Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p = 0.001), complete heart block (13.54% vs 9.36%, p = 0.01), and permanent pacemaker placement (8.03% vs 6.03%, p = 0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p = 0.679).

A systematic review on smoldering multiple myeloma: Whether treatment is beneficial

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Background: Smoldering multiple myeloma (SMM) is an asymptomatic proliferative disorder of plasma cells. There are multiple early intervention strategies investigated in the last ten years, including single v/s combination therapy, which can either delay progression or be used as an aggressive therapy to cure SMM. This study aims to summarize the reported outcomes of interventions in SMM within the past decade. Methods: We performed a literature search following PRISMA guidelines and used the following bibliographic databases: PUBMED, EMBASE, Cochrane Library, Web of Science, and clinical trials.gov. A total of 1474 articles were found from the above-mentioned databases and a total of seven articles were included in the final analysis. Results: Seven clinical trials were finalized, which included 599 patients, gender was specified in five studies and constituted 51 percent female patients, and the remaining were males. The median age of patients ranges from 61 (21-89) years. In progression evaluation, four studies, 440 patients were considered. However, significant heterogeneity existed with treatments and the survival analysis hence cumulative PFS was not obtained. PFS greater than 90% was obtained in two studies; 95.5% was obtained with Carfilzomib (K), lenalidomide (R), and dexamethasone(d) regimen after a follow-up period of 31.9 months. PFS of 91% was obtained with Lenalidomide alone for a follow-up of 35 months. Three studies, including 200 patients, were evaluated for response rate. MRD negative CR of 70.4% was obtained with the use of the KRd regimen. Overall response (ORR) of intense and intermediate use of Daratumumab showed a rate of 56.7% and 53.1%, while the complete response in the respective arms was 4.9% and 9.8%. CR, stringent CR of 17.4% and 4.3% was obtained with the use of Isatuximab with Lenalidomide. Conclusions: No definite conclusion can be made due to variability in the data. However, based on the data analyzed from the seven clinical trials, we advocate for early therapeutic intervention in high-risk SMM patients. There are multiple ongoing clinical trials to answer whether we should treat SMM or not.[Table: see text]

Role of metformin in the treatment of cholangiocarcinoma: A systematic review

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Background: Non-cancer medications and their potential anti-cancer activity have attracted significant interest in recent years. The aim of this research is to conduct a systematic assessment of the existing evidence on the usefulness of metformin in the treatment of cholangiocarcinoma. Methods: We conducted literature search using PubMed, Clinicaltrials.gov, Embase, and Cochrane to retrieve studies evaluating the role of Metformin in the treatment of Cholangiocarcinoma. Three studies were finalized after careful screening. Results: We analyzed 3 studies. The total population was 638. The types of Cholangiocarcinoma varied from intrahepatic cholangiocarcinoma found in 293, to extrahepatic Cholangiocarcinoma in 365 and gallbladder carcinoma in 149 patients. Patients were in different stages of treatment such as undergoing chemotherapy, surgery or post- resection and/or post chemotherapy. The mean survival rate was significantly increased to 30.4 months and 13.2 months in patients using Metformin vs. 23.48 months and 10.3 months among patients not using Metformin (p < 0.0005) after resection of the tumor. An increase in the mean survival rate was reported among patients using Metformin vs. non-users after the administration of chemotherapy, i.e., 25.9 months vs. 10.6 months (p = 0.0016), respectively. Metformin in combination with Chloroquine showed favorable results regarding adverse events, however, no clinical activity was reported against IDH-1 mutated intrahepatic cholangiocarcinoma. Conclusions: Our analysis concludes while the use of Metformin is associated with significantly improved post-operative survival, it does not show any significant clinical activity against IDH-1 mutated intrahepatic cholangiocarcinoma. Metformin also showed significant improvement in patients taking chemotherapy. Studies, including trials to evaluate the effectiveness of Metformin alone or used in combination with non-cancer medications or chemotherapeutic agents could provide more definitive recommendations for the treatment of Cholangiocarcinoma.[Table: see text]

Advances in viral oncolytics for treatment of multiple myeloma - a focused review

INTRODUCTION

Oncolytic viruses are genetically engineered viruses that target myeloma-affected cells by detecting specific cell surface receptors (CD46, CD138), causing cell death by activating the signaling pathway to induce apoptosis or by immune-mediated cellular destruction.

AREAS COVERED

This article summarizes oncolytic virotherapy advancements such as the therapeutic use of viruses by targeting cell surface proteins of myeloma cells as well as the carriers to deliver viruses to the target tissues safely. The major classes of viruses that have been studied for this include measles, myxoma, adenovirus, reovirus, vaccinia, vesicular-stomatitis virus, coxsackie, and others. The measles virus acts as oncolytic viral therapy by binding to the CD46 receptors on the myeloma cells to utilize its surface H protein. These H-protein and CD46 interactions lead to cellular syncytia formation resulting in cellular apoptosis. Vesicular-stomatitis virus acts by downregulation of anti-apoptotic factors (Mcl-2, BCL-2). Based upon the published literature searches till December 2020, we have summarized the data supporting the advances in viral oncolytic for the treatment of MM.

EXPERT OPINION

Oncolytic virotherapy is an experimental approach in multiple myeloma (MM); many issues need to be addressed for safe viral delivery to the target tissue.

A systematic review of post-transplant lymphoproliferative disorder after liver transplant

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Background: Post-transplant lymphoproliferative disorder (PTLD) is a complication after liver transplantation. This study aims to explore the association of PTLD with the immunosuppression, types of PTLD, clinical presentation, and outcomes. Methods: Following the PRISMA guideline, we searched the literature on PubMed, Cochrane, Embase, and clinicaltrials.gov. 1741 articles were screened and 22 studies were included. Results: Data includes 22,235 total patients who underwent a liver transplant, and 449 (2.0%) patients who developed PTLD were studied. Of the 394 patients where gender was reported, 226 were male and 168 were female. Post-transplant EBV status was positive for 63/115 (56%). 11 studies showed that the median time from transplant to the development of PTLD was 33.4 months. Among the histological types of PTLD, the monomorphic B-cell was the most common type with 127/235 (54%) cases, followed by early lesions 25/235, polymorphic 24/235, Hodgkin lymphoma 8/235, and monomorphic T-cell type 7/235. Treatment of PTLD involved reduction or cessation of the immunosuppressive drugs along with chemotherapy surgery and radiotherapy. Mortality data from 13 studies showed 68/259 (31.3%) patients died either due to PTLD or its complication. Conclusions: PTLD is rare but associated with high mortality after liver transplantation. EBV seropositivity is associated with PTLD in the majority of cases. Monomorphic PTLD is the most common type of PTLD after liver transplantation with DLBCL being the most common subtype. Abdominal symptoms and fever are among the most common symptoms. PTLD after Liver transplant a review of studies. [Table: see text]

Various treatment options for the management of Campanacci III giant cell bone tumor

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Background: To assess the treatment effectiveness of Campanacci III giant cell bone tumours. Methods: This prospective cohort study was done using a non-probability purposive sampling technique in the orthopaedic surgery and traumatology unit-I department from February 2013 to October 2017. The sample size of 21 patients aged 33 to 60year Campanacci III giant cell bone tumour diagnosed on biopsy were included, and all patients with uncontrolled diabetes mellitus, decompensated liver disease, chronic renal failure, previously treated for giant cell tumours and malignant transformation were excluded. Treatment options included wide margin excision with fibular vascular graft with plating, mega prosthesis, and chirolin prosthesis. Treatment effectiveness was observed in terms of superficial & deep infection, limb length discrepancy, implant failure and function using musculoskeletal tumour society rating scale (MSTS). Follow-p of the patients was five years. All patients were followed up for six months in the first year and yearly till five years. Results: Out of the total 21 patients, male were 11 (52.4%) and female were 10 (47.6%). The mean age of the patients was 34.8±14.6 years, with a median age was 30year. Four (19.1%) had proximal humerus, o5 (23.8% had distal radius, 09 (42.8% had distal femur, and 03 (14.3%) had proximal thigh involvement. The MSTS was 21.8±6.8 with a median score of 22 till the last follow-up. Kaplan Meier curve was plotted, and median survival rate was 50% at 54 months for the patients treated with fibular vascular graft, 57 months for mega prosthesis and 58 months for the patients treated with chirolin prosthesis. Conclusions: Treatment of Campanacci III with mega prosthesis, fibular vascular graft and chirolin prosthesis is a good outcome except with implant failure in mega prosthesis and limb length inequality with fibular vascular grafts. [Table: see text]

Role of capmatinib in MET exon 14-mutated advanced non-small cell lung cancer (NSCLC): A systematic review

