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Objective: Identify patient characteristics and polysomnogram (PSG) parameters associated with postoperative respiratory complications after adenotonsillectomy (AT) among children with high-risk obstructive sleep apnea (OSA)., Study Design: Case series with chart review., Setting: Tertiary care children's hospital., Methods: Pediatric patients (<18 years) with high-risk OSA (any 1 of: apnea-hypopnea index [AHI] >30, O 2 nadir <80% and peak CO 2  >60 mm Hg) on overnight PSG from 2019 to 2021 were included. Primary outcomes were major respiratory intervention during the postoperative admission, prolonged hospitalization, and intensive care unit (ICU) stay., Results: A total of 307 patients met inclusion criteria. Median age was 6.5 years and 63% were male. Twenty-five (8.1%) required major respiratory intervention and 29 (9.7%) required ICU admission after AT. Major interventions and ICU admissions were significantly associated with neuromuscular disease (P < .01), higher obstructive apnea-hypopnea index (oAHI), higher CO 2 peak, and lower O 2 nadir. Prolonged admission had similar findings except oAHI was not significantly associated. Younger children were significant more likely to require ICU admission or prolonged admission., Conclusion: Increased oAHI and worsening O 2 and CO 2 parameters on preoperative PSG were associated with postoperative respiratory complications in children with high-risk OSA. Children with neuromuscular disease and age 0 to 2 had higher risk of ICU stay and prolonged hospitalization. Clinicians should recognize the importance of parameters beyond oAHI when anticipating postoperative monitoring., (© 2024 The Author(s). Otolaryngology–Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background: Personalized dosimetry improves overall survival (OS) in patients with hepatocellular carcinoma (HCC) treated with glass 90 Y radioembolization. This study evaluated personalized tumor dose (TD) as a predictor of OS, progression-free survival (PFS), and local duration of response (DOR) in patients with surgically unresectable HCC treated with resin 90 Y radioembolization., Patients and Methods: This prospective, single-center, single-arm clinical trial (NCT04172714) evaluated the efficacy of scout activity of resin 90 Y versus 99m Tc-MAA for treatment planning. A secondary aim of this study was to evaluate personalized dosimetry as a predictor of OS, PFS, and DOR. Partition dosimetry model was utilized for nonsegmental therapies with targeted TD >200 Gy and nontumoral liver dose <70 Gy. Single compartment dose of 200 Gy was used for segmentectomies. OS, PFS, and local DOR from 90 Y was estimated using Kaplan-Meier estimation with log-rank analysis used to determine predictors of prolonged survival., Findings: Thirty patients with treatment-naive HCC and 33 tumors (19 segmental and 14 nonsegmental) were included. Overall, 18 patients underwent segmental Y90-RE and 12 underwent non-segmental/lobar therapies. The mean 90 Y TD was 493 Gy. The median follow-up since enrollment into the study was 37 months. The mean OS was 32.2 months for the entire cohort. A total of 5 patients underwent orthotopic liver transplantation post 90 Y and were excluded from further survival analysis. The mean OS for the remainder of the cohort was 30.1 months (median not reached). The mean TD >250 Gy resulted in prolonged mean OS and PFS. The median local DOR was 32.7 months with mean TD 330 Gy predicting prolonged DOR., Interpretation: For patients with surgically unresectable HCC treated with resin 90 Y, there is mean TD threshold predicting prolonged OS, PFS, and local DOR. Therefore, there should be further emphasis on personalized dosimetry for optimization of patient outcomes., Competing Interests: Conflicts of interest and sources of funding: This study was jointly funded by Radiological Society of North America and Sirtex Medical Ltd. The study sponsors had no role in the design, data interpretation, or decision to publish this study. N.K. discloses he works as a consultant for Sirtex Medical Ltd. No other potential conflicts of interest relevant to this article exist., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage., Methods: A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality., Results: A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72)., Conclusions: Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community., Level of Evidence: 3 Laryngoscope, 134:2415-2421, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine whether injection laryngoplasty (IL) resolves thin liquid aspiration among children with unilateral vocal cord paralysis (UVCP) after cardiac surgery., Study Design: Retrospective case-control., Setting: Tertiary children's hospital., Methods: Consecutive children (<5 years) between 2012 and 2022 with UVCP after cardiac surgery were included. Resolution of thin liquid aspiration after IL versus observation was determined for children obtaining videofluoroscopic swallow studies (VFSS)., Results: A total of 32 children with left UVCP after cardiac surgery met inclusion. Initial surgeries were N = 9 (28%) patent ductus arteriosus ligations, N = 7 (22%) aortic arch surgeries, N = 9 (28%) surgeries for hypoplastic left heart syndrome, and N = 7 (22%) other cardiac surgeries. The mean age at initial surgery was 1.8 months (SD: 3.7). All children had a VFSS obtained after surgery that confirmed aspiration. There were 17 children that obtained an IL at 33.6 months (SD: 20.9) after cardiac surgery and 15 children observed without IL procedure. No surgical complications after IL were noted. The rate of aspiration resolution based on postoperative VFSS was N = 14 (82%) for the IL group and N = 9 (60%) for the control group P  = .24. Documented VFSS aspiration resolution after cardiac surgery occurred by 9.6 months (SD: 10.0) in the observation group and 47.4 months (SD: 24.1) in the IL group ( P  < .001)., Conclusion: IL can help treat aspiration in children with UVCP after cardiac surgery but the benefit beyond observation remains unclear. Future studies should continue to explore the utility for IL in managing dysphagia in this pediatric population., Competing Interests: None., (© 2024 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objectives: To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP., Methods: A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal., Results: Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63)., Conclusions: Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success., Level of Evidence: 4 Laryngoscope, 134:963-967, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy., Study Design: Retrospective cohort., Methods: All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse., Results: A total of 175 children met inclusion with 18% ( N  = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p  = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development ( p  = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8)., Conclusions: Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes., Level of Evidence: 3., Competing Interests: Romaine F. Johnson is editor‐in‐chief of Laryngoscope Investigative Otolaryngology. He was not involved in the editorial evaluation of or decision to accept this article for publication. All other authors have no disclosures., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Rationale and Objectives: Spinal osteoporotic compression fractures (OCFs) can be an early biomarker for osteoporosis but are often subtle, incidental, and underreported. To ensure early diagnosis and treatment of osteoporosis, we aimed to build a deep learning vertebral body classifier for OCFs as a critical component of our future automated opportunistic screening tool., Materials and Methods: We retrospectively assembled a local dataset, including 1790 subjects and 15,050 vertebral bodies (thoracic and lumbar). Each vertebral body was annotated using an adaption of the modified-2 algorithm-based qualitative criteria. The Osteoporotic Fractures in Men (MrOS) Study dataset provided thoracic and lumbar spine radiographs of 5994 men from six clinical centers. Using both datasets, five deep learning algorithms were trained to classify each individual vertebral body of the spine radiographs. Classification performance was compared for these models using multiple metrics, including the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive predictive value (PPV)., Results: Our best model, built with ensemble averaging, achieved an AUC-ROC of 0.948 and 0.936 on the local dataset's test set and the MrOS dataset's test set, respectively. After setting the cutoff threshold to prioritize PPV, this model achieved a sensitivity of 54.5% and 47.8%, a specificity of 99.7% and 99.6%, and a PPV of 89.8% and 94.8%., Conclusion: Our model achieved an AUC-ROC>0.90 on both datasets. This testing shows some generalizability to real-world clinical datasets and a suitable performance for a future opportunistic osteoporosis screening tool., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nathan Cross, Qifei Dong, Sandra Johnston, Jessica Perry, and David Haynor report financial support was provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Gang Luo reports financial support was provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and National Heart Lung and Blood Institute. Jeffrey Jarvik reports financial support was provided by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and reports a relationship with the General Electric-Association of University Radiologists Radiology Research Academic Fellowship (GERRAF) that includes travel reimbursement. Nathan Cross reports financial support was provided by the General Electric-Association of University Radiologists Radiology Research Academic Fellowship (GERRAF). Nathan M. Cross, Jeffrey Jarvik, David R. Haynor, Gang Luo, Sandra Johnston, Qifei Dong, Jonathan Renslo, Brian Chang, and Jessica Perry have patent #63/463823 pending to the University of Washington., (Copyright © 2023 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement., Methods: A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics., Results: A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66)., Conclusions: QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: To evaluate the differences in safety, effectiveness, and dosimetry between glass-based and resin-based ablative yttrium-90 ( 90 Y) transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC)., Materials and Methods: Using the modified Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events, both tumor response and adverse events (AEs) were assessed at 3 months after 90 Y-TARE. Post procedure 90 Y-bremsstrahlung single-photon emission computed tomography/computed tomography voxel-based dosimetry analysis was used to create tumor dose (TD) and normal tissue dose (NTD) volume histograms, and to calculate tumor particle loading and specific activity. The TD and NTD receiver operating characteristic curves evaluated the dose threshold able to predict objective (partial or complete) and complete tumor responses in addition to any-grade and grade ≥3 AE incidences. The chi-square test and Student t-test were used to assess variable differences where appropriate., Results: Between 2019 and 2020, 81 patients with HCC (20 in the resin-based cohort and 61 in the glass-based cohort) underwent ablative 90 Y-TARE. The resin-based cohort had more males (89% vs 65%, P = .03), lower tumor-to-normal ratio (1.81 ± 0.39 vs 2.22 ± 0.94, P = .03), higher tumor particle loading (40,172 particles/mL ± 28,039 vs 17,081 particles/mL ± 12,555, P = .0001), lower specific activity (158 Bq/particle ± 3 vs 1,058 Bq/particle ± 331, P = .001), and lower mean TD (308 Gy ± 210 vs 794 Gy ± 523, P = .0002) than the glass-based cohort. No significant differences in baseline characteristics or posttreatment AEs were noted. The overall objective and complete response rates were 85% (95% resin-based vs 82% glass-based; P = .1) and 65% (95% resin-based vs 56% glass-based; P = .003), respectively. The mean TD thresholds able to predict the objective and complete responses were 176 Gy and 247 Gy for resin-based radioembolization and 290 Gy and 481 Gy for glass-based radioembolization, respectively. A maximum NTD of 999 Gy predicted any-grade AEs in glass-based ablative 90 Y-TARE., Conclusions: Compared with glass-based ablative 90 Y-TARE, resin-based ablative 90 Y-TARE can offer comparable safety and effectiveness profiles for patients with HCC. The impact of the significantly different tumor particle loading, particle specific activities, and delivered TDs on tumor response outcomes merits further investigation., (Copyright © 2023 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: Since the declaration of COVID-19 as a pandemic, a wide between-country variation was observed regarding in-hospital mortality and its predictors. Given the scarcity of local research and the need to prioritize the provision of care, this study was conducted aiming to measure the incidence of in-hospital COVID-19 mortality and to develop a simple and clinically applicable model for its prediction., Methods: COVID-19-confirmed patients admitted to the designated isolation areas of Ain-Shams University Hospitals (April 2020-February 2021) were included in this retrospective cohort study (n = 3663). Data were retrieved from patients' records. Kaplan-Meier survival and Cox proportional hazard regression were used. Binary logistic regression was used for creating mortality prediction models., Results: Patients were 53.6% males, 4.6% current smokers, and their median age was 58 (IQR 41-68) years. Admission to intensive care units was 41.1% and mortality was 26.5% (972/3663, 95% CI 25.1-28.0%). Independent mortality predictors-with rapid mortality onset-were age ≥ 75 years, patients' admission in critical condition, and being symptomatic. Current smoking and presence of comorbidities particularly, obesity, malignancy, and chronic haematological disorders predicted mortality too. Some biomarkers were also recognized. Two prediction models exhibited the best performance: a basic model including age, presence/absence of comorbidities, and the severity level of the condition on admission (Area Under Receiver Operating Characteristic Curve (AUC) = 0.832, 95% CI 0.816-0.847) and another model with added International Normalized Ratio (INR) value (AUC = 0.842, 95% CI 0.812-0.873)., Conclusion: Patients with the identified mortality risk factors are to be prioritized for preventive and rapid treatment measures. With the provided prediction models, clinicians can calculate mortality probability for their patients. Presenting multiple and very generic models can enable clinicians to choose the one containing the parameters available in their specific clinical setting, and also to test the applicability of such models in a non-COVID-19 respiratory infection., (© 2023. The Author(s).)

