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BACKGROUND: Immune paralysis can be defined as a hypoinflammatory state associated with the incapacity of the immune system to release proinflammatory mediators despite the clearance of pathogens by antimicrobials. Persistent immune paralysis leads to failure to eradicate primary infections with a substantial increase in the risk of multiorgan dysfunction and mortality. The state of immune paralysis is caused mainly by the diminished ability of monocytes to release proinflammatory cytokines in response to endotoxin. This phenomenon is known as endotoxin tolerance. This study aimed to assess the role of dexmedetomidine in modifying immune paralysis in septic shock patients. METHODS: Twenty-four patients with septic shock were randomized into two groups of 12 patients. A continuous intravenous infusion of dexmedetomidine started at 0.15 µg kg-1 hr-1 and adjusted by 0.15 µg kg-1 h-1 to a maximum of 0.75 µg kg-1 h-1 (10 ml h-1), while midazolam was started at 1 mg h-1 (2 mL hr-1) and adjusted by 1 mg h-1 to a maximum of 5 mg h-1 (10 mL h-1). All infusions were adjusted by increments of 2 mL/hr-1 to maintain blinding. Serum levels of CD42a+/CD14+, HLADR+/CD14+, CRP, IL-6, IL-10 and TNF-α were measured at baseline (T1), 12 h (T2), and 24 h (T3). RESULTS: Treatment with dexmedetomidine yielded no significant difference in CD42a+/CD14+, HLADR+/CD14, CD24b-MFI, HLADR-MFI, IL6 and TREM1 at all time points when compared with midazolam treatment. There was no significant difference in TLR levels between the two groups. Cardiac output in the dexmedetomidine group showed a significant decrease at 6, 12 and 24 h (P = 0.033, 0.021, and 0.005, respectively) compared with that in the midazolam group. CONCLUSION: Our results indicated that dexmedetomidine did not affect CD42a+/CD14+ and HLA-DR+/CD14+ expression in septic patients. Furthermore, cytokine production and inflammatory biomarkers did not change with dexmedetomidine infusion. Trial registration Clinical trial.gov registry (NCT03989609) on June 14, 2019, https://register. CLINICALTRIALS: gov .

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In this paper, two sector beam scanning approaches (BSAs) based on element position perturbations (EPPs) in the azimuth plane are introduced. In EPP-BSA, the elements' excitations are kept constant and the elements' positions in the direction normal to the array line are changed according to a predetermined EPP pattern. The magnitude and repetition rate of the selected EPP pattern determines the steering angle of the main beam. However, EPP-BSA results in a wide scanning range with a significant increase in the side lobe level (SLL). To mitigate this drawback, a reduction in the SLL of the array pattern is firstly performed using the single convolution/genetic algorithm (SC/GA) technique and then perturbing the elements' positions in the azimuth plane. This combination between SLL reduction and EPP-BSA (SLL/EPP-BSA) results in a smaller scanning range with a relatively constant half power beamwidth (HPBW) and a much lower SLL. In addition, keeping the synthesized excitation coefficients constant without adding progressive phase shifters facilitates the manufacturing process and reduces the cost of the feeding network. Furthermore, a planar antenna array thinning approach is proposed to realize the EPP-BSA. The results are realized using the computer simulation technology (CST) microwave studio software package, which provides users with an optimized modeling environment and results in realizable and realistic designs.

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INTRODUCTION: Latent iron deficiency (LID), in which iron stores in the body are depleted without incidental anemia, poses a key diagnostic challenge. Reticulocyte hemoglobin content (Ret-Hb) is directly correlated with the functionally available iron for heme synthesis in erythroblasts. Consequently, Ret-Hb has been proposed as an efficient iron status marker. AIM: To assess the importance of Ret-Hb in detecting latent iron deficiency as well as its use in screening for iron deficiency anemia. MATERIALS AND METHODS: A study involving 108 individuals was conducted at Najran University Hospital, 64 of whom had iron deficiency anemia (IDA) and 44 of whom had normal hemoglobin levels. All patients were subjected to complete blood count (CBC), reticulocyte percentage, Ret-Hb, serum iron, total iron binding capacity (TIBC), and serum ferritin measurements. RESULTS: A significant decrease in Ret-Hb level was observed in IDA patients compared to non-anemic individuals, with a cut-off value of 21.2 pg (a value below which indicates IDA). CONCLUSION: The measurement of Ret-Hb, in addition to CBC parameters and indices, provides an accessible predictive marker for both iron deficiency (ID) and IDA. Lowering the Ret-Hb cut-off could better allow for its use as a screening parameter for IDA.

