Discordant expression of maternal SLE in twin pregnancy with a single fetal AV block: A case report

There are multiple manifestations in the neonatal period for infants born to mothers with systematic lupus erythematosus (SLE), ranging from cardiac, hematologic and dermatologic abnormalities. Cardiac complications may arise in utero in the form of heart block with a resulting increase in fetal mortality. The fetal conduction system is suspected to be affected by transplacental maternal antibodies, however additional environmental and fetal factors appear to play a role. We describe a rare case of a dichorionic-diamniotic twin pregnancy in which only one twin developed a complete heart block progressing to hydrops fetalis and fetal demise.

Comparing government (school) vs. private (non-school) dental laboratories in marginal adaptation of single porcelain-fused-to-metal crowns

AIM

The purpose of this study was to compare school and non-school dental laboratories in marginal adaptation of single Porcelain-Fused-to-Metal (PFM) crowns.

METHOD

Six dental laboratories (three school- and three non-school laboratories) participated in this study. Each dental laboratory was requested to fabricate PFM crowns for three different ivorine teeth on different typodont jaw models (n=18). The crowns received from the laboratories and fitted in their abutments using fit-checker under uniform pressure. We examined 162 sites viewed under a scanning electron microscope to measure the vertical and horizontal marginal discrepancy.

RESULTS

The mean vertical marginal discrepancy for school dental laboratories was 208.9 µm, while for non-school dental laboratories was 182.8 µm. For the horizontal marginal discrepancy, the median values were 48.5 µm for school dental laboratories and 50 µm for non-school dental laboratories.

CONCLUSIONS

There was no statistically significant difference in the mean vertical and median horizontal values between school and non-school dental laboratories. However, a significant difference was observed within the non-school laboratories.

Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case

Background

Biliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case.

Methods

Seven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD.

Results

One dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses.

Conclusion

In mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.

[The use of Arabic in the World Health Organization. Part Two]

In part one of this paper we discussed the use of Arabic as an official and working language in the Eastern Mediterranean Regional Office and WHO Headquarters. We reviewed the arrangements made to rationalize the Arabic activities in WHO, the development of an authentic Arabic version of the WHO constitution, the impact of WHO restructuring on the Arabic programme and the establishment of the Arab Centre for Medical Literature in Kuwait. In this part we address the developments in Arabic medical terminology, the establishment of the Regional Arabic Programme and the unified WHO Programme of Arabic publications, and last but not least, the production of the Eastern Mediterranean Health Journal in English, French and Arabic.

[The use of Arabic in the World Health Organization. Part One]

The course of Arabic in WHO began in September 1954 when the Regional Subcommittee "A" requested the Regional Director to study the possibility of using Arabic as a working language for WHO in the Eastern Mediterranean Region. At WHO Headquarters, Arabic was used as an official language in the World Health Assembly in May 1972, and became a working language for the Organization in May 1975. This article reviews the progression of the use of Arabic in WHO since then.

The role of transthoracic echocardiography in the diagnosis of infective endocarditis in children

BACKGROUND

Infective endocarditis (IE) is frequently suspected but infrequently diagnosed in children. Clinicians often order echocardiograms to "rule out" IE. In an era of cost constraint, clinically efficient strategies must be developed to eliminate unnecessary tests. We hypothesized that transthoracic echocardiography (TTE) is only useful in children in whom there is a high clinical suspicion of IE based on history, physical examination, and persistently positive blood cultures.

OBJECTIVE

To determine the role of TTE as a screening test for suspected IE in children.

METHODS

Echocardiographic reports and medical records were reviewed retrospectively for 173 consecutive patients who underwent TTE to rule out IE from January 1993 to August 1996.

RESULTS

Persistent fever was the predominant symptom leading to a suspicion of IE (120 patients [69.4%]). Fifty-seven (32.9%) of the 173 patients had congenital heart disease and 95 patients (54.9%) had indwelling venous catheters. Twenty-six patients (15.0%) were diagnosed and treated for IE. Twelve (46.2%) of these 26 patients had vegetations seen on TTE. The conditions of the remaining 14 patients were diagnosed clinically and these patients had persistently positive blood cultures. By univariate analysis, the risk factors associated with the diagnosis of IE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and the presence of 2 or more positive blood cultures for the same organism. The risk factors associated with positive TTE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and 2 or more positive blood cultures. The presence of an indwelling catheter or immunocompromised status were not predictive of vegetation or IE.

