Seven-Year Experience of Intramural Surgery in the Middle East: A Safety and Feasibility Analysis.

Background: Intramural surgery techniques, particularly esophageal peroral endoscopic myotomy (E-POEM), gastric peroral endoscopic myotomy (G-POEM), and peroral endoscopic myotomy for Zenker's (Z-POEM), have emerged as forefront minimally invasive endoscopic procedures. While several studies have reported on the outcomes in North America and Asia, evidence in the Middle East and North Africa remains limited. This study aims to evaluate the feasibility and safety of intramural surgery techniques within this region. Methods: This retrospective cohort study was conducted with approval from the institutional review board. All patients who underwent esophageal peroral endoscopic myotomy, gastric peroral endoscopic myotomy, and peroral endoscopic myotomy for Zenker's from January 2016 to August 2023 were included. Results: In total, 119 patients underwent intramural surgery procedures during this period. The esophageal peroral endoscopic myotomy group had 81 (68%) patients, the gastric peroral endoscopic myotomy had 34 (28.6%) patients, and the peroral endoscopic myotomy for Zenker's had 4 (3.4%) patients. The full cohort was 48.7% female, with a mean overall age of 40.5 years. The mean overall body mass index was 27.5 kg/m2. The chief complaint was dysphagia (n = 80, 67.2%). All cases were successfully completed endoscopically. During the first 30 days, the most common complications were nausea/vomiting requiring admission (n = 4, 4.76%) and pneumomediastinum (n = 2, 2.38%). At a follow-up of 19 months, there were four mortalities; the causes of death were cardiac arrest (three cases) and end-stage prostate cancer (one case). Conclusions: Intramural surgery techniques are safe and technically feasible with low complication rates. Our study suggests that clinical success in the Middle East and Northern Africa population is comparable to larger international series.

Evaluation of early apical release with bipolar Collins knife versus Thulium-Yag laser enucleation of large-sized prostate. A randomized study.

Introduction and objectives: Anatomical endoscopic enucleation of the prostate (AEEP) provides durable management for patients with lower urinary tract symptoms (LUTS) secondary to large-sized prostate over other surgical modalities. We aimed to assess the early outcomes of Collins knife-assisted bipolar enucleation (BipolEP) versus Thulium-Yag enucleation (ThuLEP) in a group of patients with LUTS secondary to a prostate larger than 80 grams. Methods: We included patients with benign prostatic hyperplasia (BPH) having a prostate volume > 80 grams, international prostate symptom score (IPSS) >7, urine flow (Q-max) <15, and post-void residual (PVR)>150 ml. We excluded those with a history of previous prostatic surgery, stone, or neurogenic bladder. Bipolar enucleation with early apical release was performed using Collins knife at an 80/100-watt setting (Lamidey Noury), while ThuLEP was conducted using 550- micron fiber and 40/15-watt energy (Lisa Laser). Patients were evaluated before then 2 weeks and 3, 6,12 months postoperatively for changes in IPSS, Q- max, PVR, and the incidence of stress incontinence. Result: One hundred and twenty patients were equally randomized with a mean prostate size of 104 ± 25 gram. The mean IPSS score was 25 ± 6, Qmax 7.6 ± 1.3 mL/S, and PVR 225 ± 39. There was no significant difference regarding enucleation time, morcellation time, and enucleated tissue volume. Irrigation volume and post-operative hemoglobin drop were significantly lower in the bipolar group (p = 0.008, p = 0.0002), respectively. At the third-month follow-up, IPSS, Q-max, and PVR were comparable across both groups, with stress incontinence at 3.3% in the bipolar group versus 1.6% in the thulium group, showing an insignificant difference (p = 0.5)." Conclusion: Both BipolEP and ThuLEP, with early apical release, provide a safe and effective management of large-size prostate resulting in significant decrease in post-operative stress incontinence incidence during early follow-up. Intraoperative irrigation saline volume, and post-operative hemoglobin drop favored the bipolar group.

Bariatric Surgical Outcomes in the Elderly: A Comparison Study Between Primary and Revisional Procedures in the United Arab Emirates.

