Left ventricular diastolic function in patients with heart failure with preserved ejection fraction

Background: Left ventricular heart failure in sitting of preserved left ventricular ejection fraction constitutes up to 50% of heart failure. It increases with age and is correlated with the presence of systemic hypertension and left ventricular hypertrophy. It has significant morbidity, approaching that of systolic heart failure. Heart failure preserved ejection fraction [HFpEF] is a clinical syndrome resulting from increased resistance in the filling of the left ventricle [LV] leading to symptoms of congestion although the exact cause continues to be unknown and the identification of markers that predict HFpEF risk have not been proven

Aim of the Work: Assessment of left ventricular diastolic function in patients with heart failure and preserved ejection fraction

Patients and Methods: This study included 90 patients with ages ranging from 30 to 70 years old referred to Al Hussein University Hospital, Bab Al Shearia University Hospital, Cardiology Outpatient Clinic suffering from low functional capacity, exertional dyspnea and even exertional chest discomfort. Over a period from November 2015 to May 2018. The study population was divided into two groups according to incidence of positive stress ECG. Group A [patient group]: Patients with positive stress ECG. Group B [control group]: Patients with negative stress ECG

Results: This study included [90] patients with their ages ranging from 30 to 70 years referred to [Al Hussein University Hospital], [Bab Al Shearia- University Hospital] cardiology outpatient clinic from November 2015 to September 2017, with low functional capacity, exertional dyspnea and even exertional chest discomfort and are evaluated to rule out coronary artery disease [CAD]. Those patients were evaluated by stress ECG and Transthoracic Echo Doppler and Tissue Doppler imaging. The study population was divided into two groups according incidence of positive stress ECG into: Groups according incidence of positive stress ECG. Group I patients group: Included 60 patients presented by chest pain with dyspnea NYHA class 1 [12 patients], class II [37 patients], or class III [11 patients] with mean age 54.05+/-7.9 years, this group included 19 females [31.7%] and 41 males [68.3%], Group II control group: Included 30 patients with mean age 52.7+/-5.11 years. Female number was 13[43%] and males were 17[60%]

Conclusion: The assessment of diastolic function is now essential on routine testing for HF. The noninvasive nature of echocardiography has allowed an increase in diagnosis and awareness of diastolic dysfunction

Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax

Background and study aims: Spontaneous bacterial empyema [SBEM] is an underestimated condition in patients with ascites and hepatic hydrothorax with a high mortality. This study aimed to find whether spontaneous bacterial peritonitis [SBP] is a prerequisite for SBEM

Patients and methods: 3000 HCV-related cirrhotic patients with ascites and hydrothorax were screened for the presence of SBP [ascitic fluid neutrophils >250/mm[3]] and SBEM [positive pleural fluid culture and neutrophils >250/mm[3] or negative pleural fluid culture and neutrophils >500/mm[3] with no evidence of pneumonia/parapneumonic effusion on chest radiograph or CT]

Results: The prevalence of SBEM in cirrhotic patients was 1.2% [36/3000] unlike SBP [1.6%; 48/3000]. SBEM was detected in 51.4% of the patients with hepatic hydrothorax [36/70]. A total of 70 patients had concomitant ascites and hydrothorax, namely SBP [n = 17], SBEM [n = 5], and dual SBP and SBEM [n = 31], whereas 17 patients had sterile concomitant ascites and hydrothorax. Age, sex, liver function, kidney function tests, complete blood count, INR, MELD, MELD-Na, blood chemistry, and culture/sensitivity for ascitic and pleural fluid were statistically not different [p > 0.05] between SBP and dual SBP and SBEM patients. Escherichia coli and Klebsiella pneumoniae were detected in the culture. From univariate analysis, no predictors of dual SBP and SBEM were detected

Conclusion: SBEM is a part of SBP in cirrhotic patients with ascites and hydrothorax

Gamma-glutamyl transpeptidase and alpha-fetoprotein: are they predictors of treatment response in patients with chronic hepatitis C?

