A prospective study of posttraumatic stress symptoms and nonadherence in survivors of a myocardial infarction (MI)

We examined a novel hypothesis that links symptoms of MI-related posttraumatic stress disorder (PTSD) to nonadherence. According to this hypothesis, patients who are traumatized by their medical illness do not take their medications as prescribed. As a part of the avoidance dimension of PTSD, patients who are traumatized may avoid being reminded of the MI by not taking the medication. MI survivors were prospectively followed for 6 months to 1 year. Adherence was assessed by pill count of Captopril. Demographic variables, medical risk factors, PTSD, and other psychiatric symptom dimensions were evaluated during follow-up. One hundred two of 140 recruited patients completed follow-up. Nonadherence to Captopril was associated with poor medical outcome (r=.93, P=.006). Above-Threshold PTSD symptoms were associated with nonadherence to medications (P=.05). No other psychiatric symptom dimensions were independently associated with nonadherence. Nonadherence to medications predicts adverse outcome during the first year after an acute MI. Nonadherence is associated with PTSD symptoms, which may either be a marker for or a cause of nonadherence. Treatment of PTSD may prove to be a useful approach for improving adherence.

Photorefractive Keratectomy and Laser In Situ Keratomileusis for Myopia Between 6.00 and 10.00 Diopters

BACKGROUND

Excimer laser photorefractive keratectomy (PRK) can be effective in correcting myopia up to -6.00 diopters (D). Between -6.00 D and -10.00 D, the procedure is considered less effective and safe because it has been associated with dense scar formation and a high rate of regression. We compared photorefractive keratectomy (PRK) in this group of myopes with excimer laser keratomileusis in situ (LASIK).

METHODS

Forty consecutive eyes with a manifest refraction between -6.00 and -10.00 D were treated with PRK using an ablation-zone diameter of 6 mm. Subsequently, 40 consecutive eyes were treated with LASIK under a hinged flap using an ablation-zone diameter of 5 mm. All procedures used a Summit OmniMed laser and were done by the same surgeon.

RESULTS

Preoperatively, 24 eyes (60%) undergoing PRK had 20/20 spectacle-corrected visual acuity; 1 year postoperatively, 20 (50%) had 20/20 vision uncorrected. Preoperatively, 13 eyes (33%) undergoing LASIK had 20/20 spectacle-corrected visual acuity; 1 year postoperatively, 24 (60%) could see 20/20 uncorrected. Sixteen (39%) PRK eyes had a spherical equivalent refraction within +/-1.00 D at 1 year; 20 (60%) eyes undergoing LASIK had a refraction within +/-1.00 D at that point. None of the eyes treated with LASIK developed corneal haze, while after PRK, 36 eyes (90%) developed haze (23 eyes [57%] +2 to +3).

CONCLUSION

LASIK under a hinged flap proved superior to PRK in treating myopia between -6.00 D and -10.00 D.

L-NMMA (a nitric oxide synthase inhibitor) is effective in the treatment of cardiogenic shock

BACKGROUND

The objective was to assess the safety and efficacy of L-NMMA in the treatment of cardiogenic shock.

METHODS

We enrolled 11 consecutive patients with cardiogenic shock that persisted after >24 hours from admission, despite coronary catheterization and primary percutaneous transluminal coronary revascularization, when feasible, and treatment with mechanical ventilation, intraaortic balloon pump (IABP), and high doses of catecholamines. L-NMMA was administered as an IV bolus of 1 mg/kg and continuous drip of 1 mg. kg(-1). h(-1) for 5 hours. Treatment with catecholamines, mechanical ventilation, and IABP was kept constant throughout the study.

RESULTS

Within 10 minutes of L-NMMA administration, mean arterial blood pressure (MAP) increased from 76+/-9 to 109+/-22 mm Hg (+43%). Urine output increased within 5 hours from 63+/-25 to 156+/-63 cc/h (+148%). Cardiac index decreased during the steep increase in MAP from 2. 0+/-0.5 to 1.7+/-0.4 L/(min. m(2)) (-15%); however, it gradually increased to 1.85+/-0.4 L/(min. m(2)) after 5 hours. The heart rate and the wedge pressure remained stable. Twenty-four hours after L-NMMA discontinuation, MAP (+36%) and urine output (+189%) remained increased; however, cardiac index returned to pretreatment level. No adverse events were detected. Ten out of eleven patients could be weaned off mechanical ventilation and IABP. Eight patients were discharged from the coronary intensive care unit, and seven (64%) were alive at 1-month follow-up.

CONCLUSIONS

L-NMMA administration in patients with cardiogenic shock is safe and has favorable clinical and hemodynamic effects.

