Intranasal Versus Buccal Versus Intramuscular Midazolam for the Home and Emergency Treatment of Acute Seizures in Pediatric Patients: A Randomized Controlled Trial.

BACKGROUND: Benzodiazepines are the recommended first-line treatment of acute seizures. We wished to compare the efficacy, side effects, and satisfaction after midazolam administration by the buccal, intranasal, or intramuscular route in the treatment of acute seizures in children at homes and in emergency room (ER). METHODS: A prospective, randomized, controlled trial was performed in children aged one month to 17 years with acute seizures lasting longer than five minutes. The primary end point was seizure cessation within 10 minutes of drug administration and no seizure recurrence within 30 minutes. RESULTS: In the home group, 67 patients received midazolam via buccal route, 60 via intranasal route, and 69 via intramuscular route, whereas in the ER group, 37 patients received buccal, 34 received intranasal, and 34 received intramuscular midazolam. The primary end point was achieved in 94.2% and 85.3% after intramuscular midazolam in the home and ER groups, respectively. The intranasal midazolam was successful in stopping seizures in 93.3% in the home group and 88.2% in the ER group. The buccal route was effective in 91% in the home group and 78.4% in the ER group. There were no significant differences in efficacy between all groups (P = 0.763 and P = 0.509) among the home and ER groups, respectively. There were no significant cardiorespiratory events in all groups. CONCLUSIONS: Intramuscular, intranasal, and buccal doses of midazolam resolved most seizures in prehospital and emergency settings. Our results indicate that there is no statistically significant difference detected between different routes of midazolam. Intranasal route showed the highest satisfaction rate among caregivers.

Efficacy of stem cells versus microvesicles in ameliorating chronic renal injury in rats (histological and biochemical study).

Chronic exposure to heavy metals as aluminum chloride (AlCl3) could result in severe health hazards such as chronic renal injury. The present study aimed to evaluate the therapeutic potential of adipose tissue-derived stem cells (ASCs) in comparison to their microvesicles (MV) in AlCl3-induced chronic renal injury. Forty-eight adult male Wistar rats were divided into four groups: Control group, AlCl3-treated group, AlCl3/ASC-treated group, and AlCl3/MV-treated group. Biochemical studies included estimation of serum urea and creatinine levels, oxidative biomarkers assay, antioxidant biomarkers, serum cytokines (IL-1ß, IL-8, IL-10, and IL-33), real time-PCR analysis of renal tissue MALT1, TNF-α, IL-6, and serum miR-150-5p expression levels. Histopathological studies included light and electron microscopes examination of renal tissue, Mallory trichrome stain for fibrosis, Periodic acid Schiff (PAS) stain for histochemical detection of carbohydrates, and immunohistochemical detection of Caspase-3 as apoptosis marker, IL-1B as a proinflammatory cytokine and CD40 as a marker of MVs. AlCl3 significantly deteriorated kidney function, enhanced renal MDA and TOS, and serum cytokines concentrations while decreased the antioxidant parameters (SOD, GSH, and TAC). Moreover, serum IL-10, TNF-α, miR-150-5p, and renal MALT1 expression values were significantly higher than other groups. Kidney sections showed marked histopathological damage in both renal cortex and medulla in addition to enhanced apoptosis and increased inflammatory cytokines immunoexpression than other groups. Both ASCs and MVs administration ameliorated the previous parameters levels with more improvement was detected in MVs-treated group. In conclusion: ASCs-derived MVs have a promising ameliorating effect on chronic kidney disease.

Salivary IL-17 and IL-10 as Potential Diagnostic Biomarkers of Different Stages of Periodontitis in Smoker and Nonsmoker Patients.

