Are there differences in risk factors, microbial aspects, and prognosis of cellulitis between compensated and decompensated hepatitis C virus-related cirrhosis?

BACKGROUND/AIMS: Cellulitis is a common infection in patients with liver cirrhosis. We aimed to compare risk factors, microbial aspects, and outcomes of cellulitis in compensated and decompensated hepatitis C virus (HCV)-related cirrhosis. METHODS: Six hundred twenty consecutive HCV-related cirrhotic patients were evaluated for cellulitis. Demographic and clinical data were evaluated, along with blood and skin cultures. Severity of cirrhosis was assessed using Child-Pugh score. In-hospital mortality was assessed. RESULTS: Seventy-seven (12.4%) cirrhotic patients had cellulitis (25 with compensated and 52 with decompensated disease). Smoking and venous insufficiency were risk factors of cellulitis in compensated cirrhosis. Leg edema, ascites, hyperbilrubinemia and hypoalbuminemia were risk factors in decompensated cirrhosis. Gram-positive bacteria (Staphylococcus spp. and Streptococcus pyogenes) were the infective organisms in compensated patients, while gram negative bacteria (Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) were the predominant organisms in decompensated cirrhosis. Fungi (Candida albicans and Aspergillus niger) were detected in 3 decompensated cases. In-hospital mortality in patients with cellulitis was 27.3%, approaching 100% in decompensated patients with gram-negative cellulitis. Prolonged hospitalization, higher model for end-stage liver disease (MELD)-Na score, septic shock, local complication, and recurrent cellulitis were predictors of mortality. CONCLUSIONS: Cellulitis in compensated cirrhosis is different from that of decompensated patients regarding microorganisms, pathogenesis, and prognosis. Cellulitis has a poor prognosis, with mortality rates approaching 100% in decompensated patients with gram-negative cellulitis. Stratifying patients according to severity of cirrhosis is important to identify the proper empirical antibiotic and to decide the proper means of care.

Management of long segment anterior urethral stricture (≥ 8cm) using buccal mucosal (BM) graft and penile skin (PS) flap: outcome and predictors of failure

ABSTRACT Purpose To evaluate the surgical outcome and predictors of failure of substitution urethroplasty using either dorsal onlay buccal mucosal (BM) graft or ventral onlay penile skin flap (PS) for anterior urethral stricture ≥ 8cm. Patients and methods Between March 2010 and January 2016, 50 patients with anterior urethral stricture ≥ 8 cm were treated at our hospital. The surgical outcome and success rate were assessed. The predictors of failure were analyzed using multivariate analysis. Failure was considered when subsequent urethrotomy or urethroplasty were needed. Results Dorsal onlay BM graft was carried out in 24 patients, while PS urethroplasty in 26 patients. There was no significant difference between both groups regarding patients demographics, stricture characteristics or follow-up period. One case in the BM group was lost during follow-up. Stricture recurrence was detected in 7 (30.4%) patients out of BM group while in 6 (23.1%) patients out of PS group (p value= 0.5). No significant differences between both groups regarding overall early and late complications were observed. Occurrence of early complications and the stricture length were the only predictors of failure in univariate analysis, while in multivariate analysis the occurrence of early complications was only significant. Conclusion On short-term follow-up, both dorsal onlay BM graft and ventral onlay PS flap urethroplasty have similar success rates. However, BM graft has a potential advantage to reduce operative time and is also technically easier. The surgeon should avoid early local complications as they represent a higher risk for failure.

