Mitral valve abnormalities in decedents of sudden cardiac death due to hypertrophic cardiomyopathy and idiopathic left ventricular hypertrophy

Background

The sole identification of left ventricular hypertrophy (LVH) in a young individual that died suddenly may often lead to an erroneous diagnosis of hypertrophic cardiomyopathy (HCM). Emerging data suggests that idiopathic LVH (ILVH) and HCM may be separate entities.

Aim

We aimed to report on the prevalence and nature of mitral valve (MV) abnormalities, in a cohort of sudden cardiac death (SCD) victims with a post-mortem examination consistent with HCM and ILVH.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre between 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. HCM was defined by the presence of LVH, in the absence of abnormal loading conditions and characterised by myocyte disarray at histology. ILVH was defined as unexplained LVH (heart weight >500 g in males and >400 g in females) and left ventricular (LV) wall thickness >15mm, in the absence of myocardial disarray or secondary causes of LVH. The MV was examined for patency, circumference, thickening, nodularity, ballooning, bulging between cords, perforation, and the presence of impact lesions in the LV outflow tract (LVOT) and aortic outlet.

Results

Of the total cases of SCD, 264 (4%) were due to HCM (mean age 41±18 years, 78% males, LV maximal wall thickness 19±6 mm) (Figure 1). Ante-mortem symptoms were reported in 44 (17%) cases and for the majority (n=217, 82%) HCM was established at post-mortem. Death was attributed to ILVH in 253 (3%) cases (mean age 43±16 years, 80% males, LV maximal wall thickness 18±4 mm). MV abnormalities were found in 58 (22%) decedents with HCM (mean age 38±17 years; 72% males) and in 13 (5%) decedents with ILVH (mean age 55±15 years; 77% male), p<0.001. Amongst the 58 (22%) cases with HCM and MV abnormalities, 15 (6%) cases had multiple MV abnormalities. These included impact lesions associated with thickening of the anterior leaflet of the MV (n=39) and degenerative changes (n=34) such as bulging and ballooning; and thickening and nodularity. Decedents with HCM exhibiting MV abnormalities were younger than decedents with a normal MV (38±17 versus 45±19 years; p=0.08). Among the 253 decedents with ILVH, 13 (5%) cases exhibited MV abnormalities, which largely included degenerative changes (n=12). Among decedents with HCM and ILVH exhibiting MV abnormalities, the former was significantly younger (38±17 versus 55±15; p=0.001). Myocardial fibrosis was observed in 162 (61%) cases of HCM and 99 (39%) cases of ILVH, p<0.001.

Conclusions

MV abnormalities are over four-fold more common in individuals with HCM than those with ILVH and may be considered as additional macroscopic features to differentiate between these two entities. Furthermore, the inherent descriptive terminologies used when assessing the MV, support a greater emphasis on the standardisation and quantification of MV abnormalities as part of the autopsy in victims of SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.

Improving the diagnostic accuracy of apical hypertrophic cardiomyopathy using machine learning

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Hughes is supported by the British Heart Foundation (grant number FS/17/82/33222).

Introduction

The imaging criteria for diagnosis of apical hypertrophic cardiomyopathy (ApHCM) is a maximum wall thickness (MWT) ≥15mm. CMR enables detection of subtle phenotypic features (e.g. loss of apical tapering, cavity obliteration) and coupled with characteristic electrocardiogram changes, ApHCM can be diagnosed without overt hypertrophy. However, these patients are not captured by current diagnostic criteria.

Purpose

We sought to use a machine learning tool to quantify wall thickness and identify patients with ‘relative’ ApHCM that do not reach current diagnostic thresholds.

Methods

CMR images from 4118 healthy participants from the UK Biobank were segmented automatically with a clinically validated machine learning algorithm and wall thickness measured at all point in the myocardium by solving a solution to Laplace’s equation. MWT were pooled into 16 AHA segments and indexed to body surface area (BSA). The non-indexed and indexed segmental upper limit of normal was calculated as the mean + 3 standard deviations (the equivalent of 95% confidence interval after correcting for multiple [16] comparisons using the Bonferroni method).

