Bone marrow embolism: should it result from traumatic bone lesions? A histopathological human autopsy study.

Bone marrow embolism (BME) is likely a consequence of fractures in which pulmonary vessels are the most affected. However, some cases of BME were reported in the absence of trauma. Thus, a traumatic injury might not be necessary for developing BME. This study discusses BME cases in patients without signs of fractures or blunt trauma. The discussion addresses various possible mechanisms for the appearance of BME. Options include cancer in which bone marrow metastasis is a suggestive cause. Another proposal is the chemical theory where bone marrow fats are released via lipoprotein lipase in a pro-inflammatory state, resulting in vascular/pulmonary obstruction. Other cases discussed in this study are hypovolemic shock and drug-abuse related BME. All autopsy cases with BME were included regardless of the cause of death for a period of 2 years. Autopsies involved complete dissection with the macroscopic evaluation of the affected organs, including the heart, lungs, and brain. Tissues were also prepared for microscopic examination. Of the 11 cases, eight showed non-traumatic BME (72%). These findings conflict with theories in the literature that BME most commonly occurs after fractures or trauma. One of the eight cases exhibited mucinous carcinoma; one is presented with hepatocellular carcinoma; and two cases showed severe congestion. Lastly, one case was found to be associated with each of the following conditions: liposuction, drug abuse, pulmonary hypertension, and heart failure. Each case suggests a different pathophysiology for developing BME, yet the exact mechanisms are not fully understood. Further study of non-traumatic associated BME is recommended.

COVID-19 and Cell Stress.

The present century will undoubtedly be marked with the COVID-19 global health crisis. It is not time yet to talk about the total number of deaths and hospitalizations, as they are enormously growing daily. Understanding the nature of COVID-19-induced pneumonia is vital in order to deal with the associated health complications. Cell stress is an established mechanism known to be associated with infection and cancer. Different proteins crucial for cellular response to stress are reported to be a possible target to stop the infection and to reduce the chemo-resistance in cancer. Heat shock protein (HSP) families of chaperones play an essential role in cells both in normal state and under stress. The upregulation of HSP5A, also termed GRP78 or Bip, is reported in different viral infections. This chapter introduces the current knowledge about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has caused the COVID-19 pandemic, and cell stress aimed at defining possible strategies to combat the COVID-19 pandemic.

Recognition of the gluconeogenic enzyme, Pck1, via the Gid4 E3 ligase: An in silico perspective.

Gluconeogenesis, the reverse process of glycolysis, is a favorable mechanism at conditions of glucose deprivation. Pck1 is a rate-limiting gluconeogenic enzyme, where its deficiency or mutation contributes to serious clinical situations as neonatal hypoglycemia and liver failure. A recent report confirms that Pck1 is a target for proteasomal degradation through its proline residue at the penultimate position, recognized by Gid4 E3 ligase, but with a lack of informative structural details. In this study, we delineate the localized sequence motif, degron, that specifically interact with Gid4 ligase and unravel the binding mode of Pck1 to the Gid4 ligase by using molecular docking and molecular dynamics. The peptide/protein docking HPEPDOCK web server along with molecular dynamic simulations are applied to demonstrate the binding mode and interactions of a Pck1 wild type (SPSK) and mutant (K4V) with the recently solved structure of Gid4 ligase. Results unveil a distinct binding mode of the mutated peptide compared with the wild type despite having comparable binding affinities to Gid4. Moreover, the four-residue peptide is found insufficient for Gid4 binding, while the seven-residue peptide suffices for binding to Gid4. The amino acids S134, K135, and N137 in the loop L1 (between ß1 and ß2) of the Gid4 are essential for the stabilization of the seven-residue peptide in the binding site of the ligase. The presence of Val4 instead of Lys4 smashes the H-bonds that are formed between Lys4 and Gid4 in the wild type peptide, making the peptide prone to bind with the other side of the binding pocket (L4 loop of Gid4). The dynamics of Gid4 L3 loop is affected dramatically once K4V mutant Pck1 peptide is introduced. This opens the door to explore the mutation effects on the binding mode and smooth the path to target protein degradation by design competitive and non-competitive inhibitors.

Recognition of gluconeogenic enzymes; Icl1, Fbp1, and Mdh2 by Gid4 ligase: A molecular docking study.

