Complex percutaneous coronary intervention in patients unable to undergo coronary artery bypass grafting during the COVID-19 pandemic: insights from the UK-ReVasc Registry

OBJECTIVES

Cardiac surgery for coronary artery disease was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with disease ordinarily treated with coronary artery bypass grafting (CABG) instead underwent percutaneous coronary intervention (PCI). We sought to describe 12-month outcomes following PCI in patients who would typically have undergone CABG.

METHODS

Between March 1 and July 31, 2020, patients who received revascularization with PCI when CABG would have been the primary choice of revascularization were enrolled in the prospective, multicenter UK-ReVasc Registry. We evaluated the following major adverse cardiovascular events at 12 months: all-cause mortality, myocardial infarction, repeat revascularization, stroke, major bleeding, and stent thrombosis.

RESULTS

A total of 215 patients were enrolled across 45 PCI centers in the United Kingdom. Twelve-month follow up data were obtained for 97% of the cases. There were 9 deaths (4.3%), 5 myocardial infarctions (2.4%), 12 repeat revascularizations (5.7%), 1 stroke (0.5%), 3 major bleeds (1.4%), and no cases of stent thrombosis. No difference in the primary endpoint was observed between patients who received complete vs incomplete revascularization (residual SYNTAX score £ 8 vs > 8) (P = .22).

CONCLUSIONS

In patients with patterns of coronary disease in whom CABG would have been the primary therapeutic choice outside of the pandemic, PCI was associated with acceptable outcomes at 12 months of follow-up. Contemporary randomized trials that compare PCI to CABG in such patient cohorts may be warranted.

Ventricular Tachycardia in Patients With Peripartum Cardiomyopathy: Prevalence, Predictors, and Associated In-Hospital Adverse Events

Introduction  The purpose of this study was to determine the prevalence of ventricular tachycardia (VT) among patients admitted with peripartum cardiomyopathy (PPCM) as well as to analyze the independent association of VT with in-hospital outcomes among PPCM patients. Methods Data were obtained from the National Inpatient Sample from January 2016 to December 2019. We assessed predictors of VT in patients admitted with PPCM. We also assessed the independent association of VT with clinical outcomes among patients admitted with PPCM. Results From 2016 to 2019, 4730 patients with PPCM were reported to the national inpatient sample database, 309 of which developed VT (6.5%). Using multivariate analysis, we found predictors of VT to include patient characteristics and factors such as age (adjusted OR (aOR)=1.020, p=0.023), chronic kidney disease (aOR=1.440, p=0.048), coagulopathy (aOR=1.964, p=0.006), and atrial fibrillation (aOR=3.965, p<0.001). Conversely, pre-eclampsia was significantly associated with a decreased risk of VT in PPCM patients (aOR=0.218, p=0.001).  Conclusion  In a large cohort of patients admitted with peripartum cardiomyopathy, we found the prevalence of VT to be 6.5%. Risk factors for VT in this patient population included conditions such as coagulopathy and atrial fibrillation.

Upregulation of BRCA1 and 2 protein expression is associated with dysregulation in amino acids profiles in breast cancer

BACKGROUND

The prevalence of breast cancer (BC) is high among cancers in Egypt, ranking it the most common cause of cancer mortality in women. BRCA1 and BRCA2 tumor suppressors proteins have a specific relationship with BC. Plasma free amino acids levels (PFAAs) have been reported to exhibit altered profiles among cancer patients. Thus, the present study aims to examine the alteration of the PFAAs profiles and investigate their association with BRCA1 and 2 circulating levels in Egyptian females diagnosed with BC and in females with family history of BC to establish potential early detection strategies for BC.

METHODS AND RESULTS

This study included 26 BC patients, 22 females with family history of BC (relatives) in addition to 38 healthy females as control group. Quantitative measurement of PFAAs was determined by the ion exchange separation method through high performance liquid chromatography. BRCA1 and BRCA2 concentrations were determined using ELISA. Our results showed PFAAs profiles in BC patients and in females with BC family history with significant upregulation in mean plasma levels of Alanine, Phenylalanine, Glutamate and Cysteine and downregulation of Taurine, Threonine, Serine, Glycine, Valine, Methionine and Histidine levels compared to controls. Also, a significant positive correlation was observed between plasma BRCA1 and Valine levels while a significant negative correlation was observed between BRCA2 and Lysine plasma levels.

