Comparative effect of deliberate hypotensive anesthesia using nitroglycerine vs. phentolamine on event related potentials and cognitive functions in patients undergoing septoplasty: a randomized controlled trial.

BACKGROUND: Postoperative cognitive dysfunction is a noteworthy complication of deliberate hypotensive anesthesia. The aim of this work was to compare the effect of deliberate hypotensive anesthesia using nitroglycerine versus phentolamine on event-related potentials and cognitive function in patients undergoing septoplasty surgery. METHODS: This prospective randomized controlled trial was conducted on 80 patients indicated for septoplasty under general anesthesia; 40 patients received intra-operative Nitroglycerine and 40 patients received intra-operative Phentolamine. Cognitive assessment (using Paired Associate Learning test (PALT) and Benton Visual Retention test (BVRT)) and P300 recording were done for all included patients pre-operatively and one week postoperatively. RESULTS: The scores of PALT and Benton BVRT significantly declined one week following surgery in both Nitroglycerine and Phentolamine groups. There was no statistically significant difference between Nitroglycerine and Phentolamine groups in the postoperative decline in either PALT or BVRT (P-value = 0.342, 0.662 respectively). The values of P300 latency showed a significant delay one week following surgery in both Nitroglycerine and Phentolamine groups (P-value ≤ 0.001, 0.001), but in Nitroglycerine group, the delay is significantly higher than in Phentolamine group (P-value = 0.003). The values of P300 amplitude significantly decreased one week following surgery in both Nitroglycerine and Phentolamine groups (P-value ≤ 0.001, 0.001), but there was no statistically significant difference between Nitroglycerine and Phentolamine groups (P-value = 0.099). CONCLUSION: Phentolamine is preferred over nitroglycerin in deliberate hypotensive anesthesia because it has less harmful effect on cognitive function than nitroglycerin.

Violence against healthcare workers during coronavirus (COVID-19) pandemic in Egypt: a cross-sectional study.

Background: Healthcare workers are on the front lines of COVID-19 and are subject to risks. A rise in the cases of violence and aggressiveness against HCWs has been observed worldwide, adding to the already existing burnout. The purpose of this research is to determine the prevalence of workplace violence, its risk variables, and the pattern of violence directed towards healthcare workers in the context of COVID-19 pandemic. The research used a cross-sectional analytic design. Purposive sampling was utilized to identify research participants using an online survey. Form's link was distributed to accessible social media groups such as Facebook and WhatsApp from July 2020 to the end of October 2020. A self-administered structured survey was adapted from the World Health Organization survey questionnaire about violence in healthcare settings. The Google Form's link was distributed to the social media groups until the total sample of 405 was collected. Results: During the COVID-19 pandemic, workplace violence against Egyptian healthcare workers was prevalent (63.2%). The most prevailing type of violence among the exposed participants was verbal violence (87.9%). Violence is more common in the (< 40 years old) age group (80.9% of exposed healthcare workers). Violence was more statistically significant against females (60.5% of the exposed healthcare workers) (p-value = 0.023). Regarding the work specialty, violence was more committed against physicians (84.3% of exposed healthcare workers) than nurses (12.8% of exposed healthcare workers). The primary perpetrators of violence were the patient's family (74.6%). The majority of the exposed HCWs (96%) reported no physical injury from the violent event, and 71.5% deemed the violent incident preventable. The majority (90.6%) of HCWs exposed to violent incidents declared non-reporting. Conclusions: Effective risk communication at all levels of society is critical for reducing fear, stigma, and ultimately workplace violence, as recent assaults on healthcare institutions demonstrate. To reduce violence and safeguard the safety of the medical profession, the government, health policymakers, media organizations, and community engagement groups must collaborate for healthcare workers' safety.

The effects of COVID-19 pandemic and its related lockdown on female sexual function and reproductive health: An observational study in Egypt.