Hepatitis C virus is a leading cause of chronic liver disease. Elevated serum alpha-fetoprotein [AFP] has been used as a marker for hepatic regeneration after the destruction of hepatocyte in viral hepatitis. Recently, gamma-glutamyl transpeptidase [GGT] has also been taken into account in the evaluation of patients with chronic hepatitis C [CHC]. This study aimed to examine the association between serum AFP and serum GGT levels, and treatment outcome in patients with CHC treated with pegylated interferon and ribavirin. We examined the association between AFP and GGT levels and sustained virological response [SVR] in 150 patients with CHC in whom antiviral therapy was initiated. Serum AFP, GGT, and hepatitis C virus RNA were tested for patients completing 48 weeks of treatment and patients who responded to treatment after 6 months. AFP and GGT levels were lesser in patients who achieved SVR than in those who did not achieve a response. The logistic regression model [univariate analysis] of factors associated with SVR showed a significant increase in SVR when AFP ranged from 2.8 to 9.9 micro g/ml, GGT less than or equal to 50 U/l, and Ishak fibrosis score less than or equal to F2. Serum AFP and GGTwere strongly correlated in multivariate analysis; only GGT less than or equal to 50 U/l and AFP from 2.8 to 9.9 micro g/ml were independent predictors of SVR, whereas Ishak score of fibrosis was a dependent predictor for SVR. AFP and GGT can be used as independent predictors of treatment response in patients with CHC receiving pegylated interferon and ribavirin

Towards an Egyptian guideline from screening to treatment of hepatocellular carcinoma [part I]

These recommendations provide a data-supported and based-evidenced approach to the screening, diagnosis, staging and treatment of Egyptian patients with hepatocellular carcinoma [HCC] in which we tried to construct an Egyptian algorithm for our Egyptian HCC patients in terms of type and timing of surveillance, readily available diagnostic tools that suit our means and the proper and efficient timely treatment that suits our resources. They are based on the experience of the authors in the specified topic and the AASLD Policy on the Development and Use of Practice Guidelines. These recommendations suggest preferred approaches to screening [for early detection of cases with hepatic nodule and/or elevated AFP], diagnosis [for accurate diagnosis of HCC cases], staging [for detection of specific category of treatment according the patient's general condition] and treatment [selection of the most suitable treatment option for the patient after his proper evaluation]. In an attempt to characterize the quality of evidence supported recommendations, the Egyptian Guidelines requires a category to be assigned and reported with each recommendation [Table I]

Towards an Egyptian guideline from screening to treatment of hepatocelhilar carcinoma [part II]

These recommendations provide a data-supported and evidence based approach to the screening, diagnosis, staging and treatment of Egyptian patients with hepatocellular carcinoma [HCC] in which we tried to construct an Egyptian algorithm for our Egyptian HCC patients in terms of type and timing of surveillance, readily available diagnostic tools that suits our means and the proper and efficient timely treatment that suits our resources. They are based on the experience of the authors in the specified topic and the AASLD Policy on the Development and Use of Practice Guidelines. These recommendations suggest preferred approaches to screening [for early detection of cases with hepatic nodule and/or elevated AFP], diagnosis [for accurate diagnosis of HCC cases], staging [for detection of specific category of treatment according the patient's general condition] and treatment [selection of the most suitable treatment option for the patient after his proper evaluation]. In an attempt to characterize the quality of evidence supported recommendations, the Egyptian Guidelines requires a category to be assigned and reported with each recommendation [Table 1]

effect of helicobacter pylori eradication on gastric apoptosis in cirrhotic patients

Helicobacter [H] pylori was found to be present in a high percentage of cirrhotic patients, H. pylori colonized stomach contain more apoptotic epithelial cells than normal stomach. The aim of this work was to evaluate efficacy and safety of a triple therapy [Lanzoprazole, Tinidazole and Clarithromycin] in eradication of H. pylori and the effect of H. pylori eradication on the gastric mucosal apoptosis among cirrhotic patients. Fifty patients were classified into two groups: Group [I]: Twenty-five patients with liver cirrhosis and H. pylori positive. Group [II]: Twenty-five non-cirrhotic patients with manifestations of peptic disease and H. pylori positive. All patients were enrolled in a 7 days triple therapy with Lanzoprazole [30 mg], Tinidazole [500 mg] and Clarithromycin [250 mg], each twice / day. Apoptosis was determined before and after 4-6 weeks of H. pylori eradications. Eradication of H. pylori was achieved in 21 patients [84%] in cirrhotic patients, while it was eradicated in 22 patients [88%] in non-cirrhotic patients. The highest apoptotic figure was recorded in-group I before eradication [14.62 +/- 2.08]; it is significantly decreased after eradication of H. pylori [4.34 +/- 1.34, P <0.01]. In-group II a significant reduction of the apoptotic index from [12.2 +/- 10.6 to 2.75 +/- 1.06, P <0.01] after eradication of H. pylori. In conclusion, one-week triple therapy by Lanzoprazole, Tinidazole and Clarithromycin was effective and safe in eradication of the H. pylori in cirrhotic and non-cirrhotic patients. Hepatic cirrhosis increased gastric apoptosis. H. pylori eradication reduced gastric apoptosis among cirrhotic and non-cirrhotic patients

