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In different geographical regions, the clincoetiological spectrum of childhood stroke varies widely and studies from Eastern India is lacking. To determine the clinicoetiological spectrum of childhood stroke and their outcome. This study was conducted in a stroke clinic of a tertiary care hospital of Kolkata over a period of 18 months. All children below 12 years diagnosed as stroke were included. On the basis of clinical examination, relevant laboratory investigations and radioimaging etiologies were determined. Appropriate statistical methods were used to analyze the data gathered from these patients using a preformed proforma. Among the 70 pediatric stroke patients, the most common clinical presentation was found to be hemiparesis (61.42%) followed by seizure (30.00%) and aphasia (25.71%), respectively. Vasculopathies (30.00%) were found to be the most common etiology of childhood stroke followed by infective meningoencephalitis and craniocervical trauma (14.28% each). Ischemic stroke comprised 71.4% of cases. During discharge, 20 cases (28.57%) showed complete recovery, whereas 40 cases (57.14%) had persistent neurodeficit [Pediatric Stroke Outcome Measure (PSOM) score >1], 12 cases (17.14%) had recurrent stroke, 8 cases (11.42%) died, and only 2 (2.85%) patients were lost to follow-up. Out of those 40 cases having persistent neurodeficits during discharge had recovered too at follow-up at 18th month. At presentation PSOM score in 40 cases (57.14%) was >5 and at follow-up at 18th month, only 8 cases (11.42%) had PSOM score of >5. The commonest etiologies of stroke in pediatric patients presenting at our hospital were found to be intracranial vasculopathies, infection, and trauma. Ischemic stroke was the predominant type. Eighteen-month follow-up showed complete recovery from acute neurological deficits in most of the patients. Dubey S, Ghosh R, Chatterjee S, et al. Pediatric Stroke: The Clinical and Etiological Spectrum: An Observational Study from a Tertiary Care Stroke Clinic, Kolkata, India. Indian J Phys Med Rehab 2019;30(3):74–80.

Purpose The purpose of this study was to describe a novel bandage contact lens (BCL) interface technique for marking the Descemet membrane endothelial keratoplasty (DMEK) graft so that a single donor cornea can be used effectively for 2 recipients during acute shortage. Methods This was a retrospective comparative case series. In group A, 37 eyes underwent DMEK using a graft marked by the [DOUBLE HIGH-REVERSED-9 QUOTATION MARK]BCL interface technique" that was compared with 49 conventional DMEK grafts marked through the stromal window (group B). In group A, a resized BCL with a central 3-mm hole with the concavity up was placed between the stroma and peeled-off DM. This BCL with DM was flipped for S-stamping on the DM side. Final trephination was performed on a second Teflon block. The remaining anterior lamellar tissues of group A were used on the same day for other keratoplasty procedures. Endothelial cell density (ECD) and endothelial cell loss between the 2 groups were compared after 3 and 6 months. Results The ECD at 3 months in group A (n = 35) versus group B (n = 45) was 2228 ± 270/mm2 versus 2302 ± 254/mm2 (P = 0.48), and the ECD at 6 months (n = 23 and 22) was 2058 ± 324/mm2 versus 2118 ± 260/mm2 (P = 0.72). The corresponding endothelial cell loss was 23.3% ± 6.8% versus 20.3% ± 6.1% (P = 0.18) at 3 months and 29.1% ± 8.4% versus 26.7% ± 8.0% (P = 0.34) at 6 months. Among anterior tissues of group A, 17 (45.9%) were used for deep anterior lamellar keratoplasty, 18 (48.6%) were used for larger therapeutic and tectonic grafts, and 2 were used as keratoprosthesis carriers. Donor detachment rate (8.6% vs. 8.9%) was similar in both groups without primary graft failures. Conclusions The BCL interface technique is a simple and safe technique for stamping DMEK grafts. Anterior corneal tissues can be used for additional keratoplasties during donor shortage.

Wilson disease (WD) is characterized by a wide variety of clinical manifestations. Our study aimed to correlate genotype with clinical and radiological features in Indian WD patients. We conducted a descriptive observational study in a tertiary care neurology referral center of eastern India over a period of 2 years. Demographic data collection, clinical examination and relevant investigations were done for all WD patients meeting the inclusion criteria. Based on previous reports of mutation hotspots for WD in Eastern India, we performed PCR-Sanger sequencing of selected exons of ATP7B gene. To understand the role of each of these covariates on the occurrence of common mutation, we applied a logistic regression as well as random forest in a supervised learning framework. Fifty-two WD patients were included in the study. c.813C > A (p.C271X) was the commonest identified mutation. The statistical methods applied to our data-set reveal the most important features for predicting common mutation or its absence. We also found that the state-of-the-art classification algorithms are good at predicting the absence of common mutation (with true positive rates being 0.7647 and 0.8823 for logistic classifier and random forest, respectively), but predicting the occurrence remains a harder modeling challenge. WD patients in eastern India have significant genotypic and phenotypic diversity. Statistical methods for binary classification show some early promise of detecting common mutations and suggest important covariates, but further studies with larger samples and screening of remaining exons are warranted for understanding the full genetic landscape of Wilson disease.

INTRODUCTION After hepatocellular carcinoma (HCC) interventional therapies, noninvasive vascular diagnostic imaging [duplex, Color/power Doppler ultrasonography, and triphasic computed tomography (CT)] determines the lesion complete/incomplete ablation. The aim was to analyze the usefulness of duplex, color/power Doppler ultrasonography in HCC ablation after percutaneous ablative therapies (PATs). METHODS We included 30 patients with 33 HCCs subjected to duplex/Doppler ultrasonography, ultrasound-guided fine-needle aspiration cytology (FNAC), and triphasic CT, all these before and after PATs. RESULTS One week after treatment ended, out of 21 lesions with pretreatment positive color-Doppler, signals disappeared in 19 (90.5%) lesions. Out of 29 lesions with pretreatment positive power-Doppler, signals disappeared in 24 (82.8%). Out of 13 lesions with pretreatment intralesional power/duplex arterial signals, signals disappeared in eight (61.5%). There was a significant correlation (P < 0.05) between power-Doppler arterial signals and FNAC. Before HCC ablation, power-Doppler demonstrated a sensitivity 40% and specificity 96% in HCC detection in relation to FNAC, it had a sensitivity 60% and specificity 85% in HCC detection compared to triphasic CT. After HCC ablation, power-Doppler had a sensitivity and specificity of 100% in viable malignancy detection in relation to FNAC. Power-Doppler had a sensitivity 89% and specificity 93% in residual malignancy detection in relation to triphasic CT. CONCLUSION Power-Doppler is a good positive test as intralesional arterial signals in a cirrhotic liver lesion is highly suggestive of HCC. Power-Doppler was sensitive in HCC ablation assessment in pretreatment positive cases only. Both triphasic CT and duplex/Doppler are complementary and the use of different diagnostic modalities after ablation is mandatory.

