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   Table of Contents - Current issue
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July-September 2019
Volume 31 | Issue 3
Page Nos. 247-387

Online since Tuesday, August 27, 2019

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ORIGINAL ARTICLES  

Vitamin D and LL-37 in cirrhotic patients with culture-positive spontaneous bacterial peritonitis Highly accessed article p. 247
Ahmed El Sayed Zeid, Perihan El Sayed Salem, Abeer S El Hadidi, Tamim G Ibrahim
DOI:10.4103/ejim.ejim_102_18  
Background and aims Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in patients with liver cirrhosis and ascites. Cirrhotic patients frequently have vitamin D (Vit-D) deficiency. Vit-D induces the production of LL-37, an important molecule of innate immunity, in macrophages. The aim of this study is to assess Vit-D and LL-37 levels in the ascitic fluid (AF) of cirrhotic patients with SBP in comparison to patients with simple ascites. Patients and methods Forty male cirrhotic patients with ascites were included and were divided into two groups, 20 with culture-positive SBP (group I) and 20 with simple ascites (group II). AF Vit-D and LL-37 levels were measured. Results Vit-D and LL-37 levels were significantly lower in patients with SBP than those with simple ascites. In univariate analysis, the risk factors for SBP were lower platelet count, higher leukocytic count, higher serum bilirubin, lower prothrombin activity, lower serum albumin, higher Child–Pugh and model for end-stage liver diseases scores, and lower AF Vit-D and LL-37 levels, while in multivariate analysis, a lower AF Vit-D level was the only risk factor for SBP. Conclusion Patients with SBP have lower levels of AF Vit-D and LL-37 than simple ascites, where an inadequate expression of LL-37 in AF due to the low Vit-D level may increase the susceptibility to SBP.
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Prognostic value of interleukin-10 and tumor necrosis factor-α polymorphisms in patients with hepatocellular carcinoma treated with transarterial chemoembolization p. 254
Ahmed A Ghafar, Elsayed Ghoneem, Salah Rozaik, Ahmed Akef, Metwaly Mortada
DOI:10.4103/ejim.ejim_110_18  
Background Transarterial chemoembolization (TACE), a locoregional therapy, is widely recommended as first-line treatment for intermediate-stage hepatocellular carcinoma (HCC). Several prognostic indices have been used to predict overall survival in HCC patients undergoing the procedure. Patients and methods A total of 73 patients with HCC, candidate for TACE attending to HCC clinic, Specialized Medical Hospital, Mansoura University, were subjected to full history taking, physical examination, laboratory profile and testing for interleukin (IL)-10 and tumor necrosis factor (TNF)-α polymorphisms. Aggressiveness index is calculated for all patients and followed-up for 4 weeks after TACE to asses response. According to IL-10 and TNF-α polymorphisms results, patients were divided into groups and compared. Results The aggressiveness index is significantly higher in the TT/AT haplotype of IL-10 and GG haplotype of TNF-α in comparison with the other haplotypes. The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are significantly associated with less favorable outcome after TACE, wherein 64.3 and 56.25% of patients showed residual active tumor tissue, respectively. Conclusion The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are associated with more aggressive pattern of HCC and less favorable outcome after TACE; hence, these patients must be treated as early as possible.
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The role of mean platelet volume in predicting severity and prognosis of liver cirrhosis in Egyptian patients p. 261
Mohamed S Mohamed, Mohamed A.A Bassiony, Ayman F. Elsayed Mohamed
DOI:10.4103/ejim.ejim_111_18  
Background and aims Liver cirrhosis is a major public health problem in Egypt due to widespread infection of hepatitis C virus. Mean platelet volume (MPV) is a noninvasive, inexpensive parameter of complete blood count. In this study we aimed at evaluating the association between MPV and clinical features, complications, and severity of cirrhosis in Egyptian patients. Patients and methods One hundred and fourteen patients with cirrhosis of various grades of severity and various presentations were enrolled in our study. The patients were evaluated to assess the association between MPV values and cirrhosis parameters, model for end-stage liver disease score, and fibrosis (FIB4) score. Results The study demonstrates the positive correlation between MPV values and international normalized ratio, serum bilirubin, lower serum albumin in cirrhotic patients. Also, the MPV values were significantly higher in patients with more severe liver disease according to the model for end-stage liver disease (r=+0.424, P=0.008) and FIB4 scores (r=+0.353, P=0.03). Conclusion MPV can be used as an important inexpensive biomarker in cirrhotic patients for the degree of severity and prognosis of the disease.