Histopathological changes in anti-HCV positive subjects with persistently normal aminotransferase levels

Approximately 30% of patients with chronic hepatitis C have normal serum alanine transaminase [ALT] levels; most of those patients have mild degrees of inflammation with mild or no fibrosis and the rate of disease progression is reduced compared to that in patients with elevated ALT levels. Is to study the histopathological characteristics of anti-HCV positive subjects with persistently normal aminotransferase levels in comparison with those patients having elevated aminotransferase levels. A comparative case control study was conducted on 80 patients who asked medical advice in outpatient clinics of National Liver Institute, Menoufiya University and Specialized Medical Hospital, Mansoura University. They were classified into two groups. Group I: were forty anti-HCV-positive subjects with normal enzymes. They were 28 males, 12 females. Their age ranged from 18 to 50 years with a mean age of 31 +/- 8.47 years. Group II: were forty chronic hepatitis C patients [31 males and 9 females] their age ranged between 17-53 years with a mean age 32.12 +/- 7.70 years with elevated ALT levels [one and half or more times of the upper limit of normal for at least six months], Both groups were subjected to thorough history taking and physical examination, complete blood counts [CBC], routine liver tests, abdominal ultrasound and percutaneous ultrasound guided liver biopsy to assess the severity of the necro-inflammatory process using histological activity index [HAT] of Knodell et al. and modification of Ishak et al. This research showed that the majority of anti-HCV positive patients with persistently normal ALT have histological features of minimal to mild necro-inflammation [HAT]. The severity of histological necro-inflammation is reduced in anti-HCV positive patients with persistently normal ALT compared with that of patients with elevated ALT levels. Also they have no or minimal to mild stage of fibrosis compared with that in patients with elevated ALT levels. Persistently normal ALT patients with steatosis had higher HAT grades and fibrosis stages than patients without steatosis and a significant correlation was found between steatosis and increased BMI. Moderate significant correlation was found between low platelet counts and fibrosis stage in patients with elevated ALT levels. The majority of anti-HCV positive patients with persistently normal ALT have histological-pathological changes of variant degrees of severity specially patients having steatosis. So it is recommended that patients with chronic hepatitis C should not be excluded from therapy based on ALT levels alone and the treatment must be individualized according to each patient

incidence of HCV infection among type-II diabetic patients, is there an association?

To study the relationship between diabetes mellitus [DM] and hepatitis C virus [HCV] infection, this study included: 200 diabetic patients of type 2 and 185 apparently healthy blood donors as their controls. It included also 50 diabetic patients of type 1 and 42 blood donors as their controls. All patients and their controls were age and sex matched. Patients were attendants of Diabetic Out-Patients Clinic, Faculty of Medicine Menoufiya University. Fasting and postprandial blood glucose levels, glycosylated haemoglobin [Hb Al[c]], kidney function tests, liver function tests, viral hepatitis markers [hepatitis B surface antigen, HBs Ag and anti-HCV antibodies] were performed for all studied subjects. All anti-HCV positive cases were evaluated for HCV viraemia by RT-PCR for HCV-RNA. On comparing results of type 2 diabetic patients with their controls, results revealed a significant high prevalence of anti-HCV seropositivity in patients group as 67 out of 200 patients [33.5%] were anti-HCV seropositive vs. 32/185 [17.3%] in their controls [p<0.01]. It was found that 55/67 [82.1%] of anti-HCV positive cases were also HCV-RNA positive. HBs Ag seropositivity was significantly higher among type 2 DM [15.5% of 200 patients vs. 4.3% of 185 controls, p<0.01]. Statistically significant differences [p<0.01] in the levels of ALT and AST were observed between HCV-seropositive and HCV-seronegative patients with type 2 DM. Blood urea and serum creatinine showed significant elevated values [p<0.01] among type 2 diabetic patients. No significant correlation was observed between HCV-seropositivity and glycaemic control [Hb Alc]. In type 1 DM there was a significant high prevalence of anti-HCV seropositivity [42% of 50 patients vs. 19.04% of 42 controls, p<0.01]. It could be concluded that both HBV and HCV infections are equally frequent in diabetes; therefore, diabetes mellitus is considered as an important risk factor for acquiring chronic liver disease. These findings, although suggestive, don't establish a cause and effect relationship and are not consistent with the conjecture that diabetes leads to HCV infection, but instead favor hypothesis suggesting that persistent HCV infection is associated with the subsequent development of diabetes