CONCLUSION

PFAAs profile can potentially be used in early screening for BC patients and for susceptible females.

The Impact of Patient Characteristics and Antiplatelet Regimes on Clot Microstructure in Patients Treated for ST Elevation Myocardial Infarction: Clot Microstructure can Evaluate Therapeutic Efficacy

BACKGROUND

Unfavourable clot microstructure is associated with adverse outcomes in ST elevation myocardial infarction (STEMI). We investigated the effect of comorbidities and anti-platelet treatment on clot microstructure in STEMI patients using fractal dimension (d_f), a novel biomarker of clot microstructure derived from the visco-elastic properties of whole blood.

METHODS

Patients with STEMI (n = 187) were recruited sequentially receiving aspirin with Clopidogrel (n = 157) then Ticagrelor (n = 30). Patient characteristics and blood for rheological analysis obtained. We quantified d_f using sequential frequency sweep tests to obtain the phase angle of the Gel Point which is synonymous with the clot microstructure.

RESULTS

Higher d_f was observed in males (1.755 ± 0.068) versus females (1.719 ± 0.061, p = .001), in patients with diabetes (1.786 ± 0.067 vs 1.743 ± 0.046, p < .001), hypertension (1.760 ± 0.065 vs 1.738 ± 0.069, p = .03) and previous MI (1.787 ± 0.073 vs 1.744 ± 0.066, p = .011) compared to without. Patients receiving Ticagrelor had lower d_f than those receiving Clopidogrel (1.708 ± 0.060 vs 1.755 ± 0.067, p < .001). Significant correlation with d_f was found with haematocrit (r = 0.331, p < .0001), low-density lipoprotein (LDL) (r = 0.155, p = .046) and fibrinogen (r = 0.182, p = .014). Following multiple regression analysis, diabetes, LDL, fibrinogen and haematocrit remained associated with higher d_f while treatment with Ticagrelor remained associated with lower d_f.

CONCLUSIONS

The biomarker d_f uniquely evaluates the effect of interactions between treatment and underlying disease on clot microstructure. STEMI patients with diabetes and elevated LDL had higher d_f, indicating denser clot. Ticagrelor resulted in a lower d_f than Clopidogrel signifying a less compact clot.

Occurrence and Distribution of Tomato Brown Rugose Fruit Virus Infecting Tomato Crop in Saudi Arabia

During the growing season of 2021-2022, a total of 145 symptomatic tomato leaf and fruit samples were collected from different locations in Riyadh Region, Saudi Arabia, showing a moderate-to-severe mosaic with dark green wrinkling, blistering, narrowing, and deformation with necrosis spot on tomato leaves, while irregular brown necrotic lesions, deformation, and yellowing spots rendering the fruits non-marketable were observed on tomato fruits. These samples were tested serologically against important tomato viruses using enzyme-linked immunosorbent assay (ELISA), and the obtained results showed that 52.4% of symptomatic tomato samples were found positive for Tomato brown rugose fruit virus (ToBRFV), wherein 12 out of 76 samples were singly infected; however, 64 out of 145 had mixed infection. A sample with a single infection of ToBRFV was used for mechanical inoculation into a range of different host plants; symptoms were observed weekly, and the presence of the ToBRFV was confirmed by ELISA and reverse transcription-polymerase chain reaction (RT-PCR). A total RNA was extracted from selected ELISA-positive samples, and RT-PCR was carried out using specific primers F-3666 and R-4718, which amplified a fragment of 1052 bp. RT-PCR products were sequenced in both directions, and partial genome nucleotide sequences were submitted to GenBank under the following accession numbers: MZ130501, MZ130502, and MZ130503. BLAST analysis of Saudi isolates of ToBRFV showed that the sequence shared nucleotide identities (99-99.5%) among them and 99-100% identity with ToBRFV isolates in different countries. A ToBRFV isolate (MZ130503) was selected for mechanical inoculation and to evaluate symptom severity responses of 13 commonly grown tomato cultivars in Saudi Arabia. All of the tomato cultivars showed a wide range of symptoms. The disease severity index of the tested cultivars ranged between 52% and 96%. The importance ToBRFV disease severity and its expanding host range due to its resistance breaking ability was discussed.