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Comparison of endoscopic ultrasound-guided tissue acquisition using 22 G versus 20 G procore needles in solid lesions: a pilot study p. 266
Ahmed Altonbary, Hazem Hakim, Doaa Bakr, Ahmed El-Shamy, Wagdi Elkashef
DOI:10.4103/ejim.ejim_118_18  
Background and aim Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) allows tissue acquisition from solid lesions. The endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle was developed to improve diagnostic yield by acquisition of histological core. The impact of the needle type (FNA or FNB) on the diagnostic yield and the technical success needs to be further studied. Therefore, the aim of our study was to compare the diagnostic accuracy and technical success of the 22-G FNA needle with the 20-G procore FNB needle in solid lesions. Patients and methods The study was designed as a pilot study conducted on cases with solid mediastinal, pancreatic, and intra-abdominal lesions, and the patients involved were then randomized for tissue sampling using either the standard 22-G FNA needle or the new 20-G procore FNB needle. Results In this six-month study, 50 patients including 29 male individuals and 21 female individuals, with a mean age of 57.1±12.3 years (range: 15–80 years) were enrolled. No significant difference was detected between FNA 22 G and FNB 20 G as regards the diagnostic accuracy or the technical success rates. However, there was a significant difference in the number of passes needed to reach diagnosis. The success rate of first pass for FNA 22 G and FNB 20 G was 69 and 92.5%, respectively (P=0.014, 95%CI). Conclusion EUS-guided FNA and FNB have comparable diagnostic accuracy for solid lesions. The 20-G FNB needles are easy to handle in anatomically challenging locations and required fewer needle passes to reach diagnosis.
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Detection of patatin-like phospholipase domain-containing protein 3 in nonalcoholic fatty liver disease among egyptian patients p. 273
Kadry M El Saeed, Ossama A Ahmed, Mohamed O Khalifa, Eman M Fahmy
DOI:10.4103/ejim.ejim_43_18  
Background and aim Recently, studies have identified patain-like phospholipase domain containing 3 (PNPLA3), which is localized in the endoplasmic reticulum and at the surface of lipid droplets. The association of PNPLA3 polymorphisms with fatty liver and histological severity of NAFLD was shown in many studies. We aimed to investigate the association of PNPLA3 with the development and severity of NAFLD in an overweight and obese Egyptian population. Patients and methods Eighty overweight and obese patients with NAFLD were enrolled in the study. Patients were divided into 2 subgroups according to results of liver biopsy: group 1 included 30 patients with simple steatosis, and group 2 included 50 patients with non-alcoholic steatohepatitis (NASH). In addition to 10 age-matched healthy subjects served as a control group. All NAFLD patients underwent a confirmatory biopsy. Laboratory investigations included fasting glucose, liver enzymes and lipid profile were done. Abdominal ultrasound was performed and PNPLA3 was detected in each patient by Quantitative ELISA. Results Levels of PNPLA3 were higher in NAFLD patients compared with controls (85.70±76.42 vs 3.10±2.11 respectively) and levels were also higher in NASH than simple steatosis (125.09±71.78 vs 20.06±8.47 vs 3.10±2.11 respectively, P<0.001). There were highly significant positive correlations between the PNPLA3 and waist circumference, BMI, ALT, AST, total cholesterol and TGs in the NAFLD patients. Conclusions Our study confirmed the association of PNPLA3 with the incidence of NAFLD and progression to NASH in the Egyptian patients.
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Rifaximin plus norfloxacin versus norfloxacin alone in primary prophylaxis of spontaneous bacterial peritonitis in patients with variceal bleeding p. 281
Ahmed A Ghafar, Salah Rozaik, Ahmed Akef
DOI:10.4103/ejim.ejim_6_19  
Background Spontaneous bacterial peritonitis (SBP) is an infection of the ascitic fluid in the absence of other intra-abdominal sources. The risk is high in those with concomitant gastrointestinal bleeding, low ascitic fluid protein, or a previous attack of SBP. Norfloxacin is used widely in the primary prophylaxis of SBP but resistance usually develops where rifaximin was introduced. Patients and methods A total of 80 patients with advanced liver cirrhosis attending the Hemostasis Unit, Emergency Hospital, Mansoura University, with upper gastrointestinal bleeding were subjected to full history, clinical examination, laboratory assessment, and ascitic fluid analysis. The patients were divided into two groups: the first group received rifaximin plus norfloxacin and the second group received norfloxacin only and the two groups were followed up for 1 year. Results The study enrolled 80 patients, 51 men and 29 women with a mean age of 58.83±5.02 years for group 1 and 58.35±4.95 years for group 2. There were no statistically significant difference between the two groups as regards the clinical or laboratory characteristics except for the presence of focal lesions that was significantly present in group 2. A significant increase in the incidence of SBP in group 2 was present with P=0.014. The median time of developing SBP was significantly shorter in the second group. Conclusion The addition of rifaximin to norfloxacin decreased the incidence rates of SBP in patients with variceal bleeding with significant improvement in patient survival.
