Systematic review and meta-analysis of endovascular treatment for acute mesenteric ischaemia

Introduction Acute mesenteric ischaemia is associated with a significant morbidity and mortality. Endovascular techniques have emerged as a viable alternative treatment option to conventional surgery. Our objective was to conduct a systematic review of the literature and perform a meta-analysis of reported outcomes. Methods Our review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards and the protocol was registered in PROSPERO (CRD42016035667). We searched electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic lists of relevant articles to identify studies reporting outcomes of endovascular treatment for acute mesenteric ischaemia of embolic or thrombotic aetiology. We defined 30-day or in-hospital mortality and bowel resection as the primary outcome measures. We used the Newcastle-Ottawa scale to assess the methodological quality of observational studies. We calculated combined overall effect sizes using random effects models; results are reported as the odds ratio and 95% confidence interval. Results We identified 19 observational studies reporting on a total of 3362 patients undergoing endovascular treatment for acute mesenteric ischaemia. The pooled estimate of peri-interventional mortality was 0.245 (95% confidence interval 0.197-0.299), that of the requirement for bowel resection 0.326 (95% confidence interval 0.229-0.439), and the pooled estimate for acute kidney injury was 0.132 (95% confidence interval 0.082-0.204). Eight studies reported comparative outcomes of endovascular versus surgical treatment for acute mesenteric ischaemia (endovascular group, 3187 patients; surgical group, 4998 patients). Endovascular therapy was associated with a significantly lower risk of 30-day mortality (odds ratio 0.45, 95% confidence interval 0.30-0.67, P = 0.0001), bowel resection (odds ratio 0.45, 95% confidence interval 0.34-0.59, P < 0.00001) and acute renal failure (odds ratio 0.58, 95% confidence interval 0.49-0.68, P < 0.00001). No differences were identified in septic complications or the development of short bowel syndrome. Conclusion Endovascular treatment for acute mesenteric ischaemia is associated with a considerable mortality and requirement of bowel resection. However, endovascular therapy confers improved outcomes compared to conventional surgery, as indicated be reduced mortality, risk of bowel resection and acute renal failure. An endovascular-first approach should be considered in patients presenting with acute mesenteric ischaemia.

Fibrosis in Chronic Hepatitis C: Correlation between Immunohistochemically-Assessed Virus Load with Steatosis and Cellular Iron Content

AIM

We aimed study impact of hepatocytic viral load, steatosis, and iron load on fibrosis in chronic hepatitis C and role of VEGF and VEGFR overexpression in cirrhotic cases in evolving HCC.

MATERIAL AND METHODS

Total of 120 cases were included from TBRI and Beaujon Hospital as chronic hepatitis C (CHC), post-hepatitis C cirrhosis, and HCC. Cases of CHC were stained for Sirius red, Prussian blue and immunohistochemically (IHC) for HCV-NS3/NS4. HCC were stained IHC for VEGF and by FISH.

RESULTS

Stage of fibrosis was significantly correlated with inflammation in CHC (P < 0.01). Noticed iron load did not correlate with fibrosis. Steatosis was associated with higher inflammation and fibrosis. The cellular viral load did not correlate with inflammation, steatosis or fibrosis. VEGF by IHC was significantly higher in cases of HCC when compared to cirrhotic group (P < 0.001). Amplification of VEGFR2 was confirmed in 40% of cases of HCC. Scoring of VEGF by IHC was the good indicator of VEGFR2 amplification by FISH (P < 0.005).

CONCLUSION

Grade of inflammation is the factor affecting fibrosis in CHC. The degree of liver damage is not related to cellular viral load or iron load. Steatosis is associated with higher inflammation and fibrosis. VEGF by IHC is correlated with overexpression of VEGFR2 by FISH.

Her2/neu Protein Expression and Oncogene Amplification in Gastric Carcinoma with Clinico-Pathological Correlation in Egyptian Patients

AIM

Amplification of the Her2/neu gene and overexpression of the Her2/neu protein in gastric carcinoma (GC) is a golden criterion for target therapy with trastuzumab (Herceptin). We aim to evaluate the immunohistochemical protein expression and amplification of the oncogene Her2/neu by FISH technique in the epithelial gastric carcinoma and to compare their association with different clinicopathologic parameters aiming at identifying positive cases that may benefit from targeted therapy.

MATERIALS AND METHODS

This study was done on eighty-five tumour tissue samples from patients with GC as well as thirty non-malignant lesions (Gastritis, intestinal metaplasia, adenoma with low-grade dysplasia, adenoma with high-grade dysplasia). All were immunohistochemically stained with Her2/neu antibody.

