Molecular epidemiology of avian influenza virus and incidence of H5 and H9 virus subtypes among poultry in Egypt in 2009-2011.

Egypt has experienced outbreaks of avian influenza (AI) since 2006. A total of 3583 cloacal swabs were collected from chickens, ducks, geese and turkeys from commercial farms, backyards and local bird markets in Qena and Luxor governorates in South Egypt during 2009-2011. These samples were examined for the presence of AI virus (AIV) and positive samples were further subtyped for the H5 and H9 by real time RT-PCR. In this way, 202 (5.64%) samples were found to be AIV-positive of which 186 (92.08%) and 7 (3.46%) belonged to H5 and H9 subtypes, respectively. Higher infection rates were observed in backyard birds and birds from local bird markets in comparison to birds from commercial farms. In conclusion, the predominance of H5 infection indicates a need for continuous monitoring of AIV among avian species and the awareness against public health risk.

Functional and prognostic relevance of -173 G/C gene polymorphism of macrophage migration inhibitory factor in sepsis patients in Egyptian intensive care units.

This study aimed to evaluate the association of plasma MIF level and -173 G/C single nucleotide polymorphism of the MIF gene with the occurrence, severity and mortality of sepsis patients. A study was conducted in adult surgical intensive care units of Zagazig University Hospitals, Egypt on 25 patients with sepsis, 27 with severe sepsis and 28 controls. Gram-negative bacilli were the most common isolates in both severe sepsis (63.0%) and sepsis (56.0%) patients. A highly statistically significant difference was found in MIF levels between sepsis cases and controls and a statistically significant difference as regards MIF level in different genotypes of the studied groups. MIF level was significantly associated with mortality in sepsis cases. High MIF levels and MIF -173G/C gene polymorphism are powerful predictors of the severity of sepsis and its outcome.

Epidemiological characterization of P. aeruginosa isolates of intensive care units in Egypt and Saudi Arabia.

This study aimed to characterize Pseudomonas aeruginosa isolates in 2 intensive care units in Egypt and Saudi Arabia. P. aeruginosa isolates from patients' and staff hands and environmental samples were typed using antibiotyping and ERIC-PCR. In Egypt, isolates from suction apparatus tubing and drainage containers (A7) and AV tubing (A8) were linked to those from patients who had these antibiotypes. In Saudi Arabia, isolates from suction apparatus tubing (A6) and AV tubing (A7) were linked to patients with the same antibiotypes. In Egypt, patients' isolates had ERIC VII, VIll and IX patterns linked to suction apparatus tubing, AV machine tubes and drainage containers. In Saudi Arabia, patients' isolates had ERIC VIII and XI patterns linked to suction apparatus tubing and AV machines. In Egypt and Saudi Arabia, ERIC typing gave higher discriminatory indices (0.801 and 0.785 respectively) than the antibiotyping (0.7123 and 0.728 respectively). ERIC was superior to antibiotyping and should be used in tracing sources of infection.

Extraspinal meningioma. Case report.

A case of ectopic extraspinal meningioma is reported which presented as a tumor at the back of the neck of a 51-year-old woman. This neoplasm was of considerable size and arose extradurally in the region of the C-2 nerve root, with its main bulk lying almost totally outside the spinal canal in the right suboccipital region. Total resection was accomplished in two stages, with no evidence of recurrence after 1 year. The rarity of such cases prompted this report.

Fatty infiltration of the liver: analysis of prevalence, radiological and clinical features and influence on patient management.

Over a 6-year period, in 1425 adult computed tomographic studies, radiological evidence of fatty infiltration of the liver (FIL) was found in 138 patients (9.7%). Patients with FIL had a mean age +/- SD of 45.9 +/- 15.7 years and 57% were males; the majority were Saudis (73%). Most patients (95%) had one or more underlying aetiological causes. Haematological and non-haematological malignancies with or without liver involvement were the most frequently encountered aetiological factors (66% of patients). FIL contributed to hepatomegaly or was associated with abnormality in one or more of the liver function tests in 30% and 39% of patients, respectively. Assessment of the various radiological patterns showed diffuse fatty changes in 68% of patients and solitary or multiple focal changes in 9% and 22%, respectively. 13 patients (9%) showed sparing of the caudate lobe within a diffuse fatty process. Patients with diffuse FIL had significantly higher values for alkaline phosphatase (p = 0.0016) and serum asparate aminotransferase (p = 0.0251) than those who had the focal pattern. FIL in 20 patients (14%) imposed a difficulty in making an appropriate diagnosis, led to inaccurate impressions, or forced unnecessary invasive or non-invasive investigations. We conclude from our large series of patients that FIL is not uncommon in hospital practice and among those at risk should always be considered as an appropriate diagnosis.

