Recipient-associated risk factors for post-liver transplantation biliary complications: A cohort study.

INTRODUCTION: Biliary complications (BCs) are a well-documented post-liver transplantation concern with potential implications for patient survival. This study aims at identifying risk factors associated with the development of BCs in recipients after liver transplantation (LT) and exploring strategies for their management. METHODS: We conducted a retrospective analysis of 1595 adult patients (age > 18 years) who underwent LT surgery between 2019 and 2021. The study assessed the incidence of BCs in this cohort. RESULTS: Of 1595 patients, 178 (11.1%) experienced BCs, while 1417 (88.8%) did not exhibit any signs of such complications. Patients who developed BCs were found to have a significantly lower average age (p < 0.001) and longer cold ischemic times (p < 0.001) compared to those without BCs. Variables such as sex, body mass index (BMI), model for end-stage liver disease (MELD) score, primary diagnosis, type of anastomosis, hepatectomy technique, type of transplanted liver and mortality did not demonstrate statistically significant differences between the two groups (p > 0.05). Univariate logistic regression analysis revealed that a cold ischemic time exceeding 12 hours and duct-to-duct anastomosis were positive predictors for BC development (odds ratios of 6.23 [CI 4.29-9.02] and 1.47 [CI 0.94-2.30], respectively). Conversely, increasing age was associated with a protective effect against BC development, with an odds ratio of 0.64 (CI 0.46-0.89). CONCLUSION: Our multi-variate analysis identified cold ischemia time (CIT) as the sole significant predictor of post-liver transplantation biliary complications. Additionally, this study observed that advancing patient age had a protective influence in this context. Notably, no significant disparities were detected between hepatectomy techniques and the etiology of liver disease types in the two study groups.

Wireless capsule endoscopy multiclass classification using three-dimensional deep convolutional neural network model.

BACKGROUND: Wireless capsule endoscopy (WCE) is a patient-friendly and non-invasive technology that scans the whole of the gastrointestinal tract, including difficult-to-access regions like the small bowel. Major drawback of this technology is that the visual inspection of a large number of video frames produced during each examination makes the physician diagnosis process tedious and prone to error. Several computer-aided diagnosis (CAD) systems, such as deep network models, have been developed for the automatic recognition of abnormalities in WCE frames. Nevertheless, most of these studies have only focused on spatial information within individual WCE frames, missing the crucial temporal data within consecutive frames. METHODS: In this article, an automatic multiclass classification system based on a three-dimensional deep convolutional neural network (3D-CNN) is proposed, which utilizes the spatiotemporal information to facilitate the WCE diagnosis process. The 3D-CNN model fed with a series of sequential WCE frames in contrast to the two-dimensional (2D) model, which exploits frames as independent ones. Moreover, the proposed 3D deep model is compared with some pre-trained networks. The proposed models are trained and evaluated with 29 subject WCE videos (14,691 frames before augmentation). The performance advantages of 3D-CNN over 2D-CNN and pre-trained networks are verified in terms of sensitivity, specificity, and accuracy. RESULTS: 3D-CNN outperforms the 2D technique in all evaluation metrics (sensitivity: 98.92 vs. 98.05, specificity: 99.50 vs. 86.94, accuracy: 99.20 vs. 92.60). In conclusion, a novel 3D-CNN model for lesion detection in WCE frames is proposed in this study. CONCLUSION: The results indicate the performance of 3D-CNN over 2D-CNN and some well-known pre-trained classifier networks. The proposed 3D-CNN model uses the rich temporal information in adjacent frames as well as spatial data to develop an accurate and efficient model.

