Endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis using radiofrequency versus coblation.

PURPOSE: To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation. METHODS: This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively. RESULTS: There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance. CONCLUSION: Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP.

Ventriculosubgaleal shunt as a proposed technique for post-infectious hydrocephalus.

BACKGROUND: The management of post-infectious hydrocephalus (PIH) remains challenging for neurosurgeons. It requires a temporary diversion procedure till the normalization of CSF parameters prior to the permanent one. Ventriculosubgaleal shunt (VSGS) was widely used in pediatric cases with post-hemorrhagic hydrocephalus (PHH). However, its role in PIH is still lacking. This study was done to elucidate the safety and efficacy of VSGS as a temporary CSF diversion procedure before the permanent one in patients with PIH. PATIENTS AND METHODS: This retrospective investigation analyzed the data of 50 consecutive cases who underwent VSGS for PIH. RESULTS: The age of the included patients ranged between 1 and 10 months. Twenty-six cases had meningitis and or ventriculitis (52%), while the remaining had shunt infection. At follow-up, arresting of hydrocephalus was noted in ten patients (20%), while another 36 cases required the permanent diversion procedure within 35 days. Regarding the shunt complications, scalp infection, tissue breakdown, and shunt exposure were encountered in ten cases (20%), while CSF leakage was noted in 12 cases (24%). Shunt migration was noted in only two patients (4%). Shunt revision was needed in 16 cases (32%). Mortality was encountered in four cases (8%) because of sepsis. Risk factors for morbimortality included younger age, lower weight, male gender, and meningitis and or ventriculitis. CONCLUSION: VSGS is a safe and effective procedure in infants awaiting definitive VPS for postinfectious hydrocephalus. It was proven that VSGS has shortened the hospital stay and the economic burden on the country.

First trimester placental volume and vascular indices in pregestational diabetic compared to nondiabetic pregnant women.

AIM: Comparing placental volume (PV) and vascular indices in pregestational diabetic and nondiabetic pregnant women at 11 and 13 weeks gestation. METHODS: A case-control study conducted at Ain Shams University Maternity Hospital in collaboration with Feto-maternal Unit for Ultrasound Assessment, Ain Shams University Maternity Hospital, Egypt. Ninety-two pregnant women divided into two groups: Group A included 46 women with pregestational diabetes mellitus and group B included 46 nondiabetic pregnant women as control. All participants had PV, vascularization index (VI), flow index (FI) and vascularization flow index (VFI) calculated using three-dimensional (3D) ultrasonography and 3D power Doppler at 11 and 13 weeks of pregnancy. RESULTS: At 11 weeks, the mean VI, FI and VFI in diabetic group (17.70 ± 12.62, 40.72 ± 11.03 and 7.77 ± 6.37, respectively) were insignificantly higher than in nondiabetic group (12.14 ± 12.62, 34.59 ± 9.66 and 6.52 ± 14.20, respectively) while mean PV in diabetic group (26.90 ± 14.74) was insignificantly lower than in nondiabetic group (27.53 ± 17.46). Also at 13 weeks, the results were not different as the mean VI, FI and VFI in diabetic group (16.51 ± 9.81, 42.52 ± 7.47 and 8.12 ± 7.55, respectively) were insignificantly higher than in nondiabetic group (16.37 ± 14.17, 40.29 ± 17.52 and 7.08 ± 4.35, respectively), and mean PV in diabetic group (52.04 ± 17.95) was insignificantly lower than in nondiabetic group (54.46 ± 17.85). There was strong positive correlation between HbA1C level and VFI measured at 13 weeks gestation. CONCLUSIONS: Placental indices in early pregnancy do not seem to be useful markers to anticipate placental pathology in pregestational diabetes, however there might be a role for HbA1C level measurement to anticipate such complications.

The Warden procedure for partial anomalous pulmonary venous connection in children: 10 years experience in 65 cases.

