Characterization of Antigen Escape Mutations in Chronic HBV-Infected Patients in Upper Egypt.

BACKGROUND: Mutations within the "a" determinant region (position 124-147) that is present in the major hydrophilic region (MHR, position 99-160) of the hepatitis B surface antigen (HBsAg) are associated with vaccine-escape, lack of diagnosis, and failure to hepatitis B immunoglobulin (HBIG) therapy. Data regarding the amino acid changes of "a" determinant region of HBsAg are limited in Egypt. The prevalence and mutations in this region among chronic HBV (CHB)-infected patients in Upper Egypt are not known. MATERIAL AND METHODS: Blood samples were collected from HBsAg-positive CHB-infected patients (n=123) admitted to Assiut University Hospitals. Serum samples were screened for HBsAg, HBeAg, anti-HBs and anti-HBe antibodies using commercially available ELISA kits. Viral load was determined by qPCR. In addition, mutational analysis was carried out targeting the HBV surface gene to determine the HBV genotype and vaccine escape mutations. RESULTS: Sequencing analysis of HBV DNA revealed that genotype D is the major circulating type (81.3%), followed by genotype E (18.7%). Analysis of the HBV genome revealed that 103/123 (83.7%) patients showed wild-type sequences and 20/123 (16.3%) showed mutations in the HBsAg gene. Mutation in seventeen patients (17/20, 85%) showed only one mutation, and three patients showed two mutations (3/20, 15%) in the "a" determinant region. The observed mutations were T115S (3/20, 15%), P120T/S (3/20, 15%), T126S (1/20, 5%), Q129R (2/20, 10%), M133T (2/20, 10%), S143L (5/20, 25%), D144E/A (3/20, 15%), and G145R/A (4/20, 20%). Mutations in the "a" determinant region were detected in genotype D isolates only. CONCLUSION: We described for the first time the prevalence and characterization of vaccine escape mutants in CHB patients in Upper Egypt. Mutational analysis of the "a" determinant region revealed the presence of a wide spectrum of mutants in the circulating HBV isolates that could be a potential threat to HBV diagnosis, therapy success, and HBV vaccination program in Upper Egypt.

Regulatory T Cells and IL35 in Chronic Hepatitis C Related Cirrhosis and Hepatocellular Carcinoma.

Regulatory T cells (Tregs) play a fundamental role in maintaining immune homeostasis to balance between the tissue-damaging and protective effects of the immune response. There are strong evidences that Treg cells and their cytokines may play an important role in the induction of tolerance in the liver and progression of HCV infection. Herein, we investigated the frequency of Treg cells and interleukin 35 (IL-35) level in blood and their potential relationship to the various chronic hepatitis C (CHC) complications and outcomes. A total of 36 HCV infected patients subdivided into, CHC complicated with cirrhosis (HCV LC; n = 18), CHC complicated with hepatocellular carcinoma (HCV- HCC; n=18) and apparently healthy control group (n=18) were enrolled in this study. Treg cells percentages were determined by flow cytometric analysis and ELISA was used to measure IL35 serum levels. A significant increase in the frequency of peripheral Tregs and serum IL35 level was found in HCV HCC, and HCV LC groups compared with the control group. The frequency of peripheral Tregs and plasma (IL-35) levels were significantly positively correlated with viral load along with disease progression. We conclude that the higher percentage of Tregs and IL35 level in peripheral blood of HCV HCC and HCV LC groups compared to the control group may suggest their contribution to viral persistence and progression of HCV infection.

Regulatory B Cells and Their Cytokine Profile in HCV-Related Hepatocellular Carcinoma: Association with Regulatory T Cells and Disease Progression.

