Problem of living liver donation in the absence of deceased liver transplantation program:Mansoura experience

We report our experience with potential donors for living donor liver transplantation(LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors(n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion(n = 792).Most of the transplant candidates(82.3%) had an experience with more than one excluded donor(median = 3). Some recipients travelled abroad for a deceased donor transplant(n = 12) and some died before finding a suitable donor(n = 14). The evaluation of an excluded donor is a time-consuming process(median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD(range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

Evolution of transanal total mesorectal excision for rectal cancer:From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision(TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life(QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision(TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending.As evidence for safety and feasibility accumulates,structured training programs to standardize teaching,training, and safe expansion will aid the safe spread of the TaTME.

Diagnostic non-invasive model of large risky esophageal varices in cirrhotic hepatitis C virus patients

AIM To build a diagnostic non-invasive model for screening of large varices in cirrhotic hepatitis C virus(HCV) patients. METHODS This study was conducted on 124 post-HCV cirrhotic patients presenting to the clinics of the Endemic Medicine Department at Mansoura University Hospital for evaluation before HCV antiviral therapy: 78 were Child A and 46 were Child B(score ≤ 8). Inclusion criteria for patients enrolled in this study was presence of cirrhotic HCV(diagnosed by either biopsy or fulfillment of clinical basis). Exclusion criteria consisted of patients with other etiologies of liver cirrhosis, e.g., hepatitis B virus and patients with high MELD score on transplant list. All patients were subjected to full medical record, full basic investigations, endoscopy, and computed tomography(CT), and then divided into groups with no varices, small varices, or large risky varices. In addition, values of Fibrosis-4 score(FIB-4), aminotransferase-to-platelet ratio index(APRI), and platelet count/splenic diameter ratio(PC/SD) were also calculated.RESULTS Detection of large varies is a multi-factorial process, affected by many variables. Choosing binary logistic regression, dependent factors were either large or small varices while independent factors included CT variables such coronary vein diameter, portal vein(PV) diameter, lieno-renal shunt and other laboratory noninvasive variables namely FIB-4, APRI, and platelet count/splenic diameter. Receiver operating characteristic(ROC) curve was plotted to determine the accuracy of non-invasive parameters for predicting the presence of large esophageal varices and the area under the ROC curve for each one of these parameters was obtained. A model was established and the best model for prediction of large risky esophageal varices used both PC/SD and PV diameter(75% accuracy), while the logistic model equation was shown to be(PV diameter ×-0.256) plus(PC/SD ×-0.006) plus(8.155). Values nearing 2 or more denote large varices.CONCLUSION This model equation has 86.9% sensitivity and 57.1% specificity, and would be of clinical applicability with 75% accuracy.

Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review

AIM: To evaluate the efficacy and safety of botulinum toxin type A(BTX-A) in the management of patients with anismus. METHODS: An organized search of published literature was conducted using electronic databases including: Pub Med/MEDLINE, and Cochrane Central Register of Control ed Trials, also an internet-based search using "Google Scholar" service was conducted. Both comparative and observational studies were included. We excluded irrelevant articles, editorials, case reports, reviews, and meta-analyses. The studies that followed the patients less than 6 mo were excluded. Variables collected were demographic data of the patients, technique of BTX-A injection and number of sessions, short-term and longterm clinical improvement, post-injection changes in electromyography(EMG), defecography, manometry, and balloon expulsion test, and complications recorded after BTX-A injection.RESULTS: Seven studies comprising 189 patients were included in the review. The median age of the patients was 41.2 years and female-to-male ratio was 1.3:1. The median dose of BTX-A injected per procedure was 100 IU(range, 20-100 IU). Lateral injection was done in five trails and combined lateral and posterior injections in two trials. Three studies used endorectal ultrasonographyguided technique, one study used EMG-guided technique,whereas the remaining three studies used manual palpation with the index finger. The median percentage of patients who reported initial improvement of symptoms was 77.4%(range 37.5%-86.7%), this percentage declined to a median of 46%(range 25%-100%) at 4 mo after injection of BTX-A. Rates of improvement evaluated by balloon expulsion test, EMG, and defecography ranged between(37.5%-80%),(54%-86.7%), and(25%-86.6%), respectively. Fourteen(7.4%) patients developed complications after injection of BTX-A. Complication rates across the studies ranged from 0% to 22.6%. CONCLUSION: Initial satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after 3 mo of the procedure. However, repeated injection may provide better sustained results with no additional morbidities. Further analysis of more patients is necessary to conclude the safety of BTX-A for the treatment of anismus.

