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   Table of Contents - Current issue
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April-June 2018
Volume 30 | Issue 2
Page Nos. 49-95

Online since Wednesday, July 25, 2018

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ORIGINAL ARTICLES  

The relationship between serum dipeptidyl peptidase-4 enzyme and nonalcoholic fatty liver disease in diabetic and nondiabetic patients Highly accessed article p. 49
Alaaeldin A Dawood, Yasser El Ghobashy, Ayman A Elgamal
DOI:10.4103/ejim.ejim_34_17  
Background Dipeptidyl peptidase-4 (DPP4) is a membrane-associated peptidase. It has widespread organ distribution throughout the body and exerts pleiotropic effects. The liver expresses DPP4 to a high degree. Nonalcoholic fatty liver disease (NAFLD) is more prevalent in patients with type 2 diabetes mellitus (T2DM), and is associated with increased mortality rates. Currently, there is no approved pharmacologic agent for the management of NAFLD. We need to discover more agents in the pathogenesis of NAFLD to attack it. Therefore, the aim of this work is to study the relationship between serum DPP4 enzyme and NAFLD in diabetic and nondiabetic patients. Patients and methods This study was conducted on 160 patients divided equally into four groups: the control group included healthy participants; the T2DM group included type 2 diabetic patients without NAFLD; the NAFLD group included nondiabetic NAFLD patients; and the T2DM-NAFLD group included T2DM patients with NAFLD. Laboratory investigation included glycosylated hemoglobin, liver enzymes, lipid profile, and serum DPP4 enzyme. Results DPP4 was significantly higher in the T2DM-NAFLD group compared with the other three groups, and in the NAFLD group and T2DM group compared with the control group. There was a significant direct correlation between serum DPP4 and BMI, glycosylated hemoglobin, serum cholesterol, triglycerides, and low-density lipoprotein (LDL). There was a significant inverse correlation between serum DPP4 and high-density lipoprotein (HDL). Conclusion DPP4 is significantly higher in diabetic patients compared with nondiabetic patients and in NAFLD patients compared with non-NAFLD patients. DPP4 can be proposed as a novel candidate in NAFLD pathogenesis.
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Study of the serum level of fasting glucagon-like peptide-1 in type 2 diabetics and its relation to the glycemic profile p. 54
Mohamed A Korani, Ahmed Sonbol
DOI:10.4103/ejim.ejim_76_17  
Background Glucagon-like peptide-1 (GLP-1) is a peptide formed of 30 amino acids. It is synthesized in and released from the enteroendocrine L cells that are present throughout the small and the large intestine. Because of the important physiological role of GLP-1 in augmenting insulin secretion, it is generally believed that GLP-1 release is deficient in type 2 diabetes mellitus (T2DM) patients. However, studies in adults have yielded conflicting results showing decreased, normal, or increased GLP-1 concentrations in prediabetics or T2DM after oral glucose or mixed meal. The aim of this work was to study the level of fasting total GLP-1 in T2DM patients and its relation to the glycemic profile. Patients and methods This study included 60 T2DM patients and 40 participants matched for age and sex as a control group, selected from the inpatient and outpatient clinics of the Internal Medicine Department in Menoufia University Hospital. After obtaining their informed consent, all participants were subjected to a full assessment of history and physical examination with estimation of BMI, insulin resistance with homeostasis model assessment-2, and investigations including fasting blood glucose (FBG), glycated hemoglobin (HbAIc), and the total fasting levels of GLP-1. Results There was no significant difference in the level of GLP-1 between T2DM patients and the controls. There were significant negative correlations between the fasting total GLP-1 and FBG, HbAIc, serum insulin, and homeostasis model assessment-2 in both the total sample and the T2DM patients. Conclusion Fasting total levels of GLP-1 are not reduced in T2DM patients and are negatively correlated with FBG, HbAIc, and insulin resistance.
