The Efficacy and Safety of Endoscopic Balloon Dilatation in the Treatment of Functional Post-Sleeve-Gastrectomy Stenosis.

Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients' clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Lupus anticoagulant activity and thrombosis post COVID-19 vaccination.

Some reports have discussed the development of a new entity called vaccine-induced immune thrombotic thrombocytopenia after COVID-19 vaccination. In this case series, we are describing four patients who have developed lupus anticoagulant-associated venous thromboembolism after Pfizer mRNA COVID-19 vaccination. All were COVID-19 negative on admission. Three had developed thrombosis after the first dose and one after the second dose of vaccination. All of them had venous thrombosis. Three patients developed thrombosis 2 weeks after vaccination and the fourth patient had developed thrombosis after 3 weeks of vaccination. None of the patients had thrombocytopenia on or during admission as seen in the case of vaccine-induced immune thrombotic thrombocytopenia. All patients had positive lupus anticoagulant and negative anticardiolipin antibodies and antibeta2 glycoprotein I. All of them were stable on discharge and were treated with low molecular weight heparin followed by warfarin. We suggest the presence of a possible link between the development of antiphospholipid antibodies and COVID-19 vaccine that requires further assessment.

Resolved hepatitis B infection in patients receiving immunosuppressive therapy: Monitor versus prophylaxis against viral reactivation.

Risk of hepatitis B virus reactivation (HBVr) in patients with resolved HBV infection receiving immunosuppressive therapy has been a growing concern, particularly in the era of biological and targeted therapies. HBV monitoring versus antiviral prophylaxis against HBVr in those patients remains controversial. The aim of the study was to determine the incidence of HBVr and HBV-related hepatitis in resolved HBV patients who received immunosuppressive therapy with or without antiviral prophylaxis. This retrospective study included 64 patients with resolved HBV infection who received different regimens of immunosuppressive medications, with moderate risk of HBVr, for variable underlying diseases. Patients who had chronic HBV infection or other viral infections were excluded. Patients who received B-cell depleting therapies were ruled out. They were divided into 2 groups: group 1 included 31 patients who received immunosuppressive therapy without antiviral prophylaxis, and group 2 included 33 patients who received antiviral prophylaxis (entecavir) within 2 weeks of commencing the immunosuppressive therapy. HBVr, HBV-related hepatitis, and HBV-unrelated hepatitis were assessed along a 1-year duration. The overall HBVr incidence was 1.56% (1/64). This patient who had HBVr was seen in group 1. There were no significant differences between the 2 groups regarding the incidence of HBVr, HBV-related hepatitis, HBV-unrelated hepatitis, and immunosuppressive therapy interruption along a 1-year duration. Based on this retrospective study, close monitoring was equal to antiviral prophylaxis regarding the outcome of resolved HBV patients who received moderate risk immunosuppressive therapy. HBV treatment should commence once HBVr is confirmed.

Association of Serum Osteoprotegerin Level With Myocardial Injury and Cardiovascular Calcification in Chronic Kidney Disease Patients.

Background: Chronic kidney disease has emerged as a significant independent risk factor for cardiovascular disease. Cardiovascular calcification is an active process involving a complex interaction of inducers and inhibitors. High sensitivity cardiac troponin T assay detects troponin T with higher sensitivity and precision at an earlier point of time than the conventional assays, and is associated with poor outcomes. Serum osteoprotegerin is classed as an inhibitory factor for cardiovascular calcification. It is involved in the pathological processes of vascular damage and linked to the excess cardiovascular morbidity. The aim of the present study was to evaluate the extent of cardiovascular calcification and serum high sensitivity cardiac troponin T level, and their association with serum osteoprotegerin level in patients with chronic kidney disease stages 3-5. Methods: 90 chronic kidney disease patients were enrolled in this study, and they were divided into two groups: group (1) included 45 non-dialysis-dependent chronic kidney disease patients (stages 3-5) and group (2) included 45 chronic hemodialysis patients. Each group further subdivided according to the presence of cardiovascular calcification into subgroup A and B. Vascular calcifications were assessed by lateral lumbar, pelvis and hands X-ray radiographs. Valvular calcification was assessed by echocardiography. Serum cardiac troponin T was measured by high sensitivity assay and serum osteoprotegerin was measured by ELISA. Results: Cardiovascular calcification distribution was 22.2% in group (1) and 33.3% in group (2). Serum osteoprotegerin and troponin T in calcification groups (1A and 2A) were significantly higher than non-calcification groups (1B and 2B; P < 0.001). Osteoprotegerin correlated positively with high sensitivity cardiac troponin T (rs = 0.72, P < 0.001). cardiovascular calcification correlated positively with osteoprotegerin, troponin T, and phosphorus. osteoprotegerin and phosphorus were significant independent predictors of cardiovascular calcification at cut-off values ≥4.6 ng/L and ≥6.95 mg/dl, respectively (P < 0.001). Serum phosphorus and creatinine were independent predictors of osteoprotegerin (P < 0.001 and 0.048, respectively). Conclusion: Osteoprotegerin is strongly associated with cardiovascular calcification and high sensitivity cardiac troponin T. In addition, there is a positive association between calcification and troponin T. This suggests a role for osteoprotegerin in the pathogenesis and risk stratification of cardiovascular calcification and myocardial injury in chronic kidney disease patients with a potential role as a therapeutic target.