OBJECTIVES: The gold standard in the field of periodontal research currently is to find a valid biomarker that can reliably be used for diagnosing periodontal diseases. Given the limitations of the current diagnostic tools that stall to predict susceptible individuals and determine whether active tissue destruction is occurring, there is an increased urge to develop alternative diagnostic techniques that would compensate for the problems inherited in these available methods, such as measuring levels of biomarkers present in oral fluids such as saliva; so the aim of this study was to determine the diagnostic potential of interleukin-17 (IL-17) and IL-10 to differentiate periodontal health from smoker and nonsmoker periodontitis, and to differentiate among different stages (severities) of periodontitis. MATERIALS AND METHODS: An observational case-control study was performed on 175 systemically healthy participants grouped into healthy as controls and periodontitis as cases. Periodontitis cases were divided according to the severity into stages I, II, and III, and each of the stages was further subdivided into smokers and nonsmokers patients. Unstimulated saliva samples were collected, clinical parameters were recorded, and salivary levels were assayed using enzyme-linked immunosorbent assay. RESULTS: Elevated levels of IL-17 and IL-10 were associated with stage I and II compared with the healthy controls. However, a significant decrease in stage III was observed compared with the control group for both biomarkers. CONCLUSION: Salivary IL-17 and IL-10 might be useful for distinguishing periodontal health from periodontitis; however, further research is needed to substantiate their use as potential biomarkers for the diagnosis of periodontitis.

Histological and biochemical evaluation of the effects of silver nanoparticles (AgNps) versus titanium dioxide nanoparticles (TiO2NPs) on rat parotid gland.

The unlimited use of nanoparticles (NPs) results in toxic impacts on different tissues. The current study aimed to compare the adverse effects of AgNPs and TiO2NPs on the parotid gland of adult male albino rats as regards the histopathological, immunohistochemical, and biochemical changes, exploring the possible underlying mechanisms and the degree of improvement after cessation of administration. Fifty-four adult male albino rats were divided into control group (I), AgNPs-injected group (II), and TiO2NPs-injected group (III). We measured the levels of tumor necrosis factor-alpha (TNF-α) and interleukin (IL-6) in the serum, and levels of MDA and GSH in parotid tissue homogenate. Quantitative real-time polymerase-chain reaction (qRT-PCR) was used to measure the expression levels of peroxisome proliferator-activated receptor-gamma coactivator 1-alpha (PGC1-α), nicotinamide adenine dinucleotide phosphate oxidase 4 (NOX4), mouse double minute 2 (MDM2), Caspase-3 Col1a1, and Occludin. Parotid tissue sections were examined by light microscope (Hematoxylin & Eosin and Mallory trichrome stains), electron microscope, and immunohistochemical examination of CD68 and anti-caspase-3 antibodies. Both NPs severely affected the acinar cells and damaged the tight junction between them by enhancing expression of the inflammatory cytokines, inducing oxidative stress, and disturbing the expression levels of the studied genes. They also stimulated fibrosis, acinar cell apoptosis, and inflammatory cells infiltration in parotid tissue. TiO2NPs effects were less severe than AgNPs. Cessation of exposure to both NPs, ameliorated the biochemical and structural findings with more improvement in TiO2NPs withdrawal. In conclusion: AgNPs and TiO2NPs adversely affected the parotid gland, but TiO2NPs were less toxic than AgNPs.

Pain mechanisms in complex regional pain syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic condition following inciting events such as fractures or surgeries with sensorimotor and autonomic manifestations and poor prognosis. This review aimed to provide conclusive evidence about the sensory phenotype of CRPS based on quantitative sensory testing (QST) to understand the underlying pain mechanisms and guide treatment strategies. DATABASES: Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes (thermal, mechanical, vibration, and electric detection thresholds, thermal, mechanical, pressure, and electric pain thresholds, wind-up ratio, mechanical pain sensitivity, allodynia, flare area, area after pinprick hyperalgesia, pleasantness after C-tactile stimulation, and pain ratings) in chronic CRPS (adults and children) versus healthy controls were included. RESULTS: From 37 studies (14 of low quality, 22 of fair quality, and 1 of good quality), adults with CRPS showed: (i) significant loss of thermal, mechanical, and vibration sensations, significant gain of thermal and mechanical pain thresholds, significant elevation of pain ratings, and no difference in wind-up ratio; (ii) significant reduction of pleasantness levels and increased area of pinprick hyperalgesia, in the affected limb. From three fair-quality studies, adolescents and children with CRPS showed loss of cold detection with cold hyperalgesia in the affected limb. There was moderate to substantial overall heterogeneity. CONCLUSION: Diffuse thermal and mechanical hypoesthesia with primary and secondary hyperalgesia, enhanced pain facilitation evidenced by increased area of pinprick hyperalgesia, and elevated pain ratings are dominant in adults with CRPS. Adolescents and children with CRPS showed less severe sensory abnormalities.

