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Background: Laparoscopic cholecystectomy (LC), is one of the most commonly performed surgical procedures worldwide, it is accepted as the gold standard in the treatment of symptomatic gallstones for its minimal invasiveness, less pain and early recovery. Purpose: To predict the difficulty of laparoscopic cholecystectomy in patients according to the recently published scoring system and select the difficult cases to be done by a senior surgeon. Patients: This is a prospective cohort study. This study took place Oct 6th University Hospital and Kasr El Aini Hospital, Cairo university; the study involved 120 patients admitted with calcular cholecystitis, arranged for laparoscopic cholecystectomy. Methods: Laparoscopic cholecystectomy after applying the scoring system. Results: In our study we found that age, sex and ultrasonographic data were significant predictive factors for assessment preoperatively difficult cases that will be operated upon. We found 14 patients above 50 years who scored to be difficult and very difficult were at outcome difficult, only three patients converted to open surgery over fifty. Conclusion: We can report that obese patient who were over fifty with history of previous upper abdominal surgery and ultrasonographic picture showed thick walled GB and pericholecystic collection had high risk of conversion. At this study scoring system was used for prediction of difficult laparoscopic cholecystectomy sensitivity was 93.75% and specificity was 52.94% of the scoring system at score 5 for prediction of easy or difficult laparoscopic cholecystectomy.

The strategy of price liberalisation and privatisation had been implemented in Sudan over the last decade, and has had a positive result on government deficit. The investment law approved recently has good statements and rules on the above strategy in particular to pharmacy regulations. Under the pressure of the new privatisation policy, the government introduced radical changes in the pharmacy regulations. To improve the effectiveness of the public pharmacy, resources should be switched towards areas of need, reducing inequalities and promoting better health conditions. Medicines are financed either through cost sharing or full private. The role of the private services is significant. A review of reform of financing medicines in Sudan is given in this study. Also, it highlights the current drug supply system in the public sector, which is currently responsibility of the Central Medical Supplies Public Corporation (CMS). In Sudan, the researchers did not identify any rigorous evaluations or quantitative studies about the impact of drug regulations on the quality of medicines and how to protect public health against counterfeit or low quality medicines, although it is practically possible. However, the regulations must be continually evaluated to ensure the public health is protected against by marketing high quality medicines rather than commercial interests, and the drug companies are held accountable for their conduct.

A knee arthroscopy in spinal anaesthesia was performed on a 67 years old male patient. During the procedure the patient was hemodynamically stable, until he suddenly turned pale and started complaining of severe pain in lower abdomen with signs of guarding. The procedure was finished as urgently as possible and after releasing the tourniquet we noticed significant difference in volume of the leg, with redness distal to tourniquet. Urgent lab results were essentially unremarkable and the patient was sent for the urgent radiological diagnostics. CD of the left leg described fluid in the soft tissues of the thigh, scrotum, and abdomen; and the unenhanced CT of the abdomen showed free fluid along the entire femoral shaft of the left thigh, extending towards pelvis and abdomen to perihepatic and perisplenic space, and retroperitoneum, with gas bubbles tracking along anterior aspect of the left thigh into the left retroperitoneum. He was admitted to the ICU, and within few hours all symptoms have resolved and his further recovery was without complications.

Introduction: Peripherally inserted central venous catheters (PICCs) have been increasingly used as an alternative to conventional central venous catheters for long-term administration of chemotherapy, antibiotics, parenteral nutrition, and hydration in patients with difficult venous access. Traumatic complications to arteries and nerves adjacent to veins selected for PICC placement have been rarely described. Case presentation: We report the case of a PICC placement in the brachial vein of the right upper limb of a 78-year-old woman that resulted in brachial artery pseudoaneurysm and median nerve lesion. Discussion: The pseudoaneurysm was successfully repaired with thrombin injection, but neurological deficits to the hand resulting from nerve injury persisted even four months after the procedure.

Left ventricular outflow tract obstruction is a well-recognized feature in hypertrophic cardiomyopathy but can occur in other clinical scenarios when anatomically susceptible heart is subjected to permissive physiological conditions that provoke systolic anterior motion of the mitral valve (SAM): ie, reduced preload, increased inotropic state, and decreased afterload. This report describes a case of hemodynamically significant latent LVOTO that was associated with hypotension, syncope, acute myocardial ischemic ECG changes, and an increase in cardiac enzymes. (Type II myocardial infarction) in a non HCM patient with excessive anterior mitral valve tissue.

