Treatment with onion bulb extract both prevents and reverses allergic inflammation in a murine model of asthma.

CONTEXT: Asthma presents a global health challenge. The main pharmacotherapy is synthetic chemicals and biological-based drugs that are costly, and have significant side effects. In contrast, use of natural products, such as onion (Allium cepa L., Amaryllidaceae) in the treatment of airway diseases has increased world-wide because of their perceived efficacy and little safety concerns. However, their pharmacological actions remain largely uncharacterized. OBJECTIVE: We investigated whether onion bulb extract (OBE) can (1) reverse established asthma phenotype (therapeutic treatment) and/or (2) prevent the development of the asthma phenotype, if given before the immunization process (preventative treatment). MATERIALS AND METHODS: Six groups of male Balb/c mice were established for the therapeutic (21 days) and five groups for the preventative (19 days) treatment protocols; including PBS and house dust mite (HDM)-challenged mice treated with vehicle or OBE (30, 60, and 100 mg/kg/i.p.). Airways inflammation was determined using cytology, histology, immunofluorescence, Western blot, and serum IgE. RESULTS: Therapeutic (60 mg/kg/i.p.) and preventative (100 mg/kg/i.p.) OBE treatment resulted in down-regulation of HDM-induced airway cellular influx, histopathological changes and the increase in expression of pro-inflammatory signaling pathway EGFR, ERK1/2, AKT, pro-inflammatory cytokines and serum IgE. DISCUSSION AND CONCLUSION: Our data show that OBE is an effective anti-inflammatory agent with both therapeutic and preventative anti-asthma effects. These findings imply that onion/OBE may be used as an adjunct therapeutic agent in established asthma and/or to prevent development of allergic asthma. However, further studies to identify the active constituents, and demonstrate proof-of-concept in humans are needed.

Osteochondrolipoma of the foot treated by surgical excision: a case report and literature review.

BACKGROUND: Osteochondromas, classified as a new benign subtype of lipomas and characterised by chondroid and osseous differentiation, are rare lesions that have been infrequently reported in previous literature. The maxillofacial region was reported as the most frequent localization, with infrequent occurrence in the lower limb. This paper represents the first documented case report of osteochondrolipoma in the foot. CASE PRESENTATION: A 51-year-old male patient presented with a chief complaint of right foot pain at the plantar aspect, accompanied by the observation of swelling between the first and the second metatarsal shafts. His complaint of pain and swelling started 10 and 4 years prior, respectively. Since their onset, both symptoms have progressed in nature. Imaging revealved a large mass exhibiting a nonhomogenous composition of fibrous tissue and bony structures. Surgical intervention through total excision was indicated. CONCLUSION: Osteochodrolipoma is a benign lesion that can affect the foot leading to decreased functionality of the foot due to the pain and swelling. Surgical excision is the recommended approach for this lesion, providing both symptomatic relief and confirmation of the diagnosis through histopathological examination.

Avoidable emergency department visits among palliative care cancer patients: novel insights from Saudi Arabia and the Middle East.

BACKGROUND: Several studies emerging from developed countries have highlighted a significant number of potentially avoidable emergency department (ED) visits by cancer patients during the end-of-life period. However, there is a paucity of information from developing nations regarding palliative care practices and the utilization of the ED by palliative care patients. Herein, we aim to characterize ED admissions among patients receiving palliative care at our tertiary center in Saudi Arabia. METHODS: This is a retrospective, cross-sectional study evaluating ED visits amongst adult patients with advanced cancer who were receiving treatment under the palliative care department. This study took place over a period of 12 months from July 2021 through to July 2022. Three palliative care specialist physicians independently and blindly reviewed each patient's ED visits and determined whether the visit was avoidable or unavoidable. RESULTS: A total of 243 patients were included in the final analysis, of which 189 (78.1%) patients had unavoidable visits and 53 (21.9%) patient visits were classified as avoidable. A significantly higher proportion of breast cancer patients presented with unavoidable admissions (14.3% vs. 3.8%, P = 0.037) compared to other cancer types. The incidence of dyspnea (23.8% vs. 5.7%, P < 0.001) and fevers/chills (23.3% vs. 5.7%, P = 0.005) was significantly higher in patients with unavoidable visits. Patients with avoidable visits had a significantly greater proportion of visits for dehydration (13.2% vs. 2.1%, P = 0.002). Notably, although hospital stay was significantly longer in the unavoidable group (P = 0.045), mortality for palliative care patients-regardless of whether their ED visit was avoidable or unavoidable-was not statistically different (P=-0.069). CONCLUSION: To our knowledge, this is the largest and most comprehensive study from Saudi Arabia and the Middle East providing insights into the utilization of palliative care services in the region and the propensity of advanced cancer patients towards visiting the ED. Future studies ought to explore interventions to reduce the frequency of avoidable ED visits.