The effects of zinc supplementation on the metabolic factors in patients with non-alcoholic fatty liver disease: a randomized, double-blinded, placebo-controlled clinical trial.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic factors including obesity, dyslipidemia, insulin resistance, oxidative stress, and elevated inflammatory factors. Zinc (Zn) supplementation has been investigated as a potential adjunctive therapy in managing NAFLD outcomes. METHODS: In this randomized, double-blinded, controlled clinical trial, 50 overweight or obese participants with NAFLD were randomized into 2 groups of 25 and received either 30 mg of daily Zn or a placebo for 8 weeks. Both groups were invited to follow a balanced energy-restricted diet and physical activity recommendations. RESULTS: Based on the between-group comparison, Zn supplementation caused a significant increase in the Zn level (P < 0.001) and a significant decrease in weight (P = 0.004), body mass index (BMI) (P = 0.002), waist circumference (P = 0.010), aspartate transaminase (AST) (P = 0.033), total cholesterol (TC) (P = 0.045), and low-density lipoprotein cholesterol (LDL-C) (P = 0.014), but it had no significant effect on alanine transaminase (ALT), fasting blood sugar (FBS), insulin, homeostasis model assessment of insulin resistance (HOMA-IR), high-density lipoprotein (HDL), triglyceride (TG), high-sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), and total antioxidant capacity (TAC) (P > 0.05). CONCLUSION: The results of the present study indicated that 8-week supplementation of 30 mg daily Zn may increase the Zn serum level and decline anthropometric parameters, AST, TC, and LDL-C in NAFLD patients, so further research is suggested in the future. TRIAL REGISTRATION: The trial was retrospectively registered at IRCT.ir as IRCT20191015045113N1 (December/8/2019).

Predictive Score for Early Successful Tracheal Extubation After Liver Transplant: A Case-Control Study.

OBJECTIVES: Prolonged tracheal intubation and mechanical ventilation after liver transplant increase postoperative complications. Hence, timely extubation should be considered; however, a standard clinical criteria set or scoring system to select patients has not been established for early extubation after livertransplant.We investigated the factors that affect early extubation to design a predictive scoring system for early extubation. MATERIALS AND METHODS: This study is a case-control study of adult liver transplant patients. Preoperative, intraoperative, and postoperative clinical data were collected. Early extubation was defined as tracheal extubation immediately or up to 6 hours posttransplant. The variables were compared between the early extubation group and the delayed extubation (>6 hours) group. RESULTS: Our study enrolled 237 patients; among them, 57 patients (24%) were in the early extubation group, and 180 (76%) were in the delayed extubation group. Multiple logistic regression analysis showed that postoperative base excess level at admission to the intensive care unit, number of units of packed red blood cells transfused during surgery, urine volume, and excess base level 6 hours after surgery were the main predictors of successful early extubation. CONCLUSIONS: The initial base excess level at the entrance to the intensive care unit(postsurgery) and 6 hours after surgery, packed red blood cell volume transfused during surgery, and urine volume 6 hours after surgery are the main predictors for a successful early tracheal extubation.These factors are considered for the Shiraz Extubation Predictor formula.

Prevalence of Colonic Polyps Detected by Colonoscopy in Symptomatic Patients and Comparison Between Different Age Groups. What Age Should be Considered for Investigation?

<b>Introduction:</b> The Burden of Colorectal cancer (CRC) as one of the most common malignancies is considerable worldwide, with 1.8 million diagnoses each year. Although it is well established that most CRCs arise from colonic polyps, guidelines and recommendations indicate different ages as starting points for endoscopic examination of the colon, either as cancer screening programs or in symptomatic patients. Most standard guidelines adapt the cut-off age of 50. However, this has been challenged by the results of recent studies. This multicentric prospective study aimed to investigate the frequency, distribution, and histopathological findings of colonic polyps in patients who underwent colonoscopy with special attention to the age group of 40-49-year-olds compared with 50-59 in the population.</br></br> <b>Material and methods:</b> This multicentric, prospective study was designed to enroll adult patients referred to three universityaffiliated endoscopy units. As many as 723 patients met all the inclusion criteria. Data analysis was performed on endoscopic and histopathological characteristics of all detected lesions, including colonic polyps and neoplastic lesions.</br></br> <b>Results:</b> A total of 723 patients with a mean age of 46.03 (16.8) years were included in this study. Rectal bleeding was the most frequent symptom (40.9%). One hundred and thirteen patients (15.6%) were found to have colonic polyps, and 11 cases (1.52%) of CRC were detected. Most polyps were located in the left colon (67.5%). There was no statistical difference in the prevalence of adenomatous polyps between the age group of 40-49 years and 50-59 years (P = 0.77). Detailed examination of data using receiver operating characteristic (ROC) curve analysis not only showed age is a risk factor for the presence of colonic polyps but also revealed the cut-off age of 42.5 for the presence of all types of colonic polyps (44.5 years for adenomatous polyps).</br></br> <b>Conclusion:</b> This study has showed a similar polyp prevalence in the age group of 40-49 years as compared to 50-59. Our study suggests that appropriate colon examination should be performed at a younger age to achieve early detection of colonic polyps, specifically in patients with red flag symptoms.

