Renal transplantation for infantile and juvenile cystinosis: Two case report and review of the literature.

Cystinosis is a rare autosomal recessive lysosomal storage disorder characterized by cystine buildup in various tissues, including the kidneys. Renal involvement is the primary manifestation, leading to end-stage renal disease (ESRD) if left untreated. Kidney transplantation (KT) in patients with cystinosis has significantly improved their prognosis for the disease outcome. Detailed reports on preoperative and Long-term postoperative management in these patients remain sparse. This report discusses the outcomes of two young adult patients of Middle Eastern descent with cystinosis who underwent KT. The first patient, diagnosed with infantile nephropathic cystinosis treated by cystine-depleting therapy, was operated by KT at the age of 18. The second patient, diagnosed with juvenile cystinosis, underwent transplantation at the age of 35 after being treated with hemodialysis. Our report describes detailed pre- and postoperative managements, including laboratory results, and pharmacological interventions. Both cases highlighted the varying clinical manifestations and disease severity between infantile and juvenile cystinosis. Pre-transplant conditions included renal dysfunction, growth retardation, secondary hyperparathyroidism, anemia, and extrarenal manifestations. Following KT, both patients experienced regained renal function, resolution of extrarenal complications, and normalization of laboratory parameters. Furthermore, both patients showed excellent postoperative outcomes with no acute rejection or allograft-related complications. KT is the treatment of choice for cystinosis patients with ESRD. Long-term follow-up post-transplantation is crucial to maintain good graft function. Further studies may elucidate optimal pre- and postoperative management protocols for this rare condition.

Myopia prevalence and risk factors among medical trainees in Lebanon.

PURPOSE: Myopia is known to be one of the most common causes of impaired vision. It is on the rise, especially among high-risk groups such as medical students. Our study aims to estimate the prevalence of myopia and characterize the associated risk factors among medical trainees in Lebanon. METHODS: This descriptive cross-sectional study targeted all medical students and residents enrolled at the Lebanese University in April 2020. Ocular history data, including refractive errors and daily activities, were collected using an online survey. The primary measure was the prevalence of myopia. The secondary measures were myopia risk factors. Associations of demographic and behavioral factors were explored, and risk factors were analyzed using multivariate logistic regression. RESULTS: Among 365 participants (mean age 22.8 years), 51.6% (185) were female. Myopia was found to be prevalent in 52.8% (193) of medical trainees, with a mean reported refractive error of -2.46 diopters in the study eye (right eye) and -2.41 diopters in the fellow eye (left eye). Three factors were significantly and independently associated with myopia prevalence, namely, history of myopia in siblings (P < 0.001), more hours of near activities (P = 0.026), and less outdoor activity (P = 0.007). CONCLUSION: By quantifying the high prevalence of myopia among medical trainees in Lebanon, as well as the established familial and behavioral risk factors, our findings congruently contribute to the global perspective of this long-studied refractive error.

The impact of induction therapy in low-immunological risk kidney transplant recipients regardless of HLA matching.

BACKGROUND: Induction agents have proved to reduce the rate of acute rejection (AR) in kidney transplant recipients (KTRs) without improving long-term graft and patient survival (PS). OBJECTIVE: This study evaluates the utility of induction therapy in low immunological risk KTRs regardless of donor-to-recipient HLA matching. METHODS: We retrospectively reviewed the records of 218 patients undergoing kidney transplantation (KT). These patients were divided into two groups according to the usage of induction therapy: 82 did not receive any induction therapy (Group I), and 136 patients received either Anti-IL2 receptor antibodies or anti-thymocyte globulin (Group II). All patients had panel reactive antibody (PRA) < 20% and absence of donor-specific antibodies (DSA). The difference in outcomes were assessed at different intervals following KT. RESULTS: The rate of bacterial infections at one year (p-value = 0.032) and the frequency of CMV disease (p-value = 0.044) were significantly higher in Group II (with induction therapy). The duration of hospital stay, the rate and severity of acute rejection, the occurrence of delayed graft function, the rate and type of surgical complications at one year, and the graft function and survival at one and three years were similar between the two groups (p-value = NS). In addition, the financial burden is much less in Group I (without induction therapy), reducing the total cost of the transplant procedure. CONCLUSION: We conclude that induction therapy in low-immunological risk kidney transplant patients is not a must regardless of donor-to-recipient HLA matching. Therefore, induction therapy did not yield significant health results, but had negative financial consequences.

COVID-19-induced myocarditis in patient with anomalous origin of the left circumflex artery from the right coronary artery: a case report.