Traumatic stress in Egyptian doctors during COVID-19 pandemic.

COVID-19 pandemic has heavily burdened healthcare systems throughout the world, causing substantial mental distress to medical professionals. We aim to investigate the associated traumatic stress in a sample of practicing physicians in Egypt during the COVID-19 pandemic. This cross-sectional study assessed depression, and Post-traumatic stress disorder (PTSD) among a sample of Egyptian physicians using an electronic survey. It included demographic and practice-related data, PTSD Checklist - Civilian Version (PCL-C) and the nine-item Patient Health Questionnaire (PHQ-9). Of the 124 respondents, 66.9% were at high risk for depression and 37.9% met criteria for diagnosis of PTSD. Female gender and perceived work-related stress were significantly associated with PTSD. PTSD and depression severity scores were positively correlated. These findings highlight the importance of timely mental support and intervention for medical workers.

Pediatric vs. adult stroke: comparative study in a tertiary referral hospital, Cairo, Egypt.

Background: Even though stroke is rare in children, it is associated with serious or life-threatening consequences. Despite its rarity, the occurrence of stroke in children has age-related differences in risk factors, etiopathogenesis, and clinical presentations. Unlike adults, who have arteriosclerosis as the major cause of stroke, risk factors for pediatric strokes are multiple, including cardiac disorders, infection, prothrombotic disorders, moyamoya disease, moyamoya syndrome, and others. The goal of the current study was to compare the characteristics, clinical features, etiology, subtypes, and workup of pediatric and adult strokes. Methods: This was a hospital-based observational study conducted on 222 participants. All patients underwent a full clinical and neurological examination, full laboratory study, cardiac evaluation, and neuroimaging; CT scan, MRI, MRA, MRV, carotid duplex, and transcranial Doppler (TCD). Ischemic stroke (IS) etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, the "proposed classification for subtypes of arterial ischemic stroke in children," and the Oxfordshire Community Stroke Project (OCSP). Stroke severity was determined by the National Institutes of Health Stroke Scale (NIHSS) and PedNIHSS on admission. Results: The proportion of pediatric ischemic strokes in the current study was 63.4 percent, while hemorrhagic strokes were 36.5%. The majority of the adult patients had ischemic strokes (84.1%), while hemorrhagic strokes were noted in 15.8% of the patients. According to the original TOAST classification, in the current study, the etiology of pediatric IS was other determined causes in 63.6%, undetermined etiology in 27.2%, and cardioembolic in 9.0%. For the adult group, the major stroke subtypes were large artery disease, small vessel disease, cardioembolic, other determined causes, and undetermined etiology at 49.6%, 28.6%, 6.9%, 0.6%, and 12.5%, respectively. Conclusions: There is a greater etiological role for non-atherosclerotic arteriopathies, coagulopathies, and hematological disorders in pediatric stroke, while adults have more atherothrombotic causes. The co-existence of multiple risk factors in pediatric ischemic stroke is noticed. Thrombophilia evaluation is helpful in every case of childhood stroke. Children who have had a stroke should undergo vascular imaging as soon as possible. Imaging modalities include TCD and Doppler ultrasound, CT, MRI, MRA, and MRV, and cerebral angiography.