Vascular endothelial growth factor in hepatocellular carcinoma: Its clinical, pathological and prognostic significance

Twenty-seven patients with an age range of 36-71 years were included in this study. They were subjected to thorough clinical, radiological and biochemical assessment as well as serological testing for HCV, HBV and serum alpha fetoprotein [AFP] level. Serum vascular endothelial growth factor [VEGF] levels were measured by an enzymeournallinked immunosorbent assay kit. Samples from 15 healthy adults were obtained as controls for the assessment of serum VEGF levels. An immunohistochemical staining was done to study the tumor VEGF expression in the resected specimens. A histologic grade of tumor differentiation was also performed. Prognostic information was obtained by a close follow up every 2-3 months. The study demonstrated that serum VEGF level in HCC patients appears to reflect the disease potential activity for an aggressive behavior and can be used as a predictor of tumor recurrence

Value of serum nitric oxide in patients with coronary artery disease before and after percutaneous transluminal coronary angioplasty with or without stent

Our study was planned to assess the value of plasma NO as an early marker for endothelial injury and to detect its relation to the severity of coronary artery disease and its relation to restenosis after PCI. This study included [51] patients; [14] were normal control group [Group I]; and [37] patients were diseased [Group II], whom classified into three subgroups; subgroup [A] patients with single vessel disease [15 patients], subgroup [B] patients with two vessels disease [15 patients], subgroup [C] multi-vessels disease included [7 patients]. All patients subjected to coronary angiography with or without intervention [PTCA only, PTCA + stent or without stent]. [21] Patients accepted and respected follow-up by coronary angiography after 4 months. NO serum level was done before PCI and after 4 months in those accepted follow-up. Mean NO serum level on control group was 83 micro mol/L, while mean plasma NO serum level in subgroup [A] [34.8 +/- 10.3 micro mol/L], [17.5 +/- 3.5 micro mol/L] in subgroup [B]; and [8.9 +/- 2.2 micro mol/L in subgroup [C]. This revealed a highly significant decrease than control group, with P-value <0.05, <0.0005 and <0.0005 respectively when compared mean NO serum level in control group with each subgroup. On comparing the mean values of plasma NO level of subgroups [A, B, C]; to each other there was more or less gradual mathematical decrease in NO serum level between the subgroups, with highly significant P-values. Comparing the mean level of plasma NO of restenosis cases before and after PCI in each subgroup [A, B and C], we found a significant decrease in plasma NO level after PCI than before PCI. Endothelial dysfunction is an important contributing factor in CAD and it is associated with NO deficiency which can be considered as one of the endothelial markers for CAD. The more the degree of endothelial dysfunction, the more the deficiency of NO, the more the severity of CAD. Restenosis is a multi-factorial subject requiring a lot of work and lack of NO is related at least in part to the development of restenosis after angioplasty. We can suggest that if plasma NO level after PCI is reduced at least 30% of its initial level before PCI, most probably restenosis has occurred

Hepatic focal lestions: is needle biopsy a must?

With advanced in liver imagin, the results of recent studies have suggested a very high accuracy of preoperative evaluation of hepatic focal lesions, making tumour biopsy unnecessary in most cases. The aim of this study was to evaluate the accuracy of the diagnostic work-up, without needle biopsy, for defining the indications for surgery in patients with focal lesions of liver. Between august 1998 and february 2002. 58 patients with hepatic focal lesions. Were evaluated retrospectively. Preoperative diagnosis was established by means of laboratory parameters, tumor markers, ultrasnongraphy, compared tomography [ct], helical compared tomography, and magnetic resonance imaging [mri]. Fifty-five patients underwent surgery and the results of pathological examination were obtained for all cases. Preoperative clinical/radiological diagnosis were confirmed in 55 lesions. Hepatocellular carcinoma was present in 38 [65%] cases and cavernous hemangioma in 17 [29%] cases. Three patients had inconclusive preoperative clinical/radiological data. Accordingly, ultrasound-guided needle biopsy was performed. Non-Hodgkin lymphoma was present in 2 patients [4%] and one patients [2%] had glaucomatous hepatitis confirmed by pathological examination. The false positive rate for the clinical/radiological evaluation was 3 of 58 [5.2%] with a positive predictive value of 94.8%. Preoperative radiological diagnosis of focal lesions was accurate in lesions >/= 3cm. Tumor biopsy is unnecessary in these patients, however, in a subgroup of lesions< 3cm, there is a higher false positive rate [20%]. Tumor biopsy should be considered if lesions not radiological diagnosed