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Background: Capmatinib is a selective inhibitor of MET receptor that got accelerated FDA approval in May 2020 to treat NSCLC with MET ex 14 mutation (METex14). Here, we proclaim the first review of capmatinib efficacy and safety profile in METex14 positive NSCLC patients. Methods: A systematic literature search was conducted using PubMed, Cochrane Library, Clinicaltrials.gov, and Google Scholar. We compiled and analyzed the original studies evaluating the clinical response of capmatinib in MET ex14 mutated advanced NSCLC. Results: The most recent results (as of January 6, 2020) of the GEOMETRY Mono-1 phase 2 study showed an overall response rate (ORR) of 41% (69/97; 95% CI, 29-53) with 41% partial response (PR), and 36% stable disease (SD) in patients who previously received 1-2 prior therapy lines (cohort 4). While the ORR, PR, and SD were 68% ( n = 29/97; 95% CI, 48-84), 64%, and 25%, respectively in treatment naïve patients (cohort 5b). Median progression-free survival (mPFS) and duration of response (DOR) were 5.4 months (mon) and 9.7 mon (95%CI, 5.6-13.0) in cohort 4 vs. 12.4 mon and 12.6 mon (CI, 5.6- not estimated), respectively in cohort 5b. Moreover, disease control was shown in n = 54/69 patients in cohort 4 (95% CI 78 (97-87) and n = 27/28 patients (95% CI 96 (82-100). A post-hoc analysis of 19 patients out of 69 who were pre-treated with immunotherapy demonstrated an ORR of 57.9% (n = 11/19; 95%CI 33.5-79.7) with capmatinib. In contrast, treatment-naive had an ORR of 34% (n = 17/50; 95%CI 21.2-48.8) as per the investigator. Median PFS was 3.29 mon noted on prior therapy. In the phase 1 retrospective analysis reported by Choi et al., ORR was 50% with a median duration of 16.1 (5.3-36.4) mon. Among 45 Japanese pts with MET ex 14 mutated or MET amplified status, the ORR was 36.4% (95% CI 10.9%-69.2%) with a PFS of 4.70 mon in the MET ex 14 mutated groups who had received a second or third line of therapy. Most commonly reported adverse events were peripheral edema, nausea, vomiting, and elevated creatinine across all studies and were mostly grade 1-2. Conclusions: Our results showed that capmatinib has promising anti-tumor activity in patients with NSCLC harboring MET exon 14 skipping mutation. The efficacy and tolerability profile of capmatinib is remarkable, particularly in treatment-naïve patients. Although the GEOMETRY Mono-1 trial is still ongoing, further clinical studies with long-term follow-up are needed.

A systematic review of post-transplant lymphoproliferative disorder after lung transplant

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Background: Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid organ transplantation. This study aims to explore the association of PTLD diagnosed after lung transplant with infectious agents and immunosuppression regimen, explore types of PTLD, and their outcome. Methods: Following the PRISMA guideline, we searched the literature on PubMed, Cochrane, Embase, and clinicaltrials.gov. 1741 articles were screened and included five studies. Results: We analyzed data from five studies, n=13,643 transplant recipients with n=287 (2.10%) developed PTLD. Four studies showed that 32/63 (51%) PTLD patients were male and 31 (49%) were female. Three studies reported 53/55 (96.4%) patients were EBV positive at PTLD diagnosis. Courtwright. et al, reported that 217/224 (97%) PTLD was associated with either EBV positive donor or recipient. Four studies showed that the monomorphic B cell type 48/63 (76%) was the most common histological type of PTLD diagnosed with DLBCL the most common subtype 31/48 (64.6%). Data from 3 studies showed that the onset of PTLD following lung transplant varies with a median duration of 18.3 months (45 days to 20.2 years). Three studies showed that 26/55 (47.3%) patients had early-onset (≤ 1 yr of Tx) and 29/55 (52.7%) patients had late-onset PTLD (> 1 yr of Tx). Management of PTLD included a reduction in immunosuppression including corticosteroids, CNI, purine synthesis inhibitors, Rituximab, and chemotherapeutic agents. Three studies showed a mortality rate of 30/45 (66.7%) and 13/30 (43.3%) deaths were PTLD related. Conclusions: Our review concludes that PTLD is a serious complication, only 2% of lung transplant recipients developed PTLD. EBV seropositivity is the most factor associated with PTLD diagnosis. Monomorphic PTLD was reported as the most common type in the adult population and no association between gender and PTLD was found. The analysis shows that there is a slightly lower incidence of early (≤ 1 yr of Tx) than late-onset (> 1 yr of Tx) PTLD. Table 1 PTLD after a Lung transplant in adults - a review. [Table: see text]

Healthcare access disparity among U.S. cancer population and evaluation of social determinants of health using NHANES data for 2013-18

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Background: Ethnic minorities in US have poorer outcomes due to poor socioeconomic determinants. We evaluated association between ethnicity and insurance status among US adults with cancer who participated in National Health and Nutrition Examination survey for 2013-18. Methods: This was a cross-sectional study involving participants with history of cancer; participants with missing insurance/ethnicity information were excluded. Outcome of interest was insurance coverage in minorities vs Whites. The comparison of baseline characteristics (Table) stratified by insurance (Yes vs No) was made using Chi-square and t-tests incorporating survey procedures in SAS v. 9.4. Logistic regression was used for adjusted and unadjusted odds ratio (OR). Results: Among 29,400 participants, 1,684 had cancer. After excluding 81 participants with missing data, 1,603 were included; 5.2% were uninsured. Table summarizes characteristics of participants stratified by insurance. The uninsured individuals were 14 years younger, predominantly females, Hispanics and non-US born, and were less educated compared to the insured. Unadjusted OR of no insurance vs insurance was 4.23 (95%CI: 2.40-7.47) for Hispanics, 1.23 (95%CI: 0.64- 2.38) for Blacks and 1.50 for others (95%CI: 0.48-4.74) when compared to Whites. After adjusting for age, sex, education, US born status and routine place for medical care, OR for Hispanics, Blacks and others were 1.31 (95%CI: 0.73-2.36), 1.00 (95%CI: 0.46-2.18) and 0.86 (95%CI: 0.26-2.78), respectively. Conclusions: Poor socioeconomic indicators among US cancer population may leave them being uninsured; thereby making them vulnerable to poor outcomes in particular in the ethnic minorities including Hispanics. [Table: see text]

Role of biogenetic markers in differentiation and prognosis of giant cell tumor: A systemic review

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Background: Giant cell tumor (GCT) is a locally aggressive bone tumor. Early diagnosis and potential for recurrence are often difficult to assess due to a lack of bio-genetic markers and radiographic findings overlap with other osteolytic lesions. The purpose of this study is to explore biological and genetic markers that can be used for detection, differentiation, recurrence, and prognosis of GCT. Methods: We conducted a literature review including 24 articles out of 1568 articles, summarizing the role of biogenetic markers in the prognosis of GCT. Results: P63 is 98.6% sensitive and relatively specific for GCT as compared to other multinucleated giant cells containing neoplasms. MDM2(Mouse double minute 2 homolog), IGF1(Insulin-like growth factor 1), STAT1(Signal transducer and activator of transcription 1), and RAC1(Ras-related C3 botulinum toxin substrate 1) are associated with GCT recurrence. Increased expression of proteins like STAT5B, GRB2, and OXSR1 are related to a higher probability of metastasis. Neutrophil to lymphocyte ratio > 2.70, platelets to lymphocyte > 215.80, lymphocyte to monocyte ≤ 2.80, and AGR albumin to globulin < 1.50 ratio were significantly associated with decreased disease-free survival (DFS) (p < 0.05). Large amounts of osteoclast-related mRNA in GCTs (P < 0.05) are associated with the grade of bone resorption. We propose that subarticular primary malignant bone sarcoma with H3.3 mutations represent true malignant GCTB. IMP3 and IGF2 might be potential biomarkers in regulating the angiogenesis of GCT spine and predicting the patients’ prognosis. Conclusions: This review study has shown serological markers are significant in determining the diagnosis, differentiation, prognosis, and recurrence of GCT, which can be added to tumor work-up for definitive diagnosis and prognosis. [Table: see text]

A systematic review of post-transplant lymphoproliferative disorder after renal transplantation

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Background: Post Transplant Lymphoproliferative Disorder (PTLD) is a rare but severe complication following renal transplant. This study aims to explore the treatment modalities, histological types, and risk factors related to PTLD. Methods: Following the PRISMA guideline, we searched the literature on PubMed, Cochrane, Embase & clinicaltrials.gov. A total of 1741 articles were screened and 16 studies were included. Results: We reviewed 275915 adult patients who underwent renal transplantation out of which 2484 (0.9%) patients developed PTLD. Data for gender shows that 61.1% were males and 38.9% females. 576/2484 (23%) cases were EBV positive post-transplant. Seven studies showed the median duration from transplant to the development of PTLD was 80 months (5m-22yrs). Monomorphic PTLD was reported in 585 cases as the most common histological type. 5 studies suggested mortality due to PTLD was 41.38%. OS at 5 and 10 years was 55% and 41% respectively. Conclusions: Our study shows that PTLD is a rare complication after renal transplant which was more common in males. EBV did not show association with PTLD. Monomorphic is the most common histological type of PTLD after renal transplant. Our results show that it is associated with significantly high mortality. [Table: see text]

Profile and management of toxicity of selinexor and belantamab mafodotin for the treatment of relapsed/refractory multiple myeloma: A systematic review

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Background: Selinexor (Sel) and belantamab mafodotin (belamaf) were recently approved by the US FDA for treatment of relapsed/refractory multiple myeloma on July 2019 and August 2020 respectively. The toxicity profile of these drugs is a concern since these are approved for use in patients who have already undergone multiple lines of treatment. Methods: Six studies for Sel and two for belamaf were included after a systematic search of PubMed, Embase, Cochrane, and Clinicaltrials.gov. Results: The most common hematological toxicity associated with these two drugs is thrombocytopenia. The common G-3/4 hematological AEs of Sel were thrombocytopenia (39%-71%), anemia (16%-33%), leukopenia (8%-33%) and neutropenia (9%-33%) whereas common G-3/4 non-hematological AEs were hyponatremia (5%-26%), fatigue (13%-15%), diarrhea (5%-10%), eye disorders (9%-10%), musculoskeletal disorders (4%-10%), elevated liver enzymes (10%), peripheral neuropathy (5%) and vomiting (2-4%). Keratopathy and anemia were the major toxicities of belamaf. Most of these toxicities are manageable. Treatment modifications and dose interruption are usually needed when AEs are more than grade II. REMS program guidelines is recommended for close monitoring and evaluation of Sel and belamaf toxicities and early ophthalmological intervention. Conclusions: As these are newer drugs with limited data, continuous surveillance and monitoring is warranted during the treatment course with early mitigation strategies. The physician should be aware of thrombocytopenia and its management as well as belamaf ocular toxicity which is manageable but if missed could have serious complications.[Table: see text]

Multiple comparisons of diversity indices invaded by Lantana camara

Current study assessed the impact of Lantana camara invasion on native plant diversity in Pothohar region of Pakistan. The approach used for study was random samplings and comparisons of diversity indices [number of species (S), abundance (N), species richness (R), evenness (Jꞌ), Shannon diversity index (Hꞌ) and Simpson index of dominance (λ)] with two categorical factors i.e., invaded and non-invaded (control). Control plots harboured by an average of 1.74 more species/10m2. The control category was diverse (Hꞌ=2.56) than invaded category (Hꞌ=1.56). The higher value of species richness in control plots shows heterogeneous nature of communities and vice versa in invaded plots. At multivariate scale, ordination (nMDS) and ANOSIM showed significant magnitude of differences between invaded and control plots at all sites. The decrease in studied diversity indices in invaded over control sites indicated that plant communities become less productive due to Lantana invasion.

Anterior Mediastinal Teratoma- A Rare Variety

Anterior mediastinal teratomas are rare germ cell tumors. We report a case of such rare tumor in a 16 years old boy who presented with sudden severe right sided abdominal pain which radiating to chest for one day. CT scan of the chest was suggestive of anterior mediastinal teratoma. Patient underwent Clamshell thoracotomy. Peroperatively a large mass was found in the anterior mediastinum containing huge amount of sebum like material. It was adherent to mediastinal surface of right & left lung, pericardium and great vessels (SVC, Aorta). The tumor and was resected out except part of its posterior surface which was adherent to pericardium and great vessels and was left in situ. He had a smooth & uneventful post-operative recovery. Histopathology reported as mature (benign) teratoma with no evidence of malignancy.Pulse Vol.10 January-December 2017 p.52-56

Surgical Management of Large Mediastinal Masses–12 Years’ Experience in Apollo Hospitals Dhaka

Objective: The aim of this study was to evaluate the role of surgical treatment for large mediastinal tumors. A retrospective study was done from 6.8.2005 to 11.5.2017. Total 39 patients were included in this study. Age range was from 7 months to 70 years. Male was 24 and female was 15.Background: Most of the tumours were thymoma (12 cases). Others were thymoma with myasthenia gravis in 3 cases, Thymic carcinoma 2 cases, Nodular sclerosing Hodgkin’s lymphoma in 1 case, Schwannoma in 3 cases, Cystic mass in 5 cases, Schwannoma with cystic degeneration in 1 case, Fibromyxoma in 1 case, Dermoid in 4 cases, Teratoma in 3 cases, Fibrosing mediastinitis in thymic mass in 1 case, Lymphoid hyperplasia in 1 case, Malignant Mesenchymal tumour in 1 case, Myxoid Liposarcoma in 1 case.Method: Surgical exposure varies from sternotomy in 22 cases, to clamshell incision in 1 case, posterolateral thoracotomy in 14 cases and anterolateral thoracotomy in 2 cases. Superior Venacava was injured in 1 case, repaired successfully by 6/0 prolene controlled by partial clamp. Some of the mediastinal mass needed careful dissection from lung, pleura, encircling distal aortic arch and proximal part of left subclavian artery, encircling left brachiocephalic vein. 1 case needed reconstruction of sternum with prolene mesh, marsupialization was done in 2 cases, adjacent pleura, fatty tissue, part of pericardium was removed in 5 cases. Lobectomy was needed in 1 case. In 1 case, recurrence of fibrosing mediastinitis needed steroid therapy. Extensive growth of the tumour which involved surrounding vital structures was decided not to proceed for excision in 2 cases.Results: Overall five-years survival rate was 94.87% .2 patients of the series died due to disease process as they were cases of advanced malignant mediastinal mass.Conclusion: Surgical treatment for mediastinal mass specially involving surrounding structures though challenging, gives good outcome.Pulse Vol.10 January-December 2017 p.12-17

Left Atrial Myxoma with Mild Left Ventricular Dysfunction— A Case Report

Atrial Myxoma is the most common primary cardiac tumors accounting for about 50% of benign primary cardiac tumors, with the majority located in the left atrium. This is a case of large left atrial (LA) myxoma presented with features of mitral stenosis associated with moderate left ventricular failure (LVF) and mild pulmonary artery hypertension (PAH) The patient improved markedly after tumor excision.Pulse Vol.10 January-December 2017 p.29-33

CABG - Challenging Cases in Apollo Hospitals Dhaka, A Decade of Experience

Objective: To show outcome of challenging cases of Coronary Artery Bypass Graft (CABO)Methods: A retrospective study, done in Apollo Hospitals Dhaka from 02-05-2005 to 13.12.2014. Total 1892 CABO cases were reviewed- Emergency: 22 cases, Off-pump: 1257 cases, Arrested heart: 554 cases, On-pump beating heart: 81 cases, MIDCAB: 2 cases. Female - 213 (11.25%), male -1679 (88.74%). Associated co-morbities: peripheral vascular disease: 19 cases, COPD: 78 cases, on dialysis: 17 cases, ventricular septal ruptures :10 cases, carotid occlusive disease: 88 cases, old stroke: 58 cases, permanent pacemaker: 4 cases, preoperative ventilator: 29 cases, left ventricular aneurysm: 58 cases, severe mitral regurgitation: 5 cases, EF: 31-50% =260 cases, 21-30% =147 cases, 15- 20% = 8 cases. Associated procedures -left ventricular aneurysm repair: 42 cases, mitral valve replacement: 30 cases, aortic valve replacement: 25 cases ,double valve replacement: 3 cases, RA myxoma removal: 1 case, LV aneurysm repair with mitral valve procedure: 5 cases , LV aneurysm repair with ventricular septal rupture repair: 5 cases, ventricular septal rupture repair: 10 cases, aorto-femoral bypass: 3 cases, ileo femoral bypass: 1 case, left aorto-axillary bypass: 1 case , Bentall procedure with Brachio-cephalic artery re-implantation: 1 case, Aorto-bifemoral bipopliteal bypass: 1 case, redo CABO-7, IABP preoperatively: 12 cases.Results: Overall mortality rate 2.12% (39 cases), emergency 9.09 % (2 cases) mortality, routine mortality 1.97% (37 cases).Conclusion: Challenging cases of CABO can be done with acceptable morbidity and mortality with good long term outcome.Pulse Vol.9 January-December 2016 p.6-14

Ventricular Septal Defect with Pulmonary Valve Endocarditis with Vegetation - Successful Surgical Treatment in Apollo Hospitals Dhaka

Background: Pulmonary valve vegetation with ventricular septal defect needs early surgical intervention.Case presentation: A 21 years old man got admitted in Apollo Hospitals Dhaka, with the complaints of dyspnoea on exertion since childhood. Echocardiogram revealed a large perimembranous ventricular septal defect, moderate pulmonary stenosis, vegetation attached with pulmonary valve leaflet moving during systole & diastole. During operation ventricular septal defect was closed by dacron patch. Large vegetation was excised from anterior cusp of pulmonary valve. A perforation in right cusp of pulmonary valve was repaired with pericardial patch. Transesophageal Echocardiogram revealed well functioning ventricles and no leakage through the repaired Ventricular Septal Defect and pericardial patch in pulmonary valve leaflet.Result: Culture Sensitivity from vegetation showed no growth and histopathological examination revealed tissue consistent with vegetation of Pulmonary Valve. Post- operative echocardiogram showed no residual shunt or vegetation. The patient was discharged on 8th post operative day in good general condition and is doing well till now.Conclusion: Pulmonary valve endocarditis with vegetation with ventricular septal defect is a rare association. Early surgical intervention gives good outcome.Pulse Vol.9 January-December 2016 p.69-72

Systemic lupus erythematosus in Kuwaiti children: organ system involvement and serological findings

The course and severity of systemic lupus erythematosus (SLE) in children is generally similar to the adult form with potential serious organ system involvement, there are, however, factors that influence the prevalence and clinical behavior of the disease. Our objective was to analyse the organ system involvement and immunological findings in Kuwaiti children with SLE in relation to gender and age of onset and compare these findings to that in published reports. Organ system involvement and serologic profiles were analysed in 35 children with SLE. The major organ systems studied were: renal, hematological, cardiac, pulmonary, hepatic and the central nervous system. The prevalence of ANA, anti-dsDNA, anti-Sm, SSA, SSB and anti-cardiolipin antibodies were studied in addition to complement C3 and C4 levels. The results showed that a high percentage of children had hematological involvement (34%); thrombocytopenia (23%) and hemolytic anemia (20%). Renal involvement was proven by biopsy in only 10 children (29%). Neuropsychiatric manifestations were seen in five (14%) of patients. Males had a tendency for major organ involvement relative to females. All patients had positive ANA tests. All males had positive anti-dsDNA tests compared to 86% of female patients. The most significant finding in this study is the high frequency of hematological manifestations and the relatively low incidence of renal disease and neuropsychiatric abnormalities in Kuwaiti children with SLE.

A high risk critical mitral valve stenosis with emergency management at Apollo Hospitals Dhaka

Heart valve surgery in high-risk patients with severe jaundice, congestive hepatomegaly and renal impairment is associated with considerable morbidity and mortality. Without operation the consequences are invariably grave. A 35 years old gentleman with congestive cardiac failure was initially treated in coronary care unit (CCU). Mitral valve area was 0.5cm², pulmonary arterial systolic pressure (PASP) was 110mmHg, serum bilirubin was 20mg/dl, SGPT & SGOT were 1024iu/l and 1027iu/l respectively. Serum creatinine was 3.35mmol/l. Serum bilirubin gradually diminished to 3.1mg/dl after 12 days treatment in Coronary Care Unit but next day it increased to 3.6mg/dl. Mitral valve was replaced on an emergency basis. Echocardiogram on the 5th post operative day showed well functioning prosthetic mitral valve in situ. Serum bilirubin decreased to 2.2mg/dl, SGPT, SGOT and serum creatinine to 43iu/l, 40iu/l and 1.34mmol/l respectively. After 8 weeks of postoperative follow up his serum bilirubin decreased to 0.8mg/dl.

Insulin-like growth factor-1 gene polymorphism in rheumatoid arthritis patients

OBJECTIVES

Insulin-like growth factor-1 (IGF-1) regulates several biological functions, and low plasma levels of IGF-1 are known to contribute towards the pathogenesis of rheumatoid arthritis (RA). In view of the biological significance of IGF-1, we investigated the association of RA with the polymorphism of a 192-bp allele which is cytosine-adenosine repeat located 1 kb upstream from the IGF-1 gene transcription site and is known to regulate serum IGF-1 levels.

METHODS

Blood samples were collected from 52 healthy controls (HC) and 68 RA patients to measure the levels of IGF-1 and to isolate genomic DNA. Polymorphism of the IGF-1 gene was examined using polymerase chain reaction (PCR). Disease severity, duration, and activity were recorded for all RA patients.

RESULTS

We observed that 97% of all the subjects who participated in this study showed the presence of a 192-bp allele of the IGF-1 gene. All healthy controls exhibited the presence of 192-bp wild-type allele. All non-carriers of the 192-bp allele were Arabs and had RA. Gender correlated significantly with allele frequencies as 14% of the male and only 2% of the female RA patients were non-carriers of 192-bp allele. Plasma IGF-1 levels were significantly lower (p < 0.01) in RA patients compared to HC, and all RA patients who were non-carriers of the 192-bp allele had a significantly high disease activity score. No correlation was found between the duration of RA and the presence or absence of this allele.

CONCLUSIONS

This study suggests a possible association of the IGF-1 gene polymorphism with developing RA, particularly in males as non-carriers of the 192-bp allele.

Haptoglobin gene polymorphisms in sickle cell disease patients with different βS-globin gene haplotypes

OBJECTIVE

To investigate the prevalence of haptoglobin (Hp) gene alleles in Kuwaiti sickle cell disease (SCD) patients, who generally have a mild phenotype, and compare the pattern to Nigerian SCD patients whose SCD phenotype is more severe.

SUBJECTS AND METHODS

Hp genotyping was carried out in a group of 82 and 54 SCD patients from Kuwait and Nigeria, respectively, and appropriate Hb AA controls. The Hp genotyping was done using a PCR technique followed by agarose gel electrophoresis.

RESULTS

The frequency of the Hp-2 allele was 73.8% among Kuwaiti SCD patients, while the Hp-1 allele predominated among Nigerian patients (60.7%). However, the differences were not significant (p > 0.05) when the allele distributions were compared between Kuwaiti SCD and their AA counterparts or between Nigerian SCD and their AA controls. There was no association of Hp-2 allele with frequent vaso-occlusive crisis among the Kuwaiti SCD patients.

CONCLUSION

The distribution of Hp alleles appears to follow ethnic and geographical trends. Their role in the pathophysiology of pain crisis is not clear.

Prevalence of angiotensin-converting enzyme gene insertion-deletion polymorphism in patients with primary knee osteoarthritis

OBJECTIVE

Angiotensin converting enzyme (ACE) plays an important role in a number of inflammatory and immune related disorders. This study was undertaken to investigate an association between Angiotensin converting enzyme (ACE) gene insertion- deletion (I/D) polymorphism and primary knee osteoarthritis (OA) in Kuwait and to explore a correlation between clinical subgroups of OA and ACE I/D polymorphism genotypes.

PATIENTS AND METHODS

The prevalence of ACE gene I/D polymorphism was determined in 115 patients with primary knee OA and 111 ethnically matched healthy controls by using polymerase chain reaction (PCR) of the genomic DNA. The association of ACE gene I/D polymorphism genotypes was also studied with age of disease onset, function and radiological grading.

RESULTS

No significant difference was detected in the frequency of ACE gene I/D polymorphism genotypes and alleles between knee OA patients and the controls. The frequency of ACE gene polymorphism genotypes was also studied in subgroups on the basis of clinical parameters of age of onset of disease, function and radiological grading and no significant difference was detected between subgroups of OA patients and the controls. This is in sharp contrast to a previous report from Korea in which a significant association has been reported between ACE gene polymorphism and knee OA.

CONCLUSION

This study did not find an association between ACE gene I/D polymorphism genotypes in Kuwaiti patients with primary knee osteoarthritis and the onset or severity of the disease, which is very different from Korean knee OA patients in which an association has been reported.

Angiotensin-converting enzyme gene polymorphism in Kuwaiti patients with systemic lupus erythematosus

OBJECTIVE

To investigate the frequency of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism genotypes in patients with systemic lupus erythematosus (SLE), and to study the correlation between I/D polymorphism of the ACE gene and the clinical manifestations of SLE, especially vascular involvement, lupus nephritis and disease severity.

METHODS

The frequency of ACE gene I/D polymorphism genotypes was determined in 92 patients with SLE from Kuwait, and compared to that in 100 ethnically matched healthy controls using the polymerase chain reaction.

RESULTS

The distribution of ACE I/D polymorphism and allele frequencies in SLE patients was not significantly different from controls. Further analyses of SLE patients showed that there was a significant association between DD genotype and Raynaud's phenomenon (p=0.008, odd ratio=5.4, 95% confidence interval: 1.6-18.6). However, there was no significant association between the ACE genotype and lupus nephritis or disease severity.

