Serum trimethylamine N-oxide levels among coronary artery disease and acute coronary syndrome patients: a systematic review and meta-analysis.

Background and Aim: Recent studies have linked trimethylamine N-oxide (TMAO) to cardiovascular diseases; our study aimed to analyze the association between coronary artery disease (CAD), acute coronary syndrome (ACS), and TMAO. Methods: PubMed, Scopus, Embase, and Web of Science were searched using terms such as 'CAD' and 'TMAO'. Only observational controlled studies were included. RevMan software version 5.4 was used for the analysis. Results: A significant association was found between the CAD group and increased serum TMAO levels compared with the control group (MD=1.16, 95% CI=0.54-1.78, P=0.0003). This association remained significant among acute coronary syndrome patients (MD=0.98, 95% CI=0.73-1.23, P<0.00001) and was also detected among young and old CAD patients (MD=0.35, 95% CI=0.06-0.64, P=0.02 and MD=1.36, 95% CI=0.71-2.01, P<0.0001, respectively). On further analysis of intestinal metabolites, the authors detected an insignificant association between choline, betaine, carnitine, and CAD. According to our sensitivity analysis, TMAO is an acceptable diagnostic marker for CAD (0.721, SE was 0.0816, 95% CI: 0.561-0.881). Conclusion: TMAO is an acceptable diagnostic marker for CAD, with significantly higher levels among these patients regardless of their age. Other metabolites did not show such an association. The role of serum level TMAO in the early diagnosis of CAD should be further explored.

Anthracyclines and the risk of arrhythmias: A systematic review and meta-analysis.

BACKGROUND: There have been controversial findings from recent studies regarding anthracyclines use and the subsequent risk of arrhythmias. This study aimed to evaluate the existing evidence of the risk of arrhythmias in patients treated with anthracyclines. METHODS: PubMed, Scopus, and Web of Science databases were searched up to April 2022 using keywords such as "anthracycline" and "arrhythmia." Dichotomous data were presented as relative risk (RR) and confidence interval (CI), while continuous data were presented as mean difference (MD) and CI. Revman software version 5.4 was used for the analysis. RESULTS: Thirteen studies were included with a total of 26891 subjects. Pooled analysis showed that anthracyclines therapy was significantly associated with a higher risk of arrhythmia (RR: 1.58; 95% CI: 1.41-1.76; P < .00001), ST segment and T wave abnormalities (RR: 1.73, 95% CI: 1.18-2.55, P = .005), conduction abnormalities and AV block (RR = 1.86, 95% CI = 1.06-3.25, P = .03), and tachycardia (RR: 1.736, 95% CI: 1.11-2.69, P = .02). Further analyses of the associations between anthracyclines and atrial flutter (RR = 1.30, 95% CI = 0.29-5.89, P = .74), atrial ectopic beats (RR: 1.27, 95% CI: 0.78-2.05, P = .34), and ventricular ectopic beats (RR: 0.93, 95% CI: 0.53-1.65, P = .81) showed no statistically significant results. Higher doses of anthracycline were associated with a higher risk of arrhythmias (RR: 1.49; 95% CI: 1.08-2.05; P = .02) compared to the lower doses (RR: 1.36; 95% CI: 1.00-1.85; P = .05). Newer generations of Anthracycline maintained the arrhythmogenic properties of previous generations, such as Doxorubicin. CONCLUSION: Anthracyclines therapy was significantly associated with an increased risk of arrhythmias. Accordingly, Patients treated with anthracyclines should be screened for ECG abnormalities and these drugs should be avoided in patients susceptible to arrhythmia. The potential benefit of the administration of prophylactic anti-fibrotic and anti-arrhythmic drugs should also be explored.

Predictive value of Hajibandeh index in determining peritoneal contamination in acute abdomen: A cohort study and meta-analysis.

