The mature myeloma cells express very late antigen 5 (VLA-5) and MPC-1 antigens on their surface and adhere to bone marrow (BM) stromal cells more tightly than the VLA-5^-MPC-1^- immature myeloma cells in vitro. The VLA-5 and MPC-1 antigens possibly function as two of the molecules responsible for interaction of mature myeloma cells with BM stromal cells. However, the immature myeloma cells do interact with BM stromal cells, and it is unclear which adhesion molecules mediate their interaction. In this study, we found that both immature and mature myeloma cells expressed CD21, an adhesion molecule known to bind to CD23. CD21 was also detected on normal plasma cells. To evaluate the role of CD21 expression on myeloma cells, two myeloma cell lines, NOP-2 (VLA-5-MPC-l-) and KMS-5 (VLA-5'MPC-l'), were used as representatives of immature and mature myeloma cell types, respectively, and an adhesion assay was performed between the myeloma cell lines and BM stromal cells. Antibody-blocking results showed that adhesion of the mature type KMS-5 to KM102, a human BM derived stromal cell line, or to short-term cultured BM primary stromal cells was inhibited by monoclonal antibodies (MoAbs) against CD21, VLA-5, and MPC-1, and inhibition of adhesion of the immature type NOP-2 t o KM102 by the anti-CD21 MoAb was observed as well. Furthermore, CD23 was detected on KM102. Treatment of KM102 with an anti-CD23 MoAb also inhibited adhesion of either KMS-5 or NOP-2 to KM102. Therefore, we propose that CD21 expressed on myeloma cells likely functions as a molecule responsible for the interaction of immature myeloma cells as well as mature myeloma cells with BM stromal cells, and CD23 may be the ligand on the stroma cells for the CD21-mediated adhesion.

Several biomarkers have been checked and verified for use in improving risk rating and management resolutions in cases of community-acquired pneumonia (CAP) alongside the well-established severity scores.
Objective Our objective was to evaluate the veracity of the serum total cortisol level as a biomarker for assessing the severity of CAP.
Patients and methods Our research was a descriptive and prospective study of patients who have been diagnosed with CAP. All were admitted in the Chest Department of Assiut University Hospital between October 2017 and January 2019. The CAP severity was assessed for all enrolled patients by application of the pneumonia severity index (PSI). Serum total cortisol level was measured once in the morning (between 7 a.m. and 8 a.m.) within the first 24 h after admission. All of the patients were followed up until being discharged. The outcome variable was the intrahospital mortality.
Results This research enrolled 94 patients with CAP; of them, 62 (56%) patients survived, whereas the health of 32 (44%) patients deteriorated and they died. The nonsurvivors had significantly higher cortisol level in the serum compared with the survivors (34.15±9.78 vs. 24.90±8.89; P=0.04). Of the study population, 37 (39.4%) patients had normal cortisol level, whereas 57 (60.6%) had high cortisol level. It was noticed that patients with high cortisol level had a significantly higher PSI (140.75±48.31 vs. 103.56±43.57), and 87.2% of them had PSI class V. The serum cortisol level had a positive significant correlation with PSI points (r=0.45, P=0.01). In terms of the diagnostic performance of serum cortisol, it was noticed that serum cortisol at cutoff point more than 43 µg/dl had 80% sensitivity and 91% specificity to predict the intrahospital mortality in patients with CAP.
Conclusion The serum cortisol could be considered as a promising biomarker that is able to predict the severity and outcome of CAP. However, we recommend further larger studies with different aspects to investigate the accuracy of serum cortisol in assessing the severity of CAP and its potential effect on the treatment plan.

Prognostic markers play an essential role in the proper management of community-acquired pneumonia. This research work aimed to evaluate the association of RDW and /or MPV with mortality and morbidity in patients with CAP to improve the yield of already used prognostic scores.

Results

The current study enrolled 153 patients with community-acquired pneumonia (CAP). Out of them, 101 (64%) patients improved while 52 (36%) died. It was noticed that each of delta MPV and RDW (P < 0.001) had positive significant correlation with PSI and CURB-65. Delta MPV and RDW was significantly higher in patients who died (2.61 ± 1.01 vs. 1.78 ± 0.76; P = 0.01 for delta MPV and 16.50 ± 3.54 vs. 15.50 ± 2.81; P = 0.02 for RDW).

Conclusion

Initial RDW and rising MPV during hospitalization for CAP is associated with more severe clinical characteristics and high mortality. Moreover, the use of RDW and delta MPV in patients admitted with CAP can improve the performance of prognostic scales.

