Vitamin D and LL-37 in cirrhotic patients with culture-positive spontaneous bacterial peritonitis Ahmed El Sayed Zeid, Perihan El Sayed Salem, Abeer S El Hadidi, Tamim G Ibrahim The Egyptian Journal of Internal Medicine 2019 31(3):247-253 Background and aims Spontaneous bacterial peritonitis (SBP) is a common bacterial infection in patients with liver cirrhosis and ascites. Cirrhotic patients frequently have vitamin D (Vit-D) deficiency. Vit-D induces the production of LL-37, an important molecule of innate immunity, in macrophages. The aim of this study is to assess Vit-D and LL-37 levels in the ascitic fluid (AF) of cirrhotic patients with SBP in comparison to patients with simple ascites. Patients and methods Forty male cirrhotic patients with ascites were included and were divided into two groups, 20 with culture-positive SBP (group I) and 20 with simple ascites (group II). AF Vit-D and LL-37 levels were measured. Results Vit-D and LL-37 levels were significantly lower in patients with SBP than those with simple ascites. In univariate analysis, the risk factors for SBP were lower platelet count, higher leukocytic count, higher serum bilirubin, lower prothrombin activity, lower serum albumin, higher Child–Pugh and model for end-stage liver diseases scores, and lower AF Vit-D and LL-37 levels, while in multivariate analysis, a lower AF Vit-D level was the only risk factor for SBP. Conclusion Patients with SBP have lower levels of AF Vit-D and LL-37 than simple ascites, where an inadequate expression of LL-37 in AF due to the low Vit-D level may increase the susceptibility to SBP.

Prognostic value of interleukin-10 and tumor necrosis factor-α polymorphisms in patients with hepatocellular carcinoma treated with transarterial chemoembolization Ahmed A Ghafar, Elsayed Ghoneem, Salah Rozaik, Ahmed Akef, Metwaly Mortada The Egyptian Journal of Internal Medicine 2019 31(3):254-260 Background Transarterial chemoembolization (TACE), a locoregional therapy, is widely recommended as first-line treatment for intermediate-stage hepatocellular carcinoma (HCC). Several prognostic indices have been used to predict overall survival in HCC patients undergoing the procedure. Patients and methods A total of 73 patients with HCC, candidate for TACE attending to HCC clinic, Specialized Medical Hospital, Mansoura University, were subjected to full history taking, physical examination, laboratory profile and testing for interleukin (IL)-10 and tumor necrosis factor (TNF)-α polymorphisms. Aggressiveness index is calculated for all patients and followed-up for 4 weeks after TACE to asses response. According to IL-10 and TNF-α polymorphisms results, patients were divided into groups and compared. Results The aggressiveness index is significantly higher in the TT/AT haplotype of IL-10 and GG haplotype of TNF-α in comparison with the other haplotypes. The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are significantly associated with less favorable outcome after TACE, wherein 64.3 and 56.25% of patients showed residual active tumor tissue, respectively. Conclusion The TT/AT haplotype of IL-10 and GG haplotype of TNF-α are associated with more aggressive pattern of HCC and less favorable outcome after TACE; hence, these patients must be treated as early as possible.

The role of mean platelet volume in predicting severity and prognosis of liver cirrhosis in Egyptian patients Mohamed S Mohamed, Mohamed A.A Bassiony, Ayman F. Elsayed Mohamed The Egyptian Journal of Internal Medicine 2019 31(3):261-265 Background and aims Liver cirrhosis is a major public health problem in Egypt due to widespread infection of hepatitis C virus. Mean platelet volume (MPV) is a noninvasive, inexpensive parameter of complete blood count. In this study we aimed at evaluating the association between MPV and clinical features, complications, and severity of cirrhosis in Egyptian patients. Patients and methods One hundred and fourteen patients with cirrhosis of various grades of severity and various presentations were enrolled in our study. The patients were evaluated to assess the association between MPV values and cirrhosis parameters, model for end-stage liver disease score, and fibrosis (FIB4) score. Results The study demonstrates the positive correlation between MPV values and international normalized ratio, serum bilirubin, lower serum albumin in cirrhotic patients. Also, the MPV values were significantly higher in patients with more severe liver disease according to the model for end-stage liver disease (r=+0.424, P=0.008) and FIB4 scores (r=+0.353, P=0.03). Conclusion MPV can be used as an important inexpensive biomarker in cirrhotic patients for the degree of severity and prognosis of the disease.