Isolated thrombosis after COVID-19 vaccination: case series.

BACKGROUND: Data regarding thrombosis after COVID-19 vaccination are scarce. METHODS: Clinical and laboratory data were collected from all patients who developed thrombosis within 4 weeks of receiving the Pfizer or Oxford/AstraZeneca vaccine. None had a COVID-19-positive swab. RESULTS: Seventeen patients were included, with average age of 48.8 years and equal proportion of females to males. Our data suggest that thrombosis occurred in 1 in 163,000 of all individuals who had received any dose of any type of COVID-19 vaccine: six (1 in 123,000) patients after the first dose of Oxford/AstraZeneca, none after the second dose of Oxford/AstraZeneca, four (1 in 257,000) patients after the first dose of the Pfizer vaccine, and seven (1 in 102,000) patients after the second dose of Pfizer vaccine. Three of 17 patients with thrombosis (17.6%) died. CONCLUSIONS: We believe this report to be one of the earliest in the literature to address the question of whether isolated thrombosis is a possible complication of COVID-19 vaccination.

Acquired thrombotic thrombocytopenic purpura with possible association with AstraZeneca-Oxford COVID-19 vaccine.

Acquired thrombotic thrombocytopenic purpura is characterized by the microvascular aggregation of platelets and microangiopathic hemolytic anemia causing ischemia of multiple organs including the brain mainly and less likely the kidney and the heart. The disease is caused by severe reduction in the activity of ADAMTS 13 due to presence of inhibitory antibodies.

Gastric motility dysfunction in patients with multiple sclerosis assessed by gastric emptying scintigraphy.

BACKGROUND: Gastrointestinal tract symptoms are common in patients with multiple sclerosis (MS), especially constipation and/or fecal incontinence. AIMS: To assess gastric emptying in patients with MS to detect the severity of autonomic disturbances in the gastrointestinal tract, and to find the relationship between lower bowel disturbances and the rate of gastric emptying. METHODS: Forty-nine patients with definite MS and 20 control subjects were included in the study. All patients underwent full neurological examination and magnetic resonance imaging of the brain and spinal cord. The labelled meal for gastric emptying scintigraphy consisted of cooked eggs mixed with 3 mCi of technetium-99m colloid, and was followed by serial images at 15 min intervals for 2 h. RESULTS: Five studies were excluded due to technical artifacts. Twenty-one patients (47.7%) demonstrated slow emptying, 15 (34.1%) demonstrated normal and eight (18.2%) demonstrated fast clearance curves. The mean half-time of gastric emptying in MS patients was 96.6+/-22.4 min and the controls showed a mean half-time of 41.3+/-18.7 min (P<0.05). The half-time was longer in patients with constipation; nevertheless, it showed no significant difference compared with patients without constipation (P=0.197). Moreover, although half-time was shorter in patients with fecal incontinence, there was not a significant difference compared with those without fecal incontinence (P=0.654). CONCLUSIONS: The gastric emptying rate is slow in MS patients. As for lower bowel disturbances, the gastric emptying rate was obviously affected in patients complaining of constipation and fecal incontinence, although statistical significance was not reached.