A pilot study of the value of a stool color card as a diagnostic tool for extrahepatic biliary atresia at a single tertiary referral center in a low/middle income country.

BACKGROUND AND STUDY AIMS: Biliary atresia (BA) is a major cause of hepatic failure and consequent liver transplantation in pediatrics. If BA is not diagnosed early and the proper surgical intervention is not performed before the age of 3 months, the survival of the affected infant is significantly reduced. In 1994, a stool color card (SCC) for early detection of BA was developed and used in Japan, a country where the parents' socioeconomic and education levels are high. We aimed to assess the value of using the SCC as a screening tool for early diagnosis of BA at a tertiary referral center in Egypt (a low/middle-income country). PATIENTS AND METHODS: This prospective study enrolled 108 infants (56 females) aged 1 day to 4 months who presented with cholestasis to the Hepatology Unit of Cairo University Children's Hospital from January 2018 to August 2019. In most of our patients, the mothers were the main caregivers and the parents' socioeconomic and education levels were generally modest or low. We utilized the SCC courtesy of the Perinatal Services BC (Vancouver, Canada) with an Arabic translation. This SCC contains nine colored stool photos: the first six are ranked as abnormal colors and the last three are ranked as normal. RESULTS: We found that almost all referring physicians were unfamiliar with or unaware of the SCC concept. Twenty-six of our babies' mothers were illiterate and 36 had not completed their primary school education. In spite of this low education level, 43 mothers of babies who were finally confirmed to have BA correctly matched a stool color of BA on the SCC with their babies' stools, and 56 mothers of babies who were finally confirmed not to have BA correctly matched a stool color not of BA with their babies' stools. Only nine mothers made a wrong match. Therefore, the overall "lay" mothers' sensitivity and specificity in diagnosis of BA using the SCC were 93.48% (95% confidence interval [CI] 82.1%-98.63%) and 90.32% (95% CI 80.12%-96.37%), respectively. CONCLUSION: To the best of our knowledge, this is the first study reporting the use of the SCC (with an Arabic translation) in a low/middle-income country. Despite the referring physicians' unfamiliarity with the SCC and the mothers' relatively low education level at our center; SCC proved to be a simple, efficient, highly sensitive, specific, and applicable method for early diagnosis of BA. Therefore, SCC screening might increase mothers (as well as physicians) awareness of BA, and we recommend that it be more publicized and used as a mass neonatal screening tool in low/middle-income countries such as Egypt.

An Initial Investigation of Do Not Resuscitate Acceptance in Egypt.

BACKGROUND: The aim of this work was to obtain objective data on the extent of knowledge and attitudes of the do not resuscitate (DNR) concept in an Egyptian urban setting. METHODS: This survey was conducted in Cairo, Egypt, using a structured questionnaire including 23 questions. Questions and questionnaire were developed from literature on DNR in the region and from pilot testing. RESULTS: A total of 461 persons participated. In all, 48 participants (10.4%, 95% confidence interval [CI]: 7.8-13.7) agreed on the concept of DNR, 226 (49%, 95% CI: 36.1-45.2) stated that it depends on the patient condition, and 187 (40.5%, 95% CI: 44.4-53.7) rejected DNR. Combining the first 2 categories, agree and depends on patient condition, over 60% of the respondents in effect supported DNR. Family members (35.6%, 95% CI: 31.4-40.3) and attending physicians (43.3%, 95% CI: 30.1-39.0) were selected over religious leaders (21%, 95% CI: 17.5-25.2) and representatives from state institutions (4.6%, 95% CI: 2.9-7.0) as to who should have authority for making a DNR decisions. DISCUSSION: These and additional results provide objective evidence that DNR will not be rejected outright in Egypt. More formal surveys are justified and will provide needed guidance for implementing DNR and related end-of-life medical care in Egypt.

Circulating IL-6, IL-17 and vitamin D in hepatocellular carcinoma: potential biomarkers for a more favorable prognosis?