BACKGROUND: Hajibandeh index (HI), derived from combined levels of C-reactive protein, lactate, neutrophils, lymphocytes and albumin, is a modern predictor of peritoneal contamination and mortality in patients with acute abdominal pathology. AIM: To validate the performance of HI in predicting the presence and nature of peritoneal contamination in patients with acute abdominal pathology in a larger cohort study and to synthesis evidence in a systematic review and meta-analysis. METHODS: The STROBE guidelines and the PRISMA statement standards were followed to conduct a cohort study (ChiCTR2200056183) and a meta-analysis (CRD42022306018), respectively. All adult patients undergoing emergency laparotomy for acute abdominal pathology were eligible. The accuracy of the HI was evaluated using receiver operating characteristic (ROC) curve analysis in the cohort study and using weighted summary area under the curve (AUC) under the fixed and random effects modelling in the meta-analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 criteria were used for methodological quality assessment of the included studies. RESULTS: A total of 1437 patients were included (700 from the cohort study and 737 from the literature search). ROC curve analysis of the cohort study showed that the AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 [95% confidence interval (CI): 0.76-0.82, P < 0.0001], 0.76 (95%CI: 0.72-0.80, P < 0.0001), and 0.83 (95%CI: 0.79-0.86, P < 0.0001), respectively. The meta-analysis showed that the pooled AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 (95%CI: 0.75-0.83), 0.78 (95%CI: 0.74-0.81), and 0.80 (95%CI: 0.77-0.83), respectively. CONCLUSION: The HI is a strong and accurate predictor of intraperitoneal contamination. Although the available evidence is robust, it is limited to the studies conducted by our evidence synthesis group. We encourage other researchers to validate performance of HI in predicting the presence of intraperitoneal contamination and more importantly in predicting mortality following emergency laparotomy.

Skin Cancer Excision Analysis in a Single Rural Center in Scotland's Highlands.

Background & Aim Skin cancer is the most common cancer around the world. Regional differences have been reported affecting the demographics and the prevalence of non-melanoma skin cancers; furthermore, non-melanoma skin cancers are believed to be underreported. In this study, we aim to identify and highlight any possible significant characteristics of skin cancer in our rural center in Scotland's Highlands. Methods This is a retrospective study analyzing and reporting cancerous skin lesions excision rates among all skin lesions excised and their characteristics in our rural center for one year. Clinical and histopathological data for patients attending our services for suspicious skin lesions excision were collected. Data included the patient's age, gender, lesion's diagnosis, site, size, color, borders, resection edges, recurrence, and complications. A database was created creating two cohorts: cancer and non-cancerous lesions groups, both cohorts' data was compared using student T-tests and Z-tests. P-values were considered statistically significant if < 0.5, Overall data was analyzed revealing trends and end results. Results From December 2019 to December 2020, 96 patients underwent skin lesions excision, 30% were cancerous. Basal cell carcinoma was the most common malignant growth standing for 76.7% of all malignant lesions excised. Squamous cell carcinoma and melanoma were found in 20% and 3.3% of patients with malignant lesions, respectively. Out of the total, 76% of cancerous lesions were in males. The most common site was head and neck (58.8%). High-risk lesions were the ones on the head and neck (P= 0.00988), in the elderly over 74.5 years (P= 0.000037), and males (P= 0.001). Conclusion Basal cell carcinoma was the most common malignant lesion. Elderly men with lesions on the head and neck had higher risks for cancer. Further clarification may be required with larger multi-center studies involving general practitioners, which might help identify regional variations.

Digital Image Analysis has an Additive Beneficial Role to Conventional Cytology in Diagnosing the Nature of Biliary Ducts Stricture.