CONCLUSIONS

Transthoracic echocardiography has poor sensitivity as a screening test for IE in patients with low clinical probability of the disease. A diagnostic algorithm for IE is suggested based on these data.

Acute variceal hemorrhage: the persistent bleeder. A plea for management

A group of 1910 patients with acutely bleeding esophagogastric varices were managed in the Kasr El Aini sclerotherapy project; 458 of the patients (24%) were lost to follow-up. The remaining patients were studied in five groups: group I (294/401 patients), rigid versus flexible sclerotherapy; group II (254/336 patients), intravariceal versus paravariceal sclerotherapy; group III (174/227 patients), timing of initial sclerotherapy and the optimum frequency of sclerotherapy sessions; group IV (80/99 patients), splenectomy devascularization operation alone versus combined surgery with sclerotherapy; group V (650/847 patients), management of failures of and recurrences after sclerotherapy. The mean period of follow-up was 72 months. Rigid sclerotherapy was significantly superior to flexible sclerotherapy for emergency control of acute bleeding but was associated with significantly more morbidity. Paravariceal injection achieved insignificantly better initial control of bleeding and had more morbidity than intravariceal injection, which obliterated the varices in a significantly larger proportion of patients. Emergency injection of the acute bleeder should be carried out soon after admission, with sclerotherapy sessions repeated every 2 weeks. Combined sclerotherapy with splenectomy and devascularization was significantly more effective for controlling bleeding than surgery alone. Surgery should be done without delay for continued bleeding after the second attempt of sclerotherapy and in patients who rebleed after their third sclerotherapy session. Survival, however, was not significantly improved by the different modalities of sclerotherapy.

A simple calibration of a whole-body counter for the measurement of total body potassium in humans

A simple calibration procedure for the Inshas whole body counter for evaluating total body potassium has been adopted. More than 120 Egyptian employees in the Nuclear Research Center (N.R.C.) were studied for their total body potassium (TBK). The potassium values were found to have an average of 2.85 +/- 0.57 g K kg-1 body weight for males and 2.62 +/- 0.52 g K kg-1 for females, which are higher than the recommended value given for reference man by ICRP. The TBK varied directly with body build index and is slightly sex dependent.

Hemophilia A due to mutations that create new N-glycosylation sites

In studying the molecular defects responsible for cross-reacting material-positive hemophilia A, we have identified two patients in whom the nonfunctional factor VIII-like protein has abnormal, slower-moving heavy or light chains on SDS/PAGE. Both patients have severe hemophilia A (less than 1% of normal factor VIII activity) with a normal plasma level of factor VIII antigen. The molecular defects were identified by denaturing gradient gel electrophoresis screening of PCR-amplified products of the factor VIII-coding DNA sequence followed by nucleotide sequencing of the abnormal PCR products. In patient ARC-21, a methionine-to-threonine substitution at position 1772 in the factor VIII light chain creates a potential new N-glycosylation site at asparagine-1770. In patient ARC-22, an isoleucine-to-threonine substitution at position 566 creates a potential new N-glycosylation site at asparagine-564 in the A2 domain of the factor VIII heavy chain. The mobility of these chains on SDS/PAGE was normal after N-Glycanase digestion and procoagulant activity was generated--to a maximum of 23% and 45% of control normal plasma. Abnormal N-glycosylation, blocking factor VIII procoagulant activity, represents a newly recognized mechanism for the pathogenesis of severe hemophilia A.

Cysteamine enhances the procoagulant activity of Factor VIII-East Hartford, a dysfunctional protein due to a light chain thrombin cleavage site mutation (arginine-1689 to cysteine)