Effect of di(2-ethylhexyl) phthalate on Nrf2-regulated glutathione homeostasis in mouse kidney

Environmental toxicants such as phthalate have been involved in multiple health disorders including renal diseases. Oxidative damage is implicated in many alterations caused by phthalate especially the di(2-ethylhexyl) phthalate (DEHP), which is the most useful phthalate. However, information regarding its mechanism of renal damage is lacking. The transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) regulates gene expression implicated in free radical scavenging and cytoprotection including the antioxidant glutathione (GSH) pathway. The aim of this study was to assess whether DEHP affects the Nrf2 pathway and the GSH concentration. Mice were divided into four groups: a control group and three groups treated with DEHP at different concentrations (5, 50, and 200 mg/kg body weight) for 30 days. Our results showed that DEHP altered the normal levels of serum biochemical parameters creatinine (CREA), urea, and lactate dehydrogenase (LDH). This phthalate caused oxidative damage through the induction of lipid peroxidation and protein oxidation as marked by increase of protein carbonyl (PC) and loss of protein-bound sulfhydryls (PSH). Simultaneously, DEHP treatment decreased the protein level of Nrf-2, HO-1, and GCLC (responsible of GSH synthesis) and decreased the GSH level. Inhibition of the Nrf2 pathway is related to the activation of the mitochondrial pathway of apoptosis. This apoptotic process is evidenced by an upregulation of p53 and Bax protein levels in addition to a downregulation of Bcl-2. Collectively, our data demonstrated that depletion of Nrf2 and GSH was associated with the elevation of oxidative stress and the activation of intrinsic apoptosis in mouse kidney treated with DEHP.

Sensitivity and specificity of bispectral index for classification of overt hepatic encephalopathy: a multicentre, observer blinded, validation study

BACKGROUND

The severity of hepatic encephalopathy is currently graded clinically using West Haven criteria and psychometric tests.

OBJECTIVE

To assess the discriminative power of the bispectral index (BIS) monitor to classify the degree and progression of hepatic encephalopathy.

DESIGN

A consecutive, multicentre, observer blinded validation study.

SETTING

Medical University of Graz (Graz, Austria), Zhejiang University First Affiliated Hospital (Hang Zhou, China), and Cairo University (Cairo, Egypt).

PATIENTS

28 consecutive patients with hepatic encephalopathy were first enrolled at Medical University of Graz as a test set. The estimated BIS cut off values were subsequently tested in a validation set of 31 patients at Zhejiang University First Affiliated Hospital and 26 patients at Cairo University; 18 patients were reassessed later in a longitudinal study. Fifteen of 85 patients (18%) were excluded from the final analysis (11 became too agitated with high electromyographic activity; four fell asleep during the recording).

RESULTS

Applying the Austrian BIS cut off values of 85, 70, and 55 for discriminating West Haven grades 1 to 4 yielded agreement between BIS classification and West Haven grades in 40 of the 46 validation patients (87%), and in 16 of the 18 follow up patients (89%). Mean (SD) BIS values differed significantly between patients with West Haven grade 1 (90.2 (2.5)), grade 2 (78.4 (6.6)), grade 3 (63.2 (4.8)), and grade 4 (45.4 (5.0)).

CONCLUSIONS

BIS is a useful measure for grading and monitoring the degree of involvement of the central nervous system in patients with chronic liver disease.

Lactobacillus species as emerging pathogens in neutropenic patients

The intensive use of broad-spectrum antibiotics in the context of prolonged and severe neutropenia has contributed to the emergence of unusual pathogens. Four new cases of severe Lactobacillus infections-three of septicemia and one of pneumonia-are reported. They occurred in patients with acute leukemia who had chemotherapy-induced neutropenia. All patients were treated in the same intensive care unit and received the same antimicrobial prophylaxis which included a total bowel decontamination containing vancomycin. The four patients were treated with a combination of intravenous ceftazidime and vancomycin prior to the development of Lactobacillus infection. Improvement in the condition of all patients was obtained with a treatment including penicillin and concurrent recovery of granulopoiesis.

BAL neopterin : a novel marker for cell-mediated immunity in patients with pulmonary tuberculosis and lung cancer

BACKGROUND

Neopterin is derived from guanosine triphosphate and is produced by stimulated macrophages under the influence of gamma-interferon of lymphocyte origin. It has been suggested that it is an excellent marker for the activation of the monocyte/macrophage axis in some clinical situations. However, to our knowledge, the relationship of BAL neopterin levels to disease states has not been studied.

AIM

To assess the usefulness of BAL neopterin levels as an index of disease activity in patients with pulmonary tuberculosis and lung cancer.

