Effect of nitric oxide donors on uterine and sub-endometrial blood flow in patients with unexplained infertility: a randomized controlled trial

Background: Impaired sub-endometrial perfusion might reduce endometrial receptivity and possibly contribute to unexplained infertility. A favorable effect on sub-endometrial blood flow has been demonstrated with nitric oxide.Methods: This randomized controlled trial evaluated the effect of nitroglycerine on uterine and sub-endometrial blood flow in women with unexplained infertility. Sixty women were randomized into 2 equal groups. The study group received 5mg nitroglycerine patch daily from day 2 of the cycle till the evaluation day and the control group received no treatment. Independent of the study arms, 30 parous women were included as the fertile group. Six to eight days after detecting luteinizing hormone surge, women were assessed for endometrial thickness, uterine artery blood flow with color Doppler and sub-endometrial blood flow with three-dimensional power Doppler.Results: Compared to fertile women, cases with unexplained infertility (control group) had a significantly thinner endometrium, higher uterine artery Doppler indices and lower sub-endometrial blood flow. Women who received nitroglycerin showed a significant improvement in sub-endometrial blood flow while uterine artery blood flow did not show a significant difference; however, the values were also comparable to fertile women. In addition, no effect on endometrial thickness was found with nitroglycerin treatment. Nitroglycerin treatment side effects were headache, blurring of vision and hypotension. These adverse effects were not significant compared to controls.Conclusions: In women with unexplained infertility, nitroglycerin significantly improved the sub-endometrial blood flow but did not affect the endometrial thickness

QoS Categories Activeness-Aware Adaptive EDCA Algorithm for Dense IoT Networks

IEEE 802.11 networks have a great role to play in supporting and deploying of the Internet of Things (IoT). The realization of IoT depends on the ability of the network to handle a massive number of stations and transmissions, and to support Quality of Service (QoS). IEEE 802.11 networks enable the QoS by applying the Enhanced Distributed Channel Access (EDCA) with static parameters regardless of existing network capacity or which Access Category (AC) of QoS is already active. Our objective in this paper is to improve the efficiency of the uplink access in 802.11 networks; therefore we proposed an algorithm called QoS Categories Activeness-Aware Adaptive EDCA Algorithm (QCAAAE) which adapts Contention Window (CW) size, and Arbitration Inter-Frame Space Number (AIFSN) values depending on the number of associated Stations (STAs) and considering the presence of each AC. For different traffic scenarios, the simulation results confirm the outperformance of the proposed algorithm in terms of throughput (increased on average 23%) and retransmission attempts rate (decreased on average 47%) considering acceptable delay for sensitive delay services.Comment: 17 pages, 10 figure

Neutrophil-surface antigens CD11b and CD64 expression: a potential predictor of early-onset neonatal sepsis

Background: CD11b, an α subunit of the β2 integrin adhesion molecule, and CD64, the high affinity Fcγ receptor I, are specific neutrophil-surface antigens activated in response to systemic inflammation and, hence, they might potentially help identifying neonatal infections. Objective: We sought to evaluate the time course of expression and diagnostic and prognostic utility of CD11b and CD64 in early-onset sepsis in the suspected newborn. Methods: Sixty newborn infants (28-40 weeks gestation) with antenatal risk factors for sepsis were enrolled and subjected to sepsis work-up including complete blood count, quantification of serum C reactive protein (CRP) and flow cytometric analysis of CD11b and CD64 in cord blood (0 h). These tests were repeated at 8, 24 and 48 h postnatally. Neonates were defined, retrospectively, in two groups: sepsis and no infection, on basis of clinical observation over their first five postnatal days and sepsis work-up results. Results: A significant enhancement of neutrophil CD11b and CD64 expression was demonstrated in the sepsis group as compared to the non-infected group. CD11b over-expression had an onset at 0 h. Its mean value approached two-fold mean level of non-infected neonates by 8-24 h, and declined thereafter. CD64 rising onset was detectable at 8 h and its mean percentage reached four-fold mean value of the non-infected group at 24 h. At 24 h, an optimal cut-off value for CD11b expression of 35% (sensitivity 80%, and specificity 100%), and for CD64 expression of 17% (sensitivity 88%, and specificity 90.3%) had the best performance for prediction of sepsis. Combined use of both markers at 24 h yielded 90% sensitivity and 95% specificity for sepsis prediction. Sepsis survivors showed significantly lower mean expression for CD11b and CD64 as compared to those with fatal outcome. At 24 h, a cut-off value of 88% expression for CD11b and 50% expression for CD64 predicted mortality with sensitivity and specificity of 100%. Conclusion: Enhanced expression of neutrophil-surface antigens CD11b and CD64 could be a promising tool for prediction and therapeutic decision-making in early-onset sepsis indicating the necessity of initiation of antimicrobial therapy and reduction of its unnecessary use in non-infected neonates even before definitive microbiologic identification.Keywords: sepsis, neonate, early-onset, neutrophil activation, surface antigen, CD11b, CD64Egypt J Pediatr Allergy Immunol 2004; 2(2): 90-10

