Long-Term Outcomes of Resynchronization-Defibrillation for Heart Failure

BACKGROUND

The Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT) showed a greater benefit with respect to mortality at 5 years among patients who received cardiac-resynchronization therapy (CRT) than among those who received implantable cardioverter-defibrillators (ICDs). However, the effect of CRT on long-term survival is not known.

METHODS

We randomly assigned patients with New York Heart Association (NYHA) class II or III heart failure, a left ventricular ejection fraction of 30% or less, and an intrinsic QRS duration of 120 msec or more (or a paced QRS duration of 200 msec or more) to receive either an ICD alone or a CRT defibrillator (CRT-D). We assessed long-term outcomes among patients at the eight highest-enrolling participating sites. The primary outcome was death from any cause; the secondary outcome was a composite of death from any cause, heart transplantation, or implantation of a ventricular assist device.

RESULTS

The trial enrolled 1798 patients, of whom 1050 were included in the long-term survival trial; the median duration of follow-up for the 1050 patients was 7.7 years (interquartile range, 3.9 to 12.8), and the median duration of follow-up for those who survived was 13.9 years (interquartile range, 12.8 to 15.7). Death occurred in 405 of 530 patients (76.4%) assigned to the ICD group and in 370 of 520 patients (71.2%) assigned to the CRT-D group. The time until death appeared to be longer for those assigned to receive a CRT-D than for those assigned to receive an ICD (acceleration factor, 0.80; 95% confidence interval, 0.69 to 0.92; P = 0.002). A secondary-outcome event occurred in 412 patients (77.7%) in the ICD group and in 392 (75.4%) in the CRT-D group.

CONCLUSIONS

Among patients with a reduced ejection fraction, a widened QRS complex, and NYHA class II or III heart failure, the survival benefit associated with receipt of a CRT-D as compared with ICD appeared to be sustained during a median of nearly 14 years of follow-up. (RAFT ClinicalTrials.gov number, NCT00251251.).

Evaluation of parameters used in echocardiography and ultrasound protocol for the diagnosis of shock etiology in emergency setting

BACKGROUND

Early recognition and appropriate treatment has shown to decrease morbidity and mortality in patients with undifferentiated shock. There are many ultrasound protocols in shock; each protocol combines core ultrasound elements such as IVC and cardiac assessment which includes detection of cardiac tamponade, left ventricular function and right ventricular strain.Valvular assessment is absent in majority of ultasound protocols, while lung ultrasound is included in some of them.

OBJECTIVE

In this study we investigated which parameters used in Echo - US protocol help differentiate shock types.

METHODS

This cross sectional study was conducted on 150 patients with shock (140 patients were included while, 10 patients were excluded).Sensitivity and specificity of different parameters used in the Echo-US protocol were analyzed to detect which parameters can diffentiate shock types.

RESULTS

Velocity time integral of Aorta and IVC maximum diameter were good discriminators for distributive shock, with area under the ROC curve (AUC) = 0.8885 (95% CI 0.8144 to 0.9406) and 0.7728 (95% CI 0.6832 to 0.8473) (Z = 10.256 p < 0.0001) and (Z = 5.079 p < 0.0001) respectively. Left ventricular systolic function, presence of pneumonia, pneumothorax or valve vegetations were of great value in differentiating shock types, while CUST, FAST, TAPSE and RV diameter were not useful in differentiating shock types.

CONCLUSION

Ultrasound and echocardiography are powerful tools that can be used to identify shock etiology when the clinical picture overlaps.

Antimesenteric sleeve tapering enteroplasty with end-to-end anastomosis versus primary end-to-side anastomosis for the management of jejunal/ileal atresia

BACKGROUND/OBJECTIVE

Small bowel atresia commonly causes neonatal intestinal obstructions. Technical problems are associated with the surgical management of atresia using primary end-to-end anastomosis. Furthermore, the significantly dilated proximal loop may be associated with the stasis of intestinal fluid, thus increasing pressure on the anastomosis and prolonging fasting time before initiation of oral intake. This study aimed to perform antimesenteric tapering of the proximal loop using a linear stapler to reduce its diameter and facilitate anastomosis with the distal loop.