A male, 4 days old and 20 kg Simmental calf was evaluated for regurgitation and hyper salivation since birth. The mother became pregnant by artificial insemination and the pregnancy was the second of the mother. A membrane closed the pharynx and a diverticulum on dorsal of this membrane was seen during oropharyngeal examination through inspection. Membrane was also viewed by endoscopy under general anaesthesia. Larynx and oesophagus were imaged by bronchoscopy through the back side of the membrane. After these applications, it was decided that soft palate adhered firmly to the root of tongue causing congenital atresia. Surgical treatment of oropharyngeal membrane was carried out under general anaesthesia. Firstly, tracheotomy was performed for to ease breathing and membrane removed by electrocautery application. Intensive fluid accumulation and oedema formation at the incision area were detected by endoscopic examination following operation and the calf had severe dyspnoea two days after operation and died due to respiratory insufficiency. At necropsy, severe inflammatory reaction, laryngeal oedema and intensive salivation at the surgical side was determined. Direct imaging techniques should be used to determine in the closed oropharyngeal lumen. Moreover, nasopharyngoscopy should be considered to image larynx and oesophageal way. Present case is the first report with concern to pharyngeal membrane formation together with direct imaging and surgical procedures. Therefore, it was considered that this case report could be useful for colleagues and literatures.

Background: The rapid spread of “Coronavirus Disease 2019’ (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-type 2 (SARS-CoV-2) significantly impacted health care facilities all across the globe. To assess impact on urology practice in our country, we developed a questionnaire based on relevant questions in current scenario for information regarding challenges and changes urologists were facing in their practices. Material and methods: We conducted an online survey to find out the impact of COVID-19 on urology practice in Indian scenario. The questionnaire comprised of total 18 questions, which were relevant to day to day practice. Results: Total 310 urologists across the India participated and consented to being part of the study. The majority admits change in their practice due to the recent COVID-19 outbreak. The majority admitted to attend fixed numbers of patients per day with prior appointment and to keep detailed records. The majority responded in positive that attendees will not be allowed, opted to wear N-95 mask in OPD, opted to take the relevant history, opted for thermal screening, opted for patients to wear a mask before entering OPD room, opted for using the new prescription at new visit and opted to avoid physical examination unless very necessary. The majority wanted to take consent from the patients that they may get infected by COVID-19 in the hospital and agreed on performing COVID-19 testing for every patient posted for surgery. The majority agreed to assign a separate operation theatre to operate patients with positive COVID-19 test and also preferred open surgery over minimal invasive surgery. Conclusion: Our survey revealed that the recent pandemic led to significant impacts on urology practice in our country. The urologists working in different setups are facing different challenges in this difficult condition. They have made certain changes in their practice to safely provide effective care to their patients.

In this article, we describe the case of a fifty-year-old patient with autoimmune hemolytic anemia (AIHA) with constitutional symptoms, jaundice, unquantified fever and progressive dyspnea. The patient had history of smoking and Hepatitis A and following a physical exam she was found in a regular condition, icteric but with no other further signs. Her laboratory tests revealed hemolytic anemia with a hemoglobin of 8.5 g/dL, an increase of total and indirect bilirubin, an elevated ferritin, a decreased transferrin and haptoglobin and a positive result for direct Coomb’s test. Considering this, an immune profile was ordered finding a negative result of ANAs and ENAs and a decrease of complement C3 and C4. The patient was diagnosed with AIHA and as an initial step a corticosteroid treatment was administrated however the patient showed no clinical nor chemical improvement. At her third day of hospitalization, she was unstable hemodynamically requiring transfer to Intensive Care Unit (ICU) to optimize management. After 24 hours on ICU, due to persistence of deterioration of the patient, it was decided to manage with erythropoietin (EPO). In the following days, the patient showed a rise in her hemoglobin and an overall improvement made possible the transfer to hospitalization service. The AIHA is an uncommon disease and is not the first option that comes to mind with these symptoms, currently there are not controlled studies to the treatment due to its complexity and the heterogeneity of the results. We strongly support the use of EPO in refractory cases of this pathology.