Impact of circulating soluble CD40 concentration levels in patients with hematologic malignancies

The present study was carried on forty [40] diagnosed ALL [Acute lymphoblastic leukemia], CML [Chronic myeloid leukemia], AML [Acute myeloid leukemia] patients who attended Oncology Centre, Mansoura University. Their ages ranged from 3 to 77 years. They were 27 males and 13 female. Patients were followed up throughout the period of the study. All patients were subjected to the following: Detailed history, clinical examination and Laboratory investigations

Results: CD04 expression was not associated with any of the studied demographic, clinical or laboratory variables. No statistically significant associations were elicited between CD 04 expression and any of the studied prognostic factors of patients. However, a significant positive association was detected between patients who responded to chemotherapy and positive CD04L

Conclusion: CD04L is an independent prognostic factor for relapse free survival, and also an independent prognostic factor for the prediction of good response to chemotherapy, since CD04L positive patients are more liable to achieve complete remission, while CD 04 negative ones are more susceptible to death chemotherapeutic resistance

Serum sP-selectin level and brachial artery flow mediated dilation as predictors of no reflow in patients with ST segment elevation myocardial infarction undergoing primary PCI

Background: No reflow phenomenon is associated with major adverse cardiac events, prediction of no reflow using laboratory and noninvasive imaging techniques can help in early prevention and management of this phenomenon

Objectives: To investigate the predictive value of serum sP-selectin and endothelial dysfunction assessed by using brachial artery flow mediated dilation [FMD] in patients with STEMI undergoing primary PCI to address patients with high incidence of no reflow

Methods: The prognostic performance, clinical and angiographic correlates of sP-selectin and FMD was assessed in 96 patients admitted in National Heart Institute and Ain Shams University Hospitals by STEMI and underwent primary PCI as a reperfusion strategy. Each patient was subjected to [history taking, clinical examination, laboratory investigations including withdrawal of serum samples for detection of sP-selectin levels, echocardio-graphy, assessment of endothelial dysfunction by measuring the FMD, assessment of the angiographic results using TIMI flow grade and myocardial blush grade. Follow up of the patients during hospital stay and after one month for the incidence of MACE

Results: A significant correlation between patients with high serum sP-selectin and TIMI flow

Conclusions: Serum sP-selectin level in patients with STEMI treated by primary PCI can predict the patients who will develop no reflow phenomenon after PCI, FMD could not predict the incidence of no reflow among those patients

Rapid Simultaneous detection of AmpC and ESBLs among Enterobacteriaceae using MastD68C detection set and possible therapeutic options

Extended spectrum beta -lactamases [ESBLs] and AmpC beta -lactamases are enzymes produced by a variety of Gram-negative bacteria which confer an increased resistance to commonly used antibiotics and represent a substantial clinical threat. Several phenotypic tests have been recommended for screening and confirmation of ESBL- and AmpC-producing organisms. However, a comprehensive diagnostic algorithm integrating both screening and confirmation has not been established. This study aimed to detect ESBL and/or AmpC production by using MastD68C ESBL and AmpC detection set as a single phenotypic method and to study its sensitivity and specificity comparing to other methods. Evaluate the effect of novel antibiotics namely tigecycline and doripenem, as well as the efficacy of old reviving antibiotics as colistin and temocillin against ESBL- and AmpC-producing Enterobacteriaecae. Hundred Enterobacteriaceae isolates were screened for ESBL production using disc diffusion method and confirmed by combination disc diffusion test. Screening of AmpC production was done by cefoxitin disc test, disc approximation test and confirmation was done by AmpC disc test. Isolates screened positive for ESBL were investigated for their susceptibility to temocillin, tigecycline, colistin and doripenem by E-test. Among the 100 Enterobacteriaceae isolates, 45 were screened positive for ESBL-production using the disc diffusion test and 36 were confirmed by the combination disc test. Nine isolates were screened for AmpCproduction using the cefoxitin disc test and 5 isolates were confirmed as AmpC producers by AmpC disc test. Using MAST D68C set, 35 isolates were ESBL producers, 2 were AmpC producers, one isolate was both ESBL and AmpC producer. All isolates were sensitive to tigecycline and doripenem. Forty-three isolates were sensitive to colistin, while, thirty-seven isolates were sensitive to temocillin. MAST D68C test appears to be a promising way to detect isolates producing ESBL and/or AmpC. Tigecycline, doripenem, temocillin and colistin revealed excellent activity against ESBL- and AmpC- producing Enterobacteriaceae

