Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

BACKGROUND: Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. METHODS: Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. RESULTS: Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. CONCLUSIONS: Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. CLINICAL IMPACT: The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Predictors of recurrence after paclitaxel drug-coated balloon use for treating femoropopliteal in-stent restenosis.

OBJECTIVE: Paclitaxel drug-coated balloon (PDCB) angioplasty has been shown to be an effective treatment of in-stent restenosis (ISR) at the femoropopliteal (FP) arteries. Long-term studies, however, have shown a progressive decrease in the patency rates following PDCB. The aim of this study was to determine the predictors of stenosis recurrence after PDCB treatment of FP-ISR, and its immediate and mid-term outcomes. METHODS: This prospective, non-randomized study included all chronic lower extremity ischemia patients of Rutherford class 3-6 who underwent PDCB angioplasty to treat >50% FP-ISR between June 2017 and December 2019. The primary endpoint was primary patency, defined as freedom from binary restenosis and freedom from clinically driven target lesion revascularization (CD-TLR) at 12 months. Secondary endpoints included 12-months freedom from CD-TLR and major adverse events (MAEs). RESULTS: A total of 73 symptomatic chronic limb ischemia patients (73 limbs including 63 with limb threatening ischemia) underwent PDCB angioplasty of FP-ISR lesions (13.7% Tosaka class I, 54.8% class II, and 31.5% class III). The mean ISR lesion length was 121.8 ± 52.7 mm. Technical success was achieved in 70 (95.9%) patients. Kaplan-Meier estimate of the 12-months rates of primary patency and freedom from CD-TLR was 76.1% and 87.4%, respectively. At one year, MAEs occurred in eight patients (11.0%) including two deaths (2.7%), one major amputation (1.4%), and six (8.2%) surgical revascularizations. Multivariable analysis showed that Tosaka class III ISR (HR 4.51, CI: 1.31-15.53, p < 0.001) and reference vessel diameter (HR 0.38, 95% CI: 0.18-080, p = 0.01) were independently associated with recurrent ISR. CONCLUSIONS: PDCB is safe and effective treatment of FP-ISR lesions. Occlusive ISR lesions and reference vessel diameter were independently associated with recurrent ISR stenosis after PDCB treatment.

Interleukin 4 and Interleukin 4 receptor alpha gene variants and risk of atopy - A case control study based assessment.

INTRODUCTION: IL4 pathway is known to upregulate IgE mediated immune responses and responsible for the manifestation of Atopic disorders. The current study was aimed to elucidate the genetic variations of Interleukin 4 (IL4) and Interleukin 4 receptor alpha (IL4R) genes and their possible association with atopic subjects. METHODS: The well-designed questionnaire was used to collect the subject demographic and clinical details. Biochemical parameters were analysed using Chemiluminescent Immunoassay (CLIA) technique. The genotyping was performed using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP). RESULTS: We observed a statistically significant difference of serum Immunoglobulin-E (IgE) levels among cases and controls (P<0.05). Subjects harbouring the variant genotypes of I50V and Q576R single nucleotide polymorphisms (SNPs) in IL4R gene showed statistically differential risk towards atopic disorders. However, the variants genotype of 70 bp VNTR polymorphism in IL4 gene showed a protective role towards in predisposition to Atopy. On stratification, the above genetic variants had a significant impact on modifiable and non-modifiable factors associated with the disease. CONCLUSION: Our study demonstrates that increased IgE levels and IL4 gene variants (I50V and Q576R) are significantly associated towards predisposition to allergic disorders in this study population.

Outcomes of infrageniculate retrograde versus transfemoral access for endovascular intervention for chronic lower extremity ischemia.