RESULTS

All equivocal and some selected GC cases were submitted for FISH technique to detect Her2/neu gene amplification. By immunohistochemistry twenty-three cases (27%) were defined as positive for Her2/neu gene amplification and/or protein overexpression. The levels of Her2/neu positive (3+), Her2/neu equivocal (2+) and Her2/neu negative (1+/0) were measurable in 14.2%, 32.9% and 52.9% of the samples, respectively. FISH showed that Her2/neu gene was amplified in 22 cases, 10 Her2/neu positive (3+), 11 (39.3%) Her2/neu equivocal (2+) and 1 Her2/neu negative (1+) cases with IHC staining those who can benefit from anti Her2/neu target therapy. Her2/neu was overexpressed positivity (3+) more in intestinal type and mixed carcinoma, and moderately differentiated tumours. None of gastritis, intestinal metaplasia or adenoma with low-grade dysplasia cases showed positivity for Her2/neu (3+). The Her2/neu positivity (3+) was associated with both adenocarcinoma cases and high-grade dysplasia (P = 0.002).

CONCLUSIONS

The results highlight the necessity of FISH test for further categorization when gastric cancer cases are equivocal (2+) by IHC to determine eligibility for the targeted therapy. Stepwise increase in the expression of Her2/neu was seen in low-grade dysplasia, high-grade dysplasia and carcinoma cases implying its role in cancer evolution. Overexpression of Her 2/neu in GC patients can be promising in selecting those who can get benefit from anti-Her2/neu target therapy.

Penile fracture: surgical repair and late effects on erectile function

INTRODUCTION

Penile fracture is described as a traumatic rupture of the tunica albuginea because of blunt injury of an erect penis.

AIM

To assess the etiology, treatment maneuvers, and late effects of penile fractures treated by surgical repair.

METHODS

Thirty-three patients diagnosed provisionally as having fractured penises. Thirty patients were managed by immediate surgical repair and three by delayed repair.

MAIN OUTCOME MEASURES

International Index of Erectile Function-5 for married cases and Single-question Self-report of Erectile Dysfunction questionnaires and recording complications after 2, 3, and 6 months.

RESULTS

The most common cause of fracture penis is self-inflicted acute bending (54.5%). The tear was visualized by ultrasound in 20/30 patients (66.7%) mostly on the right proximal third of the penis. All tears were unilateral with mean length 2.0 +/- 0.9 cm (range 0.5-4 cm). All patients who completed their follow-up after 6 months (N = 24) were able to achieve an adequate erection except two married cases who felt mild erectile dysfunction. Penile nodules were the most common postoperative complication (41.7%) after 6 months' follow-up. Patients treated with immediate or delayed repair had comparable complications.

CONCLUSIONS

Fracture penis is not uncommon as an emergency that must be repaired either immediately or delayed. Clinical diagnosis is more predictive than ultrasound in diagnosis and determining the site of the tear. Ultrasound may be of value in patients where there is clinical doubt.

The disposition of theophylline in camels after intravenous administration

The pharmacokinetics of theophylline were determined after an intravenous (i.v.) dose of 2.36 mg/kg in six camels and 4.72 mg/kg body weight in three camels. The data obtained (median and range) for the low and high dose, respectively, were as follows: the distribution half-lives (t1/2 alpha) were 1.37 (0.64-3.25) and 2.66 (0.83-3.5) h, the elimination half-lives (t1/2 beta) were 11.8 (8.25-14.9) and 10.4 (10.0-13.5) h, the steady state volumes of distribution (Vss) were 0.88 (0.62-1.54) and 0.76 (0.63-0.76) L/kg, volumes of the central compartment (Vc) were 0.41 (0.35-0.63) and 0.51 (0.36-0.52) L/kg, total body clearances (Clt) were 62.3 (39.4-97.0) and 50.2 (47.7-67.4) mL/h.kg body weight and renal clearance (Vr) for the low dose was 0.6 (0.42-0.96) mL/h.kg body weight. There was no significant difference in the pharmacokinetic parameters between the two doses. Theophylline protein binding at a concentration of 5 micrograms/mL was 32.2 +/- 3.3%. Caffeine was identified as a theophylline metabolite but its concentration in serum and urine was small. Based on the pharmacokinetic values obtained in this study, a dosage of 7.5 mg/kg body weight administered by i.v. injection at 12 h intervals can be recommended. This dosing regimen should achieve an average steady state serum concentration of 10 micrograms/mL with peak serum concentration not exceeding 15 micrograms/mL.

