Primary carnitine deficiency: novel mutations and insights into the cardiac phenotype

Solute carrier family 22 member 5 (SLC22A5) encodes a sodium-dependent ion transporter responsible for shuffling carnitine across the plasma membrane. This process provides energy for the heart, among other organs allowing beta-oxidation of fatty acids. Mutations in SLC22A5 result in primary carnitine deficiency (PCD), a disorder that manifests with cardiac, skeletal, or metabolic symptoms. We hereby describe two novel mutations in SLC22A5 in two Lebanese families associated exclusively with a cardiac phenotype. The frequency of the cardiac, metabolic and skeletal symptoms in PCD patients remains undefined. All the reported eight PCD patients belonging to five different Lebanese families have an exclusive cardiac phenotype. Carnitine levels appear to be directly linked to the type and position of the mutation and the severity of the phenotypic presentation does not seem to be associated with serum carnitine levels. A comprehensive review of 61 literature-reported PCD cases revealed an exclusive cardiac manifestation frequency at 62.3% with a very low likelihood of simultaneous occurrence of cardiac and metabolic manifestation.

Mutational spectrum of cystic fibrosis in the Lebanese population

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians; it is however, considered to be rare in the Arab populations. Reports of the cystic fibrosis transmembrane regulator (CFTR) mutations from Arabs, especially from the Lebanese population, are limited.

METHODS

Twenty-two unrelated Lebanese families, with at least one child with CF, were studied. DNA extracts from blood samples of patients and parents were screened for CFTR gene mutations.

RESULTS

Eleven different mutations were identified. Of the 44 alleles studied, the most common mutations were: F508del (34%), N1303K (27%), W1282X (7%), and S4X (7%). Five mutations - not previously reported in the Lebanese population - were identified; these are: S549N, G542X, 2043delG, 4016insG, and R117H-7T.

CONCLUSIONS

The most common CFTR mutations in addition to five mutations not previously described in the Lebanese population were identified. Identification of CFTR mutations in the Lebanese population is important for molecular investigations and genetic counseling.

Goldenhar syndrome associated with prenatal maternal Fluoxetine ingestion: Cause or coincidence?

Goldenhar syndrome, also known as oculo-auriculo-vertebral spectrum, is a complex, heterogeneous condition characterized by abnormal prenatal development of facial structures. We present the occurrence of Goldenhar syndrome in an infant born to a woman with a history of prenatal Fluoxetine ingestion throughout her pregnancy. Because this is the first reported case associating maternal Fluoxetine intake with fetal craniofacial malformations, a potential mechanism of injury is discussed. The propositus, a male born from nonconsanguinous parents, had facial asymmetry with right microtia and mandibular hypoplasia; he also had bilateral hypoplastic macula, scoliotic deformity of the thoracic spine, and ventricular septal defect. The mother was under treatment with Fluoxetine 20 mg/day prior to conception and maintained the same dosage throughout her pregnancy. The drug is a selective serotonin re-uptake inhibitor, the most widely prescribed for the treatment of depression. The occurrence of developmental aberrations may be caused by a profound serotonin receptor suppressive state in utero leading to aberrant clinical manifestations of the first and second branchial arches. Despite the very many limitations of case reporting of teratogenic events, it remains an important source of information on which more advanced research is based.

Device-associated infections in the pediatric intensive care unit at the American University of Beirut Medical Center

INTRODUCTION

Device-associated healthcare-associated infections (DA-HAIs) are the principal threat to patient safety in intensive care units (ICUs).  The primary objective of this study was to identify the most common DA-HAIs in the pediatric intensive care unit (PICU) at the American University of Beirut Medical Center (AUBMC). Length of stay (LOS) and mortality, antimicrobial resistance patterns, and suitability of empiric antibiotic choices for DA-HAIs according to the local resistance patterns were also studied.

METHODOLOGY

This was a retrospective study that included all patients admitted to the PICU at AUBMC between January 2007 and December 2011. All patients admitted to the PICU having a placed central line, an endotracheal tube, and/or a Foley catheter were included. Data was extracted from the patients' medical records through chart review. A total of 22 patients were identified with 25 central line-associated bloodstream infections (CLABSI), 25 ventilator-associated pneumonia (VAP), and 9 catheter-associated urinary tract infections (CAUTIs). The causing organisms, their resistance patterns, and the appropriateness of empiric antimicrobial therapy were reported.

RESULTS

Gram-negative pathogens were found in 53% of the DA-HAIs, Gram-positive ones in 27%, and fungal organisms in 20%. A total of 80% of K. pneumonia isolates were extended-spectrum beta-lactamases (ESBL) producers, and 30% of Pseudomonas isolates were multidrug resistant. No methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) were isolated. Based on culture results, the choice of empiric antimicrobial therapy was appropriate in 64% of the DA-HAIs.

CONCLUSIONS

After the care bundle approach is adopted in our PICU, DA-HAIs are expected to decrease further.

The pattern of self-poisoning among Lebanese children and adolescents in two tertiary care centres in Lebanon

AIM

Self-poisoning in childhood and adolescence is a major problem for health authorities all over the world. The objective of this study was to determine the pattern of self-poisoning in Lebanese children and adolescents.

MATERIALS AND METHODS

This prospective study included all cases of poisoning in individuals aged 0-18 years who presented to the emergency department of two major hospitals in Beirut, Lebanon over a period of 1 year. Participants were divided into two age groups (0-12 years and 12-18 years). These cases were followed to record the applied treatment and whether the patient was admitted or discharged.

RESULTS

There were 110 self-poisoning incidents, of which 74 (67%) were in female patients. The predominant type of poisoning was with pharmaceutical products (68.2%). Accidental self-poisoning was significantly more common in the younger age group among both genders compared with the older age group (p < 0.0001). There were significantly more poisoned male children (72%) than male adolescents (28%) (p = 0.003); whereas among females, poisoned adolescents were significantly more common (64%) than poisoned children (36%) (p = 0.009). Moreover, poisoning with pharmaceuticals was significantly higher in the young male group compared to the older age group and older female group compared to the younger age group (p = 0.0007 and p = 0.01, respectively). In total, 78% of patients were discharged home following basic observation, charcoal or gastric lavage.

CONCLUSION

Female adolescents are more at risk of deliberate self-intoxication after the age of 12 years compared to males, whereas males younger than 12 years are more likely to suffer from accidental poisoning. Preventative strategies include screening adolescents at high risk of self-harm in order to offer adequate counselling, while providing anticipatory guidance for parents of children in the younger age group.

Inherited thrombophilia in childhood arterial stroke: data from Lebanon

Pediatric ischemic stroke still represents a burden, and more than half of the survivors will experience cognitive or motor disabilities. The objective of this study was to investigate the role of thrombophilia in a cohort of children with arterial ischemic stroke. The records of infants and children with clinically and radiologically confirmed stroke were reviewed. Patients with venous or perinatal stroke were not included. Thirty-three patients were diagnosed with arterial ischemic stroke. The male/female ratio was 1.75:1. The median age was 4 years. The most frequent clinical manifestations were hemiparesis (54.5%) and seizures (33.3%). Genetic thrombophilia testing was available on 24 patients. Nine of the 24 patients (37.5%) were heterozygous for factor V Leiden. None of the patients carried the factor II G20210A variant. Ten patients (41.7%) were heterozygous and 3 (12.5%) were homozygous for methylenetetrahydrofolate reductase (MTHFR) C677T variant. Fifteen patients (62.5%) had one or more genetic polymorphism. Factor V Leiden was significantly associated with arterial ischemic stroke (P < 0.001). Stroke recurred in 2 children with multiple risk factors and MTHFR C677T mutation. Factor V Leiden is one of the major genetic risk factors for pediatric arterial ischemic stroke in Lebanon. MTHFR C677T was prevalent among patients with recurrent stroke.

Acute acalculous cholecystitis in a Lebanese girl with primary Epstein-Barr viral infection

Acute acalculous cholecystitis (AAC) constitutes 5-10% of all cases of cholecystitis in adults, and is even less common in children. The recent literature has described an association between primary Epstein-Barr virus (EBV) infection and AAC, however, it still remains an uncommon presentation of the infection. Most authors advise that the management of AAC in patients with primary EBV infection should be supportive, since the use of antibiotics does not seem to alter the severity or prognosis of the illness. Furthermore, surgical intervention has not been described as necessary or indicated in the management of uncomplicated AAC associated with EBV infection. We report a case of a 16-year-old Lebanese girl with AAC associated with primary EBV infection. She presented to the emergency department, with high-grade fever, fatigue, vomiting and abdominal pain. Liver enzymes were elevated with a cholestatic pattern, and imaging confirmed the diagnosis of AAC. She was admitted to the regular floor, and initial management was conservative. Owing to persistence of fever, antibiotics were initiated on day 3 of admission. She had a smooth clinical course and was discharged home after a total of 9 days, with no complications.