Background: Bile stones are associated with numerous complications in liver transplant recipients. Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be safe and highly effective in dealing with most post-transplant biliary complications., Objective: The objective of this study was to identify the possible risk factors for bile stone formation on top of biliary stricture, the effects of stones on graft outcomes, and their management., Methods: This case-control study included 83 patients who underwent living donor liver transplant (LDLT) and suffered from postoperative biliary stricture with or without stones. Patients were divided into two groups. Group 1 ( n = 55) included patients with biliary strictures with no stones and group 2 ( n = 28) included patients who developed stones on top of biliary strictures. Data about the recipient and donor characteristics, surgical technique, blood lipid profile, immunosuppressive drugs, post-transplant complications, and interventions were collected from the medical records., Results: The frequency of hepatitis C virus (HCV) was significantly higher in group 2 compared to group 1 (71.4% vs. 47.3%, p = 0.036). The body mass index (BMI) of the donors was significantly higher in group 2 than in group 1 (25.17 ± 2.53 vs. 23.68 ± 2.63, p = 0.015). Episodes of acute rejection were significantly higher in group 2 than in group 1 (21.4% vs. 5.5%, p = 0.027). The ERCP was sufficient in most of the cases (89.2%) to ensure biliary drainage. The identified independent risk factors for biliary stones included HCV, biliary drain, donor's BMI, and serum cholesterol level., Conclusion: Positive HCV, biliary drain insertion, donor's BMI, and serum cholesterol level were independent risk factors for developing bile stones on top of biliary strictures. Biliary stones were associated with high episodes of acute graft rejection, and they could be successfully managed by the ERCP modality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dabbous, Elsayed, Salah, Montasser, Atef and Elmetenini.)