Hepatitis C virus (HCV) infects primarily hepatocytes, leads to development of fibrosis and/or cirrhosis of the liver and is a significant factor for developing hepatocellular carcinoma (HCC). Evidence indicates that liver fibrosis contains uncontrolled inflammation as a part of its etiology. Normal cell-mediated immunity plays a central role in the mechanisms involved in viral clearance/persistence in the liver. In this context, cytokines modulate the immune system and exert direct anti-viral activity. To this end, this study investigated potential associations of serum IL-17 and IL-6 with exacerbation of hepatic damage in chronic HCV patients to determine their utility as prognostic markers for potential development of HCC. Chronic HCV-patients were recruited, divided into groups according to degree of liver damage, i.e. patients with peri-hepatic fibrosis, hepatic cirrhosis, or HCC, and had their blood collected for analysis of liver function and serum IL-6 and IL-17 levels. Interestingly, increases in serum IL-17 levels in the study groups were associated with aggravation of the clinical state from HCV to cirrhosis and then to HCC. Serum IL-6 levels followed a similar pattern. The association of both cytokines with progressive exacerbation of the initial HCV-induced liver damage was further confirmed by correlation analysis that revealed positive correlations between HCV RNA titer and IL-17 (+0.951, p < 0.05) and IL-6 (+0.85, p < 0.05). A receiver operating characteristics (ROC) analysis revealed their beneficial addition as promising biomarkers for a better prognostic profile of HCC. Interestingly, a significant progressive decline in the active vitamin D status was noted in all three clinical states, and these too were associated with progressive liver disease. This study confirms the necessity of adding screening for IL-6 and IL-17 and vitamin D to that of the classic marker AFP for patients with HCV and cirrhosis to hopefully permit clinicians to initiate measures that ultimately might mitigate/delay development of HCC in these infected patients.

Correlation between maternal milk and infant serum levels of chlorinated pesticides (CP) and the impact of elevated CP on bleeding tendency and immune status in some infants in Egypt.

Chlorinated pesticides (CP) are environmentally persistent pollutants that (prenatally through the placenta and post-natally via breastfeeding) are transferred from mother to child. Considering the significant bleeding tendency noted in infants of CP-intoxicated mothers in Egypt, this study aimed to investigate any correlation between levels of these xenobiotics in mothers' milk and bleeding tendencies of their infants, as well as a possible role of any related immunosuppression in this phenomenon. This study examined 180 newborns presenting with altered bleeding tendencies and their mothers, and 180 normal newborns and their mothers (serving as a controls), selected from the Breastfeeding Unit, Center for Social and Preventive Medicine at the Cairo University Pediatric Hospital. Chlorinated pesticides (e.g., hexachlorocyclohexane, DDT, hepta-chloroepoxide, α- and ß-endosulfan, aldrin, endrin, dieldrin) levels and their derivatives were measured in mothers' milk as well as in serum of neonates using gas chromatography/high resolution mass spectrometry. To link bleeding tendency with lactational intoxication of neonates by CP, newborns' blood was assessed for: platelet count, bleeding and prothrombin time, liver enzymes, Vitamin K, TNFα, and IL-10. Breast milk CP levels were associated with a higher incidence of bleeding in infants. Interference with the coagulation cascade was supported by changes in prothrombin time (prolonged), platelet counts (decreased), liver enzymes (increased), and serum vitamin K concentrations (decreased). Moreover, the significant decrease in WBC count and lymphocytes added to depressed cytokine secretion, i.e., TNFα and IL-10, suggested an organochlorine-induced immunotoxicity in infants developmentally exposed to the agents. We conclude that maternal transfer of CP, via breastfeeding or across the placenta, was sufficient to achieve similar CP levels in the serum of their infants; this correlated with a manifesting of altered bleeding tendencies and perturbed cytokine biology in these infants.

Methylxanthines and fibrocystic breast disease: a study of correlations.

Daily methylxanthine ingestion from drug and dietary sources was studied by means of questionnaires from a sample of 102 women who visited the office of a radiologist for xeromammograms. The mammograms were used to measure the level of fibrocystic breast disease. Fibrocystic breast disease was found to be positively correlated with both caffeine and total methylxanthine ingestion. These positive findings are discussed in light of the fact that most recent studies of this link have been negative.

Radiologic aspects of Beck gastric tube in esophageal reconstruction.

Over a 28 month period, 19 patients underwent esophageal reconstruction using the Beck tube fashioned from the greater curvature of the stomach. Eighteen had unresectable carcinoma of the esophagus and one had a benign stricture secondary to reflux esophagitis. The degree of palliation was considered good in 13 cases. The surgical aspects of the Beck gastric tube are described and radiologic features in both uncomplicated and complicated cases are illustrated. Early experience with the procedure is encouraging.

Needle localization of nonpalpable breast lesions.

Mammographic identification of nonpalpable breast lesions suspicious for malignancy constitutes a valid indication for breast biopsy but localization is difficult. Percutaneous needle localization of such lesions, whether clustered microcalcifications, small masses, or focal areas of distorted mammary architecture, is an effective aid to the surgeon. The authors' experience in more than 80 cases is described and the necessity for specimen radiography is emphasized.

One-view mammographic screening?

Repeated mammographic exposures of asymptomatic women in the screening situation has raised questions regarding possible risks. Obtaining only one view, regardless of imaging technique, would approximately halve the exposure. While retrospective analysis indicates further investigation is warranted, one-view mammographic screening is not yet recommended. The lateral view, including the chest wall, would reduce exposure by approximatley 44% but little savings in technologist time could be anticipated.