Publications by authors named "Bilal Ali"

34 Publications

Acute Hepatitis A Causing Severe Hemolysis and Renal Failure in Undiagnosed Glucose-6-Phosphate Dehydrogenase Deficient Patient: A Case Report and Review of the Literature.

Case Reports Hepatol 2021 3;2021:5512883. Epub 2021 Jun 3.

Methodist University Hospital, James D. Eason Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA.

Infection with hepatitis A virus is usually a self-limited illness that rarely results in fulminant liver failure. Severe hemolysis is an uncommon complication but has been reported in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Here, we report a case with undiagnosed G6PD deficiency who presented with hyperbilirubinemia, severe hemolysis, and acute renal failure precipitated by acute hepatitis A infection.
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http://dx.doi.org/10.1155/2021/5512883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192200PMC
June 2021

A Patient with Eosinophilic Esophagitis and Herpes Simplex Esophagitis: A Case Report and Literature Review.

Case Rep Gastrointest Med 2021 25;2021:5519635. Epub 2021 May 25.

Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN 38104, USA.

Acute herpes simplex esophagitis (HSE) is common in immunocompromised patients. Eosinophilic esophagitis (EoE) is characterized by immune-mediated eosinophil-predominant esophageal inflammation. We report a patient with human immunodeficiency virus infection who presented with dysphagia and odynophagia and was found to have HSE and EoE. The combination of these two relatively rare conditions suggests possible predisposition.
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http://dx.doi.org/10.1155/2021/5519635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169267PMC
May 2021

Transplantation of liver from hepatitis C-infected donors to hepatitis C RNA-negative recipients: Histological and virologic outcome.

Clin Transplant 2021 05 29;35(5):e14281. Epub 2021 Mar 29.

James D. Eason Transplant Institute, University of Tennessee Health Science Center', Methodist University Hospital, Memphis, TN, USA.

Background: The virologic and histologic outcomes of a hepatitis C virus (HCV)-infected liver graft into an HCV-negative recipient are not well understood. We aimed to evaluate the sustained virologic response (SVR) rate and the liver histology at 1 year post-Orthotopic liver transplantation (OLT) with an HCV-infected graft.

Methods: A total of 33 patients received the HCV antibody (Ab)+/nucleic acid amplification test (NAT)+ graft. Of these patients, 23 were HCV-negative recipients and 10 were HCV-positive recipients. The 1-year biopsy data were available for 24 patients: 15 patients in HCV-negative group who received an HCV Ab+/NAT+graft and 9 patients in HCV-positive group who received an HCV Ab+/NAT+ graft. Patients with (+) HCV ribonucleic acid (RNA) were started on direct-acting antiviral (DAA) treatment approximately 107 days after OLT using either a Glecaprevir-Pibrentasvir or Sofosbuvir-Velpatasvir or Sofosbuvir-Ledipasvir.

Results: All patients (n = 33) were treated with DAA and achieved SVR. The 1-year post-OLT liver biopsies were available in 24 patients: 9 patients had F1 and F2 fibrosis and 17 patients had minimal to moderate inflammation. There was no statistical difference in fibrosis and inflammation between the HCV-negative vs. HCV-positive recipients. All patients who received the NAT+ graft developed viremia and subsequently achieved SVR with treatment.

Conclusion: At 1 year protocol liver biopsy, patients had inflammation consistent with viral hepatitis despite the successful eradication of HCV.
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http://dx.doi.org/10.1111/ctr.14281DOI Listing
May 2021

Cardiac magnetic resonance features of Loeffler's endocarditis.

Eur Heart J Cardiovasc Imaging 2021 Jul;22(8):e134

Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA.

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http://dx.doi.org/10.1093/ehjci/jeab019DOI Listing
July 2021

Defining Duplex Ultrasound Criteria for In-Stent Restenosis of the Superior Mesenteric Artery.

Ann Vasc Surg 2021 Jul 27;74:294-300. Epub 2021 Jan 27.

Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA.

Background: This study sought to define duplex ultrasound (DUS) velocity criteria predicting ≥70% stenosis in superior mesenteric artery (SMA) stents by correlating in-stent peak systolic velocity (PSV) with computed tomographic angiography (CTA) measurements of percent stenosis.

Methods: A retrospective review of 109 patients undergoing SMA stenting between 2003 and 2018 was conducted at a single institution. Thirty-seven surveillance duplex ultrasound studies were found to have a CTA performed within 30 days of study completion. Bare metal (n = 20) and covered stents (n = 17) were included. Velocities were paired to in-stent restenosis (ISR) measured by mean vessel diameter reduction on SMA centerline reconstructions from CTA. Receiver operating characteristic (ROC) curves was generated and logistic regression models for ≥70% ISR probability were used to define velocity criteria in the stented SMA.