BACKGROUND Transient elastography and acoustic radiation force impulse (ARFI) imaging are noninvasive tools for liver stiffness measurement (LSM), which may be influenced by cholestasis. AIM The aim of the study was to evaluate the performance of transient elastography and ARFI in extrahepatic cholestasis and correlate changes in LSM with biochemical activity. MATERIALS AND METHODS A total of 38 patients with extrahepatic cholestasis prospectively underwent transient elastography and ARFI. Changes in LSM by transient elastography/ARFI were evaluated after 1 week of ERCP and correlated with biochemical parameters. The optimal ARFI cutoffs according to stages of clinical interest were analyzed. RESULTS Biliary obstruction was calcular in 21 (55.3%) and noncalcular in 17 (44.7%) (benign n = 15, malignant n = 2). After 1 week, adequate biliary drainage reduced total bilirubin from 7.7 to 2.2 mg/dL (P

INTRODUCTION There is a growing need for identification of non-endoscopic, non-invasive methods that can accurately predict esophageal varices (EV). Previous studies found an inconclusive correlation between blood ammonia level and the presence and size of EV. AIM We aimed at assessing the value of serum ammonia as a non-invasive method for early prediction of EV. PATIENT AND METHODS The study included 204 patients with HCV-related cirrhosis. The selected patients were categorized into two groups: patients with EV and those without, also patients with no or small EV and with large EV group. All patients underwent a complete biochemical workup, ultrasound and upper GI endoscopy. Child-Pugh class, Model of End-Stage Liver Disease (MELD) score and platelet count/splenic diameter ratio, and serum ammonia level. RESULTS There was a statistical difference between the two groups of patients regarding the following parameters: serum ammonia, international normalized ratio, portal vein diameter, spleen diameter, Child-Pugh class, MELD score, platelet count/splenic diameter ratio, aspartate aminotransferase-to-platelet ratio index, alanine aminotransferase-to-aspartate aminotransferase ratio, Forns index, FIB-4 and King's score. Serum ammonia could predict the presence of EV using a cutoff value of 82 (µmol/L) with a sensitivity of 92.3%, specificity 92%. In addition, a cutoff of 95.5 (µmol/L) could predict large EV with a sensitivity of 92.7% and a specificity of 92.3%. Serum Ammonia in cirrhosis with large EV was 143 ± 39 µmol/L and in cirrhosis with small/without EV was 80.7 ± 9.7 µmol/L (P < 0.0001). Platelet/spleen ratio was 555.9 ± 187.3 in cirrhosis with EV and 694.4 ± 74.2 in cirrhosis without EV (P < 0.0001). Platelet/spleen ratio was 407.7 ± 107.1 in cirrhosis with large EV and 690.4 ± 103.7 in cirrhosis with small/without EV (P < 0.0001). CONCLUSION Serum ammonia can accurately predict the presence and the size of EV in patients with liver cirrhosis with high sensitivity and specificity.

Effective interventions and treatments for complex diseases have been implemented globally, however, coverage in Africa has been comparatively lower due to lack of capacity, clinical applicability and knowledge on the genetic contribution to disease and treatment. Currently, there is a scarcity of genetic data on African populations, which have enormous genetic diversity. Pharmacogenomics studies have the potential to revolutionise treatment of diseases, therefore, African populations are likely to benefit from these approaches to identify likely responders, reduce adverse side effects and optimise drug dosing. This review discusses clinical pharmacogenetics studies conducted in African populations, focusing on studies that examined drug response in complex diseases relevant to healthcare. Several pharmacogenetics associations have emerged from African studies, as have gaps in knowledge.

Objective To describe new and unusual endocrinopathies in children with de novo 18q deletion (18q-) syndrome. Methods We describe 2 patients who have atypical thyroid conditions and 1 who also developed symptomatic hypocalcemia. Results The first patient developed hyperthyroidism at the age of 3 years, with a free thyroxine level of 3.9 (range, 0.8-1.8) ng/dL. Thyroid peroxidase antibodies were 262 (range, 0-32) IU/mL, and thyroid-stimulating immunoglobulin antibodies were 384% (range, 0-139%). On low-dose methimazole treatment, she developed hypothyroidism. Thyroid-stimulating hormone (TSH) level was 163 (range, 0.4-4.5) mIU/mL. Moreover, she later developed growth hormone deficiency. The second patient developed hypothyroidism at the age of 4 years, with a TSH level of 46 mIU/mL. However, TSH remained elevated at levels of 10 to 24 mIU/mL for 3 years, despite appropriate treatment, suggesting TSH resistance. She then developed hypocalcemic seizures and was diagnosed with pseudohypoparathyroidism. Her total calcium level was 6.6 (range, 8.5-10.5) mg/dL and parathyroid hormone level was 432 (range, 15-65) pg/dL. Conclusion The first patient had a mixed picture of autoimmune hypothyroidism and hyperthyroidism, requiring a combination of methimazole and levothyroxine to achieve a euthyroid state. For the second patient, the mild TSH resistance was possibly the early suggestion of a parathyroid hormone resistant state. Although growth hormone deficiency and hypothyroidism are common in patients with 18q- syndrome, the occurrence of hyperthyroidism due to Graves’ disease with the coexistence of Hashimoto’s hypothyroidism is rare. Pseudohypoparathyroidism has not yet been reported in patients with 18q- syndrome.

Objective: To describe the rare occurrence of pediatric Hashimoto encephalopathy in 3 patients. Methods: The patients, 9 to 13 years of age, presented with new-onset seizures and other neurologic symptoms, including hemiplegia, aphasia, and memory loss. Thyroid function tests and thyroid antibodies were measured. Magnetic resonance imaging (MRI) of the brain, cerebrospinal fluid analysis, and electroencephalography were also performed. Results: The first patient had a thyroid-stimulating hormone (TSH) level of 60 μIU/mL (range, 0.4-4.5), free T4 of 0.28 ng/dL (range, 0.7-1.6), and thyroid peroxidase antibody (TPO Ab) of 1243 IU/mL (range

PURPOSE The purpose of this study was to report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) using corneas from elderly donors aged 80 years and older. METHODS Eighty eyes of 78 patients who underwent DMEK-only or DMEK combined with cataract extraction (triple-DMEK) with surgeon-prepared graft between April 2016 and March 2020 were reviewed. Corrected distance visual acuity, endothelial cell density (ECD), and endothelial cell loss after 6 months, 1 year, and 2 years were analyzed. RESULTS The mean donor age was 83.6 ± 3.7 years (range: 80-100 years), and the mean donor ECD was 2889 ± 177 cells/mm2 (range: 2604-3460 cells/mm2). The mean recipient age was 67.2 ± 6.9 years (range: 60-89 years), and the mean follow-up was 21 ± 11 months (range: 6-52 months). The mean corrected distance visual acuity improved from a preoperative value of 1.36 ± 0.67 logarithm of the minimum angle of resolution to 0.22 ± 0.18 at 6 months (n = 75), 0.21 ± 0.2 at 1 year (n = 64), and 0.23 ± 0.3 logarithm of the minimum angle of resolution at 2 years (n = 41), respectively (P < 0.001). In 72 eyes (96%), the graft remained transparent until the last follow-up visit. The mean postoperative ECD was 2073 ±336 (n = 75), 1951 ± 379 (n = 65), and 1807 ± 431 cells/mm2 (n = 41) at 6 months, 1 year, and 2 years, respectively. Five eyes (6.7%) had donor detachments of which 4 required rebubbling. Two grafts failed after 1 year, and 2 eyes (2.6%) had graft rejection, of which 1 eye was reverted successfully by medical management. CONCLUSIONS Cornea from elderly donors aged 80 years and older with good selection criteria may be considered for DMEK with successful outcomes. For India and other countries with unmet tissue needs, every best single cornea counts.

Acute interface infectious keratitis (AIIK) is a rare and devastating complication following lamellar keratoplasty. Here, we report a case of AIIK following deep anterior lamellar keratoplasty (DALK) caused by double gram-negative bacilli and required urgent therapeutic penetrating keratoplasty (TPK). Microbiology revealed co-infection with Klebsiella and E. Coli sensitive only to colistin. Donor rim culture also grew Klebsiella. TPK was successful in controlling the infection and the patient responded to topical fortified amikacin and ciprofloxacin. Since optical quality tissue was used, the patient regained 20/40 vision postoperatively. This report highlights that immediate TPK and intense antimicrobial therapy can salvage these eyes with good visual outcome.

