Progressive Multifocal Encephalopathy Holmes Tremor Successfully Treated with Bilateral Deep Brain Stimulation.

Background: We report a patient with bilateral HT treated with DBS. Case report: A 58-year-old man diagnosed with HIV/AIDS and progressive multifocal leukoencephalopathy (PML) presented with 20 years of bilateral arm tremor refractory to therapy. DBS was implanted on the left ventral intermediate nucleus and posterior subthalamic area (VIM/PSA). One year later, a right VIM/PSA DBS was implanted. At twelve months, there were no significant side-effects. With his DBS turned off and on, the Fahn-Tolosa-Marin scale was rated 82 and 58, respectively. Discussion: To our knowledge, this is the first report of bilateral DBS VIM/PSA treating HT with no significant side effects. Highlights: We report a successful treatment using deep brain stimulation of bilateral Holmes tremor that was caused by progressive multifocal encephalopathy. The patient achieved 30% improvement in tremor control with a meaningful improvement in his activities of daily living.

Outcomes Of Mesh Fixation Versus Non Fixation In Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair: A Randomized Clinical Study.

Objectives: The present study aimed to compare the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair with and without mesh fixation regarding postoperative pain, recurrence, operative time, and complications. METHODS: This randomized controlled clinical trial included 100 patients who underwent TAPP inguinal hernia with mesh fixation (group A) or a fixation-free procedure (group B) for early onset inguinal hernia at the General Surgery Department, Kafrelsheikh University Hospital, from January 2021 to June 2022. RESULTS: The parameters for pain assessment (NRS) in the first week (mean 7 (5 - 8)), the first month (mean 3 (1 - 5)), and after three months(mean 0 - (70% of patients), (mean 1- (30% of patients) were significantly higher in the fixation group (p<0.001). The fixation group had significantly more operative time than non fixation, with a mean (69.34±13.55, 60.92±10.18) respectively. Recurrence rate and postoperative complications did not show any significant difference between the studied groups. CONCLUSIONS: Mesh non-fixation for laparoscopic TAPP hernia repair is safe, practical, and effective with minimal postoperative pain and no increased risk of recurrence.

Needlescopic Primary Paediatric Inguinal Hernia Repair By Hernia Sac Disconnection And Peritoneal Closure.

Objectives: To evaluate the short-term outcome of the needlescopic hernia sac disconnection and peritoneal closure in the treatment of primary paediatric inguinal hernia. Method: The prospective study was conducted from April 2019 to April 2021 at the Paediatric Surgery Unit of the General Surgery Department at Kafrelsheikh University Hospital, Egypt, and comprised patients aged 6-144 months having uncomplicated paediatric inguinal hernia. The patients were subjected to needlescopic hernia sac disconnection and peritoneal closure. The follow-up protocol included outpatient visits at 1 week and at 1, 3 and 6 months postoperatively to check for recurrence and other complications. Data was analysed using SPSS 24. RESULTS: Of the 50 patients with 65 hernias, 37(74%) were males and 13(26%) were females. The overall mean age was 50.78± 31.74 months (range: 9-120 months) and mean internal ring diameter was 11.90±3.518mm (range: 8-20mm). The mean operative time was 20.66±2.94 minutesfor unilateral cases and 30.60±5.15 minutesfor bilateral cases. There was no conversion to conventional laparoscopy or to open herniotomy. All cases were followed up for a mean of 11.56± 3.99 months. No recurrence was encountered in any case and the scars were invisible in 40(80%) cases 6 months postoperatively. CONCLUSIONS: Needlescopic hernia sac disconnection and peritoneal closure wasfound to be feasible,safe and effective in the treatment of primary paediatric inguinal hernia.

A Clinical Score For Predicting Complications Following Breast Reduction.