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OBJECTIVES: To investigate the impact of COVID-19 on the well-being of surgeons and allied health professionals as well as the support provided by their institutions. DESIGN: This cross-sectional study involved distributing an online survey through medical organisations, social media platforms and collaborators. SETTING: It included all staff based in an operating theatre environment around the world. PARTICIPANTS: 1590 complete responses were received from 54 countries between 15 July and 15 December 2020. The average age of participants was 30-40 years old, 64.9% were men and 32.5% of a white ethnic background. 79.5% were surgeons with the remainder being nurses, assistants, anaesthetists, operating department practitioners or classified other. MAIN OUTCOME MEASURES: Participants that had experienced any physical illness, changes in mental health, salary or time with family since the start of the pandemic as well as support available based on published recommendations. RESULTS: 32.0% reported becoming physically ill. This was more likely in those with reduced access to personal protective equipment (OR 4.62; CI 2.82 to 7.56; p<0.001) and regular breaks (OR 1.56; CI 1.18 to 2.06; p=0.002). Those with a decrease in salary (29.0%) were more likely to have an increase in anxiety (OR 1.50; CI 1.19 to 1.89; p=0.001) and depression (OR 1.84; CI 1.40 to 2.43; p<0.001) and those who spent less time with family (35.2%) were more likely to have an increase in depression (OR 1.74; CI 1.34 to 2.26; p<0.001). Only 36.0% had easy access to occupational health, 44.0% to mental health services, 16.5% to 24/7 rest facilities and 14.2% to 24/7 food and drink facilities. Fewer measures were available in countries with a low Human Development Index. CONCLUSIONS: This work has highlighted a need and strategies to improve conditions for the healthcare workforce, ultimately benefiting patient care.

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Breast cancer (BC) is the most common life-threatening malignancy amongst women with high incidence worldwide. In Egypt, it is the most known malignancy amongst females. Epithelial-mesenchymal transition (EMT) participates in breast tumors' invasiveness, and metastasis, but the process is poorly understood. The involvement of voltage-gated calcium channels signaling in EMT has not yet been fully explored. Therefore, the aim of this study was to investigate the possible role of T-type calcium channels in metastasis and EMT among breast cancer patients. The study was carried out on 48 female breast cancer patients who were divided into two groups; metastatic and non-metastatic. qRT-PCR was employed to measure the expression of EMT marker genes (N- cadherin, E-cadherin, Snail, Vimentin and T-type VGCCs genes (CACNA1G, CACNA1H, and CACNA1I). The results of the present study revealed differential expression of the EMT marker genes in blood and tissue of non-metastatic and metastatic breast cancer patients, with a clear tendency for the mesenchymal markers to be significantly elevated in metastatic patients as well as malignant tissues taken from non-metastatic patients as compared to their paired tumor adjacent normal (TAN) tissue. Both CACNA1H and CACNA1I (T-type VGCCs oncogenes) were significantly elevated in blood of metastatic patients when compared to non-metastatic ones. In contrast, CACNA1G (tumor suppressor) exhibited a significant decrease in metastatic patients. The strong correlation between the expression of T-type VGCCs and mesenchymal marker genes in metastatic breast cancer patients casts light on the role of T-type VGCCs in metastasis and their involved in tumor invasiveness.

