Virologic and histologic characterisation of dual hepatitis B and C co-infection in Egyptian patients

Background and study aimsData about dual hepatitis C (HCV) and B (HBV) co-infection are still scarce, especially in endemic areas such as Egypt. Therefore, we aimed to characterise the virologic and histologic pattern of dual B/C co-infection in a tertiary care centre in Egypt.Patients and methodsAfter obtaining approval from the review board, a retrospective design to evaluate the data registry between January 2009 and December 2012 of patients with dual HCV and HBV seropositivity (BC-group) at the Viral Hepatitis Unit in Ministry of Health and Assiut University Hospital, Egypt was conducted. Data for hepatitis B e antigen (HBe-Ag) and anti-HB core status, anti-hepatitis delta virus (anti-HDV), HBV-DNA and HCV-RNA assays and liver biopsy (METAVIR scoring) results were collected. Two other matched groups of mono-HCV (C-group) and HBV (B-group) were selected as controls. All patients were naive for antiviral therapy.ResultsA total of 3300 patients were enrolled. Dual infection was observed in 25 (0.7%) patients (all males, mean = 35.2 ± 10.2 years). Four patients (16%) were HBe-Ag-positive. Six (24%) patients were HBV-DNA-negative and all were positive for HCV RNA. Between groups, raised alanine aminotransferase (ALT) was found in 76%, 41.7% and 49.2% of the BC, B and C groups, respectively (p = 0.023). HBV DNA >2000 IU ml^?1 was more in the B-group than in the BC-group (63.9% vs. 36%; p = 0.042) and HCV RNA >800,000 IU ml^?1 was more in the BC-group than in the C-group (28% vs. 12.3%; p = 0.009). Histologically, there is no statistical significant difference between the three groups.ConclusionDual hepatitis B/C infection is not uncommon and their virologic and histologic profile is modest. Further evaluation with regard to treatment and long-term follow-up is warranted.     

Study of Non–organ-specific Antibodies in Children with Genotype 4 Chronic Hepatitis C

Background/Aim:

Adult studies established a relationship between hepatitis C virus (HCV) infection and the presence of non–organ-specific antibodies (NOSAs). Most studies were carried out on genotypes 1 and 2. Only a few studies addressed that issue in pediatrics. No studies have been carried out on autoimmunity and genotype 4 in children. We aim to investigate NOSAs in 80 Egyptian children with chronic HCV infection along with studying the underlying genotype of HCV, and correlating autoimmunity with the epidemiological, clinical, biochemical, and virological features.

Materials and Methods:

HCV-RNA was assayed by the polymerase chain reaction and viral genotypes were determined. NOSAs were measured and liver biopsies were taken for histopathological examination.

Results:

Genotype4 was the only detected genotype in the included 80 patients. Anti-smooth muscle antibodies (ASMA) were the only detected antibodies in 32 (40%) patients, always with V specificity (vessels only) at titers ranging from 1:20 and 1:160. Anti-nuclear antibodies (ANA) and liver–kidney microsomal antibodies-1 (LKMA-1) were not detected in any of our patients. Epidemiologic and clinical features did not significantly differ between autoantibody-positive and -negative patients. Among biochemical features, significantly high levels of total bilirubin, albumin, immunoglobulins, alkaline phosphatase, and gamma-glutamyl transpeptidase were found in the antibody-positive group.

Conclusion:

Genotype 4 HCV is the prevailing genotype in Egyptian children with chronic HCV infection. A consistent proportion of these children with chronic HCV infection circulate non–organ-specific autoantibodies. The prevalence of ASMA and the absence of ANA and LKMA-1 might be related to the unique situation in Egypt with unique prevalence of genotype 4. More studies are warranted on larger pediatric population to validate these findings.     

Is the hepatitis C virus epidemic over in Egypt? Incidence and risk factors of new hepatitis C virus infections

Objectives: To estimate hepatitis C virus (HCV) incidence rates and identify risk factors for current HCV transmission with emphasis on the role of living with infected household family members in rural Egypt. Methods: A 4‐year population‐based, cohort study of seronegative villagers was conducted to identify incident HCV seroconversion cases. A risk factor questionnaire and blood samples for anti‐HCV EIA‐3 and HCV RNA polymerase chain reaction testing were collected at two rounds of follow‐up. Incidence rates, relative risks and 95% confidence interval (CI) were calculated based on a Poisson distribution. A matched case–control analysis to explore specific behavioural predictors of infection was conducted and odds ratios were obtained by conditional logistic regression. Results: Twenty‐five participants (11 females) seroconverted in 10 578 person years of follow‐up (PY), (incidence rate of 2.4/1000 PY; 95% CI: 1.6–3.5). The median age at seroconversion was 26 years [interquartile range (IQR) 19–35] among males and 20 years (IQR 13–24) among females. The only significant risk factor identified for these cases was receiving injections [adjusted odds ratio (OR_adj)=3.3; 95% CI: 1.1–9.8]. Two of the 17 viraemic seroconvertors were infected with the same strain as at least one of their family members. Conclusion: This study identified the important role of injections in spreading HCV infection in this rural community. National healthcare awareness and infection control programmes should be strengthened to prevent further transmission. Screening of families of infected HCV subjects should be an essential part of case management for early detection and management.     