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Prevalence and effect of occult hepatitis C infection in patients with persistent liver enzyme elevation after achieving 24 weeks of sustained virological response p. 288
Anwar A Mohamed, Ashraf M Eljaky, Eman M Abdelsameea, Tamer R Fouad, Hosam El-Din M El-Ezawy
DOI:10.4103/ejim.ejim_24_19  
Background Despite achieving sustained virological response (SVR) of chronic hepatitis C infection, some of the treated patients have persistent elevations of transaminases. Occult hepatitis C infection (OCI) could be one of the causes. Aim The aim of this study was to detect OCI in peripheral blood mononuclear cells in patients who achieved 24-week SVR with persistent elevations of transaminases. Methods We included 998 naïve chronic HCV-infected patients who received treatment at our hospital. Patients with elevated liver enzymes after achieving SVR were determined. HCV RNA PCR in peripheral blood mononuclear cells was done for those patients (group 1) and was compared with a group with normal levels of enzymes, which was matched in age and sex (group 2). Results Nine hundred and sixty-five patients achieved SVR (96.69%). Seventy-four (7.7%) patients of them had elevated enzymes. OCI was detected in 14/74 (18.9%) patients of group 1, whereas it was seen in 4/67 (5.9%) in group 2. Cirrhosis, OCI, and obesity were associated with this enzymes elevation (P=0.005, 0.024, and <0.001). By multivariate analysis, none of these three parameters were independently associated with the enzyme elevation. The presence of OCI was not significantly associated with the presence of cirrhosis or obesity. Conclusion OCI is not infrequent in patients with persistent transaminase elevations despite obtaining 24 weeks of SVR. Liver cirrhosis, OCI, and obesity could have synergistic effects and should be considered as important risk factors of this persistent enzyme elevation.
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Efficacy of chymotrypsin in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis p. 292
Ahmed A Attia, Esam A Elshimi, Tamer R Fouad, El-Sayed A Ibrahim, Wael M Abdel-Razek
DOI:10.4103/ejim.ejim_13_19  
Background Pancreatitis is common after endoscopic retrograde cholangiopancreatography (ERCP). Aim To assess the pharmacological effect of diclofenac, allopurinol and chymotrypsin in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP). Settings and design Calcular obstructive jaundice patients without pancreatitis scheduled for ERCP were randomized into three groups. Materials and methods The diclofenac group received 200 mg rectal suppositories immediately after ERCP, allopurinol received oral 300 mg 3 h before ERCP, and chymotrypsin received intramuscular injection immediately after ERCP. Serum amylase and lipase were measured before, 1, 6, and 24 h after ERCP and procedure-related risk factors for post-ERCP pancreatitis were recorded. Pancreatitis was considered when serum amylase or lipase levels elevated more than three times the upper limit of normal with newly developed abdominal pain lasting at least 24 h after ERCP. Statistical analysis Analysis of variance for continuous variables and χ2 for categorical variables. Results One hundred and fifty patients were included; diclofenac group (58 patients, 29 men, mean age 46.9±13.2 years), allopurinol (38 patients, 20 men, mean age 43.1±14.7 years) and chymotrypsin (54 patients, 28 men, mean age 40.6±17.3 years). Twelve (8%) patients developed PEP: the diclofenac group (n=4; 6.9%), allopurinol (n=6; 15.8%) while chymotrypsin (n=2; 3.7%), but this was not statistically significant (P=0.318). In patients who received chymotrypsin, regression of serum amylase and lipase to normal levels was much better compared with the other groups and was associated with better clinical improvement. Conclusion Chymotrypsin and allopurinol are comparable to diclofenac in the prevention of pancreatitis post-ERCP. Beside its prophylactic role, chymotrypsin could be effective in rapid improvement if PEP occurs.