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BACKGROUND: Patients with liver cirrhosis develop symptoms comparable to those of patients with sepsis, who have increased total vascular compliance, which may cause blood pooling in the venous pool. No previous studies have evaluated the effect of using norepinephrine on the intravascular blood volume. We investigated the norepinephrine infusion's effect on the mean systemic filling pressure, venous return, and cardiac preload in patients undergoing liver transplantation. METHODS: Overall, 33 patients who underwent living donor liver transplantation were included in this study. Cardiac output (CO) was measured using a PiCCO device (Pulsion Medical Systems, Munich, Germany). The mean systemic filling pressure was calculated using the inspiratory hold maneuver at four time intervals - at baseline, 10 min after the norepinephrine infusion, 5 min after norepinephrine discontinuation, and after infusion of 500 cc of 5% albumin. Other hemodynamic parameters, including the mean arterial pressure (MAP), pulse pressure variation, stroke volume variation, global end-diastolic volume, and mitral inflow velocity (E wave), were also evaluated. RESULTS: The norepinephrine infusion increased MAP and systemic vascular resistance in all patients. Moreover, it increased CO, mean systemic filling pressure, and global end-diastolic volume in 20 patients (60%), whereas there were no changes in these variables in 13 patients (40%). In all patients, norepinephrine infusion discontinuation caused a significant decrease in MAP, CO, resistance to venous return, and mean systemic filling pressure. Infusion of 500 cc colloid increased CO; however, interestingly, it was associated with a significant decrease in systemic vascular resistance; hence, MAP and mean systemic filling pressure showed no changes. CONCLUSIONS: The norepinephrine infusion at 0.1 µg-1 kg-1 min-1 was associated with an increase in CO in patients with liver cirrhosis undergoing liver transplantation. Norepinephrine's effect on CO was primarily attributable to an increase in venous return due to an increase in mean systemic filling pressure.

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Background: Caesarean section (CS) is a life-saving operation when vaginal delivery is risky to the mother or baby. However, if not medically indicated or performed under suboptimal conditions, it can be harmful and resource-intensive. Aims: To estimate the prevalence of CS in 6 Egyptian governorates and identify possible risk factors (including demographic, social and healthcare services factors) stratified according to geographical areas. Methods: We used secondary data collected from a large survey to investigate the sociodemographic and health indicators of 6 purposefully selected Egyptian governorates with suboptimal health indicators: 3 from Upper Egypt (Sohag, Assiut and Menia) and 3 from Lower Egypt (Sharkia, Beheira and Ismailia). The survey data were gathered using an interview questionnaire that targeted household members. Results: The CS rate was estimated at 55.1% for the 3 years preceding the study, and the highest rate was 67.8% in Behira and the lowest was 49.0% in Assiut. In most governorates, the CS rate was higher in rural than in urban areas, but the difference was not significant. High CS rates were significantly related to higher social class and lower number of children (≤ 3). Conclusion: In the governorates investigated, CS was performed more often, with higher rates than those reported in the 2015 Egypt Health Issue Survey. The adoption of protocols for elective CS should be enforced with a more multisectoral effort. Pregnant women should be well informed of the risks associated with CS and its medical indications.

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Skull base osteomyelitis is an inflammatory process that usually occurs secondary to necrotizing otitis externa or chronic mastoid infections. The involvement of the external auditory canal is typical of this condition and aids in its diagnosis. The treatment of skull base osteomyelitis is often complex and involves long-term intravenous antibiotics. Skull base osteomyelitis originating from the middle ear is a rare entity. We report a case of skull base osteomyelitis originating from the bilateral otitis media.

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Even with considerable progress in cancer researches, gastric cancer is still one of the global health problems. Recognition of the differential expressed genes in GC is the most appropriate approach for establishing new diagnostic targets. This study evaluates SEC13, SMAD7, GHRL, lncRNA GHRLOS, HIF-1α genes profiling as well as HIF-1α protein level for GC. The expression of selected genes, serum HIF-1α and CEA protein levels were determined for 50 GC patients and 50 healthy controls by real-time RT-PCR, ELISA, and ELICA respectively. The sensitivities of these parameters as diagnostic biomarkers were evaluated. SMAD7, HIF-1α expression, serum HIF-1α, and CEA level were significantly upregulated in GC patients as compared to the control group (P = 0.024, < 0.001) and had significant positive correlations between each other except SMAD7 with serum HIF-1α, and CEA level. On the other hand, SEC13, GHRL, and lncRNA GHRLOS expression were significantly downregulated in GC patients (P = < 0.001, 0.025, < 0.001 respectively) and had significant positive correlations with each other (P < 0.001). Significant negative correlations were observed between most of both groups. All studied parameters were associated with GC clinical stages except SMAD7 was associated with stage IV only (P = 0.005) and GHRL did not associate with tumor stages (P ˃ 0.05). All studied parameters may be promising biomarkers for the early diagnosis of GC. SMAD7, HIF-1α gene, and HIF-1α protein may be jointly implicated in cancer development and prognosis, while SEC13, GHRL, and lncRNA GHRLOS may act as tumor suppressors.