OBJECTIVE: Retrograde infrageniculate access is an alternative treatment strategy for patients who have failed to respond to antegrade endovascular intervention. This study compares the outcomes of infrageniculate retrograde arterial access with the conventional transfemoral access for the endovascular management of chronic lower extremity ischemia. METHODS: This was a retrospective single-center review of retrograde endovascular intervention (REI) from 2012 to 2016. Indications for intervention, comorbidities, complications, procedural success, limb outcomes, and mortality were analyzed. Technical failure was defined as the inability to complete the procedure because of failed access or unsuccessful recanalization. Infrageniculate access and transfemoral access were obtained with ultrasound or angiographic roadmap guidance. Patency rates were calculated for technically successful interventions. RESULTS: There were 47 patients (85% presenting with critical limb ischemia) who underwent sheathless REI after failed antegrade recanalization of TransAtlantic Inter-Society Consensus class D infrainguinal lesions, whereas 93 patients (83% with critical limb ischemia) underwent standard transfemoral access. There were 16 (34%) femoropopliteal, 14 (30%) tibial, and 17 (36%) multilevel interventions in the retrograde group compared with 41 (41%) femoropopliteal, 20 (20%) tibial, and 39 (39%) multilevel interventions in the transfemoral group. Access sites for the retrograde group included the dorsalis pedis (26%), midcalf peroneal (24%), anterior tibial (22%), posterior tibial (26%), and popliteal (2%) arteries. Overall technical success was achieved in 57% of the retrograde group compared with 78% of the transfemoral group. Mean follow-up was 20 months (range, 1-45 months). There were no significant differences in the primary patency rates between the two groups at 1 year and 2 years. The primary assisted patency rates were significantly better in the transfemoral group at 1 year (66% vs 46%; P = .031) and 2 years (56% vs 29%; P = .031). The secondary patency rates were higher in the transfemoral group at 1 year (93% vs 83%; P = .079) and 2 years (91% vs 76%; P = .079), although this did not reach statistical significance. The rate of reintervention was 41% for the retrograde group vs 40% for the transfemoral group. Most of the reinterventions (70% in the retrograde group and 61% in the transfemoral group) were endovascular interventions for a restenosis or occlusion. CONCLUSIONS: Infrageniculate access for REI can result in primary patency rates similar to those of antegrade interventions and does not compromise the access site. Technical failure is high in this initial experience and is mostly due to failed recanalization. Limb salvage may be achieved after technical failure with either repeated antegrade intervention or surgical bypass.

Vascular applications of contrast-enhanced ultrasound imaging.

OBJECTIVE: Contrast-enhanced ultrasound (CEUS) imaging is a powerful noninvasive modality offering numerous potential diagnostic and therapeutic applications in vascular medicine. CEUS imaging uses microbubble contrast agents composed of an encapsulating shell surrounding a gaseous core. These microbubbles act as nearly perfect intravascular reflectors of ultrasound energy and may be used to enhance the overall contrast and quality of ultrasound images. The purpose of this narrative review is to survey the current literature regarding CEUS imaging and discuss its diagnostic and therapeutic roles in current vascular and selected nonvascular applications. METHODS: The PubMed, MEDLINE, and Embase databases were searched until July 2016 using the PubMed and Ovid Web-based search engines. The search terms used included contrast-enhanced, microbubble, ultrasound, carotid, aneurysm, and arterial. RESULTS: The diagnostic and therapeutic utility of CEUS imaging has grown exponentially, particularly in the realms of extracranial carotid arterial disease, aortic disease, and peripheral arterial disease. Studies have demonstrated that CEUS imaging is diagnostically superior to conventional ultrasound imaging in identifying vessel irregularities and measuring neovascularization to assess plaque vulnerability and end-muscle perfusion. Groups have begun to use microbubbles as agents in therapeutic applications for targeted drug and gene therapy delivery as well as for the enhancement of sonothrombolysis. CONCLUSIONS: The emerging technology of microbubbles and CEUS imaging holds considerable promise for cardiovascular medicine and cancer therapy given its diagnostic and therapeutic utility. Overall, with proper training and credentialing of technicians, the clinical implications are innumerable as microbubble technology is rapidly bursting onto the scene of cardiovascular medicine.

Risk Factors for Long-Term Mortality and Amputation after Open and Endovascular Treatment of Acute Limb Ischemia.

