingly rare. Case Description: A 19-year-old male presented with a one-month history of back pain and paraparesis with loss of urinary control. The MRI revealed an intradural, extramedullary mass at the T3-T4 level. Intraoperatively, the tumor was solely extradural, without evidence of local invasion; it was entirely removed. Due to the high risk of metastasis, the patient was subsequently treated with chemotherapy and radiation. In addition, similar studies on PNETs were reviewed. Conclusion: A 19-year-old male presented with a paraparesis attributed to an extraosseous extradural ES at the T3-T4 level. Following total gross resection, he was successfully managed with chemotherapy and radiation. The patient has been in remission for one month.

Background and Purpose— Mobile Stroke Units (MSUs) provide innovative prehospital stroke care but their 24/7 operation has not been studied. Our study investigates 24/7 MSU diurnal variations related to transport frequency, patient characteristics, and stroke treatments. Methods— We compared transportation frequency, demographics, thrombolytic and mechanical thrombectomy administration, and treatment metrics across 8-hour shifts (morning, evening, and nocturnal) from our 24/7 MSU in Northwest Ohio prospective database. Results— One hundred ninety-five patients were transported by the MSU. Most transports occurred during the morning shift (52.3%) followed by evening shift (35.8%) and nocturnal shift (11.9%; P trend Conclusions— Morning and evening shifts account for the majority of our MSU transports (88.1%) and therapeutic interventions. Understanding temporal variations in a resource-intensive MSU is critical to its worldwide implementation.

Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

The choice of anesthetic technique, general anesthesia (GA) versus Monitored Anesthesia Care, may impact the outcome of patients undergoing endovascular treatment of acute ischemic stroke (AIS). The aim of this study was to identify the factors associated with good discharge outcome in patients receiving GA for AIS.Electronic medical records of patients above 18 years old who underwent endovascular treatment of AIS under GA at a Comprehensive Stroke Center from 2010 to 2014 were reviewed. Good outcome was defined as discharge modified Rankin Score 0 to 2 and poor outcome as modified Rankin Score 3 to 6; logistic regression analysis was performed to examine the association between the clinical characteristics and the outcome.In total, 88 patients (56 males), aged 63±15 years with median National Institute of Health Stroke Scale (NIHSS) score 16 (range, 4 to 38) were included. Nineteen (22%) patients had good outcome and 78 (88%) had systolic blood pressure below the guideline recommended 140 mm Hg under GA. After adjusting for age and NIHSS score, the independent predictors of good discharge outcomes were higher maximum end-tidal carbon dioxide (odds ratio [OR], 1.14; confidence interval [CI], 1.02-1.28; P=0.02) and extubation after endovascular treatment (OR, 26.31; CI, 4.80-144.12; P0.0001). A secondary analysis was performed after excluding 25 patients emergently intubated in the Emergency Department for airway protection. In the logistic regression analysis controlling for age and NIHSS score, postprocedure extubation was still associated with higher odds of good outcomes (OR, 13.35; CI, 2.58-68.90; P=0.002).These findings indicate the importance of ventilation management and extubation after endovascular intervention under GA in patients with AIS.

Background and objective: Chamomile has been used as an herbal medication sinceancient times and is still popular until today. This study aimed to investigate the potentialanticytotoxic effect of chamomile extract on the lingual mucosa of rabbits treated with5-fluorouracil (5-FU).Methods: Thirty six rabbits were used in the study. For induction of tongue mucositis forthe study group, 5-FU at a dose of (4 mg/kg) was administered intraperitoneally one timedaily for five successive days. The control animals were intraperitoneally injected bynormal saline one time daily for five successive days. The rats in each group wererandomly divided into two groups: Distilled water and chamomile extract treated groups(9 animals each). A volume of distilled water equal to chamomile extract was given bygavage tube, while the other group was gavaged with chamomile extract at a dose of (100mg/ kg) one time daily. The treatment with distilled water or the chamomile extract wascontinued for sixteen days and then the animals were sacrificed, and the tongues wereexcised for histopathological and immunohistochemical analysis.Results: The 5-FU/water treated group showed a significant increase in histologicaldamage scores, decrease in the ki-67and increase in caspase -3 epithelial immuneexpression (P

Chronic carotid occlusion is a poorly explored subject, deserving clarity regarding its definition, risks, and management. In this chapter we explore the etiologies of chronic carotid occlusion and the multitude of terminologies that have been used to describe it. We review its potential clinical manifestations, including the risk of stroke, which has varied widely in the existing body of literature. We describe diagnostic techniques to distinguish chronic carotid occlusion from acute occlusion or high-grade stenosis. Finally, we discuss management and review prior and ongoing studies which attempt to lower risk by a medical, surgical, or endovascular approach.

IntroductionThe Woven EndoBridge Intrasaccular Therapy (WEB-IT) Study is a pivotal, prospective, single-arm, investigational device exemption study designed to evaluate the safety and effectiveness of the WEB device for the treatment of wide-neck bifurcation aneurysms.MethodsOne-hundred and fifty patients with wide-neck bifurcation aneurysms were enrolled at 21 US and six international centers. Angiograms from the index procedure, and 6-month and 1-year follow-up visits were all reviewed by a core laboratory. All adverse events were reviewed and adjudicated by a clinical events adjudicator. A data monitoring committee provided oversight during the trial to ensure subject safety.ResultsOne-hundred and forty-eight patients received the WEB implant. One (0.7%) primary safety event occurred during the study—a delayed ipsilateral parenchymal hemorrhage—on postoperative day 22. No primary safety events occurred after 30 days through 1 year. At the 12-month angiographic follow-up, 77/143 patients (53.8%) had complete aneurysm occlusion. Adequate occlusion was achieved in 121/143 (84.6%) subjects.ConclusionsThe prespecified safety and effectiveness endpoints for the aneurysms studied in the WEB-IT trial were met. The results of this trial suggest that the WEB device provides an option for patients with wide-neck bifurcation aneurysms that is as effective as currently available therapies and markedly safer.Trial registration numberNCT02191618

Introduction: The pipeline embolization device (PED) is increasingly used in the endovascular management of cerebral aneurysms. Longitudinal data regarding safety and benefit of the PED in anterior communicating (ACOM) artery aneurysms are limited and particularly lacking in residual ACOM artery aneurysms. We report the use of the PED in 3 patients with ACOM artery aneurysms who were previously coiled. Methods: Three patients with ACOM artery aneurysms, all previously treated with coiling and with recurrence of the aneurysm neck, were treated with the PED. All obtained follow-up diagnostic cerebral angiograms at either 3 or 6 months. Results: Mean age of patients was 59 years. All patients received cerebral angiograms at a minimum of 3 months after treatment with the PED. Follow-up angiography was performed up to a mean of 10 months at which time point all cases demonstrated complete aneurysm occlusion, without any stenosis in the parent artery. Conclusion: The PED can be safely used for the treatment of ACOM artery aneurysms. Complete aneurysm obliteration can be achieved in cases refractory to endovascular coiling. These findings warrant replication in a larger data set.

Background: Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view. Methods: A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital’s pediatrics’ anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented. Results: The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic. Conclusion: Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.

Vascular access for cerebral angiography has traditionally been performed via the common femoral artery. It is crucial to obtain safe access to prevent complications that could lead to limb ischemia, groin hematoma, or retroperitoneal hematoma. This is especially true in neurointervention as many patients are anticoagulated or have received intravenous thrombolytics prior to their intervention. Special attention to anatomic landmarks, both grossly and radiographically, can help to assure safe access. The patient consented for this procedure. This video details rapid but safe femoral artery access in a patient undergoing emergent thrombectomy.

Nissen fundoplication (NF) is commonly performed in children with gastro-esophageal reflux disease (GERD). Patients undergoing NF often have co-morbidities. Reported outcomes of NF vary considerably. This study investigated which factors might predict multiple readmissions or death in the first year following NF at our institution. A retrospective chart review of 187 children who underwent NF at our institution between January 2004 and December 2015 was undertaken. Underlying medical conditions, age, weight, presence of malnutrition, length of hospital stay prior to surgery and type of surgery were recorded. Patients who had more than one admission in the first post-operative year were compared to those who had one or none, and patients who died within the first post-operative year were compared to those who did not. Risk factors for multiple readmissions were underlying cardiac disease (p = 0.011), esophageal atresia (EA) (p = 0.011), and esophageal stricture (p = 0.0002). Risk factors for death included younger age (p = 0.028), need for gastrostomy tube (GT) (p = 0.01) and prolonged pre-operative hospital admission (p = 0.0003). This study identified multiple factors associated with readmission and death in the first year after NF. These findings will help with the counseling patients and caregivers regarding expectations following NF.