PURPOSE: Data reported on comparing primary and revisional procedures in the elderly is still limited. The aim of this study was to compare the efficacy and safety between primary and revisional bariatric surgery in a cohort of older patients. MATERIALS AND METHODS: All patients ≥ 60 years old were divided into two cohorts, primary surgery cohort (PSC) and revisional surgery cohort (RSC). Baseline and perioperative outcomes were analyzed. RESULTS: Fifty-eight patients were included (34 PSC and 24 RSC) in the study. Forty-two (25 PSC and 17 RSC) 72.4% were female. The mean age was 64 (± 3.3 years) in the PSC and 65 (± 4.2 years) in the RSC, the median initial BMI was 46.7 and 47.4 kg/m2 (p < 0.848), respectively. The mean hospital stay was (3 PSC vs. 5 RSC, p < 0.022) days. Readmissions occurred in (1 PSC vs. 3 RSC, p = 0.158) patients within 30 days of discharge. Postoperative major complications included (1 PSC vs. 5 RSC, p < 0.0278) patients. Reoperations were reported in (0 PSC vs. 3 RSC, p < 0.034) patients. Patients who underwent surgery for weight management, the initial mean BMI was (46.7 PSC vs. 47.4 RSC kg/m2, p = 0.848). At 12-months post-procedure, the mean BMI was (34.3 PSC vs. 37.7 RSC kg/m2, p = 0.372) and (23.7 PSC vs. 19.1 RSC, p = 0.231) %TBWL. The mean overall follow-up was (12.4 PSC vs. 27.5 RSC, p < 0.004) months, and one unrelated death (cancer) was reported in the RSC. CONCLUSION: PSC and RSC are effective in the elderly, however postoperative complications occurred more often in the RSC group.

One-time definitive attachment connection versus healing abutment placement for an implant-retained mandibular overdenture: Peri-implant metabolic activity.

STATEMENT OF PROBLEM: Unscrewing the healing abutment can affect the soft tissue integration and apical migration of the biological width, which may compromise the integrity of peri-implant soft tissue. PURPOSE: The purpose of this clinical study was to determine the level of glycosaminoglycan (GAG) detected in the peri-implant crevicular fluid (PICF) between the test group (1-time abutment) and control group (healing abutment) for implant-retained mandibular overdentures. MATERIAL AND METHODS: Two dental implants were installed in the canine regions of the mandibular ridge of 18 healthy completely edentulous participants using 2-stage surgery and a delayed loading protocol. At the second stage surgery, the implant on the right side was exposed, and a healing abutment was screwed onto the implant (control group), while on the left side the definitive ball abutment was screwed onto the implant (test group). After 10 days, the healing abutment in the control group was unscrewed and replaced with the definitive ball abutment. For both groups, the ball attachment was directly picked up to incorporate the attachment house to the mandibular denture. PICF samples were collected from the participants at 7 days, 3 months, and 6 months after overdenture use. Statistical analysis was done with an independent samples t test (α=.05). RESULTS: A significant difference was found in the volume of PICF and the level of GAG between the test and control groups at the 7-day evaluation period (P=.008, P=.002, respectively), while the volumes of PICF and the levels of GAG were not significantly different (P>.05) at the other evaluation periods. CONCLUSIONS: The 1-time abutment protocol offers biochemical and economic advantages compared with the conventional method of using the healing abutment before placement of the definitive attachment for an implant-retained overdenture with single attachments.

The Effects of Post-Surgical Pregnancy on Weight Loss Trajectories after Bariatric Surgery: Are Initial Weight and Age Prognostic Factors?