Although regulatory B cells (Bregs) have been proven to play a suppressive role in autoimmune diseases, infections and different tumors, little is known regarding hepatocellular carcinoma (HCC), especially in hepatitis C-related settings. Herein, we analyzed the frequency of circulating Bregs, serum levels of IL-10, IL-35 and B-cell activating factor (BAFF) and investigated their association with regulatory T cells (Tregs) and disease progression in HCV-related HCC. For comparative purposes, four groups were enrolled; chronic HCV (CHC group, n = 35), HCV-related liver cirrhosis (HCV-LC group, n = 35), HCV-related HCC (HCV-HCC group, n = 60) and an apparently healthy control (Control-group, n = 20). HCC diagnosis and staging were in concordance with the Barcelona Clinic Liver Cancer (BCLC) staging system. Analysis of the percentage of Breg cells and peripheral lymphocyte subsets (Treg) was performed by flow cytometry. Serum cytokine levels of IL-10, IL-35 and B-cell activating factor (BAFF) were measured by ELISA. The frequency of Bregs was significantly higher in the HCV-HCC group compared to the other groups and controls. A significant increase was noted in late-HCC versus those in the early stages. The frequency of Bregs was positively correlated with Tregs, serum IL-10, IL-35 and BAFF. In conclusion, Peripheral Bregs were positively correlated with the frequency of Tregs, IL-10, IL-35 and BAFF, and may be associated with HCV-related HCC progression.

Usefulness of Circulating Methylated p16 as a Noninvasive Molecular Biomarker for Hepatitis C-Related Hepatocellular Carcinoma with Normal Serum Alpha-Fetoprotein Levels.

BACKGROUND: Screening of hepatocellular carcinoma (HCC) is challenged especially in patients with normal alpha-fetoprotein (AFP) levels. Aberrant p16 methylation has been implicated in HCC. OBJECTIVES AND AIMS: This study aimed to assess serum methylated p16 (MP16) expression levels and to evaluate MP16 diagnostic performance in HCC detection among HCV-infected Egyptian patients with normal AFP levels. METHODS: MP16 levels were quantified using real-time PCR in 230 serum samples (30 healthy controls, 95 with HCV-HCC, 40 with chronic hepatitis C "CHC" and 65 with HCV cirrhosis). Diagnostic performance of MP16 for diagnosis of HCC was done using receiver operator characteristic curve analysis. RESULTS: Serum MP16 levels were significantly higher in HCC than CHC, cirrhosis, and healthy subjects and significantly higher in HCC with normal AFP levels than those with higher AFP. ROC curves revealed promising diagnostic performance for MP16 in discriminating HCC with normal AFP levels from non-HCC cases. This predictive ability improved by combining MP16 and AFP (AUC of 0.872 with 100% sensitivity, 76.5% specificity, 79.1% positive predictive value, 100% negative predictive value, and 87.5% accuracy). CONCLUSION: MP16 can be a potential noninvasive molecular biomarker for HCC detection in patients with hepatic mass(es) and normal AFP levels especially in those where liver biopsy and radiological imaging cannot be done.

T follicular helper and T follicular regulatory cells in colorectal cancer: A complex interplay.

Colorectal cancer is considered to be one of the major causes of morbidity and mortality all over the world. T Follicular helper (TFH) and T follicular regulatory (TFR) cells are specialized providers of T-cells to help B-cells and shaping germinal centers (GC) response. Recent researches reported a high percentage of TFH and TFR in different infectious diseases and certain malignancies. However, their functional role in human colorectal cancer (CRC) is relatively unknown. Furthermore, recent studies show that the interaction of both TFH cells and TFR cells are essential to promote several diseases. Under the control of specific cytokines and B-cell lymphoma 6 transcription factor (Bcl-6), the major transcription factor of TFH cells, TFH, can expand to the other distinct CD4 + T helper cells (TH1, TH2, and TH17) which exert a different role in the development of CRC. This review aims to discuss these suggested roles of the two-opposite subset of follicular T cells in colorectal cancer immune pathogenesis.

Effect of Combined HCV Therapy on Natural Killer Cell Activity.

