Thrombotic thrombocytopenic purpura as an acute complication of COVID-19

Introduction: While disseminated intravascular coagulation (DIC) is a serious complication of COVID-19, a close differential in critically ill patients with thrombocytopenia is Thrombotic thrombocytopenic purpura (TTP). Case Report: We describe the case of a middle-aged lady admitted with COVID-19 pneumonia who developed progressive thrombocytopenia, altered sensorium and renal failure. The absence of coagulation abnormalities alerted to the possibility of TTP, strengthened by presence of schistocytes in peripheral smear. Conclusions: This case highlights the need for high index of suspicion and to pay attention to normal tests as well that might give clues to the diagnosis. New onset thrombocytopenia in COVID-19 need not always indicate DIC. A careful examination of peripheral smear may help diagnosing TTP especially if coagulation profile is normal.

Adding bit of esthetics with science modification of batwing mastopexy for breast conservation in a young patient with giant fibroadenoma breast

A 19-year-old girl presented with a lump in her right breast and with a history of surgery for the similar complaint 3 years back. Ultrasound was suggestive of benign solitary lesion of size 16 cm × 10 cm. Core biopsy was suggestive of phyllodes tumor, and the histopathology report of previous surgery was also suggestive of phyllodes tumor. Wide excision of the tumor and reconstruction was done with batwing mastopexy and with a slight modification of the described technique so that to avoid contralateral reduction mammoplasty in a young unmarried girl. Postoperative histopathology was suggestive of fibroadenoma measuring 15 cm × 8 cm with all margins free of tumor, and it is probably one of the biggest fibroadenomas reported so far. On follow-up, no significant disparity noted between the appearances of both breasts

Aberrant expression of miRNAs predicts recurrence and survival in stage-II colorectal cancer patients from Egypt

Background: Patients with stage II CRC have a varying survival outcome. Therefore, it is critical to identify prognostic biomarkers that can define more aggressive forms of the disease. We assessed the expression levels of five miRNAs that have been previously addressed in relation to the development and progression of solid and hematological tumors. Methods: We measured the expression levels of miR-21, miR-137, miR-145, miR-320 and miR-498in stage II CRC patients from Egypt (124 tissues and 41 blood samples) by quantitative real time PCR (qPCR). The results were correlated with relevant clinicopathological factors, response to treatment and survival rates of the patients. Results: miR-137, miR-145 and miR-320 were significantly reduced in 39.5%, 48.4% and 52.4%; respectively whereas miR-21 and miR-498 were significantly overexpressed in 48.4% and 40.3% of the CRC tissues compared to the control group. In patients' blood, miR-137, miR-145 and miR-320 were significantly reduced in 46.3%, 46.3% and 51. 2%; respectively whereas mir-21 and miR-498 were significantly overexpressed in 46.3% and 43.9% of the cases, respectively. The concordance between tissue and blood was weak for miR-320 and miR-145 (kappa 40-65%), intermediate for miR-498 and miR-137 (kappa 65-75%) and strong for miR-21 (kappa 75-85%). In univariate analysis performance status, over-expression of miR-21 and miR-498 and reduced miR-137, miR-145, and miR-320 associated significantly with reduced DFS and OS. However, in multivariate analysis, miR-498 and miR-320 were independent prognostic factors for DFS whereas miR-21 was independent prognostic factors for OS. Conclusions: miRNAs play an important role in the development and progression of stage II CRC. A five markers panel (miR-21, miR-498, miR-137, miR-145 and miR-320) can predict recurrence and survival in stage II CRC patients from Egypt (AU)

Epstein-Barr virus and Interleukin-28B polymorphism in the prediction of response to interferon therapy in hepatitis C patients

Background and study aims: In chronic hepatitis C virus [HCV], viral and host factors are known to be predictors for anti-viral therapy. IL-28B genotype strongly influences treatment outcome, while Epstein-Barr virus [EBV] co-infection could accelerate the course of chronic HCV infection. This study was conducted to assess whether EBV co-infection adds to the predictive value of IL-28B