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Urinary immunoglobulin G versus microalbuminuria as an indicator of diabetic nephropathy in type 2 diabetic patients p. 58
Nafesa M Kamal, Ahmed M Elsayed, Essam Amin, Amal Zedan
DOI:10.4103/ejim.ejim_80_17  
Context Diabetic nephropathy in type 2 diabetes mellitus is one of the most serious microvascular complications. Immunoglobulin G (IgG), with molecular weight of 150 kDa, is excreted in urine of normoalbuminuric diabetic patients. Aims The aim was to compare urinary IgG with microalbuminuria as an early indicator of diabetic nephropathy in patients with type 2 diabetes mellitus. Settings and design The study was conducted in Zagazig University Hospital. Materials and methods This case–control study was conducted on 88 type 2 diabetic adult patients who were divided into four groups. Group I: 22 patients with normal albumin creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR), group II: 21 patients with normal ACR (<20 mg/g creatinine) and eGFR (>120 ml/min/1.73 m2), group III: 24 patients with ACR from 20 to 200 mg/g creatinine and eGFR ranging from 60.74 to 102.48 ml/min/1.73 m2, and group IV: 21 patients with ACR more than 200 mg/g creatinine and eGFR ranging from 17.16 to 85.27 ml/min/1.73m2. Patients were subjected to complete blood count, kidney function tests (KFT), urinary albumin/creatinine ratio, urinary IgG/creatinine ratio, random blood sugar, and estimation of GFR by modification of diet in renal disease equation. Statistical analysis The data were analyzed using statistical package for the social science (SPSS), windows version 17. Description of qualitative variables was done by frequency and percentage. Description of quantitative variables was in the form of mean±SD. χ2-Test, Student’s t-test, analysis of variance (F-test), and correlation analysis were used for analytical examination. Results High significant difference among the different groups was found regarding ACR (P<0.001) and immunoglobulin G creatinine ratio (IgGCR) (P<0.001). ACR and IgGCR are highly increased in groups III and IV in comparison with groups 1 and II. There was a significant positive correlation between IgGCR and age, diabetes mellitus (DM) duration, serum creatinine (P<0.001), blood urea nitrogen, ACR, and renal sonography, and negative correlation with eGFR (P<0.001), hemoglobin, and serum albumin. Conclusion IgG appears in urine in early stages of diabetic nephropathy even before microalbuminuria, so we recommend its use to define high-risk patients, allowing prompt interventions.
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Brain natriuretic peptide as a diagnostic marker for heart failure in hyperthyroid patients with ischemic heart disease p. 63
Hazem M El-Ashmawy, Ekhlas M Hussein, Azza M Ahmed
DOI:10.4103/ejim.ejim_81_17  
Objective The aim of the study was to evaluate the value of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as an early diagnostic marker for chronic heart failure (CHF) in hypothyroid patients with ischemic heart disease (IHD). Materials and methods A total of 120 patients with an age range between 42 and 64 years participated in the study. All patients were classified into four groups: the master first group includes 30 patients with IHD, CHF functional class II–III and hyperthyroidism; the second group includes 30 patients with IHD and CHF functional class II–III, but with normal thyroid function; the third group includes 30 hyperthyroid patients without CHF or IHD; and the fourth group includes 30 hyperthyroid patients with IHD, without CHF. All patients were subjected to the following: full clinical and functional assessment, measurement of NT-proBNP, echocardiography, and the 6-min walk test. Results NT-proBNP levels were high in all studied groups. NT-proBNP levels showed no significant difference between patients of second and fourth group. The master first group had the highest significant NT-proBNP concentrations than other studied groups. Thyroid hyperfunction in patients with IHD appears to stimulate the natriuretic peptides secretion at a level exceeding what is recommended for the initial diagnosis of CHF. Conclusion The highest NT-proBNP level in hyperthyroid patients with IHD apparently is caused by stimulation of natriuretic peptide secretion by both thyroid hyperfunction and myocardial ischemic changes, which determine the need to check out the cut-off value of NT-proBNP level as a serological marker for the initial diagnosis of heart failure of such patients’ category.