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Effect of direct-acting antivirals on platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in patients with hepatitis C virus-related thrombocytopenia p. 296
Mohamed A Abd El Hafez, Zeinab Abdel Aziz Kasemy
DOI:10.4103/ejim.ejim_14_19  
Objectives To study the effect of direct-acting antivirals (DAAs) on platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in patients with hepatitis C virus (HCV)-related thrombocytopenia. Background PLR and NLR are correlated with HCV infection, HCV-related liver cirrhosis, HCV-related atherosclerosis and cardiovascular diseases. Patients and methods In the current study, we studied 100 patients with HCV-related thrombocytopenia. All patients were subjected to anti-HCV antibody, HBsAg, liver profile, blood urea, serum creatinine, fasting and postprandial blood glucose, complete blood count, iron profile, direct anti-globulin test, rheumatoid factor, antinuclear antibody, and alpha fetoprotein. Abdominal ultrasound, FibroScan, echocardiography, and electrocardiography were done for all patients. Thrombocytopenia was defined as platelets count less than 150.000/mm. The used DAAs were sofosbuvir and daclatasvir, and duration of treatment was 12 weeks. All patients were followed up during antiviral therapy (for 12 weeks) and had extended follow-up for 24 weeks after the end of therapy with DDAs. Quantitative PCR for HCV RNA was done at the start of therapy and at 12 weeks (end of treatment response). PCR for HCV was repeated at 12 weeks after the end of treatment to assess the sustained viral response at 12 weeks after end of treatment (SVR-12) and at 24 weeks after the end of treatment to assess the sustained viral response at 24 weeks after end of treatment (SVR-24). PLR and NLR were calculated by dividing platelet and neutrophil counts, respectively, by lymphocyte count at the start of treatment, then at 4 weeks, at 12 weeks (end of treatment), at 24 weeks (SVR-12), and at 36 weeks (SVR-24). Results The mean age of patients was 49.55±7.79 years, with a range of 33–64 years. They showed female predominance, with females constituting 58.7%. Patients were all Child A status. Liver fibrosis stage was either stages I, II, or III (45, 30, and 25%, respectively). Mean platelet count was 82.25±23.64, 77.01±18.58, 90.84±18.86, 85.02±18.79, and 80.26±18.67 before starting treatment with DAAs, at 4 weeks, at 12 weeks (end or treatment), at 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. PLR mean±SD was 74.07±12.76, 76.01±13.58, 65.84±13.86, 62.02±12.79, and 60.26±12.67 before starting treatment with DAAs, at 4 weeks, at 12 weeks (end or treatment), 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. NLR mean±SD was 1.61±0.24, 1.64±0.23, 1.50±0.24, 1.45±0.23, and 1.33±0.24 before starting treatment with DAAs, at 4 weeks, 12 weeks (end or treatment), 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. Both PLR and NLR initially increased at 4 weeks after the start of treatment and then both significantly decreased to reach lowest level at 36 weeks (SVR-24). Conclusion PLR and NLR are both decreased after HCV eradication by DDAs in HCV-infected patients with thrombocytopenia suggesting improvement of HCV-associated systemic inflammation.
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The association of adiponectin gene expression and serum levels with susceptibility to peripheral polyneuropathy in Egyptian patients by women with hypothyroidism p. 302
Nearmeen M Rashad, Mohamed S.S Saad, Bothina M Ramadan, Shereen M El Shabrawy
DOI:10.4103/ejim.ejim_80_18  
Background Hypothyroidism has numerous comorbidities including degenerative neurological disease and insulin resistance. Adiponectin is an adipokine secreted by adipose tissue with insulin-sensitizing, anti-inflammatory, and antioxidant properties. This study was designed to explore the expression pattern of Adiponectin and its serum level in hypothyroidism and peripheral neuropathy (PN). The aim was to also evaluate the association between the expression pattern of adiponectin and its serum level with the clinical and electrophysiological tests of PN in hypothyroid patients. Participants and methods This cross-sectional controlled study enrolled 110 hypothyroid patients and 80 control group participants. All participants were subjected to a complete neurological examination and nerve conduction study (NCS). Adiponectin level was measured using an enzyme-linked immunosorbent assay. Adiponectin expression levels were estimated using real-time PCR. Results The results showed lower values of serum adiponectin and adiponectin expression levels in hypothyroid patients, especially patients with PN. NCS in the studied group showed that motor and sensory nerve conduction in the median and posterior tibial nerves were significantly decreased in both hypothyroid patients with or without PN compared with the euthyroid group. In addition, serum adiponectin and adiponectin expression were negatively correlated with Toronto Clinical Scoring System as well as cardiometabolic risks and positively correlated with NCS of the median, sural, and tibial nerves. The diagnostic power of adiponectin expression is better than that of adiponectin serum levels. Conclusion Hypothyroid patients with PN had lower values of serum adiponectin and adiponectin expression levels than hypothyroid patients without PN; the diagnostic power of combined adiponectin serum and expression levels was thus highly significant, and they could be a useful diagnostic biomarker of PN.
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Frequency and relation of thyroid dysfunction and inflammation in chronic kidney diseases in the Nephrology Unit, Zagazig University p. 314
Nafesa M Kamal, Ahmed M El Sayed, Norhan A Sabah
DOI:10.4103/ejim.ejim_120_18  
Context Thyroid hormones play an important role in renal development, functioning renal mass, and early renal function. Pituitary–thyroid axis and metabolism of the peripheral thyroid hormones have been affected by chronic kidney disease (CKD). Aims The aim was to evaluate the frequency and relationship between thyroid disorders and high-sensitivity C-reactive protein (Hs-CRP) among CKD patients including hemodialysis (HD). Settings and design In Zagazig University Hospital. Participants and methods A case–control study that included 150 adult participants who were divided into: group I which included 50 patients with an estimated glomerular filtration rate (eGFR) of 41.8±23.6 ml/min/1.73 m2. Group II included 50 patients with an eGFR of 11.3±4.2 ml/min/1.73 m2.Group III included 50 participants with normal eGFR. All participants were evaluated for serum creatinine and albumin, complete blood count, estimation of GFR by modification of diet in renal disease (MDRD) equation, and serum thyroid-stimulating hormone (TSH), free T3, free T4, and Hs-CRP. Statistical analysis Using the Statistical Package for the Social Sciences under windows version 20. Qualitative variables were expressed by frequency and percentage, mean±SD, χ2-test, Student’s t-test, analysis of variance (F-test), and correlation analysis. Results The frequency of subclinical hypothyroidism (46%) and overt hypothyroid (42%) in groups I and II, respectively, has been much higher in CKD patients. There was a strong significant negative correlation of Hs-CRP with eGFR, FT3, FT4 (P<0.001), highly significant positive correlation with serum creatinine, TSH (P<0.001) in non-HD patients, but in HD patients there was high statistically significant negative correlation of Hs-CRP with hemoglobin, albumin, FT3 (P<0.001), FT4, and significant positive correlation with dialysis duration (P<0.001) and TSH. Conclusion the frequency of thyroid disorders mostly subclinical hypothyroid (46%) and overt hypothyroid (42%) is common in CKD patients and is highly correlated with Hs-CRP in these patients. So we recommend a thyroid investigation in chronic kidney patients for early detection and reduction of its morbidity and mortality.