INTRODUCTION: In this study, we share our experience in the Warden procedure for the repair of partial anomalous pulmonary venous connections (PAPVCs) draining high in the superior caval vein in 65 cases of the paediatric age group over a period of 10 years. PATIENTS AND METHODS: In total, 65 patients receiving the Warden procedure for the repair of high PAPVCs (draining above the cavoatrial junction) over a period of 10 years starting from January, 2010 to January, 2020 were included in this study. RESULTS: In total, 34 were males (52.3%) and 31 were females (47.7%). The mean age was 3.47 ± 1.4 years, while the mean weight was 17.3 ± 5.3 kilograms. The mean bypass time was 84.2 ± 13.9 minutes and the mean cross clamp time was 54.8 ± 12.9 minutes. The mean intensive care unit stay was 2.14 ± 0.89 days, while the mean hospital stay was 5.9 ± 1.4 days. There was no in-hospital mortality or persistent sinus node dysfunction necessitating permanent pacemaker. In total, 62 patients (95%) could be followed up for a mean period of 7.8 ± 1.2 years after discharge. During the follow-up period, no stenosis was detected in the Warden anastomosis or the rerouted pulmonary veins and only one case of late mortality (1.6%) occurred due to a non-cardiac cause. CONCLUSION: The Warden procedure is a safe approach for the repair of high PAPVCs (above the cavoatrial junction) in the paediatric age group with good long-term results and low incidence of complications like sinus node dysfunction as well as pulmonary vein and superior caval vein obstruction.

Internal rotation of the tibial component in total knee arthroplasty can lead to extension deficit.

PURPOSE: Stiffness is a common problem following total knee arthroplasty (TKA). Mal-rotated components have been claimed to be the major cause of pain and limited motion after TKA. The present study investigates whether intra-operative intentional malrotation of the tibial component would change in vivo kinematics. The hypothesis is excessive internal rotation of the tibial component would result in postoperative extension deficit. METHODS: Thirty-one patients were enrolled in this study. After completing bony cuts and proper soft tissue balancing, the femoral and tibial trials were impacted and fixed using small pins. Lateral radiographs were used to measure and compare intraoperative full knee extension during normal and after intentional internal rotation of the tibial component. The extension deficit angles were also compared between the posterior stabilised (PS) and cruciate retaining (CR) implants. RESULTS: For normal tibial component rotation, the median (interquartile range) extension deficit was 0° (4). The mean tibial trial intentional internal rotation was 21.2° (± 4.5). The median (interquartile range) extension deficit significantly increased to 6° (4) after tibial component internal rotation (p = 0.001). The use of PS spacers resulted in a significantly greater extension deficit after intentional internal rotation 9° (5) compared to that of the CR implant 1° (4) (p = 0.001). CONCLUSION: Internal rotation of the tibial component in total knee arthroplasty can lead to postoperative extension deficit. This could be attributed to interference with "screw home" mechanism that requires full external rotation of the tibia on the femur. Consequently, this deficit may cause pain and knee stiffness following TKA. LEVEL OF EVIDENCE: III.

Variations in implementation of bladder training for overactive bladder: an online international survey.

We distributed an online questionnaire to 365 health care professionals specialising in urogynaecology, using the International Urogynaecology Association (IUGA) and British Society of Urogynecolgoy (BSUG) directories to investigate how the bladder training (BT) is provided in their units. We assessed the techniques provided, who provides them, and how these techniques are implemented and taught to the patients. Two hundred and thirteen (59%) completed responses have been received. 88% of the respondents felt that BT is an important and effective tool in treating overactive bladder. 50.7% indicated those physiotherapists are the health care practitioners responsible to deliver BT in their units. 88.3% of respondents use face-to-face consultation to deliver BT, 11% only use leaflets sent to patients. 87% use bladder diaries before implementing their BT. 26.4% use anti-muscarinic medications with BT from the start.IMPACT STATEMENTWhat is already known on this subject? Bladder training (BT) is a well-established behavioural therapy used to treat overactive bladder with comparable efficacy to pharmacotherapy with less side effects. It I recommended to be offered as first line therapy for at least 6 weeks. However, there is no clarity about the techniques and the methods used to deliver it.What do the results of the study add? The current study aimed to find out how the BT programme delivered to patients using an online questionnaire directed to a mixed group of medical urogynecology practitioners in different geographical regions. It showed that there is a wide variation in how the BT is delivered and lack of consistency in the techniques used and the duration recommended.What are the implications of these findings for clinical practice and/or further research? Future well-designed research is needed to look at the best ways to give BT instructions, the frequency of supervision of patients who use BT, the appropriate time length of the BT programme, and the best strategies to control urgency.