Background: Pulmonary artery bleeding secondary to iatrogenic injury is a troublesome intraoperative complication. The likelihood of encountering this complication is significantly higher in redo surgery for a number of reasons, including distortion of anatomical structures, adhesions and loss of tissue planes. Significant blood loss, although rare, remains a concern, and can occasionally be life-threatening. When significant bleeding from the pulmonary artery occurs, it can be a challenging situation to manage. Case Report: A 65 year old female was undergoing redo thoracic surgery in the setting of a completion lobectomy for biopsy-proven primary adenocarcinoma of the lung. Iatrogenic injury to the pulmonary artery resulted in significant bleeding that could not be managed by gaining proximal control due to dense adhesions. The novel decision to utilize a Foley catheter for balloon tamponade was taken, in order to provide sufficient haemostasis for definitive surgical repair of the defect to be undertaken Conclusion: The increased technical difficulties of redo thoracic surgery are well recognised. We describe the first case of Foley catheter balloon tamponade being utilized in the context of iatrogenic pulmonary artery bleeding during thoracic surgery.

Priapism is currently defined as a prolonged painful erection without sexual stimuli, if priapism persists > 36 hours, conservative treatment does not lead to detumescence. The most common etiologies are: medications into corpora cavernosa, anti-psychotics, anti-hypertensives, hematological disorders (chronic myeloid leukemia). The Penile prosthesis is the choice treatment for restoring the erectile function after the failure of the conservative treatment. But the corporal fibrosis makes it very difficult, with high risk of complications [1].

Introduction: Diffuse axonal injury (DAI) is a major cause of disability in the pediatric patient. Herein we describe the MRI/DWI findings in a case with DAI. We also discuss the current role of CT and MRI with DWI in the evaluation of DAI. Aim of the study: To stress the role of diffusion-weighted imaging in diffuse axonal injury. Methods: A pediatric patient, who was hospitalized in the ICU, was submitted to MRI with DWI for the evaluation of brain lesions. The patient was scanned with T1-weighted images, T2-weighted images, FLAIR, T2*-weighted images and diffusion weighted images. Result: Brain lesions caused by DAI were more conspicuous on diffusion-weighted images compared to FLAIR images. T2*-weighted images were a helpful adjunct in showing micro-hemorrhages. Conclusion: T2*-weighted images and FLAIR images alone underestimate the true extent brain lesions in DAI compared to DWI.

A 27-year-old man presented to our hospital for abdominal pain and a cheesy discharge from the umbilicus which lasted for a few days. He was afebrile. The physical examination revealed periumbilical tenderness and discharge from the umbilicus. There were no signs of general infection. Otherwise, he had neither specific symptoms nor a palpable abdominal mass. Pelvic computerized tomographic (CT) scanning) confirmed the presence of a cyst in the midline of the abdominal wall, with communication with the bladder and peripheral calcification. The mass was infiltrated to the perivesical fat (Figure 1). The patient was prepared for surgery. During laparotomy, a urachal cyst with the cuff of the bladder dome were removed (Figure 2). Recovery was unremarkable. The resected specimen was a partial cystectomy specimen with perivesical fat and the median umbilical ligament

The increasing use of highly conformal radiation deliberates a higher accurate targeting. Contouring and clinical judgment are presumably the crucial point, thus positron emission tomography/magnetic resonance imaging PET/MRI with somatostatin analogs appears to be useful in radiotherapy target definition. A case report of a 43-year-old woman presented with a recurrence of a meningioma (World Health Organization group I classification) in skull base, 2 years after resection. Magnetic resonance imaging (MRI) revealed a left sided skull base mass on sphenoid wing, anterior clinoid and with a soft tissue component in the lateral portion of the orbit. Contrast-enhanced MRI and a computed tomography (CT) dedicated were used to the radiotherapy planning. Aiming an improvement on target volume delineation, 68Ga-DOTATOC-PET/MRI was also performed due the difficult localization of the tumor in skull base. Was treated using intensity-modulated radiotherapy (IMRT) to a total dose of 54 Gy in 28 fractions. It was prescribed to the planning target volume (PTV), defined based of both imaging modalities. In our case PET/MRI helped to define the target, which volume becomes bigger than that based exclusively on MRI and CT.

Gallstone ileus is a rare complication of cholelithiasis and a type of mechanical obstruction involving impaction of a gallstone within the intestinal tract [1,2]. This entity occurs in 0.15% - 1.5% of cholelithiasis cases and < 0.1% of ileus cases overall [1]. Gallstone ileus is more common in the elderly and up to 80% - 90% of affected patients have medical comorbidities [2]. The ratio of occurrence in females to males is 3.5:1 [3]. The following report presents a case of gallstone ileus with associated perforated small bowel diverticulitis, demonstrating the importance of considering this condition as a differential diagnosis of an acute abdomen.

