Publications by authors named "Ahmed Helmy"

67 Publications

Ramadan and Diabetes: A Narrative Review and Practice Update.

Diabetes Ther 2020 Sep 9:1-44. Epub 2020 Sep 9.

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

Electronic Supplementary Material: The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.
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http://dx.doi.org/10.1007/s13300-020-00886-yDOI Listing
September 2020

Ramadan and Diabetes: A Narrative Review and Practice Update.

Diabetes Ther 2020 Nov 9;11(11):2477-2520. Epub 2020 Sep 9.

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.
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http://dx.doi.org/10.1007/s13300-020-00886-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480213PMC
November 2020

COVID-19, Diabetes and Ramadan.

Diabetes Ther 2020 Nov 3;11(11):2447-2451. Epub 2020 Sep 3.

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.

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http://dx.doi.org/10.1007/s13300-020-00887-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471486PMC
November 2020

Rare encounter: hydrocoele of canal of Nuck in a Scottish rural hospital during the COVID-19 pandemic.

BMJ Case Rep 2020 Aug 11;13(8). Epub 2020 Aug 11.

General Surgery, NHS Highland, Fort William, Scotland, UK

We report the case of a 32-year-old woman who presented with reducible indirect inguinal hernia and a challenging constellation of symptoms, signs and radiographic findings. Surgical approach superseded conservative management when the patient's abdomen became acute, with a rising lactate and haemodynamic instability. Specifically, the presence of a fluid collection was concerning for sinister acute pathology. Our patient was rediagnosed intraoperatively with hydrocoele of canal of Nuck. This so-called 'female hydrocoele' is an eponymous anatomical rarity in general surgery, presenting as an inguinolabial swelling with variable clinical profile. Hydrocoele of canal of Nuck takes origin from failure of transitory reproductive anlagen to regress and is thus analogous to patent processus vaginalis. Its true incidence is speculative, with just several hundred cases globally. We aim to provide insights into surgical patient management for a rare entity during the COVID-19 outbreak, from the unique perspective of a small rural hospital in Scotland.
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http://dx.doi.org/10.1136/bcr-2020-237169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418684PMC
August 2020

Neurobehavioral effects of alcohol in overcrowded male adolescent rats.

Neurosci Lett 2020 07 30;731:135084. Epub 2020 May 30.

Department of Pharmacology & Toxicology, Faculty of Pharmacy, Cairo University, Egypt.

Being a critical neurodevelopmental stage that is affected by social conditions, the period of adolescence was chosen as the age of examining possible modification of alcohol neurobehavioral effects by overcrowding. Adolescent male rats (postnatal day 35±1) were subjected to overcrowding and/or injected with ethanol, 2 g/kg, 20% w/v, (i.p.) for one week. 24 h after the last dose, motor, exploratory behavior, sociability and fear responses were assessed using open field, social interaction and defensive probe burying tests, respectively. Wet brain tissue nitric oxide and reduced glutathione contents as well as monoamine levels, namely dopamine, norepinephrine and serotonin, in addition to 5-HIAA were estimated. Overcrowding increased social play and freezing time. Alcohol administration under overcrowding condition impaired sociability and interfered with active fear response. Alcohol in normal or in under overcrowding condition, impaired motor and exploratory behavior and increased anxiety. These results indicate that concomitant exposure of male adolescent rats to overcrowding and alcohol induced adverse behavioral changes.
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http://dx.doi.org/10.1016/j.neulet.2020.135084DOI Listing
July 2020

Surveillance of antibiotic resistance among uropathogens in Aljouf region northern Saudi Arabia.

Iran J Microbiol 2019 Dec;11(6):468-477

Department of Microbiology, Microbiology Laboratory, Prince Mutaib Hospital, Sakaka, Saudi Arabia.

Background And Objectives: Urinary tract infections are common health problem affecting millions worldwide. Antibiotic resistance among uropathogens (Ups) is prevalent in many countries. In the absence of any available data in the region, this hospital-based study investigated the pattern, frequency and susceptibility of Ups at Prince Mutaib Bin Abdulaziz Hospital, Aljouf Region, Saudi Arabia.

Materials And Methods: A retrospective assessment of UPs and their antibiotics susceptibility was conducted from January 2017 to December 2017 using the fully automated Vitek2 system (BioMérieux, France).

Results: Among the 415 uropathogens isolates, the most prevalent bacteria were Gram-negatives comprising 137 (51%) ; 46 (17.2%) spp.; 30 (11.2%) spp.; 25 (9.3%) spp.; 14 (5.2%) and 16 (5.9%) others. On the other hand, spp. were predominant among Gram-positive isolates representing 54 (36.7%), 47 (32.0%) spp., 22 (15.1%) spp., and 13 (8.8%) , and 11 (7.5%) others. Gram-negative Ups showed multidrug resistance towards the majority of the tested antimicrobials (ampicillins, cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, aztreonam, and nitrofurantoin). While high resistance patterns by Gram-positives was also seen against cephalosporins, penicillins, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole, clindamycin, erythromycin and tetracycline.

Conclusion: The observed widespread multidrug resistance clearly warrant implementing stricter control measures, local guidelines of antimicrobials usage, and continuous epidemiological surveys at hospitals and communities.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048966PMC
December 2019

Encapsulation of cinnamon oil in whey protein counteracts the disturbances in biochemical parameters, gene expression, and histological picture of the liver and pancreas of diabetic rats.

Environ Sci Pollut Res Int 2020 Jan 13;27(3):2829-2843. Epub 2019 Dec 13.

Food Toxicology & Contaminants Department, National Research Center, Dokki, Cairo, Egypt.