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Vitamin D level in patients with type 1 diabetes and its relation to tissue transglutaminase immunoglobulin A antibodies p. 320
Asmaa K Ahmad, Omnia A Hussein, Ahmed A Saedii
DOI:10.4103/ejim.ejim_31_19  
Introduction Type 1 diabetes mellitus (T1DM) is a lifelong metabolic disorder, which accounts for ∼10% of all cases of diabetes. Vitamin D deficiency is extensively studied in the pathogenesis of T1DM. Vitamin D regulates both innate and adaptive immunity, and this indicates its potential role in preventing and treating T1DM. T1DM is also associated with celiac disease which is an autoimmune-mediated, chronic inflammatory disorder of the small intestine. Vitamin D deficiency has been described in patients with celiac disease and T1DM. Aim The study’s primary aim was to investigate the 25-hydroxyvitamin D [25(OH)D] level in patients with T1DM and relation between vitamin D level and the presence or absence of tissue transglutaminase immunoglobulin A [tTG (IgA)] antibodies. Patients and methods The study estimated 25(OH)D level in 75 patients with T1DM and 15 healthy participants. It also studied the relation between vitamin D level and the presence or absence of tTG (IgA) antibodies. Results Patients with T1DM had significantly lower level of 25(OH)D (82.7%) compared with control participants (46.7%) (P=0.003). In all, 5.3% of patients were positive for tTG (IgA) antibody, and antibody titer was significant higher in patients with T1DM, with mean of 1.57±3.38, compared with control participants, with mean of 0.31±0.07 (P=0.001). Vitamin D level was low in diabetic patients with positive tTG (IgA) antibody than diabetic patients with negative tTG (IgA) antibody, but this change did not achieve significant value. Conclusion Vitamin D deficiency is high in children and adolescents with T1DM. Its level was decreased in diabetic patients with positive tTG (IgA) antibody than diabetic patients with negative tTG (IgA) antibody.
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High prevalence of malnutrition among hospitalized patients in a tertiary care hospital by using malnutrition universal screening tool p. 326
Mervat E Behiry, Marwa R Salem
DOI:10.4103/ejim.ejim_126_18  
Background Estimating the prevalence of malnutrition among the hospitalized patients is challenging. Malnutrition is associated with a variety of poor outcomes including long hospital stay and mortality as well as increased hospital costs. Aim The study aims to assess the risk of malnutrition in hospitalized patients and to identify the main factors and clinical parameters associated with the risk of malnutrition. Materials and methods The researchers conducted a cohort study to screen for the risk of malnutrition following hospital admission in a population of adult patients recently admitted to a tertiary care hospital in Egypt using the malnutrition universal screening tool (MUST) and simplified nutritional appetite questionnaire and to assess the effect of malnutrition on duration of hospital stay. Results The study included 1000 patients with a mean age of 49±13.7 years. The median duration of hospitalization was 5 (4–7) days, with a range of 2–30 days. All those included in the study presented a risk for malnutrition (1.0% medium risk and 99.0% high risk). High risk malnutrition was most common among those with diabetes (P=0.001) and renal problems (P=0.03), and in patients who had been admitted for longer hospital stay (P=0.037). A statistically positive correlation was seen between the age of the patients (P=0.031, r=−0.031), length of stay (P=0.353, r<0.001), and MUST score. However, there was a statistically significant negative weak correlation between simplified nutritional appetite questionnaire (appetite) (P=0.003, r=−0.094), BMI (P<0.001, r=−0.120), albumin (P<0.001, r=−0.117), and MUST score. Malnourished patients had a longer hospital stay than those who are well nourished (P=0.002). Conclusion We have identified an overall malnutrition risk of 100% among the hospitalized patients and ascertained that malnutrition is a risk of prolonged length of hospital stay. MUST questionnaire should be implemented to screen and early recognize the malnourished hospitalized subjects for better intervention.
