Comparison of endoscopic ultrasound and computed tomography for detecting and staging malignant pancreatic masses

Introduction: Endoscopic ultrasound [EUS] is now established as a valuable imaging test for diagnosing and staging pancreatic cancer. But, with significant recent improvements in spiral computed tomography [CT] scanners, particularly higher resolution and ability to reconstruct 3D images, spiral CT is now increasingly accepted as being better for pancreatic cancer staging. The debate continues, however, about the best diagnostic test or combination of tests in patients with suspected pancreatic cancer. Spiral CT is more readily available than endoscopic ultrasound guided fine needle aspiration [EUS-FNA], cheaper and, therefore, more frequently used In this study, we evaluated the use of EUS-FNA in comparison with spiral CT for detection and staging of malignant pancreatic massesMethods: This prospective study was carried in El-Ebrashi unit of Gastroenterology and Hepatology, Internal Medicine department, Cairo University over 3 years from 2011 to 2014. It included 68 patient with suspected pancreatic mass lesions based on abdominal ultrasound, CT or MRI and patients with obstructive jaundice due to common bile duct [CBD] stricture as proved by endoscopic retrograde cholangiopancreatography [ERCP] or Magnetic resonance cholangiopancreatography [MRCP]. The patients were subjected to dual phase pancreatic control multi-detector computed tomography [MDCT] to be followed by EUS-FNA, then cytopathological examination of the studied patients to determine the nature of pancreatic masses, normal and benign cases are followed up after 6 months by EUS for exclusion of malignancy

Results: The final diagnosis in this study was that, 61 patients were malignant and 7 benign cases. The sensitivity of CT was 75% compared to 100% for EUS. While the specificity for CT was 14% compared to 100% for EUS. The negative predictive value for CT was 6.25% compared to 100% for EUS. With an overall accuracy of MDCT was 69% compared to 100% for EUS for diagnosing pancreatic cancer. The sensitivity of CT for detection of small lesions

Conclusion: EUS is more accurate than CT for detection of pancreatic cancer especially in small tumors. EUS is more accurate than CT in staging of pancreatic cancer in early stages

Recommendation: Early diagnosis of pancreatic cancer is the most important step in the way of decreasing its mortality rate. For screening of patients with suspected pancreatic cancer, initially CT should be performed to be followed by EUS whether to exclude masses in negative CT patients or to confirm the mass and to provide a tool for sample/or cytopathological diagnosis in patients with positive CT We recommend a future study to correlate the accuracy of staging by EUS and CT with post-operative histopathological staging

Fasting adiponectin in relation to the metabolic syndrome in patients with coronary artery disease

Metabolic syndrome and coronary artery disease [CAD] are increasing worldwide. The relationship between metabolic syndrome and fasting serum adiponectin concentration in CAD patients is not well elucidated. The aim of present study is to explore the relationship between serum adiponectin concentrations and the presence of metabolic syndrome [MetS] among patients with CAD. Sixty five patients with CAD; defined as more than 50% stenosis in any segment by coronary angiography, and twenty five matched controls, were enrolled in this study. The study was carried out in Cardiology Department Assuit University hospital between October 2009 and July 2010. Metabolic syndrome was defined according to International Diabetes Federation criteris. The blood samples including complete blood count, fasting blood glucose, liver function tests, creatinine, urea, adiponectin, high sensitive-C reactive protein [hs-CRP], insulin and lipids profile were obtained after overnight fasting. The homeostatic model assessment of insulin resistance [HOMA-IR] was calculated as: HOMA-IR = fasting blood glucose [mmol/l] x fasting serum insulin [micro U/ml]/22.5. Patients with CAD had significantly lower plasma adiponectin concentrations than those without CAD [P<0.013] and higher hs-CRP [P<0.009] and HOMA-IR [P<0.03]. Metabolic syndrome was present in 41 patients [63%] among CAD group. Fasting adiponectin values for these patients tended to decrease significantly in comparison to patients without metabolic syndrome [P value= 0.037]. Negative correlations were found between adiponectin and body mass index [BMI] [r=-0.205, P<0.05], waist circumference [WC] [r= -0.306, P<0.003], triglycerides [r= -0.222, P < 0.036] and hs-CRP [r= -0.223, P< 0.035] whereas a positive correlation was found between adiponectin and HDL [r= 0.273, P<0.003]. Also, adiponectin was significantly lower in patients with multi-vessel disease compared to other [P<0.05] whereas hs-CRP and HOMA-IR were significantly higher in patients with multi-vessel disease with [P<0.01 and 0.03] respectively. Serum adiponectin concentration is inversely correlated with metabolic syndrome among patients with CAD. Lower adiponectin concentration, and higher HOMA-IR and hs-CRP are associated with Cad and metabolic syndrome, and may be useful for risk stratification of CAD patients. The measurement of plasma adiponectin, HOMA-IR and hs-CRP levels may be useful for prediction of severity of coronary artery disease