CONCLUSION

No difference was found between the distribution of the ACE genotype in SLE patients and the general pop-ulation in Kuwait. However, the presence of the DD genotype may confer susceptibility to the development of vascular morbidity.

Lack of an association between candidate gene loci and idiopathic generalized epilepsy in Kuwaiti Arab children

Idiopathic generalized epilepsies (IGEs) are the most common types of epilepsy in childhood and adolescence. A variety of data suggest that IGEs have a predominant genetic etiology. Recently, a number of gene mutations have been found to be associated with various types of epilepsy in mainly the Caucasian populations. The objective of this study was to investigate the association of three different candidate genes with IGE in Kuwaiti Arab children. This study includes 123 Kuwaiti patients with a confirmed diagnosis of epilepsy. Most of the patients have had a diagnostic EEG with generalized spike-wave discharges (GSWs). All patients were evaluated by using a validated seizure questionnaire. The clinical type of epilepsy was determined by a trained neurologist/pediatrician. The study also include 100 controls, the control subjects were children which did not have any history of neurological disorders. Blood samples were collected from all patients and control subjects after taking informed consent. DNA was isolated and analyzed by molecular methods. A FokI polymorphism in neuronal nicotinic acetylcholine receptor alpha-4 subunit (CHRNA4) gene was detected by PCR-RFLP method. A missense mutation (Ser248Phe) in CHRNA4 gene was analyzed by PCR-RFLP using HpaII. A C121W mutation in sodium-channel beta-1 subunit (SCN1B) gene was screened by a PCR-RFLP method using HinPI. A 2-bp deletion in Cystatin B gene was detected by PCR-RFLP using XcmI. The incidence of three FokI polymorphism genotypes in Kuwaiti IGE patients was 1,1 (85%), 1,2 (14%) and 2,2 (1%) respectively. The missense mutation Ser248Phe of CHRNA4 gene was not detected at all in Kuwaiti IGE patients. The C387G transversion resulting in C121W change in third exon of the SCN1B gene was detected in 3/123 patients (2%). The patients carrying this mutation also exhibited febrile seizures. The incidence of 2 bp deletion in the cystatin B gene was found to be 4% (5/123 IGE patients). The data obtained from molecular analysis show a lack of association between three candidate genes and clinical expression of IGE in Kuwaiti Arab children. This is completely different from the findings reported from Caucasian populations of France, Australia and USA in which case a strong association has been reported between IGE and these genes.

HLA-DRB1 alleles in Hb SS patients with avascular necrosis of the femoral head

Strong associations have been established between various HLA alleles and different complications of sickle cell disease (SCD). Recently, the HLA-DRB1*03 allele was shown to be associated with susceptibility to stroke while the HLA-DRB1*02 allele may be protective. While stroke and silent brain infarcts (SBI) are unusual in Kuwaiti children with SCD, avascular necrosis of the femoral head (AVNFH) is quite common. The modulatory association factors must still be elucidated. An investigation of HLA-DRB1 alleles was carried out in a group of 68 Kuwaiti SS patients, of age 7-44 years, of whom 20 (29.4%) had AVNFH, confirmed by magnetic resonance imaging. A group of 167 apparently healthy age- and sex-matched individuals served as controls. Comparison of the HLA alleles between the whole SS group and the controls showed a significant over-representation of DRB1*01 (P < 0.01) and DRB1*10 (P < 0.05) in the patient group. No significant differences in the allele frequencies in the SS patients with or without AVNFH were observed. It therefore appears that the HLA-DRB1 locus does not play a significant role in the pathogenesis of AVNFH Kuwaiti patients.

The prevalence of human leukocyte antigen (HLA) DR/DQ/DP alleles in Kuwaiti children with oligoarticular juvenile idiopathic arthritis

We have determined the prevalence of human leukocyte antigen (HLA)-DR, DQ and DP alleles in Kuwaiti children with oligoarticular juvenile idiopathic arthritis (OA-JIA) and healthy controls using the PCR-SSP (sequence specific primers) method. The analysis took into account the presence of antinuclear antibodies and chronic anterior uveitis. DRB1*03 (RR 2.20, P<0.001), DRB1*08 (RR 5.280, P<0.026), DQA1*0501 (RR 1.930, P<0.001), DQB1*0304 (RR 7.920, P<0.002), DQB1*0501 (RR 3.080, P<0.007) and DPB1*0101 (RR 8.8, P<0.001) were the main HLA alleles associated with OA-JIA in Kuwaiti Arabs in this study. DRB1*03 was detected in 71% of children with positive ANA, and in 50% of children with anterior uveitis. DQA1 alleles *0501, *0103 and *0105 (P<0.001; 0.029 and 0.024 respectively) were found to be associated with OA-JIA. In contrast, DQA1*0301 and DQA1*0302 alleles appear to be protective in Kuwaiti children (RR 0.153, P<0.001 and RR 0.278, P<0.016 respectively). The DQB1 alleles *0304 and *0501 were associated with OA-JIA (P<0.002 and P<0.007 respectively). In the case of DPB1, only one allele (*0101) was associated with OA-JIA (P<0.001). Most Kuwaiti Arab patients with OA-JIA who carried a DQ or DP susceptibility allele also had an accompanying DRB1*03 or *8 allele.

Pulmonary function studies in Kuwaiti children with sickle cell disease and elevated Hb F

Conflicting ventilatory defects have been reported in children with sickle cell disease (SCD). In Kuwait, the disease is relatively mild with a low incidence of acute chest syndrome and other complications, presumably due to the Arab-Indian haplotype chromosomal background and elevated Hb F levels. There have been no previous studies of pulmonary function in patients with this haplotype. Pulmonary function test (PFT) was carried out on 28 steady state children with SCD (21 homozygous sickle cell (SS), seven S beta(o) thal) and two group of controls: 17 age- and sex-matched healthy children and 10 children with HbH disease. The charts of the SCD patients were reviewed for frequency of acute chest syndrome and vaso-occlusive crisis. The mean values of forced vital capacity (FVC) (83.2 +/- 11.9 vs. 91.2 +/- 11.7) and vital capacity (VC) (81.5 +/- 11.8 vs. 90.5 +/- 10.9) were significantly lower in the SS patients compared with healthy controls (p < 0.05). Similarly, these values were significantly lower than in those of the HbH group (p < 0.001 for VC and p < 0.01 for FVC). The mean forced expiratory volume in 1 s (FEV1) was lower in SS patients (86.4 +/- 11.5) compared with healthy controls (94.2 +/- 14.2), but the difference was not significant (p = 0.07). Also, the FEV1 was significantly lower in SS patients than in the HbH group (p < 0.001). There was no significant difference in the PFT parameters between SS patients with acute chest syndrome and those without. Although patients with frequent vaso-occlusive crisis had lower PFT parameters, the differences were not significant in comparison to those with infrequent crisis. This study revealed an early restrictive and obstructive pulmonary function pattern in steady state children with SCD. The finding also indicates that the changes of PFT parameters in SS patients could not be attributed to anaemia per se as patients with HbH who also have chronic anaemia did not show similar changes. This observation underscores the early occurrence of pulmonary involvement, even in patients with an otherwise relatively mild SCD.

Angiotensin-converting enzyme gene polymorphism and lipid profiles in Kuwaiti children with type 1 diabetes

METHODS

We studied angiotensin-converting enzyme (ACE) gene polymorphism and lipid profiles in Kuwaiti children with uncomplicated type 1 diabetes. A total of 125 children with type 1 diabetes were matched in a case-control study on age and gender to 125 non-diabetic children as controls. Serum lipids (total cholesterol, TC; high-density lipoprotein cholesterol, HDL; low-density lipoprotein cholesterol, LDL-c; triglycerides, TG; apolipoprotein A1 and B, apo A1 and B; lipoprotein(a), Lp(a)); and glycated hemoglobin, HbA1c were evaluated according to ACE genotypes.

RESULTS

Genotype distributions were found to be similar in cases [ACE insertion/insertion (II) 9.6%, ACE insertion/deletion (ID) 38.4%, ACE deletion/deletion (DD) 52.0%], and controls (II 8.8%, ID 43.2%, DD 48.0%), and were characterized by higher frequencies of DD, ID, and lower frequencies of II. Diabetic children with DD genotype showed significantly higher levels of TC (p < 0.01), HDL (p < 0.001), and apo A1 (p < 0.001) than controls. There was a higher proportion of diabetic children with family history of cardiovascular disease (CVD) in the DD genotype group (51.9%) than those with II genotype group (11.1%) (p < 0.001). Also, there was a significant increase in the frequency of diabetic children with Lp(a) > 30 mg/dL in children with a family history of CVD (p = 0.008). Lp(a) levels were correlated with HbA1c in the diabetic group (r = 0.239, p = 0.019), but when patients with poor glycemic control (HbA1c > 9%) were excluded, the significant correlation disappeared (r = 0.127, p = 0.381). After adjusting confounding between variables, the logistic regression analysis showed that the two significantly related variables with the rise in Lp(a) were increasing TC level and poor glycemic control.