PURPOSE To evaluate the clinical outcomes and endothelial cell density (ECD) after Descemet membrane endothelial keratoplasty using peripherally trephinated donor tissue (DMEK-pD) and compare with DMEK using centrally trephinated donor tissue (DMEK-cD) in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS This was a prospective comparative interventional case series. One hundred twenty-five eyes of 110 patients with FECD and cataract who underwent either DMEK-pD (n = 60) or DMEK-cD (n = 65) combined with phacoemulsification, between June 2016 and November 2018, were included. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA) and ECD were recorded at 6 months and 1 year. RESULTS All eyes had visually symptomatic FECD and cataract with a preoperative mean BSCVA of 1.03 logarithm of the minimum angle of resolution in both groups. Baseline donor mean ECD was 2944 ± 201 and 2907 ± 173 cells/mm in the DMEK-pD and DMEK-cD groups, respectively (P = 0.12). BSCVA improvement was comparable at 6 months and 1 year (P = 0.23 and P = 0.34). Mean ECD recorded after 6 months and 1 year was significantly higher in the DMEK-pD group than in the DMEK-cD group: 2508 ± 201 versus 2084 ± 298 cells/mm (P < 0.01) and 2338 ± 256 versus 1907 ± 339 cells/mm (P < 0.01), respectively. Complication rates were similar in both groups. CONCLUSIONS DMEK-pD exhibited similar clinical outcomes with higher ECD compared with conventional DMEK-cD after 6 months and 1 year. The possibility of transplanting peripherally trephinated donor tissue in DMEK with more endothelial cells needs to be explored further in the future.

PURPOSE To report the clinical outcome and postoperative course of Descemet membrane endothelial keratoplasty (DMEK) in irreversible corneal edema due to herpes simplex virus (HSV) endotheliitis. METHODS This is a retrospective, noncomparative, interventional case series. Nineteen eyes of 19 patients underwent standard DMEK combined with cataract surgery (triple DMEK) between May 2016 and April 2018. All patients received perioperative oral acyclovir (ACV) and prednisolone. Patients were followed up on day 1, on day 7, at 1 month, and then at 3 monthly intervals. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), graft clarity, pachymetry, and endothelial cell loss after 1 year were recorded. Postoperative complications and HSV recurrence were noted until the last follow-up visit. RESULTS All eyes were phakic with variable grades of cataract with a preoperative BSCVA of 1.0 logarithm of the minimum angle of resolution or worse. The mean follow-up period was 19.3 ± 5.4 months. After 1 year, 14 (73.7%) eyes achieved a BSCVA of 0.3 or better. Seventeen (89.5%) patients had a clear graft at the last visit without any rejection episode. One graft failed after 16 months. After 3 months, the mean pachymetry reduced from 667.1 ± 62.1 to 512.8 ± 27.1 μm (P < 0.001). The mean endothelial cell loss after 1 year was 36.7 ± 13.4%. Three (15.8%) eyes had recurrence: one with recurrent endotheliitis and 2 with dendritic keratitis despite oral ACV, which responded to oral valacyclovir and ACV eye ointment. One patient had re-recurrence of endotheliitis after 20 months. CONCLUSIONS DMEK in persistent corneal edema after HSV endotheliitis remains challenging but has encouraging outcomes. The postoperative course may be complicated by HSV recurrence. Prophylactic oral antivirals for 1 year or more and topical antivirals are useful for the prevention of recurrence.

We aimed at determination of the usefulness of elastography [acoustic radiation force impulse (ARFI) and FibroScan] for evaluation of nonalcoholic fatty liver disease (NAFLD) patients.A prospective cross-sectional study included 60 biopsy-proven NAFLD patients (mean age: 45 years) was carried out. All patients were subjected to lab works, liver biopsy, and measurement of liver stiffness by ARFI and FibroScan and steatosis by controlled attenuation parameter (CAP). CAP measurements were adjusted for the presence of NAFLD and presence or absence of diabetes and according to BMI.Linear regression analysis showed that CAP is an independent predictor for significant hepatic steatosis (P0.001). No significant difference was found in diagnostic accuracy between adjusted and nonadjusted CAP values for diagnosis of mild (S1) or significant (S2) hepatic steatosis (P=0.17 and 0.29 respectively). The median ARFI velocities for F1, F2, F3, and F4 were 0.92, 1.08, 1.07, and 2.58 m/s, respectively. Although there was an overall significant increase in ARFI values across the fibrosis grades (P0.04), the difference in ARFI values was only significant between fibrosis grades F1 and F4 (P=0.02).Elastography is a promising noninvasive tool for diagnosis and grading of hepatic steatosis and fibrosis in patients with NAFLD/nonalcoholic steatohepatitis with good sensitivity and specificity, especially in moderate to marked grades.

Background. During the last decade, vitamin D status was a major concern in the health and biomedical fields. This study assessed the level of awareness and knowledge regarding vitamin D and investigated the factors associated with the level of awareness such as knowing general facts about vitamin D, sources, benefit, and consequences of its deficiency. Methods. This cross-sectional study was conducted among the general population in Jeddah, Saudi Arabia, above the age of 18 years who were in 3 malls during the period of August and September 2017. A self-administrated questionnaire in paper forms was utilized and was divided into two parts to collect data. It was designed by the authors after revising the previous studies and validated by three pediatric consultants. An ethical approval was obtained from the ethical committee in King Abdulaziz University. We did an initial sample and tested it with the Cronbach test. The questionnaire had 2 parts with 19 questions. The first part was demographic information, and the second part was general information about vitamin D. An ethical approval was obtained from the ethical committee in King Abdulaziz University. Each participant received explanations about the aim of the study, and a verbal consent was taken from participants. The scoring system was as follows: for each right answer, 1 score was given and for wrong answer, 0 score was given, and the overall score was 14. The collected data were statistically analyzed using descriptive statistics using IBM SPSS statistics for windows version 20.0 (SPSS Inc., Chicago, IL). Result. Out of 1022 participants, 472 (46.1%) were aged 18–28 years, 830 (82.1%) were of Saudi ethnicity, 702 (68.7%) had a university degree, 275 (26.9%) attended high school, more than half were married (55.6%), and 54.4% had children. The majority of the participants agreed that vitamin D is important in the maintenance of bone and tooth health (88.4%). It is important in the maintenance of calcium and phosphates (76.6%), and it strengthens immunity (69.4%). Of the total participants, 86.2% were aware that sunlight exposure encourages vitamin D production in the skin. The overall knowledge mean score was 5.9 ± 1.2 (39.3%). Conclusion. This study highlighted a high level of inadequate knowledge of vitamin D deficiency among participants. There was a significant association between knowledge level and education level. The awareness of vitamin D deficiency is high regarding its benefits. The study revealed that participants who did not have children had the highest score for benefits. Nongovernment organizations and social workers may work together with government health-care organization to teach parents and children about the uses and benefits of vitamin D.

Background and study aim: Cholangiocarcinoma (CCA) is a rarely curable cancer and is infrequently diagnosed early. There is a ‎growing interest in evaluating CCA biomarkers in serum and bile. CCA cells express insulin-like growth ‎factor-I (IGF-I) which modulates cell growth and reduces apoptosis.‎ The aim of this study is to evaluate biliary and serum IGF-I as diagnostic biomarkers in patients with extrahepatic ‎cholangio-carcinoma vs. benign biliary obstruction‎‎‎‎. Patients and Method: We conducted a prospective cross-sectional study on 60 patients with extrahepatic biliary obstruction ‎divided into: CCA group (n=30) and benign obstruction (n=30). All patients had diagnostic and therapeutic ‎ERCP with IGF-I assessment in serum and bile‎‎.‎ Results: The CCA group mean age was significantly higher than the benign obstruction group (69.0±4.68 vs. ‎‎56.0±6.47years, p˂0.001). The etiologies of benign biliary obstruction were bile duct stones (n=18), benign ‎stricture (n=11) and cholangitis (n=2). The mean biliary IGF-I in CCA patients was significantly higher (19-‎‎20 folds) than the benign biliary obstruction group (639.14±86.77 vs. 33.60±8.75, p˂0.001). The mean ‎serum IGF-I in the CAA group was higher than the benign group, however, this was non-significant ‎‎(223.06±76.53 vs. 198.34±38.74, p=0.192). Biliary IGF-I cutoff of 292.24ng/ml in CCA vs. benign group ‎showed 100% sensitivity and specificity (AUC=1, p=

