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Background and Context: Unplanned readmission within 30 days following elective spine surgery is a key indicator of quality of care, as readmissions often signal early complications or poor recovery. The Hospital Readmission Reduction Program (HRRP) and the Centers for Medicare and Medicaid Services (CMS) utilizes this metric to assess hospital and surgeon performance., Purpose: Here we aim to delineate quality of care metrics for full-endoscopic spine surgery (FESS) compared to traditional spine surgery., Design: The study was a retrospective multicenter analysis comparing outcomes of propensity matched cohorts., Patient Sample: The study included 908 FESS patients operated between 2014 and 2023 and a matched cohort of 73,906 non-FESS patients., Outcome Measures: Our primary outcome measures were postoperative 30-day hospital readmissions and revision surgery. Furthermore, demographic data, hospitalization, surgical details and comorbidities were included., Methods: Data were collected from 6 participating institutions. Patients older than 18 years undergoing noninstrumented FESS spine surgeries for degenerative lumbar spinal pathologies from 2016 to 2023 were included. A matched non-FESS cohort was identified in the ACS-NSQIP database (2015-2019). Propensity-score matching was used to compare the cohorts., Results: Before matching, the 30-day readmission rate was significantly lower in the FESS cohort (1.1% vs. 4.4%, p <.001), which remained consistent after matching (1.1% vs. 4.5%, p<.001). The rate of 30-day surgical revisions was similar between cohorts (1.0% vs. 1.1%, p=.63). Multivariate analysis indicated a significant correlation between FESS and reduced 30-day readmissions (odds ratio [OR] 0.28, 95% CI 0.14-0.57, p<.001)., Conclusion: This study is the first to compare 30-day hospital readmissions between FESS and nonendoscopic surgeries in a large, matched multicenter cohort. FESS significantly reduces both the length of postoperative hospital stay and 30-day readmission rates compared to nonendoscopic approaches, underscoring the safety and effectiveness of outpatient FESS. Future studies are needed to define the role of FESS in more complex spine procedures., Competing Interests: Declaration of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: An abdominal aortic aneurysm (AAA) is a potentially life-threatening condition, the management of which has dramatically evolved over the past 2 decades with an increasing tendency toward endovascular repair (EVAR) rather than open surgical repair. Classically, contrast-enhanced multislice computed tomography (CT) angiography (CTA) is performed preoperatively for procedure sizing and EVAR planning. This entails voluminous contrast injection with risk of allergic reaction, nephropathy, and radiation exposure. Intra-vascular ultrasound (IVUS) has been increasingly used to guide EVAR procedures intraoperatively. The aim of this study is to investigate the accuracy of IVUS in sizing AAAs, device selection, and EVAR planning compared to the gold standard CTA., Design: This is a prospective observational study enrolling 10 patients who underwent standard infrarenal EVAR procedures performed for unruptured infrarenal AAAs over the course of 1 year. All patients had a preoperative CTA done upon which aneurysm sizing and device planning were performed, and the measurements obtained were compared to those obtained from intraoperative IVUS., Methods: All participating patients had unruptured infrarenal AAA, had no renal impairment, and had anatomical suitability for EVAR according to the instructions for use (IFU) of the device manufacturer. Primary endpoint was comparing anatomical measurements recorded by IVUS with those obtained from the preoperative CTA., Results: Mean age was 65.6 (±6.19), all patients were males and hypertensives and 4 (40%) had a positive family history for AAA. On comparing mean measurements taken by CTA and IVUS, there was no statistically significant differences with exception of maximal aortic diameter and aortic diameter at site of bifurcation (both p-values <.001). There were no statistically significant differences in length measurements between the 2 imaging modalities. Computed tomography angiography was more associated with neck thrombus detection, and IVUS was more associated with calcification detection., Conclusion: Although CT angiography is still the gold standard imaging modality for AAA, IVUS use is very beneficial in EVAR sizing and planning, in addition to intra-operative guidance of the procedure, saving the patient significant time, contrast administration, and radiation exposure, especially in patients with renal impairment and contrast allergy., Clinical Impact: A preoperative CT angiogram is the gold standard required investigation for planning and sizing EVARs, with subsequent contrast injection entailing a risk of contrast induced nephropathy and allergic reactions. IVUS has been used as an adjuvant technique to guide EVAR stent graft deployment. However, our study concluded that it can also be reliably used in sizing and planning of the EVAR stent graft along with complementary non contrast imaging, especially in patients with high risk for contrast induced nephropathy and contrast allergy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ischemic heart disease (IHD) remains a leading cause of mortality among the elderly population, particularly in low- and middle-income countries like Egypt, where public health infrastructure may struggle to meet the needs of a growing aging population. Awareness of the risk factors and warning signs associated with IHD is critical for early detection and intervention. This study aimed to evaluate the level of awareness and knowledge regarding IHD risk factors and warning signs among elderly individuals in Egypt, focusing on differences between urban and rural populations., Results: Among 595 participants aged 60 years and above, only 18.7% demonstrated good knowledge of IHD risk factors, whereas 47.2% were categorized as having poor knowledge. In terms of warning signs, 7.2% exhibited good awareness, while 47.9% showed poor awareness. Overall, more than half (51.8%) of the participants were found to have poor knowledge of IHD, and just 15.1% had good overall awareness of both risk factors and warning signs. Urban participants exhibited significantly higher knowledge compared to rural participants (p < 0.05). Educational attainment was a strong predictor of knowledge, with participants holding postgraduate degrees scoring the highest. Economic status also influenced awareness, with those in the excellent category demonstrating significantly higher knowledge (p < 0.05). Occupation had a notable impact, with engineers exhibiting the highest levels of awareness and farmers the lowest. Gender, however, was not a significant factor, with males and females showing similar levels of awareness., Conclusions: The study reveals a significant knowledge gap concerning IHD risk factors and warning signs among Egypt's elderly population, particularly in rural areas and among individuals with lower levels of education and economic status. This gap underscores the need for targeted public health campaigns and interventions, particularly in rural regions, to raise awareness and reduce the burden of IHD among Egypt's elderly. Enhanced education and community-based programs could be effective in mitigating the risks associated with poor awareness of IHD., Competing Interests: Declarations. Ethics approval and consent to participate: This study was carried out in full compliance with the ethical standards set forth in the Declaration of Helsinki. Approval for the study was granted by the Institutional Review Board (IRB) of the Faculty of Medicine at Mansoura University, under the reference number (R.23.10.2355). Prior to involvement, all participants were thoroughly informed about the research's objectives and procedures. Sufficient information was provided to allow participants to make an informed and voluntary decision about their participation, in accordance with the guidelines approved by the Ethics Committee. Informed consent was obtained from each participant, confirming their voluntary participation. Data collection was conducted through an anonymous online survey via Google Forms, ensuring participants' privacy and confidentiality. No financial incentives were provided, and participation was entirely voluntary. Consent for publication: Not applicable. Competing interests: There were no conflicts of interest disclosed by the authors., (© 2024. The Author(s).)