Comparison of endoscopic ultrasound-guided tissue acquisition using 22 G versus 20 G procore needles in solid lesions: a pilot study Ahmed Altonbary, Hazem Hakim, Doaa Bakr, Ahmed El-Shamy, Wagdi Elkashef The Egyptian Journal of Internal Medicine 2019 31(3):266-272 Background and aim Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) allows tissue acquisition from solid lesions. The endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle was developed to improve diagnostic yield by acquisition of histological core. The impact of the needle type (FNA or FNB) on the diagnostic yield and the technical success needs to be further studied. Therefore, the aim of our study was to compare the diagnostic accuracy and technical success of the 22-G FNA needle with the 20-G procore FNB needle in solid lesions. Patients and methods The study was designed as a pilot study conducted on cases with solid mediastinal, pancreatic, and intra-abdominal lesions, and the patients involved were then randomized for tissue sampling using either the standard 22-G FNA needle or the new 20-G procore FNB needle. Results In this six-month study, 50 patients including 29 male individuals and 21 female individuals, with a mean age of 57.1±12.3 years (range: 15–80 years) were enrolled. No significant difference was detected between FNA 22 G and FNB 20 G as regards the diagnostic accuracy or the technical success rates. However, there was a significant difference in the number of passes needed to reach diagnosis. The success rate of first pass for FNA 22 G and FNB 20 G was 69 and 92.5%, respectively (P=0.014, 95%CI). Conclusion EUS-guided FNA and FNB have comparable diagnostic accuracy for solid lesions. The 20-G FNB needles are easy to handle in anatomically challenging locations and required fewer needle passes to reach diagnosis.

Detection of patatin-like phospholipase domain-containing protein 3 in nonalcoholic fatty liver disease among egyptian patients Kadry M El Saeed, Ossama A Ahmed, Mohamed O Khalifa, Eman M Fahmy The Egyptian Journal of Internal Medicine 2019 31(3):273-280 Background and aim Recently, studies have identified patain-like phospholipase domain containing 3 (PNPLA3), which is localized in the endoplasmic reticulum and at the surface of lipid droplets. The association of PNPLA3 polymorphisms with fatty liver and histological severity of NAFLD was shown in many studies. We aimed to investigate the association of PNPLA3 with the development and severity of NAFLD in an overweight and obese Egyptian population. Patients and methods Eighty overweight and obese patients with NAFLD were enrolled in the study. Patients were divided into 2 subgroups according to results of liver biopsy: group 1 included 30 patients with simple steatosis, and group 2 included 50 patients with non-alcoholic steatohepatitis (NASH). In addition to 10 age-matched healthy subjects served as a control group. All NAFLD patients underwent a confirmatory biopsy. Laboratory investigations included fasting glucose, liver enzymes and lipid profile were done. Abdominal ultrasound was performed and PNPLA3 was detected in each patient by Quantitative ELISA. Results Levels of PNPLA3 were higher in NAFLD patients compared with controls (85.70±76.42 vs 3.10±2.11 respectively) and levels were also higher in NASH than simple steatosis (125.09±71.78 vs 20.06±8.47 vs 3.10±2.11 respectively, P<0.001). There were highly significant positive correlations between the PNPLA3 and waist circumference, BMI, ALT, AST, total cholesterol and TGs in the NAFLD patients. Conclusions Our study confirmed the association of PNPLA3 with the incidence of NAFLD and progression to NASH in the Egyptian patients.

Rifaximin plus norfloxacin versus norfloxacin alone in primary prophylaxis of spontaneous bacterial peritonitis in patients with variceal bleeding Ahmed A Ghafar, Salah Rozaik, Ahmed Akef The Egyptian Journal of Internal Medicine 2019 31(3):281-287 Background Spontaneous bacterial peritonitis (SBP) is an infection of the ascitic fluid in the absence of other intra-abdominal sources. The risk is high in those with concomitant gastrointestinal bleeding, low ascitic fluid protein, or a previous attack of SBP. Norfloxacin is used widely in the primary prophylaxis of SBP but resistance usually develops where rifaximin was introduced. Patients and methods A total of 80 patients with advanced liver cirrhosis attending the Hemostasis Unit, Emergency Hospital, Mansoura University, with upper gastrointestinal bleeding were subjected to full history, clinical examination, laboratory assessment, and ascitic fluid analysis. The patients were divided into two groups: the first group received rifaximin plus norfloxacin and the second group received norfloxacin only and the two groups were followed up for 1 year. Results The study enrolled 80 patients, 51 men and 29 women with a mean age of 58.83±5.02 years for group 1 and 58.35±4.95 years for group 2. There were no statistically significant difference between the two groups as regards the clinical or laboratory characteristics except for the presence of focal lesions that was significantly present in group 2. A significant increase in the incidence of SBP in group 2 was present with P=0.014. The median time of developing SBP was significantly shorter in the second group. Conclusion The addition of rifaximin to norfloxacin decreased the incidence rates of SBP in patients with variceal bleeding with significant improvement in patient survival.

