P–386 Uterine Natural Killer Cell function in Recurrent Miscarriage and Implantation Failure: A Systematic Review

Study question

Does uterine natural killer cell functional activity differ in women with recurrent miscarriage (RM) or implantation failure (RIF) compared to fertile controls?

Summary answer

There is insufficient data to conclusively determine differences in uterine natural killer (NK) cell activity between women with RM/RIF and controls.

What is known already

Uterine NK cell (uNK) function is central to maintaining healthy pregnancy by promoting placentation and spiral artery vascular remodelling.

The range of uNK activity is diverse and includes cytokine secretion, such as IFN-γ, or angiogenic factors which promote vascular remodelling. Despite an abundance of studies investigating peripheral blood NK cell cytotoxicity, there is limited evidence of uNK cytotoxicity. uNK-trophoblast interactions are facilitated by uNK receptors such as CD94, LILRB1 and KIRs.

It is possible that dysfunction of these diverse uNK activities plays a more important role in early pregnancy failure than uNK levels.

Study design, size, duration

We conducted a systematic review of prospective case-control studies investigating uterine natural killer cell activity in patients with RM or RIF versus controls.

The aim was to determine whether there was a distinct variation in uNK activity between RM/RIF and controls. We stratified uNK activity into four broad categories: i) regulation and receptors; ii) cytotoxicity; iii) expression of cytokines; iv) effect on uterine vasculature.

Participants/materials, setting, methods

The electronic database search included MEDLINE, EMBASE, Web of Science and bibliographies from included articles from inception to December 2020 using a combination of MESH and keywords. Search, screen, and data extraction were performed by two reviewers independently. Quality assessment was conducted with ROBINS-I. Out of 4636 studies screened, 30 studies (1696 women) were analysed for uNK activity.

Main results and the role of chance

Different methods were used to measure uNK activity including immunohistochemistry, flow cytometry, ELISA, PCR and Western blot. Samples were obtained from endometrium during mid-luteal phase or decidua following surgery.

14 studies reported on uNK phenotypes associated with regulation and receptors. RM/RIF patients, compared to controls, demonstrated a reduced expression of KIR2DL4, KIR2DL3/L2/S2 and inhibitory receptors (NKG2A); whereas there was a higher expression of the activating receptor (NKp46) and CD161. One study reported correlation between FoxP3+ T-cells and CD56+ NK cells but another reported no similar correlation with CD57+/CD56+ ratio.

Two studies investigating dNK cytotoxicity, using chromium release or lactate dehydrogenase release assays, concluded higher dNK cytotoxicity in RM patients.

Eight studies reported on cytokine expression. Interestingly, two studies found lower expression of IFN-g, but four studies reported otherwise in RM patients. Two studies found a higher ratio of dNK producing IFN-γ/TNF-α to those producing IL–4. The rest of the studies reported lower expression of IL–1RA, IL–10, TNF-α, Lnc–49A and higher expression of granzyme B, perforin and PRF–1.

Finally, six studies reported on effect of uNK on vasculature. Among the findings were negative correlation between CD16+ uNK and endometrial IL–6 and VEGF, as well as higher angiogenin, VEGF and bFGF expression.

Limitations, reasons for caution

Functional activity investigated amongst studies varied significantly; this heterogeneity precluded meta-analysis of the data. Heterogeneity also prohibited definitive conclusions on uNK function and pregnancy outcome.

Studies presented data in a combination of qualitative and quantitative analysis and variation was seen in the criteria for inclusion of RM, RIF and controls.

Wider implications of the findings: uNK levels alone may be insufficient to guide management of early pregnancy failure. Clarification of underlying functional activity may guide therapeutic intervention and help develop new treatments.

This review highlights the need for a greater understanding of the role of uNK activity in healthy pregnancy and early pregnancy failure.

Trial registration number

N/A

Hyponatraemia compounding pre-eclamptic toxaemia in a patient with type 1 diabetes

We report a case of profound, symptomatic hyponatraemia in association with pre-eclamptic toxaemia (PET) in a 38-year-old nulliparous woman with type 1 diabetes mellitus. This patient developed hypertension and proteinuria at 31+6 weeks' gestation and was admitted for management of pre-eclampsia. Severe headache, visual disturbance and nausea were associated with a hyponatraemia of 115 mmol/L followed by ketoacidosis. This was reversed through fluid restriction, supplementation with 1.8%-3.0% hypertonic saline and a volume-reduced variable-rate insulin infusion. Clinical stability was achieved and she was subsequently worked up for an induction of labour for worsening pre-eclampsia. Hyponatraemia in the context of PET has been previously reported as rare. However, it has complications that may significantly compound the sequelae of severe PET. We propose that specific and focused monitoring of serum sodium levels should become common practice in the management of women with this condition to allow for timely, measured correction of abnormalities.

Is the Host Viral Response and the Immunogenicity of Vaccines Altered in Pregnancy?

The intricacy of the maternal immune system arises from its ability to prevent a maternal immune response against a semi-allogenic fetus, while protecting the mother against harmful pathogens. However, these immunological adaptations may also make pregnant women vulnerable to developing adverse complications from respiratory viral infections. While the influenza and SARS pandemics support this theory, there is less certainty regarding the clinical impact of SARS-CoV-2 in pregnancy. In the current COVID-19 pandemic, vaccine development is key to public preventative strategies. Whilst most viral vaccines are able to induce a seroprotective antibody response, in some high-risk individuals this may not correlate with clinical protection. Some studies have shown that factors such as age, gender, and chronic illnesses can reduce their effectiveness and in this review, we discuss how pregnancy may affect the efficacy and immunogenicity of vaccines. We present literature to support the hypothesis that pregnant women are more susceptible to respiratory viral infections and may not respond to vaccines as effectively. In particular, we focus on the clinical implications of important respiratory viral infections such as influenza during pregnancy, and the pregnancy induced alterations in important leukocytes such as TFH, cTFH and B cells, which play an important role in generating long-lasting and high-affinity antibodies. Finally, we review how this may affect the efficacy of vaccines against influenza in pregnancy and highlight areas that require further research.

Human labour is associated with altered regulatory T cell function and maternal immune activation

During human pregnancy, regulatory T cell (T_reg ) function is enhanced and immune activation is repressed allowing the growth and development of the feto-placental unit. Here, we have investigated whether human labour is associated with a reversal of the pregnancy-induced changes in the maternal immune system. We tested the hypothesis that human labour is associated with a decline in T_reg function, specifically their ability to modulate Toll-like receptor (TLR)-induced immune responses. We studied the changes in cell number, activation status and functional behaviour of peripheral blood, myometrial (myoMC) and cord blood mononuclear cells (CBMC) with the onset of labour. We found that T_reg function declines and that T_reg cellular targets change with labour onset. The changes in T_reg function were associated with increased activation of myoMC, assessed by their expression of major histocompatibility complex (MHC) class II molecules and CBMC inflammatory cells. The innate immune system showed increased activation, as shown by altered monocyte and neutrophil cell phenotypes, possibly to be ready to respond to microbial invasion after birth or to contribute to tissue remodelling. Our results highlight changes in the function of the adaptive and innate immune systems that may have important roles in the onset of human labour.

Sepsis: Precision-Based Medicine for Pregnancy and the Puerperium

Sepsis contributes significantly to global morbidity and mortality, particularly in vulnerable populations. Pregnant and recently pregnant women are particularly prone to rapid progression to sepsis and septic shock, with 11% of maternal deaths worldwide being attributed to sepsis. The impact on the neonate is considerable, with 1 million neonatal deaths annually attributed to maternal infection or sepsis. Pregnancy specific physiological and immunological adaptations are likely to contribute to a greater impact of infection, but current approaches to the management of sepsis are based on those developed for the non-pregnant population. Pregnancy-specific strategies are required to optimise recognition and management of these patients. We review current knowledge of the physiology and immunology of pregnancy and propose areas of research, which may advance the development of pregnancy-specific diagnostic and therapeutic approaches to optimise the care of pregnant women and their babies.

C1q Nephropathy in a Patient of Neurofibromatosis Type 1: A Rare Case Report

C1q nephropathy is a rare glomerular disease defined by the presence of characteristic mesangial dominant or codominant C1q deposition on immunofluorescence microscopy. Neurofibromatosis type 1 (NF-1) is an autosomal dominant syndrome caused by a mutation of a gene located on chromosomal segment 17q11.2. Nephrotic syndrome has rarely been reported in patients of NF-1, and the relation of NF-1 with nephrotic syndrome is unclear. Here, we present a rare case of C1q nephropathy in a patient of NF-1.