The prevalence of coronary artery anomalies has been increasing due to the increasing usage of coronary angiography. There is a paucity of literature concerning management of viral-induced myocarditis in patients with anomalous coronary artery. We present a very unusual case of a 44-year-old man with anomalous origin of the left circumflex artery from the proximal ostium of the right coronary artery who was admitted for COVID-19-induced myocarditis. He presented with signs of heart failure and coronary angiography revealed the left circumflex artery with a separate ostium originating from the proximal right coronary artery. He was treated medically with Bisoprolol, Perindopril Arginine, Rivaroxaban, and Furosemide. His condition improved rapidly and he resumed regular life within 1 month. Coexistence of cardiac disease such as viral-induced myocarditis with an underlying anomalous origin of the coronary artery is challenging to spot and can lead to worse outcomes in case of misdiagnosis and inaccurate management.

A prevalência de anomalias da artéria coronária vem aumentando devido ao uso crescente da angiografia coronariana. Há uma escassez de literatura sobre o manejo da miocardite induzida por vírus no contexto de artéria coronária anômala. Apresentamos um caso incomum de um homem de 44 anos com origem anômala da artéria circunflexa esquerda do óstio proximal da artéria coronária direita admitido por miocardite induzida por COVID-19. O paciente apresentava sinais de insuficiência cardíaca, e a cineangiocoronariografia revelou artéria circunflexa esquerda de óstio separado originando-se da artéria coronária direita proximal. Ele foi tratado clinicamente com bisoprolol, perindopril arginina, rivaroxabana e furosemida. Sua condição melhorou rapidamente, e o paciente recuperou uma vida normal em 1 mês. A coexistência de doença cardíaca, como miocardite induzida por vírus com uma origem anômala subjacente da artéria coronária, é difícil de detectar e pode levar a resultados piores em caso de diagnóstico incorreto e manejo impreciso.

Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery.

Background: Little is known about gender disparity in the surgery specialty in Lebanon. Aims: To assess the status of female surgeons and possible gender gaps in surgery specialty in Lebanon. Methods: The study was conducted in May 2021. Data were retrieved from the Lebanese Order of Physicians website, indicating the number of physicians in the different specialties, their gender, hospitals, and locations. The c2 test of homogeneity was used to establish whether the gender distribution was equal. Results: Women only accounted for 21.84% (3,370) of physicians in Lebanon, with surgery having the lowest number of female physicians in (n = 65; 2.30%). Women accounted for 1.63% of all surgeons in Lebanese hospitals, there were more female plastic and reconstructive surgeons (n = 12; 7.14%), while neurosurgery, oncological surgery and vascular surgery had no females. There was no significant difference in gender between academic and non-academic institutions (χ2 = 2.164, P = 0.149), or between public and private hospitals (χ2 = 1.277, P = 0.234). Conclusion: The surgical specialty had the widest gender gap among all the medical fields in Lebanon. Therefore, the healthcare systems, including public and private hospitals, have a long and difficult road in narrowing the gender gap. Different strategies to incorporate women into surgery should be explored to assure equitable opportunities for all physicians, based on competency rather than gender.

Intraocular lens power calculation after excimer laser corneal refractive surgery: A retrospective study to compare the predictability and the efficacy of commonly used and modified formulas.

PURPOSE: Our article aims to assess the accuracy of modified and commonly used formulas of intraocular lens (IOL) power calculation after excimer laser corneal refractive surgery. METHODS: This is a retrospective study, with data retrieved for 50 eyes of 32 patients who underwent uncomplicated cataract surgery after excimer laser corneal refractive surgery. The expected spherical equivalent was calculated using the American Society of Cataract and Refractive Surgeons (ASCRS) IOL power calculator for Shammas and Barrett True-K, using three-fourth generation formulas (Haigis-L, Barrett True-K no history, and Holladay 2), and using three-third generation formulas (SRKT, Holladay 1, and Hoffer Q) with single k, as a reference, and adjusting these formulas by calculating the keratometry readings by two methods (Jarade's index and formula). The mean refractive error and mean absolute refractive error (MARE) were calculated at the 1 postoperative month. RESULTS: When all data was available (eight eyes), 13 formulas were compared. Holladay 1 as modified by Jarade's index and formula, and Hoffer Q as modified by Jarade's formula resulted in MARE <0.75D (P < 0.05). In the group of 25 eyes with only ablation available, the formulas with MARE <0.75D were Haigis L, Barrett TK (from ASCRS), Hoffer Q, and the three conventional formulas in Jarade's index (P < 0.001). In the group of 17 eyes with no available prerefractive data, only Haigis-L and Barret TK (no history) had a MARE <0.75 D. CONCLUSION: The use of Hoffer Q or Holladay 1, when prerefractive data are available, gives reliable results with Jarade's index.

Epidemiology of Ocular Malignancies Among the Lebanese Population: A 12-Year Review.