Hepatitis C virus (HCV) is a major health problem all over the world with the highest prevalence reported in Egypt. Various treatment regimens have been developed over the last years. Interferon (IFN) based regimen was the standard of care regimen and then the IFN-free therapies were emerged. Host innate immunity through the activity of natural killer (NK) cell is one of the major players in competing infections and tumors, by producing perforin and granzymes that cause cytolysis of target cells, or by the production of various cytokines such as natural interferon gamma. Natural cytotoxicity receptors (NCRs), including Nkp30, Nkp44 and Nkp46, are a group of activating receptors that almost have restricted expression on the surface of NK cells and their density correlates with NK cytotoxicity. The role of these cells is not fully elucidated in patients with chronic HCV infection either treatment-naive or treatment experienced. Therefore, this study aimed to investigate the change that occurs in NK cell activity and cytotoxicity in response to successful elimination of HCV from blood after triple therapy with PEG-IFN-α, ribavirin and sofosbuvir. A total of 56 (50 male: 6 female) HCV patients with mean age of 41.6± 12.1 years were included in this study. They were divided into two groups: treatment naive group (20 patients) and the sustained virologic response (SVR) group (36 patients). All patients were investigated for their NK cell profile, NCRs, perforin and granzyme B expression by flow cytometry. Data was expressed as mean fluorescence intensity (MFI). Results revealed significant increase in MFI of granzyme B (P=0.001) and decrease in MFI of NKp30 (P=0.042) in the SVR group as compared to treatment naïve group. These findings indicated that triple therapy of HCV (IFN, Ribavirin and Sofosbuvir) effected NK activation and cytotoxicity.

Increased frequency and FOXP3 expression of human CD8+CD25High+ T lymphocytes and its relation to CD4 regulatory T cells in patients with hepatocellular carcinoma.

The mechanism of action of CD8+CD25High+FOXP3+ T cells in hepatocellular carcinoma (HCC) has not been fully understood. Herein, the role of CD8+CD25High+FOXP3+ T cells in HCC was compared with that of CD4+CD25High+FOXP3+ regulatory T cells (conventional Tregs). Thirty-five patients with HCC and twenty age and sex-matched healthy adults (controls) were enrolled. The percentage of CD8+CD25High+FOXP3+ T cells and conventional Tregs in peripheral blood was measured by flow cytometry. Our results revealed that the percentage of peripheral CD8+CD25High+FOXP3+ T cells in HCC patients was significantly higher than controls (P = 0.005). The conventional Tregs showed the same trend with a higher level in HCC than controls (P < 0.0001). FOXP3 expression of CD8+CD25High+ T cells is higher than that of CD8+CD25low+ and CD8+CD25Negative T cells. The percentage of CD8+CD25High+FOXP3+ T cells positively correlated with that of conventional Tregs in HCC patients but not in controls. The higher alpha-fetoprotein positively correlated with the higher CD8+CD25High+FOXP3+ T cells and conventional Tregs (R2 = 0.481, P < 0.0001 and R2 = 0.249, P = 0.001, respectively). The frequency of both CD8+CD25High+FOXP3+ T cells and conventional Tregs was significantly increased in HCC with multiple lesions compared with those with one or two lesions. In conclusion: CD8+CD25High+FOXP3+ T cells similar to conventional Tregs might be used as biomarkers of HCC progression. Therapy targeting the peripherally expanded CD8+CD25High+FOXP3+ T cells may provide a novel perspective for HCC treatment.

Prevalence and predictors of occult hepatitis C virus infection among Egyptian patients who achieved sustained virologic response to sofosbuvir/daclatasvir therapy: a multi-center study.