Results

73 overt ApHCM subjects (MWT>15mm) and 31 relative ApHCM subjects underwent CMR scanning. In healthy controls, the non-indexed (and indexed) upper limits were calculated for the apical-anterior 10.2mm (5.2 mm/m2), apical-septal 11.1mm (5.6 mm/m2), apical-inferior 10.5mm (5.3 mm/m2) and apical-lateral 10.1mm (5.2 mm/m2) segments. With a non-indexed cut-off, all (73 of 73) overt ApHCM and 84% (26 of 31) relative ApHCM were classified as having an abnormally thick apex. 3% (127 of 4118) of the healthy UK Biobank cohort were classified as abnormal, as expected. Using an indexed cut-off, all overt ApHCM and 87% (27/31) relative ApHCM were classified as abnormal, and 3% (123 of 4118) of the healthy UK Biobank cohort were misclassified.

Conclusion

We can successfully classify 87% of relative ApHCM patients from a normative reference range derived from a large cohort of healthy patients – a significant improvement on existing methods. We show that the specificity and sensitivity is increased when MWT is indexed to BSA. For practical clinical application, we recommend a cut-off of 10mm or an indexed cut-off of 5mm/m2 in any apical segment to diagnose apical LVH. Overt and relative apical HCM examplesHealthy controls AHA maps (non-indexed)

Adopting digital health interventions for secondary prevention of cardiovascular disease: clinician perspectives

Background

Cardiovascular disease (CVD) remains the leading cause of death globally, taking an estimated 18 million lives each year. Digital health interventions (DHI), such as wearables and smartphone applications, have shown promise in CVD detection, prevention, and management. However, there are scarce data regarding clinician perspectives on the utility of DHI and identification of key elements to support adoption in clinical practice.

Method

In this cross-sectional study, a web-based survey was administered to 107 clinicians directly involved in the care of cardiac inpatients across multiple academic health care systems in the United States, between January 2020 and March 2021. Participants (1) reported their perceptions of DHI impact on their ability to care for patients with CVD, (2) rated the importance of factors related to DHI adoption, and (3) shared perspectives on using DHI for secondary CVD prevention to support guideline-directed medical therapy in patients after acute myocardial infarction. Descriptive statistics were analyzed and summarized as frequencies with percentages.

Results

Among survey respondents, 41% were women; 22% specialized in cardiovascular medicine; and 31% were practicing attendings (Table). Overall, 92% (86/94) of respondents believed that DHI would be important in offering advantages in cardiovascular patient care (Figure). Increasing patient adherence was reported as the most important benefit of DHI adoption by 39% of clinicians, followed by improvement in the patient-clinician relationship (29%), enabling remote care (18%), and improving patient experience (14%). Clinicians under age 40 years old, cardiologists, and internists were the groups more likely to consider DHI important in remote patient care, disease monitoring, and tele-visits, as compared to clinicians over age 40 years old or in other clinical specialties.

Conclusion

Our results highlight clinician perspectives on the advantages of DHI and the potential for its adoption for secondary prevention of CVD.

Funding Acknowledgement

Type of funding sources: None. Table 1. Characteristics of RespondentsFigure 1. Clinician Survey

Race, gender and clinical presentation in apical hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

The apical variant of hypertrophic cardiomyopathy (ApHCM) has male predominance and is a relatively rare phenotype in Western population. Characteristics of female and black patients diagnosed with ApHCM are very limited in the existing literature.

Purpose

We aimed to investigate whether gender and race are associated with a different clinical presentation and CMR findings in apical HCM.

Methods

We retrospectively analysed 150 patients (113 males and 37 females) with a diagnosis of apical HCM who have been followed in our inherited cardiac conditions (ICC) clinic between 2010 and 2020. Only patients with a CMR study and apical hypertrophy defined as ≥ 13mm at the time of diagnosis were included.

Demographics and clinical characteristics were obtained from electronic records. Volumetric CMR data were taken from confirmed reports while other parameters were measured by standard protocol. "Pure" ApHCM was defined as isolated apical hypertrophy and "mixed" with both apical and septal hypertrophy but with the apex thickest (1). Apical displacement of papillary muscles (PM) was defined when the base of PM originated from the apical one-third of the left ventricle (LV) in the apical 4- or 2-chamber views. Giant T-wave inversion was defined as T-wave inversion that is equal or greater than 10 mm (1 mV) in any electrocardiogram lead.