The pharmacokinetics of promethazine after intravenous administration in camels

The pharmacokinetics of promethazine were determined in seven camels (Camelus dromedarius) after an intravenous dose of 0.5 mg kg body weight.-1 The data obtained (median and range) were as follows: the elimination half-life (t1/2 beta) was 5.62 (2.84-6.51) h; the steady state volume of distribution (Vdss) was 8.90 (7.10-12.00) L kg-1, total body clearance (CT) was 24.5 (17.22-33.65) ml kg-1 min-1 and renal clearance (Clr) was 4.81 (1.97-5.48) ml kg-1 min-1.

Pharmacokinetics of tolfenamic acid and its detection time in urine after intravenous administration of the drug in camels (Camelus dromedarius)

OBJECTIVE

To document tolfenamic acid disposition variables, identify its major phase-1 metabolite and fragmentation pattern, and establish detection time in urine after single IV bolus administration to make recommendations on avoiding violative residues in racing camels.

ANIMALS

7 healthy camels (6 males, 1 female), 8 to 11 years old and weighing from 300 to 480 kg.

PROCEDURE

Blood samples were collected at 0, 5, 10, 15, 30, 45, and 60 minutes and at 1.5, 2, 2.5, 3, 3.5, 4, 5, 6, 8, 12, 13, 14, 15, and 16 hours after IV administration of tolfenamic acid (2.0 mg/kg of body weight). Urine samples were collected daily for 14 days after drug administration. Serum tolfenamic acid concentration was measured; limit of quantification was 50 ng/ml. A metabolite of tolfenamic acid in urine was isolated and identified, and its major fragmentation pattern was verified. Screening for tolfenamic acid and its metabolite in urine was performed.

RESULTS

Mean +/- SEM tolfenamic acid elimination half-life was 5.76+/-0.26 hours. Total body clearance was 0.109+/-0.011 L/kg/h, and steady-state volume of distribution was 0.68+/-0.06 L/kg. Detection time for tolfenamic acid and its hydroxylated metabolite in urine after IV administration of a dose of 2.0 mg/kg was 5 and 7 days, respectively.

CONCLUSIONS

Camels eliminate tolfenamic acid mainly via metabolism more slowly than do cattle. The extrapolated dose regimen from cattle to camels appears inappropriate. Veterinarians are advised not to use tolfenamic acid in camels for at least 8 days prior to racing.

Effect of octreotide on the pathology of hepatic schistosomiasis

In clinical practice, octreotide (CAS 83150-76-9) has its greatest impact in the management of bleeding varices. The present work is the first one which was undertaken to investigate the possible use of octreotide as an antifibrotic agent and to study its effect on hepatic vasculature in Schistosoma mansoni infection. The material of this investigation consisted of two groups of albino mice (A, B), subdivided each into normal control, infected control, subgroups treated with octreotide, praziquantel (CAS 55268-74-1), and a combination of octreotide and praziquantel. Groups A and B were sacrificed at the 8th week and the 18th week post infection, respectively. By analysis of the obtained results, octreotide induced a reduction of the portal pressure, the weight of the spleen and the liver, the liver egg load (number of eggs) granuloma size and cellularity, and of the degree of hepatic fibrosis quantified by serum N-terminal peptide of type III procollagen in serum, serum laminin and tissue collagen using a Picrosirius red dye assay. Moreover, the biochemical state of hepatocytes has been improved. The subgroups treated with octreotide in association with praziquantel revealed better results than the subgroups treated with praziquantel alone. These obtained data were analysed in terms of histological extent of liver fibrosis in sections stained with Masson trichrome and sirius red, hepatocytic and sinusoidal changes at an ultrastructural level and by immunohistochemical demarcation of endothelial cells of blood vessels through the determination of factor VIII-related antigen. The promising results detected in this study may encourage to further investigate the positive findings of this drug with the intention of its possible application on a clinical level.

Identification of a flunixin metabolite in camel by gas chromatography-mass spectrometry

A flunixin metabolite, a hydroxylated product, has been identified in camel urine and plasma samples using gas chromatography-mass spectrometry (GC-MS) and GC-MS-MS in the electron impact and chemical ionization modes. Its major fragmentation pattern has been verified by GC-MS-MS in daughter ion and parent ion scan modes. The method could detect flunixin and its metabolite in camel urine after a single intravenous dose of 2.2 mg of flunixin/kg body weight for 96 and 48 h, respectively, which increases the reliability of antidoping control analysis.