BackgroundPooled individual data from the landmark stroke trials of 2015 conclude that the benefit of endovascular thrombectomy for patients with intracranial arterial occlusion also extends to patients with concomitant (so-called ’tandem') occlusions of proximal vessels. However, there is heterogeneity and debate in the management of these patients, without a clear standard of care. In particular, there is contention regarding whether the proximal or distal lesion should be treated first. We present a case control study and describe the Simultaneous Extracranial, Intracranial Management of (tandem) LESsions in Stroke (SEIMLESS) technique, an efficient approach to the acute ischemic stroke (AIS) patient who presents with tandem lesions (TLs).MethodsWe describe 5 patients, presenting with AIS and TLs between 2015 and 2017, who we treated with SEIMLESS. Cases were reviewed for clinical data, including arterial puncture to intracranial reperfusion, total fluoroscopy time, amount of contrast, age, and gender. Our series was matched to 5 patients treated with the standard ’sequential' approach (angioplasty followed by thrombectomy) in the same time period by the same operator.ResultsArterial access to intracranial recanalization time was significantly shorter in patients treated with SEIMLESS versus those who had angioplasty followed by thrombectomy (39.6±5.9 min vs 85.2±20.6 min; P=0.014). Patients treated ’seimlessly' also received significantly less iodinated contrast (117±13.5 mL vs 213±48.9 mL; P=0.005) and significantly less fluoroscopy time (21.1±5.2 min vs 55.9±17.8 min; P=0.003). There was no difference in the post-procedural Thrombolysis in Cerebral Infarction score for patients treated with SEIMLESS versus the sequential method (p=0.658).ConclusionSEIMLESS is an efficient procedural method that simultaneously treats a distal intracranial occlusion and a more proximal one. Our small case controlled study finds that this technique is feasible and can lead to faster intracranial recanalization compared with the standard ’sequential' method, utilizing less contrast and radiation in the process. Larger studies are needed to verify our findings.

Background and purpose Our mobile stroke unit (MSU) is the first 24/7 MSU worldwide. This provides a unique opportunity to report the temporal variation of its transports, types of patients treated, and therapy administered on the MSU. Methods This was a prospective, observational study conducted over the first year of the MSU’s operation. We compared different variables and metrics across the following times segments: hourly, 8 hour work shifts (morning 07:00–15:00, evening 15:01–23:00, and nocturnal 23:01–06:59), and 12 hour periods (daytime 07:00–19:00, nighttime 19:01–06:59). Results A total of 195 patients were treated and transported by the MSU. Based on hourly segments, the majority of MSU runs occurred from 13:00 to 14:00 (10.4%). The highest rate of transport was 52.3% in the morning shift, followed by 35.8% in the evening shift, and 11.9% during the nocturnal shift. When comparing daytime to nighttime, rate of transport was 73.1% vs 26.9%, respectively. A total of 23 patients received tPA; the most frequent hourly time segment was between 13:00–14:00 (21.7%), and the least frequent period was 02:00 to 07:00 with no tPA given. Of the total tPA administered, 56.5% was given during the morning shift, 34.7% in the evening shift, and 8.6% in the nocturnal shift. Twenty (86.9%) patients received tPA during the daytime and 3 (13%) received it during nighttime runs. Only 7 patients had mechanical thrombectomy (MT), all of which were done during the daytime. Conclusions MSU utilization varies with time of the day, with the highest rate of transport between 13:00–14:00. Higher rates of transport occur during the morning shift, compared to evening and nocturnal shifts; daytime period also has a higher rate of transport compared to nighttime period. tPA administration follows a similar trend. Staffing and utilization of a MSU can be managed more effectively if this variation is taken into account. Disclosures K. Changal: None. A. Sultan-Qurraie: None. V. Calderon: None. E. Lin: None. J. Goins-Whitmore: None. O. Zaidat: None.