Intestinal polypoid arteriovenous malformation: unusual presentation in a child and review of the literature

AIM

We report a jejuno-jejunal intussusception with a polypoid arteriovenous malformation as a lead point in a 12-year-old boy, presenting with lower abdominal pain and non-bloody non-projectile vomiting.

METHODS

A computed tomography scan of the abdomen and pelvis showed proximal jejuno-jejunal intussusception in the right upper quadrant. Exploratory laparotomy revealed a 5.5 × 2.5 × 2 cm polypoid mass within the wall of the jejunum. Consequently, jejunal segment resection was performed with end to end jejunostomy. Our case is distinctive because it involves a rare vascular lesion at an atypical site, the jejunum, in a child with an unusual presentation of intussusception treated surgically.

CONCLUSION

Many paediatric benign and surgical conditions present with similar clinical symptoms; the physician in the emergency department should try to narrow the differential diagnosis and recognize surgical emergencies to avoid any delay in intervention that could be life-threatening.

A Lebanese family with autosomal recessive oculo-auriculo-vertebral (OAV) spectrum and review of the literature: is OAV a genetically heterogeneous disorder?

Oculo-auriculo-vertebral (OAV) spectrum summarizes a continuum of ocular, auricular, and vertebral anomalies. Goldenhar syndrome is a variant of this spectrum and is characterized by pre-auricular skin tags, microtia, facial asymmetry, ocular abnormalities, and vertebral anomalies of different sizes and shapes. Most cases are thought to be sporadic. However, a few families were reported to have an autosomal recessive inheritance and other families' presentation of the syndrome strongly supported an autosomal dominant inheritance. We report OAV in a female infant presenting with tracheomalacia, diaphragmatic hernia, encephalomeningocele, sacral neural tube defect, and cardiac defect and her brother having no more than dysmorphic features. The mode of inheritance in this family supports an autosomal recessive inheritance where the transmission was from normal first-degree consanguineous parents to one of the sons and to the daughter. This report further broadens the clinical presentation and symptoms of OAV and supports the hypothesis advancing OAV as a genetically heterogeneous disorder.

A Novel Somatic Variant in HEY2 Unveils an Alternative Splicing Isoform Linked to Ventricular Septal Defect

Congenital heart defects (CHDs) are the leading cause of death in infants under 1 year of age. Aberrations in the expression and function of cardiac transcription factors (TFs) are a major contributor to CHDs. Despite the numerous studies undertaken to functionally characterize these TFs, their exact role in different stages of cardiogenesis is still not fully elucidated. Here we focused on HEY2, a basic helix loop helix transcriptional repressor, and its potential role in human ventricular septal defects. Genetic analysis was performed based on sequencing of DNA and cDNA obtained from post-operational cardiac tissues and blood of 17 Lebanese patients with various CHDs. The screen covered the entire coding regions of the GATA4, NKX2.5, TBX5, TBX20 and HEY2 genes. Our results revealed two novel somatic mutations, namely p.Ala229Thr and p.161_190 del, affecting HEY2 in the diseased cardiac tissues of two patients with VSD. These results suggest a potential role of HEY2 in regulating ventricular septation in humans.

Congenital infantile fibrosarcoma: Association with bleeding diathesis

PATIENT

Male, 2 month

FINAL DIAGNOSIS

Congenital infantile fibrosarcoma Symptoms: Bleeding Medication: Vincristine • actinomycin • cyclophosphamide Clinical Procedure: Surgical resection Specialty: Pediatric Oncology.

OBJECTIVE

Diagnostic/therapeutic accidents.

BACKGROUND

Congenital infantile fibrosarcoma (CIF) is a soft-tissue tumor occurring during the first 2 years of life, most commonly in the extremities. CIF is frequently initially misdiagnosed as a vascular tumor, but its association with bleeding and coagulopathy has not been well characterized.

CASE REPORTS

We describe 2 infants with CIF presenting with bleeding and coagulopathy, requiring urgent intervention. Both patients did well; one underwent partial resection followed by chemotherapy, and the other received 2 cycles of chemotherapy followed by gross total resection. We also provide a review of all reported cases of coagulopathy in the setting of CIF in the English literature, uncovering an association that seems to be more prevalent in patients diagnosed in the neonatal period, with associated anemia and thrombocytopenia, and a significant mortality rate.

