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Background: The timing of initiation of Norepinephrine (NEP) in septic shock is controversial., Aim of the Study: We evaluated the impact of early NEP simultaneously with fluids in those patients., Methods: We randomized 101 patients admitted to the emergency department with septic shock to early NEP simultaneously with IV fluids (early group) or after failed fluids trial (late group). The primary outcome was the in-hospital survival while the secondary outcomes were the time to target mean arterial pressure (MAP) of 65 mmHg, lactate clearance and resuscitation volumes., Results: There was no significant difference between the two groups regarding the baseline characteristics. NEP infusion started after 25 (20-30) and 120 (120-180) min in the early and late groups (p = 0.000). MAP of 65 mmHg was achieved faster in the early group (2 [1-3.5] h vs. 3 [2-4.75] h, p = 0.003). Serum lactate was decreased by 37.8 (24-49%) and 22.2 (3.3-38%) in both groups respectively (p = 0.005). Patients with early NEP were resuscitated by significantly lower volume of fluids (25 [18.8-28.7] mL/kg vs. 32.5 [24.4-34.6] mL/kg) in the early and late groups (p = 0.000). The early group had survival rate of 71.9% compared to 45.5% in the late group (p = 0.007). NEP started after 30 (20-120 min) in survivors vs. 120 (30-165 min) in non-survivors (p = 0.013)., Conclusions: We concluded that early Norepinephrine in septic shock might cause earlier restoration of blood pressure, better lactate clearance and improve in-hospital survival., (Copyright © 2019 IMSS. Published by Elsevier Inc. All rights reserved.)

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

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

An in vitro study has been carried out to monitor changes to the female reproductive system in adult triclabendazole (TCBZ)-resistant Fasciola hepatica following treatment with a commercial preparation of myrrh ("Mirazid"). Flukes were immersed for 6 h and 24 h in myrrh extract at a concentration of 200 µg/ml, then processed for histological and transmission electron microscope (TEM) examination of the uterus, Mehlis' gland, ovary and vitellaria. Egg production had become abnormal at 6 h post-treatment (pt), with the uterine lumen being filled with free vitelline cells and masses of shell protein material; few eggs were present. At 24 h pt, no eggs were present. Distinct changes to the ovary and Mehlis' gland were only observed after 24 h incubation in Mirazid. The ovary contained numbers of apoptotic oogonia and oocytes. In the Mehlis' gland, the S1 cells were disorganised and the processes from them were vacuolated, although the disruption was not significant. More severe changes were observed in the vitelline cells and follicles. After 6 h incubation in Mirazid, although the gross organisation of the vitelline follicles appeared to be normal, nuclear changes indicative of the early stages of apoptosis were observed in the stem cells and shell protein production by the mature cells had decreased. At 24 h pt, a distinct shift in cell population was evident, with the follicles containing mainly mature cells and spaces were present between the cells. The shell globule clusters in the mature cells were disorganised. In more severely-affected follicles, cells were seen to be breaking down, with karyolytic nuclei and disintegrating cytoplasm. Overall, the results have shown that exposure to Mirazid treatment had a severe impact on egg production by TCBZ-resistant flukes, an effect that was mediated by disruption of the vitelline cells and of the mechanism co-ordinating egg formation in the ootype.