Novel prognostic biomarkers for HCC progression in Egyptian patients

Objectives: To evaluate values of Cyclin D and Cdk4 in HCC, chronic hepatitis C, HCV related liver cirrhosis and healthy controls, their clinico-radiological correlations and prognosis of HCC

Methods: Group 1: Fifty patients with HCC, Group 2.Fifty patients with chronic hepatitis C with or without cirrhosis and Group 3: Thirty healthy controls were enrolled. All patients were positive for hepatitis C virus [HCV] antibody and confirmed by HCV RNA. Calculation of Barcelona-Clinic Liver Cancer [BCLC] staging system, MELD and Child-Pugh scores. mRNA for cyclin Dl and Cdk4 were analyzed by quantitative RT-PCR

Results: The mean Cyclin Dl and Cdk4 values were higher in HCC group compared with the other two groups [p value= 0.001]. In HCC group, the mean Cdk4 and cyclin Dlvalues were significantly higher among HCC patients with multiple hepatic focal lesion [HFL] [p value= 0. 0001, and003 respectively] compared with those with single lesion. A significant correlation between size of [HFL], alpha-Fetoprotein[AFP] and mean Cdk4 value [p value= 0.028, 0.0001 respectively]

Conclusions: Significant values of cyclin Dl and Cdk4 were found in HCC, compared to normal and chronic hepatitis C and correlated to the number, size of HFL and AFP level. Thus, the assessment of cyclin Dl and Cdk4 may provide a novel strategy for prognostication and targeted therapy of HCC

Tongue metastasis as an initial manifestation of distant metastasis in oesophageal adenocarcinoma

Metastasis to the head and neck region from primary is rarest manifestation. Lung and breast carcinomas are the commonest malignancies to metastasize to the head and neck region. Oesophageal adenocarcinoma with metastasis to the oral cavity is a rarest presentation and is associated with dismal prognosis. Only few related case reports have been published so far. Her-in we report a case of 55 years old male who underwent radical oesophagectomy for adenocarcinoma of lower oesophagus twelve months back, now presented with hard mass in the right margin of tongue which was suspected as primary tongue carcinoma; subsequently was confirmed as metastatic oesophageal adenocarcinoma following excision. Two months after tongue excision, patient died of progressive metastatic disease

Prospective, randomized controlled study to assess the role of dexmedetomidine in patients with supratentorial tumors undergoing craniotomy under general anesthesia

Preliminary data on the perioperative use of dexmedetomidine in patients undergoing craniotomy for brain tumor under general anesthesia indicate that the intraoperative administration of dexmedetomidine is opioid-sparing, results in less need for antihypertensive medication, and may offer greater hemodynamic stability at incision and emergence. Dexmedetomidine, alpha 2 adrenoceptor agonist, is used as adjuvant to anesthetic agents. Relatively recent studies have shown that dexmedetomidine is able to decrease circulating plasma norepinephrine and epinephrine concentration in approximately 50%, decreases brain blood flow by directly acting on post-synaptic alpha 2 receptors, decreases CSF pressure without ischemic suffering and effectively decreases brain metabolism and intracranial pressure and also, able to decrease injury caused by focal ischemia. This prospective, randomized, double-blind study was designed to assess the perioperative effect of intraoperative infusion of dexmedetomidine in patients with supratentorial tumors undergoing craniotomy under general anesthesia. Fourty patients with CT-scanning proof of supratentorial tumors were classified equally into 2 groups [twenty patients in each group]. Group A:-Dexmedetomidine was given as a bolus dose of 1 microg/kg in 20 minutes before induction of anesthesia, followed by a maintenance infusion of 0. 4 microg/kg/hr. The infusion was discontinued when surgery ended. Group B:-The patients received similar volumes of saline. Heart rate and mean arterial blood pressure, decreased significantly in patients of group A [dexmedetomidine group] compared to group B [placebo group] [p-value<0.05]. There was no significant statistical difference between the two groups regarding the central venous pressure and arterial partial pressure of carbon dioxide [p-value>0.05]. The intraoperative end-tidal sevoflurane [%] in patients of group A was less than in patients of group B [p-value<0.05]. The intracranial pressure decreased in patients of Group A more than group B [p-value<0.05]. The Glasgow coma scale [GCS] improved in patients of group A and deteriorated in patients of Group B with significant statistical difference between the two groups [p-value<0.05]. The total fentanyl requirements from induction to extubation of patients increased in patients of group B more than in patients of group A [p-value<0.05]. The total postoperative patients' requirements for antiemetic drugs within the 2 hours after extubation decreased in patients of group A more than group B [p-value<0.05]. The postoperative duration from the end of surgery to extubation decreased significantly in patients of group A more than group B [p-value<0.05]. The total urine output during the duration from drug administration to extubation of patients increased in patients of group A more than group B [p-value<0.05]. Continuous intraoperative infusion of dexmedetomidine during craniotomy for supratentorial tumors under general anesthesia maintained the hemodynamic stability, reduced sevoflurane and fentanyl requirements, decreased intracranial pressure, and improved significantly the outcomes