Modeling aspects of the language of life through transfer-learning protein sequences.

BACKGROUND: Predicting protein function and structure from sequence is one important challenge for computational biology. For 26 years, most state-of-the-art approaches combined machine learning and evolutionary information. However, for some applications retrieving related proteins is becoming too time-consuming. Additionally, evolutionary information is less powerful for small families, e.g. for proteins from the Dark Proteome. Both these problems are addressed by the new methodology introduced here. RESULTS: We introduced a novel way to represent protein sequences as continuous vectors (embeddings) by using the language model ELMo taken from natural language processing. By modeling protein sequences, ELMo effectively captured the biophysical properties of the language of life from unlabeled big data (UniRef50). We refer to these new embeddings as SeqVec (Sequence-to-Vector) and demonstrate their effectiveness by training simple neural networks for two different tasks. At the per-residue level, secondary structure (Q3 = 79% ± 1, Q8 = 68% ± 1) and regions with intrinsic disorder (MCC = 0.59 ± 0.03) were predicted significantly better than through one-hot encoding or through Word2vec-like approaches. At the per-protein level, subcellular localization was predicted in ten classes (Q10 = 68% ± 1) and membrane-bound were distinguished from water-soluble proteins (Q2 = 87% ± 1). Although SeqVec embeddings generated the best predictions from single sequences, no solution improved over the best existing method using evolutionary information. Nevertheless, our approach improved over some popular methods using evolutionary information and for some proteins even did beat the best. Thus, they prove to condense the underlying principles of protein sequences. Overall, the important novelty is speed: where the lightning-fast HHblits needed on average about two minutes to generate the evolutionary information for a target protein, SeqVec created embeddings on average in 0.03 s. As this speed-up is independent of the size of growing sequence databases, SeqVec provides a highly scalable approach for the analysis of big data in proteomics, i.e. microbiome or metaproteome analysis. CONCLUSION: Transfer-learning succeeded to extract information from unlabeled sequence databases relevant for various protein prediction tasks. SeqVec modeled the language of life, namely the principles underlying protein sequences better than any features suggested by textbooks and prediction methods. The exception is evolutionary information, however, that information is not available on the level of a single sequence.

Ring, Band or Suture in Tricuspid Annuloplasty for Functional Tricuspid Regurgitation; Which is Better and More Durable?

BACKGROUND: In this study, we evaluate different annuloplasty modalities to repair functional tricuspid regurgitation. PATIENTS AND METHODS: Between January 2011 and January 2017, 200 patients with moderate or greater functional tricuspid regurgitation received tricuspid valve repair as part of primary surgeries on the left side of their cardiac valves. Of these, 39 patients received rings (Group A), 84 patients received bands (Group B), and 77 patients received suture annuloplasty (Group C). RESULTS: Two patients from Group C were operated on again, during the primary hospital stay due to severe symptomatic tricuspid regurgitation. The degrees of early postoperative tricuspid regurgitation - mean vena contracta and mean jet area - significantly were higher in Group C. During a mean follow-up period of 26 ± 12.6 months, 5 patients within Group C (6.85%) and one patient in Group B (1.3%) were operated on again with tricuspid valve replacement due to severe symptomatic tricuspid incompetence. Also during follow up, mean degrees of tricuspid regurgitation, mean vena contracta, and mean jet areas significantly were higher in Group C. CONCLUSION: Patients who received rings followed by band annuloplasty had better early and late results with lower recurrence rates than those who received suture annuloplasty.

AlphaVBeta3 Integrin expression within uterine endometrium in unexplained infertility: a prospective cohort study.