Background: Degenerative spondylolisthesis is an important cause of chronic low back pain and radiculopathy in the adult U.S., Population: Open decompression with or without fusion is considered the standard for management, yet optimal treatment remains controversial. Full endoscopic spine surgery offers an alternative surgical approach with possible advantages. There is a paucity of data on the use of full endoscopic spinal surgery in degenerative spondylolisthesis. Therefore, we present the clinical and radiographic outcomes of 73 patients with low-grade degenerative spondylolisthesis with severe stenosis, who underwent lumbar endoscopic unilateral laminectomy for bilateral decompression., Methods: Patients with low-grade degenerative spondylolisthesis who underwent a lumbar endoscopic ULBD at 6 spine centers in North America were included in this study. Patients were followed up at 3, 9, and 12 months. Static and dynamic imaging was performed and evaluated routinely before surgery to identify the pathology and grade of spondylolisthesis. Patient-reported outcomes were prospectively collected., Results: This study included 73 patients from 6 spine centers. Sixty-two patients were diagnosed with grade I spondylolisthesis, whereas 11 were diagnosed with grade II spondylolisthesis. Postoperatively, 70 patients reported improved symptoms and pain resolution, whereas 3 patients reported worse pain. Mean visual analog scale back and visual analog scale leg scores and Oswestry Disability Index showed a statistically significant improvement at 3, 9, and 12 months compared with the preoperative period. Radiographically, no patient in our study had progression of the grade of spondylolisthesis., Conclusions: Patients with low-grade degenerative spondylolisthesis causing severe stenosis can safely be treated with lumbar endoscopic unilateral laminectomy for bilateral decompression. A head-to-head trial should be undertaken to provide a higher level of clinical evidence., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Spinal metastases can be contained in the bone or have epidural spread. Whether the extent of epidural involvement changes tumor response to therapy is unknown. The decision of when to treat disease progression with focal radiation therapy with or without surgery vs. systemic therapy is debated. The present study compared outcomes and local tumor control after stereotactic body radiation therapy (SBRT) between patients with spine metastases localized to the bone (Bilsky 0) vs. patients with mild epidural spread (Bilsky 1). A retrospective analysis of a prospectively maintained database of adult oncological patients who underwent SBRT to the spine at a single, large, tertiary care facility from August 2010 to January 2021 was performed. Patients with Bilsky grades 1a, 1b and 1c were grouped and compared. Approximately half (53.7%) of the 255 patients identified had Bilsky grade 1 epidural disease. Of the 311 spine treatment sites, 86 (27.7%) had a radiosensitive histology, 116 (37.3%) had intermediate radiosensitivity and 109 (35.0%) had a radioresistant histology. Patients with Bilsky grade 1 were more predisposed to receive surgery followed by SBRT compared with those with Bilsky grade 0 (21.0% vs. 6.3%; P=0.0002). Patients with Bilsky grade 0 compression had 92.0% local control at 12 months and 85.8% local control at 24 months; patients with Bilsky grade 1 compression had 85.6% local control at 12 months and 77.6% local control at 24 months. Biologically effective dose and infield progression between patients presenting with Bilsky grade 0 and 1 compression were not statistically different. Local control rates did not differ significantly between Bilsky grade 0 and grade 1 patients following treatment with spinal SBRT. However, patients with grade 1 disease were more likely to receive surgery before SBRT. Overall, evidence indicates that patients may benefit from treatment with SBRT before epidural disease progresses to requiring separation surgery., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2024 Linzey et al.)

Background and Objectives: Emergency department (ED) utilization and readmission rates after spine surgery are common quality of care measures. Limited data exist on the evaluation of quality indicators after full-endoscopic spine surgery (FESS). The objective of this study was to detect rates, causes, and risk factors for unplanned postoperative clinic utilization after FESS., Methods: This retrospective multicenter analysis assessed ED utilization and clinic readmission rates after FESS performed between 01/2014 and 04/2023 for degenerative spinal pathologies. Outcome measures were ED utilizations, hospital readmissions, and revision surgeries within 90 days postsurgery., Results: Our cohort includes 821 patients averaging 59 years of age, who underwent FESS. Most procedures targeted the lumbar or sacral spine (85.75%) while a small fraction involved the cervical spine (10.11%). The most common procedures were lumbar unilateral laminotomies for bilateral decompression (40.56%) and lumbar transforaminal discectomies (25.58%). Within 90 days postsurgery, 8.0% of patients revisited the ED for surgical complications. A total of 2.2% of patients were readmitted to a hospital of which 1.9% required revision surgery. Primary reasons for ED visits and clinic readmissions were postoperative pain exacerbation, transient neurogenic bladder dysfunction, and recurrent disk herniations. Our multivariate regression analysis revealed that female patients had a significantly higher likelihood of using the ED (P = .046; odds ratio: 1.77, 95% CI 1.01-3.1 5.69% vs 10.33%). Factors such as age, American Society of Anesthesiologists class, body mass index, comorbidities, and spanned spinal levels did not significantly predict postoperative ED utilization., Conclusion: This analysis demonstrates the safety of FESS, as evidenced by acceptable rates of ED utilization, clinic readmission, and revision surgery. Future studies are needed to further elucidate the safety profile of FESS in comparison with traditional spinal procedures., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Objective: Computed tomography is considered the gold-standard imaging tool to evaluate spinal implant accuracy. However, there are no studies that evaluate the accuracy of robotic sacroiliac joint (SIJ) implant placement using CT to date. The aim of this study was to compare the accuracy of implant placement on CT between robotic and fluoroscopic navigation for SIJ fusion and the subsequent complications and clinical outcomes of suboptimally placed screws., Methods: A retrospective analysis of SIJ fusions utilizing either robotic or fluoroscopic guidance at a single institution was conducted from 2014 to 2023. Implant placement accuracy was evaluated on intra- or postoperative CT. Primary endpoints were SIJ screw placement accuracy and complications. Secondary endpoints were pain status at the first and second follow-ups and rates of 2-year revision surgery. Statistical analysis was performed using chi-square tests., Results: Sixty-nine patients who underwent 78 SIJ fusions were included, of which 63 were robotic and 15 were fluoroscopic. The mean age of the cohort at the time of surgery was 55.9 ± 14.2 years, and 35 patients (50.7%) were female. There were 135 robotically placed and 34 fluoroscopically placed implants. A significant difference was found in implant placement accuracy between robotic and fluoroscopic fusion (97.8% vs 76.5%, p < 0.001). When comparing optimal versus suboptimal implant placement, no difference was found in the presence of 30-day complications (p = 0.98). No intraoperative complications were present in this cohort. No difference was found in subjective pain status at the first (p = 0.69) and second (p = 0.45) follow-ups between optimal and suboptimal implant placement. No patients underwent 2-year revision surgery., Conclusions: Use of robotic navigation was significantly more accurate than the use of fluoroscopic navigation for SIJ implant placement. Complications overall were low and not different between optimally and suboptimally placed implants. Suboptimally placed implants did not differ in degree of subjective pain improvement or rates of revision surgery postoperatively.

Objective: Achieving appropriate spinopelvic alignment has been shown to be associated with improved clinical symptoms. However, measurement of spinopelvic radiographic parameters is time-intensive and interobserver reliability is a concern. Automated measurement tools have the promise of rapid and consistent measurements, but existing tools are still limited to some degree by manual user-entry requirements. This study presents a novel artificial intelligence (AI) tool called SpinePose that automatically predicts spinopelvic parameters with high accuracy without the need for manual entry., Methods: SpinePose was trained and validated on 761 sagittal whole-spine radiographs to predict the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), T1 pelvic angle (T1PA), and L1 pelvic angle (L1PA). A separate test set of 40 radiographs was labeled by four reviewers, including fellowship-trained spine surgeons and a fellowship-trained radiologist with neuroradiology subspecialty certification. Median errors relative to the most senior reviewer were calculated to determine model accuracy on test images. Intraclass correlation coefficients (ICCs) were used to assess interrater reliability., Results: SpinePose exhibited the following median (interquartile range) parameter errors: SVA 2.2 mm (2.3 mm) (p = 0.93), PT 1.3° (1.2°) (p = 0.48), SS 1.7° (2.2°) (p = 0.64), PI 2.2° (2.1°) (p = 0.24), LL 2.6° (4.0°) (p = 0.89), T1PA 1.1° (0.9°) (p = 0.42), and L1PA 1.4° (1.6°) (p = 0.49). Model predictions also exhibited excellent reliability at all parameters (ICC 0.91-1.0)., Conclusions: SpinePose accurately predicted spinopelvic parameters with excellent reliability comparable to that of fellowship-trained spine surgeons and neuroradiologists. Utilization of predictive AI tools in spinal imaging can substantially aid in patient selection and surgical planning.