Results

Our study population included patients of White (55, 37%), Black (37, 25%), Asian (36, 24%) and Mixed/Others (22, 15%) ethnicity.  Black patients were more likely to have a diagnosis of hypertension at presentation when compared to White (70% vs 40%, p = 0.01) and to Asian and Mixed/Other patients (70% vs 48%, p = 0.03). Similarly, they were more likely to have "mixed" ApHCM than White (49% vs 20%, p = 0.003) and Asian and Mixed/Other (49% vs 26%, p = 0.02) patients.

Females were diagnosed at an older age (63 ± 12 vs 52 ± 14, p < 0.001) and were less likely to have deep T-wave inversion on their ECG at presentation (14% vs 32%, p = 0.03) compared to their male counterparts. Females in this cohort also had higher representation of black ethnicity and were more likely to have hypertension (68% vs 47%, p = 0.03). Apart from the expected gender related differences in volumes and LV mass, there were no differences in cardiomyopathy-specific parameters we investigated.

Conclusions

In our cohort, females with ApHCM presented at an older age and were less likely to have giant T-wave inversion on ECG. Black patients with ApHCM were more likely to have hypertension and the "mixed" type of the disease.

Enhanced Synthetic Access to Tris-CF3-Substituted Corroles

Separate focus on the oligomerization and oxidative cyclization steps required for the synthesis of 5,10,15-tris(trifluoromethyl)corrole revealed [bis(trifluoroacetoxy)iodo]benzene (PIFA) as a superior alternative oxidant. Under optimized conditions, the pure free-base corrole was obtained with a 6-fold increase in chemical yield and an 11-fold rise in isolated material per synthesis. The corresponding gallium(III) and manganese(III) complexes were isolated by adding the appropriate metal salt prior to corrole purification.

Abdominal Fascia Closure Techniques During Laparoscopy

Due to its decreased recovery time and increased patient satisfaction, laparoscopic surgery has witnessed an exponential rise in the last decade. In fact, the indications for laparoscopic surgery are currently numerous and involve multiple disciplines, including gastro-intestinal and gynecological surgery. With this boom, there is much focus on decreasing the rate of complications due to laparoscopy. This includes, but is not limited to, an increased interest in decreasing the risk of port-site herniation by ensuring proper closure of the abdominal wall at the site of port-insertion.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Measurement of Hemodynamic and Anatomic Parameters in a Swine Arteriovenous Fistula Model

Purpose

Although arteriovenous fistulae (AVFs) are currently the preferred mode of permanent hemodialysis access they do have significant problems due to initial non-maturation and a later venous stenosis. These problems appear to have been exacerbated following a push to increase AVF prevalence in the US. The reasons for both AVF non-maturation and the later venous stenoses are unclear but are thought to be related to abnormal hemodynamic wall shear stress (WSS) profiles. This technical note aims to describe the successful development of measurement techniques that can be used to establish a complete hemodynamic profile in a pig model with two different configurations of AVF.

Methods and results

The curved and straight AVF configurations were created in an in vivo pig model. Flow and pressure in the AVFs were measured using the perivascular flow probes and Doppler flow wires while the pressure was recorded using a pressure transducer. The anatomical configuration was obtained using two different approaches: a) combination of intravascular ultrasound (IVUS) and angiograms, (b) 64 slice CT angiography. 3D models were reconstructed using image processing and computer modeling techniques. Numerical calculations were then performed by applying the measured flow and pressure data into the configurations to obtain the hemodynamic WSS profiles.

Conclusion

The described methodologies will allow the calculation and optimization of WSS profiles in animal models. This information could then be translated to the clinical setting where it would have a positive impact on improving the early maturation rates of AVFs as well as reducing the late venous stenoses.