Placental pouch closure: a novel, safe and effective surgical procedure for conservative management of placenta accreta

Background: Placenta accreta spectrum (PAS) has become a global problem secondary to the high rate of cesarean delivery (CD). The current study presents an effective surgical procedure (placental pouch closure) for uterine preservation in patients with PAS. Methods: We applied this procedure in sixty cases at a tertiary university hospital between September 2017 and January 2019. We included women who were diagnosed as PAS based on preoperative ultrasound and Doppler evaluation, and who had the desire for uterine preservation. Results: The procedure was successful in almost all cases; the uterus was conserved 98.33 % of participants, with no associated severe maternal morbidities or mortality. In all cases, no additional surgical procedures were needed. The mean blood loss was 1263 ml, and the mean number of units of blood required for transfusion was 2.31 units. Conclusion: Identifying and meticulously closing the placental pouch is a novel surgical procedure for conservative management of PAS. In well-selected cases with the availability of facilities and expertise, the technique could have a place as a safe and effective surgical technique in women presenting with placenta accreta who desire uterine preservation. Trial registration number: NCT03241849. Registered on August 8, 201

Exercise-induced bronchoconstriction and atopy in Tunisian athletes

<p>Abstract</p> <p>Background</p> <p>This study is a cross sectional analysis, aiming to evaluate if atopy is as a risk factor for exercise induced bronchoconstriction (EIB) among Tunisian athletes.</p> <p>Methods</p> <p>Atopy was defined by a skin prick test result and EIB was defined as a decrease of at least 15% in forced expiratory volume in one second (FEV1) after 8-min running at 80–85% HRmaxTheo. The study population was composed of 326 athletes (age: 20.8 ± 2.7 yrs – mean ± SD; 138 women and 188 men) of whom 107 were elite athletes.</p> <p>Results</p> <p>Atopy was found in 26.9% (88/326) of the athletes. Post exercise spirometry revealed the presence of EIB in 9.8% of the athletes including 13% of the elite athletes. Frequency of atopy in athletes with EIB was significantly higher than in athletes without EIB [62.5% vs 23.1%, respectively].</p> <p>Conclusion</p> <p>This study showed that atopic Tunisian athletes presented a higher risk of developing exercise induced bronchoconstriction than non-atopic athletes.</p

Modelling urban growth evolution and land-use changes using GIS based cellular automata and SLEUTH models: the case of Sana'a metropolitan city, Yemen.

An effective and efficient planning of an urban growth and land use changes and its impact on the environment requires information about growth trends and patterns amongst other important information. Over the years, many urban growth models have been developed and used in the developed countries for forecasting growth patterns. In the developing countries however, there exist a very few studies showing the application of these models and their performances. In this study two models such as cellular automata (CA) and the SLEUTH models are applied in a geographical information system (GIS) to simulate and predict the urban growth and land use change for the City of Sana’a (Yemen) for the period 2004–2020. GIS based maps were generated for the urban growth pattern of the city which was further analyzed using geo-statistical techniques. During the models calibration process, a total of 35 years of time series dataset such as historical topographical maps, aerial photographs and satellite imageries was used to identify the parameters that influenced the urban growth. The validation result showed an overall accuracy of 99.6 %; with the producer’s accuracy of 83.3 % and the user’s accuracy 83.6 %. The SLEUTH model used the best fit growth rule parameters during the calibration to forecasting future urban growth pattern and generated various probability maps in which the individual grid cells are urbanized assuming unique “urban growth signatures”. The models generated future urban growth pattern and land use changes from the period 2004–2020. Both models proved effective in forecasting growth pattern that will be useful in planning and decision making. In comparison, the CA model growth pattern showed high density development, in which growth edges were filled and clusters were merged together to form a compact built-up area wherein less agricultural lands were included. On the contrary, the SLEUTH model growth pattern showed more urban sprawl and low-density development that included substantial areas of agricultural lands

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised