Never too old: A case of fatal epstein barr virus pneumonia in an immunocompetent adult

A 67-year-old immunocompetent male with COPD on supplemental oxygen presented with shortness of breath and was initially treated for bronchitis exacerbation with initial suspicion of bacterial pneumonia. He was later found to have EBV pneumonia diagnosed via positive EBV on bronchoalveolar lavage PCR. Severe lung involvement has been rarely reported in context of acute EBV infection. Treatment for this entity has not yet been established, with few reports of acyclovir and steroid use. This report describes the presentation, diagnosis, and treatment of acute EBV pneumonia.

Cavitary lung lesion as sequelae of mild COVID-19 in a patient with HIV

Cavitary lung lesions involve a large spectrum of acute to chronic infections, chronic systemic diseases, and malignancies. During the COVID-19 pandemic, we have seen an increase in lung cavitation, mainly secondary to bacterial infection however, there have been limited reports of these lesions with mild COVID-19 disease. There has been an association between severe COVID-19 infection and secondary bacterial/fungal infections and cavitary lung lesions. We report the first case of a 32-year-old man with well-controlled HIV who presented with cough and fever from what appeared to be a cavitary lesion as a sequela of his recent COVID-19 infection.

Erythrocytes from patients with ST-elevation myocardial infarction induce cardioprotection via the purinergic P2Y13 receptor and nitric oxide signalling

Background

Red blood cells (RBC) are suggested to act as important mediators in the regulation of cardiovascular function by exporting nitric oxide (NO) bioactivity and ATP under hypoxic/ischemic conditions. In addition, RBCs are known to protect from ischemia-reperfusion injury via the export of NO bioactivity in experimental settings. However, it remains unknown if such beneficial effects of RBCs are protective in patients with acute myocardial infarction.

Purpose

To investigate whether RBCs from patients with ST-elevation myocardial infarction (STEMI) protect against myocardial ischemia-reperfusion injury and whether such effect involves activation of purinergic and NO signalling in the RBCs.

Methods

RBCs were collected from patients with STEMI undergoing primary percutaneous coronary intervention and age- and gender-matched healthy controls. The RBCs were administered into the coronary circulation of isolated Langendorff-perfused rat hearts at the onset of global ischemia for 25 min followed by reperfusion of 60 min. Recovery of left ventricular developed pressure (LVDP) during reperfusion and infarct size were determined. All animal experiments and procedures were performed according to the guidelines by the U.S National Institutes of Health (NIH publication no 85–23, revised 1996). The present study was performed following The Code of Ethics of the World Medical Association outlined in the Declaration of Helsinki of 1975 and revised in 1983 for experiments that involve human subjects.

Results

Administration of RBCs from STEMI patients improved recovery of LVDP and reduced infarct size in hearts subjected to ischemia-reperfusion in comparison with RBCs from healthy controls (Figure 1A, B). Pre-incubation of the RBCs with the NO synthase (NOS) inhibitor L-NAME (Figure 1C, D) and the inhibitor of the NO receptor soluble guanylyl cyclase (sGC) ODQ abolished the cardioprotective effect of RBCs from STEMI patients. The cardioprotective effect was also attenuated by inhibition of cardiac cGMP-dependent protein kinase (PKG). Further, the purinergic P2Y13 receptor antagonist MRS2211 (Figure 1E, F), but not the P1 receptor antagonist 8PT applied to RBCs, attenuated the cardioprotection induced by RBCs from STEMI patients. Moreover, administration of RBCs from healthy subjects pre-incubated with a cell permeable ATP analogue improved post-ischemic recovery of LVDP and reduced infarct size. This cardioprotective effect was abolished by co-incubation of the RBCs with ODQ (Figure 2) and MRS2211.

Conclusion

Our findings demonstrate a novel function of RBCs in patients with STEMI that provides protection against myocardial ischemia-reperfusion injury via the activation of P2Y13 receptor and the NO-sGC pathway in RBCs and cardiac PKG.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung Foundation; Swedish Research Council

A Case of SGLT2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis

While rare, serious adverse effects including euglycemic diabetic ketoacidosis (EDKA) have been associated with sodium-glucose cotransporter-2 inhibitor (SGLT2i) use. We present an interesting case of SGLT2i-induced EDKA occurring two years after initiation of therapy. Most patients with EDKA recover with prompt recognition and treatment. Patient education about identifying early signs remains a cornerstone of early identification and response to SGLT2i-induced EDKA.

Black esophagus: a syndrome of acute esophageal necrosis associated with active alcohol drinking

Black esophagus, also known as acute esophageal necrosis (AEN) syndrome, is a rare entity characterized by patchy or diffuse circumferential black pigmentation of the esophageal mucosa from ischemic necrosis. It may present with life-threatening upper gastrointestinal hemorrhage resulting in high mortality in immunocompromised patients. Advanced age with multiple comorbidities compounded with compromised hemodynamic states are poor prognostic factors. Findings on laboratory work-up and radiological imaging are non-specific. After initial resuscitation, endoscopic evaluation and histological examination of esophageal biopsy are diagnostic. Early recognition and aggressive resuscitation are the fundamental principles for the management of AEN and better outcome of the disease. We report a case of a 56-year-old woman with diabetes mellitus, gastro-esophageal reflux disease, and active alcohol binging who presented with hematemesis and acute epigastric pain due to AEN. This case illustrates a rare etiology of AEN due to active alcohol drinking, which may be overlooked. Physician awareness about this etiology is important as early recognition and timely management may improve survival.

Three-year Clinical Performance of Two Giomer Restorative Materials in Restorations

CLINICAL RELEVANCE

The clinical performance of both conventional and flowable giomer restorative materials was particularly good in Class I restorations after three years of service.

SUMMARY

This study evaluated and compared the clinical performance of a flowable and a conventional giomer restorative material after three years. Forty-four pairs of restorations (total n=88) were placed in Class I cavities with either a flowable giomer (Beautifil Flow Plus F00; Shofu Inc, Kyoto, Japan) or a conventional giomer restorative material (Beautifil II; Shofu Inc) after the application of a dentin adhesive (FL-Bond II; Shofu Inc) and a flowable liner (Beautifil Flow Plus F03; Shofu Inc). After 3 years, 39 pairs of restorations were evaluated with the modified United States Public Health Service criteria, and digital color photographs of restorations were taken at each patient visit. The evaluation parameters were as follows: color match, marginal integrity, marginal discoloration, retention, secondary caries formation, anatomic form, surface texture, and postoperative sensitivity. Evaluations were recorded as a clinically ideal situation (Alpha), a clinically acceptable situation (Bravo), or a clinically unacceptable situation (Charlie). Data were analyzed with Fisher's exact and McNemar tests (α=0.05).None of the restorations showed retention loss, postoperative sensitivity, secondary caries, or color change. The performance of Beautifil II in terms of marginal integrity, marginal discoloration, and surface anatomic form was significantly lower at the 36-month follow-up than at baseline (p=0.007). There were no significant differences between the baseline and 36-month follow-up scores for the other criteria for Beautifil II (p>0.05). No differences were found between the baseline and the 36-month follow-up scores for any of the criteria for Beautifil Flow Plus F00 (p>0.05). No statistically significant difference in overall clinical performance was found between the 2 materials after 36 months (p>0.05).The three-year clinical performance of both restorative materials (Beautifil Flow Plus F00 and Beautifil II) was very good and not significantly different for any of the parameters evaluated.

An exploratory randomised controlled trial evaluating text prompts in Lebanon to encourage health-seeking behaviour for hypertension

AIMS OF THE STUDY

The current study evaluates the effectiveness of an opportunistic mobile screening on the percentage of people who are aware of whether they may be hypertensive (in an observational study) and the effectiveness of reminder prompts on the percentage of people who seek further medical attention (in a randomised controlled trial).

METHODS USED TO CONDUCT THE STUDY

The screening of 1227 participants (529 female) was conducted during the registration period of the 2018 Beirut International Marathon in Lebanon. Next, 266 participants whose screening indicated hypertension (64 Female) were randomly allocated to a treatment group or a control group in a 1:1 fashion. The treatment group received a reminder prompt to seek further medical attention for their potential hypertension and the control group did not. The overt nature of the text message meant that participants in the treatment group could not be blinded to their group allocation. The primary outcome is participants' self-reports of whether they sought further medical attention.

RESULTS OF THE STUDY

For the opportunistic screening, a 25% prevalence rate and a 24% awareness rate of hypertension was indicated. A McNemar analysis suggested that the screening increased participant awareness (X² (N = 1227) = 72.16, P < .001). For the randomised controlled trial, 219 participants provided follow-up data via a phone call (82% retention). A Chi-squared analysis suggested that the reminder prompt successfully encouraged more participants to seek further medical attention, 45.5% treatment group vs 28.0% control group (X² (1, N = 219) = 7.19, P = .007, φ = 0.18).

CONCLUSIONS DRAWN AND CLINICAL IMPLICATIONS

Extra support in the form of a brief reminder message can increase the percentage of people who seek further medical attention after attending an opportunistic screening at a marathon event. The discussion reviews how the results align with previous research, strengths and limitations of the current study, and implications for future research and practice.

P6599Upregulation of protein and gene expression of arginase-1 in patients with ST elevation myocardial infarction

Background

The mechanisms underlying rupture of a coronary atherosclerotic plaque and development of myocardial ischemia-reperfusion injury in ST-elevation myocardial infarction (STEMI) remain unknown. Increased arginase-1 activity leads to reduced nitric oxide production and increased formation of reactive oxygen species due to uncoupling of the endothelial nitric oxide synthase (eNOS). These events lead to endothelial dysfunction, plaque instability and increased susceptibility to ischemia-reperfusion injury in acute myocardial infarction. Experimental studies have shown that arginase-1 expression and activity are increased in atherosclerosis and during myocardial ischemia-reperfusion. Accordingly, inhibition of arginase-1 reduces atherosclerotic lesion development and limits the extent of infarct size during ischemia-reperfusion via an eNOS-dependent mechanism. Furthermore, arginase-1 inhibition improves endothelial function in patients with coronary artery disease but the potential role of arginase-1 in patients with STEMI is poorly understood.

Purpose

The purpose of the current study was to test the hypothesis that arginase-1 is upregulated and correlate to infarct size in STEMI patients.