Objectives: To establish a clinical score for morbidity prediction based on patient-related risk factors after breast reduction surgery. Method: The retrospective study was conducted at the Department of Plastic and Reconstructive Surgery, Kafrelsheikh University Hospital, Egypt, and comprised data of female patients with bilateral macromastia who underwent breast reduction, using the inferior pedicle invertedT technique between February 2019 and June 2020. After data retrieval, risk factors and complications were documented and related to the patients'risk factors Data was analysed using SPSS 20. RESULTS: Of the 30 cases, 20(66.7%) were aged ≥35 years, 16(53.3%) had body massindex ≥37kg/m2 and 27(90%) were non-smokers. The mean preoperative haemoglobin level was 12.15±1.115g/dL and the mean weight of tissue resected on both sides was 2074.17±696.12gm. Factors significantly associated with complications included smoking, suprasternal notch to nipple distance ≥38cm, haemoglobin <12.5g/dL, the weight of excised tissue ≥2000gm and a positive family history of macromastia. The total score of the morbidity prediction scale ranged 2-190, with the best cut-off value being ≥93. The scale had 100% sensitivity,specificity, positive predictive value, negative predictive value and 100 percent accuracy. CONCLUSIONS: Ability to predict postoperative surgical-site morbidity may optimise safety as well as outcome after reduction mammaplasty.

Effect Of Laparoscopic Sleeve Gastrectomy On Vitamin D, Parathormone Hormone, And Serum Calcium Levels.

Objectives: To evaluate the effect of laparoscopic sleeve gastrectomy on vitamin D status, parathyroid hormone,serum calcium and the effectiveness of vitamin D supplementation. Method: The prospective study was conducted at the General Surgery Department of Kafrelsheikh University Hospital, Egypt, in November 2019, and comprised morbidly obese patients of either gender who were managed with laparoscopic sleeve gastrectomy. Serum levels of vitamin D, calcium and parathyroid hormone were assessed at baseline and at 6 and 12 months after the surgery. All subjects were given 400 IU/day of vitamin D. If the level of vitamin D was <30ng/ml, further doses of calcifediol 200,000 IU were added every two weeks. Data was analysed using SPSS 22. RESULTS: Of the 40 patients, 28(70%) were females and 12(30%) were males. The overall mean age was 33.9±10.8, mean weight was 136±18.29kg and mean body massindex was 50±4.9kg/m2 . The mean operative time was 64.5±13.6 minutes, and the mean hospitalstay was 1.8±1.1 days. There wassignificant reduction in body massindex values after the surgery (p<0.05). Vitamin D level was 19.2±3.2 ng/ml at baseline, which rose to 21.4±2.7 ng/ml at 6 months and 26.6±2.8 ng/ml at 12 months post-surgery (p<0.05). Preoperative parathyroid hormone level was 58.3±7.8 pg/ml , which went down to 48.6±7.4 pg/ml at 6 months, and 41.3±6.5 pg/ml at 12 months postoperatively (p<0.05). The mean serum calcium level at baseline was 9±0.4mg/dL, which rose to 9.2 ±0.3mg/dL and 9.5±0.4 mg/dL at 6 and 12 months post-surgery (p<0.05). CONCLUSIONS: Low vitamin D complications could be decreased postoperatively by administering vitamin D as a routine treatment. Postoperative monitoring of vitamin D, parathyroid hormone and serum calcium levels is essential.

Clinical Significance Of Baseline And Post-Treatment CXCR1 Expression In Women With Breast Cancer Having Received Neoadjuvant Chemo Therapy.