CONCLUSIONS

In children with type 1 diabetes, the role of ACE polymorphism as a probable contributor to CVD seems to be partially mediated through other factors such as poor glycemic control, TC, and Lp(a) level. A longitudinal study is recommended with a larger number of patients in each ACE genotype group in order to assess such associations.

Avascular necrosis of the femoral head in adult Kuwaiti sickle cell disease patients

While sickle cell disease (SCD) is generally mild in most Kuwaitis, because of their elevated fetal Hb levels, avascular necrosis of the femoral head (AVNFH) appears to be a common complication. It was recently documented in 26.7% of Kuwaiti children with SCD. There have, however, been no previous studies of adult patients. This is a 1-year study of consecutive, steady-state SCD patients seen in the hematology clinic of Mubarak Al-Kabeer Hospital. The patients' charts were reviewed for frequency of hospitalizations, any documented complications and steady-state complete blood count (CBC). MRI was performed using T1- and T2-weighted FATSAT sequences in coronal and axial planes with 4-mm-thick slices on a 1.5-tesla GE super-conducting magnet. Thirty-five patients were studied, consisting of 25 SS and 10 Sbeta(0)Thal patients aged between 17 and 44, with a mean age of 26.7 +/- 9.3 years. Seventeen (48.6%) had varying degrees of AVNFH; among the 70 hips examined, 29 (41.1%) were affected. Of the 17 patients affected, 11 (64.7%) were SS, while 6 (35.3%) were Sbeta(0)Thal. There were 14 (82.4%) males and 3 (17.6%) females (chi(2) = 8.6, p < 0.01). The mean age of those affected, 27.5 +/- 10.7 years, was not significantly higher than that of the unaffected (26.3 +/- 8.0 years). Eleven (64.7%) of those affected had a history of frequent vaso-occlusive crisis. No significant differences could be demonstrated in the mean CBC and Hb F values of the two groups; coexistent alpha-thal trait was not a factor in the SS group. Male gender was the only significant predisposing factor identified. While more patients with frequent vaso-occlusive crises were affected, the difference was not significant. AVNFH is, indeed, quite common among Kuwaiti SCD patients and there is a need for early institution of preventive and therapeutic protocols.

Silent brain infarcts in adult Kuwaiti sickle cell disease patients

Although overt stroke is a common complication of sickle cell disease (SCD), its incidence is very low in Kuwaiti patients. On the other hand, the prevalence of silent brain infarcts, which is reported to be about 17-20% in American patients, has not been documented in adult Kuwaiti patients. This is a 1-year study of consecutive, asymptomatic SCD patients seen in the hematology clinic of Mubarak Al-Kabeer Hospital. Patients with a past history of seizure or any other neurological abnormality were excluded. The patients' charts were reviewed for frequency of hospitalizations, any documented complications, and steady-state CBC. MRI was done with a 1.5-Tesla unit with super-conducting magnet. T1- and T2-weighted sagittal and axial sections and proton-density axial images were obtained in 5-mm-thick sections. Thirty-five patients were studied, made up of 25 SS and 10 Sbeta(0)Thal, aged between 17 and 44 years, with a mean age of 26.9 +/- 9.3 years. MRI findings consistent with infarcts were found in 7 (20.0%) patients-6 SS and 1 Sbeta(0)thal-with a mean age of 31.8 +/- 8.2 years, which was significantly higher (P < 0.05) than the mean age of the unaffected group (25.1 - 9.0 years). There were also no differences in the mean Hb, Hb F, or any other hematological parameter in the two groups. Among the affected 6 SS, 2 had co-existent alpha-thal trait. It is interesting that, while silent infarcts are prevalent in young American patients, it is in the older age group that they occur in Kuwaiti patients. Further studies are needed to investigate the factors modulating this heterogeneity.

Role of human leukocyte antigen DRB1*0307 and DRB1*0308 in susceptibility to juvenile rheumatoid arthritis

OBJECTIVE

To study the prevalence of Human Leukocyte Antigen (HLA) DR alleles in children with juvenile rheumatoid arthritis (JRA).

METHODS

DNA samples from 64 children with oligoarticular and seronegative polyarticular JRA and 64 controls of the same ethnic background were analyzed using PCR-sequence specific primers (PCR-SSP) method. Analysis took into account the onset subtype, the presence of antinuclear antibodies (ANA) and the presence of chronic anterior uveitis, a recognised serious complication of JRA.

RESULTS

A high prevalence of DR3 alleles were detected in children with oligoarticular JRA compared to controls (p < 0.05). DR3 alleles were the commonest also in patients with positive ANA as well as those with chronic anterior uveitis. The interesting finding in this study is the absence of two DR3 alleles, namely DRB1*0307 and DRB1 *0308 in the control group while present in significant proportion in children with JRA. DRB1*0307 was present in 16% of children with oligoarticular subtype and 15% of those with polyarticular JRA. DRB1*0308 was only detected in children with oligoarticular JRA, none of the children with polyarticular JRA or the controls had this allele.

CONCLUSION

These findings support earlier observations linking these two DR3 alleles, namely 0307 and 0308, to the genetic susceptibility to JRA.

Angiotensin-converting enzyme gene insertion/deletion polymorphism in Kuwaiti children with retinopathy of prematurity

Retinopathy of prematurity (ROP) is a disease characterized by neovascularization which occurs in infants with short gestational age and low birth weight and can lead to retinal detachment and blindness. In a proportion of ROP cases, the disease progresses to advanced stages despite rigorous intervention. The genotypes for angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism were determined in 181 premature Kuwaiti infants using a polymerase chain reaction (PCR) method. The incidence of different I/D genotypes was compared in ROP cases (n = 74) and non-ROP controls (n = 107) and within 2 subgroups of ROP patients: (1) in which ROP regressed spontaneously (stages 1-3, n = 53), and (2) in which ROP progressed to advanced stages (stages 4 and 5, n = 21). When the ROP cases were considered collectively as one group, the incidence of the DD genotype was almost identical to that of non-ROP controls. The incidence of heterozygous ID genotype was higher in non-ROP controls. The incidence of the II genotype was higher in ROP cases compared to non-ROP controls (p < 0.01). In contrast to this, when ROP cases were divided in 2 subgroups the incidence of the DD genotype was significantly higher in advanced stage ROP cases compared to spontaneously regressing ROP cases (p < 0.04). The incidences of ID and II genotypes were not significantly different amongst the 2 subgroups of ROP patients.

Silent brain infarcts are rare in Kuwaiti children with sickle cell disease and high Hb F

Overt stroke is rare among sickle cell disease (SCD) patients in Kuwait. However, there are no previous studies of silent cerebral infarcts, which have been described in up to 20% of American children with Hb SS. We have carried out a prospective brain MRI study among otherwise normal SCD patients, who were consecutive patients seen in a 1-year period to document the prevalence of silent cerebral infarcts in children with sickle cell disease in Kuwait. Any patient with a previous seizure or other neurological abnormality was excluded. MRI was done with a 1.5 Tesla unit with super-conducting magnet. T1- and T2-weighted sagittal and axial sections and proton density axial images were obtained in 5-mm thick sections. The study group consisted of 30 (23 SS and 7 Sbeta(0)Thal) patients-19 males and 11 females-whose ages ranged from 6 to 17 (mean of 9.8 +/- 3.5) years. Hb F ranged from 11% to 35% with a mean of 22.8% +/- 5.7%. Only one patient, a 10-and-a-half-year-old boy with Hb SS, showed hyperintense signals in the parietal white matter, consistent with small infarcts, thus giving a prevalence of 3.3%. Silent brain infarcts are uncommon in our patients, and the protective factors remain to be fully elucidated.