Objective: To validate a prediction model for vaginal birth after cesarean (VBAC) that incorporates variables available at admission for delivery among Middle Eastern women., Methods: The present prospective cohort study enrolled women at 37weeks of pregnancy or more with cephalic presentation who were willing to attempt a trial of labor (TOL) after a single prior low transverse cesarean delivery at Al-Jahra Hospital, Kuwait, between June 2013 and June 2014. The predicted success rate of VBAC determined via the close-to-delivery prediction model of Grobman et al. was compared between participants whose TOL was and was not successful., Results: Among 203 enrolled women, 140 (69.0%) had successful VBAC. The predicted VBAC success rate was higher among women with successful TOL (82.4%±13.1%) than among those with failed TOL (67.7%±18.3%; P<0.001). There was a high positive correlation between actual and predicted success rates. For deciles of predicted success rate increasing from >30%-40% to >90%-100%, the actual success rate was 20%, 30.7%, 38.5%, 59.1%, 71.4%, 76%, and 84.5%, respectively (r=0.98, P=0.013)., Conclusion: The close-to-delivery prediction model was found to be applicable to Middle Eastern women and might predict VBAC success rates, thereby decreasing morbidities associated with failed TOL., (Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Rationale, Aims and Objectives: Pharmacists are expected to play an important role in applying pharmacogenomics discoveries to patient care. Despite the increased attention to genetic research in Qatar, clinicians' attitudes towards the application of pharmacogenomics are not yet explored. The aim of this study was to assess the awareness and attitude of pharmacists compared with doctors towards pharmacogenomics and its implications by submitting an electronic-based survey to all pharmacists and doctors currently working in a large medical corporation in Qatar., Methods: A cross-sectional survey instrument was developed based on literature review. Eligible participants were pharmacists and doctors currently practicing in Hamad Medical Corporation hospitals in Qatar. The survey comprised questions on demographic and professional characteristics. It also evaluated the awareness, attitudes and challenges towards pharmacogenomics and its application., Results: We collected 202 surveys, 108 (53.2%) of which were pharmacists and the remaining 94 (46.5%) were doctors. The overall participants' mean total awareness score percentage was low (39% ± 22) and there were no difference between the mean score achieved by pharmacists and doctors. Pharmacists had significantly more positive attitudes than doctors towards: (i) taking the responsibility of applying pharmacogenomics to drug therapy selection, dosing and monitoring; (ii) perceiving a positive role of pharmacogenomics testing on the control of drug expenditure; and (iii) their willingness to participate in pharmacogenomics-related training sessions. Both pharmacists and doctors perceived lack of knowledge and guidelines as major challenges towards the application of pharmacogenomics in Qatar., Conclusion: Despite doctors' and pharmacists' low level of awareness towards pharmacogenomics, they both have positive attitudes towards the clinical implications of pharmacogenomics. Pharmacists are more motivated to learn about pharmacogenomics and are more willing to take initiatives in its clinical application and patient education., (© 2015 John Wiley & Sons, Ltd.)

Purpose: This study was undertaken to prospectively analyse, at a mean five-year follow-up, the clinical, functional, and radiographic outcomes in patients who developed postoperative acute septic knee arthritis following anterior cruciate ligament (ACL) reconstruction using hamstring autograft. We also assessed the effect of multiple arthroscopic debridement and graft retention on the functional outcomes in comparison with the matched control group., Methods: From a consecutive case series of 2,560 ACL-injured patients who were treated with arthroscopic ACL reconstruction, we report on 24 cases with postoperative septic knee arthritis. These patients were individually matched for age, sex, comorbidity, body mass index (BMI) and preinjury Tegner activity scale in a ratio of 1/1. Clinical, laboratory, synovial fluid analysis and culture were performed. Arthroscopic debridement and graft retention was done for all cases, in addition to antibiotic therapy i.v.. A detailed physical examination, KT1000 laxity testing, Lysholm knee score, Tegner activity level scale, International Knee Documentation Committee (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed., Results: In all cases, treatment of infection was successful after a median of three (range one to six) repeated arthroscopic graft debridement and retention, in addition to antibiotic therapy i.v.. At an average of five years follow-up, two patients had over five millimetres manual maximum side-to-side difference in laxity. There were no significant differences between groups regarding Lysholm score, IKDC and KOOS. Median final Tegner activity score was 5.5 versus 7 in the control group (p = 0.004). Complications included graft rupture in three patients, loss of range of motion in five, Sudeck's atrophy in one and moderate joint narrowing in two. There were no recurrences of septic arthritis or bone infection., Conclusion: Graft retention seems not only possible but appropriate in view of the experience presented in this article for postoperative septic knee arthritis using hamstring autograft. A potential residual complication is arthrofibrosis, which deserves maximum attention.

Objectives. To assess the standard practice of care of surgeons regarding surgical antibiotic prophylaxis, to identify gaps, and to set recommendations. Methods. A retrospective analysis of data obtained from different surgical units in a single center in Qatar over a 3-month period in 2012. A total of 101 patients who underwent surgery and followed regimes for surgical prophylaxis as per hospital guidelines were included in the study. Results. The overall use of antibiotic was 89%, whereas the current practice did not match the recommended hospital protocols in 53.5% of cases. Prolonged antibiotics use (59.3%) was the commonest reason for nonadherence followed by the use of an alternative antibiotic to that recommended in the protocol (31.5%) and no prophylaxis was used in 9.2% of cases. The rate of compliance was significantly higher among clean surgery than clean contaminated group (P = 0.03). Forty-four percent of clean and 65% of clean-contaminated procedures showed noncompliance with the recommended surgical antimicrobial prophylaxis hospital guidelines. Conclusion. Lack of adherence to hospital protocols is not uncommon. This finding remains a challenge to encourage clinicians to follow hospital guidelines appropriately and to consistently apply the surgical antibiotic prophylaxis. The role of clinical pharmacist may facilitate this process across all surgical disciplines.

