Evaluation of in vitro anticancer potential of pharmacological ethanolic plant extracts Acacia modesta and Opuntia monocantha against liver cancer cells

Abstract Acacia modesta (AM) and Opuntia monocantha (OM) are distributed in Pakistan, Afghanistan and India. Both of these plants have different pharmacological properties. This study was designed to evaluate anticancer potential of Acacia modesta (AM) and Opuntia monocantha (OM). Liver cancer cell line HepG2 was used for assessment of anticancer activity. For the evaluation of anti-proliferative effects, cell viability and cell death in all groups of cells were evaluated via MTT, crystal violet and trypan blue assays. For the evaluation of apoptosis ELISA of p53 performed. Furthermore, LDH assay to find out the ability of malignant cells to metabolize pyruvate to lactate and antioxidant enzymes activity (GSH, CAT and SOD) at the end HPLC was performed to find active compound of AM and OM. Cytotoxicity (MTT), Viability assays (trypan blue, crystal viability, MUSE analysis) showed more dead, less live cells in plant treated groups with increase of concentration. Scratch assay for the anti-migratory effect of these plants showed treated groups have not ability to heal scratch/wound. ELISA of p53 for cellular apoptosis showed more release of p53 in treated groups. Antioxidant assay via glutathione (GSH), superoxide dismutase (SOD), catalase (CAT) showed less anti-oxidative potential in treated cancer groups. LDH assay showed more lactate dehydrogenase release in treated groups compared with untreated. HPLC analysis showed the presence of phytochemicals such as steroids, alkaloids, phenols, flavonoids, saponins, tannins, anthraquinone and amino acids in AM and OM plant extracts. Based on all these findings, it can be concluded that ethanolic extracts of Acacia modesta and Opuntia monocantha have promising anti-cancer potential.

In-silico analysis of interacting pathways through KIM-1 protein interaction in diabetic nephropathy

Background

Human Kidney Injury Molecule-1, also known as HAVCR-1 (Hepatitis A virus cellular receptor 1), belongs to the cell-surface protein of immunoglobulin superfamily involved in the phagocytosis by acting as scavenger receptor epithelial cells. The study focused on pinpointing the mechanisms and genes that interact with KIM-1.

Methods

This in-silico study was done from March 2019 to December 2019. The Enrichment and protein-protein interaction (PPI) network carefully choose proteins. In addition, the diagramed gene data sets were accomplished using FunRich version 3.1.3. It was done to unveil the proteins that may affect the regulation of HAVCR1 or may be regulated by this protein. These genes were then further considered in pathway analysis to discover the dysregulated pathways in diabetic nephropathy. The long list of differentially expressed genes is meaningless without pathway analysis.

Results

Critical pathways that are dysregulated in diabetic nephropathy patients have been identified. These include Immune System (Total = 237, P < 0.05), Innate Immune System (Total = 140, P < 0.05), Cytokine Signaling Immune system (Total = 116, P < 0.05), Adaptive Immune System (Total = 85) and Neutrophil degranulation (Total = 78).

Conclusion

The top 5 genes that are interacting directly with HIVCR1 include CASP3, CCL2, SPP1, B2M, and TIMP1 with degrees 161, 144, 108, 107, and 105 respectively for Immune system pathways (Innate Immune System, Cytokine Signaling Immune system, Adaptive Immune System and Neutrophil degranulation).

Behavioral features in Williams Beuren syndrome: A Tunisian Cohort study

Introduction

The low prevalence of some genetic neuro-developmental syndromes associated to psychiatric disorders requests to be integrated in human genome-phenome databases from which pleiotropy can be compiled from by systematic integration of phenotypes associated with genetic loci using phenomic inference tools. Williams-Beuren syndrome (WBS) is a neurodevelopmental disorder related to elastin gene at 7q11.23. Anxiety, depression and attention problems are the main behavioral problems found in WBS with no gender differences. Significant differences between cohorts are reported in particular regarding somatic complaints and aggressive behavior.

Objectives

Here, we report a Tunisian cohort of WBS patients for whom clinical behavioral phenotypes as well as genetic features are detailed.