Objective: Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors., Methods: This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses., Results: Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits., Conclusions: The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

Objective: Lateral-access spine surgery has many benefits, but adoption has been limited by a steep learning curve. Virtual reality (VR) is gaining popularity and lends itself as a useful tool in enhancing neurosurgical resident education. We thus sought to assess whether VR-based simulation could enhance the training of neurosurgery residents in lateral spine surgery., Methods: Neurosurgery residents completed a VR-based lateral spine module on lateral patient positioning and performing lateral lumbar interbody fusion using the PrecisionOS VR system on the Meta Quest 2 headset. Simulation occurred 1×/week every other week for a total of 3 simulations over 6 weeks. Pre- and postintervention surveys as well as intrasimulation performance metrics were assessed over time., Results: The majority of resident participants showed improvement in performance scores, including an automated PrecisionOS precision score, number of radiographs used within the simulation, and time to completion. All participants showed improvement in comfort with anatomic landmarks for lateral access surgery, confidence performing lateral surgery without direct supervision, and assessing fluoroscopy in spine surgery for hardware placement and image interpretation. Participant perception on the utility of VR as an educational tool also improved., Conclusions: VR-based simulation enhanced neurosurgical residents' ability to understand lateral access surgery. Immersive surgical simulation resulted in improved resident confidence with surgical technique and workflow, perceived improvement in anatomical knowledge, and simulation performance scores. Trainee perceptions on virtual simulation and training as a curriculum supplement also improved following completion of VR training., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Many drugs have been restricted in the treatment of gastric ulcers (GU). So, herbal medicines are now in great demand for their better cultural acceptability, compatibility, and minimal side effects. Therefore, our study aimed to assess the protective efficacy of Aloe vera gel and Geranium robertianum extracts against Aspirin®-induced GU in Wistar rats., Methods: Antioxidant activity and chemical composition of both herbs were analysed. Then, we divided forty female Wistar rats into five groups: a negative control group, a positive control group of Aspirin®-induced GU, and pretreated groups with Aloe Vera, geranium, and Famotidine (reference drug). The locomotor disability, anxiety-like behaviour, and ultrasonography were assessed. Ultimately, scarification of animals to determine gastric juice pH and ulcer index. Then the collection of stomach and liver for histopathological and immunohistochemical examinations, besides tracing the oxidative stress biomarkers and related genes., Results: High content of polyphenols was revealed in both extracts. The pretreatment with Aloe vera gel and geranium showed significant antioxidant activities with free radical scavenging and ferric-reducing power (FRAP). Moreover, they improved the stomach architecture and alleviated anxiety-like behaviour and motor deficits. They significantly reduced the expression of proinflammatory cytokine (TNF-α), inflammatory, and oxidative stress genes (NF-KB, HO-1, Nrf-2) while increasing the Keap-1 in gastric mucosa., Conclusion: Data presented a significant protective effect of Aloe vera gel and geranium against Aspirin®-induced GU; they reduced gastric mucosal injury with potential anxiolytic effects through their anti-inflammatory and antioxidant properties. Therefore, they may be considered promising agents for preventing or treating gastric ulceration., (© 2023. The Author(s).)

Background and Objective: Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting., Methods: A PubMed search was conducted on "spinal cord compression" and "radiation therapy." Articles were analyzed for the purpose of this narrative review., Key Content and Findings: If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of high-grade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis., Conclusions: MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.

Background: The outcomes for patients with metastatic renal cell carcinoma (RCC) to the spine who underwent stereotactic body radiotherapy (SBRT) through a multidisciplinary spine oncology program are not well described. We sought to describe the clinical course and local control rates at 1 and 2 years for these patients., Methods: A retrospective analysis of a prospectively maintained database of adult oncologic patients receiving SBRT to the spine through a multidisciplinary spine oncology program at a single institution from 2010 to 2021 was performed. Patients with a pathologic diagnosis of RCC were included., Results: A total of 75 spinal sites were treated in 60 patients. Of the 60 patients, 75.0% were men, and the mean patient age was 59.2 ± 11.3 years. At 1 year after treatment, 6 of the 60 patients were lost to follow-up. Of the remaining 54 patients, 18 were censored by death and 7 treatment sites showed local recurrence, for 37 of 44 treatment sites with local control (87.8%). At 2 years, 1 additional local recurrence had developed, 15 patients were censored by death, and no additional patients had been lost to follow-up, resulting in 28 of 36 treatment sites with local control (83.2%). None of the patients who had undergone repeat SBRT had local recurrence at 1 or 2 years. For those with local recurrence, the average time from treatment to progression was 6.6 ± 6.5 months., Conclusions: In this cohort, one of the largest reported studies of spine SBRT for metastatic RCC, local control was high at 1 and 2 years. Our findings support the role of coordinated, algorithmic treatment for these patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system (CNS). In its early stages, it results in inflammation, demyelination, and axonal loss. Egypt has the highest rates in the Middle East region. The pathogenicity of MS involves mitochondrial function. Damage to mitochondrial DNA (mtDNA) can produce variation in the copy number (CN) and decline in mitochondrial function. Our goal was to determine the potential of mtDNA-CN as a biomarker of MS and the progression of the disease. The study included 25 patients with relapsing remitting MS (RRMS) and 25 age and sex matched apparently healthy control. Two peripheral blood samples were collected from each patient, one during the remission phase and the other during the phase of relapse. A quantitative real-time polymerase chain reaction (qPCR) was performed to assess CN of mitochondrial DNA. There was a statistically significant decline in the number of mtDNA copies during the remission phase as compared to controls (p < 0.01), yet no difference was seen between mtDNA-CN in relapsing subjects versus controls. Moreover, the copy number of mtDNA during the relapse phase was significantly higher than the remission phase suggesting the ability of mtDNA to differentiate between remission and relapse phases (p < 0.05). Our study observed that mtDNA-CN at a cut off (0.75), can differentiate between RRMS patients in the remission phase and controls with a sensitivity of 56%, specificity 84%, positive predictive value (PPV) 65.6% and negative predictive value (NPV) 77.8%, and at a cut off (1), mtDNA-CN can differentiate between remission and relapse MS patients with a sensitivity 72%, specificity 56%, PPV 62.1% and NPV 66.7%. In conclusion, mtDNA-CN can be proposed as a biomarker of MS., (Copyright© by the Egyptian Association of Immunologists.)

Background: As cancer therapies have improved, spinal metastases are increasingly common. Resulting complications have a significant impact on patient's quality of life. Optimal methods of surveillance and avoidance of neurologic deficits are understudied. This study compares the clinical course of patients who initially presented to the emergency department (ED) versus a multidisciplinary spine oncology clinic and who underwent stereotactic body radiation therapy (SBRT) secondary to progression/presentation of metastatic spine disease., Methods: We performed a retrospective analysis of a prospectively maintained database of adult oncologic patients who underwent spinal SBRT at a single hospital from 2010 to 2021. Descriptive statistics and survival analyses were performed., Results: We identified 498 spinal radiographic treatment sites in 390 patients. Of these patients, 118 (30.3%) presented to the ED. Patients presenting to the ED compared to the clinic had significantly more severe spinal compression (52.5% vs. 11.7%; p < 0.0001), severe pain (28.8% vs. 10.3%; p < 0.0001), weakness (24.5% vs. 4.5%; p < 0.0001), and difficulty walking (24.5% vs. 4.5%; p < 0.0001). Patients who presented to the ED compared to the clinic were significantly more likely to have surgical intervention followed by SBRT (55.4% vs. 15.3%; p < 0.0001) compared to SBRT alone. Patients who presented to the ED compared to the clinic had a significantly quicker interval to distant spine progression (5.1 ± 6.5 vs. 9.1 ± 10.2 months; p = 0.004), systemic progression (5.1 ± 7.2 vs. 9.2 ± 10.7 months; p < 0.0001), and worse overall survival (9.3 ± 10.0 vs. 14.3 ± 13.7 months; p = 0.002)., Conclusion: The establishment of multidisciplinary spine oncology clinics is an opportunity to potentially allow for earlier, more data-driven treatment of their spinal metastatic disease., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

This work is an attempt to employ the electric arc furnace (EAF) slag as a by-product material to develop an alternative and environmentally friendly material for gamma-radiation protection applications such as in medical and industrial areas. For this purpose, different concentrations of micro-sized EAF slag (0, 20, 40, 60, 80, 100, 500, and 800 phr) were incorporated as fillers in the natural rubber (NR) matrix to produce the shielding composites. In addition, nano-sized EAF slag particles were prepared by using a high-energy ball milling technique to investigate the effect of particle size on the gamma-radiation shielding properties. The synthesized micro and nano EAF/NR composites were tested as protective materials against gamma-radiation by employing NaI(Tl) scintillation detector and standard radioactive point sources ( 152 Eu, 137 Cs, 133 Ba, and 60 Co). Different shielding parameters such as linear and mass attenuation coefficient, half value layer (HVL), tenth value layer, mean free path, effective atomic number (Z eff ), and effective electron density (N eff ) were determined to assess the radiation shielding capability of the EAF/NR composites. Furthermore, equivalent atomic number (Z eq ) and the exposure buildup factor values for photon energy in the range from 0.015 to 15 MeV were also computed by Geometric Progression method. The experimental results of micro EAF/NR composites showed that at 121.78 keV, EAF0 composite (without EAF slag content) had the lowest μ value of 0.1695 cm -1 , while the EAF800 composite (which was loaded with 800 phr of micro EAF slag) had the highest μ value of 0.2939 cm -1 at the same energy, which in turn decreases the HVL from 4.09 to 2.36 cm, respectively. Therefore, increasing the filler weight fractions of EAF slag in the NR matrix, increases the shielding properties of the composites. Moreover, the NR composite reinforced with 800 phr of nano EAF slag has better gamma-radiation shielding efficiency compared to that filled with 800 phr of micro EAF slag. The success of this work was to prepare a flexible, lightweight, low-cost, and lead-free material with better shielding capability., (© 2023. Springer Nature Limited.)

