Patients and Methods. We retrospectively reviewed clinicopathological, radiological, and outcome data of 19 patients with unresectable LMUM treated with 43 PHP-M (median 2 PHP-M) between 2014 and 2019. Tumor response and adverse events were evaluated using RECIST 1.1 and the Clavien–Dindo classification. Kaplan–Meier methods and Cox regression hazard proportional models were used.  Percutaneous hepatic perfusion with melphalan (PHP-M) for hepatic metastasis of uveal melanoma (LMUM) achieves high local response rates, but the individual clinical benefit is poorly defined. We aimed to determine cofactors of response and clinical outcomes including the probability of long-term (5-years) overall survival (OS) in PHP-M-treated patients with LMUM. p < 0.05), and female patients were at a lower risk compared with males ). Estimates of the overall survival were 0.213  from first imaging  to 5 years and 0.793  and 0.604  for 1 and 2 years after chemosaturation, respectively. Discussion. PHP-M for nonresectable LMUV provides a safe and locally efficient liver-directed procedure that offers patients a chance for long-term OS, especially for patients with a low hepatic tumor burden. Of 19 patients, 10 (53%) achieved a partial response (PR) and 9 (47%) had stable disease (SD). There was no progressive disease (PD) and no adverse events exceeding Clavien–Dindo grade IV. Median OS was 16.7 months after the first PHP-M treatment and 26.4 months after initial diagnosis. Low hepatic tumor volume (median of 10 mL vs. 150 mL) was an independent predictor of favorable OS : 0.190 ;  Metastatic uveal melanoma (UM) carries a poor prognosis with 1-year survival rates reported as low as 10–25%  with repNo effective adjuvant systemic therapy has been demonstrated to reduce the risk of metastasis, as stated by Triozzi and Singh . A meta-Immune checkpoint inhibitors, such as ipilimumab, nivolumab, and pembrolizumab, achieve long-term OS with 5-year OS rates of 34–52% in metastatic cutaneous melanoma –9 but yiPercutaneous isolated hepatic perfusion with melphalan (PHP-M) has been licensed in the European Union (EU) with a CE mark. Although evidence to date is limited, liver-targeted therapies such as PHP-M chemosaturation hold promising results for patients in this setting. However, the OS reported so far was within a large range from 245 days to 27 months , 15, andTo enable better stratification of patient selection for this procedure in the future, we sought to evaluate cofactors of prognosis in this setting using a retrospective search from our database. We also aimed to determine cofactors of response and clinical outcomes including the probability of long-term (5-years) OS in PHP-M-treated patients with LMUM.Patients: from 2014 to 2019, patients were treated by percutaneous PHP-M as a last-line therapy in our center. All treatments were recommended by the multidisciplinary tumor board for clinical indication, and all cases were treated according to the Declaration of Helsinki of 1964. Informed consent was obtained. Patients' baseline and outcome data are given in For this evaluation, data were collected and evaluated in a retrospective fashion based on the medical records and the PACS database; these data are available on request.μL, bilirubin ≤ 3 × upper limit of normal (ULN)) were included.Only patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0–1 and with adequate hematologic, renal, and hepatic function data , contraindications to general anesthesia, or significant chronic obstructive or restrictive pulmonary disorders were considered as contraindications for PHP-M.n = 1).The patients had to have at least one follow-up including an MRI- or CT-based restaging; patients lost to follow-up were not included in this evaluation (Seven patients received previous systemic treatment (most often pembrolizumab), four patients received transarterial chemoembolization (TACE) or transarterial chemoperfusion (not chemosaturation), and three patients received previous surgical of ablative therapy, and these therapies were terminated for either side effects or progressive disease. Six patients had no specified previous therapy.For the procedure itself, a dedicated filter system  was used as previously described . For artThese procedures were performed under general anesthesia. All patients were then supervised for the first night under intensive care, in order to monitor blood pressure, coagulation, access sites, and laboratory findings. On the day after the procedure, in our institution, G-CSF (Neulasta®) was given routinely.The treatment outcome was measured retrospectively according to the response evaluation criteria in solid tumors (RECIST 1.1) , based oOverall survival was calculated from initial diagnosis and from the first PHP-M until the last available follow-up or death. Progression-free survival (PFS) was calculated and is given either from first imaging or from the first PHP. For tumor volume analysis, the patient cohort was stratified to approximately 10 mL tumor volume versus approximately 150 mL.We monitored for adverse events and they were classified according to the Clavien–Dindo classification .Tumor volume was determined using Advantage Workstation 4.1.2 . For volumetric evaluation, the venous phase was chosen, and the lesions were outlined manually. Volumetry was performed on CTs directly prior to chemosaturation. Portal branches and bile ducts were excluded by thresholding the outlined volume.Tumor stability was defined as stable disease (SD according to RECIST 1.1) in comparison to partial response (PD according to RECIST 1.1).N (%).Continuous data were summarized as means ± standard deviations or as medians [25th and 75th percentiles] as appropriate. Categorical data were presented as Overall survival was estimated with the Kaplan–Meier method. Univariable Cox proportional hazards models were used to associate the covariables to overall survival. Effects on mortality were presented with hazard ratios and 95% confidence intervals.Univariable logistic regression models were used to relate age, gender, and tumor size to tumor stability . The logistic regression models were presented with parameter estimates, standard errors, odds ratios and 95% confidence intervals.p values of likelihood ratio tests were presented. All p values were two-sided and a p value <0.05 was considered significant. All calculations were performed with the statistical analysis software R .In 19 patients, there were 43 procedures of chemosaturation with a median of 2 chemosaturation per patient. The interval between first and second PHP was on average of 119 days (SD of 145 days).Median OS following initial diagnosis was 26.4 months and following first PHP-M treatment was 16.7 month, as determined by the Kaplan–Meier method . Progresp value was not significant (0.695).A lower tumor volume decreases the risk of mortality: increased OS was found associated with lower tumor volume  for the tumor volume as stratified in 10 mL versus 150 mL: 0.190 ). However, there was only a weak correlation between age and survival (HR (95% CI) for 65 versus 50 years: 0.627 ; p=0.104). An increase in the sum of tumor diameter had a hazard ration of 2.503 (lower/upper HR: 0.732 8.556) in our cohort; but did not reach statistical significance (p 0.143).Elevation of serum LDH (in steps of 200 units) resulted in a hazard ration of 1.934 (lower/upper HR: 0.873/4.282); however, this trend was not significant  from first imaging  to 5 years and 0.793  and 0.604  for 1 and 2 years after chemosaturation, respectively.Ten of 19 patients achieved a partial response , and 9/19 had stable disease  following the initial treatment. There was no progressive disease (PD) and no complete response (CR).For the statistical analysis, SD and tumor stability  were referred to as an undesired event. Tumor stability  was inversely correlated to lower age  of age = 50 years versus age = 65 years: 0.179 ) . HoweverAdverse events according to the Clavien–Dindo classification until discharge: In our cohort of the 43 procedures, there were no or minor complications—grade ≤1 in 39 procedures, one case with grade II, in 2 cases grade IIIa (coronary ischemia), and in one case grade IIIb ; no grade IV-V occurred. Details are given in There were changes in the hematological state, most profoundly in platelet count (from 251.7/nL (SD 65.8) before the first PHP-M procedure to an average of 104.2/nL (SD 45.4) following the procedure). Bilirubin following the procedure was stable at an average of 0.9 (SD 0.6), and erythrocytes following the procedure were stable at 4.1/pL (SD 0.5).Uveal melanoma (UM) once metastatic carries a poor prognosis. Unfortunately, even modern agents such as immune checkpoint inhibitors—ipilimumab, nivolumab and pembrolizumab—yield poor outcome results in metastatic uveal melanoma (UM) with a median OS of 10–14 months . At presOf the metastatic UM, more than every second uveal melanoma develops hepatic metastasis , suggestIn our study treating unresectable liver metastasis with PHP-M and in part refractory to systemic therapy, median OS was 26.4 months following initial diagnosis and 16.7 months from first PHP-M treatment. Thus, we were able to show that PHP offers as second-line option the chance of the long-term OS outcome.p < 0.0001), the median OS was not significantly different (PHP-Mel 10.6 months vs. BAC 10.0 months) [Our data on OS were compared positively with published reports. Karydis et al. reported an overall survival of 15.3 months following treatment in a larger retrospective bicenter evaluation with over 50 patients . Data fr months) .In our cohort, the main factor found to be beneficial for prolonged OS was lower tumor volume. This observation needs to be verified; however, no such tumor volume-associated analysis has, to the best our knowledge, been published. Also, the influence of gender was estimated: in our patient cohort, females had only 15% of the risk of male patients; this is in accordance with a recently published multivariate analysis on an international patient population that showed male patients (and those with elevated LDH and elevated ALP) were all associated with a shorter PFS . In our In this retrospective single-institutional study, we observed a disease control in all of the metastatic melanoma patients after the first PHP-M, either by SD or by PR as classified by RECIST 1.1. There was no case of progressive disease following the PHP-M treatment by chemosaturation in our cohort.A factor found to be beneficial for a PR (in comparison to SD) was lower age  of age = 50 years versus age = 65 years: 0.179 ); however, there was only weak evidence that female gender or a lower tumor volume was associated with a lower risk of SD instead of a PR.The PHP-M procedure itself can be considered as standardized and safe, as no AEs of grades 4-5 occurred during the procedure or in the hospitalization period; thereafter, the observed adverse events up to grade IIIB were within the range of previously published data .We did monitor hematological changes with a most pronounced drop in platelets; these changes were within the range of previous reports and occurred after the PHP-M procedure, frequently improving after 5–7 days. These known effects were most likely due to side effects of dilution and the use of the extracorporeal filter system, as previously described , 21. A sμL, bilirubin ≤ 3 × upper limit) should be excluded from PHP-M [However, as other authors have recommended, we suggest that patients with a tumor volume higher than 50% of the total liver volume and with abnormal liver functions (ECOG) and especially with inadequate hematological and renal functions   or radioLimitations of the reported observations comprise mainly its single-center database, its retrospective nature, and the cutoff in follow-up. Uveal melanoma is a relatively rare disease overall, and larger patient numbers are likely to be achieved only by the use of pooled data analysis from multiple centers. This retrospective approach in turn may be limited due to the inconsistency of treatment regimens and postprocedural patient care. As a result, a single center was used to minimize these confounding effects at the cost of a more limited sample size.In conclusion, PHP-M for nonresectable liver metastasis of uveal melanoma provides a safe and locally efficient liver-directed procedure that offers patients a chance for long-term survival. PHP offers as second-line option the chance of long-term OS outcome, especially for patients with a low hepatic tumor burden.