Fas antigen in serum and liver tissue of patients with chronic hepatitis C

Fas [APO-1/CD95], a member of the tumor necrosis factor receptor Family, can mediate apoptosis when engaged by its ligand or by anti-Fas antibody. Fas is upregulated on the surface of hepatocytes in patients with a variety of liver pathologies, including hepatitis, alcoholic cirrhosis, and acute liver failure. Moreover, expression of Fas ligand is substantially upregulated, in areas of lymphocytic infiltration, in liver diseases, suggesting Fas/FasL interactions may mediate liver damage in humans. The purpose of this study was to evaluate the relationship of serum soluble Fas [sFas] levels and hepatic Fas antigen expression with the degree of hepatic inflammatory activity in patients with chronic hepatitis C infection. The effect of concomitant schistosomiasis, as an endemic liver disease in Egypt, on serum and liver Fas expression was also studied. Serum sFas levels were measured by enzyme-linked immunosorbant assay in 69 chronic hepatitis C patients; 16 of them were under 18 years and compared with those in normal volunteers, and patients with chronic HBV infection. The results of serum tests were compared with ALT levels. HCV-RNA titer, histological inflammatory activity, and Fas expression in liver biopsies. The effect of combined HCV infection and schistosomal infestation on serum sFas and tissue Fas expression was also studied. Serum sFas and tissue Fas expression were then evaluated with each components of histological inflammatory activity scoring system [modified Knodell's HAI]. Serum sFas levels in chronic hepatitis C patients were significantly higher than those in normal volunteers [p<0.001]. They showed no difference from those in patients with chronic HBV infection [p>0.05]. Hepatic schistosomiasis didn't affect serum sFas levels or tissue expression of Fas antigen in chronic hepatitis C patients. Histologically, serum sFas levels showed strong correlation with tissue Fas expression [p<0.001] and with the degree of hepatic inflammatory activity [p<0.01]. Likewise, tissue Fas expression correlated with the degree of histological inflammatory activity [p<0.05]. Moreover, positive correlation was found between serum sFas and tissue Fas expression and the degree of interface hepatitis [piecemeal necrosis] in chronic hepatitis C patients with mild [p<0.01] and moderate and severe activity [p<0.05]. However, no correlation was observed between serum sFas and serum ALT levels. Also, no correlation was observed between HCV-RNA titer and sFas levels or tissue Fas expression. Our findings suggest that serum sFas levels may reflect the expression of Fas antigen on hepatocytes and the severity of liver inflammation in chronic hepatitis C and may be used as a serological indicator of histological inflammatory activity. They also support the concept that immune-mediated apoptosis may play a crucial role in the pathogenesis of chronic hepatitis C. Hepatic schistosomiasis seems to have no impact on serum sFas levels or hepatic tissue Fas expression

Value of transoesophageal echocardiography on assesment of intracardiac left to right shunts in adults

Transoesophageal echocardiography is a new method of evaluation of congenital heart disease and it is superior than transthoracic echocardiography in visualization of intra atrial septum. To demonstrate the ability of transoesohageal echocardiography to perform high resolution imaging of intra cardiac septum and diagnosis of intracardiac left to right shunt in adults in comparison with transthoracic echo and cardiac catheterization. Transoesophageal echocardiography was performed in 30 patients with suspected intra cardiac left to right shunts and the results obtained compared with that obtained from transthoracic echo and cardiac catheterization. 30 patients with suspected clinically to have left to right intracardiac shunt were examined by transesophageal echo and contrast echo by injection of agitated saline with blood to evaluate the negative jet of left to right shunt at the level of the intra atrial septum and also color flow Doppler study performed at the same time. We found that transesophageal echocardiography is more sensitive and specific in diagnosis and assessment of intracardiac shunts than transthoracic echocardiography especially in patient with sinus venosus defect Transesophageal echocardiography is recommended for all adults patients with intracardiac left to right shunts in whom transthoracic echocardiography is not adequate for diagnosis or assessment of its severity