Prevalence and effect of occult hepatitis C infection in patients with persistent liver enzyme elevation after achieving 24 weeks of sustained virological response Anwar A Mohamed, Ashraf M Eljaky, Eman M Abdelsameea, Tamer R Fouad, Hosam El-Din M El-Ezawy The Egyptian Journal of Internal Medicine 2019 31(3):288-291 Background Despite achieving sustained virological response (SVR) of chronic hepatitis C infection, some of the treated patients have persistent elevations of transaminases. Occult hepatitis C infection (OCI) could be one of the causes. Aim The aim of this study was to detect OCI in peripheral blood mononuclear cells in patients who achieved 24-week SVR with persistent elevations of transaminases. Methods We included 998 naïve chronic HCV-infected patients who received treatment at our hospital. Patients with elevated liver enzymes after achieving SVR were determined. HCV RNA PCR in peripheral blood mononuclear cells was done for those patients (group 1) and was compared with a group with normal levels of enzymes, which was matched in age and sex (group 2). Results Nine hundred and sixty-five patients achieved SVR (96.69%). Seventy-four (7.7%) patients of them had elevated enzymes. OCI was detected in 14/74 (18.9%) patients of group 1, whereas it was seen in 4/67 (5.9%) in group 2. Cirrhosis, OCI, and obesity were associated with this enzymes elevation (P=0.005, 0.024, and <0.001). By multivariate analysis, none of these three parameters were independently associated with the enzyme elevation. The presence of OCI was not significantly associated with the presence of cirrhosis or obesity. Conclusion OCI is not infrequent in patients with persistent transaminase elevations despite obtaining 24 weeks of SVR. Liver cirrhosis, OCI, and obesity could have synergistic effects and should be considered as important risk factors of this persistent enzyme elevation.

Efficacy of chymotrypsin in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis Ahmed A Attia, Esam A Elshimi, Tamer R Fouad, El-Sayed A Ibrahim, Wael M Abdel-Razek The Egyptian Journal of Internal Medicine 2019 31(3):292-295 Background Pancreatitis is common after endoscopic retrograde cholangiopancreatography (ERCP). Aim To assess the pharmacological effect of diclofenac, allopurinol and chymotrypsin in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP). Settings and design Calcular obstructive jaundice patients without pancreatitis scheduled for ERCP were randomized into three groups. Materials and methods The diclofenac group received 200 mg rectal suppositories immediately after ERCP, allopurinol received oral 300 mg 3 h before ERCP, and chymotrypsin received intramuscular injection immediately after ERCP. Serum amylase and lipase were measured before, 1, 6, and 24 h after ERCP and procedure-related risk factors for post-ERCP pancreatitis were recorded. Pancreatitis was considered when serum amylase or lipase levels elevated more than three times the upper limit of normal with newly developed abdominal pain lasting at least 24 h after ERCP. Statistical analysis Analysis of variance for continuous variables and χ2 for categorical variables. Results One hundred and fifty patients were included; diclofenac group (58 patients, 29 men, mean age 46.9±13.2 years), allopurinol (38 patients, 20 men, mean age 43.1±14.7 years) and chymotrypsin (54 patients, 28 men, mean age 40.6±17.3 years). Twelve (8%) patients developed PEP: the diclofenac group (n=4; 6.9%), allopurinol (n=6; 15.8%) while chymotrypsin (n=2; 3.7%), but this was not statistically significant (P=0.318). In patients who received chymotrypsin, regression of serum amylase and lipase to normal levels was much better compared with the other groups and was associated with better clinical improvement. Conclusion Chymotrypsin and allopurinol are comparable to diclofenac in the prevention of pancreatitis post-ERCP. Beside its prophylactic role, chymotrypsin could be effective in rapid improvement if PEP occurs.