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Helicobacter pylori and its hematological effect p. 332
Yousryeia Abdel Rahman, Lobna Abdel wahid Ahmed, Rania Mohamed mahmoud Hafez, Rasha Mohamed Mahmoud Ahmed
DOI:10.4103/ejim.ejim_103_18  
Background Helicobacter pylori causes several gastric, intestinal, and extraintestinal manifestations. It also causes persistent infection and can cause serious various hematological effects. Aims To investigate the hematological effect of H. pylori infection. Patients and methods This is a cohort study that included 50 adult (age range: 18–75 years) patients infected with H. pylori and 50 adult patients who presented with symptoms suggestive of gastritis. All patients underwent upper endoscopy, and biopsies were taken. Moreover, the patients underwent complete blood count, iron studies, hepatitis C virus antibodies, vitamin B12 level, and bone marrow aspirate. Result The results showed that hemoglobin level, serum iron level, vitamin B12 levels, and platelets count were much lower in patients infected with H. pylori than the control group. Conclusion H. pylori causes iron-deficiency anemia, vitamin B12 deficiency, and thrombocytopenia, and treatment of H. pylori causes much improvement in these parameters.
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Urinary neutrophil gelatinase-associated lipocalin as a marker of kidney injury in Egyptian patients with thalassemia p. 343
Ibrahim Z Fouad, Maggie S ElNahid, Maha F Youssef, Yasmine M Amroussy
DOI:10.4103/ejim.ejim_114_18  
Background Renal disease is a long-term complication that should be recognized in thalassemia, especially with the rise in the average age of this population. Proper assessment of renal function abnormalities in thalassemia can be challenging because of the increased use of iron chelators, which themselves can affect renal function. There is a trend toward earlier detection of glomerular and tubular abnormalities, using early biomarkers of renal dysfunction. However, conflicting data make conclusive correlations difficult to achieve and strong diagnostic statistical parameters for these biomarkers are still lacking. Examples include albumin/creatinine ratio which can predict the initial signs of glomerular impairment, serum cystatin-C, and serum or urinary β-2 microglobulin have received attention as better tools to assess sensitive changes in glomerular filtration rate (GFR) and creatinine clearance in thalassemia as compared with serum creatinine and eGFR. Neutrophil gelatinase-associated lipocalin (NGAL) excretion in urine occurs when there is proximal tubular injury that disrupts NGAL reabsorption or increases NGAL synthesis. Significant correlations between the levels of urinary neutrophil gelatinase-associated lipocalin (uNGAL) and the degree of proteinuria in patients with chronic renal disease from diverse etiologies have been reported. Aim The study was to assess the markers of renal injury in β-thalassemia (β-TM) patients and to detect the significance of urinary albumin/creatinine ratio and uNGAL levels, as markers of kidney injury in Egyptian patients with thalassemia. Materials and methods This case–control study was conducted on 40 β-TM patients and 45 age-matched and gender-matched healthy controls, 27 women and 13 men, with a mean age of 29±9 years and for controls 28±5 years. The majority of enrolled patients (22) were thalassemia intermediate. One-third of the patients were receiving iron chelation therapy, 78.6% on deferasirox, and 21.4% on deferiprone. All patients were subjected to through history taking, physical examination, and routine laboratory investigation. Tests were done for the diagnosis of thalassemia and to identify the type of thalassemia. Type and dose of Iron chelation therapy was recorded treatment: type and dose of chelation. Measurement of uNGAL and calculation of uNGAL/creatinine ratio were done. eGFR was calculated according to the original modification of diet in renal disease equation eGFR (ml/min/1.73 m2). Chronic kidney disease was defined and graded according to KDIGO 2012. Results The results show that there is a statistically significant difference between cases and controls regarding uNGAL level as median was 498.0 ng/ml for cases compared with controls 423.3 ng/ml with a P value of 0.034. There is a statistically significant difference between cases and controls regarding uNGAL/creatinine ratio as the median was 481.75 ng/mg for cases compared with 333.79 with a P value of 0.003. There is no significant correlation between uNGAL (ng/ml) and dose of iron chelator, duration of iron chelator, eGFR, hemoglobin (Hg) level, serum ferritin, and albumin/creatinine ratio. There is no significant correlation between uNGAL/creatinine ratio (ng/mg) and eGFR, Hg level, serum ferritin, and albumin/creatinine ratio. eGFR was significantly higher (hyperfiltration) in cases compared with controls, with a median of 169.8 ml/min/1.73 m3 compared with 119.6 ml/min/1.73 m3, with a P value of less than 0.001. There was a statistically significant difference between cases and controls regarding albumin/creatinine ratio (μg/mg creatinine) as the median was 29.4 μg/mg creatinine for cases compared with controls 10.0 μg/mg creatinine with a P value of less than 0.001. Conclusion This study showed that assessment of albumin/creatinine ratio, uNGAL, and uNGAL/creatinine ratio, can be regarded as potential early biomarkers of renal dysfunction in β-TM patients.