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The relation between plasma levels of nesfatin-1 and different grades of diabetic kidney disease in patients with type 2 diabetes p. 68
Mohamed A Korani, Ahmed Sonbol
DOI:10.4103/ejim.ejim_82_17  
Background Diabetic kidney disease (DKD) is the leading cause of renal failure. Diabetic patients with microalbuminuria typically progress to proteinuria and overt diabetic nephropathy. Nesfatin-1 is an anoretic polypeptide with potent metabolic regulatory effects and its circulating levels are shown to be elevated in type 2 diabetes mellitus (T2 DM). Nesfatin-1 may be involved in the pathogenesis of DKD through inflammatory mechanisms. The aim of the work was to study the relation between plasma nesfatin-1 levels and different grades of DKD in patients with T2 DM. Patients and methods This study was conducted on 120 patients with T2 DM and 20 controls selected from the inpatient department and outpatient clinics of the Internal Medicine Department in Menoufia University Hospital. The selected individuals were grouped into four groups: group 1 included 20 healthy individuals, group 2 included 40 patients with T2 DM with normoalbuminuria, group 3 included 40 patients with T2 DM with microalbuminuria, and group 4 included 40 patients with T2 DM with macroalbuminuria. Members of the study were subjected to thorough history with special emphasis on age, sex, and duration of the DM. Investigations included fasting blood glucose, glycosylated hemoglobin, complete urine analysis, serum creatinine, urine albumin–creatinine ratio, estimated glomerular filtration rate, and plasma nesfatin-1. Results Plasma nesfatin-1 was significantly higher in group 4 compared with other groups, in group 3 compared with groups 1 and 2, and in group 2 compared with group 1. There was a positive significant correlation between plasma nesfatin-1 and serum creatinine, urine albumin–creatinine ratio, and glycosylated hemoglobin and negative significant correlation between plasma nesfatin-1 and estimated glomerular filtration rate in the studied diabetic patients. There was no correlation between plasma nesfatin-1 and BMI and duration of diabetes in the diabetic patients. Conclusion From this study, we can conclude that plasma nesfatin-1 is significantly higher in patients with DKD, and there is a positive correlation between plasma nefatin-1 level and the grades of DKD. So, plasma nesfatin-1 may be considered for prediction of developing DKD in a previously unaffected patients with DM.
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Esophageal varices predictive score in liver cirrhosis p. 72
Dala G Ashraf, Ibrahim El-Sayed
DOI:10.4103/ejim.ejim_85_17  
Background Endoscopic surveillance of esophageal varices (EV) in patients with cirrhosis is expensive and uncomfortable for many patients. Therefore, there is a particular need for noninvasive predictors for EV. Objective The aim of the present study was to evaluate the accuracy of ultrasound and blood indices as noninvasive EV predictors among patients with cirrhosis. Patients and methods A total of 500 patients with cirrhosis were enrolled in this study and were divided according to their endoscopic findings into nonvariceal group (90 patients) and variceal group (410 patients). All patients underwent serum albumin, prothrombin time, aspartate aminotransferase, alanine aminotransferase, serum bilirubin, platelet count, hemoglobin level, abdominal ultrasonography (portal vein diameter and splenic size), and Child–Pugh score assessments. Results By evaluation of studied parameters, as predictors for EV, the splenic size was significant at cut-off greater than 13 cm. Platelet count was significant at a cut-off less than 12 3000/ml. Portal vein diameter was significant at a cut-off greater than 12 mm. Serum albumin was significant at a cut-off less than 3.2 g/dl. Prothrombin time was significant at a cut-off greater than 13.29 s. Child–Pugh score was significant with advanced scores. By multivariate regression analysis of the significant parameters, we reported that splenic size was the most significant parameter followed by platelet count followed by Child–Pugh score. EV prediction score can predict EV with sensitivity of 79.3, specificity of 83.3, and accuracy of 87.6%. Conclusion EV prediction score is a noninvasive parameter that can predict the presence of EV in patients with cirrhosis. Hence, its application may decrease the burden of endoscopy and provide a tool for selecting patients for whom endoscopy may be more beneficial.
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Spleen size in patients with metabolic syndrome and its relation to metabolic and inflammatory parameters p. 78
Rokaya Abd El-Aziz, Mervat Naguib, Laila A Rashed
DOI:10.4103/ejim.ejim_86_17  
Introduction Spleen may be enlarged in patients with metabolic syndrome (MS). Many factors that are encountered in MS were incriminated as etiology of the splenomegaly. The aim of this study was to assess spleen longitudinal diameter (SLD) in patients with MS and to investigate the possible factors affecting spleen size. Patients and methods The study included 60 patients with MS and 30 healthy controls. Assessment of full medical history, anthropometric measurements, and abdominal ultrasound to identify SLD and hepatic steatosis was carried out. Liver enzymes, lipid profile, and interleukin-10 (IL-10) were measured. Fatty liver index, which is considered a marker of nonalcoholic fatty liver disease, was calculated from serum triglyceride, BMI, waist circumference, and γ-glutamyl transferase. Results SLD was significantly higher in patients with MS than controls (123.57±13.88 vs. 101.20±5.44 mm, P<0.001), but IL-10 level was significantly lower (65.24±23.47 vs. 129.41±27.65 pg/ml, P<0.001). Spearman correlation in patients with MS showed significant positive correlation between SLD and waist circumference (r=0.398, P=0.002), alanine aminotransferase (r=0.295, P=0.027), aspartate aminotransferase (r=0.442, P=0.001), alkaline phosphatase (r=0.444, P=0.001), but not with IL-10 (r=−0.047, P=0.730). Linear regression analysis revealed that waist circumference (β=0.265, P=0.044) and alkaline phosphatase (β=0.340, P=0.011) were the only determinants of SLD. Conclusion In this study, patients with MS had larger spleen size than healthy controls. SLD significantly correlated with waist circumference but not IL-10 in patients with MS.
