Ahmed Hassouna

To investigate the diagnostic ability of a non-invasive biological marker to predict liver fibrosis in hepatitis C genotype 4 patients with high accuracy. A cohort of 332 patients infected with hepatitis C genotype 4 was included in this cross-sectional study. Fasting plasma glucose, insulin, C-peptide, and angiotensin-converting enzyme serum levels were measured. Insulin resistance was mathematically calculated using the homeostasis model of insulin resistance (HOMA-IR). Fibrosis stages were distributed based on Metavir score as follows: F0 = 43, F1 = 136, F2 = 64, F3 = 45 and F4 = 44. Statistical analysis relied upon reclassification of fibrosis stages into mild fibrosis (F0-F) = 179, moderate fibrosis (F2) = 64, and advanced fibrosis (F3-F4) = 89. Univariate analysis indicated that age, log aspartate amino transaminase, log HOMA-IR and log platelet count were independent predictors of liver fibrosis stage (P < 0.0001). A stepwise multivariate discriminant functional analysis was used to drive a discriminative model for liver fibrosis. Our index used cut-off values of ≥ 0.86 and ≤ -0.31 to diagnose advanced and mild fibrosis, respectively, with receiving operating characteristics of 0.91 and 0.88, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio were: 73%, 91%, 75%, 90% and 8.0 respectively for advanced fibrosis, and 67%, 88%, 84%, 70% and 4.9, respectively, for mild fibrosis. Our predictive model is easily available and reproducible, and predicted liver fibrosis with acceptable accuracy.

Objectives To assess the prevalence of awareness and use of massive open online courses (MOOCs) among medical undergraduates in Egypt as a developing country, as well as identifying the limitations and satisfaction of using these courses. Design A multicentre, cross-sectional study using a web-based, pilot-tested and self-administered questionnaire. Settings Ten out of 19 randomly selected medical schools in Egypt. Participants 2700 undergraduate medical students were randomly selected, with an equal allocation of participants in each university and each study year. Primary and secondary outcome measures Primary outcome measures were the percentages of students who knew about MOOCs, students who enrolled and students who obtained a certificate. Secondary outcome measures included the limitations and satisfaction of using MOOCs through five-point Likert scale questions. Results Of 2527 eligible students, 2106 completed the questionnaire (response rate 83.3%). Of these students, 456 (21.7%) knew the term MOOCs or websites providing these courses. Out of the latter, 136 (29.8%) students had enrolled in at least one course, but only 25 (18.4%) had completed courses earning certificates. Clinical year students showed significantly higher rates of knowledge (p=0.009) and enrolment (pConclusions About one-fifth of Egyptian medical undergraduates have heard about MOOCs with only about 6.5% actively enrolled in courses. Students who actively participated showed a positive attitude towards the experience, but better time-management skills and faster Internet connection speeds are required. Further studies are needed to survey the enrolled students for a better understanding of their experience.

The continuation of warfarin throughout pregnancy in patients with a mechanical valve prosthesis is a valid anticoagulation regimen, provided that warfarin dose does not exceed 5 mg/day. Two decades after being introduced, the efficacy and safety of this regimen merit evaluation. We performed a systematic review for cases published between January 1991 and January 2013. We compiled our prospective data on 55 pregnancies and calculated pooled estimates (95% confidence interval) of adverse foetal and maternal outcomes. Events were expressed as proportions of total pregnancies, except embryopathy and maternal death, which were related to the number of live births and number of patients, respectively. There were 494 eligible pregnancies reported in 11 studies. The rate of embryopathy was 0.9% (0.4–2.4%) and most of the 13.4% (8.4–24.7%) foetal losses were due to the 12.8% (7.7–22.7%) rate of spontaneous abortion. No maternal mortality was encountered (0–1.3%) but 0.6% (0.3–2%) prosthetic valve thrombosis, 1.8% (1.1–3.6%) total thromboembolic events and 3.4% (2–5.1%) major maternal bleeding events were recorded. Foetal loss, spontaneous abortions and foetal embryopathy dropped to 8.1% (2.9–13.7%), 7.3% (3.1–11.8%) and 0.6% (0.1–2.1%) among the 344 pregnancies (69.6%) observed in the 6 prospective studies (54.5%). Prosthetic valve thrombosis (0.6%; 01–2%), total thromboembolic (2.3%; 1.2–4.6%) and major bleeding events (2.9%; 1.8–6%) remained comparable with overall results. Foetal embryopathy and prosthetic valve thrombosis were not robust on sensitivity analysis, regardless of the study design. A prospective subgroup of 96 patients (19.4%) received smaller warfarin dose, through targeting a lower international normalized ratio (INR) between 1.5 and 2.5. The associated rate of foetal loss (2.1%; 0.5–6.9%) was significantly lower than that observed in the remaining patients targeting a higher INR between 2.5 and 3.5 (16.1%; 13.1–34.4%). Adverse maternal outcomes were also fewer but rates remained comparable. Limited dose warfarin throughout pregnancy was associated with improved foetal outcomes, without jeopardizing maternal safety. Foetal outcomes were better when patients were followed up prospectively or receiving smaller warfarin doses through targeting a lower INR than recommended (1.5–2.5). Large randomized controlled trials are mandatory to evaluate our findings.