This retrospective observational online study was carried out to evaluate the effect of the COVID-19 pandemic and its related lockdown on female sexual functions and reproductive health. It included 409 sexually active females. The sexual function was assessed using the Female Sexual Function Index (FSFI). The reproductive life was assessed by a structured self-administered questionnaire modified from Egypt Demographic and Health Survey. The study revealed a significant decrease in the overall FSFI score during the pandemic lockdown compared to the pre-pandemic score (19.3 ± 6 vs. 21.3 ± 6.4, P<0.001). Below half (41.6 %) of women were using contraception methods during the pandemic, while 27.9% had stopped taking contraception during the pandemic, 30.6% (57/186) of the pregnant women only tended to get pregnant. So, the COVID-19 pandemic and its related lockdown were associated with an elevated risk for female sexual dysfunction and altered women's reproductive health quality. Heath system should therefore develop new methods to provide basic reproductive health service, family planning services, and to ameliorate the female sexual function during COVID-19 pandemic including consults with physicians, counsellors, and psychologists, as well as health education programs, either in person or virtually via telemedicine.

Newly Diagnosed Diabetes in Patients with COVID-19: Different Types and Short-Term Outcomes.

A great global concern is currently focused on the coronavirus disease 2019 (COVID-19) pandemic and its associated morbidities. The goal of this study was to determine the frequency of newly diagnosed diabetes mellitus (DM) and its different types among COVID-19 patients, and to check the glycemic control in diabetic cases for three months. After excluding known cases of DM, 570 patients with confirmed COVID-19 were studied. All participants were classified as non-diabetic or newly discovered diabetic. According to hemoglobin A1c (HbA1c) and fasting insulin, newly discovered diabetic patients were further classified into pre-existing DM, new-onset type 1 DM, and new-onset type 2 DM. Glycemic control was monitored for three months in newly diagnosed diabetic patients. DM was diagnosed in 77 patients (13.5%); 12 (2.1%) with pre-existing DM, 7 (1.2%) with new-onset type 1 DM, and 58 (10.2%) with new-onset type 2 DM. Significantly higher rates of severe infection and mortality (p < 0.001 and p = 0.046) were evident among diabetic patients. Among survived diabetic patients (n = 63), hyperglycemia and the need for anti-diabetic treatment persisted in 73% of them for three months. COVID-19 was associated with a new-onset of DM in 11.4% of all participants and expression of pre-existing DM in 2.1% of all participants, both being associated with severe infection. COVID-19 patients with newly diagnosed diabetes had high risk of mortality. New-onset DM persisted for at least three months in more than two-thirds of cases.

Ramadan fasting and liver diseases: A review with practice advices and recommendations.

Ramadan fasting is obligatory for Muslim healthy adults. However, there are many exemptions from fasting; including patients, whose diseases will be aggravated by fasting. Muslim patients with different liver diseases are frequently seen in the clinics discussing their intent to fast this month with their treating physicians. To answer our patients' inquiries about the expected benefits and/or risks of fasting and delivering them the best care, we carried out this review and we draw advices and recommendations based on the available evidence. A web-based search, combining multiple keywords representing different liver diseases with Ramadan fasting had been carried out. To answer the research question: Do adult Muslim patients with different liver diseases who fast the month of Ramadan have had a deleterious effect on their health in comparison to those who did not fast? Relevant publications were retrieved. No randomized controlled trials were focusing on Ramadan fasting and liver diseases in the filtered databases, eg Cochrane library. Consequently, non-filtered databases, eg PubMed, Google Scholar and Egyptian Knowledge Bank searched and full-text high-quality research articles were carefully analysed to draw recommendations. Other relevant publications with low quality of evidence like case studies and short communications were also reviewed to address practice advices. Although Ramadan fasting was found beneficial for patients with NAFLD, it was found deleterious to patients with Child B and C cirrhosis and patients with peptic ulcer. Patients with chronic hepatitis, Child A cirrhosis and those with non-complicated liver transplant can fast with prefasting assessment and strict follow up.

Morbidity and mortality during hepatitis C treatment using sofosbuvir and daclatasvir with or without ribavirin, in a cohort of Egyptian patients.