Molecular study of astrovirus, adenovirus and norovirus in community acquired diarrhea in children: One Egyptian center study

Objective: To determine the prevalence of astrovirus, norovirus, adenovirus in children below five years old with diarrhea by multiplex reverse transcriptase polymerase chain reaction(RT-PCR) along with rotavirus antigen detection by enzyme linked immunosorbant assay.Methods: The study was conducted on children below five years old complaining of acute diarrhea. The study included stool examination by molecular method for detection of norovirus, adenovirus and astrovirus by multiplex RT-PCR. Rotavirus antigen was detected in the stool by enzyme linked immunosorbant assay.Results: The study included 100 children below 5 years old with acute diarrhea.Multiplex RT-PCR was positive in 34% of the children. The most frequently detected virus was rotavirus(44%), followed by norovirus(30%), adenovirus(20%) and astrovirus(14%). The clinical symptoms were more significantly associated with viral diarrhea such as fever(P = 0.03), bloody diarrhea(P = 0.025), vomiting(P = 0.000 1) and watery diarrheas(P = 0.05). The frequency of diarrhea with viral pathogen was significantly presented in winter season(39.7%). There were significant frequencies of norovirus and adenovirus in age ranging 1–2 years old(P = 0.04, P = 0.01 respectively).Conclusions: The present study spotlights on the prevalence of viral pathogens as an important etiology in diarrhea in children below five years old. Astrovirus, norovirus and adenovirus are common along with rotavirus in this group of patients. Multiplex PCR leads to improve the laboratory diagnosis of these viruses along with antigen detection method. Further longitudinal studies are required to evaluate the epidemiological data associated with these viruses and for proper management of such drastic infection.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

BACKGROUND Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome(ODS).AIM To assess the current literature in regard to the outcome of the classical transperineal repair(TPR)of rectocele and its technical modifications.METHODS An organized literature search for studies that assessed the outcome of TPR of rectocele was performed.PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020.The main outcome measures were improvement in ODS symptoms,improvement in sexual functions and continence,changes in manometric parameters,and quality of life.RESULTS After screening of 306 studies,24 articles were found eligible for inclusion to the review.Nine studies(301 patients)assessed the classical TPR of rectocele.The median rate of postoperative improvement in ODS symptoms was 72.7%(range,45.8%-83.3%)and reduction in rectocele size ranged from 41.4%-95.0%.Modifications of the classical repair entailed omission of levatorplasty,addition of implant,concomitant lateral internal sphincterotomy,changing the direction of plication of rectovaginal septum,and site-specific repair.CONCLUSION The transperineal repair of rectocele is associated with satisfactory,yet variable,improvement in ODS symptoms with parallel increase in quality-of-life score.Several modifications of the classical TPR were described.These modifications include omission of levatorplasty,insertion of implants,performing lateral sphincterotomy,changing the direction of classical plication,and site-specific repair.The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

Contrast-Enhanced CT-Guided Core Biopsy of Retroperitoneal Masses

Objective: To evaluate the efficacy, feasibility and safety of contrast-enhanced CT-guided core biopsy of retroperitoneal masses. Materials and Methods: Contrast-enhanced CT-guided biopsy of retroperitoneal masses was performed in 26 patients. Histopathological diagnosis was obtained and accuracy was calculated. Two blinded radiologists determined feasibility of biopsy procedures on routine CT-guidance, and compared accessibility of target lesions using contrast-enhanced and non-contrast-enhanced CT. Results: Satisfactory samples were obtained in all 26 patients and pathological diagnosis was made in 24. Accuracy was 95.5%. Routine CT-guided biopsy punctures were not satisfaction in 4/26 patients, and contrast-enhanced CT scans rendered the target lesions more accessible in 16 patients. Conclusion: Contrast-enhanced CT-guided biopsy increases the feasibility of biopsy of retroperitoneal masses.