Background: Saphenous vein reflux is one of the leading causes of cosmetic and functional disabilities. The recent European Society of Vascular Surgery guidelines recommend endovenous thermal ablation over surgery or sclerotherapy for the treatment of great saphenous vein (GSV) reflux in patients with chronic venous disease. The aim of this study is to compare different laser fiber tip configurations to outcome regarding technical success and incidence of complications., Design: A retrospective analysis conducted on patients with documented GSV reflux from 2020 to 2022, comparing baseline parameters and outcome between 2 groups of laser tip fibers used; radial tip and jacketed tip. Primary end point was technical success. Secondary endpoints included incidence of complications in each group, and VCSS score difference in both groups., Methods: Inclusion criteria entailed patients with primary varicose veins over the age of 18 years, free from malignancy, hematological disorders, and having documented GSV reflux of more than 0.5 sec. All patients had endovenous laser ablation (EVLA) of the GSV, with complementary foam sclerotherapy or ambulatory phlebectomies as required., Results: A total of 74 patients underwent EVLA (85 limbs). Fifty-four were done using the radial laser fibers, and 32 using jacketed fibers. Technical success was achieved in 78 limbs (92.9%), 6 limbs (7.1%) had recanalization of the proximal 3 cm of the GSV at 1 month, 2 patients experienced hematomas, and 5 patients had superficial vein thrombosis. There was no significant association between postoperative pain, bruising, recanalization, hematoma formation, and superficial vein thrombosis with different laser fiber tip configurations (P-value 0.95, 0.6, 0.18, 1, and 1, respectively), nor was there any significant difference in VCSS between them (P-value 0.14).Technical success was 90% in the jacketed fibers and 94.1% in the radial fibers group (P-value 0.18)., Conclusions: Neither does laser fiber tip configuration nor its make have a significance on outcome of EVLA of GSV reflux. Both radial and jacketed laser fiber tips exhibit similar safety and efficacy in EVLA., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Robot-assisted pedicle screw placement in spinal fusion has been well studied. However, few studies have evaluated robot-assisted sacroiliac joint (SIJ) fusion. The aim of this study was to compare surgical characteristics, accuracy, and complications between robot-assisted and fluoroscopically guided SIJ fusion., Methods: A retrospective review of 110 patients with 121 SIJ fusions done at a single academic institution was conducted from 2014 to 2023. Inclusion criteria included adult age and a robot- or fluoroscopically guided approach to SIJ fusion. Patients were excluded if the SIJ fusion was part of a longer fusion construct, not minimally invasive, and/or had missing data. Demographics, approach type (robotic vs fluoroscopic), operative time, estimated blood loss (EBL), number of screws, intraoperative complications, 30-day complications, number of intraoperative fluoroscopic images (as a surrogate for radiation exposure), implant placement accuracy, and pain status at the first follow-up were recorded. Primary endpoints were SIJ screw placement accuracy and complications. Secondary endpoints were operative time, radiation exposure, and pain status at the first follow-up., Results: Ninety patients were included who underwent a total of 101 SIJ fusions, of which 78 were robotic and 23 were fluoroscopic. The mean age of the cohort at the time of surgery was 55.9 ± 13.8 years; 46 patients were females (51.1%). No difference was found in screw placement accuracy between robotic and fluoroscopic fusion (1.3% vs 8.7%, p = 0.06). Chi-square analysis of robotic versus fluoroscopic fusion found no difference in the presence of 30-day complications (p = 0.62). Mann-Whitney U-test analysis found that robotic fusion had a significantly longer operative time than fluoroscopic fusion (72.0 vs 61.0 minutes, p = 0.01); however, robot-assisted fusions involved significantly lower radiation exposure (26.7 vs 187.4 fluoroscopic images, p < 0.001). No difference in EBL was noted (p = 0.17). No intraoperative complications were present in this cohort. Subgroup analysis comparing the 23 most recent robotic cases against the 23 fluoroscopic cases found that robotic fusion still was associated with significantly longer operative times than fluoroscopic fusion (74.0 ± 26.4 vs 61.0 ± 14.9 minutes, respectively; p = 0.047)., Conclusions: SIJ screw placement accuracy did not significantly differ between robot-assisted and fluoroscopic SIJ fusion. Complications overall were low and similar between the two groups. The operative time was longer with robotic assistance, but there was markedly less radiation exposure to the surgeon and staff.

Rationale: Risperidone is the first antipsychotic to be approved by Food and Drug Administration (FDA) for treating autism spectrum disorder (ASD). The potential efficacy of metformin in preventing and/or controlling ASD behavioral deficits was also recently reported. Suppression of hippocampus autophagy was suggested as a potential pathologic mechanism in ASD., Objectives: Is metformin's ability to improve ASD clinical phenotype driven by its autophagy-enhancing properties? And does hippocampus autophagy enhancement underlie risperidone's efficacy as well? Both questions are yet to be answered., Methods: The effectiveness of metformin on alleviation of ASD-like behavioral deficits in adolescent rats exposed prenatally to valproic acid (VPA) was compared to that of risperidone. The potential modulatory effects of risperidone on hippocampal autophagic activity were also assessed and compared to those of metformin., Results: Male offspring exposed to VPA during gestation exhibited marked anxiety, social impairment and aggravation of stereotyped grooming; such deficits were efficiently rescued by postnatal risperidone or metformin therapy. This autistic phenotype was associated with suppressed hippocampal autophagy; as evidenced by reduced gene/dendritic protein expression of LC3B (microtubule-associated proteins 1 light chain 3B) and increased somatic P62 (Sequestosome 1) protein aggregates. Interestingly, compared to risperidone, the effectiveness of metformin in controlling ASD symptoms and improving hippocampal neuronal survival was well correlated to its ability to markedly induce pyramidal neuronal LC3B expression while lowering P62 accumulation., Conclusions: Our work highlights, for the first time, positive modulation of hippocampus autophagy as potential mechanism underlying improvements in autistic behaviors, observed with metformin, as well as risperidone, therapy., (© 2023. The Author(s).)

Objective: Patient-reported outcomes (PROs) have become the standard means to measure surgical outcomes. Insurers and policy makers are also increasingly utilizing PROs to assess the value of care and measure different aspects of a patient's condition. For cervical myelopathy, it is currently unclear which outcome measure best reflects patient satisfaction. In this investigation, the authors evaluated patients treated for cervical myelopathy to determine which outcome questionnaires best correlate with patient satisfaction., Methods: The Quality Outcomes Database (QOD), a prospectively collected multi-institutional database, was used to retrospectively analyze patients undergoing surgery for cervical myelopathy. The North American Spine Society (NASS) satisfaction index, Neck Disability Index (NDI), numeric rating scales for neck pain (NP-NRS) and arm pain (AP-NRS), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale were evaluated., Results: The analysis included 1141 patients diagnosed with myelopathy, of whom 1099 had an NASS satisfaction index recorded at any of the follow-up time points. Concomitant radiculopathy was an indication for surgery in 368 (33.5%) patients, and severe neck pain (NP-NRS ≥ 7) was present in 471 (42.8%) patients. At the 3-month follow-up, NASS patient satisfaction index scores were positively correlated with scores for the NP-NRS (r = 0.30), AP-NRS (r = 0.32), and NDI (r = 0.36) and negatively correlated with EQ-5D (r = -0.38) and mJOA (r = -0.29) scores (all p < 0.001). At the 12-month follow-up, scores for the NASS index were positively correlated with scores for the NP-NRS (r = 0.44), AP-NRS (r = 0.38), and NDI (r = 0.46) and negatively correlated with scores for the EQ-5D (r = -0.40) and mJOA (r = -0.36) (all p < 0.001). At the 24-month follow-up, NASS index scores were positively correlated with NP-NRS (r = 0.49), AP-NRS (r = 0.36), and NDI (r = 0.49) scores and negatively correlated with EQ-5D (r = -0.44) and mJOA (r = -0.38) scores (all p < 0.001)., Conclusions: Neck pain was highly prevalent in patients with myelopathy. Notably, improvement in neck pain-associated disability rather than improvement in myelopathy was the most prominent PRO factor for patients. This finding may reflect greater patient concern for active pain symptoms than for neurological symptoms caused by myelopathy. As commercial payers begin to examine novel remuneration strategies for surgical interventions, thoughtful analysis of PRO measurements will have increasing relevance.