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OBJECTIVE: To compare efficacy of lidocaine-prilocaine (LP) cream versus misoprostol versus placebo before levonorgestrel-releasing intrauterine device (LNG-IUD) insertion. METHODS: This randomized controlled trial (RCT) was conducted in a tertiary referral hospital from April 30, 2020 to March 1, 2021 on 210 parous women willing to receive LNG-IUD and delivered only by elective cesarean delivery (CD). Participants received 200 µg vaginal misoprostol or 5 ml of LP cream 5% or placebo 3 h before LNG-IUS insertion. Primary outcome was pain during LNG-IUD insertion, while secondary outcomes were pain 10 min post-procedure, ease of insertion, patient satisfaction, insertion time, and drug side effects. RESULTS: Pain during LNG-IUS insertion was reduced in LP group and misoprostol group compared to placebo group (2.1 ± 1.0 vs 3.7 ± 1.6; p <0.001) and (2.3 ± 1.3 vs 3.7 ± 1.6; p <0.001), respectively. Ease of procedure and patient satisfaction were significantly higher in LP and misoprostol groups than placebo (P <0.001). Need for additional analgesia was significantly higher in placebo group than in the other two groups (P = 0.009). Adverse events were not significantly different between the three groups except vomiting and abdominal cramps, which were higher with misoprostol. CONCLUSION: LP cream and 200 µg of vaginal misoprostol administration before LNG-IUD insertion in women delivered only by elective CD effectively reduced pain during insertion and 10 min post-procedure with easier insertions, high patient satisfaction, and tolerable side effects. Pain reduction with LP cream was clinically significant.

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BACKGROUND: Obesity is a risk factor for cholelithiasis. Besides, rapid weight loss after bariatric surgery upsurges the rate of cholelithiasis and acute cholecystitis. This study aimed to compare gallstone development frequency after LSG under ursodeoxycholic acid (UDCA) prophylaxis. METHODS: This prospective controlled study included 332 patients scheduled for LSG randomized to receive 500 mg UDCA daily for 12 months (UDCA Group) or no treatment (Control Group). Ultrasonography was done 6 and 12 months after surgery to detect gallstones. Cholecystectomy was done for complicated cases of cholelithiasis. RESULTS: Seventy-one patients were lost to follow-up, and 3 developed severe adverse effects of UDCA and excluded. Data are presented for 130 patients in the UDCA group and 128 in the Control group. Collectively, 11 patients (8.5%) of the UDCA group and 41 (32.0%) of the Control group developed gall stones during the first postoperative year (p < 0.001). Cholecystectomy was indicated in 3 patients (2.3%) of the UDCA group and 9 (7.0%) of the Control group (p = 0.072). On multivariate analysis, higher BMI, dyslipidemia, and lacking UDCA prophylaxis were the independent factors significantly associated with stone development. Also, stone development was associated with higher weight loss after 6 and 12 months. CONCLUSION: UDCA 500 mg once daily for 12 months after LSG is effective in reducing gallstone formation at 1 year. UDCA administration reduced the frequency of cholecystectomies from 7 to 2.3%. High BMI and dyslipidemia are the independent preoperative factors significantly associated with stone development.

