Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients.

Global warming is a major public health concern. Volatile anaesthetics are greenhouse gases that increase the carbon footprint of healthcare. Modelling studies indicate that total intravenous anaesthesia is less carbon intensive than volatile anaesthesia, with equivalent quality of care. In this observational study, we aimed to apply the findings of previous modelling studies to compare the carbon footprint per general anaesthetic of an exclusive TIVA strategy vs. a mixed TIVA-volatile strategy. This comparative retrospective study was conducted over 2 years in two French hospitals, one using total intravenous anaesthesia only and one using a mixed strategy including both intravenous and inhalation anaesthetic techniques. Based on pharmacy procurement records, the quantity of anaesthetic sedative drugs was converted to carbon dioxide equivalents. The primary outcome was the difference in carbon footprint of hypnotic drugs per intervention between the two strategies. From 1 January 2021 to 31 December 2022, 25,137 patients received general anaesthesia in the hospital using the total intravenous anaesthesia strategy and 22,020 in the hospital using the mixed strategy. The carbon dioxide equivalent footprint of hypnotic drugs per intervention in the hospital using the total intravenous anaesthesia strategy was 20 times lower than in the hospital using the mixed strategy (emissions of 2.42 kg vs. 48.85 kg carbon dioxide equivalent per intervention, respectively). The total intravenous anaesthesia strategy significantly reduces the carbon footprint of hypnotic drugs in general anaesthesia in adult patients compared with a mixed strategy. Further research is warranted to assess the risk-benefit ratio of the widespread adoption of total intravenous anaesthesia.

Using chitosan nanoparticles and N-acetyl thiazolidine 4-carboxylic acid for olive trees efficiency raising, improving fruits properties and oil quality.

Recently exposure of olive trees to many stresses particularly oil varieties led to decline in the olive yield. The target of the study is to improve vegetative growth and increase olive fruits quality as well as the fruit oil % and oil quality by applying chitosan nanoparticles (CHNPs) and N-acetyl thiazolidine 4-carboxylic acid (N-ATCA) under the conditions of Egypt. The experiment was carried out in the seasons of 2021 and 2022 on Arbosana olive trees 8 years old and 4×6 m apart the trees sprayed three times on 15th Sept., 1st Oct. and 15th Oct. with (CHNPs at 500, 1000 and 1500 ppm), (N-ATCA at 50, 100 and 150 ppm) and a combination between them and evaluate the vegetative growth of trees, fruit physiochemical characteristics, and oil properties during both study seasons. The application of CHNPs and N-ATCA and a combination of them led to increasing leaf area, total chlorophyll and proline content also increment fruit weight, flesh weight, oil color and oil % moreover improving the quality of produced oil. The improvement in growth, fruit quality, oil % and oil quality, were associated with increasing concentrations of CHNPs, N-ATCA and a combination of them especially (CHNPs at 1500 ppm + N-ATCA at 100 ppm and CHNPs at 1500 ppm + N-ATCA at 150 ppm). Spraying (CHNPs at 1500 ppm + N-ATCA at 150 ppm) is recommended to improve the tree growth, fruit quality, oil % and quality of Arbosana olive.

Report of ß-lactam antibiotic-induced vancomycin-resistant Staphylococcus aureus from a university hospital in Egypt.

We report a case of hospital-acquired pneumonia that to our knowledge is the first description in Egypt of the emergence of vancomycin (VA)-resistant Staphylococcus aureus due to the concomitant use of ß-lactams. The combination of ß-lactam antibiotics and VA in the treatment of methicillin-resistant S. aureus must be avoided to refrain from inducing VA resistance; further, if there is coinfection with Gram-negative bacilli, ß-lactams must be avoided. If ß-lactam antibiotic-induced VA-resistant methicillin-resistant S. aureus is isolated, then ß-lactams must be avoided until the organism's sensitivity to VA is restored if VA is the only therapeutic option available.

ABO-Incompatible Kidney Transplantation: Low Rates of Infectious Complications and Excellent Patient Survival.