Value of serum and synovial fluid activin A and inhibin A in some rheumatic diseases

Activin is a growth and differentiation factor of many cell types and has recently been implanted in inflammatory processes. Clinical data demonstrating roles of activin and its antagonist inhibin in inflammatory arthropathies, are lacking. The Study is to measure serum and synovial fluid levels of activin A and inhibin A in patients with rheumatoid arthritis [RA] systemic lupus erythematosus [SLE] and osteoarthritis [OA] and correlate them with disease activity parameters. This study included 60 patients with three rheumatic diseases [20 with RA, 20 with SLE and 20 with OA], as well as ten healthy subjects as a control group. All of them were subjected to complete history, physical and musculoskeletal examination and estimation of disease activity index [DAS- 28] for RA and [SLEDAI] for SLE. The following investigations were done for all subjects; serum and synovial activin A and inhibin A; in addition to complete blood picture, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP],rheumatoid factor [RF], antinuclear antibodies [ANA],anti-dsDNA, serum complement [C 3, 4] and Xrays on affected joints. The mean values of serum activin A were significantly higher in RA, SLE and OA than controls [P<0.001] also in RA and SLE versus OA [P<0.05 for both]. The mean values of serum inhibin A were significantly higher in all studied groups than controls [P<0.05 for RA and OA and P<0.001 for SLE]. Also serum inhibin levels were significantly higher in SLE versus OA P<0.001, but there was no significant differences between RA and SLE. Synovial fluid activin and inhibin A were significantly higher in RA than OA [P<0.05 for both]. Positive correlations were found between serum activin A and disease activity parameters of RA morning stiffness [MS], Ritchie index [RI], ESR, CRP and DAS 28] P<0.05, for all. Also positive correlation was found between serum inhibin A and RI in RA patient [P<0.05]. In SLE, positive correlations were found between serum activin A and inhibin A with ESR [P<0.001 for activin and P<0.05 for inhibin A and SLEDAI [P<0.001 for both activin and inhibin]. No correlation were found between synovial activin and disease activity and negative correlation between synovial inhibin and ESR. The significant increase of serum and synovial activin A and inhibin A in RA and SLE and their positive correlations with disease activity parameters of RA and SLE suggest pro-inflammatory action. However the lack of correlations or negative correlation of their synovial levels with disease activity may indicate their anti inflammatory action, We recommended further studies to detect the exact role of activin A and inhibin A

Relationship of PAI-1, P-selectin, and VWF levels with target organ damage in essential hypertension

To study the relationship between plasminogen activator inhibitor-1[PAL-1], soluble P-selectin[sP-selectin] and von Willebrand factor[vWF] activity with target organ damage [TOD] in essential hypertension, this case-control study was conducted on 51 patients with essential hypertension [30 men and 21 women], attending the hypertensive clinic of Assiut university hospital. Their mean age was 47.3 +/- 8.6 years. Patients were classified into two groups, a group without TOD [included 18 patients]. The second group included 33 patients with an evidence of TOD. Out of the latter group, 18 patients had echocardiographic left ventricular hypertrophy [LVH], 12 patients had microalbuminuria and 3 patients with hypertensive retinopathy. Twenty normotensive age and sex matched healthy individuals served as a control group. We measured plasma levels of von Willebrand factor [vWF, a marker of endothelial damage/dysfunction], soluble P-selectin [sP-sel, a marker of platelet activation] and plasminogen activator inhibitor-1 [PAI-1 as an index of fibrinolysis], all were assayed by ELISA. Fibrinogen level was measured by Clauss method. The results of this study revealed that the levels of sP-sel, PAI-I, vWF and fibrinogen were significantly higher in hypertensive patients than controls [with P value < 0.001, <0.001, <0.001 and <0.01 respectively]. When patients with TOD were compared with those without TOD, a significant increase was detected for PAI-1, vWF and fibrinogen in the TOD group [with P value <0.01, <0.05 and <0.01 respectively], SP-sel was not statistically different between the two groups. In comparing patients with LVH and patients without TOD, only vWF and fibrinogen levels were significantly higher in LVH patients [P<0.01 for both]. For all the studied markers, no significant difference could be detected between microalbuminuric patients and those without TOD. PAI-I was positively correlated with both systolic [r = 0.613, P<0.001] and diastolic [r = 0.480, P<0.001] blood pressure in hypertensive patients. Elevated vWF and fibrinogen levels and decreased fibrinolytic potential [elevated PAI-I] are associated with TOD, and could be considered as risk markers that may predict preclinical TOD. However, only raised fibrinogen and vWF levels are associated with LVH which may predispose those patients to hypertensive complications

effects of therapeutic plasmapheresis on patients with systemic lupus erythematosus