Perioperative Mortality and the Long-Term Outcome of Endovascular Abdominal Aneurysm Repair (EVAR): A Single-Centre Experience.

Background Abdominal aortic aneurysm (AAA) is a dangerous disorder characterised by abnormal enlargement of the abdominal aorta. The severity of the aneurysm and the presence of symptoms determine the necessary monitoring or treatment to prevent potential fatalities. The objective of this study is to estimate the perioperative mortality and long-term outcome of endovascular abdominal aneurysm repair (EVAR). Patients and methods This is a descriptive, retrospective, observational study. We retrieved the data of the AAA patients who underwent EVAR at Glan Clwyd Hospital from January 2015 to January 2023. The study sample consisted of patients diagnosed with isolated AAA, with or without iliac branch involvement, who were deemed suitable for EVAR based on factors such as advanced age, presence of comorbidities, the complexity of the condition, history of prior surgery, fulfillment of indication criteria, and patient desire. The data was analysed using SPSS statistical software, version 21.0 (IBM Corp., Armonk, NY). Results Two hundred and twenty-two patients were studied. The outcome of the EVAR among the patients was endo-leak 28.4% (n = 63); migration 1.4% (n = 3); blockage 0.5% (n = 1); infolding 0.5% (n = 1); perioperative mortality 1.4% (3); and other complications like access site or acute kidney injury were 1.4% (n = 3). However, no complications were reported in most of the patients, 66.7% (n = 148). Upon evaluating the variables that could affect the outcome, we observed that the ASA grade, comorbidities, and the indication of the intervention had a significant effect on the outcome (P values = 0.000, 0.048, and 0.014, respectively). Conclusion The findings demonstrate that when EVAR is performed by a skilled team adhering to proper criteria, the results are optimal. The mortality rate during the perioperative period was 1.4%. Furthermore, we have shown a satisfactory rate of complications when compared to international data.

Extracorporeal blood purification with Oxiris® filter in critically ill patients with COVID-19 requiring continuous renal replacement therapy.

INTRODUCTION: Severe COVID-19 is associated with a dysregulated immune response that usually leads to cytokine release syndrome. This study aimed to compare the use of extracorporeal blood purification therapy (Oxiris®) versus standard continuous renal replacement therapy (CRRT) in critically-ill patients with severe COVID-19. METHODS: This was a national, multicenter, retrospective study of patients with COVID-19 admitted to the intensive care unit (ICU) between March and October 2020 who required CRRT. Patients were categorized into two groups: Oxiris® CRRT and standard CRRT. The primary outcome was the number of patients alive and ventilator-free at 30-days post-CRRT treatment. Key secondary endpoints included change in inflammatory markers, Sequential Organ Failure Assessment (SOFA) scores, and PaO2/FiO2 ratio at 24- and 72-h post Oxiris® initiation. RESULTS: Thirty-five patients received Oxiris® CRRT and 23 patients received standard CRRT. The primary outcome was 31.4% in the Oxiris® group versus 4.3% in the standard CRRT group (adjusted odds ratio 5.97, 95% confidence interval [CI], 0.64-55.6; p = 0.117). In the Oxiris® group, interleukin-6 (IL-6) concentrations significantly decreased at 24 and 72-h (p = 0.033) and PaO2/FiO2 ratio significantly increased at 24 and 72 h after Oxiris® initiation (p = 0.001). There was no significant change in SOFA scores at 24- and 72-h after Oxiris® initiation. CONCLUSION: The number of patients alive and ventilator-free at 30-days was higher in the Oxiris® group than that in the standard CRRT group; however, the difference did not reach statistical significance after adjusting for the baseline severity of illness. There was a significant reduction in IL-6 and significant improvement in PaO2/FiO2 ratio after Oxiris® CRRT initiation.