Laparoscopic Excision of an Unusual Presentation of a Nabothian Cyst: Case Report and Review of the Literature

Nabothian cysts are mucinous retention cysts formed through the accumulation of cervical mucus inside blocked cervical crypts leading to non-neoplastic mucinous cystic lesion in relation to the uterine cervix. The formation of Nabothian cysts is a common gynecological benign condition in women of reproductive age. While the presence of small-sized Nabothian cysts is usually clinically asymptomatic and requires no treatment or intervention, the diagnosis of larger Nabothian cysts can be mistaken with malignant tumors, including mucin producing carcinomas such as Adenoma malignum. In this study, we report the case of a large Nabothian cyst that was correctly diagnosed preoperatively using ultrasonography and magnetic resonance imaging (MRI), and successfully treated through laparoscopic excision, avoiding the performance of unnecessary hysterectomy. A 44-year old Lebanese patient presented with chronic dyspareunia and pelvic pain. An ultrasound was performed and revealed an 8cm multiloculated anechoic pelvic cystic lesion with no solid components. An MRI was performed and showed an 8cm mass lateral to the right vaginal wall, suggestive of a Nabothian cyst. The patient was scheduled for laparoscopic removal of the Nabothian cyst. The patient tolerated the procedure well and was discharged under stable condition a few hours after the operation. Careful preoperative examination, including the use of imaging methods such as ultrasonogoraphy and MRI, is crucial for diagnosis and differentiation of atypical presentation of benign, but large and complex, Nabothian cysts from other differential conditions of malignancies, consequently avoiding unnecessary hysterectomy. Use of laparoscopy as a minimally-invasive technique to excise such cysts is considered a valid option, allowing for a fast recovery for the patients.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: the Middle East North Africa Committee for Treatment and Research In Multiple Sclerosis (MENACTRIMS)

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need re-evaluation and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate multiple sclerosis (MS) therapy selection is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, secondary progressive MS, and primary progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Consensus guidelines for the diagnosis and treatment of multiple sclerosis

The diagnosis of multiple sclerosis (MS) is dependent on the presence of clinical and paraclinical evidence demonstrating dissemination of central nervous system lesions in both space and time, as well as the exclusion of other disorders. Diagnostic criteria were originally promulgated in 1965 by the Schumacher committee and modified subsequently by the Poser committee to include paraclinical evidence. The most recent criteria are the 2010 modifications of the 2001 McDonald criteria, which are focused on making an earlier diagnosis of MS. This article provides guidelines, derived from clinical experience as well as evidence-based medicine, for the diagnosis and management of MS with special emphasis on practices in the Middle East.

HLA B*44: protective effects in MS susceptibility and MRI outcome measures

OBJECTIVE

In addition to the main multiple sclerosis (MS) major histocompatibility complex (MHC) risk allele (HLA DRB1*1501), investigations of the MHC have implicated several class I MHC loci (HLA A, HLA B, and HLA C) as potential independent MS susceptibility loci. Here, we evaluate the role of 3 putative protective alleles in MS: HLA A*02, HLA B*44, and HLA C*05.

METHODS

Subjects include a clinic-based patient sample with a diagnosis of either MS or a clinically isolated syndrome (n = 532), compared to subjects in a bone marrow donor registry (n = 776). All subjects have 2-digit HLA data. Logistic regression was used to determine the independence of each allele's effect. We used linear regression and an additive model to test for correlation between an allele and MRI and clinical measures of disease course.

RESULTS

After accounting for the effect of HLA DRB1*1501, both HLA A*02 and HLA B*44 are validated as susceptibility alleles (p(A*02) 0.00039 and p(B*44) 0.00092) and remain significantly associated with MS susceptibility in the presence of the other allele. Although A*02 is not associated with MS outcome measures, HLA B*44 demonstrates association with a better radiologic outcome both in terms of brain parenchymal fraction and T2 hyperintense lesion volume (p = 0.03 for each outcome).

CONCLUSION

The MHC class I alleles HLA A*02 and HLA B*44 independently reduce susceptibility to MS, but only HLA B*44 appears to influence disease course, preserving brain volume and reducing the burden of T2 hyperintense lesions in subjects with MS.