Epidemiological Aspects of Intrafamilial Spread of HCV Infection in Egyptian Population: A Pilot Study

Aim: Liver disease is a leading cause of morbidity and mortality among Egyptians. The major cause is infection with HCV, with 70 000 up to 140 000 newly reported cases annually. The objectives of this study were to determine the prevalence of anti-HCV antibodies among household contacts of HCV index cases and to identify the possible risk factors of transmission of HCV among Egyptian families. Material and Methods: The present external pilot study (double centre study) was performed on a convenient sample of 125 index cases and their 321 household family contacts recruited from Mansoura & Cairo University where 2 questionnaires were used to collect data from the index & their related contacts. The all were exposed to clinical examinations, routine laboratory testing & screening for the prevalence of Anti-HCV antibodies. Results: The prevalence of anti-HCV seropositivity among household contacts of index cases was found to be 13.7% which husbands of female index cases ranked first followed by wives of male index cases (36.36% versus 17.86% respectively,

Angiographic characteristics of central serous chorioretinopathy in an Egyptian population

· AIM: To describe and analyze the demographic characteristics and to determine the angiographic features of acute central serous chorioretinopathy(CSCR) in an Egyptian population. ·METHODS: A series of consecutive patients presenting with acute idiopathic CSCR to Mansoura Ophthalmology Center Mansoura University who underwent fluorescein angiography (FA) within a 3 -year -period (between January 1, 2007 and December 31, 2009) was retrospectively studied. Patient demographics and angiographic features were studied. Results were compared to those of other Western and Asian populations. ·RESULTS: Fluorescein angiograms of 86 patients were analyzed. 91% were males. The age range of patients was 24 -49 years, with a mean age of (38±6) years. The right eye was the presenting eye in 47% of patients. Eighty seven percent of eyes showed delayed choroidal filling. Thirty -five percent of patients had more than one point of leakage. The macula was the most common site of fluorescein leakage seen in 79% of patients. Peripheral leakage was seen in 14% of patients while peripapillary leakage was seen in 12% of patients. The inkblot leakage pattern was found in 53% of patients. The presenting eye had RPE atrophic changes in 84% of cases. The other eye was assessed in 44 patients (51%). Fifty-five percent of them had signs of RPE atrophic changes. ·CONCLUSION: In the Egyptian population, CSCR is seen at younger age with higher male -to -female ratio and more frequent smokestack leaks than other populations. Despite younger age group, this series of patient showed higher frequency of bilateral and multifocal disease compared to other studies. Roles of psychological stress and choroidal ischemia in pathogenesis of CSCR need further evaluation. ·

Imaging appearance of bone tumors of the maxillofacial region

This paper reviews the imaging appearance of benign and malignant bone tumors of the maxillofacial region.A benign bone tumor commonly appears as a well circumscribed lesion.The matrix of the tumor may be calcified or sclerotic.Malignancies often display aggressive characteristics such as cortical breakthrough, bone destruction,a permeative pattern and associated soft-tissue masses.Computed tomography scan is an excellent imaging modality for accurate localization of the lesion,characterization of the tumor matrix and detection of associated osseous changes such as bone remodeling,destruction or periosteal reaction.Magnetic resonance imaging is of limited value in the evaluation of maxillofacial bone tumors.

Evaluation of Acute Toxicity and Dosimetric Parameters in High Risk Prostate Cancer Patients Treated by High Radiation Doses

For high risk prostate cancer, the treatment volumes and even dose levels are still a controversial issue. The aim of this study is to evaluate the dosemetric parameters and acute toxicity of dose-escalated whole pelvis (WP) Intensity Modulated Radiation Therapy (IMRT) and volumetric modulated arc therapy (VMAT) prostate boost following neoadjuvant and concomitant with androgen deprivation therapy in high-risk prostate cancer patients. This analysis included 73 high-risk prostate cancer patients treated with WP-IMRT followed by boost to the prostate by VMAT to total dose of 80 Gy;between January 2014 and October 2016. Androgen deprivation therapy (ADT) was given for all patients before and during radiation therapy. Drawing the dose volume histograms (DVHs) was done for planning target volumes (PTVs), including Prostate PTV & nodal PTV, and organs at risk including rectum, bladder, femoral heads, and bowel bag for the plans. Acute radiation toxicities were reported during the radiation course and the following 3 months. The DVH analysis showed good coverage of PTVs and organs at risk doses were acceptable. No recorded acute Grade ≥ 3 toxicity. Acute grade 1 toxicity for Gastrointestinal (GI) and Genitourinary (GU) were 65% and 35% respectively, while Grade 2 toxicity was 30% for both. The Proctitis and frequency were the commonest acute toxicity and were maximal during the 5th week of radiation therapy. Dose escalation in two phases utilizing Simultaneous integrated boost (SIB) combined with ADT in high risk prostate cancer patient is feasible and associated with acceptable acute GI and GU toxicity.

