Sixty five (65) rats were exposed to one tenth LD50 of crude latex of Calotropis Procera (CP) day by day for 12 weeks (long-term toxicity). Clinical signs, post-mortem lesions, and histopathological examination were made. Post-mortum examination showed marked dilatation of the stomach and contained the latex of crude CP . The stomach revealed severe necrosis of the entire mucosal epithelium. The kidney was the most affected organ with a variety of changes in long-term exposure. Absence of spermatozoa in the epididymal lumen was observed. Moreover, immature cells and cellular debris in the lumen were observed while the epithelium was intact. The livers of exposed rats in long term exposure had marked proliferation of Kupffer cells as well as dilatation of the hepatic sinusoids. In conclusion, calotropis procera crude latex is moderately toxic; in large doses has hazardous local and remote toxic effects in different body organs.

Since the introduction of microvascular surgeries, the sophisticated ideas and techniques of tissue transplantations are continually advancing and searching for the best work conditions to present the best outcomes in these critical interferences. Every tissue transplant has its donor vessels, artery and vein, which should be anastomosed to recipient vessels. A new instrument, the double transverse microvascular clamp (DTMC), has been developed to be applied simultaneously, as one clamp, to both the artery and its accompanying vein. The transverse design of this clamp keeps the artery separate from its vein, allowing each anastomosis to be performed more easily. The limited clamp surface area minimizes the glazing and blurring effects. Applying only one clamp to the two vessels presents more work space and overcomes the crowdedness caused by the use of two single clamps. Using a DTMC on both the recipient and donor vessels provides optimal suture maneuverability and ideal work situation compared with the use of two double approximating clamps. We believe this DTMC would be a valuable addition to the microsurgical instruments market. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

BACKGROUND: Dorsal nasal augmentation plays an important role in cosmetic and reconstructive rhinoplasties performed to achieve an aesthetically pleasing result while creating facial harmony. Although it is known that the ideal implant should be biocompatible, biointegrated, nonabsorbable, and without inflammatory response, the selection of an ideal implant still remains controversial as to whether it should be biologic or synthetic. This study introduces a new question: ''What is better for the nasal dorsum, a soft or a hard implant?''. METHODS: In this study, 21 women and 7 men with a mean age of 23.5 years underwent augmentation rhinoplasty between December 2007 and July 2011. Conchal and septal cartilage grafts and Medpor were categorized as hard implants and applied for 15 patients. Soft implants, inserted in 13 patients, included diced auricular cartilage wrapped in Surgicel sheets, dermofat blocks, and rolls of Prolene mesh. RESULTS: Patient satisfaction was assessed through simple postoperative questionnaires. The satisfaction rate in the soft implant group was 100 %, whereas the overall satisfaction rate was 82.2 %. Unsatisfactory results and complications were recorded in the hard implant group, which had a dissatisfaction rate of 33.3 %, contributing to a general dissatisfaction rate of 17.8 % in the whole series. CONCLUSION: The authors recommend soft implants for both aesthetic and reconstructive surgeries because of their better ability to achieve a dorsum with a smoother contour and pad. Soft implants have fewer complications and higher satisfaction rates and can be applied for most indications using both closed and open methods. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: There is no general consensus about the best vascularized layer between the neourethra and the skin in tubularized incised plate urethroplasty (TIPU) of Snodgrass. Inclusion of 1 surgeon to repair specific forms of hypospadias by using determined surgical materials and exclusion of definite patients and conditions and definite anomaly parameters may present the needed reliable data about the role of a specific type of interpositional coverage of the neourethra. PATIENTS AND METHODS: The 37 patients had been operated by TIPU with a ventral subcutaneous dartos flap covering the neourethra who designed as group A, while 26 patients had been operated by the standard TIPU without urethral coverage who designed as group B. RESULTS: Good cosmetic results were obtained in 93.65% of the patients. In group A, urethral fistulae were encountered in 2 cases of distal hypospadias and 1 case of midpenile hypospadias with a total fistula rate of 8.1%. In group B, urethral fistulae were found in 5 cases of distal hypospadias and 3 cases of midpenile hypospadias with a total fistula rate of 30.7%. CONCLUSIONS: Flapless repair should not be tried as long as there is the needed experience to harvest a well-vascularized coverage. Interpositional flap coverage of the neourethra is crucial to decrease the rate of fistula in primary hypospadias TIPU repair. However, before designating a relative study, different forms of the anomaly, surgeon's experience, the potential harvesting complications, complexity degrees of different repairs, and the used surgical materials should be really considered.

