Changes in the Etiologies of Liver Cancer in Upper Egypt over a Decade from 2010 to 2020: A Single Tertiary Care Center Study.

Yasser Fouad The profile of liver diseases in Egypt is changing dramatically and viral hepatitis is declining, while the fatty liver disease is increasing dramatically. However, the impact of these changes on the profile of hepatocellular carcinoma (HCC) remains uncertain. Therefore, we determined the temporal trends in the etiologies of HCC in Egypt over a decade. We retrospectively analyzed data from consecutive patients who were diagnosed with HCC over 10 years (2010-2020) in a large center in Upper Egypt. Standard tests were utilized to diagnose hepatitis C virus (HCV) and hepatitis B virus. In the absence of other liver disorders, the presence of obesity, or diabetes in the absence of other risk factors, metabolic dysfunction-associated fatty liver disease (MAFLD) was diagnosed. A total of 1,368 HCC patients were included, in which 985 (72%) had HCV, 58 (4%) had hepatitis B virus, and 143 (10.5%) had MAFLD, 1 patient had hemochromatosis, 1 had autoimmune liver disease, and 180 (13%) patients were with unknown cause. The annual proportions of MAFLD-related HCC were increased significantly between 8.3% in 2010 and 20.6% in 2020 ( p = 0.001), while HCV-related HCC declined from 84.8 to 66.7% ( p = 0.001). Throughout the study period, there were significant increases in the age at diagnosis of HCC, the proportion of female patients, obesity, diabetes, and less severe liver dysfunction at diagnosis ( p < 0.05 for all). With the decline of HCV, MAFLD is becoming a major cause of HCC in Egypt, which has increased substantially over the past 10 years. This study urges the creation of comprehensive action strategies to address this growing burden.

Hepatologists' awareness and knowledge toward NAFLD and the familiarity with renaming from NAFLD to MAFLD.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is an emerging epidemic; it is a negative diagnosis that depends mainly on the presence of hepatic steatosis with or without inflammation after exclusion of other chronic liver diseases and excess alcohol intake. However, the new definition of MAFLD is a shift towards a diagnosis of inclusion based on the presence of metabolic dysfunction, regardless of alcohol consumption or other concomitant liver diseases. Given the growing relevance of the disease, data on hepatologists' views and understanding of NAFLD are limited, we aimed to determine hepatologists' awareness and expertise of NAFLD screening, diagnosis, and therapeutic options as well as the influence of changing the NAFLD name to MAFLD on awareness of the fatty liver disease (FLD). OBJECTIVE: Most of the hepatologists agreed that NAFLD can cause serious hepatic illness and may be linked to metabolic risk factors, necessitating a multidisciplinary approach to treatment. Hepatologists have a poor understanding of NAFLD care. The shift in terminology from NAFLD to MAFLD will be more known to hepatologists, and it may offer a better awareness of FLD. METHODS: A multicenter online questionnaire of 655 hepatologists was carried out, giving a sample of 207 respondents. A survey composed of 36 questions was used to assess the level of hepatologists' awareness and practices in the screening, diagnosis, and management of NAFLD/MAFLD, as well as their familiarity with the nomenclature change from NAFLD to MAFLD. RESULTS: A total of 207 hepatologists were included, of which 107 (51.4%) were males, with a mean age was 36.4 years. 50.2% (n=104) of the hepatologists were oriented with NAFLD. Only 41 (19.8%) realized that NAFLD may frequently result in severe hepatic disease. NAFLD is rarely screened by the majority of the participating hepatologists (118, 57%), and (135, 65.2%) of them use liver biopsy for diagnosis of NAFLD. In (104, 50.2%) of hepatologists, changing the nomenclature of NAFLD was relatively familiar. Furthermore, 71.9% of hepatologists thought that the new nomenclature offers a better awareness of FLD. CONCLUSION: A small percentage of hepatologists agreed that NAFLD can cause serious hepatic illness and may be linked to metabolic risk factors, and around half of them realize that NAFLD necessitates a multidisciplinary approach to treatment. Hepatologists have a poor understanding of NAFLD care. The shift in terminology from NAFLD to MAFLD will be more known to hepatologists, and it may offer better awareness of FLD.