Bruxism physiology and pathology: an overview for clinicians

Awake bruxism is defined as the awareness of jaw clenching. Its prevalence is reported to be 20% among the adult population. Awake bruxism is mainly associated with nervous tic and reactions to stress. The physiology and pathology of awake bruxism is unknown, although stress and anxiety are considered to be risk factors. During sleep, awareness of tooth grinding (as noted by sleep partner or family members) is reported by 8% of the population. Sleep bruxism is a behaviour that was recently classified as a 'sleep-related movement disorder'. There is limited evidence to support the role of occlusal factors in the aetiology of sleep bruxism. Recent publications suggest that sleep bruxism is secondary to sleep-related micro-arousals (defined by a rise in autonomic cardiac and respiratory activity that tends to be repeated 8-14 times per hour of sleep). The putative roles of hereditary (genetic) factors and of upper airway resistance in the genesis of rhythmic masticatory muscle activity and of sleep bruxism are under investigation. Moreover, rhythmic masticatory muscle activity in sleep bruxism peaks in the minutes before rapid eye movement sleep, which suggests that some mechanism related to sleep stage transitions exerts an influence on the motor neurons that facilitate the onset of sleep bruxism. Finally, it remains to be clarified when bruxism, as a behaviour found in an otherwise healthy population, becomes a disorder, i.e. associated with consequences (e.g. tooth damage, pain and social/marital conflict) requires intervention by a clinician.

[Left innominate artery arising from the ascending aorta in the absence of right innominate artery]

It is important to detect anatomic variants of the supraaortic trunks prior to cardiovascular surgery in order to adjust the surgical technique. We report here, an anatomic variant that was not described previously, detected on a chest multidetector CT and confirmed during surgery. This variant consists of a left innominate artery, arising from the ascending aorta before the right subclavian and common carotid arteries that arise separately from the aortic arch. It is important to notice the absence of associated cardiovascular malformations. We formulate a possible explanation of the described variant through an embryologic study of the vasculogenesis.

Measurement of hemodynamic and anatomic parameters in a swine arteriovenous fistula model

PURPOSE

Although arteriovenous fistulae (AVFs) are currently the preferred mode of permanent hemodialysis access they do have significant problems due to initial non-maturation and a later venous stenosis. These problems appear to have been exacerbated following a push to increase AVF prevalence in the US. The reasons for both AVF non-maturation and the later venous stenoses are unclear but are thought to be related to abnormal hemodynamic wall shear stress (WSS) profiles. This technical note aims to describe the successful development of measurement techniques that can be used to establish a complete hemodynamic profile in a pig model with two different configurations of AVF.

METHODS AND RESULTS

The curved and straight AVF configurations were created in an in vivo pig model. Flow and pressure in the AVFs were measured using the perivascular flow probes and Doppler flow wires while the pressure was recorded using a pressure transducer. The anatomical configuration was obtained using two different approaches: a) combination of intravascular ultrasound (IVUS) and angiograms, (b) 64 slice CT angiography. 3D models were reconstructed using image processing and computer modeling techniques. Numerical calculations were then performed by applying the measured flow and pressure data into the configurations to obtain the hemodynamic WSS profiles.

CONCLUSION

The described methodologies will allow the calculation and optimization of WSS profiles in animal models. This information could then be translated to the clinical setting where it would have a positive impact on improving the early maturation rates of AVFs as well as reducing the late venous stenoses.

[Unusual variation of popliteal arterial branches: 4 axes by early division of the peroneal artery]

Embryonic development of arteries of the lower limb results from the union of dorsal and ventral systems, explaining many variations at different levels. Some of these are important to recognize during the radiological exam because they can affect therapeutic management. These variations are most often bilateral and symmetrical predominating at the popliteal and subpopliteal levels. Lippert classified them into three types: normal level of popliteal arterial branching, high division of popliteal artery, hypoplastic or aplastic branching with altered distal supply. The length of the tibioperoneal trunk may also vary, rarely measuring more than 5 cm. We report a case combining three variations, two of them previously described in the literature and the third one not yet reported: our patient presented four arteries due to early bifurcation of the peroneal artery.

Intracellular calcium dynamics--sparks of insight

Calcium ions are of key importance in a large number of cellular functions. In the past decade a large variety of cells have been found to show localized increases in the intracellular calcium concentration named calcium sparks. In this brief review, the methodology of detecting calcium sparks by confocal microscopy is summarized. Some of the properties of calcium sparks in muscle (cardiac, skeletal and smooth muscles), neurons, nerve terminals and oocytes aredescribed. Speculations are put forward regarding their possible role in microcontrol of cell function.

