Nahed A. Makhlouf

Clinicopathologic features and genotyping of patients with chronic HBV infection in the Upper Egypt

The aim of this study was to determine the clinicopathologic features and Hepatitis B virus genotypes in HBV-infected patients in the Upper Egypt. Eighty-three HBsAg-positive patients (28 carriers, 14 with chronic hepatitis, 32 with liver cirrhosis and 9 with hepatocellular carcinoma) were enrolled. Blood was collected and serum samples obtained were screened for Hepatitis markers genotyping was conducted for 6 HBV genotypes (A through F) using a method for genotyping HBV by primer specific polymerase chain reaction. Genotype D was the only genotype detected in different clinical forms of chronic HBV infection (carriers, chronic hepatitis, cirrhosis and hepatocellular carcinoma) and, in all patients who had elevated or normal alanine aminotransferase levels and in all ages. HBeAg was absent in 78 patients suggesting the presence of pre-core or core mutations. Positive correlation was found among serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), histological activity index and grade of hepatitis. This study provides the first indication about the clinicopathologic features of HBV-infected patients in the Upper Egypt. It also reports the predominance of genotype D in this region.

Renal failure after upper-gastrointestinal bleeding among cirrhotic patients in Upper Egypt.

BACKGROUND AND STUDY AIMS Renal dysfunction is a common and serious problem in patients with advanced liver disease. The study aims to assess the incidence, risk factors and short-term prognosis of renal failure after upper-gastrointestinal bleeding among cirrhotic patients in Upper Egypt. METHODS We recruited 159 cirrhotic patients with 168 episodes of upper-gastrointestinal bleeding from Tropical Medicine and Gastroenterology Department, Assiut University Hospital. For all participants, the following were conducted: clinical evaluation, abdominal ultrasonography (US) examination, laboratory investigations and upper endoscopy. Risk factors of renal failure were identified using univariate, then multivariate analysis. RESULTS The incidence of renal failure among bleeding episodes was 28%. Higher risk of renal failure among cirrhotic patients with upper-gastrointestinal bleeding was observed with shock (odds ratio (OR) 0.171, 95% confidence interval (CI) 0.047:0.624), bacterial infection (OR 0.310, 95% CI 107:897), Child-Pugh class C (OR 2.79, 95% CI 1.018:7.62), higher serum bilirubin (OR 0.122, 95% CI 0.000:0.002), lower serum albumin (OR -0.188, 95% CI -0.288:-0.056) and raised baseline blood urea (OR 0.181, 95% CI 0.003:0.017) and serum creatinine (OR 0.533, 95% CI 0.002:0.004). Mortality among patients with renal failure was 31.9%. CONCLUSION Renal failure is a frequent event among cirrhotic patients with upper-gastrointestinal bleeding and there are many contributing factors for its development. Mortality is relatively high among patients with renal failure in cirrhotics with upper-gastrointestinal bleeding.

Types and microbiological spectrum of infections in patients with cirrhosis: A single-centre experience in Upper Egypt

BACKGROUND AND STUDY AIMS Egypt has a high prevalence of hepatitis C virus (HCV) and high morbidity and mortality related to cirrhosis complications. Patients with cirrhosis have an increased risk of bacterial infections. Approximately 25-35% of cirrhotics had infections at admission or during hospitalisation. Data on infection among cirrhotics in Egypt are limited. This study aimed to determine the frequency and microbiological spectrum of infections in cirrhotics and possible risk factors. PATIENTS AND METHODS This study was conducted at a tertiary care hospital. The frequency and microbiological spectrum of infections in cirrhotics were determined. The risk factors for infection were evaluated. RESULTS Of the 100 patients with liver cirrhosis, 61% had infection. Ascitic fluid infection (AFI) was the most common infection (44.3%), followed by urinary tract infection (UTI) (21.3%), respiratory tract infection (RTI) (19.7%), gastroenteritis (6.6%) and skin infection (4.9%). The only risk factor for infection among cirrhotics was diabetes mellitus (DM) (p=0.047). The mean value of mid-arm muscle circumference was significantly lower in the infected group (p=0.047). Among all the cirrhotics, 32.0% had mild to moderate malnutrition and 52.0% had severe malnutrition. The frequency of infection was higher in severe malnutrition (71.2%). CONCLUSIONS The frequency of infections among cirrhotics was 61%. Many types of infections including AFI, RTI, UTI and skin infections were present in patients with liver cirrhosis, but AFI was the most common. DM was the only risk factor for infection, and independent predictors for infection were elevated WBC count and C-reactive protein levels. The frequency of infection was related to the degree of malnutrition.

