Albumin- bilirubin score as a non-invasive serum biomarker for advanced liver fibrosis and cirrhosis in Egyptian patients with chronic hepatitis C infection: A case-control study

Background: In many health systems, primary care is the main source of health care services. Liver cirrhosis is a silent disease that causes no signs or symptoms until decompensation occurs. Therefore, a simple and readily accessible tool for predicting advanced liver fibrosis and cirrhosis is needed to aid general practitioners in primary care settings. Aim: To explore the predictive performance of Albumin Bilirubin (ALBI) score as a non-invasive serum biomarker for advanced liver fibrosis and cirrhosis. Methods: This case-control study was conducted at Zagazig University Hospitals, Egypt, and comprised 400 participants divided into two equal groups. Group (I): 200 chronic HCV patients with advanced liver fibrosis and cirrhosis [F3-F4] and Group (II): 200 healthy controls. ALBI score was calculated for all study participants. Results: The AUROC for the ALBI score was 0.832 (95% CI: 0.787-0.872) (p-value) Conclusion: ALBI score is reliable for predicting advanced liver fibrosis and cirrhosis and could be valuable in primary care

Spontaneous pneumomediastinum mimicking angioedema in an asthmatic teenager

Spontaneous pneumomediastinum [SPM] often presents with chest pain, cough, and/or dyspnea. The presentation with facial swelling is less frequently mentioned and may be misinterpreted as angioedema. A palpable subcutaneous crepitus, an audible mediastinal crunch, and subcutaneous or mediastinal air in chest X-ray should be carefully sought. We present a boy with an asthma exacerbation and bronchopneumonia who developed facial swelling following an antibiotic injection. Careful scrutiny of the Chest X-ray for an evidence of subcutaneous air would have negated an initial thinking of angioedema. SPM should be included in the differential diagnosis of acute swelling of the face during asthma exacerbations

Central pontine myelinolysis in the hyperosmolar hyperglycaemic state

To report a rare association of central pontine myelinolysis [CPM] with hyperosmolar hyperglycaemic state [HHS]. A diabetic female presented with HHS and prolonged severe hypernatraemia. The metabolic derangement was adequately treated with proper correction of both hyperglycaemia and hypernatraemia. Lack of improvement in the presenting confusional state and the development of a fresh neurological deterioration led to the suspicion of CPM that was confirmed with magnetic resonance imaging. She fully recovered after 4 weeks with no specific medical treatment. This case report showed that osmotic demyelination was linked to hypernatraemia and that CPM could result from severe hypernatraemia of HHS

Hypothermia with pneumonia: a rare presentation of brucellosis

To report a very rare form of brucellosis presenting with hypothermia and pneumonia. Clinical Presentation and Intervention: A 41-year-old male shepherd presented with a depressed level of consciousness. Clinically, his rectal temperature was 29.5°C, and he was cold, apathetic, hyporeflexic, and hypotensive, with atrial fibrillation. He had clinical and radiological evidence of bilateral bronchopneumonia. Blood culture and serologic testing were positive for Brucella melitensis. The patient recovered completely after proper management of the hypothermia and treatment of the brucellosis with antibiotics [doxycycline 100 mg orally twice daily for 6 weeks and streptomycin 1 g i.m. daily for 21 days]. This case shows that brucellosis should be considered in the differential diagnosis of septicemic patients presenting with hypothermia

Seasonal variation in cardiac conductive disorders in Egyptian patients

To evaluate seasonal variation in cardiac conductive disorders leading to permanent pacemaker implantation. Conductive disorders of all patients who had implanted cardiac pacemakers during the period from January 2007 to end of March 2009 were evaluated. All conduction disorders in atrial and atrio-ventricular node were included. Statistical analysis was done by SPSS version 13. 627 patients, 346 males and 281 females were included in the study divided into multiple age groups. We recorded seasonal variability in the incidence of conductive disorder with two peaks in months march and June i.e. at the end of winter and end of spring. incidence of conduction disorders which lead pacemaker implantation was higher at the end of Winter and the end of Spring than other seasons. This recorded observation opens the discussion about the etiology and provocation in cardiac conductive disorders

Clinical predictors and outcomes associated with acute return of pulmonary vein conduction during pulmonary vein isolation for treatment of atrial fibrillation