Transcription factors (TFs) play a cardinal role in the development and maintenance of human physiology by acting as mediators of gene expression and cell state control. Recent advancements have broadened our knowledge on the potency of TFs in governing cell physiology and have deepened our understanding of the mechanisms through which they exert this control. The ability of TFs to program cell fates has gathered significant interest in recent decades, and high-throughput technologies now allow for the systematic discovery of forward programming factors to convert pluripotent stem cells into numerous differentiated cell types. The next generation of these technologies has the potential to improve our understanding and control of cell fates and states and provide advanced therapeutic modalities to address many medical conditions., (© 2023. The Author(s), under exclusive license to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)., Methods: PubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI., Results: Thirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, -0.54 [95% CI, -0.88 to -0.21]; P=.002; I 2 =96%), IL-6 (WMD, -0.84 [95% CI, -1.03 to -0.64]; P<.001; I 2 =0%), and TNF-α (WMD, -12.75 [95% CI, -17.20 to -8.29]; P<.001; I 2 =99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, -1.34 [95% CI, -2.65 to -0.04]; P=.04; I 2 =85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, -1.07 to -0.27]; P=.001; I 2 =94%) and in patients with coronary artery disease (WMD, -0.75 [95% CI, -1.17 to -0.33]; P<.001; I 2 =96%)., Conclusion: Based on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only., (Copyright © 2022 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Retropleural, retrodiaphragmatic, and retroperitoneal approaches are utilized to access difficult thoracolumbar junction (T10-L2) pathology. The authors present a 58-year-old man with chronic low-back pain who failed years of conservative therapy. Preoperative radiographs demonstrated significant levoconvex scoliosis with coronal and sagittal imbalance. He underwent a retrodiaphragmatic/retroperitoneal approach for T12-L1, L1-2, L2-3, and L3-4 interbody release and fusion in conjunction with second-stage facet osteotomies, L4-5 TLIF, and T10-iliac posterior instrumented fusion. This video focuses on the retrodiaphragmatic approach assisted by 3D navigation. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2215., Competing Interests: Disclosures Dr. Park reported personal fees from Globus, NuVasive, DePuy Synthes, and Accelus; and grants from DePuy Synthes, Cerapedics, SI-BONE, and ISSG, outside the submitted work.Dr. Park reported personal fees from Globus, NuVasive, DePuy Synthes, and Accelus; and grants from DePuy Synthes, Cerapedics, SI-BONE, and ISSG, outside the submitted work., (© 2022, The Authors.)

The present study was done to evaluate the protective and therapeutic role of mango pulp (M), eprosartan drug (E), and their co-administration (EM) against hepatotoxicity induced by thioacetamide (T). Seven groups of rats were prepared as follows: the control (C) group (normal rats), T group (the rats were injected with T), T-M group (the rats were injected with T, and then treated with M), T-E group (the rats were injected with T, and then treated with E), T-EM group (the rats were injected with T, and then treated with E and M), M-TM-M group (the rats were administered with M before, during, and after T injection), and M group (the healthy rats were administered with M only). Firstly, the characterizations of M were determined. Also, the markers of hepatic oxidative stress [malondialdehyde (MDA) and glutathione (GSH) levels and the activities of superoxide dismutase (SOD), glutathione peroxidase (GPx), and glutathione reductase (GSR)], inflammation and fibrosis [(tumor necrosis factor-α (TNF-α) and platelet-derived growth factor-BB (PDGF-BB) levels and gene expression of transforming growth factor-beta1(TGF-β 1 )], and liver functions and microscopic examination were evaluated. The present results revealed that M contains 419 ± 1.04 μg total phenolics as gallic acid equivalent and 6.8 ± 0.05 μg total flavonoids as quercetin equivalent. The analysis of phenolics and flavonoids showed the presence of chlorogenic, caffeic, 2,5-dihydroxy benzoic, 3,5-dicaffeoylquinic, 4,5-dicaffeoylquinic, tannic, cinnamic acidS, and catechin, phloridzin, and quercetin with different concentrations. Also, M contains various minerals with different concentrations involving potassium, calcium, magnesium, sodium, iron, copper, zinc, and manganese. The current results showed that the total antioxidant capacity of 1 g of M was 117.2 ± 1.16 as μg ascorbic acid equivalent. Our biochemical studies showed that all treatments significantly reduced T-induced hepatotoxicity and liver injuries, as the oxidative stress and inflammatory and fibrotic markers were diminished where MDA level and the activities of GST, GSSG, and GR were decreased when compared with T group. In contrast, GSH level and the activities of SOD and GPx and GSH/GSSG ratio were increased. In addition, TNF-α and PDGF-BB levels were reduced, and the gene expression of TGF-β1 was down-regulated. Consequently, the liver functions were significantly improved. In conclusion, each E, M, and EM has a therapeutic effect against T-induced hepatotoxicity via the reduction of the OS, inflammation, and fibrosis. Unfortunately, treatment with M and E simultaneously revealed the less effectiveness than the treatment with M or E demonstrates the presence of anti-synergistic effect between them. Additionally, M-TM-M treatment showed a better effect than T-M treatment against T-induced hepatotoxicity revealing the prophylactic role of M. The administration of healthy rats with M for 12 weeks has no side effect., (© 2022. The Author(s).)

Objective: Image guidance requires placement of a dynamic reference frame (DRF), often either onto local spinous process or by freehand intraosseous DRF placement into the ilium via the posterior superior iliac spine (PSIS). There is a paucity of studies in the literature that describe the complications of intraosseous DRF placement. The aim of this study was to describe the radiographic location, prevalence and nature of complications, and long-term clinical outcomes of attempted DRF placement into the PSIS., Methods: All lumbosacral spine surgical procedures performed between August 2019 and February 2021 at a single institution were queried, and operations in which a DRF was targeted to the PSIS were included. Patient demographic characteristics, indications for surgery, surgical outcomes, and complications were extracted. Intraoperative CT scans were reviewed by 2 independent researchers to determine the accuracy of DRF placement into the PSIS and to assess for DRF malposition., Results: Of 497 lumbar spine operations performed between August 2019 and February 2021 by 4 surgeons, 85 utilized intraoperative navigation with a PSIS pin. Thirteen operations were excluded due to an inability to visualize the entirety of the pin on intraoperative CT. Of 72 DRFs evaluated, 77.8% had been correctly placed in the PSIS. Of the 22.2% of DRFs not placed into the PSIS, 11 entered the sacrum, 6 crossed the sacroiliac joint, and 2 were deep enough to enter the pelvis. Pain at the pin site was present in 4 patients, of whom 3 had resolution of pain at the last follow-up evaluation. There were no significant complications due to DRF placement: no sacral fractures, significant navigation errors, retroperitoneal hematomas, or neurological deficits. Over a mean ± SD follow-up period of 9 ± 5.2 months, there were no incidences of pin site infection. Interrater reliability between the reviewers was 95.8%., Conclusions: This was the first study to examine radiological and clinical outcomes after DRF placement in the PSIS. In this study, a majority of pins were correctly placed within the PSIS, although 22.2% of pins were malpositioned. There were no serious complications, and a majority of those patients with persistent pin site pain had resolution at last follow-up.