Magnetic resonance imaging of tuberculous spondylitis.

STUDY DESIGN: This retrospective study analyzed the magnetic resonance imaging characteristics of tuberculous spondylitis. OBJECTIVE: To describe the magnetic resonance imaging characteristics of tuberculous spondylitis and compare the diagnostic yield of magnetic resonance imaging versus other modalities. SUMMARY OF BACKGROUND DATA: Tuberculous spondylitis is not an uncommon occurrence with extrapulmonary disease. It requires prompt diagnosis and management. In the pre-magnetic resonance imaging era, computed tomography was used to delineate the associated radiologic changes. Data are limited that describe the magnetic resonance imaging pattern of tuberculous spondylitis and the effect of post-contrast enhancement. METHODS: The magnetic resonance imaging characteristics of 28 vertebrae in 12 patients with tuberculous spondylitis were studied. RESULTS: The thoracic spine was the most commonly involved region, with involvement occurring in the thoracic spine alone in 12 vertebrae (43%) and with other areas of the spine in an additional five (18%). Partial involvement was detected in the majority of the vertebral lesions (24; 86%). Magnetic resonance imaging evidence of disc space involvement was apparent in only 46% of the lesions. Paraspinal abscess and epidural extension were documented by magnetic resonance imaging in 71% and 61% of lesions, respectively. Decreased signal intensity on T1-weighted images was demonstrated in 13 vertebrae (46%), with increased signal intensity on T2-weighted images seen only in five (18%). CONCLUSION: Magnetic resonance imaging is a useful diagnostic modality for patients with suspected tuberculous spondylitis. Partial vertebral involvement and paraspinal and epidural extension were delineated. Study of the signal intensity on T1- and T2-weighted images revealed a pattern that may be dissimilar to that commonly reported. Post-contrast enhancement adds more certainty to the diagnosis of tuberculous spondylitis.

Effect of granulocyte-macrophage colony-stimulating factor on chemotherapy-induced oral mucositis in non-neutropenic cancer patients.

The aim of this study was to assess prospectively the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the management of chemotherapy-induced oral mucositis in non-neutropenic cancer patients. In a prospective open study, 30 cancer patients with chemotherapy-induced, neutropenia-independent oral mucositis were treated with GM-CSF (Schering Plough Corp, Kenilworth, NJ) prepared as a mouthwash solution (5-10 micrograms ml-1). GM-CSF was administered within 24 hours of occurrence of oral mucositis x 4 to 6 times daily. Systemic GM-CSF was not permissible. Oral mucositis was graded according to the modified Radiation Therapy Oncology Group criteria. Six patients were subsequently excluded as they experienced neutropenia during GM-CSF therapy. The remaining 24 patients were all evaluable. Most patients had either Grade 3 or 4 gross (76%) or functional (54%) mucositis. The mean +/- SEM gross oral mucositis scores for all 24 patients combined decreased from 3.08 +/- 0.18 at baseline to 2.04 +/- 0.19 (p < 0.0001) after 2 days, 0.92 +/- 0.16 (p < 0.0001) after 5 days, and 0.25 +/- 0.09 (p < 0.0001) after 10 days of therapy. Likewise, the mean +/- SEM functional oral mucositis scores decreased from 2.71 +/- 0.18 at baseline to 1.58 +/- 0.19 (p < 0.0001) after 2 days, 0.75 +/- 0.16 (p < 0.0001) after 5 days, and 0.17 +/- 0.08 (p < 0.0001) after 10 days of therapy. The duration of severe oral mucositis was also shortened as Grade 0 or 1 (gross mucositis score) was evident in seven (29%), 20 (83%), and 24 (100%) patients by the 2nd, 5th, and 10th day of therapy, respectively. Similarly, Grade 0 or 1 (functional mucositis score) reported in 13 (54%), 19 (79%), and 24 (100%) by the 2nd, 5th, and 10th day of therapy respectively. It was found that GM-CSF mouthwash as used in this study has a significant recuperative efficacy on the severity, morbidity, and duration of chemotherapy-induced oral mucositis. A large randomized, placebo-controlled study is warranted to ascertain that benefit and determine the optimal dosages and schedule.