Methods

Sixteen patients from Sfax, Tunisia were referred for genetic assessment due to a suspected WBS syndrome.

Results

Genetic evaluation using fluorescent in situ hybridization confirmed 7q11.23 microdeletion in only eight patients. Comparison of detailed behavioral phenotypes revealed differences between age groups, gender groups and genetic groups. Anxiety and depression were recorded in the two older male patients and aggressive behavior was recorded in only two boys. The severity of behavioral features were dependent to familial environment and to parental socio-economic and educational levels.

Conclusions

A more complete understanding of phenomic space is critical for elucidating genome-phenome relationships mediating neurodevelopmental disorder associated to psychiatric diseases for assessing and managing psychiatric and behavioral risks in young syndromic children.

Disclosure

No significant relationships.

AB1268 CLINICAL ASPECT AND THERAPEUTIC MANAGEMENT OF SUBACUTE OSTEOMYELITIS IN CHILDREN

Background

Subacute osteomyelitis in children is a distinct entity encompassing primary localized

osteomyelitis. It poses a diagnostic problem related to its few or no constitutional

symptoms, misleading radiological manifestations and often a negative bacteriological

investigations. The treatment remains very controversial.

Objectives

The aim of this study was to identify the main epidemiological, clinical, histological and evolutionary characteristics of this affection and to propose an adequate therapeutic attitude.

Methods

It was a retrospective longitudinal study, carried out over a period of 25 years from January 1995 to December 2019 in the orthopedic department of Taher Sfar Hospital,Mahdia, that included 37 cases of subacute osteomyelitis in children.

Results

The mean age of the patients was seven years nine months with a male predominance (sex ratio: 2.27). The average time to hospitalization was 41 days. A diagnostic delay was very likely because of delay in consultation which was related to clinical latency, reported in all cases. The imaging showed osteolysis in all cases, setting in long bones in 54% of cases and in 46% other cases in short and flat ones. The lesion was multiple in two different bones only in one case and was found in pure epiphyseal location in seven cases. The bacteriological investigation allowed the isolation of a germ only in eight cases. In all cases, it was a Staphylococcus aureus. Surgical treatment was performed in 21 cases (60% of patients). The outcome was favorable in 35 cases (95% of cases). An infectious awakening was noted in 2 cases.

Conclusion

Subacute osteomyelitis poses a diagnosis and therapeutic problem. Magnetic resonance imaging is a valuable examination. Surgical treatment combined with appropriate antibiotic therapy is indicated for any suspicious lesion. It can be useful in taking samples for diagnosis, improve distribution of the antibiotic in injury and accelerate healing radiation.

Disclosure of Interests

None declared

Psychological benefits of pre-conceptional and pre-marital genetic diagnosis in conservative societies

Introduction

Preconceptional genetic diagnosis help couples of genetic disorders carrier risk making an informed reproductive decision. The risk is considerably higher for consanguineous couples. Premarital screening can also offers a crucial health assessment of soon-to-be married couples with genetic risk factors based on specific family history. However, such approach is not usually easy to manage in conservative societies, particularly when the affected family refuse to deliver the necessary information about the genetic condition considered as a taboo.

Objectives

Here, we addressed the psychological benefits of preconceptional and premarital genetic diagnosis through a retrospective study about the preconceptional diagnosis inquiries in our genetic counselling.

Methods

In order to assess requests for autosomal recessive disorders during ten years of our genetic counselling activity at the medical university of Sfax, we reviewed 2500 medical files.

Results

Three couples were recorded for genetic preconceptional diagnosis. Another couple was documented for seeking a premarital screening for an unknown neuropathy before wedding engagement decision. This single case was referred to us because of a familial history of a severe neuropathy that was noted in the offspring of a shared cousin. The couple was unable to bring us more information about the genetic condition because of the familial repugnance.

Conclusions

Although our study is limited at the genetic level, it could be socially interesting because it showed the negative attitudes of the general population towards the genetic conditions and the familial responsiveness, as well as the reticence of physicians towards genetic preconceptional and premarital carrier diagnosis.