Methods and results

Two independent cohorts of STEMI patients were included. In cohort 1, plasma and buffy coat leukocytes were collected from 53 STEMI patients at the time of arterial puncture for percutaneous coronary intervention, at 24–48 hours post STEMI and at 3 months post STEMI. Gene expression in leukocytes was determined in 51 patients with Affymetrix Human Transcriptome Array 2.0. In cohort 2, plasma was collected from 82 STEMI patients at admission and at 6 months for determination of plasma arginase-1. These patients underwent cardiac magnetic resonance imaging performed at day 4–7 and at 6 months post STEMI. Plasma arginase-1 levels were quantified with ELISA. Control blood samples were collected from 56 healthy age matched subjects. In cohort 1, ARG1 gene expression was four-fold higher in STEMI patients at admission compared to controls (Figure A). This expression returned to control levels within 3 months. Plasma arginase-1 levels were two times higher in STEMI patients at admission compared to controls, and remained elevated at 24–48 hours and at 3 months post STEMI (Figure B). The increase in plasma arginase-1 in STEMI patients was confirmed in cohort 2 (Figure C). Arginase-1 levels did not correlate with infarct size.

Conclusions

STEMI patients demonstrate increased gene expression and plasma levels of arginase-1 in the acute setting. In contrast to gene expression plasma arginase-1 levels remain significantly elevated over time. The markedly increased expression of arginase-1 already at admission may suggest a mechanistic role of arginase-1 in the development of STEMI. Further studies are needed to elucidate whether increased expression, induction and activity of arginase-1 are contributing factors for the development of STEMI.

P6400Risk for heart failure after acute myocardial infarction, a nationwide report on 73 303 patients with and without diabetes 2012–2017 in the SWEDEHEART-SCAAR registry

Background

Impressive improved one-year survival rates after acute myocardial infarction (AMI) have been achieved the last decades while long-term cardiovascular events still are a challenge particularly when diabetes is present. Recently several glucose lowering drugs with preventive effects on heart failure (HF) and MACE have entered the market however still used in low proportion by cardiologists.

Purpose

To explore the real-life complication rates of HF after AMI in patients with and without diabetes.

Methods

All patients with AMI admitted for coronary angiography in Sweden 2012–2017 were followed for time to first hospitalisation with HF diagnosis (ICD-10 code I50) until December 2017. Kaplan-Meier curves were used to estimate the cumulative heart failure event stratified by previous MI. Hazard ratios (HR) were calculated in a Cox proportional hazard regression model adjusting for age, gender, smoking, creatinine, previous CABG/cancer/dementia/dialysis/hypertension/COPD/renal failure/stroke, year, indication, hospital, angiographic findings, primary decision after angiography, cardiac chock, medications at discharge.

Results

Of 73 303 patients, mean age was 69 years (SD±12), 69% were men and 24% had diabetes. In all, HF occurred in 14% with a higher rate in patients with diabetes than those without (22% vs 12%). The highest HF rates were seen in patients with previous MI (33% if diabetes was present vs. 23% if no diabetes). After adjustments, patients with diabetes without previous MI had about the same HF risk (HR 1.52 [95% CI 1.44–1.61]) as patients without diabetes with previous MI (1.48 [1.40–1.57]) where patients without diabetes and previous MI served as a reference. The same pattern was seen regardless of STEMI/NSTEMI and also after excluding patients with previous HF (n=4567, 6%; Figure; patients with diabetes without previous MI 1.48 [1.40–1.57] and patients without diabetes with previous MI 1.27 [1.19–1.36]).

Conclusion

Heart failure is a common complication after AMI in patients with diabetes, particularly if previous MI, and regardless of previous reported heart failure. Diabetes increases the risk of heart failure by 30–50% compared to those without diabetes. These data indicate the existence of a large diabetes population at heart failure risk after AMI where heart failure protective glucose lowering drugs could be suitable.

Acknowledgement/Funding

The Swedish Heart and Lung foundation, Department of Research and Development Region Kronoberg, the Kamprad Family Foundation

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

The antioxidant resveratrol acts as a non-selective adenosine receptor agonist

Resveratrol (RSV) is a natural polyphenolic antioxidant with a proven protective role in several human diseases involving oxidative stress, although the molecular mechanism underlying this effect remains unclear. The present work tried to elucidate the molecular mechanism of RSV's role on signal transduction modulation. Our biochemical analysis, including radioligand binding, real time PCR, western blotting and adenylyl cyclase activity, and computational studies provide insights into the RSV binding pathway, kinetics and the most favored binding pose involving adenosine receptors, mainly A_2A subtype. In this study, we show that RSV target adenosine receptors (AdoRs), affecting gene expression, receptor levels, and the downstream adenylyl cyclase (AC)/PKA pathway. Our data demonstrate that RSV activates AdoRs. Moreover, RSV activate A_2A receptors by directly binding to the classical orthosteric binding site. Intriguingly, RSV-induced receptor activation can stimulate or inhibit AC activity depending on concentration and exposure time. Such subtle and multifaceted regulation of the AdoRs/AC/PKA pathway might contribute to the protective role of RSV. Our findings suggest that RSV molecular action is mediated, at least in part, by activation of adenosine receptors and create the opportunity to interrogate the therapeutic use of RSV in pathological conditions involving AdoRs, such as Alzheimer.

A New Lebanese Medication Adherence Scale: Validation in Lebanese Hypertensive Adults

BACKGROUND

A new Lebanese scale measuring medication adherence considered socioeconomic and cultural factors not taken into account by the eight-item Morisky Medication Adherence Scale (MMAS-8). Objectives were to validate the new adherence scale and its prediction of hypertension control, compared to MMAS-8, and to assess adherence rates and factors.

METHODOLOGY

A cross-sectional study, including 405 patients, was performed in outpatient cardiology clinics of three hospitals in Beirut. Blood pressure was measured, a questionnaire filled, and sodium intake estimated by a urine test. Logistic regression defined predictors of hypertension control and adherence.

RESULTS

54.9% had controlled hypertension. 82.4% were adherent by the new scale, which showed good internal consistency, adequate questions (KMO coefficient = 0.743), and four factors. It predicted hypertension control (OR = 1.217; p value = 0.003), unlike MMAS-8, but the scores were correlated (ICC average measure = 0.651; p value < 0.001). Stress and smoking predicted nonadherence.

CONCLUSION

This study elaborated a validated, practical, and useful tool measuring adherence to medications in Lebanese hypertensive patients.

Bimetallic gold(i) complexes of photoswitchable phosphines: synthesis and uses in cooperative catalysis

The first photoswitchable bimetallic gold catalysts based on an azobenzene backbone have been synthesized and their catalytic properties have been investigated.

THE EFFECT OF SALBUTAMOL ON PGC-1 α AND GLUT4 mRNA EXPRESSION IN THE LIVER AND MUSCLE OF ELDERLY DIABETIC MICE

Background

Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) plays an important role in the regulation of cellular energy metabolism, and it is involved in obesity and type 2 diabetes mellitus (T2DM). Its expression is elevated in the liver of T2DM mouse models. Literature reports show that chronic β2 stimulation improved insulin sensitivity in T2DM.

Objectives

We aimed to test the hypotheses that chronic β2 stimulation-induced improvement in insulin sensitivity involves changes in the expression of PGC-1α and glucose transporter 4 (GLUT4).

Animals and Methods

We fed a locally inbred, 8 months old mice, a high fat diet (HFD) to induce diabetes. These mice gained weight and became insulin resistant. The β2 agonist salbutamol had a beneficial effect on both glucose tolerance and insulin sensitivity after 4 weeks.

Results

Salbutamol beneficial effect persisted after 4 weeks of its discontinuation. HFD caused an up regulation of the hepatic PGC-1 α expression by 5.23 folds (P< 0.041) and salbutamol reversed this effect and caused a down regulation by 30.3 folds (P< 0.0001). PGC-1 α and GLUT4 expression in the muscle was not affected by salbutamol (P> 0.05).

Conclusion

Down regulation of the liver's PGC-1 α contributes to the beneficial effect of the chronic β2 stimulation on glucose tolerance and insulin sensitivity in T2DM mice.

Mortality and extent of coronary artery disease in 2776 patients with type 1 diabetes undergoing coronary angiography: A nationwide study

Background In a modern perspective there is limited information on mortality by affected coronary vessels assessed by coronary angiography in patients with type 1 diabetes. The aim of the present study was to characterise distribution of coronary artery disease and impact on long-term mortality in patients with type 1 diabetes undergoing coronary angiography. Design The design of this research was a nationwide population-based cohort study. Methods Individuals ( n = 2776) with type 1 diabetes undergoing coronary angiography 2001-2013 included in the Swedish National Diabetes Registry and Swedish Coronary Angiography and Angioplasty Registry were followed for mortality until 31 December 2013 (mean 7.1 years). In 79% the indication was stable or acute coronary artery disease. Coronary artery disease was categorised into normal (21%), one- (23%), two- (18%), three- (29%) and left main-vessel disease (8%). Results Mean age was 57 years and 58% were male. Mean diabetes duration was 35 years, glycated haemoglobin was 67 mmol/mol and 44% had normal or one-vessel disease. In multivariate Cox proportional analyses hazard ratio for mortality compared with normal findings was 1.09 (95% confidence interval 0.80-1.48) for one, 1.43 (1.05-1.94) for two, 1.47 (1.10-1.96) for three and 1.90 (1.35-2.68) for left main-vessel disease. Renal failure 2.29 (1.77-2.96) and previous heart failure 1.76 (1.46-2.13) were highly associated with mortality. Standard mortality ratio the first year was 5.55 (4.65-6.56) and decreased to 2.80 (2.18-3.54) after five years. Conclusions In patients with type 1 diabetes referred for coronary angiography mortality is influenced by numbers of affected coronary vessels. The overall mortality rate was higher compared with the general population. These results support early intensive prevention of coronary artery disease in this population.

Improved slow magnetic relaxation in optically pure helicene-based DyIII single molecule magnets

Racemic and optically pure [Dy(hfac)₃(L)] complexes with L = 3-(2-pyridyl)-4-aza[6]-helicene have been synthesized and characterized.

[Substance use among Lebanese university students: prevalence and associated factors]

Scientific research on use and misuse of substances in Lebanon is scarce. This study aimed to evaluate the rate of use and abuse of substances among Lebanese youth and identify the determinants and risk factors behind these behaviours. An observational survey was conducted on 1945 university students selected from the different faculties of the Lebanese University and other private universities. A self-administered questionnaire based on ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) was administered. The prevalence of ever consuming alcohol was 20.9%. Cannabis (12.3%) and tranquilizers (11%) had the highest rates of ever use among the drugs, whereas cocaine (3.3%) and hallucinogens (3.6%) had the lowest rates. Smoking cigarettes and waterpipes, going out at night, peer pressure and having no specific leisure time activity were associated with problematic substance use, while a better relationship with parents, reading and working were inversely associated with use. There is a high prevalence of substance use among university students in Lebanon. Multidisciplinary support for addicted students is needed to meet their diverse needs.

[Asthma, indoor and outdoor air pollution: A pilot study in Lebanese school teenagers]

INTRODUCTION

Many studies have demonstrated that outdoor pollution might exacerbate respiratory symptoms and childhood asthma. Our objective was to evaluate the relationship between asthma and outdoor and indoor pollution.