Pregnancy-associated breast cancer: a case-control study in a young population with a high-fertility rate.

Pregnancy-associated breast cancer (PABC) is not a rare event. The association frequently imposes a management challenge. We intended to review the clinical features, therapy, and outcome of patients with PABC seen at a single institution over a five-year period and to compare those with that seen in a matched control group. Data of all patients with PABC diagnosed during pregnancy were retrospectively reviewed (Group I). For each patient in Group I, three matched controls with breast cancer without pregnancy were identified (matched for age, stage, and year of diagnosis, Group II). 72 patients in Group I and 216 in Group II were identified. Their median age was similar (34 vs 35 y, respectively). The median number of prior pregnancies for patients in Groups I and II was 5. Patients had shorter duration of symptoms prior to diagnosis as compared with their controls (5.6 vs 9.4 months, P < 0.0001). 3%, 31%, 40%, and 26% of patients had Stage I to IV, respectively. A pattern that was similar to that seen in our breast cancer population. Pregnancy was terminated in 34 patients (47%), while 38 (53%) had normal spontaneous vaginal delivery. 47 patients in Group I had surgery; 37 (52%) had modified radical mastectomy and 10 (14%) had conservative surgery. In 37 patients surgery was performed after termination of pregnancy and 10 had surgery performed during pregnancy. The median number of positive lymph nodes in Group I was 4 as compared with 2 for patients in Group II. No patients in Group I had systemic chemotherapy during first trimester, while only 4 (6%) and 3 (4%) received adjuvant or neoadjuvant during second and third trimester, respectively. No congenital malformation in the newborns was diagnosed. None of the patients in Group I received radiotherapy during pregnancy. Over a median of 47.5 months, 48 (67%) patients in Group I were alive as compared to 126 (58%) in Group II, with no difference in the median survival (P= 0.79). Comparing overall survival (OS) between the two groups stage for stage also showed no significant difference. Also there was no difference in progression-free survival between the two groups. Cox proportional hazard model identified advanced stage as the only independent adverse prognostic variable that influenced OS in Group I. Despite that this series included a relatively young population with a high fertility rate, the study confirmed the lack of a survival difference between patients with PABC and their matched controls.

Adding high-dose tamoxifen to CHOP does not influence response or survival in aggressive non-Hodgkin's lymphoma: an interim analysis of a randomized phase III trial.

PURPOSE: CHOP is the standard regimen currently used in the management of the majority of patients with aggressive non-Hodgkin's lymphoma (NHL). However, CHOP only produces 30-35% long-term survival. We hypothesized that adding high-dose tamoxifen, which is known to have multiple drug resistance-modulatory effects, to the CHOP regimen could increase the response rate, and consequently enhance the survival of patients with NHL. PATIENTS AND METHODS: In a prospective, controlled, and randomized study, eligible adult patients with aggressive NHL were randomized between CHOP only (Group I), or CHOP plus high-dose tamoxifen (Group II). The primary aim was to assess the effect of tamoxifen on complete response (CR) rate, with the secondary evaluation of tamoxifen potential impact on survival. The interim analysis of this study is presented. RESULTS: Fifty-one and forty-seven evaluable patients were randomized to Group I and Group II, respectively. The median age of all patients was 53 y (range 18-78 y). The two groups had comparable distributions of the pretreatment prognostic variables. The CR for patients in Group I was 80% (41 patients) as compared with 74% (35 patients) in Group II (P=0.48). Likewise, there was no apparent difference in the partial remission rates between the two groups (6% vs 15%, respectively). Of patients who initially attained CR, 15 (37%) and 10 (29%) subsequently relapsed in Groups II and I respectively (P = 0.45). The NHL International Prognostic Index (IPI) was the only factor that predicted attaining CR. At the time of this interim analysis, the actuarial-estimated overall survival (OS) probability (+/-S.E.) for the entire population at 5 y was 58% (+/-6) with no survival difference between the two groups (P=0.51). Only attaining CR and the IPI predicted OS probability. The probability of remaining event-free at 5 y (+/-SE) for those achieving CR was 72% (+/-9), and there was no significant difference between the two treatment groups (P=0.68). Toxicity profile was similar in the two groups. CONCLUSION: Based on this interim analysis, combining high-dose tamoxifen, as used in this study, with the CHOP regimen has failed to have any favorable effect on the outcome of patients with aggressive NHL, and therefore cannot be recommended for future trials.

Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population.

In the Kingdom of Saudi Arabia (KSA), breast cancer constitutes 18% of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA. The relative frequency of locally advanced disease among our breast cancer population and the lack of a uniform consensus in the literature about its optimal management have prompted this retrospective analysis of the medical records of patients with Stage III breast cancer patients seen at King Faisal Specialist Hospital and Research Center between 1981 and 1991. In all, 315 patients were identified. Their median age +/- SD was 46 +/- 11.6 years which is distinctly different from the 60-65 years median age in industrial Western nations. Most patients were younger than 50 years (64%) and premenopausal (62%). Patients were approximately equally divided between Stage IIIA and Stage III B. Patients received multimodality treatment, including surgery, adjuvant chemotherapy, tamoxifen, and adjuvant radiotherapy. Sixty-one patients were excluded from survival analysis as they were considered lost to follow-up. Of the remaining 254 patients, 73 (29%) were alive and disease free, and 18 patients (7%) were alive but with evidence of the disease. The remaining 163 (64%) had died from breast cancer or its related complications. Their median overall survival (OS) was 54 months, (95% CI, 27 to 121 months) and the median progression-free survival (PFS) was 28.8 months (95% CI, 14.2 to 113 months). Cox proportional hazard model identified Stage III B and the number of positive axillary lymph nodes as poor predictors of OS and PFS. Radiotherapy was the only adjuvant modality that affected survival favourably. The prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach. The overall young age of our patients may have contributed to the poor outcome. Moreover, the adverse effect of Stage III B disease (as compared with Stage III A) and axillary nodal status was evident. Whilst the favourable effect of radiotherapy on survival was demonstrated, the lack of independent efficacy of other modalities (adjuvant chemotherapy and tamoxifen) or the apparent deleterious effect of neoadjuvant chemotherapy should be addressed with discretion in such retrospective analysis. Optimal management of patients with locally advanced breast cancer disease should be appraised in well designed, prospective, randomised studies.

Breast cancer in the eastern province of Saudi Arabia.

