A Rare Case of Left Ventricular Outflow Tract Obstruction 18 Years after a Mechanical Mitral Valve Replacement

Background: Left ventricular outflow tract (LVOT) obstruction is a serious complication that can occur after various mitral-valves, surgical or percutaneous, interventions. It was rarely described in mechanical mitral valve replacements. Aim: to describe a rare case of late LVOT obstruction after a mitral valve replacement by a low-profile mechanical prosthesis. Case Presentation: A 48-year woman, with a history of rheumatic mitral valve disease and mechanical mitral replacement by a hemi-disc valve 18 years ago, presented for a recent dyspnea. Echocardiography showed a narrowing of the LVOT, with anterior position of the mitral prosthesis, aorto-mitral annular angulation, septal thickening and remnant native sub-valvular tissue attached to the septum in the LVOT region. This resulted in LVOT obstruction with a peak gradient of 75 mmHg. The heart team opted for a redo surgery, but the surgical decision was refused by the patient. Discussion: This is a rare case of late LVOT obstruction after mitral valve replacement by mechanical low-profile prosthesis. Preserved native mitral valve tissue, which is the main described cause of LVOT obstruction after mechanical mitral valve replacements was not the unique cause of obstruction in this patient who had also a septal thickening and anterior prosthetic position. Aorto-mitral annular angulation that was identified as a risk factor of LVOT obstruction after trans-catheter mitral valve replacements, should be, probably, also took into account and assessed pre-operatively in patients undergoing surgical mitral replacements. Conclusion: LVOT obstruction can occur after mechanical mitral replacements event with low profile prosthesis. In patients with identified risk factors of LVOT obstruction, preservation mitral anterior leaflet should be avoided, and preservation of other native mitral tissue should be discussed.

Serum 25-hydroxy vitamin D in asthmatic children and its relation to disease severity

Background: Asthma is a chronic immunological disorder of the lungs. Vitamin D has several effects on the innate and adaptive immune systems. Little is known about vitamin D level and its impact on severity of asthma in children. This study aimed to determine vitamin D levels in asthmatics versus control children; studying the relation if any between these levels and asthma severity.Methods: This cross-sectional study was conducted on 60 asthmatic children and 20 apparently healthy children as controls. Asthma patients were divided into 3 groups (mild, moderate, severe; 20 each). Asthma severity was based on GINA criteria. Vitamin D level was measured to all study group.Results: The difference between the mean values of vitamin D level in control and asthmatic patients was statistically significant (p<0.001). This difference between control group and each asthma subgroup and between asthma subgroups versus each other were statistically significant being highest in control and lowest in patients with severe asthma (p<0.001). Differences in vitamin D status in control and all asthmatic patients were statistically significant (p<0.001). The difference between control group and each asthma subgroup according to vitamin D status were statistically significant (p<0.001). Concerning asthma subgroups the difference in vitamin D status between severe versus mild and moderate asthma were statistically significant (p<0.001), while between mild and moderate asthma it was not.Conclusions: Significantly lower vitamin D level in asthmatic children compared to controls and a differential decrease in vitamin D levels in asthmatic children being lowest in severe asthma was confirmed.

Popliteal Vein Aneurysm Associated with Varicose Veins, Hydrocele, and Multiple Congenital Osteomas: A Case Report and Review of the Literature

Popliteal vein aneurysms (PVAs) represent a rare form of venous aneurysms and necessitate prompt management because of their well-established risk of pulmonary embolism (PE). Herein, we report a rare case of PVA without PE, successfully treated with open surgical repair. A 27-year-old man presented to our vascular clinic with chronic pain and swelling in his left lower limb. He had a long history of facial surgeries for the removal of congenital multiple osteomas. Physical examination revealed varicosities with an abnormal distribution. Duplex ultrasound showed a left PVA measuring 2.3 cm in diameter and 4 cm in length. Open surgical excision of the PVA with lateral venorrhaphy was performed through a medial approach. Prophylactic anticoagulation was performed postoperatively. In this case, the PVA was detected, with a high degree of suspicion by the clinician, before it caused fatal PE. The patient was successfully treated with aneurysm excision and lateral venorrhaphy.

effects of estrogen receptor gene-alpha polymorphism on bone mineral density and serum osteoprotegerin levels in postmenopausal Egyptian women