Results: At a PSV of 300 cm/sec, the sensitivity is 100% and specificity 80% for a ≥70% in-stent SMA stenosis. At a PSV of 400 cm/sec, the sensitivity and positive predictive value (PPV) is 63% and the specificity and negative predictive value (NPV) is 90%. A PSV of 450 cm/sec was consistent with the highest specificity (100%) and PPV (100%) but lower sensitivity (50%) and NPV (87.9%). One patient with a PSV of 441 cm/sec on surveillance DUS died from complications of acute-on-chronic mesenteric ischemia.

Conclusions: A PSV of 400 cm/sec on mesenteric DUS can predict ≥70% ISR with high sensitivity and should be considered as a diagnostic threshold for SMA in-stent restenosis.
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http://dx.doi.org/10.1016/j.avsg.2020.12.023DOI Listing
July 2021

Post-liver transplant outcomes in patients with major psychiatric diagnosis in the United States.

Ann Hepatol 2021 May-Jun;22:100311. Epub 2021 Jan 19.

Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI, United States; Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, United States. Electronic address:

Introduction And Objectives: Higher rates of psychiatric disorders are reported among cirrhotic patients. This study examines the demographic and clinical outcomes post-liver transplant (LT) among cirrhotic patients with a major psychiatric diagnosis (cases) compared to those without psychiatric diagnosis (controls).

Materials And Methods: Retrospective case control design was used among 189 cirrhotic patients who had undergone LT at Methodist University Hospital Transplant Institute, Memphis, TN between January 2006 and December 2014. Multivariable regression and Cox proportional hazard regression were conducted to compare allograft loss and all-cause mortality.

Results: The study sample consisted of a matched cohort of 95 cases and 94 controls with LT. Females and those with Hepatic Encephalopathy (HE) were more likely to have psychiatric diagnosis. Patients with hepatocellular carcinoma (HCC) were twice as likely to have allograft loss. Psychiatric patients with HCC had two and a half times (HR 2.54; 95% CI: 1.20-5.37; p = 0.015) likelihood of all-cause mortality. Data censored at 1-year post-LT revealed that patients with psychiatric diagnosis have a three to four times higher hazard for allograft loss and all-cause mortality compared to controls after adjusting for covariates, whereas when the data is censored at 5 year, allograft loss and all-cause mortality have two times higher hazard ratio.

Conclusions: The Cox proportional hazard regression analysis of censored data at 1 and 5 year indicate higher allograft loss and all-cause mortality among LT patients with psychiatric diagnosis. Patients with well-controlled psychiatric disorders who undergo LT need close monitoring and medication adherence.
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http://dx.doi.org/10.1016/j.aohep.2021.100311DOI Listing
January 2021

Spectrum of microarchitectural bone disease in inborn errors of metabolism: a cross-sectional, observational study.

Orphanet J Rare Dis 2020 09 16;15(1):251. Epub 2020 Sep 16.

Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, 28 Oki Drive NW, Calgary, Alberta, T3B 6A8, Canada.

Background: Patients diagnosed with inborn errors of metabolism (IBEM) often present with compromised bone health leading to low bone density, bone pain, fractures, and short stature. Dual-energy X-ray absorptiometry (DXA) is the current gold standard for clinical assessment of bone in the general population and has been adopted for monitoring bone density in IBEM patients. However, IBEM patients are at greater risk for scoliosis, short stature and often have orthopedic hardware at standard DXA scan sites, limiting its use in these patients. Furthermore, DXA is limited to measuring areal bone mineral density (BMD), and does not provide information on microarchitecture.

Methods: In this study, microarchitecture was investigated in IBEM patients (n = 101) using a new three-dimensional imaging technology high-resolution peripheral quantitative computed tomography (HR-pQCT) which scans at the distal radius and distal tibia. Volumetric BMD and bone microarchitecture were computed and compared amongst the different IBEMs. For IBEM patients over 16 years-old (n = 67), HR-pQCT reference data was available and Z-scores were calculated.

Results: Cortical bone density was significantly lower in IBEMs associated with decreased bone mass when compared to lysosomal storage disorders (LSD) with no primary skeletal pathology at both the radius and tibia. Cortical thickness was also significantly lower in these disorders when compared to LSD with no primary skeletal pathology at the radius. Cortical porosity was significantly greater in hypophosphatasia when compared to all other IBEM subtypes.

Conclusion: We demonstrated compromised bone microarchitecture in IBEMs where there is primary involvement of the skeleton, as well as IBEMs where skeletal complications are a secondary outcome. In conclusion, our findings suggest HR-pQCT may serve as a valuable tool to monitor skeletal disease in the IBEM population, and provides insight to the greatly varying bone phenotype for this cohort that can be used for clinical monitoring and the assessment of response to therapeutic interventions.
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http://dx.doi.org/10.1186/s13023-020-01521-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493311PMC
September 2020

Development of the Bereavement and Interpersonal Domains codebook.

Death Stud 2020 Jul 21:1-9. Epub 2020 Jul 21.

Department of Psychiatry, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.