We describe a new case of duodenal wound with complete transection in a 22-year-old patient following a motorcycle accident. He presented to the emergency room of the rural Regional Hospital of Edéa in Cameroon with a clinical picture of acute abdomen and post-trauma hemodynamic instability. A peritoneal puncture brought back an incoagulable blood. An exploratory laparotomy revealed a large hemoperitoneum mixed with food debris. A tear of the omentum and transverse mesocolon and a complete section of the third duodenum at the beginning of its free portion were observed. The surgeon performed emergency closure of both duodenal stumps and performed an isoperistaltic lateral gastrojejunal bypass. A transfer to a specialized center for a more anatomical continuity was considered, but the imminence of a humanitarian mission in the hospital prompted the surgeon to seize the opportunity of this mission for the reoperation. This surgical revision was performed on the fifth postoperative day. A resection of the distal duodenal stump and the adjacent jejunal segment including the anastomosis was performed. Continuity was restored by a mechanical duodenal-jejunal anastomosis. The patient was discharged on the 18th postoperative day. This type of lesion is difficult to manage in an emergency situation in a structure with limited technical resources. Unfortunately, surgeons treating polytraumatized civilians are encountering an increasing number of blunt duodenal wounds requiring laborious management.

COVID-19 virus structural components: The 2019-nCoV, also called SARS-CoV-2, was first reported in Wuhan, China in December 2019. The disease was named Coronavirus Disease 2019 (COVID-19) and the virus responsible for it as the COVID-19 virus, respectively, by WHO. The 2019-nCoV has a round, elliptic or pleomorphic form with a diameter of 60–140 nm. It has single-stranded RNA genome containing 29891 nucleotides, a lipid shell, and spike, envelope, membrane and hemagglutinin-esterase (HE) proteins. Steps in progression of COVID-19 illness: Once inside the airways, the S protein on the viral surface recognizes and mediates the attachment to host ACE-2 receptors and gains access to endoplasmic reticulum. The HE protein facilitates the S protein-mediated cell entry and virus spread through the mucosa, helping the virus to attack the ACE2-bearing cells lining the airways and infecting upper as well as lower respiratory tracts. With the dying cells sloughing down and filling the airways, the virus is carried deeper into the lungs. In addition, the virus is able to infect ACE2-bearing cells in other organs, including the blood vessels, gut and kidneys. With the viral infestation, the activated immune system leads to inflammation, pyrexia and pulmonary edema. The hyperactivated immune response, called cytokine storm in extreme cases, can damage various organs apart from lungs and increases susceptibility to infectious bacteria especially in those suffering from chronic diseases. The current therapeutics for COVID-19: At present, there is no specific antiviral treatment available for the disease. The milder cases may need no treatment. In moderate to severe cases, the clinical management includes infection prevention and control measures, and symptomatic and supportive care, including supplementary oxygen therapy. In the critically ill patients, mechanical ventilation is required for respiratory failure and hemodynamic support is imperative for managing circulatory failure and septic shock. Conclusion: Confusion, despair and hopes: There is no vaccine for preexposure prophylaxis or postexposure management. There are no specific approved drugs for the treatment for the disease. A number of drugs approved for other conditions as well as several investigational drugs are being canned and studied in several clinical trials for their likely role in COVID-19 prophylaxis or treatment. The future seems afflicted with dormant therapeutic options as well as faux Espoir or false hopes. As obvious, not all clinical trials will be successful, but having so many efforts in progress, some may succeed and provide a positive solution. Right now, though, confusion and despair prevail.