The gene coding for estrogen receptor-alpha [ER-a] is a potential candidate for the regulation of bone mineral density [BMD] in postmenopausal women. The present study was aimed at elucidating the role of two restriction fragment lengths Pvu II and Xba I polymorphisms of the ER-a gene as determinants of bone mineral density; special attention was paid to the correlation between serum osteoprotegerin [OPG] levels and BMD in different ER-a genotypes in postmenopausal [PM] Egyptian women. BMD was measured at the femur neck [FN-BMD]. ER-a gene polymorphisms were detected by PCR-RFLP. Serum OPG levels were measured by an enzyme linked immunosorbent assay. There were significant differences in BMD and OPG according to different genotypes of Pvu II Single-nucleotide polymorphism [SNP]. Carriers of the pp genotype were more likely to have lower BMD and lower OPG values than noncarriers. While there was no significant relationship between Xbal polymorphism and these variables. Postmenopausal [PM] women were stratified into; those with osteoporosis and those without osteoporosis. The difference in BMD and OPG among genotypes were significant in PM with osteoporosis. Further we confirmed that the frequency of p allele. and pp genotype of Pvu II polymorphism were significantly higher in PM with osteoporosis as compared to PMwithout osteoporosis. Xba I failed to show any significant difference in genotype and allele frequencies between the two groups. Genotypes modulate the relationships between BMD and OPG levels, in women with the PP [r=0.512, p<0.000l] and Pp [r=0.346, p<0.0009] genotypes but not in women with the other genotypes [p>0.05]. These results suggest that the Pvu II polymorphism of ER-a may be associated with the FN-BMD in PM Egyptian women. Further, P allele carriers supposed to protect against PM osteoporosis at least partly by increasing serum OPG

Multi-drug resistance 1 genetic polymorphisms gene expression and prediction of chemotherapy response in breast cancer Egyptian patients

Although anthracycline-based chemotherapy is a crucial treatment for breast cancer, its outcome is limited by the multidrug resistance MDR. Overexpression of P-glycoprotein [Pgp] a transmembrane active efflux transporter of various drugs and carcinogenic substrate, may result in MDR. The impact of MDR1 polymorphisms on MDR1 expression and risk of breast cancer, and whether it can alter chemotherapeutic agents response in breast cancer is unclear. The present work studied the relevance between MDR1 C3435T, C1236T, G2677T/A polymorphisms and MDR1 gene expression and susceptibility to breast carcinoma as well as sensitivity to anthracyine-based chemotherapy in Egyptian females with breast cancer [BC]. We determined mRNA levels of MDR1 in breast tumor specimens [n=190] by real-time rt-PCR. Blood samples from BC female patients and healthy controls were obtained for genotyping. ARMS-PCR assay was used for detection of C3435T, C1236T and G2677T/A Polymorphisms. This study revealed that C3435 TT patients showed a significant decrease in MDR1 mRNA level compared -with CC genotypes. No association was found between the MDR1 C1236T, G2677T/A polymorphisms and MDR1 mRNA expression. The frequency of C3435 TT genotype and T allele were significantlyhigher in BC patients compared to the controls [P < 0.05]. C3435 TT and C3435 CT had odds ratio [p-value] 5.6 [0.001] and 2.28 [0.01] for response to anthracycline-based chemotherapy, respectively, compared to CC genotype. No statistically significant differences were observed between patients and control regarding the allelic and genotypic frequencies of MDR1 C1236T, G2677T/A polymorphisms as well as no correlation was detected to the response rate to anthracycline-based chemotherapy. Our results suggested that C3435T, but not C1236T or G2677T/A, was associated with changes in MDR1 gene expression and hence alters the response after anthracyclin based chemotherapy

[Sedative practice in intensive care units: results of a Maghrebian survey]

sedation is central to the management of intensive care patients. The aim of this study was to establish the current sedation practice in Maghrebian intensive care units [ICUs]. The use of sedation policies with or without a written protocol. The use of scoring systems, the influence of costs on drug choice, the most common drugs for sedation and the use of neuromuscular blocking agents. A self-administered questionnaire composed of 20 items was sent to 138 intensivists in the Maghreb working in 25 teaching hospitals and 16 private clinics 50 of 138 questionnaires were returned [response rate = 36.2%]. Midazolam and Fentanyl were the sedative agents used [respectively 98% and 87%] less than 14% of the ICUs used the Propofol mainly in the first 48 hours. A sedation policy was adopted in 63.6% with a written protocol in 20% of cases. Sedation scoring systems were noted in 14.3% of cases [RAMSAY scale in 100%]. Economic aspect was important for 64.6% of ICUs. sedation may seem secondary in the initial management of intensive care patients,only 63% of our respondents had a sedation policy and 20% a written protocol though its use is thought to improve outcome and reduce costs. Economic aspect was important for the choice of the drug to use [64%], this may explain the preferential use of Midazolam 98% in association with an analgesic [Fentanyl: 85%] while Propofol is used only in 14% though pharmacoeconomic studies may be in fact in favor of the latter. Neuromuscular blocking agents are less frequently used [16%] mainly because of the risk of complications