Prevalence of occult hepatitis B virus infection in hemodialysis patients from egypt with or without hepatitis C virus infection

Background

While prevalence of Hepatitis B virus (HBV) in patients with end-stage renal failure (ESRF) who are undergoing dialysis has decreased significantly during the past few decades, it still remains a distinct clinical problem. The immunosuppressive nature of renal disease often leads to chronicity of the HBV infection and an opportunity for nosocomial spread of the infection among dialysis patients. Egypt is among the countries with intermediate endemicity of HBsAg (range, 2%–7%). Large-scale geographic heterogeneity in HBV prevalence has been reported worldwide and HBV prevalence is especially heterogeneous in Egypt.

Objectives

To assess the prevalence of occult HBV infection (OBI) in hemodialysis patients with or without chronic hepatitis C (HCV) from Minia and Assuit, Upper Egypt, using HBV DNA assays.

Patient and Methods

Sera from 145 hemodialysis patients with negative HbsAg were investigated for HBV DNA using real-time polymerase chain reaction (RT-PCR). Only serum samples with repeatedly detectable HBV DNA were considered positive. Patients were divided into 2 groups: HCV RNA positive and HCV RNA negative, based on the results of a third generation enzyme linked immunosorbent assay (ELISA) anti-HCV test and HCV RNA PCR.

Results

HBV DNA was detected in 6 of the 145 patients (4.1%) and HBcAb was detected in 29/145 patients (20%). There were no statistically significant differences in the age, duration of hemodialysis, biochemical parameters, serological markers of HBV, or HBV DNA between patients with and without HCV infection.

Conclusions

Four percent of the hemodialysis patients had OBI. There was no significant difference in the prevalence of OBI between hemodialysis patients with or without HCV co-infection.     

Elder mistreatment in a rural area in Egypt

Aim: Mistreatment of the elderly is a hidden problem frequently cloaked under the shroud of family secrecy. The aim of the present study was to determine the extent of mistreatment of older people living at their homes in the rural area of Mansoura city, Dakahlia governorate, Egypt. Methods: The present cross‐sectional study was carried out on 1106 respondents, 518 men (mean age 67.6 ± 6.3 years) and 588 women (mean age 68.5 ± 8.4 years), who answered face‐to‐face survey questionnaires. The questionnaires used were; Questionnaire to elicit elder abuse, Actual abuse tool, Elder Assessment Instrument, Risk of abuse tool, Katz index and Geriatric depression scale 15 items. Results: Of the respondents, 43.7% reported mistreatment by family members. The predominant type of reported mistreatment was neglect (42.4%) followed by physical abuse (5.7%), psychological abuse (5.1%) and financial abuse (3.8%). Conclusions: The independent risk factors for overall mistreatment of the elderly were older age, insufficient pension and caregiver other than spouse. Although being dependent, the number of children being three or less and caregiver other than spouse were significant independent attributes for “neglect” as a form of elder mistreatment. Geriatr Gerontol Int 2012; 12: 532–537.     

Clinical Outcome of Acute Upper Gastrointestinal Hemorrhage among Patients Admitted to a Government Hospital in Egypt

Background/Aim:

Acute upper gastrointestinal hemorrhage (AUGIH) is a life-threatening emergency that results in high morbidity and mortality. The mortality rate varies between 4% and 14%. The aim of the study was to determine the clinical outcome of AUGIH among patients admitted to a government hospital in Egypt.

Patients and Methods:

This was a cross-sectional hospital-based study performed in 1000 patients presenting with AUGIH over a 7-year period between January 2004 and January 2011.

Results:

One thousand patients were analyzed. Fifty-four percent were male. Mean age was 52 ± 17 years. Eighty-eight percent were emergency admissions and 12% were inpatients at the time of bleeding. At presentation 68% had major comorbidity and 50% had liver disease. Seven hundred and twenty-four patients (72%) underwent endoscopy. Bleeding varices accounted for 31% of AUGIH and peptic ulcer 28%. Two hundred and thirty-two patients had endoscopically diagnosed bleeding varices or peptic ulcer with a visible vessel or active bleeding. These received endoscopic therapy. Initial hemostasis was achieved in 207 (89%). Thirteen patients (6%) had therapy at a subsequent endoscopy for further bleeding. Surgery was performed on 9 patients (0.9%) with AUGIH. Complications were reported in 70 patients (7%) mainly liver failure (4%). Six hundred and eighty-four patients (68%) were discharged improved, 162 (16%) left hospital without a diagnosis and 4 (0.4%) were referred to another facility. The overall mortality was 15%. Mortality was 24% in patients ≥60 years, 37% among inpatients, and 21% in those who had a major comorbidity. Mortality was 22% in patients who had liver disease and 9% in variceal bleeding.