[ heart, mind and brain]

It has been a general observation that in many cultures throughout history, the heart has been considered the source of emotions, passion and wisdom. However, scientists in the past emphasized the role of the brain in the head, to be responsible for such experiences. Interestingly, recent studies explored physiological mechanisms by which the heart communicates with the brain, thereby influencing information processing, perceptions, emotions and health. These studies provided the scientific basis to explain how and why the heart affects mental clarity, creativity and emotional balance. Also research indicates that the heart is far more than a simple pump. The heart is, in fact a highly complex, self-organizing information processing centre with its own functional "brain" that communicates with and influences the cranial brain via the nervous system, hormonal system and other pathways. These influences profoundly affect brain function and most of the body's major systems. In this review, I shall try to summarize and integrate the interesting findings in this area

Referrals to psychiatric service in United Arab Emirates: an analysis of the content of referral letters

To study all psychiatric referrals by General Practitioners [GPs] to the psychiatric service at Al-Ain Hospital for 7 years starting from July 1997 till December 2003. The study examined the appropriateness of referrals and the quality of information presented in the referral document. Also, it studied the outcome of this referral including the response of the psychiatrist. The case notes of all patients referred from the Primary Health Centres to the psychiatric service of Al-Ain Hospital for the period specified were studied. The data related to the GP referral were obtained from the copy of the referral letter, in the case notes. The information included: identifying data, reason for referral, symptomatology, relevant medical history and investigations, provisional diagnosis, recommended action, and the response of the psychiatrist. The diagnosis in the referral letter was compared to the International Classification of Diseases, 10th edition, Primary Health Care version [ICD-10 [PHC]], and to the final diagnosis in the case notes for agreement. Among the whole sample of 503 GP referrals there were 309 males [61.4%] and 179 [35.6%] females and 15 [3%] missing data. The mean age was 32.8 years [SD=13.7], with mean age for UAE nationals 31.4 years [SD=15.58] and expatriates as 34.3 years [SD=11.32] with significant difference between the two groups [t=2.253, p=0.03], 74.2% expatriates males with significant difference, and 15 missing data. Analysis of the referral letters showed that Diagnosis was clearly indicated in 380 [77.2%], was not mentioned in 112 [22.8%] of the referral letters, with 11 missed data. Psychiatrists agreed with the GP diagnosis in 205 of them [41.7%], but considered diagnosis inaccurate in 175 [35.6%] of these cases. All the referred patients had been seen by psychiatrists. However, replies of the psychiatrists to the GPs referrals were made only in 29 patients [5.9%]; 4 of these replies were written and the 2 copies of the letter were kept in the file. No reply was written in 460 cases and 14 missing data. Also physical examination and investigations were not mentioned in the majority of referrals. There is poor quality of GP referral letters and obvious poor response rate of psychiatrists to the GPs. This is an indication for urgent need for intensive training to GPs advising them to include particular items of information in future referrals