Alarm of non-communicable disease in Iran: Kavar cohort profile, baseline and 18-month follow up results from a prospective population-based study in urban area.

The PERSIAN Kavar cohort study (PKCS) aims to investigate the prevalence, trends, and relevant prognostic risk factors of non-communicable diseases in participants aged 35-70 years living in the urban area of Kavar County. Kavar County is located at the center of Fars province in the southwest of Iran. Overall, 5236 adults aged 35-70 years old were invited to participate in the PKCS. From whom, 4997 people comprising 2419 men and 2578 women met the inclusion criteria and were recruited in the study (participation rate: 95.4%). This study is aimed to follow participants for at least 10 years; it is designed to perform all procedures similar to the primary phase including biological sampling, laboratory tests, physical examinations, and collecting general, nutritional, and medical data at the 5th and 10th years of follow-up. In addition, participants are annually followed-up by phone to acquire data on the history of hospitalization, any major diagnosis or death. At the enrollment phase, trained interviewers were responsible for obtaining general, nutritional, and medical data utilizing a 482-item questionnaire. The results of the baseline phase of this study show that the overweight category was the most prevalent BMI category among the registered participants (n = 2005, 40.14%). Also, almost one-third of Kavar adult population suffered from metabolic syndrome at the baseline phase (n = 1664, 33.30%). The rate of eighteen-month follow-up response was 100% in the PKCS. Hypertension (n = 116, 2.32%), cardiovascular outcomes (n = 33, 0.66%), and diabetes (n = 32, 0.64%) were the most prevalent new-onset NCDs during eighteen months of follow-up in the participants.

Impact of Multimedia CD Education on the Quality of Colon Preparation; A Single-Blind Randomized Study.

Background: Routine bowel preparation instructions are usually given to patients in the form of oral explanations with written instructions. The purpose of this study was to evaluate the effectiveness of multimedia training in the form of video CDs on the quality of colon preparation and other related indicators. Methods: 201 outpatients in three referral academic colonoscopy centers were randomly assigned to two groups. The first group (n=100) received supplementary video CD education besides the routine instructions (VCD group). The second group (n=101) received only routine instruction, which included oral and printed instructions (non-VCD group). Results: Complete use of colon cleansing medication was statistically and significantly better in the VCD group (P=0.038). Duration of colonoscopy was shorter in the VCD group (P=0.001), demand for conscious sedation was lesser in the VCD group (P=0.049), and the quality of colon preparation was better in the VCD group (P<0.00). There was no statistically significant difference in pain sensation (P=0.1), cecal intubation rate (P=0.3), and technical difficulty of the colonoscopy (P=0.1) in both groups. Conclusion: Supplementary education in the form of multimedia CD increases the patients' compliance to cleansing mediation consumption, improves the quality of bowel preparation, and decreases the duration of colonoscopy with lesser demands for conscious sedation.

Cholangiocarcinoma and liver transplantation: What we know so far?

Cholangiocarcinoma (CCA) is a type of cancer with increasing prevalence around the world that originates from cholangiocytes, the epithelial cells of the bile duct. The tumor begins insidiously and is distinguished by high grade neoplasm, poor outcome, and high risk for recurrence. Liver transplantation has become broadly accepted as a treatment option for CCA. Liver transplantation is expected to play a crucial role as palliative and curative therapy for unresectable hilar CCA and intrahepatic CCA. The purpose of this study was to determine which cases with CCA should be subjected to liver transplantation instead of resection, although reported post-transplant recurrence rate averages approximately 20%. This review also aims to highlight the molecular current frontiers of CCA and directions of liver transplantation for CCA.

COVID-19 infection and liver injury: Clinical features, biomarkers, potential mechanisms, treatment, and management challenges.