Purpose Our article aims to assess the epidemiology of eye cancer in Lebanon and compare it with other regions worldwide and to study its future trends among Lebanese males and females. Methods Data on eye cancer cases from 2005 to 2016 were obtained from the Lebanese National Cancer Registry (NCR). Age-specific rates, crude rates, and age-standardized rates (ASRs) were subsequently calculated. Joinpoint was used to determine the changes in the slope of trends. A projection for the next 14 years was predicted using linear and logarithmic regression models. Results Among all tumors, eye cancer ranked 40 in females and 41 in males. The eye cancer ASR was 0.24 and 0.22 per 100,000 in males and females, respectively. However, the mean age of eye cancer was 31.94 years in males and 22.04 years in females. The cumulative risk between 0 and 74 years was 0.02%. From 2004 till 2016, a negative trend of eye cancer was observed, with a parallelism of trends between males and females. Age-specific rates showed a bimodal distribution in males. The first cluster was witnessed in the age group of 0-4 years and the second one in those above 50. An additional cluster of distribution was observed in females between 35 and 44 years of age. Forecasts for the next 14 years revealed a steady rate of eye cancer incidence of about 0.2 per 100,000. Moreover, Lebanon showed a relatively low eye cancer ASR compared to other regions worldwide, especially Zimbabwe with 5.8 and 4.8 per 100,000 in females and males, respectively. Conclusion Ocular malignancies showed a negative trend of incidence. A 14-year projection predicts a steady incidence rate in Lebanon and worldwide. Eye cancer seems to be affected by many risk factors. Future efforts are needed for a better understanding of the disease and a better outcome.

Complete recovery of complicated methotrexate-induced liver cirrhosis in a patient with psoriasis: A case report.

Cirrhosis is the most common indication for liver transplant. Literature addressing methotrexate (MTX)-induced liver cirrhosis in patients with psoriasis is sparse. We present a case of a nonalcoholic patient diagnosed with psoriasis that was treated with a weekly 5 mg dose of methotrexate, a chemotherapeutic and immunological modulator, for five years. The patient presented after five years with abdominal distension and lower limb edema along with ascites and esophageal varices and was diagnosed with liver cirrhosis. Upon the discontinuation of MTX, the patient showed clear regression of ascites and esophageal varices, and recovery of liver cirrhosis by de-escalating from Child-Pugh B to A. After five years of follow-up, Echography and Transient Elastography (Fibroscan) of the liver confirmed the full recovery of liver cirrhosis by the absence of steatosis and fibrosis. This study emphasizes the reversibility of MTX-induced liver cirrhosis: cirrhosis is not aggressive, can be reversible, and is dose- and duration-dependent.

COVID-19-induced myocarditis in patient with anomalous origin of the left circumflex artery from the right coronary artery: a case report / Miocardite induzida por COVID-19 em paciente com origem anômala da artéria circunflexa esquerda da artéria coronária direita: relato de caso

Abstract The prevalence of coronary artery anomalies has been increasing due to the increasing usage of coronary angiography. There is a paucity of literature concerning management of viral-induced myocarditis in patients with anomalous coronary artery. We present a very unusual case of a 44-year-old man with anomalous origin of the left circumflex artery from the proximal ostium of the right coronary artery who was admitted for COVID-19-induced myocarditis. He presented with signs of heart failure and coronary angiography revealed the left circumflex artery with a separate ostium originating from the proximal right coronary artery. He was treated medically with Bisoprolol, Perindopril Arginine, Rivaroxaban, and Furosemide. His condition improved rapidly and he resumed regular life within 1 month. Coexistence of cardiac disease such as viral-induced myocarditis with an underlying anomalous origin of the coronary artery is challenging to spot and can lead to worse outcomes in case of misdiagnosis and inaccurate management.

Resumo A prevalência de anomalias da artéria coronária vem aumentando devido ao uso crescente da angiografia coronariana. Há uma escassez de literatura sobre o manejo da miocardite induzida por vírus no contexto de artéria coronária anômala. Apresentamos um caso incomum de um homem de 44 anos com origem anômala da artéria circunflexa esquerda do óstio proximal da artéria coronária direita admitido por miocardite induzida por COVID-19. O paciente apresentava sinais de insuficiência cardíaca, e a cineangiocoronariografia revelou artéria circunflexa esquerda de óstio separado originando-se da artéria coronária direita proximal. Ele foi tratado clinicamente com bisoprolol, perindopril arginina, rivaroxabana e furosemida. Sua condição melhorou rapidamente, e o paciente recuperou uma vida normal em 1 mês. A coexistência de doença cardíaca, como miocardite induzida por vírus com uma origem anômala subjacente da artéria coronária, é difícil de detectar e pode levar a resultados piores em caso de diagnóstico incorreto e manejo impreciso.