Purpose: To analyze the overall clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) in 600 consecutive cases. Methods: Retrospective, consecutive interventional case series operated by a single surgeon. Six hundred consecutive eyes of 524 patients with endothelial dysfunctions of different etiologies scheduled for DMEK were included in this study. All donor tissues were prepared by the operating surgeon during the procedure, using McCarey Kaufman medium or Cornisol-preserved cornea with endothelial cell density (ECD) of ≥2500 cells/mm2. Indications, postoperative best spectacle-corrected visual acuity (BSCVA), ECD, endothelial cell loss (ECL), and complications were analyzed postoperatively between 3 months and 2 years. Results: The commonest indication was post-cataract corneal edema/bullous keratopathy in 262 (43.7%) eyes followed by Fuchs' endothelial corneal dystrophy 218 (36.3%). Vision affected comorbidities were present in 91 (15.2%) eyes. In phakic eyes with cataract (222; 37%), DMEK was combined with cataract surgery (Triple-DMEK). BSCVA of ≥20/25 was achieved in 41.0%, 46.4%, 49.2%, and 48.7% of eyes at 3, 6, 12, and 24 months, respectively and stabilized at 6 months (P = 0.54). Mean ECD decreased from 2884 ± 178 cells/mm2 (n = 600) before surgery to 2223 ± 321 (n = 597), 2099 ± 354 (n = 524), 1918 ± 373 (n = 374), and 1772 ± 439 cells/mm2 (n = 158) at 3, 6, 12, and 24 months respectively. The corresponding mean ECL was 22.9 ± 11.4%, 27.2 ± 12.4%, 33.5 ± 13.0%, and 38.6 ± 14.3%, respectively (P < 0.05 for all-time points). The commonest complication was DM detachment in 59 (9.8%) eyes of which 23 (3.8%) eyes required rebubbling. Three (0.5%) eyes had primary graft failure. Endothelial rejection occurred in 7 (1.2%) eyes until the last follow-up. Conclusion: DMEK is a safe and effective procedure in different types of endothelial diseases with encouraging surgical and clinical outcomes. Complications are less and ECL percentage up to 2 years is acceptable.

Botulinum toxin type-A is a standard treatment of a variety of neurological disorders. Here, the authors report a rare ocular adverse effect after periocular Botulinum Toxin-A injection for hemifacial spasm. Three weeks after the injection, facial spasm was relieved, but the patient had dimness of vision OS. Examination revealed corneal edema, anterior-chamber reaction, keratic precipitates, and elevated intraocular pressure in OS suggesting reactivation of herpes simplex viral endotheliitis with trabeculitis. The case was successfully treated with oral acyclovir (400 mg) and topical fluorometholone 0.1% for 6 weeks. Pre- and posttreatment anterior segment optical coherence tomography clearly demonstrated the evidence of keratic precipitates. To the best of the authors' knowledge, this is the first report of herpetic reactivation in the form of corneal endotheliitis with trabeculitis after Botulinum toxin-A injection. The aim of reporting this case is to alert the clinician about the possibility of such consequence of botulinum toxin injection.

Parkinson's disease (PD) is a major neurodegenerative disorder characterized by a variety of non-motor symptoms in addition to the well-recognized motor dysfunctions that have commanded primary interest. We previously described a new PD mouse model based on heterozygous disruption of the B4galnt1 gene leading to partial deficiency of the GM1 family of gangliosides that manifested several nigrostriatal neuropathological features of PD as well as movement impairment. We now show this mouse also suffers three non-motor symptoms characteristic of PD involving the gastrointestinal, sympathetic cardiac, and cerebral cognitive systems. Treatment of these animals with a synthetic form of GM1 ganglioside, produced by transfected E. coli, proved ameliorative of these symptoms as well as the motor defect. These findings further suggest subnormal GM1 to be a systemic defect constituting a major risk factor in sporadic PD and indicate the B4galnt1(+/−) (HT) mouse to be a true neuropathological model that recapitulates both motor and non-motor lesions of this condition.

Conjunctival stromal tumour (COST) is a recently described rare conjunctival tumour of mesenchymal origin with only four publications describing a handful of cases thus far. In this report, we describe the anterior-segment optical coherence tomography (AS-OCT) characteristics in a case of COST for the first time, in addition to the clinical and histopathological characteristics. The AS-OCT showed an elevated, dome-shaped hyporeflective homogenous lesion in the conjunctival stroma lined by hyperreflective outer layer with mild posterior shadowing, consistent with histological description of a paucicellular tumour with large myxoid collagenous material inside. Immunohistochemistry showed positive CD34 and vimentin but negative S100 and smooth muscle actin, thereby differentiating it from conjunctival myxoma.

Background:Descemet Membrane Endothelial Keratoplasty (DMEK) is now becoming the popular form of endothelial keratoplasty using only donor DM with healthy endothelium as true component lamellar corneal surgery.Objective:To analyze the results of visual outcomes, endothelial cell loss and complications of Descemet membrane endothelial keratoplasty in first consecutive 100 Indian eyes.Methods:100 eyes of 95 consecutive patients with endothelial dysfunctions of different etiologies scheduled for DMEK, were included in this study. In each case, surgeon prepared tissue using McCarey Kaufman medium- or Cornisol-preserved donor cornea with a cell count of ≥2500 cells/mm2. Surgical complications, Best Spectacle Corrected Visual Acuity (BSCVA); Endothelial Cell Density (ECD) and Endothelial Cell Loss (ECL) were analyzed for each patient after a minimum follow-up of three months.Results:The Main indication was pseudophakic corneal edema or bullous keratopathy in 52 (52%) eyes. 38 (38%) eyes had Fuchs′ dystrophy with various grades of cataract. In 43 phakic eyes, DMEK was combined with cataract surgery and intraocular lens implantation. Mean DM-roll preparation time was 7.5 ± 2.8 min and in 3 eyes, DM-graft were damaged. After 3-months, BSCVA was ≥20/25 in 57 (57.6%) cases. Mean ECD was 2123 ± 438/mm2(range: 976 - 3208/ mm2) and the mean endothelial cell loss after 3-months was 26.92 ± 13.40 (range: 4.90 - 66.6%). Partial DM detachment occurred in 8 (8.0%) eyes and rebubbling required in 4 eyes. Iatrogenic primary graft failure occurred in one eye.Conclusion:Descemet membrane endothelial keratoplasty is a safe and effective procedure in several types of endothelial diseases among Indian patients with encouraging surgical and visual outcomes. Complications are less and endothelial cell loss percentage is acceptable.

Recent novel eras of research are opening for the effective management of obesity, in general and childhood obesity, in specific through gene and nutrient intake interactions, Nutrigenomics. The causes of obesity are complex and multifactorial. Here we investigated whether Leptin/MMP2 genes promoters' methylation were associated with childhood obesity. Folic acid level was measured by ELISA, methylation state within promoters of the selected genes in extracted DNA from blood samples was evaluated by methylation-specific PCR (MS-PCR). Obese children with high weight percentile showed a highly significant hypomethylation state in Leptin/MMP2 genes' promoters when compared to the obese follow up group after folic acid intake and to age-sex matched group with normal weight percentile, (p

Aim Obesity is currently a worldwide public health problem which is associated with a number of polymorphisms of genes involved in its pathogenesis. This study aimed to clarify the association between genetic variations within methylene tetrahydrofolate reductase ( MTHFR ) and ATP-binding cassette transporter A1 ( ABCA1 ) genes and obesity in an Egyptian children and adolescents population. Method Anthropometric parameters along with serum total cholesterol, triglycerides, high-density lipoprotein-cholesterol and low-density lipoprotein-cholesterol were measured, in addition to genotyping of MTHFR C677T and ABCA1 G656A polymorphisms using allelic discrimination assay in 51 obese child and adolescent and 30 sex and age-matched healthy subjects. Results Compared to control, obese subjects showed a significant difference in the presence of C677T polymorphism, but not G656A ( p = 0.001 and p = 0.214, respectively). Neither single nucleotide polymorphisms (SNPs) showed significant differences in serum lipid levels among different genotypes in control and obese groups except for high-density lipoprotein-cholesterol which appeared to be influenced by G656A polymorphism ( p = 0.020 and p = 0.032, respectively). C677T polymorphism increased the susceptibility to obesity under all genetic models while G656A polymorphism failed to show any association with the predisposition of developing obesity. SNP-SNP interaction showed that CT/AG carriers are at a higher risk to develop obesity compared to wild type carriers ( p = 0.005). Conclusion MTHFR C677T polymorphism may contribute to the development of obesity while there is no association related ABCA1 G656A polymorphism with simple obesity among Egyptian children and adolescents. Joint effects of the two genes revealed that the carriers of the mutant alleles of both MTHFR and ABCA1 are at high risk to develop obesity.