BACKGROUND & AIM: Conventional cytological evaluation (CCE) fails to identify nature indeterminate biliary duct stricture (IBDS) in many cases. Digital image analysis (DIA) has the ability to identify and analyze the DNA content of cells. This study assesses the role of DIA in recognizing the nature of IBDS compared to CCE. METHODS: A prospective observational study was conducted at the Al-Rajhi University Hospital. Fifty patients with IBDS, based on abdominal imaging, were subjected to endoscopic retrograde cholangiopancreatography (ERCP) and brush sampling. These samples were evaluated with CCE and DIA. Follow-up for at least 9 months and cost-analysis had also been done. RESULTS: Based on the final diagnosis, 32 (64.0%) patients had malignant stricture, and 39 (78.0%) had distal stricture. DIA had 84.40% (95% CI; 67.20-94.70) sensitivity and 94.40% (95% CI; 72.70-99.90) specificity in identifying nature of IBDS, whereas CCE had 19.0% (95% CI; 7.20-36.40) sensitivity and 89.0% (95% CI; 65.30-98.60) specificity. Combination of both modalities had 84.40% (95% CI; 67.20-94.70) sensitivity and 83.30% (95% CI; 58.60-96.40) specificity in identification nature of IBDS. Based on CCE alone, only 6/32 (18.80%) of malignant stricture were diagnosed, and 26/32 (81.20%) were missed. However, DIA alone was able to diagnose 27/32 (84.40%) of malignant stricture, and only 5 cases were missed. Both procedures had detection rate of malignant stricture as DIA alone. Benign stricture was correctly diagnosed in 16/18 (88.80%), 17/18 (94.40%), and 15/18 (83.30%) using CCE alone, DIA alone, and both procedures together, respectively. Cost per detection additional one malignant stricture using DIA required 99.4$. CONCLUSION: DIA is substantially better than CCE in diagnosing the nature of IBDS but at an increase cost and thus suggests its application in a wider role in clinical practice. CLINICAL TRIAL NUMBER: NCT04112030.

Ramadan and Diabetes: A Narrative Review and Practice Update.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.

Ramadan and Diabetes: A Narrative Review and Practice Update.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

Rare encounter: hydrocoele of canal of Nuck in a Scottish rural hospital during the COVID-19 pandemic.

We report the case of a 32-year-old woman who presented with reducible indirect inguinal hernia and a challenging constellation of symptoms, signs and radiographic findings. Surgical approach superseded conservative management when the patient's abdomen became acute, with a rising lactate and haemodynamic instability. Specifically, the presence of a fluid collection was concerning for sinister acute pathology. Our patient was rediagnosed intraoperatively with hydrocoele of canal of Nuck. This so-called 'female hydrocoele' is an eponymous anatomical rarity in general surgery, presenting as an inguinolabial swelling with variable clinical profile. Hydrocoele of canal of Nuck takes origin from failure of transitory reproductive anlagen to regress and is thus analogous to patent processus vaginalis. Its true incidence is speculative, with just several hundred cases globally. We aim to provide insights into surgical patient management for a rare entity during the COVID-19 outbreak, from the unique perspective of a small rural hospital in Scotland.

Differential Expression of RAGE, EGFR and Ki-67 in Primary Tumors and Lymph Node Deposits of Breast Carcinoma

Background: Breast cancer is a complex disease that results from the inheritance of a number of susceptible genes. Intensive search wok was conducted world-wide on molecular bases of breast cancer in order to achieve the best therapeutic modalities; however, breast cancer still remains a challengeable task. It is very important to determine if the biological parameters in metastatic regional lymph nodes are similar to that in the primary breast cancer because therapy is indicated for patients with synchronous metastatic regional lymph nodes of breast cancer. Difference in therapeutic response in cases of breast cancer may be assumed partially to variability in the biological behavior of tumor tissue in primary breast cancer and lymph node metastasis. Aim: Our aim is to evaluate any variability in the expression of three types of tissue markers in both the primary breast tumors and corresponding axillary lymph nodes in order to expect the targeted therapeutic effect on both sites. Material and Methods: Three markers from different categories; RAGE, EGFR and Ki-67 were immunohistochemicalyl studied for their expression in biopsy specimens from primary breast tumors and their corresponding axillary lymph nodes. Results: There was a statistically significant difference in the expression of these markers between benign and malignant breast lesions.Although we found some differences in the expression of the three studied markers between primary breast cancer and corresponding axillary lymph nodes, yet these variations were mostly not statistically significant. Conclusion: Our findings support the validity of anti-RAGE and anti-EGFR therapy for treatment of both primary and nodal metastatic breast cancer in immunopositive cases.