CONCLUSIONS

CIF needs to be considered in the differential diagnosis of vascular congenital tumors, especially when there is evidence of bleeding, anemia, or thrombocytopenia.

Acute Kidney Injury Post-cardiac Surgery in Infants and Children: A Single-Center Experience in a Developing Country

Introduction: The incidence of acute kidney injury (AKI) in pediatric patients following cardiac surgery varies between 15 and 64%, with a mortality rate of 10-89% among those requiring dialysis. This variation in the incidence and mortality of AKI across studies is probably due to the inconsistent definitions used for AKI. The purpose of this study is to present our experience with AKI post-cardiac surgery with emphasis on predisposing or aggravating factors. Patients and Methods: We evaluated the incidence of AKI using the KDIGO criteria in 150 infants and children undergoing cardiac surgeries between 2015 and 2017. Post-operatively, all patients were admitted to the pediatric intensive care unit (PICU) at a tertiary care center in a developing country. This is a retrospective chart review in which data collected included age, gender, type of heart disease, prior cardiac surgeries, RACHS-1 category, and pre- and post-operative creatinine levels. Neonates were not included in this study. Results: Six percent of the studied patients were below 1 year of age, 84% 1-10 years, and 10% 10-18 years. Fourteen patients (9.3%) developed AKI. Patients with cyanotic heart disease were more prone to develop AKI (78%) compared to those with non-cyanotic heart disease (44%). Children with AKI had a higher length of stay in PICU, 2.56 ± 1.44 vs. 4 ± 2.66 (p- 0.02). Serum lactic acid was higher in patients who developed AKI with a mean value of 6.8 ± 6.9 vs. 2.85 ± 1.55 mmol/l in the non-AKI group (p- 0.03). Lower hemoglobin levels and hyperlactic acidemia were significantly more prevalent in the AKI group. There were five deaths in this series (3.3%), and four of those (80%) were in the AKI group. Conclusion: Using the KDIGO criteria, the incidence of AKI in infants and children following cardiac surgery was 9.3%. This is slightly lower than in previously published studies where the range was between 15 and 64%. Children with cyanotic cardiac disease, hyperlactic acidemia, and anemia were more prone to developing AKI. Identifying patients at risk might help decrease the risk of post-operative AKI.

Establishing an ECMO program in a developing country: challenges and lessons learned

Aim:

The ECMO (extracorporeal membrane oxygenation) Program at the American University of Beirut Medical Center was established in November 2015 as the first program serving adult and pediatric population in a low-resource setting. The aim of the study is to describe the challenges faced during the establishment of the program and factors leading to its success.

Methods:

The program establishment is described. The preparation phase, included the strategic, financial, and clinical planning by administration, nursing, and a multidisciplinary team of physicians. The training and education phase included all the involved nurses, perfusionists, and physicians. Concerns were heard from various stakeholders, and the challenges were analyzed and discussed.

Results:

The preparation committee chose the adequate equipment, responded to the concerns, defined roles and responsibilities through credentialing and privileging, wrote policies and protocols, and established a strategy to decide for the ECMO indication. Selected team of nurses, physicians, and perfusionists are identified and trained locally, and abroad. A full-time ECMO physician was recruited to launch the program. Twelve patients (6 adults, 3 children, and 3 neonates) were supported by ECMO, for cardiac and respiratory indications. Eleven patients were supported by veno-arterial ECMO, and 1 patient (a neonate) with veno-venous ECMO. Overall, 75% survived to decannulation and 41% survived to discharge.

Conclusion:

With limited human and financial resources, new ECMO centers need to carefully establish selection criteria that may differ from those used in developed countries. Indications should be discussed on a case by case basis, taking into account clinical, social, and financial issues. This experience might help other institutions in developing countries to build their own program despite financial and human limitations.