Introduction: COVID-19 severity and mortality predictors could determine admission criteria and reduce mortality. We aimed to evaluate the clinical-laboratory features of hospitalized patients with COVID-19 to develop a novel score of severity and mortality., Methodology: This retrospective cohort study was conducted using data from patients with COVID-19 who were admitted to five Egyptian university hospitals. Demographics, comorbidities, clinical manifestations, laboratory parameters, the duration of hospitalization, and disease outcome were analyzed, and a score to predict severity and mortality was developed., Results: A total of 1308 patients with COVID-19, with 996 (76.1%) being moderate and 312 (23.9%) being severe cases, were included. The mean age was 46.5 ± 17.1 years, and 61.6% were males. The overall mortality was 12.6%. Regression analysis determined significant predictors, and a ROC curve defined cut-off values. The COVEG severity score was defined by age ≥ 54, D-dimer ≥ 0.795, serum ferritin ≥ 406, C-reactive protein ≥ 30.1, and neutrophil: lymphocyte ratio ≥ 2.88. The COVEG mortality score was based on COVEG severity and the presence of cardiac diseases. Both COVEG scores had high predictive values (area under the curve 0.882 and 0.883, respectively)., Conclusions: COVEG score predicts the severity and mortality of patients with COVID-19 accurately., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2022 Mohamed El-Kassas, Maha El Gaafary, Mohamed Elbadry, Mohamed Ahmed Medhat, Hany Dabbous, Essam Ali Hassan, Ahmed Abdelmoaty, Haidi Karam-Allah, Hamdy Sayed, Amr Abdalazeem, Ahmed Fouad Sherief, Eman Fares, Maha Alsadik, Ehab Moustafa, Wagida Anwar, Hossam Abdelghaffar, Khaled Abdelghaffar.)

Background: Patients who undergo living donor liver transplantation (LDLT) may suffer complications that require intensive care unit (ICU) readmission., Aim: To identify the incidence, causes, and outcomes of ICU readmission after LDLT., Methods: A retrospective cohort study was conducted on patients who underwent LDLT. The collected data included patient demographics, preoperative characteristics, intraoperative details; postoperative stay, complications, causes of ICU readmission, and outcomes. Patients were divided into two groups according to ICU readmission after hospital discharge. Risk factors for ICU readmission were identified in univariate and multivariate analyses., Results: The present study included 299 patients. Thirty-one (10.4%) patients were readmitted to the ICU after discharge. Patients who were readmitted to the ICU were older in age (53.0 ± 5.1 vs 49.4 ± 8.8, P = 0.001) and had a significantly higher percentage of women (29% vs 13.4%, P = 0.032), diabetics (41.9% vs 24.6%, P = 0.039), hypertensives (22.6% vs 6.3%, P = 0.006), and renal (6.5% vs 0%, P = 0.010) patients as well as a significantly longer initial ICU stay (6 vs 4 d, respectively, P < 0.001). Logistic regression analysis revealed that significant independent risk factors for ICU readmission included recipient age (OR = 1.048, 95%CI = 1.005-1.094, P = 0.030) and length of initial hospital stay (OR = 0.836, 95%CI = 0.789-0.885, P < 0.001)., Conclusion: The identification of high-risk patients (older age and shorter initial hospital stay) before ICU discharge may help provide optimal care and tailor follow-up to reduce the rate of ICU readmission., Competing Interests: Conflict-of-interest statement: All the authors declare that they have no conflict of interest., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background and Study Aims: Chronic hepatitis C virus (HCV) infection has always been identified as a major health threat and a potential cause of liver cirrhosis, portal hypertension, and other associated problems. The introduction of direct-acting antiviral agents (DAAs) has represented a paradigm shift in HCV management. In this study, we aim to observe the rate of sustained virologic response (SVR12) in a large scale of patients at a single center as well as record the post-treatment changes in the hematologic, hepatic, and renal biochemical profiles., Patients and Methods: In total, 1933 chronic HCV genotype 4 mono-infected non-HCC patients who completed the treatment with six different DAA regimens in the Faculty of Medicine, Ain Shams University Research Institute (MASRI), were retrospectively enrolled in this study. The rate of sustained virologic response after 12 weeks off-therapy (SVR12) was assessed. The baseline characteristics to predict the SVR12 were then analyzed. The post-treatment changes in many profiles were recorded and analyzed., Results: The overall SVR12 rate was 96.2% (after excluding 84 cases who were lost to follow-up). It was achieved in 346/375 patients (92.3%), 466/477 patients (97.7%), 60/62 patients (96.8%), 11/11 patients (100%), 532/545 patients (97.6%), and 445/463 patients (96.1%) who received sofosbuvir/daclatasvir (SOF/DCV), sofosbuvir/daclatasvir/ribavirin (SOF/DCV/RBV), sofosbuvir/ledipasvir (SOF/LDV), sofosbuvir/ledipasvir/ribavirin (SOF/LDV/RBV), sofosbuvir/simeprevir (SOF/SMV), and ombitasvir/paritaprevir/ritonavir/ribavirin (OBV/PTV/r + RBV), respectively. In total, 73 patients (3.8%) failed to achieve SVR12. The baseline aspartate aminotransferase (AST), cirrhotic status, and treatment regimen were determined to have a significant impact on SVR12. In the overall treated population, the levels of serum AST, alanine aminotransferase, albumin, creatinine, bilirubin, and hemoglobin and platelet count improved significantly after treatment. Furthermore, sustained virologic response was strongly related to cirrhosis and its degree., Conclusion: The interferon-free DAA regimens offered high SVR12 rates in Egyptian patients with chronic HCV infection. They were associated with a significant improvement in the hematologic, hepatic, and renal biochemical profiles. The baseline AST, liver cirrhosis, and treatment regimen might have an impact on achieving SVR., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