Non-invasive assessment of liver fibrosis in patients with hepatitis C: Shear wave elastography and colour Doppler velocity profile technique versus liver biopsy

BACKGROUND AND STUDY AIMS Determination of the presence and degree of liver fibrosis is essential for the prognosis and treatment of patients with chronic hepatitis C. Non-invasive methods of assessing fibrosis have been developed to reduce the need for biopsy. We determined the efficacy of shear wave elastography (SWE) and colour Doppler velocity as non-invasive methods for the assessment of liver fibrosis compared to liver biopsy among patients with chronic hepatitis C virus (HCV) infection. PATIENTS AND METHODS In total, 117 patients with chronic HCV infection and 50 healthy age- and sex-matched control subjects were included. For each patient and control, abdominal ultrasonography, Doppler ultrasonography of the right portal vein (PV), and SWE were performed, whereas liver biopsy was performed for patients. RESULTS The mean value of the right PV maximum velocity was lower in patients with different stages of fibrosis than in controls (p<0.001). The mean value of liver stiffness determined by SWE was significantly higher in patients with different stages of fibrosis than in controls. Cutoff values for liver stiffness determined by SWE for assessing fibrosis stages were F2⩾4.815, F3⩾6.335, and F4=7.540 with a sensitivity of 84.6%, 96.2%, and 100.0%; specificity of 88.5%, 93.8%, and 100.0%; positive predictive value (PPV) of 93.6%, 98.0%, and 100.0%; negative predictive value (NPV) of 74.2%, 88.2%, and 100.0%; and overall accuracy of 85.9%, 95.6%, and 100.0% [area under the ROC curve (AUC): 0.89, 0.96, and 1.0], respectively. Cutoff values for the right PV maximum velocity for assessing fibrosis stages were F2<23.4, F3<21, and F4<20 with a sensitivity of 65.0%, 57.4%, and 57.1%; specificity of 59.8%, 76.4%, and 75.5%; PPV of 33.8%, 58.3%, and 32.0%; NPV of 84.4%, 75.7%, and 89.7%; and overall accuracy of 61.1%, 69.5%, and 72.5% (AUC: 0.614, 0.696, and 0.625), respectively. CONCLUSION SWE is effective for the non-invasive assessment of liver fibrosis in patients with HCV infection. SWE provides a more accurate correlation with liver fibrosis stage than colour Doppler velocity profile for the assessment of liver fibrosis, especially in advanced stages (F3 and F4).

The efficacy of hepatitis B vaccination program in upper Egypt: Flow cytometry and the evaluation of long term immunogenicity.