Dietary Zinc Intake and Plasma Zinc Concentrations in Children with Short Stature and Failure to Thrive

Background: The burden of zinc deficiency on children includes an increased incidence of diarrhea, failure to thrive (FTT) and short stature. The aim of this study was to assess whether children with FTT and/or short stature have lower dietary zinc intake and plasma zinc concentrations compared to controls. Methods: A case-control study conducted at the American University of Beirut Medical Center included 161 subjects from 1 to 10 years of age. Results: Cases had a statistically significant lower energy intake (960.9 vs. 1,135.2 kcal for controls, p = 0.010), lower level of fat (30.3 vs. 36.5 g/day, p = 0.0043) and iron intake (7.4 vs. 9.1 mg/day, p = 0.034). There was no difference in zinc, copper, carbohydrate and protein intake between the 2 groups. The plasma zinc concentration did not differ between the cases and controls (97.4 vs. 98.2 μg/dl, p = 0.882). More cases had mild-to-moderate zinc deficiency when compared to controls with 10.3 vs. 3.6%, p = 0.095. Conclusion: Our study did not show statistically significant difference in dietary zinc intake and plasma zinc concentrations between children with FTT and/or short stature compared to healthy controls. A prospective study is planned to assess the effect of zinc supplementation on growth parameters in FTT children.

Comparing febrile children presenting on and off antibiotics to the emergency department: a retrospective cohort study

Background

It is not yet known how antibiotics may affect Serious Bacterial Infections (SBI). Our aim is to describe the presentation, management, and serious bacterial infections (SBI) of febrile children on or off antibiotics.

Methods

Retrospective, cohort study of febrile Emergency Department patients, 0–36 months of age, at a single institution, between 2009and 2012.

Results

Seven hundred fifty-three patients were included: 584 in the No-Antibiotics group and 169 (22%) in the Antibiotics group. Age and abnormal lung sounds were predictors for being on antibiotics (OR 2.00 [95% CI 1.23–3.25] and OR 1.04 [95% CI 1.02–1.06] respectively) while female gender, and lower temperatures were negative predictors (OR 0.68 [95%0.47–0.98] and OR 0.47 [95% CI 0.32–0.67] respectively). Antibiotics were prescribed by a physician 89% of the time; the most common one being Amoxicillin/Clavulanic Acid (39%). The antibiotic group got more blood tests (57% vs 45%) and Chest X-Rays (37% vs 25%). Overall, the percent of SBIs (and pneumonias) was statistically the same in both groups (6.5% in the No-antibiotic group VS 3.6%).

Conclusions

Children presenting on antibiotics and off antibiotics were significantly different in their presentation and management, although the overall percentages of SBI were similar in each group. Further investigations into this subgroup of febrile children are needed.

The status of pediatric cardiology at a tertiary center in Lebanon

PROBLEM

Cardiac disease, both congenital and acquired, contributes significantly to morbidity and mortality in children.

METHODS

This article describes the status of pediatric cardiology at the Children's Heart Center in the American University of Beirut Medical Center. It addresses the available clinical services as well as the research and educational activities that are present at a tertiary center in Lebanon, a developing country with a population of 4 million.

RESULTS

Lebanon has witnessed major developments in the field of pediatric cardiology over the past few years. About 650 babies are born with heart disease every year, with more than 425 needing treatment. Nearly all types of interventional catheterization procedures are currently being performed. About 300 open and closed pediatric cardiac surgeries are performed per year in Lebanon. In 2008, the in-hospital surgical mortality rate at our center was 2.6%, reflecting the good level of care in the treatment of children with congenital heart disease (CHD) in Lebanon. Basic research in the field of pediatric cardiology is emerging at our center. Our team has been studying the effect of chronic hypoxemia on the neonatal myocardium in an animal model of chronic hypoxia, as well as the study of molecular basis of CHD.

CONCLUSION

Appropriate identification of cardiac disease, its epidemiology, and outcome is of utmost importance in guiding adequate care. Centralization of facilities is important to improve results and level of care.

Dubowitz syndrome: common findings and peculiar urine odor

Background

Dubowitz syndrome is a rare, autosomal recessive disorder characterized by intrauterine and postnatal growth retardation, severe microcephaly, psychomotor retardation, hyperactivity, eczema, and characteristic dysmorphic facial features. Although many cases have been reported, the cause of this disease is still unknown.

Case

We present here the case of a Lebanese girl with Dubowitz syndrome in whom an unpleasant urine odor was persistently reported since birth.

Conclusion

Although Dubowitz syndrome has been largely described in the medical literature, this is the first time that a peculiar urine odor was reported. This case report adds a new and unusual feature to the numerous findings related to this rare polymorphous syndrome.

Correction to: A Novel Somatic Variant in HEY2 Unveils an Alternative Splicing Isoform Linked to Ventricular Septal Defect

The original version of this article unfortunately contained a mistake in the author name. The first author name should be Manal Fardoun instead of Manal Fardon. The original article has been corrected.