METHODS

We undertook a survey in May-June 2012 about schoolchildren aged 12-19 years in six Lebanese schools. This combined the International Study of Asthma and Allergies in Childhood (ISAAC) standardized questionnaire with other questions addressing outdoor and indoor exposure.

RESULTS

Among 717 subjects (response rate 71.7%), 4.5% had physician-diagnosed asthma, 34.7% had probable asthma and 60.8% were asymptomatic. Exposure to indoor contaminants was positively associated to asthma. The risk for asthma was higher in those residing near heavy road traffic (ORa=4.30 [95% CI 1.45-12.71], P<0.05), those previously exposed to fire (ORa=1.84 [95% CI 1.01-3.36]), and those exposed to smog (ORa=4.15 [95% CI 1.42-12.12]). Airing the house in the morning or in case of indoor smoking had a protective effect against asthma.

CONCLUSION

These results suggest that the risks of asthma or having respiratory symptoms are not only related to indoor pollution but also to outdoor pollution especially from road traffic.

Spectroscopic studies of keto–enol tautomeric equilibrium of azo dyes

Keto–enol tautomeric equilibrium of an azo dye is shifted to the keto form as the solvent polarity is increased.

Homocysteine and other cardiovascular risk factors in patients with lichen planus

BACKGROUND

Chronic inflammation was found to play an important role in the development of cardiovascular risk factors. Homocysteine (Hcy) and fibrinogen have been identified as a major independent risk factor for cardiovascular disease. Lichen planus is assumed to be closely related to dyslipidaemia. Several cytokines involved in lichen planus pathogenesis, could explain its association with dyslipidaemia. Also chronic inflammation with lichen planus has been suggested as a component of the metabolic syndrome.

OBJECTIVE

The aim of this study was to detect a panel of cardiovascular risk factors in patients of lichen planus.

PATIENTS AND METHODS

This study was done on 40 patients of lichen planus and 40 healthy controls. All patients and controls were subjected to clinical examination. Serum levels of homocysteine, fibrinogen and high-sensitive C-reactive protein (hs-CRP) were measured by enzyme-linked immunosorbent assay technique (ELISA). Metabolic syndrome parameters including anthropometric measures, lipid profiles, blood sugar and blood pressure were studied.

RESULTS

Patients with lichen planus showed significant association with metabolic syndrome parameters than controls (P < 0.001). Serum homocysteine, fibrinogen and hs-CRP were significantly higher in lichen planus patients than controls (P < 0.001). Serum homocysteine correlated with both serum hs-CRP and serum fibrinogen. However, there was no correlation between serum levels of homocysteine and fibrinogen with any metabolic syndrome criteria and related disorders except for a negative correlation of fibrinogen with high-density lipoprotein (HDL).

CONCLUSION

In the present work, patients with lichen planus were found to have higher makers of both metabolic and cardiovascular risk factors in relation to controls most probably due to long standing inflammation.

Long-term mortality in patients with type 2 diabetes undergoing coronary angiography: the impact of glucose-lowering treatment

AIMS/HYPOTHESIS

The aim of this study was to analyse whether the increased mortality rates observed in insulin-treated patients with type 2 diabetes and coronary artery disease are explained by comorbidities and complications.

METHODS

A retrospective analysis of data from two Swedish registries of type 2 diabetic patients (n = 12,515) undergoing coronary angiography between the years 2001 and 2009 was conducted. The association between glucose-lowering treatment and long-term mortality was studied after extensive adjustment for cardiovascular- and diabetes-related confounders. Patients were classified into four groups, according to glucose-lowering treatment: diet alone; oral therapy alone; insulin in combination with oral therapy; and insulin alone.

RESULTS

After a mean follow-up time of 4.14 years, absolute mortality rates for patients treated with diet alone, oral therapy alone, insulin in combination with oral therapy and insulin alone were 19.2%, 17.4%, 22.9% and 28.1%, respectively. Compared with diet alone, insulin in combination with oral therapy (HR 1.27; 95% CI 1.12, 1.43) and insulin alone (HR 1.62; 95% CI 1.44, 1.83) were associated with higher mortality rates. After adjustment for baseline differences, insulin in combination with oral glucose-lowering treatment (HR 1.22; 95% CI 1.06, 1.40; p < 0.005) and treatment with insulin only (HR 1.17; 95% CI 1.02, 1.35; p < 0.01) remained independent predictors for long-term mortality.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes patients treated with insulin and undergoing coronary angiography have a higher long-term mortality risk after adjustment for measured confounders. Further research is needed to evaluate the optimal glucose-lowering treatment for these high-risk patients.