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BACKGROUND: Obesity is an independent risk factor for cardiovascular diseases. Coronary artery calcium (CAC) is a direct measure of coronary atherosclerosis. The study investigated the effect of bariatric surgery on CAC scores in people with severe obesity subjected to laparoscopic sleeve gastrectomy (LSG). METHODS: This prospective study included 129 people with severe obesity in two groups; the LSG group (n=74) subjected to surgery and the diet group (n=55), managed by a diet regimen and lifestyle modification. Cardiovascular risk was assessed by Framingham risk score (FRS) and coronary calcium score (CCS) measured by computed tomography initially and after 3 years. RESULTS: The two groups had a comparable CAD risk before treatment according to FRS or CCS. After treatment, CCS improved significantly in the LSG group (p=0.008) but not in the diet group (p=0.149). There was no correlation between FRS and CCS (r=0.005, p=0.952). Treatment resulted in significant weight reduction and improved fasting blood glucose and lipid profile in the two groups. The change of weight, blood glucose, and HDL, and remission of diabetes mellitus (DM) were significantly higher in the LSG group compared to the diet group. CONCLUSION: LSG may reduce the risk of developing future cardiovascular comorbidities evidenced by reducing CAC scores. Significant weight reduction and improvement of cardiovascular risk factors may recommend LSG as a cardioprotective procedure in people with severe obesity.

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BACKGROUND: This work endeavored to explore the effect of hypothyroidism on mortality in subjects with HCC who underwent living-donor liver transplantation (LDLT). METHODS: This prospective study included 107 patients with HCC subjected to LDLT, divided into hypothyroid group (n=53) and euthyroid group (n=54). The primary objectives were overall and disease-free survival (DFS). RESULTS: Euthyroid and hypothyroid groups were comparable in all baseline characteristics except the age of patients. Overall survival (OS) of the whole group at 48 months was 68.8%, while the DFS was 60.2%. On univariate analysis, OS was negatively affected by the older age of the patients (p<0.001) or the donor (p<0.001), hypothyroidism (p=0.008), HBV (p=0.029), larger tumor size (p=0.023), and defective Milan criteria (p=0.022). On multivariate analysis, the age of the patients and donors was the independent factor affecting OS. On univariate analysis, DFS was negatively affected by older age of the patients (p < 0.001) or the donor (p=0.005), hypothyroidism (p=0.005), HBV (p=0.019), larger tumor size (p=0.023), and defective Milan criteria (p=0.020). On multivariate analysis, the age of the patients, thyroid status, and Milan criteria were the independent factors affecting DFS. CONCLUSION: Hypothyroidism is a risk factor for worse outcomes in HCC patients after liver transplantation.

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BACKGROUND: Tocilizumab is an anti-IL-6 therapy widely adopted in the management of the so-called "cytokine storm" related to SARS-CoV-2 virus infection, but its effectiveness, use in relation to concomitant corticosteroid therapy and safety were unproven despite widespread use in numerous studies, mostly open label at the start of the pandemic. METHODS: We performed a systematic review and meta-analysis of case-control studies utilising tocilizumab in COVID-19 on different databases (PubMed/MEDLINE/Scopus) and preprint servers (medRxiv and SSRN) from inception until 20 July 2020 (PROSPERO CRD42020195690). Subgroup analyses and meta-regressions were performed. The impact of tocilizumab and concomitant corticosteroid therapy or tocilizumab alone versus standard of care (SOC) on the death rate, need for mechanical ventilation, ICU admission and bacterial infections were assessed. RESULTS: Thirty-nine studies with 15,531 patients (3657 cases versus 11,874 controls) were identified. Unadjusted estimates (n = 28) failed to demonstrate a protective effect of tocilizumab on survival (OR 0.74 ([95%CI 0.55-1.01], p = 0.057), mechanical ventilation prevention (OR 2.21 [95%CI 0.53-9.23], p = 0.277) or prevention of ICU admission (OR 3.79 [95%CI 0.38-37.34], p = 0.254). Considering studies with adjusted, estimated, tocilizumab use was associated with mortality rate reduction (HR 0.50 ([95%CI 0.38-0.64], p < 0.001) and prevention of ICU admission (OR 0.16 ([95%CI 0.06-0.43], p < 0.001). Tocilizumab with concomitant steroid use versus SOC was protective with an OR of 0.49 ([95%CI 0.36-0.65], p < 0.05) as was tocilizumab alone versus SOC with an OR of 0.59 ([95%CI 0.34-1.00], p < 0.001). Risk of infection increased (2.36 [95%CI 1.001-5.54], p = 0.050; based on unadjusted estimates). CONCLUSION: Despite the heterogeneity of included studies and large number of preprint articles, our findings from the first eight of the pandemic in over 15,000 COVID-19 cases suggested an incremental efficacy of tocilizumab in severe COVID-19 that were confirmed by subsequent meta-analyses of large randomized trials of tocilizumab. This suggests that analysis of case-control studies and pre-print server data in the early stages of a pandemic appeared robust for supporting incremental benefits and lack of major therapeutic toxicity of tocilizumab for severe COVID-19.