It is hypothesized that liver impairment caused by coronavirus disease 2019 (COVID-19) infection might play a central role in severe clinical presentations. Liver injury is closely associated with severe disease and, even with antiviral drugs, have a poor prognosis in COVID-19 patients. In addition to the common hepatobiliary disorders caused by COVID-19, patients with pre-existing liver diseases demand special considerations during the current pandemic. Thus, it is vital that upon clinical presentation, patients with concurrent pre-existing liver disease associated with metabolic dysfunction and COVID-19 be managed properly to prevent liver failure. Careful monitoring and early detection of liver damage through biomarkers after hospitalization for COVID-19 is underscored in all cases, particularly in those with pre-existing metabolic liver injury. The purpose of this study was to determine most recent evidence regarding causality, potential risk factors, and challenges, therapeutic options, and management of COVID-19 infection in vulnerable patients with pre-existing liver injury. This review aims to highlight the current frontier of COVID-19 infection and liver injury and the direction of liver injury in these patients.

Tenofovir in the treatment of hepatitis B virus infection after liver transplantation, a single center large population study.

AIM: This study investigated the safety and efficacy of tenofovir disoproxil fumarate (TDF) compared with lamivudine (LAM) in the prevention of recurrent HBV infection after liver transplantation (LT). BACKGROUND: Although the recurrence of hepatitis B virus after liver transplantation (LT) is now very uncommon with both nucleoside and nucleotide analogs represented with lamivudine and tenofovir disoproxil fumarate, respectively, few studies have compared the two classes. METHODS: A total of 302 HBV-related post-transplant patients who received liver transplants from deceased donors were enrolled in this retrospective study from 2011 to 2015 in the Shiraz Organ Transplant Center, Iran. The demographic data, kidney function, recurrence, resistance rate, and acute rejections at 1-, 6-, and 12-month intervals and after 12 months were compared on TDF (n=209) and lamivudine (n=93) groups. RESULTS: During a median follow-up period of 42.9 months, mean creatinine level was not significantly different between the two groups. Hepatitis B virus recurrence rate as well as acute graft rejection episode had no statistical difference in either group over the study period. CONCLUSION: Kidney function, creatinine level, disease recurrence, and acute graft rejection were comparable between tenofovir disoproxil fumarate and lamivudine in patients who received follow-up periods.

Endoscopic mucosal resection: still a reliable therapeutic option for gastrointestinal neuroendocrine tumors.

BACKGROUND: Neuroendocrine tumors (NETs), as a rare and heterogeneous category of solid tumors, feature various morphologies and behaviors. In recent years, the incidence of NETs has continued to increase. Endoscopic mucosal resection (EMR) is one of the therapeutic modalities for the treatment of gastric and rectal NETs. METHODS: We evaluated patients with well-differentiated NETs of the stomach, duodenum, or rectum between 2011 and 2018. In this study, all cases with tumors confined to the mucosal or submucosal layers and smaller than 20 mm were resected using the EMR technique. We used EUS, CT scan, or MRI to exclude patients with advanced disease. All patients were actively monitored for recurrence according to the recommended protocols. RESULTS: A total of 36 patients with NETs entered the study; 17 (47.2%) were female and the remaining 19 (52.8%) were male, with a total age range of 20-74 years (mean: 52.47 ± 13.47 years). Among the tumors, 31 cases (86.1%) were G1 and the remaining 5 (13.9%) were G2. Based on the pathology reports, 22 tumors (61.1%) were smaller than 1 cm, while the remaining 14 (38.9%) were between 1-2 cm. Twenty-two patients (61.1%) had a margin of specimen involved with the tumor. No recurrence was observed during the mean follow-up time of 63.5 ± 19.8 months (range: 39-103 months). All 36 cases survived during the study period. CONCLUSION: Conventional EMR procedure provides low chance of R0 (complete resection) achievement in gastrointestinal NETs smaller than 20 mm and limited to the mucosa or sub mucosa. However, it could be an option if patients are closely followed. Postoperative marginal involvement is not a reliable predictor of disease recurrence, which may be explained by the deleterious effect of heat coagulation and cauterization applied during tumor removal.

Clinical Outcome of Vancomycin-Resistant Enterococcus Colonization Among Liver Transplant Recipients at Shiraz Organ Transplant Center.

