Validation of prognostic indices in Egyptian Budd-Chiari syndrome patients: A single-center study.

AIM: To compare predictive ability of Budd-Chiari syndrome (BCS) prognostic indices (PIs) for one-year survival and Transjugular intrahepatic portosystemic shunt (TIPS) patency. METHODS: This retrospective study enrolled 194 Egyptian patients with primary BCS who presented to the Budd-Chiari Study Group of Ain Shams University Hospital. Calculation of the available PIs was performed using Child-Pugh and model for end-stage liver disease scores, BCS-specific PIs (Clichy, New Clichy and Rotterdam) for all patients, and BCS-TIPS PI only for patients who underwent TIPS. The overall one-year survival rate and the one-year shunt patency rate for TIPS were reported. RESULTS: The overall one-year survival rate was 69.6%, and the New Clichy PI revealed the best validity for its prediction at a cut-off value of 3.75, with sensitivity and specificity of 78% and 73.3%, respectively [area under receiver operating characteristic curve (AUC) = 0.806]. The one-year survival rate post-TIPS was 89.7%, and the BCS-TIPS score demonstrated validity for its prediction at a cut-off value of 3.92 (sensitivity and specificity were 71.4% and 64.5%, respectively) (AUC = 0.715). Logistic regression analysis revealed that the New Clichy PI (P = 0.030), high serum total bilirubin (P = 0.047) and low albumin (P < 0.001) were independent factors for predicting mortality within one year. The one-year shunt patency rate in TIPS was 80.2%, and none of the PIs exhibited significant validity for its prediction. CONCLUSION: The New Clichy score could independently predict the one-year survival in Egyptian BCS patients.

Characteristics of hepatocellular carcinoma in Egyptian patients with primary Budd-Chiari syndrome.

BACKGROUND & AIM: Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aimed at analyzing characteristics and factors associated with development of hepatocellular carcinoma (HCC) in patients with primary BCS. METHODS: A total of 348 Egyptian BCS patients were included. They were presented to the Budd-Chiari Study Group of Ain Shams University Hospital. BCS was confirmed using abdominal Doppler US. Abdominal magnetic resonance imaging (MRI), MR venography and/or multislice computed tomography (CT) were performed to confirm all diagnoses and to assess vascular anatomy. Hepatic focal lesions detected during the study period (2005-2011) were evaluated using serum alpha foetoprotein (AFP) level, imaging features and histopathological examination. RESULTS: Diagnosis of HCC was confirmed in 15/348 patients (4.3%). Imaging studies showed that 60% had multiple hepatic focal lesions ranging from 2 to 6.3 cm in size. The median level of serum AFP in BCS with HCC was 300 ng/mL vs 11 ng/mL in those without HCC (P<.001). A cut-off level >24.5 ng/mL for serum AFP showed sensitivity 80%, specificity 97.9%, positive predictive value 93.18% and negative predictive value 99.1% for detection of HCC in BCS patients. Male gender, older age, cigarette smoking, serum AFP (>24.5 ng/mL) and shrunken liver by ultrasonography were independent factors associated with HCC development. CONCLUSION: Male gender, older age and cigarette smoking are independent risk factors for development of HCC in BCS. Serum AFP is a good screening test in BCS.

Role of low-molecular-weight heparins in prevention of thromboembolic complication after transarterial chemoembolization in hepatocellular carcinoma.

BACKGROUND AND AIM: Portal vein thrombosis (PVT) is a common complication after transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC). This is the first clinical study to evaluate the role of low-molecular-weight heparins (LMWHs) with TACE in HCC for the prevention of thromboembolism complications (PVT). PATIENTS AND METHODS: This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department, Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals starting from April 2015. Patients were divided in two groups: group I included 20 patients with HCC treated by TACE only. Group II included 20 patients with HCC treated by TACE and an adjuvant dose of LMWH. Radiological assessment of efficacy of procedure and detection of PVT as a complication was performed using ultrasound abdomen and pelvis and triphasic spiral computed tomography with contrast. RESULTS: This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department of Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals. The incidence of PVT after TACE was higher in group I than group II, with seven cases in group I and only one case in group II. CONCLUSION: LMWH with TACE in HCC is strongly recommended for prevention of thromboembolism complications (PVT). However, larger randomized-controlled studies are needed to confirm these obvious findings.

Transvaginal cervical length measurement at 22- to 26-week pregnancy in prediction of preterm births in twin pregnancies.