Octreotide decreases connective tissue formation and improves vascular changes associated with hepatic schistosomiasis

In clinical practice, Octreotide has its greatest impact in the management of bleeding varices. The present work is the first one which was undertaken to investigate the possible use of Octreotide as an antifibrotic agent and to study its effect on hepatic vasculature in Schistosoma mansoni infection. The material of this investigation consisted of two groups of albino mice (A&B) subdivided each, into normal control, infected control, Octreotide treated, Praziquantel treated and Octreotide with Praziquantel treated subgroups. Groups A & B were sacrificed at the 8th week and the 18th week post infection respectively. By analysis of the obtained results, Octreotide has induced reduction of the portal pressure, the weight of the spleen and the liver, the number of liver egg load, granuloma size and cellularity, and of the degree of hepatic fibrosis quantified by serum PIIINP, serum laminin and tissue collagen using sirius red dye assay. Moreover, the biochemical state of hepatocytes has been improved. The subgroups treated with Octreotide in association with Praziquantel revealed better results than the subgroups treated with Praziquantel alone. Data were analysed in terms of histological extent of liver fibrosis in sections stained with Masson trichrome and sirius red, hepatocytic and sinusoidal changes at an ultrastuctural level and by immunohistochemical demarcation of endothelial cells of blood vessels through the determination of factor VIII related antigen. The promising results detected in this study may encourage to further investigate the positive findings of this drug with the intention of its possible application on a clinical level.

The activity of mixed function oxidases, estimated by in vivo antipyrine clearance, is similar in horses and camels

The activity of hepatic mixed function oxidases was compared in horses and camels (Camelus dromedarius) by studying the pharmacokinetics of antipyrine in seven camels and five horses following intravenous administration of a single dose of antipyrine (25 mg/kg). The data obtained (mean +/- SEM and median in brackets) in camels and horses, respectively, were as follows: the elimination half-lives were 3.25 +/- 0.23 (3.19) and 3.09 +/- 0.25 (2.90) hr; the apparent volumes of distribution (area method) were 0.691 +/- 0.045 (0.648) and 0.642 +/- 0.034 (0.676) l/kg; the volumes of distribution at steady state were 0.659 +/- 0.040 (0.607) and 0.620 +/- 0.030 (0.653) l/kg; the volume of the central compartment of the two-compartment pharmacokinetic model were 0.386 +/- 0.0523 (0.349) and 0.298 +/- 0.05 (0.308) l/kg; total body clearances were 0.148 +/- 0.008 (0.158) and 0.145 +/- 0.007 (0.147) l/kg/hr; the areas under the curves to infinity were 171.0 +/- 9 (165) and 175 +/- 8.0 (170) micrograms.ml.hr. There was no statistical significance in any parameter between camels and horses which suggests that the activity of hepatic mixed function oxidases is similar in horses and camels.

Pharmacokinetics of tobramycin in the camel

The pharmacokinetics of tobramycin were determined in six healthy camels (Camelus dromedarius) following the intravenous (i.v.) and intramuscular (i.m.) administration of single doses of tobramycin sulphate (40 mg/ml). The half-life to tobramycin was 189 +/- 21 min and the mean residence time was 254 +/- 26 min. The apparent volume of distribution (area method) was 245 +/- 21 ml/kg, while volume of the central compartment of the two-compartment pharmacokinetic model was 110 +/- 12 ml/kg. The clearance (systemic) of tobramycin was 0.90 +/- 0.10 ml/min/kg. Values of the pharmacokinetic parameters suggest that glomerular filtration rate is lower in camels than in other ruminant species, horses, dogs and cats. Following i.m. administration of the dose (1.0 mg/kg), the drug was rapidly absorbed with peak serum concentration of 3.32 +/- 0.59 micrograms/ml at 20-30 min; the absorption half-life was 3.9 +/- 0.9 min. The systemic availability of tobramycin was 90.7 +/- 14.4%. The apparent half-life was 201 +/- 40 min, which was not significantly longer than the half-life following i.v. administration of the drug. Based on the pharmacokinetic values obtained in this study, a dosing rate of 2.5 mg/kg administered by i.m. injection at 12-h intervals can be recommended. This dosage regimen should achieve an average steady state serum concentration of 4 micrograms/ml with peak serum concentration approaching, but not exceeding, 10 micrograms/ml.

Schistosomal orchitis simulating malignancy

We report a case of schistosomal orchitis simulating malignancy. The patient presented with a unilateral hydrocele, testicular enlargement and loss of testicular sensation. Orchiectomy was performed because of suspected malignancy. Tissue diagnosis was schistosomiasis. The incidence, pathogenesis and pathology of genital schistosomiasis are discussed, and the literature is reviewed.