Objective: Cervical spine injury screening is common practice for traumatic brain injury (TBI) patients. However, risk factors for concomitant thoracolumbar trauma remain unknown. We characterized epidemiology and clinical risk for concomitant thoracolumbar trauma in TBI., Methods: We conducted a multi-center, retrospective cohort analysis of TBI patients in the National Trauma Data Bank from 2011-2014 using multivariable logistic regression., Results: Out of 768,718 TBIs, 46,654 (6.1%) and 42,810 (5.6%) patients were diagnosed with thoracic and lumbar spine fractures, respectively. Only 11% of thoracic and 7% of lumbar spine fracture patients had an accompanying spinal cord injury at any level. The most common mechanism of injury was motor vehicle accident (67% of thoracic and 71% and lumbar fractures). Predictors for both thoracic and lumbar fractures included moderate (thoracic: OR 1.26, 95%CI 1.21-1.31; lumbar: OR 1.13, 95%CI 1.08-1.18) and severe Glasgow Coma Scale (GCS) score (OR 1.71, 95%CI 1.67-1.75; OR 1.17, 95%CI 1.13-1.20) compared to mild; epidural hematoma (OR 1.36, 95%CI 1.28-1.44; OR 1.1, 95%CI 1.04-1.19); lower extremity injury (OR 1.38, 95%CI 1.35-1.41; OR 2.50, 95%CI 2.45-2.55); upper extremity injury (OR 2.19, 95%CI 2.14-2.23; OR 1.15, 95%CI 1.13-1.18); smoking (OR 1.09, 95%CI 1.06-1.12; OR 1.12, 95%CI 1.09-1.15); and obesity (OR 1.39, 95%CI 1.34-1.45; OR 1.29, 95%CI 1.24-1.35). Thoracic injuries (OR 4.45; 95% CI 4.35-4.55) predicted lumbar fractures, while abdominal injuries (OR 2.02; 95% CI 1.97-2.07) predicted thoracic fractures., Conclusions: We identified GCS, smoking, upper and lower extremity injuries, and obesity as common risk factors for thoracic and lumbar spinal fractures in TBI., Competing Interests: Declaration of Competing Interest The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Objective: Despite understanding the associated adverse outcomes, identifying hospitalized patients at risk for sepsis is challenging. The authors aimed to characterize the epidemiology and clinical risk of sepsis in patients who underwent vertebral fracture repair for traumatic spinal injury (TSI)., Methods: The authors conducted a retrospective cohort analysis of adults undergoing vertebral fracture repair during initial hospitalization after TSI who were registered in the National Trauma Data Bank from 2011 to 2014., Results: Of the 29,050 eligible patients undergoing vertebral fracture repair, 317 developed sepsis during initial hospitalization. Of these patients, most presented after a motor vehicle accident (63%) or fall (28%). Patients in whom sepsis developed had greater odds of being male (adjusted OR [aOR] 1.5, 95% CI 1.1-1.9), having diabetes mellitus (aOR 1.5, 95% CI 1.11-2.1), and being obese (aOR 1.9, 95% CI 1.4-2.5). Additionally, they had greater odds of presenting with moderate (aOR 2.7, 95% CI 1.8-4.2) or severe (aOR 3.9, 95% CI 2.9-5.2) Glasgow Coma Scale scores and of having concomitant abdominal injuries (aOR 1.9, 95% CI 1.5-2.5) but not cranial, thoracic, or lower-extremity injuries. Interestingly, cervical spine injury was significantly associated with developing sepsis (OR 1.4, 95% CI 1.1-1.8), but thoracic and lumbar spine injuries were not. Spinal cord injury (OR 1.9, 95% CI 1.5-2.5) was also associated with sepsis regardless of level. Patients with sepsis were hospitalized approximately 16 days longer. They had greater odds of being discharged to rehabilitative care or home with rehabilitative care (OR 2.4, 95% CI 1.8-3.2) and greater odds of death or discharge to hospice (OR 6.0, 95% CI 4.4-8.1)., Conclusions: Among patients undergoing vertebral fracture repair, those with cervical spine fractures, spinal cord injuries, preexisting comorbidities, and severe concomitant injuries are at highest risk for developing postoperative sepsis and experiencing adverse hospital disposition.

The quail populations are considered to be one of the largest among the poultry species. Although quail egg and meat production are growing rapidly, still, quail farming practices and welfare aspects are not well established. Stocking density is one of the factors that can significantly affect the welfare, health, and performance of birds, but according to The Expert Group for Technical Advice on Organic Production, no allowed space standards have been reported for new hybrids and different breeds of quail. This review presents an overview of 1) the benefits of egg and meat of quail, 2) the global market of quail products, 3) the factors affecting the stocking density rate, and 4) the effects of stocking density rates and housing systems on the social behavior, welfare, physiological indices, and performance parameters of broiler and laying quail. Conclusively, larger space and enriched aviaries reduce aggressive behavior, and improve the quail welfare and immunological indices. However, the effect of stocking density on some blood biochemical indices and growth performance parameters showed mixed results. A better understanding of the relationship between housing, health, growth performance, and welfare aspects would assist in the implementation of welfare-economic standards for quail production. According to available data, stocking density ranges for broiler and laying Japanese quail are suggested; however, these stocking rates should be tested under different conditions., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Background : Sarcoidosis is multisystem inflammatory granulomatosis that can potentially affect any organ of the human body. We aimed to estimate the prevalence of diabetes mellitus (DM) in sarcoidosis patients and determine the association between sarcoidosis and DM. Method : All relevant articles reporting the prevalence of DM in sarcoidosis published until September 19 th , 2020, were retrieved from ten electronic databases. We used the random effect model to perform the meta-analysis. Results : After screening 2,122 records, we included 19 studies (n = 18,686,162). The prevalence of DM in sarcoidosis patients was 12.7% (95% CI 10-16.1). The prevalence was highest in North America with 21.3% (13.5-31.8), followed by Europe 10.4 (7.9-13.7) and Asia 10% (1.8-39.7). Sarcoidosis patients had higher rates of DM compared to controls (OR 1.75; 95% CI 1.49-2.05). Sensitivity analysis, after removing the largest weighted study, did not reveal any effect on the significance of the results (OR 1.73; 95% CI 1.33-2.25). Conclusion : The prevalence of DM in sarcoidosis is considerably high, with increased odds of DM in sarcoidosis compared to healthy controls. Further research with a wide range of confounders is required to confirm the association of sarcoidosis with DM.

Objective: Venous thromboembolism (VTE) can cause significant morbidity and mortality in hospitalized patients, and may disproportionately occur in patients with limited mobility following spinal trauma. The authors aimed to characterize the epidemiology and clinical predictors of VTE in pediatric patients following traumatic spinal injuries (TSIs)., Methods: The authors conducted a retrospective cohort analysis of children who experienced TSI, including spinal fractures and spinal cord injuries, encoded within the National Trauma Data Bank from 2011 to 2014., Results: Of the 22,752 pediatric patients with TSI, 192 (0.8%) experienced VTE during initial hospitalization. Proportionally, more patients in the VTE group (77%) than in the non-VTE group (68%) presented following a motor vehicle accident. Patients developing VTE had greater odds of presenting with moderate (adjusted odds ratio [aOR] 2.6, 95% confidence interval [CI] 1.4-4.8) or severe Glasgow Coma Scale scores (aOR 4.3, 95% CI 3.0-6.1), epidural hematoma (aOR 2.8, 95% CI 1.4-5.7), and concomitant abdominal (aOR 2.4, 95% CI 1.8-3.3) and/or lower extremity (aOR 1.5, 95% CI 1.1-2.0) injuries. They also had greater odds of being obese (aOR 2.9, 95% CI 1.6-5.5). Neither cervical, thoracic, nor lumbar spine injuries were significantly associated with VTE. However, involvement of more than one spinal level was predictive of VTE (aOR 1.3, 95% CI 1.0-1.7). Spinal cord injury at any level was also significantly associated with developing VTE (aOR 2.5, 95% CI 1.8-3.5). Patients with VTE stayed in the hospital an adjusted average of 19 days longer than non-VTE patients. They also had greater odds of discharge to a rehabilitative facility or home with rehabilitative services (aOR 2.6, 95% CI 1.8-3.6)., Conclusions: VTE occurs in a low percentage of hospitalized pediatric patients with TSI. Injury severity is broadly associated with increased odds of developing VTE; specific risk factors include concomitant injuries such as cranial epidural hematoma, spinal cord injury, and lower extremity injury. Patients with VTE also require hospital-based and rehabilitative care at greater rates than other patients with TSI.