Hepatitis B Reactivation Following Eradication of HCV with Direct-Acting Antiviral Drugs (DAAs) in a Cohort of Patients from Different Institutions in Egypt.

Background: Concerns about HBV reactivation (HBVr) have been raised with the introduction of DAA for HCV treatment. The aim of the study was to assess the risk of HBVr in chronic HCV patients during or after DAA. Methods: A cohort of 166 chronic HCV patients who were treated with SOF-based DAA regimens and initially positive for HBcAb total were evaluated; 10 HBsAg-positive, 156 had past HBV exposure (HBsAg-negative/HBcAb-positive). Laboratory investigations, including liver functions tests, HBV-DNA, LSM by Transient elastography, and ARFI together with serum markers of fibrosis; APRI and FIB-4 were done at baseline and after 12 weeks of DAAs therapy. HBV-DNA levels and liver functions were monitored for assessment of HBVr. Results: Virological HBVr was diagnosed by ≥ 1 log10 IU/ml HBV-DNA levels in 2/166 patients (1.2%) among the whole HCV cohort, who were initially positive for HBsAg; 20%. Clinical HBVr (>3 folds liver enzyme elevation) was detected in one patient with virological HBVr. Conversely, none of past HBV-infected patients experienced HBVr. All patients achieved SVR12 and had a significant decline in serum transaminases, bilirubin, APRI, and LSM measurements after HCV eradication. Conclusion: HBVr might be considered after successful eradication of HCV following DAAs therapy, especially among patients who are positive for HBsAg, while past HBV infection does not seem to be a predisposing condition to HBVr.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulins using chemiluminescence immunoassay and its correlation with neutralizing antibodies.

BACKGROUND: Neutralizing antibodies (NAbs) against SARS-CoV-2 infection have a pivotal role in protective immune response; however, their measurement requires specialized facilities. We evaluated the degree of correlation between NAbs and anti-SARS-CoV-2 IgG/total Ig antibodies detected by chemiluminescent immunoassay in asymptomatic and previously symptomatic SARS-CoV-2 patients. METHODS: A total of 1241 participants (previously symptomatic patients and asymptomatic individuals), who were screened for SARS-CoV-2 infection by RT-PCR or serology, were enrolled in our study. Sera were analyzed for the presence of anti-spike-1(S1)-SARS-CoV-2 IgG/total Ig antibodies, using Ortho Clinical Diagnostics, USA. A signal/cut-off value (S/CO) ≥ 1 was considered reactive. NAbs were measured in 103 random samples from groups using microneutralization assay, with titer ≥ 1:10 being considered positive. RESULTS: Asymptomatic (n = 229) and 261 previously symptomatic individuals with positive serology and negative RT-PCR were finally included. Significant higher anti-S1-IgG titers were seen in asymptomatic individuals (P < 0.0001). Conversely, anti-S1-total Ig titers were significantly higher in previously symptomatic (P < 0.0001). NAbs were detected in both groups, however, higher titers were seen in previously symptomatic patients. There is a correlation between NAbs and both IgG/total anti-S1-SARS-CoV-2 antibodies (r = 0.47, P < 0.0001 and r = 0.49, P < 0.0001, respectively). IgG and total Ig could predict a neutralization titer of ≥ 1:160 at S/CO >4.44 and >65 with AUC 0.69 and 0.67, respectively. CONCLUSION: Asymptomatic SARS-CoV-2 infection can produce comparable antibodies response to previously symptomatic individuals, however higher neutralization activity was seen in the previously symptomatic. Anti-S1-SARS-CoV-2 IgG/total Ig antibodies showed a correlation with neutralization activity and can be used to estimate the presence of protective immunity.

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.

Metabolic-associated fatty liver disease and autoimmune hepatitis: an overlooked interaction.