Acinetobacter baumannii is one of the most important causes of nosocomial infections. The purpose of this study was to identify antibiotic resistance patterns, biofilm formation and the clonal relationship of clinical and environmental isolates of A. baumannii by Pulsed Field Gel Electrophoresis method. Forty-three clinical and 26 environmental isolates of the MDR A. baumannii were collected and recognized via API 20NE. Antibiotic resistance of the isolates was assessed by the disk diffusion method, and the biofilm formation test was done by the microtiter plate method. Pulsed Field Gel Electrophoresis (PFGE) was used to assess the genomic features of the bacterial isolates.Multi-drug resistant (MDR) p > 0.05). Biofilm production capabilities revealed that 31 (44.9%), and 30 (43.5%) isolates had strong and moderate biofilm producer activity, respectively. PFGE typing exhibited eight different clusters  with two significant clusters included A and G with 21 (30.4%) and 16 (23.2%) members respectively, which comprises up to 53.6% of all isolates. There was no relationship between biofilm formation and antibiotic resistance patterns with PFGE pulsotypes.The resistance rate of clinical and environmental isolates against antibiotics were from 95 to 100%. The difference in antibiotic resistance rates between clinical and environmental isolates was not statistically significant (A. baumannii. Cross-contamination is also very important that occurs through daily clinical activities between environmental and clinical isolates. Therefore, in order to reduce the clonal contamination of MDR A. baumannii environmental and clinical isolates, it is necessary to use strict infection control strategies.The results show that there is a close relationship between environmental and clinical isolates of  Acinetobacter baumannii is a gram-negative bacterium and one of the important pathogens of nosocomial infections, including pneumonia, meningitis, bacteremia, urinary tract infections, surgical wounds and soft tissue infections [fections . It has fections , 3. Due fections .A. baumannii isolates has increased significantly. Therefore, the emergence of multi-drug resistant (MDR) and extensively drug-resistant (XDR) A. baumannii isolates as an important cause of nosocomial infections is one of the major health problems in different countries of the world [A. baumannii to cause outbreaks of nosocomial infections and to obtain resistance to antibiotics [A. baumannii to form biofilms on living and non-living surfaces is an important factor in the persistence of bacteria because it protects them against environmental stress conditions, such as desiccation and exposure to antibiotics and disinfectants, which makes biofilm infections persistent and challenging to treat [A. baumannii. The usually applied methods focus on differences in the phenotypic properties that have insufficient reproducibility and discriminatory power. Molecular approaches such as PFGE that compare the DNA differences of bacteria have been accepted because of establishing the clonal association in many bacteria including A. baumannii isolates [A. baumannii in patients admitted to intensive care units. Concurrent typing of clinical and environmental isolates of A. baumannii is an important tool for finding sources and ways of transmission of such epidemic isolates. This research aimed to identify antibiotic resistance patterns, biofilm formation and clonal association of clinical and environmental isolates of A. baumannii by PFGE technique.Recently, due to the use of broad-spectrum antibiotics, antimicrobial resistance between he world , 5, 6. The world . This pahe world . Long-tehe world . For thiibiotics . The abito treat . For epiisolates . So far,A. baumannii (100%) were susceptible to colistin and tigecycline and all isolates (100%) were resistant to ciprofloxacin and cefepime. The resistance rate against ampicillin-sulbactam, meropenem, imipenem, and amikacin in the clinical isolates were 43(100%), 42(97.7%), 42(97.7%), 43(100%) and in environmental isolates were 24(92.3%), 26(100%), 25(96.2%), and 23(88.5%), respectively. Most clinical (95.3%) and environmental (84.6%) isolates of A. baumannii were resistant to all tested antibiotics and designated as extensively drug-resistance (XDR). The difference in antibiotic resistance rates between clinical and environmental isolates was not statistically significant (p > 0.05).The results of the antimicrobial susceptibility test shown in Fig. A. baumannii is the ability of biofilm formation. Therefore, we decided to measure potential biofilm formation in XDR of clinical and environmental isolates. In our study, we found that 68 (98.6%) of the isolates were capable of forming biofilm. The mean OD 595 values for clinical and environmental isolates were 0.680 ± 0.289 and 0.540 ± 0.265, respectively. Biofilm production capabilities revealed that 31 (44.9%), 30 (43.5%), 7 (10.2%), and 1 (1.4%) isolates had strong, moderate, weak, and no biofilm producer activity in the microplate assay, respectively. No statistically significant difference in biofilm formation was seen among the clinical and the environmental isolates (p > 0.05).One of the major virulence-related features of ApaI enzyme was used for access typing and genetic relationship between the A.baumannii isolated from clinical and environmental samples. From 26 environmental and 43 clinical isolates, 8 common PFGE clusters  which, were resistant to all tested antibiotics was greater than that detected in previous studies in Germany (7.3%), United States (9.8%), and 13.1% in China [A. baumannii is polymyxin B [The results of this study show high environmental pollution in the three intensive care units in our area. The incidence of XDR in China . These rin China , 17. Of ymyxin B .A. baumannii strains isolated from patients’ respiratory tracts, the bacteria isolated from tracheal aspirate specimens were the most common respiratory isolates, which is consistent with previous studies [A. baumannii to antibiotics was 95–100% and there was no significant difference between antibiotic resistance in clinical and environmental isolates (p > 0.05) [A. baumannii is its ability to form biofilms. In our study, we determined that 68 (98.6%) isolates of XDR A. baumannii formed biofilm, which is in agreement with previous studies [A. baumannii isolates form biofilms [A. baumannii isolates [A. baumannii isolates were XDR.Of the 41 XDR  studies , 20. Con > 0.05) . One of  studies , 22. Accbiofilms , 24. Preisolates , 25, 26.To track and evaluate the outbreaks, the genetic association of the isolates, and to attribute one strain to the relevant clonal lineage, several molecular typing techniques have been developed , 28. AmoA. baumannii isolates was done for tracks of outbreak and analyses of a population survey of bacteria based on their genotypes, predominant genotypes, distribution and probability transmission of isolates between patient and environmental surfaces. By the PFGE technique, 43 clinical and 26 environmental A. baumannii isolates were typed. PFGE typing showed 8 different PFGE cluster  with two major cluster A and G with 21 (30.4%) and 6 (23.2%) members, respectively, which contains up to 53.6% of all isolates. In our study, a close genetic relationship between clinical and environmental isolates of A. baumannii was observed that is consistent with other studies [A. baumannii clones, which may be responsible for the transmission of A. baumannii isolates between patients and their surroundings.In the current study typing of XDR In our study, two clinical isolates (No 5 and 31) which were found in two distinct hospitals were clustered into pulsotype A. This issue may indicate the possible transfer of related isolates from one ICU to another in the same hospital or different hospitals from patients admitted to the ICUs or the hospital health team in the same city. This type of transmission has been reported in several countries , 29. ComIn our study, the correlation analysis of PFGE typing and antibiotic resistance profiles showed that most isolates were XDR and no difference in antibiotic resistance was found in the PFGE clusters. Therefore, there is no significant relationship between different PFGE clusters and antimicrobial resistance patterns. This indicates that antimicrobial resistance patterns have low discriminatory power for bacterial typing and highlights the necessity of genotyping techniques such as PFGE to categorize isolates with similar phenotypes and distinct genetic relatedness during the evaluation of outbreak episodes or horizontal transmission of isolates in the hospital environments .A. baumannii with a high prevalence of biofilm formation. Tracing the sources of environmental isolates indicates that there is a close genetic link between environmental and clinical isolates of A. baumannii. Besides, it suggests that the occurrence of cross-contamination events is likely to occur between environmental and clinical isolates during routine clinical activities. Therefore, the use of strict infection control strategies to reduce cross-contamination of endemic clones of A. baumannii isolates is essential.Our investigation shown the high frequency of biofilm forming XDR A. baumannii were collected from respiratory tracts of patients admitted to ICU wards of Besat, Sina, and Beheshti educational hospitals of Hamadan University of Medical Sciences in Hamadan, west of Iran, during a period between November 2015 and August 2016.In this cross-sectional study, 43 MDR A. baumannii strains isolated from different environments and equipment surfaces such as ventilators, sink, and ground, hands of Staff, trolleys, bedside table, pillow and linens. For sampling from the environment and equipment of ICU wards, an area of about 10 cm2 was selected and sampled using a sterile humidified swab with physiological serum.The Besat hospital is a major tertiary referral hospital where patients are referred from neighboring provinces and Sina and Beheshti hospitals have infectious and internal medicine departments respectively, which accept patients in Hamadan province. Simultaneously, 26 MDR Acinetobacter spp. were identified by colony morphology, growth at 44 °C, oxidase, OF (Oxidation and fermentation), Simon citrate, and API 20NE system . The A. baumannii isolates identification was confirmed by PCR of the blaOXA-51 gene. A. baumannii ATTC 19606 was used as a reference strain [After taking the samples, the swabs were inoculated in Brian heart infusion broth (BHI) media and incubated overnight at 35 °C and further subcultured on MacConkey’s agar plates at 37 °C for 24 h. The e strain .Pseudomonas aeruginosa ATCC 27853 was used as a control strain. MDR A. baumannii isolates were defined as resistant to three or more classes of antibiotics as previously described [Antimicrobial susceptibility test was accomplished by the Kirby-Bauer disk diffusion method using the ampicillin/sulbactam (10 μg /10 μg), imipenem (10 μg), meropenem (10 μg), amikacin (30 μg), cefepime (30 μg), colistin (10 μg), tigecycline (15 μg), and ciprofloxacin (5 μg), antibiotic disks . The results interpreted according to Clinical and Laboratory Standard Institute guidelines (CLSI) . Pseudomescribed .A. baumannii isolates to produce biofilm was assessed by the microtiter plate method as previously described [The ability of escribed . Brieflyescribed . The optThe results were divided into the four following categories according to their optical densities as strong biofilm producer (4 ODc < OD); medium biofilm producer (2 ODc < OD ≤ 4 ODc); weak biofilm producer (ODc < OD ≤ 2 ODc); and non-biofilm (OD ≤ ODc) .A. baumannii were investigated by PFGE as previously described [Genetic similarities among clinical and environmental isolates of escribed . BrieflyGel images were studied by BioNumerics software version 7.5 . Dendrograms were obtained for all of the isolates. A comparison of the banding patterns was done by the unweighted pair group method with mathematical averaging (UPGMA), and DNA similarity was considered by using the band-based Dice coefficient with a tolerance setting of 1.5% band tolerance and 1.5% optimization setting were applied during comparison of the DNA patterns. The PFGE results were compared according to the criteria by Tenover et al.; a PFGE cluster was based on a similarity cutoff of 80% .P-value of less than 0.05 was considered as statistically significant.Statistical analysis was performed using SPSS 23.0 . The frequency of susceptibility and biofilm formation category were determined in clinical and environmental isolates. The relationship among biofilm formation and the antibiotic resistance with PFGE type were made using chi-square tests. A