Objectives: To examine the chemokine receptor type 1 expression in breast cancer tissues before and after neoadjuvant chemotherapy, and its relationship with pathological response to neoadjuvant chemotherapy and other clinical variables. Method: The prospective study was conducted at Kafrelsheikh University Hospital, Egypt, from November 2018 to March 2021, and comprised female patients with new histopathologically proven breast cancer eligible for chemotherapy. Paraffin blocks of tumourspecimens were stained immunohistochemically using concentrated rabbit anti-human chemokine receptor type 1 polyclonal antibody kits. The patients were followed up for treatment response, disease recurrence and mortality. Data was analysed using SPSS 25. RESULTS: Of the 100 patients with mean age 50.2±12.1 years, 40(40%) in group A with mean age 55.1±9.3 showed marked response and 60(60%) in group B with mean age 47.0±12.7 yearsshowed mild/moderate response (p<0.001). Group A patients had significantly lower baseline and post-treatment chemokine receptor type 1 expression compared to group B patients (p<0.05). The change in chemokine receptor type 1 expression was not significantly different (p>0.05). Patients with tumour grade 3 had significantly higher baseline chemokine receptor type 1 expression compared to patients with tumour grade 2. Tumourstage and post-treatment chemokine receptor type 1 expression were also significantly interlinked (p<0.05). Multivariate regression analysisidentified patients'age, baseline chemokine receptor type 1 and post-treatment chemokine receptor type 1 expressions as predictors of treatment response. CONCLUSIONS: There was found to be an association between baseline and post-treatment chemokine receptor type 1 expression in breast cancer tissues and pathological response to neoadjuvant chemo therapy in such patients.

Safe Stapleless Laparoscopic Splenectomy; Use Of Hem-O-Lok To Control The Splenic Hilum.

Objectives: To evaluate Hem-o-Lok polymer clips' feasibility, safety and cost-effectiveness in controlling the splenic pedicle during paediatric laparoscopic splenectomy. Method: The prospective study was conducted from May 2019 to December 2021 at Kafrelsheikh University Hospital, Egypt, and comprised children of either gender aged <18 years who had benign haematological diseases and were indicated for laparoscopic splenectomy. During the procedure, Hem-o-Lok clips were used for controlling the splenic pedicle. Patients were encouraged to ambulate the same day, and the drain was removed 24hours postoperatively. The cases were followed up for three months postoperatively. RESULTS: Of the 23 subjects, 11(47.8%) were boys and 12(52.2%) were girls. The overall mean age was 8.74±3.44 years (range: 4-15 years). There were 6(26%) cases of spherocytosis, 1(4.3%) immune thrombocytopenic purpura and 16(69.6%) with thalassemia major. The mean operative time was 93.43±29.87 minutes(range: 65-180 minutes). There was no conversion to open splenectomy and no mortality. There were 2(8.7%) cases of minor and 1(4.3%) of major intraoperative bleeding. All the 3(100%) cases were controlled laparoscopically. No postoperative bleeding occurred and no cases required postoperative blood transfusion. CONCLUSIONS: Controlling both the splenic artery and vein using Hem-o-Lok clips was found to be feasible, safe and cost-effective.

Expanding Scope About Factors Influencing Seroma Formation After Breast Cancer Surgery.

Objectives: To determine the incidence of seroma formation after breast cancer surgery, and its association with common risk factors. Method: The correlationalstudy was conducted at the General Surgery department of Kafrelsheikh University Hospital, Egypt, from March 2020 to March 2022 and comprised patients having breast cancerstage I, II or III, as per the Tumour Node-Metastasis classification, who were scheduled to undergo modified radical mastectomy, breast conserving surgery or reconstructive surgery. Baseline, intraoperative and postoperative data was collected on a proforma. Data was analysed using SPSS 22. RESULTS: Of the 50 female patients with mean age 45±5.20 (range: 20-70 years), 30(60%) were in the elderly group aged >45 years, while 20(40%) were aged <45years. Overall, 12(24%) cases developed seroma; 9(30%) in the elderly group. There were 24(48%) cases of modified radical mastectomy, and 8(33.3%) had seroma. Electrocautery was used for breast dissection in 30(60%) cases, and, among them, seroma developed in 10(33.3%) patients. CONCLUSIONS: Age, body weight, afflicted breast side, site, and size of breast mass were not found to be significant predictors of seroma formation following breast cancer surgery.

Oncoplastic Volume Displacement Surgical Techniques For Early Primary Breast Cancer: A Case Series.