Changes in T Cell and Dendritic Cell Phenotype from Mid to Late Pregnancy Are Indicative of a Shift from Immune Tolerance to Immune Activation

During pregnancy, the mother allows the immunologically distinct fetoplacental unit to develop and grow. Opinions are divided as to whether this represents a state of fetal-specific tolerance or of a generalized suppression of the maternal immune system. We hypothesized that antigen-specific T cell responses are modulated by an inhibitory T cell phenotype and modified dendritic cell (DC) phenotype in a gestation-dependent manner. We analyzed changes in surface markers of peripheral blood T cells, ex vivo antigen-specific T cell responses, indoleamine 2,3-dioxygenase (IDO) activity (kynurenine/tryptophan ratio, KTR), plasma neopterin concentration, and the in vitro expression of progesterone-induced blocking factor (PIBF) in response to peripheral blood mononuclear cell culture with progesterone. We found that mid gestation is characterized by reduced antigen-specific T cell responses associated with (1) predominance of effector memory over other T cell subsets; (2) upregulation of inhibitory markers (programmed death ligand 1); (3) heightened response to progesterone (PIBF); and (4) reduced proportions of myeloid DC and concurrent IDO activity (KTR). Conversely, antigen-specific T cell responses normalized in late pregnancy and were associated with increased markers of T cell activation (CD38, neopterin). However, these changes occur with a simultaneous upregulation of immune suppressive mechanisms including apoptosis (CD95), coinhibition (TIM-3), and immune regulation (IL-10) through the course of pregnancy. Together, our data suggest that immune tolerance dominates in the second trimester and that it is gradually reversed in the third trimester in association with immune activation as the end of pregnancy approaches.

Abnormal social behaviors in mice lacking Fgf17

The fibroblast growth factor family of secreted signaling molecules is essential for patterning in the central nervous system. Fibroblast growth factor 17 (Fgf17) has been shown to contribute to regionalization of the rodent frontal cortex. To determine how Fgf17 signaling modulates behavior, both during development and in adulthood, we studied mice lacking one or two copies of the Fgf17 gene. Fgf17-deficient mice showed no abnormalities in overall physical growth, activity level, exploration, anxiety-like behaviors, motor co-ordination, motor learning, acoustic startle, prepulse inhibition, feeding, fear conditioning, aggression and olfactory exploration. However, they displayed striking deficits in several behaviors involving specific social interactions. Fgf17-deficient pups vocalized less than wild-type controls when separated from their mother and siblings. Elimination of Fgf17 also decreased the interaction of adult males with a novel ovariectomized female in a social recognition test and reduced the amount of time opposite-sex pairs spent engaged in prolonged, affiliative interactions during exploration of a novel environment. After social exploration of a novel environment, Fgf17-deficient mice showed less activation of the immediate-early gene Fos in the frontal cortex than wild-type controls. Our findings show that Fgf17 is required for several complex social behaviors and suggest that disturbances in Fgf17 signaling may contribute to neuropsychiatric diseases that affect such behaviors.

Reasons and correlates of contraceptive discontinuation in Kuwait

OBJECTIVES

(1) To examine the probability of discontinuation of various methods within 1, 2, and three years of use and the reasons for discontinuation; 2) to analyse the socio-demographic correlates of discontinuation.

METHODS

Data from a survey of Kuwaiti women in reproductive ages conducted in 1999 were used. Information on duration of use of modern and traditional methods, and reasons for discontinuation during the 72 months before the survey were analysed. Probabilities of discontinuation were estimated through multiple decrement life table analysis.

RESULTS

After 1 year, 30% of modern and 40% of traditional method users had discontinued; after 3 years, discontinuation increased to 66 and 70%, respectively. After 36 months, only 40% of IUD users discontinued compared with 74% of oral contraceptive users. The desire to become pregnant was the leading reason for discontinuation of most modern methods, while method failure was an equally important reason for traditional methods. Discontinuation was significantly more frequent among higher parity, non-working and Bedouin women, and among those who said Islam disapproves of contraception.

DISCUSSION

Contraception is used largely for spacing. More than two-thirds of the women studied had discontinued most methods after three years, except the IUD, which was used only by about 10% of them. Traditional methods are often discontinued due to method failure and may result in an unintended pregnancy. Better counselling is warranted for traditional methods. Health care for managing side effects of modern methods also needs improvement.

A profile of contraceptive non-use in Kuwait: implications for health and health care

OBJECTIVES

To analyze the characteristics of women who have never used contraception, and do not intend to use it in the future; examine the factors affecting such behavior and intentions; and discuss their health implications.

METHODS

Survey data from a nationally representative random sample of Kuwaiti households, collected in a study conducted in 1999 and containing 1502 currently married women, were analyzed using logistic regression analysis.

RESULTS

Based on the present study, 19% of women had never used contraception and 50% were not using contraception when interviewed. Among current non-users, 42% did not intend to use contraception, and 31% were unsure about use during the following year. Negative attitudes of the respondents and their husbands were the critical factors in non-use and future intentions for non-use. Never-users were older (average age 37.8 years) and of higher parity (6.2) than other women.