METHODS

This retrospective study included 57 neonates diagnosed with jejunoileal atresia. They were categorised into two groups: Group A (n = 29), which included neonates treated using antimesenteric sleeve enteroplasty tapering using a linear stapler and Group B (n = 28), which included neonates treated at the primary end of the proximal loop to the side of the distal loop anastomosis.

RESULTS

The mean operative time was 122.5 min in group A vs. 118 min in group B, and the mean duration to reach full oral intake was 17 days in group A vs. 20.2 days in group B (p = 0.03). The mean length of hospital stay was 25 and 35 days in groups A and B, respectively (p = 0.042).

CONCLUSION

Tapering the proximal dilated bowel loop to achieve anastomosis with the distal loop improved the transient time, reduced stasis and its associated translocation and colonisation, and allowed for early initiation and maintenance of oral intake. All these parameters shortened the overall length of hospital stay.

Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department

Background

Early diagnosis and appropriate management of shock aimed at prevention of prolonged hypoperfusion has shown to decrease morbidity and mortality in patients with undifferentiated shock. However, there is often a challenge in emergency department (ED) – where diagnosis is mainly based on clinical signs and standard monitoring parameters. Early use of point of care ultrasound could reduce the diagnostic time and improve diagnostic accuracy.

Purpose

The aim of this study is to investigate the accuracy of echocardiography - ultrasound protocol to identify the cause of shock in ED.

Method

The study was conducted on 150 shocked patients admitted to emergency department of Alexandria Main University Hospital from December 2018 to December 2020. The study was conducted to reach initial impression about shock etiology which was then compared to final diagnosis to determine accuracy, agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results

One hundred forty patients were included in the study (10 patients were excluded). The protocol was 100% accurate for diagnosing cases with obstructive and mixed obstructive distributive shock. It showed excellent rule- out characteristics for cardiogenic shock (sensitivity and NPV = 100%). There was almost perfect agreement between provisional and final shock type for mixed distributive cardiogenic shock (kappa 0.915). Echo- US protocol had lowest agreement and PPV for patients with hypovolemic shock Kappa 0.48 and 35% respectively.

Conclusion

The Echo- US protocol showed a high accuracy in identifying shock etiology in ED and is likely a promising diagnostic tool in emergency care.

Studies on the radiation dose, image quality and low contrast detectability from MSCT abdomen by using low tube voltage

Background

To study radiation dose, image quality and low-contrast cylinder detectability from multislice CT (MSCT) abdomen by using low tube voltage using the American College of Radiology (ACR) phantom. The ACR phantom (low-contrast module) was scanned with 64 MSCT scanner (Brilliance, Philips Medical System, Eindhoven, Netherlands) with 80 and 120 KVP, utilizing different tube current time product (mAs) range from 50 to 380 mAs. The image noise (SD), signal to noise ratio, contrast-to-noise ratio (CNR), and scores of low contrast detectability were assessed for every image respectively.

Results

From images analyses, the noise essentially increased with the use of low tube voltage. The CNR was 0.94 ± 0.27 at 120 KVP, and CNR was 0.43 ± 0.22 at 80 KVP. However, with the same dose, there were no differences of statistical significance in scores of low-contrast detectability between 120 KVP at 300mAs and 80 KVP at (200–380) mAs (p > 0.05). At 300 mAs, the CTDIvol obtained at 80 KVP was about 29% of that at 120 KVP. The CTDIvol obtained at 80 KVP were decreased from 5% at 50 mAs, to 37% at 380 mAs.

Conclusions

There is a possibility to decrease exposure of radiation virtually by reducing KVP from 120 to 80 KVP in examination of abdominal CT when the high tube current is used, though increasing image noise at low tube voltage.