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Predictive value of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in decompensated heart failure p. 353
Mahmoud Ashry, Rania Hafez, Essam M Atef
DOI:10.4103/ejim.ejim_101_18  
Objective Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), which are new inflammatory markers, inexpensive, widely available, and obtained from routinely used test (complete blood count), have proved to be potential predictors of outcome in many cardiovascular diseases. The aim of this study was to investigate the predictive value of NLR and PLR in detecting HF and their effect on morbidity and mortality of patients with heart failure (HF). Patients and methods This prospective study included 60 patients diagnosed with acute decompensated HF and 40 age-matched and sex-matched healthy controls. Echocardiography was done for all participants to assess cardiac function. All participants were tested for biochemical parameters (urea, creatinine, and liver function tests). Complete blood count with calculation of NLR and PLR was done for all participants. Then all cases were followed up for occurrence of cardiovascular, cerebrovascular complications, history of hospitalization, and death during the period of the study. Results NLR and PLR of patients were significantly higher than controls (P<0.02 and <0.03, respectively). There was an inverse correlation between both PLR and NLR and left ventricular ejection fraction of the study population (P<0.01 and <0.02, respectively). PLR had 70% sensitivity and 47% specificity for prediction of HF with cutoff point more than 186, whereas NLR had 97% sensitivity and 47% specificity for prediction of HF with cutoff point more than 3.56. Moreover, PLR had 83% sensitivity and 58% specificity for prediction of mortality in those patients with decompensated HF with cutoff point more than 175, whereas NLR had 92% sensitivity and 33% specificity for prediction of mortality in those patients with decompensated HF with cutoff point more than 3.56, with average 1-year follow-up. Conclusion NLR and PLR are cheap, widely available inflammatory biomarkers that can be used to predict morbidity and mortality in patients with HF.
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Serum salusin-β levels as predictors of coronary artery disease in obese Egyptian women p. 360
Nearmeen M Rashad, Wesam M.R Ashour, Ghada M Samir, Hala G Abomandour
DOI:10.4103/ejim.ejim_123_18  
Background Obesity is a growing health concern that has become an epidemic all over the world. Obesity is associated with coronary artery disease (CAD). Salusin-β is an endogenous bioactive peptide that accelerates inflammatory responses in vascular endothelial cells and increases oxidative stress. The objective of this study was to explore the potential roles of salusin-β in endothelial dysfunction in CAD. Also, we aimed to evaluate the association between salusin-β with severity of CAD in obese Egyptian women. Patients and methods This cross-sectional study enrolled 95 obese women who were classified into two groups: 58 patients without CAD and 37 patients without CAD. All patients were investigated using a 12-lead standard ECG, echocardiography, and coronary arteriography. Salusin-β levels were measured by enzyme-linked immunosorbent assay. Results Salusin-β levels were significantly higher in obese patients with CAD compared with patients without CAD. Salusin-β levels were positively correlated with cardiometabolic risks and severity of coronary occlusion. Serum salusin-β levels, high-sensitivity C-reactive protein, and BMI were independently correlated with CAD and BMI. Homeostatic model assessment of insulin resistance, high-sensitivity C-reactive protein, and uric acid were the main associated variables of serum salusin-β levels among other clinical and laboratory biomarkers. The diagnostic power of serum salusin-β levels in differentiating CAD from obese patients without CAD was highly sensitive (97.2%) and the specificity was 98.3%. Conclusion The higher levels of salusin-β levels in obesity, as well as CAD, were positively correlated with cardiometabolic risk factors and severity of coronary occlusion. Therefore, salusin-β levels seem to be a noninvasive biomarker of CAD.
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Serum C peptide and carotid intima-medial thickness are independent markers of glucose intolerance among patients with ischemic cerebrovascular stroke p. 368
Nearmeen M Rashad, Ghada M Samir, Hanan M Sabry, Nesreen M Mohy, Shereen M El Shabrawy
DOI:10.4103/ejim.ejim_97_18  
Background Stroke is the most common cause of disability worldwide. C-peptide is co-secreted with insulin from beta cells of the pancreas, thus providing a better index of endogenous insulin production and pancreatic beta cell function. The objective of the current study was to explore serum C-peptide and carotid intimamedia thickness in patients with ischemic stroke (IS) and to assess the association of serum C-peptide with vascular and metabolic risks. Patients and methods The case–control study included 50 healthy control and 150 patients with IS who were stratified into three subgroups according to their fasting plasma glucose, normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and type 2 diabetes mellitus (T2DM). All the participants were subjected to B-mode ultrasonography of both common carotid arteries to measure carotid intimamedia thickness (mm). Serum C peptide concentration was measured by enzyme-linked immunosorbent assay. Results Serum C peptide levels were higher in IS patients compared with control. Among the IS patients, C peptide was higher in T2DM compared with IGT and NGT and is associated with vascular and metabolic risks, after adjusting for the traditional risk factors. C-peptide was a statistically significance predictor of T2DM among IS patients by the logistic regression analysis test. In addition, homeostasis model assessment of insulin resistance (HOMA-IR), fasting plasma glucose, BMI, and fat mass index (FMI)% were independently correlated with C-peptide by. The diagnostic value of C-peptide by receiver operating characteristic curves was highly significant; the sensitivities and the specificities were 96 and 98%. Conclusion Serum peptide levels were higher in IS patients compared with the control. Among the IS patients, serum C peptide was higher in T2DM compared with IGT and NGT and is associated with vascular and metabolic risks.