CONCLUSION

Being older and of higher parity, never-users constitute a high-risk group that may be in need of counseling. Also, negative attitudes towards contraception need modification.

Violence against women migrant workers: issues, data and partial solutions

"Despite the creation of specific norms, procedures, and institutions to protect women migrant workers, serious gaps remain. Statistics for measuring violence are not compiled comprehensively or regularly. Two occupations that increase the risk of violence are domestic service and entertainment-related services. Migration through illegal channels and trafficking also increase the risk. This article suggests a list of indicators to measure violence of three major types: (1) economic, (2) social/psychological, and (3) physical/sexual. Evidence from several countries to document instances of violence is reviewed. Major policy issues for the sending and receiving countries are outlined, and some recommendations for addressing such violations are made."

Determinants of job satisfaction among selected care providers in Kuwait

The study reports job satisfaction among a sample of 370 physicians, nurses, pharmacists, and medical laboratory technologists in the Ministry of Health hospitals in Kuwait. Job satisfaction was measured using Dunnette's scale. The respondents in all four categories were satisfied with all aspects of their jobs except salary. The medical laboratory technologists were, however, dissatisfied with professional advancement as well. The physicians were found to be most satisfied, closely followed by nurses and pharmacists, while medical laboratory technologists were least satisfied. Multivariate analysis was used to assess the net effects of background and work environment characteristics on overall job satisfaction. Introduction to job, in-service training, and monthly income had significant positive effects on overall job satisfaction. These findings may have serious implications for health care delivery systems that recruit expatriate care providers.

Pulmonary nocardial infection and pseudomonas infection of the tongue in a patient with dermatomyositis

Opportunistic infections in immunocompromised patients are common. We report the case of a 63 year old female patient with dermatomyositis who while on oral steroids developed nocardial infection of the lung and pseudomonas infection of the tongue simultaneously. Nocardial infections are not very commonly seen in patients with dermatomyositis. Pseudomonas infection of the tongue is a rarity. We report this case for its rarity as regards the type and site of infections and review the relevant literature.

Over-the-counter use of oral contraceptives in Kuwait

Oral contraceptive pills (OCPs) are available over-the-counter (OTC) in Kuwait, and constitute a leading method for spacing and limiting children. Data from a nationally representative survey of Kuwaiti women are used to examine OTC use of OCPs. One-fourth of the women initiated use without consulting a doctor, and 50% bought OCPs from the pharmacy. No socioeconomic or demographic differences were found between those who consulted a physician, implying that women of different background have similar accessibility to the physician. Using multivariate analysis, the odds of consulting a physician were found to be significantly lower for women who first bought OCPs directly from the commercial pharmacy. The duration of first time OCP use did not differ according to physician consultation. It is concluded that OTC availability of OCPs has many advantages and prevents unwanted pregnancy. However, there is a need for better packaging and instructions that would enable high-risk women to identify themselves and to use OCPs under physician supervision.

Extramedullary plasmacytoma of the larynx: a case report

Of head and neck malignancies extramedullary plasmacytoma occurs in less than 1% cases. It is the rarest primary laryngeal malignancy. A 65-year-old man presented with dry cough and breathlessness for last 6 months. Direct laryngoscopic examination showed a gray-white submucosal mass in the subglottic region. Histopathological examination showed presence of pseudostratified columnar epithelium with underlying stroma having mature and immature plasma cells. The cells were mono to bi-nucleated having eccentric nuclei and condensed spoke like chromatin. Few cells had centrally placed nuclei with small but conspicuous nucleoli. Some cells resembling Reed-Sternberg cells were also seen. The patient was successfully treated with primary radical radiotherapy and showed no signs of local recurrence after a 12-month follow-up.

Accidental self-injection with Freund's complete adjuvant

The case of a research worker who accidentally injected herself with Freund's Complete Adjuvant (FCA) in the right forearm is reported. This resulted in a serious granulomatous inflammation of the hand an forearm. She was treated with corticosteroids and chloroquine with good result. The course of this reaction and the hazards of injection with FCA are emphasised and the relevant literature reviewed.