Oncoplastic breast surgery (OPS) is a new strategy for expanding breast-conserving surgical options, lowering mastectomies rates, and preventing deformities. OPS is based on the use of plastic surgical reconstruction after breast cancer removal. The study aims to assess volume displacement oncoplastic procedures for early primary breast cancer in terms of recurrence and cosmoses. A case series study was done on 20 patients with early breast cancer who underwent oncoplastic volume displacement techniques in the period from March 2019 to March 2021 in Kafrelsheikh University Hospital, Egypt. OPS techniques included were Racquet, Benelli, Batwing and Grisotti technique. The study concluded that OPS are oncologically safe (100%) with no recurrence and a better aesthetic outcome (90%).

Cluster analysis of COVID-19 recovery center patients at a clinic in Boston, MA 2021-2022: impact on strategies for access and personalized care.

BACKGROUND: There are known disparities in COVID-19 resource utilization that may persist during the recovery period for some patients. We sought to define subpopulations of patients seeking COVID-19 recovery care in terms of symptom reporting and care utilization to better personalize their care and to identify ways to improve access to subspecialty care. METHODS: Prospective study of adult patients with prior COVID-19 infection seen in an ambulatory COVID-19 recovery center (CRC) in Boston, Massachusetts from April 2021 to April 2022. Hierarchical clustering with complete linkage to differentiate subpopulations was done with four sociodemographic variables: sex, race, language, and insurance status. Outcomes included ICU admission, utilization of supplementary care, self-report of symptoms. RESULTS: We included 1285 COVID-19 patients referred to the CRC with a mean age of 47 years, of whom 71% were female and 78% White. We identified 3 unique clusters of patients. Cluster 1 and 3 patients were more likely to have had intensive care unit (ICU) admissions; Cluster 2 were more likely to be White with commercial insurance and a low percentage of ICU admission; Cluster 3 were more likely to be Black/African American or Latino/a and have commercial insurance. Compared to Cluster 2, Cluster 1 patients were more likely to report symptoms (ORs ranging 2.4-3.75) but less likely to use support groups, psychoeducation, or care coordination (all p < 0.05). Cluster 3 patients reported greater symptoms with similar levels of community resource utilization. CONCLUSIONS: Within a COVID-19 recovery center, there are distinct groups of patients with different clinical and socio-demographic profiles, which translates to differential resource utilization. These insights from different subpopulations of patients can inform targeted strategies which are tailored to specific patient needs.

Treatment of segmental continuous hypertrophic myokymia of the limb with botulinum A toxin.

Myokymia is defined as fluctuating hyperexcitability of muscle fibers caused by repetitive spontaneous contraction of motor units. Myokymia is generally benign with self-resolution, although symptomatic treatment with benzodiazepines, anticonvulsants, and muscle relaxants can be used. Botulinum toxins can also be utilized, although they are mostly used for symptomatic facial myokymia. Here, we report two patients who developed continuous myokymia, resulting in secondary hypertrophy, stiffness, and discomfort in the affected muscles. The first patient had a history of a tethered spinal cord and developed continuous myokymia in the S1 and S2 radicular regions of the left leg. The second patient underwent radiation therapy for lung cancer and developed brachial plexopathy with abnormal activity in the muscles supplied by the musculocutaneous nerve in the right arm. Both patients experienced sleep disturbance, focal discomfort, and restlessness. The anticonvulsants and muscle relaxants were ineffective. Chemodenervation with botulinum A toxin was initiated using either onabotulinumtoxinA or abobotulinumtoxinA. Both patients experienced a substantial reduction in myokymia, with ongoing reversal of muscle hypertrophy and significant improvement in reported subjective symptoms. Treatment with botulinum toxins can be highly effective in patients with symptomatic segmental continuous hypertrophic myokymia and may be considered first-line therapy.

Efficacy of Sterculia diversifolia Leaf Extracts: Volatile Compounds, Antioxidant and Anti-Inflammatory Activity, and Green Synthesis of Potential Antibacterial Silver Nanoparticles.