This study aimed to evaluate the protective role of encapsulated cinnamon oil emulsion (COE) in whey protein concentrate (WPC) against the disturbance in lipid profile, oxidative stress markers, and gene expression in streptozotocin (STZ)-treated rats. COE was analyzed using GC-MS, and the emulsion was prepared and characterized. In the in vivo study, six groups of male rats were treated orally for 4 weeks, including the control group, the group treated with STZ (D-rats), the groups received a low or high dose of COE (200 or 400 mg/kg B.w.), and the D-rats groups received COE at the low or high dose. Blood and tissue samples were collected after the end of the treatment period for biochemical, genetical, and histological analyses. The GC-MS results revealed that the major components of the oil were cinnamaldehyde, 1,8 cineole, acetic acid, 1,7,7-trimethylbicyclo[2.2.1]hept2yl ester, α-Pinene, and α-Terpineol. The size, zeta potential, and polydispersity index (PDI) of COE were 240 ± 1.03 nm, - 7.09 ± 0.42, and 0.36, respectively. The in vivo results revealed that COE at the two tested doses improved the levels of glucose, insulin, amylase, lipid profile, hepatic MDA, SOD, and GSH. COE also downregulated hepatic GLU2, FAS, SREBP-1c, and PEPCK gene expression and upregulated IGF-1 mRNA expression in diabetic rats in a dose-dependent manner. Moreover, COE improved and the histological picture of the liver and pancreas. It could be concluded that COE overcomes the disturbances in biochemical, cytological, and histopathological changes in D-rats via the enhancement of antioxidant capacity; reduces the oxidative stress; modulates the concerned gene expression; and may be promising to develop new drugs for diabetic treatment.
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http://dx.doi.org/10.1007/s11356-019-07164-wDOI Listing
January 2020

Differential Expression of RAGE, EGFR and Ki-67 in Primary Tumors and Lymph Node Deposits of Breast Carcinoma

Asian Pac J Cancer Prev 2018 Aug 24;19(8):2269-2277. Epub 2018 Aug 24.

Department of Pathology, Theodor Bilharz Research Institute, Cairo, Egypt. Email:

Background: Breast cancer is a complex disease that results from the inheritance of a number of susceptible genes. Intensive search wok was conducted world-wide on molecular bases of breast cancer in order to achieve the best therapeutic modalities; however, breast cancer still remains a challengeable task. It is very important to determine if the biological parameters in metastatic regional lymph nodes are similar to that in the primary breast cancer because therapy is indicated for patients with synchronous metastatic regional lymph nodes of breast cancer. Difference in therapeutic response in cases of breast cancer may be assumed partially to variability in the biological behavior of tumor tissue in primary breast cancer and lymph node metastasis. Aim: Our aim is to evaluate any variability in the expression of three types of tissue markers in both the primary breast tumors and corresponding axillary lymph nodes in order to expect the targeted therapeutic effect on both sites. Material and Methods: Three markers from different categories; RAGE, EGFR and Ki-67 were immunohistochemicalyl studied for their expression in biopsy specimens from primary breast tumors and their corresponding axillary lymph nodes. Results: There was a statistically significant difference in the expression of these markers between benign and malignant breast lesions.Although we found some differences in the expression of the three studied markers between primary breast cancer and corresponding axillary lymph nodes, yet these variations were mostly not statistically significant. Conclusion: Our findings support the validity of anti-RAGE and anti-EGFR therapy for treatment of both primary and nodal metastatic breast cancer in immunopositive cases.
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http://dx.doi.org/10.22034/APJCP.2018.19.8.2269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6171384PMC
August 2018

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

Prog Transplant 2018 09 19;28(3):256-262. Epub 2018 Jun 19.

1 Faculty of Medicine, Department of Tropical Medicine and Gastroenterology, Assiut University, Assiut, Egypt.

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).
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http://dx.doi.org/10.1177/1526924818781565DOI Listing
September 2018

Expression of hnRNPK & Claudin-4 in HCV-Induced Early HCC and Adjacent Liver Tissue.

Open Access Maced J Med Sci 2017 Aug 31;5(5):595-602. Epub 2017 Jul 31.

Department of General Surgery, Theodor Bilharz Research Institute (TBRI), Imbaba, Giza, Egypt.

Background: HCC in Egypt usually occurs in HCV cirrhotic livers with poor prognosis due to late diagnosis. High hnRNPK & low Claudin-4 profiles indicate Epithelial Mesenchymal Transition (EMT), malignant transformation and high-grade tumours.

Aim: We studied the immunohistochemical expression of hnRNPK and Claudin-4 in HCV induced early HCC (eHCC) and adjacent liver tissue in Egyptian patients to improve eHCC detection in cirrhotic livers with better curative therapy options.

Method: We studied the immunohistochemical expression of hnRNPK and Claudin-4 in 100 Egyptian patients resection specimens of HCV induced early HCC (eHCC) and adjacent liver tissue, in order to improve eHCC detection in cirrhotic livers, thus improving their therapeutic options.

Results: Early HCC grade significantly directly correlated with nuclear hnRNPK/5HPFs count and inversely correlated with Claudin-4 expression %, with a converse correlation between hnRNPK and Claudin-4. Moreover in eHCC, combined hnRNPK ≥ 30/5HPFs & Claudin-4 ≥ 40% significantly distinguished low grade eHCC (G1) from high grade eHCC (G2&G3), with sensitivity 97% & specificity 69.7% for hnRNPK ≥ 30/5HPFs, and with sensitivity 70% & specificity 94.3% for Claudin-4 ≥ 40%. Moreover in the adjacent liver, both markers expressions significantly directly correlated with each other and with METAVIR fibrosis score but not with activity. Furthermore, 58% of eHCCs showed hnRNPK ≥ 30 Claudin-4 < 40% profile, indicating EMT type 3, compared to 26% with hnRNPK ≥ 30 Claudin-4 ≤ 10% profile in adjacent cirrhotic/ precirrhotic liver, with significant use of combined hnRNPK ≥ 30/5HPFs & Claudin 4 ≤ 10% as eHCC prediction cut offs in cirrhosis (p < 0.05).

Conclusion: Combination of hnRNPK and Claudin-4 can indicate early HCC development in HCV cirrhotic livers using hnRNPK ≥ 30/5HPFs & Claudin-4 ≤ 10% cut offs. Also, combination of hnRNPK ≥ 30/5HPFs & Claudin-4 ≥ 40% can distinguish low grade eHCC (G1) from high grade eHCC (G2&G3).
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http://dx.doi.org/10.3889/oamjms.2017.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591587PMC
August 2017

On-X versus St Jude Medical Mechanical Prosthesis in mitral position: are we moving forward in design technology?