The pro/N-degron pathway is an evolved protein degradation pathway through the ubiquitin-proteasome system. It is a vital pathway to attain protein homeostasis inside the liver cells with varying glucose levels. N-terminal proline exists in more than 300 proteins in Saccharomyces cerevisiae, but only three of them are the gluconeogenic enzymes; isocitrate lyase (Icl1), fructose-1,6-bisphosphatase (Fbp1), and malate dehydrogenase (Mdh2). The present in silico study aims to structurally illustrate the binding of Icl1 enzyme to Gid4 ligase concerning its peers; Fbp1 and Mdh2. Based on the molecular docking scores and interactions, one can attribute the binding stability of Gid4 with degrons, to peptides of length six up to eight from the N-terminal. Moreover, the percent change in the docking score provides a rationale for the unique Gid4-Icl11-4 interaction. The present study provides insights on the binding attitude of Gid4 ligase to degrons of different lengths, so one will consider in designing peptidomimetics to target Gid4 ligase.

Clinical application of fetal left modified myocardial performance index in the evaluation of fetal growth restriction.

OBJECTIVE: This study aims to evaluate cardiac function in fetuses with intrauterine growth restriction (IUGR) compared with healthy fetuses, using the left modified myocardial performance index (MPI) and the association between MPI and perinatal outcome. METHODS: Pregnant women between 34 and 39 weeks of gestation, who met the criteria for IUGR and were scheduled for delivery at an Egyptian tertiary medical center, were prospectively enrolled in the study. Women in the same gestational-age group with uncomplicated pregnancies were included as a control group. MPI was measured in all fetuses. The IUGR group was analyzed based on normal and abnormal umbilical artery (UA) Doppler. Perinatal outcomes were recorded. RESULTS: The mean left MPI was significantly higher in IUGR fetuses with abnormal UA Doppler (mean 0.58±SD 0.093) compared with healthy fetuses (mean 0.45±SD 0.070) (P<0.001). IUGR fetuses with abnormal left MPI showed significantly worse perinatal outcome and increased morbidity compared with the control group. IUGR fetuses with abnormal left MPI also showed significantly worse perinatal outcome compared with IUGR fetuses with normal MPI (whether the UA Doppler was normal or abnormal). The fetal MPI was associated with the severity of fetal compromise in IUGR fetuses based on the perinatal outcome. CONCLUSION: MPI is a potentially useful tool in evaluating fetuses with suspected IUGR, which is crucial in classifying IUGR pregnancies into critical and non-critical cases and in predicting neonatal outcome.

Prevalence and risk factors of obstetric violence in the Gaza strip: A retrospective study from a conflict setting.

OBJECTIVES: To assess the prevalence and risk factors of obstetric violence (OV) among laboring women in the past 5 years in the Gaza Strip (GS). METHODS: Women who delivered between January 2017 and December 2021 were invited to complete an anonymous online survey between November 2021 and February 2022 to explore their experiences of labor. RESULTS: Seven hundred twenty-two women completed the online questionnaire. Two-thirds (484; 67.2%) were in their 20s, and half (362; 50.1%) were from low socioeconomic households. A vast majority (508; 70.4%) delivered in a government hospital. Four out of ten (300; 41.6%) reported experiencing at least one form of OV. Among these women, the types of OV reported were physical (143; 47.8%), psychological (122; 40.8%), verbal (109; 36.4%), and sexual (13; 4.4%). Delivery in private facilities (adjusted odds ratio [AOR] 0.45, 95% confidence interval [CI] 0.32-0.74) and prior knowledge of the care provider (AOR 0.37, 95% CI 0.23-0.59) were both independently protective for OV. In contrast, women's awareness of OV increased their likelihood of reporting it (AOR 3.45, 95% CI 2.37-5.01). CONCLUSION: GS has an alarming prevalence of reported OV. Increasing awareness of OV, identifying its causes, and developing locally led initiatives to eliminate it are urgently needed.

E-Learning Medical Education in Gaza During COVID-19: Students' Experiences and Policy Recommendations.