BACKGROUND: Acute limb ischemia (ALI) is a highly morbid and fatal vascular emergency with little known about contemporary, long-term patient outcomes. The goal was to determine predictors of long-term mortality and amputation after open and endovascular treatment of ALI. METHODS: A retrospective review of ALI patients at a single institution from 2005 to 2011 was performed to determine the impact of revascularization technique on 5-year mortality and amputation. For each main outcome 2 multivariable models were developed; the first adjusted for preoperative clinical presentation and procedure type, the second also adjusted for postoperative adverse events (AEs). RESULTS: A total of 445 limbs in 411 patients were treated for ALI. Interventions included surgical thrombectomy (48%), emergent bypass (18%), and endovascular revascularization (34%). Mean age was 68 ± 15 years, 54% were male, and 23% had cancer. Most patients presented with Rutherford classification IIa (54%) or IIb (39%). The etiology of ALI included embolism (27%), in situ thrombosis (28%), thrombosed bypass grafts (32%), and thrombosed stents (13%). Patients treated with open procedures had significantly more advanced ischemia and higher rates of postoperative respiratory failure, whereas patients undergoing endovascular interventions had higher rates of technical failure. Rates of postprocedural bleeding and cardiac events were similar between both treatments. Excluding Rutherford class III patients (n = 12), overall 5-year mortality was 54% (stratified by treatment, 65% for thrombectomy, 63% for bypass, and 36% for endovascular, P < 0.001); 5-year amputation was 28% (stratified by treatment, 18% for thrombectomy, 27% for bypass, and 17% for endovascular, P = 0.042). Adjusting for comorbidities, patient presentation, AEs, and treatment method, the risk of mortality increased with age (hazard ratio [HR] = 1.04, P < 0.001), female gender (HR = 1.50, P = 0.031), cancer (HR = 2.19, P < 0.001), fasciotomy (HR = 1.69, P = 0.204) in situ thrombosis or embolic etiology (HR = 1.73, P = 0.007), cardiac AEs (HR = 2.25, P < 0.001), respiratory failure (HR = 2.72, P < 0.001), renal failure (HR = 4.70, P < 0.001), and hemorrhagic events (HR = 2.25, P = 0.003). Risk of amputation increased with advanced ischemia (Rutherford IIb compared with IIa, HR = 2.57, P < 0.001), thrombosed bypass etiology (HR = 3.53, P = 0.002), open revascularization (OR; HR = 1.95, P = 0.022), and technical failure of primary intervention (HR = 6.01, P < 0.001). CONCLUSIONS: After the treatment of ALI, long-term mortality and amputation rates were greater in patients treated with open techniques; OR patients presented with a higher number of comorbidities and advanced ischemia, while also experiencing a higher rate of major postoperative complications. Overall, mortality rates remained high and were most strongly associated with baseline comorbidities, acuity of presentation, and perioperative AEs, particularly respiratory failure. Comparatively, amputation risk was most highly associated with advanced ischemia, thrombosed bypass, and failure of the initial revascularization procedure.

Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia.

OBJECTIVE: Thrombolysis and open surgical revascularization are current options for the treatment of acute limb ischemia (ALI). Despite the several randomized controlled trials comparing the two options, no single treatment can yet be recommended as a universal initial management of ALI. The purpose of this study was to evaluate contemporary endovascular and surgical revascularization for ALI. METHODS: Consecutive patients with ALI treated with endovascular revascularization (ER) or open revascularization (OR) between 2005 and 2011 were identified and reviewed. Procedural success and outcomes were compared between the two groups. Limb salvage and survival were assessed by time-to-event methods, including Kaplan-Meier estimation and competing-risks regression models. RESULTS: A total of 154 limbs were treated in 147 patients in the ER group, compared with 326 limbs in 296 patients in the OR group. The mean follow-up was 14 ± 18.5 months. The majority of patients presented with Rutherford II ischemia (83% for OR, 90% for ER). In Rutherford II patients, technical success was achieved in 90.7% of the OR group vs 79.9% of the ER group (P = .002), with amputation rates of 10.0% vs 7.2% (P = .35) at 30 days and 16.3% vs 13.0% (P = .37) at 1 year, respectively. In Rutherford II patients with failed bypass graft, technical success rate was 95.0% (OR) vs 75.0% (ER) (P = .001), whereas the amputation rate was 6.3% vs 15.38% (P = .13) at 30 days and 24.1% vs 23.1% (P = .90) at 1 year, respectively. The overall 30-day mortality rate was 13.2% (OR) and 5.4% (ER) (P = .012). Overall amputation rates were 13.5% (OR) vs 6.5% (ER) at 30 days (P = .023) and 19.6% (OR) vs 13.0% (ER) at 1 year (P = .074). The primary patency rate was 57% (OR) and 51% (ER) at 1 year (P = .74). Predictors of limb loss by life-table analysis included coronary artery disease (hazard ratio [HR], 2.0; P = .007) and Rutherford category III (HR, 19.0; P < .001). Predictors of death by life-table analysis included age (HR, 1.03; P < .001), end-stage renal disease (HR, 7.28; P < .001), cancer (HR, 1.65; P = .005), and chronic obstructive pulmonary disease (HR, 1.61; P = .005). CONCLUSIONS: In patients presenting with class II ALI, ER or surgical OR resulted in comparable limb salvage rates. Although technical success is higher with OR for patients presenting with failed bypass grafts, the amputation rates are comparable. Overall mortality rates are significantly higher at 30 days and 1 year in the OR group.

Contemporary outcomes of endovascular interventions for acute limb ischemia.