BACKGROUND: Occult hepatitis C virus (HCV) infection (OCI) is characterized by the detection of HCV-RNA in non-serum reservoirs, such as peripheral blood mononuclear cells (PBMCs) and/or hepatocytes with undetectable HCV-RNA or antibodies in the serum. In this study, we tried to evaluate the prevalence and possible predictors of OCI in patients who achieved sustained virologic response (SVR) post sofosbuvir/daclatasvir (SOF/DCV) therapy. PATIENTS AND METHODS: A cross-sectional multicenter study was designed to enroll 1,280 HCV-infected patients who received SOF (400 mg) plus DCV (60 mg) once daily ± ribavirin regimen for 12 weeks and achieved SVR 12 weeks post treatment. They were randomly recruited from three dedicated Egyptian centers for management of HCV. Real-time PCR was performed to detect HCV-RNA in serum and PBMCs and to evaluate the different risk factors pertaining to the existence of OCI. RESULTS: HCV-RNA was detected in PBMCs of 50 (3.9%) of them. All OCI cases exhibited significant fibrosis score and raised pre-treatment alanine aminotransferase (ALT) levels. Logistic regression analysis comparing OCI with non-OCI revealed that high pre-treatment viral load, raised ALT, advanced fibrosis score, prolonged prothrombin time, low albumin, Child B score, antiviral experienced patients, and raised bilirubin are the most significant predictor for the possibility of OCI presence with Odds Ratio as 7.03, 5.13, 4.4, 2.68, 2.52, 1.9, 1.5, and 1.2, respectively. CONCLUSION: In spite of its remote possibility, OCI post SOF/DCV therapy may be present in some cases, and this may entail a re-auditing for the definition of SVR by dual testing in both serum and PBMCs.

Frequency and Implications of myeloid-derived suppressor cells and lymphocyte subsets in Egyptian patients with hepatitis C virus-related hepatocellular carcinoma.

BACKGROUND AND AIM: Myeloid-derived suppressor cells (MDSCs) play a pivotal role in tumor immunity and induction of immune tolerance to a variety of antitumor effectors, including T lymphocytes. Herein, we tried to evaluate the frequency and clinical significance of MDSCs and different lymphocyte subsets in hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC). METHODS: Four groups were enrolled; chronic HCV (CHC; n = 40), HCV-related liver cirrhosis (n = 40), HCV-related HCC (HCV-HCC; n = 75), and healthy control group (n = 20). The percentage of peripheral lymphocytes subsets and total MDSCs with their main two subsets; monocytic (M-MDSCs) and granulocytic (G-MDSCs) was evaluated by flow cytometry. RESULTS: The frequency of total MSDCs and M-MDSCs was significantly elevated in HCV-HCC especially patients with advanced stage HCC compared with those with early-stage HCC. The frequency of total MSDCs and M-MDSCs was positively correlated with ALT, AFP, and HCV viral load and negatively correlated with CD8+ T-cell frequency. CD4 + T cells were significantly decreased in HCV-HCC patients. The frequency of CD4 + T cells and CD8 + T cells was negatively correlated with AFP and AST, but not with albumin or HCV viral load. CONCLUSION: Taken together, our data suggest that MDSCs, M-MDSCs, and lymphocyte subsets are associated with the development and progression of HCV-related HCC.

Efficacy of ombitasvir/paritaprevir/ritonavir/ribavirin in management of HCV genotype 4 and end-stage kidney disease.

BACKGROUND: Till now, pooled data about the safety and efficacy of different direct-acting antiviral (DAAs) regimens in different renal situations are still under evaluation. AIM: To evaluate a real-life experience of the efficacy and safety of ombitasvir/paritaprevir/ritonavir plus ribavirin (OBV/PTV/r plus RIB) in patients with end-stage kidney disease (ESKD). PATIENTS AND METHODS: Between January 2017 and January 2018, an open-label multicenter prospective study was designed to enroll all consecutive patients with proven CHC genotype 4 infections and concomitant ESKD based on estimated glomerular filtration rate (eGFR) with (HD group) or without hemodialysis (non-HD group). Patients were given a co-formula of OBV/PTV/r (25/150/100 mg) once-daily plus RIB was given for 12 weeks. Sustained virologic response (SVR 12) was the primary endpoint. RESULTS: A total of 110 patients were enrolled. An overall SVR 12 was reported in 104 (94.5%) patients, and treatment failure were reported in 6 patients [2 patients (1.8%) were relapsed, and 4 patients (3.6%) patients were non-responders]. SVR12 was 96% in HD and 91.4% in non-HD patients (P = 0.286). There were no reported serious adverse events. Anemia was reported in 66.6% (n = 50) in HD group and in 31.4% (n = 11) in non-HD group. CONCLUSION: Although it is still challenging, achievement of SVR12 in patients with chronic HCV and concomitant end-stage kidney disease in the era of DAAs became possible with a 12 weeks course of a co-formula of ombitasvir/paritaprevir /ritonavir plus ribavirin. CLINICALTRIALS. GOV ID: NCT03341988.