The interpretation of code status concept among pediatric health care workers, a multicenter cross sectional study across Lebanon

Background

Cardiopulmonary resuscitation (CPR) use with no considerations given to patient selection or therapeutic aim resulted in extension of the agony, pain and dying process for terminally ill patients. Four Resuscitation-limiting Codes other than Full Code exist. In a conservative country like Lebanon, several factors can influence such decisions, namely the ethical, legal, religious perspectives, pediatric population, and more importantly the lack of protocol, healthcare workers (HCWs) knowledge, understanding and readiness to discuss terminal care with the parents. The objectives of the study are to evaluate the knowledge, behavior and comfort level of Lebanese pediatric HCWs in code status discussions, and to determine major obstacles encountered.

Methods

This is a cross-sectional observational study. An anonymous questionnaire has been sent electronically for 400 pediatric HCWs from different hospitals across Lebanon, over a period of 3 months.

Results

Of the 400 pediatric HCWs recruited, 235 completed the survey. 39.9% of medical doctors (MDs), and 62% of registered nurses (RNs) did not know about code status subtypes. Most of the MDs are using the paternalistic approach. There were significant differences between MDs and RNs regarding their point of view toward code status, but both thought that it was not defined in the Lebanese law (86.7% of MDs vs. 87% of RNs), and are not comfortable in such discussions (79% for MDs vs. 84.8% for RNs). The decisions taken by MDs regarding life-sustaining treatments (LSTs) in different resuscitation-limiting codes showed clearly the knowledge gap. Moreover, attendings and trainees differed significantly in their decisions, where the latter seemed more conservative. Pediatric HCWs in Lebanon are facing major obstacles when it comes to code status decisions.

Conclusion

Code status in Lebanon is an immature concept, and pediatric HCWs are challenged with conflicting decisions and obligations when it comes to code status discussions and LSTs. A multidisciplinary approach, with good communication between different members of the medical team would be the best. Addressing the obstacles encountered, and set a clear protocol will not only unify and solidify the HCWs decisions, but will have positive impact and repercussions on the patient care as well.

Challenges in institutional ethical review process and approval for international multicenter clinical studies in lower and middle-income countries: the case of PARITY study

Background

One of the greatest challenges to conducting multicenter research studies in low and middle-income countries (LMICs) is the heterogeneity in regulatory processes across sites. Previous studies have reported variations in requirements with a lack of standardization in the Institutional Review Board (IRB) processes between centers, imposing barriers for approval, participation, and development of multicenter research.

Objectives

To describe the regulatory process, variability and challenges faced by pediatric researchers in LMICs during the IRB process of an international multicenter observational point prevalence study (Global PARITY).

Design

A 16-question multiple-choice online survey was sent to site principal investigators (PIs) at PARITY study participating centers to explore characteristics of the IRB process, costs, and barriers to research approval. A shorter survey was employed for sites that expressed interest in participating in Global PARITY and started the approval process, but ultimately did not participate in data collection (non-participating sites) to assess IRB characteristics.

Results

Of the 91 sites that sought IRB approval, 46 were successful in obtaining approval and finishing the data collection process. The survey was completed by 46 (100%) participating centers and 21 (47%) non-participating centers. There was a significant difference between participating and non-participating sites in IRB approval of a waiver consent and in the requirement for a legal review of the protocol. The greatest challenge to research identified by non-participating sites was a lack of research time and the lack of institutional support.

Conclusions

Global collaborative research is crucial to increase our understanding of pediatric critical care conditions in hospitals of all resource-levels and IRBs are required to ensure that this research complies with ethical standards. Critical barriers restrict research activities in some resource limiting countries. Increasing the efficiency and accessibility of local IRB review could greatly impact participation of resource limited sites and enrollment of vulnerable populations.

Absence of GJA1 gene mutations in four patients with anomalous left coronary artery from the pulmonary artery (ALCAPA)

PROBLEM

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare form of congenital heart disease with no known genetic cause. It is usually diagnosed within the first year of life; it results in myocardial cell death, congestive heart failure and lethality if left untreated. Connexin 43alpha1 is a member of the gap junction family of proteins demonstrated by animal studies to have a role in coronary artery patterning during development. No previous studies have investigated the role of this gene in patients with ALCAPA.

METHODS

We forth herein describe the clinical presentation of four patients who presented to the Children's Heart Center at AUBMC and had the final diagnosis of ALCAPA. Screening the GJA1 gene coding for connexin 43alpha1 was undertaken.