METHODS

BAL and serum neopterin levels were evaluated in 20 patients with pulmonary tuberculosis, 20 patients with bronchogenic carcinoma, and 10 healthy individuals. The concentration of neopterin was evaluated by radioimmunoassay technique. The BAL level of neopterin was standardized using the BAL urea level.

RESULTS

The neopterin levels (mean +/- SD) in the BAL and serum of tuberculous patients (88.6 +/- 27.4 nmol/L epithelial lining fluid [ELF], 61.3 +/- 29.4 nmol/L, respectively) were significantly higher when compared with those in lung cancer patients (40.7 +/- 16.6 nmol/L ELF, 26.8 +/- 6.58 nmol/L, respectively, p < 0.001) and when compared with those in control subjects (26.3 +/- 11.3 nmol/L ELF, 6.8 +/- 2.7 nmol/L, respectively, p < 0.001). In the tuberculous group, BAL and serum neopterin levels in patients with far-advanced disease were significantly higher when compared with those in patients with moderately and minimally advanced diseases (p < 0.001). BAL and serum neopterin levels were significantly higher in patients with small cell carcinoma than in those with adenocarcinoma (p < 0.05). BAL neopterin levels were significantly (p < 0.001) higher than serum levels in all patients and control groups. In addition, there were significant positive correlations between BAL and serum neopterin levels in tuberculous (r = 0.92, p < 0.001), lung cancer (r = 0.62, p < 0.001), and control groups (r = 0.93, p < 0.001).

CONCLUSIONS

The levels of neopterin in BAL fluid may reflect the degree of disease activity in pulmonary tuberculous patients. In addition, BAL neopterin levels are elevated in patients with lung cancer, especially the small-cell carcinoma type.

Glucocorticoid treatment in patients with septic shock: effects on vasopressor use and mortality

Corticosteroids were proposed for the treatment of sepsis as early as 1940. Several RCTs cast serious doubts on the usefulness of high dose corticosteroids and doubt still persists regarding the efficacy of replacement therapy. Adrenal insufficiency (non-responders to the 250 microg corticotropin test: increase in cortisol < 9 microg/dl) is present in about half of patients with septic shock and is associated with higher rates of refractory hypotension and mortality. Peripheral glucocorticoid resistance, which may even occur more frequently, can be easily assessed at bedside using skin tests. Cortisol antagonizes the migration of inflammatory cells, the synthesis or action of virtually all proinflammatory mediators, promotes virtually all anti-inflammatory components and enhances humoral immunity by means of transcriptional interference between its receptor and both AP-1 and NF-kappaB. Cortisol mediates cardiovascular tolerance to endotoxin and the maintenance of vascular sensitivity to catecholamines. Low doses (about 300 mg daily for 5 days or more) of hydrocortisone increase vasoconstrictor response to catecholamines in animals, in healthy volunteers challenged with LPS and in several RCTs. Hydrocortisone also increases arterial pressure and decreases the duration of shock. A meta-analysis of all available clinical controlled studies showed a reduction in 28 days, all-cause mortality with glucocorticoids (RR = 0.88, 95% CI: 0.78 - 1.00; p = 0.04). However, there was a significant heterogeneity across the trials (p = 0.006). On the other hand, analysis of studies where low doses of glucocorticoids were given for prolonged periods showed a 24% reduction in the risk of all-cause mortality at 28 days in treated patients (RR = 0.76, 95% CI: 0.64 - 0.90; p = 0.002) without heterogeneity across the trials (p = 0.28). In conclusion, in severe sepsis, high doses of corticosteroids should not be given. Septic shock should be treated with a replacement dose of hydrocortisone.

Plasma angiotensin II, renin activity and serum angiotensin-converting enzyme activity in non-insulin dependent diabetes mellitus patients with diabetic nephropathy