INTRODUCTION: Metabolic-associated fatty liver disease (MAFLD) is the most common liver disease globally, and affects about a quarter of the general population. Autoimmune hepatitis (AIH) is a severe (sometimes fatal) liver disease that affects children and adults, with a rising prevalence. Thus, not surprisingly, both conditions can frequently coexist, with potential synergistic impact on the course of the disease and response to therapy of both entities. AREAS COVERED: In this work, the authors aimed to provide a narrative updated review on this interaction, diagnosis, and management of MAFLD/AIH and the current challenges. EXPERT OPINION: Clarifying the nature of the complex interaction between the two diseases was hampered by a myriad of factors, particularly the previous diagnosis of exclusion for fatty liver disease associated with metabolic dysfunction. The recent redefinition of fatty liver disease that led to the development of positive diagnostic criteria for MAFLD has the premise to help in circumventing some of these challenges.

Prevalence of SARS-CoV-2 infection and dynamics of antibodies response among previously undiagnosed healthcare workers in a university hospital: A prospective cohort study.

BACKGROUND: Healthcare workers (HCWs) are a presumed high-risk population for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Identifying factors associated with seroprevalence can help establish better practices in healthcare settings. In this study, we evaluate prevalence of SARS-CoV-2 infection among previously undiagnosed HCWs and describe profiling of antibody responses against SARS-CoV-2, including neutralizing antibodies (NAbs). METHODS: We analyzed a cohort of 386 HCWs in a university hospital in Egypt and 725 volunteers not affiliated to any healthcare facility (non-healthcare workers - NHCWs). Participants provided a nasopharyngeal swab and serum samples for SARS-CoV-2 nucleic acid and SARS-CoV-2-specific antibodies, respectively. HCWs who tested positive by either test were sequentially monitored. RESULTS: At baseline, point prevalence of viral carriage was 11.4% in HCWs (n = 44/386) and 11.9% in NHCWs (86/725). The cumulative prevalence of SARS-CoV-2 infection among HCWs considering all studies was 25.6%, which was statistically lower than in NHCWs (41.0%). Prevalence was greatest among janitorial staff (45.9%) and the most affected departments were gastroenterology (31.1%), and emergency medicine (30.0%). Prior anosmia, fever or headache were associated with higher odds of positivity for SARS-CoV-2 infection. Regarding serial antibody measurements, RT-PCR-positive HCWs displayed IgG detection rates of 29.5%, 70% and 60% at visit 1, visit 2 and visit 3, respectively with slow decline of median IgG antibody titers, whereas, corresponding detection rates for total Ig antibodies were 50%, 90.3%, and 88.9%, respectively with increasing median titers. NAbs measured at each time point were positively correlated with total Ig levels, whereas IgG levels were positively correlated with NAbs at visit 1 and visit 3. CONCLUSION: Our results demonstrate lower cumulative prevalence of SARS-CoV-2 infection in HCWs than general population and suggest that asymptomatic HCWs exhibit considerable IgG and total Ig antibodies response as well as NAbs for up to 120 days, with positive correlation in between.

Gastrointestinal manifestations of human immunodeficiency virus and coronavirus disease 2019: Understanding the intersecting regions between the two epidemics.

In March 2020, the World Health Organization declared coronavirus disease (COVID-19) a pandemic. As of February 2021, there were 107 million COVID-19 cases worldwide. As a comparison, there are approximately 38 million people living with human immunodeficiency virus (PLHIV) worldwide. The coexistence of both epidemics, and the syndemic effect of both viruses could lead to a delirious impact both at individual and community levels. Many intersecting points were found between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of COVID-19, and HIV; among which, gastrointestinal (GI) manifestations are the most notable. GI manifestations represent a common clinical presentation in both HIV and SARS-CoV-2. The emergence of GI symptoms as a result of SARS-CoV-2 infection provides a new dynamic to COVID-19 diagnosis, management, and infection control measures, and adds an additional diagnostic challenge in case of coinfection with HIV. The presence of GI manifestations in PLHIV during the COVID-19 pandemic could be referred to HIV enteropathy, presence of opportunistic infection, adverse effect of antiretrovirals, or coinfection with COVID-19. Thus, it is important to exclude SARS-CoV-2 in patients who present with new-onset GI manifestations, especially in PLHIV, to avoid the risk of disease transmission during endoscopic interventions. Structural similarities between both viruses adds a valuable intersecting point, which has mutual benefits in the management of both viruses. These similarities led to the hypothesis that antiretrovirals such as lopinavir/Rironavir have a role in the management of COVID-19, which was the target of our search strategy using the available evidence. These similarities may also facilitate the development of an efficient HIV vaccine in the future using the advances in COVID-19 vaccine development.