Introduction: A substantial percentage of patients undergoing bariatric surgery are of childbearing age. Pregnancy outcomes after bariatric surgery are known. However, there are limited data on the impact of pregnancy on weight loss after surgery. Objectives: This study aims to evaluate the effects of pregnancy on post-bariatric surgery weight loss trajectories (WLTs) and to determine the association with age and initial weight. Methods: All who had primary bariatric surgeries (Roux-en-Y gastric bypass or sleeve) between September 2015 and July 2020 were classified into two groups: post-surgery gravid (GG) and post-surgery non-gravid (NG). WLTs were examined using a random intercept mixed-effects model with repeated measures nested within patients. The post-surgery/pre-gravid time phase (PoPG) was modelled using a third-degree polynomial. For GG, two third-degree spline functions modelled the post-surgery while gravid (PoWG) and post-partum (PoPP) time phases. Age and initial weight were used to control for pre-existing differences during PoPG. Weight differences at 6 months PoPP were examined by applying general linear hypothesis testing to the mixed-model results. Results: A total of 508 patients were included, 20 in GG and 488 in NG. The mean age at surgery was 33 years in GG and 37 years in NG. The mean initial BMI was 47 kg/m2 and 43 kg/m2, respectively. During PoPG, adjusted average weight in both groups follows the path across time. For GG, weight decreases and then increases during PoWG. For GG during PoPP, weight immediately decreases after delivery and then increases over time to levels similar to NG. Weight differences at 6 months PoPP for GG and NG were not statistically different. Older age was associated with reduced weight loss during PoPG by Baseline Age, while higher initial weight was associated with increased weight loss during PoPG by Baseline Weight. In both instances, these effects attenuate over time. Conclusions: This model indicates that pregnancy following bariatric surgery affects WLT during PoWG and PoPP, and no difference in weight is expected after 6 months post-gravid. Age and initial weight could be considered prognostic factors during PoPG. Patients wishing to conceive should undergo preconception counselling and be advised to avoid pregnancy during the period of rapid weight loss. They also should be informed that WLT may vary during pregnancy and early post-partum.

Cardiovascular disease risk scores in patients with optimal vs suboptimal weight loss after bariatric surgery: Translating improvements into clinical practice.

INTRODUCTION: The aim of this study was to evaluate cardiovascular disease (CVD) risk modification in patients with optimal weight loss (OWL) versus suboptimal weight loss SWL following MBS. METHODS: This was a retrospective analysis. The 10-year risk CVD was estimated before and after one year of surgery using the "Framingham Score". RESULTS: 191 patients were included in our study. Mean baseline Framingham score was 7.2 â€‹± â€‹6.9%. According to the score, 54% of patients were classified as low risk (n â€‹= â€‹104), 23% as moderate (n â€‹= â€‹43), 20% moderately high (n â€‹= â€‹39) and 3% as high risk (n â€‹= â€‹5). One year after surgery, 91% of the patients showed reduction of their Framingham score. Mean CVD risk score decreased significantly to 4.1 â€‹± â€‹3.7% when compared to baseline (p-value is â€‹< â€‹0.001); 80% of patients classified as low risk (n â€‹= â€‹153), 13% as moderate (n â€‹= â€‹25), 7% moderately high (n â€‹= â€‹13) and 0% as high risk (n â€‹= â€‹0). CONCLUSION: Weight loss after bariatric surgery reduces CVD risk scores and the magnitude of effect correlates with the degree of weight loss.

Downregulation of MGMT expression by targeted editing of DNA methylation enhances temozolomide sensitivity in glioblastoma.

Glioblastoma is the most common and aggressive primary tumor of the central nervous system with poor outcome. Current gold standard treatment is surgical resection followed by a combination of radio- and chemotherapy. Efficacy of temozolomide (TMZ), the primary chemotherapeutic agent, depends on the DNA methylation status of the O6-methylguanine DNA methyltransferase (MGMT), which has been identified as a prognostic biomarker in glioblastoma patients. Clinical studies revealed that glioblastoma patients with hypermethylated MGMT promoter have a better response to TMZ treatment and a significantly improved overall survival. In this study, we thus used the CRISPRoff genome editing tool to mediate targeted DNA methylation within the MGMT promoter region. The system carrying a CRISPR-deactivated Cas9 (dCas9) fused with a methyltransferase (Dnmt3A/3L) domain downregulated MGMT expression in TMZ-resistant human glioblastoma cell lines through targeted DNA methylation. The reduction of MGMT expression levels reversed TMZ resistance in TMZ-resistant glioblastoma cell lines resulting in TMZ induced dose-dependent cell death rates. In conclusion, we demonstrate targeted RNA-guided methylation of the MGMT promoter as a promising tool to overcome chemoresistance and improve the cytotoxic effect of TMZ in glioblastoma.

Endovascular retrieval of left atrial appendage closure device embolized to the aorta.