Anti‐HBs levels wanes with time. Many studies discussed the B cell response to HBV vaccine. However, the data about memory T cell response are limited. To evaluate the efficacy of hepatitis B vaccine via evaluating anti‐HBs levels and HBsAg specific memory T‐lymphocytes through descriptive study. The study was conducted in a tertiary care setting. This study included 440 vaccinated persons during infancy. Group I: 6 to less than 10 years old; Group II: 10 to less than 14 years old; Group III: 14 to less than 17 years old; Group IV: 17 years old. The serum samples were screened for HBV markers. Cytokines secretion by HBsAg‐specific memory CD45RO+ CD4+ T cells was measured after in vitro culture using flow cytometry. The mean titer of anti‐HBs was higher in group I in comparison to others (P‐value = 0.000 for each). IFN‐γ and IL‐4 secreted by memory CD4+ T cells were positive in all with anti‐HBs >100 mIU/ml, while positive in 87% and 75% of participants with anti‐HBs <10 mIU/ml and positive in 73% and 32% of participants with absent anti‐HBs. The percentage of cells secreting IFN‐γ and those secreting IL‐4 were higher among participants with serum anti‐HBs >100 mIU/ml than those having <10 mIU/ml or absent (P < 0.001 for each). Anti‐HBs positivity decreased with time since childhood vaccination. Breakthrough infections are rare in vaccinated persons. Hepatitis‐B vaccine is efficient in controlling HBV infection. Flow cytometry is a useful tool to assess the long term persistence of T cell memory after childhood vaccination. J. Med. Virol. 88:1567–1575, 2016.

Button hole hernioplasty: A new technique for treatment of umblical hernia in cirrhotic patients. A prospective follow up study

BACKGROUND Surgical treatment of umbilical hernia in cirrhotic patients is still an interesting topic in many studies to achieve the best method of treatment. These patients are liable to many surgical and medical risks. AIMS to evaluate the surgical outcome as well as the postoperative course of Button hole hernioplasty as a simple, safe, and effective new technique for hernia repair in cirrhotic patients. METHODS Forty cirrhotic patients with uncomplicated umbilical hernia were included in this study through collaboration between Departments of General Surgery and Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, during one year period. Patients were categorized according to the severity of liver cirrhosis into three groups (A, B, and C). Patients were subjected to an elective hernioplasty after adjustment of the disturbed medical and biochemical factors. RESULTS There was a significant difference in operative time, hospital stay, and prothrombine (time and concentration) among the three groups (p < 0.05). The three parameters were longest in group C when compared to the other two groups. No severe complications were recorded except in only one case. Also, no recurrence, no morbidities or deaths were recorded after 6 months follow-up. CONCLUSIONS Button hole hernioplasty is a new simple surgical technique for treatment of umbilical hernia in cirrhotic patients with no significant complications.

Attitude of Upper Egypt Health-Care Professionals Toward Living Liver Donation and Transplantation

Background: In Egypt, there is no legislation for deceased donor transplant; therefore, programs provide living donation only. One possible barrier against living liver donation may be the attitude of the health-care professional. This study aimed to (1) assess the level of knowledge and attitude toward liver donation and transplantation among health-care professional in an University Hospital in Upper Egypt and (2) analyze the variables that affect such an attitude. Materials and Methods: This was a cross-sectional survey study with 300 health-care professionals. Results: The mean (standard deviation) age was 27.4 (5.3) years. Two hundred (66.7%) were females, and 257 (85.7%) were Muslims. A total of 222 (74%) were residents in University Hospitals. Of the sample, 104 (34.7%) would donate a living liver part, 122 (40.7%) discussed the matter of organ donation and transplantation with their family, and 134 (44.7%) did not discuss this issue with their family. About 40% knew the attitude of their religion toward organ donation. Most (94.7%) health professionals were <40 years and did not know the attitude of their religion toward this issue. Single persons had more correct information regarding living organ donation and transplantation. More Muslims know the attitude of their religion toward living organ donation and transplantation. Conclusions: Independent predictors of accepting living liver donation are being younger, knowledge of religion attitude, and media coverage satisfaction (P = 0.006, odd ratio [OR] = 0.2; P = 0.000, OR = 0.39; and P = 0.016; OR = 0.38).

Wandering spleen in the pelvic region in an adult man with symptoms of acute abdomen.