Rifaximin versus metronidazole in management of acute episode of hepatic encephalopathy: An open labeled randomized clinical trial.

BACKGROUND AND STUDY AIMS: Many regimens are tried in managing overt hepatic encephalopathy (HE). We investigated the efficacy of rifaximin versus metronidazole in management of an acute episode of HE on top of cirrhosis. PATIENTS AND METHODS: An open label prospective controlled trial was conducted on patients with an acute episode of HE on top of cirrhosis who were randomly divided into metronidazole-group (M-group) and rifaximin-group (R-group) with 60 patients in each. The main outcome measure was the clinical improvement of HE, duration of hospital stay and the changes in the level of serum ammonia after 3 days of starting therapy. RESULTS: Both M-group and R-group were comparable as regards age and sex (mean age 51 ±â€¯11 years and 49 ±â€¯12; male/female ratio 45:15 and 50:10, respectively). Forty-six patients (76.7%) in M-group compared with forty-five (75%) in R-group showed clinical improvement (p = 0.412). Hospital stays were comparable between both group; 4.2 ±â€¯2.1 and 3.9 ±â€¯1.7 for M-group and R-group; respectively (p = 0.435). There was no significant difference of venous ammonia levels (Mean of delta 160.77 ±â€¯185.34 µg/dL and 207.95 ±â€¯218.43 µg/dL with p 0.664 and 0.974 in M-group and R-group, respectively). No adverse events were reported throughout the whole study. CONCLUSION: Rifaximin and metronidazole are equally effective in management of acute episode of overt HE, therefore, re-auditing of treatment protocols of HE are warranted especially in limited resource settings.

Studying the frequency of aberrant DNA methylation of APC, P14, and E-cadherin genes in HCV-related hepatocarcinogenesis.

BACKGROUND: Data about the molecular pathogenesis of hepatitis C-related hepatocellular carcinoma (HCC) are still challenging. OBJECTIVES: Therefore, we tried to investigate the epigenetic study of three nominated genes (APC, P14, and E-cadherin) in the pathogenesis of HCV-related HCC in Egyptian. METHODS: Between March 2016 and March 2017, the DNA methylation, and quantification using (epigenetic ELISA kit) for E-cadherin, APC, and P14 genes were studied in three groups of patients: HCV related liver cirrhosis without HCC group (LC-group; n= 20), HCC on top of HCV-related cirrhosis (HCC-group; n= 20), and a third apparently healthy control group (control-group; n= 10). RESULTS: E-cad methylation showed non-significant differences between groups. P14 methylation was occurred only in HCC-group (45%). APC methylation was the highest in HCC group (70%). Methylation level was high in HCC group in comparison to both LC and control groups (P< 0.001). DNA methylation at a cutoff point > 2.9 ng/ml predicts HCC in LC-group with 90% sensitivity and 80% specificity and at level > 2.3 ng/ml had 95% sensitivity and 90% specificity in control-group. The pooled sensitivity, specificity, positive and negative predictive values and accuracy were 90%, 60%, 69.2, 85.7 and 75% respectively. CONCLUSION: Aberrant DNA methylation of multiple genes is associated with disease progression in HCV related cirrhosis. Moreover, early detection of promotor methylation of these may sever as good biomarker for early detection and therapeutic targets in high risk patients.

Association between IL28B rs12979860 single nucleotide polymorphism and the frequency of colonic Treg in chronically HCV-infected patients.