Ghrelin (GHRL) has important implications for liver disease. It has anti-inflammatory effects, regulates cell proliferation, modulates the fibrogenic response and protects liver tissue. Genetic variations in the GHRL gene may play a crucial role in the development of chronic hepatitis (CH), liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Therefore, we examined the association of GHRL gene polymorphisms (rs26312 and rs27647), and its serum level to virologic responses to combined sofosbuvir and Simeprevir therapy for a course of 12 successive weeks in Egyptian chronic hepatitis C (CHC) patients. METHODS: Human genomic and clinical data were collected from 100 Egyptian participants in this study, 90 HCV patients who received sofosbuvir and Simeprevir and 10 non-HCV healthy subjects. Genotyping of GHRL rs26312 and rs27647, were determined with the TaqMan qRT-PCR allele detection assay. The serum GHRL concentrations were determined using enzyme-linked immunosorbent assay (ELISA). RESULTS: GHRL polymorphisms (rs26312 and rs27647) genotype distributions and allele frequencies did not differ between HCV patients and normal healthy subjects or between patient groups when compared according to the therapeutic response. In addition, we found significant lower serum GHRL levels in CHC patients compared with the healthy controls. However, there was no significant association of the GHRL rs26312 and rs27647 polymorphisms with GHRL levels in CHC patients. We conclude that GHRL SNPs (rs26312 and rs27647) do not affect response to combined sofosbuvir and Simeprevir treatment in chronic Egyptian HCV patients.

Objective: The objective of this report is to describe the presentation, disease course, and management of subacute thyroiditis (SAT) in children. SAT is a rare cause of thyroiditis in children and can be mistaken for acute suppurative thyroiditis, which may be more common in pediatrics.Methods: We present a 7-year-old female, who had painful thyroid enlargement, fever, and thyrotoxicosis.Results: Laboratory evaluation showed high white blood count, erythrocyte sedimentation rate, and free thyroxine levels. Thyroid-stimulating hormone was low. A computed tomography scan of the neck showed intrathyroidal fluid collection consistent with an abscess. She was treated with clindamycin, with no relief of fever and pain. Thyroid ultrasound showed diffuse enlargement of the thyroid lobes with hypoechoic areas, and no fluid accumulation, consistent with SAT. She was treated with intravenous ketorolac with relief of pain and fever, but these symptoms recurred when she was changed to oral ibuprofen. Her symptoms resolved with prednisolone at 1 mg/kg.Conclusion: Based on the limited number of reports in the literature, SAT in children appears to be unusual and may be less common than acute bacterial thyroiditis. In pediatric practice it is important to make the distinction between SAT and acute bacterial thyroiditis.Abbreviations: AST = acute suppurative thyroiditis; FT4 = free thyroxine; SAT = subacute thyroiditis; TSH = thyroid-stimulating hormone

Aims: To evaluate the behavioural and psychological symptoms of dementia (BPSD), to determine their correlation with types and stages of dementia and patient demographics, and to assess the impact on caregiver distress. Methods: This cross-sectional study recruited consecutive dementia patients and caregivers who attended our cognitive clinic. Standard criteria were used to classify types of dementia. BPSD were assessed with the Neuropsychiatric Inventory, and its distress scale was used for caregiver distress. Results: Of a total 107 patients, nearly all (99.1%) had at least one BPSD; 71% had ≥4 symptoms. Most frequent were apathy and agitation, followed by irritability, sleep and appetite disorders, and mood disorders; disinhibition and euphoria were least frequent. BPSD were less prominent with increasing age; males showed more agitation. Apathy and eating disorders were more prevalent in the rural community. BPSD were highest in frontotemporal dementia (FTD), followed by dementia with Lewy bodies (DLB), and least in vascular dementia. Hallucinations were more common in DLB, aberrant motor behaviour in FTD. All domains of BPSD, except for anxiety and euphoria, were more prominent with increasing severity of dementia. Increasing BPSD (except for euphoria) caused higher caregiver distress. Conclusion: BPSD are universally present, bear correlates with dementia type and severity, and cause significant caregiver distress.

Objectives Hepatitis C virus (HCV) infection in Egypt is the most serious health problem, where 10%–15% of the population is infected. The severity of the disease and diagnostic decision-making is evaluated by liver biopsy; an invasive technique with many drawbacks. Recently, attention has been directed to non-invasive, accurate alternatives using serum biochemical markers. Thus, CTGF, IL-17and TGF-β1 were assessed versus liver biopsy in relation to hepatic inflammatory and fibrotic status in chronic HCV patients. Design and methods 58 chronic HCV patients and 30 normal healthy controls were enrolled in the study. Serum samples were collected for detection of CTGF, IL-17and TGF-β1 levels using ELISA. Liver biopsies were obtained from some patients for revaluation of the expression levels of the studied biomarkers genes by quantitative Real Time PCR and for histopathological assessment of grades of inflammation and stages of fibrosis. Results CTGF, IL-17and TGF-β1serum levels were significantly higher in HCV patients versus healthy controls, and decreased significantly in response to antiviral therapy. There were significant differences in their serum levels and the relative expression levels of their genes in relation to hepatic fibrotic stages and inflammatory grades. Significant Correlation existed between the Serum levels of measured biomarkers and the relative expression levels of their genes in the corresponding liver tissue; verifying the hepatic source of serum biomarkers. Conclusion CTGF, IL-17and TGF-β1are serum promising biomarkers, being non-invasive, specific, sensitive and accurate method for assessment of liver fibrosis and inflammation in Chronic HCV infection. They could be alternatives to invasive liver biopsy.

Evaluation of liver fibrosis stage is crucial in the assessment of chronic HCV patients, regarding decision to start treatment and during follow-up. Our aim was to assess the validity of the enhanced liver fibrosis (ELF) score in discrimination of advanced stage of liver fibrosis in naïve chronic HCV patients. We prospectively evaluated liver fibrosis stage in one hundred eighty-one naïve chronic HCV Egyptian patients by transient elastography (TE)-FibroScan. Patients were categorized into mild to moderate fibrosis (≤F2) group and advanced fibrosis (≥F3) group. The ELF score components, hyaluronic acid (HA), amino-terminal propeptide of type-III-procollagen (PIIINP) and tissue inhibitor of metalloproteinase type-1 (TIMP-1), were done using ELISA test. The mean values of ELF and its individual components significantly correlated with the hepatic fibrosis stage as measured by TE-FibroScan (P value 0.001). ELF cutoff value of 9.8 generated a sensitivity of 77.8%, specificity of 67.1%, area under the receiver operator characteristic curve (AUROC) of 0.76 with 95% confidence interval [CI] (0.68-0.83) for detecting advanced fibrosis (F ≥ 3). ELF panel is a good, reliable noninvasive test and showed comparable results to TE-FibroScan in detecting liver fibrosis stage in treatment naïve chronic HCV patients.