In the Kingdom of Saudi Arabia (KSA), hospital and population based statistics have shown that breast cancer has the highest crude frequency rate among Saudi women. The scarcity of reports about the disease in the KSA has been the impetus to this analysis about breast cancer in the eastern province of KSA. Data on female patients with invasive breast carcinoma seen at King Fahd Hospital of the University in the eastern province of KSA, were retrospectively reviewed. The analysis intended to examine the pattern of the disease and the outcome for patients. Between 1985 and 1995, 292 patients were identified. Their median age +/- SD (standard deviation) was 42 +/- 10.5 years. Most patients were younger than 50 years (78%) and were predominantly premenopausals (79%). Only 25 (9%) of patients had stage I cancer, whilst 130 (44%), 90 (30%), and 47 (16%) had stage II, III, and IV, respectively. Among patients with known axillary nodal status (242 patients), only 37% were node-negative whilst 32% and 31% had 1-3, and > or = 4 positive nodes, respectively. Adjuvant chemotherapy and tamoxifen were commonly offered; nonetheless, other adjuvant modalities were rarely utilised. The median follow-up +/- SD of all patients was 62.3 +/- 8.9 months: 152 patients (52%) were alive with no evidence of disease, 25 (9%) were alive with evidence of disease, and 115 (39%) were dead from breast cancer or its related complications. The median survival of the entire group was not obtained, but the 10-year projected survival was 55%. For stage I and II patients, 118 (76%) were alive with a projected 10-year actuarial survival of 64%. On the other hand, only 51 (57%) of patients with stage III disease were alive with a median survival of 41.5 months (95% Confidence interval (CI), 18.9 to 51.3). Patients with stage IV disease demonstrated a poor outcome with a median survival of 23.5 (95%, CI 12.2 to 31.4). Multivariate analyses were performed to explore the influence of independent variables on overall survival (OS) for patients with non-metastatic disease. Besides the expected adverse effect of disease progression, the favourable influence of adjuvant chemotherapy and tamoxifen prevailed. The amount of benefit gained from tamoxifen, however, was small. Similar analyses were undertaken to determine the influence of independent variables on progression-free survival (PFS). These analyses ascertained the adverse effects of advanced stage and the favourable impact of adjuvant chemotherapy. Breast cancer in the KSA has features that are distinctive from those of industrialised countries. Survival data, however, were comparable. The favourable influence of adjuvant chemotherapy was evident on both OS and PFS. Adjuvant tamoxifen, however, had little effect. Due to its infrequent use, the role of other adjuvant modalities could not be asserted.

Primary hepatocellular carcinoma in the eastern province of Saudi Arabia: treatment with combination chemotherapy using 5-fluorouracil, Adriamycin and mitomycin-C.

An analysis is done of 40 evaluable patients treated with a combination of 5-Fluorouracil, adriamycin and mitomycin-C for primary hepatocellular carcinoma in Saudi Arabia. In only 5 patients (12.5%) objective partial remission was achieved. The duration of remission for responding patients was: 6, 6, 8, 12 and 20 weeks, respectively. Responders demonstrated a short survival time of 8, 8, 10, 15 and 33 weeks. The median survival time of non-responders was 8 weeks, which was not different from that of responders. An analysis of potential factors that might contribute to our poor results is presented.

Campylobacter pylori in Saudi patients undergoing upper gastrointestinal endoscopy: prevalence and effect of conventional therapy.

Patients with symptoms of gastritis or peptic ulcer disease were recruited to study the prevalence of Campylobacter pylori. On the basis of the endoscopic diagnosis only, the isolation rates of the organisms in normal, gastritis or gastroduodenitis (GD), and peptic ulcer (PU) disease patients, were not significantly different among the 89 patients evaluated. However, analysis based on histopathological evaluation (in 73 out of these 89 patients) revealed a significant difference (p = 0.00016) in the isolation rate between histologically normal individuals (14%) and those with GD (89%). Also, a significant (p = 0.03) difference was observed in the C. pylori detection rate among patients with GD and those with PU disease (61%). After adjustment for multiple comparisons, only the difference in C. pylori prevalence between normal and GD patients was maintained. After conventional therapy, 23 patients who initially had GD or PU disease were submitted to re-endoscopy. In the latter group, a correlation between presence or absence of organisms and histological healing was noted. The potential pathogenesis of C. pylori in gastritis and peptic ulcer disease, and designs for future trials are discussed.

The outcome of head injuries: the Saudi experience.

One analysis of the outcome of 159 cases of head injuries was based on patients' admission Glasgow Coma Scale (GCS), score, age, CT scan findings and uniform protocol of management. Fifty-three percent of the patients were children below the age of 10 years and 70% of all patients were Saudis. Eighty-point-five percent (80.5%) of the patients had a GCS score of 8 or more and their outcome was favorable. By contract, the 19.5% who had an initial GCS score of 7 or less tended to be older and had a worse prognosis (mortality 68%). A high initial GCS score, old age, associated multiple injuries and a shift of more than 4 mm of the midline structures on CT scan of the brain are useful prognostic indices in predicting the outcome of head injury.

A single nocturnal dose of famotidine for the treatment of duodenal ulcer: evaluation of efficacy and safety.