We describe the development of an empirically-derived codebook for qualitative data concerning the impact of grief on the interpersonal relationships of bereaved individuals. Relatives ( = 39) of deceased military service members participated in focus groups concerning how grief influenced their relationships across multiple interpersonal domains, including family, friends, community, and with the deceased. Focus group transcripts were coded using a stepwise process consistent with grounded theory to identify and categorize recurrent themes. The process yielded a comprehensive codebook containing 44 nodes with definitions and examples. The codebook provides researchers with an empirically-grounded analytic tool for future studies on bereavement.
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http://dx.doi.org/10.1080/07481187.2020.1793430DOI Listing
July 2020

Colonic diaphragm disease secondary to nonsteroidal anti-inflammatory drug use.

Proc (Bayl Univ Med Cent) 2020 Jul 6;33(3):391-392. Epub 2020 Mar 6.

Department of Gastroenterology and Hepatology, College of Medicine, The University of Tennessee Health Science CenterMemphisTennessee.

Diaphragm disease is a rare condition associated with the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and can lead to severe complications. Most strictures occur in the small bowel, and occurrence in the colon is rare. We report a case of an asymptomatic patient with colonic diaphragm disease secondary to NSAID use.
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http://dx.doi.org/10.1080/08998280.2020.1732162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340423PMC
July 2020

Effect of opioid treatment on clinical outcomes among cirrhotic patients in the United States.

Clin Transplant 2020 06 16;34(6):e13845. Epub 2020 Mar 16.

Department of Gastroenterology and Hepatology, Henry Ford Health System, Detroit, MI, USA.

Background: Opioid medications are frequently used to address pain among patients with cirrhosis, including those on the liver transplant (LT) waitlist and after transplantation. However, opioid use has been associated with poor allograft outcomes and reduced transplant survival. We examined the impact of opioid use across the spectrum of advanced liver disease, from the initial hepatology consultation for cirrhosis through transplant referral, listing, and the post-LT process.

Methods: The study includes all patients referred for cirrhosis management in a single healthcare system in the United States. Data were extracted retrospectively through medical chart review.

Results: Of 414 patients included in the study, 104 (25%) were treated with opioid. Patients on opioids were more likely to be White, have body mass indices (BMI) >30, have HCV, suffer from hepatic encephalopathy, cigarette smokers, and use benzodiazepines concurrently. Higher doses of opioids were associated with multiple emergency department (ED). Eighty-nine underwent LT, including 20 opioid-treated patients. There was no difference found between the opioid and non-opioid groups with regard to allograft loss, ED visits, and hospital readmissions at 2 years post-LT follow-up.

Conclusions: Opioid treatment was common among patients with cirrhosis. We did not find increased negative outcomes among opioid users across the spectrum of cirrhosis. However, the sample for LT patients was small.
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http://dx.doi.org/10.1111/ctr.13845DOI Listing
June 2020

Liver Injury in Patients With Cholestatic Liver Disease Treated With Obeticholic Acid.

Hepatology 2020 04 24;71(4):1511-1514. Epub 2020 Mar 24.

Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN.

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http://dx.doi.org/10.1002/hep.31017DOI Listing
April 2020

Clinical Prognostic Factors and Outcome in Pediatric Osteosarcoma: Effect of Delay in Local Control and Degree of Necrosis in a Multidisciplinary Setting in Lebanon.

J Glob Oncol 2019 04;5:1-8

Children's Cancer Institute, American University of Beirut, Beirut, Lebanon.

Purpose: Outcomes in pediatric osteosarcoma have dramatically improved over the past few decades, with overall survival rates of 70% and 30% for patients with localized and metastatic disease, respectively.

Patients And Methods: We retrospectively reviewed clinical characteristics and outcomes of 38 patients treated between 2001 and 2012 at a single institution in Lebanon. All patients received a uniform three-drug chemotherapy regimen consisting of cisplatin, doxorubicin, and methotrexate. Ifosfamide and etoposide were added to the adjuvant treatment regimen in case of metastatic disease and/or poor degree of tumor necrosis (< 90%).

Results: After a median follow-up of 61 months (range, 8 to 142 months), patients with localized disease had 5-year overall and event-free survival rates of approximately 81% and 68%, respectively, whereas for metastatic disease, they were approximately 42%. The most common primary site was the long bones around the knee (n = 34; 89.5%). Six patients (15.8%) had metastatic disease to lungs, and three (7.9%) had synchronous multifocal bone disease with lung metastases. Adverse prognostic factors included nonlower extremity sites, metastasis, poor degree of necrosis, and delay of more than 4 weeks in local control. In bivariable analysis, only degree of necrosis was a prognostic predictor for survival and disease recurrence.

