Rate and determinants of antiviral treatment initiation for patients with HBeAg-negative chronic hepatitis B

Most clinic attenders with chronic hepatitis B (CHB) are serum HBeAg-negative, and a minority will require suppressive antiviral treatment. Expert guidelines propose schedules for the monitoring of untreated patients, but the recommended frequency of patient review does not reflect recognised demographic determinants of HBeAg-negative chronic hepatitis. Also, the impact of patient ethnicity on risk has not been defined. The aim of our study was to determine the rates and determinants of antiviral treatment initiation in a large multi-ethnic cohort of CHB patients attending a single centre. We undertook a retrospective study using entirely electronic sources of patient information. Treatment initiation dates were identified from electronic pharmacy records. Crude and time-dependent statistical analyses were undertaken to identify rate and risk factors for treatment initiation. Treatment was initiated for 232/1256 (18.5%) patients with rates of 23.2% and 33.2% at 5 and 10 years. An increased risk of treatment was associated with male sex (RR 1.803), older age at presentation (RR 1.027 per year increase) and with non-Black ethnicity (RR 1.654). Patient sex, baseline age and ethnicity also determined risk for treatment in the subset of patients with normal serum ALT and low HBV DNA at baseline, though overall treatment rate in this group was low (only 2% per annum). Thus, patient demographics permit risk stratification for treatment initiation and could determine to a significant extent the frequency of review required for untreated HBeAg-negative patients. Black ethnicity is associated with a significant reduction in risk of treatment initiation.

Acute Kidney Injury and Diffuse Pulmonary Hemorrhage Secondary to IgA Nephropathy and Henoch-Schönlein Purpura: A Case Report

IgA nephropathy (IgAN), characterized as immune complex-mediated glomerulonephritis, can occasionally manifest alongside the pulmonary-renal syndrome. Henoch-Schönlein purpura (HSP), an inflammatory condition affecting small vessels through leukocytoclastic vasculitis, exhibits a close association with IgA nephropathy. Nonetheless, HSP's infrequent complications encompass pulmonary hemorrhage. Notably, the onset of pulmonary hemorrhage can rapidly precipitate a grave decline in the patient's health status, carrying a potentially fatal outcome for both disorders. Moreover, the existing literature regarding this specific complication and its management, particularly among adults, remains relatively limited. We report a rare case of a 43-year-old male with acute renal failure secondary to IgA nephropathy associated with HSP, whose condition was further complicated by pulmonary hemorrhage. He was treated with extensive plasmapheresis, pulse steroids, rituximab, and cyclophosphamide, which led to the successful recovery of his kidney function. Recognizing the potential of various presentations can significantly contribute to early diagnosis and prompt treatment, potentially leading to an improved prognosis for these patients.

The Diagnostic and Therapeutic Dilemma of Seronegative Pulmonary Renal Syndrome: A Case Report

Pulmonary renal syndrome (PRS) is a combination of rapid progressive glomerulonephritis (RPGN) and diffuse alveolar hemorrhage (DAH) caused by a variety of immunological and non-immunological etiologies. The difficulty in identifying and reporting seronegative PRS cases could be attributed to the lack of specific immunological markers. Thus, we report a rare case of a 13-year-old boy who was initially diagnosed with idiopathic pauci-immune pulmonary capillaritis (IPIPC). A year later, his condition became complicated, and was referred for further workup. During his hospital stay, he underwent a renal biopsy that showed stage II membranous nephropathy (MN). He tested negative for immunological markers and a diagnosis of seronegative PRS was established. He responded well to the immunosuppression therapy with monthly follow-ups. As in our patient, PRS may manifest as acute renal failure symptoms and non-specific respiratory symptoms that require extensive workup. The severity of the disease is inferred from the renal function at the time of presentation. Management involves immunosuppression and treatment of the underlying condition, with dialysis dependency occurring in a significant percentage of patients and a high mortality rate, especially in critically ill and older patients. In conclusion, timely diagnosis and treatment are essential given the condition's rapid progression and high mortality rate.

Usefulness of combined diffusion tensor imaging, arterial spin labelling and spectroscopic interictal analysis in refractory epilepsy

Background

Epilepsy is a common neurological disorder especially in pediatric population. Patients with non-lesional epilepsy have normal conventional MRI findings. In the recent era of advances in neuroimaging studies, diffusion tensor imaging (DTI) and MR spectroscopy (MRS) can assess the tissue microstructure. Also, arterial spin labeling (ASL) is a noninvasive modality that evaluates cerebral blood flow. Multiple recent publications aimed at use of single or two new modalities in lateralization of epileptogenic focus in epilepsy, but the current study aimed to evaluate the added value of combined (DTI, ASL and MRS) in vivo localization of interactable epilepsy with negative conventional MRI findings.

Results

This prospective case control study was carried out in the period from January 1st, 2022 to October 1st, 2022 after approval of local ethical committee in our institution. Written informed consent was obtained from patients and healthy volunteers who were enrolled in this study. The current study included 46 patients with temporal lobe epilepsy and 20 age- and sex-matched healthy volunteers as a control group. The mean age in the patient group was 22.3 ± 12.2 years, and in the control group, it was 23.8 ± 15.1 years. The highest area under the curve (AUC) was for spectroscopy (0.913), the difference in NAA/Cr showed sensitivity of 94.1% and a specificity of 90%, while NAA/Cho + Cr showed a sensitivity of 91.8% and a specificity of 88%, the difference in rCBF showed an AUC of 0.89, with a cutoff value of 3.815 had a sensitivity of 80.4% and a specificity of 85%. As regards DTI, the changes in DTI parameters show sensitivity of 79.6% and a specificity of 80% in lateralization of the epileptic focus. The difference in FA only showed an AUC of 0.86, with a cutoff value of 0.01 had a sensitivity of 77% and a specificity of 75% and the difference in MD only showed an AUC of 0.771, with a cutoff value of 0.545 had a sensitivity of 67.4% and a specificity of 70%. The diagnostic performance of MRS in terms of the AUC was significantly higher than ASL parameters (difference in NAA/Cr, p = 0.033 and difference in NAA/Cho + Cr, p = 0.044), and MD (p = 0.02). No other statistically significant differences were shown between the studied parameters. When the three methods were combined, all patients’ epileptogenic foci were correctly localized and lateralized.