OBJECTIVES: Liver transplant recipients are more susceptible to vancomycin-resistant enterococci colonization than healthy individuals. We investigated the prevalence of vancomycin-resistant enterococci colonization and its effect on the outcomes of liver transplant recipients. MATERIALS AND METHODS: Patients who had undergone primary liver transplant at the Shiraz Organ Transplant Center from 2015 to 2017 were enrolled in this study. Demographic characteristics, laboratory test results, duration of stay in the intensive care unit, total duration of hospital stay, and clinical outcome data were extracted from the Shiraz Organ Transplant Center database. Posttransplant outcomes such as graft rejection, mortality, hospital stay, and kidney function tests were included for the first 90 days after transplant. RESULTS: A total of 753 liver transplant recipients (470 males and 283 females) were included in this study. Vancomycin-resistant enterococci colonization was identified in 51 patients (6.8%) after transplant at the time of intensive care unit admission. Our study found no significant difference between outcomes for patients with vancomycin-resistant enterococci colonization and outcomes for patients without colonization, including graft rejection, mortality, hospital stay, and kidney function tests. CONCLUSIONS: Our study revealed that asymptomatic vancomycin-resistant enterococci colonization in liver transplant patients has no adverse effect on the duration of posttransplant hospital stay, early mortality rate, graft rejection rate, or kidney function compared with noncolonized patients.

Post liver transplant complications of Budd-Chiari syndrome.

BACKGROUND/PURPOSE: Budd-Chiari syndrome (BCS) is a rare, life-threatening disease characterized by hepatic venous outflow obstruction. Liver transplantation (LT) is widely accepted as an effective therapeutic measure for irreversible liver failure due to BCS. There is debate on differences in the post LT course and complications in patients with BCS as compared to non-Budd-Chiari (NBC) patients. METHOD: In this retrospective study, data on all patients who received a liver transplant for BCS at the Shiraz Organ Transplantation Center between January 1996 and September 2017 were reviewed and compared to data of a control group who had received liver transplants over the same period but due to other causes (NBC). RESULTS: Out of 4225 patients who received liver transplants in the study period, 108 had BCS and an age- and gender-matched control group consisted of 108 NBC cases. The mean ± standard deviation (SD) of model for end-stage liver disease (MELD) scores were 19.1 ± 3 and 20 ± 3 for BCS and NBC groups, respectively (p = 0.33). One-, 3-, 5-, and 10-year survival rates in the BCS group were as follows: 82%, 78%, 76%, and 76% compared with the NBC rates of 83%, 83%, 83%, and 76%, respectively (p = 0.556). There was no difference between the two groups in complication rates after 6 months. In the later period, vascular thrombosis was more common in BCS. CONCLUSIONS: Whole-organ LT from deceased donors in patients with BCS had comparable outcomes with LT due to other causes of end-stage liver disease. In most instances, these patients should receive lifelong anticoagulation.

Hepatitis E Virus Seroprevalence Among Liver Transplant Recipients with Persistent Elevation of Liver Enzymes: A Single Center Report.

BACKGROUND: Chronic hepatitis E infection has been reported in solid organ transplant recipients following acute hepatitis due to the compromised immune status. Almost all reports are from areas where hepatitis E virus (HEV) genotypes 3 and 4 are the dominant genotypes. This study was conducted to investigate the role of hepatitis E infection as an etiology for liver enzymes elevation in liver transplant recipients from the largest liver transplant program in Iran. METHODS: In a prospective study from June to December 2015, in a single liver transplantation center in Iran, all adult liver recipients who were investigated for the etiology of persistent elevation of liver enzymes were tested for HEV serology status. RESULTS: Of 122 patients included in the study, 19 (15.6%) were positive for HEV serology. Seropositive patients were significantly older than seronegative ones (mean age 43.79 vs. 31.58, P < 0.001); however, they were not different in other characteristics including sex distribution and mean of liver enzymes in each occasion. Liver biopsies were done in 16 HEV seropositive patients and none of the biopsies showed evidence for acute or chronic viral hepatitis. CONCLUSION: In this study, with 15.6% rate of HEV seropositivity in liver recipients with persistent elevation of liver enzymes, we were not able to confirm any clinical evidence for active acute or chronic hepatitis E infection. This could theoretically be attributed to the fact that the dominant prevalent HEV genotype in our endemic area is not associated with a chronic form of infection.

Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review.

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

Comparison of the efficacy of oral fenugreek seeds hydroalcoholic extract versus placebo in nonalcoholic fatty liver disease; a randomized, triple-blind controlled pilot clinical trial.