OBJECTIVE: Thrombolysis as a treatment for acute limb ischemia (ALI) has become a first-line therapy based on studies published over 2 decades ago. The purpose of this study was to assess outcomes of patients treated for ALI using contemporary thrombolytic agents and endovascular techniques. METHODS: Consecutive patients with ALI of the lower extremities treated between 2005 and 2011 were identified, and their records were retrospectively reviewed. All patients were treated with tissue plasminogen activator delivered via catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombolysis (PMT), with other adjunctive endovascular or surgical interventions. Procedural success, thrombolysis duration, and 30-day and long-term outcomes were obtained for the whole series and were also compared between the CDT and PMT groups. Limb salvage and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models. RESULTS: A total of 154 limbs were treated in 147 patients presenting with ALI (Rutherford class I, 9.7%; class IIa, 70.1%; class IIb, 20.1%). The mean follow-up was 15.20 months (range, 0.56-56.84 months). Indications for intervention included embolization (14.3%), thrombosed bypass (36.4%), thrombosed stent (26.6%), native artery thrombosis (24.0%), and thrombosed popliteal aneurysm (3.2%). Technical success was achieved in 83.8% of cases, with a 30-day mortality rate of 5.2%. Procedural complications included systemic bleeding (5.2%), access site hematoma (4.5%), acute renal failure (1.9%), and distal embolization (9.7%). The mean runoff score decreased from 13.42 preintervention to 7.43 postintervention. Adjuvant revascularization procedures were required in 89.0% of patients and were endovascular (68.8%), hybrid (9.1%), or open (11.0%). Only 3.2% of patients required a fasciotomy. The overall rate of major amputation was 15.0% (18.1% for CDT only, 11.3% for PMT; P = NS). Predictors of limb loss by Cox proportional hazards models included end-stage renal disease (hazard ratio [HR], 8.563; P < .001) and poor pedal outflow, with an incremental protective effect for improved pedal outflow (HR, 0.205; P < .001 for one pedal outflow vessel; HR, 0.074; P < .001 for ≥ two pedal outflow vessels). Gender, smoking, diabetes, Rutherford score, runoff score, thrombosed popliteal aneurysm, and PMT were not significant predictors of limb loss. The use of PMT was a significant predictor of technical success (odds ratio, 2.67; P = .046). CONCLUSIONS: Endovascular therapy with thrombolysis using tissue plasminogen activator remains an effective treatment option for patients presenting with mild or moderate lower extremity ALI, with equal benefit derived with CDT or PMT. Patients with end-stage renal disease or poor pedal outflow have an increased risk of limb loss and may benefit from alternative revascularization strategies.

Comprehensive analysis of adverse events associated with transmural use of LAMS in patients with liver cirrhosis: International multicenter study.

Background and study aims Endoscopic ultrasound (EUS)-guided transmural (TM) deployment of lumen-apposing metal stents (LAMS) is considered relatively safe in non-cirrhotic patients and is cautiously offered to cirrhotic patients. Patients and methods This was a retrospective, multicenter, international matched case-control study to study the safety of EUS-guided TM deployment of LAMS in cirrhotic patients. Results Forty-three cirrhotic patients with model for end-stage liver disease score 12.5 ± 5, with 23 having ascites and 16 with varices underwent EUS-guided TM LAMS deployment, including 19 for pancreatic fluid collection (PFC) drainage, 13 gallbladder drainage, six for endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP), three for EDGI, one for endoscopic ultrasound-directed transenteric ERCP, and one postsurgical collection drainage. Technical failure occurred in one LAMS for PFC drainage. Clinical failure was encountered in another PFC. Nine adverse events (AEs) occurred. The most common AE was LAMS migration (3), followed by non-bleeding mucosal erosion (2), delayed bleeding (2), sepsis (1), and anesthesia-related complication (pulseless electrical activity) (1). Most AEs were graded as mild (6), followed by severe (2), and moderate (1); the majority were managed conservatively. On univariable comparison, risk of AE was higher when using a 20 × 10 mm LAMS and the absence of through-the-LAMS plastic stent(s). Conditional logistic regression of matched case-control patients did not show any association between potential predicting factors and occurrence of AEs. Conclusions Our study demonstrated that mainly in patients with Child-Pugh scores A and B cirrhosis and despite the presence of mild-to-moderate ascites in over half of cases, the majority of AEs were mild and could be managed conservatively. Further studies are warranted to verify the safety of LAMS in cirrhotic patients.

Duplex-Guided Ipsilateral Antegrade Approach for Flush Superficial Femoral Artery Occlusion.