Patients with atrial fibrillation with contraindications to anticoagulation can undergo left atrial appendage closure with a device. Hours after a 73-year-old man had undergone left atrial appendage closure, he lost perfusion to his lower extremities. Imaging studies showed that the device had migrated to the infrarenal aorta. After right common femoral artery cutdown and sheath placement, the device was retrieved with a balloon embolectomy catheter, and a balloon was simultaneously deployed in the proximal left common femoral artery to prevent device embolization. To the best of our knowledge, this report represents the first documented device retrieval from the aorta using balloon embolectomy and contralateral lower extremity embolic protection.

Knowledge, attitude and practice of medical students towards COVID19 in Sudan: A cross sectional study among 19 universities.

Background: Since December 2019, an outbreak of severe respiratory infection (COVID-19) emerged in the city of Wuhan in China. The knowledge, awareness and practice of medical students toward COVID-19 pandemic is of most importance as it demonstrates their preparedness to deal with this pandemic. The objective of this study is to assess the knowledge, awareness and practice of medical students in Sudan universities about COVID 19. Methodogy: This is a cross-sectional study conducted on 19 universities that have medical schools in Sudan. Data from at least 100 medical students from each university were included in the study. Data were collected using an online questionnaire in April 2020. Statistical analysis was conducted using the Statistical Package for Social Science software, version 25. Results: About 2603 medical students from 19 universities were included. Overall good knowledge and practice were demonstrated by the medical students (88.9%) and (78.6%), respectively. Respondents who answered that the most common clinical symptoms of COVID-19 were the main combination of dry cough, fatigue and fever were (27.7%), and the first initial symptom was headache were (48.3%.). (60.2%) Wear medical masks, (95%) said that avoiding crowded places protects against the spread of COVID-19, and (50.7%) have confidence that Sudan can win the battle against the COVID-19. Finally, (68.8%) agreed that COVID-19 will finally be successfully controlled. Conclusion: This study has found that medical students in Sudan demonstrated good knowledge and good practice toward Covid19.

Third wave of COVID-19 pandemic in Africa: Challenges and recommendations.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has evolved in different waves and is currently in its third wave for the majority of countries around the world. Each wave emanated with its own set of challenges. Lower- and middle-income countries such as most African countries have faced additional challenges compared to high-income countries. This paper highlights the challenges faced by Africa during the third wave of COVID-19 and proposes recommendations and strategies to contain the spread. We conducted a mini-review for the newly released articles and researches about the challenges faced by Africa during COVID-19. Fragmented healthcare sectors, limited healthcare resources and emergence of co-infections in COVID-19 patients, inadequate vaccination rollout and political conflicts are the major challenges faced by the African countries. Our recommendations to defeat this outbreak and subsequent pandemics is to raise the public's awareness about vaccines through campaigns and social media in order to lessen vaccine hesitancy. Governments as well should focus on under-served and vulnerable populations, patients with comorbidities, and communities living in endemic-striking settings as these people are more prone to the severe form of the disease. Moreover, by adopting socio-ecological perspectives, one can implement multi-level integrated interventions to help control COVID-19 more effectively.

Personalized Health Care Technology in Managing Postoperative Gastrointestinal Surgery Complications: Proof of Concept Study.

Background: Advances in three-dimensional (3D) printing technology have allowed the development of customized medical devices. Endoscopic internal drainage (EID) is a novel method to facilitate drainage of an abscess cavity into the lumen of the gastrointestinal tract by placing a double pigtail biliary stent through the fistula opening, originally designed for biliary drainage. They are available in manufacture-determined sizes and shapes. The aim of this study is to explore the feasibility of 3D printing personalized internal drainage stents for the treatment of leaks following gastrointestinal surgery over a sequential period. Methods: We retrospectively identified patients who underwent gastrointestinal anastomotic surgery complicated by postoperative leaks and underwent serial EID for treatment. Computerized Tomography scans were reviewed over a period of time, abscess cavity dimensions and characterizations were evaluated, and 3D reconstructions were obtained. The stents were designed, their shape and size were customized to the unique dimensions of the abscess and lumen of the patient. Stereolithography (SLA) 3D printing technique was used to produce the stents. Results: A total of 8 stents were produced, representing 3 patients. These stents corresponded to 2 or 3 stents per patients. Each patient underwent several endoscopic treatments, before resolution of leak. Conclusions: Customized stents may improve drainage of intra-abdominal abscesses after gastrointestinal surgery, if based on unique anatomy. This proof-of-concept study is a real-world application of personalized health care, which introduces the novel description of customizable 3D printed stents to manage complications following gastrointestinal surgery and may advance therapy for this complex clinical condition. Research Ethics Committees (REC) number is A-2021-012.