The IL28B gene is associated with spontaneous or treatment-induced HCV viral clearance. However, the mechanism by which the IL28B single nucleotide polymorphism (SNP) affects the extra-hepatic HCV immune responses and its relationship to HCV pathogenesis have not been thoroughly investigated. To examine the mechanism by which IL28B affects HCV clearance. Forty Egyptian patients with chronic HCV infection receiving an Interferon/ribavirin treatment regimen were enrolled into this study. There were two groups: non-responders (NR; n = 20) and sustained virologic responders (SVR; n = 20). The initial plasma HCV viral loads prior to treatment and IL28B genotypes were determined by quantitative RT-PCR and sequencing, respectively. Liver biopsies were examined to determine the inflammatory score and the stage of fibrosis. Colonic regulatory T cell (Treg) frequency was estimated by immunohistochemistry. No significant association between IL28B genotypes and response to therapy was identified, despite an odds ratio of 3.4 to have the TT genotype in NR compared to SVR (95 % confidence interval 0.3-35.3, p = 0.3). Patients with the TT-IL28Brs12979860 genotype (unfavorable genotype) have significantly higher frequencies of colonic Treg compared to the CT (p = 0.04) and CC (p = 0.03) genotypes. The frequency of colonic Treg cells in HCV-infected patients had a strong association with the IL-28B genotype and may have a significant impact on HCV clearance.

Galactin-3 and brain natriuretic peptide versus conventional echocardiography in the early detection of cirrhotic cardiomyopathy.

BACKGROUND/AIMS: Cirrhotic cardiomyopathy (CCM) is defined as an abnormal heart structure and function in cirrhotic patients. CCM includes systolic and diastolic dysfunction, electrophysiological abnormalities, and structural changes, both microscopic and macroscopic. Currently, there is no one diagnostic test that can identify patients with CCM. Evaluation of the validity of galactin-3 and brain natriuretic peptide (BNP) as biomarkers in the early detection of CCM in comparison to conventional echocardiography. MATERIALS AND METHODS: A case control study was carried out in the Departments of internal medicine and tropical Medicine, Assuit University, Egypt. Seventy-one subjects were divided into the following three groups: 26 cirrhotic patients without ascites, 25 cirrhotic patients with ascites, and 20 healthy controls. All groups underwent clinical examination, and laboratory investigation including BNP, galactin-3, and echocardiography. RESULTS: There was a significant difference between the three groups (p < 0.001) with regard to corrected QT (cQT), BNP and galactin-3. Left ventricular diastolic dysfunction with different grades was the most recorded cardiac abnormality in the patient group I and II (88.5% and 96%; respectively) with significantly increased frequency and severity in ascetic patients and with the advancement of liver cirrhosis. BNP and galactin-3 were sensitive and specific biomarkers for the detection of diastolic dysfunction in cirrhotic patients (77.6%, 95.5%, 89.9% and 86.4%; respectively). CONCLUSION: Diastolic dysfunction is a common cardiac abnormality in cirrhotic patients that worsens with the advancement of cirrhosis. BNP and galactin-3 had higher sensitivity and specificity in the early detection of CCM compared with those of conventional echocardiography.

Extra-hepatic infection of hepatitis C virus in the colon tissue and its relationship with hepatitis C virus pathogenesis.

Extra-hepatic compartments might contribute to hepatitis C virus (HCV) persistence and extra-hepatic manifestations. Therefore, we investigated HCV infection in colonic tissue in patients with chronic hepatitis C (CHC) and its relationship with HCV pathogenesis. Colonic biopsies were collected from three groups with CHC infection: treatment naïve (TN; n=12), non-responders (NR; n=10) to anti-HCV therapy (pegylated interferon-α and ribavirin) and sustained virologic response (SVR; n=10) and from a fourth healthy control group (n=10). Liver biopsies were examined to assess inflammation and fibrosis. HCV infection and colonic T regulatory (Treg) frequency were detected by immunohistochemistry. HCV core and NS3 proteins were detected in B cells and macrophage/monocytes of 42 % and 25 % of TN and 50 % and 30 % of NR, respectively, but not in SVR or control group. The numbers of cells expressing HCV proteins were positively correlated with both HCV viral load and colonic Treg frequency. A significant negative correlation between HCV-expressing cells with both liver inflammation and fibrosis was identified. Our study provides evidence that HCV can infect B cells and macrophages of the colon. The correlations between HCV infection in colonic tissue and HCV viral load and liver pathology underline the significance of this extra-hepatic infection in HCV pathogenesis and response to therapy.