Conclusions

Combining ASL, DTI and H-MRS provided excellent diagnostic performance in localization and lateralization of the epileptogenic focus. If this combination is not applicable in clinical practice, ASL could provide a considerably accurate and feasible method in this context. The present study supported the value of the new noninvasive MRI techniques in the elaboration of hidden brain pathology.

Effects of ketamine or dexmedetomidine on postoperative cognitive dysfunction after cataract surgery: A randomized controlled trial

Background and Aims

Ketamine and dexmedet omidine have neuroprotective effects that may reduce the occurrence of postoperative cognitive dysfunction (POCD) when they are used by intravenous infusion in geriatric patients scheduled for cataract extraction.

Methods

Ninety patients aged 65-85 years old, ASA physical status II and III, and scheduled for cataract extraction under peribulbar block were randomly distributed equally among three groups: control group, in which patients received normal saline; ketamine group, in which patients received 0.3 mg/kg/h of ketamine; and dexmedetomidine group, in which patients received 0.5 µg/kg/h of dexmedetomidine. Medications were administrated by intravenous infusion and started 10 min before the surgery and continued throughout the duration of surgery. The analysed parameters included the incidence of POCD (primary outcome) through composite score of neuropsychological testing at one week and 3 months after surgery, postoperative pain score, postoperative sedation score, changes in haemodynamic parameters, changes in intraocular pressure, and incidence of complications.

Results

In comparison with control group, ketamine and dexmedetomidine groups exhibited a significant decline in number of patients who developed POCD (P < 0.0001), a decrease in the postoperative pain score 4 h after surgery (P = 0.038), and an increase in the postoperative Ramsay sedation Score (P = 0.0002, 0.0003, and 0.011), without significant changes in the vital parameters, intraocular tension, or incidence of complications. Ketamine and dexmedetomidine groups were comparable.

Conclusion

Intravenous administration of ketamine or dexmedetomidine in elderly patients undergoing cataract surgery under peribulbar anesthesia significantly decreases the incidence of POCD.

Accuracy of noninvasive methods for the diagnosis of liver fibrosis in children with chronic viral hepatitis

BACKGROUND

Liver biopsy is the reference standard for assessing liver fibrosis. Moreover, it is an invasive procedure. Transient elastography (TE) is an accurate, noninvasive method for evaluating liver stiffness as a surrogate of liver fibrosis. The aspartate aminotransferase to platelet ratio index (APRI) and Hyaluronic acid (HA) are noninvasive alternatives to liver biopsy for detecting hepatic fibrosis. This study aimed to identify the accuracy of APRI, HA, and TE concerning liver biopsy in children with chronic viral hepatitis.

METHODS

This cross-sectional study included 50 children, 5-18 years with chronic viral hepatitis B (HBV) or hepatitis C (HCV) who underwent liver biopsy within nine months of laboratory tests, determining APRI & performing TE. Twenty healthy children of age and sex-matching patients were included as a control group for the serum HA levels.

RESULTS

The histopathological findings of the studied cases showed seven cases with (F0) fibrosis, 36 cases with mild (F1,2), two children with moderate (F3,4), and five children with severe (F5,6). The median (IQR) of steatosis was 4 (three had HCV). When correlating TE, APRI, and HA values in all cases with their laboratory data, there was a positive correlation between ALT and APRI values (P-value = 0.000), a positive correlation between AST and HA values (P-value = 0.02), and a negative correlation between stiffness and APRI. The sensitivity of HA, APRI, and TE compared to fibrosis detected by histopathology was 60.5, 65.1, and 60.5%, and their specificity was 71.4, 57.1, and 85.7%, respectively. TE was significantly higher in a group with (moderate to severe) fibrosis.

CONCLUSION

APRI, HA, and TE are good indicators of the presence of fibrosis almost with the same accuracy. TE is the only method to differentiate mild cases from those with significant fibrosis.

Hepatitis B e antigen and e antibody in a multi-ethnic cohort of adult chronic hepatitis B virus patients followed at a single liver unit for a period of 20 years

Hepatitis B virus e antigen (HBeAg) loss and the appearance of antibodies to HBeAg (anti-HBe) are favourable events in the history of chronic hepatitis B virus (CHB) infection. Most CHB patients have the HBeAg/anti-HBe profiles +/- or -/+, and little is published on the derivation or fate of the +/+ and -/- profiles. We have used electronically accessible patient data to study the HBeAg and anti-HBe profiles of a multi-ethnic cohort of adult HBV patients seen at a single centre over a period of more than 20 years. 3594 HBsAg-positive patients were identified and patients with viral coinfection or acute HBV infection were excluded. Cross-sectional and longitudinal analyses of HBeAg/anti-HBe status were undertaken. Compared with White or Black patients, Chinese and Asian patients are more likely to be HBeAg positive during child-bearing years. Patients with +/+ profile are likely to undergo HBeAg loss and seroconversion during relatively short follow-up. Chinese patients have a relatively increased rate of seroconversion. For HBeAg-positive patients, the risk of seroconversion diminishes with advancing age. Despite HBeAg loss, seroconversion is seldom observed after age 60 years. The proportion of HBV patients with -/- increases with age, and most acquire this profile by HBeAg loss but without antecedent seroconversion. -/- patients can lose HBsAg and develop anti-HBs. It was not possible to demonstrate a favourable impact of antiviral treatment on the rate of HBeAg seroconversion.