BACKGROUND: Implantation defect is one of these contributing factors for unexplained infertility. In the mid-luteal phase, when implantation is expected to happen, Integrins expression is remarkably increased. So, Integrins could potentially serve as markers for the frame of the window of implantation. αVß3 integrin could have a role as a potential receptor for embryonic attachment. The aim of the current study is to investigate whether the women with unexplained infertility have a pattern of expression of endometrial αvß3 integrin that could differ from those who have normal fertility or not. METHOD: Two groups of women have been included in this study. The first group was the Unexplained Infertility Group. This group included women diagnosed with unexplained primary infertility. The second group was the fertile Group, which included fertile parous women presented to the family planning clinic seeking contraception. 2D transvaginal ultrasound scan (TVS) was performed six days after detecting urinary LH surge. (TVS) was used to measure endometrial thickness, and subendometrial blood flow color Doppler Resistance Index (RI). On the same day of transvaginal ultrasound, endometrial samples were taken using the Endocell® office suction sampler for Immunohistochemistry (IHC) study using monoclonal mouse IgG antibodies to detect endometrial αvß3 integrin. RESULTS: Thirty-five fertile women with a diagnosis of unexplained infertility were included as a group I [Unexplained infertility Group] along with an equal number of fertile women as group II [Fertile Group]. The group of women with a diagnosis of unexplained infertility had a significantly lower αvß3 integrin score when compared to the fertile group (median score 0, range:0-2 and median score 1, range: 1-3 and for infertile and fertile groups respectively, P < 0.0001). In addition, the unexplained infertility group had significantly higher subendometrial flow RI and Significantly thinner endometrial thickness. CONCLUSION: This study showed that Alpha v Beta 3 integrin is a significantly lower in endometrium in cases of unexplained infertility, which may suggest that underexpression of Alpha v Beta 3 integrin in human endometrium could be linked to defective uterine receptivity, and play a role as an unrecognized cause of infertility in this population of women. We need larger studies of adequate statistical power, ideally investigating more than one menstrual cycle in the same woman, to investigate the usefulness of using these molecular molecules in clinical practice.

Rectal misoprostol for myomectomy: A randomised placebo-controlled study.

BACKGROUND: Uterine leiomyomas are the most common benign tumours in women. Misoprostol, which is widely used in the treatment and prevention of postpartum haemorrhage in obstetrics, may decrease intra-operative bleeding in abdominal myomectomies when haemorrhage constitutes a challenging problem. AIMS: To assess the effect on intra-operative blood loss of using a single pre-operative dose of rectal misoprostol in abdominal myomectomy surgeries. MATERIALS AND METHODS: In a randomised double-blind placebo-controlled trial, 50 women undergoing abdominal myomectomy for symptomatic uterine leiomyomas were randomly assigned to receive a single dose of pre-operative of rectal 400 µg misoprostol (n = 25) or placebo (n = 25) 1 h before the operation. The primary outcome was intra-operative blood loss. This clinical trial was registered in clinicaltrial.gov registry with number: NCT02061657. RESULTS: Intra-operative blood loss was significantly lower in those women randomised to receive rectal misoprostol versus the placebo group (574 ± 194.8 mL vs 874 ± 171.5 mL). Additionally, the drop in postoperative haemoglobin was significantly less in the misoprostol group (1.7 ± 0.4 g/dL) compared with the placebo group (2.1 ± 0.5 g/dL). CONCLUSION: A single pre-operative dose of rectal misoprostol (400 µg) is a simple applicable method for reducing intra-operative blood loss and operative time in abdominal myomectomy.

Microbiological profile and biofilm formation on removed intrauterine contraceptive devices from a sample of Egyptian women.