The frequency of fungal infections of the lung has increased particularly in immunocompromised pa-tients. Early diagnosis and treatment is important to start antifungal therapy and to avoid unnecessary use of toxic antifungal agents. This study aimed to identify the common fungal species causing pulmonary infection in immunocom-promised patients and their in vitro antifungal sensitivity pattern in Assiut University Hospitals (AUH).
Subjects and Methods: This was a hospital based descrip-tive study conducted on 135 patients admitted at different Intensive Care Units (ICUs) and Oncology Department at Assiut University Hospitals (AUH). Collected respiratory specimens were subjected to direct microscopic examination and inoculation on Sabouraud Dextrose Agar (SDA). Identi-fication of isolated yeasts was done using phenotypic methods including chromogenic media (Brilliance Candida agar and CHROMagar Candida differential media), germ tube test, cornmeal agar and API candida while mould isolates identifi-cation was mainly dependent on macroscopic and microscopic features. Some isolates had confirmed using rRNA gene sequencing. In vitro antifungal susceptibility testing was done using disc diffusion method.
Results: In this study 80/135 (59.3%) of collected samples were positive for fungal infection. The most common fungal pathogens isolated were Candida and Aspergillus species. In vitro sensitivity test showed that the yeast isolates had the highest sensitivity to Nystatin (90.9%) followed by Ampho-tericin B (80.3%) while for mould isolates, the highest sensi-tivity was to Voriconazole (71.4%) followed by Amphotericin B (57.1%).
Conclusion: Pulmonary fungal infection appears to be an important problem in immunocomprimised patients with Candida albicans was the most commonly isolated yeast from various clinical specimens; also the increase in the resistance especially to azoles is a major concern.

Aim of the work: To investigate the association of single nucleotide polymorphism (SNP) (rs2073618) of the OPG gene and of serum OPG with subclinical carotid atherosclerosis in RA patients. Patients and methods: Eighty RA patients with no previous history of a cardiovascular disease were studied and forty healthy controls were enrolled in the study. Carotid atherosclerosis was evaluated by highresolution B-mode ultrasound and the carotid intimal medial thickness (CIMT) measured. rs2073618 OPG genotyping was performed by polymerized chain reaction (PCR) and serum OPG concentrations were measured. The high sensitive C reactive protein (hs-CRP), rheumatoid factor (RF) titer and anti-cyclic citrullinated peptide (anti-CCP) were assessed. The disease activity score (DAS28) was evaluated. Results: The patients mean age was54.1 ± 6.2 years, disease duration of 12.5 ± 8.5 years and were 72 females and 8 males. Increased IMT was found in 38 patients, 40 age and sex matched controls were included. Patients with atherosclerosis (n = 38) had longer disease duration, higherDAS28, hs-CRP, RF titer and anti-CCP. The serum OPG levels were higher in patients with atherosclerosis (1106.4 ± 1157.1 ng/l) compared to those without (658.3 ± 151.1 ng/l)(p = 0.001). Serum OPG significantly correlated with disease duration (r = 0.42, p = 0.005), DAS28 (r = 0.53, p = 0.001), hs-CRP (r = 0.41, p = 0.007), anti-CCP (r = 0.47, p = 0.003) and mean CIMT (r = 0.37, p = 0.02). The frequencies of CC, CG and GG genotypes were comparable between those with and without atherosclerosis (39.5%, 50%, 10.4% vs 42.9%, 47.6% and 9.5% respectively). Conclusion: rs2073618 OPG gene may not be associated with subclinical atherosclerosis, although the serum level could be a reliable marker for disease activity and for early detection of carotid artery atherosclerosis in RA.

Background
The pancreatic leak is the most dangerous complication
postpancreaticoduodenectomy. There are many risk factors for the development
of pancreatic fistula (PF) such as texture of the pancreas and its duct size.
The aim was to decrease the incidence of PF in these risky patients.
Patients and methods
A retrospective study was performed on 20 periampullary tumors patients treated
by subtotal pancreatectomy between April 2015 and September 2017, which were
performed in Assiut Al Rajhi Liver Hospital. Subtotal pancreatectomy was
performed in patients with soft pancreas which could not hold stitches and small
duct size of less than 3 mm. Also, the authors follow the results of postoperative
pancreatic leakage, other morbidity and mortality.
Results
A PF type A developed in three cases and did not require any further management,
one case developed PF type B who also developed delayed gastric emptying and
improved after 3 months; one case of abdominal abscess was managed by
insertion of pig tail; two cases of wound infection improved by repeated
dressing; the mean hospital stay was 7 days except for the patient who
developed PF type B and delayed gastric emptying whose hospital stay was
prolonged to 1 month; the mortality rate was one case, who was a female
patient of 70 years old and died by myocardial infarction 1 week postoperatively.
Conclusion
Subtotal pancreatectomy with stapling can be done safely in risky patients to
decrease the incidence of PF, but further large randomized trials are needed.
Keywords:
pancreatic fistula, periampullary tumors, subtotal pancreatectomy