Disclosure

No significant relationships.

[BCG multifocal osteomyelitis. A case report]

Multifocal osteomyelitis is a rare complication of the Bacille Calmette-Guerin (BCG) vaccine. It particularly affects immunocompromised children and poses a difficult diagnostic problem. A 6-month-old boy had BCG vaccination postnatally and developed extensive disseminated skeletal osteomyelitis. He was found to have severe combined immunodeficiency. Despite antibiotic therapy and bone marrow grafting, the disease was fatal.

Three novel CYP11B1 mutations in congenital adrenal hyperplasia due to steroid 11Beta-hydroxylase deficiency in a moroccan population

BACKGROUND/AIMS

Steroid 11beta-hydroxylase deficiency (11OHD), the second cause of congenital adrenal hyperplasia (CAH), accounts only for 5% of all CAH. To date, only 51 different mutations have been reported with poor clinical and biological data. Most of them could be considered as private mutations except one, p.R448H, identified especially in Moroccan Jews but also in Caucasian patients. As two other CYP11B1 mutations have a high incidence in Tunisian patients, we report from another Maghreb population the clinical, follow-up and molecular genetics of 5 Moroccan patients with classical 11OHD.

METHODS

Patients belonging to 3 families were recruited on clinical data. The diagnosis was confirmed by 11-deoxycortisol determination. Sequencing of the CYP11B1 gene and molecular modeling were performed.

RESULTS

Clinical, hormonal and follow-up data were consistent with a severe form of 11OHD. Gender reassignment and evolution of hypertension were discussed. Three novel mutations, p.Ala259Asp, p.Gly446Val and IVS5+2T>G were identified. As each patient was homozygous for one mutation, we could deduce from their phenotype and our modeling studies that the p.Gly446Val mutation was more severe than p.Ala259Asp.

CONCLUSION

This study shows a good correlation between phenotype and genotype. Each CYP11B1 mutation is new and private, contrasting with the high incidence of two Tunisian mutations.

Primary hydatid disease of the thigh. A rare location

Primary muscle hydatidosis is very rare, accounting for less than 1% of hydatid cyst locations. Clinical symptoms are insidious and non-specific causing a frequent delay in diagnosis. Intramuscular hydatid disease can cause a variety of diagnostic problems, especially in the absence of typical radiologic findings. We report the observation of an 82-year-old man consulting for inguinal tumefaction with radiological exploration suggestive of hydatid cyst of the adductors muscles. Magnetic resonance imaging (MRI) is helpful in diagnosis, since it reveals a very suggestive aspect and demonstrates the relationship between cysts and adjacent structures. Treatment of muscle echinococcosis is based on surgery, which is curative and incurs a low risk of local relapse.

A rare cause of non discal sciatica: schwannoma of the sciatic nerve

Schwannomas are peripheral nerve sheath tumors. Schwannomas arising in the sciatic nerve are considered a rare condition. Their symptomatology usually mimics sciatic pain due to a herniated disc, which can delay the diagnosis. We report the case of a patient with chronic sciatica in whom Magnetic Resonance Imaging (MRI) examination of the right thigh revealed a tumor of the sciatic nerve. Excision of the tumor was easily performed without neural lesioning. Histopathological examination revealed the tumor to be a schwannoma. No neurologic deficit was noted postoperatively which confirms the good prognosis of this tumor.

Syndromic approach to sexually transmitted infections in Tunisian women: bacteriological validation

The World Health Organization emphasizes an integrated primary care approach using syndromic management of sexually transmitted infections. The objective of our study was to evaluate the quality of care of the syndromic management of sexually transmitted disease in women in Rabta hospital in Tunisia. Algorithms have been developed for: cervicitis due to Neisseria gonorrhoeae or Chlamydia (algorithm 3a), vaginitis due to Trichomonas vaginalis or Chlamydia trachomatis (algorithm 3b) and vaginitis due to Candida (algorithm 3c). A total of 116 women were enrolled in the study during February 2003 to April 2004. The prevalence of each bacterium was Chlamydia (10%), N. gonorrhoeae (1%), Treponema pallidum (1%), T. vaginalis (5%) and Candida (21%). Algorithm '3a' had a sensitivity of 45%, a specificity of 42% and positive predictive value (PPV) of 11.9%. Algorithm '3b' had a sensitivity of 35.7%, a specificity of 68.9% and PPV of 20.8%. Algorithm '3c' had a sensitivity of 12%, a specificity of 88% and PPV of 33.3%. To improve the sensitivity of the syndromic approach, we suggest improving the quality of history taking.