AIM: The aim of this study was to investigate the presence of biofilm formation around intrauterine contraceptive devices (IUCD) and to correlate the microbiological profile of the IUCD-associated genital infections to the microbiological profile of specimens retrieved from vaginal discharge. MATERIAL AND METHODS: Samples of the vaginal discharge in the posterior fornix were collected from 50 women attending the Family Planning Clinic in Ain Shams University Hospital using two high vaginal swabs. Swabs were immediately sent for Gram staining as well as microbiological culture. The IUCD was then removed. A 0.5-cm piece of the removed IUCD was cut and sent for culture. Growing colonies were tested for their abilities to form a biofilm (colorimetric method). Another 0.5-cm piece of the removed IUCD was examined by electron microscopy (EM) for detection of biofilm formation. RESULTS: Among the included 50 women, 24 (48%) women showed biofilm formation (via colorimetric methods). EM scanning was able to detect biofilm formation in the prepared pieces of the removed IUCD of 48 (96%) women. There was no significant agreement between the isolated microorganisms on the removed IUCD and the vaginal swab (proportion of agreement was 14 [11.4%]; κ = -0.089, P = 0.892). CONCLUSION: Scanning EM is a useful tool in detection of biofilm formation on removed IUCD.

Subgaleal drain versus dissection of subgaleal space and closure without drain after burr-hole drainage of chronic subdural hematoma.

Background: Chronic subdural hematoma (CSDH) is a collection of blood, blood degradation products, and fluid that accumulate on the surface of the brain between its arachnoid and dural coverings. This study is to evaluate the efficacy of subgaleal drain (SGD) versus subgaleal dissection without drainage as adjuncts to burr-hole evacuation of CSDH. Methods: A retrospective study was conducted utilizing the data of 60 patients operated for symptomatic CSDH. Patients were divided into two groups, each thirty consecutive patients: Group I, in which a SGD was inserted after CSDH evacuation through a burr-hole; and Group II, the hematoma was evacuated as in the Group I, but with no SGD insertion but instead a subgaleal pocket was created for drainage. Results: The neurological improvement at 24 h, discharge, 2 weeks, and 6 months after surgery was comparable in both groups. The overall recurrence was 4 cases (4/60, 6.7%). The rate of recurrence and surgical infection rate were comparable in both groups. Both groups showed similar incidences of postoperative seizures, bleeding, rates of medical complications, and neurological deficits. The overall postoperative mortality was five cases (5/60, 8.3%) with no significant difference between groups. Conclusion: Blunt dissection to open the subgaleal space and closure without a drain is a safe and efficient alternative to the insertion of a drain after the burr-hole evacuation of CSDH.

Microvascular Decompression versus Radiofrequency Ablation in Trigeminal Neuralgia of the Maxillary and Mandibular Divisions.

Background Although medical treatment is the mainstay of therapy, in trigeminal neuralgia (TN), patients failing to respond to it make them candidates to ablative or nonablative procedures. Objective The aim of this study was to compare the outcome of Microvascular decompression (MVD) and radiofrequency (RF) thermocoagulation in the management of TN affecting the mandibular and maxillary divisions. Materials and Methods Retrospective analysis of the data of 40 patients suffering from intractable classical TN affecting the maxillary or mandibular divisions or both was carried out. Twenty patients were operated upon by MVD of the trigeminal nerve; and 20 had RF ablation of the maxillary or mandibular divisions of the trigeminal nerve or both. Results In MVD the overall successful outcome was achieved in 16 patients (80%), while the failure was in 4 patients (20%) of which 3 had a fair outcome and 1 patient had a poor outcome. Whereas in RF the overall successful outcome was achieved in 17 patients (85%), while the failure was in 3 patients (15%) of which 2 had a fair outcome and 1 patient had a poor outcome. Outcome was insignificantly different between both groups ( p -value 0.806). Conclusion MVD and RF ablation represent safe and efficacious surgical choices for addressing TN that encompasses both the mandibular and maxillary divisions. Long-term follow-up studies demonstrate that MVD consistently yields favorable outcomes, establishing it as the preferred primary surgical technique, unless contraindicated by the patient's general health and specific needs.

Radiofrequency Versus CO2 Laser in Posterior Cordotomy for Managing Bilateral Abductor Vocal Fold Immobility.