Radiofrequency ablation has become a common trend in management of cases of AF refractory to medical treatment. Recurrence of AF is a common observation both acutely and late during follow up. To determine the clinical predictors of acute reconnection of pulmonary vein potentials during PVI and late recurrence of AF on follow-up, respectively. A cohort of 14 patients referred to the EP labs of the NHI and Ain Shams University for PVI between January 2007 and February 2008 were studied. PVI of arrhythmogenic PVs was performed segmentally. PVI was defined as entry and exit block using a multipolar Lasso catheter. All veins were resampled to confirm isolation after 20-60niinutes. There were 14 patients who underwent isolation of 56 pulmonary veins during the study period. Acute reconnection of at least one vein occurred in 7 patients [50%] and 10 of the 56 pulmonary veins targeted [18%]. The left superior PV was most likely to acutely recover conduction compared with the other veins. Predictors of acute reconnection could not be accounted for given possible technical difficulties and the small sample size. During the three month follow up period, recurrence of AF occurred in 3 patients representing 21.4% of the cohort. It was found to be higher in female gender, left atrial size>or equal 4.Scms, age older than 50 years, non-paroxysmal type of AF and an EF of less than 50%. Many clinical criteria can affect acute reconnection of PVPs during PVI for patients with AF. According to previous studies large left atrium, older age, hypertension, non-paroxysmal type of AF are the most likely acute predictors. As regards short term follow-up, factors that could be considered include gender, age, left atrial size, EF and type of AF. The importance of detection of acute recurrence of PVPs and re-isolation has also become evident through this study

Early detection of malignant showers in blood of colorectal cancer patients using carcinoembryonic antigen mRNA Reverse Transcriptase-polymerase Chain Reaction

Serum CEA is among the most widely accepted marker for diagnosing and monitoring colorectal cancer [CRC] yet it has many limitations. The objective of the present study was to evaluate the utility of plasma CEA-mRNA as a marker for early detection of micrometastasis and assess its usefulness versus that of serum CEA in CRC patients. This study included 36 patients with CRC who were staged according to Dukes' staging system into stage A [n = 4], B [n = 8] C [n = 14] and stage D [n = 10]. Patients included in Dukes' stages A and B [n = 12] had non-metastatic lesion and were considered as one group [group I] while those having stages C and D [n = 24] had metastatic lesions. Patients with metastatic lesions who weren't receiving chemotherapy were included in one group [group II, n = 20] while those on chemotherapy [5 fluorouracil and leukovorin] were considered as group III [n = 4]. Six patients suffering from benign colorectal disease [ulcerative colitis n = 2, diverticulitis n = 1 and polyps n=3] and six healthy age and gender matched and with normal serum CEA concentration were included in the study and were considered as the control group [group IVa, group IVb respectively]. All CRC patients were subjected to clinical, radiological, endoscopic, histopathological and laboratory assessment. Control subjects were assessed both clinically and laboratory wise. Serum CEA was assayed by chemiluminescent sequential immunometric assay while plasma CEA-mRNA was determined by semi nested reverse transcription RT-PCR. The median and inter-quartile values for serum CEA in groups I, II and III were 2.5 [1.5-3.4], 4.6 [2.8-9.9] and 4.2 [2.9-5.3] ng/mL respectively. As for the control groups, it was 2 [0.9-2.2] ng/mL in group IVa and 3.3 [2.1-4.0] ng/mL in group IVb. When compared to controls, serum CEA was significantly higher only in metastatic patients [group II and III], however, when compared to non-metastatic CRC, serum CEA was significantly higher only in patients not on chemotherapy [group II]. The degree of tumor differentiation had no significant impact on serum CEA concentration. Our results also demonstrated that the percent positivity for CEA-mRNA increase with advancing CRC stage where a highly significant increase was observed in metastatic patients [65%] when compared to non metastatic ones [8.3%]. Our results also showed that CEA- mRNA may be positive in subjects with benign colorectal diseases [8.3%] and that chemotherapy may result in negative results for m-RNA. Again, the degree of differentiation had no impact on percent positivity of CEA- mRNA. Finally, our results showed that serum CEA and percent positivity of CEA- mRNA do not correlate and that the recurrence rate in patients with positive CEA-mRNA is significantly high [70%]. Reverse-trancriptase polymerase chain reaction for CEA-mRNA is a sensitive method for detection of circulating cancer cells in CRC patients. Colorectal cancer patients with postoperative CEA-mRNA positive cells in peripheral blood have less disease free survival than patients who demonstrate absence of these cells. Studies involving a larger group of patients with a longer follow-up period should be done to implement the clinical relevance of this phenomenon. Patients receiving chemotherapy should not be tested for CEA-mRNA during the treatment course. They should be tested repeatedly thereafter at longer time intervals following the last dose of chemotherapy