The aim of this study was to compare efficacy and safety of different combination regimens in re-treatment of HCV in the setting of inaccessibility of resistance testing. This real-life prospective study included 86 chronic HCV infected patients who experienced failure of treatment treated at Faculty of Medicine Ain shams Research Institute (MASRI) since 2018. 64% of the patients were males, with median age 50.2 years. They were re-treated using 1 of 3 proposed regimens of DAA combinations. One group received PAR/OMB/SOF/RBV for 12 weeks, another group received SOF/DAC/SIM/RBV for 12 weeks and a third received SOF/DAC/RBV for 24 weeks. Response to different regimens was assessed by comparing sustained virologic response (SVR) of each. Monitoring the occurrence of adverse events was performed. SVR was achieved in all but 3 patients (96.5% SVR), one in the SOF/DAC/SIM/RBV group and two in the SOF/DAC/RBV group. The group receiving RBV had more anaemia and hyperbilirubinemia. The first treatment regimen used was a significant predictor to SVR achievement. This study presents alternative treatment regimens for re-treatment of HCV patients in areas with limited resources in the case of non-availability of other regimens as velpatasvir, voxilaprevir, grazoprevir, elbasvir., Competing Interests: Conflict of interestThe authors report no conflicts of interest., (© Indian Virological Society 2021.)

The etiology of vocal fold paralysis is multifaceted. One of the rare causes is internal jugular vein thrombosis secondary to central venous catheterization. The palsy is usually ipsilateral to the site of indwelled catheterization, self-limited and reversible. The authors of this manuscript report a rare case of contralateral recurrent laryngeal nerve palsy induced by subclavian vein thrombosis following central venous catheterization. The patient developed irreversible vocal fold paralysis that necessitated office-based injection laryngoplasty., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

COVID-19 is an emerging pandemic. The course and management of the disease in the liver transplant setting may be difficult due to a long-standing immunosuppressive state. In Egypt, the only available option is living donor liver transplantation (LDLT). In our centre, we have transplanted 440 livers since 2008. In this study, we report a single-centre experience with COVID-19 infection in long-term liver transplant recipients. A total of 25 recipients (5.7 %) had COVID-19 infections since March 2020. Among these recipients, two developed COVID-19 infections twice, approximately three and two months apart, respectively., (© 2021 The Author(s). Published by Elsevier Masson SAS.)

Introduction: Syrian patients injured in the war frequently undergo rudimentary primary wound closure in combat zones. These patients are later transferred to Lebanon where their wounds need to be secondarily managed. This often leads to the creation of unorthodox approaches for reconstruction of orbital injuries., Case Presentation: The authors of this manuscript demonstrate a few cases of peri-ocular trauma with a delayed presentation, in which adaptations of conventional reconstructive methods had to be implemented had to be undertaken for optimal results., Conclusion: Modified techniques for reconstruction of peri-ocular injuries with delayed presentation are discussed in this paper. The patients are cases of trauma secondary to war in the region of Lebanon and Syria. The unique presentations of these patients have led to the use of "opportunity flaps" surrounding highly fibrotic and scarred tissue, in an attempt to allow for delayed reconstruction.

Aim of the Study: The current study aimed to evaluate the efficacy of different DAAs regimens in the treatment of chronic hepatitis C (CHC) Egyptian patients who failed to achieve SVR after their treatment with SOF-based regimens., Methods: This was a retrospective observational multicenter study that included CHC patients that failed to achieve cure on SOF-based regimens who were re-treated using different DAAs regimen and were allocated according to national guidelines for the treatment of hepatitis C. Primary outcome was to assess the SVR12 rate among prior non-responders after retreatment with a second course of DAAs., Results: Our study included 172 patients who failed to achieve SVR after treatment with SOF-based treatment regimen [age: 51.2 ± 11.3, 58.7% men]. Included patients were retreated using SOF/DCV/RBV, SOF/ r/PAR /OMB /RBV, SOF/DCV/SIM, SOF/LDV ± RBV or SIM/SOF. SVR12 was successfully attained in 95.35% (164/172) of the included non-responders., Conclusion: The current multicenter study proved the efficacy of various DAAs regimens issued by the National Committee for Control of Viral Hepatitis for retreatment of relapsed CHC Egyptian patients., (Copyright © 2020. Published by Elsevier Ltd.)