[Diverticulum of the left atrium detected antenatally. Management of a case]

Cardiac diverticulae are rare, most often affecting the ventricles rather than the atria. We report the case of a diverticulum of the left atrium discovered during routine fetal echocardiography. The diagnosis was confirmed at birth with cardiac echography and an MRI. In view of the patient's age and asymptomatic nature, it was decided to defer surgery and to observe the infant with regular echocardiography. Surgery was eventually performed via a left thoracotomy after the appearance of signs of cardiac compression, and there were no complications in the post-operative period.

[Rare cause of acute carpal tunnel syndrome: acute metacarpal osteomyelitis]

Acute carpal tunnel syndrome resulting from acute metacarpal osteomyelitis is an exceptional etiopathogenic entity. A 6-year-old boy developed an acute carpal tunnel syndrome on the left four days after trauma. The carpal tunnel was opened in an emergency setting and exploration revealed a pale median nerve with infiltration of neighboring tissue. After release, pus issued from the depth of the tunnel. A posterior approach disclosed the collection and a total loss of the 4th metacarpal periosteum, leading to the diagnosis of acute osteomyelitis. Edema and pain regressed rapidly with antibiotic therapy. A pathologic fracture of the 4th metacarpal discovered three months later was treated conservatively. At 10 months, the child has a very good functional result despite persistence of a short 4th metacarpal after healing. There was no motor or sensitive neurological deficit and thumb opposition was complete. We have been unable to find any other report of acute metacarpal osteomyelitis leading to acute carpal tunnel syndrome. Emergency treatment is crucial. Opening the annular ligament is the only way to achieve complete nerve recovery.

[Predictive factors for late complete atrio-ventricular block after surgical treatment for congenital cardiopathy]

The late occurrence of complete atrio-ventricular block (CAVB) after cardiac surgery is rare but potentially responsible for cases of late sudden death. We searched for factors allowing prediction of this complication, retrospectively reviewing the case notes of 11 patients in hospital with complete AVB, 2 months to 10 years after correction of a cardiac malformation. All had a normal pre-operative ECG. The diagnosis had been made based on symptoms in 8 patients: syncope or collapse (4 cases) symptoms on effort (3 cases) or fatigue (1 case). In the others the diagnosis had been made on ECG. The block was infra-His in 5 patients who had electrophysiology. ECG analysis showed that all the patients had CAVB immediately post-operatively lasting 3-14 days. After restoration of conduction the ECGs showed the following anomalies compared to the pre-operative ECGs: long PR (1 case), long PR + right bundle branch block (2 cases), long PR + left axis deviation (1 case), RBBB + left deviation or rotation of the QRS axis (3 cases), long PR + RBBB + left axis deviation (4 cases). All of these patients had been fitted with a cardiac stimulator. In conclusion, the children who had CAVB immediately post-operatively lasting more than 48 hours and who then had an ECG showing different QRS compared to the pre-operative QRS and/or long PR had a risk of late complete AVB. These patients should have electrophysiology and a stimulator must be implanted in those who have an infra-His block.

Optimization of low pre-operative hemoglobin reduces transfusion requirement in patients undergoing transurethral resection of prostate

OBJECTIVE

To identify factors that influence peri-operative hemorrhage in view of reducing the need for transfusions in patients undergoing trans uretheral resection of prostate (TURP).

METHODS

All patients undergoing TURP between January 1997 and December 1999 were identified using ICD 9CM coding and indexing system. Overall 430 patients were identified, however, 384 charts were included and reviewed for demographics, pre and intra-operative data and post-operative morbidity. Patients were divided into two groups on the basis of presence of significant hemorrhage.