Value of Copeptin Measurement as A Novel Biomarker for Prognosis in Acute Heart Failure

Background

Copeptin, C-terminal segment of pro-arginine vasopressin, is expected to be a strong novel biomarker for prognosis in acute heart failure (AHF).

Aim

Evaluate the prognostic role of copeptin in AHF either de novo or on top of chronic heart failure and its correlation with adverse cardiac events.

Methods

The study included 45 patients with acute decompensated heart failure (ADHF) to assess the relationship of serum copeptin level on admission and 72 hours after admission with adverse cardiac events (death, re-hospitalization and arrhythmias) in patients hospitalized with ADHF between May 2019 and November 2019 with median follow up period 6 months.

Results

In this study, 15 patients died, re-admission for heart failure occurred in 22 patients and arrhythmias were documented in 14 patients with atrial fibrillation (n = 9) and ventricular arrhythmias (n = 5). Mortality rate was higher among the elderly, smokers and patients with higher heart rate, lower left ventricular ejection fraction, more frequent arrhythmias, impaired kidney function and higher copeptin level. Furthermore, copeptin level at day 1 with cutoff value of &gt; 2.54 pmol/l predicted mortality with sensitivity of 86.67% and specificity of 53.33% while at day 3 copeptin level with cutoff value &gt; 2.74 pmol/l predicted mortality with sensitivity of 93.33% and specificity of 83.33%. Finally, change in copeptin level between day 1 and day 3 was associated with increased mortality. (p&lt;0.001)

Conclusion

Serum copeptin is suggested to be a strong biomarker to predict adverse clinical outcomes in patients with acute decompensated heart failure.

Outcomes and risk factors for death in patients with coronavirus disease-2019 (COVID-19) pneumonia admitted to the intensive care units of an Egyptian University Hospital. A retrospective cohort study

Background

The characteristics, outcomes, and risk factors for in-hospital death of critically ill intensive care unit (ICU) patients with coronavirus disease-2019 (COVID-19) have been described in patients from Europe, North America and China, but there are few data from COVID-19 patients in Middle Eastern countries. The aim of this study was to investigate the characteristics, outcomes, and risk factors for in-hospital death of critically ill patients with COVID-19 pneumonia admitted to the ICUs of a University Hospital in Egypt.

Methods

Retrospective analysis of patients with COVID-19 pneumonia admitted between April 28 and July 29, 2020 to two ICUs dedicated to the isolation and treatment of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Cairo University Hospitals. Diagnosis was confirmed in all patients using real-time reverse transcription polymerase chain reaction on respiratory samples and radiologic evidence of pneumonia.

Results

Of the 177 patients admitted to the ICUs during the study period, 160 patients had COVID-19 pneumonia and were included in the analysis (mean age: 60 ± 14 years, 67.5% males); 23% of patients had no known comorbidities. The overall ICU and hospital mortality rates were both 24.4%. The ICU and hospital lengths of stay were 7 (25–75% interquartile range: 4–10) and 10 (25–75% interquartile range: 7–14) days, respectively. In a multivariable analysis with in-hospital death as the dependent variable, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death, whereas greater PaO₂/FiO₂ ratio on admission to the ICU was associated with a lower risk.

Conclusion

In this cohort of critically ill patients with COVID-19 pneumonia, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death.

Serum Level of CD48 and Its Expression on Blood Leukocytes in Persistent Asthmatic Patients