P900 The Heart Model: Automated LVEF calculation in the real world

Background

Heart Model (HM) is a proprietary, model-based algorithm for measurement of left ventricular ejection fraction (LVEF) in a 3D dataset acquired from an apical 4-chamber view by transthoracic echocardiography (TTE). There is evidence for superior reproducibility compared to 2D echo methods for LVEF measurement.

Objective

To assess the correlation of LVEF by HM with conventional, 2D LVEF methods.

Methods

All TTEs performed between 04-08/02/2019 by 2 HM-trained sonographers were included. Demographic characteristics, indication for TTE, LVEF by Simpson"s (LVEF_S), by "eyeballing" (LVEF_EB) and by HM (LVEF_HM), were recorded; LVEF for each study was also estimated by eye-balling by an experienced observer unaware of the reported LVEF (LVEF_IND). We compared LVEF by each method, their reciprocal correlations and their correlation with LVEF_HM. Image quality was rated excellent (endocardial border visible for all segments in the 3 apical views), good (&lt; 1 segment was not visible / view), adequate (&lt; 3 segments were not visible) and limited (&lt;4 segments were not visible). Indications for TTE were: assessment of LVEF in 1/3 of the studies, murmurs in 1/5, and other indications in the rest.

Results

We included 74 patients (42 M, mean age (SD) 69.8(13.9), range 18-92 years). Forty-nine (66%) patients were in sinus rhythm, 23 (31%) were in AF, and the rest were in various paced rhythms. Fifty patients (68%) had excellent, good or adequate images. The EFs calculated by different methods are shown in the Table (p &gt; 0.05 for all), an the Bland Altman plot (LVEF_EB vs HM) in the figure. LVEF_HM correlated modestly with the other methods if all studies were included (r = 0.535 LVEF_HM vs. LVEF_EB); the correlation improved if only good-quality studies were included (r = 0.769, p &lt; 0.001 for both). All combinations of LVEF_IND, LVEF_EB and LVEF_S had correlation coefficients &gt;0.93.

Conclusions

The Heart Model algorithm for LVEF measurement correlates well with traditional 2D methods in patients with good endocardial border definition, where its use can potentially improve reproducibility and reduce exam duration.

LVEF by method (good-quality studies) N = 50 Simpson"s Eyeballing HeartModel Independent Mean(%) 48.6 48.9 50.9 48.8 SD(%) 17.8 16.6 14.9 15.7 Median(%) 54.5 52.5 53 50 Range(%) 16-74 17.5-72.5 19-88 15-75 SD - standard deviation Independent - LVEF estimate (eyeballing) by independent observer unaware of reported EFs. LVEF_EB was chosen as it was available inall the reports.

Abstract P900 Figure. Bland Altman Plot (LVEF_EB vs LVEF_HM)

In vitro clot model to evaluate fibrin-thrombin effects on fractal dimension of incipient blood clot

INTRODUCTION

This aim of this study is to investigate the individual effects of varying concentrations of thrombin and fibrinogen on clot microstructure (characterised through the fractal dimension of the incipient clot network, df) and clot formation time (TGP) using a fibrin-thrombin clot model. df and TGP markers are measured using a haemorheological method that has already been investigated for whole blood.

METHODS

This is an in vitro study using three thrombin concentrations (0.1, 0.05 and 0.02 NIH/ml) and two fibrinogen concentrations (8 mg/ml and 12 mg/ml) to investigate a fibrin-thrombin clot model. The haemorheological changes were measured at the gel point using df and TGP.

RESULTS

Fractal dimension (df) increased with increasing concentrations of thrombin both at 8 mg/ml (1.60±0.024, 1.67±0.022, 1.74±0.079) and 12 mg/ml fibrinogen concentrations (1.63±0.02, 1.87±0.019, 1.95±0.014). On the other hand, TGP decreased for both 8 mg/ml (1089±265, 637±80, 223±22 seconds) and 12 mg/ml fibrinogen concentrations (2008±247, 776±20, 410±20 seconds). In contrast to previous studies investigating whole blood, TGP increased with higher fibrinogen levels.

