Usefulness of AF Lactoferrin Levels in Patients with Liver Cirrhosis to Diagnose Spontaneous Bacterial Peritonitis

Background Cirrhosis represents the final common histological pathway for a wide variety of chronic liver diseases. Occurrence of ascites is the most common presentation of liver cirrhosis. Spontaneous bacterial peritonitis (SBP) is observed in 15–26% of patients hospitalized with ascites. Objectives The aims of this study was to evaluate the usefulness of AF lactoferrin for the diagnosis of SBP and to identify a clinically useful cut-off level that can be used for future development of an important clinical, economic and time saving rapid bedside test for the diagnosis of SBP in cirrhotic ascites. Patients and Methods This study was conducted on 40 patients with decompensated chronic liver disease and ascites with and without spontaneous bacterial peritonitis admitted to Nasser institute for researches and treatment Hospital and Internal Medicine department, Faculty of Medicine, Ain Shams University from November 2017 to April 2018. Results Females were affected more than males by SBP, SBP has higher incidence in elderly compared to control group, no significant difference between studied groups regards to risk factors and Child class, HCV infection was the main etiology of liver cirrhosis in both groups while HBV infection was much less common with no significant difference between studied groups. Patients in SBP group showed positive reaction to CRP compared to control group with significant difference between them. No statistical significant differences between studied groups regards to abdominal ultrasonographic findings. Liver enzymes (ALT) and ALP were higher in SBP patients compared to non SBP patients with significant difference between them. SBP patients have higher TLC and lower MCV and platelets count compared to non SBP patients with significant difference between them. No statistical significant difference between studied groups regards to INR, Hb and MCH values. Conclusion Outcomes of our study provide evidence of the clinical usefulness of AF lactoferrin levels in patients with cirrhosis to differentiate those with and without SBP.

Characteristics of De novo Hepatocellular carcinoma (HCC) in Chronic HCV Egyptian patients received Direct Acting Antivirals (DAAs) therapy: A pilot study

Background Direct-acting antiviral agents for chronic hepatitis C have initiated a revolution in the management and control of this important liver disease with cure rates over 90%. However, it has been suggested that HCC may occur or recur in patients with chronic HCV infection who received DAAs therapy. Aim To compare characteristics and behavior of de novo Hepatocellular carcinoma (HCC) in chronic HCV patients who received direct acting antiviral treatment with those who didn't receive DAAs . Patients and methods The current study was conducted on patients with de novo HCC presented at HCC clinic, Tropical medicine department Ain Shams University Hospitals between December 2017 and December 2018, aged (18-70 years old) . Total number of HCC cases visited the clinic during the study period was 416 patients. 160 patients with de novo HCC were enrolled in the study fullfiling the inclusion criteria and divided to two groups, 80 patients with HCC who received Direct antiviral treatment, the other 80 patients who didn't receive Direct antiviral treatment. Results Unlike some previous concerns about increased biologic aggressiveness of HCC after DAA treatment, resulting in infiltrative pattern and multinodular HCC outside Milan criteria, our results on de novo HCC after DAAs were mostly single, small, and diagnosed in early stages, resulting in BCLC stage 0-B in the majority of patients. There were no statistical differences regarding total size of tumor,or vascular invasion or AFP, but there’s a statistical difference in largest size of HFLs that was more significant in group (A) P = 0.04 The mean Child score was 5.75 in group A, with 61 patients (76.3%) were Child class A,19 patients (23.8%) were Child class B and 0 patients were child C. For the patients in group (B) the mean Child score was 6.15, with 50 patients (62.5%) were Child class A, 26 patients (32.5%) were Child class B and 4 patients (5%) were child C. Conclusion The current study shows no differences between the 2 studied groups as regard tumor aggressiveness, but data on risk of HCC and behaviour after DAAs is still conflicting and further studies are needed