Twenty patients with systemic lupus erythematosus [SLE], who did respond to conventional therapy for a long time were treated with short time therapeutic plasmapheresis [TPP] and immunosuppression. There was marked and dramatic clinical improvement including pericardial and pleural effusion in all patients with SEL after TPP. Also, there was significant reduction in the ESR and the level of antibodies on the RBCs in all patients after TPP compared with that before the procedures. Five patients with SLE had lupus nephritis and nephrotic syndrome with mild impairment in renal functions, all patients had rapid and distinct improvement in clinical and laboratory parameters after TPP. The procedure is very effective in treatment of patients with SLE, so it is recommended to use it beside the drug therapy. TPP is easy and safe. Any side effects or complications among the patients were not reported during the procedures

Serum electrolytes and parathyroid hormone in coronary artery disease

This study included sixty patients with coronary artery disease, thirty patients with acute myocardial infarction [AMI] and thirty patients with myocardial ischemia in whom any diseases known to affect serum electrolytes or parathyroid hormone[PTH] were excluded. Besides, twenty age and sex matched healthy controls were included in the study. All patients and controls were subjected to complete clinical examination and investigations including ECG, echocardiography, blood urea and serum creatinine, liver functions, blood gas analysis, serum sodium, potassium, magnesium, calcium and serum PTH. It was found that serum potassium was significantly lower in six patients with AMI and in one patient with myocardial ischemia compared with the controls. Also, serum magnesium was significantly decreased in ten patients with AMI and nine patients with myocardial ischemia compared with the controls. The results were disccused

Serum cytokine levels and cardiovascular variables in septic shock

The concentrations of serum interleukin-IB [IL-I beta], interleukin-6 [IL- 6] tumor necrosis factor alpha [TNF alpha]and interferon gamma [IFG] in serum of 20 healthy individuals and 21 patients with septic shocks were measured within four hours after the initial recognition of shock [zero time] and samples were followed up after four and twelve hours. The survivors were six and non survivors fifteen, seven of them with multiple system organ failure [MSOF]. Bacteremia was found in fourteen patients, while urine culture was positive in twelve. On admission, there was no significant difference in all hemodynamic/cardiovascular parameters monitored between survivors and non survivors groups except a significant increased heart rate in non survivors than survivors. Within 24 hours, heart rate of survivors fell to normal. The serum cytokine levels mean + SE of IL-I beta, IL-6, TNF alpha and IFG at all times were significantly higher in patients than controls and no peak values of these cytokines were recorded. A significant correlation was found between serum levels of IL-6 and IFG at four hours and twelve hours. As regard serum cytokine levels and outcome, there was significant increase in serum levels at four hours of IL-6, TNF-alpha and also in total serum levels of TNI alpha and IFG in non survivors compared with survivors group. However, in relation of these cytokines to organ failure both serum levels of IL-6 and IFG were significantly increased in patients with hepatic failure, whereas those with hepatic cirrhosis and heart failure had significant increased levels of IFG only. There was also significant increase in serum levels of IL-6 at four hours, total IL-6 and IFG at twelve hours in patients with MSOF compared with patients without MSOF

Up-date insight into joint damage in rheumatoid arthritis study of serum and synovial fluid markers: soluble interleukin-2 receptor, hyaluronan, and alpha acid glycoprotein

This study aimed to measure serum and synovial fluid [SE] levels of soluble interleukin-2 receptor [sIL-2R], hyaluronic [hyaluronic acid, HA] and alpha-1 acid glycoprotein [AGP] in patients with rheumatoid arthritis and determined whether they correlated with clinical and laboratory parameters of disease activity and evaluate their values as specific markers for inflammation and joint damage. The sIL-2R levels were determined by ELISA, whereas serum and synovial fluid levels of both hyaluronan and AGP were determined by colorimetric methods. Twenty-five serum and eleven SF samples were obtained from patients with RA and twenty serum samples from age and sex matched controls. The results indicated that serum and synovial fluid of sIL-2R and HA might be more relevant markers of synovitis and inflammation. Their measurements in RA patients is useful in assessing disease activity, while serum and synovial fluid levels of AGP is considered as a useful marker in early rheumatoid arthritis

Serum osteocalcin, fibronectin and insulin autoantibodies in patients with diabetes mellitus