CD48 is a surface receptor (mCD48) expressed on most hematopoietic cells, as well as in a soluble form (sCD48). It seems to play a major role in asthma through the interactions of mast cells with eosinophils via its ligand CD244. Hence, this study was done to evaluate the role of CD48, in its membrane and soluble forms, as a novel biomarker in asthma with various degrees of severity. One hundred participants were enrolled in this study and divided into 4 equal groups matched in age and sex; mild asthma, moderate asthma, severe asthma and apparently healthy controls. All were investigated for blood leukocytes mCD48 expression using flow cytometry and sCD48 in serum using ELISA. Our results revealed that the sCD48 was significantly elevated in patients with mild asthma compared with the controls (P<0.001) while significantly decreased in severe asthma than mild asthma (P<0.001) and moderate asthma (P=0.002) patient groups. Expression of mCD48 on eosinophils in moderate asthma group was significantly elevated compared with the control and the mild asthmatic groups (P<0.001). However, it was significantly decreased in severe asthma compared with moderate and mild asthma (P<0.001 and P=0.03, respectively). While it was significantly upregulated in severe asthmatic group compared to controls, patients with mild and moderate asthma on T-cell, B cells, Monocytes and NK cells (P<0.001 for all). In conclusion, CD48 may play a role in asthma and its level varies with severity of the disease being a useful marker in mild asthma.

A novel serum index for accurate diagnosis of spontaneous bacterial peritonitis in cirrhotic patients without other infections

Background

The accurate non-invasive diagnosis of spontaneous bacterial peritonitis (SBP) in patients with decompensated liver cirrhosis has not been achieved yet. The aim of the study was to obtain an unmistakable diagnosis of SBP using a new simple serum bioscore, made by combined measurement of procalcitonin (PCT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which we called the PEC index. This cross-sectional analytic study comprised 178 cirrhotic patients with ascites (60 patients with SBP and 118 patients with sterile ascites), after excluding non-SBP infection, during the period from March 2019 until September 2019. In all participants, serum levels of PCT, ESR, and CRP were measured, and PEC index was calculated [PEC index = PCT × (ESR + CRP)].

Results

Patients with SBP (n = 60) had significantly higher serum PEC index than those with sterile ascites (n = 118) (41.0/31.2–93.0 vs. 9.9/5.9–15.0, P < 0.001). PEC index distinguished culture positive cases significantly (P < 0.001). Using receiver operating characteristic (ROC) statistics, the sensitivity and specificity of PCT, at a cutoff value of 0.590 ng/mL, for SBP diagnosis, were 81.67% and 93.33%, respectively (area under the curve [AUC] = 0.879; 95% confidence interval [CI] 0.809–0.948). The sensitivity and specificity of ESR, at a cutoff value of 27.0 mm/hour, were 73.33% and 61.67%, respectively (AUC = 0.679; 95% CI 0.581–0.776). The sensitivity and specificity of CRP, at a cutoff value of 21.0 mg/L, were 93.33% and 51.67%, respectively (AUC = 0.736; 95% CI 0.639–0.833). While, the sensitivity and specificity of PEC index, at a cutoff value of 20, were highest (98.33% and 96.67%, respectively, AUC = 0.977; 95% CI 0.940–0.996).

Conclusion

Serum PEC index makes an accurate noninvasive diagnosis of SBP, after excluding other infections.

ACTH-Secreting Neuroendocrine Carcinoma of the Cecum: Case Report and Review of the Literature

BACKGROUND

Approximately 30% of neuroendocrine tumors (NETs) present with secretory syndromes or develop one during the course of the disease. Cushing syndrome caused by a gastrointestinal tract NET is rare, with limited published information. We describe a patient with florid Cushing syndrome due to ectopic adrenocorticotropic hormone (ACTH) from a NET of colonic origin. A literature review was conducted to describe the spectrum of this clinical and pathologic entity as reported in the scientific literature.

PATIENT AND METHODS

Next-generation sequencing and microsatellite instability testing was carried out on the tumor from our case. A preliminary PubMed search was conducted using the following terms under the publication type "Case Reports": "Cushing" AND "colon," "neuroendocrine" AND "colon" and "neuroendocrine AND Cushing AND "colon." A manual search was performed to review all references for inclusion and relevant clinical, biochemical and pathologic data was abstracted.