Background and Study Aims: Several factors affect the quality of life and personal well-being of transplant recipients, including Ramadan fasting for Muslims. This study aimed to assess the effect of Ramadan fasting on the renal and liver functions of liver transplantation recipients and to propose a protocol for adapting an Immunosuppression regimen and follow-up schedule for patients wishing to fast after liver transplantation., Patients and Methods: This prospective study was conducted on 45 recipients who wished to fast Ramadan from 17th May to 14th June 2018, at Ain Shams Center for Organ Transplantation, Cairo, Egypt., Results: The mean age of the patients was 55.5 ± 7.2 (37-68) years, and 84.4% were males; the mean time from liver transplantation was 51.6 ± 28 months (14-117). Thirty-seven patients (82.2%) completed Ramadan fasting, three patients (6.6%) had interrupted fasting, and five patients (11.1%) had to stop fasting because of an unacceptable rise in renal function. There was a statistically significant difference between the pre- and post-fasting states in terms of the serum creatinine level (p = 0.004).However, the serum creatinine did not exceed the upper normal value in the patients who completed fasting., Conclusion: Our data seem promising for Ramadan fasting with an adapted immunosuppression protocol and regular follow-up for recipients wishing to fast. Further multicentre studies on a larger number of patients are warranted., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

Background: Given the paucity of data and widely variable rates that have been reported, the main objective of this study was to examine the prevalence of HPV-positivity in oropharyngeal squamous cell carcinoma (OPSCC) in Middle Eastern patients presenting to one of the region's largest tertiary care centers using polymerase chain reaction (PCR) amplification of the HPV E6/E7 oncogenes, a highly sensitive and specific method of detection., Methods: Medical charts and archived pathological specimens were obtained for patients diagnosed with biopsy proven oropharyngeal cancer who presented to the American University of Beirut Medical Center between 1972 and 2017. DNA was extracted from paraffin-embedded specimens and tested for 30 high-risk and low-risk papilloma viruses using the PCR-based EUROarray HPV kit (EuroImmun)., Results: A total of 57 patients with oropharyngeal cancer were initially identified; only 34 met inclusion/exclusion criteria and were included in the present study. Most patients were males (73.5%) from Lebanon (79.4%). The most common primary tumor site was in the base of tongue (50%), followed by the tonsil (41.2%). The majority of patients (85.3%) tested positive for HPV DNA., Conclusion: The prevalence of HPV-positivity amongst Middle Eastern OPSCC patients, specifically those from Lebanon, may be far greater than previously thought. The Lebanese population and other neighboring Middle Eastern countries may require a more vigilant approach towards HPV detection and awareness. On an international level, further research is required to better elucidate non-classical mechanisms of HPV exposure and transmission., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2020.)

Infection with Brucella spp. is endemic to the Middle East and the eastern Mediterranean basin. Brucellosis can mimic infectious and non-infectious febrile illnesses and therefore it can pose a diagnostic challenge. A wide range of deep-seated infections have been ascribed to brucellosis including breast abscesses and infections of prosthetic endovascular devices. The latter are usually rare but difficult to treat short of excision of the infected device. Here, we present the case of a middle-aged Lebanese woman who presented with simultaneous breast abscesses and a pacemaker infection due to brucellosis. To our knowledge, a similar manifestation has not been reported in the literature.

Aim: To determine risk factors, causative organisms and antimicrobial resistance of bacterial infections following living-donor liver transplantation (LDLT) in cirrhotic patients., Methods: This prospective study included 45 patients with hepatitis C virus-related end-stage liver disease who underwent LDLT at Ain Shams Center for Organ Transplant, Cairo, Egypt from January 2014 to November 2015. Patients were followed-up for the first 3 mo after LDLT for detection of bacterial infections. All patients were examined for the possible risk factors suggestive of acquiring infection pre-, intra- and post-operatively. Positive cultures based on clinical suspicion and patterns of antimicrobial resistance were identified., Results: Thirty-three patients (73.3%) suffered from bacterial infections; 21 of them had a single infection episode, and 12 had repeated infection episodes. Bile was the most common site for both single and repeated episodes of infection (28.6% and 27.8%, respectively). The most common isolated organisms were gram-negative bacteria. Acinetobacter baumannii was the most common organism isolated from both single and repeated infection episodes (19% and 33.3%, respectively), followed by Escherichia coli for repeated infections (11.1%), and Pseudomonas aeruginosa for single infections (19%). Levofloxacin showed high sensitivity against repeated infection episodes ( P = 0.03). Klebsiella , Acinetobacter and Pseudomonas were multi-drug resistant (MDR). Pre-transplant hepatocellular carcinoma (HCC) and duration of drain insertion (in days) were independent risk factors for the occurrence of repeated infection episodes ( P = 0.024)., Conclusion: MDR gram-negative bacterial infections are common post-LDLT. Pre-transplant HCC and duration of drain insertion were independent risk factors for the occurrence of repeated infection episodes., Competing Interests: Conflict-of-interest statement: None of the authors have any conflicts of interest or financial disclosures.