Patients and methods: A total of 105 patients with chronic HCV were classified according to their response to treatment into two groups: 38 sustained virological responders [SVRs] and 67 nonresponders [NRs]. Collected sera at baseline and follow-up [FUP] were used for assessing EBV antibodies by enzyme-linked immunosorbent assay [ELISA] and the expression of EBV genes [BNLF-1, BZLF-1, and EBER-2] by polymerase chain reaction [PCR]. Collected peripheral blood was used for detecting IL-28B rs.12979860 single-nucleotide polymorphism

Results: Regarding IL-28B genotype frequencies, a significant difference [p = 0.003] was observed between SVRs [C/C = 51.4%, C/T = 48.6%, T/T = 0%] and NRs [C/C = 25%, C/T = 55%, T/T = 20%]. On assessing EBV infection at baseline and FUP, it was found that 61% and 55% were positive, respectively, with no significant difference between SVRs and NRs. As for anti-viral capsid antigen [VCA] antibodies, the NRs had significantly higher baseline anti-VCA immunoglobulin M [IgM] levels than SVRs [p = 0.01]. While FUP anti-Epstein-Barr nuclear antigen-1 [EBNA-1] IgG reported a significant decline within SVR patients [p = 0.02], neither baseline nor FUP anti-VCA IgG levels showed a statistically significant viral response. Finally, on comparing EBV markers with CC versus CT and TT genotypes, it was found that FUP anti-VCA IgG levels were significantly increased in CC genotype [p = 0.003]

Conclusion: Interleukin-28B polymorphism could be a possible predictor of response to pegylated interferon/ribavirin therapy [PEG-IFN/RBV]. Furthermore, co-infection with EBV did not affect the response to IFN-based therapy in HCV-infected patients

Availability Of Instrument And Material In The Orthodontic Clinic, Faculty Of Dentistry University Of Malaya- An Audit

The audit aimed to investigate the availability oforthodontic instruments and materials at Faculty ofDentistry, University of Malaya. The standard was set as100% of instruments and materials should be availablewhen required for orthodontic treatment. The formcomprised of six sections, which listed the commonlyused instruments and materials involved in the proceduresof impression taking, fitting and removal of molar bands,bonding and debonding of orthodontic brackets andactivation of orthodontic appliances. The fifth section listedthe less commonly used instruments and materials and apart for the clinician to list down instruments that wereused but not listed in the form. Whilst the last section is forthe clinician to list down the instruments or materials thatwere not available when requested. A total of 567 formswere completed and it was found that 97.6% instrumentsand 98.6% materials were available. Overall, 22 types ofinstruments were temporary not available with frequencymean of 2.1 (Minimum: 1; Maximum: 7) whilst 6 types ofmaterials were temporary not available with a frequencymean of 2.3 (Minimum: 1; Maximum: 8). In conclusion,majority of the instruments and materials required duringorthodontic clinical sessions were available. The check listof frequently used orthodontic instruments and materialsfrom this audit could aid inventory and help futuremanagement of the material and instruments.

Expression of MMTV-like env gene in Egyptian breast cancer patients

Mouse mammary tumor virus [MMTV] causes breast cancer in mice. DNA sequences related to MMTV-like env gene is detected in human breast cancer [EC] tissue suggesting its etiology in human BC. The objective of our study was to assess the significance of MMTV-like env gene in Egyptian BC women. One hundred and fifty archival formalin-fixed paraffin embedded breast tissues were used and divided into 2 groups; group one included 100 malignant, group two included50 benign tissues. To amplify the MMTV-like env gene, semi-nested PCR was used and to confirm the homology with the MMTV genome direct sequencing was used. MMTV-like env was efficiently detected in36%ofmalignantand 4% of benign breast tissues. Sequence analysis was evident revealed 96% homology with the MMTV genome, but no other significant similarities with the human genome

The presence of the viral sequences was associated significantly with estrogen and progesteron positive cases and insignificantly the other pathological parameters studied. The molecular analysis of breast cancer tissue confirmed the presence of MMTV-like env sequences with significant high percentages in cancerous tissues than in benign one. These data raising the possibility that MMTV viral infection may be involved in the neoplastic process

Peak Expiratory flow Rate in Pregnat Women.