Searching for socioeconomic risk factors in perinatal mortality in Kuwait: a case control study

The aim of this paper was to investigate whether socioeconomic factors such as parent's education, occupation, and income constitute risk factors in perinatal mortality after controlling for biological variables such as birth weight and length of gestation, and maternal factors such as age, parity and reproductive history. A case-control study covering all perinatal deaths in Kuwait was conducted for one year from 1 October, 1997 to 30 September, 1998. Each case (perinatal death) was matched with a control (live birth). Matching criteria were: father's nationality, place, and date of birth. Information was successfully collected on 463 matched pairs, 274 Kuwaitis and 189 non-Kuwaitis. Only singleton births were included in the analysis. Bivariate analysis showed that several of the socioeconomic variables (e.g. lower education, lower income) increased the risk of a perinatal death. However, none of these variables remained significant in the multivariate analysis in which birth weight and length of gestation emerged as the two major determinants of perinatal deaths among both nationality groups. Among the Kuwaitis, primiparity and high parity, and previous history of miscarriage were also significant risk factors. Among the non-Kuwaitis, none of the socioeconomic factors, or the maternal factors, were significant predictors of perinatal mortality. For Kuwaitis, it appears that the government's policies and programs aimed at reducing social inequalities in the society have been effective in eliminating perinatal mortality differences between socioeconomic groups. Among non-Kuwaitis, the lack of differences is reflective of the fact that this group is relatively homogenous and selective of the more affluent who can bring the family to Kuwait. Both nationality groups benefit from the government's free health services. However, charges for non-Kuwaitis are due to be levied soon which may increase disparities in access to health care.

Circumferential periosteal sleeve resection: results in limb-length discrepancy secondary to poliomyelitis

We report the results of circumferential periosteal sleeve resection of lower-limb bones for mild degrees of limb-length discrepancy (mean, 3.5 cm) secondary to postpolio residual paralysis in 23 patients. Results were expressed by calculating percentage of length discrepancy of the operated-on limb with respect to the normal limb and gain in length in centimeters of the operated-on limb over the normal limb. All patients had a uniform trend of gain in length with response in the femur lasting for approximately 1 year, whereas that in the tibia persisted >2 years. Circumferential periosteal sleeve resection is a safe and reliable method of longitudinal bone-growth stimulation, providing consistent results, especially for mild to moderate discrepancies.

Chain migration through the social network: experience of labour migrants in Kuwait

Labour migration to the Gulf countries is predominantly contract based and a majority of workers fall below the salary ceiling necessary for sponsoring family members. Despite this, social networks have expanded in Kuwait, primarily in the form of sponsorship of additional labour migrants by those already in the country.

The objectives of the article are to describe how the process of arranging sponsorship works, to delineate the predictors of moving through a friend or relative, or arranging sponsorship for a subsequent labour migrant, and to assess the “multiplier” effect of the above process. The article is based on a survey among 800 South Asian skilled and unskilled male migrants, 200 each from Bangladesh, India, Pakistan and Sri Lanka.

About 34 per cent of all respondents moved through friends or relatives, 50 per cent through agents and 16 per cent through direct hiring or the government bureau. Logistic regression analysis indicated that the factors most likely to predict a move through the social network consisted of being a Pakistani or Indian, being a Muslim, and possessing some skills.

One‐quarter of all migrants had arranged the visa for another migrant since they came to Kuwait. Logistic regression analysis showed the respondent’s duration of stay in Kuwait to be an exceptionally important predictor for arranging sponsorship for an additional migrant.

Monthly income, being married and being a Muslim were also positively associated with arranging sponsorship. In terms of the multiplier effect, about 0.78 visas had been arranged per migrant. Pakistanis, who had the longest average duration of stay in Kuwait, arranged the maximum number (1.6) of visas on average.

Malignant schwannoma of the sinonasal tract

Malignant Schwannoma of the sinonasal tract is an extremely rare tumour. So far, only 19 cases have been reported in the literature. We report herein a case of malignant schwannoma involving nasal cavity, maxillary antrum and ethmoid sinus in a 60-year-old male patient. The patient was treated with surgery and post-operative radiotherapy. He currently remains free of the disease 15 months after the diagnosis and twelve months after completing therapy.

Attitudes of Kuwaiti parents toward physical punishment of children

OBJECTIVE

The major aim was to describe parental attitudes to physical punishments and examine their sociodemographic correlates. A related aim was to assess the association of parents' own experience of physical punishment with attitudes to punishment of children.

METHOD

A cross-sectional survey was conducted during the second week of December, 1996 in five general clinics covering the major administrative areas of Kuwait: 337 Kuwaiti mothers and fathers with at least one living child were contacted; 95% were successfully interviewed using a structured questionnaire.

RESULTS

Eighty-six percent of parents agreed with physical punishment as a means of child disciplining. Agreement with punishment was higher in case of serious misbehaviors such as stealing (63%), sniffing glue and using drugs (77%). Multiple regression results showed that parent's lower level of education and Bedouin ethnicity were positively associated with agreement on physical punishment. Larger percentages of parents who had experienced physical punishments themselves agreed with such punishment to discipline their children, but this was not statistically significant.