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Hepatic microcirculatory thrombosis in acute-on-chronic hepatic failure p. 83
Ehab F Mostafa, Waleed A Ismael, Amr El Hawary, Ayman Marei, Sameh Saber
DOI:10.4103/ejim.ejim_5_18  
Background Acute-on-chronic hepatic failure is an increasing number of identified distinct disorders encompassing an acute deterioration of hepatic functions in patients with chronic liver disease Aim The aim was to evaluate the possibility of hepatic microcirculatory thrombosis in acute-on-chronic hepatic failure and the value of plasma fibrin monomer (FM) and D-dimer in the diagnosis. Patients and methods A total of 50 patients with chronic hepatitis C infection developing new-onset ascites, encephalopathy, and/or jaundice with raised international normalisation ratio (INR) (group 1); group 2 included 30 patients with compensated chronic hepatitis C virus infection who served as the control group. Ascetic fluid examination and culture were done for group 1, in addition to complete blood count, liver enzymes, INR, serum bilirubin and albumin, blood culture, α-fetoprotein, D-dimer, plasma FM, abdominal ultrasound, and Doppler for portal vein were done for all patients groups. Results Group 1was subdivided according to the level of FM into subgroups A and B. FM showed a significant difference between group 1A and other groups; group IB showed nonsignificant elevation of the level of FM and a significant increase in D-dimer compared with the control group. A marked reduction in portal flow mean velocity in group 1A was recorded with further deterioration of portal flow direction after 2 weeks from the admission time. Three months follow-up showed significant reduction of FM, improvement of portal flow mean velocity and direction in group 1A; FM was significantly positively correlated with portal flow mean velocity. Conclusion Hepatic microcirculatory thrombosis may occur in acute-on-chronic hepatic disease; determination of the FM and D-dimer level may be useful biomarkers predicting hepatic microcirculatory thrombosis.
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A comparison between conventional triple therapy and sequential therapy on tolerance of treatment and eradication of Helicobacter pylori infection in Egyptian patients p. 90
Waleed A Ismail, Ehab F Mostafa
DOI:10.4103/ejim.ejim_6_18  
Context Antimicrobial resistance has decreased eradication rates for Helicobacter pylori (H. pylori) infection worldwide. Sequential therapy (ST) has been suggested as an alternative to conventional triple therapy (TT) for the first-line treatment of H. pylori. Aim The purpose of this study was to compare the efficacy and tolerance of levofloxacin-based ST with clarithromycin-based TT. Materials and methods This is a randomized open-label clinical trial carried out on 134 patients with dyspepsia selected from Outpatient Clinic of Hepatology and Gastroenterology Department, Zagazig University Hospital, from October 2015 till September 2016. All patients were H. pylori positive as evidenced by C13-urea breath test and rapid urease test. Patients were divided into two groups: group I 67 patients received levofloxacin-based ST whereas group II 67 patients received clarithromycin-based TT for 14 days. Eradication rates, drug compliance, and adverse events were compared among the two regimens. Results The intention-to-treat eradication rates were 71.6% for TT and 91% for ST (P=0.004). The adverse effects including nausea, vomiting, abdominal pain, and diarrhea were less in levofloxacin-based ST than clarithromycin-based TT, but there was no statistically significant difference (all P>0.05). Conclusion The efficacy of levofloxacin-based ST is significantly better in the treatment of H. pylori than TT, and it also shows good tolerability. Countries like Egypt seem to have a high clarithromycin resistance, and a large-scale clinical trial is needed to choose the first-line therapy for eradication of H. pylori infection.
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