The renin-angiotensin system (RAS) has been unequivocally implicated as a mediator of diabetic complications. The present study was designed to evaluate the RAS in non-insulin dependent diabetic patients with diabetic nephropathy. Plasma renin activity, plasma angiotensin II and serum angiotensin-converting enzyme (ACE) activity were measured in 45 non-insulin dependent diabetes mellitus (NIDDM) patients and 15 healthy non-diabetic controls. Diabetics were subdivided into 15 normoalbuminuric NIDDM subjects, 15 NIDDM patients with microalbuminuria and 15 diabetics with macroalbuminuria. Mean plasma renin activity for macroalbuminuric diabetics (0.65+/-0.10 ng/ml/hr) was significantly reduced than the controls (1.28+/-0.37 ng/ml/hr) (P<0.001), the diabetic group with microalbuminuria (1.08+/-0.48 ng/ml/hr) (P<0.05) and normoalbuminuric patients (1.56+/-0.82 ng/ml/hr) (P<0.001). A significant negative correlation was obtained between serum creatinine and plasma renin activity (r=-0.842, p<0.001) in macroalbuminuric NIDDM patients. Plasma angiotensin II was significantly decreased in non-complicated diabetics compared to healthy controls (4.36+/-1.49 pg/ml vs 14.87+/-3.48 pg/ml respectively, p<0.001). Non-insulin dependent diabetic patients with nephropathy had significantly higher plasma angiotensin II levels (28.99+/-5.88 pg/ml) than non-complicated diabetics (p<0.001). Serum ACE activity was increased in 53.3% of NIDDM patients. All diabetic groups showed increased serum ACE activity (normoalbuminuric NIDDM 114.9+/-28.3 nmol/min/ml, microalbuminuric NIDDM 127.9+/-31.2 nmol/min/ml and macroalbuminuric NIDDM 127.0+/-29.3 nmol/min/ml) when compared to the normal control group (76.3+/-16.5 nmol/min/ml) (p<0.001). No significant difference in serum ACE activity was obtained between normoalbuminuric and nephropathic diabetics or between diabetics with and without retinopathy. No significant correlation was obtained between serum ACE activity and blood pressure, blood glucose level and duration of diabetes. Thus plasma renin activity is decreased in diabetic nephropathy and negatively correlates with serum creatinine. Plasma angiotensin II is decreased in normoalbuminuric diabetics and elevated in diabetic nephropathy. Serum ACE activity is raised in NIDDM patients with no relation to albumin excretion rate. The role of increased ACE activity in NIDDM remains to be established.

Citrinin induces apoptosis in human HCT116 colon cancer cells through endoplasmic reticulum stress

The mycotoxin citrinin (CTN) is a natural contaminant of various human foods that may produce serious adverse health problems. Several studies demonstrated that citrinin exerts cytotoxic and genotoxic effects in both in vivo and in vitro systems. However, the precise mechanisms of action (MOA), particularly in intestinal cells remain unclear. The aim of the present study was to examine the precise MOA of citrinin in vitro. Data demonstrated that CTN significantly decreased the number of viable human intestinal HCT116 cells and induced apoptotic events including (1) decrease in ΔѰm indicative of mitochondrial membrane permeabilization, (2) activation of caspase 3, (3) elevated production of reactive oxygen species (ROS) and (4) relative persistence of plasma membrane integrity. Further, the genetic deficiency of the pro-apoptotic protein Bax protected cells against CTN-induced apoptosis, indicating that Bax is required for CTN-mediated toxicity. It was also found that CTN triggered endoplasmic reticulum (ER) stress and activated different arms of the unfolded protein response (UPR) as demonstrated by increase in expression of GRP78 (glucose-regulated protein-78), GRP94 (glucose-regulated protein-94), GADD34 (growth arrest and DNA damage-inducible protein-34), the protein disulfide isomerase associated 6 (PDIA6), CHOP (C/EBP-homologous protein) and the splicing of XBP1 (X-Box Binding Protein 1). Pretreatment of cells with the chemical chaperone 4-phenylbutyrate (PBA), known to alleviate ER stress, prevented significantly the apoptotic process triggered by CTN. Taken together, these results suggest that CTN exerts its cytotoxic effects in HCT116 cells by inducing apoptosis, at least in part, through induction of ER stress.

Influence of bifentrin, a pyrethriod pesticide, on human colorectal HCT-116 cells attributed to alterations in oxidative stress involving mitochondrial apoptotic processes

The widespread use of pesticides is beneficial for food production; however, there are numerous adverse consequences reported in the ecosystem and humans associated with exposure to these contaminants. The pyrethriod bifenthrin (BIF) is utilized for (1) maintenance, growth, and storage of agricultural products; (2) control of internal and external parasites of farm animals; and (3) eradication of insects threatening public health. Numerous data are available regarding environmental and ecological impact of pyrethriods on the central and peripheral nervous systems; however few studies focused on non-target tissues especially in humans. Therefore, the aim of this investigation was to determine the potential cytotoxic effects of BIF on a non-target tissue using human colorectal HCT-116 cells as a model. Data demonstrated that BIF reduced cell viability and disrupted mitochondrial functions which were accompanied by increased reactive oxygen species (ROS) levels indicating the presence of oxidative stress. BIF produced a significant elevation in levels of malondialdehyde (MDA) supporting the role of oxidative stress in pesticide-mediated toxicity. Concomitantly, a fall of mitochondrial transmembrane potential (Δψ), consequently producing perturbation of fluidity as well as excitability of cellular membranes was noted. Our results also indicated that BIF induced a rise in DNA damage as evidenced by the comet assay. An increase in mitogen-activated protein kinases (MAPKs), JNK (N-terminal Kinase), p38, and ERK (extracellular-signal-regulated kinase) suggested an apoptotic effect. Data thus indicated that BIF-induced cytotoxicity in human colorectal HCT-116 cells was associated with oxidative stress, mitochondrial dysfunction, and apoptosis.