Many non-fusion instrumentation techniques were shown to be effective in controlling the progression of spinal deformity in young children, and maintaining the growth potential of the immature spine. Of these, the Vertical Expandable Prosthetic Titanium Rib (VEPTR) has been approved by the FDA in the treatment of Thoracic Insufficincy Syndrome (TIS) in skeletally immature patients. The aim of this presentation is to demonstrate the effect of expansion thoracoplasty and implantation of a VEPTR in three children with progressive spinal deformity despite previous convex- sided hemiepiphysiodesis. Three patients with progressive congenital thoracic scoliosis, who had previously undergone anterior and posterior convex hemiepiphysiodesis of the thoracic spine at the age of 17 to 36 months, were treated with expansion thoracoplasty of the concavity using the VEPTR device at the age of 5 to 9 years. They were evaluated after a minimum of two years in order to assess the effect of the procedure on the spinal deformity, spinal growth, and chest wall expansion. At the latest follow-up, the Cobb angle of the fused segments, the length of the thoracic spine from T1 o T12, and the Space Availabel for the Lungs (SAL) improved in all three patients. Detailed results are listed in the next table. Thoracic spinal height increased from 11.25 to 15.68 cm in patient 1, from 15.40 to 17.15 cm in patient 2, and from 16.35 to 18.25 cm in patient 3. Sagittal Balance improved from +4.5 cm to neurtral in patient 1, and from +6 cm to +1 cm in patient 2, but deteriorated from -0.5 cm to -1.5 cm in patient 3. Expansion Thoracoplasty and VEPTR implantation seem to be effective in rigid congenital scoliosis even after prior convex-sided hemipepiphysiodesis.

Objective: Recurrent miscarriage is one of the most common clinical problems in reproduction. Many pathophysiological mechanisms postulated including hypercoagulability and immunological causes from undetectable autoantibodies. The current study aims to evaluate the effect of LMWH versus no heparin in treatment of women with recurrent miscarriage who were negatively tested for antiphosholipid antidodies. Design: It is an open labeled randomized controlled trial. Materials and Methods: Women who attend the outpatient Clinic in a University Hospital in Egypt and fulfilling the ACOG criteria of recurrent unexplained ptegnancy loss were approached for participation. Eligible participants were randomly assigned into 2 groups. The study group includes 91 patients received LMWH ( Tinzaparin sodium 4500IU) subcutaneous daily injection with 500 micrograms folic acid once daily started once positive pregnancy test. The control group includes 59 patients received folic acid alone. The primary outcome ( upon which sample size estimated ) was the continuation of a viable pregnancy up to 20 weeks pregnancy. Results: There was no significant difference between the study and the control groups as regard age, parity or socioeconomic level .There was a significant increase in the number of patients who continued beyond 20 weeks of gestation in the study group compared with the control 70.1% versus 54.5% , respectively (p=0.002) . The take home baby rate were also significantly higher in the heparin in the heparin group compared with the control group 65.7% versus 35.3%; respectively (p=0.001). Conclusions: Early start of LMWH decrease the incidence of miscarriage in the first 20 weeks of pregnancy in patients with recurrent unexplained pregnancy loss negative for antiphospholipid antibodies.