Facteurs associees a la mortalite maternelle chez les preeclamptiques: a propos de 55 cas

Retrospective study about 55 preeclamptic parurients. Data was collected from the medical files of the patients hospitalized during two consecutive years. Admittance of preeclamptic women in the intensive care unit was 6,37% [55/689]. Mortality rate was 11% [6 deaths]. Complications associated with the maternal death were renal failure, disseminated intravascular coagulopathy and Hemorrhagic shock after subcapsular liver hematoma. Advanced maternal age is a factor associated to maternal mortality. All these risk factors of deaths may be avoided if adequate management is performed

Primary hyperparathyroidism in breast cancer

The coexistence of primary hyperparathyroidism and breast cancer is herein reported to emphasize the proper work-up for patients with hypercalcaemia. We present the clinical, laboratory', radiological and pathology findings and describe the clinical course of the patient. A 49-year-old Arab female with a recent diagnosis of right breast cancer was evaluated because of persistent hypercalcaemia despite repealed intravenous pamidronate treatment. Evaluation revealed hypercalcaemia with elevated intact parathyroid hormone [PTH].Parathyroid scan and neck ultrasound were suggestive of double parathyroid adenomas. The patient underwent resection of the right lower and left upper parathyroid glands. Three months later, she remained hypercalcaemic with high intact parathyroid hormone level. Primary hyperparathyroidism and breast cancer may possibly coexist. Therefore PTH level must be checked in the evaluation of hypercalcaemia in breast cancer patients. Neck exploration is superior to imaging in localising the "anatomic" aetiology of hyperparathyroidism

Predictive value of faecal helicobacter antigen detection in diagnosis and post eradication follow up of patients with helicobacter pylori infection

This study was carried out in its first stage - on 50 dyspeptic patients [Group A] who were positive for H. pylon infection in two simultaneously done tests: biopsy unease test [HUT test] and serological test for - anti H. pylon lgG, and 15 patients [Group B] with negative both tests. All subjects were tested for the presence of H. pylori antigen in their stools using a novel test [premier platinum Hp SA test]. 48 patients of group A were positive while 14 of group B were negative with a sensitivity and specificity 96% and 93.3% respectively. In the second stage of this study; the 48 patients with positive Hp SA test received a triple therapy of Omepazole 20 mg, Tinidazole 500 mg and Calrithromycin 250 mg in a bid dosage for one week. Omeprazole 20 mg daily was given for further 3 weeks as a consolidation therapy. After at least 4 weeks or more both HUT test and Hp SA test were repeated. 8 patients were still positive for both tests while 40 patients were negative for HUT test; 37 of them were negative for Hp SA test with a sensitivity and specificity 100% and 92.5% respectively. Comparison between the results of Hp SA test before eradication therapy revealed non statistically significant difference between the sensitivity, specificity and negative predictive value of the test. However; the positive predictive value of the test was significantly higher during initial estimation than during post eradication assessment [P <0.05]. So, we concluded that Hp SA is a test with a high sensitivity and specificity in comparison to biopsy urease test either for the first diagnosis of H. pylori infection or for post-eradication assessment of treatment. It is easy to be done in any laboratory. Collection of faecal specimen is easy either in the elderlies or children and who refuse gastroscopy on when this is not available

Femoral condylar buttress plate

Nineteen cases with intercondylar femoral fractures treated surgically using the condylar buttress plate are presented in this study. Fifteen patients were males, four were females. The average age was 48 years and the follow up period was 6 to 9 months after surgery. Although the condylar buttress plate is not commonly in use nowadays, this plate proved to be very suitable to fix comminuted intercondylar fractures where its lower cloverleaf shaped end can be mounted to the lateral aspect of the lateral femoral condyle, with its anterior and posterior tongue-like extensions fitting to the anterolateral and posterolateral curvatures of the condyle allowing easy orientation of cancellous screws in all possible planes and this versatility permits fixation of different fragments easily and safely. Fracture reduction and stability of fixation achieved were satisfactory in all cases. Healing was manifested radiographically at an average of eleven weeks [range 9 to 17 weeks]. The knee joint range of flexion at the end of follow up was more than 95 degrees in all cases. We recommend the use of this implant especially in comminuted intercondylar femoral fractures