The anterior cerebral artery (ACA) is a unique artery with many important variations with substantial clinical significance. Tortuous intracranial arteries usually occur in basilar, communicating, anterior, posterior cerebral arteries and in the white matter arterioles. This could happen for many reasons including but not limited to ageing, hypertension, patients with Moyamoya disease, congenital malformation, or increased flow associated with elastin degradation. While dolichoectasia of the ACA has been described even in children, to our knowledge, a serpiginous ACA without ectasia has not been reported, especially in the pediatric population.

Intracranial atherosclerotic disease (ICAD) accounts for 9–15% of ischemic stroke in the United States. Although highly stenotic ICAD accounts for most of the strokes, it is assumed that nonstenotic ICAD (nICAD) can result in stroke, despite being missed on standard luminal imaging modalities. We describe a patient with nICAD who suffered recurrent thromboembolic stroke and TIA but had a negative conventional stroke workup. As a result, they were referred for high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall, which identified a nonstenotic plaque with multiple high-risk features, identifying it as the etiology of the patient’s thromboembolic events. The diagnosis resulted in a transition from anticoagulation to antiplatelet therapy, after which the patient’s clinical events resolved. HR-MRI is an imaging technique that has the potential to guide medical management for patients with ischemic stroke, particularly in cryptogenic stroke.

Introduction The efficacy of the endovascular treatment of acute ischemic stroke has been substantiated by several recent randomized clinical trials. While intra-arterial therapy has significantly evolved in recent years, anatomic cerebrovascular variants and disease burden can present challenges to timely recanalization. We present the first reported case of anterior-to-posterior mechanical clot retrieval with use of a stent retriever. Case description A 53-year-old man presented with basilar artery thrombosis. Endovascular mechanical clot retrieval was performed. The typical, antegrade, access to the basilar artery thrombus was precluded by the findings of a hypoplastic left vertebral artery and an occluded proximal right vertebral artery. Given a number of factors including the patient’s worsening symptoms and the high morbidity and mortality associated with basilar stroke, cross-circulation—anterior-to-posterior—intra-arterial therapy was performed. Thrombectomy of the basilar thrombus was achieved via the right internal carotid artery and right posterior communicating artery. Conclusion To our knowledge, we report the first case of cross-circulation, anterior-to-posterior thrombectomy, with the use of a stent-retriever device. Cross-circulation stroke treatment may be beneficial in cases of proximal vessel occlusion or anatomical constraints. Larger studies will need to evaluate the safety and efficacy of these approaches.

Introduction: The effect of platelet transfusion (PT) has been studied in patients with intracerebral hemorrhage, but has not been reported for aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effect of PT on the outcome of patients with aSAH. Methods: We retrospectively evaluated 84 patients admitted with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015. Charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and complications related to endovascular treatment of cerebral aneurysm. Intergroup differences were evaluated with the Chi-squared and Student’s t-test. mRS was evaluated using multivariate ordinal logistic regression. Variables with a univariate p-value Results: Patient demographics and clinical variables are seen in Table 1. 30% of patients received PT. PT was associated with male gender, Hunt-Hess score, Fisher Score, external ventricular drain placement, and longer hospital length of stay. After multivariate ordinal regression, PT was associated with higher mRS and there was a trend for association with Hunt-Hess score (Table 2). Conclusion: Our findings suggest that platelet transfusion is common in patients presenting with aSAH. Platelet transfusion in these patients is associated with longer hospital stay and a significantly lower rate of good clinical outcome, with a nearly 4- to 6-fold higher odds of a one-point increase in mRS at 3 months. The association of platelet transfusion to worse outcome in patients with aSAH warrants further study.

Although the association between patent foramen ovale and ischemic stroke is controversial, the evaluation for a right-to-left shunt remains part of the standard workup for cryptogenic stroke. Transthoracic and transesophageal echocardiogram (TTE and TEE) are the screening test and gold standard to evaluate for right-to-left shunt, respectively. Studies comparing TTE or TEE to transcranial Doppler (TCD) have shown that 15-25 % of patients test positive for right-to-left shunt on TCD but are negative on TTE or TEE. We sought to further explore this phenomenon in patients with recent ischemic stroke. Between 2011 and 2013, 109 ischemic stroke patients had both a TCD and TTE or TEE bubble study. We abstracted 12 comorbid medical conditions and stroke subtype according to the TOAST classification. The majority of TCD and TTE or TEE showed agreement on right-to-left shunt status (80/109, 73 %). Two percent (2/109) of patients were negative on TCD and positive on TTE or TEE, while 25 % (27/109) had a positive TCD and negative TTE or TEE (TCD+Echo-). The TCD+Echo- patients were more likely to have active malignancy and the delayed arrival of contrast bubbles than the remainder of the cohort (15 vs. 2 %, p = 0.032; 51 vs. 18 %, p = 0.001). Our results confirm previous reports that TCD is superior to echocardiography in the detection of right-to-left shunt. The TCD+Echo- patients were more likely to have active malignancy and findings suggestive of an extracardiac shunt. These results could lead to more comprehensive evaluation for occult malignancy or a pulmonary arteriovenous malformation, both potentially treatable etiologies of ischemic stroke.