J Cardiovasc Surg (Torino) 2018 Apr 28;59(2):252-258. Epub 2017 Jul 28.

Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, Banha University, Banha, Egypt.

Background: Continuous effort is still provided in designing optimal artificial heart valves with better hemodynamic function and reduced thromboembolic potential. The question is do we have moved forward toward this goal or not.

Methods: A prospective, randomized comparative study was done on 360 patients scheduled for elective mitral valve replacement. Patients were grouped into an On-X group (N.=180), who received On-X mechanical valve, and a SJM group (N.=180), who received St Jude mechanical valve. Echocardiographic and clinical assessments were performed for all patients at 6 and 12 months follow-up period.

Results: Rheumatic heart disease was the most common cause of valve affection (94.2%). Early mortality was 6.4%. The mean follow-up time was 3.11±2.44 years. No structural or non-structural valvular dysfunction and no thromboembolism cases were encountered. Late valve thrombosis was1.9%/patient-year in On-X group and 2.1%/patient-year in SJM group. The mean EOA was higher in On-X group (2.0±0.3 cm2) than in SJM group (1.9±0.2 cm2), (P≥0.05). The mean EOAI was higher in On-X group (1.1±0.1 cm2/m2) than in SJM group (1.0±0.1 cm2/m2), (P=0.034), especially significant in small valve size (25 mm) where it was 1.09±021 cm2/m2 in On-X group and 0.93±0.12 cm2/m2 in SJM group (P=0.02).

Conclusions: On-X and St Jude prosthetic valves have a comparable hemodynamic performance in mitral position. However, On-X prosthesis might have a forward step on the way of design technology that may allow better function in terms of EOA and EOAI especially in smaller valve size.
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http://dx.doi.org/10.23736/S0021-9509.17.10044-3DOI Listing
April 2018

Potential ultrastructure predicting factors for hepatocellular carcinoma in HCV infected patients.

Ultrastruct Pathol 2017 May-Jun;41(3):209-226. Epub 2017 May 11.

g Hepatogastroenterology Department , Theodor Bilharz Research Institute , Giza , Egypt.

Hepatitis C virus represents one of the rising causes of hepatocellular carcinoma (HCC). Although the early diagnosis of HCC is vital for successful curative treatment, the majority of lesions are diagnosed in an irredeemable phase. This work deals with a comparative ultrastructural study of experimentally gradually induced HCC, surgically resected HCC, and potential premalignant lesions from HCV-infected patients, with the prospect to detect cellular criteria denoting premalignant transformation. Among the main detected pathological changes which are postulated to precede frank HCC: failure of normal hepatocyte regeneration with star shape clonal fragmentation, frequent elucidation of hepatic progenitor cells and Hering canals, hepatocytes of different electron density loaded with small sized rounded monotonous mitochondria, increase junctional complexes bordering bile canaliculi and in between hepatocyte membranes, abundant cellular proteinaceous material with hypertrophied or vesiculated rough endoplasmic reticulum (RER), sequestrated nucleus with proteinaceous granular material or hypertrophied RER, formation of lipolysosomes, large autophagosomes, and micro-vesicular fat deposition. In conclusion, the present work has visualized new hepatocytic division or regenerative process that mimic splitting or clonal fragmentation that occurs in primitive creature. Also, new observations that may be of value or assist in predicting HCC and identifying the appropriate patient for surveillance have been reported. Moreover, it has pointed to the possible malignant potentiality of liver stem/progenitor cells. For reliability, the results can be subjected to cohort longitudinal study.
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http://dx.doi.org/10.1080/01913123.2017.1316330DOI Listing
March 2018

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

Arab J Gastroenterol 2017 Mar 3;18(1):6-12. Epub 2017 Mar 3.

Assuit University, Tropical Medicine & Gastroenterology Department, Assiut, Egypt.

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).
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http://dx.doi.org/10.1016/j.ajg.2017.01.004DOI Listing
March 2017

Polycystic ovary syndrome and endometrial hyperplasia: an overview of the role of bariatric surgery in female fertility.

Eur J Obstet Gynecol Reprod Biol 2016 Dec 17;207:220-226. Epub 2016 Oct 17.

Bariatric Unit, Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK.

One of the most effective methods to tackle obesity and its related comorbidities is bariatric surgery. Polycystic ovary syndrome (PCOS) and endometrial hyperplasia (EH), which are associated with increased risk of endometrial carcinoma, have been identified as potentially new indications for bariatric surgery. PCOS is the most common endocrine disorder in women in the reproductive age and is associated with several components of the metabolic syndrome such as obesity, insulin resistance and hypertension. EH is a pre-cancerous condition which arises in the presence of chronic exposure to estrogen unopposed by progesterone such as both in PCOS and obesity. The main bariatric procedures are Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. These procedures are well established and when correctly selected and performed by experienced bariatric surgeons, they can achieve significant weight loss and remission of obesity related co-morbidities. Studies have shown that bariatric surgery can play an important role in the management of patients with PCOS and improve fertility. Similarly, bariatric surgery has a positive effect on endometrial hyperplasia, making surgically induced weight loss a potentially attractive option for endometrial cancer prevention and treatment. Obesity has an adverse impact on spontaneous pregnancy, assisted reproduction methods and feto-maternal outcomes. After bariatric surgery obese women with subfertility can achieve spontaneous pregnancy. However, while bariatric surgery reduces the risk of pre-eclampsia and gestational diabetes, there is an increased risk of small for gestational age and possible increased risk of stillborn or neonatal death. In this article we will review the evidence regarding the use of bariatric surgery as a treatment modality in patients with PCOS and EH. We also provide an overview of the common bariatric procedures.
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http://dx.doi.org/10.1016/j.ejogrb.2016.10.001DOI Listing
December 2016

Asian-Pacific Association for the Study of the Liver (APASL) consensus guidelines on invasive and non-invasive assessment of hepatic fibrosis: a 2016 update.