BACKGROUND: A significant gap exists between demand and supply of organs for patients with end-stage renal disease. To increase the donor pool, kidney transplantation is performed across ABO- and HLA-incompatible barriers. ABO-incompatible kidney transplant (ABOi-KT) recipients are at increased risk of antibody-mediated rejection, infection, and mortality. Hypogammaglobulinemia secondary to immunosuppression is highly prevalent after solid organ transplantation, and intravenous immunoglobulin (IVIG) has been reported to reduce the risks of infections in various settings. We use high-dose IVIG in ABOi-KT recipients perioperatively. We aimed to determine the rate of infectious complications along with graft and patient survival in our ABOi-KT recipients. METHODS: We included all adult patients who underwent ABOi-KT from the year 2007 to 2016. Patients received rituximab, plasma exchange, and IVIG (2 g/kg body weight). Thymoglobulin and intravenous methylprednisolone were used as induction treatment. Oral prednisone, mycophenolate mofetil, and tacrolimus were used as maintenance therapy. RESULTS: A total of 77 ABOi-KTs were performed, and the recipients were followed up for a median of 1557 days. Two patients were diagnosed as having BK nephropathy. No patients were diagnosed as having pneumocystis infection, cytomegalovirus disease, herpes simplex, varicella zoster, or fungal infection. One-year graft and patient survival was 94.8% and 100%, respectively. CONCLUSIONS: In our series of ABOi-KTs, we observed a low risk of infectious complications and excellent patient survival. High-dose IVIG might have reduced infections.

GATA3 rs3824662 gene polymorphism as possible risk factor for systemic lupus erythematosus.

BACKGROUND: There is no report about the association between GATA3 rs3824662 polymorphism and systemic lupus erythematosus (SLE). OBJECTIVE: To investigate the possible role of GATA3 rs3824662 polymorphism as a susceptibility risk factor for either adult SLE (aSLE) or pediatric SLE (pSLE) and to evaluate its role in the development of lupus nephritis (LN) in pSLE. METHODS: Typing of GATA3 rs3824662 polymorphism was done using real-time polymerase chain reaction for three groups; 104 pSLE patients, 140 aSLE patients and 436 age- and sex-matched healthy controls. RESULTS: Non-significant differences were found between SLE patients and healthy controls for the allele and genotype frequencies of GATA3 rs3824662 ( p > 0.05). In pSLE; the AC genotype was associated with LN ( p = 0.04); the A allele and AC genotype were associated with persistent proteinuria ( p = 0.036 and 0.01, respectively) and both the A allele and AA genotype were associated with higher chronicity index ( p = 0.031 and 0.04, respectively). In aSLE; the C allele was associated with cellular cast ( p = 0.03) and thrombocytopenia ( p = 0.01). Logistic regression analysis revealed significant association between the AC+AA genotypes and the prediction of LN and renal active disease in pSLE ( p = 0.04 and 0.01, respectively). CONCLUSION: GATA3 rs3824662 is not associated with susceptibility to SLE either in adult or in pediatric patients; however, in pSLE patients, the heterozygous AC genotype could be considered a risk factor for LN. At the same time, the AC and AA genotypes could be considered as predictors for LN and active renal disease. However, the small sample size is a limiting factor of the present study when interpreting the positive association.

Angiotensin-converting enzyme insertion/deletion gene polymorphism in Egyptian children with systemic lupus erythematosus: a possible relation to proliferative nephritis.