Eugenol protects against citrinin-induced cytotoxicity and oxidative damages in cultured human colorectal HCT116 cells

This study aimed to investigate the protective effects of Eugenol (EUG), an effective antioxidant phenolic compound with a radical scavenging activity against citrinin (CTN)-induced toxicity in vitro using HCT116 cells. CTN is a well-known mycotoxin found in different constituents of the food chain. This environmental contaminant produces free radicals which interacts with cellular macromolecules and produces oxidation of protein, lipid, and DNA. The cytotoxic effects were monitored by measuring cell viability, reactive oxygen species (ROS) generation, antioxidant enzyme activities, malondialdehyde (MDA) production, protein oxidation, and DNA fragmentation. Our results have shown that the pretreatment of HCT116 cells with EUG, 2 h prior to citrinin (CTN) exposure, significantly decreased CTN-induced cell death, inhibited ROS generation, modulated activities of both catalase (CAT) and superoxide dismutase (SOD), and reduced MDA production. Level of protein-bound sulfhydryls and DNA fragmentation were also declined as compared with CTN-treated cells. These findings suggest that EUG would be an effective protective agent against CTN-induced oxidative stress, and thereby, it may complement and add to the functions of antioxidant vitamins and enzymes as a protection against the cytotoxicity of this mycotoxin.

Association of ficolin-2 gene polymorphisms and susceptibility to systemic lupus erythematosus in Egyptian children and adolescents: a multicenter study

BACKGROUND

Pediatric-onset SLE (pSLE) is a multisystem autoimmune disease. Recently, the ficolin-2 (FCN2) gene has emerged as a potential candidate gene for susceptibility to SLE.

OBJECTIVES

The objective of this study was to evaluate the association of the FCN2 gene polymorphisms at positions -986 (G/A), -602 (G/A), -4 (A/G) and SNP C/T (rs3124954) located in intron 1, with susceptibility to pSLE in Egyptian children and adolescents.

METHODS

This was a multicenter study of 280 patients diagnosed with pSLE, and 280 well-matched healthy controls. The FCN2 promoter polymorphisms at -986 G/A (rs3124952), -602 G/A (rs3124953), -4 A/G (rs17514136) and SNP C/T (rs3124954) located in intron 1 were genotyped by polymerase chain reaction, while serum ficolin-2 levels were assessed using enzyme-linked immunosorbent assay.

RESULTS

The frequencies of the FCN2 GG genotype and G allele at -986 and -602 positions were significantly more represented in patients with pSLE than in controls (p < 0.001). Conversely, the FCN2 AA genotype and A allele at position -4 were more common in patients than in controls (p < 0.001). Moreover, patients carrying the FCN2 GG genotype in -986 position were more likely to develop lupus nephritis (odds ratio: 2.6 (95% confidence interval: 1.4-4.78); p = 0.006). The FCN2 AA genotype at position -4 was also identified as a possible risk factor for lupus nephritis (odds ratio: 3.12 (95% confidence interval: 1.25-7.84); p = 0.024).

CONCLUSION

The FCN2 promoter polymorphisms may contribute to susceptibility to pSLE in Egyptian children and adolescents. Moreover, the FCN2 GG genotype at position -986 and AA genotype at position -4 were associated with low serum ficolin-2 levels and may constitute risk factors for lupus nephritis in pSLE.

Different Score Systems to Predict Mortality in Living Donor Liver Transplantation: Which Is the Winner? The Experience of an Egyptian Center for Living Donor Liver Transplantation

INTRODUCTION

Many scoring systems have been proposed to predict the outcome of deceased donor liver transplantation. However, their impact on the outcome in living donor liver transplantation (LDLT) has not yet been elucidated. This study sought to assess performance of preoperative Model for End-Stage Liver Disease (MELD) score in predicting postoperative mortality in LDLT and to compare it with other scores: MELDNa, United Kingdom End-Stage Liver Disease (UKELD), MELD to serum sodium ratio (MESO), updated MELD, donor age-MELD (D-MELD) and integrated MELD (iMELD).

METHODS

We retrospectively analyzed data from 86 adult Egyptian patients who underwent LDLT in a single center. Preoperative MELD, MELDNa, MESO, UKELD, updated MELD, D-MELD, and iMELD were calculated. Receiver-operator characteristic (ROC) curves and area under the curve (AUC) were used to assess the performance of MELD and other scores in predicting postoperative mortality at 3 months (early) and 12 months.