BACKGROUND: Though direct-acting antiviral agents (DAAs) therapy is associated with a high cure rate of hepatitis C virus infection, a potential risk of serious adverse events (SAEs) exists. The aim of this study was to determine the incidence and predictors of morbidity and mortality related to DAAs therapy. METHODS: This prospective study was conducted on a real word cohort of 1562 treatment naïve chronic hepatitis C (CHC) Egyptian patients, who received 12-weeks therapy with sofosbuvir (SOF) plus daclatasvir (DCV) ± ribavirin (RBV). The incidence and predictors of SAEs and mortality during treatment course and over the following 12 weeks were recorded. RESULTS: The mean age of study participants was 51.38 ± 9.70 years (55.22%, males). Liver cirrhosis was defined in 72.4% of participants. SAEs were recorded in 120 participants (7.68%), including hepatic decompensation, gastrointestinal bleeding, anemia and hepatocellular carcinoma. Nine patients (0.58%) died and 69 patients (4.42%) discontinued therapy due to SAEs. Severity of cirrhosis was the significant predictor of morbidities and mortality. Hepatic decompensation was predicted by baseline serum albumin [cutoff value: 3.00 g/dL, area under the receiver operating characteristic curve (AUROC): 0.953] and serum bilirubin (cutoff value: 1.75 mg/dL, AUROC: 0.940). CONCLUSION: The risk of morbidity and mortality related to SOF/DCV ± RBV therapy in CHC patients is small and is significantly linked to advanced cirrhosis.

Randomized controlled trial of polyethylene glycol versus lactulose for the treatment of overt hepatic encephalopathy.

BACKGROUND: Overt hepatic encephalopathy (HE) is a frequent complication of cirrhosis and one of the most debilitating manifestations that necessitates hospitalization. Although many treatment modalities are being investigated, none of them are satisfactory. So, newer treatment modalities have to be tried. OBJECTIVE: To evaluate the safety and efficacy of polyethylene glycol (PEG) versus lactulose in the management of HE. PATIENTS AND METHODS: This clinical trial included 100 patients with post-hepatitis C cirrhosis who were admitted with HE. Patients were randomized into two equal groups: group I patients received lactulose and group II patients received PEG. The clinico-epidemiological characteristics of patients, Child-Pugh score, and HE scoring algorithm were registered before and 24 h after administration of the drug. Moreover, any suspected adverse effects were recorded. RESULTS: All 100 patients received treatment. Three patients died within 24 h of admission and did not complete the follow-up period. According to intention-to-treat approach, they were considered as treatment failure. On analysis, 36/50 (72%) patients improved one grade or more in HE scoring algorithm score after 24 h of lactulose therapy versus 47/50 (94%) of those on PEG therapy (P<0.05). The time needed for resolution of HE and length of hospital stay were significantly lower in PEG group versus lactulose group (P<0.001). Both therapies were tolerated, and no significant adverse events were reported. CONCLUSION: Both lactulose and PEG were safe and effective in the treatment of HE. PEG significantly decreased the time needed for resolution of HE and significantly shortened the hospital stay.

Higher Grades and Repeated Recurrence of Hepatic Encephalopathy May Be Related to High Serum Manganese Levels.

Hepatic encephalopathy is a serious complication of liver failure. Until now, the precise pathophysiologic mechanisms are not fully determined. It has been demonstrated that manganese plays an important role in the pathogenesis of hepatic encephalopathy. Therefore, we studied manganese levels in serum of cirrhotic patients with hepatic encephalopathy in relation to grading and recurrence of hepatic encephalopathy. One hundred persons were enrolled in the study, 80 cirrhotic patients with or without encephalopathy and 20 healthy controls. Hepatic encephalopathy was diagnosed clinically and by laboratory findings. Serum manganese levels were measured in all participants. The grading of hepatic encephalopathy was significantly correlated to the severity of liver dysfunction. The mean serum manganese level was significantly higher in cirrhotic patients than in controls and in cirrhotic patients with encephalopathy than in those without encephalopathy. It was also significantly higher in patients with advanced grading of hepatic encephalopathy. Serum manganese level was positively correlated to number of recurrences of encephalopathy during a 6-month follow-up period. Serum manganese levels were able to predict recurrence of hepatic encephalopathy within 6 months following the episode. Serum manganese levels are positively correlated to the modified Child-Pugh score of cirrhosis as well as grading and number of recurrences of hepatic encephalopathy. Higher manganese levels seem to be related to worsening of the condition, and its measurement may be used as a predictor of repeated recurrences.

Can Lactobacillus acidophilus improve minimal hepatic encephalopathy? A neurometabolite study using magnetic resonance spectroscopy.