Fusion Navigation Technique for Management of Difficult to Access Hepatocellular Carcinoma: A Single Center Experience

Introduction: Sonography is the most universally used imaging technique for planning and performing thermal ablation in Hepatocellular carcinoma patients due to its efficiency and safety. However, the presence of HCC nodules that are hardly visible on traditional sonography is a major drawback to its use during thermal ablation. Real-time image fusion (fusion imaging) or real-time virtual sonography is a new technology that has been developed. Aim: To determine the value of fusion/navigation guided percutaneous thermal ablation in the management of hepatocellular carcinoma that has poor conspicuity at conventional sonography. Subjects and Methods: This study included 70 HCC patients (BCLC A and B). Percutaneous radiofrequency ablation was done via real-time image fusion for 14 patients with poorly visible HCC nodules (study group), while Percutaneous radiofrequency ablation was done via traditional sonography for 56 patients with HCC nodules (control group). Results: The median time to reach the tumor was significantly shorter by using fusion navigation technique (P = 0.034). By using fusion navigation technique 92% of the lesions were completely ablated while 55% only were completely ablated by using ultrasonography (P = 0.014). One year after the procedure , by using fusion navigation technique 92% of the patients had complete response and only 55% of the patients had complete response by using conventional ultrasonography (P = 0.011). The survival distributions for both interventions were statistically significantly different, χ2 = 10.12, P = 0.001. Conclusion: Fusion imaging-guided percutaneous RFA is a reasonable and efficient treatment of patients with HCC undetectable by traditional ultrasonography.

Psychiatric Co-Morbidity and Quality of Life in Egyptian Type 2 Diabetic Patients

Background: Diabetes is a risk factor for depression, but little is known about anxiety and other psychiatric disorders and quality of life. The aim of this study was to assess the prevalence of depression, anxiety in diabetic patients in our locality and to assess the quality of life in type 2 DM. Subjects & Methods: This study was a cross-sectional study and was carried out in outpatient clinics of specialized medical hospital, Mansoura university for a period of one year. From 217 diabetes mellitus subjects, only 202 patients were matched with 247 healthy people as a control group. All subjects were examined by using socioeconomic data, clinical data, and anthropometric examinations to assess body mass index and waist circumference. All patients were interviewed by using the Mini-International Neuropsychiatric Interview (MINI) version 5, MINI, Hospital Anxiety and Depression scale (HAD) and health-related quality of life (HRQOL) scales. Laboratory investigation in the form of fasting and two-hour postprandial blood sugar (FBS & 2hpp) and HbA1C levels were done. Results: 18.3% were found to be major depressive disorder;and 2.5% panic disorder, 1% other phobia. Generalized anxiety disorder and obsessive-compulsive disorder were found in one patient, no patients were found to be diagnosed as Bipolar disorder, schizophrenia, or substance abuse. Although there was no statistically significant difference between subjects and control groups regarding height, there was statistically significant difference between weights, BMI, with more scores among DM group. Moreover our study showed that HbA1c, fasting blood sugar, two hours post prandial blood sugar were more among DM patients and control groups. Anxiety, depression, and poorer quality of life were found to be more prevalent among DM patients than control groups. Conclusion: DM is associated with depression anxiety disorder with poorer quality of life.

A case report on aggressive fibromatosis of the arm and shoulder

Background:Aggressive fibromatosis is a locally aggressive tumor that originates from the deep musculo-aponeurotic structures.In this report,we describe the case of an adolescent male with painless,progressively growing swelling in his right arm necessitated surgical excision and postoperative pathologic examination revealed aggressive fibromatosis.Case presentation:A 15-year-old boy presented with a painless,progressively growing swelling of his right arm.The swelling was firm,non-tender and with restricted mobility.MRI imaging revealed a well-defined,heterogenous,lobulated swelling extending beneath arm and shoulder muscles.Wide local excision of the swelling was done under general anesthesia and pathologic examination revealed aggressive fibromatosis of the arm.Adjuvant radiotherapy was provided to the patient to reduce the risk of local recurrence of the tumor.Conclusion:Aggressive fibromatosis of the upper limb presents as a painless,progressively growing swelling.Assessment with MRI is imperative for making a preliminary diagnosis.Wide local excision with safety margin with adjuvant radiotherapy is the main line of treatment to minimize the incidence of recurrence and preserve the limb.