Sterculia diversifolia, widely distributed in Jordan as an ornamental plant, is a synonoum for Brachychiton populneus. Phytochemical studies examining the volatile chemicals in Sterculia diversifolia leaves are limited, despite the rising demand for their numerous applications. Furthermore, it was only recently that a report described the friendly synthesis of silver nanoparticles (AgNPs) using aqueous extract derived from Brachychiton populneus leaves. Therefore, AgNPs were produced using either aqueous plant extracts (AgWPE) or ethanolic plant extracts (AgEPE), and Shimadzu GC-MS equipment was used to detect volatile compounds in the ethanolic leaf extracts. GC-MS profile of leaf ethanolic extracts of the Jordanian chemotypes of S. diversifolia revealed the existence of major components: (3ß)-Lup-20(29)-en-3-ol acetate (30.97%) and 1-octadecyne (24.88). Other compounds are squalene (7.19%), germanicol (6.23), dl-α-tocopherol (5.24), heptacosane (4.41), phytol (3.54) and pentacosane (2.89). According to published studies, these reported chemicals have numerous uses, including as animal feed, vitamin precursors, possible eco-friendly herbicides, antioxidants, and anti-inflammatory agents. Aqueous extracts of S. diversifolia leaves had total phenolic of 5.33 mg GAE/g extract and flavonoid contents of 64.88 mg QE/g extract, respectively. The results indicated the contribution of phenolic and flavonoids to this plant's anti-inflammatory and antioxidant properties. The reduction in AgNO3 to AgNPs using S. diversifolia leaf extracts was confirmed by the change in solution color from colorless to dark black. Further characterization was attempted by X-ray diffraction, Malvern zeta-sizer and scanning electron microscope. The efficacy of synthesized Ag nanoparticles using aqueous or ethanolic plant extract of S. diversifolia against the Gram-negative bacteria Escherichia coli and Gram-positive bacteria Staphylococcus aureus showed appreciable activity at 25 µg/mL concentration compared to the source plant extracts.

Miller Fisher Syndrome Presenting Without Areflexia, Ophthalmoplegia, and Albuminocytological Dissociation: A Case Report.

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barré syndrome (GBS) with a prevalence of one to two people per million each year. Viral and/or bacterial infection often precedes the classic triad of areflexia, ophthalmoplegia, and ataxia. Bulbar involvement is uncommon but can lead to extensive workup to rule out stroke, myasthenia gravis (MG), and other neuromuscular disorders. We present a case of a 32-year-old healthy male with a past medical history of Lyme disease as a teenager and sore throat two weeks prior. He presented to the hospital with rapidly ascending paresthesias in bilateral upper and lower extremities, urinary incontinence, and mild slurred speech. Exam on presentation revealed mild dysmetria in bilateral upper and lower limbs. The remainder of the exam was negative. Neuroradiological imaging, including magnetic resonance imaging (MRI) with and without contrast of the brain and the cervical and lumbar spine, did not show any acute process or abnormal enhancement. Lumbar puncture revealed cerebrospinal fluid (CSF) with normal protein and cell count, and hence no albuminocytological dissociation (ACD). Immunoserology was positive for Epstein-Barr virus (EBV) immunoglobulin G (IgG) but negative for immunoglobulin M (IgM). Despite the absent ACD, areflexia, and no third, fourth, and sixth cranial nerve deficits, there was high suspicion for GBS due to acutely rapid ascending paresthesia, mild dysarthria, and mild ataxia. The patient was started on intravenous immunoglobulin (IVIG) 2 mg/kg divided into five days within 24 hours of admission. The patient developed areflexia in all limbs on the second day of admission and complained of double vision. On the third day of admission, the patient's negative respiratory force (NIF) declined to -23, and he was intubated for airway protection. Our patient completed five days of IVIG. Positive anti-GQ1b antibodies further supported the diagnosis of MFS. After a seven-day ICU stay and 20 days of aggressive inpatient rehabilitation, the patient could do most of the activities of daily living independently. After six weeks, he was back to his normal baseline and restarted his job.

Early Postoperative Sequelae After Open Sky Access in Nasal Osteotomy: A Comparative Study.