A UWB-Based Lighter-Than-Air Indoor Robot for User-Centered Interactive Applications

Features such as safety and longer flight times render lighter-than-air robots strong candidates for indoor navigation applications involving people. However, the existing interactive mobility solutions using such robots lack the capability to follow a long-distance user in a relatively larger indoor space. At the same time, the tracking data delivered to these robots are sensitive to uncertainties in indoor environments such as varying intensities of light and electromagnetic field disturbances. Regarding the above shortcomings, we proposed an ultra-wideband (UWB)-based lighter-than-air indoor robot for user-centered interactive applications. We developed the data processing scheme over a robot operating system (ROS) framework to accommodate the robot's integration needs for a user-centered interactive application. In order to explore the user interaction with the robot at a long-distance, the dual interactions (i.e., user footprint following and user intention recognition) were proposed by equipping the user with a hand-held UWB sensor. Finally, experiments were conducted inside a professional arena to validate the robot's pose tracking in which 3D positioning was compared with the 3D laser sensor, and to reveal the applicability of the user-centered autonomous following of the robot according to the dual interactions.

COVID-19’s effects on the Egyptian population’s brain: Could MRI and specialized MR spectroscopic analysis be beneficial?

Background

The recent pandemic of COVID‐19 has thrown the world into chaos due to its high rate of transmissions. Recently viewed neurological manifestations among hospitalized Egyptian patients with COVID‐19 in quarantine centres. Ataxia, disturbed consciousness and convulsions should be further evaluated by MRI and MRS for CNS involvement by SARS‐CoV‐2. How COVID-19 targeting the CNS is still under study, as it is difficult to predict which diagnostic neurological tests will be used to identify high-risk COVID19 patients. MR spectroscopy represents a non-invasive in vivo diagnostic technique for evaluation of metabolic profile of the brain and can reveal important information about the underlying pathologies. Multiple recent reports in the medical literature had confirmed the neurological complications in COVID-19 infection, though few studies has reported the MR spectroscopic findings in these patients. This cross-sectional study aimed to use MRI and MR spectroscopic findings for evaluation of the neurological manifestation of Egyptian COVID‐19 patients.

Results

Ninety-one male and twenty-seven female met the inclusion criteria, with a mean age of 52 years ± 10 (SD) (age range; 12–78 years). The commonest neurological manifestations were disturbed conscious level (82.2%). The most common MRI findings were acute ischemic insult with/without haemorrhagic areas (42.3%), demyelinating patches of altered signal intensity (31.3%). Sixty cases who had haemorrhagic areas were excluded to perform MRS due to contamination of the spectra by blood component. However, the remaining 67 patients had NAA reduction, choline elevation, glutamate/glutamine and lactate elevation in short TE35, with mean of NAA/Cr ratio = 1.04 ± 0.14, Choline/Cr = 0.49 ± 0.04 and Glx/Cr = 1.56 ± 0.22.

Conclusions

During the current pandemic of COVID-19, radiologists should be aware of wide spectrum of MRI and MRS findings of COVID-19-related CNS involvement.

The hierarchy of different treatments for myogenous temporomandibular disorders: a systematic review and network meta-analysis of randomized clinical trials

The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo.  At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling  therapy (71.2%, moderate quality), and occlusal appliances  (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances  (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments.  This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances  . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.

Reinforced Aortic Root Reconstruction in Type A Aortic Dissection: A Prospective Study

BACKGROUND

Type A aortic dissection is a challenging surgical emergency associated with high morbidity and mortality. Many techniques have evolved to repair the dissected sinus segments and restore aortic valve dynamics. Herein, we evaluate the early outcome of a novel technique for reconstruction of dissected aortic root.

METHODS

A prospective study was conducted on 300 patients to evaluate the early results of repair of dissected root in type A aortic dissection. The mean age was 59.65±8.52 years, and 76% of patients were males. All patients had four standard steps for aortic reconstruction: 1) commissural resuspension; 2) right coronary sinus reinforcement with pericardial and Dacron bands; 3) non-coronary sinus reinforcement using external Dacron patch; 4) circumferential inversion of adventitial layer of the root. Patients were followed up clinically, echocardiographically, and by CT scan.

RESULTS

The in-hospital mortality was 8%. The mean cross-clamp time was 120±30 minutes, and circulatory arrest time was 25+10 minutes. Twenty-seven patients (9%) experienced postoperative complications, including bleeding and acute kidney injury. During a mean follow-up time of 48±12 months, there were no recurrent aortic dissection, aortic dilatation, pseudoaneurysm, or progression of aortic regurgitation during the entire study period.

CONCLUSIONS

This reconstructive technique technically is undemanding, feasible, safe, and durable with good early results. A larger cohort of patients with longer period of follow up should generate a more powerful evaluation of this technique.

PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis

BACKGROUND & AIMS

Acute decompensation (AD) of cirrhosis may present without acute-on-chronic liver failure (ACLF) (AD-No ACLF), or with ACLF (AD-ACLF), defined by organ failure(s). Herein, we aimed to analyze and characterize the precipitants leading to both of these AD phenotypes.

METHODS

The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome.

RESULTS

Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90-day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality.

CONCLUSIONS

This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis.