PURPOSE: This study aimed to assess the outcomes of posterior cordotomy in cases with bilateral abductor vocal fold immobility (BAVFI), either by radiofrequency or CO2 laser. METHODS: This prospective comparative randomized study included 80 patients with BAVFI of different etiologies. They were divided randomly into two groups. Group A included 44 patients for whom radiofrequency was used for posterior cordotomy, while the other group (group B) included 36 patients managed by CO2 laser-assisted posterior cordotomy. RESULTS: The postoperative respiratory chink improved significantly in both groups, with a significant improvement in the dyspnea, especially in group B. The postoperative voice handicapped VHI-10 scores showed significant deterioration in both groups. CONCLUSIONS: CO2 laser and radiofrequency-assisted posterior cordotomy were effective and safe for managing cases with BAVFI. Moreover, the CO2 laser has the upper hand regarding breathing and exercise tolerance outcomes, significantly impacting the quality of life.

CardioRiskNet: A Hybrid AI-Based Model for Explainable Risk Prediction and Prognosis in Cardiovascular Disease.

The global prevalence of cardiovascular diseases (CVDs) as a leading cause of death highlights the imperative need for refined risk assessment and prognostication methods. The traditional approaches, including the Framingham Risk Score, blood tests, imaging techniques, and clinical assessments, although widely utilized, are hindered by limitations such as a lack of precision, the reliance on static risk variables, and the inability to adapt to new patient data, thereby necessitating the exploration of alternative strategies. In response, this study introduces CardioRiskNet, a hybrid AI-based model designed to transcend these limitations. The proposed CardioRiskNet consists of seven parts: data preprocessing, feature selection and encoding, eXplainable AI (XAI) integration, active learning, attention mechanisms, risk prediction and prognosis, evaluation and validation, and deployment and integration. At first, the patient data are preprocessed by cleaning the data, handling the missing values, applying a normalization process, and extracting the features. Next, the most informative features are selected and the categorical variables are converted into a numerical form. Distinctively, CardioRiskNet employs active learning to iteratively select informative samples, enhancing its learning efficacy, while its attention mechanism dynamically focuses on the relevant features for precise risk prediction. Additionally, the integration of XAI facilitates interpretability and transparency in the decision-making processes. According to the experimental results, CardioRiskNet demonstrates superior performance in terms of accuracy, sensitivity, specificity, and F1-Score, with values of 98.7%, 98.7%, 99%, and 98.7%, respectively. These findings show that CardioRiskNet can accurately assess and prognosticate the CVD risk, demonstrating the power of active learning and AI to surpass the conventional methods. Thus, CardioRiskNet's novel approach and high performance advance the management of CVDs and provide healthcare professionals a powerful tool for patient care.

Acute Appendicitis Incidence, Diagnostic Markers, and Sequelae; Dallah Hospital-Based Study in Riyadh, Saudi Arabia.

Background: Acute appendicitis is currently considered one of the most common acute surgical diseases of the abdomen and requires emergency surgery. It is also one of the most common abdominal emergencies in both developed and developing countries. The current study is aimed at assessing the specificity and sensitivity of Ultrasound and Computed Tomography in the diagnosis of appendicitis as well as the prevalence of its complications. The association of appendicitis with several laboratory findings will also be evaluated. Methodology: A retrospective study was conducted at Dallah-Namar Hospital, Riyadh City, Saudi Arabia. Results: 720 patients were differentially diagnosed with appendicitis in the study area. Of these, 618 patients had US abdomen/pelvis, with 15 (2.4%) showing positive findings. Amongst the 203 patients noted to have undergone abdominal CT,8 (4.0%) was found to have positive findings. Conclusion: The sensitivity of the US was determined to be relatively low. Also, serum creatinine was found to be elevated among all patients diagnosed with appendicitis. Further research with a larger sample size is needed to be conducted to further support the current findings.

A modified form of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes.