Introduction. Airway management plays an essential role in anaesthesia practice, during both elective and urgent surgery procedures and emergency medicine.  The aim of the study was to compare Macintosh laryngoscope (MAC), McGrath, and TruView PCD in 5 separate airway management scenarios.  This prospective cross-over simulation study involved 93 paramedics. All paramedics performed intubation using direct laryngoscope (MAC), McGrath, and TruView PCD video laryngoscopes. The study was performed in 5 different scenarios: (A) normal airway, (B) tongue oedema, (C) pharyngeal obstruction, (D) cervical collar stabilization with tongue oedema, and (E) cervical collar stabilization with pharyngeal obstruction. p < 0.001). Intubation time was 44 s (IQR: 24–46) for MAC, 22 s (IQR: 20–27) for McGrath, and 39 s (IQR: 30–57) for PCD. In scenario C, the success rate with MAC was 74%, 97% with McGrath, and 72% with PCD (p < 0.001). Intubation time was 44 s (IQR: 24–46) for MAC, 22 s (IQR: 20–27) for McGrath, and 39 s (IQR: 30–57) for PCD. In scenario C, the success rate with MAC was 74%, 97% with McGrath, and 72% with PCD (p < 0.001). Intubation time was 44 s (IQR: 24–46) for MAC, 22 s (IQR: 20–27) for McGrath, and 39 s (IQR: 30–57) for PCD. In scenario C, the success rate with MAC was 74%, 97% with McGrath, and 72% with PCD (p < 0.001). Intubation time was 44 s (IQR: 24–46) for MAC, 22 s (IQR: 20–27) for McGrath, and 39 s (IQR: 30–57) for PCD. In scenario C, the success rate with MAC was 74%, 97% with McGrath, and 72% with PCD  for MAC, 18 s (IQR: 16–21) for McGrath, and 27 s (IQR: 23–34) for PCD. In scenario B, the success rate was 61% with MAC, 97% with McGrath, and 97% with PCD , number of optimization manoeuvres, severity of dental compression, and ease of use. Advanced airway management is crucial in the treatment of severely injured or sick patients . EndotraEndotracheal intubation in the out-of-hospital setting is especially challenging, as paramedics have to deal with difficult circumstances and suboptimal positions . Direct The McGrath video laryngoscope  is a portable video laryngoscope with Macintosh-style blades for paediatric and adult patients. It is in clinical use for many years now and is widely used in both in-hospital and out-of-hospital settings , 8. The The aim of the study was to compare MAC, McGrath, and PCD in 5 different simulated airway management scenarios. Our hypothesis was that the video laryngoscopes are superior in terms of intubation success rate compared to MAC if used by paramedics in a manikin setting.The study protocol was approved by the institutional review board of the Polish Society of Disaster Medicine . After obtaining written informed consent, 93 paramedics were enrolled in the study. The inclusion criteria were as follows: more than 5 years of professional work experience, previous experience with endotracheal intubation using MAC, and no previous experience with any type of video laryngoscopes.All paramedics participating in the study underwent a 45-minute lasting lecture covering basic aspects of airway management using direct laryngoscopy and video laryngoscopy. Afterwards, paramedics were allowed to familiarize themselves with the McGrath and TruView PCD laryngoscopes and were asked to perform at least one successful intubation with each device. All intubations were performed on a MegaCode Kelly advanced life support manikin .Direct laryngoscopy using a Macintosh blade size 3 (MAC)McGrath video laryngoscope equipped with a size 3 Macintosh blade (McGrath)TruView video laryngoscope.Paramedics were then randomly assigned to 1 out of 3 groups.A 7 mm I.D. endotracheal tube   was usedhttp://www.randomizer.org) software. The airway of the manikin as well as the tubes was well lubricated. The tubes were equipped with a hockey-stick-shaped stylet, prepared by an experienced researcher. All study participants were allowed to adjust the stylet as desired. After randomization, paramedics were asked to perform 5 intubations in 5 subsequent airway scenarios.Scenario A: normal airway.Scenario B: tongue oedema.Scenario C: pharyngeal obstruction.Scenario D: cervical collar stabilization with tongue oedema. Collar stabilization was performed with a standard patriot cervical extraction collar , applied to the manikin's neck by an independent instructor.Scenario E: cervical collar stabilization with pharyngeal obstruction. Collar stabilization was performed with a standard patriot cervical extraction collar , applied to the manikin's neck by an independent instructor.Randomization was based on the Research Randomizer . With the minimum of 80 participants necessary, 93 paramedics were included to compensate for potential doubts.The sample size was based on expected differences of time to intubation and calculated with G × Power 3.1 using a two-tailed p < 0.05. Data are presented as number (percentage), mean ± standard deviation (SD), or median (interquartile range [IQR]), as appropriate. Nonparametric tests were used for the data that did not have normal distribution, which was tested with the Lilliefors test and the Shapiro–Wilk test. All statistical tests were two-sided. The one-way ANOVA on ranks was applied to compare the different times and to determine the statistical difference for each group (post hoc Bonferroni correction was used to counteract the problem of multiple comparisons).The statistical analysis was performed with the Statistica software version 13.3EN for Windows . The level of significance was set at the value of Ninety-three paramedics with a median of 8.5 years [IQR: 5.5–11] of experience participated in this study. All of the paramedics had a previous experience with direct laryngoscopy guided endotracheal intubation (median 54 intubations (IQR: 42–77)) and none had any experience with any video laryngoscope.p=0.011).Detailed results obtained in scenario A are presented in The intubation time varied between 17 (IQR: 16–21) seconds for MAC, 18 (IQR: 16–21) seconds for McGrath, and 27 (IQR: 23–34) seconds for PCD. Cormack-Lehane score was best for McGrath and PCD and worst for MAC. A similar correlation was observed for POGO score, with a value of 81% during intubation with MAC and 100% with McGrath and PCD.The ease of use averaged 20 (IQR: 11–23) for McGrath, 24 (IQR: 10–27) for MAC, and 31 (IQR: 17–35) for PCD.Results of scenario B are presented in The intubation time was 22 (IQR: 20–27) seconds for McGrath, 39 (IQR: 30–57) seconds for PCD, and 44 (IQR: 24–46) seconds for MAC.Cormack-Lehane score was best for McGrath and PCD and worst for MAC. Average POGO score was the highest with 93% for McGrath, compared to 90% for PCD and 37% for MAC.p < 0.001) and PCD (p < 0.001). McGrath also had the fewest number of tooth compressions in comparison with MAC (p < 0.001) and PCD (p < 0.001).Endotracheal intubation with McGrath was associated with the fewest optimization manoeuvres in comparison with MAC (The ease of use averaged 74 (IQR: 50–80) for MAC, 34 (IQR: 26–47) for McGrath, and 46 (IQR: 38–61) for PCD.Results obtained in scenario C are presented in The intubation time with the studied methods varied between 21 (IQR: 19–29) seconds for MAC, 18 (IQR: 18–24.5) seconds for McGrath, and 30 (IQR: 23–39) seconds for PCD.The best POGO score was obtained for McGrath and for PCD (100% each), and the worst for MAC (80%).p=0.021) and PCD (p < 0.001). McGrath also had the fewest number of tooth compressions in comparison with MAC (p=0.006) and PCD (p < 0.001).Endotracheal intubation with McGrath was associated with the fewest optimization manoeuvres in comparison with MAC (The ease of use averaged 27 (IQR: 14–38) for MAC, 20 (IQR: 11–24) for McGrath, and 39 (IQR: 24–49) for PCD.Detailed results obtained in scenario D are presented in The intubation time was 26 (IQR: 20–29) seconds for McGrath, compared to 54 (IQR: 39–71) seconds for MAC and 45 (IQR: 33–56) seconds for PCD.The Cormack-Lehane score was the best for McGrath. The highest POGO score was obtained for McGrath and equaled 86%, compared to 80% for PCD and 35% for MAC.p < 0.001) and PCD (p=0.023). McGrath also had the fewest number of tooth compressions as compared with MAC (p < 0.001) and PCD (p < 0.001).Endotracheal intubation with McGrath was associated with the fewest optimization manoeuvres in comparison with MAC (The ease of use averaged 81 (IQR: 63–90) for MAC, 34 (IQR: 28–48) for McGrath, and 57 (IQR: 45–75) for PCD.Detailed results of the parameters obtained in scenario E are presented in The intubation time with the studied methods was the least for McGrath and equaled 19 (IQR: 18–26) seconds; the values were 28 (IQR: 25–39) seconds for MAC and 34 (IQR: 27–45) seconds for PCD.Again, the best Cormack-Lehane score and highest POGO score were obtained for McGrath.p < 0.001) and PCD (p=0.012). McGrath also had the fewest number of tooth compressions as compared with MAC (p < 0.001) and PCD (p < 0.001).Endotracheal intubation with McGrath was associated with the fewest optimization manoeuvres in comparison with MAC (The ease of use averaged 68 (IQR: 51–80) for MAC, 31 (IQR: 28–45) for McGrath, and 51 (IQR: 36–64) for PCD.The most important finding of our randomized cross-over simulation study is the superiority of the McGrath video laryngoscope compared to conventional Macintosh laryngoscope intubation, considering the overall success rate, duration of intubation attempt, Cormack-Lehane grade, POGO score, number of optimization manoeuvres, severity of dental compression, and ease of use in all 5 tested scenarios of normal and difficult airways.Overall, the success rate for MAC ranged between 15% in scenario E and 99% in scenario A. While the success rate in the normal airway is acceptable, a success rate of only 15% is far from acceptable. Consequently, MAC should not serve as the first airway intubation device for paramedics.For PCD, the success rate varied between 57 and 97% in the several airway scenarios. It is worth noting that, in all difficult airway scenarios, the overall success rate for McGrath was between 69% and 94%. We noticed that paramedics performed endotracheal intubation with best results when using McGrath as compared with PCD and MAC. In contrast to our results, Altun et al., in a simulation study on Macintosh, McGrath, McCoy, and C-MAC laryngoscopes among 41 anaesthesiology residents, revealed that McGrath offered the longest intubation time, especially in a difficult airway (tongue oedema) scenario . In an op=0.019). In our study in scenario D: cervical collar stabilization and tongue oedema, the values of 69% versus 32% (p < 0.001) were obtained for McGrath and Macintosh laryngoscope [Choi et al. in a manikin study compared tracheal intubation by novice users applying the McGrath series 5 video laryngoscope versus the Macintosh laryngoscope in a cervical immobilized manikin and revealed that the first-attempt success rate was higher for the McGrath compared with the Macintosh laryngoscope in cervical immobilizations . In the