Consultation on the Libyan health systems: towards patient-centred services.

The extra demand imposed upon the Libyan health services during and after the Libyan revolution in 2011 led the ailing health systems to collapse. To start the planning process to re-engineer the health sector, the Libyan Ministry of Health in collaboration with the World Health Organisation (WHO) and other international experts in the field sponsored the National Health Systems Conference in Tripoli, Libya, between the 26th and the 30th of August 2012. The aim of this conference was to study how health systems function at the international arena and to facilitate a consultative process between 500 Libyan health experts in order to identify the problems within the Libyan health system and propose potential solutions. The scientific programme adopted the WHO health care system framework and used its six system building blocks: i) Health Governance; ii) Health Care Finance; iii) Health Service Delivery; iv) Human Resources for Health; v) Pharmaceuticals and Health Technology; and vi) Health Information System. The experts used a structured approach starting with clarifying the concepts, evaluating the current status of that health system block in Libya, thereby identifying the strengths, weaknesses, and major deficiencies. This article summarises the 500 health expert recommendations that seized the opportunity to map a modern health systems to take the Libyan health sector into the 21st century.

Late complex biventricular repair after bidirectional cavopulmonary shunt.

A child diagnosed with transposition of great arteries, multiple (Swiss cheese) ventricular septal defects, and a small right ventricle underwent pulmonary artery banding and patent ductus arteriosus ligation at the age of six months. At the age of three years bidirectional cavopulmonary shunt was performed as a first stage for univentricular repair. However, the patient was lost follow-up for four years, following which further evaluation showed that the right ventricle was reasonably adequate to support pulmonary circulation if the ventricular septal defects (VSDs) were closed using percutaneous techniques. Four VSDs were then closed using Amplatzer devices (AGA Medical Corporation, Plymouth, MN, USA). At the age of eight years she underwent complex biventricular repair in the form of arterial switch, closure of atrial septal defect, take down of Glenn shunt, and reanastomosis of the distal end of the superior vena cava to the distal superior vena cava stump on the right atrium. One year later the patient is alive and well. In conclusion; biventricular repair may be considered before completion of Fontan whenever cardiac anatomy allows.

PI3 K/Akt/mTOR-mediated translational control regulates proliferation and differentiation of lineage-restricted RoSH stem cell lines.

BACKGROUND: We have previously derived highly similar lineage-restricted stem cell lines, RoSH and E-RoSH cell lines from mouse embryos and CD9hi SSEA-1- differentiated mouse embryonic stem cells, respectively. These cell lines are not pluripotent and differentiate readily into endothelial cells in vitro and in vivo. RESULTS: We investigated the signaling pathway that maintains proliferation of these cells in an undifferentiated state, and demonstrate that PI3 K/Akt/mTOR, but not Raf/MEK/Erk, signaling in these cells was active during proliferation and was downregulated during endothelial differentiation. Inhibition of PI3 K/Akt/mTOR signaling, but not Raf/MEK/Erk, reduced proliferation and induced expression of endothelial specific proteins. During differentiation or inhibition of PI3 K/Akt/mTOR signaling, cyclinD2 transcript abundance in ribosome-enriched RNA but not in total RNA was reduced with a corresponding reduction in protein level. In contrast, transcript abundance of endothelial-specific genes e.g. Kdr, Tek and Pdgfralpha in ribosome-enriched RNA fraction was not reduced and their protein levels were increased. Together these observations suggested that translational control mediated by PI3K/Akt/mTOR signaling was critical in regulating proliferation and endothelial differentiation of lineage-restricted RoSH-like stem cell lines. CONCLUSION: This study highlights translation regulation as a critical regulatory mechanism during proliferation and differentiation in stem cells.

Total arterial coronary revascularization using arterial bypass circle with multiple inflows.

Coronary artery bypass techniques, currently applied to maximize the benefits of multiple arterial coronary conduits, render the newly constructed myocardial flow dependent on a single source "inflow" of blood. We describe a technique for total arterial coronary revascularization with multiple inflows; the distal end of the pedicled right internal thoracic artery is anastomosed to the distal end of a free radial artery, and the other end of the radial artery is then connected to the ascending aorta. This vascular circle, passed in a retro-cardiac fashion, is used to revascularize the inferio-lateral surface of the heart using multiple side-to-side anastomoses. The "sacred" left internal thoracic artery is reserved to revascularize the anterior wall of the myocardium, independent of the arterial circle.

Stem cell transplantation: potential impact on heart failure.

Cell transplantation is a promising new modality in treating damaged myocardium after myocardial infarction and in preventing postmyocardial infarction LV remodelling. Two strategies are plausible: the first uses adult tissue stem cells to replace the scar tissues and amend the lost myocardium, whilst the second strategy uses embryonic stem cells in an attempt to regenerate myocardium and/or blood vessels.

Anastomosis of small arteries: implications for coronary artery grafts in Asians.

The internal mammary artery (IMA) in patients with small body surface area, frequently found in the Asian population, is often small and delicate and can be easily damaged during suturing, particularly at the "toe" of the anastomosis. This may lead to less frequent utilization of the IMA as a bypass conduit. We describe a technique for anastomosing a small-caliber IMA to a coronary artery, using the tip of the graft as an autologous buttress to reinforce the toe of the anastomosis.

Coronary bypass surgery in patients on thyroxin replacement therapy.

The outcome of coronary bypass surgery was analyzed in 25 patients who were on thyroxin replacement therapy for chronic thyroid disorders at the time of operation. It was hypothesized that if such patients were given only their routine dose of thyroxin on the day of surgery, hemodynamic and cardiorespiratory recovery may be poor. All the patients on thyroxin replacement therapy were given their routine dose of thyroxin orally or via a nasogastric tube in the perioperative period. No supplemental dose was used. Based on preoperative levels of thyroid stimulating hormone, 68% of these patients were biochemically hypothyroid prior to surgery. Analysis of a large number of variables showed no difference in outcome against a control group who had no previous thyroid problems. We conclude that routine thyroxin administration is all that is required for a satisfactory outcome in patients undergoing coronary bypass surgery while on thyroxin replacement therapy.