Diagnostic performance and factors influencing the accuracy of EUS-FNA of pancreatic neuroendocrine neoplasms.

BACKGROUND: Multiple studies have investigated sampling adequacy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic neuroendocrine neoplasms (pNENs). However, none have described the diagnostic performance of EUS-FNA for pNENs, or the influencing factors. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA, with post-operative pathological diagnosis as the gold standard, and factors predictive of inadequate EUS sampling. METHODS: From 1998 to 2014, a total of 698 patients underwent pancreatic resection and 1455 patients underwent EUS-FNA sampling for pancreatic lesions. A total of 410 cases underwent both surgical resection and preceding EUS-FNA. Of these, 60 cases (49 true pNEN, nine non-diagnostic, two misdiagnoses) were included. We studied diagnostic performance of EUS-FNA and factors that were associated with failed diagnosis. RESULTS: Of the 60 cases, EUS-FNA yield was 49 true-positive cases, two misdiagnoses, and nine non-diagnostic cases (including six suggestive cases). Sensitivity, specificity, and accuracy were 84.5, 99.4, and 97.3 %, respectively; including the six suggestive cases, diagnostic values were 94.8 % sensitivity (55/58), 99.4 % specificity (350/352), and 98.7 % accuracy (405/410). In multivariate analysis, sampling adequacy rates were significantly lower when lesions were located in the pancreatic head [odds ratio (OR) = 10.0] and in tumor-rich stromal fibrosis (OR = 10.45). Tumor size, needle type, tumor grading, presence of cystic component, and time period were not significant factors. CONCLUSIONS: EUS-FNA offers high accuracy for pNEN. However, location of the tumor in the pancreatic head and presence of rich stromal fibrosis negatively impacts sampling adequacy.

Incidence, causes, and outcomes of renal failure among cirrhotic patients.

BACKGROUND/AIMS: To evaluate the incidence, risk factors of RF among cirrhotic and its impact on patient's outcome. MATERIALS AND METHODS: A total of 573 cirrhotic patients were evaluated for renal failure (RF) and its causes, 212 patients (37%) were enrolled. RESULTS: Majority of the patients had post hepatitis C liver disease (n=190, 89.6%) with Child-Pugh score C (88.2%), HCC was in 21.2% of cases baseline characteristics. Infections were observed in 45.8% (n=97) of patients whereas, spontaneous bacterial peritonitis (SBP) was the most type of infection (19.3%) among cirrhotic patients with renal failure, followed by pneumonia (9.9%). Infection-induced represents 30.2% followed by hypovolemia (29.7%), whereas HRS was in 11.3%. Reversibility of the condition was seen in 81 patients (38.2%), whereas mortality was seen in 58 (27.4%) patients of RF. The reversibility was more common in the patients with infection, followed by hypovolemia. Mortality was higher in the patients with HRS followed by parenchymal renal disease. CONCLUSION: Infection-induced and hypovolemic-induced RF represent the most common and also the most correctable causes and must be considered in management protocols for early detection and treatment that will serve for a better prognosis.

Human fascioliasis: a re-emerging disease in upper Egypt.