CONCLUSIONS

In recent years education has become widespread for both sexes. An inverse association between educational level and agreement on physical beating suggest that attitudes to this form of child disciplining are changing. Those with a Bedouin ethnic background still adhere more strictly to the traditional forms of child disciplining including physical beating. There is a need for conducting research on the possible negative psychosocial impacts of physical punishment in view of findings from other countries.

Liposarcoma of the larynx treated with radiotherapy

Liposarcoma of the larynx is an extremely rare malignancy. Only 18 cases have been reported in the literature. We herein report the first case of primary liposarcoma of supra-glottic larynx in a 53-years old male patient successfully treated with radiotherapy in August-September 1992. He currently remains free of the disease 4.5 years since the initial diagnosis.

Cell lineage determination and the control of neuronal identity in the neural crest

The molecular mechanisms underlying the determination of neuronal identity in the vertebrate peripheral nervous system are only just beginning to come into focus. Many of these mechanisms, such as the involvement of cascades of bHLH transcription factors and lateral inhibition via the Notch-Delta system, appear to have been conserved from Drosophila (Ghysen et al. 1993; Jan and Jan 1993). The way in which these genetic circuits are controlled by instructive growth factors, and the manner in which they lead to expression of a particular neuronal identity, is far from clear. This process is being elucidated by studies of neurogenesis in the peripheral autonomic lineage, which is arguably the best-understood neurogenic lineage in vertebrates. Emerging evidence is beginning to suggest that neuronal diversity within the autonomic and sensory lineages may be generated by related, but distinct, mechanisms. All autonomic progenitors express a common bHLH protein, MASH1, which appears to be induced by members of the BMP2 subfamily secreted by the tissues to which these progenitors migrate. Additional signals may then act on these progenitors in different locations to induce the expression of other transcription factors, which act in conjunction with MASH1 to specify the final phenotypes of the different autonomic neuron subtypes (sympathetic, parasympathetic, and enteric). Although different classes of autonomic neurons develop in very different locations within the body, different classes of sensory neurons are located together in dorsal root ganglia. The finding that distinct but related subtypes of bHLH proteins, the neurogenins, are expressed by different classes of sensory neuron precursors early in development suggests that sensory neuron diversity, in contrast to autonomic neuron diversity, may be pre-specified at or before the time neural crest cells begin their emigration from the neural tube.

Outcome of patients with anticardiolipin antibodies: a 10 year follow-up of 52 patients

We report a 10-year follow-up on 52 patients with raised levels of anticardiolipin antibodies (aCL) who were first seen at our tertiary referral centre in 1986. The clinical and serological features of these 52 patients are described. Thirty-one patients had the antiphospholipid syndrome (APS) in 1986. Nine of these patients (29%) had further thrombotic events during the follow-up period. Of the other 21 aCL positive patients without clinical manifestations of APS, 11 (52%) developed the syndrome over this period. Five patients (10%) died during the follow-up. Close monitoring of patients with connective tissue diseases and aCL is essential as the likelihood of developing antiphospholipid syndrome is high.

Integration of multiple instructive cues by neural crest stem cells reveals cell-intrinsic biases in relative growth factor responsiveness

Growth factors can influence lineage determination of neural crest stem cells (NCSCs) in an instructive manner, in vitro. Because NCSCs are likely exposed to multiple signals in vivo, these findings raise the question of how stem cells would integrate such combined influences. Bone morphogenetic protein 2 (BMP2) promotes neuronal differentiation and glial growth factor 2 (GGF2) promotes glial differentiation; if NCSCs are exposed to saturating concentrations of both factors, BMP2 appears dominant. By contrast, if the cells are exposed to saturating concentrations of both BMP2 and transforming growth factor beta1 (which promotes smooth muscle differentiation), the two factors appear codominant. Sequential addition experiments indicate that NCSCs require 48-96 hrs in GGF2 before they commit to a glial fate, whereas the cells commit to a smooth muscle fate within 24 hr in transforming growth factor beta1. The delayed response to GGF2 does not reflect a lack of functional receptors; however, because the growth factor induces rapid mitogen-activated protein kinase phosphorylation in naive cells. Furthermore, GGF2 can attenuate induction of the neurogenic transcription factor mammalian achaete-scute homolog 1, by low doses of BMP2. This short-term antineurogenic influence of GGF2 is not sufficient for glial lineage commitment, however. These data imply that NCSCs exhibit cell-intrinsic biases in the timing and relative dosage sensitivity of their responses to instructive factors that influence the outcome of lineage decisions in the presence of multiple factors. The relative delay in glial lineage commitment, moreover, apparently reflects successive short-term and longer-term actions of GGF2. Such a delay may help to explain why glia normally differentiate after neurons, in vivo.