Electron microscopic study on the effect of chronic fluoxetine treatment on pituitary gland and the possible therapeutic effect of adipose-derived mesenchymal stem cells in adult male albino rats.

BACKGROUND: Adipose-derived mesenchymal stem cells (ADSCs) have therapeutic potential for the treatment of a variety of disorders due to their self-renewal and multipotential differentiation capabilities. AIM OF THE WORK: This study was planned to demonstrate the electron microscopic structure of the pituitary gland after chronic fluoxetine treatment and the possible therapeutic effect of ADSCs. MATERIALS AND METHODS: Thirty healthy male adult albino rats were classified into Control group (Group I). Fluoxetine treated (Group II) received 24 mg/kg/day of fluoxetine dissolved in 1.0 mL of tap water once a day. Fluoxetine group treated with ADSCs (Group III) received fluoxetine as group (II) for 30 days and then was injected once by ADSCs at a dose of 1 × 106 cells/rat in the tail vein suspended in 0.5 ml of phosphate-buffered saline (PBS). Recovery group (Group IV) received fluoxetine for 30 days and then received no treatment till the end of the experiment. RESULTS: The ultrastructural observations of the fluoxetine-treated group revealed major histological changes in both the pars distalis and nervosa. Pars distalis revealed cells with different shapes, sizes, nuclei, and variable profiles of the cytoplasm. Pars nervosa, on the other hand, revealed pituicytes with electron-lucent cytoplasm and small apoptotic nuclei. Administration of ADSCs greatly improved the microscopic appearance of cells, while the recovery group showed similar histological changes as the fluoxetine group. CONCLUSION: Fluoxetine caused various deleterious changes in the pituitary gland of albino rats, as evidenced by electron microscopy. These changes were almost corrected by the ADSCs treatment.    .

Therapeutic efficacy of adipose-derived mesenchymal stem cells after chronic fluoxetine treatment on pars distalis in adult male albino rats.

BACKGROUND: Fluoxetine hydrochloride is one of the most commonly used antidepressants in the selective serotonin reuptake inhibitor class. THE AIM OF WORK: The study was conducted to detect the effect of chronic fluoxetine treatment on pars distalis and the possible therapeutic effect of adipose-derived mesenchymal stem cells (ADSCs). MATERIAL AND METHOD: Thirty healthy male adult albino rats were classified into four groups. Control group (Group I) included fifteen rats. Fluoxetine treated (Group II) included five rats that received 24 mg/kg/day of fluoxetine dissolved in 1.0 ml of tap water once a day for 30 days. Fluoxetine group treated with ADSCs (Group III) included five rats that received fluoxetine as group (II) for 30 days, then supplied once by ADSCs at a dose of 1 × 106 cells/rat in the tail vein suspended in 0.5 ml of phosphate-buffered saline (PBS). Recovery group (Group IV) included five rats that received fluoxetine as the group (II) then received no treatment till the end of the experiment. Samples from pars distalis were processed for light, electron microscopic examination, morphometrical and statistical analyses. RESULTS: In the fluoxetine-treated group, there was a disruption in cellular architecture, size, shape, and staining characteristics of pars distalis cells. The administration of ADSCs significantly improved the microscopic appearance of cells, while the recovery group showed some histological changes similar to the fluoxetine group. CONCLUSION: Fluoxetine induced various deleterious changes in the pars distalis of albino rats. These changes were almost corrected by the ADSCs treatment.

Neurological complications in Egyptian children with nephrotic syndrome.