LAY SUMMARY

Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes.

How to Interact with a Fully Autonomous Vehicle: Naturalistic Ways for Drivers to Intervene in the Vehicle System While Performing Non-Driving Related Tasks

Autonomous vehicle technology increasingly allows drivers to turn their primary attention to secondary tasks (e.g., eating or working). This dramatic behavior change thus requires new input modalities to support driver–vehicle interaction, which must match the driver’s in-vehicle activities and the interaction situation. Prior studies that addressed this question did not consider how acceptance for inputs was affected by the physical and cognitive levels experienced by drivers engaged in Non-driving Related Tasks (NDRTs) or how their acceptance varies according to the interaction situation. This study investigates naturalistic interactions with a fully autonomous vehicle system in different intervention scenarios while drivers perform NDRTs. We presented an online methodology to 360 participants showing four NDRTs with different physical and cognitive engagement levels, and tested the six most common intervention scenarios (24 cases). Participants evaluated our proposed seven natural input interactions for each case: touch, voice, hand gesture, and their combinations. Results show that NDRTs influence the driver’s input interaction more than intervention scenario categories. In contrast, variation of physical load has more influence on input selection than variation of cognitive load. We also present a decision-making model of driver preferences to determine the most natural inputs and help User Experience designers better meet drivers’ needs.

Comparison of Conventional Microscopic and Exoscopic Experimental Bypass Anastomosis: A Technical Analysis

BACKGROUND

Recently, the use of digital exoscopes has been increasingly promoted as an alternative to microscopes. The aim of this study is to compare experimental bypass quality in both visualization methods.

METHODS

This study used two hundred 1-mm chicken wing vessels, which were used for either exoscopic or microscopic (100 samples each) bypass procedures. All procedures were recorded between July 2018 and September 2018. The bypass quality was evaluated according to our published practical scale (time, stitch distribution, intima-intima attachment, and orifice size).

RESULTS

Both methods are effective in doing bypass suturing (practical scale score was good, 86% vs. 85%; P = 0.84). There were no significant differences regarding intima-intima attachment (P = 0.26) and orifice size (P = 0.25). However, suturing time (P < 0.001) was less using the microscope, whereas stitch distribution (P = 0.001) was better using the exoscope. Different suturing techniques (interrupted vs. continuous) had overall comparable results (P = 0.55).

CONCLUSIONS

Both methods produced equally satisfactory results in experimental bypass procedures. The exoscope has the potential for better 3-dimensional visualization and sharing the surgeon's view with others for teaching purposes.

Does intraoperative perforation of Schneiderian membrane during sinus lift surgery causes an increased the risk of implants failure?: A systematic review and meta regression analysis

PURPOSE

There is still debate whether intraoperative Schneiderian membrane (SM) perforation in the maxillary sinus lift causes an increase the risk of implants failure. The aim of this study was to assess an association between SM perforation and implants loss following the maxillary sinus lift.

MATERIALS AND METHODS

A systematic review and meta-analysis of clinical studies assessing association between SM perforation and implants failure based on PRISMA was conducted. Three major databases were used to gather research dating from their respective inception up until March 2018. All clinical studies expressly reported the number of the SM perforation and implants loss that installed in the perforated and nonperforated sinuses were included. The statistical analyses used were Pearson's correlation, simple linear regression, and meta regression. The risk ratio (RR) of implant loss between perforated and nonperforated sites was estimated.

RESULTS

A total of 2947 patients with 3884 maxillary sinuses augmentations who received 7358 implants, enrolled in 58 studies were included in this study. There was a significant relationship between the implants' failure and SM perforation according to simple linear regression (P < .001) and meta regression analysis (P = .06). There was a significant decrease (moderate quality evidence) in implant loss in the nonperforated sinuses compared to perforated sunrises (RR = 2.17, CI: 1.52-3.10, P = .001). There was also no significant association between implant loss in the perforated sinuses and the surgical devices used (piezosurgical or rotary), surgical approach applied (lateral or crestal sinus lift), barrier membrane used and type of bone grafting materials.

CONCLUSION

The results of this study showed that an intraoperative SM perforation could increase the risk of implant failure after the sinus lift surgery.

Identification of occult active infection using PET-CT in a combined liver-kidney transplant candidate

This case describes a patient being considered for combined liver-kidney transplantation for Caroli's disease with a failed renal transplant. A chronic septic focus could not be located with standard imaging techniques, such as ultrasonography and computed tomography. This case report highlights the observation that a retained non-functioning transplant can be the cause of fever of unknown origin and PET-CT can be useful in diagnosing these challenging cases.

Sofosbuvir-based treatment regimens: real life results of 14 409 chronic HCV genotype 4 patients in Egypt

BACKGROUND

Chronic hepatitis C virus infection is one of the most important health problems in Egypt. The Ministry of Health's National Treatment Programme introduced sofosbuvir-based therapy in October 2014.

AIM

To assess the clinical effectiveness and predictors of response to SOF-based treatment regimens, either dual therapy, with SOF/ribavirin (RBV) for 6 months or triple therapy with SOF/peg-IFN-alfa-2a/RBV for 3 months, in a cohort of patients treated in National Treatment Programme affiliated centres in Egypt.

METHODS

Between October 2014 and end of 2014, patients who were eligible for treatment were classified according to their eligibility for interferon therapy: Group 1 (interferon eligible) were treated with triple therapy for 12 weeks and Group 2 (interferon ineligible) were treated with dual therapy for 24 weeks. Difficult to treat patients included those with F3-F4 on Metavir score, Fib-4 >3.25, albumin ≤3.5, total Bilirubin >1.2 mg/dL, INR >1.2 and platelet count <150 000 mm³ .