Purpose: Advanced glycation end products (AGEs) are created by non-enzymatic glycation or after their interaction with exact receptors. Facts of the role of the soluble receptor's of advanced glycation end products (sRAGE) in pediatric heart failure (HF) resulting from either idiopathic dilated cardiomyopathy (IDCM) and chronic renal failure (CRF) in children are very limited on the contrary to numerous investigations in adults. We hypothesized the relationships between plasma levels of sRAGE in IDCM and CRF as well as plasma levels of oxidized low-density lipoprotein (oxLDL), as a marker of oxidative stress and serum levels of high sensitivity C-reactive protein as a marker of inflammation (hsCRP) compared to healthy controls (HC). Methods: Sixty HF children (aged 4–14 years) were recruited [30 child with IDCM were compared to 30 child with CRF, will be prospectively included in the study, advancing New York Heart Association functional class score (NYHA) will be defined for all patients] and 20 healthy controls HC].Plasma Levels of sRAGE and ox LDL were measured by ELISA and serum hsCRP levels were determined by a nephelometry, arterial blood gases and hemodynamic data were also obtained. Results: Plasma levels of sRAGE, oxLDL and serum levels hsCRP values were significantly higher in children with CRF compared to HC (p0.0001). CRF patients had significantly elevated sRAGEs levels compared IDCM patients [1617(1456-1678);1226 (982.5 –1263) ;p0.0001], respectively. IDCM patients had significantly elevated sRAGEs levels compared HC[1226 (982.5 –1263);820.5 (678 –987);p0.01], correspondingly. There were significantly higher plasma level of oxLDL and serum levels of hsCRP in CRF and IDCM compared to HC subjects (p 0.0001). No significance difference in plasma levels of oxLDL in CRF compared to IDCM (p=NS). Significant correlations (Spearman’s rho) were evident between sRAGE and serum level of creatinine in CRF (r = 0.50; p0.05). Conclusions: Abnormal levels of all indices were supposed to be a predictor of HF severity. Findings from these studies will assist clinicians in formative the significance of targeting advanced glycation as a therapeutic approach for reducing cardiovascular diseases complications, which may reflect relative roles in the biology of HF.

This study is conducted during the period between January 2005 and December 2010 in the ENT department, Assiut University Hospital, Egypt. The study included 93 ears in 91 patients (2 patients had bilateral operations). Each ear had either total (6) or near total (87) perforation of the tympanic membrane (TM). All operations were done under general anesthesia using endo-tracheal inhalation route. In each case the TM is grafted using underlay TFG taken through post-oral incision supported externally by STSG taken from the medial surface of the lobule of the ear using no 15 scalpel. The lobule is stretched between 2 hands and the graft is taken. The round knife is used to abrade the mucosa of the lateral wall of the Eustachian tube and attic anterior to the malleus, floor of the middle ear (ME) and the undersurface of any remaining parts of the TM. Next, a small rim of the remaining TM is trimmed to freshen the edge for better healing. The ME is then packed with small pledges of gelatin sponge, then, the dried TFG is laid over the gelatin sponges and positioned to be under the skin of the posterior meatal wall and any remaining part of the TM. The STSG is then laid partly over the TFG and partly over the deep meatal skin. It could be used as one piece or cut into pieces. The assembly is supported externally by other pieces of gelatin sponge. The external ear is packed with antibiotic-containing Vaselinesed gauze. The wound is closed in layers and the patient is discharged from the hospital next morning. Patients come for the first post-operative visit at 5-7 days where the stitches are removed and so the aural pack and the patient is given steroid-containing antibiotic ear drops twice a day. The next visit is usually at 3-4 weeks where the external canal is dry-cleaned and the graft is checked and the patient is asked to continue the ear drops if needed. The 3rd post-operative visit is usually at the 3rd month where the ear is examined again for the status of the graft and checked audiologically where the post-operative air-conduction threshold is compaired with the pre-operative one at frequencies 500, 1000, and 4000Hz.to calculate the hearing improvement. Pure-tone average PTA change is calculated again for the 54 patients who came for follow up at one year. Results The success rate for this technique to close the large defects of the TM was about 92% (86 out of 92 operations). The average PTA improvement was 16.3 decibel (dB) at 3 month follow up, dropped to 15.5 dB at one year. Failure to close the TM defect was noticed in 7 patients ( 8 %), 2 of them had total perforation and 5 had near-total ones. The cause of failure was local infection in 3 cases and unidentified in 4 cases. All failures were in the anterior half of the tympanic membrane. Prolonged swelling of the graft was noticed in 2 cases (with formation of a tag-like part in one of them) .It persisted for more than 2 months both recovered during follow-up. Local infection with some muco-purulent discharge occurred in 3 cases, one of them improved with treatment and the other one ended with breakdown of the graft. Bleeding from the Jugular bulb or one of its tributaries occurred twice during abrading the mucosa of the floor of the ME. One of them stopped with oxidized cellulose and the other required extraluminal packing of the sigmoid sinus after cortical mastoidectomy. In both cases the operation could be continued successfully. No complications were noticed from any of the donor sites.