Introduction Angiotensin-converting enzyme (ACE) is crucial in the pathogenesis of systemic lupus erythematosus through angiotensin II which regulates vascular tone and endothelial functions. Objectives To study the frequency of ACE insertion/deletion (I/D) gene polymorphism in Egyptian children with systemic lupus erythematosus and its possible relation to the renal pathology in cases with lupus nephritis. Subjects and methods The frequency of ACE gene insertion/deletion polymorphism genotypes was determined in 78 Egyptian children with systemic lupus erythematosus and compared to a matched group of 140 healthy controls using polymerase chain reaction. Results The DD genotype of the ACE gene was higher in systemic lupus erythematosus patients when compared to controls ( P<0.0001; odds ratio (OR) 2.4; 95% confidence interval (CI) 1.7-3.3) and the D allele was more frequent than the I allele in systemic lupus erythematosus patients in comparison to controls ( P < 0.0001; OR = 2.2; 95% CI = (1.6-3.1). In the lupus nephritis group, the DD genotype was significantly higher in those with proliferative lupus nephritis when compared to those with non-proliferative lupus nephritis ( P = 0.02; OR = 1.45; 95% CI = 1.4-1.6). Also, patients with proliferative lupus nephritis showed a higher frequency of the D allele ( P < 0.001; OR = 1.98; 95% CI = 1.3-2.9). Conclusion The D allele and DD genotype of the ACE gene appear to be a risk factor for the susceptibility of systemic lupus erythematosus and occurrence of proliferative nephritis in Egyptian children.

Rapid diagnostic test and use of antibiotic against methicillin-resistant Staphylococcus aureus in adult intensive care unit.

Ventilator-associated pneumonia (VAP) due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with excess mortality and costs. Molecular biology test allows rapid identification of MRSA in sputum with high negative predictive value. We hypothesized that use of a rapid diagnostic test in patients with suspected VAP was associated with reduced use of antibiotics directed against MRSA. This retrospective, observational study was conducted in a polyvalent intensive care unit (ICU) of a university hospital. We compared two periods: before (2007-2010) and after (2010-2015) the implementation of a rapid diagnostic test, which uses RT-PCR to detect pathogens in 60 minutes. The primary endpoint was the effect on the empirical use of anti-MRSA antibiotics. The second endpoint was the effect of this strategy on the cost regarding antibiotic treatment. The first group included 120 suspected VAP (88 patients) and the second group 121 suspected VAP (89 patients). Empirical use of vancomycin and linezolid decreased by 50 % between the two periods. Twenty-seven VAP (22 %) were treated with an anti-MRSA treatment between 2007 and 2010, and 13 (11 %) between 2010 and 2015 (p = 0.04). The mean cost of anti-MRSA treatment by patients in the first group was 63 ± 223 €, and 13 ± 52 € in the second group (p < 0.001). This study shows that a rapid diagnostic test was associated with reduced use and cost of anti-MRSA antibiotics in patients with suspected VAP. These results should be confirmed by further multicenter prospective studies.

Pelvic fracture in multiple trauma: A 67-case series.

INTRODUCTION: Severe pelvic trauma remains associated with elevated mortality, largely due to hemorrhagic shock. OBJECTIVE: The main study objective was to test for correlation between fracture type and mortality. The secondary objective was to assess the efficacy in terms of mortality of multidisciplinary management following a decision-tree in multiple trauma victims admitted to a level 1 trauma center. MATERIAL AND METHODS: Between July 2011 and July 2013, 534 severe trauma patients were included in a single-center continuous prospective observational study. All patients with hemorrhagic shock received early treatment by pelvic binder. Patients with active bleeding on full-body CT or persisting hemorrhagic shock underwent arteriography with or without embolization. Pelvic trauma was graded on the Tile classification. The principle end-point was mortality. RESULTS: Median age was 40 years (range, 26-48 years), with a 79% male/female sex ratio. Thirty-two of the 67 patients with pelvic trauma (48%) were in hemorrhagic shock at admission. Median injury severity score (ISS) was 36 (range, 24-43). On the Tile classification, 22 patients (33%) were grade A, 33 (49%) grade B and 12 (18%) grade C. Overall mortality was 19%, and 42% in case of hemorrhagic shock. Mortality was significantly higher with Tile C than A or B (58% vs. 9.1% and 12.1%, respectively; P=0.001). CONCLUSION: Vertical shear fracture (Tile C) was associated with greater mortality from hemorrhagic shock. LEVEL OF EVIDENCE: IV, case series.