A C597-->A polymorphism in the Norrie disease gene is associated with advanced retinopathy of prematurity in premature Kuwaiti infants

Retinopathy of prematurity (ROP) is a retinal vascular disease which occurs in infants with a short gestational age and low birth weight and may lead to retinal detachment and blindness. In some premature infants, ROP progresses to advanced stages despite rigorous intervention, but in the majority, it spontaneously regresses before the threshold stage. Genetic factors, e.g. mutations in the Norrie disease (ND) gene, have been implicated in determining the progression of ROP to advanced stages. We have identified a novel C597A polymorphism of the ND gene; we screened this and another mutation in the ND gene, C110G, in 210 premature Kuwaiti infants using PCR-RFLP, DNA sequence analysis and DNA enzyme immunoassay hybridization to investigate their association with advanced-stage ROP. In this cohort of premature Kuwaiti newborns, 115 of 210 babies had no eye problems and served as controls, while 95 were found to have ROP. In 71 of the 95 ROP cases, the disease spontaneously regressed at or before stage 3, while in 24 of 95 ROP cases, the disease progressed to advanced stages 4 or 5. The incidence of the AA genotype of the C597A polymorphism was considerably higher in advanced-stage ROP cases (83.3%) compared to spontaneously regressing ROP cases (0%) and the normal controls (10.4%) (p < 0.0001). For the other genotypes, no significant difference was detected between the controls and ROP cases. In the case of the C110G mutation in the ND gene, no significant differences were detected between the controls and ROP cases, and the majority of subjects had a CC genotype in all three groups.

Prevalence of human leukocyte antigen (HLA) DRB1 alleles in Kuwaiti children with juvenile rheumatoid arthritis

The prevalence of human leukocyte antigen (HLA) DR alleles has been determined in 69 Kuwaiti Arab children with juvenile rheumatoid arthritis (JRA) and compared to that in 212 ethnically matched normal healthy controls using a PCR-sequence specific primers (PCR-SSP) method. A very high incidence of DR3 was detected in JRA patients compared to the controls (P < 0.0001, RR = 2.235). The high incidence of HLA-DR3 in JRA patients was accounted for mainly by an excess of DRB1*0307 (P < 0.05, RR = 3.072) and DRB1*0308 (P < 0.009, RR = 2.663) compared to the controls. Moreover, DR3 was more prevalent when patients with ANA-positive JRA were analysed separately; 73% compared to 58% for the whole JRA patient group. The frequency of DR1 was also higher in the JRA group compared to controls (P = 0.019, RR = 3.585). Although the incidence of some alleles was higher in the control group (DR13 and DR7), none reached a statistically significant level. All the patients with iridocyclitis had either a DR1 or DR3 allele, except for one child. The frequency of DRB1*03 was found to be much higher in the polyarticular subtype of Kuwaiti JRA cases compared to the oligoarticular subgroup and the controls. Also, a non-significant increase in the frequency of the DRB1*04, *11 and *15 alleles was detected in the polyarticular subtype of the Kuwaiti JRA cases compared to the controls.

Temporal sequence of splenic dysfunction in sickle cell disease

Sickle cell patients develop splenic dysfunction early in the course of their disease as shown by failure to visualize the organ on technetium-99m colloid scintigraphy. However, preliminary studies from our center have shown that, when the spleen is not demonstrable on colloid uptake, it may be visualized on technetium-99m heat-denatured RBC scintigraphy. With time, however, the spleen can no longer be visualized with both tests in many patients. We have studied 46 patients aged 2 to 16 years, which included 36 SS, 7 Sbeta(0) thal, and 3 SD. Eighteen (39.1%) had normal splenic colloid uptake (Group 1), 15 (32.6%) had partial uptake (Group 2), and 13 (28.3%) had absent uptake (Group 3). When the patients in Group 1 were compared to those in the two other groups, there was no significant difference in the mean age and Hb F values. However, the mean Hb of 10.2 g/dl in Group 1 was significantly higher than the value of 9.0 g/dl in the other two groups. In addition, 60% of the SS patients with normal uptake and 40% of those with partial or absent uptake had co-existing alpha-thal trait; the difference in this proportion is significant (chi(2) = 85, P < 0.0001). Heat-denatured RBC scintigraphy was carried out on five patients in Group 2, and the spleen was visible in all, while of 12 children in Group 3, the spleen was visible only in 4 patients. This study demonstrates that the phagocytic function of the spleen, which is tested by colloid uptake, is the first to be lost while the filtration function, tested by denatured RBC uptake, persists for much longer. This finding may have significant implications for the clinical symptomatology and therapeutic strategies of sickle cell disease.

Avascular necrosis of the hip in children with sickle cell disease and high Hb F: magnetic resonance imaging findings and influence of alpha-thalassemia trait

Avascular necrosis (AVN) of the hip is a common cause of morbidity in sickle cell disease (SCD). Its prevalence increases with age and predisposing factors include coexistent alpha-thalassemia trait, frequent vaso-occlusive crisis and a high hematocrit (Hct). SCD is relatively mild among Kuwaiti patients because of their elevated Hb F levels, but a subset exists with severe recurrent vaso-occlusive crises. We carried out a prospective magnetic resonance imaging (MRI) study of the hip in a group of patients being followed in the Pediatric Hematology clinics of Al-Mubarak and Al-Amiri Hospitals. The association of AVN with age, frequency of hospitalization, alpha-thal trait, steady-state Hb, Hct, Hb F, WBC and platelet counts was investigated. MRI was carried out with a 1.5-tesla GE unit with a super-conducting magnet. Thirty patients (19 males, 11 females) (23 SS and 7 SbetaThal) were studied. Their ages ranged from 6 to 17 years, with a mean of 9.8 +/- 3.5 years, and Hb F from 11 to 35% with a mean of 22.8 +/- 5.7%. Among the SS patients, 11 (47.8%) had coexistent alpha-thal trait (-3.7-kb deletion). A total of 8 (26.7%) patients (6 SS and 2 SbetaThal) had varying degrees of osteonecrosis of the hip. Four (36.4%) of the 11 SS patients with alpha-thal trait and 2 (16.7%) of those without alpha-thal trait had osteonecrosis. This difference is, however, not statistically significant (chi(2) = 0.3, p = 0.5). While there was also no significant difference in the mean age and hematological parameters (Hb, Hct, Hb F, WBC, platelets), the SS patients with osteonecrosis had a significantly higher number of hospitalizations for vaso-occlusive crisis in the preceding 3 years than those without osteonecrosis.

Angiotensin converting enzyme gene insertion/deletion polymorphism in idiopathic nephrotic syndrome in Kuwaiti Arab children

OBJECTIVE

Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism influence the circulating and cellular levels of ACE and has been shown to be a risk factor in a number of diseases including IgA nephropathy. We have investigated the association of ACE gene I/D polymorphism with the clinical presentation of idiopathic nephrotic syndrome (INS) in Kuwaiti children.

MATERIALS AND METHODS

The genotypes for ACE gene I/D polymorphism were determined in 102 subjects (54 INS cases and 48 healthy controls) using a PCR method.

RESULTS

The distribution of DD, ID and II genotypes was 70%, 20% and 10% in INS cases compared with 52%, 46% and 2% in the controls. The mean age of onset of the disease was significantly lower in the INS cases with DD genotype (37 months) compared with cases with II genotype (65 months, p < 0.05). The clinical manifestation of the disease was considerably severe in cases with DD genotypes compared with cases having ID and II genotypes. The INS cases with DD genotype also showed a significantly higher incidence of steroid sensitivity and steroid dependence. Seventy-three per cent of the INS cases with minimal change lesion had a DD genotype. Also 70% of the cases which needed cytotoxic drugs had DD genotype.

CONCLUSION

Our data suggest an association of the D-allele of the ACE gene I/D polymorphism with the clinical manifestation of INS in Kuwaiti Arab children.

Frequency of the 677 C-->T mutation of the methylenetetrahydrofolate reductase gene among Kuwaiti sickle cell disease patients

Sickle cell disease (SCD) is relatively mild among Kuwaiti Arabs. However, an atypical subset of patients exists with frequent, severe vaso-occlusive crisis and osteonecrosis. The thermolabile variant of MTHFR, resulting from a C-->T mutation at nucleotide 677, has been shown to be associated with hyperhomocysteinemia, which is an important risk factor for premature vascular disease. We have screened an unselected group of 41 Kuwaiti SCD patients (33 SS and 8 Sbeta(0)-thal) attending the Hematology Clinic of Kuwait University Teaching Hospital for the MTHFR mutation, using a PCR-RFLP method. The patients were aged 2-41 years (mean of 12.8 +/- 8.6). One (2.4%) individual was homozygous for the mutation while 15 (36.6%) were heterozygous, giving an allele frequency of 20.7%. Twenty-one patients (14 SS and 7 Sbeta(0)-thal) were screened for osteonecrosis using MRI of the hip (spin-echo T1- and T2-weighted images). Seven (33.3%) had varying degrees of osteonecrosis, among whom the frequency of the 677 C-->T allele was 21.4%. The frequency was identical among those without osteonecrosis. Although the allele frequency is higher among our patients compared to American SS patients, our results do not suggest an association with osteonecrosis.