The infectivity and pathogenesis: SARS-CoV-2, the causative agent of Covid-19, involves Angiotensin-converting enzyme 2 (ACE2) receptors on type II alveolar type 2 (AT2) cells in lungs. Apart from, the upper and lower respiratory tracts, the disease affects the gastrointestinal system prominently, as evidenced by the significant GI symptoms, early in the course of the disease. In addition, the virus infects ACE2-bearing cells in other organs including the heart and blood vessels, brain, and kidneys. Clinical features and morbidity: The clinical spectrum of COVID-19 varies from asymptomatic or pauci-symptomatic presentation to moderate to severe states characterized by respiratory failure necessitating mechanical ventilation and ICU support and those manifesting critical clinical condition with complications like sepsis, septic shock, and multiple organ dysfunction failure. The CT chest is an important tool for early identification of COVID-19 pneumonia as well as for prognostic purposes. The recovery and residual damage: The recovery and other outcomes vary depending on age and other aspects including sex, comorbidities, and genetic factors. The outlook for older adults, who account for a disproportionate share of critical disease, is unfavorable, and most of those who survive are unlikely to return to their previous level of functioning. The disease affects their long-term health and quality of life as well as brings in propensity for truncated post-disease survival. COVID-19 aftermath and follow up: The patients discharged from hospital following severe COVID-19, continue to suffer with lingering impact of the disease as well as that of the emergency treatments that saved their life. The post-infection reduced exercise tolerance and other subtle factors, like post viral fatigue syndrome, post-traumatic stress disorder, impaired concentration, delirium, and disturbed sleep-wake cycle often underly the functional impairment. In fact, there is need of step-down care and later a multidisciplinary support involving regular clinical assessment, respiratory review, physiotherapy, nutritional advice, and psychiatric support. Conclusion: The life after COVID-19: After recovery from the disease, the virus SARS-CoV-2, may persist for uncertain period. In addition, the chance of reinfection cannot be ruled out. The vitamin D supplementation may be helpful. In general, the quality of life (QOL) in ICU survivors improves but remains lower than general population levels, but most of the patients adapt well to their level of self-sufficiency and QOL. Also, the debility due to co-morbidities may further compromise the activity of daily living and QOL issues. The Age and severity of illness appear to be the major predictors of post-discharge physical functioning.

Before actual COVID-19 pandemia coronavirus was not so dangerous like now. In December 2019 - January 2020 in Wuhan first and then in other places this coronavirus was responsible of a first wave of severe pulmonitis responsible of many deaths. Wuhan and other region involved first was high level air polluted and industrial area. New COVID-19 variant in last part of 2020 and in first month of 2021 was responsible of great diffusion of this pandemic disease. UK, South Africa and brasilian new variant show higher diffusion then the first wave of COVID-19. Aim of this work is to analyze relationship with air pollution and the possibility that mutagen substantia inside of this microenvironment can produce new variant trough an genetic pressure process. RNA viruses are normally subjected by natural mutation but some phenomena can contribute to accelerate this process and their airborne – aeresols microenvironment is relevant. Some air pollutants are recognized as mutagen factors by literature.

Calcium phosphates are of great interest in medicine, biology, agriculture and materials sciences. The present study evaluates the effect of calcium phosphates nanoparticles on biochemical changes in rice. Nanoparticles increased the growth rate and affect the physiology of the plant. Calcium phosphate nanoparticles may help in the formulation of new nano growth promoter and nano-fertilizers for agricultural use. Therefore, it could potentially help in reduction of the quantity of fertilizer applied to crops and contributing to precision farming as it reduces fertilizer wastage and in turn environmental pollution due to agricultural malpractices. However, detail physiological and molecular understanding of its impact on rice crop plant is needed in future to validate its prospective application in agriculture.

Nanoparticles affects growth and development of Plant. Zinc is an important micronutrient that regulates various physiological responses in plant. Application of nanoparticles for modulating plants physiological response is a recent practice. Zinc nanoparticles has been widely used in industry for several decades. However, no significant work had been made on its potential use in agriculture. Understanding physiological effect of Zn NP on rice seed germination could suggest the basis for its prospective application in agriculture to improve plant growth. In the present experiment effect of Zn NP was studied in Kmj-6-1-1 which is a commonly growing rice cultivar of Karimganj district of Assam, India. An exposure to Zn NP (0 mg/L, 5mg/L,10mg/L, 15mg/L, 20mg/L & 50mg/L) caused significant changes in radicle and plumule length , mass ( fresh & dry mass) and seed moisture content in rice. Antioxidant enzymes like guaiacol peroxidase (GPx), catalase (CAT), superoxide dismutase (SOD) and gluthathione reductase (GR) also increased due to ZnNP treatment. This suggest that Zn NP may significantly alters antioxidant metabolism during rice seed germination. In conclusion, Zn NP protected rice plants from ROS damage by improving levels of antioxidant enzyme activities during germination. As a consequence the Zn NP treated seeds, showed better potential for germination. Further, genomic analysis of germinating rice seeds are needed to elucidate the molecular mechanisms by which Zn NP modulates germination process in rice.