The egyptian clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease.

The landscape of chronic liver disease in Egypt has drastically changed over the past few decades. The prevalence of metabolic-associated fatty liver disease (MAFLD) has risen to alarming levels. Despite the magnitude of the problem, no regional guidelines have been developed to tackle this disease. This document provides the clinical practice guidelines of the key Egyptian opinion leaders on MAFLD screening, diagnosis, and management, and covers various aspects in the management of MAFLD. The document considers our local situations and the burden of clinical management for the healthcare sector and is proposed for daily clinical practical use. Particular reference to special groups was done whenever necessary.

Human papillomavirus, gene mutation and estrogen and progesterone receptors in breast cancer: a cross-sectional study.

INTRODUCTION: recent studies show a good relationship between breast cancer (BC) and human papillomaviruses (HPV) wich is responsible for about 18% of BC cases. This study aimed to assess the relationship between different genotypes of HPV and the expression of P53 and retinoblastoma (RB) genes and estrogen and progesterone receptors in BC among Sudanese women. METHODS: one hundred and fifty tissue blocks were obtained from females diagnosed with BC. Positive samples were used to determine genotypes with an applied biosystem (ABI 3730XL) genetic analyzer for sequencing and immunohistochemistry. RESULTS: 13/150 samples showed HPV DNA. High-risk HPV-16 was detected in 5 cases, high-risk-HPV-58 was found in four cases, and HPV-18 was detected in three cases. Low-risk-HPV-11 was detected in a single invasive lobular carcinoma (ILC) case. P53 and RB gene mutations were detected in 35 and 30 BC cases, respectively. P53 gene mutation was frequently identified in grade (III) BC while RB gene mutation was positive in grade (II). Grade (II) BC had a higher incidence of HPV-16 and 58. On the other hand, HPV-18 had a higher incidence in grade (III). Estrogen and progesterone receptors were expressed in 94 and 79 HPV cases among the study group, respectively. CONCLUSION: this study elucidates the associations between HPV genotypes and BC. A statistically significant association was observed among p53 and RB gene mutations and different BC histological types. On the other hand, there was a statistically insignificant association between HPV genotyping and different BC gradings, BC histological types, P53 and RB genes mutations, and estrogen and progesterone receptor expression. Also, there was a statistically insignificant association among estrogen and progesterone receptors expression and BC grading. RB gene mutation was significantly associated with different BC grades. On the other hand, there was a statistically insignificant association between progesterone receptor expression and BC.

The Effect of Fasting during Ramadan on Outcomes after Bariatric Surgery at an Academic Medical Center in the Middle East.

INTRODUCTION: Ramadan is characterized by a month of fasting between dawn and sunset. Cleveland Clinic Abu Dhabi is located in the United Arab Emirates, where the majority of our patients observe Ramadan. In many practices, bariatric surgery has been delayed until after Ramadan in order to avoid postoperative complications. However, there are no studies that evaluate this theory. OBJECTIVES: Our study aimed to evaluate perioperative outcomes between bariatric surgeries performed before/during Ramadan and at times distant to Ramadan. METHODS: All patients who underwent primary bariatric surgery at Cleveland Clinic Abu Dhabi between September 2015 and July 2019 were retrospectively reviewed. The Pre-Ramadan (PR) cohort included patients that underwent surgery during the month of Ramadan and up to 3 months before Ramadan. The Non-Ramadan (NR) cohort included patients from the remainder 8 months. RESULTS: Our study included 542 patients: 185 patients in the PR cohort and 357 patients in the NR cohort. Baseline characteristics were similar. There were no statistically significant differences in perioperative outcomes, including emergency department (ED) visits (23.2% PR vs. 24.4% NR, p = .77), readmission rates (2.2% PR vs. 4.5% NR, p = .17), reoperation (1.1% PR vs. 3.6% NR, p = .09), and complications within 30 days (3.8% PR vs. 7.0% NR, p = .13). CONCLUSIONS: There is no difference among patients who undergo surgery before/during Ramadan and at times distant to Ramadan. Based on this data, there does not appear to be an increased risk of performing bariatric surgery prior to or during Ramadan in a comprehensive, multi-disciplinary program.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on pediatric oncology care in the Middle East, North Africa, and West Asia region: A report from the Pediatric Oncology East and Mediterranean (POEM) group.