Objectives: The continuation of warfarin throughout pregnancy in patients with mechanical heart valve prostheses is a valid anticoagulation regimen, provided that warfarin dose does not exceed 5 mg/day. Two decades after being introduced, the efficacy and safety of this regimen merit evaluation. Methods: We performed a systematic review of cases published between 1991 and January 2012. We compiled our prospective data on 55 pregnancies and calculated pooled estimates (95% confidence interval) of adverse foetal and maternal outcomes. Events were expressed as proportions of total pregnancies, except embryopathy and maternal death, which were related to the numbers of live births and number of patients respectively. Results: There were 429 eligible pregnancies, 56.4% of which were studied prospectively. The rate of embryopathy was 0.85% (0.2-1.8%) and most of the 15.3% (7.3-24.6%) foetal losses were due to the 14.5% (7.5-23.5%) rate of spontaneous abortion. No maternal mortality was encountered (0-1.3%) but 0.8% (0.2-1.9%) prosthetic valve thrombosis, 1.9% (0.9-3.4%) total thromboembolic events and 3.6% (2.1-.6%) major maternal bleeding events were recorded. On the other hand, no embryopathy, prosthetic valve thrombosis or maternal mortality was recorded among the 242 prospective cases (0-1.49%). Although foetal loss and spontaneous abortion dropped to 7% (4.1-10.5%) and 6.7% (3.9-10.1%), total maternal thromboembolic complications and major bleeding events were slightly increased to 2.26% (0.8-4.5%) and 4.1% (2-6.9%), compared to overall results. Conclusions: Low dose warfarin throughout pregnancy was associated with improved foetal outcomes, without jeopardizing maternal safety. Those outcomes were better when patients were followed up prospectively, as expected.

To evaluate the impact of the preoperative patient characteristics on the results of coronary surgery in a developing country compared with a developed country.Preoperative risk factors for coronary artery disease (CAD) and intraoperative and immediate postoperative variables for coronary surgery were compared. Sixty patients were operated at Ain Shams University in Cairo (Egypt) between March and September 1999, compared with 60 patients operated at Hannover medical school (Germany) between March and September 2001. By using univariate analysis and multivariate logistic regression, model predictors for hospital mortality were determined.Groups were comparable regarding a majority of risk factors except age, diabetes, chronic obstructive pulmonary disease (COPD), and hypertension. Seventy percent of the Egyptian patients presented in New York Heart Association (NYHA) class III, whereas 50% of the German patients were in NYHA class II. Fifty percent of the German patients showed left ventricular ejection fraction (LVEF) >60%, whereas 52% of the Egyptian patients had LVEF between 40% and 59%. Diabetes (56.6%) and COPD (43.3%) are the major predictors of hospital mortality among the Egyptian patients as proved by high odds ratio (4.6 and 3.4, respectively). Egyptian patients required prolonged mechanical ventilation and extended intensive care unit and hospital stay. Hospital mortality was 6.7% in the Egyptian versus 1.7% in the German group.Diabetes mellitus, COPD, and prolonged mechanical ventilation are the major predictors of hospital mortality in Egypt. This study tries to underline problems of coronary artery bypass graft surgery in different populations.

Background: Although the addition of 300 mg dipyridamole to oral anticoagulants has been shown to decrease thromboembolic events after cardiac valve replacement, reports of combined therapy were few and some showed significant dipyridamole-related side effects and intolerance. The aim of this study was to compare the clinical effect of a standard monotherapy (targeting an international normalized ratio — INR — between 2.5 and 3.5) to a less intensive regimen (targeting an INR between 2 and 2.5) combined to a small dose of dipyridamole (225 mg/day). Methods: Between January 1990 and December 1998, 486 young rheumatic patients with a St Jude mitral valve prosthesis were assigned to follow either standard monotherapy (294 patients) or low-level combined therapy (192 patients). Phenindione has been the anticoagulant of choice. Up to a maximum daily dose of 100 mg, patients failing to achieve their target INR range were shifted to warfarin therapy. Prothrombin time was checked monthly and asymptomatic patients with a too low or a too high INR (5) were briefly hospitalized for INR control. Complete blood picture, renal and hepatic profiles and full echocardiographic study were done biannually. Results: With the exception of a significantly larger left atrium in patients on low-level combined therapy (P=0.001), both groups were comparable as regards to age and sex distribution, number of patients with atrial fibrillation, left atrial thrombus and history of stroke. Patients were monitored for 1712.6 pt yr and follow-up was 96.7% complete. No phenindione-related complications were observed (mean dose 62.3±21.4 mg), 20 patients (4.1%) had failed to achieve their target INR range and were switched to warfarin and only three patients (1.6%) had tolerable dipyridamole-related side effects. Compared to standard monotherapy, patients on low-level combined therapy showed significantly lower annualized rates: thromboembolism (1.6 vs 0.43%: risk reduction 71%; P=0.05), thromboembolism and hemorrhage (2.7 vs 0.7%: risk reduction 72%; P=0.005), death due to valve thrombosis or stroke (1.17 vs 0.14%: risk reduction 81%; P=0.04) as well as both non-fatal (3.3 vs 1.57%: risk reduction 51%; P=0.04) and total late postoperative complications (5.35 vs 3.14%: risk reduction 40%; P=0.04); respectively. However, total late mortality (32 patients; 1.8% per pt yr) was comparable among both groups. Conclusion: Low-level anticoagulation with phenindione combined to low dosage of dipyridamole was clinically more effective than the higher standard monotherapy. With respect to the prescribed doses, both drugs were well tolerated by almost all patients. Use of dipyridamole did not influence overall patients' survival.