RESULTS

No mutations were found in the patients or their parents, except for one polymorphism in one of the parents in the 3' untranslated region. All four patients underwent surgical repair with excellent outcome.

CONCLUSION

This paper raises the awareness of this rare condition enabling physicians to reach the adequate diagnosis which will allow early surgical intervention and better prognosis. Our patient sample did not exhibit any evidence of association between connexin 43alpha1 and the clinical phenotype.

Cardiac involvement in a child post COVID-19: a case from Lebanon

We report on an 8-year-old boy, who presented to the emergency department at our institution with fever, generalised oedema and hypotension. Investigations revealed anaemia, thrombocytopenia in addition to elevated serum inflammatory markers, a negative COVID-19 PCR test and a positive COVID-19 IgG. His echocardiography was consistent with carditis in otherwise morphologically normal heart with depressed cardiac function, moderate-to-severe mitral valve regurgitation, moderate tricuspid regurgitation with an estimated right ventricular systolic pressure half systemic, trace aortic regurgitation, bilateral small pleural effusions, distended inferior vena cava and normal coronaries. He was started on inotropic support, intravenous immunoglobulin and methylprednisolone, and was transferred to the paediatric intensive care unit. To the best of our knowledge, this was the first case of multisystem inflammatory syndrome in children encountered in Lebanon. The presentation and management were thoroughly described in this article aiming to share our experience and to contribute to the rapidly emerging literature on this syndrome.

Mitochondrial depletion syndrome type 3: the Lebanese variant

Introduction: Mitochondrial DNA depletion syndrome type 3 is an emerging disorder linked to variants in the deoxyguanosine kinase gene, which encodes for mitochondrial maintenance. This autosomal recessive disorder is frequent in the Middle East and North Africa. Diagnosis is often delayed due to the non-specificity of clinical presentation with cerebro-hepatic deterioration. The only therapeutic option is liver transplantation, although the value of this remains debatable. Methods: We describe the clinical, biochemical, and molecular profiles of Lebanese patients with this rare disorder. We also present a review of all cases from the Middle East and North Africa. Results: All Lebanese patients share a unique mutation, unreported in other populations. Almost half of patients worldwide originate from the Middle East and North Africa, with cases reported from only 7 of the 21 countries in this region. Clinical presentation is heterogeneous, with early-onset neurological and hepatic signs. Liver failure and lactic acidosis are constants. Several variants can be identified in each population; a unique c.235C>T p. (Gln79*) pathogenic variant is found in Lebanese patients. Outcome is poor, with death before 1 year of age. Conclusion: The pathogenic nonsense variant c.235C>T p. (Gln79*) in the deoxyguanosine kinase gene may be considered a founder mutation in Lebanon. Further genotypic delineation of this devastating disorder in populations with high consanguinity rates is needed.

Do patients want their spirituality addressed during their hospital journey; a cross-sectional study at a tertiary care center in Lebanon

BACKGROUND

Spirituality (including religiosity) is a powerful concept in Middle Eastern populations for members of all religious affiliations. This study aims to assess the desire of cancer and critically ill adult inpatients to be asked about their spiritual history, the impact their religious and spiritual beliefs have on their medical decisions, and if such beliefs help them cope with their illnesses.

METHODS

A questionnaire consisting of demographics and spirituality questions was developed and administered to 100 patients in a cross-sectional study. We performed psychometric analysis of the questionnaire through reliability and validity testing including construct validity using PCA with a Promax rotation to define components/constructs. Analysis was performed to study the association between patient characteristics and outcomes.

RESULTS

The scale was shown to be valid and reliable and can be used to assess spiritual needs in our population of critically ill and cancer patients. 45% of patients wanted to be asked about their spirituality, only 4% had discussed it with their medical team. Christian and Muslim patients were equally likely to want their spiritual history taken. Non-Lebanese patients were 4.8 times more equally likely to want their spiritual history taken and twice more likely to believe that their spirituality helps them cope with their illness compared to Lebanese patients (p < 0.05). Critical care patients as compared to cancer patients, and patients with a lower number of hospital visits during the past year, were significantly more likely to want to be asked about their spirituality (p < 0.05).

CONCLUSION

More structured training of healthcare personnel on addressing spirituality in the cultural context is needed. In our society, advocacy for patients with chronic illness embodies enquiring and addressing their spiritual needs through all the stages of their illness.