Background: Terlipressin, in general, is a vasopressor which acts via V1 receptors. Its infusion elevates mean blood
pressure and can reduce bleeding which has a splanchnic origin. The primary outcome was to assess the impact of
intraoperative terlipressin infusion on portal venous pressure during hepatobiliary surgery; the 2ry outcomes
included effects upon systemic hemodynamics, estimated blood loss, and postoperative renal functions.
Methods: This prospective randomized study involved 50 patients undergoing hepatobiliary surgery who were
randomly and equally allocated into terlipressin group, or a control group. The terlipressin group received an initial
bolus dose of (1 mg over 30 min) followed by a continuous infusion of 2 μg/kg/h throughout the procedure and
gradually weaned over the first four postoperative hours, whereas the control group received the same volumes of
normal saline. The portal venous pressure changes were measured directly through a portal vein angiocatheter.
Results: Portal pressure was significantly reduced over time in the terlipressin group only (from 17.88 ± 7.32 to
15.96 ± 6.55 mmHg, p < .001). Mean arterial blood pressure was significantly higher in the terlipressin group.
Estimated blood loss was significantly higher in the control group than the terlipressin group (1065.7 ± 202 versus
842 ± 145.5 ml; p = 0.004), and the units of packed RBCs transfused were significantly higher in the control group
((0–2) versus (0–4) p = 0.003). There was no significant difference between groups as regards the incidence of acute
kidney injury.
Conclusion: Intraoperative infusion of terlipressin during hepatobiliary surgery was shown to improve
intraoperative portal hemodynamics with subsequent reduction in blood loss.
Trial registration: Clinical trial number and registry URL: Trial registration number: NCT02718599. Name of registry:
ClinicalTrials.gov. URL of registry: https://clinicaltrials.gov/ct2/show/NCT02718599. Date of registration: March 2016.
Date of enrolment of the first participant to the trial: April 2016.
Keywords: Terlipressin, Portal pressure, Hemodynamics, Blood loss

Context
Multivisceral resections including Whipple procedure are among the foremost common
oncologic procedures during which massive bleeding and transfusion might happen
intraoperatively or postoperatively. Terlipressin is a synthetic vasopressin analog with relative
specificity for the splanchnic circulation where it causes vasoconstriction, with a hypothetical
reduction in blood loss during abdominal surgeries.
Aims
We aim to assess the effect of terlipressin infusion on blood loss and blood transfusion
requirements during Whipple procedure.
Settings and design
The current study was a prospective single center randomized placebo‑controlled trial. The
study was carried out in Al Rajhy Liver Hospital, Assiut University, Egypt between May 2016
and July 2017.
Patients and methods
In this trial 40 patients scheduled for Whipple procedure were randomly assigned either to
receive terlipressin at the beginning of surgery as an initial bolus dose of (1 mg over 30 min)
followed by a continuous infusion of 2 μg/kg/h throughout the procedure and gradually weaned
over the first 4 h postoperatively (terlipressin group) or to receive the same volume and rate
of 0.9% saline for the same duration (control group).The primary outcome was the amount
of intraoperative blood loss.
Statistical analysis used
Statistical analysis was established using SPSS, version 16.0.
Results
The amount of intraoperative blood loss was significantly lower in the terlipressin
group (690.00 ± 449.44) in comparison with the control group (1020.00 ± 284.88). Five (25%)
patients received blood transfusion in the terlipressin group compared with 13 (65%) patients
in the control group (P = 0.011). Significantly greater number of packed red blood cells units
were transfused to the control group (P = 0.013).
Conclusion
Terlipressin infusion during Whipple procedure was associated with less bleeding and lower
rates of blood transfusion requirements compared with placebo.
Keywords:
blood loss, terlipressin, transfusion needs, Whipple procedure

Abstract
Background
Scarcity of published research that comprehensively and meticulously analyzed the patient, disease, and treatment factors of prognostic significance in Ewing sarcoma (EWS) in Egypt.
Aim
To assess survival outcomes of EWS in Upper Egypt, delineating factors of prognostic significance in comparison to other leading oncology centers in Egypt and internationally.
Methods
We retrospectively reviewed medical records of 85 patients with a verified diagnosis of EWS at Pediatric Oncology department and Medical Oncology department at South Egypt Cancer Institute to gather data relevant to the patient, disease, and treatment variables of the study in the period from 2001 to 2015. Survival was estimated using the Kaplan Meier method and differences between various groups were determined by log rank test. Univariable and multivariable analyses were performed using Cox regression.
Results
With a median follow-up period of 62.7 months (95CI% 52.2-73.2, SE= 5.4) for the study patients, the estimates of event-free survival (EFS) and overall survival (OS) at 3 and 5 years were 42.1% and 50.6%, and 40.8% and 48.5%, respectively. Metastatic disease at initial presentation (HR=8.91, 95%CI, 4.00-19.9; P< 0.0001) stood as the most powerful predictor of OS in the multivariable analysis, followed by surgery used as a local modality (HR=0.16, 95%CI, 0.06-0.44; P= 0.0004). Response to neoadjuvant chemotherapy (HR=2.61, 95%CI, 1.11-6.13; P= 0.028), primary tumor size (HR=2.49, 95%CI, 1.03-6.03; P= 0.044) were also shown to be significantly associated with OS. Radiotherapy as a local modality, whose effect, apparently shown to increase the hazard of events occurrence in the univariable analysis, an effect that was reversed to reveal EFS advantage (HR=0.41, 95%CI, 0.18-0.95; P= 0.036) after control of other variables.
Conclusion
With 5-year OS of 48.5%, our survival results were comparable to those previously published from Egypt; however, differences still exist between centers due to varied representative study samples. However, outcomes in Egypt in general are still inferior to internationally published studies