On-X versus St Jude Medical Mechanical Prosthesis in mitral position: are we moving forward in design technology?

BACKGROUND: Continuous effort is still provided in designing optimal artificial heart valves with better hemodynamic function and reduced thromboembolic potential. The question is do we have moved forward toward this goal or not. METHODS: A prospective, randomized comparative study was done on 360 patients scheduled for elective mitral valve replacement. Patients were grouped into an On-X group (N.=180), who received On-X mechanical valve, and a SJM group (N.=180), who received St Jude mechanical valve. Echocardiographic and clinical assessments were performed for all patients at 6 and 12 months follow-up period. RESULTS: Rheumatic heart disease was the most common cause of valve affection (94.2%). Early mortality was 6.4%. The mean follow-up time was 3.11±2.44 years. No structural or non-structural valvular dysfunction and no thromboembolism cases were encountered. Late valve thrombosis was1.9%/patient-year in On-X group and 2.1%/patient-year in SJM group. The mean EOA was higher in On-X group (2.0±0.3 cm2) than in SJM group (1.9±0.2 cm2), (P≥0.05). The mean EOAI was higher in On-X group (1.1±0.1 cm2/m2) than in SJM group (1.0±0.1 cm2/m2), (P=0.034), especially significant in small valve size (25 mm) where it was 1.09±021 cm2/m2 in On-X group and 0.93±0.12 cm2/m2 in SJM group (P=0.02). CONCLUSIONS: On-X and St Jude prosthetic valves have a comparable hemodynamic performance in mitral position. However, On-X prosthesis might have a forward step on the way of design technology that may allow better function in terms of EOA and EOAI especially in smaller valve size.

Expression of hnRNPK & Claudin-4 in HCV-Induced Early HCC and Adjacent Liver Tissue.

BACKGROUND: HCC in Egypt usually occurs in HCV cirrhotic livers with poor prognosis due to late diagnosis. High hnRNPK & low Claudin-4 profiles indicate Epithelial Mesenchymal Transition (EMT), malignant transformation and high-grade tumours. AIM: We studied the immunohistochemical expression of hnRNPK and Claudin-4 in HCV induced early HCC (eHCC) and adjacent liver tissue in Egyptian patients to improve eHCC detection in cirrhotic livers with better curative therapy options. METHOD: We studied the immunohistochemical expression of hnRNPK and Claudin-4 in 100 Egyptian patients resection specimens of HCV induced early HCC (eHCC) and adjacent liver tissue, in order to improve eHCC detection in cirrhotic livers, thus improving their therapeutic options. RESULTS: Early HCC grade significantly directly correlated with nuclear hnRNPK/5HPFs count and inversely correlated with Claudin-4 expression %, with a converse correlation between hnRNPK and Claudin-4. Moreover in eHCC, combined hnRNPK ≥ 30/5HPFs & Claudin-4 ≥ 40% significantly distinguished low grade eHCC (G1) from high grade eHCC (G2&G3), with sensitivity 97% & specificity 69.7% for hnRNPK ≥ 30/5HPFs, and with sensitivity 70% & specificity 94.3% for Claudin-4 ≥ 40%. Moreover in the adjacent liver, both markers expressions significantly directly correlated with each other and with METAVIR fibrosis score but not with activity. Furthermore, 58% of eHCCs showed hnRNPK ≥ 30 Claudin-4 < 40% profile, indicating EMT type 3, compared to 26% with hnRNPK ≥ 30 Claudin-4 ≤ 10% profile in adjacent cirrhotic/ precirrhotic liver, with significant use of combined hnRNPK ≥ 30/5HPFs & Claudin 4 ≤ 10% as eHCC prediction cut offs in cirrhosis (p < 0.05). CONCLUSION: Combination of hnRNPK and Claudin-4 can indicate early HCC development in HCV cirrhotic livers using hnRNPK ≥ 30/5HPFs & Claudin-4 ≤ 10% cut offs. Also, combination of hnRNPK ≥ 30/5HPFs & Claudin-4 ≥ 40% can distinguish low grade eHCC (G1) from high grade eHCC (G2&G3).