BACKGROUND: Childhood cancer is a highly curable disease when timely diagnosis and appropriate therapy are provided. A negative impact of the coronavirus disease 2019 (COVID-19) pandemic on access to care for children with cancer is likely but has not been evaluated. METHODS: A 34-item survey focusing on barriers to pediatric oncology management during the COVID-19 pandemic was distributed to heads of pediatric oncology units within the Pediatric Oncology East and Mediterranean (POEM) collaborative group, from the Middle East, North Africa, and West Asia. Responses were collected on April 11 through 22, 2020. Corresponding rates of proven COVID-19 cases and deaths were retrieved from the World Health Organization database. RESULTS: In total, 34 centers from 19 countries participated. Almost all centers applied guidelines to optimize resource utilization and safety, including delaying off-treatment visits, rotating and reducing staff, and implementing social distancing, hand hygiene measures, and personal protective equipment use. Essential treatments, including chemotherapy, surgery, and radiation therapy, were delayed in 29% to 44% of centers, and 24% of centers restricted acceptance of new patients. Clinical care delivery was reported as negatively affected in 28% of centers. Greater than 70% of centers reported shortages in blood products, and 47% to 62% reported interruptions in surgery and radiation as well as medication shortages. However, bed availability was affected in <30% of centers, reflecting the low rates of COVID-19 hospitalizations in the corresponding countries at the time of the survey. CONCLUSIONS: Mechanisms to approach childhood cancer treatment delivery during crises need to be re-evaluated, because treatment interruptions and delays are expected to affect patient outcomes in this otherwise largely curable disease.

Age, absolute CD4 count, and CD4 percentage in relation to HPV infection and the stage of cervical disease in HIV-1-positive women.

A subgroup of women who are co-infected with human immunodeficiency virus type 1 (HIV-1) and human papillomavirus (HPV), progress rapidly to cervical disease. We characterized HPV genotypes within cervical tumor biopsies, assessed the relationships of cervical disease stage with age, HIV-1 status, absolute CD4 count, and CD4 percentage, and identified the predictive power of these variables for cervical disease stage in a cohort of South African women.We recruited 181 women who were histologically diagnosed with cervical disease; 87 were HIV-1-positive and 94 were HIV-1-seronegative. Colposcopy-directed tumor biopsies were confirmed by histology and used for genomic DNA extraction. The Roche Linear Array HPV genotyping test was used for HPV genotyping. Peripheral whole blood was used for HIV-1 rapid testing. Fully automated FC500MPL/CellMek with PanLeucogate (PLG) was used to determine absolute CD4 count, CD4 percentage, and CD45 count. Chi-squared test, a logistic regression model, parametric Pearson correlation, and ROC curves were used for statistical analyses. We used the Benjamini-Horchberg test to control for false discovery rate (FDR, q-value). All tests were significant when both P and q were <.05.Age was a significant predictor for invasive cervical cancer (ICC) in both HIV-1-seronegative (P < .0001, q < 0.0001) and HIV-1-positive women (P = .0003, q = 0.0003). Sixty eight percent (59/87) of HIV-1-positive women with different stages of cervical disease presented with a CD4 percentage equal or less than 28%, and a median absolute CD4 count of 400 cells/µl (IQR 300-500 cells/µl). Of the HIV-1-positive women, 75% (30/40) with ICC, possessed ≤28% CD4 cells vs 25% (10/40) who possessed >28% CD4 cells (both P < .001, q < 0.001). Furthermore, 70% (28/40) of women with ICC possessed CD4 count >350 compared to 30% (12/40) who possessed CD4 count ≤ 350 (both P < .001, q < 0.001).Age is an independent predictor for ICC. In turn, development of ICC in HIV-1-positive women is independent of the host CD4 cells and associates with low CD4 percentage regardless of absolute CD4 count that falls within the normal range. Thus, using CD4 percentage may add a better prognostic indicator of cervical disease stage than absolute CD4 count alone.