RESULTS

Mutations in BRAF V600E and TP53 were detected in our case. We retrieved 18 previously reported cases of Cushing syndrome associated with a NET of colonic origin, none of which had next-generation sequencing performed. Median age at diagnosis was 54.5 years (range, 24-74 years), with equal gender distribution. ACTH was detected by immunohistochemistry in the primary tumor and/or metastatic lesion in 61.5%. Review of the reports suggested that ectopic ACTH secretion from a colonic tumor might be more common in mixed glandular and NETs, including mixed adenocarcinoma-neuroendocrine carcinoma. Among studies reporting outcomes, the unadjusted mortality rate was 77.7%, with median overall survival from presentation of 63 days (range, 17-380 days).

CONCLUSION

Cushing syndrome associated with ectopic ACTH from tumors of colonic origin is a rare phenomenon with poor outcomes and can be associated with pure NETs, adenocarcinomas, and mixed-phenotype tumors, including mixed adenocarcinoma-neuroendocrine carcinoma.

First Acid-Fracturing Using New Fluid Technology Unlocks the Production Potential of Tight Carbonate, Mauddud Reservoir in North Kuwait

High reservoir heterogeneity and tightness necessitate the application of new stimulation technology targeting good fracture conductivity and deep penetration for effective productivity and recovery enhancement. With efforts of multidisciplinary team, new Acid Fracture fluid, diverter and high leak off control technologies have been designed and executed successfully as first time ever covering multiple layers in Mauddud carbonate reservoir in Bahra field.

Mauddud is heterogeneous, tight multilayer limestone reservoir especially in Bahra field which is still under exploration phase despite having initial production early 1975. Owing to the low reservoir transmissibility, production performance has historically been poor, even with Artificial Lift and conventional Stimulation. Therefore, full-scale commercial exploitation of the Mauddud/Bahra reservoir requires advanced technologies for productivity enhancement.

One of the oldest Mauddud vertical wells in Bahra field was drilled in 1974, completed across all Mauddud layers. It was initially produced naturally at very low rate and intermittent flow periods till ceased to flow in 2001. ESP was installed in 2007, and conventional Matrix Acid stimulation was performed with very steep post-treatment decline rate. It was produced intermittently for 4 months, and then closed in due to too low reservoir inflow. This well was selected for first application of Acid-Fracturing due to its relatively good reservoir development with high (~virgin) pressure, but low production rates.

The job was designed to implement one-stage Acid Fracturing using new acid fluid diverter technology to enable covering all perforated Mauddud layers, and maximizing fracture conductivity and penetration. Many technical and operational challenges were faced and properly handled through integrated communication between different concerned teams with lessons learned are to be considered in next designs and executions.

Post-Acid-Fracturing Production results showed initial high rate at high bottom-hole flowing pressure, followed by a gradual decline in rate and pressure representing transient flow period until reached reasonable stabilization. The nodal analysis has estimated post stimulation reservoir productivity improvement by ~3 folds based on the average stabilized rate and pressure.

The positive results of this first Acid Fracturing has set up the foundation for productivity enhancement and Mauddud reservoir development strategy for existing and new planned wells in Bahra field. As a prompt action, 2 more wells (1 existing and 1 new) have been acid fractured with good results.

It is expected that the oil gain potential will be significantly more in Horizontal Completions due to more extended reservoir coverage. Therefore, Acid Fracturing Stimulation for horizontal wells is under study for Bahra Mauddud Reservoir. The success of such application will formulate the drilling, completion and stimulation development strategy for the entire Mauddud Reservoir including early stimulation to improve initial productivity that will contribute significantly to the North Kuwait production target.