Potential ultrastructure predicting factors for hepatocellular carcinoma in HCV infected patients.

Hepatitis C virus represents one of the rising causes of hepatocellular carcinoma (HCC). Although the early diagnosis of HCC is vital for successful curative treatment, the majority of lesions are diagnosed in an irredeemable phase. This work deals with a comparative ultrastructural study of experimentally gradually induced HCC, surgically resected HCC, and potential premalignant lesions from HCV-infected patients, with the prospect to detect cellular criteria denoting premalignant transformation. Among the main detected pathological changes which are postulated to precede frank HCC: failure of normal hepatocyte regeneration with star shape clonal fragmentation, frequent elucidation of hepatic progenitor cells and Hering canals, hepatocytes of different electron density loaded with small sized rounded monotonous mitochondria, increase junctional complexes bordering bile canaliculi and in between hepatocyte membranes, abundant cellular proteinaceous material with hypertrophied or vesiculated rough endoplasmic reticulum (RER), sequestrated nucleus with proteinaceous granular material or hypertrophied RER, formation of lipolysosomes, large autophagosomes, and micro-vesicular fat deposition. In conclusion, the present work has visualized new hepatocytic division or regenerative process that mimic splitting or clonal fragmentation that occurs in primitive creature. Also, new observations that may be of value or assist in predicting HCC and identifying the appropriate patient for surveillance have been reported. Moreover, it has pointed to the possible malignant potentiality of liver stem/progenitor cells. For reliability, the results can be subjected to cohort longitudinal study.

Non-invasive assessment of liver fibrosis in patients with hepatitis C: Shear wave elastography and colour Doppler velocity profile technique versus liver biopsy.

BACKGROUND AND STUDY AIMS: Determination of the presence and degree of liver fibrosis is essential for the prognosis and treatment of patients with chronic hepatitis C. Non-invasive methods of assessing fibrosis have been developed to reduce the need for biopsy. We determined the efficacy of shear wave elastography (SWE) and colour Doppler velocity as non-invasive methods for the assessment of liver fibrosis compared to liver biopsy among patients with chronic hepatitis C virus (HCV) infection. PATIENTS AND METHODS: In total, 117 patients with chronic HCV infection and 50 healthy age- and sex-matched control subjects were included. For each patient and control, abdominal ultrasonography, Doppler ultrasonography of the right portal vein (PV), and SWE were performed, whereas liver biopsy was performed for patients. RESULTS: The mean value of the right PV maximum velocity was lower in patients with different stages of fibrosis than in controls (p<0.001). The mean value of liver stiffness determined by SWE was significantly higher in patients with different stages of fibrosis than in controls. Cutoff values for liver stiffness determined by SWE for assessing fibrosis stages were F2⩾4.815, F3⩾6.335, and F4=7.540 with a sensitivity of 84.6%, 96.2%, and 100.0%; specificity of 88.5%, 93.8%, and 100.0%; positive predictive value (PPV) of 93.6%, 98.0%, and 100.0%; negative predictive value (NPV) of 74.2%, 88.2%, and 100.0%; and overall accuracy of 85.9%, 95.6%, and 100.0% [area under the ROC curve (AUC): 0.89, 0.96, and 1.0], respectively. Cutoff values for the right PV maximum velocity for assessing fibrosis stages were F2<23.4, F3<21, and F4<20 with a sensitivity of 65.0%, 57.4%, and 57.1%; specificity of 59.8%, 76.4%, and 75.5%; PPV of 33.8%, 58.3%, and 32.0%; NPV of 84.4%, 75.7%, and 89.7%; and overall accuracy of 61.1%, 69.5%, and 72.5% (AUC: 0.614, 0.696, and 0.625), respectively. CONCLUSION: SWE is effective for the non-invasive assessment of liver fibrosis in patients with HCV infection. SWE provides a more accurate correlation with liver fibrosis stage than colour Doppler velocity profile for the assessment of liver fibrosis, especially in advanced stages (F3 and F4).