Retinopathy of prematurity: mutations in the Norrie disease gene and the risk of progression to advanced stages

BACKGROUND

Retinopathy of prematurity (ROP) is a retinal vascular disease that occurs in infants with short gestational age and low birth weight and may lead to retinal detachment and blindness. Missense mutations in the Norrie disease (ND) gene have been associated with the risk of progression to advanced stages in cases of ROP from the US and also in clinically similar ND and familial exudative vitreoretinopathy.

METHODS

We have screened two ND gene mutations, namely A105T and Val60Glu, by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and allele-specific PCR methods, respectively, in 210 Kuwaiti premature newborns to replicate these findings in a different ethnic group.

RESULTS

In the Kuwaiti premature newborn cohort, 115 of 210 babies had no eye problems and served as controls, while 95 were cases of ROP. In 71 of 95 ROP cases, the disease regressed spontaneously on or before stage 3, while in 24 of 95 ROP cases the disease progressed to advanced stages 4 and 5. In case of missense mutation (A105T), the AA genotype was detected in 96% of controls compared with 87% of ROP cases (NS); similarly no significant difference was found between spontaneously regressed ROP cases and those who progressed to advanced stages. For the Val60Glu mutation, no significant association was detected between the genotype and progression of ROP to advanced stages.

CONCLUSIONS

Unlike data from the US, our findings from a Kuwaiti cohort of ROP cases and controls suggest a lack of association between the two ND gene mutations (A105T and Val60Glu) and ROP and the risk of progression of the disease to advanced stages.

Influence of alpha-thalassemia trait on the prevalence and severity of anemia in pregnancy among women in Kuwait

Alpha-thalassemia is very common in the Kuwaiti population, but its influence on anemia of pregnancy has not been previously investigated. We have screened a group of 59 anemic (Hb < 11 g/dl) pregnant women for the alpha-thal-2 (-alpha-3.7 kb) deletion which is the commonest alpha-thal allele in this community, using a polymerase chain reaction method. A control group of 35 nonanemic (Hb > or = 11 g/dl) pregnant women was studied for comparison. All the women were in the second or third trimester of pregnancy. Among the 94 women in both groups, 69 (73.4%) had a normal complement of alpha-globin genes (alphaalpha/alphaalpha), 18 (19.1%) were heterozygotes (-alpha/alphaalpha) and 7 (7.4%) were homozygotes (-alpha/-alpha) giving an allele frequency of 17.0%. Among the anemic group, there were 44 (74.6%) individuals with a normal genotype, 9 (15.3%) heterozygotes and 6 (10.2%) homozygotes. In the nonanemic group, the corresponding prevalence figures were 25 (71.4%), 9 (25.7%) and 1 (2.9%), respectively. The difference between these distributions was statistically significant (chi2 = 37.5, p < 0.0001). However, the mean Hb values were similar in heterozygotes, homozygotes and normal individuals. We, therefore, conclude that while the alpha-thal trait affects the prevalence of anemia among pregnant Kuwaiti women, it does not affect its severity.

Gene deletion patterns in spinal muscular atrophy patients with different clinical phenotypes

Spinal muscular atrophy (SMA) is an autosomal recessive disorder characterized by degeneration of lower motor neurons. We have assayed deletions in two candidate genes, the survival motor neuron (SMN) and neuronal apoptosis inhibitory protein (NAIP) genes, in 108 samples, of which 46 were from SMA patients, and 62 were from unaffected subjects. The SMA patients included 3 from Bahrain, 9 from South Africa, 2 from India, 5 from Oman, 1 from Saudi Arabia, and 26 from Kuwait. SMN gene exons 7 and 8 were deleted in all type I SMA patients. NAIP gene exons 5 and 6 were deleted in 22 of 23 type I SMA patients. SMN gene exon 7 was deleted in all type II SMA patients while exon 8 was deleted in 19 of 21 type II patients. In 1 type II SMA patient, both centromeric and telomeric copies of SMN exon 8 were deleted. NAIP gene exons 5 and 6 were deleted in only 1 type II SMA patient. In 1 of the 2 type III SMA patients, SMN gene exons 7 and 8 were deleted with no deletion in the NAIP gene, while in the second patient, deletions were detected in both SMN and NAIP genes. None of the 62 unaffected subjects had deletions in either the SMN or NAIP gene. The incidence of biallelic polymorphism in SMN gene exon 7 (BsmAI) was found to be similar (97%) to that (98%) reported in a Spanish population but was significantly different from that reported from Taiwan (0%). The incidence of a second polymorphism in SMN gene exon 8 (presence of the sequence ATGGCCT) was markedly different in our population (97%) and those reported from Spain (50%) and Taiwan (0%).

Th1 and Th2 cytokine profiles in sickle cell disease

We have investigated the levels of Th1 (IL-2 and IFN-gamma) and Th2 (IL-4) cytokines in the plasma and supernatants following peripheral blood mononuclear cell culture and mitogen stimulation in a group of 39 patients with sickle cell disease (SCD) made up of 29 SS, 8 Sbeta-thal and 2 Hb SD in steady state. Five SS patients were studied during 7 episodes of vaso-occlusive crisis. Twenty-four control (3 Hb AS and 21 Hb AA) were also studied; 10 were acutely ill while 14 were healthy at the time of the study. The plasma levels of IL-2 and IFN-gamma were similar in the patients and the controls. However, plasma IL-4 was significantly higher among the steady-state SS patients than in the controls. While there was no significant difference in cytokine levels following mitogen stimulation in the different groups, plasma IL-2 to IL-4 and IFN-gamma to IL-4 ratios were significantly lower among the steady-state SS patients, indicating a possible Th2 bias in our sickle cell patients and suggesting a possible mechanism to explain the predisposition of SCD patients to bacterial infections. However, SS patients with good splenic function showed a relative Th1 bias, which may be an additional explanation for the protection against bacterial infections in such patients.

Influence of consanguinity and IgE receptor genotypes on clinical manifestations of asthma in Kuwaiti children

An association between IgE receptor FcepsilonRIbeta polymorphism and atopy has been reported and proposed to be maternally transmitted. In a previous communication we reported high prevalence of the IgE receptor FcepsilonRIbeta variant (Leu 181/Leu 183) in Kuwaiti Arabs with asthma. This study investigates the association of this variant with parental consanguinity, maternal vs paternal inheritance, gender, and severity of asthma in 52 Kuwaiti families in whom at least one person had asthma. Using an allele refractory mutation screening (ARMS) test, blood (from 212 subjects, including asthmatic children, their parents and siblings) was tested for the presence of the normal and variant sequence of the IgE receptor FcepsilonRIbeta [homozygous normal sequence (Ile 181/Val 183, NN), the variant sequence (Leu 181/Leu 183, LL) and the heterozygous state NL]. In the 52 families 99 subjects were asthmatic. The consanguinity rate was 42 per cent which is similar to the 54 per cent reported for the Kuwaiti population as a whole. There were slightly more asthmatic fathers (27 per cent) than mothers (21 per cent) but this difference is not significant. The male to female ratio amongst the asthmatics was 1.5:1 and there was no gender effect on the frequency of the homozygous variant. Fifty-eight subjects (59 per cent) had severe and 41 (41 per cent) moderate asthma. Significantly more patients with severe asthma (58 per cent) were homozygous for the variant (Leu 181/Leu 183) than those with moderate disease (33 per cent) (p < 0.018). Our data suggest an equal maternal and paternal contribution to the inheritance of asthma and an association of the homozygous variant (Leu 181/Leu 183) of the IgE receptor FcepsilonRIbeta with disease severity.

Human leukocyte antigen (HLA) DRB1 alleles in Kuwaiti Arabs with schizophrenia

The frequency of human leukocyte anti- gen DRB1 alleles was determined in a cohort of 194 Kuwaiti Arabs consisting of 80 schizophrenia patients and 114 ethnically matched healthy controls, using a polymerase chain reaction-sequence specific primers method. A total of 12 DRB1 alleles were identified in this Kuwaiti cohort. A statistically significant difference was detected in the frequency of alleles DRB1(*)04 and DRB1(*)13 between the schizophrenia patients and controls. Allele frequency of DRB1(*)04 in schizophrenia patients was 14% compared with nearly 7% in controls (P = 0.028). For DRB1(*)13, the allele frequency was found to be 18% in schizophrenia patients compared with 9% in the controls (P = 0.015). For alleles, DRB1(*)03, DRB1(*)07, and DRB1(*)16 the frequency was higher in controls compared with schizophrenia patients. The frequency of DRB1(*)01, DRB1(*)08, DRB1(*)10, DRB1(*)11, and DRB1(*)15 alleles was almost identical in schizophrenia patients and controls. For the remaining alleles, the differences between the two groups were not statistically significant. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:870-872, 2000.