The Lebanese left ventricular assist device experience, a success story despite the odds.

BACKGROUND AND AIM: Heart failure is still a leading cause of mortality and morbidity. Assist devices are reserved for advanced heart failure patients with no other therapeutic options. We aim in this paper to describe the characteristics and outcome of Lebanese left ventricular assist device (LVAD) patients. RESULTS: From 2010 till December 2019, 78 patients were implanted with assist devices at the Beirut cardiac Institute, 82 pumps were used. To the most recent follow up after 10 years, 26 patients died (34%). 24 patients of 35 (68%) survived more than 5 years. Seven patients only (9%) died during one month of surgery. One year mortality was 19% (15 patients). The leading cause of early mortality was infection, whereas cerebrovascular accidents CVA were the leading cause of late mortality. Pump thrombosis occurred in 12% of the cases. The most serious long term complication was haemorrhagic CVA. Only seven patients (9%) received heart transplantation, with a mean time on support prior to transplantation of 1303 ± 213 days. CONCLUSION: In this manuscript we reported the characteristics and outcome of the largest population of LVAD patients in Lebanon. The survival rate was 81% at one year. These findings were comparable to the international registries except for rates of heart transplantation. More efforts should be made to encourage organ donation in Lebanon.

How effective is endovascular intracranial revascularization in stroke prevention? Results from Borgess Medical Center Intracranial Revascularization Registry.

BACKGROUND AND PURPOSE: The WASID study established the risk of subsequent ischemic stroke at 1 year in subjects with symptomatic intracranial atherosclerotic stenosis (70%-99%) at 18%. The efficacy of different methods of endovascular revascularization in stroke prevention still has not been established. We compared the stroke rate in our registry at 1 year following intervention with the WASID results to identify which method, if any, provides the most benefit in stroke prevention. This result from the BMC-IRR follows a previously published article comparing stent placement and angioplasty outcomes. MATERIALS AND METHODS: We maintained a nonrandomized single-center single-operator registry of consecutive symptomatic patients who underwent endovascular intracranial revascularization. Data were collected prospectively and retrospectively and analyzed retrospectively. Patients were treated with angioplasty, BMS, or self-expanding WS. To make our data comparable with that in the WASID study, we selected patients with a single lesion of 50%-99% stenosis undergoing a single intervention. Data was collected on patients until symptom recurrence, repeat intervention, or 1 year postintervention, whichever occurred first. RESULTS: We found that 115 patients fit the inclusion criteria, with 38 angioplasty, 28 BMS, and 49 WS cases. For patients with 70%-99% stenosis, the overall probability of stroke at 1 year postintervention was 19.3%. The overall stroke probability per device, independent of clinical presentation, was 12.5% for angioplasty, 20.2% for BMS, and 24.1% for WS. CONCLUSIONS: Compared with the WASID data, angioplasty appears to have a lower stroke rate after 1 year than medical therapy alone. However, neither stent-placement arm compared favorably with the WASID results.

Predictors of unfavorable outcome in intracranial angioplasty and stenting in a single-center comparison: results from the Borgess Medical Center-Intracranial Revascularization Registry.

BACKGROUND AND PURPOSE: Intracranial angioplasty and stent placement are used to treat intracranial atherosclerotic disease. The 2 interventions have not been directly compared. MATERIALS AND METHODS: This was a single-center, single-operator registry of consecutive, symptomatic subjects receiving treatment (angioplasty, BMS, or WS, chosen based on safety as judged by the operator). After November 2005, angioplasty alone was abandoned following the introduction of the WS. The primary end point was stroke rate per intervention at 30 days. The secondary end point was stroke rate per patient beyond 30 days. Success, dissection, restenosis, and occlusion rates were tracked. RESULTS: From April 2002 to January 2009, 140 subjects with 159 lesions (50%-100% stenosis) underwent 209 interventions: 89 angioplasty, 47 BMS, and 73 WS cases. Overall stroke rate at 30 days was 12.9%. The angioplasty arm had the lowest stroke rate (4.5%), whereas the WS arm had the highest (24.7%; P = .0002), leaving the BMS with 10.7%. Stroke rate beyond 30 days was 9%. The success rate was 58.4% for angioplasty, 81.3% for BMS, and 94.4% for WS, whereas the restenosis rates were 28.2%, 5.8%, and 13.3%, respectively. Dissection increased the risk of stroke in the first 30 days (P = .0439) and restenosis (P = .0051). Perforator vessels were more likely than nonperforators to have stroke within 30 days (P = .008). Eccentric lesions were more likely to have stroke than concentric lesions (P = .0726). CONCLUSIONS: In this comparison, angioplasty had a significantly lower stroke rate than WS. Certain lesion locations, morphologic characteristics, and the presence of dissection after treatment were other predictors of unfavorable outcome.

Vertebroplasty: what is important and what is not.

BACKGROUND AND PURPOSE: It is important to try to clarify the methodology of vertebroplasty such as amount of cement needed, how many needles to use and the significance of cement extravasation. This prospective study evaluated the potential of vertebroplasty to increase the likelihood of an adjacent vertebral compression fracture (VCF) 1 year or less after vertebroplasty, the correlation between the cement volumes injected and pain relief, and the consequences of cement extravasation. MATERIALS AND METHODS: Pain relief and the incidence of a subsequent fracture of adjacent vertebrae 1 year or less after vertebroplasty were evaluated in 357 patients (660 vertebrae) of mean age 77.5 years with osteoporotic VCFs. The correlation between cement volume and pain relief was assessed with a Pearson correlation coefficient; factors potentially predictive of subsequent adjacent VCFs were explored by multiple logistic regression analysis. RESULTS: Refracture of any vertebrae (adjacent or nonadjacent to the primary fracture) occurred in 18% of the patients 1 year or less after vertebroplasty. Refracture of adjacent vertebrae occurred 1 year or less after vertebroplasty in 12% of the patients. Neither cement volume nor extravasation of cement into the intravertebral disk was a significant predictor of adjacent VCFs. No correlation was found between cement volume and pain relief (r = -0.029). Extravasation of cement into the veins, soft tissue, or disk was observed in 33% of all of the treated VCFs and resulted in no complications. CONCLUSIONS: The incidence of an adjacent VCF 1 year or less after vertebroplasty was comparable with that expected for untreated osteoporotic VCFs. Neither the volume of cement injected nor extravasation of cement into the intravertebral disk affected the likelihood of subsequent adjacent VCFs. Cement volume did not correlate with pain relief.

Strongyloidiasis: challenges in diagnosis and management in non-endemic Kuwait.

Among immunocompromised individuals, hyper-infection with Strongyloides stercoralis may occur and lead to fatal strongyloidiasis. To clinicians and laboratory diagnosticians in non-endemic countries such as Kuwait, this severe infection poses a particular problem. The clinical histories and signs and symptoms of four Kuwaiti cases of S. stercoralis hyper-infection were reviewed. Each of the four was found not only to have lived in an area where S. stercoralis was endemic but also to have been treated with immunosuppressive steroids (for medical problems unrelated to the nematode infection). When they presented with undiagnosed hyper-infections their clinical features were confusing. Three of the cases, all with low eosinophil counts, died but the other, who was treated with thiabendazole, survived. In the light of these observations, healthy medical examinees who had recently moved from endemic zones were checked for asymptomatic S. stercoralis infection, both by stool examination and ELISA-based serology. Of 381 stool samples investigated over a 3-month period, 183 (48%) were found positive for helminths, 7% for S. stercoralis. Of 198 individuals from endemic zones who were screened after another medical examination, 71 (35.8%) were found positive for intestinal helminth parasites, including one (1.45%) infected with S. stercoralis. Although ELISA appear reliable in making a presumptive diagnosis of strongylodiasis, the results of such assays are not very specific and are best interpreted in conjunction with the patient's clinical status. The concurrent administration of anthelminthics to patients prescribed steroids who, because they live or have lived in an area where S. stercoralis is endemic, are at risk of infection with the nematode, should be considered.

Modified Giemsa staining for rapid diagnosis of malaria infection.

OBJECTIVES: To develop and evaluate a rapid method for the diagnosis of malaria infection by microscopy of stained blood films. SUBJECTS AND METHODS: Blood specimens were collected from randomly selected confirmed malaria cases (n = 75) and suspected malaria cases (n = 175). The microscopy was done on each set of blood films stained by modified and the standard Giemsa staining methods. RESULTS: All the 75 previously diagnosed malaria cases were confirmed by the microscopy of blood films stained by both methods. Forty-nine (28%) of the 175 cases suspected for malaria infection showed malarial parasites on microscopy of blood films stained by both methods. However, due to homogeneous staining and clearer background of the blood films it was possible to determine the parasite species in 65% of the cases on microscopy of the thick films stained with the modified method compared to only 20% with the standard method. Further, the turnaround time for reporting the microscopy test result was 15-20 and 45-50 min with modified and standard staining methods, respectively. CONCLUSION: Our data showed that performance of the modified staining method in detecting malarial parasites was comparable to that of the standard staining method. Moreover, the modified staining method was rapid, easy to use, and reliable.

Invasive amebiasis: challenges in diagnosis in a non-endemic country (Kuwait).

Invasive zymodemes of the enteric protozoan Entamoeba histolytica infect the large intestine and cause extra-intestinal lesions such as amebic liver abscess (ALA). The clinical manifestations of ALA are protean, particularly in patients presenting in a non-endemic, desert country such as Kuwait, and diagnosis becomes problematic. In this study, we present cases of ALA to illustrate the clinical and diagnostic challenges. For serodiagnosis of ALA, we compared the sensitivity and specificity of the indirect hemagglutination assay (IHA) with the ImmunoTab assay and an enzyme-linked immunosorbent assay (ELISA) for this geographic region. We tested sera of 110 patients with ALA, 1,224 patients suspected of having invasive amebic infection, and 50 Europeans with no travel history to an amebic-endemic area. The IHA was simple, rapid, easy to perform, and reliable (sensitivity = 99%, specificity > 95%). The performance of the IHA in detecting ALA in suspected cases was significantly better than that of the ELISA and the ImmunoTab test. Compared with the IHA, both the ELISA and ImmunoTab assay detected relatively higher numbers of false-positive cases (4.7% and 3.6%, respectively). With the availability of ultrasound and computed tomography scans, the serology correlates excellently with the clinical presentation. In chronic cases where fibrosis may be present around the abscess, the IHA has limitations, as in the follow-up of treated patients. Pitfalls in diagnosis are highlighted by discussing the differential diagnosis of ALA from bacterial hepatic abscesses and infected hydatid cysts. Most importantly, the IHA in such cases was invariably at a titer that is considered not significant.

Cryptosporidiosis in Kuwaiti children: seasonality and endemicity.

OBJECTIVE: To detect the incidence of cryptosporidial infection in children presenting with gastrointestinal symptoms at the local hospital in Kuwait. METHODS: Over a period of 3 years, September 1995 to August 1997, a single fecal sample from 3549 children was analyzed by modified saframin-methylene blue (SM-B) staining and a direct immunofluorescence test for the presence of Cryptosporidium oocysts. RESULTS: Cryptosporidium oocysts were detected in 51 (10%) children with diarrhea. Prevalence was highest (73%) in children > 2 years of age compared with children < 2 years of age. The maximum number of cases, 38 of 51 (75%), was seen during the months January to April, indicating a marked seasonal variation. Polyparasitism was common in children with diarrhea; however, 43 of the 51 (84%) children with cryptosporidiosis had cryptosporidium infection only. Blastocystis hominis and Endolimax nana were the most common parasites detected (38% and 15%, respectively). Forty-seven of the 51 (90%) children with cryptosporidiosis were Kuwaiti and gave no history of travel abroad, suggesting that the infection was acquired indigenously. Sociodemographic information on children with cryptosporidiosis suggests three possible modes of transmission of infection: drinking contaminated water stored in overhead water tanks, person to person, or contact with infected animals. CONCLUSION: In this study, we observed water-borne transmission of cryptosporidium infection in children with diarrhea. The infection is seasonal and endemic.

Simplified method of estimating masticatory performance.