Efficacy of pulsed Nd:YAG laser in the treatment of patients with knee osteoarthritis: a randomized controlled trial.

The purpose of this study was to investigate the effects of pulsed Nd:YAG laser plus glucosamine/chondroitin sulfate (GCS) in patients with knee osteoarthritis (KOA) by examining changes in pain and knee function, as well as synovial thickness (ST) and femoral cartilage thickness (FCT). Sixty-seven male patients participated, with a mean (SD) age of 53.85 (4.39) years, weight of 84.01 (4.70) kg, height of 171.51 (3.96) cm, and BMI of 28.56 (1.22). Group 1 was treated with high-intensity laser therapy (HILT), GCS, and exercises (HILT + GCS + EX). Group 2 was treated with GCS plus exercises (GCS + EX), and group 3 received placebo laser plus exercises (PL + EX). The outcomes measured were pain level and functional disability using the visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively. ST and FCT were measured by ultrasound examination. Statistical analyses were performed to compare differences between baseline and after 6 weeks of treatment and then after 3 months of follow-up. Statistical significance was set at p < 0.05. VAS and WOMAC were significantly decreased in all groups after 6 weeks, with nonsignificant differences between 6 weeks and 3 months of follow-up. ST was significantly decreased in the HILT + GCS + EX group posttreatment, with nonsignificant decreases in the GCS + EX and PL + EX groups, as well as nonsignificant differences to FCT in all groups. Overall, pulsed Nd:YAG laser combined with GCS and exercises was more effective than GCS + EX and exercises alone in the treatment of KOA patients.

Asian-Pacific Association for the Study of the Liver (APASL) consensus guidelines on invasive and non-invasive assessment of hepatic fibrosis: a 2016 update.

Hepatic fibrosis is a common pathway leading to liver cirrhosis, which is the end result of any injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Despite the fact that liver biopsy (LB) has been considered the "gold standard" of assessment of hepatic fibrosis, LB is not favored by patients or physicians owing to its invasiveness, limitations, sampling errors, etc. Therefore, many alternative approaches to assess liver fibrosis are gaining more popularity and have assumed great importance, and many data on such approaches are being generated. The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The first consensus guidelines of the APASL recommendations on hepatic fibrosis were published in 2009. Due to advances in the field, we present herein the APASL 2016 updated version on invasive and non-invasive assessment of hepatic fibrosis. The process for the development of these consensus guidelines involved review of all available published literature by a core group of experts who subsequently proposed consensus statements followed by discussion of the contentious issues and unanimous approval of the consensus statements. The Oxford System of the evidence-based approach was adopted for developing the consensus statements using the level of evidence from one (highest) to five (lowest) and grade of recommendation from A (strongest) to D (weakest). The topics covered in the guidelines include invasive methods (LB and hepatic venous pressure gradient measurements), blood tests, conventional radiological methods, elastography techniques and cost-effectiveness of hepatic fibrosis assessment methods, in addition to fibrosis assessment in special and rare situations.

Single-stage, three-fold repair for Ebstein's anomaly.