CONCLUSIONS

The findings from this fibrin-thrombin clot model confirmed that df and TGP can detect changes in the incipient clot following manipulation of fibrinogen and thrombin concentration. df increases (indicating stronger clot) with higher concentrations of thrombin and fibrinogen. On the other hand, TGP decreased as expected with higher thrombin level but not with higher fibrinogen concentrations.

Quantitative Analysis of SSEA3+ Cells from Human Umbilical Cord after Magnetic Sorting

Multilineage-differentiating stress-enduring (Muse) cells are a population of pluripotent stage-specific embryonic antigen 3 (SSEA3)+ mesenchymal stem cells first described by Mari Dezawa in 2010. Although some investigators have reported SSEA3+ mesenchymal cells in umbilical cord tissues, none have quantitatively compared SSEA3+ cells isolated from Wharton’s jelly (WJ) and the cord lining (CL) of human umbilical cords (HUCs). We separated WJ and the CL from HUCs, cultured mesenchymal stromal cells (MSCs) isolated from these two tissues with collagenase, and quantified the percentage of SSEA3+ cells over three passages. The first passage had 5.0% ± 4.3% and 5.3% ± 5.1% SSEA3+ cells from WJ and the CL, respectively, but the percentage of SSEA3+ cells decreased significantly (P < 0.05) between P0 and P2 in the CL group and between P0 and P1 in the WJ group. Magnetic-activated cell sorting (MACS) markedly enriched SSEA3+ cells to 91.4% ± 3.2%. Upon culture of the sorted population, we found that the SSEA3+ percentage ranged from 62.5% to 76.0% in P2–P5 and then declined to 42.0%–54.7% between P6 and P9. At P10, the cultures contained 37.4% SSEA3+ cells. After P10, we resorted the cells and achieved 89.4% SSEA3+ cells in culture. The procedure for MACS-based enrichment of SSEA3+ cells, followed by expansion in culture and a re-enrichment step, allows the isolation of many millions of SSEA3+ cells in relatively pure culture. When cultured, the sorted SSEA3+ cells differentiated into embryoid spheres and survived 4 weeks after transplant into a contused Sprague-Dawley rat spinal cord. The transplanted SSEA3+ cells migrated into the injury area from four injection points around the contusion site and did not produce any tumors. The umbilical cord is an excellent source of fetal Muse cells, and our method allows the practical and efficient isolation and expansion of relatively pure populations of SSEA3+ Muse cells that can be matched by human leukocyte antigen for transplantation in human trials.

Characterisation of clot microstructure properties in stable coronary artery disease

Background

Coronary artery disease (CAD) is associated with an increased prothrombotic tendency and is also linked to unfavourably altered clot microstructure. We have previously described a biomarker of clot microstructure (d_f) that is unfavourably altered in acute myocardial infarction. The d_f biomarker assesses whether the blood will form denser or looser microstructures when it clots. In this study we assessed in patients with stable chest pain whether d_f can differentiate between obstructed and unobstructed CAD.

Methods

A blood sample prior to angiography was obtained from 251 consecutive patients undergoing diagnostic coronary angiography. Patients were categorised based on angiographic findings as presence or absence of obstructive CAD (stenosis ≥50%). The blood sample was assessed using the d_f biomarker, standard laboratory markers and platelet aggregometry (Multiplate).

Results

A significant difference (p=0.028) in d_f was observed between obstructive CAD (1.748±0.057, n=83) and unobstructive CAD (1.732±0.052, n=168), where patients with significant CAD produce denser, more tightly packed clots. d_f was also raised in men with obstructive CAD compared with women (1.745±0.055 vs 1.723±0.052, p=0.007). Additionally d_f significantly correlated with the platelets response to arachidonic acid as measured by the ASPItest area under the curve readings from platelet aggregometry (correlation coefficient=0.166, p=0.008), a low value of the ASPItest indicating effective aspirin use was associated with looser, less dense clots.

Conclusions

For the first time, we characterise clot microstructure, as measured by d_f, in patients with stable CAD. d_f can potentially be used to risk-stratify patients with stable CAD and assess the efficacy of therapeutic interventions by measuring changes in clot microstructure.