In recent years, the number of humans infected with Fasciola has risen rapidly. Diagnosis is based mainly on detection of eggs in stool analysis. The rate of infection in Egypt is unknown. In this retrospective study, we describe 23 cases of hepatic fascioliasis, and only 2 of these cases showed eggs in stools. The symptoms of infection, such as pyrexia of unknown origin, epigastric pain, and abdominal distension, were suggestive. Imaging techniques, including abdominal ultrasonography and computed tomography, were very helpful in detecting hepatic changes. An indirect hemagglutination assay proved to be of value for diagnosis. Treatment using a 2-day triclabendazole regimen cured the infection and signs of hepatic involvement disappeared. Combining both imaging techniques and laboratory tests is essential for diagnosis of fascioliasis in the early stage.

Association of colonic regulatory T cells with hepatitis C virus pathogenesis and liver pathology.

BACKGROUND AND AIM: Forkhead box protein P3 (FoxP3)(+) regulatory T (Treg ) cells play a fundamental role in maintaining the balance between the tissue-damaging and protective immune response to chronic hepatitis C (CHC) infection. Herein, we investigated the frequency of Treg cells in the colon and their potential relationship to the various CHC outcomes and hepatic histopathology. METHODS: Colonic biopsies were collected from three groups with CHC: treatment naïve (TN; n = 20), non-responders (NR; n = 20), sustained virologic response (SVR; n = 20), and a fourth healthy control group (n = 10). The plasma viral loads and cytokines levels were determined by quantitative real-time polymerase chain reaction, and ELISA, respectively. Liver biopsies were examined to assess inflammatory score and fibrosis stage. Colonic Treg frequency was estimated by immunohistochemistry using confocal microscopy. RESULTS: A significant increase in the frequency of colonic Treg was found in TN, and NR groups compared with the control and SVR group. The frequency of colonic Treg , plasma interleukin (IL)-10 and IL-4 levels were significantly positively correlated with viral load and negatively correlated with METAVIR inflammatory score, and fibrosis stages. CONCLUSION: Colonic Treg cells are negatively correlated with liver inflammation and hepatitis C virus (HCV) viral load, which suggests a strong linkage between gut-derived Treg cell populations and HCV infection.

Does the WHO 2010 classification of pancreatic neuroendocrine neoplasms accurately characterize pancreatic neuroendocrine carcinomas?

BACKGROUND: The WHO classified pancreatic neuroendocrine neoplasms in 2010 as G1, G2, and neuroendocrine carcinoma (NEC), according to the Ki67 labeling index (LI). However, the clinical behavior of NEC is still not fully studied. We aimed to clarify the clinicopathological and molecular characteristics of NECs. METHODS: We retrospectively evaluated the clinicopathological characteristics, KRAS mutation status, treatment response, and the overall survival of eleven pNEC patients diagnosed between 2001 and 2014 according to the WHO 2010. We subclassified WHO-NECs into well-differentiated NEC (WDNEC) and poorly differentiated NEC (PDNEC). The latter was further subdivided into large-cell and small-cell subtypes. RESULTS: The median Ki67 LI was 69.1% (range 40-95%). Eleven WHO-NECs were subclassified into 4 WDNECs and 7 PDNECs. The latter was further separated into 3 large-cell and 4 small-cell subtypes. Comparisons of WDNEC vs. PDNEC revealed the following traits: hypervascularity on CT, 50% (2/4) vs. 0% (0/7) (P = 0.109); median Ki67 LI, 46.3% (40-53%) vs. 85% (54-95%) (P = 0.001); Rb immunopositivity, 100% (4/4) vs. 14% (1/7) (P = 0.015); KRAS mutations, 0% (0/4) vs. 86% (6/7) (P = 0.015); response rates to platinum-based chemotherapy, 0% (0/2) vs. 100% (4/4) (P = 0.067), and median survival, 227 vs. 186 days (P = 0.227). CONCLUSIONS: The WHO-NEC category may be composed of heterogeneous disease entities, namely WDNEC and PDNEC. These subgroups tended to exhibit differing profiles of Ki67 LI, Rb immunopositivity and KRAS mutation, and distinct response to chemotherapy. Further studies for the reevaluation of the current WHO 2010 classification are warranted.