Clinicopathological and immunological studies on toxoids vaccine as a successful alternative in controlling clostridial infection in broilers

The present study was conducted to evaluate the efficacy and safety of three vaccination regimes of Clostridium perfringens (C. perfringens) type A, C and combined A&C toxoids based on their clinical signs and immunological effects. The vaccines were administered two times at two weeks interval (7 & 21 days old), then the birds were challenged (35 days old) with virulent strains of C. perfringens type A, C and combined A&C. Blood samples were taken one week after the first and second vaccination as well as after challenge. The evaluated parameters in this study included: clinical signs, gross intestinal lesions, complete blood count (CBC), serum protein, liver profiles, and enzyme-linked immunosorbent assay (ELISA) test for detecting serum antibody titers. The results revealed that immunization of broilers with C. perfringens type A, C and combined A&C toxoids resulted in a significant decrease in numbers of chickens with intestinal lesions particularly with the A&C toxoids vaccine. Results of the CBC values were significantly increased in all treated groups and challenged groups. Total leukocytic count decreased in challenged non vaccinated group while increased in challenged vaccinated birds. Results of biochemical assays implicated that there were a significant increase in serum protein and liver profiles. ELISA results explored a significant increase in antibody titers after immunization of broilers with C. perfringens type A, C and combined A&C toxoids particularly after the second dose of vaccination. We concluded that immunization of broilers with toxoid vaccines particularly the combined type A & C is safe, well-tolerated and can protect broiler chickens against necrotic enteritis particularly after the second booster dose of the vaccine.

Prevalence and determinants of fecal incontinence in premenopausal women in an Arabian community

OBJECTIVES

The aim of this study was to determine the prevalence, awareness and determinants of fecal incontinence among Qatari women.

METHOD

In the cross-sectional community-based study in primary health-care centers, using a multistage sampling design, a representative sample of randomly selected 776 Qatari women aged from 40 to 48 years were approached from January to August 2007; only 596 women, with a response rate of 76.8%, gave consent and were included in the analysis. Participants completed a questionnaire assessing fecal incontinence in the previous 12 months and health care-seeking behavior for fecal symptoms. Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review.

RESULTS

Of the studied Qatari women, 62 (10.4%) were found to have fecal incontinence. There was a significant difference between fecal incontinent and continent groups with regard to menopause (p < 0.0001), surgical repair of genital prolapse (p < 0.0001) and constipation (p < 0.0001). Only 31 incontinent patients (50%) had sought medical advice. Of the fecal incontinent women, 77.4% felt embarrassment in consulting a doctor and 77.4% believed their condition was worth reporting to a doctor. Aging (51.6%) was the major cause of fecal incontinence in women, followed by childbirth (40.3%), then menopause (25.8%) and lastly paralysis (14.5%). Most of the sufferers were troubled by their inability to pray (64.5%). Their relationship with their husband (41.9%) was the significant consequence for fecal incontinent Qatari women (p = 0.02); 37.1% isolated themselves from social activities and going out to shop.

CONCLUSIONS

The study findings revealed that fecal incontinence is a common symptom among women in the community. There was a correlation between fecal incontinence and menopause. Overall, most of the fecal incontinent women reported that fecal incontinence significantly affected quality of life and only half of the studied women had consulted a physician for the symptom.

Ultrasound Prediction of Fetal Macrosomia in Diabetic Women and its Effect on the Route of Delivery and the Outcome of Pregnancy

Objective: The purpose of this study is to review the maternal and neonatal outcome in pregnant diabetic women given a trial of labor and delivered macrosomic infants (>4000 grams) and to assess the accuracy of birth weight prediction by ultrasound examination at term.

Methods: One hundred and twenty-nine charts of pregnant diabetic women were reviewed, sixty eight women were given a trial of labor and delivered macrosomic fetuses (>4000 grams), fifty of them had vaginal delivery and the other eighteen had caesarean delivery. In the other group, 61 patients delivered by elective caesarean section, for 41 of them the indication was fetal macrosomia (>4000 grams) as estimated by ultrasound examination and in the other 20, it was due to clinical estimation of big baby. Maternal and neonatal complications were reviewed in each group. Maternal complications included lacerations, hemorrhage and infection and the neonatal complications evaluated were shoulder dystocia and associated birth trauma, asphyxia, and mortality. The accuracy of ultrasound in estimating fetal weight was also evaluated.

Results: Sixty eight (52.7%) women attempted a trial of labor; 73.5% delivered vaginally and 26.5% had a caesarean delivery. All, except two, had macrosomic fetuses (>4000 grams). Only one woman, of those who delivered vaginally, had postpartum hemorrhage due to atonic uterus. The incidence of shoulder dystocia for infants weighing 4000-4499 grams was 6.3% and those infants had the same incidence (6.3%) of brachial plexus injury. There was no perinatal asphyxia or perinatal mortality among those infants who were delivered vaginally. There were no maternal complications for women who had caesarean delivery after labor (18 patients) but there was perinatal asphyxia in two infants who were treated properly without any neurological sequele. Elective caesarean delivery was performed in 47.3% of the study population. There were no neonatal complications or perinatal mortality in this group of patients and only one woman had wound infection. The sonographic prediction of fetal weight was accurate in 52.4% of the cases. The over estimation was in 50.8% of the estimated fetal weights and 49.2% of them were underestimated when compared to actual birth weights.

Conclusions: Caution should be taken in the use of sonographic estimations of fetal weight to guide obstetric decisions concerning labor and delivery. Special consideration should be given to diabetic patients having fetuses with estimatedfetal weights between 4000 and 4500 grams. Flexibility in the management of these patients is best, taking in consideration their previous obstetric performance and if the estimated fetal weight is closer to 4500grams than to 4000 grams, it is perhaps, better to proceed to a primary caesarean delivery.

Fetal Echocardiography Service in Qatar: Establishment, Challenges and Outcome

A prospective observational study at the newly estab-lished Fetal Medicine Unit, Hamad Hospital, Qatar; evalu-ated the impact of the service on the detection rate of criti-cal congenital heart defects, patterns of referral and sub-sequent yield for structural congenital heart disease in a population with a significant proportion of high risk fac-tors.