Conclusion: Treatment of pediatric osteosarcoma in a multidisciplinary cancer center in Lebanon resulted in survival similar to that in developed countries. Delay in local control was associated with worse outcome. The only statistically significant inferior outcome predictor was poor degree of necrosis at the time of local control.
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http://dx.doi.org/10.1200/JGO.17.00241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528739PMC
April 2019

Reevaluating the Importance of Modified Ultrafiltration in Contemporary Pediatric Cardiac Surgery.

J Clin Med 2018 Dec 1;7(12). Epub 2018 Dec 1.

School of Medicine, University of Belgrade, 11 000 Belgrade, Serbia.

Objective(s): Modified ultrafiltration has gained wide acceptance as a powerful tool against cardiopulmonary bypass morbidity in pediatric cardiac surgery. The aim of our study was to assess the importance of modified ultrafiltration within conditions of contemporary cardiopulmonary bypass characteristics.

Methods: Ninety⁻eight patients (overall cohort) weighing less than 12 kg undergoing surgical repair with cardiopulmonary bypass were prospectively enrolled in a randomized protocol to receive modified and conventional ultrafiltration (MUF group) or just conventional ultrafiltration (non-MUF group). A special attention was paid to forty-nine neonates and infants weighing less than 5 kg (lower weight (LW) cohort).

Results: Post-filtration hematocrit was significantly higher in the MUF group for both cohorts (overall cohort = 0.001; LW cohort = 0.04), but not at other time points. During the postoperative course, patients in the MUF group received fewer packed red blood cells, (overall cohort = 0.01; LW cohort = 0.07), but required more fresh frozen plasma (overall cohort = 0.04; LW cohort = 0.05). There was no difference between groups in hemodynamic state, chest tube output, duration of mechanical ventilation, respiratory parameters, duration of intensive care unit, and hospitalization stay.

Conclusions: If conventional ultrafiltration provides adequate hemoconcentration modified ultrafiltration does not provide additional positive benefits except for reduction in blood cell transfusion, This, however, comes at the cost of needing more fresh frozen plasma. Of particular importance is that this also applies to infants with weight bellow 5 kg where modified ultrafiltration was supposed to have the greatest positive impact.
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http://dx.doi.org/10.3390/jcm7120498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306792PMC
December 2018

Achieving Sustained Virological Response in Liver Transplant Recipients With Hepatitis C Decreases Risk of Decline in Renal Function.

Liver Transpl 2018 08;24(8):1040-1049

Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.

The effect of antiviral therapy (AVT) on kidney function in liver transplantation (LT) recipients has not been well described despite known association of hepatitis C virus (HCV) infection with chronic kidney disease (CKD). We compared the incidence of CKD and end-stage renal disease (ESRD) in 204 LT recipients with HCV based on treatment response to AVT. The mean estimated glomerular filtration rate (eGFR) at baseline (3 months after LT) was similar in the sustained virological response (SVR; n = 145) and non-SVR group (n = 59; 69 ± 21 versus 65 ± 33 mL/minute/1.73 m ; P = 0.27). In the unadjusted Cox proportional regression analysis, the presence of SVR was associated with an 88% lower risk of CKD (hazard ratio, 0.12; 95% confidence interval [CI], 0.05-0.31) and 86% lower risk of ESRD (odds ratio, 0.14; 95% CI, 0.05-0.35). Similar results were found after adjusting for propensity score and time-dependent Cox regression analyses. The estimated slopes of eGFR based on a 2-stage mixed model of eGFR were calculated. Patients with SVR had a less steep slope in eGFR (-0.60 mL/minute/1.73 m /year; 95% CI, -1.50 to 0.30; P = 0.190) than recipients without SVR (-2.53 mL/minute/1.73 m /year; 95% CI, -3.99 to -1.07; P = 0.001), and the differences in the slopes were statistically significant (P = 0.026). In conclusion, in LT recipients with chronic HCV infection, achieving SVR significantly lowers the risk of decline in renal function and progression to ESRD independent of the AVT therapy used.
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http://dx.doi.org/10.1002/lt.25059DOI Listing
August 2018

Efficacy and Safety of Sofosbuvir-Based Direct Acting Antivirals for Hepatitis C in Septuagenarians and Octogenarians.

J Clin Exp Hepatol 2017 Jun 15;7(2):93-96. Epub 2017 Mar 15.

Department of Surgery, Methodist University Hospital Transplant Institute, 1211 Union Ave, Suite 340, Memphis, TN 38104, USA.

Background/aims: Treatment of chronic hepatitis C (HCV) with newer direct acting antiviral (DAA) agents has been highly effective. Unfortunately, patients over 70 years old are underrepresented in studies. Given current recommendations to screen patients born between 1945 and 1965 for HCV, it is essential to determine the efficacy and safety of DAAs within the elderly population. This study aims to evaluate clinical outcomes of patients aged 70 years or older treated for HCV with DAAs at a single tertiary care center.