Hepatol Int 2017 Jan 6;11(1):1-30. Epub 2016 Oct 6.

Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India.

Hepatic fibrosis is a common pathway leading to liver cirrhosis, which is the end result of any injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Despite the fact that liver biopsy (LB) has been considered the "gold standard" of assessment of hepatic fibrosis, LB is not favored by patients or physicians owing to its invasiveness, limitations, sampling errors, etc. Therefore, many alternative approaches to assess liver fibrosis are gaining more popularity and have assumed great importance, and many data on such approaches are being generated. The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The first consensus guidelines of the APASL recommendations on hepatic fibrosis were published in 2009. Due to advances in the field, we present herein the APASL 2016 updated version on invasive and non-invasive assessment of hepatic fibrosis. The process for the development of these consensus guidelines involved review of all available published literature by a core group of experts who subsequently proposed consensus statements followed by discussion of the contentious issues and unanimous approval of the consensus statements. The Oxford System of the evidence-based approach was adopted for developing the consensus statements using the level of evidence from one (highest) to five (lowest) and grade of recommendation from A (strongest) to D (weakest). The topics covered in the guidelines include invasive methods (LB and hepatic venous pressure gradient measurements), blood tests, conventional radiological methods, elastography techniques and cost-effectiveness of hepatic fibrosis assessment methods, in addition to fibrosis assessment in special and rare situations.
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http://dx.doi.org/10.1007/s12072-016-9760-3DOI Listing
January 2017

Single-stage, three-fold repair for Ebstein's anomaly.

Interact Cardiovasc Thorac Surg 2017 02;24(2):245-250

Department of Cardiovascular and Thoracic Surgery, Ain-Shams University Hospital, Faculty of Medicine, Cairo, Egypt.

Objectives: Favourable outcomes in the repair of Ebstein's anomaly are predicated on tricuspid valve competence, right ventricular function and presence of arrhythmia. We report our experience with a single-stage, three-fold repair of Ebstein's anomaly, namely, cone reconstruction of the tricuspid valve supplemented by bidirectional cavopulmonary anastomosis and right atrial electrocautery maze.

Methods: From 2010 to 2014, 37 consecutive patients with Ebstein's anomaly, median age 17.3 (9.1-56.2) years, underwent this single-stage, three-fold surgical procedure. The principal elements of the procedure include (i) cone reconstruction of the tricuspid valve, limited plication at the level of the displaced valve, insertion of a homemade annuloplasty ring, defect repair and reduction atrioplasty supplemented by (ii) right atrial electrocautery maze and (iii) bidirectional cavopulmonary anastomosis. Postoperatively, all patients were followed up regularly for a mean period of 2.3 (1-4) years by clinical, electrocardiographic and echocardiographic examinations.

Results: The in-hospital mortality rate was 2.7% (1 patient) with no late deaths. Mean cardiopulmonary bypass time was 110 ± 18.3 min and aortic cross-clamp time was 48.5 ± 7.4 min. Echocardiographic examination showed significant improvement of valve regurgitation (P < 0.0001). NYHA functional class was I in 77.8% of the survivors and II in 22.2%. The cardiothoracic ratio decreased significantly (P < 0.05). No deleterious effects of the Glenn shunts have been reported. Sinus rhythm has remained stable in 31 patients (86.1%) during the follow-up period.

Conclusions: Single-stage, three-fold repair for the management of Ebstein's anomaly offers good outcome in terms of low mortality and morbidity rates. It can achieve a durable valve-sparing repair, good functional mid-term outcomes and good quality of life among survivors.
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http://dx.doi.org/10.1093/icvts/ivw333DOI Listing
February 2017

The intraoperative therapeutic equivalence of balanced vs saline-based 6% hydroxyethyl starch 130/0.4 and their influence on perioperative acid-base status and renal functions.

J Clin Anesth 2016 Aug 23;32:267-73. Epub 2016 Apr 23.

Anesthesia & SICU Department, Faculty of Medicine, Cairo University, Cairo, Egypt.

Study Objective: This study was designed to evaluate the therapeutic equivalence of balanced 6% hydroxyethyl starch (HES) 130/0.4 (Tetraspan) vs saline-based 6% HES 130/0.4 (Voluven) regarding the volume effect and the effect on acid-base status and renal functions in patients undergoing major urologic procedures.

Design: Randomized comparative trial.

Setting: Operating room and ward.

Patients: Forty patients, American Society of Anesthesiologists statuses 1 and 2.

Intervention: Patients were randomly allocated to receive either Voluven (n = 20) or Tetraspan (n = 20).

Measurements: Hemodynamic variables. Laboratory variables in the form of arterial blood gases, serum chloride and sodium levels, hemoglobin level, international normalized ratio, and kidney and liver functions were measured after induction of anesthesia (T1), at the end of surgery (T2), and on the first postoperative day (T3).

Main Results: Both groups were comparable regarding the total amount of study drugs and crystalloid consumption. No significant difference in hemoglobin levels between both groups, but there were significant differences between T1 and T2 hemoglobin within both groups and T3 hemoglobin in the Tetraspan group. Both groups were comparable regarding the renal functions, but there was a significant difference between T1 and T2 creatinine within both groups. No significant differences between both groups in liver functions and coagulation profile, but there were significant differences between values at T1, T2 and T3 within each group. Relative to baseline, both pH and bicarbonate decrease significantly in both groups. In the Voluven group, bicarbonate decreased significantly at the end of surgery relative to the Tetraspan group. Serum electrolytes did not vary between both groups.

Conclusion: Both balanced 6% HES 130/0.4 (Tetraspan) and saline-based 6% HES 130/0.4 (Voluven) were equally effective for hemodynamic stabilization of patients undergoing major urologic procedures without any significant impact on acid-base status or renal functions.
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http://dx.doi.org/10.1016/j.jclinane.2016.01.025DOI Listing
August 2016

The role of Fibroscan in predicting the presence of varices in patients with cirrhosis.