Of 391 pregnant females examined between January 2003 and December 2004, 58 (14.8%) had fetal cardiac abnormalities of which 23 (5.8% of total referrals) had major structural malformations of the heart. Cases of fetal congenital heart disease had further evaluation us-ing real time three-dimensional echocardiography (RT3DE) which is new equipment in the paediatric cardi-ology department. All cases with cardiac defects whether minor or major had follow up fetal echocardiography. Neonatal echocardiography confirmed the diagnosis in all cases with major defects (100% specificity). False positive cases that were found to be normal post natal were 1% of the total cases referred (12% of cases with congenital mal-formation). False negative cases were 1% and all had a small ventricular septal defect (VSD) except for one Down's syndrome with a very large VSD.

Three patients needed urgent Caesarean section (CS) deliveries, one with complete heart block (HB) and two with supraventricular tachycardia (SVT). One patient traveled abroad as the fetus had left isomerism and major cardiac defects and complete HB. Fifteen newborns had to receive prostaglandin based on the fetal diagnosis before being seen by paediatric cardiologists. There was no termination of pregnancy due to major cardiac defects even in cases of HLHS.

The preliminary results of this clinic are very satisfac-tory and have affected favorably the outcome of the new-borns with congenital heart defects. It is hoped that the results of this study will encourage more referrals to the FMU.

Skin dose alarm levels in cardiac angiography procedures: is a single DAP value sufficient?

Maximum estimated skin doses to patients undergoing coronary angiography procedures were obtained using radiographic slow film and diode dosemeters. Conversion factors of maximum entrance skin dose versus dose-area product (MESD/DAP) for diagnostic (coronary angiography (CA); 20 patients; 2 operators) and interventional procedures (percutaneous transluminal coronary angiography (PTCA); 10 patients; 1 operator) were 4.3 (mean value of 10 CA; operator A), 3.5 (mean value of 10 CA; operator B) and 9.7 (mean value of 10 PTCA; operator B) mGy(Gycm2)(-1), respectively. The results emphasise a need for both operator- and procedure-specific conversion factors. Compared with a single, global factor for all cardiac procedures and/or operators that is commonly applied today, such a refinement is expected to improve the accuracy in skin dose estimations from these procedures. Consequently, reference DAP values used in the clinic to define patients who could suffer from a radiation induced skin injury following a cardiac procedure, should be defined for each operator/procedure. The film technique was found to be superior to the diode in defining conversion factors in this study, and allowed for a rapid and accurate estimation of MESD for each patient. With appropriate positioning of the diode, a combined film/diode technique has a potential use in the training of new angiography operators. The patient body mass index (BMI) value was a good indicator of the variation in average lung dose (critical organ) between patients. The highest lung dose/DAP value was obtained for normal sized patients (BMI: 19-26), and was close to 1.5 mGy(Gycm2)(-1) with both CA and PTCA procedures.

Pregnancy Outcome in Grand and Great Grand Multiparity

Objective: To study the obstetric performance and neonatal outcome of patients of extreme multiparity, Para 10 and more, compared to control group of Para 2 to 4.

Study Design: It is a retrospective comparative study. Data were collected from Medical Records ofpatients during the period from January-December 2000. The total number of deliveries during that period was 10,999. 240 patients records were reviewed, 120 records in each group.

Result: The incidence of great-grand multiparity was 1.09%. The incidence of lack of perinatal care among great grand multipara was statistically significant. However; there are no differences in the perinatal morbidity and mortality; also there was no difference in the rate of instrumental delivery and mal-presentation in the two groups. The duration of pregnancy is similar in the two groups. There was no difference in incidence of antepartum hemorrhage, rate of caesarean section rate. However; the only statically significant difference in the two groups was the increased incidence of large babies (macrosomia).

Conclusion: This study showed that extreme grand multiparity carry the added risk of macrosomia (> 4000mg), this was not reflected on any adverse perinatal outcome. However, the number of patients in this study is limited and it is difficult to draw firm conclusion.

Prevalence, awareness and determinants of health care-seeking behaviour for urinary incontinence in Qatari women: a neglected problem?

OBJECTIVES

The aim of this study was to determine the prevalence, awareness and determinants of urinary incontinence (UI) among Qatari women and the sociodemographic factors involved in their health care-seeking behaviour.

DESIGN

A cross-sectional study was used to determine the symptoms of UI experienced by Arabian Gulf women.

SETTING

Primary Health Care (PHC) Centres and community-based study in Qatar.

SUBJECTS

A multistage sampling design was used and a representative sample of 1000 Qatari women aged 45 years and above were included from January to June 2003.

MEASUREMENTS

Participants completed a questionnaire assessing UI in the previous 12 months and health care-seeking behavior for urinary symptoms.

RESULTS

Of 1000 women living in urban and semiurban areas who were asked, 798 (79.8%), representing the study sample, agreed to participate and completed the questionnaire. Of these, 164 (20.6%) were found to have UI. Overall, the reason for not seeking medical attention was mainly embarrassment (40.6%) at having to speak with doctor. Of the total study sample, 562 subjects (70.4%) believed that UI was abnormal and worth reporting to a doctor. Coping mechanisms among incontinent women included frequent washing (58.3%) and wearing a protective perennial pad (42.4%), changing underwear frequently (41.3%), decreasing fluid intake (19.8%) and stopping all work (4.9%). Sufferers were most troubled by their inability to pray (64%) and their marital relationship (47%), limitation of their social activities (20%), difficulty in doing housework (14%) and inconvenience during shopping (13%). Most (71.9%) of the incontinent subjects were self-conscious, ashamed of themselves and troubled by guilt (P < 0.001); 56% found it most embarrassing to discuss UI with their husbands. The majority of women (51.9%) believed child birth to be the major cause of UI, followed by ageing (49.5%), menopause (34.2%) and paralysis (25.3%). Most of the subjects (62.3%) believe that UI can cause infection, some (20.5%) believe that it can cause skin allergy and very few think that it can cause cancer or other disorders.