presented study, in some difficult airway scenarios, the time of intubation attempt was shorter as compared with MAC (scenarios B and D). This finding is generally supported by other studies. Bag et al. found the mean time necessary for intubation equaled 21.10 ± 5.64 seconds for Truview and 15.79 ± 2.76 seconds for Macintosh [The duration of the intubation attempt is a clinically important factor and differences of 15 seconds or more can be clinically important, especially in severe hypoxia or cardiac arrest patients. In our study, the shortest time of intubation attempt among all difficult airway scenarios was obtained for McGrath intubation; however, only in normal airway the time was not statistically significantly shorter , and the times to endotracheal intubation were significantly shorter for McGrath [From a clinical point of view, each intubation attempt is important, with repeated intubation attempts leading to an increased risk of complications including bleeding and oedema of the airways, which reduce the chance of successful endotracheal intubation . Alvis e McGrath .The Cormack-Lehane grade in our study was assessed by the paramedics. In all difficult airway scenarios, better glottis view was obtained for McGrath compared with PCD and MAC. This finding is supported by other studies, including a meta-analysis by Hoshijima et al., who revealed that McGrath was superior to Macintosh in terms of glottic visualization .p < 0.01). The number of necessary external manoeuvres was fewer in the Truview PCD than in the Macintosh group [In our study, POGO score was better for McGrath compared with MAC and PCD. This finding is concordant with other studies. Singh et al. published the results of their study on intubation using Truview PCD, C-MAC, and Macintosh laryngoscopes in paediatric patients. They concluded that POGO scores were significantly better with Truview PCD than with Macintosh laryngoscopes (94.7 ± 12.9 versus 85.1 ± 17.1; sh group .As a limitation, higher success rates and shorter intubation times obtained with MAC compared with video laryngoscopes may be due to greater experience with MAC. Expertise with standard direct laryngoscopy does not translate to that with video laryngoscopy, and separate training and experience with video laryngoscopy are required. Our study included only paramedics experienced with MAC, with no prior experience in any video laryngoscopes. We enrolled paramedics because this group of medical personnel must provide airway management including endotracheal intubation in out-of-hospital settings with no support from experienced personnel, for example, anaesthesiologists.A further limitation is the nature of any manikin study. Results of any manikin study need to be confirmed in clinical studies, which is extremely challenging due to ethical concerns, especially if investigated by less experienced providers like paramedics. However, manikin studies are generally considered reliable. Another limitation is the potential of bias, as it is impossible to blind participating paramedics. The POGO score and ease of use were subjective measures. The application of manikins allows for enough statistical power while performing cross-over studies with no risk for humans.In conclusion, in this randomized cross-over simulation study performed among a group of paramedics, the McGrath video laryngoscope was demonstrated to be superior to the Truview PCD video laryngoscope and direct laryngoscopy guided intubation using a Macintosh laryngoscope in terms of success rate, duration of intubation attempt, Cormack-Lehane grade, POGO score, number of optimization manoeuvres, severity of dental compression, and ease of use.


Flow-mediated dilation (FMD) test was performed to assess endothelial function. Anthropometry and blood pressure parameters were measured. Lipid profile, glycaemic indices, serum creatinine as well as CD4 count and viral load were assayed in blood. Urinary albumin to creatinine ratio (ACR) was determined as a marker of cardiovascular risk. Obesity and albuminuria were positively associated with HIV, and HIV+ART+ participants had significantly higher HDL cholesterol. Dyslipidaemia markers were significantly higher in hypertensive HIV+ART+ participants compared with the controls (HIV+ART− and HIV− participants). FMD was not different between HIV+ART+ participants and the controls. Moreover, HIV+ART+ participants with higher FMD showed lower total cholesterol and LDL cholesterol comparable to that of HIV− and HIV+ART− participants. A positive relationship between FMD and CD4 count was observed in HIV+ART+ participants. In conclusion, antiretroviral treatment was associated with cardiovascular risk factors, particularly dyslipidaemia, in hypertensive South Africans of African ancestry with HIV. Although, ART was not associated with endothelial dysfunction, flow-mediated dilatation was positively associated with CD4 count in HIV-positive participants on ART.Limited information on the effect of antiretroviral treatment (ART) on vascular function in South Africans of African descent living with human immunodeficiency virus (HIV) is available. The relationship between ART, vascular function and cardiovascular risk factors in South Africans of African ancestry with HIV was therefore studied. This cross-sectional study recruited 146 HIV-positive individuals on ART (HIV Global reports show that approximately 17.9 million deaths recorded globally are due to cardiovascular diseases (CVDs) , In SoutCardiovascular risk in HIV is a complex interplay of several factors. Studies show that obesity and dyslipidaemia are prevalent in HIV patients . HyperteEndothelial dysfunction, resulting in altered vasodilation, endothelium-mediated vasomotor and anti-inflammatory responses , is an iThe introduction and increased use of antiretroviral treatment (ART) has greatly reduced the global burden of HIV/AIDS. There has been a dramatic decline in immunodeficiency-related events, including deaths, in HIV-infected individuals ,22. In SThere is also paucity of information on the effects of ART on vascular function in sub-Saharan Africa . Though +) and currently on ART medication (HIV+ART+) were classified separately from participants who were newly diagnosed with HIV and not yet on ART (HIV+ART−), while those who were HIV-negative (HIV−) served as control. Participants considered HIV+ART+ are those who had received ART for ≥4 months. Participants were tested and their HIV status was confirmed before allocation to any of the study groups, and appropriate pre- and post-test counselling was performed. This study was part of the EndoAfrica South African Project [− and 300 were HIV+ (HIV+ART− and HIV+ART+).This was a cross-sectional study that involved adult (≥18 years) South Africans of African ancestry with/without HIV attending the Gateway Clinic, a primary healthcare centre in Mthatha, Eastern Cape Province. Study participants were randomly recruited between June 2016 and December 2019. Participants who were HIV-positive  as well as local and national regulations in South Africa. Ethical approval was obtained from the Health Sciences Ethics Committee of Walter Sisulu University, South Africa (Ref No:005/2015). After careful explanation of the study aims and methods, written informed consent was obtained from participants before recruitment into the study. The study adhered to the standards of reporting and in accordance with the National Data Protection Act, wherein each participant was assigned a code and data/samples were stored anonymously.A validated interviewer-administered questionnaire was adopted from the WHO STEPwise approach to Surveillance (STEPS) guidelines for non-communicable diseases (NCDs) . It was Anthropometric measurements were performed in accordance with the International Standards for Anthropometric Assessments  on all pBlood pressure was measured in a quiet room using the Omron automated sphygmomanometer . After resting for 5 min, arm-size-appropriate cuffs were fitted to the upper arm and systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were measured trice automatically at 2 min intervals and the average of the three readings was computed. Hypertension was classified as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg .Fasting blood and urine samples were collected. Serum was obtained after centrifugation and the fasting glucose (FG), glycated haemoglobin (HbA1c), triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), blood creatinine, CD4 count and HIV viral load were determined. Urine creatinine and albumin were quantified from early morning urine samples and the albumin-to-creatinine ratio (ACR) was calculated. The FG, HBA1c, CD4 count, TC, TG, LDL-c, creatinine and urea were determined using a cobas 501/502 panel/system  according to the manufacturer’s protocol, while HDL-c was calculated using the Friedewald equation. The cobas 6800/8800 HIV-1 test  was used to determine HIV viral load by quantifying RNA copies according to the manufacturer’s protocol. All assays were performed in the clinical pathology, haematology and virology units of the National Health Laboratory Service (NHLS) of the Nelson Mandela Academic Hospital, Walter Sisulu University, Mthatha, South Africa. Lipid profile measures were classified as high when TC ≥ 6.2 mmol/L, LDL-c ≥ 4.15 mmol/L and TG ≥ 1.7; and low when HDL-c ≤ 0.90 mmol/L according to the Adult Treatment Panel (ATP) III guideline . AlbuminA mobile Esaote MyLab Five portable ultrasound device  with an Esaote Doppler probe  connected to computerized software with edge detection technology (Cardiovascular Suite (CVS); Quipu, Pisa, Italy) was used to measure endothelium-dependent flow-mediated dilation (FMD) of the brachial artery. Participants who had fasted overnight and had not smoked or exercised for at least 4 h were asked to lie down on the exam bed in the supine position with their right arm placed on the probe holder of the CVS ultrasound. A blood pressure cuff was placed around the forearm, as close as possible to the elbow and participants rested for 5–10 min prior to FMD measurement. An electrostatic gel probe was used to scan through the upper right arm in a transverse plain to visualize the pulsating brachial artery. Once the brachial artery was visualized on the CVS ultrasound screen, the probe was fixed to the probe holder and maintained in place for the rest of the measurement. The CVS software was turned on for the baseline recording at rest which lasted for 60 s (1 min), after which the artery was occluded by raising the blood pressure to 200 mmHg and maintaining it at this level for 5 min. At the end of the 5 min, the cuff was deflated to allow blood to flow freely in the brachial artery for 2 min after which the recording was stopped. The software then automatically calculated baseline diameter (the diameter of the artery at rest), maximum diameter (the diameter of the artery at occlusion), recovery diameter, baseline shear rate, maximum shear rate and percentage FMD. FMD (%) was calculated as the difference between maximum and baseline diameter, expressed as a percentage of baseline diameter. FMD (%) was classified into interquartile ranges to assess cardiovascular risk factors exceeding critical threshold for endothelial function. Concordance in the operation of the device by operators was checked to ensure reproducibility of the technique.