OBJECTIVES: The aim of this study is to investigate the therapeutic property of hydroalcoholic extract of Fenugreek seeds in nonalcoholic fatty liver disease (NAFLD) in adult patients. METHODS: This randomized, placebo-controlled, parallel trial was conducted from November 2014 to June 2017. Patients aged between 18 and 70 years old with confirmed NAFLD were recruited from the Motahhari clinic, affiliated to Shiraz University of Medical Sciences, Iran. Participants either received 1 g hydroalcoholic extract of Fenugreek seeds or placebo daily for 3 months. The primary outcomes were changes in serum alanine transaminase and FibroScan controlled attenuation parameter score. Secondary outcome measures were changes in other laboratory data, liver stiffness measure, liver steatosis percent, and anthropometric variables. Participants were randomly assigned to the groups using blocked randomization method. Participants, investigators, and statistician were blinded to treatments allocation. RESULTS: After screening eighty patients, thirty patients met the inclusion criteria and were divided into two groups (1:1). After 3 months, two and four patients did not complete the trial in Fenugreek and placebo group, respectively. The changes in the anthropometrics, laboratories and FibroScan measurements were not statistically significant between the two groups. CONCLUSION: The evidence to prove the efficacy of the Fenugreek seeds' hydroalcoholic extract in NAFLD was not strong enough; hence, further experiments are still needed to assess the possible efficacy of Fenugreek on the treatment of NAFLD.

Association Between Non-Alcoholic Fatty Liver Disease and Metabolic Syndrome with Gallstone Disease, South Iran: A Population-Based Study.

AIM: Gallstone disease (GSD), non-alcoholic fatty liver disease (NAFLD), and metabolic syndrome (MetS) are common problems. The aim of this study was to investigate the association between NAFLD, MetS and its components with GSD. MATERIALS AND METHODS: This cross-sectional study was conducted as a part of the Kavar Cohort Study (KCS) affiliated to Shiraz University of Medical Sciences, Shiraz, Iran between January 2012 and January 2018. A total of 2239 participants of the general population of the KCS were selected randomly. Ultrasonography for GSD and NAFLD diagnosis and clinical and laboratory assaying for MetS evaluation were performed for the participants. The National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP-III) and Criteria for Clinical Diagnosis of MetS in Iranian Adults (CCDMIA) were used for diagnosis of MetS. RESULTS: Overall, 59 patients with GSD and 177 age- and sex- matched participants without gallstones as a comparison group were enrolled. According to GSD groups, NAFLD was observed in 42.4% and 22.6% of patients with and without GSD, respectively, and the difference between the two groups was statistically significant (P = 0.003). MetS was present in 33.9% and 39.0% of GSD subjects, compared with 32.8% and 33.3% of the non-GSD group, based on NCEP/ATPIII and CCDMIA, respectively. Although the mean of all components of MetS except HDL-cholesterol were higher in the GSD group than in the non-GSD group,  the difference was only significant in waist circumference (P = 0.041). CONCLUSION: The present study found an obvious association between NAFLD and GSD. This study also showed a significant association between increasing waist circumference and risk of GSD. We recommend that patients with GSD should be evaluated for the likelihood of NAFLD and its treatment in addition to lifestyle changes to gain proper weight. However, further researches are needed to clarify the relationship between the nature of GSD, NAFLD, and obesity.

Association Between Metabolic Syndrome and Its Components with Severity of Acute Pancreatitis.