OBJECTIVE: To investigate the predictive role of transvaginal ultrasonographic measurement of cervical length (CL) at 22-26 weeks of gestation in determining preterm deliveries in twin pregnancies. METHODS: The study included 150 twin pregnancies. CL was measured by transvaginal ultrasonography at 22-26 weeks. Signs of preterm labor, ruptured membranes, vaginal bleeding, patients with systemic disease, and cervical incompetencies were excluded. The patients had monthly digital cervical examinations but no routine TVCL ultrasound examinations. The primary outcome was spontaneous preterm birth at before 37 weeks of gestation. RESULTS: Ninety-two percent of twin pregnancies delivered by cesarean section and 16% babies had a neonatal intensive care unit requisitioned. Ninety-two patients were delivered in smaller than 37 gestational weeks and the mean CL measurement (CLM) was <37.64 ± 6.23 mm. According to the ROC curve analysis, CLM was found to be a discriminating parameter in patients. The area under the curve, cutoff values, sensitivity, and specificity were 0.794, 34.95, and 70-80%; respectively (p = 0.029). CONCLUSION: In women with twin pregnancy, the risk of preterm birth can be evaluated using the ultrasonographic measurement of CL at 22-26 weeks of gestation.

Comparison of single-session transarterial chemoembolization combined with microwave ablation or radiofrequency ablation in the treatment of hepatocellular carcinoma: a randomized-controlled study.

BACKGROUND: Globally, hepatocellular carcinoma (HCC) is the third most frequent cause of cancer-related mortality. In recent years, transarterial chemoembolization, radiofrequency ablation, and microwave ablation (MWA) have been accepted as treatment modalities for patients with surgically unresectable HCC. AIM OF THIS WORK: This study aimed to compare combination treatment with radiofrequency or MWA, followed by transarterial chemoembolization, and performed in a single session. PATIENTS AND METHODS: This study was carried out on 50 patients with nonresectable single-lesion HCC, who were divided into three groups: group A included 20 patients treated by transcatheter hepatic arterial chemoembolization, group B included 20 patients treated by radiofrequency thermal ablation combined with transcatheter arterial chemoembolization, and group C included 10 patients treated by MWA combined with transcatheter arterial chemoembolization. The combined treatments were performed in a single session, with the ablation performed first. RESULTS: The total success rate in this study at 6 months following the procedure was 50% in group A, 70% in group B, and 80% in group C. Major complications were recorded in 22% of patients. The number of complications was the highest in group A. CONCLUSION: Combined ablation with chemoembolization is superior in the treatment of nonresectable single masses larger than 4 cm. Transcatheter arterial chemoembolization and ablation can be performed safely and successfully during a single session, which has not been found to decrease the response rates to treatment. Combined treatment with MWA is more effective in terms of tumor response, and results in the same complication rate as with radiofrequency, but less than chemoembolization alone.

Comparison of letrozole versus tamoxifen effects in clomiphen citrate resistant women with polycystic ovarian syndrome.

BACKGROUND: The objective of this prospective randomized study was to make a comparison between the effects of letrozole and tamoxifen (TMX) in ovulation induction in clomiphene (CC)-resistant women with polycystic ovarian syndrome (PCOS). METHODS: The study comprised a total of 60 infertile women (180 cycles) with CCresistant PCOS selected from the clinics affiliated to the Department of Obstetrics and Gynecology of Tanta University. Patients were randomized to treatment with 2.5 mg of letrozole daily (30 patients, 90 cycles) or 20 mg of TMX daily (30 patients, 90 cycles) for 5 days from day 5 of menses and 10000 IU hCG when mature follicles become =18 mm in diameter. The chi-square and t-test were used for comparing two groups and p < 0.05 was considered significant. RESULTS: The total number of follicles (=18 mm) in the letrozole group was more than TMX group. The endometrial thickness at the time of hCG administration was significantly higher (p < 0.05, at 95% CI) in the letrozole group than that of TMX group (10.2±0.7 vs. 9.1±0.2 mm). Ovulation occurred in 23.33% of cycles in the letrozole group and in 8.89% in the TMX group, whereas pregnancy occurred in 5.56% of the letrozole group and 2.22% of the TMX group. CONCLUSION: Both letrozole and TMX should be considered as optional therapies for CC-resistant women. In addition, letrozole was superior to TMX in achieving a higher pregnancy and ovulation rate and also lesser side effects in comparison to tamoxifen.

Strategies for Pituitary Down-regulation to Optimize IVF/ICSI Outcome in Poor Ovarian Responders.