Cytogenetic study in juvenile myoclonic epileptic patients

The association of chromosomal imbalance and neurological abnormalities is well known. These chromosomal abnormalities may indicate that chromosomal sites where atypical neurological characteristics could be mapped. The purpose of our study was to search for cytogenetic abnormalities in patients with juvenile myoclonic epilepsy. This work was carried out on fifteen patients presenting to Epilepsy Centerof Neurology Department of Alexandria Main University Hospital. The age of juvenile myoclonic patients ranged from 16 to 38 years. Ten patients have myoclonic and generalized Tonic-Clonic seizures, 3 patients have myoclonic, absences, and generalized tonic-clonic seizures, and 2 patients have myoclonic seizures only. All patients were cytogenetically normal as all of them had normal karyotypes

Tubeless percutaneous nephrolithotomy in the management of renal calculi

To evaluate the status of tubeless percutaneous nephrolithotomy [PCNL] after managing uncomplicated renal calculi in selected patients. From August 2006 to May 2007, 28 patients with single renal stones were selected for tubeless PCNL. At the end of the procedure, a 6 Fr ureteral catheter was left in place and a nephrostomy tube was avoided. The outcomes measured were the operative time, change in the haematocrit value, urinary leak, blood transfusion requirement, hospital stay and the success rate. The mean age was 48 +/- 11 years. There were 25 male and 3 females. The mean stone size in these patients was 35 +/- 10 mm. The operative time was 56 +/- 20 minutes. 25 [89.3%] patients were stone free and three patients [10.7%] had residual fragments less than 5 mm. Two patients had prolonged urine leakage for more than three days and managed by DJ insertion. No patient required blood transfusion or had postoperative urinoma. The mean hospital stay was 2.6 +/- 1.1 days. Tubeless percutaneous nephrolithotomy is an option in selected patients when there is no bleeding, perforation, or repeat PCNL required

Early detection of renal impairment among epileptic children on anti-epileptic medication

Epilepsy is defined as a paroxysmal electrical discharge affecting a group of neurons, starting in one part of the brain but often spreading to become a generalized abnormality. Despite the recent advances in surgery, the management of epilepsy depends mainly on medication. Treatment with anti-epileptic drugs [AED] was reported to cause changes in hepatic and renal functions. Nephrotoxicity is suggested by evidence of glomerular and/or tubular dysfunction. Glomeruiar damage may present as hematuria, increased 24 hour urinary protein excretion, elevated blood urea nitrogen [BUN] and serum creatinine and lowered creatinine clearance. Tubular dysfunction is reflected by low urine specific gravity and increased levels of urinary enzymes. The present study was conducted at Damanhour Medical National Institute [DMNI] at Beheira Governorate. It aims at the early detection of renal impairment among epileptic children on AED therapy. It comprises sixty epileptic newly diagnosed patients aged 5 -16 years suffering from different types of epilepsy. They were divided into three groups according to the type of medication. Patients in-group 1 were treated with Carbamazine [CBZ], group 2 was treated with Valproate [VPA], and group 3 was treated with Phenantoin [PHE]. Patients were compared to thirty healthy children [group 4] not suffering from any disease. All groups were compared as regards age, nutritional status and renal function to provide a baseline before the start of the study. The same procedures were repeated six months later to evaluate the renal function after the treatment with AED. At the end of the study, no clinical manifestation of renal dysfunction was observed following AED therapy. Furthermore, our results revealed no significant difference between blood urea [P=0.91], blood urea nitrogen [P=0.91], serum creatinine [P=0.66], creatinine clearance [P=0.72], routine urine analysis, and 24 hour urinary albumin in all patients before and after AED therapy. On the other hand, there was a significant increase in urinary NAG in the three groups of patients after AED therapy. This increase was highest in patients receiving VPA monotherapy [2.34 +/- 2.00 U/g versus 1.68 +/- 1.76U/g and 1.9121. +/- 0U/g creatinine for the patients treated with CBZ and with PHE respectively]. The three groups did not differ as regards NAG level after AED therapy, but there was a significant difference in dMG/24h between the three groups at P=0.01