In the present study peak expiratory flow rate (PEFR) were estimated in pregnant women during different trimester to observe the alteration in air flow rate during pregnancy. This study was carried out in the department of Physiology of Dhaka Medical College from July 2004 to June 2005. For this purpose, total 100 women with age ranged from 25 years to 35 years without any recent history of respiratory diseases were selected and divided into 25 healthy non-pregnant women as control and 75 normal pregnant women as study group. Study group was further divided into 25 in first trimesters, 25 in second trimester and 25 in third trimesters of pregnancy. All the subjects belonged to lower socioeconomic class. The PEFR was estimated by using an automatic spirometer. The measured values and percentage of predicted values of PEFR were estimated during the 1st, 2nd, 3rd trimesters of pregnant women and non-pregnant women. Statistical analysis of data were done by un paired student’s “t” test. The PEFR was significantly lower in both 2nd and 3rd trimester pregnant women than that of nonpregnant women. Again the PEFR was significantly lower in 3rd trimester than that of 1st trimester of pregnant women. There were no statistically significant difference of PEFR between the non-pregnant and 1st trimester; between the 1st trimester and 2nd trimeste ; and between the 2nd trimester and 3rd trimester of pregnant women. It may be concluded that PEFR were progressively decreased throughout the pregnancy, most likely due to mechanical effects of progressively increased size of uterus that progressively decreases lung volumes and capacities.

The use of an In House Scoring System Scale versus Glasgow Coma Scale in non-traumatic altered states of consciousness patients: can it be used for triaging patients in Southeast Asian developing countries?

Non-traumatic Altered States of Consciousness (ASC) are a non-specific consequence of various etiologies, and are normally monitored by Glasgow Coma Scale (GCS). The GCS gives varriable results among untrained emergency medicine personel in developing countries where English is not the first language. An In House Scoring System (IHSS) scale was made by the first author for the purpose of triaging so as to quickly asses patients when seen by medical personel. This IHSS scale was compared to the GCS to determine it's specificity and sensitivity in the accident and emergency department (ED) of Hospital University Sains Malaysia (HUSM). All patients with non-traumatic ASC were selected by purposive sampling according to pre-determined criteria. Patients were evaluated by the two systems, IHSS and GCS, by emergency physicians who were on call. Patient demographics, clinical features, investigations, treatment given and outcomes were collected and followed for a period of 14 days. A total of 221 patients with non-traumatic ASC were studied, 54.3% were males. The mean age of the patients was 56 years old. The mean overall GCS score on presentation to the ED was 10.3. The mean duration of ASC was 11.6 hours. One hundred thirty patients (58.8%) experienced ASC secondary to general or focal cerebral disorders. The mortality rate was 40.3% 2 weeks after the ED visit. Fifty-four point three percent of the patients were awake and considered to have good outcomes while 45.7% of the patients had poor outcomes (comatose or dead) 2 weeks after the ED visit. The mean overall GCS score, verbal and motor subscores as well as the IHSS had significantly decreased (worsened) after treatment in the ED. A poor IHSS scale, hypertension, current smoking, abnormal pupillary reflexes and acidosis were associated with a worse 2-week outcome. The mean age and WBC count was lower and the mean overall GCS score and eye, verbal and motor subscores were higher as well as those having a lower IHSS scale for the good outcome category. Multivariate analysis revealed that smokers and hypertensives were at higher risk for a poor outcome. Higher eye scores on the GCS were associated fewer poor outcomes. There was significant agreement between the IHSS scale and GCS scores in the assessment of non-traumatic ASC. The sensitivity and specificity of the IHSS score versus GCS were 71.9% and 100.0%, respectively.

Evaluation of objective structured practical examination and traditional practical examination.

To evaluate the competency of Objective Structured Practical Examination (OSPE) as an assessment technique compared to Traditional Practical Examination (TDPE) in assessment of laboratory component of physiology, the results of Physiology practical examination of 400 students from 4 Medical Colleges, two Government and two non Government (Dhaka Medical College, Mymensingh Medical College, Bangladesh Medical College, Uttara Women's Medical College) under Dhaka University were studied. Students' performance in OSPE and TDPE was compared. Mean score obtained in OSPE was 77.72+/-0.66 and found significantly higher than that for TDPE (64.44+/-0.61). Again mean scores achieved in OSPE were compared among different Medical Colleges and significant difference was noted. In OSPE, male students achieved significantly higher score than that of female students, especially in responding question station. The outcome of the present study thus indicates that OSPE is a better choice as an assessment technique over the Traditional method measuring wide range of practical skill. It may be concluded that it is important for competency based performance discrimination and it also helps improving students performance quality in laboratory exercise.