RESULTS

Twelve weeks post-treatment data were available on 14 409 patients; 8742 in group 1 and 5667 in group 2. In group 1, the sustained virological response at week 12 (SVR12) was 94% and in group 2 the SVR12 was 78.7%. Multivariate logistic regression analysis in which treatment failure is the dependent variable was done. Male gender, being a difficult to treat patient and previous interferon therapy were significant predictors of nonresponse in both treatment groups.

CONCLUSION

Results of sofosbuvir-based therapies in Egypt achieved similar rates of SVR12 as seen in phase III efficacy studies.

Superficial Temporal Artery: Distal Posterior Cerebral Artery Bypass through the Subtemporal Approach: Technical Note and Pilot Surgical Cases

BACKGROUND: Posterior cerebral artery (PCA) aneurysms are rare and the majority are fusiform in shape. Proximal occlusion of PCA represents a treatment option for these lesions. However, this procedure carries a high risk of ischemic complications.

OBJECTIVE: To describe the technique of trapping a fusiform PCA aneurysm and revascularization of the distal PCA using a superficial temporal artery (STA) graft through the same microsurgical approach.

METHODS: From September 2012 to October 2014, we retrospectively identified 3 patients harboring a fusiform PCA aneurysm (P2 segment aneurysm) who underwent trapping of the aneurysm and reconstruction of the distal PCA through the same subtemporal approach. We analyzed immediate morbidity, surgical complications, and the patency of the bypass to determine the feasibility of this procedure.

RESULTS: All 3 patients underwent successful trapping of the fusiform PCA aneurysm and revascularization of the distal PCA. The origin of P3 segment or posterior temporal artery (PTA) served as recipient arteries. In all 3 cases, adequate blood flow was evident after performing the STA-P3/PTA bypass. None of the patients experienced a new permanent neurological deficit. At 1-year follow-up, the STA-PTA/PCA bypasses remained patent.

CONCLUSION: The STA-P3/PTA bypass through the subtemporal approach is a feasible option to maintain blood flow in cases of PCA fusiform aneurysms requiring trapping of the P2 segment.

Development and validation of a dynamic outcome prediction model for paracetamol-induced acute liver failure: a cohort study

BACKGROUND

Early, accurate prediction of survival is central to management of patients with paracetamol-induced acute liver failure to identify those needing emergency liver transplantation. Current prognostic tools are confounded by recent improvements in outcome independent of emergency liver transplantation, and constrained by static binary outcome prediction. We aimed to develop a simple prognostic tool to reflect current outcomes and generate a dynamic updated estimation of risk of death.

METHODS

Patients with paracetamol-induced acute liver failure managed at intensive care units in the UK (London, Birmingham, and Edinburgh) and Denmark (Copenhagen) were studied. We developed prognostic models, excluding patients who underwent transplantation, using Cox proportional hazards in a derivation dataset, and tested in initial and recent external validation datasets. Mortality was estimated in patients who had emergency liver transplantation. Model discrimination was assessed using area under receiver operating characteristic curve (AUROC) and calibration by root mean square error (RMSE). Admission (day 1) variables of age, Glasgow coma scale, arterial pH and lactate, creatinine, international normalised ratio (INR), and cardiovascular failure were used to derive an initial predictive model, with a second (day 2) model including additional changes in INR and lactate.

FINDINGS

We developed and validated new high-performance statistical models to support decision making in patients with paracetamol-induced acute liver failure. Applied to the derivation dataset (n=350), the AUROC for 30-day survival was 0·92 (95% CI 0·88-0·96) using the day 1 model and 0·93 (0·88-0·97) using the day 2 model. In the initial validation dataset (n=150), the AUROC for 30-day survival was 0·89 (0·84-0·95) using the day 1 model and 0·90 (0·85-0·95) using the day 2 model. Assessment of calibration using RMSE in prediction of 30-day survival gave values of 0·1642 for the day 1 model and 0·0626 for the day 2 model. In the external validation dataset (n=412), the AUROC for 30-day survival was 0·91 (0·87-0·94) using the day 1 model and 0·91 (0·88-0·95) using the day 2 model, and assessment of calibration using RMSE gave values of 0·079 for the day 1 model and 0·107 for the day 2 model. Applied to patients who underwent emergency liver transplantation (n=116), median predicted 30-day survival was 51% (95% CI 33-85).

INTERPRETATION

The models developed here show very good discrimination and calibration, confirmed in independent datasets, and suggest that many patients undergoing transplantation based on existing criteria might have survived with medical management alone. The role and indications for emergency liver transplantation in paracetamol-induced acute liver failure require re-evaluation.

FUNDING

Foundation for Liver Research.

Changes in Pulmonary Function After A Caffeine Loading Dose and Extubation Outcome in Preterm Infants with Respiratory Distress Syndrome

BACKGROUND: Prolonged endotracheal intubation in preterm infants leads to adverse outcomes including bronchopulmonary dysplasia, pneumonia and sepsis. Extubating preterm infants early can lead to apneas, respiratory distress and hypoxemia with reintubation, a destabilizing and traumatic event. Identifying readiness for extubation would avoid these harmful events. Current clinical criteria perform poorly in predicting extu-bation outcome in preterm infants. Caffeine is used to facilitate extubation and also affects pulmonary function.

OBJECTIVES: To determine pulmonary functions before and after a caffeine loading dose in preterm infants &lt; 31 weeks gestation with respiratory distress syndrome (RDS) undergoing their first trial of extubation and use them to predict extubation outcome.