Gliosarcoma is an aggressive brain tumor with histologic features of glioblastoma (GBM) and soft tissue sarcoma. Despite its poor prognosis, its rarity has precluded analysis of its underlying biology. We used a multi-center database to characterize the genomic landscape of gliosarcoma. Sequencing data was obtained from 35 gliosarcoma patients from Genomics Evidence Neoplasia Information Exchange (GENIE) 5.0, a database curated by the American Association of Cancer Research (AACR). We analyzed genomic alterations in gliosarcomas and compared them to GBM (n = 1,449) and soft tissue sarcoma (n = 1,042). 30 samples were included (37% female, median age 59 [IQR: 49-64]). Nineteen common genes were identified in gliosarcoma, defined as those altered in > 5% of samples, including TERT Promoter (92%), PTEN (66%), and TP53 (60%). Of the 19 common genes in gliosarcoma, 6 were also common in both GBM and soft tissue sarcoma, 4 in GBM alone, 0 in soft tissue sarcoma alone, and 9 were more distinct to gliosarcoma. Of these, BRAF harbored an OncoKB level 1 designation, indicating its status as a predictive biomarker of response to an FDA-approved drug in certain cancers. EGFR, CDKN2A, NF1, and PTEN harbored level 4 designations in solid tumors, indicating biological evidence of these biomarkers predicting a drug-response. Gliosarcoma contains molecular features that overlap GBM and soft tissue sarcoma, as well as its own distinct genomic signatures. This may play a role in disease classification and inclusion criteria for clinical trials. Gliosarcoma mutations with potential therapeutic indications include BRAF, EGFR, CDKN2A, NF1, and PTEN., (© 2021. The Author(s).)

Objective: Sports injuries are known to present a high risk of spinal trauma. The authors hypothesized that different sports predispose participants to different injuries and injury severities., Methods: The authors conducted a retrospective cohort analysis of adult patients who experienced a sports-related traumatic spinal injury (TSI), including spinal fractures and spinal cord injuries (SCIs), encoded within the National Trauma Data Bank from 2011 through 2014. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were estimated., Results: The authors included 12,031 cases of TSI, which represented 15% of all sports-related trauma. The majority of patients with TSI were male (82%), and the median age was 48 years (interquartile range 32-57 years). The most frequent mechanisms of injury in this database were cycling injuries (81%), skiing and snowboarding accidents (12%), aquatic sports injuries (3%), and contact sports (3%). Spinal surgery was required during initial hospitalization for 9.1% of patients with TSI. Compared to non-TSI sports-related trauma, TSIs were associated with an average 2.3-day increase in length of stay (95% CI 2.1-2.4; p < 0.001) and discharge to or with rehabilitative services (adjusted OR 2.6, 95% CI 2.4-2.7; p < 0.001). Among sports injuries, TSIs were the cause of discharge to or with rehabilitative services in 32% of cases. SCI was present in 15% of cases with TSI. Within sports-related TSIs, the rate of SCI was 13% for cycling injuries compared to 41% and 49% for contact sports and aquatic sports injuries, respectively. Patients experiencing SCI had a longer length of stay (7.0 days longer; 95% CI 6.7-7.3) and a higher likelihood of adverse discharge disposition (adjusted OR 9.69, 95% CI 8.72-10.77) compared to patients with TSI but without SCI., Conclusions: Of patients with sports-related trauma discharged to rehabilitation, one-third had TSIs. Cycling injuries were the most common cause, suggesting that policies to make cycling safer may reduce TSI.

Coronavirus disease 2019 (COVID-19) continues to burden society worldwide. Despite most patients having a mild course, severe presentations have limited treatment options. COVID-19 manifestations extend beyond the lungs and may affect the cardiovascular, nervous, and other organ systems. Current treatments are nonspecific and do not address potential long-term consequences such as pulmonary fibrosis, demyelination, and ischemic organ damage. Cell therapies offer great potential in treating severe COVID-19 presentations due to their customizability and regenerative function. This review summarizes COVID-19 pathogenesis, respective areas where cell therapies have potential, and the ongoing 89 cell therapy trials in COVID-19 as of 1 January 2021., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution License 4.0 (CC BY).)

Background: Current evidence from randomized controlled trials on statins for primary prevention of cardiovascular disease (CVD) in older people, especially those aged > 75 years, is still lacking. We conducted a systematic review and meta-analysis of observational studies to extend the current evidence about the association of statin use in older people primary prevention group with risk of CVD and mortality., Methods: PubMed, Scopus, and Embase were searched from inception until March 18, 2021. We included observational studies (cohort or nested case-control) that compared statin use vs non-use for primary prevention of CVD in older people aged ≥ 65 years; provided that each of them reported the risk estimate on at least one of the following primary outcomes: all cause-mortality, CVD death, myocardial infarction (MI), and stroke. Risk estimates of each relevant outcome were pooled as a hazard ratio (HR) with a 95% confidence interval (CI) using the random-effects meta-analysis model. The quality of the evidence was rated using the GRADE approach., Results: Ten observational studies (9 cohorts and one case-control study; n = 815,667) fulfilled our criteria. The overall combined estimate suggested that statin therapy was associated with a significantly lower risk of all-cause mortality (HR: 0.86 [95% CI 0.79 to 0.93]), CVD death (HR: 0.80 [95% CI 0.78 to 0.81]), and stroke (HR: 0.85 [95% CI 0.76 to 0.94]) and a non-significant association with risk of MI (HR 0.74 [95% CI 0.53 to 1.02]). The beneficial association of statins with the risk of all-cause mortality remained significant even at higher ages (> 75 years old; HR 0.88 [95% CI 0.81 to 0.96]) and in both men (HR: 0.75 [95% CI: 0.74 to 0.76]) and women (HR 0.85 [95% CI 0.72 to 0.99]). However, this association with the risk of all-cause mortality remained significant only in those with diabetes mellitus (DM) (HR 0.82 [95% CI 0.68 to 0.98]) but not in those without DM. The level of evidence of all the primary outcomes was rated as "very low.", Conclusions: Statin therapy in older people (aged ≥ 65 years) without CVD was associated with a 14%, 20%, and 15% lower risk of all-cause mortality, CVD death, and stroke, respectively. The beneficial association with the risk of all-cause mortality remained significant even at higher ages (> 75 years old), in both men and women, and in individuals with DM, but not in those without DM. These observational findings support the need for trials to test the benefits of statins in those above 75 years of age.

Cholera is a negative public health event caused by Vibrio cholerae. Although V. cholerae is abundant in natural environments, its pattern and transmission between different niches remain puzzling and interrelated. Our study aimed to investigate the occurrence of nonpathogenic V. cholerae in the natural environment during endemicity periods. It also aimed to highlight the role of molecular ecoepidemiology in mapping the routes of spread, transmission, and prevention of possible future cholera outbreaks. V. cholerae was detected in different aquatic environments, waterfowl, and poultry farms located along the length of the Nile River in Giza, Cairo, and Delta provinces, Egypt. After polymerase chain reaction amplification of the specific target outer membrane gene (Omp W) of suspected isolates, we performed sequence analysis, eventually using phylogenetic tree analysis to illustrate the possible epidemiological relationships between different sequences. Data revealed a significant variation in the physicochemical conditions of the examined Nile districts related to temporal, spatial, and anthropogenic activities. Moreover, data showed an evident association between V. cholerae and the clinically diseased Synodontis schall fish. We found that the environmental distress triggered by the salinity shift and elevated temperature in the Middle Delta of the Nile River affects the pathogenesis of V. cholerae , in addition to the characteristics of fish host inhabiting the Rosetta Branch at Kafr El-Zayat, El-Gharbia province, Egypt. In addition, we noted a significant relationship between V. cholerae and poultry sources that feed on the Nile dikes close to the examined districts. Sequence analysis revealed clustering of the waterfowl and broiler chicken isolates with human and aquatic isolated sequences retrieved from the GenBank databases. From the obtained data, we hypothesized that waterfowl act as a potential vector for the intermediate transmission of cholera. Therefore, continuous monitoring of Nile water quality and mitigation of Nile River pollution, in addition to following good managemental practices (GMPs), general hygienic guidelines, and biosecurity in the field of animal production and industry, might be the way to break this cyclic transmission between human, aquatic, and animal sectors.