Studies in object-oriented programming backbone implementations

This work is a combination of conceptual and hands on based study aimed at laying a foundation for practical Object-Oriented software construction. First it presents a conceptual study of a number of backbone concepts of modern Object-Oriented Programming (OOP) languages. Secondly, it attempts to demonstrate real-life implementations of these concepts using Python Programming Language. This work touches on practical issues on Class and Object Creation, especially on the syntax and creation, and demystifies the subject matter using a simple table of rules. The OOP concept of Inheritance was studied, with focus on the three major types of inheritance. The self-argument, and constructors were studied, with focus on the three constructors - default, parameterized, and non-parameterized constructors. A brief discussion, and pictorial illustration was also made on the disparity between normal mathematical functions and OOP method calls. Further areas of studies are the concept of overriding between the parent and child class, as well as the OOP puzzle commonly known as Diamond Problem, including code segment and diagrammatic illustration of Python-based solutions. There are a number of other back-bone concepts in OOP not covered in this study, such as Encapsulation, Abstraction, Meta-Programming, among others, which will form areas of focus in future studies. Effort was made to enhance the overall presentation through practical illustrations using source codes, annotated diagrams, and discussions. It is hoped that this work will be very useful to researchers and other practitioners in Object Oriented implementations.

Clinical Profile, Precipitating Factors and Outcome of Hepatic Encephalopathy in Patients with Liver Cirrhosis

Introduction: Hepatic encephalopathy (HE) is characterized by reversible neuropsychological features and is observed with advanced and decompensated cirrhosis of the liver. Patients outcomes and survival depends on clinical presentation, identification of the precipitating factor, early management, and treatment of complications. This study aims to find out the clinical profile of cirrhotic patients with hepatic encephalopathy, their precipitating factors, and clinical outcomes in patients admitted at a tertiary care Teaching Hospital in Gandaki province, Nepal. Materials and Methods: An observational, cross-sectional, hospital-based prospective study comprising of 140 cirrhotic patients with encephalopathy was conducted over a study period of 18 months. Their clinical profile, precipitating factors, and outcomes during hospitalization including mortality were studied. The data analysis was done using SPSS version 20 and a P-value of ≤0.05 was considered significant. Results: Majority (36.5%) of the patients presented with Grade II HE. Upper gastrointestinal (GI) bleeding and spontaneous bacterial peritonitis were the most common precipitating factors. Inpatient mortality was 22.9%. The increased mortality rate was observed in patients with Child class C and with higher grading (Grade III and IV) of hepatic encephalopathy and in presence of more than two precipitating factors Conclusion: Most of the patients presented with Grade II HE. Upper gastrointestinal bleed and infections were the most common precipitating factors. Patients with Hepatic encephalopathy of Grades III and IV, those with CTP Child class C, and in presence of more than two precipitating factors have high mortality.

Plasma cell free DNA methylation markers for hepatocellular carcinoma surveillance in patients with cirrhosis: a case control study

Background Hepatocellular carcinoma (HCC) is the leading cause of death in patients with cirrhosis, primarily due to failed early detection. HCC screening is recommended among individuals with cirrhosis using biannual abdominal ultrasound, for earlier tumor detection, administration of curative treatment, and improved survival. Surveillance by imaging with or without biomarkers such as alpha-fetoprotein (AFP) remains suboptimal for early stage HCC detection. Here we report on the development and assessment of methylation biomarkers from liquid biopsies for HCC surveillance in cirrhotic patients. Methods DNA methylation markers including the HCCBloodTest (Epigenomics AG) and a DNA-methylation panel established by next generation sequencing (NGS) were assessed using a training/testing design. The NGS panel algorithm was established in a training study (41 HCC patients; 46 cirrhotic non-HCC controls). For testing, plasma samples were obtained from cirrhotic patients (Child class A or B) with (60) or without (103) early stage HCC (BCLC stage 0, A, B). The assays were then tested using blinded sample sets and analyzed by preset algorithms. Results The HCCBloodTest and the NGS panel exhibited 76.7% and 57% sensitivities at 64.1% and 97% specificity, respectively. In a post-hoc analysis, a combination of the NGS panel with AFP (20 ng/mL) achieved 68% sensitivity at 97% specificity (AUC = 0.9). Conclusions Methylation biomarkers in cell free plasma DNA provide a new alternative for HCC surveillance. Multiomic panels comprising DNA methylation markers with other biological markers, such as AFP, provide an option to further increase the overall clinical performance of surveillance via minimally invasive blood samples. Trial Registration: Test set study—ClinicalTrials.gov (NCT03804593) January 11, 2019, retrospectively registered.