This study included 80 patients with diabetes mellitus. They were subdivided into 40 patients with IDDM and 40 patients with NIDDM. Each were classified into two groups, 20 patients with complications and 20 without. Ten healthy subjects were also included as controls. Serum osteocalcin was significantly lower [p < 0.001] in all diabetic patients compared with controls, and there was no significant difference between diabetics with complications and patients without complications. No significant correlations were found between serum osteocalcin and either HbA1c, post-prandial blood glucose or the disease duration among the studied patients. Serum fibronectin was significantly higher [p < 0.001] compared with controls, and higher in IDDM than NIDDM and also in complicated than non-complicated patients [p < 0.001]. A significantly positive correlation was found between serum fibronectin with post-prandial blood glucose and duration of the disease. A significant correlation was found between serum fibronectin and HbA1c. Insulin autoantibodies were detected in 67.5% of all IDDM and in 20% NIDDM. Significantly increased levels of IAA in IDDM were found compared with either NIDDM or controls, but no significant difference was found between complicated and non- complicated patients. In conclusion, a decreased serum level of osteocalcin below normal level may be an indicator of diabetic osteopenia and an increased serum fibronectin above normal value can be used to predict early diabetic microvascular complications. IAA can be used to discriminate IDDM patients and determine immunogenecity of insulin used. So, in those with high IAA levels, a non-immunogenic insulin [human insulin] should be used in order to decrease the level of IAA

value of estimation of serum glucose, glycosylated hemoglobin and cortisol in cerebrovascular stroke patients

This study includes 40 patients with acute cerebrovascular stroke [CVS], within 24 hours of their onsets. Twenty four patients were males and 16 were females. Their ages ranged from 25-90 years with a mean +/- SD of 57.8 +/- 12.2 years. Twenty "age and sex" matched healthy subjects were selected as a control group. The patients were followed up for 2 weeks, during their hospitalization and their conditions on discharge were graded as good-fair or poor. There was a significant increase in the admission blood glucose level, glycosylated haemoglobin [HbA1c], serum cortisol and total leucocytic count in patients with CVS compared to the control group [P < 0.001]. But there was no difference of any significance in all the studied parameters related to the sex of patients. CVS occurred predominantly among males with cigarette smoking [60%], hypertension [62.5%], old myocardial infarction [15%] and uncontrolled diabetics [50%]. There was a significant [P < 0.005 and 0.001] rise in the mean age, blood glucose level and serum cortisol in patients with severe clinical disablity compared with mild disability. No significant difference could be detected in blood glucose, or neurologic out come between diabetic and non diabetic patients. The percentage of poor prognosis was higher among diabetics [80%] compared to non diabetics [70%], in hypertensive [84%] compared to normotensives [66.7%] but these differences are not statistically significant. A significant increase in poor neurologic outcome was found among comatosed patients compared to fully conscious patients [P < 0.001], in older age group than younger one [P < 0.001], patients with high admission blood glucose level, high serum cortisol level, and severe cases with high total leucocytic count [P < 0.05, < 0.001, < 0.01 respectively]. Determination of HbA1c is important to identify diabetic patients from hyperglycemia as a response to stress

Serum alpha2 macroglobulin and plasma fibrin monomer in diabetic neuropathy and retinopathy

Impairment of neural function is one of the most frequent disabling complications of diabetes mellitus. No part of the peripheral nervous system seems spared. Progressive neural impairment may occur in sensory and motor peripheral nerves producing pain, parasthesia or distal muscle weakness [Ward, 1972]. This also occurs in autonomic nervous system producing orthostatic hypotension, sexual impotence and urinary and bowel incontinence [Clarke, et al. 1979]. Although these complications are prominent, the exact cause is still unknown. However, Anderson [1976] suggested that slowing of peripheral nerve activity may be related to metabolic derangements. A relationship between hyperglycemia and peripheral nerve function as measured by nerve conduction velocity has been demonstrated to human subjects. Diabetic retinopathy is considered to be a multifactorial disorder. A relationship between duration of diabetes and development of retinopathy has long been recognised [Caird et al., 1969], mean blood glucose concentration have been reported to be higher, particularly in severe retinopathy. Data related to other factors as cigarette smoking, obesity, blood pressure and. genetic susceptibility are conflicting. William et al., [1983] stated the risk factors in diabetic retinopathy include increasing duration of the disease, presence of other microvascular complications of diabetes and probably hyperglycemia itself. Plasma fibrin-monomer and raised serum gamma 2 macroglobulin have recently been implicated [Wardle et a1., 1973]. The aim of the study is to define and evaluate the various risk factors in diabetic retinopathy and neuropathy in Assiut with particular reference to fibrin monomer and gamma 2 macroglobuin