Strong association between long and heterogeneous telomere length in blood lymphocytes and bladder cancer risk in Egyptian

Although it is widely recognized that telomere dysfunction plays an important role in cancer, the relationship between telomere function and bladder cancer risk is not well defined. In a case-control study of bladder cancer in Egypt, we examined relationships between two telomere features and bladder cancer risk. Telomere fluorescent in situ hybridization was used to measure telomere features using short-term cultured blood lymphocytes. Logistic regression was used to estimate the strength of association between telomere features and the risk of urothelial carcinoma of the bladder. High telomere length variation (TLV) across all chromosomal ends was significantly associated with an increased risk of bladder cancer [adjusted odds ratios (OR) = 2.22, 95% confidence interval (CI) = 1.48-3.35], as was long average telomere length (OR = 3.19, 95% CI = 2.07, 4.91). Further, TLV and average telomere length jointly affected bladder cancer risk: when comparing individuals with long telomere length and high TLV to those with short telomere length and low TLV, the adjusted OR was 14.68 (95% CI: 6.74-31.98). These associations were stronger among individuals who are 60 years of age or younger. In summary, long and heterogeneous telomere length in blood lymphocytes was strongly associated with an increased bladder cancer risk in Egyptian and the association was modulated by age.

The outcome of the seminal fluid parameters collected via coitus interruptus versus masturbation

A one year study was carried out to determine the outcome of the seminal fluid parameters collected via masturbation and coitus interruptus in 151 patients who were undergoing intrauterine insemination (IUI) and patients who came for seminal analysis. There were no statistically significant differences in terms of volume, concentration, progressive motility and normal morphology from specimens collected via coitus interruptus compared to specimens collected via masturbation. Pregnancy outcomes were also comparable.

Blood lead levels in Egyptian children from high and low lead-polluted areas: impact on cognitive function

OBJECTIVES

Many children are harmed by low-level lead exposure which impairs cognitive development with subsequent poor scholastic achievement. We investigated blood lead levels in children in relation to cognitive function.

MATERIALS AND METHODS

Blood lead levels were measured in 100 children recruited from high (n = 50) and low (n = 50) lead-polluted areas.

RESULTS

Blood lead levels ranged between 3 and 28 microg/dl (median 9, interquartile range 6 microg/dl). In addition, 43% of children had levels > or =10 microg/dl, of whom 90.1% were living in high-risk areas for lead pollution. Cognitive dysfunction was found in 37% of children. Children with cognitive dysfunction had significantly higher blood lead and lower hemoglobin than those without (P < 0.001).

CONCLUSIONS

Increased blood lead level in many children is one of the health problems in Egypt which may be the reason, at least in part, for cognitive dysfunction with subsequent poor scholastic achievement. Thus, interventions to control lead exposure are mandatory.

Diet, nutritional knowledge and health status of urban middle-aged Malaysian women

The objective of the study was to assess nutritional and health status as well as nutritional knowledge in urban middle-aged Malaysian women. The impact of menopause on diet and health indices was also studied. The study included 360 disease free women, non users of HRT,aged > or =45 years with an intact uterus recruited from November 1999 to October 2001. Personal characteristics, anthropometric measurements and blood sample were acquired followed by clinical examination. Nutrient intake and nutritional knowledge was determined by a quantitative FFQ and KAP. The findings showed that urban middle-aged women, aged 51.65+/-5.40 years had energy intakes (EI) 11% below RDA, consisting of 53% carbohydrates, 15% protein and a 32% fat which declined with age. The sample which comprised of 42.5% postmenopausal women had a satisfactory diet and healthy lifestyle practices. Premenopausal women consumed more dietary fat (6%) with other aspects of diet comparable to the postmenopausal women. Iron intake was deficient in premenopausal women, amounting to 56% RDA contributing to a 26% prevalence of anaemia. Overall, calcium intake reached 440 mg daily but dairy products were not the main source. The postmenopaused had a more artherogenic lipid profile with significantly higher total cholesterol (TC) and LDL-C, but more premenopausal women were overweight/obese (49% versus 35%). EI was the strongest predictor for BMI and waist circumference (WC), with WC itself an independent predictor of fasting blood sugar and TC with BMI strongly affecting glucose tolerance. High nutritional knowledge was seen in 39% whereas 20% had poor knowledge. Newspapers and magazines, followed by the subject's social circle, were the main sources of nutritional information. Nutritional knowledge was positively associated with education, household income, vitamin/ mineral supplementation and regular physical activity but inversely related to TC. In conclusion, middle-aged urban women had an adequate diet with low iron and calcium intakes. Nutritional knowledge was positively associated to healthier lifestyle practices and lower TC. A comparable nutrient intake and lifestyle between pre and postmenopausal women suggested that health changes associated with menopause was largely independent of diet.