C1q rs292001 polymorphism and C1q antibodies in juvenile lupus and their relation to lupus nephritis.

C1q deficiency is related strongly to systemic lupus erythematosus (SLE), but very few and inconsistent studies explored the single nucleotide polymorphisms of the C1q gene in relation to juvenile SLE (jSLE) and lupus nephritis (LN). The objective of this study was to analyse whether C1q rs 292001 polymorphism is associated with SLE and disease phenotype, especially nephritis, and to investigate the relation between this polymorphism and clinical data, treatment outcome, serum level of C1q protein and antibodies. Typing of C1q rs292001 polymorphism using restriction fragment length polymorphism and measuring serum levels of C1q protein and antibodies by enzyme-linked immunosorbent assay (ELISA) were performed for 130 children with SLE and 208 healthy controls. The A allele of C1q rs292001 was associated with jSLE and LN (P = 0·005 and 0·013, respectively) and the AA genotype was associated with jSLE (P = 0·036). Low serum levels of C1q protein were found in jSLE and LN (P < 0·001 and 0·009, respectively), and these levels were increased after treatment in patients with LN (P = 0·009) and active renal disease (P = 0·027). Higher titres of C1q antibodies were found in patients with LN (P = 0·015) and correlated negatively with C1q protein level (P < 0·001) and patient age (P = 0·04). The A allele and AA genotype of C1q rs292001 can be considered a susceptibility risk factor and the GG genotype could be considered protective for jSLE and LN in the studied cohort of Egyptian children. Decreased serum levels of C1q protein and increased titres of C1q antibodies may be involved in the pathogenesis of jSLE, especially LN.

Implementation of lung ultrasound in polyvalent intensive care unit: Impact on irradiation and medical cost.

OBJECTIVE: To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU). STUDY DESIGN: Retrospective study comparing two consecutive periods. PATIENTS: All patients hospitalized for longer than 48 hours in a polyvalent ICU. METHODS: Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round. RESULTS: No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P<0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

Bioactivity of indigenous medicinal plants against the cotton whitefly, Bemisia tabaci.

Forty-one methanol extracts of 28 indigenous medicinal plant species were tested for their insecticidal bioactivity against cotton whitefly, Bemisia tabaci (Gennadius) (Hemiptera: Aleyrodidae), adults and second nymphal instars under controlled conditions. This study is within a bioprospection context, in the form of utilizing local plant species as an alternative in sustainable agriculture development. Eighteen and nine plant extracts caused a significant decrease in number of live adult and nymphal whiteflies, respectively, compared to the control. This is the first report for the potential effect on survival of insects for 22 out of 28 tested medicinal plant species. Whole plant extracts of Ranunculus myosuroudes Boiss. and Kotschy (Ranunculaceae), Achillea damascena L. (Asteraceae), and Anthemis hebronica Boiss. and Kotschy (Asteraceae) and leaf extracts of Verbascum leptostychum DC. (Scrophulariaceae) and Heliotropium rotundifolium Boiss. (Borangiaceae) caused both repellent and toxic effects against the adult and second nymphal instars, respectively. Extracts of leaves and stems of Anthemis scariosa Boiss. (Asteraceae) and Calendula palestina Pers. (Asteraceae) were found to be more bioactive against the adult and nymphal instars, respectively, than extracts of other plant parts, such as flowers. Thus, the bioactive extracts of these medicinal plants have the potential to lower whitefly populations in a comprehensive pest management program in local communities, pending cultivation of these medicinal plant species.

Comparative study of three methods of estimation of creatinine clearance in critically ill patients.