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Adiponectin and its polymorphism: relation to coronary artery disease p. 376
Nashwa S Ghanem, Naglaa M El-Sayed, Ahmed K Abbas, Ollfat G Shaker
DOI:10.4103/ejim.ejim_11_19  
Background Adiponectin is an adipocytokine with important role in atherosclerosis. Increasing interest has been directed toward the role of adiponectin gene polymorphism in the human genome and its implication in the pathogenesis of coronary artery disease (CAD). Objectives The present study investigates the association between the single nucleotide polymorphism +276 G/T of the adiponectin gene and serum adiponectin level in patients with CAD. Methods In this study, 100 Egyptian patients with CAD of both sexes and 100 age-matched and sex-matched control volunteers were investigated. All patients were genotyped for +276 G/T polymorphism of adiponectin gene. Lipid profile, fasting blood glucose, and hemoglobin A1c were measured. Adiponectin and high-sensitivity C-reactive protein (hsCRP) levels were determined by ELISA technique. PCR based on restriction fragment length polymorphism was used to determine the genotypes of the studied population. Results The lowest serum adiponectin value was observed in patients with CAD compared with control group. The T allele of single nucleotide polymorphisms (SNPs) +276 G/T in the adiponectin gene was found to be associated with CAD (odd ratio 2.23; 95% confidence interval: 1.44–3.45; P=0.001). The significant association of the T allele (GT+TT) of this SNP with lower adiponectin level and hsCRP levels was confirmed in the study (P=0.003 and 0.006, respectively). Conclusions Our results concluded that +276 G/T SNP in the adiponectin gene is associated with CAD. Furthermore, carriers of the at-risk T allele had lower serum adiponectin level and higher serum hsCRP, causingin turn an increased risk to develop CAD.
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Screening and management of statin cause a case of prediabetes in an outpatient clinic in Afghanistan: a case report in Andkhoy City p. 382
Mohammad Shoaib Hamrah, Mohammad Hassan Hamrah, Mohammad Hussain Hamrah, Toba Dahi, Mohammad Hashem Hamrah
DOI:10.4103/ejim.ejim_109_18  
Dyslipidemia is known as an independent risk factor for cardiovascular disease. Recently, interest has been raised on the risk of new onset of diabetes mellitus with statin treatment. We report on a 41-year-old man with dyslipidemia. His blood tests at the time of admission showed that there was a rise in low-density lipoprotein levels (155 mg/dl), low high-density lipoprotein levels (34 mg/dl), normal triglyceride levels (82 mg/dl), normal fasting blood sugar levels (85 mg/dl), and normal glycated hemoglobin (HbA1c) (5.3%). Follow-up for about 2.5 years for statin use revealed that the patient’s lipid profile has improved; however, his HbA1c increased from 5.3 to 6.1%. The patient was prescribed Metformin and the statin was replaced with Ezetimibe. Little changes in blood HbA1c levels were observed at 1-year follow-up. Then, dipeptidyl peptidase-4 inhibitors, Sitagliptin, was introduced at 25 mg once per day, and Metformin was discontinued. One year later, the patient’s laboratory tests showed: low-density lipoprotein (77 mg/dl), high-density lipoprotein (33 mg/dl), triglycerides (108 mg/dl), and HbA1c (5.5%). This finding revealed that the dipeptidyl peptidase-4 inhibitor, Sitagliptin is more likely to be the successful drug for the treatment of prediabetes with statin therapy.
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Spontaneous chest wall haematoma in chronic myeloid leukaemia p. 385
Mohamed Dwebi, Peter Cumber
DOI:10.4103/ejim.ejim_59_18  
Chronic myeloid leukaemia can have different presenting signs. Here, we present a case of nontraumatic spontaneous chest wall haematoma in an 84-year-old man under investigation for myeloproliferative disorder before his admission. He was admitted with a 2-day history of sudden onset posterior chest wall pain and progressive bruises. Computed tomography showed a chest wall haematoma, while blood tests found a mild coagulation abnormality. He required fresh frozen plasma and red blood cell transfusions as part of his management, but his symptoms improved after starting hydroxycarbamide.
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