A deeper understanding of biological materials and the design principles that govern them, combined with the enabling technology of 3D printing, has given rise to the idea of "building with biology." Using these materials and tools, bio-hybrid robots or bio-bots, which adaptively sense and respond to their environment, can be manufactured. Skeletal muscle bioactuators are developed to power these bio-bots, and an approach is presented to make them dynamically responsive to changing environmental loads and robustly resilient to induced damage. Specifically, since the predominant cause of skeletal muscle loss of function is mechanical damage, the underlying mechanisms of damage are investigated in vitro, and an in vivo inspired healing strategy is developed to counteract this damage. The protocol that is developed yields complete recovery of healthy tissue functionality within two days of damage, setting the stage for a more robust, resilient, and adaptive bioactuator technology than previously demonstrated. Understanding and exploiting the adaptive response behaviors inherent within biological systems in this manner is a crucial step forward in designing bio-hybrid machines that are broadly applicable to grand engineering challenges., (© 2017 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background & Aim: Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aimed at analyzing characteristics and factors associated with development of hepatocellular carcinoma (HCC) in patients with primary BCS., Methods: A total of 348 Egyptian BCS patients were included. They were presented to the Budd-Chiari Study Group of Ain Shams University Hospital. BCS was confirmed using abdominal Doppler US. Abdominal magnetic resonance imaging (MRI), MR venography and/or multislice computed tomography (CT) were performed to confirm all diagnoses and to assess vascular anatomy. Hepatic focal lesions detected during the study period (2005-2011) were evaluated using serum alpha foetoprotein (AFP) level, imaging features and histopathological examination., Results: Diagnosis of HCC was confirmed in 15/348 patients (4.3%). Imaging studies showed that 60% had multiple hepatic focal lesions ranging from 2 to 6.3 cm in size. The median level of serum AFP in BCS with HCC was 300 ng/mL vs 11 ng/mL in those without HCC (P<.001). A cut-off level >24.5 ng/mL for serum AFP showed sensitivity 80%, specificity 97.9%, positive predictive value 93.18% and negative predictive value 99.1% for detection of HCC in BCS patients. Male gender, older age, cigarette smoking, serum AFP (>24.5 ng/mL) and shrunken liver by ultrasonography were independent factors associated with HCC development., Conclusion: Male gender, older age and cigarette smoking are independent risk factors for development of HCC in BCS. Serum AFP is a good screening test in BCS., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Aim: To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT)., Methods: A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival., Results: Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups., Conclusion: A MELD score > 20 may predict mortality after LDLT.

Splanchnic circulation is the primary mechanism that regulates volumes of circulating blood and systemic blood pressure in patients with cirrhosis accompanied by portal hypertension. Recently, interest has been expressed in modulating splanchnic circulation in patients with liver cirrhosis, because this capability might produce beneficial effects in cirrhotic patients undergoing a liver transplant. Pharmacologic modulation of splanchnic circulation by use of vasoconstrictors might minimize venous congestion, replenish central blood flow, and thus optimize management of blood volume during a liver transplant operation. Moreover, splanchnic modulation minimizes any high portal blood flow that may occur following liver resection and the subsequent liver transplant. This effect is significant, because high portal flow impairs liver regeneration, and thus adversely affects the postoperative recovery of a transplant patient. An increase in portal blood flow can be minimized by either surgical methods (e.g., splenic artery ligation, splenectomy or portocaval shunting) or administration of splanchnic vasoconstrictor drugs such as Vasopressin or terlipressin. Finally, modulation of splanchnic circulation can help maintain perioperative renal function. Splanchnic vasoconstrictors such as terlipressin may help protect against acute kidney injury in patients undergoing liver transplantation by reducing portal pressure and the severity of a hyperdynamic state. These effects are especially important in patients who receive a too small for size graft. Terlipressin selectively stimulates V1 receptors, and thus causes arteriolar vasoconstriction in the splanchnic region, with a consequent shift of blood from splanchnic to systemic circulation. As a result, terlipressin enhances renal perfusion by increasing both effective blood volume and mean arterial pressure.

Objective: Understanding issues pertaining to quality of life is essential for any disease, particularly in recipients of liver transplantation. The aim of this study was to evaluate the impact of liver transplantation on Egyptian recipients' health-related quality of life (HRQOL)., Methods: A prospective study carried out at the Ain Shams Center for Organ Transplantation (Cairo, Egypt), including 35 recipients for the evaluation of HRQOL using short form 36 score (Arabic version) and Beck Depression Inventory scores pre-transplantation and 1 and 6 months afterwards., Results: The mean age of the recipients was 49.27 ± 8.16 years. Among them, 17 patients were highly educated. A statistically significant improvement in all dimensions of their HRQOL was observed after liver transplantation. Their physical functioning was 45.00 ± 34.34 before liver transplantation while after 1 and 6 months it was 57.50 ± 20.66 and 74.83 ± 19.27, respectively (P < 0.001). All 17 patients completed their first year after transplantation, showing a statistically significant improvement in all dimensions of their HRQOL one year after liver transplantation except that in mental health, role limitation due to emotional health emotional and social functioning domains., Conclusion: HRQOL is an important aspect of liver transplantation that should not be neglected., (© 2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Purpose: Recurrence of HCV after LDLT is almost universal. Different factors affect response to treatment. Few data are available regarding outcome of recurrent HCV genotype 4. The purpose of this study is to improve outcome of recurrent HCV genotype 4 after LDLT., Methods: An IRB approved chart review of 243 patients transplanted for ESLD, HCV genotype 4 over 4 years were reviewed. Protocol liver biopsies were taken 6 months after transplant. Patients received pegylated interferon and ribavirin in case of histological recurrence. Five patients had FCH were excluded., Results: Thirty-seven patients were included. Sustained Virological Response (SVR) was achieved in 29 (78.3%). Patients with Metavir fibrosis stage (F0) and (F1) had SVR in 5/5 (100%) and 20/24 (83.3%). Two patients with F1 had to stop treatment because of thrombocytopenia and 2 were non responders. Three out of 6 patients (50%) with (F2) had SVR, 2 were non responders and one had to discontinue treatment because of severe depression. One of 2 patients (50%) with F3 had SVR and the other patient decompensated within 4 months before treatment and died., Conclusion: Protocol biopsies allow early detection of inflammatory changes in the graft before fibrosis occurs. Early treatment of recurrent HCV genotype 4 after LDLT results in better response., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety., Objectives: The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process., Materials and Methods: From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected., Results: One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation., Conclusions: Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Aim: To describe the socio-demographic features, etiology, and risk factors for Budd-Chiari syndrome (BCS) in Egyptian patients., Methods: Ninety-four Egyptian patients with confirmed primary Budd-Chiari syndrome were presented to the Budd-Chiari Study Group (BCSG) and admitted to the Tropical Medicine Department of Ain Shams University Hospital (Cairo, Egypt). Complete clinical evaluation and laboratory investigations, including a thrombophilia workup and full radiological assessment, were performed to determine underlying disease etiologies., Results: BCS was chronic in 79.8% of patients, acute or subacute in 19.1%, and fulminant in 1.1%. Factor V Leiden mutation (FVLM) was the most common etiological cause of disease (53.1%), followed by mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) (51.6%). Current or recent hormonal treatment was documented in 15.5% of females, and BCS associated with pregnancy was present in 17.2% of females. Etiology could not be determined in 8.5% of patients. Males had significantly higher rates of MTHFR gene mutation and Behçet's disease, and females had significantly higher rates of secondary antiphospholipid antibody syndrome. A highly significant positive relationship was evident between the presence of Behçet's disease and inferior vena caval occlusion, either alone or combined with occlusion of the hepatic veins (P < 0.0001)., Conclusion: FVLM is the most common disease etiology and MTHFR the second most common in Egyptian BCS patients. BCS etiology tends to vary with geographic region.