Previous studies and systematic reviews have not provided conclusive evidence on the effect of N-acetylcysteine (NAC) in non-acetaminophen-induced acute liver failure (NAI-ALF). We aimed to study the value of intravenous NAC in reducing liver transplantation and mortality in NAI-ALF. In a prospective, multicenter, observational study, acute liver failure patients without clinical or historical evidence of acetaminophen overdose were enrolled. NAC infusion (in empirical dose) was given as 150 mg/kg in 100 ml dextrose 5% over half an hour, then 70 mg/kg in 500 ml dextrose 5% over 4 h, then 70 mg/kg in 500 ml dextrose 5% over 16 h. Thereafter continuous infusion was administered over 24 h of 150 mg/kg in 500 ml dextrose 5% until up to two consecutive normal international normalized ratios (INRs) were obtained. Our endpoints were recovery, transplantation, or death. The primary outcome of the study was to assess reduction in mortality or liver transplantation. The secondary outcome was the evaluation of other clinical outcomes (length of ICU and hospital stays, organ system failure, and hepatic encephalopathy). The study included a total of 155 adults; the NAC group (n = 85) were given NAC between January 2011 to December 2013 and the control group (n = 70) were not given NAC and were included from files dating between 2010 and 2011. Both groups (before NAC) were comparable with regard to etiology, age, sex, smoking, presence of co-morbidities, encephalopathy, liver profile, and INR. The success rate (transplant-free survival) in the NAC group was 96.4%. While in the control group, 17 patients (23.3%) recovered and 53 (76.6%) did not recover, of these 37 (53.3%) had liver transplantation and 16 (23.3%) died (p

Zinc is essential for the activation of approximately 300 metallo-enzymes. Serum and hepatic zinc is decreased in chronic liver disease patients, and zinc depletion has been suggested to accelerate liver fibrosis. The study was designed to assess Zinc status in chronic HCV Egyptian patients and its relationship to fibrosis stage diagnosed by FibroScan. This was a cross-sectional study on 297 Egyptian patients with naive chronic HCV. All patients underwent laboratory tests (including assessment of serum Zinc) and liver stiffness measurement (LSM) by Transient Elastography (FibroScan®). The study included 170 (57.2%) females and 127 (42.8%) males with a mean age 52.4 ± 10.2 years. Most of the patients had zinc deficiency as the mean zinc level was 55.5 ± 30.7 μg/dl. The FibroScan scores showed that 97 patients had mild to moderate fibrosis (≤F2), while 200 patients had advanced to severe fibrosis (˃F2). Zinc level was significantly lower in patients with ˃F2 than those with ≤F2 (52 ± 30.7 vs 62.5 ± 29.7, p value: 0.005), as the zinc values decreased with the progression of liver fibrosis. Serum zinc level had a negative significant correlation with INR and negative significant correlation with FibroScan score but no correlation to bilirubin, ALT, AST, or albumin. Most of Egyptian chronic liver disease patients had zinc deficiency. Zinc level gets significantly lower with progression of fibrosis. Zinc supplementation is essential before and during antiviral therapy for HCV.

Purpose: To compare the serology profile of donors from Hospital Cornea Retrieval Programme-donors (HCRP-D) and voluntary cornea donors (VC-D) from a large eye bank in Eastern India. Methods: This is a retrospective analysis of donor details from January 2011 to December 2016. Donor demographics, cause of death, and serology reports were compiled. Postmortem blood was tested for human immunodeficiency virus 1 and 2 (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis using government-approved kits as per the National Programme for Control of Blindness Standards of Eye Banking. Donors for whom serology was not possible were excluded. Results: A total of 4300 of 4353 donors were included of which 74.3% were hospital donors and 25.7% were voluntary donors. A total of 93 (2.2%) donors with 94 seropositive reports were noted: 79 (84.9%) from HCRP-D and 14 (15.1%) from VC-D which was statistically significantly higher (P = 0.02). Among seropositive reports, HIV, HBV, HCV, and syphilis accounted for 12 (12.8%), 38 (40.4%), 36 (38.3%), and eight (8.5%), respectively. There was no correlation between the cause of death and seropositivity. A statistically significant decreasing trend in seroprevalence among hospital donors was observed over the years (5.3% in 2011 to 1.4% in 2016; P = 0.004). Two (0.47%) of 421 hospital donors with prior negative serology were found to be seropositive. Conclusion: Seropositive rates are significantly higher among hospital donors in spite of medical prescreening compared to nonscreened voluntary donors. Serology should be repeated even when prior reports are available.

Aim: Evaluation of the efficacy and safety of sofosbuvir/daclatasvir/ribavirin (SOF/DCV/RBV) in treating non-sustained virological responders (non-SVR12) to prior sofosbuvir-based therapy, in absence of RAS testing in mass treatment, and determination of the optimal timing to start re-treatment. Methods: Real-life prospective observational study included prior non-responders to 24-weeks SOF-RBV (n = 679, 67%) or 12-weeks SOF- RBV- PEG (n = 335, 33%). Patients were re-treated with daily SOF/DCV/RBV for 12 (n = 270) or 24 weeks (n = 744). The primary efficacy endpoint was SVR12. The primary safety endpoints were reported adverse events (AEs) from baseline to SVR12 time point. Results: We included 1,014 patients [age 52 ± 9 years, 58.48% men]. Cirrhosis was documented in 46.98% and 27.5% of SOF-RBV and SOF-RBV-PEG non-responders respectively. Overall, SVR12 was 90.6% [92.2% for 12 weeks therapy and 90.05% for 24 weeks therapy]. Mild AEs occurred in 5.13% (n=52) and 3.1% (n=32) discontinued treatment including eight on-treatment mortalities. Higher baseline FIB-4 and shorter interval before starting retreatment (Conclusion: SOF/DCV/RBV is an effective and safe treatment option for non-responders to prior sofosbuvir-based therapy. Six months interval before retreatment is optimal for achieving favorable SVR.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) has a poor prognosis if managed late. Percutaneous microwave ablation (MWA) emerged as one of the top therapeutic decisions for non-surgical patients. The aim of the present study aim was to evaluate the efficacy, side effects, and survival after MWA of hepatitis C virus (HCV)-related HCC tumors with spectrum sizes up to 5 cm. MATERIALS AND METHODS: Fifty-nine patients with early HCC were treated in the Hepatology Department using percutaneous MWA. Patients were assessed for side effects and efficacy that includes the rate of complete ablation, primary or de novo recurrence, and survival. RESULTS: Complete ablation was achieved in 57 (96.6%) patients treated by MWA, with a minor complication rate of 3.3% (n=2) including liver abscess formation and abdominal skin burn. The ablation rates in lesions 3 cm), and 2 (3.3%) had malignant portal vein thrombosis. The survival rates were 95.4% and 69% at 1 and 2 years, respectively. CONCLUSION: Percutaneous MWA had achieved a safe and effective treatment with good overall survival in patients with HCV-related HCC.

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common cause of chronic liver disease worldwide. Multiple diagnostic noninvasive methods for NAFLD were studied (both serological and imaging), either single or combined. Attention has been focused on cytokeratin-18 (CK18) as a novel serological marker for the diagnosis of steatosis/fibrosis in NAFLD and hepatitis C virus (HCV) patients.The aim of this study was to evaluate serum CK18 in NAFLD and HCV fibrosis/steatosis and also to correlate its performance with the diagnostic accuracy of transient elastography (TE) and controlled attenuation parameter (CAP) in the diagnosis of fibrosis/steatosis in these patients.Three equal groups of participants were enrolled (n=135): group I included patients with chronic HCV, group II included NAFLD patients, and group III included control participants. For all groups, TE/CAP and labs including serum CK18 were performed. Liver biopsy was performed for the NAFLD group.Serum CK18 was significantly higher in the NAFLD group (19.01±3.49 ng/ml) versus the HCV group (8.95±1.06 ng/ml) and the control group (4.83±1.6 ng/ml) (P0.001). The CK18 levels in biopsy stages (steatosis, ballooning, inflammation, and fibrosis) and FibroScan/CAP degrees showed that CK18 increased significantly with steatosis and fibrosis stages (biopsy or FibroScan/CAP), but did not reach significance with ballooning or inflammation grades. CK18 was significantly different in nonalcoholic steatohepatitis versus non-nonalcoholic steatohepatitis patients (P=0.041). The best CK18 cutoff to detect steatosis (S≥2) in NAFLD and HCV was 11.65 and 6.84 ng/ml, respectively with an overall sensitivity and specificity over 97%. The CK18 cutoff for significant fibrosis (F≥2) by FibroScan in the NAFLD/HCV groups was 9.115 ng/ml, with 62.5%/69.2% sensitivity/specificity (P=0.031). However, inflammation had a cutoff with a marginal P value (P=0.080), and a reliable cutoff for ballooning was not attained (P=0.386). There was a positive correlation between CK18 and fibrosis (by FibroScan) in the NAFLD and HCV groups (P0.05). The correlation between CK18 and steatosis in CAP and the nonalcoholic fatty liver disease activity score was very good (P0.001).Serum CK18 is related strongly to the development/progression of NAFLD and HCV-related fibrosis/steatosis. TE was correlated highly with liver biopsy results. The combination of CK18 with other noninvasive modalities increases the diagnostic yield of these tests.