−, HIV+ART− and HIV+ART+ participants. Multivariate analysis of variance (MANOVA) was done to assess the interaction of antiretroviral treatment with endothelial function, hypertension or obesity among study groups. The relationship of HIV and ART with cardiovascular risk factors was assessed using the Chi-square test of association. Pearson’s correlation was used to assess relationship between endothelial function and CVD risk factors. The standardized beta coefficient (β) was determined by stepwise linear multiple regression analysis adjusted for age, sex and smoking status to identify factors that are predictors of endothelial (dys)function. An alpha error (α) of 0.05 was taken and p-value ≤ 0.05 was considered to be significant.Statistical Package for Social Sciences (SPSS) version 23.0  was used for data analysis. Descriptive statistics was employed and data were presented as mean ± standard deviation (SD). Analysis of variance (ANOVA) was used to compare mean differences between HIV− participants, 146 were HIV+ participants on ART (HIV+ART+) and 163 were HIV+ participants not on ART (HIV+ART−). Among the 146 HIV+ART+ participants, 120 (82.2%) were on TEE (tenofovir disoproxil fumarate + emtricitabine + efavirenz), 11 (7.5%) on TLD (tenofovir disoproxil fumarate + lamivudine + dolutegravir), 7 (4.8%) on zidovudine + lamivudine + efavirenz, 3 (2.1%) on stavudine + lamivudine + nevirapine, 3 (2.1%) on zidovudine + didanosine + lopinavir/ritonavir and 2 (1.4%) on zidovudine + lamivudine + lopinavir/ritonavir. The age and heights of the participants were different (p < 0.05) among the three study groups. The HR of HIV+ART+ participants was significantly (p < 0.001) lower than that of HIV+ART− and HIV− participants. HDL-c level was significantly (p < 0.01) increased in HIV+ART+ participants compared with HIV+ART− participants. The CD4 count was significantly (p < 0.001) lower in HIV+ART− and HIV+ART+ participants than in HIV− subjects. The HIV viral load was significantly (p < 0.01) lower in HIV+ART+ participants than in HIV+ART− participants and 23.3% of the HIV+ART+ participants had undetectable viral load levels.The baseline characteristics of the study population are shown in +ART− participants were obese compared with HIV− and HIV+ART+ participants and thus, obesity was associated with HIV . Fewer HIV+ART+ participants had low HDL-c compared with HIV− and HIV+ART− participants and thus, ART was associated with increased HDL-c . More HIV+ participants (n = 16) had albuminuria compared with HIV− participants (n = 1) and thus, albuminuria was associated with HIV status .The relationship of HIV and ART with cardiovascular risk factors is shown in  = 5.349; p = 0.006) and LDL-c  = 5.675; p = 0.005) level was observed in hypertensive HIV+ART+ participants compared with the controls. The concentration of TG was also significantly higher  = 4.455; p = 0.014) in hypertensive HIV+ART+ participants and hypertensive HIV− participants. These findings indicated that ART administration was associated with lipid abnormalities in hypertensive HIV participants on ART  was performed. A significantly increased TC (Fs on ART .+ART+ participants with low FMD (second quartile) showed a significantly (p < 0.05) higher level of TC and LDL-c compared with HIV+ART− and HIV− participants. Moreover, HIV+ART+ participants with higher FMD (third and fourth quartiles) showed lower TC and LDL-c comparable to that of HIV− and HIV+ART− participants. This implied that improved endothelial function was associated with reduced TC and LDL-c in HIV participants on ART  or cardiovascular risk factors  in the overall cohort and various study groups. In addition, there was no correlation between FMD and CD4 count in HIV+ART− participants  or in HIV− participants . However, a significant positive correlation  was observed between FMD and CD4 count in HIV+ART+ participants  showed CD4 count as a positive predictor for FMD  in HIV+ART+ participants, indicating that ART increases CD4 count which may improve endothelial function in HIV-infected individuals.FMD was not associated with viral load , suggesting a positive association between ART and dyslipidaemia in hypertensive PLHIV on ART  compared with HIV+ART− and HIV− participants, HIV+ART+ participants with higher FMD (third and four quartiles) showed lower TC and LDL-c comparable to that of HIV− and HIV+ART− participants (+ART+ participants (Endothelial dysfunction is one of the key steps that contributes to the initiation and clinical manifestations of atherosclerosis and known to be an early predictor of future cardiovascular events in patients with or without a known cardiovascular risk ,62. Someicipants . The undicipants . This inicipants  and CD4 Several influencing participant-related covariates and environmental factors could lead to low reproducibility of FMD measurements , but strAntiretroviral treatment was associated with cardiovascular risk factors, particularly dyslipidaemia, in hypertensive South Africans of African ancestry living with HIV, but it was not associated with endothelial function. Moreover, antiretroviral treatment was associated with increased HDL-c in HIV participants. Although ART was not associated with endothelial function, flow-mediated dilatation was positively associated with CD4 count in HIV-positive participants on ART. Considering that this was a cross-sectional study which may be limiting, there is a need for longitudinal studies in the future to further assess the relationship of ART with cardiovascular risk factors in this population.


Bolanusoides shaanxiensis was sequenced and annotated. The mitogenome is 15,724 bp in length, containing 37 typical genes and a control region. The A + T content of the whole mitogenome is 78.9%. Most of PCGs started with ATN and stopped with TAA, except for ATP8 started with TTG, COX2, COX3 and ND5 used incomplete T as stop codon. The phylogeny tree is monophyletic among 31 related species. The relationships of B. shaanxiensis and Typhlocyba sp. were closer than others. This study further enriched mitogenome database of the tribe Typhlocybini.The mitochondrial genome of one leafhopper species  Bolanusoides was established by Distant , in September 2018. Total DNA was extracted from entire body without its abdomen using the DNeasy Blood and Tissue Kit (Cat. No. 69504). And voucher specimen’s genome DNA and male genitalia were deposited in the Institute of Entomology of Guizhou University, Guiyang, China (GUGC), accession number of them is GUGC-IDT-00188 . The reads were assembled and annotated using Generous Prime (v2019.1.3.). All tRNA genes were identified by ARWEN v1.2 , and a control region. The A + T content of genes are 78.9%, which is similar to other typhlocybine leafhopper mitogenomes  to 72 bp (tRNA-K and tRNA-V). Genes of 16S rRNA and 12S rRNA are 1,174 bp and 789 bp, respectively. The results of phylogeny confirmed that relationship of selected taxon categories was monophyletic. The species of B. shaanxiensis and Typhlocyba sp. were clustered into one clade, indicating closest relationship. This work further enriched mitogenome database of the tribe Typhlocybini, with facilitating future studies on Taxonomy and Molecular systematics (Mitogenome of tematics .


Anterior shoulder dislocations (ASD) are commonly seen in Emergency Departments (ED). ED overcrowding is increasingly burdening many healthcare systems. Little is known about factors influencing ED length-of-stay (LOS) for ASD. This study defines the factors influencing ED LOS for ASD patients.Retrospective chart reviews were performed on all patients ≥12 years admitted with an anterior shoulder dislocation at two regional hospitals in the Netherlands between 2010 and 2016. The electronic patient records were reviewed for baseline patient characteristics, trauma mechanism, reduction methods, medication used, complications and the LOS at the ED. The main objective was determining factors influencing the LOS in patients with an anterior shoulder dislocation at the ED.p < 0.001), younger age group (p < 0.03) and in patients who received no medications in the ED (p < 0.001). Traction-countertraction and leverage techniques were associated with a significant more use of ED medication compared to other techniques. Although the use of more medication might suggest the LOS would be longer for these techniques, we did not find a significant difference between different reduction techniques and LOS.During the study period, 716 ASD occurred in 574 patients, 374 (65.2%) in males. There were 389 (54.3%) primary ASD; the remainder  were recurrent. Median LOS was 92 min (IQR 66 min), with a significantly shorter LOS in those with recurrent dislocations (To our knowledge this study is the largest of its kind, demonstrating ED LOS in ASD patients is influenced by age, the need for medication and dislocation history, primary versus recurrent. Notably, we found that biomechanical reduction techniques, which are not primarily traction-countertraction or leverage techniques, e.g. scapular manipulation and Cunningham, were associated with less ED medication use. Further research is needed to define how reduction methods influence ED medication use, patient satisfaction and ED throughput times. The highly mobile glenohumeral joint is the most commonly dislocated large joint with an annual incidence of 8–27 per 100,000 population . The incOver 2000 years ago Hippocrates of Kos described a reduction method that is still used today. Many more reduction techniques have been described and are currently practiced. Techniques can be divided in three categories. Primarily traction-based, e.g. Hippocrates, Milch, primarily leverage-based, e.g. Kocher and so-called “biomechanical” techniques, e.g. scapular manipulation, FARES, modified Milch and Cunningham –8.Worldwide, Emergency Departments are increasingly busy and overcrowded, leading to increased “door-to-provider” times and prolonged ED throughput times. The overall mean LOS for discharged patients in the Netherlands is 119 min . This isASD patients often require significant ED resources, such as medications, materials, monitoring and attention by ED personnel, further impacting and lengthening ED LOS and potentially effecting waiting times for other patients , 12, 13.The present literature contains little on factors determining ED LOS for ASD patients. We therefore initiated this study to determine which factors influence ED LOS for ASD patients. We postulated that reduction method, medication use, patient age and patient dislocation history (primary vs. recurrent) would influence LOS.Westfriesgasthuis (WFG) in Hoorn, and the Flevoziekenhuis (Flevo) in Almere, the Netherlands. These two community EDs have approximately 50,000 visits a year combined. WFG is a level 2 trauma centre with 14 rooms at the ED and provides a training program for Emergency Medicine residents. Flevo is a level 3 trauma centre, with 16 rooms and without an Emergency Medicine residents training program. Ethics committee approval was obtained at both facilities.Study data was collected from Using the DBC-code, ‘Diagnose-Behandel-Combinatie’, meaning Diagnosis Treatment Combination, for “shoulder dislocation” we identified all the patients that visited the ED at WFG and Flevo Hospital between January 2010 and July 2016. The DBC is a unique code used in the Netherlands to identify certain combinations of diagnosis and treatment. In Flevo the orthopaedic and surgical department have a weekly schedule in supervising the ED and because of administrative issues we only included those patients that were seen for the orthopaedic department. The medical records were checked to only include the anterior shoulder dislocations, i.e. other directions of dislocation were excluded. Other exclusion criteria were age younger than 12 years, reduction before arrival at the ED and patients presenting after multitrauma or other health issues that made the ASD not the first priority of treatment. Repeated presentations of the same patient were recorded as different cases.p-value of 0.05 was used.The patient characteristics were extracted from the electronic patient records . Data and statistical analysis was managed with IBM SPSS Statistics, version 20 for MacOSX. Continuous variables were compared for subgroups with the non-parametric Kruskall-Wallis