Background: Liver cysts are often asymptomatic. Symptomatic liver cysts are uncommon and can be managed by percutaneous aspiration, laparoscopic/open marsupialization, or resection. Our aim is to review our experience with management of giant liver cysts (GLC)., Materials and Methods: An IRB approved chart review of patients with liver cysts between 1995-2009 was performed. There were 34 GLC in 24 patients, 20 (83%) were females (mean age of 59.2 y). Pain was the main symptom in 20 patients. The average cyst size was 15.66 cm (6-32 cm) with 14 cysts over 15 cm in size. Two patients with GLC (11 and 15 cm) decided not to have surgery; 16 patients underwent laparoscopic surgery with one recurrence. One patient with laparoscopic marsupialization at another center was managed by open marsupialization and repair of the bile leak. Four of the patients underwent open marsupialization and one underwent open resection. Four patients with prior percutaneous aspiration had recurrences (100%), three underwent laparoscopic and one open marsupialization. An 8-wk pregnant patient underwent percutaneous aspiration of a 32 cm cyst to alleviate symptoms until delivery., Results: The mean hospital stay for laparoscopic marsupialization was 5.57 d compared with 9.2 d for open procedure. Three (18.7%) postoperative complications (bile leak, recurrence, bleeding) occurred in the laparoscopic group, and one (20%) bile leak in the open group, with a mean follow-up of 41 mo., Conclusion: Laparoscopic marsupialization of GLC is as effective and safe as open procedures in preventing cyst recurrence regardless of cyst size and location, and affords a relatively shorter hospital stay., (Copyright © 2011 Elsevier Inc. All rights reserved.)

In tile present study the clinicopathological aspects of H. pylori infection in different parts of the stomach were investigated in 36 patients. The results showed that 28 patients (77.8%) were H. pylori positive and 8 patients (22.2%) were H. pylori negative by histopathology and confirmation with modified Giemsa stain. There was no statistically significant difference belween H. pylori positive and negative patients regarding dyspeptic symptoms or intestinal metaplasia histopathologically. Histopathological examination revealed chronic gastritis with mononuclear cell infiltration in all studied patients. According to the degree of cell infiltration, chronic gastritis was graded as mild, moderate and severe. There was a statistically significant difference between H. pylori positive and H. pylori negative patients regarding both severity and activity of chronic gastritis in the antrum and body compared to the fundus. Also, there was significant correlation between the grade of H. pylori colonization and the grade of chronic active gastritis on one hand and between H. pylori infection and atrophic gastritis. The serum anti-H. Pylori - IgG positive cases who were H pylori negative by history, showed atrophic gastritis acid intestinal metaplasia. This may be due to the fact that the mucosa has become inhospitable for H. pylori.

The aim of the study was to detect a possible aetiological association between chronic hepatitis C virus (HCV) infection and diabetes mellitus (DM). Among the 591 HCV seropositive chronic liver disease (CLD) patients, 150 (25.4%) had associated diabetes mellitus while only 25 of 223 HCV seronegatives (11.2%) were diabetics. The HCV seropositive patients were three times more likely to suffer from diabetes mellitus than those who were HCV seronegative and the results were highly significant (odds ratio = 2.7, CI = 1.7-4.4, P < 0.0001). Liver biopsy showed cirrhosis in 24 out of 53 (45.3%) HCV seropositive diabetics and 9/20 (45%) of the HCV seronegative diabetics. The association between the degree of liver disease and the development of diabetes mellitus did not differ statistically between the two groups. Islet cell antibody (ICA) was present in 44.4% of HCV seropositives compared to 73.3% of seronegative diabetics, while NIDDM showed 40% ICA positivity. Although ICA level was highest in HCV seronegative diabetics, the difference between the various groups was not significant statistically. About 29% of HCV seropositive diabetics were on insulin therapy while only 16% of HCV seronegative diabetics received insulin therapy. HCV seropositives were about 2 times more prone to require insulin therapy than HCV seronegatives (odds ratio = 2.0, CI = 1.2-5.7, P = 0.010). We conclude that chronic hepatitis C patients in Egypt are three times more likely to develop DM than HCV seronegative patients. Pancreatic beta -cells might be an extrahepatic target of HCV.

Many studies have demonstrated a very high prevalence of HCV antibodies among blood donors (BD) and chronic liver disease (CLD) patients in Egypt. This high prevalence might be attributed to cross reactivity between HCV antibodies and schistosome antibodies. We decided to study the association and cross serology between the presence of anti-HCV and Schistosomal infection among BD and CLD patients. Sera of blood donors and CLD patients were tested for anti-HCV by second generation ELISA. Antibodies to Schistosoma species were quantified by IHA test. Two tailed z score was used to detect significant difference. To test for cross reactivity between the two antibodies 20 BD and 20 CLD patients positive for both HCV-antibody and schistosome antibody were taken as controls. Another 20 samples also served as a control group; 10 of them seropositive for HCV only and 10 positive for IHA for schistosomiasis alone. All were subjected to: 1) RIBA-2 confirmatory test 2) Adsorption of schistosome antibodies using 100 microgram schistosome antigens per 100 microliters serum 3) Both HCV-ELISA-2 and RIBA-2 were checked after adsorption. The titre of schistosome antibodies in positive sera ranged from 1:128 to 1:1536. HCV seroprevalence was more pronounced among antischistosomal positive sera. This was seen in both BD and CLD patients where antischistosomal positive sera were at double risk to show positive HCV antibody. After adsorption of schistosome antibody, there was no change in reactivity of both ELISA-2 and RIBA-2. We conclude that HCV antibodies were significantly higher in schistosomal antibody positive Egyptians, there was no cross reactivity between the two antibodies and the high prevalence could be due to HCV transmission during anti-bilharzial parenteral therapy or due to depressed cell mediated immunity associated with schistosomal infection.