RESULTS

Among the 86 patients, mean age 48 ± 7 years, 76 (88%) were of male sex and 27 (31.4%) had died. Preoperative MELD failed to predict early mortality (AUC = 0.63; P = .066). Comparing preoperative MELD with other scores, all other scores had better predictive ability (P < .05), with D-MELD on the top of the list (AUC = 0.68, P = .016), followed closely by UKELD (AUC = 0.67, P = .025). After that were iMELD, MESO, and MELDNa with the same predictive performance (AUC = 0.65; P < .05); updated MELD had the lowest prediction (AUC = 0.640; P = .04). Moreover, all scores failed to predict mortality at 12 months (P > .05).

CONCLUSIONS

Preoperative MELD failed to predict either early or 1-year mortality after LDLT. D-MELD, UKELD, MELDNa, iMELD, and MESO could be used as better predictors of early mortality than MELD; however, we need to develop an effective score system to predict mortality after LDLT.

Pleural Lavage: A Novel Diagnostic Approach For Diagnosing Exudative Pleural Effusion

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy.

Dysregulated endothelial cell markers in systemic lupus erythematosus: a systematic review and meta-analysis

OBJECTIVES

To perform a systematic literature review and meta-analysis on endothelial cell (EC) markers that are involved and dysregulated in systemic lupus erythematosus (SLE) in relation to disease activity, as EC dysregulation plays a major role in the development of premature atherosclerosis in SLE.

METHODS

Search terms were entered into Embase, MEDLINE, Web of Science, Google Scholar and Cochrane. Inclusion criteria were 1) studies published after 2000 reporting measurements of EC markers in serum and/or plasma of SLE patients (diagnosed according to ACR/SLICC criteria), 2) English language peer reviewed articles, and 3) disease activity measurement. For meta-analysis calculations, the Meta-Essentials tool by Erasmus Research Institute and of Management (ERIM) was used. Only those EC markers, which were 1) reported in at least two articles and 2) reported a correlation coefficient (i.e. Spearman's rank or Pearson's) between the measured levels of the EC marker and disease activity were included. For meta-analyses, a fixed effect model was used.

RESULTS

From 2133 hits, 123 eligible articles were selected. The identified SLE-related endothelial markers were involved in EC activation, EC apoptosis, disturbed angiogenesis, defective vascular tone control, immune dysregulation and coagulopathy. Meta-analyses of primarily cross-sectional studies showed significant associations between marker levels and disease activity for the following endothelial markers: Pentraxin-3, Thrombomodulin, VEGF, VCAM-1, ICAM-1, IP-10 and MCP-1. Dysregulated EC markers without associations with disease activity were: Angiopoeitin-2, vWF, P-Selectin, TWEAK and E-Selectin.

CONCLUSIONS

We provide a complete literature overview for dysregulated EC markers in SLE comprising a wide range of different EC functions. SLE-induced EC marker dysregulation was seen with, but also without, association with disease activity. This study provides some clarity in the eminent complex field of EC markers as biomarkers for SLE. Longitudinal data on EC markers in SLE are now needed to guide us more in unravelling the pathophysiology of premature atherosclerosis and cardiovascular events in SLE patients.

Predictors of Mortality in Living Donor Liver Transplantation

BACKGROUND

Egypt has the highest prevalence of the world hepatitis C virus (HCV) load. Hence, the problem of end-stage liver disease (ESLD) is considered a huge burden on the community. Living donor liver transplantation (LDLT) is the only source of donation in Egypt till now. Survival rates had shown significant improvement in the past decades. This study provides analysis of the mortality rates and possible predictors of mortality following LDLT. It also aids in developing a practical and easy-to-apply risk index for prediction of early mortality.

PATIENTS AND METHODS

This study is a retrospective study that was designed to analyze data from 128 adult patients with ESLD who underwent LDLT in the Liver Transplantation Unit at Faculty of Medicine, Cairo University. Early and late mortality were identified. All potential risk factors were tested using univariate regression for association with early and late mortality. Significant variables were then entered into a multivariable logistic regression model for identifying the predictors for mortality.

RESULTS

Sepsis was the most common cause of early mortality. Early mortality and 1-year mortality were 29 (23%) and 23 (18%), respectively. Model for End-Stage Liver Disease (MELD) score, intraoperative packed red blood corpuscles (RBCs), and duration of intensive care unit (ICU) stay were found to be independently associated with early mortality.

CONCLUSION

A MELD score >20, intraoperative transfusion >8 units of packed RBCs, and ICU stay >9 days are three independent predictors of early mortality. Their incorporation into a combined Risk Index can be used to improve outcomes of LDLT.