Eur J Gastroenterol Hepatol 2015 Nov;27(11):1307-12

aGastroenterology Unit Department of Medicine, Departments of bMedical Education cPathology, College of Medicine dKing Saud University Liver Disease Research Center, King Saud University, Riyadh eGastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia fDepartment of Tropical Medicine & Gastroenterology, College of Medicine, Assuit University, Asyut, Egypt.

Background/aim: Transient elastography is a relatively new, noninvasive method of measuring liver stiffness. This study aimed to evaluate the diagnostic accuracy of transient elastography and other noninvasive methods for the diagnosis of esophageal varices (EV) in patients with cirrhosis.

Methods: This cross-sectional study graded EV according to size in 145 consecutive patients with cirrhosis who underwent endoscopy, Fibroscan, and other noninvasive diagnostic methods. The accuracy of these diagnostic methods in diagnosing EV was evaluated on the basis of area under receiver operating characteristic (AUROC) curves.

Results: Elastography was successful in 123 patients. Of these, 54.5% had hepatitis C and 10.6% had hepatitis B. EV were absent in 39.8%, small EV was present in 24.4%, and large EV was present in 35.8% of patients. Fibroscan, aspartate aminotransferase-to-platelet ratio index, and international normalized ratio showed low accuracy in diagnosing EV in non-viral-related cirrhosis patients (AUROCs 0.66, 0.68, and 0.67, respectively). Fibroscan and aspartate aminotransferase-to-platelet ratio index were more accurate in measuring EV with a viral etiology (AUROCs 0.704 and 0.703, respectively). A cutoff value of 16.9 kPa was 83.8% sensitive in diagnosing EV in non-viral-cirrhotic patients, whereas a cutoff value of 19.9 kPa was 83.4% sensitive in diagnosing EV in patients with viral hepatitis. Fibroscan was moderately accurate in diagnosing grade I EV and less accurate in diagnosing grades II and III EV in all cirrhotic patients, irrespective of the underlying etiology.

Conclusion: Fibroscan might be useful in predicting the presence of EV in patients with cirrhosis with a viral etiology. However, endoscopy remains the gold standard for EV screening.
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http://dx.doi.org/10.1097/MEG.0000000000000432DOI Listing
November 2015

Randomized clinical trial comparing two different techniques of local anesthesia (subcutaneous versus subcutaneous & deep infiltration) for postoperative pain in patients undergoing open appendecectomy.

J Egypt Soc Parasitol 2015 Apr;45(1):177-82

This study compared the postoperative analgesic effect of local anesthetic (LA) injected subcutaneous (SC) alone versus local anesthetic injected both SC and deep in patients undergoing open appendecectomy operations. Sixty patients ASA class I-II undergoing open appendecectomy for presumed acute appendicitis will be randomly assigned into three groups. After routine monitoring, anesthesia induction was performed with propofol, fentanyl and, cis-atracurium; later, maintenance was continued with isoflurane. GA received local infiltration of the skin prior to incision with bupivacaine 0.25% (10 ml), GB received received half the bupivacaine infiltrated into the skin and other half deep-to external oblique prior to incision to create a local nerve field blockade & GC received half dose of saline subcutaneous & half deep to external oblique muscle prior to incision. Postoperative pain was assessed using visual analogue score (VAS) at 1, 4, 8, & 24 hours post extubation. Pethidine 1 mg/kg was given if VAS is ≥ 4. All patients in GA (SC) and Control required postoperative analgesics, compared to only 60% of the patients in GB (SC+deep). Time for the first analgesic requirement was prolonged in GB compared to other groups (P < 0.01). VAS scores were significantly lower in patients of GB in the first 8 hr. postoperative compared to GA &GC (P < 0.01).
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http://dx.doi.org/10.12816/0010863DOI Listing
April 2015

Rare extraperitoneal involvement with fatal outcome in a case of bilateral luteinized thecoma of the ovaries with sclerosing peritonitis.

Case Rep Oncol Med 2014 5;2014:904581. Epub 2014 Jun 5.

Department of Internal Medicine, College of Medicine, 231 Albert Sabin Way, University of Cincinnati, Cincinnati, OH 45267-0557, USA ; The Vontz Center for Molecular Studies, 3125 Eden Avenue, University of Cincinnati, Cancer Institute, Cincinnati, OH 45267-0508, USA ; The Vontz Center for Molecular Studies, 3125 Eden Avenue, Division of Hematology and Oncology, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0508, USA.

We report the case of a woman diagnosed with bilateral luteinized thecoma of the ovaries with sclerosing peritonitis, multiple intraperitoneal cystic lesions, and extraperitoneal lesions of the liver, inferior to the spleen, and high suspicion of bone marrow involvement. The patient developed profound pancytopenia with rapid clinical deterioration and a fatal outcome.
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http://dx.doi.org/10.1155/2014/904581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4068060PMC
July 2014

Impact of liver biopsy on the decision to treat patients with chronic hepatitis B genotype D virus infection.

Intervirology 2014 28;57(5):248-53. Epub 2014 Jun 28.

Department of Infection and Immunity, The Research Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.

Objectives: Patients with chronic hepatitis B virus (HBV) may exhibit significant liver pathology despite alanine aminotransferase (ALT) and HBV DNA levels below the cutoff values advised by treatment guidelines. We evaluated candidacy for HBV therapy when baseline histopathological changes are taken into consideration.

Methods: Clinical, biochemical, serological, virological, and histopathological (METAVIR score) data of 117 patients with HBeAg-negative chronic HBV genotype D were collected and analyzed.

Results: Significant pathology (≥F2 and/or ≥A2) and fibrosis (≥F2 ± ≥A2) were found in 73 (62.4%) and 59 (50.4%) patients, respectively. Based on HBV DNA (>2,000 IU/ml) and ALT levels >2 × 40 U/l (the standard cutoff value), only 31 (26.5%) patients were candidates for therapy. This increased to 58 (49.6%) patients when the new ALT cutoff values (30 U/l for males, and 19 U/l for females) were applied. Relying on either ≥F2 and/or A ≥2 or ≥F2 ± ≥A2 increases the treatment candidacy to 73 (62.4%) and 59 (50.4%) patients, respectively. Also, when compared with standard ALT cutoff values, applying both new ALT cutoff values with either significant pathology or fibrosis increases treatment candidacy to 28 (23.9%) and 42 (35.9%) patients, respectively.