Conclusion: urinary excretion of NAG and urinary dMG/24h are good indicators of early renal tubular damage that could affect epileptic children as a result of the long term use of AE3 therapy when other routine renal function tests are still within normal limits

Mammographic and plasma lipoprotein changes associated with hormone replacement therapy in postmenopausal women

Objective: To evaluate the effects of tissue-specific tibolone and continuous combined hormone replacement therapy [ccHRT] on mammographic parenchymal density and plasma lipoprotein profile in healthy postmenopausal women

Design and Setting: This was a prospective double-blind, randomised placebo-controlled study conducted at Al-Azhar University Hospitals in Damietta and Cairo

Subjects and Methods: 90 healthy postmenopausal women aged 48 to 55 years with a normal mammogram and lipid profile at baseline were equally randomized to receive one of three treatment arms: [1] tibolone 2.5 mg [group I. n=30]; [2] continuous combined 17-beta estradiol 2 mg plus norethisterone acetate 1 mg [E2/NETA] [group II, n=30]; [3] placebo [group III, n=30]. Mammograms were performed at baseline and after 12 months of treatment. Mammographic density was quantified according to the Wolfe classification and by the percentage area of the breast that had a dense pattern. Plasma levels of total cholesterol, low-density lipoprotein [LDL-C], high- density lipoprotein [HDL-C] cholesterol; triglycerides [TG]; lipoprotein [a] [Lp[a]]; apolipoprotein A [apoLpA] and apolipoprotein B [apoLpB] were determined on four occasions [i.e., baseline. 3-, 6- and 12-month visits]

Results: An increase in mammographic density was much more common among women receiving continuous combined hormone replacement therapy [43% - 50%] than among those receiving tibolone [3% - 6%] and placebo [0%] treatment. The difference between E2 /NETA and placebo was highly significant [p[c]<0.001]. Treatment with tibolone did not differ from that with placebo. In the tibolone group, 6% 13% of the women showed an involutionary change in breast density in the 12-month reevaluation. In contrast, none of the women receiving E2/NETA or placebo showed an involutionary changes in breast density. Considering the effects of treatment regimens on lipids profile, it was found that tibolone therapy was associated with a statistically significant reduction in serum triglycerides, HDL-C, apolipoprotein A and lipoprotein [a] by [22%, 20%. 10%. 20%, respectively] [p[a] <0.05], whilst no significant changes were seen in LDL-C and apolipoprotein B levels. In E2/NETA-group, there was a significant reduction of total cholesterol, LDL-C ,apolipoprotein B. HDL-C and lipoprotein [a] by [9%. 11%. 10.7%. 7.4%. 18%. respectively] [p[a] <0.05], whilst no significant changes were seen in triglycerides levels [p[a] >0.05]. Decrements were observed within 3 months of active treatments and maintained thereafter. Group I showed a more pronounced reduction of HDL-C, apolipoprotein A and triglycerides than Group II and Group III. The levels of LDL-C and apolipoprotein B declined significantly only in Group II [P[a] <0.05], while LDL-C/HDL-C ratio increased significantly in Group I by 23% when compared with GII [2.3%] and GIII [10.2%] after 12 months of treatment [P[b] and P[c]<0.05]

Conclusion: An increase in mammographic parenchymal density should be regarded as an unwanted side effect of HRT. In contrast to conventional estrogen/progestogen treatment, tissue-specific tibolone seems to exert little stimulation of breast tissue with no impairment of mammogram interpretation. Both tibolone and continuous combined HRT induced a favorable plasma lipid response. These therapeutic effects may contribute to the reduction or prevention of atherogenesis in postmenopausal women. Larger longterm studies are needed to confirm the impact of prolonged tibolone or continuous combined HRT administration on mammography and plasma lipoproteins