Ethnicity, nationality and health care accessibility in Kuwait: a study of hospital emergency room users

In mid-1994, non-Kuwaiti expatriates constituted 61.7% of the total population of Kuwait (1.75 million). Despite this numerical majority, non-Kuwaitis exist as a social minority. Non-Kuwaitis may be grouped into three broad categories along ethnic/nationality lines into Bidoon (without nationality), Arabs, and Asians. The objective of this paper was to compare the relative accessibility of the various groups to health care services in Kuwait. The study is based on data collected as part of a survey of 2184 Emergency Room (ER) users in January-February 1993. All patients attending the hospital ERs between 7:30 am and 9:00 pm were interviewed about their reasons for coming to the ER instead of going to the primary health care (PHC) centres, as required. The major reason given was low accessibility of the PHCs. Compared to Kuwaiti nationals, 92% of whom were registered at the PHC centres, only 62% of the Arabs and 39% of the Asians were registered. Multiple logistic regression of the factors in registration indicated that nationality was the most important reason for lack of registration, with Asians only about one-quarter as likely to be registered as Kuwaitis. Also, people who had been in Kuwait for shorter durations (< 5 years) were less likely to be registered than the Kuwaiti nationals or expatriates who had been here for 10 years or longer. In the absence of registration at the PHC centre, the civil identification card (ID) may be used as a valid means to enter the health system. Among the Arabs and Asians, 22% and 29% did not have a civil ID card. Thus, for many expatriates, the hospital ER, which does not provide the necessary follow-up care is often the only source of health care available.

Tubercular splenic abscesses in a patient with AIDS

Opportunistic infections are common in patients with AIDS. There is an increasing incidence of tuberculosis, especially extrapulmonary tuberculosis. Splenic abscesses is one such, though rare, extrapulmonary manifestation. We report such a case discuss the diagnosis and treatment in these cases.

Alternative neural crest cell fates are instructively promoted by TGFbeta superfamily members

How growth factors influence the fate of multipotent progenitor cells is not well understood. Most hematopoietic growth factors act selectively as survival factors, rather than instructively as lineage determination signals. In the neural crest, neuregulin instructively promotes gliogenesis, but how alternative fates are determined is unclear. We demonstrate that bone morphogenic protein 2 (BMP2) induces the basic-helix-loop-helix protein MASH1 and neurogenesis in neural crest stem cells. In vivo, MASH1+ cells are located near sites of BMP2 mRNA expression. Some smooth muscle differentiation is also observed in BMP2. A related factor, transforming growth factor beta1 (TGFbeta1), exclusively promotes smooth muscle differentiation. Like neuregulin, BMP2 and TGFbeta1 act instructively rather than selectively. The neural crest and hematopoietic systems may therefore utilize growth factors in different ways to generate cellular diversity.

Predictors of non-urgent utilization of hospital emergency services in Kuwait

Utilization of the emergency rooms (ERs) in Kuwait has increased considerably during the last decade. Such an increase is a concern for health planners because of the burden on ER services, lack of continuous service provided by the ER and the higher cost of such services. Based on a study of 2011 patients attending the medical ERs in the six government hospitals in early 1993, the predictors of non-urgent utilization were analyzed. Patients were asked about their reasons for visiting the ER rather than the primary health care (PHC) centre. Both patients and doctors were asked to rate the urgency of the visit. According to the doctors' judgement, 61% of the visits were for non-urgent problems that did not require emergency care, while 23% of the patients viewed their visits to be non-urgent. Multiple logistic regression analysis indicated that perceived urgency of the visit was the most important predictor of a non-urgent visit to the ER, after controlling for several predisposing and enabling factors. Patients who perceived their visit to the ER to be non-urgent were about four times more likely to visit the ER for a non-urgent condition as judged by the doctor. The level of education had a significant, positive effect on non-urgent utilization among both Kuwaiti nationals and expatriates. Several factors may explain the above finding. Employment of educated persons in the hospital was one route through which education facilitated ER use. It is also likely that educated persons had more influential contacts or wasta in the hospital. Also, the less educated might have delayed seeking care while the educated consulted for non-urgent reasons as soon as they noticed the symptoms. Like education, the level of non-urgent utilization was higher among Kuwaiti nationals with higher incomes. Thus, a higher social class seems to facilitate ER use for non-urgent reasons. Among the non-Kuwaitis, lack of registration at the PHC centre was a significant reason for non-urgent use of the ER. It is recommended that hurdles in the utilization of PHC facilities should be removed. Registration of non-Kuwaitis at the PHC must be improved, and referrals to the PHC back from the ER should be instituted to ensure the necessary follow-up care.