The ovarian stimulation of poor responders still remains a challenging task for clinicians. There are numerous strategies that have been suggested to improve the outcome in poor responders but there is still no one pituitary down-regulation protocol that best suits all women with such condition. Traditional GnRH agonist flare and long luteal phase protocols do not appear to be advantageous. Reduction of GnRH agonist doses, "stop" protocols, and microdose GnRH agonist flare regimes all appear to improve outcomes, although the proportional benefit of one approach over another has not been convincingly established. GnRH antagonists improve outcomes in this patient population, although, in general, pregnancy rates appear to be lower in comparison to microdose GnRH agonist flare regimes.

Low-dose vaginal misoprostol in the management of intrauterine fetal death.

OBJECTIVES: To assess the effectiveness and side effects of vaginal misoprostol (Vagiprost® tablet) termination of second and third trimester pregnancy complicated with intrauterine fetal death (IUFD). DESIGN: A prospective observational cohort study. SETTING: Tanta University Hospital. Patients. The study carried out on 324 women with fetal demise in the second and third trimesters, from January 2008 to December 2009. INTERVENTION: All patients were subjected to history taking, physical examination, and the Bishop Scoring. Application of 25 µg misoprostol in the posterior fornix of the vagina, this was repeated every 4 h over 24 h. We assessed the adverse effects, progress, and outcomes. RESULTS: The success rate was 90% and 45% in women in the third and second trimesters, respectively. The mean induction-termination interval was 8.95 ± 2.63 and 15.3 ± 5.37 h for women in the third and second trimesters, respectively. The induction termination interval correlated negatively with the duration of gestation. Approximately, 90% of second trimester and 55% of third trimester women required oxytocin augmentation. The mean value of total required dose of misoprostol was 166.3 ± 7.5 and 120 ± 28.79 µg for women in the second and third trimesters, respectively. CONCLUSION: Vagiprost appears to be a safe, effective, practical, and inexpensive method for termination of third trimester pregnancy complicated with of IUFD.

Maternal serum inhibin-A for predicting preeclampsia.

OBJECTIVE: To evaluate the use of late first trimester maternal serum inhibin-A concentrations in prediction of preeclampsia. DESIGN: Prospective study. SETTING: Tanta University Hospital. METHODS: All cases (327) were subjected to complete history taking, clinical and ultrasound examination, CBC, liver function tests, estimation of 24 h urine protein and venous blood samples were taken during the late first trimester for estimation of serum level of inhibin-A. RESULTS: First trimester maternal serum inhibin-A concentrations were significantly higher in women who subsequently develop preeclampsia than the corresponding values in healthy matched control pregnant women. CONCLUSIONS: Measurement of inhibin-A during late first trimester of pregnancy can be useful in the prediction of preeclampsia.

Prediction and diagnosis of poor ovarian response: the dilemma.

Failure to respond adequately to standard protocols and to recruit adequate follicles is called 'poor response'. This results in decreased oocyte production, cycle cancellation and, overall, is associated with a significantly diminished probability of pregnancy. It has been shown that ovarian reserve tests, such as basal FSH, antimullarian hormone (AMH), inhibin B, basal estradiol, antral follicular count (AFC), ovarian volume, ovarian vascular flow, ovarian biopsy and multivariate prediction models, have little clinical value in the prediction of a poor response. Although recent evidence points that AMH and AFC may be better than other testsbut they still continue to be used and form the basis for the exclusion of women from fertility treatments. Despite the rigorous efforts made in this regard, a test that could reliably predict poor ovarian response in all clients that undergo IVF is currently lacking.

Cytogenetic aberrations and the development of uterine leiomyomata.

This study was conducted to define the cytogenetically critical regions of uterine leiomyomata, hoping to demonstrate the presence of possible genes involved in their evolution. It was carried out on 25 randomly selected uterine leiomyoma specimens obtained from 16 patients during hysterectomy or myomectomy operations. Successful tissue culture and karyotyping were performed in 19 specimens. There was no correlation between patient age, gravidity, or presenting symptom and the presence of chromosomal abnormality. A significant correlation was found between short culture turnaround time and the occurrence of chromosomal abnormality. Abnormal clonal karyotypes were present in 6 specimens, non-clonal abnormalities in 4 specimens and normal karyotypes were found in 9 specimens. Myomas with cross section >4 cm showed an increased incidence of abnormal karyotypes and a statistically significant higher incidence of clonal abnormalities. On the other hand, submucous myomas presented fewer clonal abnormalities than did intramural or subserosal myomas. Clonal chromosomal abnormalities involved 5 different chromosomes (2, 7, 8, 12, 22), which indicate genetic heterogeneity of such benign tumors and the need of molecular cytogenetic studies or molecular studies to characterize possible candidate genes at specific chromosomal breakpoints.