OBJECTIVE: Recanalization of flush ostial superficial femoral artery (SFA) occlusion is a very challenging procedure. Using the ipsilateral antegrade approach in such lesions has some difficulties. This study aimed to assess the feasibility, efficacy, and outcomes of duplex-guided ipsilateral antegrade access for endovascular treatment of atherosclerotic flush occlusion of the SFA. METHODS: This is a prospective two-center study that included chronic lower extremity ischemia patients with flush occlusion of SFA who underwent duplex-guided ipsilateral antegrade endovascular revascularization due to unfeasible contralateral femoral approach. Flush occlusions were preoperatively documented by duplex ultrasound and computed tomography angiography in all patients. The outcome measures were technical success, patency rates, perioperative morbidity and mortality, limb salvage, and amputation free survival rates. RESULTS: Between April 2019 and March 2021, 49 patients were enrolled in the current study with a mean age of 63.7 ± 5.7 years. Diabetes was the most common risk factor and was found in 40 (81.6%) patients. Associated popliteal lesions were found in seven (14.3%) patients, while 10 (20.4%) patients had combined tibial disease. Selective stenting was done in nine (18.4%) patients. Technical success was achieved in 43 (87.8%) patients. All failures were due to inability to cross the lesion rather than failure to access the common femoral artery. All complications were minor and occurred in seven (14.3%) patients. Primary, assisted primary, and secondary patency rates were 63.9% ± 7.1%, 82.8% ± 5.6%, and 93.5% ± 3.7% at 12 months, respectively. The overall 12-month limb salvage and amputation free survival rates were 91.8% and 83.3% ± 5.4%, respectively. CONCLUSION: Duplex-guided ipsilateral antegrade femoral access is a feasible, safe, and effective endovascular treatment option for flush SFA occlusion when contralateral femoral access is not possible.

A challenging case of pancreaticogastric anastomotic stricture in a patient with surgically altered anatomy.

Video 1EUS-guided gastro-jejunostomy using a lumen-apposing metal stent to access the surgical pancreaticogastric anastomotic site and perform EUS-guided de novo pancreatico-gastrostomy for the management of a postsurgical pancreaticogastric anastomotic stricture with pancreatic insufficiency.

Full-thickness resection device for management of lesions involving the appendiceal orifice: Systematic review and meta-analysis.

Background and study aims Endoscopic resection of lesions involving the appendiceal orifice is technically challenging and is commonly referred for surgical resection. However, post-resection appendicitis is a concern. Many studies have varying rates of post-procedure appendicitis. We aim to report the rate of post-resection appendicitis by performing a systematic review and meta-analysis. Methods Studies that involved the use of a full-thickness resection device (FTRD) for management of appendiceal polyps were included. The primary outcome was appendicitis after FTRD and a subgroup analysis was performed on studies that only included FTRD performed at the appendiceal orifice. Results Appendicitis was encountered in 15% (95%CI: [11-21]) of the patients with 61% (95% CI: [44-76]) requiring surgical management. Pooled rates of technical success, histologic FTR, and histologic R0 resection in this sub-group (n=123) were 92% (95% CI: [85-96]), 98% (95% CI: [93-100]), and 72% (95% CI: [64-84%]), respectively. Post-resection histopathological evaluation revealed a mean resected specimen size of 16.8 ± 5.4 mm, with non-neoplastic pathology in 9 (7%), adenomas in 103 (84%), adenomas + high-grade dysplasia (HGD) in nine (7%), and adenocarcinoma in two (2%). The pooled rate for non-appendicitis-related surgical management (technical failure and/or high-risk lesions) was 11 % (CI: 7-17). Conclusions FTRD appears to be an effective method for managing appendiceal lesions. However, appendicitis post-resection occurs in a non-trivial number of patients and the R0 resection rate in appendiceal lesions is only 72%. Therefore, caution should be employed in the use of this technique, considering the relative risks of surgical intervention in each patient.

Evaluation of SOCS5 mRNA and its association with serum IL-12 levels and rs41379147 SNP in various subsets of allergic disorders: A case control study.