Prospective utilization of boron nitride and beryllium oxide nanotubes for Na, Li, and K-ion batteries: a DFT-based analysis.

CONTEXT: In the present work, we investigated the adsorption mechanism of natural sodium (Na), potassium (K), and lithium (Li) atoms and their respective ion on two nanostructures: boron-nitride nanotubes (BNNTs) and beryllium-oxide nanotubes (BeONTs). The main goal of this research is to calculate the gain voltage for Na, K, and Li ionic batteries. Density function theory (DFT) calculations indicated that the adsorption energy between Na + is higher than that of the other cations, and this is particularly clear in the BeONT. Furthermore, gain voltage calculations showed that BNNTs generate a higher potential than BeONTs, with the most significant difference observed in BNNT/Na + . This research provides theoretical insights into the potential uses of these nanostructures as anodes in Na, K, and Li-ion batteries. METHOD: Density function theory used to compute the ground state properties for BeONT and BNNT with and without selected atoms and their ions (Li, K, and Na). B3LYP used for exchange correlation between electrons and ions, and 6-31G* basis set used for all atoms and ions. Gauss Sum 2.2 software used for estimate the density of state (DOS) for all structure under investigation.

Myths and facts about functional neurological disorders: a cross-sectional study of knowledge and awareness among medical students and healthcare professionals in Iraq.

Background: Functional neurological disorder (FND) is a complex condition with neurological symptoms but no clear structural or biochemical explanation. Myths and misconceptions about FND can lead to misdiagnosis and inappropriate treatment. This study aimed to assess knowledge and common myths about FND among medical students and practitioners. Methods: Data were collected from 324 participants using a structured questionnaire. The questionnaire included demographics, general information about FND and myths about FND. Data were analysed using non-parametric tests and Spearman's r for correlations. Results: The majority of participants were clinical-years medical students (65.1%) and female (59.6%). Overall, knowledge about FND was limited, with a mean score of 42.3% of correct answers. Common myths included the belief that FND is a psychological disorder and that patients feign symptoms. Knowledge scores differed significantly among different grades/experience levels, with postgraduate practitioners having the highest scores. There was a positive correlation between knowledge scores and confidence in managing FND. Conclusion: This study highlights the prevalence of myths and misconceptions about FND among medical students and practitioners, emphasising the need for accurate education to improve diagnosis and management. Healthcare professionals should take a biopsychosocial approach to FND, considering the complex interplay between biological, psychological and social factors. Efforts to increase awareness and reduce stigma associated with FND are crucial for promoting better care. Targeted educational interventions may be beneficial to improve the understanding and management of FND among medical professionals.

Molecular docking and dynamics simulation analysis of the human FXIIa with compounds from the Mcule database.

The human factor XIIa is a serine protease enzyme that is implicated in the pathological thrombosis. This coagulation factor represents an interesting molecular target to design safer antithrombotic agents without adversely influencing physiological hemostasis. Therefore, it is of interest to virtually screen the human factor XIIa crystal with millions of compounds in Mcule database in order to identify potential inhibitors. For this purpose, both molecular docking and dynamics simulation were employed to identify potential hits. Also, various predictive approaches were utilized to estimate chemical, pharmacokinetics and toxicological features for the top hits. As such, we report here that compound 4 (1-(4-benzylpiperazin-1-yl)-2-[5-(3,5-dimethylpyrazol-1-yl)-1,2,3, 4-tetrazol-2-yl]ethanone) may be a potential ligand against the human factor XIIa for further consideration in the design and development of novel antithrombotic agents.