INTRODUCTION: Nasal osteotomy is a powerful cornerstone step in almost all rhinoplasty procedures and is a major cause of postoperative periorbital ecchymosis and edema after rhinoplasty. Different accesses for osteotomy have been described, the most popular of which is the external perforating and the internal continuous methods. These accesses are blind maneuvers and have some drawbacks such as possible visible scar formation in the percutaneous access or high rate of mucosal tear in the endonasal access. Open sky access osteotomy after wide subperiosteal dissection had been described to overcome those disadvantages. Early postoperative sequelae have not been assessed in the literature after using this access. In the present study, we aim to assess early postoperative sequelae after using this technique in comparison with percutaneous perforating osteotomy. MATERIALS AND METHODS: The study was conducted between November 2017 and January 2021. Forty patients were randomly assigned into 2 equal groups. Group A was subjected to lateral osteotomy by percutaneous perforating method, whereas group B underwent lateral osteotomy by the open sky access technique using a 2-mm curved osteotome. Early postoperative periorbital sequelae were assessed on the second and seventh postoperative days, using the grading system suggested by Kara et al (Plast Reconstr Surg. 1999;104:2213-2218). Mucosal tear was assessed on the second postoperative day using nasal endoscopy after removal of nasal packs. RESULTS: There was a statistically nonsignificant difference between the studied groups regarding ecchymosis and edema occurring on the second or seventh days. Meanwhile, mucosal tear was significantly less in the open sky access osteotomy group. CONCLUSIONS: Open sky access osteotomy is a safe method for lateral nasal osteotomy with direct visualization of the surgical field. It does not require a skin incision that could lead to a scar formation. It produces less mucosal tear than percutaneous perforating osteotomy. No statistically significant difference is found between both techniques regarding postoperative periorbital ecchymosis and edema on the second and seventh postoperative days.

Incidence and Nature of Respiratory Events in Patients Undergoing Bronchoscopy Under Conscious Sedation.

BACKGROUND: During diagnostic bronchoscopies, conscious sedation improves patient tolerance, but it can contribute to hypercapnia and hypoxia by various mechanisms including depression of ventilatory drive. This prospective study was undertaken to determine the frequency of respiratory events and associated oxygen desaturations during bronchoscopy with conscious sedation. PATIENTS AND METHODS: The Nox-T3 monitoring system was placed before starting the bronchoscopy and remained in place for 30 minutes following the procedure. The primary endpoint was the occurrence of obstructive and central apneic events during bronchoscopy under conscious sedation. RESULTS: Obstructive events (apnea and hypopnea) occurred in 100% of patients (n=31), and central apneas occurred in 58% of patients (n=18) during the procedure with a median of 9 and 2 events per patient, respectively. During recovery, a significant proportion of patients had detectable obstructive (86%) and central (36%) events. Higher body mass index was associated with oxygen desaturation to <90% and with the need for escalation of care. Furthermore, a conscious sedation regimen that included propofol was significantly associated with central apneic events. CONCLUSION: Respiratory events are common during and immediately postprocedure after conscious sedation for bronchoscopy. Most events are obstructive, and the use of propofol predisposes to central apneas during the procedure. Both types of events are associated with a higher body mass index. Oxygen desaturation to <90% triggers escalation of care. A further prospective study will be required to determine the clinical significance of these apneic events and whether alleviating these events will improve the safety and outcomes of bronchoscopic procedures performed under conscious sedation.

Pseudotumor Cerebri Syndrome Without Headache in an Obese Male With Eight Restricted Cerebrospinal Fluid (CSF) Oligoclonal Bands: A Case Report.

Pseudotumor cerebri syndrome (PTCS) is a condition caused by an abnormal elevation of intracranial pressure (ICH), which may be primary (idiopathic intracranial hypertension) or because of an identifiable secondary cause. We present a rare case of an obese male who complained of gradual bilateral vision loss for one year without headaches and tinnitus. On fundoscopy, he had high-grade bilateral papilledema and, on lumbar puncture, he had an elevated intracranial pressure of 260 mmH2O. Cerebrospinal fluid (CSF) was unique for eight restricted oligoclonal bands while extensive other demyelinating workup was negative. He was started on acetazolamide initially and subsequently proceeded with bilateral optic nerve sheath fenestration (ONSF) with mild improvement in the right eye and no improvement in the left eye. Although the causative mechanism of PTCS is a matter of debate, immune-mediated processes are one of the proposed mechanisms that may play a role in the pathophysiology of PTCS, evidenced by the presence of oligoclonal bands (OCBs) and pro-inflammatory markers in CSF. PTCS diagnosed in men and patients with OCBs poses an increased risk of vision loss as this case and literature documented. Therefore, prompt treatment through therapeutic lumbar punctures, acetazolamide therapy concurrently with weight loss, and surgical intervention in severe or refractory cases are necessary.