BACKGROUND: The SOCS proteins act as suppressors of cytokine signaling by impeding certain signaling pathways. SOCS5, a constituent of the SOCS family, has been associated with the management of allergic reactions, primarily by impeding the signaling of interleukin-4 (IL-4), which is known to have a cardinal function in accelerating the development of an allergic reaction. The key goal of our research was to explore the probable ramifications of the SOCS5 single nucleotide polymorphism (SNP) namely rs41379147 on the expression of SOCS5 mRNA and serum IL-12 levels, as well as to analyze the interaction between SOCS5 genotypes and various clinicopathological parameters in atopic diseases. METHODS: The study involved the enrollment of 314 subjects comprising 154 atopic individuals and 160 healthy controls. PCR-RFLP was employed to conduct SNP analysis. Real-Time PCR was employed to quantify SOCS5 mRNA. The enzyme-linked immunosorbent assay (ELISA) technique was used for the quantification of interleukin-12 and total IgE levels in the serum while as chemiluminescence was used to determine Vitamin D levels. RESULTS: The PCR-RFLP analysis indicated a lack of statistically significant variation in genotypic and allelic frequencies between the cases and controls (p > 0.05) for - 9147 C/T SNP either in total atopy (OR-0.70, 95% CI=0.43-1.12, p =0.15), and on subgroup stratifications of chronic urticaria (OR-0.81, 95 % CI = 0.42-1.59, p = 0.61), allergic rhinitis (OR-0.63, 95 % CI = 0.33-1.19, p = 0.16) and bronchial asthma (OR-0.66,95% CI = 0.29-1.4, p=0.32). There was reduced mRNA expression of SOCS5 in total atopic cases, allergic rhinitis, bronchial asthma and chronic urticaria in comparison to controls which advocates the fact that SOCS5 has a protective role in allergic disease development. Despite the reduced amounts of IL-12 in total atopic cases and different allergic disorders in comparison to controls, IL-12 showed significant positive correlation with SOCS5 mRNA expression (p < 0.05). CONCLUSION: SOCS5 SNP rs41379147(C/T) does not pose any significant risk towards the development of any allergic disorder and has no impact on the expression of SOCS5 and IL-12. Our study has shown the reduced mRNA expression of SOCS5 among individuals diagnosed with chronic urticaria, allergic rhinitis and bronchial asthma and the expression of SOCS5 showed complete dependence on the cytokine milieu of IL12. The modulation of SOCS5 and IL-12 may represent potential curative targets for treating the menace of allergic diseases and present promising avenues for future investigation.

Surgical Site Bacterial Infection in a General Hospital, Al-Jouf Region, Saudi Arabia: A Retrospective Study.

Background Surgical site infection (SSI) is a major healthcare problem with a great impact on patient morbidity, mortality, and healthcare cost all over the world. It accounts for 20% of healthcare-associated infections (HAIs), with higher frequency in low- and middle-income countries where it affects about 30% of the patients undergoing surgery. Aim The current study aims to assess the prevalence of SSI in a general hospital in Sakaka, Al-Jouf region, Saudi Arabia. The types of bacteria causing SSI were also determined. Subjects and methods A retrospective cross-sectional study was done by reviewing the hospital records of patients who got SSI during the period between 2020 and 2022. Data collection was done during 2022 and 2023 after taking ethical approval and permission from the hospital management. Results The number of patients who underwent surgical procedures during 2020, 2021, and 2022 were 689, 867, and 1119, respectively. Most of the cases were cholecystectomy and appendectomy. The cases that developed surgical site infection after cholecystectomy and/or appendectomy during 2021 and 2022 were 15.45% and 9.29% cases, respectively, and they were mainly associated with appendectomy. A culture and sensitivity test revealed methicillin-resistant Staphylococcus aureus (MRSA) and Klebsiella pneumonia. Nearly all patients have received ciprofloxacin for seven days and improved with treatment. Conclusion The number of cases that developed SSI has decreased gradually due to the application of infection control measures and strict follow-up.

Nonlinear saturation controller simulation for reducing the high vibrations of a dynamical system.

This paper studies the nonlinear vibrating behaviour of a nonlinear cantilever beam system (primary system) using a nonlinear absorber (the secondary system). The nonlinear vibrating behavior for the present dynamical system is considered with the effect of the external force. The one controller type, nonlinear saturation controller (NSC), is introduced to decrease the vibration of this system. Perturbation method treatment is produced to get the mathematical solution of the equations for the dynamical modeling with NSC. The perturbation technique is used to obtain the approximate solution of the dynamical system. This research focuses on resonance case with primary and 1:2 internal resonance. Time histories of the primary system and the controller are shown to demonstrate the reaction with and without control. The time-history response, as well as the impacts of the parameters on the system and controller, are simulated numerically using the MATLAB program. Routh-Hurwitz criterion is used to examine the stability of the system under primary resonance. A numerical simulation, using the MATLAB program, is obtained to show the time-history response, the effect of the parameters on the system and the controller. The effects of system parameters on the performance of the primary system and the controller are investigated. A comparison between all the obtained solutions made to confirm the results. Validation curves are provided to show how closely the perturbation and numerical solutions are related. A comparison is made with recently released papers.