The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.

Hypoxic-ischemic encephalopathy carries an uncertain prognosis. We sought to retrospectively assess the prognostic value of arterial spin-labeling MR imaging in 22 adult patients diagnosed with hypoxic-ischemic encephalopathy. Quantitative CBF maps were generated from the M0 map, and arterial spin-labeling data on a per-voxel basis were regionally interrogated via visual inspection and ROI placement. Hyperperfusion was defined as regional increases in CBF of >20% (relative to global CBF) and/or >100 mL/100 g/min. Eleven of 22 patients had prominent bilateral medial occipital lobe hyperperfusion, all of whom died before hospital discharge. One patient who had nondistinct arterial spin-labeling hyperperfusion and restricted diffusion survived. Medial occipital lobe hyperperfusion is a distinctive pattern that merits prospective investigation in a cohort of patients with moderate hypoxic-ischemic encephalopathy to determine its predictive ability in patients with a higher likelihood of survival.

Background and Objectives: Gastrointestinal mucositis is a severe and debilitating side effect of chemotherapy. Methotrexate (MTX) represents one of the most potent classical anti-tumor drugs. The aim of this study was to determine the preventive effects of honey on the intestinal mucositis caused by methotrexate in rats. Materials and Methods: In current study forty females Albino rats, weighing 250-300g were used in the study. For the induction of mucositis, 60 mg/kg of MTX was administered intraperitoneally to each animal in the study group on day 4. The control animals were intraperitoneally injected by normal saline in the same manner and dose like MTX. At the beginning of the experiment, the rats in each group were randomly divided into two groups: Distilled water treated group and honey treated group (10 animals each). A volume of distilled water equal to honey was given by intragastric gavage tube, while the other group was gavaged with honey at a dose of (2.5g/kg) two times daily. The body weight for each rat was measured and then the animals were sacrificed on day 8. In each experiment, one centimeter of prox¬imal jejunum was removed for histopathological, intestinal morphometry, and immunohistochemical analysis using Ki-67 and Bcl-2 immunolabeling. Results: The MTX / honey treated group showed significantly (p 0.05) were seen in the Ki-67 and Bcl-2 immune expression in comparison with the MTX/water treated group. Conclusion: Honey at a dose of 2.5g/kg two times daily, produced a partial protection against methotrexate induced mucositis in rat by decreasing the histopathological scores.

Background and Objectives: Mucositis can be a dose-limiting toxicity of cancer chemotherapy with direct effects on patient survival; therefore an effective intervention is considered a high priority in cancer patient. The aim of the present study was to evaluate the effectiveness of honey as a preventive treatment for the methotrexate (MTX) induced oral mucositis. Materials and Methods: In current study forty females Albino rats, weighing 250-300 g were used in the study. For the induction of oral mucositis, 60 mg/kg of MTX was administered intraperitoneally to each animal in the study group at day 4. The control animals were intraperitoneally injected by normal saline in the same manner and dose like MTX. At the beginning of the experiment, the rats in each group were randomly divided into two groups: Distilled water treated group and honey treated group (10 animals each). A volume of distilled water equal to honey was given by intragastric gavage tube, while the other group was gavaged with honey at a dose of 2.5 g /kg two times daily (with a total of 5 g/kg/day). The animals were sacrificed at day 8. In each experiment, the middle third of tongue was removed for histopathological and immunohistochemical analysis using Ki-67 and Bcl-2 immunolabeling. Results: The result showed that, the MTX/honey group showed a significant increase in the thickness of the epithelium (p 0.01), and significant increase in Bcl- 2 immune expression (p