DESIGN/METHODS: We determined dynamic compliance (Cdyn), tidal volume (TV), minute ventilation (MV), and dynamic airway resistance (Rdyn) before and after a loading dose of 10 mg/kg of caffeine base in preterm infants &lt;31 weeks gestation with RDS prior to extubation. These measurements were taken as an average of ten non-distorted breaths with &lt; 10% endotracheal air leak. Infants were ventilated with the EvitaXl Neo (Draeger, Germany). Pulmonary function readings were downloaded from the ventilator. Extubation failure was defined as the need for reintubation within 72 h after extubation. Exclusion criteria included grade 3-4 intra-ventricular hemorrhage, sedation, pneumothorax, medications affecting pulmonary function, chromosomal and congenital malformations. Mann Whitney test was used for continuous variables and the χ2 or Fisher’s exact test for dichotomous data. A p value &lt;0.05 was considered significant.

RESULTS: Blood gas values and ventilator parameters were similar between the groups before extubation.There was significant improvement in pulmonary function after a loading dose caffeine. Amongst pulmonary functions, ratio of Cdyn before and after caffeine performed best in predicting extubation outcome with an area under the curve of 0.85 (95% CI 0.79-0.94).

CONCLUSION: Caffeine improves pulmonary function in preterm infants. A ratio of dynamic compliance before and after caffeine best predicted extu-bation outcome. Our results need validation in a prospective study.

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Lateral supraorbital approach to ipsilateral PCA-P1 and ICA-PCoA aneurysms

Background:

Aneurysms of the posterior cerebral artery (PCA) are rare and often associated with anterior circulation aneurysms. The lateral supraorbital approach allows for a very fast and safe approach to the ipsilateral lesions Circle of Willis. A technical note on the successful clip occlusion of two aneurysms in the anterior and posterior Circle of Willis via this less invasive approach has not been published before. The objective of this technical note is to describe the simultaneous microsurgical clip occlusion of an ipsilateral PCA-P1 and an internal carotid artery - posterior communicating artery (ICA-PCoA) aneurysm via the lateral supraorbital approach.

Case Description:

The authors present a technical report of successful clip occlusions of ipsilateral located PCA-P1 and ICA-PCoA aneurysms. A 59-year-old female patient was diagnosed with a PCA-P1 and an ipsilateral ICA-PCoA aneurysm by computed tomography angiography (CTA) after an ischemic stroke secondary to a contralateral ICA dissection. The patient underwent microsurgical clipping after a lateral supraorbital craniotomy. The intraoperative indocyanine green (ICG) videoangiography and the postoperative CTA showed a complete occlusion of both aneurysms; the parent vessels (ICA and PCA) were patent. The patient presents postoperative no new neurologic deficit.

Conclusion:

The lateral supraorbital approach is suitable for the simultaneous microsurgical treatment of proximal anterior circulation and ipsilateral proximal PCA aneurysms. Compared to endovascular treatment, direct visual control of brainstem perforators is possible.

Comparison of liver biopsy and noninvasive techniques for liver fibrosis assessment in patients infected with HCV-genotype 4 in Egypt

In Egypt, as elsewhere, liver biopsy (LB) remains the gold standard to assess liver fibrosis in chronic hepatitis C (CHC) and is required to decide whether a treatment should be proposed. Many of its disadvantages have led to develop noninvasive methods to replace LB. These new methods should be evaluated in Egypt, where circulating virus genotype 4 (G4), increased body mass index and co-infection with schistosomiasis may interfere with liver fibrosis assessment. Egyptian CHC-infected patients with G4 underwent a LB, an elastometry measurement (Fibroscan(©)), and serum markers (APRI, Fib4 and Fibrotest(©)). Patients had to have a LB ≥15 mm length or ≥10 portal tracts with two pathologists blinded readings to be included in the analysis. Patients with hepatitis B virus co-infection were excluded. Three hundred and twelve patients are reported. The performance of each technique for distinguishing F0F1 vs F2F3F4 was compared. The area under receiver operating characteristic curves was 0.70, 0.76, 0.71 and 0.75 for APRI, Fib-4, Fibrotest© and Fibroscan©, respectively (no influence of schistosomiasis was noticed). An algorithm using the Fib4 for identifying patients with F2 stage or more reduced by nearly 90% the number of liver biopsies. Our results demonstrated that noninvasive techniques were feasible in Egypt, for CHC G4-infected patients. Because of its validity and its easiness to perform, we believe that Fib4 may be used to assess the F2 threshold, which decides whether treatment should be proposed or delayed.

Anatomic risk factors for middle cerebral artery aneurysm rupture: computed tomography angiography study of 1009 consecutive patients

BACKGROUND

The middle cerebral artery (MCA) is the most frequent location for unruptured intracranial aneurysms. Controversy remains as to which unruptured MCA aneurysms should be treated prophylactically.

OBJECTIVE

To identify independent topographical and morphological variables that could predict increased rupture risk of MCA aneurysms.

METHODS

A retrospective analysis of computed tomography angiography data of 1009 consecutive patients with 1309 MCA aneurysms, referred between 2000 and 2009 to Helsinki University Hospital, was carried out. Morphological and topographical parameters examined for MCA aneurysms comprised aneurysm wall regularity, size, neck width, aspect ratio, bottleneck factor, height-width ratio, location along the MCA, side, distance from the internal carotid artery bifurcation, and dome projection in axial and coronal computed tomography angiography views. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors for rupture.