Methods which measure masticatory performance include gravimetric, volumetric and direct observation which depend on the weight, volume and size, respectively, of a test food once chewing is completed. Almonds, one of the most common test foods used, have a convenient size and texture. However, due to their oily content and mixing with saliva, washing and drying is required to overcome the clumping of chewed particles. A method has been developed using bagged almonds to exclude saliva and preventing loss of almond particles in the mouth. In addition, microwaving the whole almond reduces the oil content of the almond, reducing clumping, and potentially eliminating the need for washing and drying the particles. A dentate volunteer was asked to chew seven blanched almonds and seven microwaved almonds. The chewed particles were separated using two sieves, weighed and optically scanned to measure the number and area of the particles. Results were obtained both before and after washing and drying of the chewed particles. The overall results for the test of masticatory performance is very similar whether or not a washing stage is used for microwaved almonds. For untreated almonds washing has a more noticeable effect and may still be considered necessary.

Chewing performance and occlusal contact area with the shortened dental arch.

The aim of this study was to investigate the effect of the loss of posterior teeth on the effectiveness of mastication. To evaluate this, chewing performance and occlusal contact area were investigated in 10 edentate subjects having implants stabilising a mandibular overdenture. A copy of the original lower denture was made for each subject, with removable teeth, which could be separated to convert a complete dental arch to a shortened dental arch, an extremely shortened dental arch, or a broken dental arch. Both post canine occlusal contact area and chewing performance demonstrated significant differences between the different arches. It was concluded that chewing performance is reduced by removing posterior teeth from implant stabilised mandibular complete dentures.

Necrotizing enterocolitis: diagnosis with CT examination of urine after enteral administration of iodinated water-soluble contrast material.

PURPOSE: To develop a new method for diagnosing necrotizing enterocolitis with use of computed tomography (CT). MATERIALS AND METHODS: Urine specimens from 22 neonates were obtained 8-12 hours after iohexol was administered enterally. Twelve neonates had suspected (n = 5) or definite (n = 7) necrotizing enterocolitis, and 10 neonates without necrotizing enterocolitis underwent routine upper gastrointestinal study. Urine from another 13 neonates without necrotizing enterocolitis who did not receive iohexol was collected. The attenuation coefficient of each urine specimen was determined with CT. RESULTS: The mean CT attenuation coefficient of urine from neonates who did not receive iohexol was 5.6 HU +/- 3.9, and that from neonates without necrotizing enterocolitis who underwent upper gastrointestinal study was 6.7 HU +/- 3.2. The mean CT attenuation coefficient of urine from patients with suspected necrotizing enterocolitis was 26.0 HU +/- 3.4, and that in patients with definite necrotizing enterocolitis was 71.0 HU +/- 18.8. The mean CT attenuation coefficients in neonates with necrotizing enterocolitis were significantly different from that in patients without necrotizing enterocolitis who underwent upper gastrointestinal study. CONCLUSION: Urine from neonates with necrotizing enterocolitis show significantly higher CT attenuation coefficients than those from patients without necrotizing enterocolitis. CT examination of urine may allow early detection of necrotizing enterocolitis.

The associations between feeding modes and diarrhoea among urban children in a newly developed country.

The protective effect of breastfeeding against infantile diarrhoea may be less pronounced in areas with modern water supply and sanitation facilities. This finding raises the question whether protection by breastfeeding against infantile diarrhoea in developing countries will decline with improvement in water supply and sanitation. To address this question a historical cohort study of the associations between feeding modes and diarrhoea incidence and severity in children aged 0-14 months at baseline was done in Al Ain city, United Arab Emirates. In this city in a newly developed country, modern water supply and sanitation facilities have become available to everyone during the last two decades. During three months of follow-up of 249 children, the nonbreastfed had more diarrhoea than did the partly breastfed, who in turn had more diarrhoea than did the fully breastfed. After multivariate adjustment, this dose-response effect was consistent for three measures of diarrhoeal morbidity in each child: occurrence or non-occurrence of incidence episodes, number of episodes, and total severity score. However, significant differences were seen only between the nonbreastfed and fully breastfed subgroups. These results indicate that in Al Ain, despite the universal access to modern water supply and sanitation facilities, breastfeeding plays an important role in reducing the incidence and severity of infantile diarrhoea. This observation is particularly important given the growing concern that, as an unwanted effect of 'modernisation', breastfeeding is on the decline in Al Ain and comparable populations elsewhere.