OBJECTIVES: re-evaluation and modification of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes. STUDY DEIGN: a prospective cohort study. PATIENTS: children (n = 20) between 2 to 8 years old who received a unilateral cochlear implant, all had difficult round window visibility and/or accessibility for electrode insertion. 10 had a round window insertion through the endoscopic assisted cochlear implantation and the remaining 10 had the same insertion using the retro-facial approach. THE SURGERY: two alternative techniques were used to overcome the difficult cases of round window electrode insertion: 1Endoscopic assisted cochlear implantation 2Transmastoid retro-facial approach RESULTS: both techniques proved to be effective and practical to overcome cases with difficult round window visibility and/or accessibility for electrode insertion. CONCLUSION: Round window insertion is associated with superior cochlear implantation outcomes, so we recommend a new modification to the STH classification to bypass the cochleostomy insertion.

Is quadratus lumborum block combined with low dose-spinal anesthesia an effective alternative to general anesthesia in patients undergoing percutaneous nephrolithotomy?

BACKGROUND: General anesthesia in high-risk patients has many complications and needs long preoperative preparations and postoperative intensive care unit (ICU). Therefore the present study aimed to evaluate the efficacy of combined low-dose spinal anesthesia with quadratus lumborum block (QLB) as an alternative to general anesthesia for patients undergoing percutaneous nephrolithotomy. PATIENTS AND METHODS: A prospective study was conducted at the urology department of Al-Azhar University Hospitals in Cairo, Egypt, from January 2021 to January 2022. The study included 60 patients of ASA ll-lll scheduled for percutaneous nephrolithotomy. All patients received low-dose spinal anesthesia (5 mg bupivacaine) and QLB (QL1-QL2-QL3) approaches. The primary observation parameter was the efficacy of this technique as an alternative to general anesthesia. The secondary parameters measured were evaluation of need for intraoperative narcotics, postoperative pain score (VAS), and patients satisfaction as assessed using a 5-point Likert Scale. RESULTS: None of the patients was given general anesthesia, and intraoperative sedation was given to nineteen patients (32.2%). No hemodynamic changes were observed in all patients. There was a significant correlation between the use of intraoperative sedation and stone site, intraoperative blood loss, and hospital stay. Pain intensity on VAS at rest and movement was low until the 24th postoperative hour. Patient satisfaction score was 3, 4, and 5 in 1 (1.7%), 4 (6.7%), and 55 (91.6%) patients, respectively. CONCLUSIONS: Combined low-dose spinal anesthesia with quadratus lumborum block is an effective alternative to general anesthesia in patients undergoing PCNL procedures with good postoperative analgesia. Patients with lower calyceal punctures have a lower incidence of intraoperative sedation requirements.

Effect of Intravenous Ketamine Infusion on Hemodynamics of Patients Undergoing Cesarean Delivery after Spinal Anaesthesia: A Randomized, Double-Blind, Controlled Trial.

Objective: Hypotension is the most frequent side effect of intrathecal anaesthesia, with an incidence of more than 80%. Following neuraxial anaesthesia, perioperative shivering is a serious complication affecting 40-60% of patients undergoing surgery. This study aimed to determine the effectiveness of low-dose ketamine on blood pressure in patients undergoing cesarean delivery after spinal anaesthesia. Methods: We included 126 female patients undergoing cesarean deliveries, American Society of Anesthesiologists (ASA)-(II and III), and aged 21-40 selected from the outpatient clinics of the anaesthesia department. Patients were randomized to two groups; Group K (63 patients), who received 0.3 mg kg-1 of ketamine IV diluted to 10 mL, followed by an infusion of 0.1 mg kg-1 h-1. Group C (Controlled) (63 patients) received 10 mL of normal saline, followed by an infusion of 0.1 mL kg-1 h-1, which started before spinal anaesthesia. Results: Compared with the saline group, the average heart rate, blood pressure, and level of sedation were significantly higher in the ketamine group (P < 0.05). The ketamine group reported a significantly lower incidence of shivering (P < 0.01). The ketamine groups exhibited significantly less mild or severe hypotension (P < 0.05). There was no significant difference between the two groups in terms of nystagmus, diplopia, hallucinations, or neonatal outcomes (P > 0.05). Conclusion: Ketamine decreases the incidence of hypotension and shivering in patients undergoing spinal anaesthesia during cesarean delivery. In addition, it resulted in improved sedation for the mother and prolonged postoperative analgesia without neonatal illness.