RESULTS

Of the 1309 MCA aneurysms, 69% were unruptured and 31% were ruptured. Most unruptured MCA aneurysms were smaller than 7 mm (78%), with a smooth wall (80%) and a height-width ratio of 1 (47%) and were located at the main bifurcation (57%). Ruptured MCA aneurysms, mostly 7 to 14 mm in size (55%), had an irregular wall (78%) and a height-width ratio greater than 1 (72%) and were located at the main bifurcation (77%). Thirty-eight percent of MCA bifurcation aneurysms, 74% of large aneurysms, 64% of aneurysms with an irregular wall, and 49% of aneurysms with a height-width ratio greater than 1 were ruptured.

CONCLUSION

Location at the main MCA bifurcation, wall irregularity, and less spherical geometry were independently associated with rupture of MCA aneurysms with a correlation with aneurysm size. artery.

Characteristics of Posterior Cerebral Artery Aneurysms

BACKGROUND:

Posterior cerebral artery (PCA) aneurysms are rare lesions. Because of their low incidence, the individual or institutional experience is usually limited.

OBJECTIVE:

To identify specific anatomic features related to PCA aneurysms based on the analyses of pretreatment angiograms.

METHODS:

We performed a detailed angiographic study of 81 patients with a diagnosis of 93 PCA aneurysms. Fifty-three patients underwent computed tomography angiography, 49 underwent digital subtraction angiography, and 6 underwent magnetic resonance angiography. Between 1980 and 2012, a total of 120 patients with 136 PCA aneurysms and 11 352 patients with 16 444 intracranial aneurysms were treated at our institutions.

RESULTS:

There were 29 ruptured and 64 unruptured PCA aneurysms. The distribution of the aneurysms along the PCA segments was P1 (n = 39; 9 ruptured), P1/P2 junction (n = 25; 9 ruptured), P2 (n = 21; 5 ruptured), and P3 (n = 8; 6 ruptured). The median aneurysm size was 7 mm for the ruptured and 4 mm for the unruptured aneurysms. Saccular aneurysms (n = 69, 74%) had a typical projection for each location: P1 segment, upward (67%); P1/P2 junction, anterior/upward (80%); P2 segment, lateral (67%); and P3 segment, posterior (50%). Multiple aneurysms were seen in 43 patients. PCA aneurysms related to arteriovenous malformations were observed in 10 patients.

CONCLUSION:

PCA aneurysms are infrequent lesions, often associated with multiple aneurysms and arteriovenous malformations and are fusiform in shape. Most ruptured PCA aneurysms are smaller than 10 mm and usually distally located. At each PCA segment, saccular PCA aneurysms have a typical dome orientation.

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms

BACKGROUND

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique.

METHOD

A 3D image-based anatomic orientation, clipping field-focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10-15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field.

RESULTS

The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches.

CONCLUSION

The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.

A New, More Accurate Classification of Middle Cerebral Artery Aneurysms

BACKGROUND:

Classification of middle cerebral artery (MCA) aneurysms is sometimes difficult because the identification of the main MCA bifurcation, the key for accurate classification of MCA aneurysms, is inconsistent and somewhat subjective.

OBJECTIVE:

To use the meeting point of the M1 and M2 trunks as an objective, generally accepted, and angiographically evident hallmark for identification of MCA bifurcation and more accurate classification of MCA aneurysms.

METHODS:

We reviewed the computed tomographic angiography data of 1009 consecutive patients with 1309 MCA aneurysms. The M2 trunks were followed proximally until their meeting with the M1 trunk at the main MCA bifurcation. The aneurysms were classified according to their relative location: proximal, at, or distal to the MCA bifurcation. The M1 aneurysms were further subgrouped into M1 early cortical branch aneurysms and M1 lenticulostriate artery aneurysms, extending the classic 3-group classification of MCA aneurysms into a 4-group classification.

RESULTS:

The main MCA bifurcation was the most common location for MCA aneurysms, harboring 829 aneurysms (63%). The 406 M1 aneurysms comprised 242 M1 early cortical branch aneurysms (60%) and 164 M1 lenticulostriate artery aneurysms (40%). We found 106 MCA aneurysms (8%) at the origin of large early frontal branches simulating M2 trunks liable to be misclassified as MCA bifurcation aneurysms. Even though 51% of the 407 ruptured MCA aneurysms were associated with an intracerebral hematoma, this did not affect the classification.

CONCLUSION:

Studying MCA angioarchitecture and applying the 4-group classification of MCA aneurysms is practical and facilitates the accurate classification of MCA aneurysms, helping to improve surgical outcome.

Early microsurgical treatment for spinal hemangioblastomas improves outcome in patients with von Hippel-Lindau disease

Background:

Spinal hemangioblastomas (HB) are rare, histologically benign, highly vascularized tumors often associated with von Hippel–Lindau (VHL) disease. The aim of the current study is to demonstrate the benefit of early surgical resection of large spinal HBs in selected asymptomatic patients with VHL.

Methods:

Seventeen patients underwent microsurgical resection of 20 spinal HBs at the Department of Neurosurgery at Helsinki University Central Hospital (HUCH). Thirteen tumors were in the cervical spine, five in thoracic and one patient had two lumbar lesions. MRI tumor showed an associated syrinx in 16 patients (94%). Tumor volume ranged from 27 to 2730 mm³. Out of 17 patients, 11 (65%) tested positive for VHL in mutation analysis. Five of these patients with tumors ranging from 55 to 720 mm³ were treated prophylactically.

Results:

Complete tumor resection was performed in 16 patients (94%) who were followed up for a median of 57 months (range 2–165 months). No patient had neurological decline on long-term follow-up. Among the patients with VHL, five patients with preoperative sensorimotor deficits showed improvement of their symptoms but never regained full function. One patient who presented with tetraplegia remained the same. Otherwise, all five patients with prophylactic surgery remained neurologically intact.