BACKGROUND Transient elastography (TE) and acoustic radiation force impulse (ARFI) imaging enable a noninvasive assessment of liver stiffness measurement (LSM) and liver fibrosis/cirrhosis staging. However, their use in cholestatic diseases is still scarce. AIM The aim of this study was to evaluate the performance of TE and ARFI for the initial assessment of hepatic fibrosis in intrahepatic cholestatic (IHC) diseases and assess LSM changes after 3 months of specific therapy. PATIENTS AND METHODS This prospective study was carried out on 50 IHC patients. Assessment at baseline and after 3 months of LSM by TE and ARFI was performed. RESULTS Overall, 60% of the patients were women (36.5±9.2 years). IHC etiologies were 23 (46%) autoimmune hepatitis, eight (16%) primary sclerosing cholangitis, eight (16%) drug induced, and five (10%) primary biliary cirrhosis. TE could diagnose ≥F2, ≥F3, and F4 stages at cutoffs of at least 6.7, 9.4, and 14.0 kPa, sensitivity/specificity were 100/50% for ≥F2, 88.2/83% for ≥F3, and 90/100% for F4. Moreover, the sensitivity and specificity of ARFI were 93/50% for ≥F2 (cutoff: 1.53 m/s); 71/67% for ≥F3 (cutoff 1.77 m/s); and 90/100% for F4 (cutoff: 2.43 m/s).Follow-up showed a significant decrease in TE and ARFI values by 27 and 22.3% (P

Background and aim Although hepatitis B virus (HBV) recurrence after liver transplantation (LTx) has been reduced since the application of the combination of hepatitis B immunoglobulin (HBIG) and nucleos(t)ide analogs (NUCs), the optimum regimen to prevent HBV recurrence with LTx favorable outcome is still not clear. Aim The aim was to evaluate the efficacy and safety of NUCs prophylaxis (±HBIG) against HBV recurrence after LTx. Patients and methods This was a retrospective cohort-longitudinal study on 44 HBV-related post-LTx patients on anti-HBV prophylactic therapy. They included the entecavir (ETV)-based (n=34, 30 males) and the other NUC-based (n=10, 7 males) groups±HBIG. Results The median age was 63.5 (60-70) years in ETV and 62.5 (55-65) years in other NUCs groups. The mean follow-up duration was 6.09±1.83 years in ETV-based group and 6.3±1.89 years in other NUCs-based group. The mean ETV duration was 3.47±3.04 years. In ETV+HBIG patients, none of them developed HBV recurrence throughout the ±8 years. In the 14 patients on ETV+other NUC+HBIG, four developed HBsAg positive and then transformed to HbsAb positive at the end of ±8 years without hepatitis or detectable HBV-DNA. Liver graft function showed nonsignificant difference for ETV-based patients, in comparison with other NUC groups (P=0.09). With subdivision, the graft function was maintained significantly better in ETV+HBIG or other NUCs+HBIG (P=0.04) groups. None of our patients reported NUCs-related complications or adverse effects. Conclusion ETV and other NUCs were effective and safe as a long-term prophylaxis of HBV recurrence after LTx, leading to a good graft function. HBsAg temporally reappeared in a minority of patients, where all showed HBsAb seroconversion without detectable HBV-DNA or clinical hepatitis.

Background: Anti-N-methyl D-aspartate receptor (anti NMDAR) antibody encephalitis is an immune-mediated entity characterised by a constellation of neuro-psychiatric symptoms. Objective: To describe clinical profile and treatment outcomes of patients with anti NMDAR antibody encephalitis. Settings and Design: Subjects were selected by screening for all patients satisfying Graus et al.'s criteria for probable anti NMDAR antibody encephalitis, admitted in neurology department of a tertiary care centre in Eastern India. Materials and Methods: A prospective, longitudinal study was conducted by identifying 25 patients with anti NMDAR antibodies in CSF and or serum, between September 2018 to February 2020. Statistical Analysis: Chi square test was used to compare variables. Results: Out of 98 patients screened, 25 subjects (14 females: 11 male) were positive for anti NMDAR autoantibodies, with a mean age of 17 years. 13 subjects belonged to paediatric age group. Most common presenting feature was memory/learning deficit (88%) followed by behavioural abnormalities (84%) and seizures (68%). 11 patients (44%) patients needed escalation to second line therapy, rituximab. Seven (28%) and twelve (48%) patients underwent complete (mRS 0-1) and partial recovery (mRS 2-3) respectively, while 4 (16%) became disabled (mRS 4-5). Mortality was 8%. Paediatric population had a better outcome in terms of disability (p = 0.043). Conclusion: Anti NMDAR-Ab encephalitis is the most common cause of antibody positive autoimmune encephalitis worldwide. There are important clinical markers and investigational profiles which carry prognostic significance.

Objectives The aim of this study was to evaluate the sensitivity and specificity of various outcomes of acute levodopa challenge test (ALCT) namely improvement of motor function, development of dyskinesia and intolerance; to predict the diagnosis of idiopathic Parkinson's disease (IPD) or Parkinson-plus syndrome; to predict levodopa responsiveness and levodopa-induced dyskinesia (LID) during long-term therapy. Methods ALCT was performed on 89 patients with parkinsonism of

Background: Egypt has one of the highest prevalence of hepatitis C virus (HCV) worldwide. Ophthalmological side effects are recognized complications of interferon (IFN) therapy. This study aimed to evaluate IFN-induced ophthalmological manifestations in patients receiving PEGylated interferon (PEG IFN) and ribavirin (RBV) and to assess the effect of IFN duration, response and systemic risk factors on the severity. Methods: We retrospectively analyzed 100 patients with chronic HCV who were candidates for PEG-IFN and RBV therapy. All patients were subjected to clinical and ophthalmological examination, laboratory investigations, abdominal ultrasound, colored fundus photography and fundus fluorescein angiography, follow up was made at weeks 12, 24, and 48 of treatment. Results: IFN-induced retinopathy had been found in (9/100; 9%), 5 (5/9; 55.5%) of them had bilateral lesions, (3/9; 33.3%) were treatment responders and (6/9; 66.6%) non responders. The time of retinopathy appearance was mainly at W12. Retinopathy was asymptomatic in most of the affected patients (7/9; 77.77%) and reversible, cotton wool spots was the major associated sign. Patients with older age, DM and or HTN, and non-responders to antiviral therapy were associated with more severe retinopathy. Conclusions: Retinopathy is not a rare complication of IFN therapy for chronic HCV infection, but fortunately it’s asymptomatic and reversible. Ophthalmological assessment at base-line and at follow up during IFN treatment is very important.

Postoperative spinal wound infection increases the morbidity of the patient and the cost of healthcare. Despite the development of prophylactic antibiotics and advances in surgical technique and postoperative care, wound infection continues to compromise patient outcome after spinal surgery. Spinal instrumentation also has an important role in the development of postoperative infections. This review analyses the risk factors that influence the development of postoperative infection. Classification and diagnosis of postoperative spinal infection is also discussed to facilitate the choice of treatment on the basis of infection severity. Preventive measures to avoid surgical site (SS) infection in spine surgery and methods for reduction of all the changeable risk factors are discussed in brief. Management protocols to manage SS infections in spine surgery are also reviewed.