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BACKGROUND: This study aimed to evaluate the accuracy of pulse oximetry-derived oxygen saturation (SpO2) on room air, determined at hospital admission, as a predictor for the need for mechanical ventilatory support in patients with Coronavirus Disease-2019 (COVID-19). METHODS: In this retrospective observational study, demographic and clinical details of the patients were obtained during ICU admission. SpO2 and respiratory rate (RR) on room air were determined within the first 6 h of hospital admission. As all measurements were obtained on room air, we calculated the simplified respiratory rate­oxygenation (ROX) index by dividing the SpO2 by the RR. Based on the use of any assistance of mechanical ventilator (invasive or noninvasive), patients were divided into mechanical ventilation (MV) group and oxygen therapy group. The accuracy of the SpO2, CT score, and ROX index to predict the need to MV were determined using the Area under receiver operating curve (AUC). RESULTS: We included 72 critically ill patients who tested COVID-19-positive. SpO2 on the room air could predict any MV requirement (AUC [95% confidence interval]: 0.9 [0.8-0.96], sensitivity: 70%, specificity 100%, cut-off value ≤78%, P < 0.001). Within the MV group, the use of noninvasive ventilation (NIV) was successful in 37 (74%) patients, whereas 13 patients (26%) required endotracheal intubation. The cut-off ROX value for predicting early NIV failure was ≤1.4, with a sensitivity of 85%, a specificity of 86%, and an AUC of 0.86 (95% confidence interval of 0.73-0.94, P < 0.0001). CONCLUSIONS: A baseline SpO2 ≤78% is an excellent predictor of MV requirement with a positive predictive value of 100%. Moreover, the ROX index measured within the first 6 h of hospital admission is a good indicator of early NIV failure.

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Collision avoidance and autonomous control of vehicles have become essential needs for providing a high-quality and safe life. This paper introduces a new generic scheme for a virtual antenna array (VAA) and its application in a train collision-avoidance system (TCAS). The proposed TCAS shall have the capability of identifying the range and angle of an object in front of a moving train and provide the required alerts. Thereby, a new virtual array distribution for both the transmitting and the receiving antenna arrays is introduced to get a long-range object detection and high-resolution multi-input multi-output (MIMO) system. This can be accomplished because the VAA radiation pattern is the multiplication of the radiation patterns for both the transmitting and receiving antenna arrays, which is different than each one of them alone. In this work, the VAA is utilized in radar systems in which the radar range depends on the multiplication of the gain of the transmitting and receiving antennas. So, we introduce a new scheme for the general design of VAA-based radars. A prototype for the antenna system was fixed on a of Texas Instruments platform for the cascading radar. One of the main problems of the VAA is the loss of radiated power in undesired directions, which affects the maximum detection range in beamforming systems and degrades the diversity gain in MIMO applications. These issues have been solved by the introduction of the practical implementation of a proposed high-gain, low side lobe level VAA system for automotive radar that is based on the integration of four AWR1243 RF chips operating in a frequency range of 76 GHz to 81 GHz. It was implemented using low-power 45 nm (TI) RFCMOS technology. The measured gain of the realized VAA was 47.2 dBi, which was 1.815 times higher than that of the Texas instrumentation linear frequency modulated continuous wave (TI' LFMCW) radar, which was 26 dBi. The proposed VAA saved 45% of the required implementation area compared to the TI' LFMCW antenna array. The VAA system was fabricated and tested in an anechoic chamber, and it was found that the simulated and measured patterns of the proposed VAA were highly matched in terms of half-power beamwidth and side lobe level.