AIM: This study aimed at describing the incidence, risk factors and outcomes for neurological manifestations in Egyptian children with nephrotic syndrome (NS) and determining correctable factors that could lower the risk for these complications. METHODS: The medical records of all children with NS who presented to Nephrology clinic, Ain Shams University Children hospital (a tertiary hospital) from April 2018 to April 2020 were reviewed retrospectively for the clinical progression of NS with special emphasis on neurological manifestations, contributory risk factors and outcomes. RESULTS: Among 67 children with NS, 13 children had neurological events. Seven patients had posterior reversible encephalopathy syndrome (PRES), four patients suffered from cerebral sinovenous thrombosis (CSVT) and two patients presented with arterial strokes. Hypertension was significantly higher in patients with NS and neurological manifestations (NS/N+) when compared to patients with NS without neurological manifestations (NS/N-) (76.9% vs. 40.7%; P = 0.019). NS/N+ group had significantly higher levels of triglycerides and cholesterol (209.7 ± 41.4 and 323.6 ± 40.7 in NS/N+ vs. 181.96 ± 31.8 and 243.8 ± 38.8 in NS/N-). Prothrombotic tendency was significantly higher in NS/N+ group as compared to NS/N- group. All patients recovered totally except patients with arterial strokes who had residual hemiparesis. CONCLUSION: Neurological complications in form of PRES, CSVT and arterial strokes were detected in children with NS. The outcome was favourable in most of the cases. Investment in parental education about the importance of follow up of blood pressure, dietary modification and good hydration could help in minimising the risk of patients with NS to develop neurological complications.

A Single-Center Assessment of Delayed Graft Function in Recipients of Simultaneous Liver and Kidney Transplant.

BACKGROUND: The effects of delayed graft function on long-term kidney allograft outcomes are poorly defined among simultaneous liver and kidney transplant recipients. METHODS: We analyzed data of all simultaneous liver and kidney recipients transplanted at the University of Wisconsin between 2010 and 2017. Risk factors for the development of delayed graft function, kidney graft failure, and patient mortality were outcomes of interest. RESULTS: There were a total of 60 simultaneous liver and kidney recipients; 28 (47%) had delayed graft function. After adjustment for multiple variables, we found that pretransplant dialysis >6 weeks (hazard ratio [HR] = 5.6, 95% CI: 1.23-25.59, P = .02), pretransplant albumin <3 g/dL (HR = 5.75, 95% CI: 1.76-16.94, P = .003), and presence of pretransplant diabetes (HR = 2.5, 95% CI: 0.97-4.77, P = .05) were significantly associated with delayed graft function. Multivariate analysis showed that pretransplant albumin <3 (HR = 4.86, 95% CI: 1.07-22.02, P = .02) was associated with a higher risk of all-cause kidney allograft failure, whereas the duration of delayed graft function (HR = 1.07 per day, 95% CI: 1.01-1.14, P = .01) was associated with a higher risk of death-censored kidney allograft failure. The presence of delayed graft function was not associated with all-cause or death-censored kidney or liver allograft failure. Similarly, the presence of delayed graft function was not associated with patient mortality. CONCLUSION: The incidence of delayed graft function was high in simultaneous liver and kidney recipients. However, with appropriate management, delayed graft function may not have a negative impact on patient or kidney allograft survival.

Core muscles' endurance in flexible flatfeet: A cross - sectional study.

OBJECTIVE: Flexible flatfoot is a common deformity in adults that has been thought to be a causative factor of a lot of lower limb injuries and back pain. Core muscles act as stabilizers for the trunk and weak core places a person at greater risk of low back pain and lower limb injuries. We aimed to compare the core muscles' endurance between individuals with and without flatfeet. METHODS: Thirty subjects with bilateral flexible flatfeet (study group) were compared with thirty healthy subjects (control group). Navicular drop test was used to evaluate the medial longitudinal arch. Modified back extensors, modified flexion and lateral muscles' endurance tests were used to evaluate the endurance of the core muscles. RESULTS: The lateral muscles' endurance time in the flatfeet group was found to be significantly lower than that of the healthy group on both sides (p=0.0001). However, no significant difference was found in the trunk flexors' (p=0.15) and trunk extensors' (p=0.27) endurance time between both groups. CONCLUSIONS: Impairment of the lateral core muscles' endurance was observed in subjects with bilateral flexible flatfeet which may predispose to low back pain and other lower limb injuries in those subjects.