A case of Cheyne-Stokes breathing emerging in a patient with atrial fibrillation and an implanted hypoglossal nerve stimulator.

Treatment emergent central sleep apnea (TECSA) can occur with positive airway pressure (PAP) therapy, mandibular advancement devices, and now recent cases with hypoglossal nerve stimulator (HNS) therapy during treatment for obstructive sleep apnea (OSA). There have been few published reports of Cheyne-Stokes breathing (CSB) emerging after implantation of an HNS. We present a case of a 76-year-old male with chronic atrial fibrillation and OSA who developed significant CSB after implantation of an HNS device. As popularity increases for alternative treatments of OSA, there should be close monitoring for emergence of CSB, especially in those who may have a propensity for high loop gain abnormalities contributing to central sleep apneas, such as patients with chronic atrial fibrillation. Further research is needed on CSA in patients with HNS implantation and atrial fibrillation, the prevalence of TECSA in the growing HNS therapy population, and the development of future management strategies. CITATION: Hong H, Oster J, Grover A, Ismail K. A case of Cheyne-Stokes breathing emerging in a patient with atrial fibrillation and an implanted hypoglossal nerve stimulator. J Clin Sleep Med. 2021;17(8):1731-1735.

The role of indocyanine green fluorescence in endoscopic endonasal skull base surgery and its imaging correlations.

OBJECTIVE: The use of endoscope-integrated indocyanine green (E-ICG) has recently been introduced in skull base surgery. The quantitative correlation between E-ICG and T1-weighted gadolinium-enhanced (T1WGd) images for skull base tumors has not been previously assessed, to the authors' knowledge. In this study, the authors investigated the indications for use and the limitations of E-ICG and sought to correlate the endoscopic fluorescence pattern with MRI contrast enhancement. METHODS: Following IRB approval, 20 patients undergoing endoscopic endonasal skull base surgery between June 2017 and August 2018 were enrolled in the study. Tumor fluorescence was measured using a blue color value and blood fluorescence as a control. Signal intensities (SIs) of tumor T1WGd images were measured and the internal carotid artery (ICA) SI was used as a control. For pituitary adenoma, the pituitary gland fluorescence was also measured. The relationships between ICG fluorescence and MRI enhancement measurements were analyzed. RESULTS: Data showed that in pituitary adenoma there was a strong correlation between the ratios of gland/blood fluorescence to gland/ICA SI (n = 8; r = 0.92; p = 0.001) and tumor/blood fluorescence to tumor/ICA SI (n = 9; r = 0.82; p = 0.006). In other pathologies there was a strong correlation between the ratios of tumor/blood fluorescence and tumor/ICA SI (n = 9; r = 0.74; p = 0.022). The ICG fluorescence allowed perfusion assessment of the pituitary gland as well as of the nasoseptal flaps. Visualization of the surrounding vasculature was also feasible. CONCLUSIONS: Defining the indications and understanding the limitations are critical for the effective use of E-ICG. Tumor fluorescence seems to correlate with preoperative MRI contrast enhancement.