H test and the Mann-Whitney U Test. The Pearson Chi-square test was used for evaluating differences between groups in categorical variables. Testing for normality was done with the Kolmogorov-Smirnov test. Numerical data are presented with median and interquartile range (IQR). As a cut-off point for significance, a All medical record inconsistencies (e.g. radiograph interpretation discordance) were discussed by a panel consisting of the lead researcher, an emergency medicine resident and an emergency physician. Only panel consensus findings were used in these cases. The first author performed all data collection and 10% of this data was checked for reliability by the panel.Records for 716 ASD occurring in 574 patients were available for analysis. Primary (first time) ASD numbered 389 (54.3%) and 327 (45.7%) were recurrent (more than one same-sided) ASD. Males sustained 475 (66.3%) of the ASD. There was a trimodal age distribution, with peaks at 21, 43 and 65 years.p < 0.001). Recurrent ASD occurred in younger individuals  compared with primary ASD  (p < 0.001).The overall median age was 35 years (IQR 39). The median age for males was 30 years (IQR 23) and 59 years (IQR 39) for females Fig. . This diThe most common ASD mechanisms were falls 34.1%), sports (25.0%) and non-traumatic causes (23.0%). Primary dislocations most commonly resulted from falls. Most recurrent dislocations were non-traumatic .In fall-related ASD, more than half the patients were older than 55. In sports-related ASD nearly ¾ (72.6%) of the patients were under the age of 35 Table . ASD duep = 0.011), traffic (p < 0.001), and falls (p < 0.001) with the median age being 26 years (IQR 17).Sports-related dislocations occurred in younger patients compared to non-traumatic causes , subcapital humerus fractures (p = 0.015), nerve damage (p = 0.008) and damage to the rotator cuff muscles (p < 0.001), all being more common in the elderly. Although 52.0% of the Hill Sachs lesions occurred in patients under the age of 35, we did not find a significant difference in age (p = 0.253).A Hill Sachs lesion was the most common associated local injury , followed by Bankart’s lesion  and greater tubercle fractures   cases the reduction method used was not specified.n = 70) of biomechanical reductions, no medications were used. When traction-countertraction or leverage techniques were employed, a non-medication approach occurred in only 16.3% (n = 22) of cases (p < 0.01).Medication use  differed significantly with reduction methods used. In 33% (p < 0.001), the median LOS being 78 min (IQR 54.5) for recurrent dislocations and 102 min (IQR 68) for primary dislocations.The median length-of-stay (LOS) was 92 min (IQR 66). The LOS was not obtainable from 16 charts. LOS differed significantly between recurrent and primary ASD (p < 0.001). There was also a significant difference in LOS for those who received procedural sedation and analgesia, median 139 min (IQR 89) and those who received other kinds of analgesia, median 90 min (IQR 54.0) (p < 0.001)  for the medicated group compared to a LOS of 61 min (IQR 60) for the un-medicated group . The LOS was longer for the more elderly compared to the younger ones. This difference was significant in both the overall population as in the recurrent or primary dislocation groups Table .p > 0.05). The ED LOS was not influenced by the ASD reduction method used.When we compared the LOS for the different kind of reduction methods used, we did not find any significant differences  and was longer for the elderly, in those with primary dislocations and in those cases in which medication was administered. Other literature generally describes a bimodal age distribution –16. In y5,29,33 This could be due to underreporting or our focus on ED records only, since some nerve injury presentations are delayed. Some of our patients may have had follow up at other hospitals also leading to missing data on associated injuries.Our incidence of Hill Sachs lesions, Bankart’s lesions and greater tubercle fractures were similar to other series , 17–19. ASD is a stressful painful experience. It has been suggested that successful reduction depends primarily on local muscle relaxation , 20. ForThe availability to make X-ray’s at the ED is an important factor for the LOS. Both the WFG as the Flevo have a dedicated room for making X-ray’s for the emergency department, but the radiological technician making the x-rays can also be busy with operating the CT-scanner during evening and night shifts. So maybe hospitals with more capacity, facilities or staff might provide shorter LOS, but some delay will always be a part of the day to day routine of an emergency department.WFG there is an Emergency Medicine residency training program, while the Flevo does not have this program. This could have led to a different treatment approach or more delay in treatment. For the Flevo we only included the patients when the orthopaedic department was on call , leading to an incomplete view of the patients that visited the ED.Our study is a retrospective chart review, therefore uncontrolled. Patient evaluation and treatment was performed according to individual physician preference. Some data, like individual physician experience, physician workload, ED census at a given time and a variety of other information which may impact physician decision making or approach, are not obtainable from electronic health records and are therefore not taken into account. In the Patient characteristics were abstracted from electronic health records, which are not designed for research purposes. Factors like patient build, comorbidities and time from presentation to reduction, all of which could influence LOS, could not be retrieved from available health records , 23. SomWe found no significant correlation between reduction methods used and LOS, although the reduction method was unknown in 51.5% of cases. It might be that only successful reduction methods were recorded and failed reduction methods omitted. The number of attempts and the time needed for the reduction itself were not recorded either.To our knowledge this is the largest chart review focused on the length of stay at the emergency department (ED) for patients with an anterior shoulder dislocation.In our study the median length of stay at the ED of patients with an anterior shoulder dislocation was 92 (IQR 66) minutes. An increased length of stay was found in patients with a primary dislocation, elderly patients and in those given any kind of medication before or during reduction. The administration of medication could lengthen the stay with more than 30 min.We also found that medications were much more likely to be given to those undergoing traction-countertraction or leverage-based techniques, such as Hippocrates and Kocher, compared to biomechanical reduction techniques, such as scapular manipulation, Cunningham and (modified) Milch (84 vs 67%).ED crowding and resultant prolonged lengths-of-stay are increasing worldwide. In case of the commonly-seen anterior shoulder dislocation little can be done about patient characteristics. Our results suggest that ED LOS in this patient category can be significantly reduced if anterior shoulder dislocations are treated with reduction techniques that minimize medication use, especially procedural sedation and analgesia.Development of an evidence based algorithmic approach to ASD reduction starting with, and focused on, pain-minimizing techniques is warranted.


Method and Results. From Jan 2016 to Dec 2017, 304 patients diagnosed with nonvalvular, drug-refractory PAF were included, who underwent either CBA alone (n = 262) or combined procedure (n = 42). Instant pulmonary vein isolation (PVI) with CBA was achieved in all patients, while successful LAAC achieved in 41 (97.6%) of combined procedure patients. 1-year freedom of AF rate was lower in combined procedure group , with unadjusted hazard ratio (HR = 1.97) and 95% confidence interval (CI) 1.03–3.77. However, the multivariate COX model revealed left atrial diameter , rather than procedure type , was the predictor for freedom of AF. Only 2 patients in the CBA group had stroke, contributing to the nonsignificant higher stroke incidence (p = 1.00). Transoesophageal echochardiography (TEE) achieved in 35 patients (83.3%) showed complete occlusion with no obvious residual flow (>3 mm), Device-related thrombosis, or pericardial perfusion. All-cause mortality, rehospitalization, and complication rates were similar.  Catheter ablation combined with left atrial appendage closure (LAAC) was reported as a feasible strategy for atrial fibrillation (AF) patients with high risk of stroke or contraindications of oral anticoagulants. We aimed to observe the short-term safety and efficacy of combining cryoballoon ablation (CBA) with LAAC in paroxysmal (PAF) patients.  Combining CBA with LAAC in a single procedure is a feasible strategy for PAF patients, with comparable short-term safety and efficacy to CBA alone. Atrial fibrillation (AF) is a commonly faced cardiac arrhythmia, which has been a heavy worldwide burden with a prevalence over 10 million in China . Further2DS2-VASc score ≥2 in male and ≥3 in female), oral anticoagulants (OACs) has been suggested to be effective, with class I, level A recommendation [To prevent stroke and embolic events in AF patients with high thrombotic risk  was conducted to evaluate cardiac function quantitatively, including left ventricular ejection fraction (LVEF), left atrial and ventricular size, and valvular function. Meanwhile, transoesophageal echocardiography (TEE) was applied to evaluate left atrial (LA) size and left atrial appendage (LAA) size and shape, and rule out thrombus in LA or LAA beforehand. Patients considered eligible for combined procedure are as follows: (a) drug-refractory nonvalvular paroxysmal atrial fibrillation patients and (b) patients with one of the following conditions: (a) CHA2DS2-VASc score ≥2, (b) HAS-BLED score ≥3, (c) contraindications to long-term OACs, and (d) refuse OACs as antithrombotic regimen according to personal willingness. Patients with the following conditions were excluded from interventional procedure: (a) thrombus in LA or LAA presented and confirmed by TEE, (b) oversized LA (LA diameter >65 mm) by TTE or LAA (LAA opening >35 mm) through TEE, (c) pericardial perfusion (volume ≥4 mm by TTE or TEE), (d) hemodynamic unstable patients, (e) patients with active hemorrhagic diseases, and (f) ischemic or hemorrhagic stroke within 30 days. Our study complied the Declaration of Helsinki (1964). From each patient, informed consent was obtained before the procedure, with procedural risks and possible complications fully informed. The study was approved by the Ethical Committee of Shanghai Tenth People's Hospital. Both CBA and LAAC combined procedures were performed by the same proficient electrophysiologist, with CBA procedure over 100 cases and LAA closure 50 cases per year.We retrospectively investigated 399 continuous patients with documented nonvalvular, atrial fibrillation from Jan 2016 to Dec 2017, who underwent either CBA or combined procedure of CBA and LAA closure at Atrial Fibrillation Center of Shanghai Tenth people's hospital. Among them, 323 were diagnosed as paroxysmal atrial fibrillation (PAF) and included. PAF was defined as atrial fibrillation recorded and confirmed either by a 7-day or 24-hour ECG monitor, which converted to sinus rhythm spontaneously or by intervention (cardioversion or antiarrhythmic drugs) within 7 days . FurtherThe procedures were accomplished under local anesthesia by subcutaneous administration of lidocaine at the groin region. Through femoral vein access, guidewire and vessel dilator were applied ensuing a single transseptal puncture. A 23 mm or 28 mm second-generation cryoballoon  was advanced through a steerable sheath  into