Conclusion:

The most common cause of AUGIH was variceal in origin. Endoscopic therapy was successful in most cases. Mortality after AUGIH was particularly high among elderly patients, inpatients, and patients who had a major comorbidity, liver disease, and variceal bleeding.     

Simeprevir plus sofosbuvir for eight or 12 weeks in treatment‐naïve and treatment‐experienced hepatitis C virus genotype 4 patients with or without cirrhosis

The OSIRIS study investigated efficacy and safety of simeprevir plus sofosbuvir for eight or 12 weeks in hepatitis C virus (HCV) genotype 4‐infected patients with METAVIR F0‐F4 fibrosis. Sixty‐three patients (33 treatment‐naïve and 30 peg‐interferon/ribavirin (Peg‐IFN/RBV)‐experienced) enrolled in a partly randomized, open‐label, multicentre, phase IIa study. Patients with F0‐F3 fibrosis were randomized (1:1) into two groups (A1 and A2), stratified according to treatment experience and METAVIR score, to receive either eight weeks (Group A1, n=20) or 12 weeks (Group A2, n=20) of treatment. Patients with compensated cirrhosis (METAVIR F4) received 12 weeks of treatment (Group B, n=23). Treatment comprised simeprevir 150 mg and sofosbuvir 400 mg daily. The primary efficacy endpoint was sustained virologic response 12 weeks after planned end of treatment (SVR12). Safety and tolerability were assessed throughout. Overall, 92% (95% CI: 82‐97) of patients achieved SVR12; 75% (15/20) in Group A1 and 100% in groups A2 and B. Patients who did not achieve SVR12 (n=5) experienced viral relapse during the first 32 days following treatment and were all prior Peg‐IFN/RBV null responders. The most commonly reported treatment‐emergent adverse events (TEAEs) were asymptomatic lipase increase (14%), pruritus (14%), headache (13%) and hyperbilirubinaemia (11%). No patients discontinued due to TEAEs. In conclusion, simeprevir plus sofosbuvir for 12 weeks achieved a 100% SVR rate in HCV genotype 4‐infected patients with or without compensated cirrhosis (ClinicalTrials.gov: NCT02278419). The AE and laboratory profile were favourable and consistent with previous data for simeprevir plus sofosbuvir in eight‐ and 12‐week regimens.     

Insomnia symptoms and their correlates among the elderly in geriatric homes in Alexandria,Egypt

The prevalence of sleep complaints increases steadily with age. Studies investigating insomnia among elderly people living in geriatric homes, especially among Egyptians, are scarce. This study aimed to determine the prevalence of insomnia symptoms among the elderly living in geriatric homes in Alexandria and their correlates. A cross-sectional survey of a representative sample of elderly population of geriatric homes in Alexandria was implemented. A total of 177 persons aged 60 years or older participated. Difficulty initiating sleep was reported by 65% of the participants. Approximately half of them had difficulty maintaining their sleep (50.8%) or had non-restful sleep (51.4%). Short sleep was reported by 43.5% of the participants, while early morning awakening was reported by 28.2%. Advanced age (≥75 years) was significantly associated with increased risk for early morning awakening, non-restful sleep and short sleep. Women had approximately a fourfold risk of non-restful sleep as opposed to men. Short stay in geriatric homes (<1 year) was associated with 2.5-fold increased risk of non-restful sleep. Unmarried status was strongly and positively related to difficulty to maintain sleep and non-restful sleep. Depressive status was significantly associated with an increased risk of difficulty to maintain sleep and decreased risk of early morning awakening. Conclusively, the present study showed that insomnia symptoms are highly prevalent among the elderly living in geriatric homes. It also revealed that although age, gender, and other socio-demographic factors are correlated with insomnia symptoms, other factors are highly important. Health care providers should take these factors in consideration when dealing with elderly patients who complain of insomnia.     