Conclusion: Liver pathology is more reliable than ALT and HBV DNA in the decision to treat patients with HBeAg-negative chronic HBV genotype D.
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http://dx.doi.org/10.1159/000360858DOI Listing
April 2015

One-stage percutaneous triple procedure for treatment of endoscopically unmanageable patients with malignant biliary obstruction and marked ascites.

Arab J Gastroenterol 2013 Dec 4;14(4):148-53. Epub 2013 Dec 4.

Department of Tropical Medicine & Gastroenterology, Assiut University Hospital & Faculty of Medicine, Assiut 71517, Egypt.

Background And Study Aims: To assess the feasibility, safety and efficacy of one-stage percutaneous triple procedure including; ascites drainage, primary metallic biliary stenting, and tract embolisation with N-butyl 2-cyanoacrylate (NBCA), in treatment of patients with malignant biliary obstruction and marked ascites.

Patients And Methods: This study involved 25 patients with malignant biliary obstruction and marked ascites (age range, 46-78y; mean age±SD, 65y±5) for whom endoscopic treatment failed or was unsuitable. Ascites drainage, percutaneous primary metallic biliary stenting, and tract embolisation with lipiodol/NBCA mixture were performed in a one-stage procedure. The mean±SD follow up period was 26±2weeks.

Results: The technical and clinical success rates were 96% and 88% respectively. No procedure related deaths or major complications were observed. The reported minor complications included; moderate pain and vomiting during and after balloon dilation, postprocedural cholangitis, and bile leakage in 44%, 16%, and 8% of the patients respectively. Primary stent patency was achieved in 96%. The 30-days mortality was 8%. The stent obstruction occurred in 3 (13%) of the 23 patients who survived more than 30-days.

Conclusions: Percutaneous drainage of ascites followed immediately by primary biliary stenting, together with tract embolisation with NBCA is technically feasible, safe, and effective alternative palliative treatment for endoscopically unmanageable patients with malignant biliary obstruction and marked ascites.
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http://dx.doi.org/10.1016/j.ajg.2013.10.004DOI Listing
December 2013

Correlation between hepatitis B surface antigen titers and HBV DNA levels.

Saudi J Gastroenterol 2013 Nov-Dec;19(6):252-7

Department of Medicine, College of Medicine; Liver Disease Research Center, King Saud University, Riyadh 11461, Saudi Arabia, .

Background/aim: To assess the correlation between serum HBsAg titers and hepatitis B virus (HBV) DNA levels in patients with hepatitis B envelop antigen-negative (HBeAg -ve) HBV genotype-D (HBV/D) infection.

Patients And Methods: A total of 106 treatment- naïve, HBeAg -ve HBV/D patients were included; 78 in the inactive carrier (IC) state and 28 in the active hepatitis (AH) stage. HBV DNA load and HBsAg titers were tested using TaqMan real-time polymerase chain reaction (PCR) and automated chemiluminescent microparticle immunoassay, respectively.

Results: The median (range) log10 HBsAg titer was significantly lower in the IC group compared with AH group, 3.09 (-1 to -4.4) versus 3.68 (-0.77 to 5.09) IU/mL, respectively; P < 0.001. The suggested cutoff value of HBsAg titer to differentiate between the two groups was 3.79 log10 IU/mL. In addition, there was a significant positive correlation between HBsAg and HBV DNA levels in the whole cohort, AH, and IC groups (r = 0.6, P < 0.0001; r = 0.591, P = 0.001; and r = 0.243, P = 0.032, respectively).

Conclusion: Serum HBsAg titers may correlate with HBV DNA in treatment-naïve HBeAg -ve HBV/D patients, and supports the use of HBsAg levels in clinical practice as a predictor of serum HBV DNA levels.
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http://dx.doi.org/10.4103/1319-3767.121035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3958972PMC
July 2014

Patient safety in the operating room at a governmental hospital.

J Egypt Public Health Assoc 2013 Aug;88(2):85-9

aDepartments of Public Health, Anaesthesia and General Surgery, Theodor Bilharz Research Institute bDepartment of Public Health, Faculty of Medicine, Cairo University, Cairo, Egypt.

Background: Patient safety is a fundamental principle of healthcare; it is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical errors that often lead to adverse healthcare events.

Objectives: The aim of this study is to aid any hospital in attaining better quality of patient care in the operating room (OR) by achieving patient safety according to the WHO safety guidelines. Specific objectives include the assessment of patient safety status in OR, the identification of hazards, and the assessment of risks that jeopardize this safety.

Materials And Methods: This is a descriptive observational study carried out in three ORs of a governmental hospital. The study was carried out from December 2008 through April 2009. A total of 100 patients undergoing general surgical and urological surgical procedures were selected. The data collection tools included the WHO surgical safety checklist, nonstructured interviews, patient records, anesthesia checklist, and the risk assessment matrix.

Results: According to the WHO safety checklist, patients' safety was checked during three stages. During the 'sign in' stage, only 3% of all the patients had the operation site marked for surgery and an incident of a single wrong side surgery was recorded. There was a clear lack of communication between doctors and patients. During the 'time out' stage, 80% of surgeries lacked organized discussion among surgical team members for anticipated critical events. Prophylactic antibiotics were administered to 59% of patients undergoing surgeries. The 'sign out' stage was properly carried out in 100% of the procedures. Risk assessment in the 'sign in' stage showed six of 11 procedures leading to a major risk to patients. Also, in the 'time out' stage, three of eight procedures had a major risk.

Conclusion And Recommendations: To reach an optimal level of patient safety in the OR, it is recommended that the checklist should be implemented as part of the daily surgical routine. Identification of the hazards to which patients could be exposed and assessment of risks must be the ultimate goal in any OR.
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http://dx.doi.org/10.1097/01.EPX.0000430955.28520.e5DOI Listing
August 2013

IL28B polymorphisms predict the virological response to standard therapy in patients with chronic hepatitis C virus genotype 4 infection.