UNLABELLED Wandering or ectopic spleen is a condition characterised by migration of spleen in the abdomen or pelvis. This anomaly is rare, with a reported incidence of <0.2%. It occurs mostly in women between 20 and 40years of age. Clinical diagnosis is difficult because of lack of precise signs, symptoms, and nonspecific laboratory data. Diagnosis of a wandering spleen highly depends on the results of imaging studies such as abdominal ultrasound and abdominopelvic computed tomography (CT) scanning. Treatment includes surgery with the choice between splenopexy in a noninfarcted spleen and splenectomy when infarction has occurred. We report a rare case of wandering spleen in a 27-year-old man with infarction due to torsion of its pedicle, which was diagnosed by CT and treated by splenectomy. CONCLUSION Despite the rarity of wandering spleen, the possibility of torsion of its long pedicle with acute splenic infarction should be considered in the differential diagnosis of acute abdomen.

Multidisciplinary decision making in the management of hepatocellular carcinoma: A hospital-based study.

BACKGROUND/AIMS To evaluate the short-term outcome of the decision taken by the Hepatoma Board for the treatment of Hepatocellular carcinoma (HCC). MATERIALS AND METHODS This was a prospective descriptive study involving 74 patients with HCC diagnosed by the known criteria. The decisions taken by the Hepatoma Board for the 74 patients were as follows: 1- surgical resection (7 patients), 2- local ablative therapy (LAT) (22 patients), 3- conventional transarterial chemoembolization (TACE) (24 patients), and 4- palliative supportive care (21 patients). RESULTS The short-term mortality rate was 25.7% of the total patients. The success rate was nearly equal in LAT (68.2%) and surgery (71.4%), whereas the success rate was approximately 33.3% in TACE. There was no difference in the mean total bilirubin level before and after LAT, surgery, or TACE (p>0.05 for each). There was a significant decrease in the mean serum albumin level after TACE (p=0.000). There was a decrease in the mean alpha fetoprotein level after surgery and LAT (p=0.033) for surgery and (p=0.048) for LAT. CONCLUSION The management of HCC is better performed through a multidisciplinary team decision. Surgery has comparable outcome to LAT but is more invasive. According to our local experience, conventional TACE has a success rate of 33.3%.

Ante-natal screening of pregnant women for hepatitis B virus infection in Upper Egypt: A Tertiary Care Center Based Study

Background Vertical transmission of hepatitis B virus (HBV) is known to be the most common cause of perinatal infection. Purpose of the study The aim of the study was to demonstrate the prevalence and possible risk factors for HBV infection among pregnant women in upper Egypt and to target women for postpartum immunization. Patients and methods A total of 294 pregnant Egyptian women were consecutively recruited from outpatients’ clinic of women healthcare center of Assiut University hospital. Clinical evaluation and questionnaire about risk factors for HBV transmission were performed. Blood samples were tested for hepatitis B surface antigen (HBsAg), antibody against hepatitis B surface (anti-HBs), and antibody against hepatitis B core (anti-HBc). Positive samples for HBsAg were tested for hepatitis B envelope antigen (HBeAg) and quantitative PCR for HBV. Newborns of HBsAg-positive mothers were tested for HBsAg immediately after labor and 9 months later. Passive-active immunization was given to newborns of HBsAg-positive mothers. Results The prevalence of HBsAg among pregnant women was 4.8%. Target women for postpartum vaccination were 82.3% (those with negative anti-HBs). PCR for HBV was positive in 50% of HBsAg-positive pregnant women. None of the newborns of infected mothers were positive for HBsAg at birth and after 9 months. Previous blood transfusion, HBV infection in the family, and family history of liver disease were significant predictive factors for HBV infection in univariate analysis among Egyptian pregnant women. HBV infection in the family was the only independent predictor for HBV infection among pregnant women. Conclusion There is an intermediate prevalence (4.8%) of HBV infection among upper Egyptian pregnant women. Family history of HBV infection is the only independent risk factor for HBV infection among pregnant women. Passive-active immunization to newborns of infected mothers resulted in 100% reduction of perinatal HBV infection.