Molecular analysis of black coatings and anointing fluids from ancient Egyptian coffins,mummy cases,and funerary objects

Black organic coatings and ritual deposits on ancient Egyptian coffins and cartonnage cases are important and understudied sources of evidence about the rituals of funerary practice. Sometimes, the coatings were applied extensively over the surface of the coffin, resembling paint; in other cases, they were poured over the mummy case or wrapped body, presumably as part of a funerary ritual. For this study, multiple samples of black coatings and ritual liquids were taken from 20 Egyptian funerary items dating to a specific time period (c. 943 to 716 BC). Multiple sampling from each object enabled several comparisons to be made: the variability of the black coating within one application, the variability between two applications on one object, and the variability from object to object. All samples were analyzed for lipids using gas chromatography–mass spectrometry (GC-MS), and 51 samples from across the 20 items were further analyzed for the presence of bitumen using solid phase separation followed by selected ion monitoring GC-MS. The majority of the black substances were found to comprise a complex mixture of organic materials, including bitumen from the Dead Sea, conifer resin, and Pistacia resin, providing evidence for a continuation in international trade between Egypt and the eastern Mediterranean after the Late Bronze Age. Both the coating and the anointing liquid are very similar to mummification balms, pointing to parallels with Egyptian embalming rituals and raising questions about the practical aspects of Egyptian funerary practice.

To the ancient Egyptians, black symbolized the underworld and Osiris (often shown with black skin) and also night, especially when used in contrast with yellow and gold (for the sun) and the rich black soil of fertility and regeneration (1–3). The practice of using black coatings on Egyptian coffins is first attested in the Middle Kingdom (e.g., the cartonnage cases of Nepthys and Hapiankhtifi, Metropolitan Museum of Art 11.150.15 and 12.183.11c.1-0.2) and occurs in the New Kingdom, when black coatings are also used on funerary objects such as divine figures, shabtis, and shabti boxes (3–5). A secondary application of a black anointing liquid in a funerary context is known from at least as early as the burial of Tjuyu (18th Dynasty, c. 1375 BC), whose gilded funerary mask was anointed with black fluid (6).The application of black substances as coatings and anointing liquids on coffins and mummy cases also occurs in the Third Intermediate Period c. 1086 to 664 BC. This period in Egypt was a time of decentralized rule. In its first phase (21st Dynasty c. 1086 to 943 BC), kings based in the eastern Delta ruled the northern part of Egypt, sharing power with a line of generals, who also acted as high priests of Amun at Thebes, and controlled the southern stretch of the Nile valley. A return to centralized administration in the early 22nd Dynasty (c. 943 to 716 BC) was followed by a gradual fragmentation of the country into smaller political units, some of which were ruled by individuals claiming kingly status, while others were controlled by rulers of Libyan chiefdoms (7), thus Dynasties 22 to 24 and the early 25th Dynasty overlap. The end of the Bronze Age had seen catastrophic events across the eastern Mediterranean, with the Mycenaean and Hittite states collapsing (8, 9). Egypt itself saw incursions and lost control of land in Syria Palestine. Evidence from Egypt and the Levant during this time suggests fluctuating levels of contact and influence (10).During this period, burial practices were changing; instead of a decorated tomb and a wide array of tomb goods, the focus turned toward the body and the coffin (11, 12). The elite continued to lavish expenditure on their burials, but due to high levels of tomb raiding and tomb and coffin appropriation, emphasis was no longer placed on the funerary goods placed in the tomb, as was common in the New Kingdom (13). Instead, the expenditure was concentrated on the body and the coffin, which could be moved to a more secure location if necessary. The 21st Dynasty saw developments in mummification that indicate an increase in the resources allocated for those procedures (14). In the 22nd Dynasty, further changes in the treatment of the body were introduced, most notably the introduction of the cartonnage case, into which the mummy was tightly laced (3). Cartonnage is made with layers of linen, plaster, and glue, similar to papier maché, which can be molded to shape and which dries to make a hard case. These cases were valuable in terms of a vehicle for display as they could be highly decorated and gilded (14), and cartonnage is much more difficult to repurpose than other funerary goods because the body of the deceased is sewn inside. Concentrating resources into the preparation of the body, mummy case, and coffin allowed the elite to display their wealth and power while at the same time securing their investment.Black substances painted on the inside and/or outside of coffins and other funerary items or poured over cartonnage as part of the funerary ritual are a material source of evidence for examining the resourcing of funerary activities during this time of political upheaval. A research project on the 22nd-Dynasty coffins, cartonnage mummy cases, shabti boxes, and Osiris figures in the collection of the British Museum offered the opportunity to address this subject. Using analytical chemistry to examine the complex molecular composition of the black ritual substances, the study aimed to identify the materials used and their likely sources. Determination of chemical composition also offered a means to investigate how the materials were processed and applied as well as patterns of use within the funerary context.Previous research on similar materials has been limited and varied in terms of analytical techniques, covering multiple time periods and considering ritual applications alongside mummification balms (15, 16) or considering a small subset of samples (5, 17–19).^* By focusing on burial goods of the 22nd Dynasty, this research is a more targeted examination of funerary ritual residues than has been previously undertaken.