Bone health in urban midlife Malaysian women: risk factors and prevention

The aim of this study was to identify risk factors associated with osteoporosis in urban midlife Malaysian women and to assess the effectiveness of lifestyle intervention in bone loss prevention with hormone replacement therapy (HRT) as a positive control. A total of 514 disease-free, uterus-intact, non-HRT-using women aged 45 years and older were recruited into the study. After initial bone mineral density (BMD) assessments, they were randomized into three groups: GI (control), G2 (lifestyle intervention), and G3 (lifestyle intervention with HRT). The study group was composed of 67.5% Chinese, 27.8% Malay, and 4.2% Indians with a mean age of 51.07+/-5.28 years. Two-fifths were postmenopausal, and the prevalence of osteoporosis was 24.1%, seen predominantly at the hip. Postmenopausal women had significantly lower mean BMD and a higher incidence of osteoporosis compared with the premenopausal women, 42.1% vs. 11.1% (p<0.0005). A lower incidence of osteoporosis was found in women who took calcium supplementation regularly as opposed to those who do not, 18.7% vs. 29.3% (p=0.036). Age and a greater postmenopausal duration showed a significant negative association with BMD, whereas higher family income, weight, body mass index, and waist and hip circumference were positively correlated. After 18-20 months, the effect of intervention was assessed based on BMD values of 279 women at baseline and after intervention. Lifestyle intervention alone was effective in premenopausal women, preventing over 90% of spinal bone loss compared with the controls, who lost 11.6% (0.046 g/cm2) bone mass with similar losses of hip bone, 2.0% (0.026 g/cm2) vs. 1.5% (0.020 g/cm2). Premenopausal women on HRT also showed a substantial decrease in spine and hip BMD, 18.6% (0.081 g/cm2) and 9.0% (0.122 g/cm2), respectively. The lifestyle intervention program retarded postmenopausal bone loss by 21% and 37% compared with controls, who lost 9.6% (0.141 g/cm2) and 6.0% (0.138 g/cm2) bone mass at the spine and hip. In comparison, lifestyle intervention with HRT increased postmenopausal BMD by 12.7% (0.216 g/cm2) at the spine and 1.9% (0.042 g/cm2) at the hip. The changes in hip BMD were influenced by current age, ethnicity, and income, while intervention had the strongest effect on spine BMD changes. In conclusion, lifestyle intervention prevented spinal bone loss in premenopausal women and retarded postmenopausal spine and hip bone loss compared with controls. The benefits of physical activity on spine and hip BMD highlight its potential as a safe and cost-effective alternative to HRT, which is not advocated because of its potential adverse effects.

Living Related Liver Transplantation for Hepatocellular Carcinoma in Egypt

BACKGROUND

Living related liver transplantation (LRLT) for hepatocellular carcinoma (HCC) in cirrhotic patients has emerged as a rewarding therapy for a cure. Extensions of the Milan criteria have been proposed with encouraging results.

PATIENTS AND METHODS

From October 2001 to June 2004, 47 adult patients with end-stage liver disease (ESLD) have been treated using LRLT, including 11 (9 males and 2 females) with HCC superimposed on hepatitis C virus (HCV)-related (n = 10) or hepatitis B virus-related (n = 1) cirrhosis. Their mean age was 50 years (range, 40-61). HCC was confirmed preoperatively in 9 subjects whereas it was an incidental finding in 2 cases. Alpha fetoprotein (AFP) levels were elevated in 5 of them. Radiologically, tumor number and sizes ranged from 1 to 2 nodules and from 1.5 to 7 cm, respectively. Five of the 11 subjects underwent pretransplantation tumor control therapy.