In Kidney Transplant Recipients With a Positive Virtual Crossmatch, High PRA was Associated With Lower Incidence of Viral Infections.

BACKGROUND: There is little information on the incidence, risk factors, and outcomes associated with CMV and BK infections in sensitized patients. METHODS: We examined 254 consecutive kidney transplant recipients with positive virtual crossmatch and negative flow crossmatch. RESULTS: A total of 111 patients (43%) developed CMV disease or BK infection or nephropathy (BKVN). Specifically, 78 patients (30.7%) developed BK infection, 19 (7.5%) had BKVN, and 33 (12.9%) presented with CMV disease. Four patients (1.5%) developed both infections. Mean time from transplant to diagnosis for BK and CMV was 4.07 ± 3.10 and 8.35 ± 5.20 months, respectively. African American (HR, 2.64; 95% CI, 1.37-5.07; P = 0.003), thymoglobulin induction (HR, 2.18; 95% CI, 1.38-3.43; P = 0.0008), DSA greater than 500 MFI at transplant (HR, 1.64; 95% CI, 1.05-2.57; P = 0.03), history of diabetes (HR, 1.62; 95% CI, 1.01-2.60; P = 0.04), CMV D+/R- (HR, 2.30; 95% CI, 1.06-5.01; P = 0.03), and acute rejection (HR, 1.49; 95% CI, 0.99-2.24; P = 0.05) were associated with increase incident of BK/CMV, whereas rituximab (HR, 0.47; 95% CI, 0.24-0.91; P = 0.02), peak PRA greater than 80% (HR, 0.48; 95% CI, 0.27-0.84; P = 0.01), and living donor transplant (HR, 0.57; 95% CI, 0.36-0.87; P = 0.01) were associated with a lower likelihood of infection. Thymoglobulin induction (HR, 2.50; 95% CI, 1.02-6.13; P = 0.04), and peak PRA greater than 80% (HR, 0.45; 95% CI, 0.23-0.86; P = 0.02) remained significant predictors of infection after multivariate adjustment. CONCLUSIONS: Although more than 40% of patients with a positive virtual crossmatch presented with BK infection/CMV disease, high PRA greater than 80% seemed to be protective.

Physical performance and a test of gaze stabilization in older adults.

OBJECTIVE: The purpose of this study was to assess the feasibility of a standardized gaze stabilization test (GST) as an indicator of vestibular function in community-dwelling older adults and to examine the relationship between gaze stabilization and physical performance. DESIGN: Descriptive, cross-sectional. SETTING: Tertiary medical center. SUBJECTS: Eighty-six healthy older adults (22 men) of mean (standard deviation [SD]) age 76.8 (5.8) years were recruited from the Pittsburgh community. MAIN OUTCOME MEASURES: Performance on the GST, measures of physical performance (standing balance, chair rises, and gait speed individually and combined into the Short Physical Performance Battery) and self-reported balance. RESULTS: Whereas more than 90% of participants completed testing in the pitch and yaw planes, only 85% (73 of 86) had interpretable scores due to prolonged perception time independent of vestibulo-ocular reflex. The mean (SD) head movement velocity in the pitch plane was 94.5 (26.7) degrees per second, whereas the mean (SD) head movement velocity in the yaw plane was 95.5 (29.3) degrees per second. There was a strong association between age and GST performance in the pitch and yaw planes (r = 0.68; p < 0.001). Poor GST performance in the yaw plane was associated with balance capacity with eyes closed. Additionally, there was a trend toward an association between self-reported balance and GST performance in both pitch (p = 0.08) and yaw planes (p = 0.10). CONCLUSION: Although most older adults completed GST testing, estimates were not interpretable in almost 15% due to prolonged perception time. Gaze stabilization test in the yaw plane was worse than previously reported in healthy older adults and was associated with poor ability to balance with eyes closed. Self-reported balance tended to be associated with an objective assessment of vestibulo-ocular reflex in this population of older adults.