Safety and Efficacy of Hybrid Angiography in Chronic Lower Extremity Ischemia Patients at Risk of Contrast-Induced Acute Kidney Injury.

AIM: The aim of the study was to assess the feasibility and safety of hybrid angiography consisting of carbon dioxide (CO2) angiography supplemented by small doses of iodinated contrast medium (ICM) in the endovascular treatment of chronic limb threatening ischemia (CLTI) patients with pre-existing chronic kidney disease (CKD). PATIENTS AND METHODS: This prospective study comprised all non-dialysis-dependent CKD patients presenting for endovascular management of CLTI. All endovascular interventions were done using CO2 as a contrast medium whether alone or supplemented by ICM (hybrid angiography) to treat unilateral arterial steno-occlusive lesions of iliac, femoropopliteal, or BTK arteries. Study outcomes included feasibility of the device, technical success, and freedom from contrast-induced acute kidney injury (CI-AKI), renal replacement therapy, and CO2 angiography-related complications. RESULTS: A total of 206 CKD patients underwent endovascular intervention using CO2 only as a contrast medium (159 patients, 77.2%), or hybrid CO2-ICM angiography (47 patients, 22.8%). The overall technical success was 95.6%. Patients were followed up for a mean period of 17.9 ± 4.6 months. The mean volumes of CO2, and ICM consumption were 200.7 ± 95.1 mL, and 11.8 ± 4.4 mL, respectively. The mean procedural, and fluoroscopy times were 95.6 ± 12.5 and 49.5 ± 10.8 minutes, respectively. BTK lesions were significantly associated with the need for hybrid angiography (P = <.0001). The mean pre- and postoperative serum creatinine levels were comparable (P = .08). Two patients (4.3%) showed transient manifestations of CI-AKI, but neither required renal replacement therapy. No statistically significant differences were encountered between the two study groups regarding procedure outcomes. CONCLUSION: Hybrid CO2-ICM angiography is safe, feasible, effective, and a fairly simple alternative during endovascular interventions to treat chronic lower extremity ischemia. Using supplemental small volumes of ICM to overcome the suboptimal images generated by CO2 alone does not jeopardize the renal functions in CKD patients.

Simultaneous determination of ofloxacin and bromfenac in combined dosage form using four different spectrophotometric methods.

Four simple, precise, accurate and validated spectrophotometric methods have been developed for the simultaneous determination of ofloxacin (OFL) and bromfenac sodium (BROM). Firstly, first and second derivative spectrophotometric methods (1D &2D) using a zero-crossing technique utilizing 309.3 and 257.5 nm for OFL and 290.7 and 246.5 nm for BROM as optimum working wavelengths in a binary mixture, respectively. Secondly, the first derivative ratio spectrophotometric method (1DD) in which peak amplitudes at 297.3 nm and 260.7 nm were chosen to simultaneously estimate OFL and BROM, respectively. Thirdly, dual wavelength (DW) method based on two selected wavelengths for each drug in such a way that the difference in absorbance is zero for the second one. At wavelengths 296.4, 348.4 nm BROM has equal absorbance values, therefore, these two wavelengths have been used to determine OFL. Similarly, 271.7 nm and 313.1 nm were selected to determine BROM in the combined formulation. Finally, the fourth method depends on ratio difference spectrophotometry (RDSM), in which the difference between amplitudes at 305.6 nm and 326.5 nm on the ratio spectrum of the mixture was directly proportional to the concentration of OFL; independent of the interfering components. Similarly, the difference between amplitudes at 265.1 nm and 275.4 nm on the ratio spectrum was used for the determination of BROM. The linearity was confirmed in the range of 4 - 18 µg/ml for OFL and BROM for the four methods. The proposed methods were used to determine both drugs in their laboratory prepared mixture and combined formulation with mean percentage recoveries of 99.41 ± 1.35% for OFL and 99.98 ± 1.30 % for BROM in method (A). In method (B), the mean percentage recoveries were 101.70 ± 1.61% for OFL and 101.90 ± 1.45% for BROM. In method (C) OFL was 99.57 ± 1.61% and 100.90 ± 1.62% for BROM. Finally, in method (D) the mean percentage recoveries were 99.37 ± 1.67% for OFL and 100.70 ± 1.59% for BROM. The developed methods were successfully employed for determination of OFL and BROM in laboratory prepared mixtures and combined formulation showing satisfactory recoveries. Methods validation was performed according to the International Conference on Harmonization (ICH) guidelines. The obtained results conformed to the accepted ranges of recovery, precision and repeatability.

Atopy in Kashmir-validation from a case control study with respect to IgE and Interleukin genes.