SARS-CoV-2 infection among asymptomatic healthcare workers of the emergency department in a tertiary care facility.

BACKGROUND: Healthcare workers (HCWs) represent a high-risk category during the coronavirus disease 2019 (COVID-19) pandemic crisis, with frontline HCWs at emergency departments (EDs) may be at an even higher risk. Determining the spread of infection among HCWs may have implications for infection control policies in hospitals. This study aimed to detect severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection among asymptomatic HCWs of the ED of a large tertiary center in Cairo, Egypt. METHODS: The study was conducted from June 1st to June 14th, 2020. All the recommended national and international indications on infection control measures were followed. Two hundred and three HCWs were included in the study and tested by nasopharyngeal swab (NPS) and rapid serological test (RST). Descriptive statistical analyses were used to summarize the data. RESULTS: Of the 203 HCWs, 29 (14.3 %) tested positive by real-time reverse transcription polymerase chain reaction (RT-PCR). Thirty-seven (18.2 %) HCWs tested positive with RST: 20 with both IgM and IgG; 14 with IgM only, and 3 with IgG only. Age, gender, and/or occupation were not risk factors for SARS-CoV-2 infection. CONCLUSIONS: Point prevalence of COVID-19 in asymptomatic HCWs in ED of tertiary care facility is 14.3 % by RT-PCR. This illustrates the importance of screening all HCWs regardless of symptoms, and the need for strict measures in securing HCWs to reduce transmission from healthcare facilities to the community during the current pandemic.

SARS-CoV-2 infection among healthcare workers of a gastroenterological service in a tertiary care facility.

BACKGROUND AND STUDY AIMS: Frontlines healthcare workers (HCWs) during the coronavirus disease 2019 (COVID-19) pandemic are at increased risk of infection by SARS-CoV-2, but there are limited data on the prevalence of COVID-19 among HCWs in Egypt. This study aimed to assess SARS-CoV-2 infection among HCWs providing gastroenterological services. SUBJECTS AND METHODS: Seventy-four HCWs at the gastroenterological service of Al-Manial University Hospital, the main hospital of the largest tertiary university hospitals complex in Egypt (Kasr Al-Ainy Faculty of Medicine, Cairo University) were tested using real-time reverse transcription-polymerase chain reaction (RT-PCR) on nasopharyngeal samples, and rapid serological IgM/IgG tests (RST). A questionnaire was used to collect demographic, occupational and clinical data. RESULTS: Of the 74 HCWs, 10 tested positive by RT-PCR (13.5%). In 9/74 (12.2%) HCWs, antibodies could be detected by RST: three with both IgM and IgG lines; six with IgM line only and none with IgG line only. Frequency of positive tests was more among subjects with minor symptoms compared to completely asymptomatic HCWs (50% vs 16.1%, respectively). Neither age, gender or occupation was a risk factor for SARS-CoV-2 infection. CONCLUSIONS: Point prevalence of COVID-19 in gastroenterology HCWs is 13.5% by RT-PCR. Continued measures are warranted to assure HCWs safety and reduce transmission from healthcare settings to the community during COVID-19 pandemic. Presence of positive test results among asymptomatic HCWs illustrates the importance of screening all HCWs irrespective of symptoms.

Diarrhoea and the COVID-19 pandemic.

The new COVID-19 pandemic has been initially linked to respiratory manisfestations. However, there is increasing evidence that other systems are affected by SARS-CoV2; one of which is the gastrointestinal system with several organ-related symptoms and possible implications on prognosis and spread. Diarrhoea is one of the main symptoms of gastrointestinal involvement. In this review the mechanisms, characteristics, prognostic significance and managment of of COVID-19 related diarrhoea are discussed. The possibility of faecal transmission of disease is reviewed.