The efficacy and safety of a single nocturnal dose of famotidine (40 mg) was evaluated in 30 consecutive patients of duodenal ulcer (DU). Three patients were lost for follow-up and therefore were excluded. The mean age of remaining 27 patients was 34.3 (+/- 9.9) years and male to female ratio was 8:1. The mean size of the DU was 1.21 (+/- 0.79) cm. After a 4-week therapy all patients showed significant improvement and repeat endoscopy in 24 out of 27 patients (89%, 95% confidence interval; 78% to 100%) showed healed ulcer. Clinical assessment of pain relief at 4-week showed significant drop in the mean score of baseline daytime (from 1.85 to 0.13) and baseline nocturnal pain (from 1.70 to 0.10) (p less than 0.0001 and less than 0.0001, respectively). Also shown was the significant decrease in the mean gastrointestinal symptoms score from 5.89 at baseline to only 0.89 at 4-week (p less than 0.0001). Despite that all those who failed to show ulcer healing at 4-week were smokers, logistic regression analysis could not identify smoking or any other risk factors as adverse predictors of ulcer healing. None of the patients experienced significant side effects or adverse reactions. We conclude, that a single nocturnal dose of famotidine is a practical, highly effective and safe approach for the management of DU.

The outcome of head injury: the Saudi experience.

The outcome in 159 cases of head injury was evaluated in terms of the Glasgow Coma Scale (GCS) score, age, and computed tomographic (CT) findings. Children below the age of 10 accounted for 30% of the head-injured patients, and 69% were Saudis. 81% of the patients had a GCS score of 8 or higher, and in this group the outcomes were favorable. In contrast, 19% had an initial GCS score of 7 or less, tended to be older, and had worse outcomes, with a mortality rate of 68%. The initial GCS score, age, presence or absence of associated injuries, and the degree of midline shift according to CT were useful prognostic indices in patients with head injury.

Late relapse of Hodgkin's disease after 25 years.

This short report documents a late relapse of Hodgkin's disease 25 years later after initial complete remission. The case represents the second longest ever reported disease-free survival that was followed by late recurrence. Data about late occurrence in Hodgkin's disease of relapses are reviewed. The biological and clinical significances of those events of late relapses are emphasized.

Malignant bone tumours in pregnancy (a report of two cases and review of literature).

Two cases of malignant bone tumours in pregnancy are reported. The optimum management is not clearly defined due to the rarity of the condition and limited individual experience. Our patients delivered healthy babies without any signs of maternal malignant disease. Cancer chemotherapy was instituted during the postmortem period. Pregnancy did not appear to exacerbate the tumour growth nor in any way affect the ultimate outcome of the patients.

Tuberculosis in patients with malignant disease.

Of 2,143 biopsy proven cancer patients seen at our hospital over a six year period, 4 (0.19%) patients developed active tuberculosis (TB) during anticancer therapy or shortly after its completion. The cancer diagnoses of those patients were non-Hodgkin's lymphoma, breast cancer, chronic myelogenous leukemia, and astrocytoma. Institution of antituberculous therapy was successful in three patients, however, the TB course was rapidly fatal in the fourth patient with non-Hodgkin's lymphoma despite therapy. The association between TB and neoplasia is emphasized. TB complicating malignant disorders represents complex problem regarding its early recognition and its managements.

The pattern and outcome of burn injuries at a burn unit in Saudi Arabia: Retrospective analysis of consecutive 501 patients.

We retrospectively reviewed the cases of 501 consecutive patients with burn injuries who were seen between June 1983 and December 1988. The population consisted predominantly of young patients under 20 years of age (53%); 65% were males and 72% were Saudi nationals. Most burn injuries were the result of domestic accidents (75%) and scald burns were the cause in 55% of patients. There was an inhospital mortality of 8% during first hospitalizations. Multivariate analysis identified several independent adverse prognostic factors: increased total burn surface area, inhalation injury, thrombophlebitis, documented septicemia, and deep circumferential burn over the extremities. Using these poor prognostic factors, we were able to stratify patients into three risk categories, each presenting a significant difference in the probability of survival. Our analysis yielded data about the pattern of burn injuries, prognostic factors, and outcome at a dedicated burn unit in Saudi Arabia.