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Cerebrovascular disorders (CVDs) are widespread in cancer patients, exacerbating their condition and lowering their prognosis. Approximately 15% of cancer patients have a coexisting CVD. Stroke may occur after the initial cancer diagnosis or before the diagnosis of malignant disease. The underlying causes of stroke in cancer patients are distinct from those in noncancer patients and are related to both cancer itself and the type of treatment. Cardio-embolism, large vessel atherosclerosis, and small vessel occlusion have all been identified as important causes of ischemic stroke, but nonbacterial thrombotic endocarditis has been documented only infrequently. We present a case of a 64-year-old female with recurrent ischemic stroke of unknown cause and involving different arterial territories, who was discovered to have metastatic pancreatic cancer. The initial workup with brain imaging revealed multiple acute/subacute ischemic strokes and a negative cardiac assessment. Accordingly, she underwent a whole-body positron emission tomography-computed tomography which revealed a hypermetabolic mass lesion in the pancreaticoduodenal area. Our case indicates that cancer-associated stroke should be seriously evaluated. It demonstrates the critical nature of contemplating hidden cancer in survivors of ischemic stroke and identifies factors that may necessitate further investigation as part of a comprehensive approach to ischemic stroke, especially embolic stroke of unknown sources.

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The interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In a patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from the systemic circulation into the splanchnic bed, which decreases the effective blood volume. Moreover, rapid volume loading in these patients has less impact on the cardiac output because a higher proportion of infused fluid is shifted to the splanchnic area. Thus, in dissection phase, the traditional approach of volume loading to maintain intraoperative hemodynamic stability not only seems ineffective, but it may also aggravate surgical bleeding. Two approaches of volume therapy have been mentioned to maintain hemodynamic stability during liver transplantation: splanchnic volume reduction by volume restriction with or without phlebotomy to maintain low central venous pressure (CVP), and splanchnic decongestion using splanchnic vasoconstrictors. After reperfusion, an increase in the central blood volume was thought to have a deleterious effect on the new graft function; however, the precise central venous pressure value that causes hepatic congestion after reperfusion is unknown.

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OBJECTIVE: To determine the effectiveness of 3 mg vaginal dinoprostone administered six hours prior to copper intrauterine device (IUD) insertion compared to placebo in increasing ease of insertion and reducing insertion pain among nulliparous women. STUDY DESIGN: This was a single-center double-blinded randomized controlled trial (RCT). We randomly divided the two hundred nulliparous women requesting a copper T380A IUD to receive 3 mg vaginal dinoprostone or placebo six hours before IUD insertion. The primary outcome was provider ease of insertion. Patients reported their perceived insertion pain using a 10 cm visual analog scale (VAS). We also reported number of failed IUD insertions. RESULTS: Baseline characteristics were similar between groups. Ease of insertion score was lower in dinoprostone group than placebo group (3.6 ±â€¯2.5 vs. 5.4 ±â€¯2.8; p < 0.01) denoting easier insertion for clinicians in dinoprostone group. Mean pain score during copper IUD insertion was lower in dinoprostone group (3.7 ±â€¯2.3 vs. 5.0 ±â€¯2.8; p < 0.01). Failed IUD insertion occurred in two cases of dinoprostone group (2%) versus four cases in control group (4%) (p-value; 0.68). CONCLUSIONS: Although vaginal dinoprostone administration six hours prior to copper IUD insertion in nulliparous women leads to an easy IUD insertion, we do not routinely advise it as the reduction in IUD insertion pain scores with vaginal dinoprostone lacked clinical significance. IMPLICATIONS: In settings where it is feasible to provide dinoprostone vaginally six hours before copper IUD insertion, clinicians will find insertion easier, and nulliparous women may experience somewhat less pain during the procedure. Where waiting six hours is practical, this may prove to be useful.

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