The impact of gadolinium-based MR contrast on radiotherapy planning for oropharyngeal treatment on the MR Linac

PURPOSE

Gadolinium-based contrast agents (GBCAs) may add value to magnetic resonance (MR)-only radiotherapy (RT) workflows including on hybrid machines such as the MR Linac. The impact of GBCAs on RT dose distributions however have not been well studied. This work used retrospective GBCA-enhanced datasets to assess the dosimetric effect of GBCAs on head and neck plans.

METHODS

Ten patients with oropharyngeal squamous cell carcinoma receiving RT from November 2018 to April 2020 were included in this study. RT planning included contrast-enhanced computed tomography (CT) and MR scans. A contrast agent "contour" was defined by delineating GBCA-enhanced regions using an agreed window/level threshold, transferred to the planning CT and given a standardized electron density (ED) of 1.149 in the Monaco treatment planning system (Elekta AB). Four plans were per patient calculated and compared using two methods: (1) optimized without contrast (Plan A) then recalculated with ED (Plan B), and (2) optimized with contrast ED (Plan C) then without (Plan D). For target parameters minimum and maximum doses to 1cc of PTVs, D95 values, and percent dose differences were calculated. Dose differences for organs-at-risk (OARs) were calculated as a percentage of the clinical tolerance value. For the purposes of this study, ±2% over the whole treatment course was considered to be a clinically acceptable dose deviation. Wilcoxon-signed rank tests were used to determine any dose differences within and between the two methods of optimization and recalculation (p < 0.05). Pearson's correlations were used to establish the relationship between gadolinium uptake volume in a structure (i.e., proportion of structure covered by a density override) and the resulting dose difference.

RESULTS

The median percent dose differences for key reportable dosimetric parameters between non-contrast and simulated contrast plans were <1.2% over all fractions over all patients for reportable target parameters (mean 0.34%, range 0.22%-1.02%). The percent dose differences for maximum dose to 1cc of both PTV1 and PTV2 were significantly different after application of density override (p < 0.05) but only in method 2 (Plan C vs. Plan D). For D95 PTV1, there was a statistically significant effect of density override (p < 0.01), however only in method 1 (Plan A vs. Plan B). There were no significant differences between calculation methods of the impact of contrast in most target parameters with the exception of D95 PTV1 (p < 0.01) and for D95 PTV2 (p < 0.05). The median percent dose differences for reportable OAR parameters as a percentage of clinical planning tolerances were <2.0% over a full treatment course (mean 0.65%, range 0.27%-1.62%). There were no significant differences in dose to OARs within or between methods for contrast impact assessment.

CONCLUSIONS

Dose differences to targets and OARs in oropharyngeal cancer treatment due to the presence of GBCA were minimal, and this work suggests that prospective in vivo evaluations of impact may not be necessary in this clinical site. Accounting for GBCAs may not be needed in daily adaptive workflows on the MR Linac.

Faciometrics: a new syntax for facial feature analysis

A little neglect appears to exist in current cephalometric soft tissue analysis. Specifically, some areas of the facial integument are not accessible to cephalometric analysis. Further, no method of frontal cephalometric soft tissue analysis has been described. Faciometrics, a new cephalometric, nonradiographic system for facial feature analysis, may carry professional diagnostic capacity to another dimension by providing an evaluation for previously inaccessible facial areas and by supplying a beginning for frontal cephalometric soft tissue analysis. The reliability and the validity of the proposed system were tested on a random sample of 20 subjects. The system was found to be reliable and valid. A method for rapid checking of facial symmetry is also described, and some equations for facial proportions are presented as guidelines for good facial esthetics. The faciometric system is proposed as a complement to, rather than a replacement for, available soft tissue cephalometric analysis.

Monitoring Of IGF-1 Levels In Type 2 Diabetic Patients With Macro And Microvascular Complications

Introduction/Objective

Introduction: Type-2 diabetes have a risk factor of multiple complications such as coronary artery diseases (CAD), premature atheroscalerosis and diabetic retinopathy. IGF-1 is regulated by a balance of hormones such as growth hormone and insulin. It is important that circulating IGF1 in serum has normal levels to maintain glucose metabolism.

Objectives: Monitoring of IGF-1levels in T2DM with macrovascular complications (CVD) and microvascular complications (retinopathy).

Methods

Subjects and methods: The collection of samples started in June 2018 and ended in December 2018. A total of 114 subjects were enrolled in this study; 98 clinically diagnosed T2D patients who were recruited from the outpatient clinic of the National Institute for Diabetes and Endocrinology “NIDE”, in addition to 16 healthy comparable control subjects (without diabetes). The subjects divided into 3 groups. Group 1; a population of 44 T2D patients with macrovascular complications (28 females and 16 males), the mean age was 57.4 years. Group 2; a population of 54 T2D patients with microvascular complicatios (34 females and 20 males), the mean age was 59.1 years. Group 3; a population of 16 healthy subjects (12 female and 4 males), the mean age was 59.2 years. Levels of FBS, C-peptide, HbA1c, Lipid profile, lipoprotein(a), hs-CRP and microalbuminurea were measured in all subjects. Seum concentration of IGF-1 was measured by commercially immunoenzymatic ELIZA method.