CONCLUSIONS

Our findings indicate that although UI is relatively common in the community, it is underreported by Qatari women because of social and cultural attitudes and-most importantly-lack of information. This findings suggest that strategies to promote care-seeking for incontinence must be developed and employed in the community.

Identification of Leishmania strains from Jordan

The enzymatic profiles of 22 Jordanian Leishmania isolates obtained from humans, Psammomys obesus and Phlebotomus papatasi were determined using starch-gel electrophoresis and a 15-enzyme system. Thirteen of the isolates were typed as L. major and the other nine, all from Mediterranean or sub-Mediterranean regions, as L. tropica. The two zymodemes of L. major encountered, MON-26 and MON-103, differed in terms of purine nucleoside phosphorylase 2. The MON-26 isolates came from the Jordanian plateau whereas those of MON-103 were only collected from the Jordan valley. The four zymodemes of L. tropica observed (MON-7, MON-137, MON-200 and MON-265) were identical for only two of the 15 enzymes studied (i.e. isocitrate dehydrogenase and glucose phosphate isomerase), confirming the high level of enzymatic polymorphism of L. tropica. So far, MON-200 and MON-265 have only been found in Jordan.

C-reactive protein and myocardial infarction during percutaneous coronary intervention

OBJECTIVE

To evaluate the prognostic information of preprocedural C-reactive protein (CRP) levels in serum to predict myocardial infarction during percutaneous coronary interventions (PCI).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

A total of 400 consecutive patients with normal serum troponin T levels (</=0.03 microg L-1) presenting with stable or unstable angina pectoris.

INTERVENTIONS

PCI.

MAIN OUTCOME MEASURES

C-reactive protein levels in serum measured by a high sensitive method. Myocardial infarction defined as a serum troponin T elevation the day after PCI to a level >0.05 microg L-1.

RESULTS

Eighty-three patients (21%) experienced a myocardial infarction during PCI. The median value of CRP before the procedure was 1.83 (0.12-99.7) mg L-1. No difference was seen in CRP levels before PCI between patients without or with myocardial infarction during PCI. Multivariate analysis identified stent implantation (OR 2.68, 95% CI 1.18-7.28, P = 0.03), procedure time (OR 2.15, 95% CI 1.28-3.67, P < 0.005) and complications during the procedure (OR 3.62, 95% CI 1.72-7.58, P < 0.001) as independent predictors of myocardial infarction during PCI.

CONCLUSION

Increased CRP levels in serum before PCI were not associated with myocardial infarction during the procedure. Furthermore, patients with an expected long procedure and a high probability of stent implantation have an increased risk of developing myocardial infarction during PCI. This finding may be useful to help the operator to decide the antithrombotic regime before, during and after the procedure and the need for observation after the procedure.

Laser-energy transfer and enhancement of plasma waves and electron beams by interfering high-intensity laser pulses

The effects of interference due to crossed laser beams were studied experimentally in the high-intensity regime. Two ultrashort (400 fs), high-intensity (4 x 10(17) and 1.6 x 10(18) W/cm(2)) and 1 microm wavelength laser pulses were crossed in a plasma of density 4 x 10(19) cm(3). Energy was observed to be transferred from the higher-power to the lower-power pulse, increasing the amplitude of the plasma wave propagating in the direction of the latter. This results in increased electron self-trapping and plasma-wave acceleration gradient, which led to an increased number of hot electrons (by 300%) and hot-electron temperature (by 70%) and a decreased electron-beam divergence angle (by 45%), as compared with single-pulse illumination. Simulations reveal that increased stochastic heating of electrons may have also contributed to the electron-beam enhancement.

Loop diathermy excision compared with cervical laser vaporisation for the treatment of intraepithelial neoplasia: a randomised controlled trial

OBJECTIVE

To determine whether loop diathermy excision of the transformation zone and laser vaporisation are equally effective in the treatment of cervical intraepithelial neoplasia.

DESIGN

Randomised controlled trial.

POPULATION

Women referred for evaluation of cytological abnormality who were considered suitable for outpatient local destructive treatment.

SETTING

Seven colposcopy units in the North West Region.

METHODS

Loop diathermy excision of the transformation zone and laser vaporisation.

MAIN OUTCOME MEASURE

Smear reported as moderate dyskariosis or worse following treatment.

RESULTS

Of 289 women randomised, 285 had one or more smears following treatment. Women were more likely to have a smear reported as moderate dyskariosis or worse following laser vaporisation [hazard ratio 3.01 (95% CI 1.27 to 7.12)]. The cumulative risk of a smear reported as moderate dyskariosis or worse was 6.0% at six months and 12.1% at three years in those allocated laser vaporisation, and 2.0% at six months, and 3.3% at three years in those allocated loop diathermy excision of the transformation zone.

CONCLUSIONS

Loop diathermy excision is a more effective treatment of cervical intraepithelial neoplasia than laser vaporisation.