Orbital inflammatory disease:Pictorial review and differential diagnosis

Orbital inflammatory disease(OID) represents a collec tion of inflammatory conditions affecting the orbit. OID is a diagnosis of exclusion, with the differential diagno sis including infection, systemic inflammatory conditions and neoplasms, among other conditions. Inflammatory conditions in OID include dacryoadenitis, myositis, cel lulitis, optic perineuritis, periscleritis, orbital apicitis, and a focal mass. Sclerosing orbital inflammation is a rare condition with a chronic, indolent course involving dense fibrosis and lymphocytic infiltrate. Previously though to be along the spectrum of OID, it is now considered a distinct pathologic entity. Imaging plays an importan role in elucidating any underlying etiology behind orbita inflammation and is critical for ruling out other condi tions prior to a definitive diagnosis of OID. In this re view, we will explore the common sites of involvemen by OID and discuss differential diagnosis by site and key imaging findings for each condition.

Ejaculatory dysfunction in men with diabetes mellitus

Diabetes mellitus(DM)is a metabolic disorder that is characterized by elevated blood glucose levels due to absolute or relative insulin deficiency,in the background ofβ-cell dysfunction,insulin resistance,or both.Such chronic hyperglycemia is linked to long-term damage to blood vessels,nerves,and various organs.Currently,the worldwide burden of DM and its complications is in increase.Male sexual dysfunction is one of the famous complications of DM,including abnormal orgasmic/ejaculatory functions,desire/libido,and erection.Ejaculatory dysfunction encompasses several disorders related to DM and its complications,such as premature ejaculation,anejaculation(AE),delayed ejaculation,retrograde ejaculation(RE),ejaculatory pain,anesthetic ejaculation,decreased ejaculate volume,and decreased force of ejaculation.The problems linked to ejaculatory dysfunction may extend beyond the poor quality of life in diabetics as both AE and RE are alleged to alter the fertility potential of these patients.However,although both diabetes patients and their physicians are increasingly aware of diabetic ejaculatory dysfunction,this awareness still lags behind that of other diabetes complications.Therefore,all these disorders should be looked for thoroughly during the clinical evaluation of diabetic men.Besides,introducing the suitable option and/or maneuvers to treat these disorders should be tailored according to each case.This review aimed to explore the most important findings regarding ejaculatory dysfunction in diabetes from pre-clinical and clinical perspectives.

儿童头、颈部肿块的扩散加权成像检查

本研究的目的是评价由扩散加权平面回波MR成像计算出的表观扩散系数对儿童头、颈部肿瘤肿块的临床价 值。研究包括78例头、颈部肿块儿童（男46例、女32例，年龄范围3个月～15岁，平均为6岁）。在1．5T MR设备上行常规MRI和扩散加权成像，采用单次激发平面回波成像（EPI），b值为0．500和1000s／mm^2,测量ADC值。

Clinical asthma phenotyping:A trial for bridging gaps in asthma management

Asthma is a common disease affecting millions of people worldwide and exerting an enormous strain on health resources in many countries. Evidence is increasing that asthma is unlikely to be a single disease but rather a series of complex, overlapping individual diseases or phenotypes, each defined by its unique interaction between genetic and environmental factors. Asthma phenotypes were initially focused on combinations ofclinical characteristics, but they are now evolving to link pathophysiological mechanism to subtypes of asthma. Better characterization of those phenotypes is expected to be most useful for allocating asthma therapies. This article reviews different published researches in terms of unbiased approaches to phenotype asthma and emphasizes how the phenotyping exercise is an important step towards proper asthma treatment. It is structured into three sections; the heterogeneity of asthma, the impact of asthma heterogeneity on asthma management and different trials for phenotyping asthma.