Introduction and aim Fatigue is one of the most common and prominent symptoms in liver cirrhosis and was reported in 60–80% of these patients. The study outcome was to prospectively evaluate the etiology and the degree of fatigue and how to improve it in chronic liver disease patients. Patients and methods A prospective cross-sectional study on fatigue in chronic liver diseases was conducted on 500 patients: 475 patients had hepatitis C virus (HCV) and 25 had combined HCV and hepatitis B virus. They were divided into five groups: group 1 included 100 patients with chronic hepatitis, group 2 included 100 patients with Child class A cirrhosis, group 3 included 100 patients with Child class B cirrhosis, group 4 included 100 patients with Child class C cirrhosis, and group 5 included 100 patients with hepatocellular carcinoma (HCC). They were administered the Fatigue Impact Scale and the Fatigue Severity Scale questionnaires (translated into Arabic) as well as subjected to laboratory investigations, abdominal ultrasonography, and upper endoscopy. Results All (100%) patients complained of longstanding fatigue. HCC had the highest prevalence of high fatigue (65%) and Child class C cirrhosis had the longest fatigue duration. Female sex and anemia were significantly related to both the Fatigue Impact Scale and the Fatigue Severity Scale in each group separately and all patients collectively. Age had a significant relation with all patients collectively but not separately. Fatigue scores were related to Child score but not related to liver profile, α-fetoprotein, varices, ascites, and HCV load. Conclusion Correction of anemia, not liver profile, helps in alleviating fatigue in cirrhotic patients. Female patients suffered from fatigue more frequently compared with male patients. HCC patients had highest fatigue and patients with Child class C cirrhosis had longest fatigue indices.

To report 2 cases of keratitis occurring after post-kala-azar dermal leishmaniasis (PKDL) in immunocompetent patients.Case report and literature review.Two male patients presented with a dense stromal infiltrate in the temporal and superior aspects of the cornea, respectively. Microbiological workup in both patients did not show any offending organism. Both patients were undergoing treatment for PKDL in the form of oral miltefosine. After careful deliberation, topical prednisolone was started under antibiotic cover for both patients with close follow-up. There was a dramatic improvement with resolution of the infiltrate and a good visual outcome.We present the first reported cases of keratitis after PKDL, which responded to topical corticosteroid therapy. The treating clinician must be made aware of such a presentation of leishmaniasis especially in endemic areas.

A 68-year-old woman with end-stage Stevens–Johnson syndrome developed cystoid macular edema (CME) 3 months following Boston keratoprosthesis type II (KPro-II) implantation and treated with single-dose injection of triamcinolone acetonide (TA) in the inferior peribulbar region. After 14 days, CME resolved completely, and she regained 20/30 vision. Seven months later, she developed recurrent CME. She was again treated with a similar peribulbar injection of TA. CME was resolved completely after 2 weeks with full visual and anatomical recovery. Here, we present a case of recurrent CME following KPro-II implantation responsive to peribulbar injection of TA, which may be the only effective treatment option.

Background & Aims: Various genetic polymorphisms play a key-role in the pathogenesis of NAFLD and progression to NASH with fibrosis to cirrhosis. We aimed to study the association between single-nucleotide polymorphisms (SNPs) in NNMT gene, namely rs694539 and the development of different stages of NAFLD diagnosed by controlled attenuation parameter (CAP) of FibroScan Echosens®. Methods: Transient elastography (FibroScan®) with controlled attenuation parameter (CAP) measurement was performed in 81 NAFLD patients (35 of them with liver biopsy) and 80 non-NAFLD controls. The accuracy of CAP and FibroScan for the detection and quantification of hepatic steatosis/fibrosis, respectively, was assessed based on liver biopsy aspect. Genetic variants of NNMT gene rs694539 were analyzed using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Results: According to BMI (kg/m2), among the patients, 17 (21%) were overweight, 56 (69.1%) obese, and 8 (9.9%) morbidly obese. CAP and FibroScan diagnosed steatosis/fibrosis correlated significantly with liver biopsy. There was a significant association between polymorphisms of rs694539-NNMT gene and NAFLD presence and stages. The mutant type (AA-genotype) was found in 33% NAFLD patients versus 1.2% controls (P

Purpose To report the outcomes of the Boston type I keratoprosthesis (KPro) as the primary penetrating corneal procedure. Methods In this retrospective review of all KPro procedures performed by 2 surgeons from May 1, 2004, to December 31, 2015, indications and outcomes were compared between KPros performed as the primary keratoplasty procedure (primary KPro) versus after failed keratoplasty (previous keratoplasty). Results A total of 262 KPros were implanted in 231 eyes, including 67 primary KPro procedures. The most common indications for primary KPros were corneal scarring/vascularization (43%), Stevens-Johnson syndrome (22%), and chemical/thermal injury (22%). Although preoperative corrected distance visual acuity (CDVA) was similar in the 2 groups (P = 0.36), a significantly higher proportion of the eyes in the primary KPro group had a CDVA ≥ 20/200 each of the first 4 years after surgery (all P ≤ 0.023). The most common postoperative complications in the primary KPro and previous keratoplasty groups were retroprosthetic membrane (40% vs. 51%, P = 0.15), persistent epithelial defect (37% vs. 24%, P = 0.05), and elevated intraocular pressure, which was the only complication significantly more common in either group (31% vs. 18%, P = 0.03). No difference in KPro retention was observed between the 2 groups (P = 0.63). Conclusions In the setting of preexisting ocular comorbidities in which PK is associated with poor outcomes and KPros have been associated with an increased incidence of postoperative complications, primary KPro is associated with significantly greater % of eyes with CDVA ≥ 20/200 in the first 4 years. However, given a significantly higher incidence of postoperative intraocular pressure elevation in these eyes, longer follow-up is needed to determine whether the difference in CDVA is maintained.

Objective: To illustrate the rare occurrence of rhabdomyolysis presenting in adolescents with autoimmune thyroid disease and to briefly review the literature regarding pathophysiology and treatment. Methods: We present 3 children who developed rhabdomyolysis in the setting of concurrent thyroid disease: a 17-year-old female with undiagnosed hyperthyroidism, a 16-year-old female with undiagnosed hypothyroidism, and a 12-year-old female who had been treated for hypothyroidism for several years but was noncompliant. Each one presented with severe proximal muscle pain and weakness. They were afebrile and had no history of trauma. Results: All 3 patients had dark urine (urinalysis was heme positive but had no red blood cells) and very high creatine kinase (CK) levels. They were treated with aggressive hydration since the most dangerous complication of rhabdomyolysis is acute renal failure. The urine cleared in a few days in all patients and CK normalized in a few months. Conclusion: Even though rhabdomyolysis is a rare complication of autoimmune thyroid disease, physicians should be aware of its possibility. CK levels and urinalysis should be checked in any patient with thyroid disease who presents with muscle pain, weakness, and dark urine. Also, physicians should know that rhabdomyolysis can be the presenting feature of new-onset thyroid disease. The prognosis is excellent in pediatrics.

Objectives The present study examined the effect of combined exposure to repeated challenge using low doses of lipopolysaccharide (LPS) and chronic mild stress (CMS) together. This combined exposure is thought to expose the animals to more realistic challenges, testable on different levels (behavioral, neurochemical, immunohistochemical and gene expression). The role of glial cells was examined, as well. Additionally, the effects of chronic administration of the tricyclic antidepressant imipramine and the anti-TNF-α pentoxyphylline were investigated. Methods Wistar rats were exposed to either repeated LPS (50 μg/kg i.p.) over 2 weeks, CMS protocol for 4 weeks or LPS over 2 weeks then 4 weeks of CMS. Two groups of rats were exposed to LPS/CMS protocol and treated with either imipramine or pentoxifylline. Rats were examined for behavioral, neurochemical and gene expression changes. Results Animals exposed to LPS/CMS elaborated depressive-like symptoms with significant increase in both serum corticosterone and TNF-α levels compared to those in the saline, LPS or CMS groups. Hippocampal kynurenine/tryptophan ratio and TNF-α gene expression showed significant increase in the LPS/CMS model compared to those in saline, LPS or CMS groups. The immunohistochemical findings scrutinized the topography of the examined effects. Chronic treatment with imipramine or pentoxifylline significantly ameliorated the behavioral, neurochemical, immunohistochemical and TNF-α gene expression changes induced by the LPS/CMS protocol. Conclusion This study gave a clue to the neurobiological processes underlying, at least, the subtypes of depressive disorders. It highlighted the possible interactions between stress and immune-inflammatory pathways in the pathogenesis of depression and suggested a new animal model of depression that addresses these pathways.