Effects of unidirectional flow shear stresses on the formation, fractal microstructure and rigidity of incipient whole blood clots and fibrin gels

Incipient clot formation in whole blood and fibrin gels was studied by the rheometric techniques of controlled stress parallel superposition (CSPS) and small amplitude oscillatory shear (SAOS). The effects of unidirectional shear stress on incipient clot microstructure, formation kinetics and elasticity are reported in terms of the fractal dimension (d_f) of the fibrin network, the gel network formation time (T_GP) and the shear elastic modulus, respectively. The results of this first haemorheological application of CSPS reveal the marked sensitivity of incipient clot microstructure to physiologically relevant levels of shear stress, these being an order of magnitude lower than have previously been studied by SAOS. CSPS tests revealed that exposure of forming clots to increasing levels of shear stress produces a corresponding elevation in d_f, consistent with the formation of tighter, more compact clot microstructures under unidirectional flow. A corresponding increase in shear elasticity was recorded. The scaling relationship established between shear elasticity and d_f for fibrin clots and whole blood confirms the fibrin network as the dominant microstructural component of the incipient clot in terms of its response to imposed stress. Supplementary studies of fibrin clot formation by rheometry and microscopy revealed the substantial additional network mass required to increase d_f and provide evidence to support the hypothesis that microstructural changes in blood clotted under unidirectional shear may be attributed to flow enhanced thrombin generation and activation. CSPS also identified a threshold value of unidirectional shear stress above which no incipient clot formation could be detected. CSPS was shown to be a valuable haemorheological tool for the study of the effects of physiological and pathological levels of shear on clot properties.

Assessment of platelet function in patients with stroke using multiple electrode platelet aggregometry: a prospective observational study

Background

There is a link between high on-treatment platelet reactivity (HPR) and adverse vascular events in stroke. This study aimed to compare multiple electrode platelet aggregometry (MEA), in healthy subjects and ischaemic stroke patients, and between patients naive to antiplatelet drugs (AP) and those on regular low dose AP. We also aimed to determine prevalence of HPR at baseline and at 3–5 days after loading doses of aspirin.

Methods

Patients with first ever ischaemic stroke were age and sex-matched to a healthy control group. Three venous blood samples were collected: on admission before any treatment given (baseline); at 24 h and 3–5 days after standard treatment. MEA was determined using a Mutliplate® analyser and agonists tested were arachidonic acid (ASPI), adenosine diphosphate (ADP) and collagen (COL).

Results

Seventy patients (mean age 73 years [SD 13]; 42 men, 28 women) were age and sex-matched to 72 healthy subjects. Thirty-three patients were on antiplatelet drugs (AP) prior to stroke onset and 37 were AP-naive. MEA results for all agonists were significantly increased in AP-naive patients compared to healthy subjects: ADP 98 ± 31 vs 81 ± 24, p < 0.005; ASPI 117 ± 31 vs 98 ± 27, p < 0.005; COL 100 ± 25 vs 82 ± 20, p < 0.005. For patients on long term AP, 33% (10/30) of patients were considered aspirin-resistant. At 3–5 days following loading doses of aspirin, only 11.1% were aspirin resistant based on an ASPI cut-off value of 40 AU*min.

Conclusions

Many patients receiving low dose aspirin met the criteria of aspirin resistance but this was much lower at 3–5 days following loading doses of aspirin. Future studies are needed to establish the causes of HPR and potential benefits of individualizing AP treatment based on platelet function testing.

The changes in clot microstructure in patients with ischaemic stroke and the effects of therapeutic intervention: a prospective observational study

Background

Stroke is the second largest cause of death worldwide. Hypercoagulability is a key feature in ischaemic stroke due to the development of an abnormally dense clot structure but techniques assessing the mechanics and quality of clot microstructure have limited clinical use. We have previously validated a new haemorheological technique using three parameters to reflect clot microstructure (Fractal Dimension (d_f)) ex-vivo, real-time clot formation time (T_GP) and blood clot strength (elasticity at the gel point (G’_GP)). We aimed to evaluate these novel clotting biomarkers in ischaemic stroke and changes of clot structure following therapeutic intervention.