Assessment Of regional diastolic dysfunction in coronary artery disease by tissue doppler during dobutamine stress echocardiography

The present study aimed to evaluate the role of tissue Doppler imaging in diagnosis of diastolic dysfunction during Dobutamine stress echocardiography and to compare it with coronary angiography. Sixty patients were included in this study, 40 of them were with ischemic heart disease according to the result of coronary angiography and 20 of them were coronary arteries free also according to the coronary angiography. All patients were subjected to thorough clinical examination, resting ECG, conventional transthoracic echocardiography and Dobutamine stress echocardiography. Dose of Dobutamine was 5 micro g/kg/min in each stage [3 min for each stage] up to 50 micro g/kg/min or target heart rates achieved, detection of wall motion abnormality or dangerous arrhythmias occur [Mc Neil et al., 1992] [1]. Tissues Doppler echocardiography was used at baseline, low dose and peak stress. Tissue Doppler echocardiography wave form at mitral annulus in 4 left ventricular sectors [lateral, septal, anterior and inferior] were used to measure early filling wave [Em cm/sec], late filling wave [Am cm/s] and deceleration time [DTm ms]. Coronary angiography was performed to each patient and control.1- Higher association of ischemic heart disease and male sex, diabetes, hypercholesterolemia and positive family history for ischemia.2- Low accuracy of mitral E/A ratio for diagnosis of coronary artery disease, as there was non-significant difference between both groups.3- The presence of heterogeneity of regional contraction and relaxation in control group.4- Reduced Em wave in ischemic area when comparing it with the corresponding wall in healthy subject.5- Biphasic response of Em wave in ischemic region during Dobutamine stress test i.e. increase with low dose and decreased with high dose.6-Progressive increment of Am wave in each work step of Dobutamine infusion in both healthy and ischemic patients.7- Shorter DTm in ischemic group when it compared with that of control group.8- Progressive decrement of DTm during Dobutainine stress from low to peak in ischemic patients.9- Low accuracy of wall motion score index in diagnosis of coronary artery disease when compared it with tissue Doppler accuracy.10- Higher agreement between tissue Doppler and results of coronary angiography, which is the golden standard for diagnosis of ischemic heart disease. The presents study demonstrate the usefulness and advantage of combining these techniques in diagnosis of ischemic heart disease. The biphasic response of Em velocity is characteristic and diagnostic of ischemic heart disease

Management of post laparoscopic cholecystectomy major bile duct injury: comparison of MRCP with conventional methods

Postlaparoscopic cholecystectomy bile duct injury remains one of the devastating complications seen in current surgical practice. Aim of study: This study describes the diagnostic role of magnetic resonance cholangiopancreatography [MRCP] in such injuries compared with conventional methods. Patients and Eighteen patients referred to the Division of Hepatobiliary Surgery, King Khalid University Hospital from July 1998 to September 2000 were retrospectively studied. The technique of the repair was by utilizing Roux- en- Y hepaticojejunostomy with establishment of mucosa- to- mucosa anastomosis. The study included presentation, age and gender. The presentation of patients were variable and frequently included pain, Jaundice with or without cholangitis in 13 patients, bile leakage with development of biliary peritonitis in three, and development of external biliary fistula in two patients. Beside lower incidence of complication, MRCP was more diagnostic and informative in planning surgery by mapping both ducts proximal and distal to site of injury or stricture in 14 out of 18 patients. The Bismuth level of bile duct injuries were type I in one, type II in five, type III in 11 and type IV in one patient. All patients are alive, well and no complications occurred in the immediate postoperative period. Only two patients developed stricture within four months after surgery, one of them treated conservatively with repeated dilatation and stenting was done for the other. Hepaticojeunostomy is the procedure of choice for repair of bile duct injuries and provides adequate bilairy drainage. MRCP is an ideal diagnostic test when bile duct injury is suspeted following laparoscopic cholecystectomy