RESULTS

Overall 384 patients were analyzed. Nineteen patients had hemorrhage--group I whereas 365 had no significant hemorrhage--group II. Mean age and co-morbidities in the two groups were similar. However, in group I, 58% presented with urinary retention compared to 33% in group II. In group I, factors that reached statistical significance include; operative time (p<0.05), mean resected tissue weight (p<0.02), and patient presentation (urinary retention) (p<0.032). There was no significant difference in the two groups with respect to type of anesthesia (regional versus general) and histology of the resected tissue. Patients with mean pre-operative hemoglobin of 10.6 % had a 37% transfusion rate.

CONCLUSION

Operative time, weight of resected prostate tissue are inter related and are only partly controllable. Low pre-operative hemoglobin is the only reversible factor in reducing transfusion following TURP.

[Role of surgery in subaortic stenosis. Report of 56 cases]

INTRODUCTION

Subaortic stenosis is a rare congenital heart disease defined as a left ventricular outflow tract obstruction. We reviewed our surgical experience in this cardiac disease with particularly attention to the different anatomical types of the obstruction.

PATIENTS AND METHODS

From January 1987 to December 1998, 56 patients with a mean age of 12.4 years underwent surgical treatment of subaortic stenosis in our Institution. The diagnosis included: subaortic membrane in 44 cases, fibromuscular process in seven and tunnel like hypertrophy in five.

RESULTS

There were two hospital deaths (2/56 = 3.5%) and three patients presented postoperative heart block. The first postoperative echocardiographic control showed a mean fall in left ventricleaorta gradient of 78%. In a mean follow-up of 36 months, there were no deaths. All patients periodically controlled, showed an echocardiographic progression of the gradient and it was not related to the different anatomical types of the obstruction. There were no signs of aortic insufficiency progression.

CONCLUSION

We can affirm that the surgical treatment of the subaortic obstruction is simple and safe. The medium and long-term progression toward the recurrence is independent to the anatomical type and justify the need of serial echocardiographic control.

[Influence of age at operation on the results of aortic coarctation surgery]

The aim of our study is to determine the ideal operative age of aortic coarctation. 30 patients (20 male and 10 female) have had surgery for coarctation of the aorta between 1990 and 1998. Mean operative age is 4.5 years (range 2 months and 13 years). Crafoord technique was performed in 23 cases, modified Crafoord technique in 3 cases, Waldhausen operation in 3 cases and coarctectomie with insertion of a prosthetic material in one case. A post-coarctectomy syndrome was noted in one case. There were no early deaths. The mean follow-up period is 4.5 years. 8 patients were noted to have late systemic hypertension (26.5%). It is more frequent in patients that have been operated after the age of 5 years (43%). One patient has had a recoarctation (3%). No late death was noted. 4 patients had to undergo a reoperation for cardiac associated anomalies.

[Complete repair of a corrected transposition of the great vessels by double switch. A case report]

We report the observation of a female patient with a corrected transposition of the great arteries, ventricular septal defect and complete atrio-ventricular block. This complex cardiac disease originated heart failure and was discovered at the age of 4 months. This baby has been operated at the age of 7 months, in April 1998. She had a complete repair by the double switch, closure of the ventricular septal defect and implantation of a permanent pace-maker. Short term results are favorable. Total repair of the corrected transposition of the great arteries is currently possible thanks to the recent technique of the double switch. It remains a difficult operation but with satisfactory short term results.

[Rheumatic spondylodiscitis in spondylarthropathies]

The involvement of enthesis like disc space is the typical lesion of spondylarthropathies. Out of 240 patients with spondylarthropathies, 10 (7 M, 3 W; mean age: 37 years) have spondylodiscitis, affecting a total of 13 disc spaces: 1 cervical, 2 thoracic, 10 lumbar. The mean duration of spondylarthropathy at the time of diagnosis of spondylodiscitis is 10 years. Spondylodiscitis has a variable clinical presentation: painful (6 cases), asymptomatic (4 cases). Its coexistence with typical radiographic signs of spondylarthropathy added to the exclusion of bacterial origin, permit to link it to spondylarthropathy. Its evolution is generally favourable.