p53 Mutation in HCV-genotype-4 associated hepatocellular carcinoma in Egyptian patients

HCV-associated hepatocellular carcinoma [HCC] is a common neoplasm in Egypt where genotype-4 is prevalent. In the present study the incidence and pattern of p53 mutations was assessed in relation to HCV-genotype-4 in Egyptian HCC patients. We investigated 25 HCV positive HCCs for p53 mutations over expression in relation to HCV-N53 by immunohistochemistry, SSCP and sequencing. Genotyping was done using LiPA-Il and TRUGENE 5 NC sequencing kit. Results were correlated to standard clinicopathologic prognostic factors for HCC. Thirteen cases showed p53 overexpression, and 10 showed p53 mutation [13 mutations] by sequencing [72% concordance]. The highest mutation rate was in exons 6 and 7 [30%] followed by exons 5 and 8 [20%]. Mutations included 3 transitions, 5 transversions, 3 deletions, and 2 insertions. All exon 7 mutations were at codon 249 specific for AFB1 [AGG-AGT, Arg-Ser] and codon 248 specific for vinyl chloride contamination [CGG-TGG, Arg-Trp]. Other mutations reported are novel. Immunostaining for HCV N53 was detected in 19 cases independent of p53 mutation. p53 aberrations were significantly associated with poor prognostic factors for HCC. However, no specific pattern for p53 mutations was observed in HCV genotype 4-associated HCC and no significant relation between p53 mutations, HCV-N53 expressions or any HCV sub-genotype-4 sequence

Genetic distance and heterogenecity between quasispecies is a critical predictor to IFN response in Egyptian patients with HCV genotype-4

HCV is one of the major health problem in Egypt, where it is highly prevalent. Genotype 4 is the most common genotype of HCV and its response to treatment is still a controversy. HCV genotype 4 quasispecies diversity within the 5' untranslated region [5'UTR] was studied in a series of 22 native Egyptian patients with chronic hepatitis C virus with no previous treatment who satisfied all NIH criteria for combined treatment of pegylated IFN and ribavirine and was correlated with the outcome of treatment. The study also included 7 control patients with no antiviral treatment. HCV sequencing was done using the TRUGENE HCV 5-NC genotyping kit. At the 48[th] week of treatment, 15 patients [68%] showed virological response. Whereas HCV-RNA was still detected in 7 patients [32%] in this period; of those, 6 experienced a partial virological response followed by viral breakthrough during treatment. Only one patient did not show any virological or chemical response. The four females included in this study were all responders. There was a significant correlation between the response rate and lower fibrosis [p=0.026] as well as the total number of mutation spots [including all the insertions, deletions, transitions and transversions] [p=0.007, p= 0.035]. Patients who responded to interferon treatment had statistically significant less number in both transitions [p=0.007] and the genetic distances between the quasispecies [p= 0.035]. So, viral genetic complexity and variability may play a role in the response to IFN treatment. The consensus alignment of all three groups revealed no characteristic pattern among the three groups. However, the G to A transitions at 160 was observed among non responders who need further study to confirm this observation

Role of mismatch repair genes [h MLHI, h PMS1, h PMS2, GTBP/h MSH6, h MSH2] in the pathogenesis of hepatocellular carcinoma