Clinical management of premalignant lesions of the prostate. WHO Collaborative Project and Consensus Conference on Public Health and Clinical Significance of Premalignant Alterations in the Genitourinary Tract

The presence of high-grade prostatic intraepithelial neoplasia (PIN) in a prostate biopsy is a considerable risk factor for the presence of prostate cancer, with up to 73% of patients having cancer on rebiopsy. The risk is related to the clinical setting (screening vs urological practice) and patient factors such as prostatic serum antigen (PSA) and findings on digital rectal examination (DRE). Thus, high-grade PIN has serious clinical implications. The aim of this paper is to propose practical guidelines for the clinical management of PIN. Based on current knowledge we recommend that: Only patients considered for curative treatment of prostate cancer be further investigated for a PIN biopsy finding; A palpable nodule or tumor-suspicious transrectal ultrasonography (TRUS) finding, in conjunction with a finding of high-grade PIN on prostate biopsy, should prompt rebiopsy; An elevated PSA level or an elevated PSA density should also warrant repeat biopsy, as the most likely cause of PSA elevation is concomitant prostate cancer; The presence of high-grade PIN on biopsy without concomitant prostate cancer in patients suitable for curative treatment, notwithstanding normal DRE, TRUS or PSA, should prompt repeat biopsies, as the association with prostate cancer is significant; The presence of PIN alone on biopsy does not warrant treatment, as a substantial number of rebiopsies yield only PIN.

[Dedifferentiation of mature teratomas secondary to testicular cancer: report of 2 cases]

The authors report two cases of adenocarcinomatous dedifferentiation of a recurrent mature teratoma arising 3 and 20 years after the initial resection. This is a rare event, occurring after macroscopically or microscopically incomplete resection of a mature teratoma. The nature of this recurrence was difficult to determine prior to histological examination. However, PET scan suggests the diagnosis of malignant teratoma in the presence of increased uptake by the lesion. These tumours have a poor prognosis. Treatment consists of complete resection of the tumour mass. The possibility of long-term malignant dedifferentiation of a teratoma therefore requires prolonged and regular life-long surveillance of patients presenting a mature teratoma after chemotherapy for non-seminomatous germ cell tumour of the testis.

Seroprevalence of hepatitis C virus (HCV) infection among blood donors: a hospital-based study

Insofar as chronic hepatitis C virus (HCV) infection in many individuals is asymptomatic, and as the prevalence of antibodies to hepatitis C virus (anti-HCV) among blood donors in Lebanon is scarce, this study addressed the prevalence of anti-HCV in 5,115 blood donors. Data obtained were compared to other world regions. Of the blood donors screened, 57 were initially tested positive or doubtful for anti-HCV Ab. Subsequent testing by two-third generation enzyme immunoassays confirmed that, of the 57 initially tested positive/doubtful, only 18 were positive for anti-HCV giving a prevalence rate of 0.4%. While there was no difference in HCV prevalence with respect to age or gender, a higher rate was seen in non-Lebanese compared to Lebanese subjects (3.4% vs 0.3%, P < 0.001). These results demonstrate a low prevalence of HCV infection among Lebanese blood donors, which was comparable to those established for western countries.

Seroprevalence of hepatitis C infection among health care personnel in Beirut, Lebanon

BACKGROUND

Health care workers are at risk of contracting hepatitis C virus (HCV) infection more than the general population, and chronic HCV infection may be asymptomatic. Therefore, the purpose of this study was to determine the seroprevalence of HCV among health care workers at St Georges-Orthodox Hospital, the first study done for a major teaching hospital in Lebanon.

METHODS

Health care personnel at St Georges-Orthodox Hospital, Beirut, were offered anonymous testing for anti-HCV antibody. Seroprevalence rates of health care personnel were compared with the rates of blood donors screened during the same year.

RESULTS

Of the 502 persons screened, 13 (2.60%) initially tested either positive or doubtful-positive by the SM-HCV rapid test; 2 (0.4%) were confirmed positive by 2 commercial enzyme-linked immunosorbent assay kits and reverse transcriptase-polymerase chain reaction. This prevalence rate was comparable with the rate obtained for blood donors (n = 600) during the same period.

CONCLUSION

The seroprevalence of HCV infection among health care workers at St Georges-Orthodox Hospital was similar to the rate observed in local blood donors, which suggests that the occupational risk of HCV infection was low.

Single vital capacity breath for preoxygenation

PURPOSE

The report investigates, in awake patients before induction of anesthesia, the effect of preoxygenation by the single vital capacity breath technique following forced exhalation on the mean arterial PO2 (PaO2).