Background and objectives: 5-Fluorouracil (5-FU) is a commonly used drug for the treatment of malignant cancers. Approximately 80% of patients undergoing 5-FU treatment suffer from gastrointestinal mucositis. The aim of this study was to investigate the effect of chamomile extract on the pathogenesis of 5-FU induced intestinal mucositis in Albino rat.Materials and methods: In current study forty females Albino rats, weighing 220-280 g were used in the study. For the induction of mucositis, 60 mg/kg of 5-FU was administered intraperitoneally to each animal in the study group on day 0, and 40 mg/kg was administered on day 2. The control animals were intraperitoneally injected by normal saline in the same manner and dose like 5-FU on day 0 and 2. Then the rats in each group were randomly divided into two groups: Distilled water treated group and chamomile extract treated group (10 animals each).A volume of distilled water equal to chamomile extract was given by intragastric gavage tube, while the other group was gavaged with chamomile extract at a dose of (100 mg/ kg) two times daily. The treatment with distilled water or the chamomile extract was initiated on day 5 and the experiment continues for twelve days. The body weight for each rat was measured and then the animals were sacrificed on day 8 and 12 (five animals each). In each experiment, one centimeter of proximal jejunum was removed for histopathological, intestinal morphometry, and immunohistochemical analysis using Ki-67 and Bcl-2 immunolabeling.Results: Chamomile can protect the jejunum from fluorouracil-induced cytotoxicity and attenuate or decrease the associated injury. The chamomile in 5-FU/chamomile group causes significant increase in villi length, crypt depth, number of goblet cells, and Ki-67 and Bcl-2 immunexpression in comparison with 5-FU/water group at day 8. But longer duration of taking chamomile can cause cytotoxic and damaging effect to the jejunum. Conclusion: Chamomile can protect the jejunum from fluorouracil-induced mucositis, it attenuate the associated injury if it taken for short duration, but the reverse was occurred if it taken for longer period.

Background and objectives: 5-Fluorouracil (5-FU) is a commonly used drug for the treatment of malignant cancers. The control of oral mucositis result from 5-FU use is becoming increasingly more important, and effective intervention is considered a high priority in cancer patient care. The aim of this study was to investigate the effect of chamomile extract on the pathogenesis of 5-FU induced tongue mucositis in Albino rat.Materials and methods: In current study forty female Albino rats, weighing 220-280 g were used. For the induction of mucositis, 60 mg/kg of 5-FU was administered intraperitoneally to each animal in the study group on day 0, and 40 mg/kg was administered on day 2. The control animals were intraperitoneally injected by normal saline in the same manner and dose like 5-FU on day 0 and 2. Then the rats in each group were randomly divided into two groups: Distilled water treated group and chamomile extract treated group (10 animals each).A volume of distilled water equal to chamomile extract was given by intragastric gavage tube, while the other group was gavaged with chamomile extract at a dose of (100 mg/ kg) two times daily. The treatment with distilled water or the chamomile extract was initiated on day 5 and the experiment continues for twelve days. The animals were sacrificed on day 8 and 12 (five animals each). In each experiment, the middle third of the tongue was removed for histopathological and immunohistochemical analysis using Ki-67 and Bcl-2 immunolabeling.Results: Chamomile can protect the tongue from fluorouracil-induced cytotoxicity and attenuate or decrease the associated injury. The chamomile in 5-FU+chamomile group causes significant increase in Ki-67 and Bcl-2 immunoexpression in comparison with 5-FU+water group at day eight. But longer duration of taking chamomile can cause cytotoxic and damaging effect to the tongue mucosa.Conclusion: Chamomile can protect the tongue mucosa from fluorouracil-induced mucositis. It attenuate the associated injury if it taken for short duration, but the reverse was occurred if it taken for longer period.