the left atrium (LA). Once a pulmonary vein (PV) confirmed, the cryoballoon was inflated and advanced to the ostium of the PV, following angiography by injection contrast dye ensuring complete PV occlusion. Accompanying Achieve catheter  cannulated distally into the PV to detect electric activity and confirm PV isolation (PVI), a standard 180 s freeze was adopted for each pulmonary vein. Freezing time was adjusted according to time to isolation (TTI) recorded. When TTI ≤30 s, freezing time was set to 150–180 s. While TTI between 30 and 60 s, freezing time was set to 180 s. A bonus freeze of 120 s was applied only when TTI >60 s. If TTI could not be recorded, a 180 s freeze would be adopted, with a bonus freeze of 120 s when temperature declined over −40°C before 60 s from application.nd month since the procedure. Heparin was intravenously infused during the whole procedure with monitoring activated clotting time (ACT) between 250 and 350 s.Continuous phrenic pacing  with electrode placed at superior vena cava was applied during freezing of right superior PV (RSPV) and right inferior PV (RIPV). Through observation of the decrement of diaphragm movement under fluoroscopy, phrenic nerve palsy was detected, when freezing procedure was subsequently halted to prevent further injury. The vital signs were continuously monitored during the procedure. Freezing was instantly halted for esophageal protection, once the patient complained about nausea, vomiting, chest distress, or pain. Additionally, a proton pump inhibitor (PPI) was prescribed to all patients till the 2Under local anesthetic state, an LAA closure device was implanted instantly after CBA in eligible patients. The first 23 patients were implanted with Lefort , followed 11 patients with Lacbes , and latest 8 patients with WATCHMAN , presented in st, 3rd, 6th, and 12th month after the procedure. Meanwhile, transtelephonic follow-up was carried out at the same time point to evaluate individual condition and guarantee timely reexamination. For reexamination at inpatient or outpatient, medical history and physical examination were achieved, and either a 24-hour or 7-day electrocardiograph (ECG) monitor was applied to detect the recurrence of AF and other arrhythmias.All patients were informed and continuously followed to reexamine at 1rd month from the procedure was defined as blank period, when no recorded AF was considered recurrence.In our study, primary endpoints were stipulated as AF recurrence and stroke incidence, while secondary endpoints included all-cause mortality, acute myocardial infarction, heart failure, pericardial effusion, and device-related thrombosis. Recurrence of AF was defined as AF lasting longer than 30 s, while the time before the 3rd month and the 12th month to evaluate the positioning of the device, sealing of LAA, device-related thrombosis, and other structual changes.For patients who underwent combined procedure, TEE was performed at the 3th month, following single antiplatelet medication as a long-term therapy (aspirin or clopidogrel), while the continuation of OACs in the CBA group was based on the CHA2DS2-VASc score individually. If CHA2DS2-VASc ≥2 in male or ≥3 in female, OACs were recommended for long-term anticoagulation.For postprocedural medications, antiarrhythmic drugs  were generally prescribed to every patient during the blank period. Anticoagulation therapy for 2–3 months was recommended to all PAF patients underwent either procedure. For patients underwent combined procedure, warfarin or new oral anticoagulants  were prescribed and discontinued for 2–3 months. Once satisfied device positioning, no obvious residual flow (>3 mm) and no thrombus presented were confirmed by TEE; antiplatelet therapy was thenceforth substituted by double antiplatelet treatment (aspirin and clopidogrel) till the 6p value was analyzed from a two-sample t-test if the variance was equal or Mann–Whitney test if not. Categorical variables were described as percentage (%), with p value analyzed from the χ2 test or Fisher exact test if there was theoretical frequency lower than 5. The Kaplan–Meier estimate analyzed the freedom of atrial arrhythmia with p value achieved by the log-rank test. Hazard ratio was calculated through the univariate COX proportional hazard regression model. The multivariate COX model (forward and backward stepwise selection with p < 0.05) was applied to determine the prognostic factors of the freedom of AF. 2-side p value <0.05 was considered significant in all analyses. We used SAS 9.4 software  to conduct the analysis.Continuous variables were described as mean ± standard deviation (SD) or median (interquartile range), and 2DS2-VASc score  and HAS-BLED score  were significantly higher in the combined procedure group than in the CBA only group. Besides, the combined procedure group was elder , with larger LA diameter , higher prevalence of hyperlipidemia , and previous stroke history . Routine medications also differed, with higher rate in the combined procedure group, including antiplatelet agents  and statins . Other characteristics were comparable between two groups.We included 42 and 262 patients underwent CBA + LAAC procedure and CBA only, respectively. Baseline characteristics are described in p = 0.47) and similar number of applications. Touch-up ablation of other arrhythmogenic sites was applied in 5 patients in the CBA only group, encompassing 2 at LAA, 1 at superior vena cava, 1 at mitral isthmus, and 1 at tricuspid isthmus.Details about CBA are listed in p=0.20). Transient phrenic nerve palsy occurred only in 3 patients in the CBA only group, observed as transient decrease of diaphragm movement in 2 patients and halted diaphragm movement in 1 patient during ablation of the right superior pulmonary vein (RSPV).For periprocedure complications, no obvious pericardial effusion (>3 mm) was observed in both the groups. Vagal reflex monitored by blood pressure and heart rate was observed in 11 (26.7%) and 29 (11.5%) patients and not statistically significant  and 12 (29.3%) patients experienced late recurrent AF. Among which, 5 patients in the CBA group and 1 patient in the combined procedure group underwent redo-ablation. Survival analysis as presented in p=0.04, hazard ratio (HR)  = 1.9, 95% confidence interval (CI) 1.0, 3.7). However, the multivariate COX regression model incorporating totally 10 parameters showed only LA diameter , rather than procedure type , was the significant predictor of freedom of AF  patients were reexamined by TEE, showing LAA closure device was well positioned and sealed in all 35 patients. No obvious residual flow nor device-related thrombus was observed. No obvious pericardial perfusion was detected.rd month of follow-up, one resulted from intracerebral hemorrhage and the other from interstitial pneumonia. Besides, the rehospitalization (due to cardiovascular events) rate was comparable betweenthe CBA only and combined procedure groups . Notably, although not statistically significant, 2 patients had intracerebral hemorrhage (1 as described above and 1 occurred at the 2nd month from the procedure) and 2 had myocardial infarction  in the CBA only group. No stroke, myocardial infarction, or systemic embolic event occurred in the combined procedure group.Two patients in the CBA only group died at the 3Combined procedure of CA and LAA closure was developed as a novel and efficient approach which can be manipulated from the same femoral vein access and atrial septal puncture in a single procedure. Meanwhile, cryoablation, as a noninferior  and less2DS2-VASc ≥3, or HAS-BLED score ≥2, or strictly or relatively contraindicated OACs, there were significant differences at baseline in combined procedure group compared with CBA only group, including advanced age, high CHA2DS2-VASc and HAS-BLED scores, large LA diameter, high prevalence of previous stroke, and high proportion of anticoagulants intake. In addition, the prevalence of hyperlipidemiaand the proportion of statins intake were higher in the combined procedure group as well, in line with the inverse relation between dyslipidemia and AF incidence during follow-up [Our study incorporated 304 nonvalvular PAF patients underwent either CBA only or combined procedure at our center. Because the patient was considered eligible for combined procedure only when CHAollow-up .rd month follow-up since the procedure. In spite of the results, we still recommend plugging a LAAC device such as WATCHMAN as a first choice when considering LAAC immediately after cryoablation, in order to avoid device displacement after the ridge edema subsided. Long-term evalutation is warranted to provide stronger evidences. Successful PVI by CBA was achieved in all patients, and LAAC achieved in 97.6%, with 1 patient failed to implant due to unmatched device size with LAA. The success rate was in accordance with studies reported . Only trp = 0.04) and procedure type was indicated as a predictor of freedom of AF as well . As discussed above, the baselinecharacteristics differed, including CHA2DS2-VASc [p = 0.002, HR = 1.10, and 95% CI 1.04, 1.17) rather than procedure type , was the predictor of freedom of AF. Our results showed combining LAAC in CBA procedure could achieve AF rhythm control with comparable efficacy to CBA alone. . More trials are warranted to support the conclusion.With a meanfollow-up time of 22 ± 11 months in the CBA only group and 20 ± 9 months in the combined procedure group, the recurrence of AF was significantly higher in the latter  in the CBA only group). Of note, both cases were resulted from lethal intracranial hemorrhage. Results from the CABANA trial showed LAAC performed effectively in preventing hemorrhagic stroke . AlthougAmong 35 patients underwent LAAC assessed by TEE, no device-related thrombosis, obvious residual flow, or complications as pericardial perfusion was observed. Besides, severe vascular events were only observed in the CBA only group, where 2 patients who had intracerebral hemorrhage and 2 who had myocardial infarction underwent PCI. The low incidence rate of complication of combined procedure was comparable to studies with or without specifying the ablation strategy , 14, 18.rd month. Although single LAAC procedure was recommended with anticoagulation (either warfarinor NOACs) for at least 45 days [From the aspect of anticoagulation, all patients received OACs therapy were discontinued (either warfarinor NOACs) for at least 2 months since the procedure in the combined procedure group, whether or not shifted to antiplatelet therapy after the reexamination by TEE at the 3 45 days , as ther 45 days , 20. Mor 45 days . Hence, Our nonrandomized, retrospective study design limited the application of the conclusion. With relatively small number of combined procedure patientsand specific inclusion criteria, the conclusion cannot be extrapolated in gerenal AF population. Meanwhile the incidence of complications like stroke might be underestimated due to short follow-up period.Additionaly,TEE was available only in 35 (83.3%) of combining procedure group, the device-related complication rates might be higher than reported. Owning to the intolerance of TEE, a better evaluation approach and follow-up strategy should be considered in order to ensure safety and relief patients' painfulness.Furthermore, we applied 3 types of LAAC devices in our study, with only 1 case failed to implant. While the safety and efficacy among devices were not validated due to the small sample size and relatively short follow-up period. Further long-term, large scaled, randomized, prospective study is warranted to support our conclusion.Combined procedure of CBA and LAA closure is a feasible strategy for PAF patients, with comparable safety and efficacy to CBA and OACs. Long-term, largescaled, prospective trials are warranted to provide stronger evidences.