Objectives: Favourable outcomes in the repair of Ebstein's anomaly are predicated on tricuspid valve competence, right ventricular function and presence of arrhythmia. We report our experience with a single-stage, three-fold repair of Ebstein's anomaly, namely, cone reconstruction of the tricuspid valve supplemented by bidirectional cavopulmonary anastomosis and right atrial electrocautery maze. Methods: From 2010 to 2014, 37 consecutive patients with Ebstein's anomaly, median age 17.3 (9.1-56.2) years, underwent this single-stage, three-fold surgical procedure. The principal elements of the procedure include (i) cone reconstruction of the tricuspid valve, limited plication at the level of the displaced valve, insertion of a homemade annuloplasty ring, defect repair and reduction atrioplasty supplemented by (ii) right atrial electrocautery maze and (iii) bidirectional cavopulmonary anastomosis. Postoperatively, all patients were followed up regularly for a mean period of 2.3 (1-4) years by clinical, electrocardiographic and echocardiographic examinations. Results: The in-hospital mortality rate was 2.7% (1 patient) with no late deaths. Mean cardiopulmonary bypass time was 110 ± 18.3 min and aortic cross-clamp time was 48.5 ± 7.4 min. Echocardiographic examination showed significant improvement of valve regurgitation (P < 0.0001). NYHA functional class was I in 77.8% of the survivors and II in 22.2%. The cardiothoracic ratio decreased significantly (P < 0.05). No deleterious effects of the Glenn shunts have been reported. Sinus rhythm has remained stable in 31 patients (86.1%) during the follow-up period. Conclusions: Single-stage, three-fold repair for the management of Ebstein's anomaly offers good outcome in terms of low mortality and morbidity rates. It can achieve a durable valve-sparing repair, good functional mid-term outcomes and good quality of life among survivors.

Polycystic ovary syndrome and endometrial hyperplasia: an overview of the role of bariatric surgery in female fertility.

One of the most effective methods to tackle obesity and its related comorbidities is bariatric surgery. Polycystic ovary syndrome (PCOS) and endometrial hyperplasia (EH), which are associated with increased risk of endometrial carcinoma, have been identified as potentially new indications for bariatric surgery. PCOS is the most common endocrine disorder in women in the reproductive age and is associated with several components of the metabolic syndrome such as obesity, insulin resistance and hypertension. EH is a pre-cancerous condition which arises in the presence of chronic exposure to estrogen unopposed by progesterone such as both in PCOS and obesity. The main bariatric procedures are Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. These procedures are well established and when correctly selected and performed by experienced bariatric surgeons, they can achieve significant weight loss and remission of obesity related co-morbidities. Studies have shown that bariatric surgery can play an important role in the management of patients with PCOS and improve fertility. Similarly, bariatric surgery has a positive effect on endometrial hyperplasia, making surgically induced weight loss a potentially attractive option for endometrial cancer prevention and treatment. Obesity has an adverse impact on spontaneous pregnancy, assisted reproduction methods and feto-maternal outcomes. After bariatric surgery obese women with subfertility can achieve spontaneous pregnancy. However, while bariatric surgery reduces the risk of pre-eclampsia and gestational diabetes, there is an increased risk of small for gestational age and possible increased risk of stillborn or neonatal death. In this article we will review the evidence regarding the use of bariatric surgery as a treatment modality in patients with PCOS and EH. We also provide an overview of the common bariatric procedures.

The intraoperative therapeutic equivalence of balanced vs saline-based 6% hydroxyethyl starch 130/0.4 and their influence on perioperative acid-base status and renal functions.

STUDY OBJECTIVE: This study was designed to evaluate the therapeutic equivalence of balanced 6% hydroxyethyl starch (HES) 130/0.4 (Tetraspan) vs saline-based 6% HES 130/0.4 (Voluven) regarding the volume effect and the effect on acid-base status and renal functions in patients undergoing major urologic procedures. DESIGN: Randomized comparative trial. SETTING: Operating room and ward. PATIENTS: Forty patients, American Society of Anesthesiologists statuses 1 and 2. INTERVENTION: Patients were randomly allocated to receive either Voluven (n = 20) or Tetraspan (n = 20). MEASUREMENTS: Hemodynamic variables. Laboratory variables in the form of arterial blood gases, serum chloride and sodium levels, hemoglobin level, international normalized ratio, and kidney and liver functions were measured after induction of anesthesia (T1), at the end of surgery (T2), and on the first postoperative day (T3). MAIN RESULTS: Both groups were comparable regarding the total amount of study drugs and crystalloid consumption. No significant difference in hemoglobin levels between both groups, but there were significant differences between T1 and T2 hemoglobin within both groups and T3 hemoglobin in the Tetraspan group. Both groups were comparable regarding the renal functions, but there was a significant difference between T1 and T2 creatinine within both groups. No significant differences between both groups in liver functions and coagulation profile, but there were significant differences between values at T1, T2 and T3 within each group. Relative to baseline, both pH and bicarbonate decrease significantly in both groups. In the Voluven group, bicarbonate decreased significantly at the end of surgery relative to the Tetraspan group. Serum electrolytes did not vary between both groups. CONCLUSION: Both balanced 6% HES 130/0.4 (Tetraspan) and saline-based 6% HES 130/0.4 (Voluven) were equally effective for hemodynamic stabilization of patients undergoing major urologic procedures without any significant impact on acid-base status or renal functions.