Methods: We identified 25 patients aged 70 years or older who were treated for HCV with a sofosbuvir-based regimen. Baseline demographics, prior HCV treatment history, HCV treatment regimen, adverse effects, and interruption or discontinuation of therapy were collected. The primary endpoint was sustained virologic response at 12 weeks after end of treatment (SVR12). Secondary outcomes were self-reported side effects, drug interactions, and changes in medical regimen of treated patients.

Results: All patients were genotype 1 (13 1a, 9 1b, 3 unspecified). Seventeen (68%) had cirrhosis including 1 Child's Pugh class B. Fifteen patients were treatment-naïve and 10 previously failed treatment with interferon. Seventeen patients were on ledipasvir/sofosbuvir, 4 on simeprevir/sofosbuvir/ribavirin, and 4 on simeprevir/sofosbuvir. Of 25 patients included, 96% (24/25) patients achieved SVR12. Two patients had a greater than 2 g/dL drop in hemoglobin from baseline and both were on ribavirin. Ribavirin was discontinued in 1 patient. One patient required a change in proton pump inhibitor. No patients discontinued therapy due to side effects.

Conclusions: Patients aged 70 years or older with genotype 1 achieved high rates of sustained virologic response with treatment with newer sofosbuvir-based DAAs without any undue adverse events.
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http://dx.doi.org/10.1016/j.jceh.2017.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478933PMC
June 2017

Efficacy of self-expandable metal stents in management of benign biliary strictures and comparison with multiple plastic stents: a meta-analysis.

Endoscopy 2017 Jul 24;49(7):682-694. Epub 2017 May 24.

Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA.

There is burgeoning interest in the utilization of covered self-expandable metal stents (CSEMSs) for managing benign biliary stricture (BBS). This systematic review and meta-analysis evaluated cumulative stricture resolution and recurrence rates using CSEMSs and compared performance of CSEMSs and multiple plastic stents (MPS) in BBS management. Searches in several databases identified studies including ≥ 10 patients that utilized CSEMSs for BBS treatment. Weighted pooled rates were calculated for stricture resolution and recurrence. Pooled risk ratios (RRs) comparing CSEMSs with MPS were calculated for stricture resolution, stricture recurrence, and adverse events. Pooled difference in means was calculated to compare number of endoscopic retrograde cholangiopancreatographies (ERCPs) in each group.   The meta-analysis included 22 studies with 1298 patients. Weighted pooled rate for BBS resolution with CSEMS was 83 % (95 % confidence limits [95 %CLs] 78 %, 87 %;  = 72 %). On meta-regression analysis, resolution in chronic pancreatitis patients and post-orthotopic liver transplant patients were significant predictors of heterogeneity. Weighted pooled rate for stricture recurrence with CSEMSs was 16 % (11 %, 22 %). Overall rate of adverse events requiring intervention and/or hospitalization was 15 %. Four randomized controlled trials with 213 patients compared CSEMSs with MPS: the pooled RRs for stricture resolution, recurrence, and adverse events were 1.07 (0.97, 1.18), 0.88 (0.48, 1.63), and 1.16 (0.71, 1.88), respectively with no heterogeneity. Pooled difference in means for number of ERCPs was - 1.71 ( - 2.33, - 1.09) in favor of CSEMS. CSEMSs appear to have excellent efficacy in BBS management. They are as effective as MPS but require fewer ERCPs to achieve clinical success.
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http://dx.doi.org/10.1055/s-0043-109865DOI Listing
July 2017

Hemorrhagic Cystitis in a Liver Transplant Recipient Secondary to BK Virus.

ACG Case Rep J 2017 10;4:e67. Epub 2017 May 10.

Department of Transplant Surgery, Methodist University Hospital, Memphis, TN.

The association between BK virus infection and hemorrhagic cystitis (HC) in hematopoietic stem cell transplant (HSCT) recipients is well established. However, BK virus-associated HC has not been described in liver transplant (LT) recipients. We present a case of BK virus-associated HC in a LT recipient. Our patient presented with worsening liver function tests 2 years after transplantation and was found to have acute cellular rejection. He was treated with increased immunosuppression and subsequently developed hematuria. He was eventually diagnosed with BK virus-associated HC.
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http://dx.doi.org/10.14309/crj.2017.67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5425281PMC
May 2017

A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment.

Endosc Int Open 2017 May;5(5):E363-E375

Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA.

 The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples.  Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles.  We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest.  Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), ( = 51 %)]. Although not statistically significant ( = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), ( = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy ( = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), ( = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), ( = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), ( = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist.  There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.
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http://dx.doi.org/10.1055/s-0043-101693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5425293PMC
May 2017

Long-term outcomes of early compared to late onset choledochocholedochal anastomotic strictures after orthotopic liver transplantation.

Clin Transplant 2017 07 11;31(7). Epub 2017 Jun 11.

Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA.

Background: Endoscopic treatment of anastomotic biliary stricture (ABS) after liver transplantation (LT) has been proven to be effective and safe, but long-term outcomes of early compared to late onset ABS have not been studied. The aim of this study is to compare the long-term outcome of early ABS to late ABS.