HLA-DQB1 * 等位基因和基因危险性到类型 1 糖尿病 mellitus

AIM: To determine human leukocyte antigen (HLA)DQB1 allele association with susceptibility to type 1 diabetes (T1D) and to clinical and laboratory findings. METHODS: This study was conducted on 85 unrelated Egyptian children with T1D recruited consecutively from the Pediatric Diabetes Endocrinology outpatients Clinic; Mansoura University Children’s Hospital, Egypt. Patient mean follow up period was 2.5 years. Patients were subdivided according to level of HbA1c (optimal/suboptimal control 【 8.5% and poor control ≥ 8.5%). Thecontrol group consisted of 113 unrelated ageand sexmatched healthy subjects without T1D or other autoimmune diseases. Genomic DNA extraction was done for all subjects using a DNA isolation kit. HLA-Class Ⅱ-DQB1 allele typing was carried out with a polymerase chain reaction-sequence-specific oligonucleotide probe using a INNO-LiPA HLA-DQB1 update kit. RESULTS: Significant differences were detected between Egyptian patients with T1D and control groups in the frequencies of DQB1*02 [44.4% vs 18.6%, corrected P value (Pc) 【 0.001] and DQB1*03 (41.2% vs 24.4%, Pc 【 0.001). Significant differences were also observed between control groups and T1D patients in the frequencies of DQB1*05 (14.6% vs 7.2%, P = 0.029) and DQB1*06 (34.1% vs 7.2%, P 【 0.001). However, after correction for multiple comparisons, the significance was retained for HLA-DQB1*06 (Pc 【 0.001) but lost for HLA-DQB1*05. HLA-DQB1*0201, *0202, *030201 were positively associated with T1D (Pc = 0.014, Pc 【 0.001, and Pc 【 0.001 respectively), while HLA-DQB1*060101 was negatively associated (Pc 【 0.001) with the condition. Although the HLA-DQB1 alleles 030101 and 050101 were significantly higher in controls (P = 0.016, P = 0.025 respectively), both of them lost statistical significance after correction of P value. The frequency of the HLA-DQB1 genotypes 02/02, 02/03, and 03/03 was higher in T1D patients, and the frequency of the genotypes 03/06, 05/06, and 06/06 was higher in controls, these differences being statistically significant before correction. After correction, the genotypes 02/02, 02/03 in T1D, and the genotypes 03/06, 06/06 in controls were still significant (Pc = 0.01, Pc 【 0.001, Pc 【 0.001, and Pc = 0.04, respectively). Non-significant associations were found between the frequency HLA-DQB1 alleles and genotypes in T1D in relation to the grade of diabetic control, Microalbuminuria, age, gender, age of presentation, weight, height, frequency of diabetic ketoacidosis (P =0.42), serum cholesterol, and fasting and post-prandial level of C-peptide (P = 0.83, P = 0.9, respectively). CONCLUSION: The Current work suggests that HLADQB1 alleles *030201, *0202, *0201, and genotypes 02/03, 02/02 may be susceptibility risk factors for development of T1D in Egyptian children, while the HLADQB1*060101 allele, and 03/06, 06/06 genotypes may be protective factors. HLA-DQB1 alleles and genotypes do not contribute to microalbuminuria or grade of diabetic control.

Could ketamine be the answer to treating treatment-resistant major depressive disorder?

Major depressive disorder(MDD)is a common,serious,debilitating condition affecting 350 million people worldwide,which remains to be unsatisfactorily treated with 53%of patients still complaining of symptoms after completing their courses with the correct dosage.Ketamine,which was approved by the Food and Drug Administration in 2019,is a potential treatment option for those recalcitrant cases.The mechanism of ketamine is not fully understood,but as type it is classified as an N-methyl-D-aspartate(NMDA)glutamate receptor antagonist,and can be given intravenously,intranasally and orally.It is used to treat treatment-resistant depression,depression associated with suicidal ideation,mood and anxiety disorders and depressions associated with either type of bipolar disorder.Although ketamine is considered relatively safe,several side effects have been reported with the major ones being psychiatric in the form of worsening mood,anxiety and agitation;psychotomimetic in the form of dissociation,perceptual disturbance and abnormal sensations;cardiovascular in the form of increased blood pressure and increased heart rate;and neurological in the form of headache and dizziness.Ketamine is still not approved worldwide for usage in patients with treatment-resistant MDD,but if it is approved sometime in the future with relatively fewer side effects,it is expected to significantly save millions of dollars spent yearly on patients with treatment-resistant depression and that will lift this major burden off the shoulders of healthcare professionals.This study was designed to measure the effects of ketamine,an NMDA receptor antagonist,on patients with treatment-resistant MDD and to analyse the concept that makes it different and relatively safer than other major antidepressants like selective serotonin reuptake inhibitors,monoamine oxidase inhibitors and TCAs(tricyclic antidepressants).