Design and construction of multi epitope- peptide vaccine candidate for rabies virus.

Rabies virus is a zoonotic pathogen that causes lethal encephalitis with a case fatality rate of almost 100% in unvaccinated individuals. The currently available vaccines against rabies are composed of inactivated viral particles that only confer a short-term immune response. It is well-known that the entry of rabies virus into host cells is mediated by a trimeric glycoprotein presents on the surface of viral envelope. As the sole viral surface protein, this trimeric glycoprotein represents a promising molecular target to design new vaccines and neutralizing antibodies against rabies virus. Epitope mapping studies had identified several antigenic sites on the surface of trimeric pre-fusion glycoprotein of rabies virus. Therefore, it is of interest to screen the rabies virus glycoprotein by different web-based immuno-informatics tools to identify potential B-cells and T-cells linear epitopes. Here, we present a construct of peptide vaccine that consists of these predicted linear epitopes of rabies virus glycoprotein together with appropriate linkers and adjuvant. Various online prediction tools, molecular docking and dynamics simulation assume that the vaccine construct may be stable, safe and effective. However, validation of these in-silico results is necessary both in vitro and in vivo setting.

Role of endoscopic ultrasound and endoscopic ultrasound-guided tissue acquisition in diagnosing hepatic focal lesions.

BACKGROUND: Endoscopic ultrasonography (EUS) has become an established method in diagnostic and therapeutic procedures in gastroenterology; however, it has recently gained a growing role in hepatology. AIM: To evaluate the role of EUS features, strain elastography (SE), and EUS-tissue acquisition in diagnosing hepatic focal lesions (HFLs) that could affect further management. METHODS: This cross-sectional study included 215 patients with pancreatic, biliary, or gastrointestinal malignancies referred for EUS examination. HFLs were identified in 43 patients (20%), and EUS-guided tissue acquisition was performed from these lesions. RESULTS: EUS features were highly sensitive (100%) but much less specific (57%) in diagnosing HFLs; the overall accuracy was 94%. Real-time elastography was also very sensitive (97%) but less specific (67%) in diagnosing HFLs; however, the overall accuracy was 92%. EUS tissue acquisition was extremely sensitive (100%) and specific (100%), with a 100% overall diagnostic accuracy. CONCLUSION: The diagnostic utility of EUS-guided tissue acquisition was extremely accurate in diagnosing HFLs. EUS characteristics and real-time SE accurately predicted the histological diagnosis of both benign and malignant HFLs.

Thromboprophylaxis in Patients Admitted to the Surgical Ward: Clinical Audit.

Background: Hospital-acquired thrombosis (HAT) is associated with significant morbidity, mortality, and financial burden globally. Following trusted guidelines for VTE prevention has shown effective, safe, and satisfactory results. This prompts national collaborative efforts to maintain a consensus approach for the safe risk assessment of inpatients and the prescription of thromboprophylaxis. Objective: This study aimed to detect and estimate deviations from international thromboprophylaxis protocols. The study also aimed to raise the quality of practice and adherence to evidence-based protocols in Alshuhada Teaching Hospital. Methods: A cross-sectional audit of general surgical inpatients was performed from October 2021 to May 2022. The first cycle was from 1/10/2021 to 21/10/2021, and the second cycle was from 13/5/2022 to 31/5/2022. The target population was adults aged >18 years. Data were collected via an online checklist on two separate occasions. The criteria were based on the NICE guideline for venous thromboembolism in individuals aged over 16 years: "Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism NG89". Results: Forty-five surgical inpatients were included in this study: 20 in the first cycle and 25 in the second cycle. The first-cycle report showed that only 25% of VTE candidates received this regimen. In the second cycle, practice significantly improved, with 92% of admitted patients having their risk assessment tool completed within 24 h of admission. 79% of VTE prophylaxis candidates were prescribed adequate pharmacological prophylaxis within 14 h of admission. Conclusion: The rate of adequate thromboprophylaxis for inpatients undergoing surgery was very low before clinicians received education on VTE prevention, whereas was evidently high after they had received them. The cause of non-adherence in the pre-intervention phase was a lack of adequate knowledge regarding the magnitude and burden of HAT and the importance of thromboprophylaxis, which has a potential role in preventing the majority of HAT.