Methods: Of the 806 adult LT recipients (04/2006-12/2012), 93 patients met the criteria for inclusion, and were grouped into non-ABS (no stenosis on ERCP, n=41), early ABS (stenosis <90 days after LT, 18 [19.3%]), and late ABS (stenosis ≥90 days after LT, 34 [36.5%]). A propensity matched control group for the ABS group (n=42) was obtained matched for outcome variables for age, gender, and calculated MELD score at listing.

Results: Mean number of ERCPs (2.33±1.3 vs 2.56±1.5, P=.69) were comparable between the groups; however, significantly better long-term resolution of the stricture was noted in the early ABS group (94.44% vs 67.65%, P=.04). Kaplan-Meier analysis revealed worst survival in the early ABS group compared to the non-ABS, late ABS, and control groups (P=.0001).

Conclusion: LT recipients with early ABS have inferior graft survival despite better response to endoscopic intervention.
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http://dx.doi.org/10.1111/ctr.13003DOI Listing
July 2017

Outcome of Liver Transplant Recipients With Revascularized Coronary Artery Disease: A Comparative Analysis With and Without Cardiovascular Risk Factors.

Transplantation 2017 04;101(4):793-803

1 Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN. 2 Department of Internal Medicine, University of Tennessee Health Sciences Center, Memphis, TN. 3 School of Public Health, University of Memphis, Memphis, TN. 4 Department of Cardiology, Methodist University Hospital, University of Tennessee Health Sciences Center, Memphis, TN.

Background: Coronary artery disease (CAD) is a significant problem during evaluation for liver transplantation (LT). We aim to assess survival in LT recipients based on presence, severity, extent of CAD, and cardiac events within 90 days of LT.

Methods: Eighty-seven LT recipients with history of pre-LT angiogram (December 2005 to December 2012) were compared with 2 control groups without prior angiogram, 72 LT recipients matched for cardiovascular risk factors (control group I), and 119 consecutive LT recipients without any CV risk factors (control group II). CAD was assessed by (1) vessel score (≥50% reduction in luminal diameter), and (2) Extent score (Reardon scoring system).

Results: Of the 87 LT recipients (study group), 58 (66.7%) had none or less than 50% stenosis, 29 (33.3%) had obstructive CAD (≥50% stenosis), 7 (8%) with single-vessel disease, and 22 (25.3%) with multivessel disease. In the study group, irrespective of prerevascularization severity of CAD (P = 0.357), number of segments involved (0, 1-2, > 2 segments, P = 0.304) and extent of CAD based on Reardon score (0, 1-9, >10, P = 0.224), comparable posttransplant survival was noted. Overall, patient survival in the revascularized CAD group was comparable to angiogram group without obstructive CAD, and both control group I and control group II (P = 0.184, Log Rank). Postoperative cardiac events within 90 days of LT predicted poor survival in study group as well as control groups.

Conclusions: Severity or extent of CAD does not impact post-LT survival, if appropriately revascularized. Early postoperative cardiac events are associated with inferior survival in LT recipients, irrespective of underlying CAD.
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http://dx.doi.org/10.1097/TP.0000000000001647DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228601PMC
April 2017

Efficacy and safety of EUS-guided biliary drainage in comparison with percutaneous biliary drainage when ERCP fails: a systematic review and meta-analysis.

Gastrointest Endosc 2017 May 4;85(5):904-914. Epub 2017 Jan 4.

Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA.

Background And Aims: EUS-guided biliary drainage (EUS-BD) is increasingly used as an alternate therapeutic modality to percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction in patients who fail ERCP. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures.

Methods: We searched several databases from inception to September 4, 2016 to identify comparative studies evaluating the efficacy and safety of EUS-BD and PTBD. Primary outcomes of interest were the differences in technical success and postprocedure adverse events. Secondary outcomes of interest included clinical success, rate of reintervention, length of hospital stay, and cost comparison for these 2 procedures. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. These were analyzed using random effects model of meta-analysis.

Results: Nine studies with 483 patients were included in the final analysis. There was no difference in technical success between 2 procedures (OR, 1.78; 95% CI, .69-4.59; I = 22%) but EUS-BD was associated with better clinical success (OR, .45; 95% CI, .23-.89; I = 0%), fewer postprocedure adverse events (OR, .23; 95% CI, .12-.47; I = 57%), and lower rate of reintervention (OR, .13; 95% CI, .07-.24; I = 0%). There was no difference in length of hospital stay after the procedures, with a pooled standard mean difference of -.48 (95% CI, -1.13 to .16), but EUS-BD was more cost-effective, with a pooled standard mean difference of -.63 (95% CI, -1.06 to -.20). However, the latter 2 analyses were limited by considerable heterogeneity.