Objectives: We explored medical students' perspectives on and experiences of e-learning in Gaza and proposed relevant policy recommendations. Methods: We administered an online questionnaire to medical students in Gaza exploring (1) demographics, computer skills, and time spent on e-learning; (2) students' perception and challenges of e-learning; and (3) students' preferences of continuing medical e-learning in the future. Analysis was done using SPSS version 23. Results: Out of 1830 students invited, 470 responded, and 227 of them were basic-level students. More female students responded (58.3%, n = 256). Most participants (n = 413, 87.9%) reported moderate to high computer skills allowing them to access e-learning. Before coronavirus disease-19 (COVID-19), over two-thirds (n = 321, 68.3%) spent 0-3 hours on e-learning. After COVID-19, the majority shifted, and 306 students (65.1%) reported spending at least 7 hours on various e-learning sources. The challenges for clinical-level students were mainly related to lack of practical training in the hospital (n = 196, 80%), followed by lack of interactions with real patients (n = 167, 68.7%). As for basic-level students, a majority (n = 120, 52.8%) reported lack of practical skills (eg, lab skills) as a challenge followed by unreliable internet access (n = 119, 52.4%). Pre-recoded lectures, readily available educational videos were used more than live lectures. Less than a third of all students (n = 147, 31.3%) wanted e-learning in the next term. Conclusions: Medical students in Gaza don't have a favourable experience with online medical education. There need to be actions to help overcome the challenges faced by students. This requires orchestrated actions by the government, universities, and local and international organizations.

A late diagnosis of primary intestinal lymphangiectasia in a Syrian girl.

Primary intestinal lymphangiectasia is a rare disease that affects children and young adults, causing mainly gastrointestinal disorders that lead to edema and immunologic abnormalities. The majority of patients typically present bilateral lower limb edema, along with pericarditis, pleural effusion, or chylous ascites. The goal of the treatment is to restrict the consumption of long-chain fats and administer a formula that includes protein and medium-chain triglycerides. Here, we report 11-year-old Syrian girl presented to the hospital with 2 years history of diarrhea and generalized edema. Furthermore, investigation showed ascites and pleural effusion. The disease was detected by several biopsies from duodenum that showed dilation of the lymph vessels within the lamina propria without any evidence for inflammation. She was managed by modifying her diet and albumin transfusion, which caused significant improvement in the child's condition.

Influence of COVID-19 infection/vaccination on menstrual regularity and hormonal function in Saudi females of reproductive age.

The COVID-19 pandemic has had a profound impact on women's health, particularly on their menstrual cycles. The menstrual cycle serves as a crucial indicator of fertility and reproduction. Objectives: This study aimed to examine the impact of COVID-19 infection and vaccination on menstrual regularity in Saudi women of childbearing age. Additionally, it sought to explore the potential effects of COVID-19 vaccination on serum hormonal levels during the follicular phase of the menstrual cycle, along with their relationship with Vit.D. Methods: This case‒control study investigated the impact of COVID-19 infection and vaccination on menstrual regularity and hormonal function in Saudi women of reproductive age. Data were collected from 79 women who attended the Outpatient Department of Obstetrics and Gynaecology at King Faisal Medical Complex in Taif, Saudi Arabia. All participants had received COVID-19 vaccines. The data collection process was comprehensive, encompassing various participant characteristics, such as demographic information, history of COVID-19 infection, and details about menstrual patterns before and after infection and vaccination. Furthermore, hormonal measurements, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol, prolactin, thyroid-stimulating hormone (TSH), and vitamin D (Vit.D) levels, were extracted from the participants' medical records. Results: Among the participants, 39.24 % had a history of COVID-19 infection, and following the infection, there was a significant increase in the proportion of women experiencing irregular menstruation. After receiving the COVID-19 vaccine, 72.15 % of the participants continued to have irregular menstrual cycles. The study found that a considerable number of participants had menstrual cycles outside the normal range, with 43.80 % having cycles shorter than 21 days and 35.10 % having cycles longer than 35 days. Comparing participants with regular and irregular cycles after COVID-19 vaccination, no significant changes were observed in most hormonal levels. However, the prolactin hormone showed a significant increase in participants with irregular cycles, while Vit.D levels were significantly decreased in this group. Conclusion: The study findings indicate a higher prevalence of irregular menstruation among participants, particularly after vaccination. Notably, irregular menstrual cycles were found to be associated with elevated levels of prolactin hormone and decreased levels of Vit.D.

Knowledge, attitudes and practices toward cervical cancer and screening among sexually active Saudi females visiting a primary care center in Saudi Arabia.