We have recently identified the molecular defect responsible for cross-reacting material-positive hemophilia A in two unrelated patients in which the substitution of cysteine for arginine-1689 (Factor VIII-East Hartford[FVIII-EH]) abolishes a critical Factor VIII light chain thrombin cleavage site. As other mutant proteins with a cysteine for arginine substitution have been modified in the presence of cysteamine, we have determined the effect of this and other reducing agents on FVIII-EH function. Cysteamine concentrations between 0.1 and 10 mM caused dose- and time-dependent increases in FVIII-EH VIII:C activity, as much as 14-fold (to 35 and 62 U/dl for the two patients tested). Comparable data were obtained in a standard one-stage VIII:C coagulation assay and in a chromogenic substrate assay measuring Factor Xa generation. Thrombin cleavage of the FVIII-EH light chain in the presence of cysteamine was documented by immunoadsorption and analysis. Cystamine and cysteamine-S-phosphate, similar compounds that do not possess a free thiol group, had no effect. Cysteamine augmentation of FVIII-EH VIII:C was abolished by the simultaneous addition of N-ethyl maleimide or iodoacetamide, but these sulfhydryl blocking agents did not prevent the VIII:C increase and light chain cleavage by thrombin if the plasma samples were dialyzed to remove the inhibitors before adding the cysteamine. However, incubation with DTT before iodoacetamide prevented the cysteamine effect after dialysis. These data suggest that when isolated from patient plasma, FVIII-EH cysteine-1689 is present in a disulfide bond. This bond is cleaved by cysteamine to form a new mixed disulfide, a pseudolysine that restores a thrombin cleavage site that is essential for procoagulant function.

Factor VIII-East Hartford (arginine 1689 to cysteine) has procoagulant activity when separated from von Willebrand factor

Factor VIII East Hartford (FVIII-EH) procoagulant activity is reduced because the substitution of cysteine for arginine 1689 abolishes an essential Factor VIII light chain thrombin cleavage site. Incubation of FVIII-EH plasma with penicillamine or DTT causes a five- to sixfold increase in FVIII-EH VIII:C, at 80 and 1 mM, respectively. While there is no FVIII-EH light chain cleavage when thrombin is added in the presence of penicillamine or DTT, these reducing agents disrupt the FVIII-vWf complex. For example, the addition of 5 mM DTT to normal or FVIII-EH plasma causes a 50% reduction in Factor VIII binding to vWf. These observations suggested that DTT increases FVIII-EH VIII:C by partial dissociation of FVIII-EH from vWf. This was verified by showing that vWf-free FVIII-EH had VIII:C activity of 21 U/dl, while the starting plasma level was 2.5 U/dl. Removal of other FVIII-EH plasma proteins by agarose gel filtration had no effect on VIII:C activity. The demonstration that this mutant Factor VIII has cofactor function when separated from vWf indicates that the dissociation of Factor VIII from vWf is an essential effect of Factor VIII light chain cleavage at arginine-1689.

Histocompatibility antigen patterns in haemophilic patients with factor VIII antibodies

A number of studies suggest that there is a genetic basis for the formation by some haemophilia A patients of antibodies that inactivate factor VIII. In our study, human leucocyte antigen (HLA)-A, B, C, DR and DQ typing was carried out for 44 haemophilia A patients, including 16 who had developed an antibody to factor VIII. In contrast to previous reports, we found no association between HLA-DR antigens and haemophilia A per se or the formation of a factor VIII inhibitor. However, there was an absence of HLA-Cw5 in the 16 haemophilic patients who had formed an antibody to factor VIII. This finding, consistent with a previous report, identified a statistically significant difference in HLA-Cw5 frequency when the inhibitor patient group was compared to multi-transfused haemophilic patients who had no inhibitor (11/28).

The effect of prophylactic heparinization on the venous blood flow using the Doppler ultrasonic flowmeter

The effect of prophylactic heparinization on the postoperative venous blood flow was prospectively studied in 100 lower limbs of 50 patients. Patients were randomized into two groups of 25 patients each: a control group and a heparin group. Changes in the venous blood flow were monitored using the Doppler ultrasonic flowmeter. The study illustrated the protective role of prophylactic heparinization in maintaining a near normal venous blood flow after surgery. The postoperative reduction in venous blood flow in heparinized patients was significantly less than the decrease in blood flow in non-heparinized patients during the same postoperative period. This significant difference between the two groups of patients applied to the steady and the augmented blood flow rates. The beneficial role of prophylactic heparinization was shown to act significantly in patients undergoing minor surgery, in obese subjects and in those suffering malignant disease. Patients undergoing major surgery also benefited significantly from prophylactic heparinization apart from their steady venous blood flow during the first postoperative day.