Hepatol Int 2013 Jun 8;7(2):533-8. Epub 2013 Feb 8.

Division of Gastroenterology, Department of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia ; Liver Disease Research Centre, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Background: Genome-wide association studies have recently revealed that several single-nucleotide polymorphisms (SNPs) in the interleukin (IL) 28B genes can predict the sustained virological response (SVR) to pegylated interferon-α2a/b plus ribavirin in hepatitis C virus (HCV)-genotype 1 patients. However, data for patients infected with HCV genotype 4 (HCV-G4) are limited.

Aim: We analyzed the association of IL28B SNPs (hematological, biochemical, virological, and pathological factors) with SVR in the HCV-G4 monoinfected cohort of patients.

Patients And Methods: One hundred twenty-nine treatment-naïve HCV-G4 patients undergoing treatment were recruited from three tertiary care centers in Saudi Arabia. Five IL28B SNPs (rs12979860, rs12980275, rs8105790, rs8099917, and rs72486680) were identified by polymerase chain reaction and DNA sequencing. SVR was statistically correlated with various clinical, histopathological, virological, and genetic parameters.

Results: SVR was significantly associated with the CC and AA alleles of rs12979860 (p = 0.008) and rs12980275 (p = 0.004), respectively. Moreover, albumin levels (p = 0.002) and platelet count (p = 0.039) showed significant differences in the SVR and No SVR groups. On multivariate analysis, the CC allele of rs12979860 (OR, 2.89; 95 % CI 1.6-6.2, p = 0.006) and albumin levels (OR, 1.2; 95 % CI 1.1-1.4, p = 0.001) independently predicted SVR.

Conclusions: IL28B polymorphism (CC allele of rs12979860) predicts the sustained response to antiviral therapy in HCV-G4.
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http://dx.doi.org/10.1007/s12072-013-9421-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695682PMC
June 2013

The natural history and long-term outcomes in patients with chronic hepatitis C genotype 4 after interferon-based therapy.

Liver Int 2013 Jul 15;33(6):871-83. Epub 2013 Mar 15.

Gastroenterology Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Background & Aims: Hepatitis C virus (HCV) genotype 4 (G4) infection is common in the Middle East. Post-treatment long-term outcomes have not been reported in these patients. This study evaluates these outcomes in patients after interferon-based therapy.

Patients And Methods: A total of 157 patients were followed from June 2001 to February 2012. Descriptive and analytical statistics, cumulative outcomes and the independent predictors of disease progression were calculated.

Results: The overall age was 48.0 ± 11.8 years, 75 (47.8%) were males and 53 (70.7%) of 75 who were genotyped had G4. The follow-up period was 63.8 ± 32.8 months. Sustained virological response (SVR) was achieved in 62 (39.5%) and 24 (45.3%) patients in the whole group and the G4 subgroup respectively. Among the whole cohort and the G4 subgroup, disease progressed in 59 (37.6%) and 21 (39.6%), respectively, with less progression in the SVR groups; 15/62 (24.2%) and 3/24 (12.5%) compared with non-responders; 44 (46.3%) and 18 (62.1%) with P = 0.01 and 0.001 respectively. Multivariate logistic regression analysis showed that having diabetes mellitus (P = 0.03), higher baseline APRI score (P = 0.00) and non-SVR (P = 0.00) were independent predictors of disease progression. G4 patients showed similar results, but 'non-SVR' (P = 0.00) was the only independent predictor of progression. Eight patients died and four developed HCC all among the non-SVR group only.

Conclusions: This study describes, for the first time, the natural history and demonstrates the beneficial long-term effects of interferon-based therapy in HCV G4 patients.
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http://dx.doi.org/10.1111/liv.12127DOI Listing
July 2013

Relationship of interferon-γ-inducible protein-10 kDa with viral response in patients with various heterogeneities of hepatitis C virus genotype-4.

Eur J Gastroenterol Hepatol 2013 Apr;25(4):404-10

Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Centre KFSH&RC, Riyadh 11211, Saudi Arabia.

Introduction: The role of serum interferon-γ-inducible protein-10 kDa (IP-10) level in the treatment of chronic hepatitis C genotype-4 (HCV-4) and its various subtypes remains unknown. We aimed to study the impact of pretreatment IP-10 levels on the sustained viral response (SVR) in HCV-4 patients (n=64) undergoing peginterferon α-2a/ribavirin therapy.

Patients And Methods: Pretreatment IP-10 levels and HCV-4 subtypes (4a=48.4%, 4d=39%, others=12.5%) were measured and correlated with treatment responses. Variables significantly associated with SVR on univariate analysis were included in a multivariate logistic regression model.

Results: Patients with SVR had lower pretreatment IP-10 levels (462.4±282.7 vs. 840.1±490.6 pg/ml; P=0.002), but the levels were not significantly different in those with a rapid (P=0.245) or an early viral response (P=0.221). IP-10 levels were similar across all subtypes. The pretreatment level was significantly lower in subtype 4d patients with SVR (465.9±349.1) compared with non-SVR patients (904.9±532.1; P<0.001), but not when compared with genotype 4a patients (564.7±288.9 vs. 658.6±374.9, respectively; P=0.330). IP-10 levels [odds ratio (OR), 0.998; 95% confidence interval (CI): 0.996-0.999; P=0.006], low viremia (OR, 8.852; 95% CI: 1.244-63.03; P=0.029), and early viral response (OR, 4.162; 95% CI: 1.023-16.94; P=0.046) were independent predictors of SVR. Receiver operating characteristic curve analysis identified a threshold IP-10 level of 359 pg/ml (area under receiver operating characteristic curve, 0.737; sensitivity, 81.8%; specificity, 45.2; positive predictive value, 43.9%; negative predictive value, 82.6%) for SVR.

Conclusion: Pretreatment serum IP-10 level is a predictor for SVR in HCV-4-infected patients. The baseline IP-10 level is significantly lower in responders among HCV genotype-4d patients as compared with 4a patients.
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http://dx.doi.org/10.1097/MEG.0b013e32835bc2cfDOI Listing
April 2013

Wilson disease in 71 patients followed for over two decades in a tertiary center in Saudi Arabia: a retrospective review.