BACKGROUND: At the bedside, the reference method for creatinine clearance determination is based on the measurement of creatinine concentrations in urine and serum (mCrCl). Several models are available to calculate the creatinine clearance from the serum creatinine concentration. This observational survey aimed at testing the hypothesis that the proposed equations are unreliable to determine accurate creatinine clearance in patients admitted to intensive care unit (ICU). METHOD: Creatinine clearance was determined by the use of mCrCl. Then, we compared three equations: Cockcroft-Gault (CG), Simplified Modification of Diet in Renal Disease (MDRDs), and Chronic Kidney Disease Epidemiology (CKD-EPI) in 156 consecutive patients within the first 24hours after ICU admission. We tested the hypothesis that the three equations were equivalent. The agreement between the three equations was evaluated by linear regression and Bland and Altman analysis. RESULTS: Bland and Altman analysis showed similar agreement between the three equations. The biases and precisions were -4.8±51, -1.3±50, and 8.2±44 for CG, MDRDs, and CKD-EPI equations, respectively (P>0.05). The precisions were similar for the three equations (P>0.05). The percentages of outliers at ±30% were 44%, 45%, and 49% for CG, MDRDs, and CKD-EPI, respectively (P>0.05). CONCLUSION: Regarding the high percentage of outliers, the use of these equations cannot be recommended in ICU patients.

[Lung ultrasound: clinical applications and perspectives in intensive care unit]. / Échographie pleuropulmonaire: applications cliniques et perspectives en réanimation.

OBJECTIVE: To describe the use of lung ultrasound in clinical practice and the new opportunities offered by this technology in intensive care unit (ICU) patients. METHOD: Review of signs identified by lung ultrasound and systematic analysis of data published within the last 5 years on its use in ICU. The literature has been extracted from the database Pubmed™. Specific keywords were used to select relevant publications. Clinical studies published in French and English languages were assessed. RESULTS: Lung ultrasound serves to diagnose, quantify, drain and monitor pleural effusions. In patients with acute respiratory failure, lung ultrasound participates to the diagnosis, the implementation of treatments and their follow-up. It helps to manage patients with pneumonia and acute lung injury. Finally, the investigation of the interstitial edema brings information about hemodynamics that can serve to manage our patients. CONCLUSION: Lung ultrasound is an easy, non-invasive, and non-irradiant technology. It brings lot of useful information at the patient's bedside.

Granular cell tumor with cirrhosis and transplantation.

Granular cell tumor is a rare cause of hepatic dysfunction. We report here on a patient who underwent liver transplantation for this ailment. In our literature review, the common bile duct was most commonly involved (56%). A wide variety of therapies were advanced for this type of lesion, spanning three decades of care. Twenty-eight patients (49%) had no follow-up reported, and another 2 (3%) were found at autopsy. Sixteen patients (28%) were followed more than 1 year, with 72% followed less than 1 year if at all. We present the first case of a granular cell tumor being treated with liver transplantation. Although adequate early excisional surgery should obviate the need for transplantation in these cases, widely disparate therapy and poor follow-up may mask generally inadequate therapy for this lesion. The authors recommend thorough excision and long-term follow-up for patients with this entity to avoid secondary biliary cirrhosis and to eliminate the preventable need for transplantation.

Early pregnancy varicella and associated congenital anomalies.

A case of congenital anomalies following varicella infection in the 8th week of gestation is described. Though the baby demonstrated a majority of the features characteristic of the congenital varicella syndrome and had positive immunofluorescent and ELISA tests for VZ specific antibodies, no vesicles or depigmented skin areas were seen.

Morphological and biochemical observations on hepatic glycogen metabolism in mice on a controlled feeding schedule. II. Streptozotocin-diabetic mice.