METHODS

In 10 adult patients undergoing elective surgery, the mean PaO2 values achieved 30 sec after preoxygenation by the single vital capacity breath technique was compared with the mean PaO2 values achieved by preoxygenation by the traditional tidal volume breathing for three minutes. Each patient served as her/his own control.

RESULTS

The mean PaO2 following the single vital capacity breath technique was higher (295 +/- 67 mmHg) than that achieved by the traditional tidal volume breathing technique at 30 sec and 60 sec, and was not significantly different from that achieved by the traditional technique after three minutes (307 +/- 70 mmHg).

CONCLUSION

The single vital capacity breath technique following forced exhalation can rapidly provide adequate preoxygenation within 30 sec.

International Consultation on Urological Diseases: a decade of progress

The International Consultation on Urological Diseases (ICUD), under the cosponsorship of the World Health Organization (WHO), the International Society of Urology (SIU), and the International Union Against Cancer (UICC), is active in the organization of global consultations on urological diseases. The major urological associations from the five continents (the American Urological Association (AUA), the Urological Association of Asia (UAA), the Confederation Americana Urologia (CAU), and the European Association of Urology (EAU)), together with societies with expertise in specific programs such as the International Continence Society, the International Society for Impotence Research, the International Prostate Health Council, the American Cancer Society, the International Union Against Cancer, and the European Organization for Research and Treatment of Cancer, came together in the late 1980s on the basis of their proven record in organizing successful international meetings on urological cancer to initiate the concept of the ICUD. At the suggestion of the WHO, a First International Consultation on Benign Prostatic Hypertrophy (BPH) was organized in 1991, not only to provide recommendations to medical practitioners but also to define and plan future research on the subject. The formula, based on global multiprofessional collaboration and expertise, exceeded expectations, and other consultations were to follow, e.g., on prostate cancer, incontinence, erectile dysfunctions, and nosocomial infections. In 1994 it became necessary to establish a legal nongovernmental organization to foster the goals of the ICUD, essentially for the creation of awareness, knowledge, and recommendations on the diagnosis and treatment of urological diseases.

Maternal obesity and pregnancy outcome

BACKGROUND

Obesity, a common condition in developed countries, is recognized as a threat to health.

OBJECTIVES

To describe the distribution of weight in pregnant women and evaluate the influence of obesity on pregnancy outcome in a high parity northern Israeli population.

METHODS

The study included 887 women who gave birth in the Western Galilee Medical Center during the period August to November 1995. The patients were classified as underweight, normal weight, overweight, or obese according to body mass index. Maternal demographic, obstetric, and perinatal variables were compared. A control group of 167 normal weight women were matched with the obese group for maternal age, parity, and gestational age.

RESULTS

Obese mothers had a higher incidence of gestational diabetes and pregnancy-induced hypertension compared to normal weight mothers (5.4% vs. 1.8%, and 7.2% vs. 0.6% respectively, P < 0.01), a higher rate of labor induction (20.4% vs. 10.2%, P < 0.01), and a higher cesarean section rate (19.6% vs. 10.8%, P < 0.05). There was also a significant difference in the prevalence of macrosomia in the offspring (16.8% vs. 8.4%, P < 0.05).

CONCLUSION

Obese pregnant women are at high risk for complications during delivery and therefore need careful pre-conception and prenatal counseling, as well as perinatal management.

Blocking costimulatory signals to induce transplantation tolerance and prevent autoimmune disease

Similar cellular and molecular mechanisms are responsible for the pathogenesis of transplant rejection and autoimmunity. Recent advances in the studies of lymphocyte activation have shown a requirement for two distinct signals for full activation and development of effector function. The first signal is antigen itself; the second is a nonspecific costimulatory signal, the best example of which is delivered through the CD28 receptor. We and others have shown that blockade of this costimulatory signal can be used as part of strategy to prevent or treat transplant rejection and autoimmune disorders in animal models. This paper will review these findings and discuss their implications for clinical use.

Multifetal pregnancies

Parturients with multiple gestation challenge all members of the perinatal team. Satisfactory maternal and fetal outcome require the experience and expertise of the obstetrician, anesthesiologist and neonatologist, all of whom must be well informed in terms of the total care and management plan.