PIP: Since the protective effect of breast feeding against infantile diarrhea may be less pronounced in areas with modern water supply and sanitation facilities, this effect may decline as developing countries make improvements in these areas. This possibility was addressed in a historical cohort study of the association between feeding modes and diarrhea incidence and severity in 249 children from Al Ain city, United Arab Emirates, who were 0-14 months of age at baseline. During the past two decades, a modern water supply and sanitation facilities have become universally available in this newly developed country. During 3 months of follow-up, 69 (28%) of the 249 children had at least 1 diarrhea episode. The 61 non-breast-fed infants had more diarrhea than the 45 partially breast-fed infants, who in turn had more diarrhea than the 143 fully breast fed ones. After multivariate adjustment, this dose-response effect was consistent for three measures of diarrheal morbidity in each child: occurrence or nonoccurrence of incidence episodes, number of episodes, and total severity score. However, significant differences were seen only between the non-breast-fed and fully breast-fed infants. These findings indicate that breast feeding remains a critical child health intervention, even in areas with universal access to modern water supply and sanitation facilities.

MRI of tracheal and esophageal compression following surgery for congenital heart disease.

OBJECTIVE: Magnetic resonance imaging has proven to be a useful diagnostic tool for the evaluation of various types of vascular rings and congenital heart disease. We report two cases showing the accuracy of MRI in detecting post-surgical complications in patients with these conditions. MATERIALS AND METHODS: The two cases reported here demonstrate the use of MRI to show the altered vascular anatomy and the mechanism of tracheal and/or esophageal compression. RESULTS: In the first case, MRI demonstrated narrowing of the right pulmonary artery due to a dilated and posteriorly displaced ascending aorta with residual coarctation, and esophageal compression by an aberrant left subclavian artery. In the second case, MRI demonstrated esophageal compression by a posteriorly displaced ascending aorta. CONCLUSION: We conclude that MRI is an effective noninvasive method for assessing the results and complications of surgical correction of aortic abnormalities.

Ophthalmomyiasis in Kuwait: first report of infections due to the larvae of Oestrus ovis before and after the Gulf conflict.

We report for the first time four cases of ophthalmomyiasis due to the larvae of Oestrus ovis in Kuwait, before and after Operations Desert Shield and Desert Storm. The larvae were easily removed under local anaesthetic. The symptom complex of acute foreign body sensation, irritation, redness, lacrimation and photophobia resolved rapidly. Ophthalmic antibiotic and corticosteroid drops were also instilled and recovery was uneventful. The ophthalmomyiasis may not always be associated with contact with sheep-rearing per se. Medical personnel should therefore be aware that in cases of what might appear initially as acute, non-specific catarrhal conjunctivitis, patients with the persistent symptom complex should be re-examined to exclude ophthalmomyiasis due to the larvae of O. ovis in endemic areas.

Clinical report of Blastocystis hominis infection in children.

During a 9-month hospital-based survey, the intestinal parasite Blastocystis hominis was detected in high numbers (five or more organisms per oil immersion field) in faecal specimens from 39 (2%) of 1960 children under 13 years old. Abdominal pain or discomfort with or without diarrhoea was present in 32 children categorized as acute (14), subacute (7) or chronic (11) cases with respective mean ages of 6.4, 7.3 and 8.7 years. They included three with other enteropathogens (Giardia lamblia, Cryptosporidium sp. or Hymenolepis nana). The remaining seven children had no gastrointestinal symptoms. The 14 acute cases (symptoms duration 1-11 days) were characterized by cramp-like abdominal pain, watery diarrhoea and vomiting. The seven subacute (3-4 weeks) and 11 chronic (3-12 months) cases presented with abdominal discomfort and/or loose non-watery stools. Four complained of flatus and eosinophilia was noted in six. All symptoms resolved with eradication of B. hominis or reduction to low numbers after metronidazole chemotherapy (28 cases) or with no treatment (four cases). This study would appear to support the role of the parasite as an enteropathogen in some children. A case control study is clearly needed to clarify the status of B. hominis as a pathogen.