Effect of direct-acting antivirals on platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in patients with hepatitis C virus-related thrombocytopenia Mohamed A Abd El Hafez, Zeinab Abdel Aziz Kasemy The Egyptian Journal of Internal Medicine 2019 31(3):296-301 Objectives To study the effect of direct-acting antivirals (DAAs) on platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in patients with hepatitis C virus (HCV)-related thrombocytopenia. Background PLR and NLR are correlated with HCV infection, HCV-related liver cirrhosis, HCV-related atherosclerosis and cardiovascular diseases. Patients and methods In the current study, we studied 100 patients with HCV-related thrombocytopenia. All patients were subjected to anti-HCV antibody, HBsAg, liver profile, blood urea, serum creatinine, fasting and postprandial blood glucose, complete blood count, iron profile, direct anti-globulin test, rheumatoid factor, antinuclear antibody, and alpha fetoprotein. Abdominal ultrasound, FibroScan, echocardiography, and electrocardiography were done for all patients. Thrombocytopenia was defined as platelets count less than 150.000/mm. The used DAAs were sofosbuvir and daclatasvir, and duration of treatment was 12 weeks. All patients were followed up during antiviral therapy (for 12 weeks) and had extended follow-up for 24 weeks after the end of therapy with DDAs. Quantitative PCR for HCV RNA was done at the start of therapy and at 12 weeks (end of treatment response). PCR for HCV was repeated at 12 weeks after the end of treatment to assess the sustained viral response at 12 weeks after end of treatment (SVR-12) and at 24 weeks after the end of treatment to assess the sustained viral response at 24 weeks after end of treatment (SVR-24). PLR and NLR were calculated by dividing platelet and neutrophil counts, respectively, by lymphocyte count at the start of treatment, then at 4 weeks, at 12 weeks (end of treatment), at 24 weeks (SVR-12), and at 36 weeks (SVR-24). Results The mean age of patients was 49.55±7.79 years, with a range of 33–64 years. They showed female predominance, with females constituting 58.7%. Patients were all Child A status. Liver fibrosis stage was either stages I, II, or III (45, 30, and 25%, respectively). Mean platelet count was 82.25±23.64, 77.01±18.58, 90.84±18.86, 85.02±18.79, and 80.26±18.67 before starting treatment with DAAs, at 4 weeks, at 12 weeks (end or treatment), at 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. PLR mean±SD was 74.07±12.76, 76.01±13.58, 65.84±13.86, 62.02±12.79, and 60.26±12.67 before starting treatment with DAAs, at 4 weeks, at 12 weeks (end or treatment), 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. NLR mean±SD was 1.61±0.24, 1.64±0.23, 1.50±0.24, 1.45±0.23, and 1.33±0.24 before starting treatment with DAAs, at 4 weeks, 12 weeks (end or treatment), 24 weeks (SVR-12), and at 36 weeks (SVR-24), respectively. Both PLR and NLR initially increased at 4 weeks after the start of treatment and then both significantly decreased to reach lowest level at 36 weeks (SVR-24). Conclusion PLR and NLR are both decreased after HCV eradication by DDAs in HCV-infected patients with thrombocytopenia suggesting improvement of HCV-associated systemic inflammation.

The association of adiponectin gene expression and serum levels with susceptibility to peripheral polyneuropathy in Egyptian patients by women with hypothyroidism Nearmeen M Rashad, Mohamed S.S Saad, Bothina M Ramadan, Shereen M El Shabrawy The Egyptian Journal of Internal Medicine 2019 31(3):302-313 Background Hypothyroidism has numerous comorbidities including degenerative neurological disease and insulin resistance. Adiponectin is an adipokine secreted by adipose tissue with insulin-sensitizing, anti-inflammatory, and antioxidant properties. This study was designed to explore the expression pattern of Adiponectin and its serum level in hypothyroidism and peripheral neuropathy (PN). The aim was to also evaluate the association between the expression pattern of adiponectin and its serum level with the clinical and electrophysiological tests of PN in hypothyroid patients. Participants and methods This cross-sectional controlled study enrolled 110 hypothyroid patients and 80 control group participants. All participants were subjected to a complete neurological examination and nerve conduction study (NCS). Adiponectin level was measured using an enzyme-linked immunosorbent assay. Adiponectin expression levels were estimated using real-time PCR. Results The results showed lower values of serum adiponectin and adiponectin expression levels in hypothyroid patients, especially patients with PN. NCS in the studied group showed that motor and sensory nerve conduction in the median and posterior tibial nerves were significantly decreased in both hypothyroid patients with or without PN compared with the euthyroid group. In addition, serum adiponectin and adiponectin expression were negatively correlated with Toronto Clinical Scoring System as well as cardiometabolic risks and positively correlated with NCS of the median, sural, and tibial nerves. The diagnostic power of adiponectin expression is better than that of adiponectin serum levels. Conclusion Hypothyroid patients with PN had lower values of serum adiponectin and adiponectin expression levels than hypothyroid patients without PN; the diagnostic power of combined adiponectin serum and expression levels was thus highly significant, and they could be a useful diagnostic biomarker of PN.