Conclusion:

Although documented growth on serial MRIs and the need for pathological diagnosis have been suggested as indications for surgery in otherwise asymptomatic patients, our series showed that a potentially larger group of asymptomatic patients with spinal HB associated with VHL would benefit from microsurgical resection. Long-term results of the surgical management of spinal HB are generally favorable. Our results suggest staging and early treatment for spinal HB larger than 55 mm³, especially in patients with VHL. Small spinal HBs may be followed up.

Complications of anterior clinoidectomy through lateral supraorbital approach

OBJECTIVE

We reviewed the surgical complications from our recent experience in vascular and tumor patients who underwent anterior clinoidectomy through the lateral supraorbital (LSO) approach.

METHODS

Between June 2007 and January 2011, a total of 82 patients with neoplastic and vascular lesions underwent anterior clinoidectomy by the senior author (J.H.) through the LSO approach. We analyzed the operative videos paying particular attention to the surgical technique used for removal of the anterior clinoid process (ACP) and compared the microsurgical nuances to postoperative complications related to anterior clinoidectomy.

RESULTS

Forty-five patients were treated for aneurysms; 35 patients for intraorbital, parasellar, and suprasellar tumors; and 2 patients for carotid-cavernous fistulas. Intradural anterior clinoidectomy was performed in 67 (82%) cases; in 15 (18%) cases an extradural approach was used. In 51 (62%) cases, ACP was removed completely, whereas in the remaining 31 (38%) a tailored anterior clinoidectomy was performed. Four (5%) patients had new postoperative visual deficits and 3 (4%) experienced a worsening of preoperative visual deficits. Twelve (15%) patients improved their preoperative visual deficits after intradural anterior clinoidectomy. Ultrasonic bone device is a useful tool but may damage the optic nerve when performing anterior clinoidectomy. There was no mortality in our series.

CONCLUSION

Anterior clinoidectomy can be performed through an LSO approach with a safety profile that is comparable to other approaches. Ultrasonic bone dissector is a useful tool but may lead to injury of the optic nerve and should be used very carefully in its vicinity.

Reproducibility of liver stiffness measurements in hepatitis C virus (HCV)-infected patients in Egypt

Elastometry has demonstrated good accuracy, but little is known about its reproducibility. The aim of this study was to assess the intra- and inter-operator reproducibility of liver stiffness measurement among hepatitis C virus (HCV)-infected patients in Egypt. The study was conducted among HCV-infected patients referred for treatment evaluation in two hepatitis treatment centres of Cairo. Two operators took liver stiffness measurement two times per patient the same day. Intra- and inter-reproducibility were estimated by different methods: Bland and Altman graphics, variation coefficient, intraclass correlation coefficient and Kappa coefficient; 7.1 kPa was used as the threshold of significant (≥F2) fibrosis whenever needed. Fifty-eight patients were included in the study, and 216 measurements were taken. Failure rate was 7% and associated with overweight. For a value of 7.1 kPa, the inter-operator 95% limits of agreement were estimated at ±2.88 kPa. Intra- and inter-operator coefficients of variation ranged between 11% and 15%, intraclass correlation coefficients [95% confidence interval] between 0.94 [0.86-0.97] and 0.97 [0.95-0.99], and Kappa coefficients between 0.65 [0.44-0.88] and 0.92 [0.81-1.00]. The reliability of liver stiffness measurement is questionable when considering the decision to initiate antiviral therapy because of the percentage of discordance between measurements is notable, especially in the intermediate fibrosis stages.

Regulation of myofibroblast transdifferentiation by DNA methylation and MeCP2: implications for wound healing and fibrogenesis

Myofibroblasts are critical cellular elements of wound healing generated at sites of injury by transdifferentiation of resident cells. A paradigm for this process is conversion of hepatic stellate cells (HSC) into hepatic myofibroblasts. Treatment of HSC with DNA methylation inhibitor 5-aza-2'-deoxycytidine (5-azadC) blocked transdifferentiation. 5-azadC also prevented loss of IkappaBalpha and PPARgamma expression that occurs during transdifferentiation to allow acquisition of proinflammatory and profibrogenic characteristics. ChIP analysis revealed IkappaBalpha promoter is associated with transcriptionally repressed chromatin that converts to an active state with 5-azadC treatment. The methyl-CpG-binding protein MeCP2 which promotes repressed chromatin structure is selectively detected in myofibroblasts of diseased liver. siRNA knockdown of MeCP2 elevated IkappaBalpha promoter activity, mRNA and protein expression in myofibroblasts. MeCP2 interacts with IkappaBalpha promoter via a methyl-CpG-dependent mechanism and recruitment into a CBF1 corepression complex. We conclude that MeCP2 and DNA methylation exert epigenetic control over hepatic wound healing and fibrogenesis.

Medical professionalism: the trainees' views

Medical professionalism is deeply embedded in medical practice in the UK but, with changes in the modern healthcare climate, its nature and role have been increasingly challenged. The Royal College of Physicians (RCP) therefore convened a working party to consider the concept of medical professionalism, to clarify its value and purpose, and to define it. As part of this project, the RCP Trainees Committee was commissioned to survey trainees to obtain their views on the matter. A questionnaire was sent to 19,190 medical and surgical trainees, and 4,576 medical students; 2,175 responses were received. The results were clear. Junior doctors and medical students see medicine as a profession which is learnt through apprenticeship and defined by responsibility towards patients, and which requires qualities such as altruism and humility. They believe that professionalism maintains and improves patient care; that standards of care should be defined and regulated by the profession; and that training should be directed by the profession. Furthermore, the overwhelming majority think that a reduction in medical professionalism would lead to people leaving the profession.