Methods

In a prospective cohort study clot microstructure was compared in ischaemic stroke patients and a control group of healthy volunteers. Further assessment took place at 2–4 hours and at 24 hours after therapeutic intervention in the stroke group to assess the effects of thrombolysis and anti-platelet therapy.

Results

75 patients (mean age 72.8 years [SD 13.1]; 47 male, 28 female) with ischaemic stroke were recruited. Of the 75 patients, 32 were thrombolysed with t-PA and 43 were loaded with 300 mg aspirin. The following parameters were significantly different between patients with stroke and the 74 healthy subjects: d_f (1.760 ± .053 versus 1.735 ± 0.048, p = 0.003), T_GP (208 ± 67 versus 231 ± 75, p = 0.05), G’_GP (0.056 ± 0.017 versus 0.045 ± 0.014, p < 0.0001) and fibrinogen (3.7 ± 0.8 versus 3.2 ± 0.5, p < 0.00001). There was a significant decrease in d_f (p = 0.02), G’_GP (p = 0.01) and fibrinogen (p = 0.01) following the administration of aspirin and for d_f (p = 0.003) and fibrinogen (p < 0.001) following thrombolysis as compared to baseline values.

Conclusion

Patients with ischaemic stroke have denser and stronger clot structure as detected by d_f and G’_GP. The effect of thrombolysis on clot microstructure (d_f) was more prominent than antiplatelet therapy. Further work is needed to assess the clinical and therapeutic implications of these novel biomarkers.

Prospective evaluation of blood coagulability and effect of treatment in patients with stroke using rotational thromboelastometry

BACKGROUND

Stroke is the second largest cause of death worldwide. Abnormalities in hemostasis play an important role in the pathophysiology of ischemic stroke (IS). These hemostatic defects can be detected using rotational thromboelastometry (ROTEM) as a global method of measuring coagulation. This study assessed the effects of IS on blood hypercoagulability using ROTEM method, before and subsequent to therapeutic interventions.

METHODS

In a prospective observational cohort study, whole blood coagulation using ROTEM, along with full blood count and standard coagulation tests, were compared between patients with IS and an age-matched control group of healthy volunteers. Further assessment took place at 2-4 hours and at 24 hours in the stroke group after therapy to assess the effects of therapeutic intervention.

RESULTS

Seventy-two patients with IS were age-matched to 71 healthy subjects. Clotting time (CT) INTEM (P = .01) and maximum clot firmness (MCF) INTEM (P = .02) were significantly different between stroke patients at baseline and healthy subjects, but this difference disappeared when controlled for by smoking status. There was no association between ROTEM parameters and time from stroke symptom onset or stroke severity as reflected in The National Institute of Health Stroke Scale score. Significant but small changes in the values of MCF-EXTEM, clot formation time (CFT) EXTEM, and alpha-EXTEM CT were observed after therapeutic intervention (thrombolysis or aspirin treatment).

CONCLUSIONS

ROTEM testing does not seem to detect a hypercoagulable state in patients with IS. Nonetheless, some ROTEM parameters had a small change after antiplatelet therapy or thrombolysis.

A new biomarker quantifies differences in clot microstructure in patients with venous thromboembolism

This study compared patients with venous thromboembolism (VTE) to non-VTE patients using a biomarker of clot microstructure (df ) and clot formation time (TGP ). df was the only marker that identified a significant difference (P < 0·001) between the VTE (n = 60) and non-VTE cohorts (n = 69). The 'abnormal' clot microstructures in the VTE patients suggests either inadequate response to anticoagulant therapy or the presence of a procoagulant state not detected by other markers of coagulation (i.e., International Normalized Ratio). Furthermore, elevated values of df in first time VTE patients who later develop a secondary event indicates that df may identify those at risk of recurrence.