Background/Aim: Women's knowledge of cervical cancer (CC) and awareness of screening procedures are important to improve adherence and reduce mortality. This study was conducted to determine the knowledge, attitudes, and practices toward cervical cancer and screening among sexually active Saudi females visiting a primary care center in Riyadh, Saudi Arabia. Methods: We conducted a cross-sectional study among sexually active Saudi females who visited the primary care center of our institution using a self-administered survey questionnaire between July and December 2020. Results: Six hundred and one Saudi women participated in the survey with a mean age of 34.0 ± 10.8 years. Three in four women (75.7%) were aware of cervical cancer and 325 (54.1%) believed that doing a Paps smear helped them diagnose and prevent CC. However, 479 participants (79.7%) do not see the need to go for CC screening (n = 199, 41.5%) and 113 (23.6%) had not heard of Paps smear screening. There were 109 women (18.1%) who has good knowledge of cervical cancer and screening and 492 women (81.9%) had poor knowledge. Conclusion: There was a high proportion of women with poor knowledge and awareness about cervical cancer and screening. Most women do not feel the need to undergo screening. Primary care physicians and healthcare providers should revisit the implementation of policies or information dissemination of programs and materials to increase awareness and knowledge for cervical cancer screening and vaccination throughout primary healthcare centers.

Survey of In Vitro Model Systems for Investigation of Key Cellular Processes Associated with Atherosclerosis.

Atherosclerosis progression is associated with a complex array of cellular processes in the arterial wall, including endothelial cell activation/dysfunction, chemokine-driven recruitment of immune cells, differentiation of monocytes to macrophages and their subsequent transformation into lipid laden foam cells, activation of inflammasome and pro-inflammatory signaling, and migration of smooth muscle cells from the media to the intima. The use of in vitro model systems has considerably advanced our understanding of these atherosclerosis-associated processes and they are also often used in drug discovery and other screening platforms. This chapter will describe key in vitro model systems employed frequently in atherosclerosis research.

Challenges During Review of COVID-19 Research Proposals: Experience of Faculty of Medicine, Ain Shams University Research Ethics Committee, Egypt.

The COVID-19 pandemic resulted in an overwhelming increase in research studies submitted to research ethics committees (RECs) presenting many ethical challenges. This article aims to report the challenges encountered during review of COVID-19 research and the experience of the Faculty of Medicine, Ain Shams University Research Ethics Committee (FMASU REC). From April 10, 2020, until October 13, 2020, the FMASU REC reviewed 98 COVID-19 research protocols. This article addressed the question of how to face an overwhelming amount of research submitted to the REC while applying the required ethical principles. Ethical challenges included a new accelerated mode of review, online meetings, balance of risks vs. benefits, measures to mitigate risks, co-enrolment in different studies, protection of a vulnerable COVID-19 population, accelerated decisions, online research, how to handle informed consent during the pandemic, and justification of placebo arm.

Clinical characteristics of non-intensive care unit COVID-19 patients in Saudi Arabia: A descriptive cross-sectional study.

INTRODUCTION: The ongoing pandemic of the coronavirus disease 2019 (COVID-19) is a global health concern. It has affected more than 5 million patients worldwide and resulted in an alarming number of deaths globally. While clinical characteristics have been reported elsewhere, data from our region is scarce. We investigated the clinical characteristics of mild to moderate cases of COVID-19 in Saudi Arabia. METHODS: This is a descriptive, cross-sectional study. Data of 401 confirmed COVID-19 patients were collected from 22 April 2020 to 21 May 2020 at five tertiary care hospitals in Riyadh, Saudi Arabia. The patients were divided into four groups according to age, Group 1: 0-<18 years, Group 2: 18-<50 years, Group 3: 50-60 years, and Group 4: >60 years; and their clinical symptoms were compared. RESULTS: The median (IQR) age in years was 10.5 (1.5-16) in group I, 34 (29-41) in group II, 53 (51-56) in group III, and 66 (61-76) in group IV. Most patients were male (80%, n = 322) and of Arabian or Asian descent. The median length of stay in the hospital was 10 (8-17) days (range 3-42 days). The most common symptoms were cough (53.6%), fever (36.2%), fatigue (26.4%), dyspnea (21.9%), and sore throat (21.9%). Hypertension was the most common underlying comorbidity (14.7%), followed by obesity (11.5%), and diabetes (10%). Hypertensive patients were less likely to present with shortness of breath, cough, sputum, diarrhea, and fever. CONCLUSION: There was no significant difference in the symptoms among different age groups and comorbidities were mostly seen in the older age group. Interestingly, hypertensive patients were found to have milder symptoms and a shorter length of stay. Further larger collaborative national studies are required to effectively understand clinical characteristics in our part of the world to efficiently manage and control the spread of SARS-CoV-2.