Arm lean mass determined by Dual-energy X-ray absorptiometry is superior to characterize skeletal muscle and predict sarcopenia-related mortality in cirrhosis

Introduction: Sarcopenia worsens survival in patients with advanced liver disease including cirrhosis. In this study we aimed to characterize skeletal muscle status by Dual-energy X-ray Absorptiometry (DXA) in patients with cirrhosis and examine the association between different skeletal muscle compartments and mortality. Methods: We included 231 men and 84 women (Child A, B, and C) with cirrhosis and 315 healthy matched controls (231 men and 84 women). Body composition was assessed with DXA. Appendicular skeletal muscle index (ASMI), arms index (AI), and legs index (LI) was calculated by normalizing lean mass to height squared. Low ASMI was defined as ASMI < 7.0 kg/m2 in men and < 5.5 kg/m2 in women. Biochemical and hemodynamic data were recorded for cirrhotic patients and mortality data retrieved from registers. Results: Low ASMI was more prevalent in both men (49%) and women (43%) with cirrhosis compared to healthy men (8%) and women (5%) (p<0.001). ASMI and LI were lowest in Child B, whereas AI decreased gradually with advancing Child Class. ASMI was inversely associated to mortality in men (HR = 0.74 [0.59-0.93], p <0.01), and this was mainly driven by AI (HR = 0.37 [0.18-0.71], p <0.01). Conclusion: AI showed closer association than ASMI or LI to both the severity of liver disease and to mortality, which may be due to increasing prevalence of leg edema with disease progression in this population. Determination of arm lean mass may add information on survival in patients with cirrhosis.

Influence of Hepatocellular Carcinoma on Platelet Aggregation in Cirrhosis

Hyper-functional platelets are being proposed as a potential therapeutic target in multiple cancers. Whether this can be considered in patients with cirrhosis and hepatocellular carcinoma (HCC) is unknown as their platelet function has not yet been investigated. We evaluated platelet function in cirrhosis patients with HCC. Patients with cirrhosis with and without HCC were prospectively recruited. Platelet aggregation, a marker of platelet function, was assessed by impedance aggregometry with adenosine diphosphate (ADP), arachidonic acid (ASPI), and thrombin (TRAP) stimulation. Plasmatic levels of Von Willebrand factor antigen (VWF) were also determined. One-hundred patients were recruited (50 cirrhotics with and 50 without HCC). Cirrhosis severity by Child class and platelet count were comparable between cirrhotics with and without HCC. Cirrhotics with HCC had higher ADP- (45 vs. 28; p < 0.001), ASPI- (47 vs. 28; p < 0.001), and TRAP- (85 vs. 75; p = 0.01) induced platelet aggregation than cirrhotics without HCC, all indicative of platelet hyper-function. The relatively increased platelet aggregation in patients with HCC was confirmed after adjusting the analysis for platelet count/severity of thrombocytopenia. Levels of VWF were higher in patients with vs. without HCC (348 vs. 267; p = 0.006), particularly in compensated cirrhosis. In patients with cirrhosis, HCC is associated with increased platelet aggregation and higher VWF. The clinical implications of these findings deserve further investigation.

Predictive factors of failure to control bleeding and 6-week mortality after variceal hemorrhage in liver cirrhosis – a tertiary referral center experience

IntroductionMortality from variceal bleeding remains high despite the therapeutic progress in severe cirrhosis. Understanding the predictive factors of failure to control bleeding (FTB) and mortality will lead to better future therapies. Comorbidities are thought to be important prognostic factors for variceal bleeding. The aim of the study was to assess the factors associated with FTB and with 42-day mortality and to evaluate the influence of comorbidities on these patients’ prognosis.Material and methodsWe prospectively included in the study all consecutive patients with cirrhosis and variceal bleeding presenting to the emergency room and we followed them up over 6 weeks. CirCom score and Charlson index were used for the assessment of comorbidities.ResultsOf the 138 patients included in the study, 27 (19.5%) were considered to have FTB. Child C class (74.07% vs. 32.43%, p < 0.001), Meld score (20.5 vs. 16.00, p = 0.004) and creatinine level (1.04 vs. 0.81, p = 0.01) were associated with FTB, but only Child class was independently associated with FTB in multivariate analysis (OR = 2.94, p = 0.006). Mortality at 42 days (21.7%) was influenced by the severity of the disease assessed through Child class (76.66% vs. 30.55% – Child C, p < 0.001) and MELD score (21.00 vs. 16.00, p < 0.001). Creatinine level (1.00 vs. 0.7, p = 0.02) and acute kidney injury (26.66% vs. 7.40%, p = 0.009) were also prognostic factors for the 6-week mortality. Comorbidities did not influence the mortality (CirCom > 1 (16.7% vs. 21.3%, p = 0.76) or Charlson index > 4 (36% vs. 47.2%, p = 0.41).ConclusionsThe severity of cirrhosis is an important prognostic factor for FTB and 42-day mortality. Identifying the factors associated with early mortality may help selecting patients needing more than conventional therapy.