Serum cytokeratin-18 and its relation to liver fibrosis and steatosis diagnosed by FibroScan and controlled attenuation parameter in nonalcoholic fatty liver disease and hepatitis C virus patients.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common cause of chronic liver disease worldwide. Multiple diagnostic noninvasive methods for NAFLD were studied (both serological and imaging), either single or combined. Attention has been focused on cytokeratin-18 (CK18) as a novel serological marker for the diagnosis of steatosis/fibrosis in NAFLD and hepatitis C virus (HCV) patients. AIM: The aim of this study was to evaluate serum CK18 in NAFLD and HCV fibrosis/steatosis and also to correlate its performance with the diagnostic accuracy of transient elastography (TE) and controlled attenuation parameter (CAP) in the diagnosis of fibrosis/steatosis in these patients. PATIENTS AND METHODS: Three equal groups of participants were enrolled (n=135): group I included patients with chronic HCV, group II included NAFLD patients, and group III included control participants. For all groups, TE/CAP and labs including serum CK18 were performed. Liver biopsy was performed for the NAFLD group. RESULTS: Serum CK18 was significantly higher in the NAFLD group (19.01±3.49 ng/ml) versus the HCV group (8.95±1.06 ng/ml) and the control group (4.83±1.6 ng/ml) (P<0.001). The CK18 levels in biopsy stages (steatosis, ballooning, inflammation, and fibrosis) and FibroScan/CAP degrees showed that CK18 increased significantly with steatosis and fibrosis stages (biopsy or FibroScan/CAP), but did not reach significance with ballooning or inflammation grades. CK18 was significantly different in nonalcoholic steatohepatitis versus non-nonalcoholic steatohepatitis patients (P=0.041). The best CK18 cutoff to detect steatosis (S≥2) in NAFLD and HCV was 11.65 and 6.84 ng/ml, respectively with an overall sensitivity and specificity over 97%. The CK18 cutoff for significant fibrosis (F≥2) by FibroScan in the NAFLD/HCV groups was 9.115 ng/ml, with 62.5%/69.2% sensitivity/specificity (P=0.031). However, inflammation had a cutoff with a marginal P value (P=0.080), and a reliable cutoff for ballooning was not attained (P=0.386). There was a positive correlation between CK18 and fibrosis (by FibroScan) in the NAFLD and HCV groups (P<0.05). The correlation between CK18 and steatosis in CAP and the nonalcoholic fatty liver disease activity score was very good (P<0.001). CONCLUSION: Serum CK18 is related strongly to the development/progression of NAFLD and HCV-related fibrosis/steatosis. TE was correlated highly with liver biopsy results. The combination of CK18 with other noninvasive modalities increases the diagnostic yield of these tests.

Perforated Duodenal Diverticulum Treated Conservatively: Another Two Successful Cases.

Diverticula of the duodenum proceed those of the colon in respect to frequency of location. Incidence at times of autopsy ranges from 15 to 23%. Despite the fact that more than 90% of duodenal diverticulum cases are asymptomatic, complications if they do occur can be calamitous. Perforation is one of these rare complications. Surgical intervention has always been the mainstay for symptomatic/complicated duodenal diverticula, but with the advancement of imaging, medical treatment, and proper intensive observation, conservative treatment came forth. We hereby present two cases of duodenal diverticula, complicated by perforation and fistulization into the retroperitoneal cavity, both treated conservatively by Taylor's approach of upper gastrointestinal tract perforation. Review of other cases of duodenal diverticulum perforation has also been presented.

Pectoralis Minor Syndrome: Case Presentation and Review of the Literature.

We present a case of a healthy young female with axillary vein compression caused by the pectoralis minor muscle. Diagnosis was made by clinical findings and dynamic venography. After pectoralis minor tenotomy, the patient had total resolution of her symptoms. Compression of the axillary vein by the pectoralis minor is a rare entity that needs a careful exam and imaging to reach its diagnosis and establish the appropriate treatment.