First detection and sequence analysis of thebla-CTX-M-15 gene in Lebanese isolates of extended-spectrum-β-lactamase-producingShigella sonnei

The emergence in Shigella species of extended-spectrum beta-lactamases (ESBL) that impart resistance to third-generation cephalosporins is a growing concern world-wide. So far, however, ESBL-producing Shigella have only been reported seven times, albeit from seven different countries. In Lebanon, three ESBL-producing clinical isolates of S. sonnei were recovered from 30 cases of shigellosis diagnosed between July 2004 and October 2005. All three were found to be resistant to amoxycillin, cefotaxime, ceftazidime, aztreonam, trimethoprim/sulphamethoxazole, gentamicin, and kanamycin. Each harboured the bla-CTX-M gene, and the results of sequence analysis indicated this to be of the bla-CTX-M-15 type and encoded on a 70-kb plasmid, flanked by an insertion element (ISEcp1). The bla-TEM-1 gene was also detected on the chromosomes of two of the ESBL-producing isolates. Class-2 integrons containing dhfr1, aadA1 and sat1 genes were detected on the chromosomes of all three isolates but not on the plasmids. Fluoroquinolone-modifying factors [QnrA, QnrB, QnrS or AAC(6')-Ib-cr] were not detected. The results of RAPD analysis, combined with data on antimicrobial susceptibility, indicated that each isolate was unique. In conclusion, the emergence of ESBL-producing isolates of S. sonnei has been demonstrated for the first time in Lebanon. The resistance of these isolates to third-generation cephalosporins was mediated by the CTX-M-15 enzyme, which was plasmid-encoded.

Dentistry a second time?

INTRODUCTION

Dentistry in Jordan is an attractive profession due to the high social standard it provides. This study aimed to investigate whether dentists would choose dentistry again and whether their professional expectations would change after years of practice. Of special interest were possible differences according to gender, age, degree and place of work.

METHODS

A self-completion questionnaire was filled by a stratified random sample of 355 dentists in Jordan using closed questions. The questionnaire included professional, social and economic factors that influenced people's choice of dentistry and whether they would choose it again and the reasons for that.

RESULTS

The results showed that 52% of dentists who returned the questionnaire had dentistry as their first choice; the most important determining factor was the dentist's grades in the general secondary education. Fifty-two per cent stated that they would not choose it for the second time, the main reason being the health problems acquired through the profession and the low income. Helping others and the social standard dentistry provides were the main reasons given for dentists to choose dentistry again.

CONCLUSION

We report that more than half of the dentists included in this study would not 'choose dentistry again' as their profession regardless of age, gender and degree. This is mainly due to health problems acquired and the low income. We found that job satisfaction is highly affected by the workplace, and that more females are dissatisfied by the profession. This suggests that cultural background strongly affects the career decision.

Meningococcal disease in children: a clinical review

Meningococcal disease is a global burden and remains one of the leading infectious causes of death in children, with an estimated annual death rate of 170,000 worldwide. Despite these figures, the management of children with severe meningococcal sepsis and septic shock remains suboptimal. This review presents an overview of this condition including the epidemiology, pathogenesis, clinical manifestations, complications, management, and prediction.

Stability and reproductive fitness of Schistosoma mansoni isolates with decreased sensitivity to praziquantel

These studies are focused on schistosomes derived from human infections not cured by three successive doses of praziquantel that also produced infections in mice that were significantly more difficult to cure than infections with control worms. Half (three of six) of these isolates retained their decreased response to praziquantel after multiple passages through the life-cycle in the absence of therapeutic pressure. Two of the isolates, including the one initially least sensitive to praziquantel; reverted, to a sensitivity not significantly different from controls. For example, the EE6 isolate initially required 680 mg/kg praziquantel to affect a 50% reduction in worm load in murine infections, but after only six passages through the life cycle over 5 years this was reduced to 113 mg/kg, not different from control infections. The stability of some of the isolates and the reversion of others indicates that the biological or genetic factors conferring decreased praziquantel response varies among the isolates. The three isolates that retained decreased sensitivity to praziquantel all showed compromises in reproductive fitness in the laboratory, expressed most frequently as a decreased cercarial production from snails infected with those isolates compared to controls. For example, the total cercarial production of snails infected with the EE10 isolate was only 57% that of controls. The reversion of some of the isolates to a praziquantel sensitive state and the decreased reproductive fitness of those that did not revert suggest that there is some biological cost associated with the relative praziquantel insensitivity of these worms, which could help limit the impact of such isolates in the field. Infections with the less sensitive isolates also produced significantly less circulating schistosomal antigen in mice, suggesting that a decrease in the host immune response elicited by these worms could be one of the factors contributing to the diminished praziquantel efficacy.