The role of Fibroscan in predicting the presence of varices in patients with cirrhosis.

BACKGROUND/AIM: Transient elastography is a relatively new, noninvasive method of measuring liver stiffness. This study aimed to evaluate the diagnostic accuracy of transient elastography and other noninvasive methods for the diagnosis of esophageal varices (EV) in patients with cirrhosis. METHODS: This cross-sectional study graded EV according to size in 145 consecutive patients with cirrhosis who underwent endoscopy, Fibroscan, and other noninvasive diagnostic methods. The accuracy of these diagnostic methods in diagnosing EV was evaluated on the basis of area under receiver operating characteristic (AUROC) curves. RESULTS: Elastography was successful in 123 patients. Of these, 54.5% had hepatitis C and 10.6% had hepatitis B. EV were absent in 39.8%, small EV was present in 24.4%, and large EV was present in 35.8% of patients. Fibroscan, aspartate aminotransferase-to-platelet ratio index, and international normalized ratio showed low accuracy in diagnosing EV in non-viral-related cirrhosis patients (AUROCs 0.66, 0.68, and 0.67, respectively). Fibroscan and aspartate aminotransferase-to-platelet ratio index were more accurate in measuring EV with a viral etiology (AUROCs 0.704 and 0.703, respectively). A cutoff value of 16.9 kPa was 83.8% sensitive in diagnosing EV in non-viral-cirrhotic patients, whereas a cutoff value of 19.9 kPa was 83.4% sensitive in diagnosing EV in patients with viral hepatitis. Fibroscan was moderately accurate in diagnosing grade I EV and less accurate in diagnosing grades II and III EV in all cirrhotic patients, irrespective of the underlying etiology. CONCLUSION: Fibroscan might be useful in predicting the presence of EV in patients with cirrhosis with a viral etiology. However, endoscopy remains the gold standard for EV screening.

Impact of liver biopsy on the decision to treat patients with chronic hepatitis B genotype D virus infection.

OBJECTIVES: Patients with chronic hepatitis B virus (HBV) may exhibit significant liver pathology despite alanine aminotransferase (ALT) and HBV DNA levels below the cutoff values advised by treatment guidelines. We evaluated candidacy for HBV therapy when baseline histopathological changes are taken into consideration. METHODS: Clinical, biochemical, serological, virological, and histopathological (METAVIR score) data of 117 patients with HBeAg-negative chronic HBV genotype D were collected and analyzed. RESULTS: Significant pathology (≥F2 and/or ≥A2) and fibrosis (≥F2 ± ≥A2) were found in 73 (62.4%) and 59 (50.4%) patients, respectively. Based on HBV DNA (>2,000 IU/ml) and ALT levels >2 × 40 U/l (the standard cutoff value), only 31 (26.5%) patients were candidates for therapy. This increased to 58 (49.6%) patients when the new ALT cutoff values (30 U/l for males, and 19 U/l for females) were applied. Relying on either ≥F2 and/or A ≥2 or ≥F2 ± ≥A2 increases the treatment candidacy to 73 (62.4%) and 59 (50.4%) patients, respectively. Also, when compared with standard ALT cutoff values, applying both new ALT cutoff values with either significant pathology or fibrosis increases treatment candidacy to 28 (23.9%) and 42 (35.9%) patients, respectively. CONCLUSION: Liver pathology is more reliable than ALT and HBV DNA in the decision to treat patients with HBeAg-negative chronic HBV genotype D.