[Cavopulmonary shunts: apropos of 40 observations]

Fourty patients with univentricular heart, underwent a cavopulmonary shunt procedure. The majority have an excellent hemodynamic status with ventricular end diastolic pressure > 12 mmHg and a mean pulmonary artery pressure > 15 mmHg. However, 11 patients have ventricular dysfunction, 9 have an incompetent systemic atrio-ventricular valve and 6 have mean pulmonary artery pressure > 15 mmHg. The pulmonary arteries were of a good size in all cases with a Nakata index > 100 mm2/m2. Cavopulmonary connections are satisfactory palliative procedures in the treatment of univentricular cardiac disease.

Eating disorders in dementia

OBJECTIVES

To examine the prevalence and associations of altered eating patterns in dementia sufferers.

DESIGN

Prospective cohort study.

SETTING

Psychiatric services and a memory clinic.

SAMPLE

124 patients with DSM-III-R dementia.

MEASURES

The Geriatric Mental State Schedule, the History and Aetiology Schedule, the Cornell Depression Scale and the CAMCOG. Additional standardized questions were asked about eating patterns in the month prior to the study.

RESULTS

Information concerning eating patterns was obtained from 105 of the 124 patients: 21% had increased food consumption, 22.1% had decreased food consumption, 2.9% tried to eat inedible substances, 11.4% had an increased preference for sweet things, 7.6% became more fussy about their food choices and 4.8% became less fussy. Decreased food consumption was significantly associated with less severe cognitive impairment and was related to RDC major depression in some patients. An increased preference for sweet things showed an association with a diagnosis of Alzheimer's disease. Increased food consumption was probably heterogeneous. Neither increased food consumption nor an increased preference for sweet foods was associated with the severity of cognitive impairment.

CONCLUSION

Altered eating patterns are common in dementia sufferers.

A prospective study of psychotic symptoms in dementia sufferers: psychosis in dementia

Eighty-seven out of a clinical cohort of 124 patients with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) dementia were followed up at monthly intervals for 1 year. Psychotic symptoms were assessed using the Burns's Symptom Checklist, and cognitive functioning was evaluated with the CAMCOG. The annual incidence rate of psychotic symptoms was 47%, although many of the incident symptoms lasted less than 3 months. Fifty-three percent of patients with psychosis experienced resolution of their symptoms. Patients either experienced brief or persistent psychotic disorders, with few having an intermediary course. Persistent psychosis was significantly associated with a 3-month duration of symptoms at baseline. Neuroleptics did not significantly influence the course of psychotic symptoms.

[Congenital mitral insufficiency. Diagnosis, prognosis and treatment]

Between September 1973 and November 1993, 30 children with CMI underwent open-heart surgery. The mean age at operation was 6.63 years with a range of 8 months to 14 years. Twenty patients underwent reconstructive mitral valvuloplasty; 3 immediate failures and 1 case of stenosis of Carpentier's ring, occurring 7 years after the operation, were observed in this group. Among the 10 patients treated by mitral valve replacement, there were 4 deaths, including 3 from specific complications of the prosthesis. Conservative mitral surgery provides better results with far fewer complications that mechanical prostheses and must therefore always be attempted as the first-line procedure.

Aortic valve replacement in children under 16 years of age with congenital or rheumatic valvular disease. A study of 64 cases