Statin-associated immune-mediated necrotizing myopathy (IMNM) is a rare presentation of a statin-associated myopathy. Patients usually present with muscle weakness and pain in the setting of statin use with elevated creatine kinase (CK) levels and a positive anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody. Muscle biopsies typically show necrosis, CD68+ macrophages, and minimal lymphocytes. We present a case of a 67-year-old woman who had 2 months of progressive weakness and bilateral lower extremity pain after initiating atorvastatin therapy with symptoms persisting after statin cessation. She was found to have high anti-HMGCR antibody titers, and the biopsy of the rectus femoris muscle showed a prominent endomysial inflammatory cell infiltrate with necrotic and regenerative fibers and an atypical extensive inflammatory infiltrate composed of both CD4+ helper T cells and CD8+ cytotoxic T cells. She showed symptom resolution and normalization of CK levels and inflammatory markers with treatment involving a prolonged prednisone taper and a brief course of azathioprine, which was stopped because of the adverse effects.

Background: Metastases to the bilateral occipital lobes pose a difficult clinical scenario due to risk of debilitating visual loss. We sought to characterize clinical outcomes following different treatment modalities to help guide management in this challenging situation., Methods: We retrospectively reviewed brain metastases patients treated at a single institution between 2008 and 2017 and assessed visual symptoms before and after treatment, the tumor and peritumoral edema volumes before treatment, and clinical outcomes including mortality., Results: Eighteen patients with metastases affecting both occipital lobes were identified. Lung cancer represented the most common primary ( n = 10). Visual deficits were present in 12 patients at the time of diagnosis of bilateral occipital metastases (67%). Patients received radiotherapy ( n = 5) or combined surgical resection and radiotherapy ( n = 13). Among symptomatic patients, two received radiation and 10 received combined surgery and radiation. Nine patients had improved visual symptoms after treatment with no new visual deficits reported as a result of treatment. Among asymptomatic patients, three were treated with radiation alone and three with resection and radiation. Three of these patients developed new visual symptoms following treatment, including one patient with Balint's syndrome., Conclusion: Patients with symptomatic bilateral occipital lobe metastases may experience visual improvement following intervention, especially if symptoms stem from compression or edema. Those without visual symptoms are at risk of developing new visual deficits during treatment, which should be included in the decision-making process and when counseling patients. Visual deficits improved after surgery in the majority of patients, with no cases of immediate visual deterioration., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Surgical Neurology International.)

Background: Growth failure is a common complication in children with beta-thalassemia major (β-TM) that has persisted despite major treatment advances. It could stem from malnutrition, especially in those who live in poor countries and who have inadequate nutrient intake., Aim: The aim of this study was to assess the influence of nutrition on growth, total body composition, and metabolic profile in Egyptian children with β-TM., Subjects and Methods: This cross-sectional study included 200 children with β-TM and 50 age-matched and sex-matched healthy children. All subjects underwent full clinical assessment, which included assessment of growth and total body composition using anthropometric measurements (weight, height, mid-arm circumference, skinfold thickness, and body mass index) and bioelectric impedance analysis device (TANITA SC330). Nutritional assessment was performed using 24-hour dietary recall. Fasting serum insulin, C-peptide, and fasting serum lipid profile (high-density lipoprotein, low-density lipoprotein, cholesterol, and triglyceride) were measured., Results: Children with β-TM had a significantly lower mean value of the daily consumption of the studied nutrient elements including kilocalories, protein, carbohydrate, calcium, and phosphorus (P<0.001). β-TM had a negative impact on anthropometric measures; the mean of all measurements recorded in children with β-TM was significantly lower than that in the control group (P<0.001). Children with β-TM had a significant abnormality in lipid profile, with higher triglyceride levels and lower cholesterol, low-density lipoprotein, and high-density lipoprotein than controls. They had significantly lower serum insulin and C-peptide. Age, sex, serum ferritin, and caloric intake have a significant impact on body composition in children with β-TM., Conclusion: Regular assessment of nutrition is crucial for the health of children with β-TM.

Objective: Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries., Methods: The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014., Results: Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital., Conclusions: Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.

Background: Atrial dyssynchrony, but not atrial enlargement/dysfunction, reflects acute atrial histopathological changes. It has been shown to be associated with new-onset atrial fibrillation (NOAF) in various clinical conditions but was not studied in the acute phase of ST-elevation myocardial infarction (STEMI) which is the aim of the current study., Methods: A total of 440 STEMI patients underwent primary percutaneous coronary intervention (PCI) and were monitored for NOAF during hospitalization. Immediately after primary PCI, P-wave dispersion was calculated and conventional/tissue Doppler echocardiography was done., Results: During a median hospitalization period of 3 days, 80 (18.2%) patients developed NOAF. The group with NOAF showed significantly higher prevalence of hypertension (P = .049), higher P-wave dispersion (P = .018), higher post-PCI-corrected TIMI frame count (P < .001), and lower incidence of post-PCI myocardial blush grade 2-3 (P = .031). Indexed left atrial maximum volume (LAVI max ), left atrial dyssynchrony, and inter-atrial dyssynchrony were significantly higher in NOAF group (P < .001, each). Using ROC curve analysis, inter-atrial dyssynchrony showed the highest diagnostic performance (AUC 85%, 95% CI: 0.77-0.94, P < .001). A cutoff value at 23.8 ms showed a good validity for predicting NOAF with a sensitivity of 93.8% and a specificity of 68.1%. Using binary logistic regression analysis, history of hypertension (OR = 10.72, P = .03), LAVI max (OR = 7.47, P = .04), and inter-atrial dyssynchrony (OR = 45.58, P = .001) were independent determinants of NOAF., Conclusions: In the acute phase after STEMI, history of hypertension, LAVI max, and inter-atrial dyssynchrony were independent determinants of inhospital NOAF, with the latter being the strongest., (© 2019 Wiley Periodicals, Inc.)

Infectious bronchitis virus (IBV) affects both vaccinated and unvaccinated flocks worldwide, with a significant impact on the poultry industry. The aim of the present study is to characterize an emerging variant pathogenic IBV originating from field outbreaks in vaccinated Egyptian layer flock. Samples were collected from disease-suspected flock with a history of administration of live and inactivated IBV vaccines (Ma5 type). Virus propagation in embryonated chicken eggs (ECEs), after three successive passages, revealed typical IBV lesions such as curling and dwarfism. The reported isolate was identified by a real-time reverse transcriptase PCR assay targeting nucleocapsid (N) gene and, further characterized by full-length spike (S1) gene sequencing. Phylogenetic analysis revealed clustering of the isolated virus within 4/91 genotype of GI-13 lineage. Deduced amino acid sequences identity revealed 75-76% and 88-90% similarity with the currently used classic (H120, Ma5, and M41) and variant vaccine strains (4/91 and CR88) in Egypt, respectively. Recombination analysis gave an evidence for distinct patterns of origin for the studied isolate providing another example of intra-genotypic recombination among IBVs and the first example of recombination within the GI-13 lineage in the Egyptian field. The studied isolate (IBV/CK/EG/Fadllah-10/2019) emerged as a result of recombination between the variant group (Egy/var I genotype, GI-23 lineage) as a major parent and the CR88 variant vaccine strain (4/91 genotype, GI-13 lineage) as minor parent. Our data suggest that both mutation and recombination may be contributing to the emergence of IBV variants which ascertain the importance of disease monitoring in vaccinated flocks as well as re-appropriation for the current vaccine strategies.

Heavy metal removal by waste material from different industry has become one of the main economical approaches for zero waste industrial activity. Therefore, iron oxide fine waste by-product from steel industry was converted into nanoparticulates (Fe 2 O 3 NPs) and further crosslinked with starch as a good stabilizer and biodegradable polymer using formaldehyde to form Fe 2 O 3 NPs-Starch nanocomposite. The scanning electron microscope (SEM) showed the average particle size (40-70 nm). The sorption behavior of this nanocomposite was investigated using Pb(II), Hg(II) and Cd(II). Different factors such as solution pH, contact time, nanocomposite dosage and metal concentration were monitored to determine the adsorptive capacity. Langmuir, Temkin, Freundlich and Dubinin-Radushkevich models were employed to study the adsorption isotherms. The maximum sorption capacities were 2000 mg g -1 for Pb(II), 133.3 mg g -1 for Hg(II) and 322.58 mg g -1 for Cd(II). The results referred that Hg(II) and Cd(II) were best fitted by all models except Pb(II) obeyed the Freundlich isotherm model only. The Fe 2 O 3 NPs-Starch nanocomposite emphasized its potential application as a sustainable low cost nanocomposite for metals extraction from tap water, marine water and industrial wastewater with percentage recovery 93-97%, 70-94% and 76-93%, respectively., (Copyright © 2019 Elsevier B.V. All rights reserved.)