The purpose of this prospective study was to evaluate the efficiency, feasibility, and surgical outcomes of microlaparoscopy-assisted pull-through (MAPT) for Hirschsprung's disease.Starting in 2005, pull-through procedures for Hirschsprung's disease were performed exclusively using 2-mm instruments and miniscopes (microlaparoscopy). Three miniports were inserted laterally in the right abdominal wall in one line, with the miniscope at the level of the umbilicus and the working trocars cranially/caudally of the scope. The left colon was dissected, and transanal pull-through was performed.MAPT was performed in 16 children (10 boys and 6 girls; average age: 5.7 months). Six patients had previous abdominal surgeries. A 1.9-mm cystoscope or a 2.4-mm arthroscope was used in the first 5 cases. In the remainder, a recently developed 2.4-mm miniscope was used for visualization. The length of the resected colon segment was up to the left colonic flexur in 5 children, up to the middle of the descending colon in 4 cases and up to the sigmoid-descending segment in 7 children. The average operation time was 185 minutes (range: 120-330 minutes). The only intraoperative complication that occurred was an injury of the right iliac vein by inadvertent slippage of an electrocautery hook requiring laparotomy. At follow-up, 80% of the parents were unable to identify the scars after microlaparoscopy.MAPT is a safe and practical procedure regardless of age or previous surgery.

The goal of the present study was to evaluate the efficacy of the LigaSure™ Vessel Sealing System (LVSS) when used for cystic duct closure during laparoscopic cholecystectomy in children and adolescents. The laparoscopic cholecystectomy was performed beginning with visualization of Calot’s triangle, and dissection of Calot’s triangle was achieved using a monopolar cautery device. Once the cystic duct was exposed, sealing was performed proximally and distally, and the cystic duct was divided midway using the LVSS. The procedure was completed in the standard fashion. The closure of the cystic duct was performed in seven cases of simultaneous cholecystectomy and splenectomy and in 15 cases of microlaparoscopic cholecystectomy. The patients’ ages ranged from 7 to 21 years (average = 14.5 years), and body weight ranged from 42 to 83 kg (average = 58 kg). There was no bile leakage noted, and the closure of the cystic duct was sufficient in all cases. We noted one case of common bile duct obstruction on postoperative day 1. In this case, an exploration of the biliary tree was performed by laparotomy. No direct injury to the common bile duct was found during exploration, but thermal changes were detected in the surrounding tissues as a result of transmitted thermal energy caused by bipolar cautery device. The closure of the cystic duct using the LVSS is feasible and effective in laparoscopic cholecystectomy in children. However, it is important to keep a safe distance from other intra-abdominal structures when using thermal energy devices to prevent thermal collateral damage.

✓ The authors describe the case of a 62-year-old woman with a Type II split cord malformation (SCM). At the initial time of workup, the authors observed an associated Klippel—Feil deformity at the level of the SCM and a low-lying conus medullaris; however, they discovered an associated Type IV perimedullary spinal cord arteriovenous fistula (AVF) only after the patient continued to deteriorate following a spinal cord untethering procedure. Although prominent blood vessels have been reported within the median cleft of SCMs, an angiographically and surgically proven perimedullary AVF has not previously been described. The potential coexistence of SCM and perimedullary AVF has significant clinical implications and its recognition is critically important prior to surgical treatment.

The authors describe the case of a woman with autoimmune thyroid disease, who presented with hypothyroidism but went on to develop hyperthyroidism.

Objective To study the relationship between chronic hepatitis C infection and microvascular complications in nondiabetic individuals. Background Several extrahepatic manifestations have been reported in the natural history of hepatitis C virus (HCV) infection. Further, extrahepatic manifestation syndromes could represent the first signal of an HCV infection, as many patients show no hepatic symptoms. As known microvascular complications of diabetes include neuropathy, nephropathy and retinopathy, this study was conducted to evaluate the effect of chronic HCV infection on microvascular complications in nondiabetic patients. Subjects and methods Fifty patients with chronic hepatitis C infection were enrolled. All were subjected to full clinical assessment including routine blood tests, fasting and 2 h postprandial blood glucose, HbA1c, HCV-RNA PCR, urinary albumin concentration indicating the presence of microalbuminuria, liver biopsy and fundus examination. Results Microalbuminuria was diagnosed in five patients (10%) with chronic hepatitis C, whereas 15 patients (30%) had peripheral neuropathy as diagnosed by clinical examination; no retinopathy was diagnosed in these patients. Peripheral neuropathy correlated with age, HCV viremia and stages of liver biopsy. Conclusion Patients with chronic HCV infection had a high incidence of developing microalbuminuria (10%), a very high incidence of developing peripheral neuropathy (30%) and no incidence of developing retinopathy (zero%). Age, the HCV-RNA level and liver fibrosis are prominent risk factors for the occurrence of peripheral neuropathy in chronic HCV-infected patients.