Introduction: Curcumin is an inducer of heme oxygenase enzyme-1 (HO-1) that is involved in erectile signaling via elevating cyclic guanosine monophosphate (cGMP)levels., Aim: To assess the effect of oral administration of a water-soluble long-acting curcumin derivative on erectile signaling., Methods: Two hundred and thirty six male white albino rats were divided into four groups; group 1 (N = 20) includes control. Group 2 (N = 72) was equally divided into four subgroups; subgroup 1 received pure curcumin (10 mg/kg), subgroup 2 received the long-acting curcumin derivative (2 mg/kg), subgroup 3 received the long-acting curcumin derivative (10 mg/kg), and subgroup 4 received sildenafil (4 mg/kg). Subgroups were sacrificed after the first, second, and third hour. Group 3 (N = 72) was equally divided into the same four subgroups already mentioned and were sacrificed after 24 hours, 48 hours, and 1 week. Group 4 (N = 72) was subjected to intracavernosal pressure (ICP) measurements 1 hour following oral administration of the same previous doses in the same rat subgroups., Main Outcome Measure: Cavernous tissue HO enzyme activity, cGMP, and ICP., Results: In group 2, there was a significant progressive maintained elevation of HO activity and cGMP tissue levels starting from the first hour in subgroups 3 and 4, whereas, the rise in HO activity and cGMP started from second hour regarding the other rat subgroups. Sildenafil effect decreased after 3 hours. In group 3, there was a significant maintained elevation of HO activity and cGMP tissue levels extended to 1 week as compared to controls for all rat subgroups that received both forms of curcumin. In group 4, long-acting curcumin derivative exhibited more significant potentiation of intracavernosal pressure as compared to control and to the pure curcumin., Conclusion: Water-soluble long-acting curcumin derivative could mediate erectile function via upregulating cavernous tissue cGMP., (© 2009 International Society for Sexual Medicine.)

Apoptosis (programmed cell death) is an important mechanism for preservation of a healthy and balanced immune system in vertebrates. Little is known, however, about how apoptosis processes regulate invertebrate immune system. Thus, the present histopathological study was performed to search for the level of apoptosis on hemocytes of three bivalve species namely, Macoma edentula, Hiatula rupelliana and Gastrana fraglis in the Timsah Lake infected with branchial Rickettsia-like parasites and ciliated parasites in the digestive gland. Microscopically, special to elongated intracytoplasmic Rickettsia-like colonies were observed in the base of gill filaments of the clams. Histologically, the distribution and shapes of apoptotic cells were classified into three main types. The aggregation of apoptotic cells were observed in the apical and the basal parts of the ciliated cells lining the gill epithelium. These results provide a first insight into apoptotic processes in mollusc immune cells.

Dicrocoelium dendriticum (D. dendriticum) is a lancet-shape liver fluke that affects sheep and mammals including man. Human and animal infections have been world widely reported particularly in some of the Eastern Mediterranean sheep raising countries. Infection is acquired by eating the second intermediate host (17 species of ants) with raw fruits, vegetables, herbs or even with the drinking water. As for the first intermediate host, there is about 54 different species of land snails. In spite of the fact that both the first and second intermediate hosts of D. dendriticum are available in Egypt, data about human and animal dicrocoeliasis is lacking. This investigation is a preliminary study to report on the presence of D. dendriticum (in sheep, goats and man in North Sinai Governorate) in Egypt.

Leishmania major promastigotes isolated from an Egyptian ZCL patient, was inoculated 4 x 10(6)/ml in a new culture medium, peptone-liver (P-L), with a final concentration of 10% of FCS (fetal calf serum), and incubated at 25+/-1 degrees C. Meanwhile, the same number of promastigotes were inoculated in Schneider's Drosophila medium as control. On the 10th day, number of L. major promastigotes reached 29,25 x 10(6)/ml. The same number was obtained with Schneider's Drosophila medium within four days. The new culture medium or P-L medium is cheap, easily prepared, and gave a very good number of promastigotes as in Schneider's Drosophila medium but in a longer time.