Liver dynamics of HCV infection amongst patients aged 50 years or older visiting a larger tertiary care centre of Hyderabad, Pakistan

Introduction: Usually chronic infection of hepatitis C virus (HCV) is asymptomatic until present as acute hepatitis, acute liver failure or development of cirrhosis with decompensation. New era of Direct-acting antiviral (DAAs) for HCV has evolved the treatment with good result and tolerability. Early diagnosis and treatment can halt the further disease progression. Methodology: In this cross sectional study, all the patients with HCV positive either acute or chronic hepatitis infection, cirrhoisis with or without decompensation , aged 50 year or above, of either gender, presenting in the outpatient department (OPD) were included. Results: A total of 281 patients were enrolled during the study period. Mean age of the study population was 56.91±7.21years (range: 50–90years) and majority were male (51.6%) and with Child class A 136 (48.4%) followed by child class B 96(34.2%). Majority of patients presented as decompensated cirrhosis and raised transamines 160 (56.9%). Most common complication was variceal bleed 95 (33.8%) followed by ascities 88 (31.3%), pedal edema24 (8.5%). More than half of the patients were not eligible for treatment. Correlation between age and gender with liver stage and comorbids was statically significant (p=0.001). Conclusion: Late diagnosis present with complication with least options of treatment. Chronic hepatitis C is curable disease and should be diagnosed as early as possible. There should be screening at younger age.

GAMBARAN PERILAKU ANAK HIPERAKTIF PADA SISWA KELAS I SD NEGERI II DEMAK IJO

AbstrakPenelitian ini bertujuan untuk menjelaskan perilaku, faktor yang mempengaruhi, dan upaya guru dalam menghadapi anak hiperaktif kelas 1 SD Negeri II Demak Ijo. Penelitian ini merupakan penelitian deskriptif kualitatif yang dilakukkan di SD Negeri II Demak Ijo pada 1 Maret 2020. Dengan subjek Guru dan Siswa Kelas I Guru SD Negeri II Demak Ijo. Teknik pengumpulan data menggunakan observasi, wawancara dan dokumentasi. Hasil wawancara dan observasi yaitu SD Negeri II Demak Ijo merupakan sekolah inklusi, di sekolah tersebut terdapat satu anak hiperaktif dan Guru mengupayakan pembelajaran dengan memberikan perhatian yang berbeda dengan siswa lain. Perilaku seorang anak hiperaktif Siswa Kelas I SD Negeri II Demak Ijo antara lain: selalu menganggu teman lain, tidak mau diatur, cenderung egois, sering meninggalkan tempat duduk saat kegiatan pembelajaran, mengerjakan tugas di sekolah sesuai dengan kemaunnya, sering malas, dan manja. Perilaku tersebut disebabkan karena faktor keluarga. Faktor tersebut dapat diatasi dengan memberikan teguran dan sanksi kepada anak, orang tua memberikan pendampingan, dan guru memberi perlakuan yang berbeda dengan siswa pada umumnya. Kata Kunci: Hiperaktif, Perilaku Anak Hiperaktif, Dan Upaya Menghadapi Anak Hiperaktif Abstract This study aims to explain the behavior, the factors that influence, and the efforts of teachers in dealing with hyperactive children in grade 1 of SD Negeri II Demak Ijo. This research is a qualitative descriptive study conducted at SD Negeri II Demak Ijo on March 1, 2020. With the subject of Teachers and Class I Teachers of SD Negeri II Demak Ijo. Data collection techniques using observation, interviews and documentation. The results of interviews and observations, namely Demak Ijo Elementary School II is an inclusive school, there is one hyperactive child in the school and the teacher is trying to learn by giving different attention to other students. The behavior of a hyperactive child Class I Elementary School II Demak Ijo students: interrupts other friends, does not want to be regulated, tends to be selfish, often leaves the seat during learning activities, does assignments at school according to his skills, is often lazy, and spoiled. The behavior is caused by family factors. These factors can be overcome by giving reprimands and sanctions to children, parents provide assistance, and teachers give different treatment from students in general. Keywords: Hyperactivity, Hyperactive Children's Behavior, and Efforts to Deal with Hyperactive Children