Sixty-four children have had a single aortic valve replacement under 16 years of age, 50 for rheumatic disease (47) or bacterial endocarditis (3) (group I) and 14 for a congenital aortic valve lesion (group II), 38 were disk prostheses and 26 were ball prostheses. Associated procedures had to be performed 31 times, with widening of a small aortic annulus by a patch in 7 patients. The early mortality was 12.5%. Of 56 survivors, 55 were followed postoperatively for a mean period of 7 years (group I: 44, group II: 11). Forty of the 55 patients were anticoagulated (correctly maintained in only 24 patients), 15 were not anticoagulated. A high rate of late complications was observed. Thrombo-embolic accidents in 5 patients with inefficient anticoagulant treatment, 2 haemorrhagic episodes, 7 prosthetic leaks; specific problems related to this group of young patients were: recurrence of rheumatic fever with increasing severity of mitral valve disease requiring mitral valve replacement in 5 patients and outgrowth of the prosthesis, which affected 7 patients; this complication is the result of either fibrous deposit around the valve annulus or such a small annulus that the surgeon could only implant a small prosthesis. Ten patients required 11 reoperations for various reasons. The main reason for reoperation was mitral valve replacement for worsening of mitral valve disease caused by recurrence of rheumatic fever. A high late mortality 10/55 (18%) was noted. The main cause of death was a perivalvular leak (5); 1 late death was caused by a stenotic number 17 Björk-Shiley valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Closed mitral valvotomy in pregnancy--a study of seven cases

Between 1977 and 1987, seven pregnant women (mean age 28 years) had closed mitral valvotomy through a left lateral thoracotomy during their first (3 cases), second (2 cases) or third (2 cases) trimester. Surgery was necessary either because of acute heart failure with pulmonary edema not responding to medical treatment (4 cases) or to prevent the complications of severe mitral stenosis affecting either the mother or the fetus in three patients with desired pregnancies. There were neither maternal nor fetal deaths. The only complication was bleeding from a low insertion of the placenta identified in the early postoperative period in one patient that required a caesarean section, which produced a normal baby. Six pregnancies continued until term with uneventful delivery and produced normal children. We conclude that closed mitral valvotomy is a simple and a low risk procedure in pregnant women. It prevents complications of severe mitral stenosis occurring in either the mother or the fetus during pregnancy and delivery.

Valve replacement in children under 15 years with rheumatic heart disease

From 1967 through 1984, single- or double-valve replacement for rheumatic heart disease (RHD) was undertaken in 184 children (aged 4 to 15 years) in Tunis. At the time of operation most patients were in an advanced state of cardiac disability, but most of them were still in sinus rhythm. A total of 222 valves were inserted. The most commonly used replacement valve was the Starr-Edwards caged-ball prosthesis, with 12 hospital deaths (6.5%). There were no hospital deaths among 19 children who had a (glutaraldehyde-treated porcine) xenograft replacement valve; however, a much higher rate of valve failure occurred later, owing to valve calcification (14 of 19 replacements, 11 requiring reoperation). There were 24 episodes of clinical thrombo-embolism in 21 children after insertion of a prosthetic valve, but only one in a child with a xenograft valve. Two thirds of the patients with prosthetic valves were on anticoagulants, but fewer than half of them had effective levels because of low compliance. For the group with prosthetic valves, the 10-year survival rate was 70%.

Prosthetic valve endocarditis. A survey

Fifty eight patients (aged 8-59 years, mean 27) treated for prosthetic valve endocarditis from January 1966 to January 1985 were studied retrospectively by review of case notes. There were 12 cases of early and 46 cases of late prosthetic valve endocarditis. These developed in 28 patients with an isolated aortic valve, in 26 with an isolated mitral valve, and in four with both aortic and mitral prosthetic valves. Streptococci were the most commonly isolated microorganisms, followed by staphylococci, Gram negative bacteria, and fungi. A surgical (34 cases) or a necropsy specimen (10 cases) from 44 cases was examined. Eighty two per cent of the patients had congestive heart failure. Twenty four of the 58 patients were medically treated and 17 died (70% mortality). Combined medical and surgical treatment was used in 34 patients; the main indication for surgery was congestive heart failure. Fourteen patients on combined treatment died (40% mortality). Persistent sepsis and prosthetic valve dehiscence were the most common early and late operative complications. The most important influences on outcome were congestive heart failure, the type of micro-organism, the severity and extent of anatomical lesions, the time of onset of prosthetic valve endocarditis, and the type of treatment. This survey indicates that only patients without congestive heart failure or embolic complications and with sensitive micro-organism should be treated medically. In view of the poor prognosis patients with prosthetic valve endocarditis associated with congestive heart failure, persistent sepsis, and repeat arterial emboli should be treated by early surgical intervention.