BACKGROUND AND STUDY AIMS: Minimal hepatic encephalopathy (MHE) is diagnosed when hepatic patients perform worse on psychometric tests compared to healthy controls. This study aimed to evaluate probiotics as alternative therapy in MHE. PATIENTS AND METHODS: This is an open-label randomised controlled trial, performed in the Department of Tropical Medicine and Infectious Diseases, Tanta University Hospitals, from March 2010 to January 2012. A total of 90 patients with MHE were allocated by simple randomisation to three parallel equal groups. Group A received lactulose, group B a probiotic (Lactobacillus acidophilus) and group C served as the control. After informed consent, patients were tested for gut micrecology, fasting blood ammonia, liver functions and magnetic resonance spectroscopy (MRS) examination to study brain metabolites, mainly choline (Cho), myo-inositol (mI), glutamine+glutamate (Glx) and creatinin (Cre). Patients who developed overt encephalopathy were excluded from analysis. The whole battery of investigations was repeated in the same order after 4weeks. RESULTS: The probiotic was better tolerated than lactulose. The relative risk reduction (RRR) of developing overt encephalopathy was 60% in the case of lactulose and 80% in the case of probiotic, with a number needed to treat (NNT) of 2.4 and 2.3, respectively. The differential but not total microecology count was significantly shifted towards saccharolytic rather than proteolytic bacteria. The mI/Cre and (Cho+mI)/Glx ratios were significantly increased and the Glx/Cre ratio was significantly reduced after 1month-follow-up in the probiotic group compared to the lactulose group and in both treatment groups compared to the control group. CONCLUSION: Both probiotic and lactulose therapy can improve blood ammonia and psychometric tests in MHE and reduce the risk of developing overt encephalopathy. MRS showed more improvement in the levels of brain neurometabolites in the probiotic group.

Prevalence of hepatitis C infection among children with ß-thalassaemia major in Mid Delta, Egypt: a single centre study.

BACKGROUND: Transfusion dependant patients are at a higher risk of acquiring bloodborne infections even under conditions of safe transfusion. This study was designed to determine sero-prevalence of hepatitis C infection and possible associated risk factors in thalassaemic children. METHODS: One hundred and twenty five children with ß thalassaemia major (ß-TM) were recruited from the Haematology/Oncology Unit, Paediatric Department, Tanta University Hospital, Egypt, between April 2010 and October 2011. Patients underwent history taking, full clinical examination, routine investigations and venous blood sampling. Serum was stored at -20°C till tested for hepatitis C (HCV Ab) and B (HBsAg) by ELISA. HCV Ab positive cases were confirmed by PCR. RESULTS: All patients were HBsAg negative. HCV Ab ELISA was positive in 76%, negative in 20% and equivocal in 4%. Fifty patients (40%) had positive PCR for HCV. PCR showed low viraemia in 78%, moderate viraemia in 20% and high viraemia in 2%. A positive family history of HCV, history of minor operative intervention and/or dental procedures were significantly associated with higher frequency of HCV infection in thalassaemic children, while amount and frequency of transfused blood, age at transfusion and chelation state were not. CONCLUSION: HCV infection is highly prevalent in children with ß-TM in Egypt despite strict pre-transfusion blood testing. This should arouse the attention for environmental and community acquired factors. Quality management to insure infection control in minor operative procedures and adding more sensitive tests for blood screening are recommended.

The role of chemokine CC ligand 20 in patients with liver cirrhosis and hepatocellular carcinoma.