Ethnic differences in contraceptive use in Kuwait: a clinic-based study

The Arab, Muslim, oil-rich nation of Kuwait has achieved unusually high levels of knowledge and use of contraception for a developing, high fertility country. Almost all women know of contraceptive pills without prompting, and 57-86% report having ever used a method (usually the oral pill or IUD) in recent studies. Based on a survey of six randomly selected clinics the present study compares the knowledge and use levels of two major ethnic groups--the Beduins and non-Beduins. It also analyses preference for various contraceptive methods and probable reasons for this. While Census or Survey data do not provide information about the size of ethnic groups analyzed in this paper, it is estimated that at least one-third of the population of Kuwait is Beduin. There is a significant difference between the levels of knowledge and use of contraception between the Beduin and non-Beduin women; current use being 42% and 65%, respectively. The differentials between the two groups are particularly marked among women of lower socioeconomic status, and tend to reduce notably once variables such as education and income are controlled. Within the subgroup of non-Beduins, socioeconomic differences in contraceptive use have virtually disappeared; the illiterate and relatively less affluent women are as likely to use a contraceptive method as the university educated, and richer women. However, among the Beduins, the usually expected differences by socioeconomic characteristics still persist. The oral pill is the best known and most commonly used method. Male sterilization is the least known and not practiced at all.(ABSTRACT TRUNCATED AT 250 WORDS)

Glial growth factor restricts mammalian neural crest stem cells to a glial fate

Growth factors and cytokines are thought to influence the development of uncommitted progenitor cell populations, but the issue of how these factors act on individual cells remains controversial. Such factors may act simply as selective mitogens or survival factors for cells that undergo lineage restrictions stochastically. Alternatively, they may instruct or bias multipotent cells to choose one lineage at the expense of others. Here we show that glial growth factor (GGF), previously defined as a Schwann cell mitogen, strongly suppresses neuronal differentiation of rat neural crest stem cells while promoting or allowing glial differentiation. Quantitative clonal analysis suggests that the action of GGF is likely to be instructive rather than selective. Taken together with the expression pattern of GGF, these data suggest a lateral signaling model for the diversification of cell types within developing peripheral ganglia.

Arab Labour Migration: A Review of Trends and Issues

"The objectives set for this paper are to: provide an analysis of volume and trends in labour migration within the Arab region; discuss the major characteristics of the migrants, including demographic features, types of economic activity, wage levels and duration of stay in host countries; [and] outline and discuss the major issues in labour migration both from the sending and receiving countries. The time period covered by the study is from the mid 1970s to the present." (SUMMARY IN FRE AND SPA)

Position of heart in relation to sternum and nipple line at various ages

Frontal X-ray pictures of 210 healthy children from birth to twelve years of age with radio-opaque markers at sternal ends and both nipples were reviewed. The position of centre of cardiac silhouette was correlated with sternal areas and internipple line. The heart was found to descend with age, its centre lying beneath mid-sternum during first six months of life and beneath lower sternum after infancy (p less than 0.001). The position did not vary with age in relation to internipple line (p greater than 0.05). In 77.6% of all children, it was below the internipple line and in 22.4% above or at the internipple line. Because of the erratic relationship of cardiac centre with internipple line, the latter should not be considered a landmark for cardiac position. External cardiac massage should be applied in relation to sternum and at different locations according to the age. Sites for optimal compression have been suggested. No sexual dimorphism was observed.

Asian women workers in Kuwait

The author examines trends in the roles of immigrant Asian women workers in Kuwait, using data from published censuses and reports and from three national-level surveys conducted in 1977-1979, 1983, and 1986-1987. "The study deals separately with the two major types of migrants: the domestic servants and the clerical and professional (or semiprofessional) workers.... The policies of sending countries and of Kuwait are discussed to reach some conclusions about the likely future patterns of migration of Asian women workers to Kuwait."

The relative economic progress of male foreign workers in Kuwait

"A human capital framework is utilized to examine the economic progress of nine nationality groups of foreign workers [in Kuwait] using data from the 1983 national Labor Survey. The sources of earnings' variations of particular interest to us included different degrees of education and experience transferability, occupational affiliation and ethnic background. In general, the results derived from the analysis suggest that 1) foreign workers achieve a discernible economic progress as their residence lengthens; 2) the rate of economic progress varies depending on worker's education, home and Kuwait-specific experience, occupational status and ethnic background; and 3) about one third of the earnings inequality is due to unexplained factors including discrimination."