Analytical procedures for the determination of tramadol (T), O-desmethyltramadol (ODT), and N-desmethyltramadol (NDT) in human urine have been developed and validated using gas chromatography–mass spectrometry (GC/MS). Sample preparation involved liquid–liquid extraction with methyl-tert-butyl ether (MTBE) and followed by back extraction with 0.1 M hydrochloric acid. Proadifen (SKF525A) was selected as internal standard (IS). Extraction efficiencies of T, ODT and NDT were 102.12, 101.30, and 98.21%, respectively. The calibration curves were linear (r2 > 0.99) in the concentration range 10–1000 ng/mL for all compounds. Limits of quantification (LOQ) were 10, 10 and 20 ng/mL for T, ODT and NDT, respectively. Intra-assay precision was within 1.29–6.48% and inter-assay precision was within 1.28–6.84% for T, ODT and NDT. Intra-assay accuracy was within 91.79–106.89% for all analytes. This method detected urine concentrations of T, ODT and NDT in six healthy volunteers for 7 days after administration of 50 mg oral doses of tramadol.

There is very little published information about the prevalence, patterns, and predictors of peripheral neuropathies. The current study is a community-based survey was conducted in the Assiut Governorate to estimate their prevalence and clinical profile. Material and methods: A door-to-door study was carried out on 42 223 persons from rural and urban communities in the Assiut Governorate, Egypt. There were 13 288 (31.5%) subjects from the urban and 28 935 (68.5%) from the rural area. All subjects filled in a questionnaire designed specifically for diagnosis of peripheral neuropathy. Positive cases were then given a complete medical and neurological examination, routine laboratory tests, neurophysiology, and neuroimaging (magnetic resonance). Results: The crude prevalence rate (CPR) of peripheral neuropathy was 3181/100 000 inhabitants. There was a significantly higher prevalence in the rural compared with the urban population (3795 versus 1844/ 100 000) and in females than males (4473 versus 1943/100 000; P,0.001 for both). The most common type reported was entrapment neuropathy (736 cases with CPR of 1743/100 000), particularly carpal tunnel syndrome (1686/100 000). Diabetic neuropathy was the most common non-compressive neuropathy with a CPR of 649/100 000. Type II diabetes was recorded in 241 patients with a CPR of 571/100 000. Compressive radiculopathy had a crude prevalence of 358/100 000; traumatic and iatrogenic radiculopathy had a prevalence rate of 149/100 000. Less common conditions were: uremic neuropathy (21/ 100 000) hepatic neuropathy (14/100 000), Bell’s palsy (28/100 000), Guillian–Barre’ syndrome (12/ 100 000), chronic inflammatory demyelinating polyneuropathy (12/100 000), hereditary sensory motor neuropathy (12/100 000), and idiopathic neuropathy (92/100 000). Conclusion: The overall prevalence of peripheral neuropathies was high in comparison to other studies. Entrapment neuropathy, diabetic neuropathy, and spondylotic radiculopathy were the most common. Overall, the prevalence of peripheral neuropathy was higher in the rural than in the urban population.