The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings

STUDY OBJECTIVE

To assess the value of a history and physical examination findings in diagnosing the carpal tunnel syndrome, and to determine whether constellations of clinical findings identify patients at high or low risk for the carpal tunnel syndrome.

DESIGN

Comparison of diagnostic tests with neurophysiologic testing.

SETTING

Patients with upper extremity complaints of diverse causes referred to a neurophysiology laboratory for diagnostic studies.

METHODS

Before nerve conduction testing, a history, demographic and physical examination data, and a hand pain diagram were obtained from each patient. Diagrams were categorized as indicating the classic carpal tunnel syndrome, or as probable, possible, or unlikely to indicate the carpal tunnel syndrome. Associations between clinical data and nerve conduction results were examined in univariate and multivariate analyses.

RESULTS

Of 110 patients in the study, 44 (40%) had the carpal tunnel syndrome. Individually, the best predictors were hand pain diagram rating (positive predictive value, 0.59; 95% CI, 0.48 to 0.68) and Tinel sign (positive predictive value, 0.55, CI, 0.45 to 0.65). The combination of a positive Tinel sign and a probable or classic diagram rating had a positive predictive value of 0.71; CI, 0.53 to 0.85. Other findings from physical examination and the history were less useful. Just 9% of patients under 40 years of age with possible or unlikely diagram ratings had the carpal tunnel syndrome.

CONCLUSIONS

With the exceptions of age, Tinel sign, and hand pain diagram rating, findings from the physical examination and the history had limited diagnostic utility. Patients under 40 years of age with possible or unlikely diagram ratings were at low risk for the carpal tunnel syndrome. This finding, which should be confirmed in an independent population, suggests that subsets of patients may be managed without nerve conduction studies.

Comparison of blood levels of histamine and total ascorbic acid in pre-eclampsia with normal pregnancy

Levels of histamine and total ascorbic acid (L-ascorbic acid plus dehydroascorbic acid) in the peripheral blood of women in pre-eclampsia have been measured. The results show that blood histamine is increased both in the moderate and severe form of pre-eclampsia. Blood ascorbic acid on the other hand is increased only in the severe form of pre-eclampsia. The rise in histamine values may be in response to the rising blood pressure in pre-eclampsia. The rise in ascorbic acid values may reflect the reduced maternal blood volume and/or restricted transport of ascorbic acid from maternal to fetal tissues.

Hemostatic system changes induced by 50 micrograms and 30 micrograms estrogen/progestogen oral contraceptives. Modification of estrogen effects by levonorgestrel

Three oral contraceptive preparations were compared for effects on blood coagulation, fibrinolysis and platelet function in a total of 86 healthy young women. Two of the preparations contained 30 micrograms ethinyl estradiol combined with levonorgestrel or norethindrone acetate, and the third contained 50 micrograms mestranol and norethindrone. Tests were conducted before use of the agents, at intervals over 48 weeks' use and after discontinuation. This study showed that the changes in coagulation activity and fibrinolysis were largely related to the dose of estrogen in the contraceptive preparation; the smallest changes occurred with the low-dose (30 micrograms) preparations. This study also showed that changes occurring in certain coagulation factors and inhibitors were significantly smaller in the preparation containing 30 micrograms of ethinyl estradiol combined with levonorgestrel, suggesting that the progestogen used in these combination oral contraceptives modifies the estrogen effects.

The pediatric corner: the varied manifestations of Crohn's disease in children and adolescents

Thirty children less than 15 years of age with Crohn's disease are reported. The mean age of onset was nine years and five months. Delay in diagnosis may stem from the varying modes of presentation. The mean delay in diagnosis was two years. Chronic diarrhea and/or recurrent abdominal pain associated with extraintestinal manifestations, particularly abnormalities of growth and development suggests the possibility of Crohn's disease in the pediatric age group. Involvement of the terminal ileum occurred in 29 of the 30 patients. In addition, colonic disease occurred in 13 and jejunal involvement in one. Four patients presented with an acute onset of their disease. A favorable response to either medical or surgical therapy occurred in all four. Twenty-six patients had an insidious onset and tended to have a chronic course despite either medical and/or surgical therapy. Thirteen patients had an intestinal resection, with recurrence occurring in three from 1-4 years postoperatively. To date there has been one death.