OBJECTIVES: Increased levels of serum Immunoglobulin-E (IgE) and different genetic variants of cytokines are common biochemical manifestation in Allergy. The current study was aimed to study the association of IgE and different variants of Interleukin-4 (IL-4), and Interleukin-13 (IL-13) genes with different kind of allergies. METHODS: A pre-tested questionnaire was used to collect all the dietary, life style and clinical details by a trained staff. A blood sample of 2 ml each was collected in coagulated and anti-coagulated vials. DNA and serum samples were extracted and stored until further use. Serum IgE were estimated by ELISA while as the genotypic analysis was done by PCR-RFLP methods. RESULTS: Statistically a significant difference of serum IgE levels were observed among cases and controls (P < 0.05). The observed significant difference of serum IgE levels were retained among subjects who also harboured variant genotypes of IL-4 and IL-13 genes (P < 0.05). Additionally, the above genetic variants significantly modified the risk of allergy when stratification was done based on various clinical characteristics. CONCLUSION: Our study suggests that increased IgE levels and in association with variant forms of IL-4 and IL-13 genes are significantly associated with different types of allergies in study population.

A comparison of carotid surgery in northern Europe and northern Africa.

BACKGROUND: Although the indications for carotid endarterectomy (CEA) are clearly defined by major trials, CEA has not been properly implemented in many developing regions, including Northern Africa represented in this study by Upper Egypt. This study was designed to estimate the need for CEA in symptomatic patients with significant internal carotid artery stenosis in Upper Egypt. The estimated needs and actual provision of CEA in Upper Egypt were compared with those of Uusimaa (Finland) and Wessex (England) regions, representing Northern Europe. METHODS: Incidence rates were derived from a community-based door-to-door survey in Upper Egypt, Oxford Community Stroke Project, and epidemiological Finnish studies. The provision of CEA was derived from the local registry of Vascular Surgery Department, Assiut University Hospitals in Upper Egypt; HUSVASC data registry at Helsinki University Central Hospital, and the published data of the Wessex region. The estimated needs were calculated using previously published proportions of patients eligible for CEA. RESULTS: The population at risk of cerebral ischemic events (>or=65 years old) is 4% of the Egyptian population compared with 16% and 15% of the British and Finnish populations, respectively. The incidence of stroke and transient ischemic attack (TIA) is comparable in England and Finland but higher than the Egyptian rates (1.9 per thousand and 2.1 per thousand vs. 1.2 per thousand for stroke; 0.5 per thousand and 0.6 per thousand vs. 0.2 per thousand for TIA, respectively). The ratio of the actual provision of CEA to the estimated need in Wessex and Uusimaa is the same (0.5), whereas it is much lower (0.003) in Upper Egypt. CONCLUSIONS: Despite the low incidence of stroke and TIA, there is a huge unmet need for CEA in Upper Egypt. Yet, Wessex and Uusimaa also seemed to be at a suboptimal level compared with the estimated need. If CEA could be offered annually to those 1,650 patients with severe symptomatic ICA stenosis, 275 strokes could be prevented in Upper Egypt in 5-year duration, provided that the operative morbidity and mortality rates are equal to those reported in the large, randomized, controlled trials.

Prediction of the final size for COVID-19 epidemic using machine learning: A case study of Egypt.

COVID-19 is spreading within the sort of an enormous epidemic for the globe. This epidemic infects a lot of individuals in Egypt. The World Health Organization states that COVID-19 could be spread from one person to another at a very fast speed through contact and respiratory spray. On these days, Egypt and all countries worldwide should rise to an effective step to investigate this disease and eliminate the effects of this epidemic. In this paper displayed, the real database of COVID-19 for Egypt has been analysed from February 15, 2020, to June 15, 2020, and predicted with the number of patients that will be infected with COVID-19, and estimated the epidemic final size. Several regression analysis models have been applied for data analysis of COVID-19 of Egypt. In this study, we've been applied seven regression analysis-based models that are exponential polynomial, quadratic, third-degree, fourth-degree, fifth-degree, sixth-degree, and logit growth respectively for the COVID-19 dataset. Thus, the exponential, fourth-degree, fifth-degree, and sixth-degree polynomial regression models are excellent models specially fourth-degree model that will help the government preparing their procedures for one month. In addition, we have applied the well-known logit growth regression model and we obtained the following epidemiological insights: Firstly, the epidemic peak could possibly reach at 22-June 2020 and final time of epidemic at 8-September 2020. Secondly, the final total size for cases 1.6676E+05 cases. The action from government of interevent over a relatively long interval is necessary to minimize the final epidemic size.