Clinical, epidemiological, and laboratory characteristics of mild-to-moderate COVID-19 patients in Saudi Arabia: an observational cohort study.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from China in December 2019 and has presented as a substantial and serious threat to global health. We aimed to describe the clinical, epidemiological, and laboratory findings of patients in Saudi Arabia infected with SARS-CoV-2 to direct us in helping prevent and treat coronavirus disease 2019 (COVID-19) across Saudi Arabia and around the world. MATERIALS AND METHODS: Clinical, epidemiological, laboratory, and radiological characteristics, treatment, and outcomes of pediatric and adult patients in five hospitals in Riyadh, Saudi Arabia, were surveyed in this study. RESULTS: 401 patients (mean age 38.16 ± 13.43 years) were identified to be SARS-CoV-2 positive and 80% of cases were male. 160 patients had moderate severity and 241 were mild in severity. The most common signs and symptoms at presentation were cough, fever, fatigue, and shortness of breath. Neutrophil and lymphocyte counts, aspartate aminotransferase, C-reactive protein, and ferritin were higher in the COVID-19 moderate severity patient group. Mild severity patients spent a shorter duration hospitalized and had slightly higher percentages of abnormal CT scans and X-ray imaging. CONCLUSIONS: This study provides an understanding of the features of non-ICU COVID-19 patients in Saudi Arabia. Further national collaborative studies are needed to streamline screening and treatment procedures for COVID-19.

Supplementation of clomiphene citrate cycles with Cimicifuga racemosa or ethinyl oestradiol--a randomized trial.

The anti-oestrogenic activity of clomiphene citrate (CC) on the cervical mucous and endometrium may be the reason for the relatively low pregnancy rates in CC induction cycles. Various follicular-phase supplements have been tried to improve cycle outcome in these patients. This study compared follicular-phase supplementation with either phytoestrogen (PE) or ethinyl oestradiol (EE) in CC induction cycles for the treatment of unexplained infertility. A total of 134 patients were randomly allocated to each treatment group (67 each). The PE group needed significantly fewer days for adequate follicular maturation, had a thicker endometrium and higher oestradiol concentration at the time of human chorionic gonadotrophin injection (all P < 0.001). The PE group had higher luteal-phase serum progesterone compared with the EE group. No significant difference was found regarding clinical pregnancy rates (14.0% versus 21.1%, respectively). In conclusion, the cycle characteristics in unexplained infertility women treated with clomiphene citrate induction and timed intercourse improved after follicular-phase supplementation with PE compared with EE supplementation. Further studies are needed to confirm the mechanism beyond these effects.

Use of human amniotic stem cells for common bile duct reconstruction: vascularized support of a free amnion graft.

BACKGROUND: Benign bile duct stricture is common in surgical practice. The complications of late stricture formation and biliary sepsis still occur in bile duct reconstruction. Many biological and artificial materials have been used to replace the damaged bile duct to avoid bilio-enteric anastomosis, which bypasses the biliary sphincter mechanism. Amniotic epithelial (AE) cells are known to have unique characteristics, such as low-level expression of major histocompatibility complex antigens and a less restricted differentiation potential. AE cells differentiate into different cell types from all three germ layers, including cardiomyocytic, myocytic, osteocytic, adipocytic (mesodermal), pancreatic, hepatic (endodermal), neural, and astrocytic (neuroectodermal) cells in vitro, suggesting a promising candidate to reconstruct the damaged bile duct. MATERIAL/METHODS: Human amniotic grafts (as a source of stem cells) with or without vascularized peritoneomuscular flap were used to repair damaged bile ducts (non-circumferential and circumferential bile duct loss) in a dog model. RESULTS: Non-circumferential bile duct loss appeared to be satisfactorily repaired using amnion graft alone. However, circumferential duct loss was not adequately repaired with amnion graft alone, but it was adequately repaired using amnion graft with a vascularized peritoneomuscular flap. In adequately repaired cases, histological examination demonstrated that the biliary mucosal endothelium had grown over the amniotic membrane graft. CONCLUSIONS: Collectively, the data presented here suggest that the use of human amnion as a source of amniotic stem cells provides a very promising tool for tissue reconstruction.

Effect of oral N-acetyl cysteine on recurrent preterm labor following treatment for bacterial vaginosis.