Therapeutic efficacy of Honey and Nigella sativa against COVID-19: A multi-center randomized controlled clinical trial (HNS-COVID-PK)

BACKGROUNDNo definitive treatment exists for Coronavirus Disease 2019 (COVID-19). Honey and Nigella sativa (HNS) have established antiviral, antibacterial, anti-inflammatory and immunomodulatory properties. Hence, we investigated efficacy of HNS against COVID-19. wide METHODSWe conducted a multicenter, placebo-controlled, randomized clinical trial at 4 centers in Pakistan. RT-PCR confirmed COVID-19 adults showing moderate or severe disease were enrolled in the study. Patients presenting with multi-organ failure, ventilator support, and chronic diseases (except diabetes mellitus and hypertension) were excluded. Patients were randomly assigned in 1:1 ratio to receive either honey (1 gm/Kg/day) and Nigella sativa seeds (80 mg/Kg/day) or placebo up-to 13 days along with standard care. The outcomes included symptom alleviation, viral clearance, and a 30-day mortality in intention-to-treat population. This trial was registered with ClinicalTrials.gov, NCT04347382. RESULTSThree hundred and thirteen patients - 210 moderate and 103 severe - underwent randomization from April 30 to July 29, 2020. Among these, 107 were assigned to HNS whereas 103 to placebo for moderate cases. For severe cases, 50 were given HNS and 53 were given placebos. HNS resulted in [~]50% reduction in time taken to alleviate symptoms as compared to placebo (Moderate (4 versus 7 days), Hazard Ratio [HR]: 6.11; 95% Confidence Interval [CI]: 4.23-8.84, P<0.0001 and severe (6 versus 13 days) HR: 4.04; 95% CI, 2.46-6.64, P<0.0001). HNS also cleared the virus 4 days earlier than placebo group in moderate (6 versus 10 days, HR: 5.53; 95% CI: 3.76-8.14, P<0.0001) and severe cases (8.5 versus 12 days, HR: 4.32; 95% CI: 2.62-7.13, P<0.0001). HNS further led to a better clinical score on day 6 with normal activity resumption in 63.6% versus 10.9% among moderate cases (OR: 0.07; 95% CI: 0.03-0.13, P<0.0001) and hospital discharge in 50% versus 2.8% in severe cases (OR: 0.03; 95% CI: 0.01-0.09, P<0.0001). In severe cases, mortality rate was four-fold lower in HNS group than placebo (4% versus 18.87%, OR: 0.18; 95% CI: 0.02-0.92, P=0.029). No HNS-related adverse effects were observed. CONCLUSIONHNS significantly improved symptoms, viral clearance and mortality in COVID-19 patients. Thus, HNS represents an affordable over the counter therapy and can either be used alone or in combination with other treatments to achieve potentiating effects against COVID-19. FUNDINGFunded by Smile Welfare Organization, Shaikh Zayed Medical Complex, and Services Institute of Medical Sciences.

An approach for adaptive automatic threat recognition within 3D computed tomography images for baggage security screening.

BACKGROUND: The screening of baggage using X-ray scanners is now routine in aviation security with automatic threat detection approaches, based on 3D X-ray computed tomography (CT) images, known as Automatic Threat Recognition (ATR) within the aviation security industry. These current strategies use pre-defined threat material signatures in contrast to adaptability towards new and emerging threat signatures. To address this issue, the concept of adaptive automatic threat recognition (AATR) was proposed in previous work. OBJECTIVE: In this paper, we present a solution to AATR based on such X-ray CT baggage scan imagery. This aims to address the issues of rapidly evolving threat signatures within the screening requirements. Ideally, the detection algorithms deployed within the security scanners should be readily adaptable to different situations with varying requirements of threat characteristics (e.g., threat material, physical properties of objects). METHODS: We tackle this issue using a novel adaptive machine learning methodology with our solution consisting of a multi-scale 3D CT image segmentation algorithm, a multi-class support vector machine (SVM) classifier for object material recognition and a strategy to enable the adaptability of our approach. Experiments are conducted on both open and sequestered 3D CT baggage image datasets specifically collected for the AATR study. RESULTS: Our proposed approach performs well on both recognition and adaptation. Overall our approach can achieve the probability of detection around 90% with a probability of false alarm below 20%. CONCLUSIONS: Our AATR shows the capabilities of adapting to varying types of materials, even the unknown materials which are not available in the training data, adapting to varying required probability of detection and adapting to varying scales of the threat object.