Trichoderma reesei in broiler’s diets on the gut bacterial growth and growth performance was investigated. It was found that when DDP are present at a rate of 10% of the broilers’ diet, it boosted gut health by increasing prebiotic production, thus serving as a growth promoter in broilers’ nutrition.In developing countries, most of the feedstuffs for animal nutrition are imported. Therefore, great attention has been focused on the use of agro-industrial by-products as feedstuffs to improve the feeding value of animal nutrition. These improvements can be induced by different means, including feed additive supplements, such as enzymes, probiotics, prebiotics, and organic acids. Other factors can also induce enhancement such as grinding, autoclaving, pelleting, and solid-state degradation by cellulolytic fungi. These methods aim to enhance the digestion of complex carbohydrates and decrease anti-nutritional constituents. In this study, the impact of non-degraded date pits (NDDP) and degraded date pits (DDP) using the cellulolytic fungus Trichoderma reesei by a solid-state degradation procedure. One-day-old Brazilian broilers were allocated into six dietary groups: (1) maize–soy diet, (2) maize–soy diet with oxytetracycline , (3) maize–soy diet with 5% NDDP, (4) maize–soy diet with 10% NDDP, (5) maize–soy diet with 5% DDP, and (6) maize–soy diet with 10% DDP. At the end of the trial, the total count of bacteria was significantly (p < 0.05) less in broilers fed 10% DDP diet (treatment 6) compared with the control group (treatment 1). In addition, DDP and oxytetracycline control diets have a similar diminishing effect on total bacterial counts and the populations of Salmonella, Campylobacter, Shigella spp., and Escherichia coli. Over 35 days of trial, weight gains were similar among the six dietary groups. Our results showed that DDP and control diets have a similar effect on growth performance. The feed conversion ratio (FCR) was poorer in broilers fed NDDP diets than other treatments. The European Production Efficiency Index (EPEI) was greater with 5% and 10% DDP than those fed NDDP at the same levels, with no significant variance from the control and antibiotic-supplemented diet (treatment 2). Overall, it can be suggested that maintaining 10% of DDP can partly replace dietary maize while also serves as a gut health enhancer and thus a growth promoter in the diet for broilers.The current study aims to assess the effect of non-degraded date pits (NDDP) and degraded date pits (DDP) in broilers’ diets on gut microbiota and growth performance. The degradation of date pits (DP) occurred via the cellulolytic fungus  Dietary energy is crucial in poultry growth and development. About 60–65% of the poultry diets’ metabolizable energy is derived from sorghum and maize . In the Currently, antibiotics are added to poultrys’ diets as growth promoters, yet using them for extended periods lead to antimicrobial resistance (AMR) in the pathogenic bacteria, especially the Gram-negative ones . The usePhoenix dactylifera L. palm trees are produced in many arid land areas where grains are not available. The United Arab Emirates (UAE) is a major date-producing country, and the annual production of raw dates reached about 775,000 metric tons in the year 2016 [−1, 50–63 g kg−1, 99–135 g kg−1, 22.5 g kg−1, and 10–18 g kg−1 of moisture, crude protein, lipid, fiber, and ash, respectively. The total sugars content is 29.3 g kg−1 [−1, and the acid detergent fiber (ADF) of DP is 460–510 g kg−1, consisting of total cellulose and lignin [Dates from While DP have been currently used as a poultry feed, due to the complex carbohydrates present, there is a limit to their use as a feed ingredient at higher levels . Ground DP up to 18% is an alternative feedstuff in diets for laying hens with little influence on productive traits, including eggs’ weight . So, DP Trichoderma reesei, was used to improve its digestion by Nile tilapia, Oreochromis niloticus [T. reesei growth and activation using their catabolic enzymes such as cellulases, hemicellulases, and pectinases [Nondigestive fibers of DP could partly break down when expose to degrading microbial enzymes such as xylanases, releasing digestible carbohydrates. Solid-state degradation (SSD) is used to improve complex carbohydrates digestion in poultry feed . Additioiloticus . DP fibectinases . Simple There is a limited amount of research focusing on degraded date pits (DDP) and its utilization as poultry feed, even though they contain a potentially useful quantity of nutrients essential for poultry health. Therefore, this study investigated the effect of inclusion of DDP in broilers’ diet on their gut microbiota and growth performance.This trial was approved, under protocol number (313072), by the College of Food and Agriculture, United Arab Emirates University, Al-Ain, United Arab Emirates. The university recommends maintaining animal welfare, inducing minimal stress and possible maximum rights, and avoiding any harm or suffering to the animals under research in agreement with the International Guidelines for Research Involving Animals (Directive2010/63/EU).P. dactylifera L.) (Raziz variety) were collected from a date factory in Al-Ain city, UAE. A medium-size grinder was used  to produce one mm diameter DP.The DP  [T. reesei ampoules , Braunschweig, Germany) were used to produce rehydrated T. reesei culture; then, it was inoculated to a potato dextrose broth  modified with 250 µg mL–1 chloramphenicol  and 100 µg mL–1 streptomycin sulfate . Using a rotary shaker  the flasks were incubated at 250 rpm at 25 ± 2 °C for seven days in the dark to produce the subsample. Fungal growth in the flasks was examined daily.. (2017) . LyophilT.reesei subsamples were supplemented to the SSD system and were spread to every cone. Then, the system units were covered to prevent contamination with constant moistened air that was disinfected with ultraviolet rays; then, they were integrated within the system, which was preserved at 90% humidity in a dark room at 30 ± 2 °C for three weeks [Using the SSD, DDP were prepared within an incubator as described by Hussein et al. . DP subsee weeks . Then, Dee weeks .−1); T3: maize–soy diet with 5% non-degraded date pits (NDDP); T4: maize–soy diet with 10% NDDP; T5: maize–soy diet with 5% DDP; and T6: maize–soy diet with 10% DDP. The levels of DP were chosen based on previous works [Six isonitrogenous and isocaloric diets were formulated for starter and finisher diets separately. The six dietary treatments were established as, T1: control, maize–soy diet; T2: maize–soy diet + antibiotic  of three replicates of 11 chicks each, and the replicate was the experimental unit. In the microbiological study described below in On the last day of the experiment, chickens in every cage were weighed to get the average weight for each group. This was followed by randomly selecting three chickens from each group to be slaughtered for gut sample collection.Salmonella spp., Campylobacter spp., Shigella spp., and Escherichia coli within the guts of chickens’ samples were determined using the tenfold dilution plate technique [−1) was used in all the surface sterilization procedures using Clorox. Chicken guts were blended in 100 mL of PBS using a sterilized tissue homogenizer  under aseptic conditions. Then, the gut macerate (triturate) was shaken on a rotary shaker  for one hour at 250 rpm and 25 °C. Then, the macerate suspension was further placed in an ultrasonicator for 55,000 cycles’ s−1 for 20 s . The macerate suspension was filtered via a sterilized No. 1 Whatman filter paper ; the filtrate was diluted in serials (10−2–10−5) in sterilized PBS [Salmonella spp. on Bismuth sulfite agar (modified Wilson and Blair medium (CM0201) , (3) Campylobacter spp. on Campy  agar medium , (4) Shigella spp. on xylose lysine deoxycholate agar (XLD agar M031) , and (5) Escherichia coli on Eosin Methylene Blue (EMB) (M317) (HiMedia). The bacterial colony counts were done at the termination of the incubation period (four days), and the total bacterial population was expressed as log10 colony-forming units (cfu) g fresh gut tissue−1.The total bacterial count and the population of some selected bacteria comprising of echnique . The chiechnique . The PBSechnique . Then, tized PBS . From thFeed intake (FI) was measured weekly. Growth performance, including FI, body weight gain (BWG), and FCR, were assessed. During the experimental period, mortality was recorded daily, and mortality rates were calculated accordingly in each replicate. The European Production Efficiency Index (EPEI) was deduced as previously reported ,22.p = 0.05 was applied to compare significant differences among means for all analyses. Before analysis of variance, all percentage data were transformed to their analogous arcsine.Statistical analysis was carried out using the statistical package for social sciences . Analysis of variance (ANOVA) was applied to study the effect of collected data concerning the effects of DDP and NDDP amendment on total and specific bacterial populations. The data for microbiological and growth performance tests were subjected to analysis of variance (ANOVA). The experimental unit was the replicate and the model was:p < 0.05) greater pathogenic bacterial counts (p < 0.05) in bacterial populations was evident in the gut samples with DDP and NDDP compared with the samples without DP . The appraised total populations of total aerobic bacteria, Salmonella spp., Campylobacter spp., Shigella spp., and Escherichia coli were considerably (p < 0.05) lesser in the gut samples of broilers consuming DDP and NDDP (treatments 3–6) compared to the gut tissues of broilers fed without DP  (p < 0.05) in populations of bacteria was evident by elevating the DDP levels. The groups fed 10% DDP (treatment 6) significantly (p < 0.05) surpassed other treatments in quashing the total bacterial counts and also showed a reduced total number of Salmonella spp., Campylobacter spp., Shigella spp., and Escherichia coli. This particular treatment was nearly as good as (p > 0.05) the antibiotic treatment, which included the addition of oxytetracycline (treatment 2)  had a considerably (l counts . A substtment 1) . A marketment 2) .p > 0.05) during either the starter or the total feeding periods (The effects of NDDP and DDP on the average BWG of broilers are shown in  periods .p > 0.05) in broilers fed the control, control with the antibiotic oxytetracycline, 5% and 10% DDP diets, while they were markedly lower (p < 0.05) than those fed 5% and 10% NDDP diets  among broilers fed all test diets. Additionally, the survival rate was similar among all tested groups  resulted in better broilers’ gut health without the use of antibiotics.The cellulolytic enzymes of