RESULTS

Nine patients are alive, all of them being disease free during follow-up periods ranging from 6 to 30 months. Two subjects died: one of HCC recurrence at 1 year posttransplantation, and another of a pulmonary embolism on day 7. AFP levels decreased to normal values in 4 cases. Excluding the 2 incidental tumors, pathological examination of the explants revealed a higher number and larger size of the nodules in 3 and 5 cases, respectively. Microvascular invasion was documented in 3 explants, 1 of which experienced HCC recurrence and the other 2 received 6 cycles of Doxorubicin following normalization of their liver profile. Postoperative complications included the following: recurrent HCC (n = 1), recurrent HCV (n = 2), acute cellular rejection (n = 3), anastomotic biliary stricture (n = 1), and subphrenic collection (n = 1).

CONCLUSION

Our current data confirm the efficacy of LRLT for treatment of HCC superimposed on liver cirrhosis.

The use of locked nails in the treatment of humeral shaft: delayed union and nonunion

OBJECTIVES

To assess the results and clinical outcome of delayed union and nonunion humeral shaft treatment using locked medullary nails.

SUBJECTS AND METHODS

The Russel and Taylor humeral locking nail was used to treat 21 patients with humeral shaft fractures at Al Razi hospital, Kuwait, from 1997 to 2001. Of these, 8 had delayed union and 13 nonunion. Also, 13 had previous operative treatment, while 8 had nonoperative treatment. Antegrade nailing was done in all cases, and all nails were fixed statically. Autogenous iliac bone grafts were used in 17 cases.

RESULTS

Of the 21 cases of fractures, 19 were united. Only 2 cases had persistent nonunion. Eighteen cases had satisfactory shoulder function, and 3 lost shoulder abduction between 40 and 65 degrees.

CONCLUSION

Our data showed that humeral locked nails can achieve satisfactory clinical results in treating humeral shaft delayed unions and nonunions.

Serum nickel concentration in normal menstrual cycle and after combined contraceptive pill

Serum nickel concentration in the different phases of the menstrual cycle and after use of a combined contraceptive pill (Anovlar) was determined by atomic absorption spectrophotometry. Twenty ovulating females had their serum nickel level measured on day 5 and on day 27 of their cycle. Forty females using Anovlar for 6 months and 40 females using it for more than 3 years had their serum nickel determined. The serum nickel concentration of the non-pill users was higher on day 5 (2.52 +/- 0.46 micrograms/L) than on day 27 (2.21 +/- 0.37 micrograms/L p less than 0.05). In long-term users, the serum nickel (0.98 +/- 0.38 microgram/L) was less than the short-term users (2.38 +/- 0.35 micrograms/L, p less than 0.01) and the non-users (p less than 0.01). There was a negative correlation between the duration of pill use and the serum nickel level (r = -0.44, p less than 0.01). The significance of the decreased serum nickel level with long-term pill use remains to be determined.

The perineal groove and canal in males and females--a third look

We present 5 uncommon cases: One case of perineal canal in a female; two cases of perineal groove in females, one with normal anus and another with ectopic perineal anus. Two cases of perineal canal in males. The canal is deep in the perineum, runs forward above the root of scrotum, close to the floor of the urethra (which is normal), and opens on the undersurface of the penis. One of them is associated with covered anus incomplete with anocutaneous fistula as well opening on the scrotal raphe. In all 5 cases the perineal canal or gutter opens posteriorly in the ectodermal anal canal, immediately below the line of anal valves. A third look to the origin of these conditions will be discussed versus the 1st and 2nd looks of Stephens and Chatterjee. Embryological and histopathological studies will support our point of view.

Chemical Examination of Local Plants. XIII. Elucidation of the Structure of a New Glycoside From the Leaves of Egyptian Hibiscus sabdariffa

The ether as well as the methanol extracts of the defatted leaves of Hibiscus sabdariffa yielded a new glycoside, the structure of which has been determined, by mass and N.M.R. spectra and by synthesis, as β- sitosteryl β-D-galactoside.