Eco-Physiological Responses of Avicennia marina (Forssk.) Vierh. to Trace Metals Pollution via Intensifying Antioxidant and Secondary Metabolite Contents.

Mangrove is one of the most precious ecosystems with the greatest losses due to climate change, human activities, and pollution. The objective of this study is to assess the accumulation and distribution of some trace metals (Cu, Cd, Ni, Pb, and Zn) in sediments and Avicennia marina roots and leaves and to discuss the antioxidant potential of A. marina under metallic pollution stress. Sediments, leaf, and root samples of A. marina were collected from five sites along the Red Sea Coast of Egypt. Several ecological pollution indices, including the geo accumulation index (Igeo), contamination factor (CF), pollution load index (PLI), bioconcentration factor (BCF), and translocation factor (TF), were used to assess the pollution load. Cu, Cd, Ni, Pb, and Zn average concentrations in sediments were 167.4, 0.75, 110.65, 39.79, and 220 µg g-1, respectively, and the average values of these metals in A. marina roots were 44.9, 0.5, 87.96, 39.02, and 54.68 µg g-1, respectively, while in leaves their concentration were 50.46, 0.5572, 88.24, 40.08, and 56.08 µg g-1, respectively. The values of the Igeo, CF, and PLI index indicated that location 1 and 5 are moderate-to-heavily contaminated sites. On the other hand, leaves and roots of A. marina grown in polluted locations 1 and 5 showed high accumulation of malondialdehyde (MDA), low chlorophyll a and chlorophyll b contents concomitant with a decrease in total soluble sugars. High total antioxidant capacity was associated with a significant increase in activity levels of antioxidant enzymes (Catalase, Polyphenol oxidase, Polyphenol peroxidase, and Ascorbic acid oxidase), accumulation of secondary metabolites (total phenols, flavonoids, and tannins), and proline and carotenoids content increase. Overall, the present study suggests that the mangrove habitat of the Egyptian Red Sea coast is under the stress of anthropogenic activities, which necessitates a conservation plan to avoid further contamination and protect the unique biota of this distinctive habitat.

Can the current monkeypox affect the heart? A systematic review of case series and case report.

BACKGROUND: Monkeypox is a zoonotic viral infection first reported in May 2022. Monkeypox cases present with prodromal symptoms, rash, and/or systemic complications. This study systematically reviews the monkeypox cases presented with any cardiac complications. METHODS: A systematic literature search was done to locate papers that discuss any cardiac complications associated with monkeypox; then, data were analyzed qualitatively. RESULTS: Nine articles, including the 13 cases that reported cardiac complications of the disease, were included in the review. Five cases previously had sex with men, and two cases had unprotected intercourse, which reveals the importance of the sexual route in disease transmission. All cases have a wide spectrum of cardiac complications, such as acute myocarditis, pericarditis, pericardial effusion, and myopericarditis. CONCLUSION: This study clarifies the potential for cardiac complications in monkeypox cases and provides avenues for future research to determine the underlying mechanism. Also, we found that the cases with pericarditis were treated with colchicine, and those with myocarditis were treated with supportive care or cardioprotective treatment (Bisoprolol and Ramipril). Furthermore, Tecovirimat is used as an antiviral drug for 14 days.

The Role of Sudanese Doctors in the United Kingdom in Mitigating COVID-19 Vaccine Hesitancy Among Their Diaspora Communities.