The objectives of this study were to define the prevalence of intrafamilial transmission of HCV and evaluate the risk factors in this setting. A cross-sectional, family-based seroepidemiological study was performed in Cairo Liver Center and Oncology Diagnostic Unit, Ain Shams University. A total of 102 index patients (72 males and 30 females) with type C chronic liver disease and their 305 family contacts were studied. Only 265 family contacts were eligible for the study as they showed no previous history of exposure to risk factors. Overall, 15 family contacts (5.7%) were positive for anti-HCV, indicating a lower anti-HCV prevalence among family contacts than the general population in Egypt. Spouses were at higher risk of infection (16.7%) than family members (2.6%). Among the repeatedly positive samples for anti-HCV, only 3 samples were HCV-RNA positive (1.1%), all were spouses. Logistic regression analysis revealed that spouses reporting promiscuous sexual relations were at higher risk than those with normal sexual relations. Contacts sharing personal objects were also at higher risk to develop HCV infection. Index cases reporting previous blood transfusion (18.6%), i.v. antibilharzial therapy (33.3%), multiple sex partners (1.0%) or advanced liver diseases were more infective to their family contacts. The contacts of index cases had increasing risk of HCV infection with increase in age and duration of contact. The prevalence rate of intrafamilial spread of HCV infection is low compared to the rate among general population, emphasizing its limited role in transmitting HCV infection. Long duration of sexual contact and promiscuous sexual activities were major risk factors in this setting.

In a randomized controlled trial, sixty chronic hepatitis B liver disease patients (HBsAg +ve and HBV-DNA +ve) were randomly allocated into 2 groups. The first group comprised of 30 patients who were subdivided into 2 subgroups according to the HBeAg/anti-HBe system. One subgroup was HBeAg-positive (12 patients) and the other was anti-HBe-positive (18 patients). All were given human lymphoblastoid IFN alpha (Wellferon-R) at a dosage of 5 MU, thrice weekly for 4 months. The other 30 patients served as a control group, six of whom were lost during the study. The initial response was loss of HBV-DNA in 66.6% of the HBeAg +ve subgroup (8/12 patients), 33% in the anti-HBe subgroup (6/18 patients) and in 8% in the control group (2/24 patients). Patients and controls were followed up for 8 months after the end of IFN therapy. A sustained response (loss of HBV-DNA) 8 months after discontinuation of IFN was attained in 5/12 patients (41.6%) of the HBeAg-positive subgroup compared to none (0/24) in the control group (p < 0.05). In the anti-HBe subgroup, a sustained response in 2/18 patients (11%) compared to none (0/24) in the controls was not significant. We conclude from this study that (Wellferon-R) at a dosage of 5 MU given thrice weekly for 4 months was significantly better (p < 0.05) than no treatment in producing a sustained response among the HBeAg +ve subgroup of patients. On the other hand, in the anti-HBe subgroup the outcome of the previous schedule was not significantly better than in controls due to the small numbers involved although 2 patients did have a sustained response.

Unlabelled: Ninety-four HCV-positive CLD cases (56 males and 38 females with a mean age of 36 years) were matched to 50 HCV-ve CLD patients as a control group (30 males and 20 females with a mean age of 43 years). HCV antibody was screened by second generation ELISA, Ortho.. Autoantibodies (SMA, ANA, AMA, LKM1, SMA-anti-actin) were screened by immunofluorescence on cryostat murine sections using 1:40 serum dilution. Screening showed that 40 of 94 42.5%) HCV-positive CLD patients were positive for autoantibodies. Thirty eight of these were +ve for smooth muscle antibody (SMA) (40.4%), but all of them were negative for anti-actin, 3 were +ve for antinuclear antibody (ANA) (3.19%), while another 2 were +ve for antimitochondrial antibody (AMA) (2.1%). In the control group, 8(16%) were autoantibody +ve, 6 (12%) were SMA +ve, 2 (4%) were ANA +ve, 1 (2%) was AMA +ve and non had LKM1-Ab. There was significant difference between cases and controls concerning the autoantibody prevalence (P < 0.05). Although the prevalence of SMA among HCV +ve CLD cases was high (40%), yet, anti-actin antibody was totally negative, disclosing the insignificance of SMA positivity. It has been reported that the relevant SMA-AIH-1 is directed to the cell actin, whereas other SMAs have nothing to do with the immuno-pathogenesis of AIH., Conclusion: It seems that the predominant HCV genotype in Egypt is hardly associated with autoimmune phenomena.

Unlabelled: In this trial, we have checked 50 anti-HCV positive, HCV-RNA PCR positive chronic liver disease cases, 44 males, 6 females with a mean age of 51 years. HCV-RNA extraction and genotyping was carried out at the Department of Medical Microbiology, University of Edinburgh, U.K. results showed that 47 (94%) of patients were of genotype 4 and 3 (6%) were of genotype 1. Liver biopsies were performed in 22 only out of the 50 patients studied. The 3 genotype 1 patients were biopsied, 2 had cirrhotic profile and one had CAH. Of 47 genotype 4 patients, 19 were biopsied, 3 were CPH, 2 had CLH, 9 had CAH, 4 had cirrhosis and one patient had HCC., Conclusion: It appears that Egypt hosts predominantly HCV genotype 4 and less commonly genotype 1. This finding might have important implications concerning the epidemiological aspects, pathogenesis and response to antiviral therapy.