Study of the possible association between systemic lupus erythematosus and Epstein-barr virus

Background and systemic lupus erythematosus [SLE] is an autoimmune rheumatic disease with no known cure. In predisposed individuals, the initial stimulus is likely to be one or more of the environmental agents interacting with susceptibility genes. For many years, investigators have suspected that Epstein-Barr virus [EBV] might somehow by involved in the aetiopathogenesis of systemic lupus. Studies have examined this possibility from various angles and have arrived at different conclusions. The present work was carried out to evaluate the role of EBV as an environmental risk factor for lupus in our population and to assess the role of this virus in the clinical course of the disease. the study included 25 lupus patients satisfying the American College of Rheumatology criteria for diagnosis of SLE. Twenty age and sex matched healthy subjects were chosen as controls. All patients were subjected to complete history taking and full clinical assessment. Routine laboratory investigations were carried out as well as study of immunologic parameters including antinuclear antibodies, anti-double stranded DNA and complement components C3 and C4. in all study subjects, serology for EBV viral capsid antigen [VCA] IgG was performed using both enzyme linked immunosorbent assay [ELISA] and indirect immunofluorescence assay [IFA]. EBV DNA was detected in peripheral blood mononuclear cells by polymerase chain reaction using primers specific for EBV nuclear antigen-1 gene. Besides, interleukin-10 [IL-10] levels were determined in sera by ELSA. Results and twenty three lupus patients [92%] were positive for EBV DNA compared to 12 control subjects [60%], the difference being statistically significant [p= 0.14]. Virtually all study subjects had seroconverted against EBV. When antibody titres were expressed as the geometric mean titre [GMT] after logarthmic transformation, patients with SLE had a significantly higher GMT compared to control subjects [mean +/- SD 3.46 +/- 0.34 vs 2.93 +/- 0.25, t = 5.12, p < 0.001]. When the anti-VCA titre of lupus patients was correlated with different clinical and laboratory findings, a significant positive correlation was detected with disease activity as measured by SLE disease activity index [SLEDAI], while a significant inverse correlation existed with each of C3 and C4. IL-10 levels in SLE patient were significantly higher than those in controls [mean +/- SD 61.37 +/- 90.65 vs 9.73 +/- 20.33 pg/ml. p = 0.002]. Moreover, elevated IL-10 levels correlated significantly with SLEDAI and with titre of anti-VCA in lupus patients. This study provide evidence that EBV infection contributes to the aetiology and/or pathogenesis of SLE and that the presence of the virus may influence the clinical course of the disease

role of xanthine oxid and andenosine deaminase in the oxidative stress of rheumatoid arthritis

Rheumatoid arthritis [RA] is an autoimmune connective tissue disease in which chemotaxis and excessive production of cytokines and reactive oxygen species [ROS] are characteristics of activated cytokines that play an important role in the generation of ROS in RA. Xanthine oxidase [XO] and adenosine deaminase [ADA] enzymes were reported to act as sources of ROS and advanced oxidation protein products [AOFP] was found to be a good marker of oxidative stress. To find out if XO or ADA has any role in the pathogenesis of RA; and to correlate their activities with a novel marker of oxidative stress, other cytokines, and markers of disease activities.: this study was carried out on 10 patients with RA [group I] and 10 healthy persons as a control group, [group II]. The levels of XO activity, ADA activity, AOPP, interleukin-6 [IL-6], interleukin-8 [JL-8], erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP] were estimated. XO activity, A OFF, IL-6, IL-8, ESR and CRF levels were all increased significantly in group I. Also XO and AOPP were found to have positive correlation to each other and to the acute phase reactants ESR and CRP. ADA activity showed no significant changes comparing the two studied groups. XO could be considered an important source of ROS in RA patients. XO and AOFP play at least a partial role in the pathogenesis of the disease and their levels could be used as one of the laboratory markers of the RA activity. On the other hand, ADA had no role in RA pathogenesis. It is suggested that the use of xanthine oxidase inhibitors as well as other antioxidants may be of benefit in preventing tissue damage in RA patients