OBJECTIVE: To evaluate the effect of N-acetyl cysteine (NAC) on gestational age at delivery in women with previous preterm labor and bacterial vaginosis. METHODS: A randomized, double-blind, placebo-controlled trial with 280 women between 16 and 18 weeks of pregnancy who had 1 previous preterm birth and had just been successfully treated for bacterial vaginosis with metronidazole for 1 week. The women were randomized to receive 0.6 g of NAC per day plus 17-hydroxyprogesterone caproate (17-OHPC) or placebo plus 17-OHPC until 36 completed weeks of pregnancy or active labor. A vaginal swab was taken during labor. RESULTS: Reaching 36 weeks of pregnancy was more frequent (P<0.05) and gestational age at delivery was significantly higher in the NAC than in the placebo group (37.4 weeks+/-0.4 weeks vs 34.1 weeks+/-1.2 weeks, P<0.05). The discontinuation rate was 11.4% in the NAC group. CONCLUSIONS: Oral NAC was found to reduce the recurrence of preterm birth in patients with bacterial vaginosis.

Molecular dynamics and docking reveal the potency of novel GTP derivatives against RNA dependent RNA polymerase of genotype 4a HCV.

AIM: To work on Hepatitis C Virus (HCV), one of the major causes of liver cirrhosis and hepatocellular carcinoma, polymerase of genotype 4a that have no solved structures deposited in the protein data bank (PDB) yet. Understanding the dynamics and testing some novel inhibitors are also covered. MATERIALS AND METHODS: Molecular Dynamics Simulation (MDS) is performed for a period of 1 µs on comparatively modeled then validated NS5b of subtype 4a. Following MDS analysis, molecular docking is performed to test the inhibitory performance of eight novels suggested guanosine derivatives using 181 different conformations of the protein model gathered during the MDS run after the equilibration period. KEY FINDINGS: The results yield that the eight modified, at position 2', GTP derivatives (fluorine, Hydroxyl, and sulphonyl oxydanyl) have binding energies comparable to the parent molecule, GTP. Besides, the eight suggested compounds have lower binding energies (and hence better in binding) compared to sofosbuvir (a drug approved by FDA in 2013 against HCV) and ribavirin (a wide range acting antiviral drug used before against HCV). SIGNIFICANCE: Combined molecular dynamics and molecular docking are able to test the hypothesis of HCV polymerase dynamics doesn't affect the nucleotides (or nucleotide inhibitors) binding to its active site. Despite the reported highly dynamic subtype 4a of HCV; all the nucleotide inhibitors under the study are able to, tightly, bind to NS5b of genotype 4a. This behavior is reported before for the Zika virus polymerase, as well.

Oral midodrine is comparable to albumin infusion in cirrhotic patients with refractory ascites undergoing large-volume paracentesis: results of a pilot study.

BACKGROUND AND AIMS: Albumin infusion reduces the incidence of postparacentesis circulatory dysfunction among patients with cirrhosis and tense ascites compared with no treatment. Less costly treatment alternatives such as vasoconstrictors have been investigated, but the results are controversial. Midodrine, an oral α1-adrenergic agonist, increases effective circulating blood volume and renal perfusion by increasing systemic and splanchnic blood pressure. Our aim is to assess whether or not morbidity in terms of renal dysfunction, hyponatremia, systemic, or portal hemodynamics derangement or mortality differed in patients receiving albumin versus midodrine. PATIENTS AND METHODS: Seventy-five patients with cirrhosis and refractory ascites were randomized to receive albumin infusion, oral midodrine for 2 days, or oral midodrine for 30 days after therapeutic large volume paracentesis (LVP). The primary endpoints were development of renal impairment or hyponatremia, change in systemic and portal hemodynamics, cost, and mortality in the short-term and long-term follow-up. RESULTS: No significant difference was found between groups in the development of renal impairment, hyponatremia, or mortality 6 and 30 days after LVP. A significant increase in 24-h urine sodium excretion was noted in the midodrine 30-day group. Renal perfusion improved significantly with the midodrine intake for 30 days only. The cost of midodrine therapy was significantly lower than albumin. CONCLUSION: Midodrine is as effective as albumin in reducing morbidity and mortality among patients with refractory ascites undergoing LVP at a significantly lower cost. Long-duration midodrine intake can be more useful than shorter duration intake in terms of improvement of renal perfusion and sodium excretion.