Morphological aspects of hepatic glycogen metabolism in streptozotocin (SZ) diabetic mice on a controlled feeding cycle (6 hr fed, 18 hr fasted) were studied and correlated with plasma glucose and insulin levels at various time intervals after feeding. Hepatic glycogen was low at initiation of feeding (approximately 0.05%) and increased to a maximum of 4.54 +/- 0.30% (N = 8) as compared to 6.90 +/- 0.20% (N = 12) in normal animals. Plasma glucose levels were similar to those of normal mice at initiation of feeding (80 +/- 5 mg/dl) but much higher during the feeding period (diabetic: 540 +/- 15 mg/dl, normal: 150 +/- 10 mg/dl). At the end of the feeding period, plasma glucose levels rapidly declined, reaching lower than normal levels. In contrast to insulin responses to feeding in normal animals, plasma insulin levels in SZ-diabetic mice remained very low, never exceeding 16 muU/ml. At maximum hepatic glycogen deposition, light microscopic studies showed atypical patterns of glycogen distribution with periportal cells having generally smaller-than-normal glycogen masses. Ultrastructural studies indicated that these cells contained more abundant quantities of smooth endoplasmic reticulum (SER) than is characteristically seen. The aberrant distribution patterns of glycogen observed in the diabetic mice provided morphological evidence for the proposal that the SER is involved in hepatic glycogenesis, with insulin deficiency resulting in abnormal functioning of the organelle.

Morphological and biochemical observations on hepatic glycogen metabolism in mice on a controlled feeding schedule. I. Normal mice.

Changes in hepatocyte morphology were correlated with chemically measured liver glycogen, blood glucose, and plasma insulin levels in control-fed mice (6 hr fed, 18 hr fasted) sacrificed at various time intervals after initiation of a 6-hr meal. At initiation of feeding hepatic glycogen was low(0.05%) but deposition proceeded rapidly, reaching a maximum of 6.99 +/- 0.13% by the sixth hour. Glycogen was depleted during the subsequent fasting period, reaching the prefeeding levels by 24 hr. A relative hyperglycemia (140-192 mg/100/ ml) predominated during all stages of glycogen deposition and depletion until the 21st hour. Plasma insulin levels were maximum during feeding (63 +/- 7 microU/ml, 3 hr) with mild hyperinsulinemia (insulin greater than 16 microU/ml) occurring during glycogen depletion (9-21 hr). Histochemical determinations (PAS) showed lobular patterns of hepatic glycogen which correlated with chemically measured glycogen levels. Six hours after initiation of feeding, periportal cells showed intensely stained masses of glycogen while centrilobular cells showed relatively diffuse staining. At 24 hours after initiation of feeding (18 hr of fasting), no significant staining was observed in the hepatocytes. Ultrastructurally, during all stages of glycogen deposition and depletion, centrilobular cells were characterized by the presence of dispersed glycogen particles with elements of smooth endoplasmic reticulum (SER) between the particles, while periportal cells showed dense glycogen deposits with SER restricted to the periphery of the glycogen masses.

Morphological and biochemical observations on hepatic glycogen metabolism in genetically diabetic (db/db) mice.

Changes in hepatocyte glycogen morphology, liver glycogen, and blood glucose and insulin levels were studied at various time points after initiation of feeding in 10 week old genetic diabetic (db/db) mice (n = 8) and their lean littermates adapted to a controlled feeding regimen (6 h fed - 18 h fast). In spite of hyperinsulinemic (insulin greater than or equal to 97.60 +/- 88 uU/ml) and hyperglycemic (glucose greater than or equal to 437.1 +/- 49.5 mg/dl) conditions favoring glycogen synthesis, feeding-induced hepatic glycogen deposition was less efficient in the diabetic mice. An apparent decreased ability to mobilize hepatic glycogen during fasting and maintenance of relatively high fasting liver glycogen concentrations were however attributable to the anti-glycogenolytic effects of high blood glucose and insulin concentrations. Histochemical determinations (PAS) on livers of db/db mice showed typical lobular patterns of glycogen distribution during deposition and depletion of the polysaccharide. At stages of maximum glycogen (6 h after initiation of feeding), periportal cells displayed intensely stained masses of glycogen with centrilobular cells staining more diffusely. Ultrastructural studies revealed smooth endoplasmic reticulum (SER) in close association with glycogen during its deposition and depletion. The preservation of normal glycogen morphology and SER-glycogen ultrastructure indicates that functioning of the SER in hepatic glycogen metabolism is normal in midly diabetic (db/db) mice.