BACKGROUND: Acute pancreatitis (AP) and metabolic syndrome (MetS) are common clinical problems with serious complications and high cost of treatment. The relationship between MetS and severity of AP is unknown, and because there are very few published articles, further studies had been recommended. Therefore, we designed this study to estimate the association between MetS and its components with AP severity. PATIENTS AND METHODS: In this prospective analytical cross-sectional study, all AP patients who referred to two referral hospitals affiliated with Shiraz University of Medical Sciences between 2016 and 2019 were evaluated. The diagnosis of MetS syndrome as well as follow-up of patients for evaluation of severity and outcome of AP was performed in all enrolled patients. National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP-III) was used for diagnosis of MetS. Bedside Index for Severity in Acute Pancreatitis (BISAP) and revised Atlanta classification (RAC) were used to estimate the severity of AP. Finally, the association between MetS syndrome and its components at different AP severities was compared. RESULTS: Of the 214 patients referred to our center, a total of 76 patients with AP were included in this study. Of the included patients, 40 (52.6%) were male and 36 (47.4%) were female. Frequency of patients in Mets and non-MetS groups was 34 (44.74%) and 42 (55.26%), respectively. The gender and mean age difference between Mets and non-MetS groups were not statistically significant. According to Mets groups, 25 (73.5%) and 9 (26.5%) AP patients with MetS had BISAP score of 0-2 and 3-5, respectively. BISAP score in MetS group was significantly higher than non-MetS group (P = 0.022). Overall, 20 (58.8%), 11 (32.4%), and 3 (8.8%) of AP patients with MetS had mild, moderately severe, and severe AP based on RAC, respectively. Severe RAC was significantly higher in the MetS group than in the non-MetS group (P = 0.029). The frequency of complications in MetS group was significantly higher than in non-MetS group (P= 0.008). The length of hospital stay was also significantly higher in the MetS group than in the non-MetS group (P = 0.001). Overall, three patients died, two of whom had MetS and all had severe RAC and BISAP 3-5. Waist circumference, fasting blood sugar, and triglyceride were significantly higher in the severe and moderately severe types of AP group than in the mild AP group, according to RAC. Although, mean of all components of MetS except HDL-cholesterol were higher in BISAP of 3-5 group than BISAP of 0-2 group, the difference was only significant in waist circumference. CONCLUSION: The present study showed that there was a significant association between the rate of MetS and its components including waist circumference, hyperglycemia and hypertriglyceridemia with increasing AP severity. This study showed that the incidence of more severe AP in patients with MetS is much higher than in patients without MetS. We recommend that the new studies with larger sample sizes are conducted with careful consideration of confounding factors to investigate the relationship between the severity of MetS and AP as well as the effect of MetS treatment on the nature of AP.

A preliminary report on the use of Midodrine in treating refractory gastroesophageal disease: Randomized Double-Blind Controlled Trial.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disease with various clinical presentations. Acid suppression with proton pump inhibitors and lifestyle modification may not lead to satisfactory response in a substantial portion of patients. We investigated the possible effect of midodrine in patients with refractory GERD. METHODS: Patients suffering from GERD and were refractory to one-month course of pantoprazole 40mg twice daily entered the study. This was a pilot, randomized, double-blind, and placebo-controlled study. After randomization, one group received Midodrine 5mg before meals for one month, and the other group received placebo for the same period. Meanwhile, pantoprazole was continued 40mg twice daily in both arms. The severity of symptoms was evaluated by the visual scoring system. Quality of life (QoL) in both groups was measured using a standardized version of Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). RESULTS: A total of twenty patients were enrolled in this study. There was a significant interaction between the groups and time on all measured scores based on QOLRAD questionnaire. All the markers in the Midodrine group had significant improvement over time, but the placebo group did not show any significant improvement. Both visual severity score and total QoL score in Midodrine arm showed a U shape change during  6 weeks. CONCLUSIONS: Midodrine before a meal could be useful in alleviating symptoms and improving QoL in the patients with refractory gastroesophageal disease.

Correlation between Serum Ferritin Level and Histopathological Disease Severity in Non-alcoholic Fatty Liver Disease.

BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease worldwide. Recently several parameters, such as serum ferritin, have emerged as possible predictors for the severity of NAFLD and insulin sensitivity. We aimed to investigate the value of serum ferritin level as a useful biomarker for the prediction of histopathological disease severity in non-alcoholic steatohepatitis (NASH), the necro-inflammatory form of NAFLD. METHODS This was a prospective cross sectional study in which demographic, clinical, histological, laboratory, and anthropometric data of 30 adult patients with biopsy-proven NAFLD/NASH were analyzed. RESULTS In our patients population with mean age of 37.9 years and mean BMI of 26.5, statistical analysis did not show a significant difference between the three grades of steatosis in the mean ferritin levels (p = 0.559). It was also observed that ferritin level did not have a significant correlation with the stage of fibrosis (p = 0.228). The mean transferrin saturation did not show significant difference in different stages and grades of NASH (p = 0.260 and 0.944, respectively), either. CONCLUSION Serum ferritin level may not be useful as a single marker for the prediction of histopathological severity of disease in young patients with NASH who are not morbidly obese.