Ann Saudi Med 2012 Nov-Dec;32(6):623-9

Section of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

Background And Objectives: Wilson disease (WD) is a rare autosomal recessive disease. Our objective was to describe the diverse patterns, therapies, and outcomes of this disease.

Design And Setting: A retrospective study over two decades on WD patients in a tertiary care center in Saudi Arabia.

Patients And Methods: Clinical and laboratory findings of 71 patients with WD were retrieved from their charts, referral notes and our hospital electronic records and were analyzed.

Results: The mean age and standard deviation was 16.8 (10.7) years and 56.5% were males. The main manifestations of WD were hepatic, neurological, and mixed in 39 (54.9%), 12 (16.9%), and 20 (28.2%) patients, respectively, and 11 (15.5%) were asymptomatic cases detected by family screening. A family history of WD was positive in 41 (57.7%) patients, and consanguinity of parents was found in 26 (36.6%) patients. The mean (SD) follow-up period was 92.2 (72.9) (range, 1-320) months. Ten (14.1%) patients died during follow up, while 45 (63.4%) and 16 (22.5%) were still on or lost from follow-up, respectively. The mean (SD) age at the end of follow-up was 25.3 (12) (range, 4-62) years. Hepatoma was discovered in 5 (7.0%) patients. Penicillamine therapy was used by 58 (81.7%) patients, while zinc and trientine were given to 32 (45.1%) and 11 (15.5%) patients, respectively. Sixteen (22.5%) patients underwent liver transplantation and one died (1.4%) on the waiting list. The liver condition remained stable or improved in 35 (49.3%), and the neurological status showed improvement in 11 (34.4%) of the 32 patients who had neurological involvement.

Conclusions: This is the biggest cohort to be reported from the Middle East. WD presentation and outcome of WD are very diverse, and its diagnosis still depends on clinical, laboratory, and radiological evidence of abnormal copper metabolism. WD should be considered in patients of any age with obscure hepatic and/or neurological abnormalities.
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http://dx.doi.org/10.5144/0256-4947.2012.623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081108PMC
November 2013

Cavopulmonary anastomosis without cardiopulmonary bypass.

Interact Cardiovasc Thorac Surg 2013 May 18;16(5):649-53. Epub 2013 Jan 18.

Department of Cardiovascular and Thoracic Surgery, Ain Shams University Hospitals, Cairo, Egypt.

Objectives: There is an increasing trend to perform the bidirectional superior cavopulmonary (Glenn) anastomosis without cardiopulmonary bypass. In this report, we present our results of off-pump bidirectional Glenn operation done without using a venoatrial shunt to decompress the superior vena cava during clamping. [corrected].

Methods: A prospective, non-randomized comparative study was conducted in 50 patients with functional single ventricle anomalies who underwent bidirectional Glenn anastomosis without cardiopulmonary bypass. The patients were divided into two groups: Group I (n = 25), where it was done without a veno-atrial shunt, and Group II (n = 25), where it was done with a veno-atrial shunt. Two patients in Group I and 4 patients in Group II had a bilateral bidirectional Glenn shunt. Five patients in Group I and three patients in Group II had a previous left modified Blalock-Taussig shunt. All patients underwent a complete neurological examination both preoperatively as well as postoperatively.

Results: The early hospital mortality was 4% (2/50), one in each group. The median follow-up was 14 months. The mean internal venous pressure on clamping the superior vena cava was 37.07 ± 7.12 mmHg in Group I and 24 ± 4.4 mmHg in Group II. The mean clamp time was 9.85 ± 3.52 min in Group I and 21.3 ± 4.4 min in Group II. The transcranial pressure gradient was 62.37 ± 15.01 mmHg in Group I, while 65.08 ± 13.89 in Group II. The mean intensive care unit stay was 2.57 ± 75 days in Group I, 3.3 ± 1.09 in Group II. There were no major neurological complications apart from treatable convulsions in one case in Group I (4%), 2 cases in Group II (8%), and delayed recovery in one case (4%) in Group I.

Conclusions: Off-pump bidirectional Glenn operation without caval decompression is a safe, simple and more economic procedure.
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http://dx.doi.org/10.1093/icvts/ivs518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3630411PMC
May 2013

Inflammatory bowel disease in Saudi Arabia: a hospital-based clinical study of 312 patients.

Ann Saudi Med 2012 May-Jun;32(3):276-82

Department of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.

Background And Objectives: The epidemiology, clinical characteristics, and natural course of inflammatory bowel disease (IBD) in Saudi Arabia are still largely unknown. Hence, we decided to conduct a large retrospective, cohort study to determine these features of the disease.

Design And Setting: Retrospective study conducted in a tertiary care hospital in Riyadh from January 1970 to December 2008.

Patients And Methods: We reviewed all the cases of IBD diagnosed and collected all data pertaining to patients with IBD.

Results: A total of 312 patients with IBD were included for this analysis, including 197 (63%) patients with Crohn disease (CD) and 115 (37%) patients with ulcerative colitis (UC). The mean age (standard deviation) of patients with IBD was 25.5 (10.6) years; 152 (48.7%) were males and 160 females. The referral rate in the past 10 years was 72.1% compared with preceding 20 years, and 56% (n=178) of patients with IBD were from the central region of Saudi Arabia. The patients were followed up for a mean duration of 9.5 years; during their follow-up, 206 patients (66%) required hospital admission and 9 patients (2.9%) with UC developed colon cancer. A total of 6 patients died during the follow-up. Fifty-three percent (n=104) of the patients with CD underwent surgeries as part of their treatment, whereas only 20% (n=23) of the patients with UC underwent colectomy.

Conclusions: The incidence of IBD has been gradually increasing in Saudi Arabia over the years. Clinical features and morbidity in patients are not different from patients with IBD seen in the West.
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http://dx.doi.org/10.5144/0256-4947.2012.276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081028PMC
October 2012