People from ethnic minority groups are at risk of adverse sequelae of COVID-19, but their vaccine acceptance and enrollment rates remain suboptimal. Diaspora communities are unique in that they continue to engage in epistemic networks related to vaccination with dwellers in their country of origin. We describe the COVID-19 vaccine awareness campaign we conducted from January 2021 to November 2021 for Sudanese diaspora groups in the United Kingdom and the various techniques and methods used by health care professionals from the same ethnocultural background to address vaccine reluctance among this cohort. We explore the impact of our joint efforts with local authorities in Sudan to overcome the initial barriers to the national vaccination program in Sudan. The influence of the intercommunication between the diaspora and their relatives at home regarding COVID-19 vaccine misinformation is also discussed. Finally, we highlight these observations as key areas for future research to improve the global impact of vaccine deployment in pandemic situations.

Nonalcoholic Fatty Liver Disease Predicts Acute Kidney Injury Readmission in Heart Failure Hospitalizations: A Nationwide Analysis.

Nonalcoholic fatty liver disease (NAFLD) has been associated with the progression of chronic kidney disease. However, limited data is available on its impact on acute kidney injury (AKI) in heart failure(HF) patients. All primary adult HF admissions from the national readmission database of 2016-2019 were identified. Admissions from July to December of each year were excluded to allow 6 months of follow-up. Patients were stratified according to the presence of NAFLD. Complex multivariate cox regression was used to adjust for confounders and calculate the adjusted hazard ratio. A total of 420,893 weighted patients admitted with HF were included in our cohort, of whom 780 had a secondary diagnosis of NAFLD. Patients with NAFLD were younger, more likely to be female, and had higher rates of obesity and diabetes mellitus. Both groups had similar rates of chronic kidney disease irrespective of the stage. NAFLD was associated with an increased risk of 6-month readmission with AKI (26.8% vs 16.6%, adjusted hazard ratio:1.44, 95% CI [1.14-1.82], P = 0.003). The mean time to AKI readmission was 150 ± 44 days. NAFLD was associated with a shorter mean time to readmission (145 ± 45 vs 155 ± 42 days, ß =  -10 days, P = 0.044). Our study from a national database suggests that NAFLD is an independent predictor of 6-months readmission with AKI in patients admitted with HF. Further research is warranted to validate these findings.

EVALUATION OF HYDROCORTISONE, VITAMIN C, AND THIAMINE FOR THE TREATMENT OF SEPTIC SHOCK: A RANDOMIZED CONTROLLED TRIAL (THE HYVITS TRIAL).

ABSTRACT: Purpose: The aim of the study is to evaluate the effect of combined hydrocortisone, vitamin C, and thiamine (triple therapy) on the mortality of patients with septic shock. Methods : This multicenter, open-label, two-arm parallel-group, randomized controlled trial was conducted in four intensive care units in Qatar. Adult patients diagnosed with septic shock requiring norepinephrine at a rate of ≥0.1 µg/kg/min for ≥6 h were randomized to a triple therapy group or a control group. The primary outcome was in-hospital mortality at 60 days or at discharge, whichever occurred first. Secondary outcomes included time to death, change in Sequential Organ Failure Assessment (SOFA) score at 72 h of randomization, intensive care unit length of stay, hospital length of stay, and vasopressor duration. Results: A total of 106 patients (53 in each group) were enrolled in this study. The study was terminated early because of a lack of funding. The median baseline SOFA score was 10 (interquartile range, 8-12). The primary outcomes were similar between the two groups (triple therapy, 28.3% vs. control, 35.8%; P = 0.41). Vasopressor duration among the survivors was similar between the two groups (triple therapy, 50 h vs. control, 58 h; P = 0.44). Other secondary and safety endpoints were similar between the two groups. Conclusion: Triple therapy did not improve in-hospital mortality at 60 days in critically ill patients with septic shock or reduce the vasopressor duration or SOFA score at 72 h. Trial Registration:ClinicalTrials.gov identifier: NCT03380507. Registered on December 21, 2017.

Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience.

Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.