Conclusions: When ERCP fails to achieve biliary drainage, EUS-guided interventions may be preferred over PTBD if adequate advanced endoscopy expertise and logistics are available. EUS-BD is associated with significantly better clinical success, lower rate of postprocedure adverse events, and fewer reinterventions.
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http://dx.doi.org/10.1016/j.gie.2016.12.023DOI Listing
May 2017

Neonatal Meningococcal Meningitis In France From 2001 To 2013.

Pediatr Infect Dis J 2016 11;35(11):1270-1272

From the *Service de Neonatalogie, Centre Hospitalier Intercommunal, Créteil, France; †Institut Pasteur, Invasive Bacterial Infections Unit, National Reference Center for Meningococci (NRCM), Paris, France; ‡Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France; §Groupe de Pathologie Infectieuse Pédiatrique, SFP Société Française de Pédiatrie, Paris, France; ¶Université Paris Est, IMRB- GRC GEMINI, Créteil, France; ‖ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France; and **Unité Court Séjour, Petits Nourrissons, Service de Néonatalogie, Centre Hospitalier Intercommunal de Créteil, Créteil, France.

Among 831 cases of neonatal bacterial meningitis occurring from 2001 to 2013, Neisseria meningitidis was the third most frequent bacterial species found. All cases occurred only in term neonates and were mainly late onset. Serogroup B accounted for 78% of cases. At diagnosis, 27% of cases had at least one sign of disease severity. All strains were susceptible to cefotaxime, but 12% showed intermediate susceptibility to penicillin G and to aminopenicillin.
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http://dx.doi.org/10.1097/INF.0000000000001296DOI Listing
November 2016

Efficacy and safety of endoscopic gallbladder drainage in acute cholecystitis: Is it better than percutaneous gallbladder drainage?

Gastrointest Endosc 2017 Jan 22;85(1):76-87.e3. Epub 2016 Jun 22.

Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA.

Background And Aims: The efficacy and safety of endoscopic gallbladder drainage (EGBD) performed via endoscopic retrograde cholangiography (ERC)-based transpapillary stenting or EUS-based transmural stenting are unknown. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these procedures and to compare them with percutaneous gallbladder drainage (PGBD).

Methods: We searched several databases from inception through December 10, 2015 to identify studies (with 10 or more patients) reporting technical success and postprocedure adverse events of EGBD. Weighted pooled rates (WPRs) for technical and clinical success, postprocedure adverse events, and recurrent cholecystitis were calculated for both methods of EGBD. Pooled odds ratios (ORs) were also calculated to compare the technical success and postprocedure adverse events in patients undergoing EGBD versus PGBD.

Results: The WPRs with 95% confidence intervals (CIs) of technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis for ERC-based transpapillary drainage were 83% (95% CI, 78%-87%; I = 38%), 93% (95% CI, 89%-96%; I = 39%), 10% (95% CI, 7%-13%; I = 27%), and 3% (95% CI, 1%-5%; I = 0%), respectively. The WPRs for EUS-based drainage for technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis were 93% (95% CI, 87%-96%; I = 0%), 97% (95% CI, 93%-99%; I = 0%), 13% (95% CI, 8%-19%; I = 0%), and 4% (95% CI, 2%-9%; I = 0%), respectively. On proportionate difference, EUS-based drainage had better technical (10%) and clinical success (4%) in comparison with ERC-based drainage. The pooled OR for technical success of EGBD versus PGBD was .51 (95% CI, .09-2.88; I = 23%) and for postprocedure adverse events was .33 (95% CI, .14-.80; I = 16%) in favor of EGBD.

Conclusions: EGBD is an efficacious and safe therapeutic modality for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD shows a similar technical success as PGBD but appears to be safer than PGBD.
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http://dx.doi.org/10.1016/j.gie.2016.06.032DOI Listing
January 2017

Mesalamine Does Not Help Prevent Recurrent Acute Colonic Diverticulitis: Meta-Analysis of Randomized, Placebo-Controlled Trials.

Am J Gastroenterol 2016 04;111(4):579-81

Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, Tennessee USA.

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http://dx.doi.org/10.1038/ajg.2016.24DOI Listing
April 2016

Approach to Non-Neutropenic Fever in Pediatric Oncology Patients-A Single Institution Study.

Pediatr Blood Cancer 2015 Dec 14;62(12):2167-71. Epub 2015 Jul 14.

Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.

Background: Pediatric oncology patients with fever, even when not neutropenic, are known to be at an increased risk of bloodstream infections. However, there are no standard guidelines for management of fever in non-neutropenic patients, resulting in variability in practice across institutions.

Procedure: We retrospectively analyzed the clinical characteristics, management, and outcome of all febrile non-neutropenic episodes in pediatric oncology patients at a single institution over the two-year period 2011-2012, to identify predictors of bloodstream infections. We assessed the efficacy of a uniform approach to outpatient management of a defined subset of patients at low risk of invasive infections.