Effect of donor-to-recipient HLA matching in low-immunological risk kidney transplant recipients without induction therapy on acute rejection, graft survival, infections, and surgical complications at 3 years: The road towards new recommendations.

BACKGROUND: Donor-to-recipient human leukocyte antigen mismatching is considered one of the strongest determinants for graft and patient survival in kidney transplant recipients (KTR). OBJECTIVE: This retrospective study discusses the impact of HLA matching as low immunological risk KTR without induction therapy. MATERIAL AND METHODS: Records of 80 adult kidney transplant patients were reviewed with three years of the follow-up. All patients had panel reactive antibodies (PRA) < 20%, absence of donor-specific antibodies (DSA) and did not receive the induction therapy. These patients were divided into two groups according to their HLA matching between donor and recipient: 55 patients with ≥ 3 HLA matches (Group I; low immunogenicity) were compared to 25 patients with <3 HLA matches (Group II; high immunogenicity). The primary endpoints included the rate and severity of acute rejection (AR) episodes, graft function (creatinine level), and survival at 1, 3, 6, 12, and 36 months. Secondary endpoints include the rate and type of infections at one-year, surgical complications at one-year, and patient survival at 1, 6, 12, and 36 months after kidney transplantation. Baseline demographic characteristics were comparable between the two groups except for recipient age, donor gender, and pre-transplant dialysis time. RESULTS: There was no significant difference observed between two groups at one-year in infection rate, the length of hospital stay, AR severity, the rate of cytomegalovirus infection, and the occurrence of delayed graft function. However, the rate of AR, the graft function upon discharge, and the rate and type of surgical complications at one-year were significantly higher in Group II (high immunogenicity). The patient and graft survival at three years, the death-censored graft survival, and the serum creatinine levels at 1, 3, 6, 12, and 36 months were similar between two groups. Two deaths occurred in each group (NS). CONCLUSION: In our center, the donor-to-recipient HLA mismatch is not considered an immunological risk factor in low-risk kidney transplant recipients (PRA < 20% and absence of DSA).

Cytomegalovirus infection in kidney transplant patients: Prevalence, risk factors, and impact on outcome - A local multicentre experience.

BACKGROUND: CMV infection prevalence in kidney transplant recipients (KTR) is reported to be high in the literature, reaching rates of over 80%. OBJECTIVES: The primary endpoints were the evaluation of the prevalence, the risks factors, and the effects of CMV infection on graft function and survival, as well as patient survival at three years after kidney transplantation. MATERIAL AND METHODS: We retrospectively reviewed the medical records of 288 kidney transplant patients operated in three Lebanese transplant centers between 1998 and 2017 with three years of follow-up. The patients were divided into two groups: those free of any CMV infection (271 patients (94%); Group I) and those who suffered from CMV infection (17 patients (6%); Group II). RESULTS: Baseline demographics of the two groups were similar, including recipient and donor gender and age, cause of renal disease, recipient body mass index, pre-transplant fasting blood sugar and dialysis duration, HLA matching between donor and recipient, degree of sensitization in the recipient, type of CMV prophylaxis, maintenance immunosuppression and immunological characteristics. The prevalence of CMV infection is 5.9% among KTR. There were significant differences between the two groups concerning the type of induction therapy and the duration of anti-CMV prophylaxis. The rate of infected patients and infectious episodes were significantly higher in Group II. At 3-years, graft function and survival, patient survival, and the rate of new-onset diabetes were similar between the two groups. CONCLUSION: The present study is the first to explore the incidence and risk factors of CMV in kidney transplant patients in Lebanon. Comprehensive nationwide studies are therefore necessary to determine the epidemiology and risk factors of CMV infection after kidney transplantation in Lebanon.

Rapid clinical recovery of posterior reversible encephalopathy syndrome in two cases of IgA nephropathy disease and nephrotic syndrome type 9 post-renal transplant.

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome often associated with immunosuppressant drug use, renal disease, and eclampsia and characterized by parieto-occipital vasogenic edema that usually resolves within days. Globally and in the settings of renal transplant, literature concerning PRES is very scattered. In this report, we provide two cases, one diagnosed with IgA nephropathy and another with nephrotic syndrome type 9 that developed episodes of tonic-clonic seizure immediately after renal transplant in case 1 and four days post-transplant in case 2. The two patients had a history of hypertension, renal disease, corticosteroid and immunosuppressant drug use. Neuro-imaging showed typical vasogenic edema involving the parieto-occipital areas. Therefore, the clinical-radiological presentation confirmed the diagnosis of PRES in both cases. Also, rapid neurologic recovery was witnessed upon administration of anti-epileptic and anti-hypertensive medications. Non-discontinuation of immunosuppressants, steroids, early symptomatic management, and blood pressure control are favorable factors that might explain the rapid recovery of these two patients.