DNA mismatch repair [MMR] is an important mechanism involved in maintaining fidelity of genomic DNA. Abnormalities in at least one of five MMR genes are implicated in the development of many cancers and the associated micro satellite instability [MSI]. By using a newly developed multiplex reverse transcription -PCR assay, the expression of the five known MMR [hMLH1, hPMS1, hPMS2, GTBP/hMSH6, hMSH2] were evaluated in 33 human HCC cases as well as 16 cases from the normal distant hepatic tissue samples [NDHT] were also evaluated. Twenty- five of them were associated with HCV infection. This was done in an attempt to determine the role of MMR genes in the development of HCC. The beta actin gene was used as an internal control for RNA degradation and DNA contamination and as well as a reference for quantifying the levels of their transcription. Out of the 33 studied HCC cases, 30 cases [90.9%] showed reduction in the expression of one or more of the 5 studied MMR genes. Reduced expression of hMSH2 was found in [71.9%], hMLH1 [53.3%], GTBP [51.1%], hPMS2 [33.3%] and hPMSI [6%]. Correlation analysis showed a strong significant correlation [P= 0.0069] between reduced expression of hPMS2 and GTBP [P=0.0034] as well as hPMS2 and non-cirrhosis [P=0.0197]. Chi-square analysis showed a significant correlation between reduced expression of hMLHl and grade II. On the other hand, 57.1%, 50%, 20%, 18.8% and 6% of the NDHT showed reduced expression of hMSH2, hMLHI, GTBP, hPMS2 and hPMSI respectively. Multivariate analysis showed significant correlation between HCC and hMSH2 [P= 0.008], hMLH1 [P=0.001] and GTBP [P=0.032], also between hPMS2, GTBP and HCC infected with HCV cases [P< 0.001, 0.002]. It could finally be concluded that reduced expression of hPMS2 is likely associated with growth advantage and stimulates proliferation changes that have encouraged malignant development in non- cirrhotic HCV infected patients via acquisition of more genetic damage and the MMR defects that occur at an early stage of hepatocarcinogenesis

Hepatitis c virus and hepatocellular carcinoma

Different etiological factors such as hepatitis viral infection, alcohol, aflatoxin and chemical carcinogens were mentioned in relation to HCC. However, the global distribution of HCC is strongly linked to the prevalence of hepatitis virus infection. The exact pathogenic mechanisms involved in viral-associated HCC are unclear although direct and indirect mechanisms are possible. Direct carcinogenicity is less certain in HCV-Induced HCC since it is a typical RNA virus and therefore the integration of viral genome into host cell chromosomes has not been shown to occur. However, the presence of two conserved potential nuclear localization signals and a DNA binding motif in the HCV core protein suggest a possible functional role as a regulatory element. Moreover, some studies demonstrated that this protein interacts with certain cellular proto-oncogenes at the transcriptional level, resulting in the promotion of cell proliferation and thus affecting normal hepatocyte growth. Therefore the pathogenesis of HCC may be attributed at least in part to the upregulation of hepatocyte growth induced by HCV core protein and other viral proteins like NS3 and NS5. However, the process of malignant transformation represents a dynamic interplay between classes of genes; oncogenes, tumor suppressor genes, mismatch repair genes, genes controlling apoptosis and cell cycle regulatory genes. In conclusion, since the exact mechanism of action of HCV in the context of HCC is still poorly understood, clarification of the molecular basis of viral replication in hepatocytes, the possible genetic and cytogenetic abnormalities that may be induced by the virus were emphasized in this review. Moreover, early detection of hepatocellular changes by molecular biomarkers may help to detect individuals at high risk of development HCC, thus allowing more effective intervention for cure or prevention

Rhabdomyolysis and Salmonella typhi infection case report and review of the literature

Typhoid fever is endemic in Lebanon. Usual presentation includes fever, headache, abdominal pain and constipation or diarrhea, extra-intestinal manifestations are not uncommon and involve variety oforgan systems. Rhabdomyolysis is rare and has been reported in various Salmonella infections. we present a case of rhabdomyolysis and renal failure that was successfully treated with imipenem/ cilastatin and hemodialysis

Comparative analysis of different PCR techniques for detection of HCV in hepatocellular carcinoma patients

Three different isolation procedures and a primer set from the 5-TUR were compared using 3 variable PCR techniques [direct PCR, semi-nested PCR and single tube RT-PCR]. This was applied for detection of HCV- RNA in sera from 30 hepatocellular carcinoma patients positive for HCV antibodies by both EIA and immunoblotting techniques. It was found that RNA extraction with silica [Boom et al., 1990] and semi-nested PCR technique were the most sensitive procedures. By this combined method the study was able to detect 20 copies of the in vitro transcribed RNA compared to 50 copies and 100 copies using 1 tube RTPCR and direct PCR techniques, respectively