Results: A total of 254 episodes in 83 patients were identified. All patients had implanted central venous catheters (port). Sixty-two episodes (24%) were triaged as high-risk and admitted for inpatient management; five (8%) had positive blood cultures. The remaining 192 episodes were triaged as low risk and managed with once daily outpatient intravenous ceftriaxone; three (1.6%) were associated with bacteremia, and 10% required eventual inpatient management. Of all the factors analyzed, only signs of sepsis (lethargy, chills, hypotension) were associated with positive bloodstream infection.

Conclusions: Treatment of a defined subset of patients with outpatient intravenous ceftriaxone was safe and effective. Signs of sepsis were the only factor significantly associated with bloodstream infection. This study provides a baseline for future prospective studies assessing the safety of withholding antibiotics in this subset of patients.
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http://dx.doi.org/10.1002/pbc.25660DOI Listing
December 2015

Outcome of Ewing sarcoma in a multidisciplinary setting in Lebanon.

Pediatr Blood Cancer 2014 Aug 7;61(8):1472-5. Epub 2014 Jan 7.

Department of Pediatric and Adolescent Medicine, American University of Beirut, Beirut, Lebanon.

Treatment of Ewing sarcoma (ES) necessitates coordinated multi-disciplinary care. We analyzed outcome for 39 patients treated at a single institution in Lebanon, a developing country with available multidisciplinary treatment modalities, where financial barriers to care are overcome by a fundraising system. Median follow-up was 58 months. Five-year overall and event-free survival were 76% and 58%, respectively, for localized disease, and 40% and 38%, respectively, for metastatic disease. We conclude that, in a country with emerging economy, by following international protocols and ensuring availability of needed resources, outcome of patients with ES is similar to that in developed countries.
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http://dx.doi.org/10.1002/pbc.24926DOI Listing
August 2014

Detection of obstructive coronary artery disease using regadenoson stress and 82Rb PET/CT myocardial perfusion imaging.

J Nucl Med 2013 Oct 12;54(10):1748-54. Epub 2013 Aug 12.

Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts; and.

Unlabelled: Our objective was to study the diagnostic performance of regadenoson (82)Rb myocardial perfusion PET imaging to detect obstructive coronary artery disease (CAD).

Methods: We studied 134 patients (mean age, 63 ± 12 y; mean body mass index, 31 ± 9 kg/m(2)) without known CAD (96 with coronary angiography and 38 with low pretest likelihood of CAD). Stress left ventricular ejection fraction (LVEF) minus rest LVEF defined LVEF reserve. The Duke score was used to estimate the anatomic extent of jeopardized myocardium.

Results: Regadenoson PET had a high sensitivity, 92% (95% confidence interval [CI], 83%-97%), in detecting obstructive CAD, with a normalcy rate of 97% (95% CI, 86%-99%), specificity of 77% (54/70 patients; 95% CI, 66%-86%), and area under the receiver-operator-characteristic curve of 0.847 (95% CI, 0.774-0.903; P < 0.001). Regadenoson PET demonstrated high sensitivity to detect CAD in patients with single-vessel CAD (89%; 95% CI, 70%-98%). The mean LVEF reserve was significantly higher in patients with normal myocardial perfusion imaging results (6.5% ± 5.4%) than in those with mild (4.3 ± 5.1, P = 0.03) and moderate to severe reversible defects (-0.2% ± 8.4%, P = 0.001). Also, mean LVEF reserve was significantly higher in patients with a low likelihood of CAD (7.2% ± 4.5%, P < 0.0001) and mild or moderate jeopardized myocardium than in those with significant jeopardized myocardium (score ≥ 6), -2.8% ± 8.3%.

Conclusion: Regadenoson (82)Rb myocardial perfusion imaging is accurate for the detection of obstructive CAD. LVEF reserve is high in patients without significant ischemia or significant angiographic jeopardized myocardium.
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http://dx.doi.org/10.2967/jnumed.113.120063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382359PMC
October 2013

Clinical Role of Hybrid Imaging.

Curr Cardiovasc Imaging Rep 2010 Oct 6;3(5):324-335. Epub 2010 Jul 6.

Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiology) and Radiology, and the Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Recent technological advances have fueled the growth in hybrid radionuclide and CT imaging of the heart. Noninvasive imaging studies are reliable means to diagnose coronary artery disease (CAD), stratify risk, and guide clinical management. Myocardial perfusion scintigraphy is a robust, widely available noninvasive modality for the evaluation of ischemia from known or suspected CAD. Cardiac CT (coronary artery calcium score and coronary CT angiography) has emerged as a clinically robust noninvasive anatomic imaging test, capable of rapidly diagnosing or excluding obstructive CAD. Both anatomic and functional modalities have strengths and weaknesses, and can complement each other by offering integrated structural and physiologic information. As we discuss below, in selected patients, hybrid imaging may facilitate more accurate diagnosis, risk stratification, and management in a "one-stop shop" setting.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586738PMC
http://dx.doi.org/10.1007/s12410-010-9033-9DOI Listing
October 2010
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