BACKGROUND AND AIM: To evaluate the role of chemokine CC ligand 20 (CCL20) as a biomarker for hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Ninety patients in four groups were enrolled in this prospective cross-sectional study: 30 with HCC (group I), 30 with liver cirrhosis (group II), 15 with hepatitis C virus infection (group III), and 15 healthy blood donors as controls. Alpha fetoprotein (AFP), CCL20 and vascular endothelial growth factor (VEGF) were measured in all groups. RESULTS: Serum levels of CCL20 were significantly different among the study groups (F=230.979, p<0.001). The highest level was found in HCC patients (57.305 ± 6.386 pg/mL) followed by patients with cirrhosis (45.999 ± 5.165 pg/mL) compared with 22.781 ± 5.986 pg/mL and 18.585 ± 3.554 pg/mL in asymptomatic patients with HCV infection and controls, respectively. In HCC patients, CCL20 significantly correlated with VEGF (r=0.559, p=0.001), AFP (r=0.814, p<0.001), Child score (r=0.748, p<0.001), and tumor size (r=0.825, p<0.001). The cutoff value of CCL20 for the detection of HCC in HCV-infected patients was 54 pg/mL with 93.1% accuracy, 89.6% negative predictive value, 92.6% positive predictive value, 83.3% sensitivity, and 93.3% specificity. In patients with cirrhosis, CCL20 significantly correlated with VEGF (r=0.455, p=0.011), AFP (r=0.975, p<0.001), and Child score (r=0.977, p<0.001). CONCLUSION: CCL20 may be used for the detection of HCC in HCV-infected patients with comparable specificity and higher sensitivity than AFP.

The impact of H. pyiori eradication on response to oral iron therapy in patients with iron deficiency anemia.

Infection with Helicobacter pylori has been associated with Iron deficiency anemia (IDA). We assessed the effect of eradication of H. pylori infection on response to oral iron treatment. Twenty patients with IDA of no obvious cause, unresponsive to oral iron therapy with positive gastric biopsy for H. pyJoril infection received sequential eradication therapy for 10 days followed by oral iron therapy. Treated patients were followed up at 6 weeks and 12 weeks post eradication to assess dynamic changes in hemoglobin, serum ferritin and transferrin saturation. While 65% of anemic H. pylori infected cases had pangpstritis, 35% had antral gastritis. In the antrum severe and moderate gastritis were found in 40% and 45% of cases, respectively. Hemoglobin and serum ferritin level correlated inversely with grade of gastritis (P <0.001). Improvement in hematological parameters and serum iron profile was observed 6 weeks and 12 weeks post successful H. eradication oral iron therapy. In conclusion, eradication of H. pylori infection enhances the response to oral iron supplementation in patients with refractory IDA. Screening and eradication of H. pylori should be a standard procedure for patients with IDA.

Expression of the signal transducer and activator of transcription factor 3 and Janus kinase 3 in colorectal carcinomas, colonic adenomas and ulcerative colitis.

BACKGROUND AND STUDY AIMS: Despite the growing understanding of the involvement of protooncogenes and tumour suppressor genes in the oncogenesis of CRC, the exact biological and molecular mechanisms underpinning this process remain poorly understood. The signal transducer and activator of transcription (STAT3) has been implicated in the regulation of growth and malignant transformation. Accumulating evidences have come to indicate that abnormalities in the Janus kinase (JAK)/STAT pathway are involved in oncogenesis of several cancers. The aim of this study was to investigate the expression of JAK3 and STAT3 in both normal and activated forms by immunohistochemistry in adenomas of the colon, ulcerative colitis and CRC compared to normal colonic mucosa. PATIENTS AND METHODS: Tissues from 30 cases with primary CRC and seven cases with ulcerative colitis (UC), removed by colectomy, were included. In addition, tissues from 10 colonic adenomas, 15 CRC and eight cases with UC, obtained by endoscopic biopsies, were examined histopathologically. Immunohistochemical evaluation of STAT3, p-STAT3, JAK3 and p-JAK3 expression in tissue sections was completed. Statistical analysis and correlation of data were then performed. RESULTS: Normal colonic mucosa showed expression of STAT3 only. Immunoreactivity of p-JAK3 increased significantly (p<0.05) and correlated with the degree of dysplasia in colonic adenomas. Immunoreactivity of p-STAT3 increased significantly (p<0.05) and correlated with the degree of dysplasia in cases with UC. In CRC a significant positive correlation was found between p-STAT3 expression and grading, STAT3, JAK3 and p-JAK3 and TNM or Dukes' staging, and p-STAT3 and nodal status excluding distant metastasis (p<0.05). CONCLUSION: JAK3 and STAT3, and particularly their activated forms, were found to correlate significantly with the degree of dysplasia in adenomas and UC, indicating their potential role in colorectal carcinogenesis. They also correlate with anaplasia and invasion, suggesting a definitive role in progression of CRC.