Results

It was found that serum concentration of IGF-1 decreased in diabetic patients groups compared to the control one. The mean±SD of group 1, group 2 and group 3 were (332.2±152.2), (316.9 ±142.2) and (625.4 ± 257.7) respectively.

Conclusion

It was observed that there was a negative correlation between serum IGF-1 levels in T2D patients compared to the control group. Also, it was found that T2D patients with microvascular complications had lower IGF-1 levels than patients with macrovascular ones. It seems that IGF-1 strongly involved in the incidence and pathogenesis of T2DM complications.

Prevalence of Rifampicin resistance tuberculosis among presumptive tuberculosis patients in Egypt-2021: a national health facility-based survey

BACKGROUND

The magnitude of MDR-TB cases was noticeable in Egypt. However, the last national survey was 11-years ago. The current survey was conducted to determine the prevalence of rifampicin resistance among sputum smear-positive pulmonary tuberculosis patients in Egypt.

METHODS

A national health facility-based cross-sectional study was conducted in 14 randomly selected governorates in Egypt between August 2020 and September 2021. All presumptive TB cases, either new or previously treated according to WHO definitions, with no gender, age, or nationality limitations, and provided informed consent were included in the study. Each patient completed a case report form (CRF). The CRF included socio-demographic and clinical data. Sputum samples were collected according to standard techniques and cultured on Lowenstein-Jensen (L-J) medium. Gene X-pert test was carried out first on the samples for simultaneous identification of MTB and rifampicin resistance. The prevalence of RR was calculated using crude, cluster, and weighted methods. Factors associated with RR were analyzed by bivariate and multivariate techniques.

RESULTS

Among the total 849 presumptive TB patients enrolled in the study, 710 (83.6%) patients were subjected to Gene X-pert testing (MTB/RIF). The crude prevalence of RR was 3.32% (95% CI: 1.89-4.76%) among the new cases and 9.46% (95% CI: 2.63-16.29%) among the retreated cases with an overall estimate of 3.99%; (95% CI: 2.51-5.47%). By cluster analysis the overall prevalence of RR was 5.01% (95% CI: 2.90-7.13). Factors associated with the prevalence of RR were co-morbidity with bronchial asthma, drug abuse and history of contact with a family member with TB.

CONCLUSION

The prevalence of RR among either new or retreated cases TB patients was lower than the previous Egyptian rates in 2010-2012. The strongest predictor associated with RR was comorbidity with bronchial asthma.

The effect of the location of arteriovenous fistula on the right ventricle in end stage renal disease patients indicated for hemodialysis

Background

End-stage renal disease (ESRD) has significantly increased in developing countries such as Egypt [1]. There are many sites for arteriovenous fistula (AVF) creation. The most common sites for AVF are radio-cephalic AVF (RC-AVF) followed by brachio-cephalic AVF (BC-AVF) [2]. To date, there are no significant studies discussing the possible correlation between the AVF location and abnormalities in the right ventricle (RV) in hemodialysis (HD) patients.

Objective

To determine the best location for AVF in order to ensure the least possible hazardous side effects of the AVF on the RV.

Methods

Our study, designed as an interventional study, included 50 ESRD patients referred for primary AVF construction to start HD for the first time. Patients were divided into two groups, 25 patients each. one group underwent a RC-AVF construction and the other had a BC-AVF. We assessed the RV by two dimensional transthoracic echocardiography (2D TTE) twice for each patient, firstly just before the AVF surgery and secondly three months after AVF construction.

Results

There was a statistically significant difference in between study groups regarding change in RV Tei index (p=0.001) with a decrease in the radial group (Mean ± SD = −0.19±0.2) and an increase in the brachial group (Mean ± SD = 0.02±0.12), and regarding the right ventricular outflow tract proximal diameter (p&lt;0.001) with a decrease in the radial group (Mean ± SD = −2.32±5.49) and a larger increase in the brachial group (Mean ± SD = 2.94±3.14). Changes in the other RV dimensions and functional parameters did not show statistically significant difference.

Conclusion

After three months follow up, despite the fact that all the RV parameters remained within the normal range, the RV indices with the RC-AVF were associated with either improvement or less decline than with the BC-AVF.

Funding Acknowledgement

Type of funding sources: None.